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Community health nursing practice and the Roy Adaptation Model.

In the current health care environment in the United States, the work performed by community health nurses is increasingly being recognized and valued by society at large. An increased societal emphasis on health promotion and disease prevention has generated many opportunities for community health nurses (CHNs) to stretch their practices from individually-oriented type practice models to more encompassing population-focused type practices. Addressing this trend, the Roy Adaptation Model of nursing has been reconceptualized and expanded to offer a framework for the systematic delivery of nursing care to aggregates in community settings. The purpose of this paper is to describe the current health promotion movement in the United States and discuss the impact of this movement on the practice of community health nursing. In recognition of the importance of theory-based nursing practice and the opportunities that CHNs will have in the health promotion movement, the use of the a specific conceptual model, the reconceptualized Roy Adaptation Model, will be presented as a theoretical framework for community health nursing practice. The nursing process according to Roy is applied to community health nursing and specific attention is paid to the performance of community assessments within the newly defined adaptive modes that relate to collectives: the physical, group identity, role function, and interdependence modes. To date, few references appear in the literature which link the Roy Adaptation Model to community health nursing.

Adaptation, Psychological↗

Community patient education and exercise for people with fibromyalgia: a parallel group randomized controlled trial.

OBJECTIVE: To evaluate the effects of a community patient education -exercise programme, using a cognitive-behavioural approach, for people with fibromyalgia. DESIGN: A randomized, parallel group trial with assessments at 0, 4 and 8 months. SETTING: Community leisure centres. SUBJECTS: People with fibromyalgia (n=183) attending a rheumatology outpatient department at a large district general hospital. INTERVENTIONS: Participants were randomized to a patient education-exercise group (n=97) or relaxation (attention control) group (n=86). MAIN MEASURES: The Fibromyalgia Impact Questionnaire (0-80; lower score means better health). Secondary outcomes included: the Arthritis Self-Efficacy Scale(pain and other symptoms subscales: 1 -10 scale; higher scores mean greater self-efficacy) and self-reported improvement. RESULTS: Fifty participants withdrew or were unable to attend and 133 completed and returned baseline questionnaires: patient education group (n=71); relaxation group (n=62); 120/133 participants were women. Average age was 48.53 (SD 10.89) years. Follow-up ranged between 73 and 82% of questionnaires returned. At four months, there was a difference in average changes in total Fibromyalgia Impact Questionnaire scores between the two groups: patient education group--3.38 (SD 9.35); relaxation group 0.3 (SD 8.85); P=0.02. Arthritis Self-Efficacy Scale scores were significantly higher in the patient education group: pain 0.59 (SD 1.45)compared to the relaxation group's--0.12 (SD 1.22); P=0.003; other symptoms (patient education group 0.72 (SD 1.33); relaxation group 0.03 (SD 1.16); P=0.002). At eight months these differences were no longer apparent. Forty-seven per cent in the patient education group self-reported improvement compared with 13% in the relaxation group (chi2=13.65; P=0.0001). CONCLUSION: Short-term improvements resulted from the education -exercise programme but were not sustained. Appropriate selection may improve efficacy.

Antidepressive Agents↗

The effect of a community intervention trial on parental knowledge and awareness of antibiotic resistance and appropriate antibiotic use in children.

BACKGROUND: Overuse of antibiotics for children's upper respiratory infections is widespread and contributes to the emergence of antibiotic-resistant bacteria. OBJECTIVE: To assess changes in knowledge and awareness regarding antibiotic resistance and appropriate antibiotic use after community-wide educational interventions to reduce inappropriate antibiotic use. DESIGN: Baseline survey conducted during June through July 1997 and postintervention survey of baseline participants during June through August 1998. SETTING: Communities in northern Wisconsin. PARTICIPANTS: Parents of 729 randomly selected children <4 years of age were called until 215 in each of the intervention and control areas were reached. Of the 430 baseline participants, 365 (85%) participated in the postintervention survey. INTERVENTION: Parent-oriented activities included distribution of materials and presentations. Physician-oriented activities included formal presentations and small group meetings. OUTCOME MEASURE: Change in awareness about antibiotic resistance and knowledge about antibiotic indications. RESULTS: A higher proportion of parents in the intervention area (53%) were exposed to 2 or more local educational messages, compared with the control area (23%). From the baseline to the postintervention survey, the percentage of parents with a high degree of antibiotic resistance awareness increased more in the intervention area (58% to 73%) than in the control area (60% to 65%). In the intervention area, there was also a larger increase in knowledge regarding appropriate indications for antibiotic use, compared with the control area. The proportion of parents who expected an antibiotic for their child and did not receive one declined in the intervention area (14% to 9%), while it increased in the control area (7% to 10%). In addition, the percentage of parents in the intervention area who brought their child to another physician because they did not receive an antibiotic decreased (5% to 2%), while it increased in the control area (2% to 4%). CONCLUSION: Parental knowledge and awareness about antibiotic indications and antibiotic resistance can be changed with educational interventions directed at parents and clinicians.

