Showing papers in "Journal of The American Academy of Nurse Practitioners in 2008"

Caregiver burden among dementia patient caregivers: a review of the literature.

Abstract: Purpose: To identify current evidence of factors influencing dementia-related caregiver burden (CB), describe patient and caregiver characteristics associated with CB, and describe evidence-based interventions designed to lessen the burden of caregiving. Data sources: Comprehensive literature review of Cumulative Index of Nursing and Allied Health Literature, MEDLINE, and Psych Info was performed for the years 1996–2006 of peer-reviewed journals using keywords CB and dementia. Conclusion: Dementia caregiving has been associated with negative effects on caregiver health and early nursing home placement for dementia patients. Many factors influence the impact of the caregiving experience such as gender, relationship to the patient, culture, and personal characteristics. Although various interventions have been developed with the goal of alleviating CB, evidence suggests that individually developed multicomponent interventions including a diversity of services will decrease burden, improve quality of life, and enable caregivers to provide at-home care for longer periods prior to institutionalization. Implications for practice: The ability to properly assess the dementia patient–caregiver dyad related to CB is critical to decreasing its negative physical and psychological health outcomes. Appropriately tailored interventions can improve the health and well-being of both caregiver and patient.

Patient-centered care and adherence: Definitions and applications to improve outcomes

Abstract: Purpose: The implementation of patient-centered care (PCC) has been hampered by the lack of a clear definition and method of measurement. The purpose of this review is to identify the fundamental characteristics of PCC to clarify its definition, propose a method for measurement of PCC, and recommend effective PCC practices. Data sources: Review of literature related to PCC, adherence and communication from Cinahl, PubMed Academic Search Premier, and Cochrane Library databases. Conclusions: Research has shown that patient-centered interactions promote adherence and lead to improved health outcomes. The fundamental characteristics of PCC were identified as (a) patient involvement in care and (b) the individualization of patient care. The use of a numeric rating scale to measure the presence of these characteristics allows quantification from the patient perspective. Effective PCC practices were related to communication, shared decision making, and patient education. Implications for practice: PCC is a measure of the quality of health care. Understanding the characteristics of PCC facilitates its implementation and measurement. Promoting PCC activities will improve adherence and encourage patient responsibility for health status.

Mindfulness-based stress reduction: a literature review and clinician's guide.

Abstract: Purpose: To provide nurse practitioners (NPs) with clinical research about Mindfulness-Based Stress Reduction (MBSR) and demonstrate its usefulness for reducing stress in a variety of populations. DataSources: A literature review was conducted using the following databases: EBSCO, Cinahl, Pschyline, and Medline. English language articles published between 2000 and 2006 in peer-reviewed journals were reviewed. Search terms ‘‘mindfulness,’’ ‘‘meditation,’’ and ‘‘stress’’ were used. Additional information was obtained through select, reputable Internet sites. Conclusions: MBSR is an effective treatment for reducing stress and anxiety that accompanies daily life and chronic illness. MBSR is also therapeutic for healthcare providers, enhancing their interactions with patients. No negative side effects from MBSR have been documented. Implications for practice: MBSR is a safe, effective, integrative approach for reducing stress. Patients and healthcare providers experiencing stress or stressrelated symptoms benefit from MBSR programs. NPs can safely and effectively use this intervention in a variety of patient populations.

Predisposing factors to phlebitis in patients with peripheral intravenous catheters: a descriptive study.

Abstract: Purpose: The purpose of this study was to investigate the predisposing factors in the development of phlebitis in peripheral intravenous (IV) catheterization sites in patients treated with a variety of IV infusion solutions and drugs. Data sources: Systematic observation of 568 IV sites inserted for fluid infusion and drug administration in 355 patients in the Department of General Surgery of a University Hospital in Turkey. A data collection tool was based on standards established by the Infusion Nurses Society. Patients’ infusion sites were monitored every 24 h during treatment and for 48 h after discontinuation of the IV. Conclusions: In contrast to the usual findings in the literature, the authors found that infusion through an infusion pump and insertion of catheters in the veins around the elbow increased the risk of phlebitis. Also, the number of times infusions were started led to an increased rate of phlebitis. However, conflicting results were obtained about the relation between phlebitis, gender, and catheter size. Implications for practice: Phlebitis causes sepsis, pain, additional diagnostic investigations, and treatments, and may lead to increased duration of hospitalization, patient’s stress level, and financial burden, as well as increasing staff workload. Advanced practice nurses need to be aware of the factors that increase the likelihood of phlebitis and take appropriate measures to prevent it.

