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PubMed2005

Spiritual caring: end of life in a nursing home.

The purpose of this qualitative study was to explore spiritual care for dying nursing home residents from the perspectives of registered nurses, practical nurses, certified nursing assistants, advanced practice nurses, and physicians. Five major themes emerged: honoring the person's dignity, intimate knowing in the nursing home environment, wishing we could do more, personal knowing of self as caregiver, and struggling with end-of-life treatment decisions. Spiritual caring was described within the context of deep personal relationships, holistic care, and support for residents. Spiritual care responses and similarities and differences in the experiences of participants are presented. Education and research about how to assist residents and families as they struggle with difficult end-of-life decisions, adequate time and staff to provide the kind of care they "wished they could," and development of models that honor the close connection and attachment of staff to residents could enhance end-of-life care in this setting.

Adaptation, Psychological↗

PubMed1996

Clinical evaluation--difficulties experienced by sessional clinical teachers of nursing: a qualitative study.

Evaluation of nursing students in the clinical field requires the clinical teacher to make judgements regarding student progress in a number of areas. In this study concepts of role theory, oppressed group behaviour and the ethics of caring emerged and were used as conceptual frameworks to interpret the data relating to the evaluation of undergraduate students. The number of experienced faculty available for clinical teaching and evaluation has become inadequate and a large number of casual or sessional clinical teachers are employed to teach students in the clinical field. Despite the well documented problems associated with clinical teaching and the use of inexperienced clinical teachers, sessional clinical teachers are nevertheless expected to evaluate student success in meeting the clinical requirements of the nursing course, often resulting in disparate decisions for students. A phenomenological study was carried out using unstructured interviews and written clinical scenarios, to explore the evaluation process from the perspective of the sessional clinical teachers. Research findings indicate that although the sessional clinical teachers were skilled at identifying student problems, they were reluctant to make difficult evaluation decisions, due to low self-esteem, role conflict and their ethic of caring. It seems that gender socialization, patriarchal dominance and apprenticeship training had effected their confidence in their own decision making. The implications of such findings are of concern for the ongoing credibility and integrity of nursing courses, as clinical teachers have an influence on the nursing profession through the preparation of its practitioners.

Clinical Competence↗

PubMed2001

Eliciting patients' values by use of 'willingness to pay': letting the theory drive the method.

OBJECTIVE: To describe the three different ways in which 'willingness to pay' (WTP) has been used to elicit patients' values of alternative interventions. DESIGN: For each of the three approaches a survey of patients or the public was undertaken. SETTING, PARTICIPANTS AND INTERVENTIONS: studied For two surveys, the setting was Aberdeen Maternity Hospital, where pregnant women were asked about their WTP for different methods of prenatal screening for cystic fibrosis. In the third survey, parents of primary and secondary schoolchildren were asked about their WTP for different ways of providing child health services. MAIN OUTCOME MEASURES: Ability of WTP to discriminate between options (i.e. to say whether one option is 'better' than another) and the consistency of WTP with stated preferences. RESULTS: Experience with some methods shows that, despite the apparent logic of the technique, it is difficult to elicit consistent responses whereby WTP values derived match the rankings of interventions compared. The most promising technique, the 'marginal approach', happens to conform more with economic theory than other approaches. Potential limitations of WTP, such as its association with ability to pay, are discussed, as are approaches to dealing with such problems. Finally, if patients prefer an intervention that is more costly than the status quo, logic dictates that those extra resources will have to be obtained from another health-care programme. In such contexts, to aid decision-making, values derived from members of the community for different programmes may be more relevant than values derived from patients. Initial studies in the use of WTP in this broader context of eliciting community values are also outlined. CONCLUSIONS: WTP has potential, but its application, and interpretation, are not straightforward. More testing of the 'marginal approach' is required and greater use of qualitative research, to assess the validity of the approach, should be made in this area.

Adult↗

PubMedDate not supplied

Coping strategies of female adolescents with HIV/AIDS.

