Publications

Abstract

OBJECTIVE: In an effort to better understand turnover rates in hospitals and the effect of new nurses on them, this study sought to describe the characteristics and attitudes toward work of newly licensed RNs, a population important to both the nursing profession and the health care system. METHODS: A survey was mailed to a random sample of new RNs in 35 states and the District of Columbia. A total of 3,266 returned surveys met the inclusion criteria, for a response rate of 56%. RNs who qualified had completed the licensing examination and obtained a first license between August 1, 2004, and July 31, 2005. Data pertaining to four areas were collected: respondent characteristics, work-setting characteristics, respondents' attitudes toward work, and job opportunities. Respondents who were not working were asked to specify why. RESULTS: Of the eligible newly licensed RNs, 58.1% had an associate's degree, 37.6% had a bachelor's degree, and 4.3% had a diploma or a master's or higher degree as their first professional degree. They were generally pleased with their work groups but felt they had only moderate support from supervisors. About 13% had changed principal jobs after one year, and 37% reported that they felt ready to change jobs. More than half of the respondents (51%) worked voluntary overtime, and almost 13% worked mandatory overtime. Also, 25% reported at least one on-the-job needlestick in a year; 39%, at least one strain or sprain; 21%, a cut or laceration; and 46%, a bruise or contusion; 62% reported experiencing verbal abuse. A quarter of them found it "difficult or impossibleg" to do their jobs at least once per week because of inadequate supplies. CONCLUSIONS: This study provides descriptive evidence that a majority of newly licensed RNs are reasonably satisfied and have no plans to change jobs, but the group is not homogeneous. The negative attitudes expressed in response to some survey questions suggest that newly licensed RNs may not remain in the acute care settings where they start out. Investing in better orientation and management may be the key to retaining them in hospitals. The authors will be following these RNs for two years and will develop predictive models of turnover rates.

Abstract

This systematic review examined the evidence on the prevalence of the Hepatitis C Virus (HCV) in non-injecting drug users (NIDUs) who sniff, smoke or snort drugs such as heroin, cocaine, crack or methamphetamine. The search included studies published from January 1989 to January 2006. Twenty-eight eligible studies were identified and the prevalence of HCV in these NIDU populations ranged from 2.3 to 35.3%. There was substantial variation in study focus and in the quality of the NIDU data presented in the studies. The results of our systematic review suggested that there are important gaps in the research of HCV in NIDUs. We identified a problem of study focus; much of the research did not aim to study HCV in users of non-injection drugs. Instead, NIDUs were typically included as a secondary research concern, with a principal focus on the problem of transmission of HCV in IDU populations. Despite methodological issues, HCV prevalence in this population is much higher than in a non-drug using population, even though some IDUs might have inadvertently been included in the NIDU samples. These studies point to a real problem of HCV in NIDU populations, but the causal pathway to infection remains unclear.

Abstract

Background: This paper describes injection risk in an out-of-treatment population of young heroin users in Hanoi, Vietnam, including use of a soft-tissue portal known as a "cay ma" (injection sac). Methods: Data from a large cross-sectional survey (N=1270) are used to describe the prevalence of this practice and its association with disease. Additionally, data from an ethnographic substudy on injectors serve to elaborate injectors' rationales for this injection practice. Results: This practice was common in this sample, appearing soon after initiation of habitual injection. Injectors report that this allows rapid and reliable access to a vein; strategic advantages in a dense urban environment where rapid injection, typically in public settings, is necessary to avoid discovery or arrest. Additionally, this practice is believed to mitigate risk for vein damage from co-morbid promethazine hydrochloride injection. Conclusions: This practice may draw lymphocytes to injection sites, thereby increasing risk for transmission of bloodborne pathogens. Structural and behavioral interventions are needed for young heroin users in Vietnam.