Overweight and obesity in nurses, advanced practice nurses, and nurse educators.

Abstract: Purpose: To quantify the incidence of overweight and obesity in nursing professionals and assess nurses’ knowledge of obesity and associated health risks. Data sources: A mailed survey to 4980 randomly selected registered nurses from one state in each of six geographic regions. Response rate was 15.5% (n= 760). Descriptive statistics were calculated for continuous variables; categorical variables were summarized with frequency counts. Results: The grand mean body mass index (BMI) of nurses surveyed was 27.2. Almost 54% were overweight or obese. Fifty-three percent of these nurses report that they are overweight but lack the motivation to make lifestyle changes. Forty percent are unable to lose weight despite healthy diet and exercise habits. Only 26% of respondents use BMI to make clinical judgments of overweight and obesity. Although 93% of nurses acknowledge that overweight and obesity are diagnoses requiring intervention, 76% do not pursue the topic with overweight and obese patients. Discussion: Many nurses provide weight-related health information to the public. These data suggest that they may benefit from continuing education on obesity and its risks. Because 76% of nurses do not pursue the topic of obesity with patients, they may benefit from education on pursuing sensitive topics during a professional encounter. Nurse practitioners may play a key role in the education of both patients and registered nurses.

Nurse practitioners' communication styles and their impact on patient outcomes: an integrated literature review.

Abstract: Purpose: The purpose of this review was to examine the published research from 1999 to 2005 describing nurse practitioner (NP)–patient interactions and to determine the best practice to enhance patient outcomes. Data sources: Databases searched included Academic Search Elite, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Source Consumer Edition, Health Source Nursing/Academic Edition, Medline, and PsychInfo. Conclusions: Two communication styles described in the literature and determined by authors were (a) biomedical and (b) biopsychosocial. The biopsychosocial style is identified as patient-centered communication. Seven studies were then analyzed for NPs’ communication styles and the impact that they had on patient outcomes. The studies analyzed demonstrated that biopsychosocial (patient-centered) communication style positively influences patient outcomes as evidenced by (a) improved patient satisfaction, (b) increased adherence to treatment plans, and (c) improved patient health. Implications for practice: The results of this review indicate that patient-centered communication incorporated into the NPs’ practice is associated with improving patient outcomes such as (a) improved patient satisfaction, (b) increased adherence to treatment plans, and (c) improved patient health. Future research needs to be performed in order to fully study the relationship between NPs using patient-centered communication style and its impact on patient outcomes. Clinical recommendations are made based on findings of the integrated literature review.

Barriers to health care and health-seeking behaviors faced by Black men.

Abstract: Purpose: To describe unique barriers to health care and health-seeking behaviors faced by Black men and to make recommendations to healthcare providers for improving healthcare access for Black men. Data sources: A PubMed search for research articles published after 1999 was conducted. Conclusions: The articles selected for this state of the science clinical paper addressed barriers to access faced by Black men and/or management strategies used to mitigate barriers and improve access. The barriers identified include socioeconomic status, masculinity, racism, lack of awareness of the need for primary care, religious beliefs, and peer influences. As singular entities, these may not appear unique, but when viewed collectively, they represent an overwhelming constellation of obstacles for Black men. Implications for practice: Individual, community, state, and national level recommendations for nurse practitioner actions to improve healthcare access for Black men include public service announcements, radio commercials, and billboards aimed at raising awareness of healthcare issues in the Black community, provision of preventive services through health fairs, and development of positive provider–patient relationships.

Patient satisfaction with nurse practitioner care in emergency departments in Canada

Abstract: Purpose: To measure patient satisfaction with care delivered by nurse practitioners (NPs) in emergency departments (EDs) in Canada using a psychometrically valid survey. Data sources: All patients who received care from an NP in six participating EDs in Ontario province over a 1-week period were asked to complete a self-administered patient satisfaction survey designed specifically to assess satisfaction with NP care in EDs. Conclusions: One hundred and thirteen patients completed the survey. Principal components analysis of the survey revealed three factors or subscales: Attentiveness, Comprehensive care, and Role clarity. Scores on the three subscales indicated that patients were satisfied with Attentiveness (M = 3.72, SD = 0.38) and Comprehensive care (M = 3.52, SD = 0.49) and had a moderate understanding of Role clarity (M = 2.99, SD = 0.66). Participants with higher income levels reported higher levels of satisfaction with the attentiveness they received, whereas patients with previous experience with an NP reported higher levels of satisfaction with the comprehensive care they received. There was no appreciable increase in patient satisfaction with the NP based on age, gender, education, or health status. Implications for practice: These findings indicate that attentiveness, comprehensive care, and role clarity are reflected by the NP in emergency healthcare settings as indicated by the patient‘s responses to the survey. This study supports that meeting expectations is a critical component of patient satisfaction.

