Understanding avoidant leadership in health care: findings from a secondary analysis of two qualitative studies

Aim To illuminate ways that avoidant leadership can be enacted in contemporary clinical settings. Background Avoidance is identified in relation to laissez-faire leadership and passive avoidant leadership. However, the nature and characteristics of avoidance and how it can be enacted in a clinical environment are not detailed. Methods This paper applied secondary analysis to data from two qualitative studies. Results We have identified three forms of avoidant leader response: placating avoidance, where leaders affirmed concerns but abstained from action; equivocal avoidance, where leaders were ambivalent in their response; and hostile avoidance, where the failure of leaders to address concerns escalated hostility towards the complainant. Conclusions Through secondary analysis of two existing sets of data, we have shed new light on avoidant leaderships and how it can be enacted in contemporary clinical settings. Further work needs to be undertaken to better understand this leadership style. Implications for nursing management We recommend that organizations ensure that all nurse leaders are aware of how best to respond to concerns of wrongdoing and that mechanisms are created to ensure timely feedback is provided about the actions taken.     

Submammary Device Implantation in Women: A Step‐by‐Step Approach

Submammary Device Implantation in Women . Introduction: The frequency of device implantation is increasing in younger patients as our ability to diagnose long‐QT syndrome, hypertrophic cardiomyopathy, Brugada Syndrome, and other life‐threatening disorders earlier has improved. Similarly, use of cardiac resynchronization therapy and ICD therapies has increased in cardiomyopathy patients. Methods and Results: Device implantation in young women has unique considerations. Standard pectoral implants lead to excessive scar formation due to skin tension and interfere with purse straps, bra straps, and seat belts. There are also privacy and body image concerns as the subclavian region is exposed with many contemporary fashions. Results: Over an 11‐year period, we implanted pacemakers, implantable converter‐defibrillators (ICDs) and cardiac resynchronization therapy (CRT) devices (defibrillators or pacemakers) in 60 women, aged 13–70 years, using a 2‐incision submammary approach. Follow‐up surveys were performed using the Florida Patient Acceptance Survey (FPAS). Women with submammary device placement reported significantly greater device acceptance (M = 92.41, SD = 6.46) than women with standard implant technique (M = 70.29, SD = 17.85); t (54) =–6.08, P < 0.001, on the FPAS. Across subscales on the FPAS, women with submammary device placement also reported significantly less body image concern (P < 0.001), less device‐related emotional distress (P < 0.001), and greater confidence in returning to life appropriately (P = 0.01) than women with standard device placement. Conclusion: We present here our technique for submammary device implantation. (J Cardiovasc Electrophysiol, Vol. 24, pp. 476‐479, April 2013)     

Clinical Experience with Steroid-Eluting Unipolar Electrodes

In continuing search of low chronic threshold leads, a new concept of electrode design which is capable of delivering corticosteroids at the myocardial tissue interface has been made available by Medtronic. Twenty-three patients, 17 females and 6 males, were either implanted with 4003 (n = 21) or 5023 (n - 2) steroid-eluting electrodes in the ventricular chamber. Pacing modes utilized were WIM (n = 13) or DDD (n = 10). Pulse generators used were Medtronic (7005. 8317, 8329) Pacesetter (285) and Intermedics (283). Thresholds at the time of implantation at 0.50 msec pulse width were 0.40 ± 0.02 volts at 0.66 ± 0.05 milliamps. Resistance and R wave measured were 565.43 ± 22.07 ohms and 9.24 ± 1.06 mv, respectively. Chronic thresholds were checked on routine follow-up visits by either decreasing pulse width and for pulse amplitude. Data is being reported between 1 and 88 (23.22 ± 4.35) weeks. Pulse width threshold at 2.5 volts were 0.10 msec (n = n) and 0.05 msec or lower (n = 12). At 5.0 volts no loss of capture was seen at 0.05 msec (n = 22) except in one patient at 0.10 msec. Pulse width thresholds in the first 24 weeks were lower than 0.20 msec at 2.5 volts (n = 15) and less than 0.70 msec, at 0.8 volts (n = 6). No loss of sensing was seen by electrocardiographic analysis at the time of threshold checks with the pulse generator at standard setting of the R wave. Thus, in this initial report, the steroid-eluting electrodes have demonstrated very low thresholds both in the early and chronic follow-up phase. Demonstration of consistently low thresholds, avoiding initial peaking, will permit routine low output setting without compromising safety and thus prolong the life of the pulse generators.     

A Review of the Biologic Effects, Clinical Efficacy, and Safety of Silicone Elastomer Sheeting for Hypertrophic and Keloid Scar Treatment and Management

Silicone elastomer sheeting is a medical device used to prevent the development of and improve the appearance and feel of hypertrophic and keloid scars. The precise mechanism of action of silicone elastomer sheeting has not been defined, but clinical trials report that this device is safe and effective for the treatment and prevention of hypertrophic and keloid scars if worn over the scar for 12 to 24 hours per day for at least 2 to 3 months. Some of the silicone elastomer sheeting products currently on the market are durable and adhere well to the skin. These products are an attractive treatment option because of their ease of use and low risk of adverse effects compared to other treatments, such as surgical excision, intralesional corticosteroid injections, pressure therapy, radiation, laser treatment, and cryotherapy. Additional controlled clinical trials with large patient populations may provide further evidence for the efficacy of silicone elastomer sheeting in the treatment and prevention of hypertrophic and keloid scars. The purpose of this article is to review the literature on silicone elastomer sheeting products and to discuss their clinical application in the treatment and prevention of hypertrophic and keloid scars.     

