Taking immunosuppressive medications effectively (TIMELink): a pilot randomized controlled trial in adult kidney transplant recipients

BACKGROUND

Immunosuppressive medication non-adherence is one of the most prevalent but preventable causes of poor outcomes in adult renal transplant recipients, yet there is a paucity of studies testing interventions in this area.

METHODS

Using a randomized controlled trial design, 30 adult renal transplant recipients were screened for medication non-adherence using electronic monitoring. Fifteen non-adherent participants were randomized to receive either a continuous self-improvement intervention or attention control management. The six-month continuous self-improvement intervention involved the participant and clinical nurse specialist collaboratively identifying the person's life routines, important people, and possible solutions to enhance medication taking. The participant then received individual monthly medication taking feedback delivered via a graphic printout of daily medication taking generated from electronic monitoring.

RESULTS

The mean medication adherence score for the continuous self-improvement intervention group (n = 8) was statistically significantly higher than the attention control group's (n = 5) mean medication adherence score (p = 0.03). The continuous self-improvement intervention effect size (Cohen's d) was large at 1.4. Participants' perceptions of the intervention were highly favorable.

CONCLUSIONS

The continuous self-improvement intervention shows promise as an effective and feasible approach to improve medication adherence in adult renal transplant recipients. A fully-powered study with a diverse sample is needed to confirm these preliminary findings.

Secrets of successful short grant applications

The National Institutes of Health has implemented new grant application guidelines that include a substantial reduction in the number of pages allowed for project descriptions. Shorter proposals will potentially decrease reviewer burden, but investigators may find the new page limits challenging. Writing more concisely while still presenting a persuasive argument requires honing certain skills with regard to preparation, construction, and editing of proposals. This article provides strategies from the Western Journal of Nursing Research editorial board for preparing competitive shorter research proposals. Two key strategies for success are fully conceptualizing the study prior to writing and obtaining assistance from experienced colleagues during the editing process.

Increasing nursing faculty research: the Iowa gerontological nursing research and regional research consortium strategies

PURPOSE

Research development and regional consortium strategies are described to assist schools in all countries extend their gerontological nursing research productivity. The strategies, collaboration and mentoring experiences, and outcomes are also shared to illustrate a highly successful approach in increasing faculty programs of nursing research in a focused area of inquiry.

DESIGN

A case description of gerontological nursing research development and regional consortium strategies in schools of nursing is used. The regional consortium included 17 schools of nursing that are working to increase faculty programs of gerontological nursing research. Survey responses describing publications, presentations, and research funding awards from 65 of 114 total faculty participants in consortium opportunities (pilot and mentoring grant participants, participants in summer scholars' grantsmanship seminars) were collected annually from 1995 through 2008 to describe outcomes.

FINDINGS

From 1994 through 2008, faculty participants from the consortium schools who responded to the annual surveys reported a total of 597 gerontological nursing publications, 527 presentations at research conferences, funding of 221 small and internal grants, and 130 external grant awards, including 47R-series grants and 4 K awards.

CONCLUSIONS

There is an urgent need for more nurse faculty with programs of research to inform the health care of persons and support the preparation of nurse clinicians and faculty. The shortage of nurse scientists with active programs of gerontological research is especially serious and limits the number of faculty who are needed to prepare future gerontological nurses, particularly those with doctoral degrees who will assume faculty positions. Further, junior faculty with a gerontological nursing research foci often lack the colleagues, mentors, and environments needed to develop successful research careers. The outcomes of the development and regional consortium strategies suggest that the principles of extending collaboration, mentoring, and resource sharing are useful to augment faculty research opportunities, networking and support, and to increase productivity in individual schools.

CLINICAL RELEVANCE

Clinical relevance includes: (a) implications for preparing nurse scientists and academicians who are and will be needed to train nurses for clinical practice, and (b) development of more faculty programs of research to provide systematic evidence to inform nursing practice.

Field testing, refinement, and psychometric evaluation of a new measure of nursing home care quality

The primary aim of this NINR-NIH-funded field test in 407 nursing homes in 3 states was to complete the development of and conduct psychometric testing for the Observable Indicators of Nursing Home Care Quality Instrument (Observable Indicators, OIQ). The development of the OIQ was based on extensive qualitative and iterative quantitative work that described nursing home care quality and did initial validity and reliability field testing of the instrument in 123 nursing homes in 1 state. The scale is meant for researchers, consumers, and regulators interested in directly observing and quickly evaluating (within 30 minutes of observation) the multiple dimensions of care quality in nursing homes. After extensive testing in this study, the Observable Indicators instrument has been reduced to 30 reliable and discriminating items that have a conceptually coherent hierarchical factor structure that describes nursing home care quality. Seven first-order factors group together into two second-order factors of Structure (includes Environment: Basics and Odors) and Process (includes Care Delivery, Grooming, Interpersonal Communication, Environment: Access, and Environment: Homelike) that are classic constructs of Quality, which was the third-order factor. Internal consistency reliability for the 7 first-order factors ranged from .77 to .93. Construct validity analyses revealed an association between survey citations and every subscale as well as the total score of the OIQ instrument. Known groups analysis revealed expected trends in the OIQ scores. The Observable Indicators instrument as a whole shows acceptable interrater and test-retest reliabilities, and strong internal consistency. Scale subscales show acceptable reliability as well. Generalizability Theory analyses revealed that dependability of scores can be improved by including a second site observer, or by revisiting a site. There is a small additional benefit from increasing observers or visits beyond two.