The illness beliefs, perceptions, and practices of Filipino Americans with hypertension.

Abstract: Purpose: The purpose of this study was to describe the illness beliefs, perceptions, and practices of Filipino Americans (FAs) with hypertension (HTN) to reveal their explanatory models (EMs) of the illness. Data sources: Audiotapes and transcripts of focus group interviews and observational notes were subjected to content analysis. Medical records and related empirical studies provided supporting data. Conclusions: In general, the EMs of FAs with HTN correspond to the biomedical model in relation to causes, consequences, and treatment of HTN. However, in spite of this biomedical knowledge, FAs with HTN have difficulty maintaining the required lifestyle changes and adhering to the medication regimen to control their illness. Implications for practice: It is important for NPs to assess the EMs of FAs with HTN, including their use of traditional folk remedies and practitioners of folk medicine. The challenge is to provide cardiovascular health promotion and education in a culturally sensitive, congruent, and tailored manner to FAs with HTN to help them control their illness.

Facilitating risk reduction among homeless and street-involved youth

Abstract: PURPOSE: The purposes of this evaluation project were to describe a group of homeless adolescents and street-involved youth who utilized a mobile unit that provided medical and mental healthcare services and to assess the efficacy of the services provided in reducing their health risk behaviors. DATA SOURCES: The records of 95 youth aged 15-25 years who used the medical mobile unit for an average of 14 months were examined and evaluated according to the national health indicators related to risk reduction. Current literature related to health risk behavior among homeless youth was reviewed, synthesized, and provided the background for this article. CONCLUSIONS: Data were obtained from the records of mostly heterosexual youth with a mean age of 20.5 years. Approximately one third of the participants were high school graduates and most were without health insurance. Living situations were transient including friends, shelters, crash pads, or the streets. Abuse accounted for the majority leaving home. Psychiatric conditions and substance abuse were common. Medical conditions were related to transient living situations, substance abuse, and sexual activity. Success of the program was associated with sustained counseling, stabilizing youth on psychotropic medications, decreasing substance use, providing birth control and immunizations, and treating medical conditions. IMPLICATIONS FOR PRACTICE: Homeless youth are one of the most underserved vulnerable populations in the United States with limited access and utilization of appropriate healthcare services. Nurse practitioners often serve as care providers but are also in a position to effectively lobby to improve health care for homeless youth through professional organizations and community activism. Furthermore, when designing and evaluating healthcare services, multidisciplinary teams need to consider risk reduction for homeless youth in the context of their environment. Language: en

Alliance not compliance: coaching strategies to improve type 2 diabetes outcomes.

Abstract: Purpose: To explore strategies for improving patient outcomes in type 2 diabetes. Data sources: The literature related to type 2 diabetes management, behavior change, communication, diabetes self-management, and coaching. Conclusions: The strategies currently suggested for improving patient outcomes, e.g., increasing provider adherence to evidence-based management guidelines, streamlining practice systems, and promoting patient lifestyle changes through intensive education, have produced mixed outcomes. Of the many complexities involved in managing type 2 diabetes, motivating patients to change behavior may be the most challenging. A suggestion for improving patient self-management of type 2 diabetes is to use coaching communication within a framework of behavior change in the context of the primary care encounter between nurse practitioners (NPs) and their patients. Implications for practice: Given the varied outcomes of current strategies, coaching by NPs may provide a feasible alternative for improving patient outcomes in type 2 diabetes. Coaching communication can be implemented during office visits as an intervention without cost. To effectively implement this approach, however, practicing NPs and NP students need more formal education in this expected but underdeveloped NP role competency. NPs are called upon to contribute to the body of knowledge needed to validate the merits of coaching for their patients.

Sodium dietary restriction, knowledge, beliefs, and decision‐making behavior of older females

Abstract: Purpose: The purposes of this qualitative/descriptive study were to (a) explore experiences and decision-making behaviors associated with adoption of a sodium-restricted diet (SRD) among older women with hypertension or heart failure and (b) identify healthcare system and contextual factors that facilitate or impede adherence to SRD. Data sources: Participants were 33 single older women, aged 65–98 years, residing in three congregate living facilities in the high-risk “coronary valley” area of the United States. A semistructured interview format was employed with three focus groups. The audio-taped transcribed data were content analyzed for themes by the researchers with the assistance of ATLAS.Ti computer software. Conclusions: Predominant themes were lack of SRD education by healthcare providers, a desire for more information about sodium, including the use of alternative herbal seasonings, and large-print informational materials. Eating alone with no motivation to cook and share meals was a contextual barrier to healthy nutrition. Implications for practice: To prevent costly hospitalizations and rehospitalization from nonadherence to SRD, clinicians need to provide more structured SRD education supplemented with printed brochures. Exploring the client’s nutritional social setting may improve SRD adherence.

