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PubMed1999

Correlates of alcohol and drug use among low-income Hispanic immigrant childbearing women living in the USA.

Alcohol and drug use is a widespread and serious problem with deleterious consequences for the health and well-being of childbearing-age women and their children. Little information exists regarding etiological factors for substance use among Hispanic childbearing-age women immigrating to the United States (USA). This research provides a correlational analysis of factors associated with alcohol and drug use. The Social Stress Model for Substance Use Prevention provided the conceptual framework for this cross-sectional, interview-administered survey of 60 low-income predominantly Mexican-American women. The outcome variable was alcohol and drug use (alcohol, cigarettes, marijuana, cocaine and opiates). Independent variables included the major constructs of the model: stress, social support, social influences, personal competencies and community resource utilization patterns. Findings suggested that the levels of drug use were lower among this study sample than in the general USA population regardless of pregnancy status. Bivariate correlations demonstrate that women with higher drug use indices had more lenient attitudes regarding drug use and were more likely to have family and friends that used alcohol and drugs. Although drug use was relatively low among this sample of women, both women who used alcohol themselves and women whose partners used alcohol and drugs reported significantly higher levels of stress, weaker social support and poorer levels of self esteem. Implications for practice and future research are suggested.

Adolescent↗
PubMed2002

Photoinduced electron-transfer processes along molecular wires based on phenylenevinylene oligomers: a quantum-chemical insight.

Quantum-chemical techniques are applied to model the mechanisms of photoinduced charge transfer from a pi-electron donating group (tetracene, D) to a pi-electron-acceptor moiety (pyromellitimide, A) separated by a bridge of increasing size (p-phenylenevinylene oligomers, B). Correlated Hartree-Fock semiempirical approaches are exploited to calculate the four main parameters controlling the transfer rate (k(RP)) in the framework of Marcus-Jortner-Levich's formalism: (i) the electronic coupling between the initial and final states; (ii) and (iii) the internal and external reorganization energy terms; and (iv) the variation of the free Gibbs energy. The charge transfer is shown to proceed in these compounds through two competing mechanisms, coherent (superexchange) versus incoherent (bridge-mediated) pathways. While superexchange is the dominant mechanism for short bridges, incoherent transfer through hopping along the phenylene vinylene segment takes over in longer chains (for ca. three phenylenevinylene repeat units). The influence of the chemical structure of the pi-conjugated phenylenevinylene bridge on the electronic properties and the rate of charge transfer is also investigated.

Journal Article↗
PubMed2004

Australian and New Zealand birth cohort studies: breadth, quality and contributions.

OBJECTIVE: To understand factors associated with successfully conducting longitudinal studies across early childhood by (i) describing the designs of Australian and New Zealand birth cohort studies; (ii) describing the breadth of variables studied; and (iii) identifying factors influencing study quality, productivity and contributions. METHODS: A systematic review was undertaken of 13 birth cohort studies. Data were collected from published papers and questionnaires administered to study investigators. RESULTS: These single cohort studies recruited children prior to their first birthday. Using an ecological model as an organizing framework, the studies were found to have contributed to knowledge about health and development in multiple domains and well beyond early childhood. Areas for increased focus included policy-relevant environmental factors such as child-care and rural/urban differences, and the influence of fathers, family factors, peers, social competence, and genetic factors. Investigators' responses indicated desires for an increased depth of data collection and stronger sampling designs. Data quality was enhanced by maintaining skilled staff and reduced by inadequate data for tracking study participants. Productivity ranged from 1 to 760 publications per study (median = 14.0). The most productive studies were those that had started before 1990, had representative samples, ongoing funding, and larger research teams. Policy impacts have included changed infant sleeping practices, reduced environmental lead emissions and regulated swimming pool safety standards. CONCLUSIONS: A suite of coordinated and nested studies could meet sampling needs and facilitate depth of inquiry. Stable, long-term funding is required to staff and maintain well-designed longitudinal studies that can address priority research areas and contribute to the development of health and social policy.

Australia↗
PubMed2006

Quality and safety by design.

Rather than continuing to try to measure the width and depths of the quality chasm, a legitimate question is how does one actually begin to close the quality chasm? One way to think about the problem is as a design challenge rather than as a quality improvement challenge. It is time to move from reactive measurement to a more proactive use of proven design methods, and to involve a number of professions outside health care so that we can design out system failure and design in quality of care. Is it possible to actually design in quality and design out failure? A three level conceptual framework design would use the six quality aims laid out in Crossing the quality chasm. The first or core level of the framework would be designing for patient centered care, with safety as the second level. The third design attributes would be efficiency, effectiveness, timeliness, and equity. Design methods and approaches are available that can be used for the design of healthcare organizations and facilities, learning systems to train and maintain competency of health professionals, clinical systems, clinical work, and information technology systems. In order to bring about major improvements in quality and safety, these design methods can and should be used to redesign healthcare delivery systems.

