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Does the nursing process reflect quality care?

The nursing process is a very linear method that does not require that the nurse use knowledge gathered over the years; instead it requires an objective assessment of data accessible to the senses. Although this method should assure uniform practice, it will not assure quality practice. Some authors liken it to the scientific method. It is not. The scientific method begins with a perceived problem which is defined as facts, events, or situations that lack explanation or that are incongruent with accepted beliefs, expectations, or preconceptions. Without expectations, and beliefs, life holds no surprises and no problems. Only with years of accumulated experiences can expert nurses quickly determine the problems and "the solutions to problems using experience-based holistic recognition of similarity which produces deep situational understanding." This understanding and the solutions to problems may be and should be different for each nurse. This is not so when nurses use the nursing process. All phenomena are abstracted from the personal; they are context free. The Dreyfus Model of Skill Acquisition, related to nursing by Benner, explains this kind of practice as Novice. The Expert, on the other hand, "knows what to do based on mature and practiced understanding. Experts solve problems using know-how, the sort of ability we all use all the time as we go about our everyday tasks." They know problems without analyzing them; they sense them. Benner states, "If experts are made to attend to the particulars or to a formal model or rule, then performance actually deteriorates."(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical Competence↗

Information system support of changes in health care and nursing practice.

The practice of nursing is changing in response to changes in health care. An effective information system can support nursing's need to streamline the process of documentation, move to standards-based practice, access standards and other reference material, and access data and information to make clinical and management decisions. Nurses will increasingly rely on information systems to provide them with the critical data and information they need to make decisions about patient care, management of the care team, efficient resource utilization, and best practice standards.

Decision Support Techniques↗

HIPAA privacy regulations and nursing research.

BACKGROUND: The Health Insurance Portability and Accountability Act (HIPAA) privacy regulations, which became effective on April 14, 2003, should have a significant impact on the conduct of nursing research. APPROACH: The requirements of the regulations are discussed in three key areas of the research process, accessing data (including recruitment and using medical records), creating data (including intervention studies, survey, and interview research), and disclosing data to others such as colleagues at other institutions. RESULTS: N/A. DISCUSSION: HIPAA will certainly impact nurses' ability to conduct research but to an unknown degree.

Confidentiality↗

A systems approach in nursing administration: structure, process, and outcome.

This article presents a systems approach for administrators to consider as they review structure, process, and outcome in their healthcare organization. Systems provide a way to access data, information, and knowledge. Systems organize and unify the complex world of nursing practice in healthcare systems. Use of King's conceptual system, Theory of Goal Attainment, and transaction process is presented as an example that helps the multiple individuals and groups use information and knowledge to structure nursing practice. The transaction process helps individuals and groups identify goals and outcomes that lead to effective nursing care, evidence-based practice, and cost-effectiveness.

Communication↗

Simultaneous antepartum testing of twin fetal heart rates.

Assessment of twin gestation in the antepartum period has been a problem because most methods either fail to distinguish twins individually or require serial study over several weeks before reaching diagnostic end points. Electronic monitoring of the fetal heart rate (FHR) allows individual focus on each twin with a high degree of specificity and permits immediate status evaluation. In this study 44 sets of twins had simultaneous Doppler monitoring in an outpatient testing center. Transducer position was aided by real-time ultrasonic location of each fetal heart; 198 tests were satisfactory, each patient receiving 3.9 +/- 2.9 (mean +/- SD) studies. The rate of unsatisfactory tests was 15.4%, though each fetus was satisfactorily tested within one week of delivery. Testing was begun at 32.9 +/- 2.9 weeks and delivery occurred at 36.8 +/- 2.6 weeks. Perinatal mortality was 22.7/1,000, significant morbidity 15.9%, and cesarean section rate 18.1%. Reactive (R) patterns were seen in 69 fetuses and nonreactive (NR) in 19. Although there were no significant differences in gestational age at delivery between R and NR groups, (36.9 vs 36.2 wk) NR fetuses had significantly lower birth weights and higher rates of neonatal depression, perinatal mortality, and retarded intrauterine growth. Similarities in FHR patterns within twin pairs were frequently observed (30/44). Twins exhibiting dissimilar patterns had significant differences in birth weight and tended to have separate rather than common placentas. Simultaneous FHR testing of twins appears to be an effective means of providing immediately accessible data on the comparative well-being of each twin.

