Ethical and Policy Considerations for Centenarians—The Oldest Old

To illustrate the incongruence of ethical standards and fiscal and policy constraints on quality care for the oldest old. As the fastest growing demographic segment in the United States, care needs of the oldest old are a special challenge to the health care system.

Design:

Narrative analysis of interviews with centenarians who used nursing home services. The sample was three participants of the Georgia Centenarian Study who had been community dwelling and cognitively intact at the onset of participation (between 1988 and 1997). Interviews were conducted in nursing homes or after discharge.

Methods:

Case histories were constructed from interviews in 1997 to improve understanding of quality of care.

Findings:

Less-than-optimal care was provided for these elders, and little consideration was given to their input to care decisions and prospects for medical improvement. Appropriate consideration was not given to providing least-restrictive environments, appropriate restraint use, and options for community care.

Conclusions:

Six policy reforms are suggested for meeting the needs of the oldest-old before and after institutionalization. These include: integration of resident involvement in care decisions; development of alternate models of care; greater input from nurses concerning nursing care of special populations; more effective family and community involvement in the caring of elderly populations; increased research to promote function and independence; and increased education of personnel and nursing students to allow for more accurate assessment of cognitive and physical status.     

Parental Self-Efficacy and Asthma Self-Management Skills

P urpose . To determine whether a formal asthma self-management program and social support using lay health advisors increases parent self-efficacy in the management of their child's asthma, and whether parent self-efficacy predicts asthma self-management skills.

DESIGN.

DESIGN. Quasi-experimental with four time points measured over 2 years.

PARTICIPANTS.

PARTICIPANTS. Low-income, primarily Hispanic parents (N = 303) of children with moderately severe to severe asthma.

SETTING.

SETTING. A Southwestern university medical setting in a rural state.

MAIN OUTCOME MEASURES.

MAIN OUTCOME MEASURES. Parent self-efficacy and parent asthma self-management skill score scales.

RESULTS.

RESULTS. Parent self-efficacy increased significantly from baseline, but there were no significant differences between the control and treatment groups. The increase in self-efficacy was apparent at 6 months, then leveled off. Parent self-efficacy at either baseline or 12 months did not predict parents' asthma self-management skill score.

CONCLUSIONS.

CONCLUSIONS. Individual education was just as effective as group education in increasing parental self-efficacy. Parents felt more comfortable treating asthma episodes than preventing them, thus clinicians need to spend time teaching preventive strategies.     

Ethnomethodologic Analysis of Accounts of Feeding Demented Residents in Long-Term Care

To describe the self-organizing activities and the unspoken knowledge that nursing assistants employ in performing the work of feeding as a routine part of their activities. In U.S. long-term care facilities, activities related to medical and nursing care are frequently based on the ability of nursing assistants to successfully accomplish the work of feeding. Nurses are not always aware of the difficulties involved in feeding nor the means by which food is offered and intake calculated.

Design:

Qualitative phenomenologic.

Methods:

Observations were conducted during 12 weekday mealtimes, October and November 1994. Data were collected using participant observation of mealtimes in the congregate dining room of one licensed long-term care facility. Data were analyzed using the framework of ethnomethodology to indicate the methods nursing assistants used to make sense of their interactions with demented residents.

Findings:

Nursing assistants used several common behaviors: grouping the "difficult feeders" together; "marking the borders" by maintaining a tidy tray; and "loading the spoon" to maximize the amount of food given at one time. Estimations of the quantity of intake varied according to ideas about the nutritional content of various foods.

Conclusions:

Unsuccessful feeding interactions have implications for the quality of life for the demented. When inadequate intake leads to significant weight loss, medical and nursing interventions should be implemented.     

A Classification Scheme for Outcome Indicators

To provide a framework for classifying outcome indicators for a more comprehensive view of outcomes and quality.

Methods:

Review of outcomes literature published since 1974 from medicine, nursing, and health services research to identify indicators. Outcome indicators were clustered inductively.

