Publications

Abstract

Decades of practice and research suggest that nurse practitioners (NPs) provide cost-effective and high-quality care. Managed care's emphasis on prevention and cost savings led some policy makers to view NPs as a way to meet the need for primary care providers. However, access to and utilization of NPs has increasingly been controlled by managed care organizations (MCOs) through their selection of providers for primary care panels. This study employed qualitative methodology to examine NPs' experiences with MCOs. Three focus groups, comprising 27 NPs in New York and Connecticut, revealed NPs' mixed reactions to managed care and a range of sentiments regarding NPs' efforts to be listed as primary care providers. The results reflected NPs' concerns about their perceived "invisibility," as well as their sense of "invincibility" in the ways in which NPs are responding to the barriers posed by MCOs. They identified barriers to, as well as ways to facilitate, being listed by MCOs, and described the importance of NPs working individually and collectively in negotiating with MCOs.

Abstract

In Mexico, an old branch of the health care system is getting a new face. Home health care services, also known as community health nursing or public health nursing in Mexico, are emerging as a possible answer for addressing the treatment of chronic conditions such as diabetes and hypertension and for improving the management of cancer treatments. Both physicians and nurses will participate in this pilot program to take place in Mexico City. This article reviews the Mexican health care system, the current role of home health care within it, and the potential of home health care to emerge. It also illustrates the possibilities for home health care services in rural areas.

Abstract

The dopamine (DA) uptake/clearance properties of the DA transporter (DAT) in the core and shell of the nucleus accumbens were measured using in vivo electrochemical recordings. Calibrated amounts of a DA solution were pressure-ejected from a micropipette/ electrode assembly placed in the core or shell of the nucleus accumbens in anesthetized male Fischer 344 rats. Initial studies in the two brain regions revealed that the core and shell have different DA clearance properties as measured by the extracellular DA signal amplitudes, clearance times, and clearance rates. Although the same number of picomoles of DA were applied, DA clearance signals recorded in shell had significantly greater amplitudes but faster clearance rates than those recorded in the core. Systemic administration of 20 mg/kg cocaine, a monoamine transporter inhibitor, greatly increased the signal amplitude from the locally applied DA in both the core and shell. Signal amplitudes were increased to a greater extent in the shell, compared with the core, after cocaine administration. However, cocaine affected the clearance time of DA only in the core and the DA clearance rate only in the shell. Taken together with previously reported data, these studies further support differential activity of the DAT in the core versus shell subregions of the nucleus accumbens. In addition, these data indicate that DATs are more sensitive to the effects of psychomotor stimulants, such as cocaine, in the shell of the nucleus accumbens.

Abstract

Executives in more than 50% of managed care organizations (MCOs) in New York and Connecticut were interviewed for information on the roles, participation, and listing of NPs as primary care providers. MCO executives are highly satisfied with their primary care provider NPs, particularly in women's health and geriatrics, secondary to spending more time teaching and explaining procedures than physicians. Among both health care professionals and the general public there is an overall lack of current knowledge and/or confusion about NPs and their practice. Eighty-two percent of executives in MCOs thought their organization should encourage the use of NPs as primary care providers. Beginning in the early 1960s, advanced practice nursing has shown steady growth. Research has found that NPs provide cost-effective, quality-driven patient care (Brown & Grimes, 1995; Cohen & Juszczak, 1997; Frampton & Wall, 1994; Hardy & Evans, 1995). Many thought health care reform would lead to an expansion of advanced practice nurses (APNs) and other nonphysician providers as primary care providers (Aiken & Salmon, 1994). Funding for and enrollment in graduate nursing programs rose nationwide (American Association of Colleges of Nursing, 1996). Anecdotal reports indicated that NPs were not included in MCO primary care provider panels. The purpose of this study was to explore MCO arrangements with nurse practitioners and the factors that influence them.

Abstract

Managed care poses special challenges to midwives providing reproductive health care. This is owing to the sensitive nature of issues surrounding reproductive health and aspects of managed care that may impede a woman's ability to obtain continuous, confidential, and comprehensive care from the provider of her choice. Variations across payers (ie, Medicare, Medicaid, and commercial insurers) regarding covered benefits and reimbursement of midwifery services also may create obstacles. Furthermore, some physicians and managed care organizations are embracing policies that threaten the ability of midwives to function as primary health care providers for women. Despite these hurdles, midwives have the potential to remain competitive in the new marketplace. This article underscores the importance of being knowledgeable about legislation and policy issues surrounding the financing of midwifery services, quality performance measurement for HMOs as they pertain to reproductive health, and discussions regarding which clinicians should be defined as primary care providers.

