New perspectives on advanced practice nursing case management for aging patients

Providing case management for older individuals is challenging in that this group rarely fits any DRG or managed-care mold. Because many people are living healthier and longer lives, intergenerational family dynamics such as that observed in Sophie and Leo's case may become more the norm than the exception. Well-intentioned family members, lacking the guidance of an experienced gerontologic APN case manager, may inadvertently place their aged loved ones at risk by attempting to arrive at health care, social, and housing solutions on their own. Even though 82-year-old Sophie stated subjectively that she "felt better than ever", an objective clinical assessment revealed that she still was in a convalescent period following major abdominal surgery at the same time that she was faced with providing in-home care for Leo, her 102-year old father. Sophie may have experienced response shift, or a reconceptualization of her own health state, in the aftermath of serious illness. The advanced practice knowledge and skills, systems acumen, talents, and creativity of two APN case managers in two different states contributed to successful health and social outcomes for two "master survivors," whose longevity and clinical presentations exceeded expectations. The value of APNs as case managers is clear: APNs possess the proficiency, tenacity, knowledge base, and nursing confidence needed to make a positive contribution toward individualizing care for members of the greatest generation.     

Advanced practice nurses in emergency care settings: A demographic profile.

INTRODUCTION: Very little is known about clinical nurse specialists and nurse practitioners (advance practice nurses [APNs]) who practice in emergency care settings. The Advanced Practice Committee of the ENA sought to determine a profile of these individuals. METHODS: Surveys were distributed to all registrants at 2 ENA conferences and posted on the ENA Web site. This survey asked 17 questions concerning the demographic characteristics of the APN respondents (eg, education, experience, certification, state recognition, and practice area). The survey was completed by 166 APNs. RESULTS: APNs had considerable experience as ED registered nurses before becoming an APN. They obtained their APN education at the master's degree or post-master's degree level. State recognition was required for 89.2% of the APNs. The majority of APNs (61.4%) obtained their certification through the American Nurses Credentialing Center. Nurse practitioners were predominantly family nurse practitioners (43%), and clinical nurse specialists were either critical care clinical nurse specialists (8.9%) or had other certifications (5.9%). APNs provided services in both the main emergency department and the fast track (45.7%) and were relatively new to their role as an APN. DISCUSSION: Consistent with current educational and certification requirements, the vast majority of APNs held a master's degree. Although relatively new to their role as APNs in emergency care, they were nonetheless very experienced as ED registered nurses. The majority of APNs were certified, even though that is not required for practice in all states. Continued research is needed to identify the most effective utilization of APNs, document their contributions to patient care outcomes, and develop strategies to meet their educational and practice needs.     

Using outcomes research to validate the advanced practice nursing role administratively

The health care system has been forced to respond to the demand for changes in care provision. The changes have produced an opportunity for APNs to become a partner in care in the ICU. With the new opportunities APNs have been challenged to quantify the quality and fiscal effectiveness of their practices in the critical care arena. Administrators have a vested interest in the success of the organization, which includes the concepts of fiscal viability and quality care and patient and family satisfaction. There are data available to help formulate the rational argument for the inclusion of APNs in critical care. By using the data APNs can prove that their presence has a positive impact on the quality and financial outcomes of care. APNs can have a positive impact on the organization in all of the ways that are important to the administration. They can transform the current practice and improve the quality of the care. In presenting the outcome data of the APN role to administrators, APNs can be successful in gaining support for their role. APNs are vital components of the healthcare system and gaining recognition of the true value of the role is key to ensuring the ability of APNs to meet today's healthcare challenges for the improvement of patient care.     

A Day in the life of RURAL advanced practice nurses

Advanced practice nurses (APNs) have been a critical component of the rural health care system for many years. This study describes the impact of APNs on primary care in Wyoming, a predominantly rural and frontier state, and illustrates a typical practice day for APNs. Wyoming APNs are experienced nurses, in their late 40s on average, and are quite independent in their practices. The APNs provided a significant amount of health care, with an average of 15 client visits per day. These APNs were heavy prescribers and performed a number of office procedures. Implications for health policy are discussed.     