Findings:

Three groups of outcome indicators were identified: patient-focused, provider-focused, and organization-focused. Although investigators tend to focus on a select few outcome indicators, such as patient satisfaction, quality of life, and mortality, many indicators exist to measure outcomes.

Conclusions:

Selecting and integrating a wide array of outcome indicators from the various categories will provide a more balanced view of health care delivery as compared with focusing on a few common indicators or only one category.     

Pediatric Nursing Resources in Cyberspace

P urpose . To provide information on pediatric nursing resources on the Internet.

POPULATION.

POPULATION. Pediatric nurses in all settings.

CONCLUSIONS.

CONCLUSIONS. A basic understanding of essentials for "surfing the web" will open the doors to unprecedented opportunities to query, find, and share information with others.

PRACTICE IMPLICATIONS.

PRACTICE IMPLICATIONS. Pediatric nurses in every setting can benefit from access to the Internet and knowledge of what resources are available to enhance their practice and support their clients.     

The Effectiveness of a Standardized Educational Program for Children Using Patient-Controlled Analgesia

purpose . To examine the effectiveness of two types of preoperative education (routine education and a standardized educational program) for children undergoing spinal fusion.

design.

design. Two group, phase-lag design.

setting.

setting. Tertiary pediatric hospital.

participants.

participants. Children ages 8-18 years (N = 93)

main outcome measures.

main outcome measures. Adolescent Pediatric Pain Tool, Child Pain Scale, Post-PCA Satisfaction Interview, and PCA infusion pump data.

results.

results. No statistically significant differences between the groups on any of the main outcome variables. Children and parents reported, however, that the SEP provided them with invaluable information regarding the use of PCA and alleviated their concerns about getting "hooked on drugs," overdosing, side effects, and being able to get pain relief when needed.

conclusion.

conclusion. Children having spine fusion surgery experienced severe postoperative pain that was not ameliorated by optimizing use of PCA through standardized education. Further testing of the SEP with other populations is needed in order to more fully realize its potential for influencing pain outcomes.     

Influence of Managed Care on Professional Nursing Practice

To explore how nurses in one U.S. state perceived that managed care influenced professional nursing in that state. The nursing community is challenged to move with haste in demonstrating, through research, the clinical and economic value that nurses add to cost-effective outcomes.

Design:

A Delphi survey in 1996 of a convenience sample of 84 clinical nurse specialists (CNSs) and nurse practitioners (NPs) in California.

Methods:

CNSs and NPs contributed to the list of managed care influences on nursing practice. Fifty-seven (68%) completed the third and final round.

Findings:

Panelist agreement was the highest for (a) exploring new approaches to providing quality care more cost-effectively, (b) expanding nurse practitioners' rote in primary care, and (c) more effectively partnering with clients in helping them assume greater self-responsibility for their health. Greatest threats were perceived to be hassles involved in seeking authorization for care and responding to payment denials; the tenuous job market for nurses; and encroachment on nursing practice by others.

Conclusions:

The findings can assist nurses in states with low managed-care concentration to create their preferred future within health care delivery. A more highly educated nurse workforce will be needed for 21st century health systems in which more care is likely to be delivered outside hospitals.     

Depression, Social Support, and Quality of Life in Older Adults With Osteoarthritis

To develop an understanding of the quality of life of older adults with osteoarthritis (OA) with varying levels of depression and social supportas a basis for nursing interventions. Osteoarthritis in the United States is the number one chronic disease in late life and the major cause of disability in older adults. In addition to the functional disability and economic effect of OA, older people with this disease experience suffering, depression, and diminished quality of life.

Design:

For this cross-sectional survey, a convenience sample of 50 older adults with OA was recruited from two U.S. hospital-based arthritis clinics in northern Ohio for 3-months during 1995.

