Variables, variability, and variations research: implications for medical informatics

Variations research is one important strategy in the quality management movement designed to improve the quality of health care and to control costs. Information systems are being utilized in variations research to provide an array of potential variables, to provide measures of the variability inherent in these variables, and to assist with the study of the linkages of patient and provider characteristics with interventions and outcomes. This article presents a systems model of inputs, processes, and outcomes with explication of factors related to client, provider, and setting as a heuristic strategy for variable specification. The implications of variable specification, the design and measurement of variability, and the key issue of control in variations research are linked with a discussion of the implications for medical informatics.

Elderly residents: perceptions of nurses' comforting touch

1. Elderly nursing home residents often feel unwanted or unloved because of a lack of physical contact with others or their caregivers' inability to communicate love and belonging. 2. In a study of 25 elderly nursing home residents, it was found that those who were subjected to comforting touch by their nurses perceived an increased feeling of affection and immediacy. 3. The conscious and intentional use of comforting touch by nurses and caregivers to elderly nursing home residents should be encouraged because of its beneficial effect of conveying love and belonging.

The phenomenon of clinical supervision in psychiatric health care

The main objective of this study is to describe how nurses experience clinical supervision in psychiatric care. The study design is explorative and descriptive. A clinical supervision process with a theoretical approach to caring includes a learning process, the application of a caring process, and a relationship process. An important aspect of this theoretical approach is the spiritual dimension of caring and its manifestation in the supervision process as well as in the development of the nurse's identity. The results indicate the following phenomena: guilt and a feeling of guilt, reconciliation, forgiveness and loneliness.

Perpetuation of ageist attitudes among present and future health care personnel: implications for elder care

The population of the western world is greying rapidly. By the year 2025, people over the age of 65 will make up 20% of the population of the USA. By the year 2000, one-half of elderly people in the United Kingdom (UK) will be over the age of 75. The increasing numbers of elderly people will be spending from 18% (males) to 27% (females) of their added years as impaired, disabled and frail individuals. The purposes of this comparative descriptive study were to: (a) describe and compare the attitudes of registered nurses (RNs) and health career work study students (HCS) who work with elderly people in the clinical setting; and (b) determine whether relevant demographic variables of the two groups were related to their attitudes. A convenience sample of 82 RNs and 68 HCSs were asked to complete Kogan's (1961) Attitudes Toward Old People Scale (KOP). Response to the survey was 91% and 74% for the HCS and RN groups respectively. There was a significant difference between the group mean scores with students holding less favourable attitudes toward elderly people on the KOP-negative scale. No significant difference was found on the KOP-positive scale. Point-biserial correlations between demographic variables and attitude scores revealed that gender and ethnicity were significantly related to RNs attitudes--males and blacks and Asians expressed more unfavourable attitudes. Educational level and primary area of clinical work were significantly associated with students' scores on the KOP-negative scale, while years of clinical experience was significantly related to KOP-positive scale scores. While both groups held attitudes that were more favourable than unfavourable, RNs and HCSs expressed stereotypical views about old people in general. Recommendations for nursing education and nursing service are proposed to prevent the negative impact on future care elderly people that the findings suggest.

Determining the National Flight Nurses Association's research priorities

INTRODUCTION

Increased federal attention to nursing research has prompted professional nursing organizations to develop research programs identifying areas of scientific knowledge most needed for professional and clinical practice. The study purpose was to identify the National Flight Nurses Association's (NFNA's) research priorities.

METHODS

A two-round Delphi technique was used, with systematic surveys in Round I mailed to 500 NFNA members. Responses from 127 members were coded to form the Round II survey that was completed by members at the NFNA meeting in St. Louis in October 1993.

RESULTS

According to frequency scores, issues of highest priority relate to specialty and nonspecialty team, crew configurations, clinical indications for transport, airway management, educational preparation and continuing education.

CONCLUSION

Identified priorities support development of research studies and programs that lead to increased knowledge, facilitate collaborative studies and also provide a basis for research funding.