This descriptive study was designed to assess coping strategies of female adolescents infected with Human Immunodeficiency Virus (HIV) or the Acquired Immunodeficiency Syndrome (AIDS) (N = 30). Results from the Adolescent Coping Orientation for Problem Experiences Questionnaire (ACOPES) revealed that the most often utilized coping strategies identified by the adolescents were: listening to music, thinking about good things, making your own decisions, being close to someone you care about, sleeping, trying on your own to deal with problems, eating, watching television, daydreaming and praying. The adolescents also reported low utilization of certain maladaptive coping strategies such as alcohol and illicit drug usage. Chronic illnesses such as HIV, cancer and diabetes are difficult for adolescents because of the unique developmental tasks needed to understand the psychological and social impact caused by chronic illnesses. The research presented illustrates the complexities of stress and the effects of coping on psychological well-being, health behavior, and health. This research explores specific coping strategies used by HIV-infected adolescents. Findings provided baseline data of the various coping strategies of female adolescents infected with HIV in an outpatient setting. These findings may serve as a foundation for future studies on coping strategies among females infected with HIV. Furthermore, the findings may also be useful in developing an outpatient behavior-modification/coping effectiveness training program that is both gender-specific and culturally appropriate.

Adaptation, Psychological↗

PubMed1997

Medical decisions concerning the end of life: a discussion with Japanese physicians.

OBJECTIVES: Life-sustaining treatment at the end of life gives rise to many ethical problems in Japan. Recent surveys of Japanese physicians suggested that they tend to treat terminally ill patients aggressively. We studied why Japanese physicians were reluctant to withhold or withdraw life-support from terminally ill patients and what affected their decisions. DESIGN AND PARTICIPANTS: A qualitative study design was employed, using a focus group interview with seven physicians, to gain an in-depth understanding of attitudes and rationales in Japan regarding medical care at the end of life. RESULTS: Analysis revealed that physicians and patients' family members usually make decisions about life-sustaining treatment, while the patients' wishes are unavailable or not taken into account. Both physicians and family members tend to consider withholding or withdrawing life-sustaining treatment as abandonment or even killing. The strongest reason to start cardiopulmonary resuscitation- and to continue it until patients' family members arrive-seems to be the family members' desire to be at the bedside at the time of death. All physicians participating in our study regarded advance directives that provide information as to patients' wishes about life-sustaining treatment desirable. All expressed concern, however, that it would be difficult to forego or discontinue life-support based on a patient's advance directive, particularly when the patient's family opposed the directive. CONCLUSION: Our group interview suggested several possible barriers to death with dignity and the appropriate use of advance directives in Japan. Further qualitative and quantitative research in this regard is needed.

Adult↗

PubMed1997

Where does all the money go? An audit of cost and waste distribution in a second-tier peri-urban hospital.

OBJECTIVE: To determine the probable effect of increasing clinical frugality on health system expenditure by measuring cost distribution and waste at an individual patient level. DESIGN: Retrospective cost analysis evaluating the distribution of variable costs (i.e. costs excluding salaries and other fixed expenses) and wastage (i.e. expenditure without adequate clinical gain). SETTING: A peri-urban regional referral (level 2) hospital and two district hospitals. SUBJECTS: 500 folders (350 inpatient and 150 outpatient). RESULTS: Accommodation costs accounted for the largest proportion of overall admission costs (42.3%), followed by drugs (19.5%), intravenous fluids (15.4%), laboratory investigations (12.9%) and radiology (10%). Waste accounted for 4.4% (R15.15, SD 41.92) of mean inpatient variable costs of R344.33 (median R208.89, minimum R19.06, maximum R5, 627.25) and this mean admission cost concealed a group of high-cost admissions, with the most expensive 5% accounting for 27.1% of total variable costs and 24.9% of waste. CONCLUSION: Four concepts important for economical bedside decision-making emerged: 1. Cumulative costs mount rapidly, even if individual items appear cheap. 2. The savings achieved by foregoing the use of an individual item (the variable cost) may be considerably less than the listed total cost to the State of that item (fixed costs are unaffected by reduced short-term utilisation.) 3. More care when ordering investigations and therapy may reduce waste. 4. Global views of hospital costs conceal a group of patients whose care is more expensive than average but who may be difficult to identify prospectively. Although the wastage rate in this group is about the same as the global rate, it may represent a useful target for future study.

Adolescent↗

PubMed2004

[Classification of medication interactions in family medicine and effectiveness of an intervention to improve them].