Living with chronic illness: a phenomenological study of the health effects of the patient-provider relationship.

Abstract: Purpose: To understand the patient–healthcare provider (HCP) relationship from the lived experience of women with chronic disease and determine how this relationship affects women’s health. Data sources: Narrative accounts of 25 women’s relationships with HCPs in repeated group and individual interviews were audio-taped and transcribed verbatim. Interpretive phenomenology was used to explore the data using three interconnected modes of paradigm cases, exemplars, and themes. Conclusions: Women with chronic disease believed their health was significantly affected by their relationships with HCPs. They experienced a greater sense of well-being and security in connected relationships and had more confidence and motivation to manage their illness. Implications for practice: This research suggests that for women with chronic disease, relationships with HCPs that are connected, and characterized by partnership, and personableness result in the women feeling better in many dimensions. The context of today’s healthcare system often pushes the nurse practitioner (NP) to provide care more attuned to medical issues, leaving little time for the development of connected relationships. In spite of this pressure, NPs need to strive to develop relationships with patients that are intersubjective/connected.

Informational needs and the experiences of women with abnormal Papanicolaou smears.

Abstract: Purpose: To describe the experience of women with abnormal Papanicolaou (Pap) smears with a particular focus on their informational needs. Data source: The small purposive sample consisted of 10 demographically diverse women with a history of at least one abnormal Pap smear, who attended one Women’s Health outpatient clinic that typically serves a multiethnic, low-income population. Individual 30- to 60-min tape-recorded interviews were conducted, transcribed verbatim, and analyzed according to Colaizzi’s eidetic method of phenomenological analysis. A manual categorizing strategy and a computer software (Qualrus, version 2.0) strategy were used for data management and coding. Conclusions: Six major themes emerged from the data: initial response to the diagnosis; dealing with stigma; seeking information and support; enduring diagnostic and treatment procedures; formulating a concept of disease; and normalizing. The essential structure of the experience of having an abnormal Pap smear in terms of informational needs involved initial anxiety at disclosure, followed by an urgent need for information. Stigma associated with a sexually transmitted disease (STD) and a dearth of information available for male partners were problematic and influenced decisions about disclosure of human papillomavirus (HPV) infection to current or future partners. Misinformation or misunderstanding of available information was common. Information obtained from the Internet was experienced as private and allowed adequate time, but Web sites that grouped HPV with general STD information were confusing and further stigmatizing. Information obtained from healthcare providers was experienced as supportive if facts were accompanied by reassurance and familiar analogies were used. Information from providers was experienced as nonsupportive if too much medical jargon was used, if not enough time was spent to explain the information, if facts were not accompanied by interpersonal concern, or if a patient–provider relationship was not established. Implications for practice: Patient education regarding abnormal Pap smears and HPV should address the concerns of those affected and should use message framing that informs but decreases stigmatization. Women should be offered the option of individualized informative and supportive counseling resources after initial disclosure of an abnormal Pap smear to adequately address concerns such as information for partners, the nature of HPV, an appropriate concept of cancer risk, and reassurance regarding potential effects on sexuality and fertility. Public information forums should address issues specific to high-risk HPV rather than generalization as an STD.

Diagnosis and management of geriatric insomnia: a guide for nurse practitioners.

Abstract: Purpose: To discuss the assessment, diagnosis, and management of geriatric insomnia, a challenging clinical condition of older adults frequently seen by primary care providers. Data sources: Extensive literature review of the published research articles and textbooks. Conclusions: Complaints of insomnia among older adults are frequently ignored, considered a part of the normal aging process or viewed as a difficult to treat condition. Geriatric insomnia remains a challenge for primary care providers because of the lack of evidence-based clinical guidelines and limited treatmentoptionsavailable.Effectivemanagementofthisconditionisnecessary for improved quality of life, which is a primary issue for the elderly and their families. Therefore, geriatric insomnia warrants thorough attention from the nurse practitioners (NPs) who provide care for older adults. Implications for practice: Undiagnosed or under treated insomnia can cause

Testing the effectiveness of an educational intervention to increase dietary intake of calcium and vitamin D in young adult women