Mapping health on the Internet: strategies for learning in an information age

Ross Scrivener Radcliffe Medical Press, Oxford 2002, 160 pages, £19.95 (PB) ISBN: 1857755936.     

Gender differences in the risk of alcohol dependence: United States, 1992

Data from a representative sample of US adults revealed that 24% of male life-time drinkers and 15% of female life-time drinkers met the DSM-IV criteria for life-time alcohol dependence, i.e. dependence during the year preceding interview or in any 12-month period prior to that year. The median interval from first drink to onset of dependence was 3.6 years for men and 3.0 years for women. After using survival techniques to adjust for potential gender differences in the exposure to risk of developing alcohol dependence, the cumulative conditional probability of having experienced onset of dependence was 35.1 % for men and 24.6% for women. The conditional probability of onset of dependence was equal for men and women in the first year after initiation of drinking, about 30% higher for men in the period 1-4 years after the first drink, and about 45% higher for men thereafter. After using proportional hazards models to adjust for the effects of age cohort, race and ethnicity, family history of alcoholism and age at first drink, these period-specific risk ratios remained virtually unchanged. Including a measure of average daily ethanol intake during periods of heaviest consumption rendered most of the gender differences statistically insignificant, revealing a slight excess risk of female dependence within the first year after initiation of drinking among the heaviest drinkers and leaving an excess male risk of dependence mostly among individuals with average daily intakes of less than one ounce of ethanol. The results suggest that different frequencies of binge drinking might help to account for these remaining gender differences and that men's and women's relative risks of developing alcohol dependence may vary as a function of life cycle stage, with men's excess risk greatest in the college/young adult years.     

A Model for Making Outcomes Research Standard Practice in Clinical Dietetics

In today's rapidly changing health care environment, it is imperative that dietitians demonstrate the importance of their role as health care providers by initiating and participating in outcomes research. Patient care should be based on empirical studies, and clinical dietitians should participate in or be at the helm of such investigations. Nutrition research is usually accomplished and reported by persons with MD or PhD degrees who do not have clinical training in nutrition and does not often address situations encountered by dietitians in clinical settings. This article examines the extent to which clinical dietitians are conducting and reporting outcomes research, their attitudes about such research, and how they think they could best acquire the skills needed to incorporate outcomes research into their practice. Results indicate that clinical dietitians are not writing a substantial percentage of articles and that reports of outcomes research are not commonly included in clinical nutrition journals. Clinical dietitians appear to value the inclusion of research in clinical practice, but they are not spending a great amount of time doing research. Dietitians report being comfortable about participating in research but not about designing, conducting, and reporting research. Results from several surveys were used to develop a model for integrating research in clinical practice. This model includes the research process as a basis for clinical practice. A model for collaborative efforts between clinical and academic dietitians is also proposed and emphasizes the responsibility of academic dietetics training programs in the integration of research and clinical practice. J Am Diet Assoc. 1998;98:451–457.     

Relationship Between Short- and Long-Term Measurements of Heart Rate Variahility in Patients at Risk of Sudden Cardiac Death

Because of technical difficulties in analyzing heart rate variability (HRV) from ambulatory Holter recordings over 24-hour periods, short-term recordings are more practical for the clinical application of HRV. However, the relationship between short- and long-term recordings is unclear. In this study, short-term (10 min) electrocardiograms were assessed in the supine position, during passive head-up tilt and on standing in 15 patients (aged 39 ± 14 years) with ventricular tachycardia/fibrillation not associated with coronary artery disease. Spectral HBV was computed as total frequency (TF: 0.01–1.00 Hz), low frequency (LF: 0.04–0.15 Hz), and high frequency (HF: 0.15–0.40 Hz) components. The short-term HRV parameters were compared with those obtained from long-term (24 hour) recordings from the same patients. There was a significant decrease in the HF component of HRV and a significant increase in LF/HF ratio during passive tilt or active standing compared with supine recordings, but no significant changes were observed in the TF or LF components. All frequency components of HRV for the 24-hour periods showed significant correlation with the values from short-term recordings (τ ranged from 0.67–0.87). Stepwise multivariate regression analysis showed that both the TF and HF components of HRV over 24 hours were predominantly related to the corresponding frequency components of HBV in the supine position, while the LF component of HRV over 24 hours was predominantly related to that on standing. Our observations suggest that the short-term HRV is related to the long-term value, but global HRV over 24 hours cannot completely be replaced by the short-term recordings. The postural effects on the frequency components of HRV should be taken into account when short-term HRV assessment is applied.