Stressors of hospice home care nurses caring for AIDS patients: a pilot study

This exploratory study identified stressors of home care hospice nurses caring for hospice patients with AIDS. Five hospice home care nurses provided data obtained from demographic questionnaires and semistructured interviews. Results of this pilot study confirmed that experienced hospice nurses believe there is a difference between caring for AIDS hospice patients and non-AIDS hospice patients, and that nurses face increased stress when caring for AIDS hospice patients. Further research is needed to provide better care for the hospice patient with AIDS, and to acknowledge and respond to the increased demand on the nurses who care for them.

Rethinking the merger of the clinical nurse specialist and the nurse practitioner roles

The clinical nurse specialist (CNS) and nurse practitioner (NP) have been distinct and separate advanced nursing practice roles since the 1960s. The forces of economics and health care reform have fostered an interest in merging these two advanced practice roles. Economic and regulatory advantages have been noted in the literature for both roles. What is not so evident are the possible disadvantages. Several aspects of the merger issue are explored as is the recent background of the creation of the CNS and NP roles. Problems and questions are asked to stimulate future discussions in nursing's professional associations and in education and service settings.

Evaluating the clinical nurse specialist. A review

This paper reviews evaluative studies on the role of clinical nurse specialists and aims to describe and categorise research according to the methods used. By using the structure, process and outcome framework a clear pattern of research development and evidence emerges. It appears that significant benefits accrue for patients from the contribution of nurse specialists, but more experimental studies with combined methods should now be applied to this area.

The emotional experience of caregivers to relatives who are chronically confused--implications for community mental health nursing

This paper examines the emotional experience of informal caregivers to family members who are chronically confused. Six informal caregivers were taken from the caseloads of community mental health nurses working with elderly people. Data were collected by means of a daily diary and in-depth interviews relating to their emotional experience as caregivers. The data are presented in the form of six vignettes and the implications for theory, practice and research in community mental health nursing are examined.

Answering a need: geropsychiatric nursing course development

1. A part of the commitment to holistic nursing care is meeting the mental health needs of its clients. 2. There exists a great need to deal with both mental and physical problems in older persons. Moreover, geropsychiatry is greatly lacking in the policy and practice of nursing education. 3. Graduate-level courses must focus on both mental health promotion and disease prevention, particularly for the older persons who are consumers.

Case-management of AIDS clients as a predictor of total inpatient hospital days

AIDS has shifted from an acute short-term terminal illness to a progressive, chronic disorder. Evaluation of AIDS case-management is imperative due to both the increasing numbers of cases and the lengthened survival of those with the disease. In 1988 the Missouri Department of Health (MDOH) initiated the first statewide system of AIDS case-management in the United States. This study was done to determine if deceased AIDS clients who received MDOH case-management services had fewer inpatient hospital days than clients who did not receive these services, during the last six months of life. Death certificates and Medicaid records were merged for 100 case-managed and 99 control, non-case-managed AIDS clients. No significant difference between groups was found in number of inpatient hospital days. Further, neither age, ethnicity, gender, cause of death, nor specific AIDS risk factors were associated with total number of inpatient hospital days. The client-centered philosophy of the program may have encouraged case managers to utilize all available service, including hospitalization, without considering cost-containment issues. Future evaluation efforts will investigate both cost-containment and quality-of-life indicators, such as satisfaction with care, of case-managed AIDS clients.

Young adolescents' identification of difficult life events

As part of a larger study of parent-child communication, young adolescents (n = 847), aged 11 to 14 years, responded with brief written answers to the question: "Using your own words, list any happenings that occurred in the family that you feel may have been difficult and have long-lasting effects." The sample was chiefly seventh- and eighth-grade students from two-parent, White, middle-class, urban homes. Content analyses of their responses resulted in the following themes: feelings of loss due to death, divorce, relocation, or a sibling leaving the family; feelings of threat toward family relationships or integrity, personal or family health, personal or family safety and well-being, and violence; feelings of being hassled due to parents' expectations and limits and siblings' disagreements and conflicts; and testing maturity. The data provide significant examples of the life events of families. Recommendations to identify and care for families and young adolescents experiencing these events are proposed.