Changes in steps per day over the course of a pilot walking intervention

The objective of this study is to explicate changes in steps per day observed over the course of a pilot study concerned with promoting walking. A pre/post single group design was used to evaluate a 12-month group intervention with 6-month follow-up with a sample of twenty-one sedentary, hypertensive African American women 25-68 years of age. A 3-hour monthly meeting was paired with an at-home walking component. Results indicated that the total group experienced a slight increase (5%) in mean steps per day at the end of the 12-month intervention, while a subgroup experienced a 13% decrease. However, mean steps per day increased from baseline to 6-month follow-up for both groups. Mean steps per day increased from 3857 to 5582 (37%) for total group and from 4659 to 7038 (51%) for the subgroup.

CONCLUSIONS

A group intervention can have a positive impact on promoting walking among African American women; however, multi-phased interventions may be necessary to assist this population meet current physical activity recommendations.

Prevalence and characteristics of nursing homes residents requiring light-care

Rising nursing home (NH) costs and the poor quality of NH care make it important to recognize elders for whom NH care may be inappropriate. As a first step in developing a method to identify these elders, we examined the characteristics of NH residents requiring light-care and changes in their care level from NH admission to 12-months. Using data from the Missouri Minimal Data Set electronic database, we developed three care-level categories based on Resource Use Groups, Version III (RUG-III) and defined light-care NH residents as those requiring minimal assistance with late-loss ADLs (bed mobility, transfer, toilet use, or eating) and having no complex clinical problems. Approximately 16% of Missouri NH residents met the criteria for light-care. They had few functional problems with mobility, personal care, communication, or incontinence; approximately 33% had difficulty maintaining balance without assistance; and 50% of those admitted as light-care were still light-care at 12-months. Findings suggest that many NH residents classified as light-care by these criteria could be cared for in community settings offering fewer services than NHs.

Nursing Home Quality, Cost, Staffing, and Staff Mix

PURPOSE

The purpose of this study was to describe the processes of care, organizational attributes, cost of care, staffing level, and staff mix in a sample of Missouri homes with good, average, and poor resident outcomes.

DESIGN AND METHODS

A three-group exploratory study design was used, with 92 nursing homes randomly selected from all nursing homes in Missouri and classified into resident outcome groups. Resident outcomes were measured by use of quality indicators derived from nursing home Minimum Data Set resident assessment data. Cost and staffing information were derived from Medicaid cost reports. Participant observation methods were used to describe the care delivery processes.

RESULTS

In facilities with good resident outcomes, there are basics of care and processes surrounding each that staff consistently do: helping residents with ambulation, nutrition and hydration, and toileting and bowel regularity; preventing skin breakdown; and managing pain. The analysis revealed necessary organizational attributes that must be in place in order for those basics of care to be accomplished: consistent nursing and administrative leadership, the use of team and group processes, and an active quality improvement program. The only facility characteristic across the outcome groups that was significantly different was the number of licensed beds, with smaller facilities having better outcomes. No significant differences in costs, staffing, or staff mix were detected across the groups. A trend in higher total costs of 13.58 dollars per resident per day was detected in the poor-outcome group compared with the good-outcome group.

IMPLICATIONS

For nursing homes to achieve good resident outcomes, they must have leadership that is willing to embrace quality improvement and group process and see that the basics of care delivery are done for residents. Good quality care may not cost more than poor quality care; there is some evidence that good quality care may cost less. Small facilities of 60 beds were more likely to have good resident outcomes. Strategies have to be considered so larger facilities can be organized into smaller clusters of units that could function as small nursing homes within the larger whole.

Getting the Basics Right: Care Delivery in Nursing Homes

In this study, the key exemplar processes of care in facilities with good resident outcomes were described. It follows that with description of these processes, it is feasible to teach facilities about the basics of care and the ways to systematically approach care so they can adopt these care processes and improve resident outcomes. However, for this to happen key organizational commitments must be in place for staff to consistently provide the basics of care. Nursing leadership must have a consistent presence over time, they must be champions of using team and group processes involving staff throughout the facility, and they must actively guide quality improvement processes. Administrative leadership must be present and express the expectation that high quality care is expected for residents, and that workers are expected to contribute to the quality improvement effort. If facilities are struggling with achieving average or poor resident outcomes, they must first make an effort to find nursing and administrative leaders who are willing to stay with the organization. These leaders must be skilled with team and group processes for decision-making and how to implement and use a quality improvement program to improve care. These leaders must be skilled at building employee relations and at retention strategies so residents are cared for by consistent staff who know them. The results of this study illustrate the simplicity of the basics of care that residents in nursing facilities need. The results also illustrate the complexity of the care processes and the organizational systems that must be in place to achieve good outcomes. Achieving these outcomes is the challenge facing those currently working in and leading nursing facilities.