Abstract: Purpose: To test the effectiveness of an educational intervention to increase dietary intake of calcium and vitamin D in young adult females aged 19–30 from two Midwestern states. Data sources: Study participants were 80 females who were not pregnant or breastfeeding and who resided in Lincoln, Nebraska, and Ankeny, Iowa. Conclusions: Knowledge of osteoporosis and the importance of dietary intake of calcium and vitamin D did improve after the intervention. Posttest scores on knowledge of osteoporosis, calcium, and vitamin D 8 weeks after the educational intervention were significantly higher than pretest scores (p ≤ .01). However, there was no change in dietary intake of calcium, vitamin D, or dairy products from pre- to post-educational intervention. In addition, at pre- and post-educational intervention, intake of calcium, vitamin D, and dairy products were not adequate based on recommended daily allowance for young adult women. Implications for practice: Osteoporosis is a painful, disabling illness and prevention of osteoporosis is a lifelong process. Older women may suffer the devastating effects of osteoporosis because of deficiencies in their diet as young adult women. Nurse practitioners (NPs) could ask young female patients who are at risk for osteoporosis to complete a dietary recall and then provide these patients feedback on their diet. NPs could provide a patient handout of calcium-rich foods and sources of vitamin D, and work with each patient to set specific goals for increasing and/or obtaining adequate calcium and vitamin D. Follow-up visits could include an evaluation of the 3-day diet record, goal progress and resetting, and visual bar or linear graphs demonstrating the patients’ progress. Finally, all patients who are progressing in meeting their goals should be provided positive reinforcement.

Trust of nurse practitioners and physicians among African Americans with hypertension.

Abstract: PURPOSE: To examine correlates of low-income African Americans' level of trust in healthcare providers. Specific aims were to (a) describe the levels and correlations of trust, mistrust, and satisfaction; (b) compare trust scores by provider type (nurse practitioner [NP] and medical doctor) and clinic type (nurse-managed clinic [NMC] and joint-managed clinic [JMC]); and (c) examine the relationship of patient and provider demographic factors (e.g., race concordance) with trust in the provider. DATA SOURCES: This descriptive cross-sectional study was conducted with 145 low-income African Americans (51% women, 49% men; mean age = 49.4 years). All participants were enrolled in a larger study that examined the effect of psychosocial variables on hypertension outcomes. Participants completed three questionnaires: Trust in Provider Scale, Cultural Mistrust Inventory, and the Michigan Academic Consortium Patient Satisfaction tool. Chart audits were performed to collect clinical data. CONCLUSIONS: Trust and satisfaction were moderately high, M = 3.9 (0.56), M = 4.1 (0.57), respectively, on the 5-point scales, and cultural mistrust was in the moderate range, M = 3.9 (0.79), on a 7-point scale. No significant differences in mistrust, t(142) =-1.43, p = .155, or satisfaction, t(142) = 0.716, p = .475, were noted by provider type. Trust was significantly higher for patients seen by NPs, t(142) = 2.57, p = .011. Additionally, patients seen in the NMC reported significantly higher levels of trust than those seen in the JMC, t(143) = 3.62, p < .001. Race concordance between provider and patient did not change these findings. IMPLICATIONS FOR PRACTICE: Low-income African American patients have experienced unequal and discriminatory treatment, which can result in a cultural mistrust of providers; yet, providers in this study were able to engender high trust and satisfaction among these respondents. Still, the sociocultural effects of race concordance require further exploration to better understand the impact on trust in the patient-provider relationship. Finally, the high levels of trust in the NMC may offer a promising solution to the health disparities of African Americans; yet, more research is needed.

Reflections on independence in nurse practitioner practice

Abstract: Purpose: To examine factors that influence the ability of nurse practitioners (NPs) to practice as independent primary care providers. Data sources: Extensive literature search on CINAHL, OVID, MEDLINE, Internet journal sources, and professional association Web sites. Conclusions: The legal authority for NPs to practice independently is recognized; however, the ability to put that authority into practice is undermined by the historical failure of political, professional, and social entities to recognize NPs as providers capable of providing primary care autonomously. Nonrecognition is responsible for complex reimbursement policies (both federal and state) that economically and professionally restrain the NP role; hence, NPs remain in a financially dependent relationship despite 40 years of proven safe practice. NPs must articulate their independence as practitioners more vociferously in order to meet society’s healthcare requirements, as well as to attain professional fulfillment and forge collegial relationships. Implications for practice: NPs will never be seen as members of a profession by either themselves or others without the practicality of independence and autonomy. Although legal independence is a fact, real practice independence in the pragmatic sense is contingent upon reimbursement. Without fiscal sustainability, practice independence is an impossibility. And, without professional autonomy, NPs will have only an employee’s voice in the dynamic healthcare system in which they are really key players in providing healthcare services to the poor and undeserved populations.