Adult↗

The value template process: a participatory evaluation method for community health partnerships.

This article presents the results of a pilot implementation of an evaluation process designed to help community health collaboratives obtain relevant information for planning and evaluation. The Value Template Process assists collaboratives to identify performance and impact indicators that are meaningful and measurable with accessible data. The process also encourages communication and engagement in assessment among collaborative members. The pilot study demonstrated that the process's underlying assumptions of social capital were valid and that the process was feasible and useful to the community health collaborative.

Community Health Services↗

Grading of atypia in nevi: correlation with melanoma risk.

Nevi with architectural disorder and cytologic atypia of melanocytes (NAD), aka "dysplastic nevi," have varying degrees of histologic abnormalities, which can be considered on a spectrum of grades of atypia. Somewhat controversial and subjective criteria have been developed for grading of NAD into three categories "mild," "moderate," and "severe." Grading involves architectural and cytological features, which often correlate with each other. Architectural criteria were intraepidermal junctional extension beyond any dermal component, complex distortion of rete ridges, and dermal fibrosis. Cytological criteria were based on nuclear size, dispersion of chromatin, prominence of nucleoli, hyperchromasia and variation in nuclear staining. Few tests have been made of the relationship between specific grades of atypia and patient risk for melanoma. Retrospective review of pathology reports was performed on 20,275 nevi examined between 1989 and 1996. From the total, 6,275 were diagnosed as NAD, which were in 4,481 patients. These patients were divided into those whose worst NAD was mild (2,504), moderate (1,657), or severe (320). Review of accession data revealed that a personal history of melanoma was present in 5.7% of patients with mild, 8.1% with moderate, and 19.7% with severe atypia. The male/female ratios were similar in each group. In the three groups, the mean ages of men were similar and of women were similar, but the mean age of men tended to be 6-11 yrs. older than women in each group. Family histories of melanoma were not considered. The odds ratio as a measure of association between NAD and personal history of melanoma, shows an odds ratio of 4.08 (2.91-5.7) for NAD-severe versus NAD mild, odds ratio 2.81 (2-3.95) for NAD-severe versus NAD-moderate and odds ratio 1.45 (1.13-1.87) for NAD moderate versus NAD-mild. These data show that the probability of having personal history of melanoma, for any given NAD patient, correlates with the NAD grade. Likewise, the risk of melanoma is greater for persons who tend to make nevi with high grade histological atypia.

Adolescent↗

Generation and analysis of 280,000 human expressed sequence tags.

We report the generation of 319,311 single-pass sequencing reactions (known as expressed sequence tags, or ESTs) obtained from the 5' and 3' ends of 194,031 human cDNA clones. Our goal has been to obtain tag sequences from many different genes and to deposit these in the publicly accessible Data Base for Expressed Sequence Tags. Highly efficient automatic screening of the data allows deposition of the annotated sequences without delay. Sequences have been generated from 26 oligo(dT) primed directionally cloned libraries, of which 18 were normalized. The libraries were constructed using mRNA isolated from 17 different tissues representing three developmental states. Comparisons of a subset of our data with nonredundant human mRNA and protein data bases show that the ESTs represent many known sequences and contain many that are novel. Analysis of protein families using Hidden Markov Models confirms this observation and supports the contention that although normalization reduces significantly the relative abundance of redundant cDNA clones, it does not result in the complete removal of members of gene families.

Adult↗

Mapping care pathways for the elderly.