Methods:

During face-to-face interviews, the Arthritis Impact Scales, Center for Epidemiological Studies Depression Scale, Social Support Questionnaire, and Quality of Life Survey, were used to measure osteoarthritis severity, depression, informal social support, and quality of life.

Findings:

Although few formal social support services were used, high levels of satisfaction from the subjects' large informal networks of family and friends were reported. In addition, satisfaction with subjects' quality of life was extremely high despite depression, co-morbid conditions, pain, and functional limitation.

Conclusions:

Social support appeared to play an important role in moderating the effects of pain, functional limitation, and depression on these subjects' quality of life. Nurses who work with older adults are in a unique position to help them adjust to living with osteoarthritis by providing them the support needed to help them manage their disease.     

From Randomized Trial to Community-focused Practice

To describe the use of findings from a randomized trial—a nursing intervention using telephone contacts to reduce the incidence of low-birth-weight and preterm births—in four community settings in North Carolina, to show that implementing research into practice is important. Low-birth-weight and preterm births are the major cause of high infant mortality in the United States. Rates are highest among African-American women. Telephone intervention as a strategy for preventive health care can be cost effective, reduce low-birth-weight and preterm births in African-American women, and provide a means of health consultation for parents of children age five and under.

Organizing Framework:

Four community programs are discussed in relation to five phases of implementing and sustaining research in communities: research, transfer, transition, regeneration, and empowerment. Modification from the original research, bonuses, and barriers are described for each program.

Methods:

The randomized trial was conducted from 1990-1995. Randomized trial data and data for subsequent projects were collected from telephone interviews and health care records from 1994-1998. A successful adaptation was made from the original randomized trial to the four programs by (a) educating the staff for each program about the methods and findings in the original research, and (b) working with program staff to make appropriate modifications for each site.

Conclusions:

Findings from a randomized trial can be used in a variety of settings. By working together, researchers and community-health nurses can integrate research findings into community-health nursing practice.     

Learning the Baby: A Maternal Thinking and Problem-Solving Process

purpose. To describe a maternal problem-solving process from new mothers' day-to-day experience of caring for and developing a relationship with their babies

design.

design. Qualitative study using grounded theory approach

setting.

setting. Mothers' homes (n = 23) and workplaces (n = 2)

participants.

participants. 25 mothers of babies from 2 weeks to 7 months

main outcome measures.

main outcome measures. Semi-structured interviews

results.

results. "Learning the Baby" was a major thinking process that emerged. Systematic thinking dominated mothers' problem-solving. Even after the babies were comforted, mothers were not certain their efforts alleviated the babies' problems, because they usually were not certain of the problem.

conclusions.

conclusions. Mothers' thinking directs their caregiving actions. The findings were related to previous problem-solving and women's thinking perspectives. Nurses must use planned and unplanned encounters effectively to collaborate with and teach mothers about baby behavior and health care.     

Assisted Dying and Nursing Practice

Nurses' views are often solicited about physician-assisted dying, a concept that incorporates both assisted suicide and active euthanasia. Yet nurses are rarely asked about their own clinical experience of assisted dying. The literature indicates that many nurses experience difficulty distinguishing professionally sanctioned end-of-life interventions from those that are not. In this article the investigator explores the social, legal, and political roots of assistance in dying, and critically examines the profession's position on nurse participation in assisted dying and the research regarding nurse-assisted dying.

Scope:

The bioethics and nursing literature was reviewed from 1990 to 1999. The databases used were the Cumulative Index to Nursing and Allied Health Literature and Medline.

Conclusions:

The complex nature of caring for highly symptomatic dying patients, and the difficulty some nurses experience in distinguishing a moral difference between hastening and assisting death, strongly indicate a need for additional nursing research that does not use a forced answer.     

Nebraska School Nurses Identify Emotional Maltreatment of School-Age Children: A Replication of an Ohio Study

P urpose . To determine how often school nurses identify emotional maltreatment using validated vignettes.

DESIGN.

