Publications

Abstract

Community interventions are rare in the field of sexually transmitted disease (STD) control and prevention. The goals of the Gonorrhea Community Action Project are to design and implement interventions for the reduction of gonorrhea in high-prevalence areas and to increase the appropriateness and effectiveness of STD care in the participating communities. Key to conducting the formative research and developing the interventions was the creation of a community-academic-health department collaborative partnership. Using a staged model, this article presents a case study of collaboration development in the community of Harlem, New York.

Abstract

Objectives. This study assessed the effectiveness of a sexually transmitted disease (STD)/HIV behavior change intervention in increasing women's use of the female condom. Methods. A total of 604 women at high risk for STDs and HIV in New York City, Baltimore, Md, and Seattle, Wash, enrolled in a randomized controlled trial of a small-group, skills-training intervention that included information and skills training in the use of the female condom. Results. In a logistic regression, the strongest predictors of use were exposure to the intervention (odds ratio [OR] = 5.5; 95% confidence interval [CI] = 2.8, 10.7), intention to use the female condom in the future (OR= 4.5; 95% CI = 2.4, 8.5), having asked a partner to use a condom in the past 30 days (OR= 2.3; 95% CI = 1.3, 3.9), and confidence in asking a partner to use a condom (OR = 1.9; 95% CI= 1.1, 3.5). Conclusions. Clinicians counseling women in the use of the female condom need to provide information, demonstrate its correct use with their clients, and provide an opportunity for their clients to practice skills themselves.

Abstract

Objectives. This study determined the effects of nurse staffing and nursing organization on the likelihood of needlestick injuries in hospital nurses, Methods. We analyzed retrospective data from 732 and prospective data from 960 nurses on needlestick exposures and near misses over different 1-month periods in 1990 and 1991. Staffing levels and survey data about working climate and risk factors for needlestick injuries were collected on 40 units in 20 hospitals. Results. Nurses from units with low staffing and poor organizational climates were generally twice as likely as nurses on well-staffed and better-organized units to report risk factors, needlestick injuries, and near misses. Conclusions. Staffing and organizational climate influence hospital nurses' likelihood of sustaining needlestick injuries. Remedying problems with understaffing, inadequate administrative support, and poor morale could reduce needlestick injuries.

Abstract

Public health, including the prevention of drug use, has long relied upon sentinel marker data obtained from national and regional tracking systems in order to forecast changes in patterns of drug abuse. More recently, these types of data have also played an important role in monitoring particular types of medical consequences associated with drug use, including the spread of HIV, HBV, HCV and other viral infections prevalent in IDU populations. While these types of data may provide an important sources of information about changes in drug use and its consequences, the limits of these sources of data have also become widely apparent. Based on a patchwork of institutionally-derived sources of data (e.g. emergency departments, drug treatment admissions, and law enforcement data on drug seizures and arrests), sentinel marker data typically fail to capture a number of "hidden populations" evidencing "hidden" drug-related risk behaviours. Many of these populations and behavioural practices only become apparent well after they have become diffused across regions and diverse drug user subpopulations, making prevention more difficult and more expensive. Furthermore, these systems cannot capture patterns of episodic use, such as those evidenced in crack injection. Ethnographic methods, including field-based community assessment, semi-structured qualitative interviews, and targeted observation of "natural" venues in which drugs are bought, sold, and used, have the potential to overcome some of the limitations from which "systems data" often suffer. Drawing on an ethno-epidemiological approach, our ongoing multi-site research on the use of injection as a mode of administration in the use of crack cocaine is a case in point, and illustrates the potential utility an ethnographic model for the identification and tracking of emergent and ongoing drug use practices.

Abstract

Continuing its commitment to patient care quality, the American Nurses Association appointed a committee in 1997 to expand nursing-sensitive quality indicators beyond acute care. This article is the final report describing the processes used to identify a core set of community-based quality indicators relevant to nurses across the care continuum and identifies next steps. The indicator categories are (a) change in symptom severity, (b) strength of the therapeutic alliance, (c) utilization of services, (d) client satisfaction, (e) risk reduction, (f) increase in protective factors, and (g) level of function/functional status. Potential indicators requiring further research and development are also described.

Abstract

New York City and Los Angeles County have the largest health systems in the United States, but they differ significantly in structure. This study compares and analyzes the structural and workforce differences between the two. The health system in New York City is centered around its large hospitals, and as a result New York employs many more health workers than Los Angeles County, where the health system is centered around physician groups. Health care is a significant contributor to the economy of both areas, but a larger contributor to the economy in New York City.