Family-centered collaborative negotiation: a model for facilitating behavior change in primary care.

Abstract: Purpose: To describe a parent–child-based model that melds a family-centered interaction approach, Touchpoints, with brief negotiation strategies (an adaptation of motivational interviewing) to address health risks in children. An application of the model for addressing childhood overweight in the primary care setting is presented. Data Sources: Selected research, theoretical, and clinical articles; national recommendations and guidelines; and a clinical case. Conclusions: Lifestyle health behaviors are learned and reinforced within the family; thus, changes to promote child health require family involvement. Interventions that engage parents and support parent–child relationships, while enhancing motivation and the abilities to change behavior, are recommended. Implications for Practice: Primary care is an appropriate setting for addressing lifestyle health behaviors. A collaborative partnership, rather than a prescriptive manner, is advocated for primary care providers when working to facilitate health-promoting behavior.

Measuring mobbing experiences of academic nurses: Development of a mobbing scale

Abstract: PURPOSE: The aims of this study were to develop a mobbing scale for academic nurses and to determine their mobbing experiences. DATA SOURCES: Data were collected between January and June 2006 with a 60-item mobbing scale and a questionnaire composed of 6 questions concerning demographics and 10 questions regarding nurses' opinions about mobbing. CONCLUSIONS: For the Mobbing Scale for Academic Nurses, the content validity index was 88%, item-to-total correlations ranged from .41 to .73, Cronbach alpha was .97, and Kaiser-Meyer-Olkin measure of sampling adequacy was .72. Barlett's test yielded quite significant results (chi2= 7905.47, p = .000). The scale was composed of eight subscales. One fifth of the academic nurses experienced mobbing, and there was evidence of mobbing at university nursing schools. IMPLICATIONS FOR PRACTICE: The mobbing scale for academic nurses can be used to collect reliable and accurate data about mobbing experienced by academic nurses. If there is mobbing in nursing faculties and schools, appropriate precautions should be taken to protect people against mobbing, and a safe and comfortable atmosphere must be created in nursing faculties and schools. Language: en

Addressing nutritional issues in the college-aged client: strategies for the nurse practitioner.

Abstract: Purpose: To educate nurse practitioners (NPs) on the nutritional risks specific to the college-aged client and provide recommendations for interventions for this group. Data sources: Information was gathered through a literature search as well as the author’s own experience. Conclusions: As young adults move into an independent living situation, there is a high risk for unhealthy eating habits. While this may not translate into the weight gain known as the “Freshman 15,” this is the time period when young adults begin to cement their eating habits. Current research has found that students who gain weight during this period tend to continue a slow, steady gain in weight. Implications for practice: NPs must take every opportunity to provide guidance toward healthy eating habits. Most clients of this age group are seen infrequently by a primary care practitioner. Thus, each visit should be used to explore the topic with clients to minimize adverse outcomes in the future.

Epidemiology, clinical manifestations, and treatment options for skin and soft tissue infection caused by community-acquired methicillin-resistant Staphylococcus aureus.

Abstract: Purpose: This article reviews the evolving epidemiology of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) and the appropriate outpatient management of CA-MRSA skin and soft tissue infection. Further, the paper will provide the basis upon which an individualized patient educational plan may be developed. Data Sources: To complete this review, a search of English language publications was conducted through Medline and CINAHL databases (1966–2006). Conclusions: The epidemiology of CA-MRSA is becoming increasingly complex. Research that addresses the impact of this organism in high-risk populations and within families is urgently needed. Implications for Practice: Nurse practitioners must remain informed of the epidemiology of common and emerging drug-resistant organisms in their patient populations.

