Obtaining informed consent for HIV antibody testing: the decision making process

All patients referring themselves for HIV antibody testing must receive pre-test counselling and must give their informed consent before testing can proceed. All patients being referred by their doctors for HIV antibody testing must also receive pre-test counselling and must give their informed consent before testing can proceed, except in very unusual circumstances. This paper is written primarily for medical and nursing staff who are considering referring a patient for testing and it is particularly relevant to those staff working in the field of mental health. This paper draws on professional guidelines and suggests that staff use a two-part decision making process. In the first part die referrer decides whether there are substantial clinical grounds for needing the test result immediately. If there are, the referral is made for pre-test counselling and testing, for example at the local Genito-Urinary Medicine (GU) clinic. In the second part experienced AIDS counsellors try to enable the patient to decide whether or not to proceed. If the patient is not able to understand or make a decision the AIDS counsellors, in consultation with other staff, will decide whether to proceed. Whatever the decision, it should be respected by professional staff.     

How do group meetings make a community Therapeutic?

Summary Following an abrupt shift from a therapeutic community with emphasis on group meetings to a hierarchical medical model on a mental hospital floor, disturbed patients required extensive individual nursing care. This increased work load for the nursing staff resulted in admissions having to be limited to the rare cases who needed little or no nursing care. As patients were discharged, the vacancy rate went up to approximately 20% for a week and remained high for another two weeks. Nursing staff-patient relations deteriorated.Subsequently, it was possible to resume the emphasis on the groups of a therapeutic community and to observe the contrast. The experience showed how groups can effect and support a therapeutic community. It clarified some of the mechanisms by which groups positively affected disturbed patients. Some mechanisms by which the staff, community, and group meetings favorably influenced the nursing staff-patient relationship and intrastaff communications became clear also.     

Mixing qualitative methods versus methodologies: A critical reflection on communication and power in inpatient care

This paper offers an illustrative example to demonstrate one way of combining qualitative methods. The context for the study was a UK inpatient psychiatric hospital. Data set one was collected from weekly ward rounds where inpatient staff met with autistic patients to review medication, listen to patient concerns and make plans or adjustments in light of this. Data set two was reflective discursive interviews with patients and staff. The research objective was to critically consider the potential reasons for discrepancies in dissatisfaction reports from patients in the interviews, compared to relative compliance exhibited by patients in the ward rounds. Utilising a video‐reflexive design and critical discursive psychology approach, both data sets were analysed together. It is possible to simultaneously analyse two different data sets, one naturally occurring and one researcher generated because of the epistemological congruence in the overall design. We have presented an argument for the benefits of mixing two qualitative methods, thereby extending the mixed‐methods evidence base beyond the traditional discussions of quantitative and qualitative paradigms.     

Spiritual care in psychiatry: Professionals’ views

In this study we explored the views of Mental Health professionals and general practitioners (GPs) regarding spiritual care and the effect of personal and cultural background on their views. Data were collected through anonymous questionnaires posted to hospital nursing and medical staff at Hollins Park Hospital, Warrington, UK, and to all GPs within the hospital catchments area. Forty-five percent of GPs, 33% of psychiatrists, and 76% of nursing staff (p < 0.05) felt strongly that human beings are made up of spirit as well as body. More nurses felt that spiritual care is equally as important as other forms of care (52%) compared with psychiatrists (33%) and GPs (29%). A higher percentage of nursing than medical staff had previous training in this area and were more likely than medical staff to consider themselves appropriate to give spiritual advice. A total of 20% of GPs and 33% of psychiatric staff stated the need for training in this area and GPs especially felt they lacked time. Professionals’ views are influenced by cultural and religious backgrounds, with significantly more non-UK born respondents feeling strongly that human beings all have a spiritual component. Many doctors do not consider spiritual care has a role for them to be involved in and many feel too pressured in daily life to take this on. Nurses are more inclined to take a holistic approach to care in this respect. Some people with mental health problems have spiritual care needs and we should be aware of this as an important facet to therapy.     

A Survey Report of Nursing Home Ministry and Perceived Needs with Implications for Pastoral Care

ABSTRACT

The last 40 years of growth in the development of pastoral care to the sick appears to have virtually bypassed persons in nursing homes. A study within 13 nursing homes in one city revealed that spiritual ministry within those institutions was generally limited to a series of 9 to 13 worship services per month, attended by approximately 20 percent of the patients/residents. Some patients receive an occasional personal visit by a pastor. The staff perceive that pastoral ministry as good, but inadequate, and expressed their views on that which is needed within their institutions and challenge the clergy with specific suggestions for pastoral care for nursing home patients/residents, their families, and staff.     