PURPOSE: Aims to describe a project carried out within Hampshire Social Services investigating potential care pathways for older people after discharge from hospital and to show the potential of the simulation methodology in such situations. DESIGN/METHODOLOGY/APPROACH: A discrete-event simulation was used to determine the system capacities and to estimate the likely associated reimbursement costs. FINDINGS: A prototype simulation model was developed showing the potential value of this approach. RESEARCH LIMITATIONS/IMPLICATIONS: Restrictions in data access shifted the focus from quantitative service mapping to a more descriptive approach. PRACTICAL IMPLICATIONS: Currently, many older patients experience delayed discharge from acute beds because of capacity limitations in Social Services' traditional post-acute care services. At the same time, new regulations require Local Authorities to reimburse NHS Acute Trusts if hospital discharge is delayed solely due to inadequate provision of social care assessments and services. In order to overcome the so-called "bed-blocking" problem, a new range of services termed "Intermediate Care" has been introduced to offer alternative options for older patients. These services are examined in terms of capacity and appropriateness. ORIGINALITY/VALUE: This paper fulfils an identified need to record and evaluate the new post-acute packages introduced by the Social Services and NHS and proposes simulation as one of the most suitable methodologies for such objectives.

Aftercare↗

A new approach to man-machine communication for computerized microscopy.

HOME is a new computerized microscope designed to assist pathologists and cytotechnicians in routine examinations. The HOME workstation is composed of a standard light microscope fitted with objective and stage encoders, and a built-in high resolution computer display which superimposes dialog, drawing, and messages onto the optical microscope image. The software runs under Windows 3.x and provides interactive facilities such as accurate localization and relocation of zones of interest, morphometric measurements, patient data access, and quality control processes.

Cell Biology↗

A smart-card-enabled privacy preserving E-prescription system.

Within the overall context of protection of health care information, privacy of prescription data needs special treatment. First, the involvement of diverse parties, especially nonmedical parties in the process of drug prescription complicates the protection of prescription data. Second, both patients and doctors have privacy stakes in prescription, and their privacy should be equally protected. Third, the following facts determine that prescription should not be processed in a truly anonymous manner: certain involved parties conduct useful research on the basis of aggregation of prescription data that are linkable with respect to either the patients or the doctors; prescription data has to be identifiable in some extreme circumstances, e.g., under the court order for inspection and assign liability. In this paper, we propose an e-prescription system to address issues pertaining to the privacy protection in the process of drug prescription. In our system, patients' smart cards play an important role. For one thing, the smart cards are implemented to be portable repositories carrying up-to-date personal medical records and insurance information, providing doctors instant data access crucial to the process of diagnosis and prescription. For the other, with the secret signing key being stored inside, the smart card enables the patient to sign electronically the prescription pad, declaring his acceptance of the prescription. To make the system more realistic, we identify the needs for a patient to delegate his signing capability to other people so as to protect the privacy of information housed on his card. A strong proxy signature scheme achieving technologically mutual agreements on the delegation is proposed to implement the delegation functionality.

Algorithms↗

Use of major and minor tranquilizers with older patients in an acute care hospital: an exploratory study.

AIM: This paper reports a study to determine how many older patients are prescribed major and/or minor tranquilizers during their hospital stay, and the perceptions of acute care nursing staff towards the use of such medications with older hospitalized patients. BACKGROUND: While considerable research exists on the use of major and minor tranquilizers (chemical restraints) with older people in long-term care, scant research has addressed the use of these drugs with older patients in acute care hospitals. Given the growing numbers of older people with dementia and delirium in hospitals, and the risks these drugs pose to older people, more research on the use of chemical restraints by nurses with older hospital patients is needed. METHODS: Computerized pharmacy records were used to access data on prescriptions of major and minor tranquilizers to older patients during one month on six hospital units (total n = 498), and 140 nursing staff from these units completed the Perceptions of (Chemical) Restraint Use Questionnaire. The data were collected in 2003. RESULTS: A minority of older patients (8.63%) were prescribed a major or minor tranquilizer during the one-month data collection period. The numbers prescribed minor tranquilizers (6.22%, n = 31) were approximately double that of major tranquilizers (3.21%, n = 16). The majority of prescriptions for minor and major tranquilizers were written as pro re nata or 'as needed' (77% and 55.8%, respectively). Nurses' scores on the Perceptions of (Chemical) Restraint Use Questionnaire indicated perceptions consistent with liberal use of chemical restraints, and several of the highly rated reasons for giving such medications could be considered inappropriate. CONCLUSIONS: While these findings suggest that only a small number of older people were prescribed chemical restraint medications in hospital, the risks these medications pose warrants ongoing prudence. More nursing research and education on the use of these medications with older people in hospital settings is needed.

