Publications

Abstract

In conflict or post-conflict situations, health system reconstruction becomes a critical component of ensuring stability. The purpose of this study was to determine the priorities for health system reconstruction among Iraqi physicians residing in the northern region of the country. A convenience sample of practicing male and female physicians residing in the Kurdish region completed a 13-item survey about health system reconstruction. A total of 1001 practitioners completed the survey with gender breakdown of 29% female and 71% male, all working in different specialty areas. Significant differences between the providers based on gender (p=0.001), specialty (p=0.001) and geographic location (p=0.004) were found to affect the responses of the participants. This study demonstrates that input from healthcare professionals is important for health system reconstruction, but that gender, geography and medical specialty make the process complex.

Abstract

Aims: New injection drug users (IDUs) are vulnerable to hepatitis C infection from risky injection practices. This article considers the range of hepatits C virus (HCV) knowledge among participants in a 2-year study examining the behaviours of new IDUs. Methods: Respondents (n 36) were members of a cohort of new IDUs recruited in the New York City metropolitan area whose first injection occurred within the previous 18 months. Respondents were offered human immuno virus (HIV), hepatits B virus (HBV) and HCV testing. Two tested HIV positive and 12 tested HCV positive. During pre-test counselling they completed a qualitative interview focusing on aspects of HCV including: transmission, symptoms, long-term effects, prevention, treatment, concern regarding contracting HCV and how this concern impacted drug use and injection practices. Findings: Substantial gaps were seen in HCV knowledge. While respondents were aware that HCV is a blood-borne virus, the majority had only approximate knowledge regarding transmission, symptoms and effects. Respondents reported little discussion of HCV with peers and minimal concern about contracting HCV, especially compared with HIV. Conclusion: Accurate HCV information is failing to reach new IDUs, and new IDUs may not value the little information they do receive. More effective and innovative efforts are required to disseminate effective HCV prevention information to new IDUs.

Abstract

Registered nurses are the largest group of health care providers in the United States. To provide 24-hour care, hospital staff nurses often work long hours and consecutive shifts, without adequate meal or rest breaks. Serious declines in functioning related to provider fatigue can lead to safety issues for patients and nurses alike. The occupational health nurse can assess the effects of nurses' work hours and break periods on employee health, educate staff on the importance of sleep and deleterious effects of fatigue, and implement programs to improve the work environment. This article examines nurses' work hours, break and meal period laws and regulations, and the role of the occupational health nurse in caring for this group of employees. Overall findings suggest that the expertise of an occupational health nurse in the hospital setting could significantly improve the health and safety of staff nurses.

Abstract

OBJECTIVE: This secondary analysis of existing qualitative descriptive data is the first to specifically report on how persons undergoing residential treatment for substance abuse think about depression and the risks of neuropsychiatric side effects associated with interferon (IFN) treatment for hepatitis C virus (HCV) infection. METHOD: Krippendorff's method for qualitative content analysis was used to describe patient perspectives about psychiatric symptoms and potential side effects of IFN treatment. Transcripts from face-to-face, semistructured interviews with 20 patients in 3 residential substance abuse treatment programs were analyzed. RESULTS: Themes included patients' powerlessness and their evaluation of risk and confidence. Participants commented that residential substance abuse treatment programs offered a unique opportunity to undergo antiviral treatment because they capitalized on a patient's heightened readiness for change. Barriers to treatment included perceived obstacles, such as compulsory waiting periods before treatment initiation, fear that neuropsychiatric treatment side effects would sabotage addiction recovery, and concern that psychiatric providers lacked sufficient HCV knowledge. However, when patients perceived clinicians as knowledgeable and genuinely caring, they were amenable to considering antiviral treatment. CONCLUSION: Increasing HCV-specific psychiatric education and staff training, exploring combined psychiatric and antiviral treatment combinations, and therapeutically supporting patient decision making are needed to better use substance abuse residential treatment programs as sites for treating HCV infection. Novel antidepressant treatment approaches are required in this population. Advanced practice psychiatric nurses are well-positioned to develop new integrative models of care addressing the medical, psychiatric, and substance abuse comorbidities in this highly vulnerable group.

