Publications

Abstract

Market-leveled changes occurring in the health care industry require new and creative models of organization, management, and service del very. One of today’s primary management challenges is the development of organizational cultures that value innovation, change, and creativity. The adoption of an ethic of innovativeness allows the organization to stretch the limits of individual and collective knowledge, skill, and ability to meet complex consumer needs. Creativity within organizations is influenced by management practices in conjunction with creativity-relevant work group skills. A common wisdom exists that professional nurses are creative in finding solutions for complex patient care needs. The expansion of this creativity within organizational systems will allow for the evolution of professional nursing practice, improvement in care delivery, and organizational performance.

Abstract

The term "facially inexpressive" is introduced to describe individuals who have lost the ability to produce facial expressions as a result of a neuromuscular disorder. Difficulties in communication may be compounded by presentation of this condition in individuals of mature appearance because the expectation of diminished functioning may increase. Practical techniques are offered to circumvent inaccurate and potentially detrimental assumptions both practitioners and laypeople tend to make when communicating with older adults whose conditions prevent the normal yield of social cues. A case study is presented and implications for the wider geriatric population are discussed.

Abstract

Growing evidence suggests that advance directives (ADs) are often ineffective. Further explanation of how these documents are viewed by the public, the expectations of how decisions about treatment are made, and, in particular, patients’ understanding of how ADs are actually used in the clinical setting, are warranted. This article details a descriptive study in which patients - were int e rviewed, during hospital stays, about their beliefs and understanding of advanced directives, as well as the processes used in completing them. The study was undertaken in a community hospital located in a rural area in the Midioest. Findings show that many patients were able to clearly articulate what an AD means in terms of making their choices known. However, misconceptions were found in patients’ understanding of ADs and only 467r reported discussing their ADs with a physician. Strategies for effective implementation of education programs related to ADs are detailed here.

Abstract

Over the past three decades, the influence and importance of social support has been well documented and the findings have suggested a beneficial effect on stress-related situations, mental and physical health, and social functioning. More recently, small group/skills training behavioral interventions have demonstrated success in changing behaviors which affect the transmission of sexually transmitted diseases, including HIV among populations at risk for these diseases. Studies of support groups to date have been conducted exclusively in research settings where women are offered financial incentives for participation. Little is known about the willingness of women to participate in ongoing support groups after successfully completing a skills training intervention. The present study examines the factors that may influence participation among women in a weekly support group after completing a structured, six session HIV/STD intervention. Both quantitative and qualitative data are collected from 265 women in the intervention arm of a multi-site randomized controlled behavioral intervention trial. Results reveal that less than a quarter (22%) of women participated in at least one support group. Participation varied significantly by site, ranging from 34% to 15% (p =.008). Participation was also strongly linked to recent use of domestic violence services. Qualitative data indicated that although monetary incentives play some role in the woman's decision to participate, other factors are also important. These include program outreach, support group size, salience of the group content, consistency of group leadership from the intervention to the support group, and use of peer leaders along with professional facilitators. Implications for design of post-intervention support groups programs are discussed.

Abstract

Couples confronted with HIV infection face significant challenges. Little is known about the impact of HIV on heterosexual couples who account for the vast majority of cases worldwide and an increasing proportion of cases in the USA, especially among women. In this study, analysis of data collected on HIV-discordant couples participating in a ten-week support group revealed four major groups of issues: (1) dealing with the emotional and sexual impact on the relationship; (2) confronting reproductive decisions; (3) planning for the future of children and the surviving partner; and (4) disclosure of the HIV infection to friends and family. These findings have implications for the design of interventions to enhance adaptation to HIV for discordant couples.

Abstract

In this pilot study a one group pretest posttest design was employed to identify resident characteristics and environmental factors associated with initiation of physical restraint. Predictors of restraint initiation for older adults were examined using secondary analysis of an existing data set of nursing home residents who were subjected to a federal mandate and significant restraint reduction efforts. Lower cognitive status (OR = 1.5 [for every 7-point decrease in Mini-Mental State Examination], 95% Cl = 1.0, 2.1) and a higher ratio of licensed nursing personnel (OR = 3.7, 95% Cl = 1.2, 11.9) were predictive of restraint initiation. Key findings suggest that restraint initiation occurs, despite significant restraint reduction efforts, when a nursing home resident is cognitively impaired or when more licensed nursing personnel (predominantly licensed practical nurses) are available for resident care. Achievement of restraint-free care in nursing homes requires specific and individualized approaches for residents who are cognitively impaired, as well as greater attention to staff mix of registered nurses, licensed practical nurses, and nursing aides.