OBJECTIVE: a) To build a detection and evaluation tool of drug interactions (DI) in family practice prescribing; b) to elaborate and to offer a DI report, including appearance mechanism, clinical consequences and appropriate alternatives; c) to evaluate their effectiveness to diminish the DI incidence, and d) to check effectiveness of different diffusion methods. DESIGN: Previous phase: we will build the tool and will elaborate the report. Intervention phase: longitudinal, interventional, multicenter. SETTING: Primary care, Murcia Region. PARTICIPANTS: Family doctors (FD) with computerized clinical history frequently used to prescribe, with indefinite contract and who don't reject to participate. INTERVENTIONS: Randomly we will form 4 FD groups to carry out monthly (6 months): a) Minimal intervention: we mail DI reports; b) generic intervention: DI report is delivered in collective session managed by a trained doctor; c) personalized intervention: discussion peer-to-peer between FD and the trained doctor; d) control group: they won't receive DI information. MAIN MEASUREMENTS: We will measure the evolution of DI incidence and their classification according to relevance and repercussions. Different aspects related with FD and patient characteristics and with organizational environment are measured for subject's describing, inclusion-exclusion criteria assurance and conditioning and confusion factors analysis. DISCUSSION: Limitations. Using a new DI classification make difficult external comparisons, although it is useful because we use generalised and prestigious data sources. Applicability. The project produces a tool to avoid prescription errors. Checking the effectiveness in different corrective measures allows to take reasoned decisions for future interventions in quality care.

Drug Interactions↗

PubMedDate not supplied

Prediction of outcome in cardiac surgery.

There has been growing interest in defining and measuring outcomes for cardiac surgical patients. Outcomes measures have been used in many hospitals as tools for measuring the quality of care, although it is difficult to infer from them how care might be improved. Traditionally, the major outcome endpoints used in cardiac surgery have been the 30-day mortality and morbidity rates. Recently, more innovative intermediate outcomes, including health-related quality of life, functional status, and patient satisfaction 6 months to one year after surgery, have received more attention. A significant proportion of the variance in health care outcomes is affected by patient-related risk factors. By using outcome prediction tools and making conclusions based on preoperative risk factor information, surgeons and anesthesiologists are able to make better decisions about treatment strategies. Additionally, operating room and intensive care unit personnel can use these data to schedule cases and allocate resources more efficiently. These data are also very important for hospital administrators and insurance providers.

Cardiac Surgical Procedures↗

PubMed2000

Suicide in the medically and terminally ill: psychological and ethical considerations.

For the clinician who works in a behavioral-medicine or primary-care setting, this article presents the association between medical illness and suicide. Specific illnesses such as HIV/AIDS, cancers of the brain and nervous system, and multiple sclerosis all are associated with an increased risk of suicide. Rates of major depression rise with increasing rates of serious medical illness; however, depression and associated suicidal ideation tend to be undertreated in the medically ill. When medical illness becomes terminal, the clinician's patient may be confronted with difficult end-of-life decisions. Great concern exists in the United States about the ethics of end-of-life decision making and the issue of physician-assisted suicide. The latter part of this article examines the terminally ill patient's right to refuse life-sustaining treatments or to have death hastened according to the principle of the "double effect." It also reviews psychologists' apparent acceptance of the concept of rational suicide, as well as assisted suicide under certain conditions, and offers several caveats. A reexamination of psychology's role, standards, and principles with respect to rational suicide is recommended.

Behavior Therapy↗

PubMed1997

Twenty-five years of obstetric patient satisfaction in North America: a review of the literature.

The North American literature on obstetric patient satisfaction of the past 25 years was reviewed using two major computerized databases. The articles identified by these searches were supplemented with other research articles identified in reference lists. The review highlights the difficulties inherent in the use of many different methodologies to study obstetric patient satisfaction. The main methodologies have been mailed questionnaires, telephone interviews, and semistructured interviews, with data collection periods ranging from 24 hours to 2 years postpartum. The various approaches to data collection make comparison of results among studies exceedingly difficult. The reluctance of patients to criticize their caregivers has been problematic and is evidenced by satisfaction ratings that are positively skewed. Factors that have been reported to be most influential in obstetric patient satisfaction include communication, control, participation in decision making, presence of a support person, information/prenatal classes, nursing care services, length of stay, and physical environment. The relative importance of these factors, however, has not been ascertained.

Communication↗

PubMed1999

[Are mortality indicators acceptable indicators for the quality of health care?].

