Social work services in home health care: challenges for the new prospective payment system era

The implementation of the Prospective Payment System (PPS) provides a unique opportunity for social workers to be better integrated into home health care. To do so, it is important for social workers to define their roles and eliminate any barriers to providing social workers services, which may improve patient outcomes. Two focus groups with home health nurses (n = 10) and social workers (n = 8) were conducted in a large urban home health agency to define social work roles and identify barriers to providing social work services. This paper categorizes the barriers to providing social work services into informational, systems/organizational, and inter-professional barriers and presents possible solutions to these barriers as home health agencies strive to provide care under PPS.     

Variation in deliberate self-harm around Christmas and New Year

Seasonal and temporal variations in suicide by patient and demographic groups, though important, have been investigated infrequently. This study examined patterns of non-fatal deliberate self-harm (DSH) during Christmas and New Year (from December 16th to January 6th) by specific patient and demographic group. The sample comprised 19,346 people who presented with 31,369 episodes of DSH to a general hospital Emergency Department in Oxford, UK. Autoregression analysis of all episodes from 1976 to 2003 (controlling for day of the week, month and year) revealed significant reductions (-30% to -40%) in the occurrence of DSH compared with expected numbers on each day from December 19th to 26th (except the 23rd), though no significant increase was found on any of the subsequent 11 days. When analysed separately, young people aged under 25 years showed decreases (-60%) in the occurrence of DSH on several days throughout Christmas (p<0.001) and New Year (p<0.01). Patients with partner relationship problems showed a decrease 3 days before Christmas Day (-80%, p<0.001) and an increase on New Year's Day (+100%, p<0.01). Patients with family relationship problems showed decreases before Christmas and after New Year (-60%, p<0.01). Patients with social isolation problems, or a previous history of DSH showed decreases (-60%, p<0.01) before Christmas only. Patients who used alcohol at the time of DSH or in the 6h beforehand, but did not chronically misuse alcohol, showed an increase (+250%, p<0.01) on New Year's Day. There was no significant variation in the occurrence of DSH for patient groups with either low/medium or high suicide intent. The findings elucidate how social and individual factors may interact in contributing to DSH. They are of theoretical interest, and have important clinical implications regarding identification of patient groups especially susceptible to DSH at New Year.     

Deliberate self harm: the hidden population

Population-based epidemiological surveys of deliberate self harm (DSH) exclude homeless people and do not represent them in their conclusions. However, DSH in the homeless is commonly seen in inner city hospitals and the homeless are probably at higher risk of eventual suicide. We examined the demographic characteristics of all patients who presented to an inner London hospital after an episode of DSH over a period of three years and found that 15% of patients were of no fixed abode. Alternative methods of studying DSH need to be explored if suicide is to be prevented in this group of people.     

The research potential of practice nurses

Little is known about the research aspirations and experiences of practice nurses. The study discussed in the present paper had three main aims: (1) to assess the level of research interest among practice nurses working in Essex and East London, UK; (2) to identify practice nurses' research priorities; and (3) to explore factors which facilitate and impede the development of practice nursing research. All practice nurses (n = 1,054) in the above areas were sent a questionnaire, and a total of 40% (n = 426) responded after two follow-up letters. Fifty-five respondents who volunteered for further participation were interviewed, either individually or in focus groups. About half (n = 207) of the survey respondents expressed an interest in undertaking research. One-third (n = 145) reported previous participation in research, and 20% (n = 85) had initiated their own research. Logistic regression showed that practice nurses educated to graduate level, and those working in practices with nurse training or participation in external research, were most likely to want to undertake research. Working in a medical training practice was found to be a negative predictor of research interest. Respondents prioritised research into long-term health problems with a high prevalence in the local population; for example, diabetes. Their reasons for wishing to engage in research included improving the service, career development, making work more interesting and reducing isolation. The main barriers identified were lack of time, lack of support from some general practitioners and poor access to higher education resources outside formal courses. The development of practice nurse research would provide a distinctive perspective on health need and service provision. It would contribute to the achievement of the national strategic objective of improving the quality of primary care, enhance the status of the profession, utilise the enthusiasm of individuals, increase job satisfaction and staff retention, and answer real questions.     

