Nurses Improving Care for Healthsystem Elders - a model for optimising the geriatric nursing practice environment

AIMS AND OBJECTIVES

To explain the relationship between a positive nurse practice environment (NPE) and implementation of evidence-based practices. To describe the components of NICHE (Nurses Improving Care for Healthsystem Elders) programmes that contribute to a positive geriatric nursing practice environment.

BACKGROUND

The NPE is a system-level intervention for promoting quality and patient safety; however, there are population-specific factors that influence the nurses' perception of their practice and its' relationship with patient outcomes. Favourable perceptions of the geriatric-specific NPE are associated with better perceptions of geriatric care quality.

DESIGNS

Discursive paper.

METHOD

In this selective critical analysis of the descriptive and empirical literature, we present the implementation of geriatric models in relation to the NPE and components of the NICHE programme that support hospitals' systemic capacity to effectively integrate and sustain evidence-based geriatric knowledge into practice.

RESULTS

Although there are several geriatric models and chronic care models available, NICHE has been the most successful in recruiting hospital membership as well as contributing to the depth of geriatric hospital programming.

CONCLUSIONS

Although all geriatric care models require significant nursing input, only NICHE focuses on the nursing staff's perception of the care environment for geriatric practice. Studies in NICHE hospitals demonstrate that quality geriatric care requires a NPE in which the structure and processes of hospital services focus on specific patient care needs.

RELEVANCE TO CLINICAL PRACTICE

The implementation of evidence-based models addressing the unique needs of hospitalised older adults requires programmes such as NICHE that serve as technical resources centre and a catalyst for networking among facilities committed to quality geriatric care. Unprecedented international growth in the ageing population compels us to examine how to adapt the successful components of NICHE to the distinctive needs of health systems throughout the world that serve older adults.

The presence of ethics programs in critical access hospitals

The purpose of this study was to assess the presence of ethics committees in rural critical access hospitals across the United States. Several studies have investigated the presence of ethics committees in rural health care facilities. The limitation of these studies is in the definition of 'rural hospital' and a regional or state focus. These limitations have created large variations in the study findings. In this nation-wide study we used the criteria of a critical access hospital (CAH), as defined by the Medicare Rural Hospital Flexibility Program (Flex Program, 2007), to bring consistency and clarity to the assessment of the presence of ethics committees in rural hospitals. The Flex Monitoring Team conducted a national telephone survey of 381 CAH administrators throughout the United States. The survey covered a wide variety of questions concerning hospitals' community benefit, impact activities, and whether the hospital had a formally established an ethics committee. About 230 (60%) of the respondents indicated they had a formally established ethics committee or ethics consultation program at their CAH. The prevalence of ethics committees declined as the CAH location became increasingly rural along a rural-urban continuum. Unlike CAHs, all rural Department of Veterans Affairs Medical Centers have ethics committees. The results of this study provide an understanding of the limited presence of ethics committee in rural America and the need to consider new approaches for providing ethics assistance. A virtual ethics committee network may be the most efficient and effective way of providing rural hospitals access to a knowledgeable ethics committee or consultant.

Early career RNs' perceptions of quality care in the hospital setting

The purpose of this study was to explore early-career registered nurses' perceptions of high-quality nursing care in hospitals. The study findings contribute to ongoing work intended to explore and define what quality nursing care is and how it ultimately impacts patients. The final sample analyzed for this article consisted of 171 narrative responses from hospital-based registered nurses. We used Krippendorff's technique for qualitative content analysis to identify themes. Three themes emerged as integral to high quality nursing care: registered nurse presence, developing relationships, and facilitating the flow of knowledge and information. Development of nursing quality indicators should focus on nursing processes in addition to patient outcomes. Such a focus would better capture the complexity of hospital nursing care.

Commuting to work: RN travel time to employment in rural and urban areas

PURPOSE

To investigate the variation in average daily travel time to work among registered nurses (RNs) living in urban, suburban, and rural areas. We examine how travel time varies across RN characteristics, job setting, and availability of local employment opportunities.

METHOD

Descriptive statistics and linear regression using a 5% sample from the 2000 Census and a longitudinal survey of newly licensed RNs (NLRN). Travel time for NLRN respondents was estimated using geographic information systems (GIS) software.

FINDINGS

In the NLRN, rural nurses and those living in small towns had significantly longer average commute times. Young married RNs and RNs with children also tended to have longer commute times, as did RNs employed by hospitals.

CONCLUSIONS

The findings indicate that travel time to work varies significantly across locale types. Further research is needed to understand whether and to what extent lengthy commute times impact RN workforce needs in rural and urban areas.