Promoting lifestyle change in the prevention and management of type 2 diabetes

PURPOSE: To present the theoretical background for lifestyle change interventions in the prevention and management of type 2 diabetes and to provide pragmatic strategies for advanced practice nurses (APNs) to incorporate such interventions into their practices. DATA SOURCES: Selected scientific literature and the Internet. CONCLUSIONS: There is an epidemic of obesity and type 2 diabetes among adults in the United States. Preventing or managing these health conditions requires significant lifestyle changes by individuals. IMPLICATIONS FOR PRACTICE: APNs are in a key role to deliver lifestyle change interventions, particularly in the primary care setting. Strategies to assist APNs with lifestyle change counseling include (a) assessment, (b) mutual decision making, (c) referral to education programs, (d) individualized treatment goals, (e) strategies to assist with problem solving, (f) continuing support and encouragement, (g) relapse prevention, and (h) ongoing follow-up.     

Promoting Early Intervention for Substance Use Disorders Through Interdisciplinary Education for Health Professionals

Substance use disorders (SUDs) impose enormous costs on individuals, families and public resources. Illegal drugs and alcohol are responsible for thousands of deaths each year, and contribute to the spread of communicable diseases such HIV and Hepatitis C, as well as some of the worst social problems in the United States, including child abuse, domestic violence and sexual assault. It is evident that in all areas of health care, untreated SUDs elevate the risk of complications and poor outcomes, and drive up the cost of health care.

Despite a general agreement that SUDs are a leading cause of death, disability and disease, front-line health professionals are not trained to identify individuals with SUDs, assess their condition, intervene on their behalf, or refer them to treatment. Numerous studies demonstrate the effectiveness and cost effectiveness of activities intended to detect and intervene early with individuals with SUDs in health care settings (Allen et al., 1997; Babor & Higgens-Biddle, 2001; Project Cork, 2004). Several forces either facilitate or inhibit efforts to detect and intervene with SUDs. This column focuses attention on a number of interdisciplinary efforts to support the training and education of health professionals and promote the development of transdisciplinary competencies for the early detection and intervention of SUDs.     

Associations of age at cannabis first use and later substance abuse with mental health and depression in young men

Purpose: This study aimed to determine if the associations between age at cannabis first use and mental health and depression persist after controlling for the misuse of cannabis, other illicit drugs, alcohol and cigarettes.

Methods: Baseline data from an ongoing cohort study on substance use risk factors were used (N?=?5521). The association between age at cannabis first use and the frequency of cannabis use was assessed using a Cox proportional hazard model. Associations with other illicit drug use, alcohol dependence, nicotine dependence, mental health and depression were tested using linear regressions and logistic regressions.

Results: Participants using cannabis “almost every day” were on an average two years younger at cannabis first use than those using cannabis “once a month or less”. Age at cannabis first use was also associated with other illicit drug use, alcohol dependence and nicotine dependence. Associations with mental health and depression were substantially attenuated after adjustment for the misuse of cannabis and other substances.

Conclusions: These findings show that early cannabis onset is associated with later impairments in mental health and depression; however, these are largely explained by later substance abuse. Effective preventive measures are needed to delay cannabis onset and to avoid the progression from cannabis to using other drugs.     

Anxiety and depression in individuals with somatic health problems. The Nord-Trøndelag Health Study (HUNT)

There is a high occurrence of depressive symptoms in patients with somatic health problems. About one-third of individuals with somatic health problems have anxiety disorders and/or depression. Comorbid anxiety disorder and depression are found to be more strongly associated with somatic health problems than pure anxiety disorder and pure depression. Objective - To examine the relationship between anxiety disorders and depression and various somatic health problems in the general population. Design - Cross-sectional study with survey methods and clinical examinations. Setting - The Health Study of Nord-Trøndelag, Norway (the HUNT study). Participants - 60 &#116 869 individuals aged 20-89 years. Main outcome measures - Anxiety disorder, depression and their comorbidity are categorized based on scores on the Hospital Anxiety and Depression Scale. All somatic health variables are self-reported, while blood pressure, height and weight are measured. Multivariate nominal logistic regression analyses are used to investigate the relationship between somatic variables and the anxiety/depression categories. Results - Most somatic health variables show a stronger association with comorbid anxiety disorder/depression than with anxiety disorder or depression alone. About one-third of individuals reporting somatic health problems also have anxiety disorder and/or depression. Conclusion - Somatic health problems carry a high risk of both anxiety disorder and depression. Active identification and treatment of these co-occurring mental disorders are of practical importance.     

