The casualisation of nursing jobs: a management response to having to do more with less

Restructuring of health care has raised a number of issues affecting nurses and nursing which have been documented over the last half decade. However, comparatively little attention has been given to staffing arrangements, particularly in relation to casualisation. This empirical South Australian study identifies three management responses to the current climate: working nurses harder, working smarter and casualising nursing jobs. The paper suggests that the identified trend to increasing casualisation, which is likely to point towards a national nursing labour market trend, needs to be considered in terms of cost and workload issues. It also suggests that the question of where responsibility for the professional development of casual nurses rests needs to be addressed.

School-based research: problems of access and consent

Public schools are enticing yet intimidating places to conduct research on children and adolescents. A public school provides a large potential subject pool; however, obtaining access to that subject pool can seem impossible with all the layers of permissions that must be obtained. If the study is federally funded, additional regulations apply. This article presents practical and proven approaches to obtaining access to and approval from schools or school systems, as well as parental consent, to conduct school-based research.

Managements for people with disorders of sexual preference and for convicted sexual offenders

BACKGROUND

The reviewers recognise that it may be thought that convicted sex offenders and those with disorders of sexual preference are quite different groups. In combining them within this review we have taken the view that legal process alone should not define the population. Illegal behaviours in one jurisdiction may not be considered so in others. Studies of those who are convicted of sexual offending describe reconviction rates for sexual offences of up to 40-60%. It would seem important to know if there are interventions that might reduce this high rate of re-offending. This review examines antilibidinal management of those who have been convicted of sexual offences or who have disorders of sexual preference.

OBJECTIVES

To determine the effectiveness of a range of management techniques to assist people who have disorders of sexual preference and those who have been convicted of sexual offences.

SEARCH STRATEGY

Biological Abstracts, the Cochrane Schizophrenia Group Register of Trials, The Cochrane Library, EMBASE, MEDLINE, and PsychLIT were searched. Further references were sought from published trials and their authors. Relevant pharmaceutical manufacturers were contacted.

SELECTION CRITERIA

All relevant randomised controlled trials.

DATA COLLECTION AND ANALYSIS

Reviewers evaluated data independently and analysed on an intention-to-treat basis. Data were extracted for short and medium term outcomes.

MAIN RESULTS

A single trial (McConaghy 1988) found the effect of antilibidinal medication (medroxyprogesterone acetate) plus imaginal desensitisation was no better than imaginal desensitisation for problematic/anomalous sexual behaviour and desire. A relapse prevention programme was trialed by Marques (Marques 1994) and participants were followed up for an average of 3 years. What data there are suggest that although there is no discernable effect on the outcome of sex offending (OR 0.76 CI 0. 26-2.28) those treated with response prevention do have less non-sexual violent offences (OR 0.3, CI 0.1-0.89, NNT 10 CI 5-85). In addition those committing both sexual and violent offences also declined in the response prevention group (OR 0.14 CI 0.02-0.98, NNT 20 CI 10-437). A large pragmatic trial investigated the value of group therapy for sex offenders (Romero 1983). This study finds no effect on recidivism at ten years.

REVIEWER'S CONCLUSIONS

It is disappointing to find that this area lacks a strong evidence base, particularly in light of the controversial nature of the treatment and the high levels of interest in the area. The relapse prevention programme did seem to have some effect on violent reoffending but large, well-conducted randomised trials of long duration are essential if the effectiveness or otherwise of these treatments are to be established.

A survey of the advertising of nine new drugs in the general practice literature

OBJECTIVE

To undertake a survey of the advertising of new drugs in the general practice literature as part of a larger study investigating the factors which influence the introduction of new drugs into clinical practice.

METHOD

The advertisements for nine new drugs from a range of therapeutic groups were monitored for 30 months in 12 journals, which are received by most GPs. The amount of prescribing, in defined daily doses, of each new drug by 50 GPs, selected as regular users of a teaching hospital, was also recorded during this period.

RESULTS

Of the journals, 798 issues were surveyed (93% of the total published). The total number of advertisements was almost 33 000, of which 2163 (6.6%) were for the study drugs. The pattern of advertising of each study drug was very complex and varied from month to month and between journals. There was no consistent pattern in the way the drugs were advertised, with large variations in the amount and timing of advertisements. The prescribing data showed wide variations in the number of GPs prescribing each drug and in the amount prescribed.

CONCLUSION

There was no clear relationship between the extent of the advertising of a drug and the amount of prescribing by the GPs. This suggests that advertising in journals is only one of many factors which are important in influencing GPs to prescribe new drugs. However, the study may have been insufficiently comprehensive to capture complex relationships between advertising and prescribing.