Knowledge and risk of cardiovascular disease in rural Alabama women

Abstract: Purpose: The purpose of this study was to describe rural women’s knowledge of cardiovascular disease (CVD) and actual risk of CVD. The research question guiding this study was: “Are there relationships between demographic factors, women’s knowledge of CVD, and women’s CVD risk score?” Data sources: Demographic data were collected from a convenience sample of 112 women at a full-service, rural medical clinic in Alabama. Two questions assessed women’s knowledge of their risk factors for CVD. The Coronary Heart Disease Knowledge Test measured knowledge of coronary heart disease (CHD). Framingham CHD prediction scores were calculated to assess the actual heart disease risk of subjects. Conclusions: Knowledge of CVD in rural Alabama women is inadequate. The mean score for the knowledge test was 8.50 out of 20. This population of women has significant risk for CVD. Women recognized that smoking and obesity are issues, but are less aware of factors such as race, personality types, oral contraceptive use, hypertension, diabetes, age, hyperlipidemia, and family history. Implications for practice: The majority of women in the study could list only one or two CVD risk factors. New strategies for educating women about CVD should be explored by nurse practitioners (NPs). For example, NPs interested in CVD in women could organize and offer to teach in local schools, colleges, universities, churches, and at sites where women work. Collaboration with the local American Heart Association and Health Department in educating women may be appropriate. By increasing women’s knowledge, their actual risk may change and thus improve their chance to live free of CVD or have it later in life or to a lesser extent.

The interaction model of client health behavior: A model for advanced practice nurses

Abstract: Purpose: To present the Interaction Model of Client Health Behavior (IMCHB) as a model to guide nurse practitioners (NPs) in their practice. Data sources: Selected research-based articles on Cox’s IMCHB and selected text and writings on the NP movement and nursing practice models. Conclusions: Many NPs practice in a medical setting where the boundaries between medicine and nursing are blurred. The IMCHB offers a nursing model to guide NPs in their practice. Implications for practice: A nursing model that examines the elements of client uniqueness and assesses the interaction between NP and client can achieve positive health outcomes.

A collaborative approach to wellness: Diet, exercise, and education to impact behavior change

Abstract: Purpose: The purpose of this study was to evaluate an interdisciplinary Wellness Program developed to help patients implement behavior changes necessary to begin weight reduction. Data sources: A 12-week program was developed to offer a choice of three diets, education, behavior change, and support groups that would allow participants to work through their concerns. A total of 109 participants provided feedback throughout the program and had varying degrees of change. Measures included education, food diaries, support, exercise, and anthropomorphic measurements. Conclusions: Participants who attended the exercise classes showed the most positive results with weight loss, and the greater the number of times attending the exercise classes, the more weight was lost. Readiness and willingness to change and the degree of involvement in the program also proved to be major factors in the program. Implications for practice: While obesity and overweight continue to be major healthcare issues in the United States, a real positive approach to helping patients with this problem has not been found. Continued study and support are needed to help patients deal with the impact of weight on overall health and well-being.

Against the grain: an overview of celiac disease.

Abstract: Purpose: To review the epidemiology, pathophysiology, clinical presentation, diagnosis, and management of celiac disease (CD). Data sources: Review of literature using Pub Med and Access Medicine. The following search terms were used: celiac disease, malabsorption syndromes, diarrhea, and gluten-free diet (GFD). There was no limitation placed on publication year. Only articles written in English were included. Conclusions: CD is a chronic systemic autoimmune disorder triggered in genetically susceptible individuals by the ingestion of gluten proteins (wheat, barley, and rye). CD often presents atypically, and diagnosis delays are common. Currently, the only effective treatment for CD is strict adherence to a GFD. This is a difficult diet to comprehend and follow. Adherence to a GFD requires ongoing education and support from a multidisciplinary healthcare team, support groups, family, and friends. Implications for practice: Once considered a rare disease of childhood, CD is now recognized as a common disorder that can occur at any age. Clinicians need to be cognizant of risk factors, clinical manifestations, conditions, and complications associated with CD in order to make a timely diagnosis, ameliorate symptoms, and minimize disease complications.

Implementation and outcomes of group medical appointments in an outpatient specialty care clinic

Abstract: Purpose:Todescribetheoutcomesofanursepractitioner(NP)-facilitatedgroup medical appointment (GMA) intervention for chronic obstructive pulmonary disease (COPD) clients in a pulmonary practice in the Midwest. Data sources: Medical records from a convenience sample of six established pulmonary patients in a Midwest specialty clinic who received care in a group format were retrospectively audited. Outcome measures included examination ofchangesintheutilizationofhealthcareservices,exercisetolerance,anduseof nonpharmacological and pharmacological interventions pre- and postparticipation in the GMA program. Conclusions: NP-facilitated GMAs are feasible and can help improve health outcomes. Results showed a significant increase in exercise tolerance measured by 6-min walkdistance. Anecdotally, patientand provider response tothe GMA was very positive. Implications for practice: The GMA format is an innovative solution for the management of chronic disease patients that is comprehensive, time efficient,

Characterizing nurse practitioner practice by sampling patient encounters: An APRNet study