Delivery of Health Care↗
PubMed1999

Cross-cultural primary care: a patient-based approach.

In today's multicultural society, assuring quality health care for all persons requires that physicians understand how each patient's sociocultural background affects his or her health beliefs and behaviors. Cross-cultural curricula have been developed to address these issues but are not widely used in medical education. Many curricula take a categorical and potentially stereotypic approach to "cultural competence" that weds patients of certain cultures to a set of specific, unifying characteristics. In addition, curricula frequently overlook the importance of social factors on the cross-cultural encounter. This paper discusses a patient-based cross-cultural curriculum for residents and medical students that teaches a framework for analysis of the individual patient's social context and cultural health beliefs and behaviors. The curriculum consists of five thematic units taught in four 2-hour sessions. The goal is to help physicians avoid cultural generalizations while improving their ability to understand, communicate with, and care for patients from diverse backgrounds.

Adult↗
PubMed1993

Humanized Mik beta 1, a humanized antibody to the IL-2 receptor beta-chain that acts synergistically with humanized anti-TAC.

Mik beta 1 is a mouse mAb directed at the beta-subunit of the human IL-2R (Tac) that inhibits IL-2 binding and inhibits IL-2 induction of large granular lymphocytes (LGL). Mik beta 1 alone does not inhibit IL-2-induced T-cell proliferation, but acts synergistically with anti-Tac to inhibit IL-2-induced proliferation of activated T cells. To evaluate these effects for possible therapy in humans, we constructed two humanized Mik beta 1 antibodies by combining the complementarity-determining regions of the murine antibody with human framework and constant regions. Compared with murine Mik beta 1, the two humanized Mik beta 1 antibodies, which differ in their degree of humanization, had similar affinities for IL-2R beta. The murine Mik beta 1 and one of the humanized Mik beta 1 antibodies were equivalent in competing for IL-2 binding to IL-2R beta and inhibiting IL-2 induction of LGL cytotoxicity. The activity of the second humanized antibody was significantly reduced. The three Mik beta 1 antibodies act synergistically to varying degrees with humanized anti-Tac to prevent IL-2-induced proliferation of activated T cells. This capacity to synergize paralleled their abilities to inhibit IL-2 binding. In addition, both humanized antibodies directed antibody-dependent cell-mediated cytotoxicity. We hope that humanized Mik beta 1 in combination with humanized anti-Tac will provide a new immunosuppressive therapy for the treatment of autoimmune diseases, graft-versus-host disease, and prevention of allograft rejection.

Amino Acid Sequence↗
PubMed1987

Interviewing and examination skills in paediatric medicine: videotape analysis of student and consultant performance.

Taking an adequate history and competently examining a patient remain essential prerequisites for making a diagnosis. Four 5th year medical students who had completed 18 months of clinical teaching were assessed at the start and end of their ten-week paediatric term and compared with 4 experienced consultants. A videorecording was made of each patient encounter. The students' history was often incomplete, at times inaccurate and imprecise, despite earlier provision of a framework to obtain the necessary information. The students spent a great proportion of their time examining the child, yet their findings were questionable particularly if the child was uncooperative. The second recording made at the end of the student's paediatric term revealed a general improvement in their confidence and knowledge, though similar deficiencies were observed. The consultants, as expected, did better. They also showed a greater awareness of understanding the child within the context of his family. They spent more time interviewing the parent and child, offered a fuller explanation of the diagnosis and carefully reviewed the management. These findings further emphasize the need to improve and assess the clinical performance of students.

Clinical Competence↗
PubMed1986

A clinical evaluation tool for nursing students based on the nursing process.