Adult↗

Teaching teenagers with autism to seek assistance when lost.

Three teenagers with autism were taught to respond to a vibrating pager to seek assistance in community settings when physically separated from their parents or teachers. A multiple baseline probe design across participants demonstrated that, upon being paged, participants successfully handed a communication card to a community member indicating that they were lost. Generalization was assessed in nontraining community sites and on outings with the participants' parents.

Adolescent↗

Assessing cognitive ability in research: use of MMSE with minority populations and elderly adults with low education levels.

The Mini-Mental State Examination (MMSE), originally designed to screen for dementia, is an instrument currently used extensively to assess cognitive status in clinical and community settings. This descriptive study compares standard MMSE scores to MMSE scores adjusted for age and education in a sample of 414 elderly Black and White women living independently in communities. After scores were adjusted, 14 participants (all Black) were moved from categories of mild cognitive impairment to unimpaired cognitive ability. However, even after scores were adjusted for age and education, White elderly adults still had higher mean scores than Black elderly adults (p = .003), suggesting that racial differences may have an effect on MMSE performance independent of age and education. Further research is needed to better understand the interaction of race and culture on MMSE outcomes. Implications are offered for appropriate use of the MMSE considering factors of age, education, and racial differences to guide evidence-based practice by gerontological nurses engaged in work with elderly populations.

Black or African American↗

Transfers to civil psychiatric inpatient services from a maximum security forensic hospital.

OBJECTIVE: To examine inpatients discharged from a forensic psychiatric hospital to a civil hospital at the completion of their correctional sentence. METHOD: Extract information from a patient database. RESULTS: About 20% of the discharges from the New York State forensic hospital that serves mentally ill state prison inmates, Central New York Psychiatric Center (CNYPC), are transferred to a civil psychiatric hospital; the remainder are returned to a correctional setting. Although their diagnoses, Global Assessment of Functioning scores, and number of prior inpatient admissions are similar, CNYPC transfers stay 1(1/2) times as long in their civil hospital admission as other civil hospital admissions. If total inpatient hospitalization before release to the community at large is considered (CNYPC plus the subsequent civil hospital), the stay is about 2(1/2) times as long. Fifty-two percent of the CNYPC transfers had been incarcerated for violent offenses and 28% are re-hospitalized within 12 months after release from the civil hospital. DISCUSSION: Longer lengths of stay in the civil hospital for these CNYPC transfers do not seem to be related to psychiatric functioning. Instead, it may be related to being harder to place in a community setting. All these CNYPC transfers have prison histories, many have a violent offense history, and all have been geographically remote from their home communities for a long time periods. As a result, the social support networks of CNYPC transfers may be weaker than those of other civil inpatients. The families and neighborhood agencies of CNYPC transfers are probably less willing to accept them on their return than those of other civil patients.Enhanced discharge planning and support services targeted specially for correctional transfers to a civil psychiatric inpatient environment should be considered. These type of service may reduce inpatient length of stay and thereby allow the inpatient resources to be used by other patients.

Forensic Psychiatry↗

Pain management in frail, community-living elderly patients.