IMPORTANCE OF PUBLISHING MORTALITY RATES: Mortality rates for certain interventions or disease states have been used over the last decade as indicators of the quality of care provided by a given hospital, unit or, medical team. If published, these rates would be a useful tool for decision makers in the process of fund allocations, for public information, and for promoting improved care in hospitals or units with a low classification. METHODOLOGICAL LIMITATIONS: It is difficult to adjust an indicator of mortality to disease-related risk factors and any modification of this adjustment can have major consequences on the validity of subsequent comparisons. The differences in mortality observed between hospitals and physicians can reflect not only differences in quality of care but also differences in approaches to disease-related risk factors, therapeutic choices, or coding practices. The lack of statistical power is a major limiting factor in interpreting differences in mortality rates. To evidence a statistically significant difference in mortality between two hospitals whose rates are respectively 0.5% and 1% (for example in total hip replacement patients), it would be necessary to include 4673 patients, a number which would correspond to 20 years data for a hospital performing 230 interventions per year. Consequently, the number of interventions performed in the most active hospitals would not be sufficient to make such comparisons. LIMITATIONS AND COUNTER EFFECTS: Some studies have demonstrated that the publication of mortality rates does not have a major influence on patients' decisions nor on physicians' choice of a referral hospital. It would have no effect on improving health care quality of the institutions cited. One the contrary, certain counter effects have been observed: modification in patient recruitment, higher-risk patients being referred to hospitals with unpublished mortality rates. For many authors, procedure indicators are more pertinent than outcome indicators for detecting differences in health care quality between different care structures.

France↗

PubMedDate not supplied

Can academic group practices survive in managed care environments?

Managed care environments have proven difficult for most health care organizations. Academic medical group practices--also called faculty practice plans--in particular have faced enormous challenges in making strategic adaptations to rapidly evolving health care markets. Recent evidence suggests that academic practices have been less than successful in implementing strategies focused on cost leadership and affiliations with primary care physicians. This article asserts that academic group practices cannot succeed by copying strategies implemented by other medical group practices because they have dissimilar missions, organizational capabilities and environmental constraints. The authors use the TOWS matrix--an acronym for threats, opportunities, weaknesses and strengths--a decision analysis framework that integrates both organizational and environmental factors, to assist executives in strategically positioning academic group practices.

Academic Medical Centers↗

PubMed2005

Copper-replacement treatment for symptomatic Menkes disease: ethical considerations.

We describe a child with classical Menkes disease with a novel ATP7A mutation, intractable seizures, severe hypotonia and developmental delay, hypopigmentation of the skin and hair, and failure to thrive, who was treated with daily subcutaneous copper histidine injections for 2(1/2) years, beginning at 15 months of age. He became seizure-free and pigmentation of his skin and hair darkened, but he continued to have severe developmental delays. His condition remains stable 8 months after stopping treatment. We review the ethical aspects of offering copper treatment for Menkes disease infants diagnosed after neurological symptoms become manifest. These include (1) the prospect for any benefits, (2) the potential risks and discomforts, (3) the parents' wishes with respect to treatment, (4) the family's understanding of the treatment's potential futility, (5) the family's understanding of the investigational nature of this treatment, (6) the potential for treatment to have an adverse impact on unaffected family members, (7) whether the ultimate decision regarding treatment should rest with health care providers or with the patient's parents, and (8) the duration of treatment. The ethical issues encountered in providing possibly futile treatment in this difficult disorder seem relevant to other pediatric medical conditions as well.

Adenosine Triphosphatases↗

PubMed2002

Nurses and English primary care groups: their experiences and perceived influence on policy development.

AIMS OF THE STUDY: To investigate the experiences and perceived influence of nurses serving on English primary care group boards. BACKGROUND: The development of the nursing workforce and nursing services in primary care have been piecemeal and nurses have not always contributed to policy development. The recent establishment of primary care groups (PCGs) in the United Kingdom (UK) potentially offers nurses the opportunity to take a concerted and strategic role in developing professional roles and planning service developments. RESEARCH METHODS: As part of a longitudinal study of a 15% random sample of English primary care groups, nurse board members were surveyed in the winter of 1999. One hundred and forty-four nurses were invited to return self-completion questionnaires. RESULTS: Completed questionnaires were returned by 106 of those invited to participate (73%). Respondents reported that combining their usual work with their role in the PCG was frequently difficult. Only 26% perceived that they had been well prepared for their new role. Compared with other board members [for example, general practitioners (GPs)], nurses perceived that their own influence was limited, with only a quarter rating the influence of nurses on decision-making as great. Most of the sample were feeding back information to other primary care and community nurses working in the locality and 52% rated communication with this wider constituency as good or better. Nurse board members were enthusiastic about their role and optimistic about the positive future impact of PCGs on health. CONCLUSIONS: PCGs are still at a relatively early stage in their development. It is still too early to assess their impact on nurses working in primary care and community settings. Board membership offers nurses a voice in local health policy development.