Smokeless tobacco use in adolescents: the Cardiovascular Health in Children (CHIC II) Study

Smokeless tobacco has seen a resurgence of popularity among adolescents despite its association with oral cancer and altered cardiovascular function. This study examined age, gender, ethnicity, self-esteem, physical activity, parental smoking, and socioeconomic status as predictors of smokeless tobacco use among middle school children. Subjects included 1,211 youth (White (64%), Black (24%), Hispanic (6%), and Other (6%); age 12.2) participating in the Cardiovascular Health in Children and Youth (CHIC II) study. All data were collected by questionnaire. Factors related to ever using smokeless tobacco included older age (p < .001), being male (p < .001), lower self-esteem (p < .001), and having parents who currently (p = .02) or formerly (p = .05) smoked. Hispanics reported a higher current usage rate than other ethnic groups (p < .001). White youth in the lowest socioeconomic status were most likely to be experimental users (p = .007), while those in the high socioeconomic status were more likely to be current users (p = .006). Physical activity was not associated with smokeless tobacco use.

The development of an individualized questionnaire measure of perceived impact of diabetes on quality of life: the ADDQoL

The objectives of the study were to design and develop a questionnaire to measure individuals' perceptions of the impact of diabetes on their quality of life (QoL). The design of the ADDQoL (Audit of Diabetes Dependent QoL) was influenced by patient-centred principles underlying the SEIQoL interview method. Respondents rate only personally-applicable life domains, indicating importance and impact of diabetes. Fifty-two out-patients with diabetes and 102 attending diabetes education open days provided data for psychometric analyses. Each of the 13 domain-specific ADDQoL items was relevant and important for substantial numbers of respondents. Factor analysis and Cronbach's alpha coefficient of internal consistency (0.85) supported combination of items into a scale. Insulin-treated patients reported greater impact of diabetes on QoL than table/diet-treated patients. People with microvascular complications showed, as expected, greater diabetes-related impairment of QoL than people without complications. Unlike other QoL measures, the ADDQoL is an individualized questionnaire measure of the impact of diabetes and its treatment on QoL. Preliminary evidence of reliability and validity is established for adults with diabetes. Findings suggest that the ADDQoL will be more sensitive to change and responsive to differences than generic QoL measures.

Doing more with less in nursing work: a review of the literature

The paper explores the literature on changes in nursing work. It examines the suggestion that changes in work practices are management responses to cost cutting imperatives. Nursing labour force issues such as staffing roles and staffing mix, the push for flexibility in the workforce and casualisation are discussed. The paper concludes that given the rise of casual work in the general Australian workforce, research needs to be conducted on the extent of casualisation of nursing, and the implications this may have for nursing practice, professional development and on the nursing labour market.

The development of an individualized questionnaire measure of perceived impact of diabetes on quality of life: the ADDQoL

The objectives of the study were to design and develop a questionnaire to measure individuals' perceptions of the impact of diabetes on their quality of life (QoL). The design of the ADDQoL (Audit of Diabetes Dependent QoL) was influenced by patient-centred principles underlying the SEIQoL interview method. Respondents rate only personally-applicable life domains, indicating importance and impact of diabetes. Fifty-two out-patients with diabetes and 102 attending diabetes education open days provided data for psychometric analyses. Each of the 13 domain-specific ADDQoL items was relevant and important for substantial numbers of respondents. Factor analysis and Cronbach's alpha coefficient of internal consistency (0.85) supported combination of items into a scale. Insulin-treated patients reported greater impact of diabetes on QoL than table/diet-treated patients. People with microvascular complications showed, as expected, greater diabetes-related impairment of QoL than people without complications. Unlike other QoL measures, the ADDQoL is an individualized questionnaire measure of the impact of diabetes and its treatment on QoL. Preliminary evidence of reliability and validity is established for adults with diabetes. Findings suggest that the ADDQoL will be more sensitive to change and responsive to differences than generic QoL measures.

Diabetes mellitus in the family: perceptions of offspring's risk

AIMS

The study aimed to explore the beliefs and concerns of people with Type 2 diabetes mellitus (DM) about their children's risk of developing the disease and the possibilities for prevention.

METHODS

Questionnaires were posted to all patients with Type 2 DM in four randomly selected general practices in South London. Two hundred and thirteen (73%) responded. The main outcome measures were: estimated risk of Type 2 DM in their offspring; worry about diabetes in their offspring; knowledge about the possibilities for prevention of Type 2 DM and its complications.