Abstract

Familial combined hyperlipidemia (FCHL) is a common lipid disorder characterized by elevated levels of plasma cholesterol and triglycerides that is present in 10% to 20% of patients with premature coronary artery disease. To study the pathophysiological basis and genetics of FCHL, we previously reported recruitment of 18 large families. We now report linkage studies of 14 candidate genes selected for their potential involvement in the aspects of lipid and lipoprotein metabolism that are altered in FCHL. We used highly polymorphic markers linked to the candidate genes, and these markers were analyzed using several complementary, nonparametric statistical allele-sharing linkage methodologies. This current sample has been extended over the one in which we identified an association with the apolipoprotein (apo) AI-CIII-AIV gene cluster. We observed evidence for linkage of this region and FCHL (P<0.001), providing additional support for its involvement in FCHL. We also identified a new locus showing significant evidence of linkage to the disorder: the lecithin:cholesterol acyltransferase (LCAT) locus (P<0.0006) on chromosome 16. In addition, analysis of the manganese superoxide dismutase locus on chromosome 6 revealed a suggestive linkage result in this sample (P<0.006). Quantitative traits related to FCHL also provided some evidence of linkage to these regions. No evidence of linkage to the lipoprotein lipase gene, the microsomal triglyceride transfer protein gene, or several other genes involved in lipid metabolism was observed. The data suggest that the lecithin:cholesterol acyltransferase and apolipoprotein AI-CIII-AIV loci may act as modifying genes contributing to the expression of FCHL.

Abstract

OBJECTIVES: Multidisciplinary care of cancer patients in varied settings is well described in the literature, but there is little specifically describing the multidisciplinary care of the patient with hepatocellular carcinoma (HCC). The purpose of this article is to describe HCC and the multidisciplinary approach at the Philadelphia Veterans Affairs Medical Center (PVAMC). MATERIALS AND METHODS: HCC is one of the most common solid tumors in the world, but it is rare in North America. It is associated with environmental carcinogens identified in animal studies, hepatitis B and C, cirrhosis of any etiology, and various metabolic diseases. No reliable therapy has been established for HCC. Surgical resection is the best treatment, but it is possible only in the patient with adequate hepatic reserve and limited-stage cancer. From January 1995 to May 1998, 22 patients at PVAMC received a diagnosis of primary HCC. One patient was a candidate for surgery, two patients received radiation therapy, and one patient underwent chemoembolization. Eighteen patients presented with an advanced-stage disease and comorbidities. RESULTS: Therapy goals in these 18 patients were limited to supportive care and enhancement of quality of life. A multidisciplinary team provided care to this challenging patient population. The multidisciplinary team treating HCC at PVAMC consisted of physicians, nurses, pharmacists, social workers, and a chaplain. Most care occurred in the outpatient setting. Supportive therapy included the controlling of ascites and abdominal discomfort, hepatic encephalopathy, and pruritus. Opioids relieved abdominal pain. Psychiatric support and counseling helped patients and families cope with the poor prognosis. CONCLUSIONS: A multidisciplinary team approach helped provide care for this challenging population. Through anecdotal reports, patients and family expressed satisfaction with their care. Research is needed to systematically test interventions designed to enhance quality of life in patients with HCC.

Abstract

Familial combined hyperlipidemia (FCHL) is a complex genetic disorder of unknown etiology. Recently, 'modifier' genes of the FCHL phenotype, such as the apolipoprotein AI-CIII-AIV gene cluster and LPL, have been identified in several populations. A 'major' gene for FCHL has been identified in a Finnish isolate which maps to a region syntenic to murine chromosome 3 where a locus for combined hyperlipidemia has been identified. We review these and other recent studies which indicate that FCHL is genetically heterogeneous.

Abstract

In a study of nurse practitioners in New York and Connecticut, more than half reported they had never applied to be credentialed by a managed care organization. The majority of nurse practioners reported that their offices billed for their services under the name of the collaborating physician and at the physician rate.