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Musculoskeletal problems have always been a large part of the general practitioner's case load. The development of sports medicine as a separate entity has helped define and increase understanding of these problems, many of which are managed in a general practice environment. This monthly series is designed to improve and update knowledge in this area and provide useful pointers for management.
This paper reports on a doctoral research project that examined the work of reference librarians in the health sciences domain. Categories of information work are derived and used to build Hyper-MedLib, a proof-of-concept h-journal. Findings from this study may be used in the design of electronic documents and information systems for the practice environments.
African American female adolescents have unique identity issues that structure developmental tasks. Qualitative data from a longitudinal research project are used to explicate a three-dimensional model of the identity developmental process in early-age African American female adolescents. The limitations of a gender analysis model of voice and connection are noted. It is suggested that the African American female adolescent experiences a relational crisis in both racial and gender identity development. Moreover, African American female adolescents develop skillful, unique, expressionistic, and assertive styles of relating to negotiating perceived hostile environments. Practice implications for child welfare are outlined.
The preceptorship is recognized as a clinical teaching strategy that eases the transition of nursing students from the educational setting into the practice environment. The role of faculty is pivotal to the success of preceptorship programs.
PURPOSE: This project was part of a national, federally sponsored effort to create a prioritized research agenda for the chiropractic profession. An overview (and a separate comprehensive annotated bibliography) of recent social sciences, medical, chiropractic and health services research literature regarding chiropractic is presented. Based on this information, key research questions and issues were identified in the areas of health services research, practice environments and account ability/quality management. Research issues were prioritized by a multidisciplinary panel. METHODS: Qualitative review of literature gathered through searches of electronic health care database retrieval systems and citation tracking. Nominal group-process methodology with an expert panel was used to identify research priorities from a comprehensive list of potential health services research questions. RESULTS: Six recommendations for a health services research agenda for the chiropractic profession were made: determine barriers to usage of chiropractic; develop models to explain chiropractic usage; determine cost-effectiveness of different chiropractic procedures; develop valid measures and predictors of quality of chiropractic care; and examine satisfaction with chiropractic services from patients, other providers, purchasers, etc.
The basic differences between fee-for-service and capitated care are characterized and how they are likely to impact the practicing vascular surgeon are explored. Likely practice scenarios under capitated care are given. If the potential problems associated with using primary care "gate keeper" physicians materialize, secondary "carveouts" by vascular specialists may prove feasible. The alternative, particularly in large patient care consortiums, is to educate gatekeepers with efficient management algorythms in exchange for appropriate referrals. In spite of demonstrable flaws and abuses, capitated, managed care is likely to persist in some form, as an effective way to control spiraling health care costs. Therefore, vascular surgeons need to be prepared to compete under such systems. The major keys to success are efficient use of diagnostic tests, applying conservative, cost conscious indications for intervention, and efficient use of hospital resources (judged by lengths of stay in the intensive care unit and hospital and readmissions under the same diagnosis). In addition to developing better practice profiles, in these and standard mortality and morbity parameters, vascular surgeons need to create or join an efficient practice environment, with a minimum number of efficient personnel and teaching and research costs tightly controlled. To negotiate contracts effectively, vascular surgeons must know their costs, of delivering care on a per capita basis in their environment, adjusted for specific (eg, working or retired) patient populations. Outcomes and cost comparisons and other management research must vie for attention with new technology and basic research.
Without access to adequate diagnostic facilities, management of vestibular and balance disorders can be a frustrating process for both clinicians and patients. Expert clinical staff and state-of-the-art tools for the evaluation of balance disorders and dizziness are available within the vestibular and balance center. These centers can provide referring physicians and their patients with access to diagnostic expertise and facilities not practical within a general practice environment. Providing detailed evaluative reports, balance centers can help the referring physician define directions for surgical and medical treatment and assist in the management and rehabilitative treatment of acute and chronic dizziness and balance dysfunction.