Deliberate self-harm in rural and urban regions: a comparative study of prevalence and patient characteristics

In countries like the U.K., people living in urban regions are more likely to suffer poor physical and mental health than rural populations, and to have increased rates of psychiatric disorder. Urban/rural differences in suicidal behaviour have most frequently focussed on variations in the occurrence of suicide. We have investigated rates of deliberate self-harm (DSH) in urban and rural districts of Oxfordshire, England, and compared characteristics of DSH patients resident in these two areas. Information was collected on 6833 DSH episodes by 4054 persons aged 15 years and over presenting to the local general hospital between 2001 and 2005. We found that urban DSH rates were substantially higher than rural rates amongst both males and females aged between 15 and 64 years. This relationship was sustained even when socio-economic deprivation and social fragmentation were taken into account. There was little difference between urban and rural rates for patients aged 65 years and over. Urban DSH patients were more likely to be younger, non-white in ethnic origin, unemployed, living alone, to have a criminal record, to have previously engaged in DSH, and to report problems with housing. Rural DSH patients were more likely to suffer from physical illness, and to have higher suicide intent scores. Results of studies such as this can help identify where resources for preventive initiatives should be primarily directed and also what types of individuals may be at most risk in different areas. However, since variation by area will in part be due to differences at the individual level, further research utilising multi-level modelling techniques would be useful.     

Providers' assessment of barriers to effective management of hypertension and hyperlipidemia in community health centers

We explored 251 providers' (47% licensed practical nurses, 27% registered nurses, 10% physicians, 10% physician assistants, 6% other) perceptions of barriers to effective management of hypertension and hyperlipidemia from 72 Midwest community health centers (CHCs). Optimal care for these diseases is difficult in any setting; little is known about the specific barriers CHCs face. Community health centers often have a multidisciplinary team that participates in patient care. Current models of quality improvement and chronic care management require virtually all CHC providers to know clinical guidelines. Providers in this study generally chose hypertension and hyperlipidemia target levels that met or were more stringent than national guidelines, but lacked confidence to address behavioral change and reported obstacles to modifying patient lifestyle. Community health centers should strengthen providers' skills in facilitating lifestyle change. Improving quality of care requires supporting providers' efforts to take patients' psychosocial and financial challenges into account, and revised policies to eliminate financial and cultural barriers to care.     

School nurses' perceptions of and experience with school health research

This survey examined school nurses' perceptions of and experience with school health research. A random sample of school nurses who were either members of the school nurse section of the American School Health Association (ASHA) or members of the National Association of School Nurses (NASN) comprised the sample (n = 590). The response rate was 81%; the nurses were all females. A plurality held masters degrees (40%) and had worked an average of 12.0 years as a school nurse. Most (67%) were employed at the elementary school level. Slightly more than one-third (37%) had ever been involved in a research study as a school nurse. Perceived barriers to engaging in research were lack of time, clerical help, and money. Perceived benefits of school nurses engaging in research were: adds new knowledge on school nursing issues (97%), benefits the health care of children at school (93%), and helps peers do their job better (86%). School nurses also indicated they would become involved in research if someone would assist them (78%).     

