Associations between hearing loss and clinical outcomes: population-based cohort study

Background

Hearing loss (HL) is a leading cause of disability worldwide, but its clinical consequences and population burden have been incompletely studied.

Methods

We did a retrospective population-based cohort study of 4,724,646 adults residing in Alberta between April 1, 2004 and March 31, 2019, of whom 152,766 (3.2%) had HL identified using administrative health data. We used administrative data to identify comorbidity and clinical outcomes, including death, myocardial infarction, stroke/transient ischemic attack, depression, dementia, placement in long-term care (LTC), hospitalization, emergency visits, pressure ulcers, adverse drug events and falls. We used Weibull survival models (binary outcomes) and negative binomial models (rate outcomes) to compare the likelihood of outcomes in those with vs without HL. We calculated population-attributable fractions to estimate the number of binary outcomes associated with HL.

Findings

The age-sex-standardized prevalence of all 31 comorbidities at baseline was higher among participants with HL than those without. Over median follow-up of 14.4 y and after adjustment for potential confounders at baseline, participants with HL had higher rates of days in hospital (rate ratio 1.65, 95% CI 1.39, 1.97), falls (RR 1.72, 95% CI 1.59, 1.86), adverse drug events (RR 1.40, 95% CI 1.35, 1.45), and emergency visits (RR 1.21, 95% CI 1.14, 1.28) compared to those without, and higher adjusted hazards of death, myocardial infarction, stroke/transient ischemic attack, depression, heart failure, dementia, pressure ulcers and LTC placement. The estimated number of people with HL who required new LTC placement annually in Canada was 15,631, of which 1023 were attributable to HL. Corresponding estimates for new dementia among people with HL were 14,959 and 4350, and for stroke/TIA the estimates were 11,582 and 2242.

Interpretation

HL is common, is often accompanied by substantial comorbidity, and is associated with significant increases in risk for a broad range of adverse clinical outcomes, some of which are potentially preventable. This high population health burden suggests that increased and coordinated investment is needed to improve the care of people with HL.

Funding

Canadian Institutes of Health Research; David Freeze chair in health services research.

Knowledge, attitudes and practices of rabies prevention and dog bite injuries in urban and peri-urban provinces in Cambodia, 2009

Rabies remains a major public health issue despite the existence of well established prevention and treatment protocols. Knowledge and methods of practice were evaluated in an urban and peri-urban province of Cambodia (Phnom Penh and Kandal, respectively). The majority of respondents (93.2%; 233/250) had heard of the disease rabies, of whom only 77.3% (180/233) knew it was fatal to humans. In addition, only 51.9% (121/233) were aware of the vaccine for dogs. The proportion of the population that reported a dog bite (2004-2009) was similar for Phnom Penh and Kandal. Nearly one-half of all victims (37/75) sought treatment at the Institut Pasteur-Cambodia (IPC) clinic, followed by a private clinic (19/75), a hospital (6/75) and traditional medicine (4/75); 7 victims sought no treatment and 2 reported other. Overall, children aged <15 years reported a significantly greater proportion of dog bite victims than adults aged ≥15 years [10.0% (28/280) vs 4.4% (47/1059), respectively]. Nearly all dog owners agreed to pay for their dogs' vaccination (96.5%; 136/141) and to use a collar (94.3%; 133/141). Only 41.8% (59/141) and 51.8% (73/141) would pay to have their dogs spayed and neutered, respectively. Further community education on the prevention of rabies transmission is needed. Focusing on responsible dog ownership and the importance of both the prevention and immediate treatment following a dog bite is essential to reduce rabies infection in Cambodia.

Assessing human-dog conflicts in Todos Santos, Guatemala: bite incidences and public perception