RESULTS

Of the 159 respondents with children, at least 35% and perhaps as many as 64% underestimated the risk of their offspring developing Type 2 DM; 44% thought it possible to reduce the risk of Type 2 DM and its complications; 28% thought altering diet and 6% taking exercise might be useful preventive strategies; 49% worried about their children developing diabetes.

CONCLUSIONS

Although risk of Type 2 DM was underestimated for their children and little was known about prevention, about half of the respondents worried about their children developing diabetes. Education and counselling about risk and prevention are needed. This is important in view of growing interest in and opportunities for both the primary and secondary prevention of Type 2 DM.

The Yck2 yeast casein kinase 1 isoform shows cell cycle-specific localization to sites of polarized growth and is required for proper septin organization

Casein kinase 1 protein kinases are ubiquitous and abundant Ser/Thr-specific protein kinases with activity on acidic substrates. In yeast, the products of the redundant YCK1 and YCK2 genes are together essential for cell viability. Mutants deficient for these proteins display defects in cellular morphogenesis, cytokinesis, and endocytosis. Yck1p and Yck2p are peripheral plasma membrane proteins, and we report here that the localization of Yck2p within the membrane is dynamic through the cell cycle. Using a functional green fluorescent protein (GFP) fusion, we have observed that Yck2p is concentrated at sites of polarized growth during bud morphogenesis. At cytokinesis, GFP-Yck2p becomes associated with a ring at the bud neck and then appears as a patch of fluorescence, apparently coincident with the dividing membranes. The bud neck association of Yck2p at cytokinesis does not require an intact septin ring, and septin assembly is altered in a Yck-deficient mutant. The sites of GFP-Yck2p concentration and the defects observed for Yck-deficient cells together suggest that Yck plays distinct roles in morphogenesis and cytokinesis that are effected by differential localization.

Using reflexivity to optimize teamwork in qualitative research

Reflexivity is often described as an individual activity. The authors propose that reflexivity employed as a team activity, through the sharing of reflexive writing (accounts of personal agendas, hidden assumptions, and theoretical definitions) and group discussions about arising issues, can improve the productivity and functioning of qualitative teams and the rigor and quality of the research. The authors review the literature on teamwork, highlighting benefits and pitfalls, and define and discuss the role for reflexivity. They describe their own team and detail how they work together on a project investigating doctor-patient communication about prescribing. The authors present two reflexive tools they have used and show through examples how they have influenced the effectiveness of their team in terms of process, quality, and outcome.

Cost effectiveness of multi-therapy treatment strategies in the prevention of vertebral fractures in postmenopausal women with osteoporosis

OBJECTIVE

The aim of this study was to evaluate the cost effectiveness of multi-therapy treatment strategies in the prevention of vertebral fractures in postmenopausal women with osteoporosis.

DESIGN

A retrospective, incremental cost-effectiveness analysis was conducted from a societal perspective. It compared 9 treatment strategies over 3 years and incorporated the willingness of patients to initiate and continue each therapy.

MAIN OUTCOME MEASURES AND RESULTS

Four nondominated strategies formed the efficient frontier in the following order: (i) calcium-->no therapy; (ii) ovarian hormone therapy (OHT)-->calcium-->no therapy [166 Canadian dollars ($Can)]; (iii) OHT-->etidronate-->calcium-->no therapy ($Can2331); and (iv) OHT-->alendronate-->calcium-->no therapy ($Can40,965). The figures in parentheses are the incremental costs per vertebral fracture averted to move to that strategy from the previous strategy for patients who had undergone a hysterectomy.

CONCLUSIONS

We identified 4 efficient multi-therapy strategies for the treatment of vertebral osteoporosis in postmenopausal women, 2 of which were consistent with the practice guidelines of the Osteoporosis Society of Canada. Decision-makers may select from among these efficient strategies on the basis of incremental cost effectiveness.

Smoking initiation in youth: the roles of gender, race, socioeconomics, and developmental status

PURPOSE

To describe smoking initiation, and to investigate factors that predict the early initiation of smoking in schoolchildren using a longitudinal approach.

METHODS

A prospective study of smoking habits of children from the third and fourth grades through the eighth and ninth grades. The initial study population was 1970; 79.8% were white and 20.2% were African-American. Children were classified as "nonsmokers," "experimental smokers," or "current smokers" at five time points over 6 years. Multivariate regression models examined relationships of demographic and developmental factors with smoking initiation.