Adult↗

Cryptogenic fibrosing alveolitis: have we made any progress?

The interstitial lung diseases (ILD) are a heterogeneous group of disorders the most common of which is cryptogenic fibrosing alveolitis (CFA). This article has summarized recent work in particular on the diagnosis, pathogenesis and treatment of CFA, by reviewing published data accessed through Medline searching. Recent reports suggest a higher prevalence of CFA than previously documented (13.2-20.2/100,000 population) and a rising mortality rate. The prognosis is universally poor with 50% of patients dying within 5 years. Although approximately 30% of patients may live for long periods (> 10 years), morbidity is significant and quality of life in the long-term survivors is poor. Diagnosis is traditionally based on an open lung biopsy, however, more recently the high resolution computer tomography (HRCT) is often used; however, its use without a tissue diagnosis remains controversial. In conclusion, we know substantially more about the pathogenesis of the disease and from this work have a number of possibilities for new therapeutic strategies that will hopefully reach the bedside in the near future. Additionally we have some new non-invasive tests that offer hope for stratifying patients but require further evaluation. For assessing both therapy and investigations we will need substantial groups of patients in multicentre studies to provide sufficient power to allow a conclusion to be reached. To ensure any further progress we must collaborate and enter our patients into such trials.

Adrenal Cortex Hormones↗

Reduced mammographic screening may explain declines in breast carcinoma in older women.

OBJECTIVES: To examine whether declines in breast cancer in the oldest-old women correspond with declines in the use of cancer testing. DESIGN: Cross-sectional evaluation of three databases. SETTING: Public access data. PARTICIPANTS: Cases recorded in the California Registry and the Surveillance, Epidemiology, and End Results Program between 1988 and 1997. The study also included respondents to the 2002 Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System. MEASUREMENTS: Cancer incidence and self-reported mammography within the previous 2 years. RESULTS: Most previous analyses have combined all individuals aged 75, 80, or 85 and older. Creating separate categories for age ranges 85 to 89, 90 to 94, 95 to 99, and 100 and older suggests different incidence patterns for a variety of cancers, including mammary carcinoma in situ (CIS). Between the ages of 40 and 74, there is a significant rise in CIS. Beginning at age 75, there is a significant decline in CIS through the highest age categories. The use of mammographic screening increases between the ages of 40 and 60. Beginning at age 75, there is a significant decline in the use of mammography that parallels the decline in incident cases of CIS. CONCLUSION: There may be a substantial reservoir of undiagnosed CIS in the population. Surveillance bias might explain the decreasing incidence of CIS with advancing age in the oldest age groups. Autopsy studies are needed to estimate the true prevalence of CIS in older women.

Adult↗

Potential cost savings by telemedicine-assisted long-term care of implantable cardioverter defibrillator recipients.

