Taking charge of the challenge: factors to consider in taking your first nurse practitioner job

PURPOSE

To describe factors that ensure a smooth transition from nurse practitioner (NP) student to independent NP during the first year of practice.

DATA SOURCES

Two contrasting case examples, the authors' experiences, and selected professional literature.

CONCLUSIONS

Key points to consider upon searching or taking a first NP job include patient, colleague, and clinic factors. Patient factors include mix of patient presentations, complexity of patient presentations, insurance status, and population. Colleague factors include mentorship, charting, mix of providers, and availability of providers. Perhaps most importantly, clinic factors include productivity expectations, practice mission, charting systems, on-call requirements, supervision of other staff, and teaching status. Together, these factors can largely determine whether an NP's days are satisfying or frustrating in a new job.

IMPLICATIONS FOR PRACTICE

The transition from NP student to independent NP can be daunting. Although nursing schools and practice sites have responsibilities to ensure the transition is smooth, the new NP is ultimately responsible for the transition.

Education predicts incidence of preclinical mobility disability in initially high-functioning older women. The Women's Health and Aging Study II

BACKGROUND

To examine the impact of educational attainment on the incidence of preclinical mobility disability (PCD).

METHODS

The Women's Health and Aging II Study is a prospective observational cohort study of 436 initially high-functioning community-dwelling women aged 70-79 years at baseline in Baltimore, Maryland. We measured the association of highest attained education level with preclinical mobility disability (PCD) over an 11-year period. PCD is defined as self-reported modification in any of four tasks without reporting difficulty in those tasks. The tasks were walking ½ mile, climbing up steps, doing heavy housework, and getting in/out of bed or chair.

RESULTS

Participants with less than 9 years of education were more likely to acquire incident PCD (hazard ratio: 3.1, 95% confidence interval = 1.2-7.7) than their counterparts with more education after adjusting for income, marital status, number of diseases, and high self-efficacy.

CONCLUSIONS

Lower education level is an independent predictor of incident preclinical mobility disability. This association has important implications for primary and secondary prevention and can be easily assessed in clinical encounters.

Life-course financial strain and health in African-Americans

Differential exposure to financial strain may explain some differences in population health. However, few studies have examined the cumulative health effect of financial strain across the life-course. Studies that have are limited to self-reported health measures. Our objective was to examine the associations between childhood, adulthood, and life-course, or cumulative, financial strain with disability, lung function, cognition, and depression. In a population-based cross-sectional cohort study of adult African-American twins enrolled in the US Carolina African American Twin Study of Aging (CAATSA), we found that participants who reported financial strain as children and as adults are more likely to be physically disabled, and report more depressive symptoms than their unstrained counterparts. Participants who reported childhood financial strain had lower cognitive functioning than those with no childhood financial strain. We were unable to detect a difference in lung function beyond the effect of actual income and education in those who reported financial strain compared to those who did not. Financial strain in adulthood was more consistently associated with poor health than was childhood financial strain, a finding that suggests targeting adult financial strain could help prevent disability and depression among African-American adults.

Socioeconomic status is associated with frailty: the Women's Health and Aging Studies

BACKGROUND

Frailty is a common risk factor for morbidity and mortality in older adults. Although both low socioeconomic status (SES) and frailty are important sources of vulnerability, there is limited research examining their relationship. A study was undertaken to determine (1) the extent to which low SES was associated with increased odds of frailty and (2) whether race was associated with frailty, independent of SES.

METHODS

A cross-sectional analysis of the Women's Health and Aging Studies using multivariable ordinal logistic regression modelling was conducted to estimate the relationship between SES measures and frailty status in 727 older women. Control variables included race, age, smoking status, insurance status and co-morbidities.

RESULTS

Of the sample, 10% were frail, 46% were intermediately frail and 44% were robust. In adjusted models, older women with less than a high school degree had a threefold greater odds of frailty compared with more educated individuals. Those with an annual income of less than $10 000 had two times greater odds of frailty than wealthier individuals. These findings were independent of age, race, health insurance status, co-morbidity and smoking status. African-Americans were more likely to be frail than Caucasians (p<0.01). However, after adjusting for education, race was not associated with frailty. The effect of race was confounded by socioeconomic position.