Abstract

Background. Older adults are susceptible to reduced saliva production related to certain medications, radiation and chronic conditions. Many of these people have many physical and oral health problems and limited access to dental care. The use of effective screening tools for xerostomia and hyposalivation would be helpful in identifying those at risk. The authors conducted a study to investigate the association between three measures of oral dryness: hyposalivation (low unstimulated salivary flow), self-reported xerostomia and clinically assessed dry mouth. Methods. The authors included a convenience sample of 252 nondemented and dentate West Virginia participants 70 years and older who were part of a larger study on oral health and cognition among older adults. Participants completed a self-reported xerostomia index, provided an unstipulated salivary sample and underwent an oral assessment for the study. Results. Twenty-eight participants (11.1 percent) had hyposalivation, eight of whom reported having xerostomia (sensitivity = 28.6 percent). Of the 43 participants who reported having xerostomia, only eight had hyposalivation (positive predictive value = 18.6 percent). Hyposalivation and self-reported xerostomia were not significantly related. Clinically assessed dry mouth correlated modestly, but significantly, with hyposalivation and self-reported xerostomia. Conclusions. Obtaining routine unstimulated salivary flow rates in addition to self-reported information and oral evaluations may increase early detection of oral dryness, which would assist in implementing early interventions to improve patients' quality of life. Clinical Implications. Visually inspecting oral tissues for dryness and asking a patient if his or her mouth is dry are insufficient measures for clinicians to use to determine if the patient has hyposalivation. The authors recommend that clinicians determine the patient's unstimulated salivary flow rate.

Abstract

Aim: To investigate impacts of practice environment factors and burnout at the nursing unit level on job outcomes and nurse-assessed quality of care in acute hospital nurses. Background: Prior research has consistently demonstrated correlations between nurse practice environments and nurses' job satisfaction and health at work, but somewhat less evidence connects practice environments with patient outcomes. The relationship has also been more extensively documented using hospital-wide measures of environments as opposed to measures at the nursing unit level. Design: Survey. Method: Data from a sample of 546 staff nurses from 42 units in four Belgian hospitals were analysed using a two-level (nursing unit and nurse) random intercept model. Linear and generalised linear mixed effects models were fitted including nurse practice environment dimensions measured with the Revised Nursing Work Index and burnout dimensions of the Maslach Burnout Inventory as independent variables and job outcome and nurse-assessed quality of care variables as dependent variables. Results: Significant unit-level associations were found between nurse practice environment and burnout dimensions and job satisfaction, turnover intentions and nurse-reported quality of care. Emotional exhaustion is a predictor of job satisfaction, nurse turnover intentions and assessed quality of care as well besides various nurse work practice environment dimensions. Nurses 'ratings of unit-level management and hospital-level management and organisational support had effects in opposite directions on assessments of quality of care at the unit; this suggests that nurses' perceptions of conditions on their nursing units relative to their perceptions of their institutions at large are potentially influential in their overall job experience. Conclusion: Nursing unit variation of the nurse practice environment and feelings of burnout predicts job outcome and nurse-reported quality of care variables. Relevance to clinical practice: The team and environmental contexts of nursing practice play critical roles in the recruitment and retention of nurses, and as well as in the quality of care delivered. Widespread burnout as a nursing unit characteristic, reflecting a response to chronic organisational stressors, merits special attention from staff nurses, physicians, managers and leaders.

Abstract

Purpose: The purpose of this study is to describe the implementation process and participant satisfaction with a lifestyle program provided by nurse practitioners (NPs) in primary care to adults at risk for type 2 diabetes (T2D) compared to enhanced standard care. Data sources: A mixed-method clinical trial design was used (n= 58). NPs were interviewed prior to beginning the program, at 3 months, and at completion of the program. NPs also completed a questionnaire on lifestyle counseling at baseline. Process data were collected on attendance, attrition, and intervention fidelity. Participants completed a satisfaction survey at completion of the program and a sub-sample were interviewed at the end of the program. Conclusions: NPs reported that they felt well-prepared and moderately effective in providing lifestyle change counseling. Participant attendance was high and in-person sessions were implemented with good success. Participants in the lifestyle program were more satisfied with the program, reporting that the program was a good experience. Implications for practice: Implementation of a lifestyle program to prevent T2D in primary care is feasible and acceptable to NPs and participants. Developing a structured program may improve health outcomes.

