Publications

Abstract

Background: Provisions of the Affordable Care Act that increase hospitals' financial accountability for preventable readmissions have heightened interest in identifying system-level interventions to reduce readmissions. OBJECTIVES: To determine the relationship between hospital nursing; that is, nurse work environment, nurse staffing levels, and nurse education, and 30-day readmissions among Medicare patients with heart failure, acute myocardial infarction, and pneumonia. Method and Design: Analysis of linked data from California, New Jersey, and Pennsylvania that included information on the organization of hospital nursing (ie, work environment, patient-to-nurse ratios, and proportion of nurses holding a BSN degree) from a survey of nurses, as well as patient discharge data, and American Hospital Association Annual Survey data. Robust logistic regression was used to estimate the relationship between nursing factors and 30-day readmission. Results: Nearly 1 quarter of heart failure index admissions [23.3% (n=39,954)], 19.1% (n=12,131) of myocardial infarction admissions, and 17.8% (n=25,169) of pneumonia admissions were readmitted within 30 days. Each additional patient per nurse in the average nurse's workload was associated with a 7% higher odds of readmission for heart failure [odds ratio (OR)=1.07; confidence interval CI, 1.05-1.09], 6% for pneumonia patients (OR=1.06; CI, 1.03-1.09), and 9% for myocardial infarction patients (OR=1.09; CI, 1.05-1.13). Care in a hospital with a good versus poor work environment was associated with odds of readmission that were 7% lower for heart failure (OR=0.93; CI, 0.89-0.97), 6% lower for myocardial infarction (OR=0.94; CI, 0.88-0.98), and 10% lower for pneumonia (OR=0.90; CI, 0.85-0.96) patients. Conclusions: Improving nurses' work environments and staffing may be effective interventions for preventing readmissions.

Abstract

Background: Provisions of the Affordable Care Act that increase hospitals' financial accountability for preventable readmissions have heightened interest in identifying system-level interventions to reduce readmissions. Objectives: To determine the relationship between hospital nursing; that is, nurse work environment, nurse staffing levels, and nurse education, and 30-day readmissions among Medicare patients with heart failure, acute myocardial infarction, and pneumonia. Method and Design: Analysis of linked data from California, New Jersey, and Pennsylvania that included information on the organization of hospital nursing (ie, work environment, patient-to-nurse ratios, and proportion of nurses holding a BSN degree) from a survey of nurses, as well as patient discharge data, and American Hospital Association Annual Survey data. Robust logistic regression was used to estimate the relationship between nursing factors and 30-day readmission. Results: Nearly 1 quarter of heart failure index admissions [23.3% (n = 39,954)], 19.1% (n = 12,131) of myocardial infarction admissions, and 17.8% (n = 25,169) of pneumonia admissions were readmitted within 30 days. Each additional patient per nurse in the average nurse's workload was associated with a 7% higher odds of readmission for heart failure [odds ratio (OR) = 1.07; confidence interval CI, 1.05-1.09], 6% for pneumonia patients (OR = 1.06; CI, 1.03-1.09), and 9% for myocardial infarction patients (OR = 1.09; CI, 1.05-1.13). Care in a hospital with a good versus poor work environment was associated with odds of readmission that were 7% lower for heart failure (OR = 0.93; CI, 0.89-0.97), 6% lower for myocardial infarction (OR = 0.94; CI, 0.88-0.98), and 10% lower for pneumonia (OR = 0.90; CI, 0.85-0.96) patients. Conclusions: Improving nurses' work environments and staffing may be effective interventions for preventing readmissions.

Abstract

The objective of this study was to analyze hospital staff nurses' shift length, scheduling characteristics, and nurse reported safety and quality. A secondary analysis of a large nurse survey linked with hospital administrative data was conducted. More than 22 000 registered nurses' reports of shift length and scheduling characteristics were examined. Extended shift lengths were associated with higher odds of reporting poor quality and safety. Policies aimed at reducing the use of extended shifts may be advisable.