Decision making in head and neck cancer care

OBJECTIVES/HYPOTHESIS

To describe patterns of patient involvement in head and neck cancer decision making.

STUDY DESIGN

Prospective longitudinal ethnography of otolaryngology patients making treatment decisions.

METHODS

Grounded theory analysis of verbatim transcripts and original voice recordings from: 1) participant-driven diaries, 2) participants' office visits with their physicians, and 3) semistructured interviews completed after a treatment decision had been made.

RESULTS

Patients with serious illness and experiencing considerable pain, discomfort, or alteration in the ability to perform activities of daily living, and who fear for their life, do not make decisions in a way that adheres to the conventional model of decision making, which presumes a sequential, office-based interaction with clear patient autonomy. These patients have the ability to interpret information they receive during office visits, but they describe making a treatment decision as "deciding to do something" not choosing a specific treatment. This group also describes "trust" or "confidence" in the physician as the most important factor in making a decision, not the type or amount of information received. They move through providers toward treatment in a linear fashion, from one physician specialty to the next, usually without doubling back to revisit previous decisions or discussions.

CONCLUSIONS

Decision making in serious illness unfolds differently than in less serious problems. The conventional model does not fit this patient population, and reliance on trust of the physician figures prominently. Decision support should be aimed at physician decision making, promoting explicit incorporation of patient-specific data into the process.

New Hampshire critical access hospitals: CEOs' report on ethical challenges

Research into the importance of organizational healthcare ethics has increasingly appeared in healthcare publications. However, to date, few published studies have examined ethical issues from the perspective of healthcare executives, and no empirical study has addressed organizational ethics with an explicit focus on rural hospitals. For our study, we sought to identify the frequency of ethical conflicts occurring within 12 general categories (domains) of administrative activities. Also, we wanted to determine what ethics resources are currently available and whether additional resources would be helpful. We conducted a structured telephone interview of all 13 chief executive officers (CEOs) of critical access hospitals in New Hampshire. All the CEOs in the study indicated that they encountered ethical conflicts. On average, the three most frequently noted domains were organizational-professional staff relations, reimbursement, and clinical care. All CEOs indicated they would like to have additional ethics resources to address these conflicts. This study verified that CEOs encounter a broad spectrum of ethical conflicts and need additional ethics resources to address them. Because this study used a small sample of CEOs and represented only one New England state, further ethics-related research in rural healthcare facilities is warranted. Follow-up study would allow for (1) a higher level of generalization of the findings, (2) clarity regarding specific ethical dilemmas that rural healthcare executives encounter, and (3) an assessment of ethics resources and training that healthcare executives need to address the ethical conflicts.

Synergistic interactions between cyclophosphamide or melphalan and VP-16 in a human rhabdomyosarcoma xenograft

Based on previous work demonstrating the activity of cyclophosphamide and melphalan in a series of human medulloblastoma and rhabdomyosarcoma cell lines and transplantable xenografts, investigations were conducted to define the effects of combining cyclophosphamide or melphalan with VP-16. These studies demonstrated a synergistic interaction between cyclophosphamide and VP-16 and melphalan and VP-16 in the treatment of the human rhabdomyosarcoma cell line TE-671 growing in athymic mice. The combination of cyclophosphamide or melphalan with VP-16 may warrant consideration as a therapeutic strategy for solid tumors sensitive to bifunctional alkylating agents.

Establishment of a melphalan-resistant rhabdomyosarcoma xenograft with cross-resistance to vincristine and enhanced sensitivity following buthionine sulfoximine-mediated glutathione depletion

A melphalan-resistant human rhabdomyosarcoma xenograft, TE-671 MR, was established in athymic mice by serial melphalan treatment of the parent xenograft, TE-671, at the 10% lethal dosage (LD10); significant resistance was evident after ten passages of the tumor. TE-671 MR demonstrated a doubling time of 3.5 days and a latency period to 1000-mm3 tumors of 27.5 days. The glutathione level of TE-671 MR was 2.36 mumol/g tumor, wet weight, 2-fold higher than the parent line. The glutathione S-transferase activity of TE-671 MR was 117.8 mumol/min/mg protein, essentially unchanged from the parent line. Although TE-671 MR demonstrated cross-resistance to vincristine, dot blot analysis did not reveal an elevated expression of mdr1 mRNA in the resistant line. TE-671 MR demonstrated a 9.7-day growth delay following treatment with melphalan at the LD10 (compared to 20.9 days for the parent line). Treatment with L-buthionine-SR-sulfoximine (BSO) resulted in increased sensitivity to melphalan subsequently administered at 50% of the LD10 (melphalan alone, growth delays of 3.7 and 4.6 days in duplicate trials; melphalan plus BSO, growth delays of 7.2 and 9.8 days). Sensitivity to melphalan equal to that of the parent line TE-671 was not achieved, however. Treatment with BSO did not result in significantly enhanced sensitivity to subsequently administered vincristine (50% of the LD10) (vincristine alone, growth delays of 6.8 and 6.9 days in duplicate trials; vincristine plus BSO, growth delays of 10.9 and 7.5 days). These results suggest that generation of melphalan resistance may be associated with development of cross-resistance to vincristine; this resistance may be associated with (although not necessarily mediated by) glutathione elevation; this resistance may be partially overcome by BSO-mediated depletion of glutathione.