Abstract

Objectives. To determine whether nurse staffing in California hospitals, where state-mandated minimum nurse-to-patient ratios are in effect, differs from two states without legislation and whether those differences are associated with nurse and patient outcomes. Data Sources. Primary survey data from 22,336 hospital staff nurses in California, Pennsylvania, and New Jersey in 2006 and state hospital discharge databases. Study Design. Nurse workloads are compared across the three states and we examine how nurse and patient outcomes, including patient mortality and failure-to-rescue, are affected by the differences in nurse workloads across the hospitals in these states. Principal Findings. California hospital nurses cared for one less patient on average than nurses in the other states and two fewer patients on medical and surgical units. Lower ratios are associated with significantly lower mortality. When nurses' workloads were in line with California-mandated ratios in all three states, nurses' burnout and job dissatisfaction were lower, and nurses reported consistently better quality of care. Conclusions. Hospital nurse staffing ratios mandated in California are associated with lower mortality and nurse outcomes predictive of better nurse retention in California and in other states where they occur.

Abstract

The Internet is increasingly used as a medium for gathering and exchanging health information exchange. Healthcare professionals and organizations need to consider barriers that may exist within their patient-oriented Web applications. One approach to making the Web more accessible for those with lower health literacy may be to supplement textual content with audio annotation using text-to-speech engines, allowing for the creation of a virtual surrogate reader. One challenge is that with numerous text-to-speech engines on the market, objective measures of quality are difficult to obtain. To facilitate comparisons of text-to-speech engines, we developed an open-source Web application that measures user reaction times, subjective quality ratings, and accuracy in completing tasks across different audio files created by text-to-speech engines. Our research endeavor was successful in building and piloting this Web application; significant differences were found for subjective ratings of quality across three text-to-speech engines priced at different levels. However, no significant differences were found with reaction times or accuracy between these text-to-speech engines. Future avenues of research include exploring more complex tasks, usability issues related to implementing text-to-speech features, and applied health promotion and education opportunities among vulnerable populations.

Abstract

UNLABELLED: The rising incidence of obesity and diabetes coincides with a marked increase in fructose consumption. Fructose consumption is higher in individuals with nonalcoholic fatty liver disease (NAFLD) than in age-matched and body mass index (BMI)-matched controls. Because fructose elicits metabolic perturbations that may be hepatotoxic, we investigated the relationship between fructose consumption and disease severity in NAFLD. We studied 427 adults enrolled in the NASH Clinical Research Network for whom Block food questionnaire data were collected within 3 months of a liver biopsy. Fructose consumption was estimated based on reporting (frequency x amount) of Kool-aid, fruit juices, and nondietary soda intake, expressed as servings per week, and classified into none, minimum to moderate (<7 servings/week), and daily (> or =7 servings/week). The association of fructose intake with metabolic and histological features of NAFLD was analyzed using multiple linear and ordinal logistic regression analyses with and without controlling for other confounding factors. Increased fructose consumption was univariately associated with decreased age (P < 0.0001), male sex (P < 0.0001), hypertriglyceridemia (P < 0.04), low high-density lipoprotein (HDL) cholesterol (<0.0001), decreased serum glucose (P < 0.001), increased calorie intake (P < 0.0001), and hyperuricemia (P < 0.0001). After controlling for age, sex, BMI, and total calorie intake, daily fructose consumption was associated with lower steatosis grade and higher fibrosis stage (P < 0.05 for each). In older adults (age > or = 48 years), daily fructose consumption was associated with increased hepatic inflammation (P < 0.05) and hepatocyte ballooning (P = 0.05).CONCLUSION: In patients with NAFLD, daily fructose ingestion is associated with reduced hepatic steatosis but increased fibrosis. These results identify a readily modifiable environmental risk factor that may ameliorate disease progression in patients with NAFLD.