Suicide mortality and pesticide use among Canadian farmers

Background An exploratory, case-control study was used to investigate a new hypothesis about suicide among farm operators. This hypothesis suggested a biologically plausible link between exposures to certain pesticides and the occurrence of suicide among farm operators. These analyses were based on data from the Canadian Farm Operator Cohort. Methods Canadian male farm operators who committed suicide between 1971–1987 (n = 1,457) were compared with a frequency matched (by age and province) sample of control farm operators (n = 11,656) who were alive at the time of death of individual cases. Comparisons focused on past exposures to pesticides reported to the 1971 Canada Census of Agriculture. Results Multivariate logistic regression analyses indicated no associations between suicide and (1) acres sprayed with herbicides, (2) acres sprayed with insecticides, and (3) the costs of agricultural chemicals purchased; after controlling for important covariates. There was, however, a suggestive increase in risk for suicide associated with herbicide and insecticide spraying among a subgroup of farm operators who were most likely to be directly exposed to pesticides: OR = 1.71 (95% CI = 1.08–2.71) for 1–48 vs. 0 acres sprayed. Additional risk factors that were identified included seasonal vs. year-round farm work (OR = 1.68; 95% CI = 1.15–2.46); and high levels of paid labor on the farm (e.g., OR = 1.61; 95% CI = 1.24–2.10, for >13 vs. 0 weeks per year). Factors that were protective included marriage (odds ratio (OR) = 0.69; 95% confidence interval (CI) = 0.58–0.81), having more than one person resident in the farm house (e.g., two vs. one person; OR = 0.62; 95% CI = 0.42–0.92); and higher levels of education (e.g., postsecondary vs. primary; OR = 0.40; 95% CI = 0.17–0.96). Conclusions This study does not provide strong support for the main hypothesis under study, that exposure to pesticides is an important risk factor for suicide among farmers. Although secondary to the main hypothesis, a number of other risk factors for suicide were suggested. These have implications for the future study and targeting of suicide prevention programs in rural Canada. Am. J. Ind. Med. 34:364–372, 1998. © 1998 Wiley-Liss, Inc.     

Barriers to managing mental health in Western Australia

Objective: To explore the views of community‐care and mental health workers on barriers to the management of mental health problems in rural Western Australia, and how these could be addressed. Design: Qualitative content analysis of semi‐structured interviews. Setting: Community and mental health services in Esperance. Subjects: One hundred per cent of relevant mental health workers, 86% of community health professionals and representatives from a wide range of community organisations were interviewed (n =38). Main outcome measures: The views of community‐care and mental health workers on barriers to the management of mental health, and how these could be addressed. Results: Barriers included confusion about the role of mental health services, limited after‐hours access and help for those in situational crisis, communication problems between services, differences in working practices and difficulties in dealing with the stigma of mental illness in rural communities. Suggested solutions were an expansion of counselling services and multi‐agency shared care with clinical streams for adults, those aged > 65 and children. Conclusion: This study revealed a number of barriers that are being addressed through a memorandum of understanding between services.     

Nurses' attitudes to active voluntary euthanasia: a survey in the ACT

National public opinion polls show a large majority of Australians are in favour of active voluntary euthanasia (AVE). However, most members of the public have had only limited direct experience with dying people. For this reason, surveys of the opinions of medical practitioners and nurses on this issue are of great interest. The present study involved a postal survey in late 1996 of 2,000 randomly selected registered nurses from the Australian Capital Territory (ACT). The ACT has had extensive public debate about this issue. The questionnaire included some questions asked in earlier Australian surveys of the general public and health practitioners. Responses were received from 1218 nurses (61%). A majority of nurses who responded supported AVE as 'sometimes right', be it homicide by request (72%) or physician-assisted suicide (71%). A slightly smaller majority believed the law should be changed to allow homicide by request (69%) and physician-assisted suicide (67%). If AVE were legal, 66% of the nurses indicated they were willing to be involved in the procedure. Only 30% were willing to assist patients to give themselves the lethal dose, while 14% were willing to administer the lethal dose to the patient. Comparing these results with previous surveys, it appears that nurses are less in favour of AVE than the public, but more in favour than medical practitioners.     

Knowledge,Practice Behaviors,and Perceived Barriers to Fertility Care Among Providers of Transgender Healthcare

Purpose

Transgender individuals may experience impaired fertility due to gender-affirming hormonal interventions (e.g., pubertal suppression treatment and/or exogenous hormones). Clinical practice guidelines recommend providers discuss fertility implications and options for fertility preservation. The goal of this study was to examine fertility knowledge, practice behaviors, and perceived barriers to fertility care among multidisciplinary providers who care for transgender pediatric and/or adult patients.