Abstract

Proteinuria is associated with adverse clinical outcomes in HIV infection. Here we evaluated whether APOL1 risk alleles, previously associated with advanced kidney disease, are independently associated with proteinuria in HIV infection in a cross-sectional study of HIV-infected women in the Women's Interagency HIV Study. We estimated the percent difference in urine protein excretion and odds of proteinuria (≥200 mg/g) associated with two versus one or no APOL1 risk allele using linear and logistic regression, respectively. Of 1285 women successfully genotyped, 379 carried one and 80 carried two risk alleles. Proteinuria was present in 124 women, 78 of whom had proteinuria confirmed on a second sample. In women without prior AIDS, two risk alleles were independently associated with a 69% higher urine protein excretion (95% confidence interval (CI): 36, 108) and five-fold higher odds of proteinuria (95% CI: 2.45, 10.37) as compared with one or no risk allele. No association was found in women with prior AIDS. Analyses in which women with impaired kidney function were excluded and proteinuria was confirmed by a second urine sample yielded similar estimates. Thus, APOL1 risk alleles are associated with significant proteinuria in HIV-infected persons without prior clinical AIDS, independent of clinical factors traditionally associated with proteinuria. Trials are needed to determine whether APOL1 genotyping identifies individuals who could benefit from earlier intervention to prevent overt renal disease.

Abstract

Sources related to demand for nurses data are more difficult to find, and also more difficult to interpret relative to supply. When people talk about the "demand" for nurses, they can have multiple concepts in mind. Even if the concept is well-defined, the data may not clearly align with the intended concept. As with data on RN supply, the relative value of different data sources on RN demand depends on the goals of the data collection and analysis. To measure the current demand for nurses, employer surveys are ideal. Such surveys can explicitly obtain information about vacant positions to measure the total demand for nurses.

Abstract

Objective:: The aims of this study were to describe the shift lengths of pediatric nurses and to measure the association of shift length with nurse job outcomes, nurse-reported patient outcomes, and nurse-assessed safety and quality of care in hospitals. Background:: Long work hours have been linked with poor patient outcomes in adult patient populations, but little is known about the relationship in pediatric settings. Methods:: A secondary analysis of cross-sectional nurse survey data was conducted. Our analysis focused on 3710 registered nurses who worked in 342 acute care hospitals that treated children. Results:: Most pediatric nurses worked 12-hour shifts, especially in intensive care settings. Nurses who worked extended shifts of more than 13 hours reported worse job outcomes and lower quality and safety for patients compared with nurses who worked 8-hour shifts. Conclusions:: Allocating resources to nursing to improve working hours may be a productive strategy for administrators to improve the health and well-being of pediatric patients and nurses.

Abstract

Objectives: Depression is very common in patients with heart failure (HF). However, little is known about how depression influences self-care (ie, adherence to diet, medication and symptom management behaviors) in ethnic minority patients with HF. The purpose of this study was to explore the meaning of depression and how depressive symptoms affect self-care in an ethnic minority Black population with HF. Design: In this mixed methods study, 30 Black patients (mean age 59.63 SD 615 years; 60% male) participated in in-depth interviews about HF self-care and mood; and completed standardized instruments measuring self-care, depression, and physical functioning. Thematic content analysis was used to explore the meaning of depression and elicit themes about how depressive symptoms affect daily self-care practices. Qualitative and quantitative data were integrated in the final analytic phase. Results: Self-care was very poor in the sample. Forty percent of the sample had evidence of depressive symptoms (PHQ-9≥10; mean 7.59 ± 6 5.29, range 0 to 22). Individuals with depressive symptoms had poorer self-care (P=.029). In the qualitative data, individuals described depressive mood as "feeling blue⋯ like I failed." "Overwhelming" sadness and fatigue influenced self-care and resulted in treatment delays. For many, spirituality was central to coping with sadness. Few discussed depressive feelings with health care providers. Conclusions: Depression in ethnic minority patients with HF may be difficult to assess. Research to develop and test culturally sensitive interventions is critically needed, since depression influences self-care and minority populations continue to experience poorer outcomes.