Developing models of pharmaceutical care (PC) for educating students and practitioners represents a fundamental role for schools of pharmacy. Virginia Commonwealth University has sought to facilitate the implementation of PC in the community by hiring faculty to practice in this setting. The mission of the faculty is to implement PC in a community pharmacy practice, to develop clerkship sites for Pharm.D. students, and to evaluate the impact of PC services in the community. Examples of an independent pharmacy model, a grocery chain model, and a retail chain model of care may serve a dual purpose for faculty members, that is, define responsibilities for the academic institution and for the community practice environment.
An era of disciplined thinking may result not only in acknowledging but also in addressing those questions that may lead to a consistent examination of existing programs within a profession. This paper is one attemp at encouraging the professional membership to continue to address: 1. the nature and focus of the content and practice environments of the field of Occupational Therapy; 2. two approaches to investigating the distinctive character of the field of Occupational Therapy-the Separate Domain Approach and the Retroductive Approach; 3. and the basic documents developed and/or sponsored by the professional organization-in this case-The Ohio State Study (1), the NIH Study (2), and the Curriculum Guide (3).
As nurses begin to develop the sensitivities and skills necessary to preserve the integrity of clinical care and professional life, they must recognize the legitimacy of their perspectives and the value and consequences they have for the well-being of patient and family care. Nurses have much to contribute to the development of ethical practice environments for patients, families, multidisciplinary team members, and themselves. The frenzied, and at times anesthetized, culture of clinical settings can mitigate against the kind of deliberate reflection that is necessary if nurses are to act with ethical integrity. Knowing the rules of the road for end-of-life care and being attentive to common warning signs and addressing them proactively, enables nurses to provide patients and families with the highest quality care at the end of life.
There has been a great deal of discussion and deliberation concerning the composition of program development. Nonetheless, the question still remains--what is program development? What are possible components in program development? In this paper the following components are described, differentiated, and integrated: Statement of Purpose, Curriculum Design, Program Competencies, Content, Content Competencies, and Practice Environments.
OBJECTIVE: To develop indications for the preoperative use of recombinant erythropoietin (rHuEPO) alone and in conjunction with preoperative autologous donation (PAD). DESIGN: A 2-round modified Delphi-consensus process. PARTICIPANTS: Nine physicians representing multiple clinical specialties, practice environments and geographic locations. METHOD: From evidence tables and a literature summary (MEDLINE database from January 1985 to August 1996) provided and using the RAND-UCLA appropriateness method, the physicians developed 264 indications for the preoperative use of rHuEPO by permuting 7 clinical factors (age, history of transfusion or antibody incompatibility, hemoglobin level, anemia of chronic disease, expected blood loss, presence of cardiovascular or cardiopulmonary disease and patient anxiety). These indications were rated on a 9-point appropriateness scale. Median scores and measures of agreement were determined. OUTCOME MEASURES: The significance of cost constraints or cost and blood supply constraints and the impact of each clinical factor on the ratings as judged by statistical analysis. RESULTS: Of the 264 indications, 54% were rated appropriate, 18% uncertain and 28% inappropriate. Expected blood loss had the greatest impact on the ratings (high expected blood loss had a 5.9 point more appropriate rating on the 9-point scale than low expected blood loss [p < 0.0001]). Preoperative hemoglobin level also significantly influenced the ratings (p < 0.0001). Compared with the clinical context, the ratings under the cost constraint were 1.0 less appropriate (p < 0.0001) for rHuEPO alone and 1.2 less appropriate for rHuEPO and PAD (p < 0.0001). The ratings for patients with moderate expected blood loss were significantly influenced by the cost constraint (less appropriate). CONCLUSIONS: Expected blood loss and preoperative hemoglobin level were the best indicators of rHuEPO appropriateness. Different contexts modify the appropriateness ratings of an expensive drug like rHuEPO.