An integrated curriculum was implemented in an upper division baccalaureate nursing program which required letter grades for clinical courses. The second semester clinical course involved student evaluation in four different settings. The original evaluation tool lacked both the discrimination needed for letter grades and the competencies common to all the settings. A computerized evaluation tool was developed to identify behaviors which could be evaluated and assigned a letter grade in all four clinical settings, and to provide formative and summative evaluation of performance for students throughout the semester. The tool focuses on the four areas of the nursing process, each of which is weighted according to the conceptual framework of the curriculum and the ability of a student at this level. In each of these four areas, entry level behaviors were identified and then built upon by progression from fundamental skills to more complex and independent behaviors. Students are rated on a criterion-referenced rating scale. A statistician verified that the tool was mathematically sound. Once developed, the tool was placed on computer where both students and faculty evaluate student clinical performance every two to four weeks. Because the tool was placed on computer, students receive immediate feedback, which facilitates formative evaluations. Trends in student performance can be identified easily, and faculty paperwork is decreased. The tool also promotes objectivity in evaluation and student awareness of expected behaviors. Finally, faculty and students have become more familiar and more comfortable with computers.

Clinical Competence↗
PubMed2003

Physicians' reasons for failing to deliver effective breast cancer care: a framework for underuse.

OBJECTIVE: Despite numerous randomized trials showing the health benefits of systemic and local therapies for early-stage breast cancer, underuse of these therapies remains a significant quality problem. Little is known about causes of underuse of effective cancer treatments. We sought to understand these causes to design effective interventions to improve care. RESEARCH DESIGN: To identify categories of causes of underuse, semistructured interviews were performed with physicians of breast cancer patients who did not receive effective adjuvant care in the 4 years following surgery. Underuse was defined by expert consensus based on evidence-based guidelines. SUBJECTS: Surgeons (n = 13) of all early-stage breast cancer cases who underwent surgical treatment at a tertiary care hospital and had underuse of local or systemic adjuvant therapies. RESULTS: Of all the 275 women with early-stage breast cancer, there were 44 episodes of underuse of effective therapies (16%). In 48% of cases, physicians thought treatment should occur but the treatment failed to take place (32%) or the patient refused (16%). For the other 52% of cases, physicians thought treatment should not occur because evidence did not support treatment in clinical circumstances such as older age (32%), a good prognosis based on tumor size or histology (11%), a second primary breast cancer (5%), or because of comorbidities (5%). All surgeons were aware of the benefits of adjuvant treatments. CONCLUSIONS: Causes of underuse can be identified and categorized. Using these categories, a framework of causes of underuse was constructed and interventions targeting the specific causes to improve the quality of care are suggested.

Aged↗
PubMed1998

Mentoring and self-efficacy for advanced nursing practice: a philosophical approach for nurse practitioner preceptors.

Nurse practitioners (NPs), frequently called upon by graduate schools of nursing to be preceptors for NP students, are asked to play an active role in the socialization of these students as capable primary care providers. Much is expected of the preceptor in the typical short-term clinical preceptorship with little guidance available to her or him. A mentoring model of clinical education, while representing a longer-term commitment for preceptors than usual precepting arrangements, may ultimately be a more effective model for student learning and more satisfying for the preceptor than currently practiced models. Eastern philosophical principles, very much in harmony with valued nursing approaches to relationships, can provide a framework for examining mentoring as a strategy for promotion of self-efficacy for advanced practice that can be of benefit to both the NP preceptor and the NP neophyte.

Clinical Competence↗
PubMed2003

Using case studies to evaluate students' ability to develop a geriatric interdisciplinary care plan.

The Geriatric Interdisciplinary Team Training (GITT) program, an educational intervention funded by The John A. Hartford Foundation of New York City, has trained more than 1800 health care professions students and clinicians throughout the United States. Evaluating the effectiveness of this training intervention has proven to be quite a challenge. Core measures were collected pre- and post-GITT training to evaluate student development as a result of GITT. This paper focuses on one of these core measures, the Test of Geriatric Interdisciplinary Care Planning (TGICP). This instrument, developed for the GITT program, is one mechanism created to test trainees' ability to develop an interdisciplinary plan of care. Using a case study methodology, this two-part instrument provides an innovative approach to quantifying and correlating responses from an interdisciplinary cohort of students. This paper will describe the development of the TGICP, including the creation and validation of the case studies, the framework for the questionnaire, and the coding and scoring mechanism created to evaluate trainee responses.

Aged↗
PubMedDate not supplied

The dilemmas of experiential teaching: toward an interpretive approach.

Continuing education in nursing uses the experience of the learner as a basis for the examination of practice issues. The unique and personal nature of this experimental learning is, however, particularly problematic where assessment of the learner or the course is required. This article offers part of the findings from an evaluative, ethnomethodological study into the reflections of learners attending an experiential course in communication in palliative care. In the part of the study described here, the critical perceptions of three learners following one experiential exercise are compared with the stated aims of the facilitators and their subsequent actions. The analysis uses the conceptual framework of Schön's reflection-in-action. It is suggested that an interpretive approach toward teaching in the experiential domain may lead to a more relevant assessment of learning.