Abstract

We studied how older people describe others with cognitive impairment. Forty-two focus groups represented African Americans, American Indians, Chinese Americans, Latinos, Vietnamese Americans, and Whites other than Latinos (Whites) (N=396, ages 50+), in nine locations in the United States of America. Axial coding connected categories and identified themes. The constant comparison method compared themes across ethnic groups. African Americans, American Indians and Whites emphasised memory loss. African Americans, American Indians, Latinos and Whites stressed withdrawal, isolation and repetitive speech. African Americans, American Indians, Vietnamese Americans and Whites emphasised 'slow thinking'. Only Whites described mood swings and personality changes. Many participants attributed dementia to stress. Terms describing others with dementia included 'Alzheimer's', 'dementia', 'senile' and 'crazy'. Euphemisms were common ('senior moment', 'old timer's disease'). Responses focused on memory, with limited mention of other cognitive functions. Differences among ethnic groups in descriptions of cognitive health and cognitive impairment underscore the need to tailor public health messages about cognitive health to ways that people construe its loss, and to their interest in maintaining it, so that messages and terms used are familiar, understandable and relevant to the groups for which they are designed. Health promotion efforts should develop ethnically sensitive ways to address the widely held misperception that even serious cognitive impairment is a normal characteristic of ageing and also to address stigma associated with cognitive impairment.

Abstract

More than 3.4 million workers have coronary heart disease (CHD) with significant work limitations and disability. Although the cohort of aging workers with CHD is growing, little is known about how older workers with CHD perceive the relationship between the work environment, including job stress, and their health. The purpose of this qualitative, descriptive study was to explore the perceptions of the health effects of work among older workers with CHD and describe how they cope with work stress. The sample was 47% female and 33% African American. Their mean age was 59.21 (± 5.4) years, and most (55%) worked in professional or managerial jobs. Themes emerged about perceptions of the health effects of work and coping strategies. Because older employees are a vulnerable work group, understanding the perceived health effects of work may guide future workplace program development and policy.

Abstract

Aim: To investigate impacts of practice environment factors, nurse perceptions of workload and self-reported burnout at the unit-level on job outcomes and nurse-assessed quality of care in psychiatric hospitals. Background: Associations between practice environments and nurse and patient outcomes have been widely described in acute care hospitals in nursing research examining variables primarily at the respondent level. Research on this topic in psychiatric hospitals is sparse. Design: A cross-sectional design with a survey. Method: Samples of registered nurses, licenced practical nurses and non-registered caregivers from 32 clinical units in two psychiatric hospitals were surveyed. Validated instruments were used to measure work environment, workload, burnout, job outcomes and nurse-perceived quality of care. Unit-level associations were examined using multilevel modelling techniques. Results: Multiple multilevel models identified depersonalization and nurse-physician relations as predictors of turnover intentions and quality of care of the interdisciplinary team. Ratings of nursing management at the unit level were predictors of all of the quality of care variables. Emotional exhaustion was predictive of quality of care at the unit level. While workload was correlated with burnout, it was not predictive of any of the outcomes examined in multiple multilevel models. Conclusion: While relatively low levels of burnout and fairly favourable job and quality of care outcomes were reported by the mental health personnel surveyed, differences across units in ratings of practice environment factors such as nurse-physician relations and nurse management as well as levels of depersonalization were predictive of outcomes. While most findings are consistent with those from other studies of acute care settings, some (slight) differences were also identified.

Abstract

Aims and objectives. To investigate the circumstances of nursing care eight hours before serious adverse events (=SAE's) on medical and surgical nursing units with subsequent in-hospital mortality in order to identify the extent to which these SAE's were potentially preventable. Background. The prevention of SAE 's in acute care is coming under increasing scrutiny, while the role nursing care plays in the prevention of acute critical deterioration of patients is unclear. Methods. Retrospective review of patient records of 63 SAE's in a Belgian teaching hospital where death was the final outcome following a cardiac arrest team call or unplanned ICU admission from an acute care unit. Data from chart reviews were combined with data regarding working conditions on the nursing unit at the time of the events and experts' opinions regarding the preventability of the outcomes. Finally, a pilot survey of staff nurses about their experiences with deteriorating patients and knowledge of vital signs and call criteria was conducted independently of the chart abstractions and case reviews. Results. Experts were almost five times more likely to designate a case as potentially preventable when a cardiac arrest team call was the terminal event and were 40% less likely to designate a case as potentially preventable when more observations were documented in patient records. Survey results revealed that nurses were often unaware that their patients were deteriorating before the crisis. Nurses also reported threshold levels for concern for abnormal vital signs that suggested they would call for assistance relatively late in clinical crises. Conclusion. Renewed attention to accurate recording, documentation and interpretation of vital signs in hospital nursing practice appears needed. Relevance to clinical practice. Timely detection of deteriorating patients to assist staff to improve their outcomes appears to be jeopardised by a number of practices and factors and merits deeper study.