CONCLUSIONS

In this population-based sample, the odds of frailty were increased for those of low education or income regardless of race. The growing population of older adults with low levels of education and income renders these findings important.

Education in time: cohort differences in educational attainment in African-American twins

OBJECTIVES

Educational opportunities for African-Americans expanded throughout the 20(th) century. Twin pairs are an informative population in which to examine changes in educational attainment because each twin has the same parents and childhood socioeconomic status. We hypothesized that correlation in educational attainment of older twin pairs would be higher compared to younger twin pairs reflecting changes in educational access over time and potentially reflecting a "ceiling effect" associated with Jim Crow laws and discrimination.

METHODOLOGY AND PRINCIPAL FINDINGS

We used data from 211 same-sex twin pairs (98 identical, 113 fraternal) in the Carolina African-American Twin Study of Aging who were identified through birth records. Participants completed an in-person interview. The twins were predominantly female (61%), with a mean age of 50 years (SD = 0.5). We found that older age groups had a stronger intra-twin correlation of attained educational level. Further analysis across strata revealed a trend across zygosity, with identical twins demonstrating more similar educational attainment levels than did their fraternal twin counterparts, suggesting a genetic influence.

DISCUSSION

These findings suggest that as educational opportunities broadened in the 20th century, African-Americans gained access to educational opportunities that better matched their individual abilities.

Association between lung function and disability in African-Americans

BACKGROUND

Impaired lung function is independently associated with higher rates of disability; however, few studies have examined the extent to which this relationship varies by sex. Because men are less likely to have disability, it is expected that the relationship between lung function and disability will be greater among women.

METHODS

Logistic regression models were specified to examine the relationship between lung function and disability in 689 African-American men and women participating in the Carolina African American Twin Study of Aging. Disability was defined as difficulty in performing at least one of seven basic activities of daily living. Impaired lung function was defined as per cent of predicted peak expiratory flow (PEF) <80.

RESULTS

Accounting for demographic and health-related characteristics, women who had impaired lung function had a higher odds (OR 1.77; 95% CI 1.02 to 3.06) of being disabled than those with normal lung function. Impaired lung function was unrelated to disability in men.

CONCLUSION

Lung function appears to vary by sex in this sample of African-Americans. Furthermore, among women, lung function should be considered as an important indicator of health. Every effort should be made to improve lung function in African-Americans, but interventions and health promoting strategies may need to be sex specific.

Effect of financial strain on mortality in community-dwelling older women

OBJECTIVES

Although it is well established that low socioeconomic status is related to mortality, little research has focused on whether financial strain predicts mortality. Still less research has examined this question by race, despite the evidence that African Americans suffer earlier mortality and more financial strain at the same levels of socioeconomic status than their Caucasian counterparts. We examined the extent to which financial strain was associated with increased mortality risk in older women and whether the relationship differed by race.

METHODS

The sample was the Women's Health and Aging Studies I and II of community-dwelling older women aged 70 to 79. We used Cox proportional hazards models to estimate the effect of financial strain on 5-year mortality rates.

RESULTS

Women who reported financial strain were almost 60% more likely to die within 5 years independent of race, age, education, absolute income, health insurance status, and comorbidities (p <.001) than their counterparts who did not. Although race was not a predictor of mortality, the association between financial strain and mortality was stronger for African Americans than for Caucasians (p <.01).

DISCUSSION

For older women, financial strain may be a better predictor of mortality than annual income, particularly in the case of older African American women.

Allostatic load and frailty in the women's health and aging studies

BACKGROUND

Frailty involves decrements in many physiologic systems, is prevalent in older ages, and is characterized by increased vulnerability to disability and mortality. It is yet unclear how this geriatric syndrome relates to a preclinical cumulative marker of multisystem dysregulation. The purpose of this study was to evaluate whether allostatic load (AL) was associated with the geriatric syndrome of frailty in older community-dwelling women.