Abstract

Many HIV positive drug users are unaware that they have the virus, either because they never obtained testing for HIV or because they submitted a biological specimen for testing but never returned to obtain the result of the test. Using data collected from a large multi-site sample of out-of-treatment HIV positive drug users (N=1, 544), we identify a variety of socio-demographic characteristics and drug use and sexual risk behaviors that differentiate HIV-positive individuals who had obtained HIV testing in the past and those who had not and, among those who had been tested, what differentiates individuals who had returned to obtain their HIV test results and those who had failed to return. Results of the analyses suggest that there is a need to target different subgroups of high risk drug users for interventions to obtain HIV testing as compared with those that need encouragement to obtain the results of this testing.

Abstract

Context The worsening hospital nurse shortage and recent California legislation mandating minimum hospital patient-to-nurse ratios demand an understanding of how nurse staffing levels affect patient outcomes and nurse retention in hospital practice. Objective To determine the association between the patient-to-nurse ratio and patient mortality, failure-to-rescue (deaths following complications) among surgical patients, and factors related to nurse retention. Design, Setting, and Participants Cross-sectional analyses of linked data from 10184 staff nurses surveyed, 232342 general, orthopedic, and vascular surgery patients discharged from the hospital between April 1, 1998, and November 30, 1999, and administrative data from 168 nonfederal adult general hospitals in Pennsylvania. Main Outcome Measures Risk-adjusted patient mortality and failure-to-rescue within 30 days of admission, and nurse-reported job dissatisfaction and job-related burnout. Results After adjusting for patient and hospital characteristics (size, teaching status, and technology), each additional patient per nurse was associated with a 7% (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.03-1.12) increase in the likelihood of dying within 30 days of admission and a 7% (OR, 1.07; 95% CI, 1.02-1.11) increase in the odds of failure-to-rescue. After adjusting for nurse and hospital characteristics, each additional patient per nurse was associated with a 23% (OR, 1.23; 95% CI, 1.13-1.34) increase in the odds of burnout and a 15% (OR, 1.15; 95% CI, 1.07-1.25) increase in the odds of job dissatisfaction. Conclusions In hospitals with high patient-to-nurse ratios, surgical patients experience higher risk-adjusted 30-day mortality and failure-to-rescue rates, and nurses are more likely to experience burnout and job dissatisfaction.

Abstract

Objective. To examine the effects of nurse staffing and organizational support for nursing care on nurses' dissatisfaction with their jobs, nurse burnout, and nurse reports of quality of patient care in an international sample of hospitals. Design. Multisite cross-sectional survey. Setting. Adult acute-care hospitals in the United States (Pennsylvania), Canada (Ontario and British Columbia), England, and Scotland. Study participants. 10 319 nurses working on medical and surgical units in 303 hospitals across the five jurisdictions. Interventions. None. Main outcome measures. Nurse job dissatisfaction, burnout, and nurse-rated quality of care. Results. Dissatisfaction, burnout, and concerns about quality of care were common among hospital nurses in all five sites. Organizational/managerial support for nursing had a pronounced effect on nurse dissatisfaction and burnout, and both organizational support for nursing and nurse staffing were directly, and independently, related to nurse-assessed quality of care. Multivariate results imply that nurse reports of low quality care were three times as likely in hospitals with low staffing and support for nurses as in hospitals with high staffing and support. Conclusion. Adequate nurse staffing and organizational/managerial support for nursing are key to improving the quality of patient care, to diminishing nurse job dissatisfaction and burnout and, ultimately, to improving the nurse retention problem in hospital settings.

Abstract

OBJECTIVE: To examine the effects of nurse staffing and organizational support for nursing care on nurses' dissatisfaction with their jobs, nurse burnout, and nurse reports of quality of patient care in an international sample of hospitals. DESIGN: Multisite cross-sectional survey SETTING: Adult acute-care hospitals in the U.S. (Pennsylvania), Canada (Ontario and British Columbia), England and Scotland. Study Participants: 10319 nurses working on medical and surgical units in 303 hospitals across the five jurisdictions. INTERVENTIONS: None Main outcome measures: Nurse job dissatisfaction, burnout, and nurse-rated quality of care. RESULTS: Dissatisfaction, burnout and concerns about quality of care were common among hospital nurses in all five sites. Organizational/managerial support for nursing had a pronounced effect on nurse dissatisfaction and burnout, and both organizational support for nursing and nurse staffing were directly, and independently, related to nurse-assessed quality of care. Multivariate results imply that nurse reports of low quality care were three times as likely in hospitals with low staffing and support for nurses as in hospitals with high staffing and support. CONCLUSION: Adequate nurse staffing and organizational/managerial support for nursing are key to improving the quality of patient care, to diminishing nurse job dissatisfaction and burnout and, ultimately, to improving the nurse retention problem in hospital settings.