Abstract

The effects of cholinergic agonists on nitric oxide (NO) release in hippocampal slices from male Sprague-Dawley rats were investigated using electrochemical recording procedures using Nafion and o-phenylenediamine- treated carbon fiber microelectrodes. These microelectrodes are highly selective for NO versus other interferents. Acetylcholine (Ach) with neostigmine, or nicotine was delivered by pressure ejection from pipettes placed within 300 μm of the NO sensors. Both Ach arid nicotine produced NO signals ranging from 0.04 to 2.14 μM in the CA1, CA3, and dentate gyrus of the rat hippocampus that lasted for 2-5 min. The Ach responses were not antagonized by the muscarinic antagonist atropine. However, nicotine-evoked responses were partially antagonized by α-bungarotoxin, a finding consistent with α7-nicotinic cholinergic receptors being involved with the effects of nicotine. These data support the hypothesis that nicotine is capable of evoking long lasting NO release in the hippocampus.

Abstract

Purpose: To examine the relationship between nurse staffing and selected adverse events hypothesized to be sensitive to nursing care, while controlling for related hospital characteristics. Efforts in the United States to reduce hospital costs, resulting in strategies to use fewer nurses, have stimulated extensive debate but little evaluation. Design: Survey using data from a 20% stratified probability sample to approximate U.S. community hospitals. The sample included 589 acute-care hospitals in 10 states. Methods: Discharge data from 1993 for patients aged 18 years and over were used to create hospital-level adverse event indicators. These hospital-level data were matched to American Hospital Association data on community hospital characteristics, including nurse staffing, to examine the relationship between nurse staffing and adverse events. Results: A large and significant inverse relationship was found between full-time-equivalent RNs per adjusted inpatient day (RNAPD) and urinary tract infections after major surgery (p<.0001) as well as pneumonia after major surgery (p<.001). A significant but less robust inverse relationship was found between RNAPD and thrombosis after major surgery (p<.01), as well as pulmonary compromise after major surgery (p<.05). Conclusions: Inverse relationships between nurse staffing and these adverse events provide information for managers to use when redesigning and restructuring the clinical workforce employed in providing inpatient care.

Abstract

Market transformations occurring within the health care industry require new patterns of organization and management to meet the increasing complexity of service delivery. A greater understanding of the innovation and entrepreneurial dynamic allows administrators, managers, and leaders to create a new vision of service delivery. Central management and leadership objectives include the development of service technologies that capitalize upon the inherent knowledge of workers to meet consumer needs. A strong sense of innovation and entrepreneurship leading to the introduction of new or improved nursing technologies is a primary component in the evolution of professional nursing practice for the 21st century.

Abstract

Few studies have addressed recruitment and retention of participants in preventive interventions directed at human immunodeficiency virus (HIV), and these generally have not focused on women. In this study, part of the Women in Group Support (WINGS) project, we examine the experience of three sites in recruiting 444 high-risk women for a small group intervention to reduce risky sexual behavior. The intervention included six structured sessions, followed by a continuing series of client-focused, drop-in sessions. Incentives for participants included child care, food, and transportation tokens. Attendees at each structured session also received a cash incentive of $10-$20. Forty-six percent of the women were recruited from community sources, 35% from clinics, and 19% from drug programs. Across all recruitment sources, almost a third of the women reported having had a sexually transmitted disease (STD) in the past year, 88%-94% reported a risky male partner (who, they believed, had sex with other partners or with sex workers, was an injecting drug user, or was HIV positive), and 10%-36% reported trading sex for money or drugs. During 18 months of recruitment, each site averaged 34 screening interviews monthly to secure 8 eligible women a month who completed baseline interviews and reported for randomization. The average number of paid sessions attended by participants was five of six (83%). Average attendance at unpaid sessions was 1 of 12 (8%). Key facilitators to recruitment and retention included linkages with community agencies and monetary incentives. Our findings suggest that researchers and community service providers need to explore alternative strategies to paying women for attending group sessions (e.g., incorporating group interventions into existing program requirements) and balance these against the costs and recruitment effectiveness.

Abstract

Identifying, managing, and preventing HIV infection and other sexually transmitted diseases (STDs) are essential components of women's health care. Biological, sociocultural, and epidemiological risks, including STDs, increase the likelihood that a woman will become infected with HIV. Infection with a STD facilitates the likelihood of infection with HIV, and many of the same risk behaviors and interventions are relevant. Promoting sexual health in the age of HIV/AIDS necessitates the acknowledgment of behavioral and social aspects of sexuality, as well as clinical approaches and skills that support safer and satisfying sexual lives for women. This article reviews the use of sexual and substance use risk assessment, individualized counseling, and risk-reduction strategies for women to improve sexual health.