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The medical director of a nurse anesthesia educational program in a Veteran's Administration medical center relates his experiences in creating an educational and practice environment where, through cooperation with the CRNA director, the capabilities of all anesthesia providers are respected and utilized.
The financial costs of the ethical dilemmas in the health care industry are profound, and the emotional ramifications for the patient and family are even more costly. As critical care nurses and as health care consumers, we must create an impetus for change. We need to ensure that we contribute to the quality of life while dealing with the conflicting values inherent in the right-to-die question. Together, we can create an ethical practice environment for ourselves, our families, and the patients for whom we care.
The author, an otolaryngologist in Ottumwa and president of the Iowa Academy of Otolaryngology, discusses that organization's goals and the current practice environment for otolaryngologists.
Nursing science and research findings are powerful ingredients in influencing health care policy makers. Policy must be influenced on several levels: practice, the environment of practice, and public policy. Nursing has successful examples of the benefits of such efforts. Doctoral students, as the future nurse scientists of our discipline, must be socialized to value and understand the process of using the profession's research base to affect health care policy at numerous levels. Nursing knowledge of these strategies and the theoretical bases undergirding them has only begun to develop. Our challenge is to develop such strategies more systematically based on the growing body of knowledge in health care policy that relates to nursing science and research.
To evaluate the adequacy of preparation for medical practice, we surveyed 320 internal medicine program graduates. The 210 respondents gave their perceptions regarding preparation in training and importance in practice of eight clinical practice skills and 27 clinical procedure skills. The skills with highest preparation scores were venipuncture, intravenous line placement, and arterial puncture for blood gases. The skills rated as the most important in practice were history taking, physical examination, and selection of diagnostic tests. For 13 of the 27 clinical procedure skills, mean preparation scores were significantly higher than mean importance scores, suggesting "overpreparation." In contrast, seven of the eight clinical practice skills had mean preparation scores significantly lower than mean importance scores, suggesting "underpreparation." Furthermore, greater preparation during training was reported by more recent graduates for five of the overprepared skills. We concluded that skills emphasized in internal medicine training are not necessarily those important for practice and that recent changes in the training and practice environments may be increasing these discrepancies.
This article has presented the basic information needed for setting up a microcomputer work station. The four basic components are the central processing unit (CPU), the monitor (CRT), the keyboard, and the disk drive. A brief overview of how the microcomputer works was presented, including the concepts of random-access memory (RAM) and read-only memory (ROM). The use of peripheral devices to enhance the operating capabilities of the microcomputer has allowed this technology to become practical and useful both at home and in business and research. Special furniture is available to assure a comfortable and practical environment. Perhaps one of the most important concepts presented in this article is the necessity of backing up data on a regular basis. Finally, computer equipment must be cleaned and maintained on a regular basis.
Historically, laboratory rodents have been used in preference to other animal species for biomedical research. Study disruptions and invalidations often have occurred due to microbial contaminants inherent to laboratory rodents. Today, many commercial suppliers and research institutions are controlling a variety of infectious diseases among laboratory rodents by careful design of animal facilities, by adaptation of managerial techniques employing precise operational policies coupled with careful supervision and attention to detail and the use of various diagnostic programs. The continued evolution of epidemiological practices, environment control systems, sophistication of barrier-sustained operations, preventative medicine and sanitation techniques, complemented by an improvement in veterinary diagnostic programs for disease surveillance further minimize microbial contamination of laboratory rodents. Such measures contribute to the fulfillment of various legislative requirements concerned with the quality of animals for biomedical research.
The managerial position held by men and women pharmacists in three primary practice settings were examined and compared. A nationwide survey, using a pretested 12-page questionnaire, was sent to 2100 pharmacists in hospitals, independently owned pharmacies, and chain-store pharmacies. The variables examined by discriminant analysis were sex, age, years with employer, the number of times a pharmacist left practice, and educational level. A total of 767 completed questionnaires were used in the analysis for a 39.6% response rate, and 57.6% of the sample was women. Women were found to be significantly under represented in managerial positions in all three practice settings; however, there were a greater percentage of women in managerial positions in hospital pharmacies than in independently owned or chain-store pharmacies (p less than or equal to 0.001). When age was controlled in the analysis, there were more women at the staff level than men in all the age categories above 25. The discriminant analysis showed that advanced education was a significant factor in a pharmacist's position in hospital pharmacies but not in community pharmacies. The sex of the pharmacist showed the highest discriminating power in classifying the position of community pharmacists. Women pharmacists were under represented in managerial positions in all three practice environments. However, hospital pharmacy had a greater percentage of women in managerial positions than community pharmacy.
The perceived benefits of PSR as a simple, sensitive and efficient tool to screen patients for periodontal diseases have contributed to its incorporation into the dental practice environment. The recent introduction of PSR to the public probably will motivate patients to seek more information about periodontal health. Used as a communication and screening tool, PSR has the potential to enhance professional and patient relationships through cooperative treatment planning and increased patient treatment acceptance.
