Critical care nurses' perspectives on elder abuse

AIMS

To explore through interviews of critical care nurses their perspectives on elder abuse to achieve a better understanding of the problems of reporting and generate ideas for improving the process.

BACKGROUND

In 44 states and the District of Columbia health care providers are required by law to report elder abuse but the patient, patient's family and health care providers all have barriers to reporting allegations of elder abuse.

DESIGN

This study design is qualitative.

METHOD

Through a mailed survey, critical care nurses were invited to participate in a taped in-depth qualitative interview.

RESULTS

Ten nurses were interviewed. A thematic analysis was used to describe the following core themes: types of elder abuse, suspicions of elder abuse, reporting of elder abuse, barriers to reporting elder abuse, legislation and improvement in practice.

CONCLUSIONS

Critical care nurses are aware of elder abuse and somewhat systematically evaluate for abuse at admission to their unit. They recognize signs and symptoms of abuse and are suspicious when it is warranted. They are aware of why an older person does not want to report abuse and take this into consideration when soliciting information. Facts, values and experience influence personally defining abuse, suspicion and dependence for each individual health care professional.

RELEVANCE TO CLINICAL PRACTICE

Critical care unit protocols and/or policies and procedure for reporting elder abuse are needed in critical care settings and are warranted for providing quality of care.

Implementation of a diabetes management program for patients in a rural primary care office

OBJECTIVE

A diabetes management program was implemented in a rural primary care office for those who did not choose to consult a multidisciplinary specialty care. The purposes of this study were to describe the current practices and health care provider management of patients with diabetes in a rural primary care office and determine differences between Hispanic and non-Hispanic persons concerning diabetes self-care behaviors, barriers to self-care, and their association with glycosylated hemoglobin level.

METHODS

A retrospective medical record review of diabetes-related medical information was completed.

RESULTS

Sixty-one (74%) of the 83 patients with diabetes completed the questionnaire and had the diabetes management program implemented (problem summary and clinical summary generated). Medical record review was completed for 83 (100%) subjects. Glycosylated hemoglobin was significantly higher for the younger group and women. Hispanic women and married persons had significantly higher glycosylated hemoglobin than did non-Hispanic and unmarried persons. Hispanic persons who were obese had significantly higher glycosylated hemoglobin. Self-care behaviors for managing diabetes were different by group. Non-Hispanic subjects reported taking their diabetes medications 99% of the time and Hispanic subjects 50% of the time.

DISCUSSION

It was feasible to implement a diabetes management program in a rural primary care setting, and its implementation highlighted the ethnic differences for Hispanics and non-Hispanics in diabetes self-care behavior, barriers to self-care, and family support for diabetes management. The implementation of the diabetes management program, though, was time-consuming and costly and was facilitated outside of the usual realm of practice.

Quality of colonoscopy services for physicians in the Iowa research network

BACKGROUND AND OBJECTIVES

Primary care physicians initiate colorectal cencer (CRC) screening and manage health care issues that present from these procedures. Quality of colonoscopy services can be determined by a set of indicators. The purpose of this study was to identify the quality of colonoscopy services provided for patients of family physicians in the Iowa Research Network (IRENE). Quality of services was delineated by (1) presence of a colonoscopy report on the medical record, if the medical record indicated a colonoscopy had been completed, (2) cecal intubation rate, (3) adenoma detection rate, and (4) the content of the colonoscopy report.

METHODS

Medical record review was conducted in 14 IRENE offices.

RESULTS

Of 581 medical records indicating a colonoscopy had been completed, 89 (15%) did not have a colonoscopy report. The main reasons for having the colonoscopy were screening and obvious blood in the stool. Polyp detection rate for all colonoscopies was 35%, and the adenoma detction rate for screening colonoscopis for men was 31% and for women was 19%. Depth of insertion to the cecum was reached for 92%. Items least mentioned in the report were the time to complete the procedure and current medications. Only 223 (45%) reports listed the follow-up interval for next colonoscopy. Quality of colonoscopy services for this group of IRENE physicians was comparable to recommended standards of depth of insertion and adenoma detection rate. Improvements are warranted to have all colonoscopy reports and follow-up interval of next colonoscopy on a patient's medical record.

Elder abuse research: a systematic review

The purpose of this research was to provide a systematic review of, and assign an evidence grade to, the research articles on elder abuse. Sixteen health care and criminal justice literature databases were searched. Publications were reviewed by at least two independent readers who graded each from A (evidence of well-designed meta-analysis) to D (evidence from expert opinion or multiple case reports) on the quality of the evidence gained from the research. Of 6,676 titles identified in the search, 1,700 publications met inclusion criteria; omitting duplicates, 590 publications were annotated and graded.