The issues surrounding dog bites are a major public health concern, particularly in areas of low income where accessibility to adequate health care, veterinary medicine and sufficient management of canine population control is low. An understanding of the risk factors associated with human-dog conflicts may be important when establishing dog bite and disease prevention strategies. In May 2008, a census of 12 consociated neighbourhoods in Todos Santos, Guatemala was conducted to investigate dog bite incidences and the public perception of free-roaming dog populations. Approximately 16.5% (78/472) of households reported at least one dog bite between May 2006 and May 2008. In total, 85 incidents occurred: 49.4% (42/85) with adults (≥18 years) and 50.6% (43/85) children (<18 years). However, there was no significant difference in cumulative incidence of dog bites by victim gender or among age categories, there was a non-significant trend of higher cumulative incidence of dog bites in children aged six to 17 years compared to other age categories. The anatomical location of the bite varied, but bites to the legs were the most common (73/85; 85.9%). Of the 85 reported dog bites, 5.9% (5/85) were from dogs from the victims' own households, 48.2% (41/85) were from a neighbour's dog, 9.4% (8/85) were from dogs regularly seen in the community, and 15.3% (13/85) were from dogs not regularly seen in the community; the ownership status of the latter two categories of dogs could not be determined. Approximately 21% (18/85) of respondents did not know the type of dog that bit. Residents were asked for their opinions on potential problems associated with dogs in the community. The majority of respondents strongly agreed that dogs posed physical risks (78.8%; 372/472), could transmit infections to people (88.6%; 418/472), scared the family (82.4%; 389/472) and were too high in number (82.6%; 390/472). There were significant but weak correlations between owning a dog and expressing negative perceptions of community dogs (Spearman rho<0.13). Reporting of a dog bite was not significantly correlated to expressing fear or negative perceptions towards community dogs. A further understanding of current programs directed at the prevention of dog bites and means of dog population control may help determine appropriate future steps for canine management. Conflicts between free roaming dogs and people are a pressing issue worldwide, and a focus on prevention strategies through education, rather than rapid extermination, would be of benefit.

The nursing outcomes classification: its relevance to school nursing

Two surveys were conducted to determine school nurses' perceptions of the relevance of 190 outcomes developed by the Nursing Outcomes Classification (NOC) research team to school nursing practice. First, a national random survey of members of the National Association of School Nurses was conducted. Participants were asked to identify the percentage of children and families for whom school nurses affect health outcomes. Usable responses were returned from 227 school nurses (22% response rate). Ninety outcomes were perceived as relevant for 30% or more of children and families; 8 outcomes were perceived as relevant for 50% or more of children and families. A second survey--targeting state representatives attending a school nursing leadership meeting--was conducted using a revised version of the instrument. The legend was changed to degree of relevance to school nursing practice, with a response scale of 0 to 10. Usable responses were returned from 31 state representatives (41% response rate). The means of 172 of 190 outcomes were above 5 (median point on the 10-point scale of relevance). The findings of both surveys indicate that a large number of NOC outcomes are useful for documentation of the effectiveness of nursing interventions in school settings.

National survey to identify the nursing interventions used in school settings

A national survey of members of the National Association of School Nurses was conducted to identify interventions from the Nursing Interventions Classification (NIC) that are used by school nurses. Usable responses were returned from 522 school nurses. The findings were that 163 interventions were used, on the average, from every day to once a year, and all but three interventions were used by one or more respondents. Certain interventions were significantly associated with special education or grade level of children served by nurses. It is concluded that the NIC is a useful tool to standardize documentation for school nursing.

Moving beyond content validation of nursing diagnoses

TOPIC

Studies to establish construct and criterion-related validity of nursing diagnoses.

PURPOSE

The overwhelming majority of previous studies addressed content validation by nurse experts. This paper describes strategies to move beyond content validation research to construct and criterion-related validation.

SOURCES

The range of studies that should be conducted for development of nursing diagnoses are reviewed with examples drawn from the field of psychology. Existing studies on the diagnoses of ineffective breathing pattern, ineffective airway clearance and impaired gas exchange are used as examples.

CONCLUSIONS

Many types of studies are needed for each nursing diagnosis. Increased funding and support for nursing diagnosis research will be facilitated by attention to the accuracy of nurses' diagnoses and outcomes of the diagnostic process.

Clinical validation of ineffective breathing pattern, ineffective airway clearance, and impaired gas exchange

PURPOSE

To describe the clinical validation of symptoms or defining characteristics of three respiratory diagnoses. The contributing factors or etiologies of the diagnoses were identified and the degree of importance of 30 nursing interventions, 15 direct care and 15 teaching, was rated for each diagnosis and each patient. Three nursing diagnoses--ineffective breathing pattern (IBP), ineffective airway clearance (IAC), and impaired gas exchange (IGE)--were among the most frequently used, yet no reported clinical studies validated the defining characteristics of these diagnoses. This study answers the research questions: What are the defining characteristics of IBP, IAC, and IGE? What are the etiologies of IBP, IAC, AND IGE? What are the most important interventions for IBP, IAC, and IGE?

DESIGN

Standardized clinical validation using a convenience sample of 76 people hospitalized with medical and surgical diagnoses, in one U.S. city, and identified as having one of the three diagnoses. Data were collected in 1992-1993.