Abstract

The United States has the world's highest prison population, and an estimated one in seven HIV-positive persons in the USA passes through a correctional facility annually. Given this, it is critical to develop innovative and effective approaches to support HIV treatment and retention in care among HIV-positive individuals involved in the criminal justice (CJ) system. Information and communication technologies (ICTs), including mobile health (mHealth) interventions, may offer one component of a successful strategy for linkage/retention in care. We describe CARE+ Corrections, a randomized controlled trial (RCT) study now underway in Washington, that will evaluate the combined effect of computerized motivational interview counseling and postrelease short message service (SMS) text message reminders to increase antiretroviral therapy (ART) adherence and linkage and retention in care among HIV-infected persons involved in the criminal justice system. In this report, we describe the development of this ICT/mHealth intervention, outline the study procedures used to evaluate this intervention, and summarize the implications for the mHealth knowledge base.

Abstract

Following the enactment of Medicare in 1965, access to health care for older adults in the United States improved. At the same time, nurse researchers and policy leaders developed individual and family-centered care interventions and programs that led to improvements in quality of health and life. In the next 20 to 30 years, U.S. and global projections of an expanding aging cohort with potential increases in health care needs, coupled with continued nursing shortage projections, present challenges and opportunities to enhance gerontological nursing's approach to aging care. Invigorating a public health nursing focus on the needs of a population of older adults could enhance nursing's ability to create policy and programs of care that promote quality of life for older adults and their families. Nurses using public health approaches can lead and support social policies regarding the physical environment and daily life circumstances that contribute to health equity. Heightened attention to competencies in community/public health nursing education and promotion of public health nursing careers will be important policy considerations as we face the looming increase in a population of older adults throughout the world.

Abstract

Aim: The aim of this study is to examine perceptions of job satisfaction among immigrant registered nurses (RNs) in Israel and the USA. Background: Former Soviet Union (FSU) RNs in Israel and Filipino RNs in the USA make up the majority of the immigrant nursing workforce in their host countries. However, little is known about their perception of job satisfaction. Methods: Data were gathered using the Index of Work Satisfaction Scale among 71 FSU RNs recruited from three different courses in baccalaureate and master's degree programmes at a central Israeli university, and 96 Filipino RNs attending a national convention hosted by the Philippine Nurses Association of America. The required sample size was obtained by means of the WINPEPI COMPARE2 program, used to determine power and sample size for comparisons of two groups in cross-sectional designs. Findings: The findings show that FSU RNs perceived pay and professional status as important, although they were least satisfied with pay. For Filipino RNs, organizational policies and interactions were most important and they were least satisfied by task requirements. Although the average length of residence in the host country was similar in the two samples, significant differences were found between FSU and Filipino RNs in selected demographic variables and components of job satisfaction. Conclusions: Different characteristics of immigrant RNs affect their distinct perceptions of job satisfaction. As successful adjustment of international immigrant RNs to their workplace could enhance perceptions of job satisfaction, nursing managers should support professional advancement of immigrant RNs through mentorship and educational programmes. There is a need to conduct longitudinal studies among international immigrant RNs in order to better understand changes in their job satisfaction over time and contributing factors. Study Limitations: Generalization of the findings is limited, because a convenience sample was used to recruit FSU and Filipino immigrant RNs.