The Need for Office Systems to Improve Colorectal Cancer Screening

Patients generally access colorectal cancer (CRC) screening through primary care physicians. National guidelines recommend CRC screening for adults beginning at age 50, yet one-third of Americans are not up to date. Methods: A self-administered questionnaire was administered to family physicians from 16 practices in a Midwestern state who attended an information session for a randomized study to improve CRC screening. The questionnaire assessed CRC screening practices, knowledge of CRC screening guidelines, and office strategies for improving screening. Results: Of 131 health care providers, 85 (65%) completed the questionnaire. Two-thirds were aware of the CRC screening guidelines; 91% knew that the follow-up interval for screening depends on the test chosen. Twenty-five percent incorrectly stated that a single-sample in-office fecal occult blood test is an acceptable screening test. Only 8% had a written policy regarding CRC screening; 18% had offices that used chart reminders; and 32% had charts organized to easily identify patient screening status. Regarding perceptions, those who agreed that they encourage their office staff to participate in screening estimated that they offer screening to more patients than those who disagreed (82.8% vs 70.2%, P < .0001); in addition, those who agreed with and tried to follow the guidelines estimated that they offer screening to more patients than those who disagreed (77.4% vs 60.5%, P = .004). Conclusion: Although physicians were knowledgeable about CRC screening guidelines, 25% mistakenly believed that single-sample in-office fecal testing was appropriate. There was a striking lack of office systems for identifying eligible patients and facilitating CRC screening.

Health care professionals' perspectives on barriers to elder abuse detection and reporting in primary care settings

The purpose of this study was to explore health care professionals' perspectives on elder abuse to achieve a better understanding of the problems of reporting and to generate ideas for improving the detection and reporting process. Through a mailed survey, nurses, physicians, and social workers were invited to participate in an interview. Nine nurses, 8 physicians, and 6 social workers were interviewed, and thematic analysis was used to identify the following core themes: preconceptions, assessment, interpretation, systems, and knowledge and education. Participants suggested a reorganization of the external reporting system. More frequent and pragmatic education is necessary to strengthen practical knowledge about elder abuse.

Essential Data Elements for Reporters of Elder Abuse

Most states' adult or elder protective services and aging agency personnel prepare annual reports about their protective services. These reports vary by state and have different terms for the reporter of abuse. Reviewing annual reports from 46 states and the District of Columbia, 248 different terms were used for the reporter of abuse. To develop essential data elements for reporters of abuse, a literature search, a compilation of state elder abuse annual report list of abuse reporters, and a sorting exercise were conducted. Eleven terms were recommended for the different reporters of abuse, encouraging all state administrators and caseworkers to reach consensus to standardize the language.

Mailed fecal-immunochemical test for colon cancer screening

Various interventions have been implemented to increase the rate of colon cancer screening. The purpose of this study was to determine if persons who are regular patients of a clinic, ages 50-64 years, and not up-to-date with colon cancer screening will complete the at-home fecal-immunochemical test (FIT) if it is mailed to them. This intervention was designed to have the subject avoid the signing of an informed consent and having to ask for the screening test; and, only one stool specimen was needed. Three hundred and fifty potential subjects were randomly selected from an electronic medical record database after meeting inclusion criteria. Eighty-seven fecal immunochemical tests were returned. Seven of the FIT kit results were positive for occult blood. Each respondent was sent a letter giving them their results. A minimal cue CRC screening intervention, a FIT kit sent in the mail without prerequisite of a signed informed consent, was offered to the study subjects. Twenty-six percent of the eligible persons were screened for colon cancer by this method. A mailed FIT kit or one handed to the patient at an office visit has minimal cost which can be recovered through insurance coverage. Commitment by health care providers is necessary for prevention. This method is one of several that could reach the hard to screen population.

Density-Gradient Centrifugation: Non-Ideal Sedimentation and the Interaction of Major and Minor Components

A small amount of southern bean mosaic virus was contained in a narrow zone after density-gradient centrifugation, but in a much wider zone after centrifugation with a large amount of a second virus. Zone-spreading of a major component by non-ideal sedimentation in density-gradient centrifugation can cause zone spreading of a minor component that the major component overlaps.

Family physician perceptions of personal health records

The purpose of this qualitative study was to examine family practice physician and staff views on the benefits of, barriers to, and use of personal health records (PHRs). Four focus groups were conducted at four family medicine practices in Iowa and included a total of 28 providers. Overall, participants seemed to view PHRs as a source of medical information for healthcare providers when the patient's medical record is not available. Providers appeared unaware of the patient-centered features available in many electronic PHRs and how such features might affect patients and their medical practice. While physicians identified numerous patient groups that could benefit from using PHRs, they also perceived several unique barriers, including the potential of PHRs to facilitate narcotic abuse, low levels of patient computer and health literacy, low levels of patient motivation, and difficulties with PHR and electronic medical record interoperability. Physicians' relatively narrow view of PHR functions and benefits and perception of barriers to using PHRs may restrict widespread support of PHR use.