Abstract

Background: The research literature linking nurse staffing and outcomes has expanded radically at a time of profound changes in human resources and financial management in hospitals and health care systems. Findings: Reviews of more than 100 peer-reviewed studies as of mid-2007 support an association between lower nurse staffing levels and poorer patient outcomes in acute care settings. Research efforts are increasingly aimed at understanding which outcomes are affected and under what circumstances and at evaluating the impact of staffing from an economic point of view. Minimal staffing levels appear to be a necessary but insufficient condition for safety in acute care hospitals. Conclusions and Implications: In the face of a deepening nursing shortage, many facilities are likely to find that various aspects of staffing, such as coverage, licensure levels, and experience, are lower than those historically in place. Advance planning by staff and supervisors and careful monitoring of outcomes are needed to ensure patient safety. Health care managers and executives need to benchmark staffing levels and nursing-sensitive outcomes in their facilities, carefully analyze recruitment and retention issues, and develop short- and long-term strategies for averting and dealing with the shortfalls in numbers and skill mix of nursing personnel that they will likely face increasingly in the coming decades.

Abstract

Background: Inadequate communication about pain can result in increased pain for patients. Objectives: The purpose of the current pilot study was to test how nurses respond when patients use their own words, a pain intensity scale, or both to communicate pain. Design: A post-test only experimental design was used with three pain description conditions, personal and numeric; personal only; numeric only. Setting: The setting included six hospitals and one school of nursing located in the northeastern United States. Participants: Participants included 122 registered medical surgical nurses. Methods: Nurses were randomly assigned to condition, and read a vignette about a trauma patient with moderately severe pain. The vignettes were identical except for the patient's pain description and age. The nurses then wrote how they would respond to the patient's pain. Two blind raters content analyzed the responses, giving nurses one point for including each of six a priori criteria derived from the Acute Pain Management Panel [1992. Acute Pain Management: operative or medical procedures and trauma. Clinical practice guideline (AHCPR Publication No. 92-0032)., Rockville, MD, USA] and the American Pain Society [2003. Principles of analgesic use in the treatment of acute pain and cancer pain, Glenville, IL, USA]. Results: Nurses planned similar numbers of pain management strategies across the three conditions, with a mean of 2.1 (SD=1.14) strategies out of the recommended six. Conclusions: Nurses did not respond with more pain management strategies when patients describe pain in their own words, or in their own words and a pain intensity scale. The relatively small number of pain management strategies planned by the nurses suggests that nurses use few strategies to respond to moderately severe pain problems.

Abstract

Context: Despite growing evidence in the US, little evidence has been available to evaluate whether internationally, hospitals in which nurses care for fewer patients have better outcomes in terms of patient survival and nurse retention. Objectives: To examine the effects of hospital-wide nurse staffing levels (patient-to-nurse ratios) on patient mortality, failure to rescue (mortality risk for patients with complicated stays) and nurse job dissatisfaction, burnout and nurse-rated quality of care. Design and setting: Cross-sectional analysis combining nurse survey data with discharge abstracts. Participants: Nurses (N = 3984) and general, orthopaedic, and vascular surgery patients (N = 118 752) in 30 English acute trusts. Results: Patients and nurses in the quartile of hospitals with the most favourable staffing levels (the lowest patient-to-nurse ratios) had consistently better outcomes than those in hospitals with less favourable staffing. Patients in the hospitals with the highest patient to nurse ratios had 26% higher mortality (95% CI: 12-49%); the nurses in those hospitals were approximately twice as likely to be dissatisfied with their jobs, to show high burnout levels, and to report low or deteriorating quality of care on their wards and hospitals. Conclusions: Nurse staffing levels in NHS hospitals appear to have the same impact on patient outcomes and factors influencing nurse retention as have been found in the USA.

Abstract

Patients with cancer often experience pain, yet studies continue to document inadequate and inappropriate assessment and management of cancer-related pain. This study aimed to evaluate the attitudes and knowledge of inpatient oncology healthcare providers toward pain management by surveying nurses, pharmacists, and physicians working on the inpatient oncology units at an academic medical center. Healthcare providers generally reported positive attitudes toward pain management but were deficient in their knowledge of pain management. The authors suggest that pharmacists become more integral members of palliative care teams and actively participate in rounds. A need exists for educational programs in pain management for healthcare providers, especially for those who do not routinely care for patients with cancer.