男性酒依赖患者心理状况、社会支持、家庭环境的调查

目的调查男性酒依赖患者的心理状况、社会支持、家庭环境,为治疗干预提供理论依据。方法采用一般情况调查表、症状自评量表(SCL-90)、社会支持评定量表(SSRS)、家庭环境量表(FES)对酒精依赖组(n=48)与正常饮酒组(n=60)进行评估,进行对照研究。结果酒精依赖组与正常饮酒组比较,职业、文化水平、婚姻状况方面存在差异,具有统计学意义(t值分别为19.1、12.0、13.2,P均<0.05)。酒精依赖组SCL-90各项因子分都高于正常饮酒组,尤其是抑郁、人际关系敏感、偏执因子(t值分别为19.80、10.94、11.40,均P<0.05),差异具有统计学意义。酒精依赖组SSRS各因子评分均低于正常饮酒组,差异具有统计学意义。酒精依赖组与正常饮酒组比较亲密度、情感表达、知识性、道德宗教观、控制性较低,矛盾性较高,差异具有统计学意义。结论男性酒精依赖患者心理状况较差,存在较明显的焦虑抑郁情绪,治疗时应予以密切关注。酒精依赖患者社会支持低、家庭环境差,应加强对心理支持治疗,积极改善家庭环境,这样才能有效地降低患者的复饮率。     

Willingness to treat drug dependence and depression: comparisons of future health professionals

PURPOSE: Stigma-related feelings, including degree of enthusiasm and willingness to work with alcohol, drug, and mental disorder (ADM) patients, as well as anticipated success in such work, will be required for the United States to be successful in its new initiatives for ADM screening, brief intervention, and effective referral to treatment and rehabilitation services (SBIRT). This study investigates students of medicine and social work with respect to their stigma-related feelings and degree of enthusiasm or willingness to treat patients affected by alcohol dependence, nicotine dependence, or major depression. Inference is strengthened by an anonymous online survey approach, with use of randomized reinforcers to gain at least partial experimental control of nonparticipation biases that otherwise are present in student survey data. MATERIAL AND METHODS: All students on required course rosters were asked to participate in a two-part in-class and online assessment; 222 participated, with a gradient of participation induced via randomly drawn reinforcers for online survey participation. Between-group comparisons were made with a multivariate generalized linear model and generalized estimating equations approach that adjusts for covariates. RESULTS: Medical and social work students did not differ from each other with respect to their willingness to treat patients affected by major depression, alcohol dependence, or nicotine dependence, but together were less willing to treat nicotine and alcohol dependence-affected patients as compared to depression-affected patients. Personal history was not associated with the students' willingness to treat, but men were less willing to treat. Drawing strength from the randomized reinforcer experimental design nested within this survey approach, the study evidence suggests potential nonparticipation bias in standard surveys on this topic. CONCLUSION: These results indicate that future health professionals may prefer to treat depression as opposed to drug dependence conditions. For SBIRT success, curriculum change with educational interventions may be needed to increase willingness to treat patients with neuropsychiatric conditions such as drug dependence. Future research requires attention to a possible problem of nonparticipation bias in surveys of this type.     

Treatment practices and barriers for depression and anxiety by primary care advanced practice nurses in Wyoming

PURPOSE: The aim of this study was to investigate barriers to treatment and screening related to depression and anxiety and the diagnostic and treatment practices of primary care advanced practice nurses (APNs) in the state of Wyoming. DATA SOURCES: Every primary care APN in Wyoming received a mailed questionnaire asking them about treatment barriers, screening and treatment practices, and attitudes toward depression and anxiety. CONCLUSIONS: Wyoming APNs in primary care routinely identify, evaluate, and treat patients with both depression and anxiety. APNs generally felt positive about treating these patients, although they reported that their patients encounter a number of financial barriers in accessing treatment. Routine screening practices for depression and anxiety were relatively low among the APNs, and they used a wide variety of interventions for these patients. IMPLICATIONS FOR PRACTICE: The findings identify a lack of standardized approaches to assessment, referral, and treatment, especially pharmacologic intervention, and may indicate the need for alterations in the educational preparation of primary providers in order to improve clinical outcomes of treatment for depression and anxiety.     

Spiraling out of control: one case of pathologic anxiety as a response to a genetic risk of cancer.