Definitions and indicators of elder abuse: a delphi survey of APS caseworkers

Instruments designed to measure specific types of elder mistreatment are not available, but they may be warranted after an initial screen indicates abuse or risk for abuse. The purpose of this study was to evaluate definitions for different types of elder mistreatment and validate the indicators as perceived by adult protective services (APS) caseworkers' opinions. Through 351 APS research network participants, a Delphi survey was completed. A 45% return rate was achieved for round one and 40% for round two with 70 same respondents from both rounds. These types of abuse, emotional abuse, exploitation of finances and/or property, neglect, physical abuse, and sexual abuse, have some similar and some extremely different indicators that singly and together expand their definition. Instruments to measure five different types of abuse are offered for caseworker or prevalence study use.

Patient clock drawing and accuracy of self-report compared with chart review for colorectal cancer (CRC) screening

The purpose of this study was to test the accuracy of patient colorectal cancer (CRC) screening self-report and CRC screening documented in their medical record for those who are cognitively impaired and those who are not based on the clock drawing task. A cross-sectional study where patient survey and medical record information were linked was conducted in 16 primary care offices. Of the 960 patients mailed questionnaires, there were 493 respondents who completed the questionnaire and clock drawing, had a chart review, and had no help in drawing the clock or completing the questionnaire. Chart review was conducted for CRC screening in physician offices. Clock drawings were scored 0-7 according to the Watson method. Accuracy of ever being screened for CRC or being up-to-date for CRC screening was determined by comparing self-report with medical records and calculating sensitivity, specificity, positive and negative predictive values, false positive rate, and false negative rate. Seventy-five clocks were abnormal, scoring 4 or more. Agreement between self-reported colonoscopy and medical record review was higher in subjects with normal clock drawings than those with abnormal clock drawings. When examining predictors of agreement/disagreement for colonoscopy screening, abnormal clock drawing was the single predictor for higher disagreement.

Multidisciplinary reports of nursing home mistreatment

OBJECTIVES

The purpose of this research was to learn about nursing home employees' knowledge and perspectives on mandatory reporting of elder abuse.

DESIGN

Mailed questionnaire and personal interviews.

SETTING

Two nursing facilities in Iowa.

PARTICIPANTS

All employees of the two nursing facilities.

MEASUREMENTS

A 28-item questionnaire that included questions on demographics, personal experiences with suspected elder abuse and reporting, legislation, facility protocols, and opinions on mandatory reporting was mailed to participants. An interview composed of 11 open-ended questions was conducted in the nursing facilities.

RESULTS

Forty-nine (15%) of the 335 employees who were sent the mailing returned the questionnaire and 22 (7%) participated in the interview. Over half (53%) of those who returned questionnaires reported suspecting a case of abuse in the facility where they currently work. Of these, 35% stated that they had not reported all the cases they suspected. Interviews of the 22 employees were about 15 minutes in length and took place at the nursing facility. Four themes emerged from these interviews, including the need for more staff education/training on the subject of elder abuse, difficulty in making judgments about whether the situation needs to be reported, barriers to reporting, and a sense that some abuse situations may occur because the staff is overworked, inexperienced, and/or frustrated from dealing with difficult residents.

CONCLUSION

Nursing home employees are knowledgeable about the mandatory reporter laws, but many remain hesitant to report suspected abuse for various reasons.

County government resources associated with dependent-adult abuse investigations in Iowa

This study evaluated on a county level the association of Iowa's domestic dependent-adult abuse investigations with the location of adult protective services (APS) offices, rurality, government resources, felony charges and prosecutions, child abuse reports, and census demographics. In 2003, the rate of dependent-adult abuse investigations for Iowa was 0.70 per 1,000 population age 18 and older. Higher rates of child abuse investigations, felony prosecutions, sheriff's annual salary, and lower rates of child abuse substantiations are associated with higher rates of dependent-adult abuse investigations and substantiations.

Nursing Home Statutes: Mistreatment Definitions

INTRODUCTION

Forty-nine states and the District of Columbia have adult protective services (APS) related statutes that define adult/elder mistreatment found in domestic settings. Institutional adult/elder mistreatment laws are administered by the nursing home licensing agencies and may contain different or duplicate APS-related mistreatment definitions. The purposes of this paper are to describe and summarize the mistreatment definitions in the nursing home licensure statutes and compare those definitions with the definitions found in the APS-related statutes.