AIM: To assess compliance with a drug regimen of two doses a day compared with one a day. PATIENTS AND METHODS: A prospective crossover study was set up in a general practice environment to compare compliance on a drug regimen of once a day versus twice a day. Data were collected by electronic monitoring in 113 patients with hypertension or angina pectoris. All patients were prescribed slow-release nifedipine twice a day during the first month and then crossed to a single daily dose of amlodipine for another month. RESULTS: Compliance, defined as the proportion of days on which the correct dose was taken, improved in 30% of patients (95% confidence interval 19-41%; P < 0.001) when the patients were switched from twice a day to once a day, but at the same time there was a 15% increase (95% confidence interval 5-25%; P < 0.02) in the number of patients with one or more no-dose days. Approximately 8% of patients displayed low compliance, irrespective of the dose regimen. Actual dose intervals were used to estimate the extent and timing of periods with unsatisfactory drug activity for various hypothetical drug durations of action. CONCLUSIONS: The apparent advantage of a single daily dose in terms of compliance appears to be clinically meaningful only when the duration of activity extends beyond the dose interval in all patients.
Case management was more cost effective in a moderately uncertain practice environment than in either a low or a high uncertainty environment. The environmental state, case manager role differentiation, and information coordination contributed most strongly to these outcomes.
A prospective cross-over study was performed in a general practice environment to assess and compare compliance data obtained by electronic monitoring on a BID or QD regimen in 113 patients with hypertension or angina pectoris. All patients were on a BID regimen (nifedipine SR) during the first month and switched to QD regimen (amlodipine) for another month. Taking compliance (i.e. the proportion of days with correct dosing) improved in 30% of patients (95% confidence interval 19 to 41%, p < 0.001), when switching from a BID to a QD regimen, but at the same time there was a 15% increase (95% confidence interval 5 to 25%, p < 0.02) in the number of patients with one or more no-dosing days. About 8% of patients had a low compliance rate, irrespective of the dosage regimen. Actual dosage intervals were used to estimate extent and timing of periods with unsatisfactory drug activity for various hypothetical drug durations of action, and it appears that the apparent advantage of QD regimen in terms of compliance is clinically meaningful only, when the duration of activity extents beyond the dosage interval in all patients.
Guidelines define the professional, ethical and legal responsibilities involved when challenging or delegating patient assignments. Maintaining safe nursing practice levels is possible through such alternatives as enabling practice environments and cross-training. These significant factors identify options available to nurse managers and their staff without compromising patient safety.
During an all-day retreat, a psychiatric nursing staff identified its patient care mission and interpersonal behaviors which inhibited accomplishing it. Collaborating with managerial interventions, staff members learned how to communicate in their practice environment effectively to their own benefit and that of their patients.
Clinical information systems that provide physicians with relevant information at the time and place where decisions are being made can positively affect the quality and cost of health care. We have developed an assessment methodology to study clinicians' information needs in the context of the work flow and operational constraints of the ambulatory care practice environment. We employed a combination of methods, including observational studies, process flowcharting, semi-structured interviews, and surveys to comprehensively define clinicians' needs. Results from our study point to functional requirements not commonly found in hospital-based systems, such as access to problem lists and medications, computer-based support for health-care team communications, and patient-specific instructions and education.
There is a relationship between iatrogenic complications of medical procedures and the quality of medical services. The risk of iatrogenic complications or diseases occurring is growing over time for several reasons: patients under medical care grow older and sicker, diagnostic and therapeutic procedures are expanding at a fast pace, and complexity and uncertainty in daily care tends to grow. This development will continue unless we actively start to prevent iatrogenic complications. The frequency of iatrogenic illness was found to be between 4 and 36% of all patients treated in a hospital setting. The wide span is a result of different definitions of what is an iatrogenic complication. When an iatrogenic illness occurs we are obliged to look for "errors in the system"in order to eliminate them. In a hospital and practice environment the respective methods are different. By eliminating unnecessary procedures the risk of possible damage is diminished. Necessary procedures must be performed at the most skilled level. We describe and discuss two cases of iatrogenic complications and the benefits and disadvantages of guidelines. The creation of guidelines should be placed on a rational and scientific basis.
Every newly hired staff member will affect hundreds of patient outcomes as well as the success of the team at large. An interview determines the applicant's values and identifies if he/she is congruent to the professional practice environment.
The evolution of the healthcare marketplace to a managed care-based system requires dramatic changes in the fragmented medical education infrastructure and curricula to more adequately train the physician workforce needed to staff and support the new system. Graduating physicians, in large numbers, feel poorly prepared to function effectively in the very areas adjudged to be essential to a successful transition, such as cost-effective care and caring for patients in outpatient settings. Managers of the new systems, such as health maintenance organizations, have expressed dissatisfaction with the skill levels of many of the practitioners whom they are hiring. Many physicians who have made the transition to a new practice paradigm by restructuring their practices are dissatisfied with several aspects of the new practice environment and equally concerned about the quality of care they can deliver. The conflict between rhetoric and incentives, and the difficulty of reforming a fragmented academic system pose barriers to effective change as the nation's academic health centers prepare to respond. Osteopathic medicine is better positioned to change because of its community-based education, its track record in primary care, and its national move to create a vertically integrated continuum of education from undergraduate through graduate study. Medical education and workforce issues are essential components of the cost, quality, and access triad. Without reform in medical education, the ability of the new paradigm to adequately address these other issues is critically compromised.