Barriers to implementing South Africa's Termination of Pregnancy Act in rural KwaZulu/Natal

INTRODUCTION: South Africa's Termination of Pregnancy Act, the most liberal abortion law in Africa, took effect early in 1997. In spite of the anticipated benefits to women's health, however, public reaction has been mixed. In the country's most populous province, KwaZulu/Natal, opposition is strong and most health care providers have refused to provide the service. This study explored attitudes and beliefs about abortion and the Termination of Pregnancy Act among primary care nurses and community members in a rural district in order to better understand barriers to implementation of the new law. METHODS: As part of a community survey on women's reproductive health (n = 138), questions on knowledge, attitudes and beliefs about abortion were asked, as well as awareness of the provisions of the Termination of Pregnancy Act. To better understand the perspectives of health care workers, a survey among primary care nurses on duty (n = 25) was also conducted. In-depth interviews were conducted with both nurses and women in the community to further pursue issues raised in the two surveys. RESULTS: Support for the Act was low (11%) among both community members and nurses, and few supported abortion on request (18 and 6%, respectively). Within each group, however, a clear hierarchy of support was observed: a majority of nurses (56%) and community members (58%) supported abortion in the case of rape or incest, or if the continued pregnancy would endanger a woman's health (61 and 56%, respectively), but few supported abortion for social or economic reasons. In-depth interviews revealed that abortion is seen as contrary to prevailing community norms; nurses were poorly informed about the Termination of Pregnancy Act and felt confused in their professional responsibilities. CONCLUSIONS AND RECOMMENDATIONS: Legalization alone cannot ensure implementation of abortion services. In South Africa, extensive media coverage prior to passage of the law ensured almost universal awareness of the Act, but little public education took place at the same time. In spite of general opposition to the law, however, there is an encouraging level of support for abortion in some circumstances. These findings suggest that abortion services can be implemented, even in conservative rural areas, but that a process of information dissemination and community consent prior to implementation is essential. Locating abortion within broader reproductive health services could be an effective way to improve access and acceptability.     

Sex differences in suicide incident characteristics and circumstances among older adults: surveillance data from the National Violent Death Reporting System--17 U.S. states, 2007-2009

Each year in the U.S. more than 7,000 adults aged 60 years and older die of suicide and as the population ages, these numbers are expected to increase. While sex is an important predictor of older adult suicide, differences between males and females are often overlooked due to low occurrence, particularly among women. The National Violent Death Reporting System (NVDRS) bridges this gap by providing detailed information on older adult suicide by sex in 17 US states (covering approximately 26% of the U.S. population). NVDRS data for 2007-2009 were used to characterize male (n = 5,004) and female (n = 1,123) suicide decedents aged 60 years and older, including incident characteristics and circumstances precipitating suicide. Stratification of NVDRS data by sex shows significant differences with regard to the presence of antidepressants (19% and 45% respectively), opiates (18%, 37%), and 14 precipitating circumstances concerning mental health, interpersonal problems, life stressors and a history of suicide attempts. No differences were found for alcohol problems, suicide/other death of family or friends, non-criminal legal problems, financial problems, or disclosure of intent to take their own life. The findings of this study demonstrate the value of using comprehensive surveillance data to understand sex-specific suicide circumstances so that opportunities for targeted prevention strategies may be considered.     

北京50家综合医院门诊患者自杀意念及自杀未遂调查

目的 了解北京市综合医院门诊患者的自杀意念和自杀未遂出现率及其危险因素.方法 采用自制量表对随机抽取的北京市50家各级综合医院2877例门诊患者进行调查,通过logistic分析筛选出其危险因素.结果 自杀意念和自杀未遂终生发生率分别为6.08%和1.18%;多因素分析显示两者的共同危险因素为近一年有绝望感、年纪轻、熟人有过自杀行为、女性.结论 北京市综合医院门诊就诊患者经常有自杀危险、抑郁等心理问题;应培养普通门诊医务人员识别、评估和处理这类问题的技能.     