Abstract

Purpose: To explore use of an interactive health communication tool- "Computer Assessment and Risk Reduction Education (CARE) for STIs/HIV.". Methods: This was a mixed method study utilizing participant observation and in-depth interviews with patients (n = 43), and focus groups with staff (5 focus groups, n = 41) from 5 clinics in 3 states (1 Planned Parenthood, 1 Teen, 2 STD, and 1 mobile van clinic). Data were managed using Atlas.ti. Inter-rater reliability of qualitative coding was .90. Results: Users were 58% nonwhite with mean age 24.7 years (74% < 25). Patients could use CARE with minimal to no assistance. Time for session completion averaged 29.6 minutes. CARE usefulness was rated an average of 8.2 on an ascending utility scale of 0 to 10. Patient themes raised as strengths were novelty, simplicity, confidentiality, personalization, and plan development, increased willingness to be honest, lack of judgment, and a unique opportunity for self-evaluation. Staff themes raised as strengths were enhanced data collection, handout customization, education standardization, behavioral priming, and expansion of services. Patient limitation themes included limited responses and lack of personal touch. Staff limitation themes were selecting users, cost, patient-provider role, privacy, and time for use. Conclusions: CARE was well-received and easily usable by most (especially 18-25-year-olds). Patient and staff perceptions support the use of CARE as an adjunct to usual practice and as a method to expand services. Honesty, reduced time constraints, and lack of judgment associated with CARE appeared to enhance self-evaluation, which may prove an important component in moving patients forward in the behavior change process.

Abstract

We developed a Web-based application delivered on PDAs (Colecta-PALM in Peru, Pambazuko-PALM in Kenya), to collect data from HIV patients and to facilitate HIV provider training. Colecta-PALM provides tailored feedback (behavioral messaging) based on risk assessment responses for HIV patients. Pambazuko-PALM collects patient risk assessment data, and delivers counseling protocol training and evaluation to nurses involved in HIV care.

Abstract

Research on adolescent mothers has revealed increasing rates of depressive symptoms in the postpartum period. This review integrated 12 research-based articles to provide a better understanding of depression among adolescent mothers in the first year postpartum. The results revealed that more family conflict, fewer social supports, and low self-esteem all were associated with increased rates of depressive symptoms in adolescent mothers during the first postpartum year. To prevent adverse outcomes associated with depression, it is important that nurse practitioners working with these families screen adolescent mothers for depression and refer them for treatment as needed.

Abstract

Background: This study described a cohort of teen mothers and their children attending an urban high school with a parent support program and school-based child care center. Specific aims of the study were to describe maternal characteristics and outcomes, and child developmental and health outcomes. Methods: A volunteer sample of 65 adolescent mothers enrolled in the parent support program and their children were interviewed, surveyed, and assessed. Fifty-three mothers had children enrolled in the school-based child care center and 12 mothers had their children cared for by family members. Maternal characteristics assessed included self-esteem and depressive symptoms, social stressors and support, self-perceived parental competence, parent-child teaching interactions, and subsequent childbearing and maternal educational outcomes. Child outcomes included child developmental assessments and health outcomes. Results: About 33% of teen mothers were mildly to moderately depressed and 39% of the sample had experienced transitional homelessness. Social support networks were small; in the past 12 months, mothers experienced a mean number of 13.2 ± 11.9 negative life events. Maternal self-report measures and mother-child observation measures indicated positive levels of parental competence. Maternal educational outcomes were positive, and only 6% of mothers had subsequent childbirths within 2 years. The mean scores on developmental assessments of children fell within the normal range, although there were 7 children identified with developmental delays. Conclusions: For at-risk teen mothers, this parent support program and school-based child care setting appears to offer promising opportunities to help young mothers with parenting, avoid rapid subsequent pregnancies, and stay engaged with school, while their children are cared for in a close and safe environment.