Abstract

This prospective study aimed to determine the nosocomial infection (NI) incidence in an Intensive Care Unit (ICU), its association with clinical characteristics and occurrence sites. It was carried out among 1.886 patients admitted in an ICU of a University Hospital, from August 2005 to January 2008. Data analysis was done using Fisher's test and Relative Risk (RR). There were 383 NIs (20.3%). The infections were in the urinary tract (n=144; 37.6%), pneumonia (n=98; 25.6%), sepsis (n=58; 15.1%), surgical site (n=54; 14.1%) and others (n=29; 7.7%). Hospitalization average was 19.3 days for patients with NI and 20.2 days for those with colonization by resistant microorganisms. The mortality was 39.5% among patients with NI (RR: 4.4; 3.4-5.6). The NI was associated with patients originated from other units of the institution/emergency unit, more than 4 days of hospitalization, community infection, colonized by resistant microorganisms, using invasive procedures and deaths resulting from NI.

Abstract

Purpose: Academic service partnerships are critical for schools of nursing to maintain credibility regarding their missions of education, research, service, and practice.Methods: In this paper, we describe a case study of a ten year program, the Living Independently For Elders (LIFE) Program at the University of Pennsylvania School of Nursing that has provided community-based long-term care to high-risk older adults.Findings: Quality of care and financial outcomes were met with nurse faculty engagement, administrative commitment, and integration of business practices.Conclusions: As a result, high risk older adults receive care in their communities rather than nursing homes, and the school- owned and -operated program is a nationally recognized innovative nursing model of care.Clinical Relevance: Strategies are described that can be used globally as more schools of nursing embrace and strengthen service partnerships.

Abstract

Background: Interdisciplinary care is fundamental to the hospice philosophy and is a key component of high-quality hospice care. However, little is known about how hospices differ in their interdisciplinary staffing patterns, particularly across nonprofit and for-profit hospices. The purpose of this study was to examine potential differences in the staffing patterns of for-profit and nonprofit hospices. Subjects and design: Using the 2006 Medicare Provider of Services (POS) survey, we conducted a cross-sectional analysis of staffing patterns within Medicare-certified hospices operating in the United States in 2006. In bivariate and multivariable analyses, we examined differences in staffing patterns measured by the existence of a full range of interdisciplinary staff (defined as having at least 1 full-time equivalent (FTE) staff in each of 4 disciplines ascertained by the survey: physician, nursing, psychosocial, and home health aide) and by the professional mix of staff within each discipline. Results: For-profit hospices had a winder range of paid staff but there were no differences by ownerships when volunteer staff were included. For-profit hospices had significantly fewer registered nurse FTEs as a proportion of nursing staff, fewer medical social worker FTEs as a proportion of psychosocial staff, and fewer clinician FTEs as a proportion of total staff (p values <0.05). Compared to nonprofit hospices, for-profit and government-owned hospices also used proportionally fewer volunteer FTEs. Conclusions: Hospice staffing patterns differed significantly by ownership type. Future research should evaluate the impact of these differences on quality of care and satisfaction among patients and families using hospice.

Abstract

Ignorance about Hepatitis-C (HCV) among drug users, treatment staff, and policy makers thwarts treatment uptake and facilitates virus transmission. We assessed knowledge about HCV among methadone patients in Israel, where effective HCV-treatment is provided at low-cost within the national health insurance framework, yet few infected methadone patients are treated. In 2006, 512 patients in two methadone clinics in Israel were interviewed, of whom 53% were HCV-positive. The clinics were purposively selected from the 11 methadone clinics in the country. Respondents exhibited poor knowledge about HCV, particularly about diagnosis and treatment. Lesser-educated respondents were three times more likely to score low on HCV-knowledge compared to those with 12+ years of schooling (AOR = 2.97, 95 CI = 1.55.7. HCV-negative patients were also three-times more likely than HCV-positive patients to score low on the HCV-knowledge scale (Adjusted Odds Ratio = 3.0, 95% Confidence Interval = 1.94.7). Enhancing HCV-knowledge may help patients avoid becoming infected and infecting others, allay exaggerated fears about hepatitis, and facilitate HCV-treatment initiation among those infected.