BACKGROUND: Pain is a common problem among older people living in different community settings. As indicated by the World Health Organization (WHO), pain can be relieved using pharmacologic agents. However, pain continues to be addressed inadequately. OBJECTIVES: To describe the prevalence of pain in frail elderly people living in the community and to evaluate the adequacy of pain management. METHODS: We analyzed data from a large collaborative observational study group, the Italian Silver Network Home Care project, that collected data on patients admitted to home health care programs. Twelve home health care agencies participated in the project evaluating the implementation of the Minimum Data Set for Home Care instrument. We enrolled 3046 patients, 65 years and older, in the present study. The main outcome measures were the prevalence of daily pain and analgesic treatment. RESULTS: A total of 1341 individuals (39%, 49%, and 41% of those aged 65-74, 75-84, and > or = 85 years, respectively) reported daily pain. Of patients with daily pain, 25% received a WHO level 1 drug; 6%, a WHO level 2 drug; and 3%, a WHO level 3 drug (eg, morphine sulfate). Patients 85 years or older were less likely to receive analgesics compared with the younger patients (univariate odds ratio, 0.73; 95% confidence interval [CI], 0.60-0.89). Another independent predictor of failing to receive any analgesic was low cognitive performance (adjusted odds ratio, 0.80; 95% CI, 0.69-0.93). CONCLUSIONS: Daily pain is prevalent among frail elderly patients living in the community and is often untreated, particularly among older and demented patients.

Aged↗

Breaking the circuit of social control: lessons in public psychiatry from Italy and Franco Basaglia.

Much public discourse in the United States and in Canada acknowledges the dismal failure of the policy to 'deinstitutionalize' mental patients and to return them to some semblance of community living. The American Psychiatric Association has recently called for a reassessment of institutional alternatives--a call for a return to the asylum--in response to the needs of the new population of so-called homeless mentally ill. Here we contrast the failures of North American deinstitutionalization with the relative successes achieved in those regions of Italy where deinstitutionalization was grounded in a grassroots alternative psychiatry movement and professional and political coalition, Psichiatria Democratica. Democratic psychiatry challenged both the medical and the legal justifications for the segregative control of the 'mentally ill': madness as disease, and the constant over-prediction of the dangerousness of the mental patient. In addition, the movement challenged traditional cultural stereotypes about the meanings of madness, and was successful in gaining broad-based community support from political parties, labor unions, student groups, and artist collectives that were enlisted in the task of reintegrating the ex-mental patient. The Italian experiment, although flawed and riddled with its own inconsistencies and contradictions, offers evidence that deinstitutionalization can work without recreating in the community setting the same exclusionary logic that was the foundation of the asylum system.

Community Psychiatry↗

Trends and outcomes associated with angiotensin-converting enzyme inhibitors.

BACKGROUND: Limited recent data are available describing the patterns of use of angiotensin converting enzyme inhibitor (ACEI) therapy in patients with acute myocardial infarction (AMI), particularly from the more generalizable population-based setting. The purpose of this study was to examine trends in the receipt of ACEIs and associated short-term outcomes in patients hospitalized with AMI in a large Northeastern community. METHODS: We conducted a community-wide study of 7991 patients hospitalized with AMI in all metropolitan Worcester, Massachusetts, medical centers during 8 annual periods between 1990 and 2003. RESULTS: Among all patients, 44% received ACEI therapy during their acute hospitalization. There was a marked increase in the use of ACEIs between 1990 (23%) and 2003 (68%), particularly among those who were not on ACEIs before hospitalization. Patients who were previously on ACEIs were more likely to receive this therapy during hospitalization for AMI than were patients who were not previously on this therapy. Patients treated with ACEIs were significantly less likely to die (adjusted odds ratio [OR] 0.33; 95% confidence interval [CI] 0.27-0.41) during hospitalization than were patients who did not receive this therapy, with benefits observed across all subgroups examined. CONCLUSIONS: The results of this observational study demonstrate marked increases in the use of ACEIs in patients with AMI in the community setting and demonstrate the benefits to be gained from use of this therapy. Despite these encouraging trends, there remains room for more optimal use of this therapy.

Aged↗

Fault-lines in community treatment order legislation.