Direct assessment of quality of care in a geriatric nursing home

Direct observation was used to examine multiple aspects of care provided in a proprietary nursing home. The samples were taken at random intervals, 7 days per week for 5 weeks, across several categories of environmental and resident conditions as well as staff and resident activity. Results showed a high degee of compliance with predefined standards (based on current federal regulations) for environmental and resident conditions. Overall distributions of resident and staff activity showed results similar to those found in previous studies, with residents spending most of their time engaged in nonsocial activity and staff spending the majority of their time engaged in nonresident work. When data were analyzed across areas of the facility, times of day, and weekdays versus weekends, some differences were noted. Weekend versus weekday comparisons showed higher resident:staff ratios on weekends and more resident inactivity, but no significant differences in environmental or resident conditions. In addition, more frequent resident care, resident interaction, and resident activity were observed in Medicare units than in non-Medicare units. Results are discussed in terms of federal requirements for monitoring the quality of care in nursing homes and the potential use of time sampling expressly for this purpose.     

Cognitive control and consistency in compliance

Abstract

The purpose of this prospective study was two-fold. First, three modes of compliance assessment were used to examine whether renal dialysis patients comply consistently across medical regimens (fluid, potassium, phosphorous, protein) and whether compliance is consistent across mode of assessment (patient self assessment, medical staff ratings, physiological data). Second. a cognitive model predicting fluid compliance was tested to see if it would generalize to predict dietary compliance and medication taking. Patients' self-control perceptions of compliance, staff assessments of compliance, and physiological data were collected prospectively for 85 end-stage renal disease (ESRD) patients. Results indicated substantial consistency across medical regimen depending on the mode of assessment; staff assessment showed the most consistency, followed by patients' self-assessments and lastly by physiological data. Despite this consistency across medical regimens, the cognitive-control model only predicted fluid compliance; the model failed to explain dietary and medication compliance. Reasons and implications for these results are discussed.     

Pastoral care in a trauma center

The pastoral staff of the Mercy Hospital of Pittsburgh, Pennsylvania, is a vital participant in the advanced trauma-care team. The staff of professionally certified chaplains take an active role in ministering to the unique temporal, psychological, and spiritual needs of both patients and patients' families. These professionals serve as hosts, counselors, confidants, and friends to people who have been suddenly thrown into chaos. The pastoral staff at a trauma center also ministers to the emotional and spiritual needs of the various medical and nursing staffs.     

采用人性化护理管理降低护理差错的思考

随着社会的迅速发展及人们生活水平的不断提高,人们对医疗服务的需求增加,护理工作者所面对的压力增大,产生护理差错的概率增加。同时,护理工作者知识结构水平的改变,整体素质上升,对护理管理要求提高,人性化管理成为当今谈论的焦点,也成为减少护理差错、提高护理质量的重要手段。     

La tarification à l’activité (T2A) : Quelles transformations pour l’activité du personnel infirmier ? Etude exploratoire

This article presents an exploratory study, which attempts to analyse the changes which have occurred in the professional life of nurses in France since the introduction of the system of payment per medical act (T2A). The theoretical background is provided by theories on the activity. The T2A system is intended to provide a means of or ganising nursing care. The main results of qualitative analysis undertaken show above all changes in the way nurses’ work is organised (pace, rhythm, productivity, value for money and turnover). The more intense workload mentioned by the nurses concerns above all an increase in technical and administrative activity rather than any personal interaction with the patients, which appears to have suffered from the changes. The repercessions identified by the nursing staff include frustration, a loss of meaning in their work and a lower standard of nursing care provided.     

Indirect Self-Destructive Behavior in Chronic Hemodialysis Patients

ABSTRACT: As one of a series of investigations of indirect self-destructive behavior, a pilot study was conducted with a group of 32 chronic hemodialysis patients for those characteristics of such behavior which had emerged as most salient in earlier studies: self-esteem, locus of control, rigidity, impulsivity, futurity, risk-taking and denial. Using an average of ratings of cooperativeness obtained from the head nurse, physician, dietician, technician, and staff nurse, the group was divided into two subgroups of more and less cooperative patients, and the demographic, medical, and psychological data from the two groups were compared. The findings suggest that the less cooperative hemodialysis patients have experienced the illness as a more severe blow to their self-concept and have failed to integrate their illness into an effective adaptive life pattern. The uncooperative patients feel less valued and less appreciated not only by their family but also by fellow patients and by hospital staff. They show significantly more anger and withdrawal than the more cooperative group and appear to have compensated for a significantly greater sense of powerlessness by the development of manipulative behaviors in relating to their medical caretakers.     