DESIGN. Survey, with 16 behavior vignettes, mailed to 550 Nebraska school nurses. Four forms represented nonwhite and white, male and female children. Demographic questionnaire included.

SETTING.

SETTING. Survey mailed with regular spring school nurses' newsletter.

PARTICIPANTS.

PARTICIPANTS. One hundred twenty-one school nurses completed and returned surveys.

MAIN OUTCOME MEASURES.

MAIN OUTCOME MEASURES. Each vignette was an example of emotional abuse; subjects indicated "refer" or "not refer" decisions about the vignette. All items were positive for emotional abuse.

RESULTS.

RESULTS. Sixty-four of 121 (53%) respondents correctly identified 13 or more vignettes as referable for emotional maltreatment. No influence of child gender and race on reporting decision. No nurse characteristics correlated with referral rates.

CONCLUSIONS.

CONCLUSIONS. None of the variables studied significantly influenced school nurses' identification of emotional abuse. Further research is needed to ascertain correlation between text vignettes and reporting, and to identify interventions to increase the rate of identifying emotional abuse.     

Parents'' Reports of "Tricks of the Trade" for Managing Childhood Chronic Illness

purpose . To examine how parents respond to and manage the challenges of childhood chronic illness.

design.

design. Qualitative, comparative, secondary analysis.

participants.

participants. Fifty-eight families (55 mothers, 44 fathers) with a school-age child (6-15 years old) with a chronic illness.

results.

results. Three approaches to illness management were identified: strict adherence, flexible adherence, and selective adherence. These approaches varied in the extent to which parents developed and relied on target management behaviors that concurred with or deviated from the treatment plan prescribed by healthcare providers.

conclusions .

conclusions . The three management approaches contribute to understanding the processes associated with differing interactions between healthcare professionals and parents when a child has a chronic illness.     

A Randomized Trial of Heparin and Saline for Maintaining Intravenous Locks in Neonates

purpose . To determine, the effects of saline, heparin 2 units (U) per ml saline, and heparin 10 U/ml saline flush solutions on the duration of intravenous (IV) locks and the incidence of IV infiltration in neonates.

design.

design. Randomized double-blind experiment.

setting.

setting. Tertiary-care nursery.

participants.

participants. Neonates (N = 90) hospitalized at birth in the intensive, intermediate care, or newborn units.

main outcome measures.

main outcome measures. Total hours from the time the IV was inserted to the time the IV was removed; hours from the time the IV was first flushed to the time the IV was removed; number of IVs removed because of infiltration.

results.

results. No statistical or clinical differences between the three groups for duration of IV nor for incidence of complications.

conclusions.

conclusions. The use of heparin in IV lock flush solution did not affect the duration of IV locks nor the incidence of infiltration in neonates.     

A Model of Chronic Dyspnea

To present an overview of dyspnea, differentiate chronic dyspnea from acute dyspnea, critique models of dyspnea found in the nursing literature, and propose a new model of chronic dyspnea to guide the care and evaluation of chronic dyspnea in patients living with chronic obstructive pulmonary disease (COPD). Dyspnea is the major symptom that impairs quality of life for nearly 16 million Americans who have COPD.

Methods and Sources:

Review of scholarly literature on dyspnea by searching CINAHL and MEDLINE (1980-1998) using dyspnea and chronic obstructive lung disease as key words. The search produced studies conducted by a variety of health care professions including those in nursing, medicine, exercise physiology, and respiratory therapy.

Findings:

The existing models fail to differentiate between acute and chronic dyspnea. These models were found to be inadequate for guiding interventions to decrease the long-term adverse consequences of chronic dyspnea.

Conclusions:

A useful model of chronic dyspnea defines chronic dyspnea as distress with varying levels of intensity and long-term physical, psychologic, and sociocultural consequences. The proposed model has implications for both research and clinical practice by identifying the consequences of chronic dyspnea as outcome measures of the effectiveness of treatment.