This article discusses the major tension points in the legislation that authorises involuntary outpatient treatment for mental disorder in six British Commonwealth jurisdictions. Particular attention is paid to the role of competence (or capacity) principles in the ruling legal criteria, to the precise powers of community treatment conferred, and to the potential impact of the legislation on clinicians' liability concerns. It is argued that the conferral on clinicians of a power to administer 'forced medication' in community settings is not required to promote active use of involuntary outpatient care, and that such a power should not be provided. The article concludes with discussion of the reasons why community treatment orders are used more frequently in some jurisdictions than others.

Ambulatory Care↗

Weight-loss practices, nutrition beliefs, and weight-loss program preferences of urban American Indian women.

OBJECTIVE: To describe health beliefs, weight concern, dieting practices, and weight-loss program preferences of American Indian women residing in an urban setting. DESIGN: Face-to-face interviews using a semistructured questionnaire were conducted and height and weight were measured. SUBJECTS/SETTING: Subjects were 203 American Indian adult women in an urban community setting. STATISTICAL ANALYSIS: Frequency distributions and chi 2 analysis were performed using the Statistical Analysis System software. RESULTS: About two-thirds of the subjects were overweight. Most women were concerned about obesity and reported attempting to manage their weight. Healthful weight-loss practices (e.g., eating more fruits and vegetables, increasing physical activity) were used most frequently. However, unhealthful practices, such as skipping meals/fasting, using laxatives/diuretics, and self-induced vomiting were also mentioned. Regular bingeing was reported by 10% of respondents. APPLICATIONS: Weight-management intervention efforts should focus on helping clients modify their diet and physical activity patterns. Low-cost programs offered in convenient locations would attract more participants, as would the provision of child care. Education about the dangers and ineffectiveness of unhealthful weight-loss practices will be necessary, given the high rates of such behaviors in this population.

Adult↗

Ten steps to create an innovative community-based pediatric experience as part of a clinical practicum: a model.

Innovative and alternative learning experiences are needed for students to obtain essential parts of the pediatric nursing clinical experience. This article presents a Ten Step approach guide for nurse educators to develop and implement a community-based pediatric primary health care model in a clinical practicum. The community pediatric primary health care experience is part of the San Jose State University School of Nursing's Nurse Managed Centers. Our approach focuses on providing community-based primary health care by faculty and nursing students to culturally diverse, underserved children and families in community settings in and around the university.

Child↗

Entry into community-based nursing practice: perceptions of prospective employers.

To better prepare new graduates for entry-level positions in community settings, faculty of one college of nursing gathered information using focus groups of prospective employers. The groups were to identify the skills and qualities nurses need to practice in the community and ways to redesign nursing curricula to better prepare undergraduates for community-based practice. Data for this qualitative study were collected in five separate focus groups conducted with prospective employers (N = 18) from four major areas of Kentucky. By collaborating with prospective employers in the community, a partnership was established between nurse educators and community health leaders to improve the marketability of baccalaureate graduates. Assessment was the most frequently named skill essential to nursing practice in the community. Independence, critical thinking, collaboration, and confidence consistently emerged as important skills and qualities. Prospective employers were positive about developing partnerships to improve under-graduate nursing curricula. Recommendations for curricula to better prepare undergraduates for community-based practice are suggested.

Community Health Nursing↗

Minor psychiatric morbidity in employed men and women and its contribution to sickness absence.

A pilot study is described on 41 men and women of similar age, social and educational backgrounds, in 2 working environments. The use of psychiatric interviews in such occupational settings is demonstrated to be acceptable to both management and employees. Preliminary coefficients of validity for the General Health Questionnaire are found to compare favourably with those in clinical or community settings. Though the prevalence of minor psychiatric morbidity in these small samples did not differ between the sexes, the women had twice as many spells of absence as the men. Considering women separately, minor psychiatric morbidity was found to be significantly correlated with absence. However, psychiatric illness was a less important predictor of absence in men.

Absenteeism↗

Sooner or later? Issues in the early diagnosis of dementia in general practice: a qualitative study.