METHODS

Westlaw and Lexis-Nexis law database systems were used to retrieve all adult protective services statutes and institutional licensure statutes. Each statute's text was reviewed and coded by two researchers.

RESULTS

Institutional mistreatment definitions are addressed in 14 of the states and District of Columbia's nursing home statutes. No one state has a list of the 27 different definitions of mistreatment identified in the literature search. The common types of mistreatment described were physical and emotional abuse, neglect, financial and property exploitation, and sexual abuse.

CONCLUSION

Standardized definitions of resident-to-resident and institutional specific types of mistreatment need to be included in nursing home statutes.

Readability and Content of Elder Abuse Instruments

Since elder abuse was first acknowledged as a health care and social problem, incidence and prevalence of mistreatment has been assessed sparingly in the United States and other countries around the world. Standardized instruments for determining the prevalence of elder abuse have not been developed and other instruments measuring a person's function and spousal violence have been adapted for the measurement of elder abuse prevalence. The purposes of this paper are to (1) ascertain the reading grade level of the most frequently used elder abuse prevalence instrument's text and (2) determine the content validity of the instruments with respect to the types of elder abuse included in them. A review of the instruments used to measure elder abuse prevalence was completed and a questionnaire was developed to measure the reading grade level and type of elder abuse content in four instruments. The Fry Readability, Flesch Reading Ease, and McLaughlin Grading formulas were used to determine reading grade level. A questionnaire regarding content validity was sent to 69 faculty and staff in one university department and a 59% return was achieved. The Conflict Tactics Scale and the Hwalek-Sengstock Elder Abuse-Screening Test had the lowest mean score at the 6th grade reading level. Results of content analysis for types of elder abuse demonstrated none of the instruments are comprehensive. Instruments to measure the prevalence are needed which balance readability and content validity.

Comparison of health and effective functioning in Russia and the United States

Background:

Global aging may increase the societal burden of providing more resources to augment elders’ disabilities. The implications of functional disabilities can vary depending on the society in which they occur.

Objective:

To determine differences in US and Russian elder citizens’ function.

Research design:

Convenience sample of persons 60 years and older were surveyed and evaluated.

Subjects:

One hundred community dwelling residents, half from Galesburg, Illinois and half from Moscow, Russia.

Measurements:

An interviewer administered questionnaire and functional assessment examination.

Results:

The Russian sample was younger than the American sample with a mean age of 67 years versus 78 years, and less likely to be widowed or living alone. Sixty percent of Russians took no medications compared with 14% of Americans, but Russians reported more cardiovascular disease, angina, and hypertension. Forty-four percent of Russians screened as being depressed and only 4% of the Americans. Self-assessed health was good for 77% of Americans and only 6% of Russians. The Medical Outcomes Study SF-36 Health Survey (MOS) eight health concepts showed favorable results for the Americans except for physical functioning, which indicated no difference.

Conclusions:

Marked health and functional differences exist between our samples. Russians had more cardiovascular disease, took less medication, drank and smoked more and were much more likely to be depressed than the US subjects.

Equine influenza vaccine containing older H3N8 strains offers protection against A/eq/South Africa/4/03 (H3N8) strain in a short-term vaccine efficacy study

REASONS FOR PERFORMING STUDY

Surveillance of equine influenza viruses has suggested that strains included in currently licensed vaccines are a poor match for those predominantly circulating in the field.

OBJECTIVE

To assess the ability of Duvaxyn IE-T Plus to provide cross protection against the newly evolved South Africa/4/03 (H3N8) strain of equine influenza virus.

METHODS

The vaccine efficacy was evaluated by challenge infection with influenza strain A/eq/South Africa/4/03 (H3N8) 2 weeks after a primary course of 2 vaccinations with Duvaxyn IE-T Plus given at a 4-week interval. The outcome of challenge in vaccinated ponies was compared with that in unvaccinated animals.

RESULTS

At the time of challenge, all vaccinated ponies had high levels of antibody to Newmarket/1/93, Newmarket/2/93 and South Africa/4/03 strains measured by single radial haemolysis. After challenge infection, there were statistically significantly decreased clinical scores and virus shedding was significantly lower in the vaccinated ponies compared to unvaccinated controls.

CONCLUSION

Two doses of Duvaxyn IE-T Plus provides good clinical and virological protection against challenge with a variant virus 2 weeks after the 2 doses of vaccine.

POTENTIAL RELEVANCE

When variant strains of equine influenza virus first emerge, booster immunisations with currently available vaccines may limit infection provided sufficiently high antibody levels are achieved, suggesting that vaccination in the face of an outbreak may be beneficial.