Changing caring behaviours in rehabilitation after a hip fracture – A tool for empowerment?

Different rehabilitation programs after surgery have been presented to improve the outcome for patients with a hip fracture. Empowerment has been suggested as useful, but requires a change in the caring behaviours of health professionals. The aim with this study was to evaluate if training and supervision of the nursing staff could alter caring behaviours. A case-control study of nursing staff treating hip fracture patients was performed at a hospital with two sites. Training and supervision was given to the nursing staff at the intervention site. The intervention focused on creating positive care interaction by using eight guidelines. The evaluation was performed with recordings of a constructed caring situation before training, and observations of care situations at the ward before and after intervention. The results showed no differences at baseline between the two sites in the caring behaviours. After intervention, significant effects of caring behaviours were seen in seven out of eight guidelines, the effect sizes ranged from medium to large. The findings indicate that the nursing staff can change caring behaviours and facilitate the empowerment of patients with a hip fracture.     

An analysis of referrals to chaplains in a community hospital in New York over a seven year period

The study analyzed the pattern of referrals to chaplains in a suburban hospital over a 7-year period. Nurses made more than half of all the referrals to chaplains, with nursing accounting for 81.74% of referrals from staff members other than pastoral care workers and volunteers. Social workers and physicians made 11.74% and 4.08% of referrals, respectively. The number of referrals from social workers (r=.86, p<.05), nurses (r=.68, p<.10) and other staff (r=.69, p<.10) increased across years, with the exception of physicians. Three quarters of referrals were requests for chaplains to visit patients and one quarter were requests to visit with family or friends. A significant difference was found in the percentage of referrals made for patients and family/friends by staff members (p<.05), with social workers making a higher percentage of referrals for relatives and friends (34.1%), compared to nurses (26.74%) and physicians (27.27%). The most common presenting problems for which patients were referred to chaplains were anxiety, depression, and pregnancy loss. The rate of referrals for patients over the entire study period was 39.04 per 1000 patient stays.     

Social interaction patterns of geriatric home and community residents

Thirty elderly nursing home residents and ten community residing older adults were observed in group settings. Their behavior was assessed for dependent personal maintenance, independent personal maintenance, and appropriate and inappropriate behaviors. Responses by staff and peers to these behaviors were classified as positive, negative, or ignore. The frequency of occurrence of these behaviors as well as the relationship of resident to peer or staff behaviors were analyzed. Results indicate that community-residing elders' behaviors differ from nursing home residents' in quantity rather than quality of interactions. There was a lower frequency of behaviors in the nursing home residents. Though older adults respond differentially to various behaviors of other nursing home residents, staff responses were consistent regardless of residents' behavior. These results suggest that geriatric home residents' behavior can be characterized as withdrawn rather than dependent.     

Prevalence of Cognitively Intact Individuals Residing in Extended Care Nursing Facilities

There appears to be a relative absence of studies that have examined the prevalence of cognitively intact individuals who reside in extended care facilities. Prevalence data were collected on 296 persons who resided in 3 extended care nursing facilities in Central Virginia. Cognitive intactness was evaluated via the Minimum Data Set Cognitive Performance Scale (CPS) and an author-generated survey (i.e., Cognitively Intact Survey [CI Survey]) of select nursing staff members at each facility. The Mini-Mental State Examination (MMSE) was utilized to examine the accuracy of the two measures in identifying cognitive intactness. Findings indicated that prevalence rates of cognitively intact residents varied as a function of the measures utilized to assess intactness. Specifically, a significantly greater proportion of the total sample of residents was judged to be cognitively intact via the CI Survey (34.12%) as compared to the CPS (26.01%). The level of interjudge agreement between the two measures was found to be moderately high (K = 0.68). When the MMSE was employed to verify individuals' levels of intactness, the percentages of residents predicted to actually be cognitively intact were somewhat lower for each measure. Specifically, based on the data obtained via the CI Survey, 22.75% of the total sample were predicted to actually be cognitively intact, whereas 17.85% of the sample were predicted to be intact based on the CPS results. Findings are discussed in light of factors that may have contributed to the differential prevalence rates of cognitively intact individuals obtained across the measures utilized in this study. Concerns regarding the utilization of the MMSE as a criterion measure of cognitive intactness in persons residing in extended care nursing facilities are provided, along with data on the living environments/roommate statuses of those residents judged to be intact via the CI Survey. Implications for the design of future extended care nursing units, as well as future research, are also included.     