Abstract

This study investigated relationships between Latino gay-identified men in metropolitan New York City and their non-gay-identified male partners. Phase 1 consisted of in-depth interviews (N = 33), and Phase 2 consisted of quantitative surveys (N = 120) with Brazilian, Colombian, and Dominican men who have sex with men (MSM). A majority of participants reported having had sex with heterosexually identified men, and in many cases, the relationship was sustained over time. We found mixed results concerning an attitude sometimes attributed to Latinos that sexual orientation is defined by sexual role, with receptive MSM seen as gay and insertive MSM seen as straight. Although there were no significant associations between partner sexual orientation and unprotected anal intercourse, gay men were less likely to take the insertive role in oral or anal sex with straight-identified male partners than with gay partners.

Abstract

This paper bridges the leadership and organizational change literatures by exploring the relationship between managers' leadership competencies (namely, their effectiveness at person-oriented and task-oriented behaviors) and the likelihood that they will emphasize the different activities involved in planned organizational change implementation (namely, communicating the need for change, mobilizing others to support the change, and evaluating the change implementation). We examine this relationship using data from 89 clinical managers at the United Kingdom National Health Service who implemented change projects between 2003 and 2004. Our results lend overall support to the proposed theory. This finding suggests that treating planned organizational change as a generic phenomenon might mask important idiosyncrasies associated both with the different activities involved in the change implementation process and with the unique functions that leadership competencies might play in the execution of these activities.

Abstract

Despite significant incidence and physical and mental health consequences, most college-age women do not tell anyone about experiences of interpersonal violence. Limited research explores the sociocultural context of seeking help related to violence in young women. The overall purpose of this research was to understand socially and culturally relevant factors associated with violence help seeking in college women. Eight focus groups were held with 64 participants. Narrative analysis was the primary method of analysis. Four qualitative categories emerged from the data: " Learning from one's mother" ; " We're strong women; we fight" ; " We didn't talk about it" ; and " Where I'm from." Findings suggest that help seeking is influenced by the messages from and experiences of mothers and extended family members. An understanding of familial and cultural determinants of help seeking is essential for relevant and effective prevention efforts.

Abstract

Purpose: Epidemiologic studies suggest that insulin-like growth factor-1 (IGF-1) is associated with obesity and, more recently, cancer. This study investigates multiple lifestyle, physiologic, and anthropometric determinants of circulating IGF-1 concentrations. Methods: Nationally representative data were used from the cross-sectional Third National Health and Nutrition Examination (NHANES III, 1988-1994) survey, which measured IGF-1 concentrations in blood, from a subsample of participants who were examined in the morning. After exclusion of persons with missing data, 6,058 men and women 20 years of age or older were included in the study. Results: The mean IGF-1 concentrations were 260 ng/mL in the entire population and were higher among men as compared with women (278.8 vs. 241.3 ng/mL; p < 0.0001). IGF-1 decreased with increasing age (p < 0.0001), body mass index (p < 0.0001), and waist circumference (p < 0.0001). Individuals with metabolic syndrome had lower IGF-1 concentrations after adjustment for covariates (p = 0.0008). IGF-1 was inversely associated with increasing number of metabolic syndrome abnormalities (p = 0.0008). All associations were stronger among women compared with men except across concentrations of glucose. IGF-1 concentrations did not vary by any other lifestyle or physiologic factors. Conclusions: Age, adiposity, hyperglycemia, and metabolic syndrome influenced circulating IGF-1 concentrations. Diet and physical activity had no impact on IGF-1 in this nationally representative population.