The threat of cancer can result in an existential crisis characterized by feelings of uncertainty and fear. Anxiety, the most common response to the threat of cancer, may be expressed in ways as varied as individual personalities and circumstances. It is a normal response to the threat of cancer, but in some it may deteriorate to pathologic anxiety and manifest somatic or avoidant patterns. Members of families diagnosed with genetic mutations that predispose to cancer are unique in that they experience a complex chain of life events. People affected with genetic mutations that increase the risk for the development of cancer may be at greater risk of manifesting abnormal anxiety. Little research exists that can guide the health professional in meeting the needs of these individuals, which leads health practitioners to approach their needs on the basis of combined theoretical assumptions about the needs of people with cancer, people who have family members with cancer, and people with recurrent cancer. Some factors may be assessed by the health professional as an aid in identifying an individual at increased risk of developing a psychopathology. These factors include age and developmental level, existence of a previous psychologic disorder, and family integrity. Advanced practice nurses may effectively intervene in the care of these patients by (a) accurately assessing the risk for and extent of the anxiety reaction in individuals and family members; (b) developing management plans that include ongoing support, education, psychotherapy, and pharmacotherapeutics for the individual; and (c) support and psychotherapy for the family. In this article, the pathologic anxiety experienced by one adolescent girl diagnosed with a genetic mutation that caused multiple endocrine neoplasia 2a is addressed, along with the treatment of her avoidant anxiety disorder--trichotillomania.     

Substance misuse, anxiety and depression and urgency of presentation to a public emergency department in Australia

Objectives: To establish the prevalence and comorbidity of substance‐related problems and anxiety and depression, among ED presentations, and to compare the prevalence of these conditions among more and less urgent presentations. Design and setting: Cross‐sectional survey of ED presentations over a 14 day period (24 h/day) at the Gold Coast Hospital Emergency Department in south‐east Queensland, Australia, in October 2002. Measures: Usual level of alcohol consumption (Alcohol Use Disorders Identification Test), acute alcohol and illicit drug use (during 24 h prior to interview), symptoms of anxiety and depression (Hospital Anxiety and Depression Scale) and triage category (Australasian Triage Scale). Results: Thirty‐one per cent of the sample reported usually consuming alcohol at a hazardous or harmful level. Twenty per cent of participants reported clinically significant levels of anxiety and/or depression, which were in turn significantly associated with hazardous and harmful levels of alcohol use. Hazardous/harmful alcohol consumption was over‐represented among less urgent ED presentations, whereas anxiety and depression were more prevalent among more urgent ED presentations. Conclusions: Emergency departments in Australia are appropriate settings for the detection of both substance use and mental health problems in the wider community. The prevalence of these problems in ED settings is high and there is a need for the development of systematic screening and referral processes. The evidence of a link between urgency of presentation and these problems needs to be further explored.     

Trends in mental health: implications for advanced practice nurses

PURPOSE: To examine current trends in mental health care for vulnerable populations and suggest how advanced practice nurses (APNs) can incorporate mental health care into primary care practice. DATA SOURCES: Original research and evidence-based clinical articles, government publications, and professional practice guidelines. CONCLUSIONS: Vulnerable populations, such as racial and ethnic minorities, adults with chronic mental illness, the elderly, the incarcerated, and those living in rural areas have long been ignored as recipients of quality, integrated health care services. There is a compelling need for APNs to participate in the integrated delivery of physical and mental health care to all Americans, especially to vulnerable populations. IMPLICATIONS FOR PRACTICE: Under the umbrella of advanced practice nursing, a variety of nurse practitioners (NPs) and clinical nurse specialists (CNSs) can offer a holistic approach to the provision of evidence-based health care in a wide variety of settings to an array of vulnerable and underserved people. By serving on provider panels, partnering with consumer groups, and advocating for the unmet health needs of vulnerable populations, APNs can have a positive impact on the health care delivery system.     

丧偶独居老年人抑郁状况及相关因素的调查

目的调查丧偶独居老年人的抑郁状况及影响因素以便采取有效的干预措施。方法采用老年抑郁量表（cos）及自行设计问卷对某社区内的160例丧偶后独居老年人进行问卷调查。结果62．5％的老人存在不同程度的抑郁情绪,其主要原因号隋感障碍、疾病的影响、经济状况、社会支持缺失及缺乏必要的社会活动有关（P〈0.01）。结论丧偶独居老人抑郁发生率高,影响因素复杂,应引起社会和家庭的关注,以改善老人的健康状况,提高生活质量。