Abstract

OBJECTIVES: To explore associations between psychiatric comorbidity and rehospitalization risk, length of hospitalization, and costs. DESIGN: Cross-sectional study of 1-year hospital administrative data. SETTING: Claims-based study of older adults hospitalized in the United States. PARTICIPANTS: Twenty-one thousand four hundred twenty-nine patients from a 5% national random sample of U.S. Medicare beneficiaries aged 65 and older, with at least one acute care hospitalization in 1999 with a Diagnostic-Related Group of congestive heart failure. MEASUREMENTS: The number of hospitalizations, mean length of hospital stay, and total hospitalization costs in calendar year 1999. RESULTS: Overall, 15.8% of patients hospitalized for heart failure (HF) had a coded psychiatric comorbidity; the most commonly coded comorbid psychiatric disorder was depression (8.5% of the sample). Most forms of psychiatric comorbidity were associated with greater inpatient utilization, including risk of additional hospitalizations, days of stay, and hospitalization charges. Additional hospitalization costs associated with psychiatric comorbidity ranged up to $7,763, and additional days length of stay ranged up to 1.4 days. CONCLUSION: Psychiatric comorbidity appears in a significant minority of patients hospitalized for HF and may affect their clinical and economic outcomes. The associations between psychiatric comorbidity and use of inpatient care are likely to be an underestimate, because psychiatric illness is known to be underdetected in older adults and in hospitalized medical patients.

Abstract

Mutations in LRRK2 were first reported as causing Parkinson's disease (PD) in late 2004. Since then, approximately a dozen LRRK2 substitutions have been identified that are believed to be pathogenic mutations. The substitution of adenine for guanine at nucleotide 4541 (4541G>A) in LRRK2 was recently reported. This substitution resulted in the replacement of an arginine at position 1514 with a glutamine (R1514Q). Although this substitution was not found in a large cohort of controls, its pathogenicity could not be verified. We have now genotyped the R1514Q substitution in a sample of 954 PD patients from 429 multiplex PD families. This substitution was identified in 1.8% of the PD patients; however, the majority of the PD sibships segregating this substitution were discordant for this putative mutation. In addition, the R1514Q substitution was detected in 1.4% of neurologically evaluated, control individuals. These data suggest that the R1514Q variant is not a pathogenic LRRK2 mutation. We believe it is imperative that the causative nature of any newly identified genetic variant be determined before it is included in any panel for diagnostic testing.

Abstract

This exploratory study of patients in Pennsylvania (PA) and Virginia (VA) hospitals in 1998-1999 measures the segregation of care for Black patients receiving inpatient care for specific medical and surgical conditions. It also examined inpatient mortality risk for Black patients and the impact of treatment in heavily segregated hospitals on mortality for Blacks and non-Blacks. Segregation of hospital care was found across both states but was more pronounced in PA. Blacks did not experience higher mortality rates than non-Blacks either before or after controls for clinical risk factors in either state and for certain admission types had lower mortality. Both Black and non-Black surgical, heart failure, and lung disease patients treated in VA hospitals with more Black patients had poorer outcomes. Future research should examine how access, patient choice, hospital organization, processes of care, and factors related to nursing care might influence hospital outcomes for patients from different racial backgrounds.

Abstract

OBJECTIVE - The purpose of this study was to assess whether the prevalence of inducible myocardial ischemia increases over time in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS - Participants enrolled in the Detection of Ischemia in Asymptomatic Diabetics (DIAD) study underwent repeat adenosine-stress myocardial perfusion imaging 3 years after initial evaluation. Patients with intervening cardiac events or revascularization and those who were unable or unwilling to repeat stress imaging were excluded. RESULTS - Of the initial 522 DIAD patients, 358 had repeat stress imaging (DIAD-2), of whom 71 (20%) had ischemia at enrollment (DIAD-1). Of 287 patients with normal DIAD-1 studies, 259 (90%) remained normal in DIAD-2, whereas 28 (10%) developed new ischemia in DIAD-2. Of the 71 patients with abnormal DIAD-1 studies, 56 (79%) demonstrated resolution of ischemia, whereas 15 (21%) remained abnormal. During this 3-year interval, medical treatment was intensified, with more patients using statins, aspirin, and ACE inhibitors than at baseline. Patients with resolution of ischemia had significantly greater increases in these medications than patients who developed new ischemia (P = 0.04). CONCLUSIONS - Thus, the majority of asymptomatic patients with type 2 diabetes demonstrated resolution of ischemia upon repeat stress imaging after 3 years. This resolution was associated with more intensive treatment of cardiovascular risk factors.