This article describes the development of a worksite survey to evaluate a continuing medical education (CME) program to improve preventive pulmonary practices and worksite environments of occupational physicians and nurses, and baseline findings from the survey. The two-part instrument assessed individual counseling practices for preventing lung disease and worksite environments. Eighty-one occupational physicians and nurses completed the survey before the CME program. Reliability coefficients (Cronbach's alpha) were calculated for five test subsections: smoking counseling (.72), workplace hazards (.70), environmental programs (.78), workplace environment (.94), and smoking policies (.91). Baseline findings indicated that 80% of respondents reported that their employees/patients were exposed to various workplace hazards. This instrument can be used to evaluate occupational health professionals' performance and worksite environments and may be useful for evaluating change over time or following a training program for occupational health professionals.
Reports from the development of the Ethics Environment Questionnaire identify three critical features for ethical environments in health care settings of registered nurses. They are the ability of nurses to engage in discussions about patient care, support from administrators, and the development of policies-procedures that support their practice. Implications for clinical practicing nurses are explored.
The role of the nurse manager is pivotal in creating a work environment in which nurse-physician collaboration is the expected norm. It is the nurse manager who clarifies the vision of collaboration, practices as a role model for collaboration, and inspires others to achieve this difficult goal. In addition, the nurse manager manipulates the environmental resources and facilitates self-confidence of staff. The management paradigm that unites the work environment with individual ability is most likely to facilitate collaborative practice.
Social work educators are confronting new challenges in preparing students for health care practice. Given the changing environment in which health care social workers practice and the changing nature of practice itself, it is surprising that there have been no surveys of health care curricula since the 1980s. This study, which is based on an analysis of the outlines for graduate-level health care practice courses from 53 accredited schools, attempts to determine what students are taught to prepare them for this altered practice environment. Content reflective of current practice issues was infrequently included in course outlines. Implications for social work education and practice are discussed.
A study was made on the cross-sectional relationship of the psychosocial work environment and personal health practices to mental health level among 15,639 male subjects aged 30-59 engaged in various kinds of occupations and firms. Mental health level was dichotomized by self-reported mental disorders. The psychosocial factors of work environment were conceptually constructed from the aspects of working conditions and occupational stress. Working conditions were assessed by work overload, work shifts and role in the organization. Occupational stress was measured by psychological work load and job characteristics (job demands and decision latitude). Various factors associated with positive health behavior--an index based on six parameters such as supper time, physical exercise, smoking, alcohol consumption, sleep, and weight--were examined. The prevalence of self-reported mental disorders was 17.5 per 1,000 population. Multiple logistic analysis showed that both psychological work load and health practice index have a significant independent effect on mental health levels after controlling for age and marital status. Limitations of the present study indicate a need for future longitudinal studies.
The weaning process varies widely among different cultures as to when the practice is initiated and terminated; in the variety, quality, and quantity of the weaning foods; and in the manner in which the endogenous food is provided. The variations in practices range from providing a food source even before the first breast-feeding to feeding nothing but breast milk for as long as 9 to 12 months, and include feeding from a cupped hand to use of a modern feeding bottle. The advice often given healthy mothers is to breast-feed for as long as possible and compatible with life-style. Most often, when breast-feeding is prolonged, the practice is to provide some complementary food from the early postpartum months onward. However, among some poor traditional societies and in deprived environments, this food may be limited and monotonous in flavor and texture. The monotony of the diet may act synergistically with the consequences of repeated infectious morbidity, and result in chronically depressed appetite and limited acceptance of additional food in quantity and variety at the time when this becomes critical for meeting the nutritional needs of the growing infant. The serious malnutrition prevalent in the 1 to 3 year olds in many deprived environments may have its antecedent etiology in the complementary feeding practices established in the first year of life. Effective interventions to reverse growth faltering of infants reared in deprived environments where breast-feeding is prolonged may require increased attention to providing variety in the weaning diet from at least 4 months onward.