Statewide strategy to improve quality of care in nursing facilities

PURPOSE

We describe the development of a statewide strategy to improve resident outcomes in nursing facilities, and we present some evaluative data from this strategy.

DESIGN AND METHODS

Key components of the strategy include (a) a partnership between the state agency responsible for the nursing home survey and certification and the school of nursing in an academic health sciences center; and (b) on-site clinical expert technical assistance and support to facilities throughout the state.

RESULTS

The partnership has resulted in state agency staff having information from analyses about resident needs and outcomes in the state and facilities having access to the quarterly electronic "Show-Me Quality Indicator Report." On-site clinical expert technical assistance is now used widely across the state, with 569 site visits conducted in 286 different facilities to help them interpret their quality indicator (QI) reports and implement quality improvement programs; statewide improvements in QI scores have been measured in several key QIs.

IMPLICATIONS

Other states should consider building partnerships with schools of nursing in an academic health sciences center. Programs using on-site clinical consultation can facilitate improving quality of care in nursing facilities.

Interventions to promote physical activity among African American women

The lack of routine physical activity among African American women places them at risk for negative health outcomes associated with inactivity. The number of studies focused on African American women has increased dramatically in the past decade. This review examined the intervention research literature testing strategies to increase activity among African American women. Eighteen studies with 1,623 subjects were retrieved. Diverse interventions, settings, and measures were reported. Common methodologic weaknesses included lack of randomization of subjects, single-group design, instruments without documented validity and reliability, significant attrition, and questionable timing of outcome variable measurement. Strategies to design and deliver culturally appropriate interventions are reviewed. Suggestions for future research, such as examining intragroup differences and communal resources, are provided.

Improving quality of care in nursing facilities. Gerontological clinical nurse specialist as research nurse consultant

It is becoming increasingly common for nursing facilities to use Quality Indicators (QI) derived from Minimum Data Set (MDS) data for quality improvement initiatives within their facilities. It is not known how much support facilities need to effectively review QI reports, investigate problems areas, and implement practice changes to improve care. In Missouri, the University of Missouri-Columbia MDS and Nursing Home Quality Research Team has undertaken a Quality Improvement Intervention Study using a gerontological clinical nurse specialist (GCNS) to support quality improvement activities in nursing homes. Nursing facilities have responded positively to the availability of a GCNS to assist them in improving nursing facility care quality.

Cognitive impairment and medication adherence

1. The findings of this study are congruent with previous work that found that subjects' knowledge about medication is not necessarily correlated with adherence to medication regimens. 2. The nature and experience of forgetting medications merits further investigation. Asking patients about forgetting medication is easy to do, and many methods of compensating for forgetfulness are available. 3. Cognitive impairment was not associated with medication adherence. Cognitively impaired elders were likely to have caregivers assisting in the administration of their medication in the period immediately after discharge from acute care facilities.

Medication management by recently hospitalized older adults

Community-dwelling older adults often manage numerous prescriptive medications. The purpose of this study was to describe prescriptive medication management by older adults recently discharged from hospitals. The sample (N = 179) included adults, 65 to 101 years old, who managed a total of 950 prescriptive medications. Overall, subjects reported high confidence in their ability to manage medications. The lowest confidence levels were reported for recognizing unwanted side effects of medications. Although "forgetting" was the most commonly given reason for missed doses, one fourth of the reasons for missed doses indicated deliberate omission. Almost half of the subjects received assistance from others with their medications; most of the assistance served to counteract the tendency to forget medication doses. The results of this study provide a research-based foundation for community health nursing efforts to strengthen the effectiveness of older adults' medication self-care behaviors.

Self-care actions taken by older adults for influenza and colds

The purpose of this study was to examine self-care behaviors that older adults use to manage cold and influenza episodes. Interviews were conducted with 160 adults aged 65 to 94. A large number and a variety of cold- and influenza-related self-care actions were reported. Medication administration was found to be common for colds (79% of subjects) and influenza (95%). Subjects reported more illness-specific preventive behaviors for influenza than for colds. Influenza vaccination behavior was related to experiences with vaccination-associated illness, health state, and talking with physicians about vaccination. Few subjects identified potential hazards associated with influenza or colds.

Non-insulin-dependent diabetes mellitus and the 5' hypervariable region of the insulin gene in two South African Indian families

The hypervariable region 5' to the human insulin gene has been characterised in two South African Indian families, each having two generations of individuals affected with non-insulin-dependent diabetes mellitus (NIDDM). Southern blot analysis, with the restriction endonuclease Pvu II and plasmid phins 310 as a probe, was used. In family 1, class 1 alleles (0.87, 0.79, 0.72 and 0.68 kilobase (kb)) were found at this locus but no linkage with NIDDM was shown. In family 2 a class 3 (2.51 kb) and two class 1 alleles (0.89, 0.76) were found. The 0.89 kb allele appears to be segregating with NIDDM in this family.