Abstract

An exploratory assessment of the impact of the September 11th attacks in New York City on drug users, including their perceptions of changes in drug use, drug availability, police activities, and access to services, was undertaken. Methods included focus groups with drug users and acquired immunodeficiency syndrome (AIDS) outreach worker supervisors and surveys of service providers. Results indicated that, while there was some immediate concern about the potential impact on drug availability, there was no perceived scarcity, although some drug users did report a decrease in drug purity. Responses included increased use of drugs and increased demand for drug treatment. The wide range of responses indicates that continued monitoring of the impact may be needed to assess long-term effects.

Abstract

The left ventricular ejection fraction (LVEF) test rate is increasingly used as a quality of care indicator for patients with heart failure. Our study produced benchmark LVEF test rates in a Medicare fee-for-service population for consideration by a clinical panel assembled by the Health Care Financing Administration. Our sample consisted of 46,583 beneficiaries admitted to the hospital for heart failure and with a complete set of Medicare fee-for-service bills dated 1996 or 1997. The national 2-year LVEF test rate was 79% for Medicare fee-for-service beneficiaries hospitalized for heart failure. Except for 1 state, the test rate ranged from 61% to 89% across states. Our analysis demonstrates the feasibility of using billing data to compute LVEF test rates. Using a 2-year time window and measuring tests performed in outpatient as well as inpatient settings, we find a higher LVEF test rate than has been reported by most previous studies.

Abstract

Ethnographic mapping plays an important role in learning more about the geographic location and temporal movement of hidden populations; it also aids in the exploration of drug use patterns and the social infrastructure of drug users. This paper presents a narrative account of the development and implementation of a mapping process for the ARIBBA project, a dual-site study of the HIV risk behaviors of Puerto Rican drug injectors and crack smokers. The overall goals of the project are to understand the differences in influences on HIV-related risk behaviors. Mapping provided the environmental context for data analysis and led to new insights on both the differences and the similarities between field locations and target populations. Mapping substantively enhanced the ability to make meaningful comparisons in the analysis of both qualitative and quantitative data.

Abstract

Introduction: The purpose of this study was to explore successful relationships between foster children and foster parents. Methods: Dyads of exemplary foster parents and foster children, identified by foster care experts, were interviewed to uncover the meaning of human bonding and attachment between the foster child and foster parent. Data were collected and analyzed with use of Colazzi's phenomenologic methodology. Results A sense of family/coming home was most important for both foster children and foster parents. The powerful desire of the foster child to attain family membership emerged from their experiences, both in and out of foster care. Discussion: The combination of a caring foster parent who worked patiently with the child to help him or her establish membership and a foster child who not only recognized caring behaviors but also was willing to respond to them created the foundation for a successful relationship.

Abstract

Drug treatment programs are a site of opportunity for the delivery of primary and secondary hepatitis C (HCV) prevention services to drug users, a population at great risk for contracting and transmitting the virus. Using data collected from a random nationwide sample (N = 439) of drug treatment programs in the United States, this study examines the extent to which various types of HCV services are provided to their patients. Findings indicate that the majority of drug treatment programs educate at least some of their patients about HCV, and provide some type of support for patients who are infected with the virus. Only 29 of the programs in the sample test all of their patients for HCV, however, and 99 programs test none of them. For the most part, residential treatment programs offer more HCV related services than outpatient drug-free programs.

Abstract

Injuries with used needles and other "sharps" put health care workers at risk for serious bloodborne infections, such as HIV and hepatitis B and C. To some extent, this risk can be lessened through safer techniques (such as not recapping needles) and safer devices (such as needleless and self-sheathing equipment). But these injuries occur within a context (often a hospital unit) with organizational features that may themselves contribute to an increased or decreased risk. This Issue Brief summarizes a series of studies that investigate whether workplace aspects of the hospital (such as staffing levels, and organizational structure and climate) affect the risk of needlestick injuries to nurses.

Abstract

Retention rates for 1-year new graduate nurses had fallen to 30% at the author's institution. Upon reviewing feedback, a lack of a new graduate orientation program was determined to be a significant factor. The challenge presented to staff development was to develop a program that would increase 1-year retention rates of new graduate nurses without incurring overtime costs or significant additional expenses. The result was a successful 8-week orientation program using multiple teaching methods. New graduates rated their own progress through the use of a self-assessment questionnaire. One-year retention rates for new graduate nurses increased to 77% after the program was implemented.