Attitude of Health Personnel↗

PubMedDate not supplied

Strategic repositioning: a practical approach to reducing costs and enhancing quality.

Sharply increased competition threatens the status quo in most healthcare organizations, which must now decrease costs while improving service. Those organizations can use strategic repositioning to evaluate their business practices and insure that they are performing at peak efficiency. Strategic repositioning (SR) is a process that changes functions within an institution--not just how people do the jobs they have done, but what they do. Meaningful cost savings come from changing the way services are delivered rather than from simple belt-tightening. This article discusses initiatives that resulted from an SR process at the University of Pittsburgh Medical Center. The radiology department was one of the first departments to participate in the process and successfully reached its goal: to reduce its operating budget by 22% over three years while increasing service quality. Generally, SR includes the following steps: assessing the status quo, project organization, benchmarking and evaluating results. Some of the changes proposed by the radiology department were: closing outpatient radiology services at an adjacent clinic, decommissioning the CT scanner in the OR, PACS implementation, consolidating ultrasound with the peripheral vascular lab, decreasing the use of non-ionic contrast media, decommissioning underutilized equipment, and consolidating services such as transcription and scheduling. As changes are suggested with an SR process, executives must make difficult decisions, such as whether a program survives or is discontinued. Radiology cannot do this alone! Establishing ambitious improvement goals at the beginning will set the stage for the program. Stretch beyond the limit. If the expectation is to decrease 15%, try to decrease 20% and in many cases quality will still be enhanced. It can be done.

Ambulatory Care Facilities↗

PubMed1979

Current pediatric roles in child abuse and neglect.

Many pediatricians are being called on to undertake expanded roles in the field of child abuse and neglect, whether as a practicing pediatrician, a hospital-based child abuse consultant, or as a child protection team pediatrician. The practicing pediatrician must consider the diagnosis of child abuse and neglect, confirm the diagnosis, report all suspected cases to child protective services, hospitalize any abused child who needs protection, and provide preventive services. The hospital-based child abuse consultant should provide consultation to primary physicians, report seriously injured cases for the primary physician or surgeon, provide expert medical testimony on difficult to prove cases, teach house staff and medical students about child abuse and neglect, and improve treatment services for abused children who are hospitalized. The child protection team pediatrician will usually become involved in the broader problem of improving team decision making and the interagency system that deals with child abuse and neglect.

Child↗

PubMed2001

[The Medical Information Systems Project clinical coding and surgeons: why should surgeons code and how?].

The clinical coding system recently instituted in France, the PMSI (Projet de Médicalisation du Système d'Information), has become an unavoidable element in funding allocations for short-term private and public hospitalization centers. Surgeons must take into serious consideration this controversial medicoeconomic instrument. Coding is a dire time-consuming task but, like the hospitalization or surgery report, is an essential part of the discharge procedure. Coding can in the long run be used to establish pricing by pathology. Surgeons should learn the rules and the logic behind this coding system: which, not being based on a medical rationale, may be somewhat difficult to understand. Choosing the right main diagnosis and the comobidity Items is crucial. Quality homogeneous coding is essential if one expects the health authorities to make good use of the system. Our medical societies have a role to play in promoting and harmonizing the coding technique.

Abstracting and Indexing↗

PubMed2003

Perinatal care at the threshold of viability--from principles to practice.

The threatened birth of an extremely-low-birth-weight (ELBW) and gestational age infant presents complex medical, social and ethical issues for the family and the health professionals. Improved survival may be accompanied by increased risks of chronic medical problems and neurodevelopmental disabilities. It is difficult to define "how small is too small" and to decide "how much is too much" in providing optimal management of the mother and infant when delivery takes place at the threshold of viability. An individualised prognostic strategy appears to be the most appropriate approach. Through a process of communication and value exploration between the well-meaning parents and well-intentioned physicians, the goal is to reach a consensual decision that respects parental authority and promotes physician beneficence, with the best interests of the infant placed in the centre of the analysis.

Decision Making↗