Abstract: Purpose: The purpose of this study was to characterize nurse practitioners’ (NPs’) practice by using reports of patient encounters to more accurately reflect practice patterns than has been previously performed. This study was part of a larger primary care practice survey by a consortium of 20 practice-based research networks (PBRNs). Therefore, comparisons, when appropriate, were also made between this network of NPs (Advanced Practice Registered Nurse Network, APRNet) and the other 19 physician-run research networks. Data sources: A descriptive survey was developed by the 20 PBRN consortium under grants from the Agency for Healthcare Research and Quality. The consortium’s goal was to collect primary care data over a 6-month period and to document and compare primary care practice in the United States. The data were collected immediately following members’ encounters with patients rather than from billing spreadsheets. Nineteen PBRNs may have had NPs in the practices that comprised their networks. However, the data from these NPs were collected under the study ID numbers of the physician owners of each practice. APRNet, therefore, was the sole research network comprised exclusively of NPs who collected and reported data under their own study ID numbers. Conclusions: Acute health problems comprised 45% of all episodes treated by NPs compared to 30% of episodes for exacerbations of chronic conditions and 24.5% for nonillness and health promotion visits. In addition, our findings suggest that NPs provide counseling in 84% (vs. 61% for physicians) of their primary care visits, regardless of the reason for visit, and the type of counseling varies by the type of NP. Implications for practice: Despite many studies on the comparability and outcomes of NP practice, the need to identify, clarify, and document the practices of NPs in primary care settings remains. The present survey provides an important and useful first step in providing a systematic way to characterize these practices through a survey of APRNs immediately following their patient encounters.

Posterior reversible encephalopathy syndrome: An emerging clinical entity in adult, pediatric, and obstetric critical care

Abstract: Purpose: To describe the signs, symptoms, causative factors, and treatment for posterior reversible encephalopathy syndrome (PRES), an emerging clinical neuroradiologic entity which may be encountered by nurse practitioners in almost any clinical setting. Data sources: Extensive review of worldwide literature, including peer-reviewed medical specialty journals, supplemented by an actual case study. Currently, a paucity of information exists in the nursing literature. Conclusions: PRES occurs as a result of disordered cerebral circulatory autoregulation and/or endothelial dysfunction, usually as a result of acute, intermittent hypertension. Clinical manifestations include mental status change, headache, visual disturbance, and seizures. Characteristic abnormalities in the posterior cerebral white matter, seen best on diffusion-weighted magnetic resonance imaging, confirm the presence of the syndrome. PRES has been documented worldwide among a diverse patient population, yet many clinicians are still unfamiliar with this diagnosis. Implications for practice: PRES is a clinical-radiographic diagnosis that requires close collaboration between the clinician and interpreting radiologist. Rapid identification and appropriate diagnostics are essential, as prompt treatment usually results in reversal of symptoms; permanent neurologic injury or death can occur with treatment delay.

A challenge in academia: Meeting the healthcare needs of the growing number of older adults

Abstract: Purpose: The purposes of this study were to survey nurse practitioners (NPs) to determine their comfort level with knowledge about caring for individuals aged 65 years and older and to obtain their input on enhancing geriatric content in the educational preparation of advanced practice nurses who provide care to older adults but are not specialists in gerontology Data sources: The sample consisted of 500 randomly selected NPs who were certified to practice in New York State The Geriatric Curriculum Survey designed by the researchers was based on the 47 “Older Adult Care” competencies developed by the American Association of Colleges of Nursing The survey was mailed to the subjects along with a stamped self-addressed envelope to facilitate its return Two hundred and twenty–two surveys (44%) were returned Conclusions: A majority of the respondents were comfortable with their assessment skill knowledge of individuals aged 65 years and older in all areas except those related to cultural/ethnic items Over half of the respondents were only “somewhat comfortable” with knowledge of management of Alzheimer’s disease, delirium, dementia, neurological problems, polypharmacy, and sleep issues Finally, respondents were asked to rate their knowledge comfort level on topics relevant to physical and psychosocial issues of individuals aged 65 years and older The majority of respondents only felt “somewhat comfortable” with their knowledge on all but one of the nine items in this category Health promotion and disease prevention was the only item that over 50% of the respondents felt “very knowledgeable” about Ninety-five percent indicated they would be better prepared to care for individuals aged 65 years and older if a didactic course in geriatrics was required in their program of study Seventy percent indicated they would consider taking an online course in geriatrics Implications for practice: Based on the results of this study, an online, four-credit geriatric-focused course “Issues in Geriatric Management” was developed The course is required in the acute care and adult NP programs Eventually, this course will be offered as continuing education credit for practicing NPs The offering of a course focused on geriatrics will help to better prepare NPs to care for the growing number of elderly in this country