METHODS

We examined the cross-sectional relationship between AL and a validated measure of frailty in the baseline examination of two complementary population-based cohort studies, the Women's Health and Aging studies (WHAS) I and II. This sample of 728 women had an age range of 70-79. We used ordinal logistic regression to estimate the relationship between AL and frailty controlling for covariates.

RESULTS

About 10% of women were frail and 46% were prefrail. AL ranged from 0 to 8 with 91% of participants scoring between 0 and 4. Regression models showed that a unit increase in the AL score was associated with increasing levels of frailty (OR = 1.16, 95% CI = 1.04-1.28) controlling for race, age, education, smoking status, and comorbidities.

CONCLUSION

This study suggests that frailty is associated with AL. The observed relationship provides some support for the hypothesis that accumulation of physiological dysregulation may be related to the loss of reserve characterized by frailty.

Relationship of race and poverty to lower extremity function and decline: findings from the Women's Health and Aging Study

Race- and poverty-related disparities in physical function are well documented, though little is known about effects of race and poverty on functional decline and the progression of disability. We examined cross-sectional and longitudinal relationships between race, poverty and lower extremity function using data from moderately to severely disabled women in the U.S. Women's Health and Aging Study. Severity of lower extremity functional limitation was determined from scaled responses of reported difficulty walking (1/4) mile, walking across a room, climbing stairs, and stooping, crouching or kneeling. Usual walking speed assessed over 4m was our objective measure of function. Of the 996 women who described themselves as black or white, 284 (29%) were black and 367 (37%) were living at or below 100% of the federal poverty level. Independent of demographic and health-related factors, among white women, the poor exhibited consistently worse lower extremity function than the non-poor; this association, however, was not observed in black women. Among the non-poor, black women had slower walking speeds, and reported more limitation in lower extremity function than their non-poor white counterparts, even after adjusting for demographic variables and health-related characteristics. After 3 years, accounting for baseline function, demographic and health-related factors, race and poverty status were unrelated to functional decline. Thus, while race and poverty status were associated with functional deficits in old age, they do not appear to impact the rate of functional decline or progression of disability over 3 years.

Allostatic load: a mechanism of socioeconomic health disparities?

Although research on health disparities has been prioritized by the National Institutes of Health, the Institute of Medicine, and Healthy People 2010, little has been published that examines the biology underlying health disparities. Allostatic load is a multisystem construct theorized to quantify stress-induced biological risk. Differences in allostatic load may reflect differences in stress exposure and thus provide a mechanistic link to understanding health disparities. The purpose of this systematic review is to examine the construct of allostatic load and the published studies that employ it in an effort to understand whether the construct can be useful in quantifying health disparities. The published literature demonstrates that allostatic load is elevated in those of low socioeconomic status (SES) as compared to those of high SES. The reviewed articles vary in the justification for inclusion of variables. Recommendations for future research are made in the contexts of measurement, methodology, and racial composition of participants.

Biological underpinnings of health alterations in women with PTSD: a sex disparity

Women develop posttraumatic stress disorder (PTSD) at twice the rate of men, even though fewer women than men experience traumatic events over their lifetimes. Current studies of individuals with PTSD provide evidence of alterations in the neuroendocrine system that involve levels and activity of cortisol and DHEA and changes in immune function that predispose these individuals toward an innate (Th1) immune response. Yet few studies have addressed the possible role of these biologic alterations in women's increased vulnerability to developing PTSD. In addition, current studies are limited in their ability to link biologic alterations to the observed fourfold increase in medical conditions in women with PTSD as compared to women without PTSD. And finally, few studies have addressed the biologic impact of co-occurring major depressive disorder (MDD) in individuals with PTSD. This critical review provides an update on neuroendocrine and immune perturbations associated with PTSD with and without co-occurring MDD to suggest links to health and possible mechanisms underlying the observed sex disparity in the development of PTSD.