Continuity of care: a challenge for ambulatory oncology nursing

Continuity of care has many facets and challenges both as a philosophy and in practice. In an abstract sense, it represents an ideal to which health care professionals strive. It is becoming a professional and consumer expectation that each health care professional contribute to continuity of care. Although a variety of organizational models for providing continuity of care have been established in which nursing plays a prominent role, recent research suggests that some frontline nursing personnel may not fully understand their responsibility to continuity of care. There is a need for nursing curricula in both basic and continuing education programs to address continuity of care concepts, models, and methodologies to strengthen awareness of patient care needs across the disease continuum and across care settings. Performance expectations that include professional accountability for continuity of care also encourage greater attention to this issue.

Teaching Strategies to Promote Critical Thinking Skills in Nursing Staff

The promotion of critical thinking skills necessary for safe, effective, state-of-the-art nursing care is discussed in this article. Definitions of critical thinking and inductive and deductive reasoning are explored. Benner's (1986) research, based on Dreyfus and Dreyfus' (1980) model of skill acquisition, provides a basis for the various strategies mentioned to teach critical thinking. Implementation and evaluation of these strategies are addressed.

The concept of supervision in psychiatric care--compared with mentorship and leadership. A review of the literature

The purpose of the paper is to describe supervision and its significance compared with mentorship and leadership in health care. In addition, supervision is compared with other forms of processes for staff training in psychotherapy and psychosocial work. Supervision can be defined as a pedagogical process, where clinical experiences are made clear and systematized in a professional context. This requires a continual and systematic review process with an emphasis on solving problems.

Maternal-fetal physical assessment in the home setting: role of the advanced practice nurse

Maternal-fetal physical assessment in the home setting reflects a review of the literature, AWHONN's practice guidelines, and the authors' clinical experience. The goals of prenatal home care and the role of the advanced practice nurse are described. Emphasis is placed on the maternal-fetal physical assessments that allow the advanced practice nurse to provide additive or substitutive prenatal care visits in the home. Delivering prenatal care in the home by the advanced practice nurse is an alternative type of health-care delivery for pregnant women.

No place of their own: an exploratory study

The purpose of the research reported here was to explore with mothers and children the experience of having no place of their own. The researcher used Parse's theory of human becoming as a framework in this exploratory descriptive study. For the participants in this study the experience of living without a place of their own is: a sense of gratitude for protection, mingling with the discomfort of restriction and exposure, giving rise to fears and reassurances as detachment from cherished others surfaces discordance with unfamiliar patterns, while novel engagements bring pleasure as insights and struggles surface new possibles as well as disillusionment. Suggestions for theory expansion and further research are discussed.

Delirium in the older person with cancer

Delirium occurs in 25-40% of patients with cancer and in as many as 85% of patients with advanced cancer. Delirium, or acute confusion, can be short term and reversible and differs from dementia, which is chronic and irreversible. Accurate assessment is critical for effective treatment and to reduce the increased mortality associated with delirium. Assessment for differentiating depression as well as dementia is needed, because mistaken diagnoses often prolong and exacerbate the symptoms of delirium. Different treatment strategies are appropriate depending on the cause(s) of confusion. In this article, risk factors and assessment tools are reviewed, and interventions for delirium in older persons with cancer are presented. Future areas for research are identified, because there is a paucity of research on delirium in older patients with cancer.

pH testing of feeding-tube aspirates to determine placement

Although radiologic confirmation of tube placement remains the "gold standard," there is growing evidence that pH testing of feeding-tube aspirates can reduce (although not totally eliminate) reliance on x-rays used for this purpose. This article describes that evidence and tells how it was obtained. Reducing the number of x-rays needed to confirm tube position can have far-reaching financial benefits.

Replication strategies for nursing research

Implementing research findings into nursing practice has been seriously hampered by the lack of replication studies. One deterrent to replication is the vague and scant treatment that replication methodology has been given in the nursing literature. Knowledge of different replication strategies will enable researchers to choose the most appropriate approach. Four of the most frequently cited classifications of replication research are compared and a review of replication studies in nursing from 1983 to 1992 is included.