OBJECTIVE: The aim of this study was to explore the perspectives of primary care practitioners on the early diagnosis of dementia. METHODS: A total of 247 GPs, 146 community nurses, 36 practice nurses, 79 community mental health nurses and others working in a range of hospital, residential and community settings attended 24 one-day workshops in 21 cities and towns in the UK. A nominal group approach was used relating to the early diagnosis of dementia in the community. RESULTS: Groups agreed on the benefits and risks of early diagnosis of dementia; disagreed about screening for dementia, and about professional resistance to making the diagnosis; constructed comprehensive guidelines on diagnosis, but without much reference to resource implications; yet described actual local resource limitations in detail; and avoided dilemmas about dementia care by framing it as a specialist activity. CONCLUSION: Practitioners situate dementia in a family context but do not yet use a disablement model of dementia which might reduce tensions about early diagnosis and the disclosure of the diagnosis. The term diagnosis could usefully be replaced by recognition, to aid this shift in model. Service gaps may emerge or widen if earlier diagnosis of dementia is pursued as a policy objective.

Attitude of Health Personnel↗

Activation symptoms and discharge in elderly chronic schizophrenic inpatients.

Three hundred thirty-three elderly schizophrenic inpatients were rated on the Positive and Negative Syndrome Scale (PANSS), and those remaining in the hospital after 1 year (N = 267) were rated and followed for an additional year. Based on previous studies showing that aggressive episodes and hostile behavior predicted inability to discharge schizophrenics, we hypothesized that low discharge rates would be correlated with high baseline ratings on the activation factor of the PANSS (PANSS-AF), obtained by summing six items (hostility, poor impulse control, excitement, uncooperativeness, poor rapport, and tension). Baseline PANSS-AF scores were found to be inversely correlated with discharge rates, independent of ratings on other symptom dimensions. PANSS-AF scores were a better predictor of outcome than any individual PANSS item (e.g., hostility), and individual item scores did not add significantly to prediction of discharge. Attention to and development of treatments for activation symptoms, highly prevalent in schizophrenia but not included in our present diagnostic systems, may increase the chances of elderly inpatients with schizophrenia of moving to community settings.

Brief Psychiatric Rating Scale↗

Enhancing students' perspectives of health through non-traditional community experiences.

The shift in emphasis to community-based health care necessitates that opportunities be provided for nursing students to acquire an understanding of the complex nature of health. A qualitative study was used to demonstrate the benefits accrued by junior baccalaureate nursing students in non-traditional community settings. Key themes that emerged from data analysis included definitions of health and illness as context specific, and environmental factors influencing health. The study demonstrated that learning experiences with diverse communities can broaden students' perspectives and understanding of health behaviours. Students gained an appreciation of the sociocultural variation in meanings of health and illness as well as of the social and political dimensions of health.

Adult↗

Houston paramedic and emergency stroke treatment and outcomes study (HoPSTO).

BACKGROUND AND PURPOSE: Establishment of stroke centers, combined with accurate paramedic diagnosis and rapid transport, is essential to deliver acute stroke therapy. We wanted to measure and improve paramedic and hospital performance through implementation of the Brain Attack Coalition and American Stroke Association guidelines. METHODS: Pre-intervention and active-intervention phases with parallel data measurement points were used. The study involved six hospitals comprising the majority of acute-stroke admissions in Houston, Tex. Hospital, paramedic, and patient data were collected prospectively pre-intervention and during the active-intervention phase on all suspected acute-stroke patients admitted by Houston Fire Department-Emergency Medical Services. A multilevel educational intervention included paramedic, hospital, and community education. Paramedic diagnostic accuracy, hospital-performance efficiency, and thrombolytic treatment rates were the main outcome measures of the study. RESULTS: Four hundred forty-six patients (74 per month) were transported in the pre-intervention phase to participating hospitals (59.8% of all suspected stroke patients transported city wide by Houston Fire Department-Emergency Medical Services), compared with 1072 patients (89 per month, or 68.7%) transported in the active-intervention phase (P<0.001). Accuracy of paramedic diagnosis of stroke increased from 61% to 79%. Admission within 2 hours of symptom onset increased from 58% to 62% (P=0.002). Thrombolysis rates increased in 4 of 6 centers, with 1 post- tissue plasminogen activator hemorrhage (3.7%) reported. CONCLUSIONS: A multilevel educational program improves rapid hospitalization and paramedic diagnostic accuracy and increases the number of patients presenting for evaluation within the 3-hour tissue plasminogen activator window. Stroke center development supports safe thrombolytic practice in community settings.

Aged↗