Quantification of absolute luminal diameter by computer-analyzed digital subtraction angiography: an assessment in human coronary arteries

Determination of absolute lumen diameters has been shown to be useful in predicting the functional importance of a coronary stenosis. In this study, both single-plane and orthogonal biplane digital subtraction angiograms were obtained in human cadaver coronary arteries. A single absolute diameter was calculated at the site of greatest narrowing in 20 segments by two automated computerized algorithms. Minimum and maximum diameters at the site of the stenosis were measured from pathologic sections prepared after pressure fixation. Method 1, which determines the edges by means of the first derivative of the videodensity curve, derived absolute diameters that fell between the pathologic minimum and maximum in 10 of 20 segments. Method 2, which determines the edges by an average of the first and second derivatives of the videodensity change, derived absolute diameters that fell between the pathologic minimum and maximum diameters in 15 of 20 segments. Method 1 correlated well with the maximum pathologic diameter (r = .76) and less well with the minrmum pathologic diameter (r = .67). Method 2 correlated very well with the maximum pathologic diameter (r = .79) and also correlated well with the minimum pathologic diameter (r = .74). As would be expected, the computerized algorithms tended to overestimate the minimum pathologic diameter and to underestimate the maximum pathologic diameter. In six segments, two orthogonal views were analyzed; no further accuracy was discernible over single-plane determinations. Thus quantitative coronary angiography by digital subtraction angiography is sufficiently accurate to be of use in the measurement of the severity of a coronary stenosis.

Assessment of coronary artery stenoses by digital subtraction angiography: a pathoanatomic validation

Automated computer assessment of coronary stenoses from digital subtraction angiographic images comparing geometric and videodensitometric algorithms was performed. Digital subtraction angiograms were acquired on a 512 X 512 X 8 bit pixel matrix at 8 frames/second. Fifteen segments from nine human cadaver coronary arteries, with lesions ranging from 0% to 97%, were analyzed. Hand injections of radiopaque dye were made during the pulsatile infusion of saline solution at physiologic pressures and flows. Individual frames best demonstrating a lesion were digitally magnified and the stenosis was measured; the operator identified only the segment of interest. The artery was then injected with a rapidly hardening gel during the same rate of infusion as that used during image acquisition. Histologic sections were cut at 2 mm intervals after fixation and elastic stains applied. Photographs of the section comparable to the site determined from the angiogram were taken, and hand planimetry by a blinded investigator was performed. There was an excellent correlation between histopathology and videodensitometry (r = 0.93; p less than 0.0001). The two geometric algorithms studied also had very good correlations (r = 0.90 and 0.84) with pathology. Two experienced angiographers, despite excellent agreement with each other, had lower correlations with pathology than any of the three computer algorithms studied (r = 0.79 and 0.83, respectively), although this difference did not attain statistical significance. This in vitro model simulating in vivo conditions validates the use of automated videodensitometric and geometric computer algorithms to interpret coronary angiography and assess severity of stenosis.

Efficacy of dichlorvos administered orally in single and repeated doses for removal of canine whipworms

A single dose of dichlorvos (2,2-dichlorovinyl dimethyl phosphate) was administered orally at a dosage of 30 mg/kg to 19 dogs naturally infected with Trichuris vulpis and to 13 dogs experimentally infected with T vulpis. Based on the presence or absence of whipworm eggs in the feces, 10 to 14 days after treatment, dogs were either killed and the number of remaining worms counted, or the dogs were given a 2nd treatment. After the initial treatment, 18 dogs had a mean of 0.5 worms (SD +/- 0.5) remaining, and 14 dogs had a mean of 55 worms (SD +/- 85) remaining. After these 14 dogs were given a 2nd treatment, the number of womrs remaining decreased to a mean of 14 (SD +/- 28). Although a high degree of efficacy was attained in 56% of the dogs after the 1st dose, the data suggested that additional treatment may often be necessary.