Nursing Documentation: A Program to Promote and Sustain Improvement

Pertinent, timely, and accurate nursing documentation promotes consistency in client care and effective communication among nurses and other health team members. Alternative documentation systems, continuing education efforts, and ongoing quality management activities are necessary to ensure that standards of record keeping are maintained. A pilot project using such methods was conducted on two hospital units to promote adherence to a specific documentation system. Education was integrated with peer auditing and follow-up over a 6-month period. The nursing staff significantly improved the quality of their documentation and sustained this improvement over time. Staff's knowledge about documentation improved significantly. Furthermore, there was a statistically significant decrease in documentation errors. The integration of peer auditing and continuing education enabled nurses to attain and maintain specific documentation standards.

The nurse's role in preventing abuse of elderly patients

Abuse of elderly people came to public awareness in the 1970s. Since that time, programs have been initiated to help combat the problem. Each state has legislation for reporting abuse. However, abuse of the elderly often goes unreported due to ignorance, fear, or lack of concern. Public education and intervention strategies appear to be the answer to abuse of the elderly. Nurses, who spend more time with patients than do any other healthcare professionals, are in an ideal position to identify, intervene in, report, and generally lead the way in preventing abuse of the elderly.

Health needs of homeless clients accessing nursing care at a free clinic

Homeless people need emotional support, caring professionals, and resources that work within their frame of reality. Each homeless community will have different demographics and health needs. The common denominators are the obstacles encountered when trying to access health care: bureaucracy, transportation, accessibility, present-time orientation, limited resources, frustration, and anxiety. Nurse-managed free clinics are an effective means of serving the needs of homeless and indigent populations. Through these clinics, clients can receive continuity of care, proper follow-up, referrals, and teaching to aid in the prevention of illness. A free clinic was established in a northwestern Georgia community to meet the health needs of homeless and indigent persons. This article describes the demographics, attitudes, values, perceived support systems, and health needs of clients accessing care at this nursing clinic.

Written Communication With Survivors of Sexual Abuse: Use of Letters in Therapy

1. Written therapeutic communication with clients can have a lasting impact by enhancing themes of a therapy session, commenting on strengths, and highlighting changes. 2. Therapeutic letters can be used to validate the sexual abuse survivor's experience, offer commendation, provide information, normalize day-to-day living, encourage reflection, and seek clarification. 3. The use of therapeutic letters is consistent with a family systems nursing approach to practice, in which the nurse focuses on strengths and resources, interactions, and reciprocity during contact with the patient.

Mode of acquiring AIDS and nurses' intention to provide care

The intention of 322 staff nurses to provide care to male patients who acquired AIDS either through sexual activity with males, sexual activity with females, sharing needles, or a blood transfusion was examined. For each mode of acquiring AIDS, respondents indicated their intent to perform 11 care-giving behaviors, whether they were comfortable performing the behaviors, and if they felt in danger by performing the behaviors. No statistically significant differences related to mode of acquiring AIDS were found in nurses' intention to provide care. Comfort was the only significant predictor of intent to provide care.

Collaborative care: pathways to quality outcomes

In 1990, The Memorial Hospital at Easton, Maryland, Inc., a not-for-profit 183-bed rural community hospital, recognized a need to explore alternative patient care methods or approaches to improve the continuity of care, focus on healthier patient outcomes, and contain costs. The concept of collaborative care became the focus for patient care delivery. Multidisciplinary teams were established to coordinate patient care activities for patient populations process. Plans of care, referred to as critical pathways, identify intermediate goals and interventions, providing guidance for the patient, family, and healthcare providers as they work to achieve quality outcomes. As the patient progresses along the critical pathway, variances from the established goals are monitored and become the focus of quality reviews.