Abstract

Inherent in many reproductive health and family planning programmes is the problematic assumption that the body, its processes and modifications to it are universally experienced in the same way. This paper addresses contraceptive knowledge and beliefs among Mexican-origin women, based upon data gathered by the qualitative component of the Border Contraceptive Access Study. Open-ended interviews explored the perceived mechanism of action of the pill, side-effects, non-contraceptive benefits, and general knowledge of contraception. Findings revealed complex connections between traditional and scientific information. The use of medical terms (e.g. 'hormone') illustrated attempts to integrate new information with existing knowledge and belief systems. Conclusions address concerns that existing information and services may not be sufficient if population-specific knowledge and beliefs are not assessed and addressed. Findings can contribute to the development of effective education, screening and reproductive health services.

Abstract

Advances in bioelectrical impedance analysis (BIA) permit the assessment of lymphedema by directly measuring lymph fluid changes. The objective of the study was to examine the reliability, sensitivity, and specificity of cross-sectional assessment of BIA in detecting lymphedema in a large metropolitan clinical setting. BIA was used to measure lymph fluid changes. Limb volume by sequential circumferential tape measurement was used to validate the presence of lymphedema. Data were collected from 250 women, including healthy female adults, breast cancer survivors with lymphedema, and those at risk for lymphedema. Reliability, sensitivity, specificity and area under the ROC curve were estimated. BIA ratio, as indicated by L-Dex ratio, was highly reliable among healthy women (ICC=0.99; 95% CI = 0.99-0.99), survivors at-risk for lymphedema (ICC=0.99; 95% CI = 0.99-0.99), and all women (ICC=0.85; 95% CI = 0.81-0.87); reliability was acceptable for survivors with lymphedema (ICC=0.69; 95% CI = 0.54 to 0.80). The L-Dex ratio with a diagnostic cutoff of >+7.1 discriminated between at-risk breast cancer survivors and those with lymphedema with 80% sensitivity and 90% specificity (AUC=0.86). BIA ratio was significantly correlated with limb volume by sequential circumferential tape measurement. Cross-sectional assessment of BIA may have a role in clinical practice by adding confidence in detecting lymphedema. It is important to note that using a cutoff of L-Dex ratio >+7.1 still misses 20% of true lymphedema cases, it is important for clinicians to integrate other assessment methods (such as self-report, clinical observation, or perometry) to ensure the accurate detection of lymphedema.

Abstract

Context: Fatigue is a prevalent symptom among adults living with HIV. There is increasing evidence that fatigue and energy are related, yet distinct constructs. Although HIV-related fatigue has been well studied, little is known about perceived energy and how it relates to fatigue, individual characteristics, and other symptoms. Objectives: To describe the experience of perceived energy in adults with HIV and evaluate its relationship to demographic and clinical characteristics as well as symptoms of fatigue, sleep disturbance, anxiety, depression, and daytime function. Methods: The design was descriptive, comparative, and correlational. The sample of 318 adults with HIV completed a demographic questionnaire; the Memorial Symptom Assessment Scale; and measures of fatigue, sleep disturbance, anxiety, depressive symptoms, and daytime function. Medical records were reviewed for disease and treatment data. Participants who reported a lack of energy were compared with those who did not on demographic, clinical, and symptom variables. Regression models of perceived energy and its interference with daytime function also were evaluated. Results: Perceived lack of energy was highly prevalent (65%) and more strongly related to interference with daytime function than more general measures of fatigue severity, even when controlling for other characteristics and symptoms. Like other aspects of fatigue, lack of energy was associated with sleep disturbance, anxiety, and depressive symptoms. Lack of energy was more strongly related to morning fatigue than to evening fatigue. Conclusion: Lack of energy interferes with daytime function and is not just the inverse of fatigue but a distinct perception that differs from fatigue.

Abstract

As the health care needs of the lesbian, gay, bisexual, and transgender (LGBT) population become increasingly important, health care professionals require appropriate academic and clinical training in preparation for the increased demand for culturally competent care. Nurses are of particular interest, as they are the core direct caregivers in many health care settings. This article explores the national climate around LGBT individuals and their related health needs. Educators and administrators who work with future nurses should strive to ensure they foster the development of knowledgeable practitioners who will be able to implement best practices in LGBT patient care. Attention should be paid to providing students with diverse clinical placements, access to LGBT interest groups, and clear expectations for LGBT-sensitive nursing care plans and course outcomes selection that promote cultural competence. Recommendations for nursing education and curricular reform are discussed.