Simple imputation methods versus direct likelihood analysis for missing item scores in multilevel educational data

Missing data, such as item responses in multilevel data, are ubiquitous in educational research settings. Researchers in the item response theory (IRT) context have shown that ignoring such missing data can create problems in the estimation of the IRT model parameters. Consequently, several imputation methods for dealing with missing item data have been proposed and shown to be effective when applied with traditional IRT models. Additionally, a nonimputation direct likelihood analysis has been shown to be an effective tool for handling missing observations in clustered data settings. This study investigates the performance of six simple imputation methods, which have been found to be useful in other IRT contexts, versus a direct likelihood analysis, in multilevel data from educational settings. Multilevel item response data were simulated on the basis of two empirical data sets, and some of the item scores were deleted, such that they were missing either completely at random or simply at random. An explanatory IRT model was used for modeling the complete, incomplete, and imputed data sets. We showed that direct likelihood analysis of the incomplete data sets produced unbiased parameter estimates that were comparable to those from a complete data analysis. Multiple-imputation approaches of the two-way mean and corrected item mean substitution methods displayed varying degrees of effectiveness in imputing data that in turn could produce unbiased parameter estimates. The simple random imputation, adjusted random imputation, item means substitution, and regression imputation methods seemed to be less effective in imputing missing item scores in multilevel data settings.     

Attributions of Agency and the Construction of Moral Order: Dementia, Death, and Dignity in Nursing-home Care

Using evidence gathered during 18 months of participant-observation in 2 nursing homes and 65 interviews with staff, this article examines how nursing-home staff use agency as a rhetorical resource to construct a dignified workplace. Staff attribute agency to dying residents, saying they choose the timing and conditions of their death. Staff equally insist that aggressive residents do not have agency. These two sets of attributions are used as counterpoints. Both go well beyond the available facts of the situation and reflect unspoken assumptions and interests of nursing-care workers. Through these attributions, the staff achieves a situated moral order in which compassionate care is provided to deserving residents in caring nursing homes. Staff attributions of agency are collectively shaped by professional philosophies, training and education, and regulatory guidelines. Finally, this article shows how it is analytically and theoretically productive to recast agency as a cultural object, whose use is subject to empirical investigation, rather than as a theoretical construct.     

Relationships between patients' perceived improvement and their evaluations of treatment components in a behaviorally-oriented psychiatric inpatient unit

Patients on a behaviorally-oriented inpatient psychiatric unit were asked to rate their perceptions of treatment outcome and the value of 16 program components in producing that outcome. Significant correlations were found between perceived outcome and positive evaluations of the overall behavioral treatment plan, individual meetings with nursing staff, individual meetings with team psychologists, assertion group training, and daily group therapy. Patients perceived individual meetings with the nursing staff to be the single most valuable program component among those related to favorable outcome. Implications for the increased utilization of nursing staff during a time of dwindling resources for mental health are discussed.     

What Makes Crohn's Disease Patients Difficult to Manage? The Role of Psychosocial Factors

Most GI clinicians face the problem of a small group Crohn's Disease (CD) patients who function poorly and consume inordinate amounts of service with poor outcome. This study examines the hypothesis that psychosocial factors differentiate the CD patients who function poorly from the typical CD patient. A prototypal sample of CD patients with problems functioning, more typical CD patients (not selected for having problems in functioning), and healthy controls each completed a battery of validated psychosocial measures of disease-specific quality of life, coping skills, social support and life stress, perceived medical symptoms and life history factors. Chart data on hospital admissions, ER, GI, Surgeon, and GP visits were also collected. The CD patients with problems functioning reported more symptoms (GI and non-GI) and had many more ER, GI, and GP visits than the typical group. Psychologically, those with problems functioning had poorer quality of life and were more likely to cope using emotional discharge and support seeking. They experienced significantly more stress and reported a more chaotic family history. No differences on an experimental method of information processing biases were found between the CD groups, however. These results indicated that patients with problems functioning, selected by GI staff because they were best-case examples of functional difficulties, shared little with a matched group of typical CD patients. These patients likely require psychological as well as medical intervention to best manage their illness.