METHODS

A literature-based concept analysis generated 37 possible defining characteristics for the three diagnoses which were included in the instrument. The nurse experts conducted a health history and physical examination of each patients and decided (a) whether the 37 defining characteristics were present or absent, (b) the degree of importance of each possible defining characteristic for making one or more of the diagnoses, (c) the etiologies, and (d) which of the 30 nursing interventions were important for each diagnosis and patient.

FINDINGS

For each diagnosis, many of the 37 possible defining characteristics were judged as present but few reached the criterion of .50 as important for making one of the diagnoses. Two of the possible defining characteristics reached this criterion for IBP, seven for IAC, and two for IGE. In contrast to the defining characteristics approved by NANDA, the subjective cues of "expresses fatigue" and "expresses anxiety" were judged as important for making one or more of the diagnoses.

CONCLUSIONS

Clinical validation methods allow discriminating among defining characteristics. Data that are present are not necessarily characteristic of a diagnosis, and the subjective cues of expresses fatigue or anxiety may be important for making these diagnoses.

Relevance of NANDA and health promotion diagnoses to school nursing. National Association of School Nurses

This is a report of a national survey of 490 members of the National Association of School Nurses which described the relevance of 109 nursing diagnoses approved by NANDA (1992) and 29 health promotion (wellness) diagnoses developed by the authors. The relevance of these 138 nursing diagnoses for school nursing was determined by the percent of participants who checked "Yes" for the diagnostic categories they observed in their practice and for which they provided one or more interventions. More than half of the sample checked "Yes" for 67 NANDA diagnoses; health promotion diagnoses were checked "Yes" by 45% to 89% of the sample. The implications are that NANDA and health promotion diagnoses are relevant to school nursing and could readily be incorporated into practice to facilitate data collection that supports both the funding of school nurses and program development for children, families, and school staff.

Validation by school nurses of the Nursing Intervention Classification for computer software

Validation of standardized nursing language for use by specialty nurses is important for the design of computer software. The purposes of this study were to validate the usefulness of the 433 interventions in the Nursing Intervention Classification (NIC) for school nurses and to identify interventions that could be omitted from computer software for school nurses. A school nursing listserv, SCHLRN-L, was used to recruit volunteers. Ninety-three volunteers from the listserv also recruited 26 school nurses who were not members of the listserv. The total sample was 102 school nurses from 25 states and other areas, 76 listserv volunteers, and 26 others. E-mail was used to send and receive the survey forms to portions of the sample. A majority of interventions (n = 241; 56%) were selected as used by more than 50% of the sample. Of these, 53 direct care interventions were selected as used by more than 80% of the sample. Fifty interventions were not used by 100% of the sample. E-mail was a useful means to obtain a national sample and collect data.

Accuracy of nurses' diagnoses of psychosocial responses

PURPOSE

To describe the accuracy of staff nurses' diagnoses or interpretations of the human responses of patients in hospital settings.

METHODS

The sample was 62 staff nurses in three hospitals who assessed and diagnosed the psychosocial problems of one to four patients. Two trained raters followed with assessment, diagnosis, and ratings of nurses' accuracy of 153 cases. A seven-point interval scale was used to judge accuracy.

FINDINGS

The means of accuracy scores across nurses were significantly different (f = 1.66; p < .05; df = 2.59). A significant percentage of nurses' diagnoses were scored at the two highest levels of accuracy (45.2%), and 12.8% were scored at the three lowest levels of accuracy. According to the expert raters, a high percentage of patients (54.4%) were experiencing fear or anxiety.

CONCLUSIONS

More attention needs to be given to the accuracy of nurses' diagnoses of psychosocial responses.

Quantitative methods for clinical validation of nursing diagnoses

CLINICAL VALIDATION STUDIES of nursing diagnoses are necessary to support use of diagnostic concepts and their defining characteristics in clinical settings. Diagnostic concepts approved by the North American Nursing Diagnosis Association, i.e., human responses to health problems and life processes, need to be tested through clinical research. Because validation studies have some unique procedures, we explain methods to be used by CNSs to conduct clinical studies.

Accuracy of interpreting human responses

Nurse managers who advocate continuous quality improvement should be examining system-level policies, procedures and attitudes to determine whether they support or detract from accuracy of nurses' interpretations of human responses. A study discusses the relationship of accuracy of nurses' diagnoses to continuous quality improvement and demonstrates why nurse managers should focus on accuracy in system-level decisions. Four guidelines, which emphasize quality of interventions and outcomes, are given.