Clinical Competence↗
PubMedDate not supplied

Forum fever.

The RCN has consulted widely on its review of the professional membership structure and its preferred option will be put before the council this month. But not all the forums are in wholehearted support. The RCN has 76 RCN forums and 46 subgroups. RCN members can join any three forums. About 80 per cent of members are not active within the organisation. By redesigning the professional development framework it is hoped more members will become active. Members say they want more professional activity at local level.

Attitude of Health Personnel↗
PubMed2005

Assessing communication competence: a review of current tools.

BACKGROUND: The assessment of communication competence has become a major priority of medical educational, policy, and licensing organizations in the United States and Canada. Multiple tools are available to assess communication competence, but there are few studies that compare the tools. METHODS: A consensus panel of six family medicine educators evaluated 15 instruments measuring the physician-patient interview. The primary evaluation criteria came from the Kalamazoo Consensus Statement (KCS), which derived from a multidisciplinary panel of experts that defined seven essential elements of physician-patient communication. We evaluated psychometric properties of the instruments and other assessment criteria felt to be important to family physicians (exploring family issues, interview efficiency, and usability/practicality). RESULTS: Instruments that received the highest ratings on KCS elements were designed for faculty raters and varied in their practicality/usability ratings and psychometric properties. Few instruments were rated high on psychometric properties or exploring family issues. CONCLUSIONS: The process successfully reviewed and provided a framework for assessing communication skills instruments. There is a need to expand the study, including use of a larger cohort of reviewers to provide more validity to the results and minimize potential biases.

Aptitude Tests↗
PubMed2007

Data protection in biomaterial banks for Parkinson's disease research: the model of GEPARD (Gene Bank Parkinson's Disease Germany).

Parkinson's disease (PD) is the second most common neurodegenerative disease. Although 10 gene loci have been identified to cause a Parkinsonian syndrome, these loci account only for a minority of PD patients. Large, systematic research programs are required to collect, store, and analyze DNA samples and clinical information to support further discovery of additional genetic components of PD or other movement disorders. Such programs facilitate research into the relationship between genotype and phenotype. The German Competence Network on Parkinson's disease (CNP) initiated the Gene Bank Parkinson's Disease Germany (GEPARD), providing an administrative and scientific infrastructure for the storage of DNA and clinical data that are electronically accessible and protective of patient rights. In this article, we offer guidance on how to establish a framework for a clinical genetic data and DNA bank, and describe GEPARD as a model that may be useful to other local, national, and international research groups developing similar programs.

Computer Security↗
PubMed2004

Challenges in the care of the acutely ill.

Health care providers, hospital administrators, and politicians face competing challenges to reduce clinical errors, control expenditure, increase access and throughput, and improve quality of care. The safe management of the acutely ill inpatient presents particular difficulties. In the first of five Lancet articles on this topic we discuss patients' safety in the acute hospital. We also present a framework in which responsibility for improvement and better integration of care can be considered at the level of patient, local environment, hospital, and health care system; and the other four papers in the series will examine in greater detail methods for measuring, monitoring, and improving inpatient safety.

Critical Care↗
PubMed2003

Should consensus be 'the commission method' in the US? The perspective of the Federal Advisory Committee Act, regulations, and case law.

This paper examines the drive for consensus from the perspective of the good government framework for federal advisory commissions in the United States. Specifically, the paper examines the Federal Advisory Committee Act (FACA)--the statute, its regulations, and case law. It shows that the FACA was intended to be an antidote to abuses in consensus-making processes, including the failure to fully include competing views on commissions. The index of suspicion in the FACA scheme rises when a group work product--including a consensus report--is to be the basis of recommendations to federal officials. Once FACA's requirements regarding committee composition are satisfied, the index of suspicion drops and FACA is indifferent to consensus-making; but the conditions for informed, meaningful participation apply to members who dissent from, as well as those who participate in, consensus. In negotiated rulemaking, the push for consensus and closure creates unacceptable tension with the good government goals of openness and accountability. Proponents of consensus-only bioethics commissions can learn from FACA-related legislative, agency, and judicial insights that consensus-seeking is not always desired by government officials; is rarely cost free; and that diversity and dissent enhance openness, accountability, and fairness. The burden of proof is therefore on proponents of a consensus-only standard for bioethics commissions to demonstrate that a drive for consensus furthers sound decision-making by government officials more than it sets back openness and accountability to a diverse public.

Advisory Committees↗