Convergence of health ratings across nephrologists,nurses, and patients with end-stage renal disease

We evaluated a health rating for renal failure patients that was completed by patients, nurses, and nephrologists. The study was a prospective inception-cohort follow-up design. Measurements were taken before initiating dialysis (n=206) or at the initiation of dialysis (n=200) and at 18 (n=225), 30 (n=181), 42 (n=162), 54 (n=137), and 66 (n=112) months after initiating dialysis. Patients, nurses, and nephrologists independently rated patients' health at each measurement occasion. Objective measures of health status, abstracted from the medical record, included emergency and non-emergency admissions, smoking, diabetes mellitus, pulmonary edema, history and number of myocardial infarctions (MI), basal rales, comorbid illnesses, and uremic symptoms. Simultaneous multiple regression analyses examined the correspondence between objective measures of health status and subjective health ratings separately for each rater and measurement occasion. Health ratings were averaged and submitted to the same analyses. Raters showed good agreement (average Pearson r=.43 overall), although agreement was higher between nephrologists and nurses (average r=.64) than between health professional and patients (average r=.34 and .31, respectively). All three ratings and the combined rating corresponded significantly to objective measures of health status. Uremic symptoms, emergency hospital admissions, diabetes mellitus, and recent MI correlated uniquely and most consistently with subjective health ratings. Despite overall convergence, objective measures of health status related to the groups' ratings in a complementary fashion. The health rating is reliable and relates to the current status of the patient. Performance was superior for the combined score that incorporated ratings by patients, nurses, and nephrologists.     

Depo provera discussion paper on clinical care, effectiveness and side effects

Recent changes to the health services have led to an increased provision of clinical care in family planning clinics. While some women may only require contraceptive services, others may demand advice on a breadth of lifestyle issues, including diet and nutrition. Obesity affects 17% of women of childbearing age in Scotland and being overweight during pregnancy has significant health risks. A postal survey of 227 nurses identified as working in family planning clinics in Scotland was conducted in 1998. After a mail shot and one reminder, a net response rate of 64% (n = 145) was achieved. Overall, it was found that obesity was perceived as the most extensive problem in women of childbearing age. Seventy nurses (48%) reported that, in addition to offering family planning services, they gave dietary advice 'frequently' or 'always' to their clients without being asked. There were differences in nutrition-related activities in consultations between nurses offering family planning services only and those who routinely offered nutritional advice. Over half (61%) of the nurses reported that they would give advice regarding weight management even if the patients were not seeking help, although there was no significant difference between the two comparison groups. In some cases, the nutritional advice offered to clients highlighted a deficit in training. Most nutrition education came from diploma and/or training courses and scientific literature, followed by 'experience'. Those nurses already embracing a nutritional advice and guidance role were more interested in further nutrition training (p = 0.018) than the other nurses. However, overall, 67% of the nurses wished to train further in nutrition and weight management. The findings suggest that family planning nurses should be supported to develop nutritional advice and guidance skills, and that there is a pressing need for training in public health nutrition and weight management for nurses working in family planning services.     

Sexual health and the practice nurse: a survey of reported practice and attitudes

BACKGROUND: Practice nurses have an important role in the provision of sexual health services in general practice. AIM: This study set out to determine practice nurses' reported practice and training in sexual health, attitudes towards sexual health, barriers to discussing sexual health with patients, and training needs. METHOD: A confidential self-administered postal questionnaire survey was sent to all 298 practice nurses in one English health district (Leicestershire). RESULTS: Completed questionnaires were returned by 234 practice nurses (response rate 79%). Most nurses routinely offered well-person checks (90%), cervical smears (89%), travel clinics (83%), saw women with genito-urinary symptoms (77%) and offered family planning advice (54%). Only a minority of nurses (13%) offered specific teenage health clinics. Sexual health issues were always discussed in a majority of consultations when giving family planning advice (65%) and in women with genito-urinary symptoms (58%). Most practice nurses (62%) had undertaken at least one course dealing with sexual health issues in the last 5 years. Uptake of training was, however, significantly lower in certain groups of nurses. An analysis of the attitude statements suggested that nurses were more comfortable discussing sexual health issues with female patients and teenagers than with male patients and those of different sexual orientations. Nurses who had received training reported more positive attitudes towards discussing sexual health issues with patients. CONCLUSION: Practice nurses offer a wide range of services in which the need to be able to take a sexual history and offer appropriate advice is important. There is scope to improve the provision of sexual health services by nurses in general practice, particularly in relation to services for teenagers.