Clinical journal: a tool to foster critical thinking for advanced levels of competence

Rapid changes in the health care system and the challenge of meeting complex patient care needs require that nurses function at the competent, or higher, levels of expertise. Advanced levels of competence are facilitated through development and application of critical thinking abilities. Journal writing is a tool that can be used by CNSs and other nurses to improve basic thinking abilities and application of critical thinking for clinical decision making. Guidelines are presented for writing this type of clinical journal and for providing feedback to others.

Taxonomic validation: an overview

A valid taxonomy legitimizes the elements that make up the taxonomy and increases trust in its generalizability and predictability. There is a concern that the NANDA Taxonomy is not a valid taxonomic structure. Despite on-going work to validate individual nursing diagnoses, there is little research that focuses on validation of groups of diagnoses (taxons) within the NANDA taxonomy. This last article in a series of four will familiarize the readers with why, what, and how a taxonomy of nursing diagnoses can be validated. This article highlights assessment of the validity and reliability of a taxonomy, compares the process of taxonomic validation to the research process, and explores examples of validation design.

Divergent productive thinking factors and accuracy of nursing diagnoses

Theories of diagnosis in nursing (Carnevali, 1983; Gordon, 1982) and a model of intelligence (Guilford, 1979) were integrated to provide a theoretical basis for this study. In contrast to previous studies, accuracy of nursing diagnoses was measured as a continuous variable. It was hypothesized that three factors of divergent productive thinking, fluency, flexibility, and elaboration, would correlate positively with accuracy of nursing diagnoses. The sample consisted of 86 female nurses, graduates of generic baccalaureate programs with 1 to 5 years experience, who met the criterion of knowledge. Three written case studies (CS1, CS2, CS3) served as the criterion for accuracy. With CS1, none of the hypotheses were supported. With CS2, the three hypotheses were supported (p less than .05) and 10% of the variance was explained by one factor, fluency (p less than .01). With CS3, elaboration and accuracy were correlated (p less than .05). The findings provide beginning support for inclusion of exercises for divergent thinking in nursing education and practice.

Axes: focus of taxonomy II

A number of persistent issues in the nursing diagnosis community have challenged the ability of one nursing diagnosis taxonomy to account for nursing's practice. The North American Nursing Diagnosis Association (NANDA) Taxonomy Committee, charged with the preparation of one taxonomy for all, has struggled with some of these issues and has initiated development of axes. The issues, figuratively speaking, become the axes. The axes are intended to describe the dimensions of the human condition. This article, third in a series of four, describes the process and development of the proposed axes.

Development of definitions for taxonomy II

In the process of placing diagnoses into Taxonomy I, certain inconsistencies became apparent. Inadequate definition of both diagnoses and human response patterns, lack of defining characteristics, and inconsistency in the levels of abstraction within the taxonomic hierarchy made the task of assigning a diagnosis to a taxonomic pattern difficult. Ambiguity in the definitions of the nine patterns resulted in ambiguity in the basic foundation, which affected the entire structure. The Taxonomy Committee, before evaluating the current structure, had to make the following decisions regarding the current human response patterns: (1) Should the nine human response patterns be retained for further taxonomic work? and (2) If they are retained, what should be the first step in examining Taxonomy I-Revised? This second article in a series of four will familiarize the readers with the process and decisions by which Taxonomy II of the North American Nursing Diagnosis Association (NANDA) is evolving through the work of the Taxonomy Committee. This article also will identify the specific problems encountered in the development of Taxonomy I and Taxonomy I-Revised, and describe the steps establishing the validity of the process of formation of the nine human response patterns.

Development of written case studies as simulations of diagnosis in nursing

Written case studies, as simulations of diagnosis in nursing, are valuable tools for research, education, and practice. This article presents guidelines and methods for systematic development of valid and reliable case studies. Examples of purposes, objectives, and methods are given. A content validity form and directions also are provided.

Accuracy of nursing diagnoses: concept development

The concept of accuracy of nursing diagnoses was developed by the author as a first step of theory development related to nursing diagnosis. Accuracy is conceptually redefined as a continuous variable and a such contrasts with the prevailing view of accuracy that diagnoses are either accurate or inaccurate. The conceptual definition of accuracy of a nursing diagnosis and a delineation of the characteristics of accuracy emphasize the relativistic nature of the concept.