Home monitoring (HM) of cardioverter defibrillators (ICD) with its automated wireless remote data access, may decrease the rate of patient visits. This study examined the potential cost savings for the long-term care of ICD assisted by HM. A French database including 502 patients from 6 university hospitals was used. Costs of conventional follow-up (FU) of ICD were calculated without, and compared with the expected cost of FU with HM. Calculations included number of visits, including physician's fees, electrocardiograms, and specific ICD surveillance, and transportation costs. The mean distance between home and institutions performing follow-ups was 69 +/- 57 km. For each visit, a mean overall cost of 215 dollars was calculated, including 121 dollars for transportation and 94 dollars for medical services. HM may obviate up to 2 visits per year. Over the 5 years of expected life of the device, the decrease in costs for FU visits was estimated at 2,149 dollars. With an additional cost of 1,200 dollars for the HM system, saving began after a mean FU of 33.5 months. The time to onset of cost saving by HM ranged between 17.4 months for patients living >150 km from the medical facility to 52.2 months for those living <50 km away. It is concluded that the HM may considerably reduce the overall costs of ICD FU by saving on transportation cost, particularly when the distance between home and medical facility is >100 km.

Cost Savings↗

The Cancer Therapy Evaluation Program (CTEP) at the National Cancer Institute: industry collaborations in new agent development.

The mission of the Cancer Therapy Evaluation Program (CTEP), a clinical research program of the National Cancer Institute (NCI), is to reduce the burden of cancer. CTEP plans, reviews, and coordinates clinical trials for investigational anticancer agents, from the inception of protocols through the preparation and submission of Investigational New Drug Applications (INDs) to the Food and Drug Administration (FDA). CTEP also serves as a liaison to the FDA for the extramural clinical research community and industry collaborators. Other CTEP functions include managing, tracking, and reviewing clinical protocols as well as monitoring, planning, and maintaining regulatory compliance of the clinical trials. In addition, CTEP coordinates the distribution of the investigational agents from industry collaborators for use in all NCI-sponsored clinical trials. The advantages of collaborating with CTEP are described as well as details about the contractual framework, either a Clinical Trials Agreement (CTA) or a Cooperative Research and Development Agreement (CRADA), for such a collaboration. Many of the concerns raised by industry collaborators with respect to intellectual property, data access, and publications are also addressed.

Clinical Trials as Topic↗

Is the in situ accessibility of the 16S rRNA of Escherichia coli for Cy3-labeled oligonucleotide probes predicted by a three-dimensional structure model of the 30S ribosomal subunit?

Systematic studies on the hybridization of fluorescently labeled, rRNA-targeted oligonucleotides have shown strong variations in in situ accessibility. Reliable predictions of target site accessibility would contribute to more-rational design of probes for the identification of individual microbial cells in their natural environments. During the past 3 years, numerous studies of the higher-order structure of the ribosome have advanced our understanding of its spatial conformation. These studies range from the identification of rRNA-rRNA interactions based on covariation analyses to physical imaging of the ribosome for the identification of protein-rRNA interactions. Here we reevaluate our Escherichia coli 16S rRNA in situ accessibility data with regard to a tertiary-structure model of the small subunit of the ribosome. We localized target sequences of 176 oligonucleotides on a 3.0-A-resolution three-dimensional (3D) model of the 30S ribosomal subunit. Little correlation was found between probe hybridization efficiency and the proximity of the probe target region to the surface of the 30S ribosomal subunit model. We attribute this to the fact that fluorescence in situ hybridization is performed on fixed cells containing denatured ribosomes, whereas 3D models of the ribosome are based on its native conformation. The effects of different fixation and hybridization protocols on the fluorescence signals conferred by a set of 10 representative probes were tested. The presence or absence of the strongly denaturing detergent sodium dodecyl sulfate had a much more pronounced effect than a change of fixative from paraformaldehyde to ethanol.

Escherichia coli↗

Computerization of a large antenatal serology service.

A computer scheme for a large antenatal serology service is described. A primary request form (for mother, father or child) has been developed. Standard reports are produced by the computer and are issued with a tear-off slip which should accompany subsequent specimens. Complicated reports are made by special letter. An instruction booklet is issued to all users. Information on patients and clinically significant antibodies is held in a special computer file and is regularly updated. The system provides an efficient and reliable day-to-day service and readily accessible data for retrospective research. A brief note on the computer elements of the system is provided.

Computers↗