RESULTS

Experimental smoking increased from 4% at Grades 3-4 to 42% at Grades 8-9, and current smoking prevalence rose from 0.4% to 9% over the same period. The mean age of initiation of smoking was 12.3 years. Smoking initiation (experimental smoking) was significantly different by racial group, socioeconomic status (SES), and pubertal development. White children and those of low SES were more likely to be experimental smokers, and also started earlier than African-American children and children of high SES. Once they started, white children advanced more rapidly to become current smokers. Boys had a higher prevalence of experimental smoking than girls at all time points. Children in rural areas were more likely than urban children to start smoking after age 12 years. Children who were at a higher pubertal stage than their peers were also more likely to experiment with smoking.

CONCLUSIONS

Race, SES, and pubertal stage are important predictors of initiation of smoking in schoolchildren. This study indicates a need for smoking prevention classes in elementary and middle school, especially in areas with large numbers of white and low-SES youth. Also, smoking cessation programs, as well as smoking prevention classes, would be useful for middle school and high school students.

Comparison of continuation of postmenopausal hormone replacement therapy: transdermal versus oral estrogen

OBJECTIVE

To determine possible differences in the rate at which hormone replacement therapy (HRT) is continued among postmenopausal women treated initially with transdermal estradiol versus those treated initially with oral conjugated estrogens.

DESIGN

A retrospective database search for prescription use.

SETTING

Northern California facilities of Kaiser Permanente, a health maintenance organization.

PATIENTS

Women aged > or = 45 years who filled index prescriptions for HRT during 1995 for either 0.05 mg transdermal estradiol semiweekly or 0.625 mg oral conjugated estrogen daily. All had filled prescriptions for medroxyprogesterone acetate (MPA) on the same day as the index estrogen prescription.

RESULTS

We found statistically significantly greater relative risk (RR) of discontinuation among women whose HRT began with transdermal estradiol compared with women whose HRT began with oral conjugated estrogens [RR = 2.6, 95% confidence interval (CI) = 1.8-3.8]. After multiple adjustments, RR was 2.7 (95% CI = 1.8-3.9). Complete discontinuation of HRT treatment accounted for most of the stopping we observed, but more women switched from transdermal to oral (25% of those discontinuing this route) than switched from oral to transdermal (0.9% of those discontinuing this route). Risk of discontinuation was not associated with whether prescriber was a gynecologist (RR = 1.2, 95% CI = 0.9-1.7). Type of progestin schedule (cyclic vs. continuous combined) also was not a predictor for discontinuation (RR = 0.9, 95% CI = 0.8-1.0). Older age at start of treatment was associated with discontinuation (RR = 1.1, 95% CI = 1.0-1.2) for every additional 5 years of age.

CONCLUSION

Among women starting HRT, those using a semiweekly transdermal estradiol regimen have a lower rate of continuation than do those using oral estrogen daily.

Bone and mineral abnormalities in childhood acute lymphoblastic leukemia: influence of disease, drugs and nutrition

In children with acute lymphoblastic leukemia (ALL), abnormalities in mineral homeostasis and bone mass were first reported by our group in the late 1980s. Prospective longitudinal cohort studies in 40 consecutive patients receiving treatment according to the Dana-Farber Cancer Institute (DFCI) protocol 87-001 and 16 children receiving DFCI protocol 91-001 afforded us the opportunity to explore various etiologies of the observed abnormalities in mineral and bone metabolism, specifically the leukemic disease process and chemotherapeutic drugs such as steroids and aminoglycoside antibiotics. At diagnosis of ALL, > 70% of children had abnormally low plasma 1,25-dihydroxyvitamin D, 73% had low osteocalcin and 64% had hypercalciuria, indicating an effect of the leukemic process on vitamin D metabolism and bone turnover. During remission induction, treatment with high-dose steroid (prednisone or dexamethasone) resulted in further reduction in plasma osteocalcin and elevated parathyroid hormone levels. During 24 months of chemotherapy-maintained remission, reduction in bone mineral content (BMC), as measured by Z-scores, occurred in 64% of children, most severely affecting those > 11 years of age. A reduction in BMC during the first 6 months had a positive predictive value of 64% for subsequent fracture. By the end of 2 years of therapy, fractures occurred in 39% of children and radiographic evidence of osteopenia was found in 83% of the entire study group. Investigations of the biochemical basis of the bone abnormalities revealed that by 6 months hypomagnesemia developed in 84% of children (of whom 52% were hypermagnesuric) and plasma 1,25-dihydroxyvitamin D remained abnormally low in 70%. Altered magnesium status was attributed to renal wastage of magnesium following cyclical prednisone therapy and treatment with aminoglycoside antibiotics such as amikacin for fever accompanying neutropenia. Dietary intake and absorption of magnesium were normal. In 10 children treated for hypomagnesemia with supplemental magnesium for up to 16-20 weeks, plasma magnesium normalized in only 50% of subjects.