Case management models. Geriatric nursing prototypes for growth

1. Geriatric nursing case management is an advocacy system and administrative service that guides clients/families through the health care system and maintains elders in a safe and nonrestrictive environment. 2. Geriatric nursing case managers can function in hospital-based geriatric assessment programs, public health departments or home health care agencies, social health maintenance organizations, or privately owned case management businesses. 3. Specific nursing interventions related to geriatric nursing case management include liaison activities to appropriately integrate clients into the health care system, health promotion and counseling, disease prevention, health education and screening, and community resource linkage. 4. Nursing case management is evolving into its own specialty because a specialized knowledge base is required to navigate our health care system and procure appropriate services for clients.

Storytelling: Using an Ancient Art to Work With Groups

1. Storytelling can be used to reduce social isolation and lack of connection. 2. Group storytelling, in which group members create a story together, has therapeutic value in the psychiatric milieu. 3. The experienced therapist/nurse-therapist is the best person to conduct a storytelling group in the psychiatric setting.

Creating a future for nursing through interactive planning at the bedside

Interactive planning is introduced as an approach to planning amidst change that may be useful in clinical practice. The underlying principles and unique characteristics of interactive planning are presented. In addition, clinical studies suggesting its inherent presence in nursing practice are identified. Effective care planning as a developmental process provides nurses with a favorable opportunity to both contribute to individualized patient care and create our own professional future.

The Defining Characteristics of Support: Results of a Research Project

Support is a central concept in nursing practice; not only for psychiatric nurses, but for all nurses. Yet, the ambiguity about the definition of support is troubling. More importantly, nurses are "doing things" to and for patients, but are these interventions truly supportive? What kinds of support do our patients want and need? As nursing advances towards a scientific basis for practice, we must be clear about the what and why of our actions (Sebastian, 1990). As nurses become more outcome oriented, we must know what patients value in their treatment. This study is an initial attempt to clarify for psychiatric nurses the concept of support; may it be the first of many.

Using Roy's adaptation model in practice: nurses' perspectives

Using a qualitative research methodology, the utility of the Roy adaptation model as a framework for nursing practice within a hospital setting was investigated. The level of integration of the model into practice varied among nurses. The model was generally found to be useful in focusing, organizing, and directing nurses' thoughts and actions regarding patient care, resulting in a perception of improved quality of nursing process and patient outcomes. Prior education on the Roy model and participation in professional advancement activities facilitated model integration, while lack of education and resistance to change inhibited implementation of model-based practice.

Transitions: a central concept in nursing

Transition is a concept of interest to nurse researchers, clinicians, and theorists. This article builds on earlier theoretical work on transitions by providing evidence from the nursing literature. A review and synthesis of the nursing literature (1986-1992) supports the claim of the centrality of transitions in nursing. Universal properties of transitions are process, direction, and change in fundamental life patterns. At the individual and family levels, changes occurring in identities, roles, relationships, abilities, and patterns of behavior constitute transitions. At the organizational level, transitional change is that occurring in structure, function, or dynamics. Conditions that may influence the quality of the transition experience and the consequences of transitions are meanings, expectations, level of knowledge and skill, environment, level of planning, and emotional and physical well-being. Indicators of successful transitions are subjective well-being, role mastery, and the well-being of relationships. Three types of nursing therapeutics are discussed. A framework for further work is described.

Descriptions of comfort by substance-using and nonusing postpartum women

OBJECTIVE

To compare definitions of comfort held by a group of postpartum substance users with those of a group of nonusers.

SETTING

The postpartum unit of a large university hospital.

PARTICIPANTS

The convenience sample constituted 36 postpartum women; half were substance users and half denied substance use. The nonusing participants were matched to the users according to age, race, type of delivery, and parity.

DESIGN

Qualitative, descriptive.

MAIN OUTCOME MEASURES

Data were collected through semistructured, individual interviews. Patients defined comfort and described the characteristics and patterns of comfort during the postpartum period.

RESULTS

Data were analyzed into three categories of themes. Attributes of comfort were resolution of pain, resolution of fatigue, satiation of hunger, resolution of individual irritants, and relaxation. Interventions for comfort were standard therapy, supportive presence, and caring nursing approach. Modifiers of comfort were individualized comfort patterns, environmental ease, and maternal concern.

CONCLUSIONS

Comfort is more than the absence of pain. A supportive presence and a caring nursing approach were the most helpful interventions.