Outcomes of recommendations for breast biopsies in women receiving mammograms from a county health van

OBJECTIVE

To describe the outcomes of breast biopsy recommendations for women screened through a mobile mammography van.

METHODS

Data on all women screened through the Mobile Mammography Program in Suffolk County, Long Island, NY, from 1990 to 1994 were analyzed to determine biopsy recommendation rates, biopsy rates, positive biopsy rates, and cancer detection rates. Follow-up information was obtained from the women's physicians.

RESULTS

The breast cancer detection rate for women screened through the Mobile Mammography Program averaged 0.33% over a five-year period. The biopsy recommendation rate based on abnormal mammograms remained stable, at about 1% to 2%, over a five-year period, as did the rate of positive biopsies among women having biopsies (36.8% to 44.4%). For women ages 50 and older, the cancer rate in 1994 was 0.36%, while for women younger than age 50, the cancer rate was 0.25% (0.32% for all ages).

CONCLUSIONS

These findings show that a breast cancer screening program using a mobile van can have comparable cancer detection rates to national figures and a fairly stable biopsy recommendation rate from which follow-up resource needs can be estimated.

Task-based estimation of past exposures to 60-hertz magnetic and electric fields at an electrical utility

OBJECTIVES

Past exposures of electric utility workers to extremely low-frequency (ELF) magnetic (B) and electric fields (E) in Quebec were estimated.

METHODS

The current intensities were measured and durations of exposures determined for tasks or work locations in 14 job categories. Past task or location intensities were extrapolated from the present on the basis of interviews with long-term workers and utility personnel. Past task or location durations were estimated for the long-term workers. Time-weighted average (TWA) exposures for past periods were reconstructed for jobs from the intensity and duration estimates.

RESULTS

Magnetic fields were estimated to have increased the most over time for substation and distribution-line jobs. Magnetic field exposures for jobs in the generation and transmission of electricity were estimated to have increased very little. For substation jobs, the ratios of magnetic fields in 1945 to those in 1990 ranged from 0.42 to 0.69; the corresponding figures for distribution-line jobs ranged from 0.36 to 0.94. For electric fields in substations, the estimated increase over time was less than for magnetic fields, the 1945:1990 ratios ranging from 0.59 to 0.88. For the distribution line jobs, the 1945:1990 ratios for electric fields were less than 1.0 in 4 cases (0.6 to 0.89), more than 1.0 in 3 others (1.13 to 2.01) and unchanged in 1.

CONCLUSIONS

Reconstruction of TWA exposures allowed changes in the intensity and the duration of exposures to be considered separately. Documentation of the intensity and duration of exposures for different tasks allows exposure reconstruction for jobs that have ceased to exist. The method is applicable elsewhere if exposure-monitoring records allow the level and duration of exposures for tasks or locations to be calculated and if estimates of past durations and intensities of exposures can be reliably obtained.

Design of a renal-dependent individualized quality of life questionnaire

The aim of this study was to design a concise, focused questionnaire to measure individuals' perceptions of the impact of their renal condition on their quality of life, taking account of the importance of life domains relevant for the individual. The design of the renal-dependent quality of life (RDQoL) questionnaire was based on that of the Audit of Diabetes Dependent Quality of Life (ADDQoL) diabetes-specific individualized quality of life questionnaire, which was influenced by patient-centered principles underlying the interview method of McGee et al. The questionnaires specify life domains, and the respondents rate personally applicable domains for the importance and impact of the renal condition. Observation in eight U.K. renal clinics, together with 40 in-depth interviews with peritoneal dialysis, hemodialysis, and transplant patients, provided the basis for item selection for the RDQoL. The results of the study were as follows: each of the 13 ADDQoL items was relevant and important for renal patients. Additional suggestions for items included physical appearance, dependency, freedom, restrictions of fluid intake, and societal prejudice. In conclusion, unlike other quality of life measures, the RDQoL is an individualized questionnaire measure of the impact of renal disease and its treatment on quality of life. Face and content validity is established for adult renal patients, and the RDQoL is being further evaluated for research and clinical use.