Relative value units in health care: Friend, foe, or necessary evil?

The purpose of this article is to describe this use of relative value units (RVUs) among nurse practitioners (NP), including the challenges NPs may experience. Relative value units were developed as a means to determine reimbursement for health care based on time spent with the patient and skills required to complete the interaction, while addressing any disparities of reimbursement based on geography or insurance. Increasingly, providers such as NPs are being evaluated based in large part on how many RVUs they generate, which seems to prioritize productivity and may overlook many nonbillable aspects of the NP role such as emotional support or patient education. Nurse practitioners working in settings that require more invasive procedures may seem to be more productive on paper, regardless of the number of patients seen. Relative value units may not adequately reflect the skill and time taken to care for patients with chronic illness. Gender differences have been noted, both in terms of the number of RVUs generated for care of male or female patients, and those generated by male or female providers. If NPs are evaluated primarily based on productivity as measured by RVUs, we must consider how this might minimize or even invalidate the therapeutic relationship and holistic approach to patient care. Relative value units may negatively affect the willingness of NPs to serve as preceptors. Finally, as NPs experience less face-to-face time with patients and more demands for productivity, there may be a loss of quality care and professional integrity, which raises the risk of burnout among NPs.

Assessing Compassion Fatigue Risk Among Nurses in a Large Urban Trauma Center.

OBJECTIVE: This study evaluated the prevalence and severity of compassion fatigue (CF) risk among nurses employed in a large southwestern hospital system. BACKGROUND: Compassion fatigue is defined as multifaceted exhaustion stemming from untreated distress that leads to physical and emotional problems. Low morale, increased medication errors, and higher turnover can result. METHODS: A descriptive design was used to identify: 1) the prevalence and severity of CF risk among a sample of registered nurses; and 2) the differences in demographic characteristics correlated with CF risk. RESULTS: Forty-six percent of nurses reported moderate to high CF risk. Compassion fatigue risk was significantly associated with years of employment, unit worked, job changes, and use of sick days. CONCLUSION: This study reports new knowledge about compassion fatigue, established risk profiles across clinical units, and clarified optimal timing for interventions for those at the highest risk for CF.

Implications and recommendations for addressing insomnia disorder.

Sleep disorders, such as insomnia, are a common complication of many physical and mental health problems. This article reviews insomnia disorder, including assessment, comorbidities, and management. It is imperative that primary care providers understand how to provide the safest pharmacologic and nonpharmacologic treatments to patients with insomnia.

Compassion Fatigue: Exploring Early-Career Oncology Nurses' Experiences
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BACKGROUND: Oncology nurses have a higher risk and rate of compassion fatigue (CF) compared to professionals in other specialties. CF exhibits tangible negative outcomes, affecting nurses' health and professional practice.
. OBJECTIVES: Early-career oncology nurses' unique CF experiences lack thorough scientific exploration. This secondary analysis seeks to qualitatively augment this paucity and illuminate targeted interventions.
. METHODS: Open-ended interviews were conducted with five early-career inpatient oncology nurses. Subsequent transcripts were explored for CF themes secondarily using thematic analysis.
. FINDINGS: Themes indicate that early-career oncology nurses enjoy connecting with patients and families, but over-relating, long patient stays, and high patient mortality rates trigger CF. Symptoms include internalizing patients' and families' pains and fears, being haunted by specific patient deaths, feeling emotionally depleted, assuming that all patients will die, and experiencing burnout, physical exhaustion, and hypervigilance protecting loved ones.

Ethnic Differences in Withdrawal of Life Support After Intracerebral Hemorrhage.

Minorities are less likely to decide on withdrawal of life support (WOLS) after acute severe illness. However, the decision-making process for WOLS after intracerebral hemorrhage (ICH) among Native Hawaiians and other Pacific Islanders (NHOPI) has not been described. To address this gap in the literature, a retrospective study was conducted on consecutive spontaneous ICH patients admitted to a tertiary center in Honolulu between 2006 and 2010. The occurrence of WOLS and time-to-WOLS were the outcome measures. Unadjusted and multivariable logistic regression models were performed to determine associations between NHOPI ethnicity and WOLS. This study assessed 396 patients (18% NHOPI, 63% Asians, 15% non-Hispanic whites [NHW], 4% others) with ICH. NHOPI was associated with lower rate of WOLS than NHW in the univariate analysis (OR 0.35, 95% CI: 0.15, 0.80). However, NHOPI ethnicity was no longer significant when adjusted for age (OR 0.59, 95% CI: 0.25, 1.43) and in the fully adjusted model (OR 0.68, 95% CI: 0.20, 2.39). Although NHOPI with ICH were initially perceived to have less WOLS compared to NHW, this observed difference was largely driven by the younger age of NHOPI rather than from underlying cultural differences that are inherent to their ethnicity.

Transitions of care for stroke and TIA.

PURPOSE: The purpose of this study was to identify elements of a stroke population that may affect transitions of care (TOC). DATA SOURCES: A retrospective analysis of the demographic characteristics of patients from an urban primary stroke center with an admitting diagnosis of transient ischemic attack, acute ischemic stroke, subarachnoid hemorrhage, or intracerebral hemorrhage was performed over an 8-month period (N = 276). A subset of this patient sample participated in a telephone survey 1 month after discharge. CONCLUSION: Hospital length of stay, age, insurance status, discharge disposition, comorbidities, and readmission rates were identified as important elements affecting TOC for stroke and TIA. Information from patient surveys indicated that emotional health, follow-up with care providers, stroke education, and point of contact are important elements during the transition periods after stroke and TIA. IMPLICATIONS FOR PRACTICE: Both providers and patients should inform the development of a comprehensive TOC program that spans in-hospital to multiple care settings, including the home, which is essential. The advanced practice nurse is ideally suited to successfully lead these programs.

Compassion fatigue among registered nurses: connecting theory and research.

Unresolved compassion fatigue often causes physical and emotional exhaustion, and can significantly impair job performance. It is also known to cause increased absenteeism and even turnover among health care providers such as registered nurses. Often those experiencing compassion fatigue attempt to self-medicate in order to numb the intense emotions, and distance themselves from patients, colleagues, friends, and even family. This article describes the challenges of applying one widely used conceptual model to research among nurses who are at risk for experiencing this important and debilitating phenomenon. Through two qualitative studies that explored compassion fatigue among registered nurses, symptoms were identified that fit within the conceptual model. Several additional elements were not adequately captured by the conceptual model, and the term was perceived as being stigmatizing.

Deaf adults and health care: Giving voice to their stories.

PURPOSE: Deaf adults often experience significant healthcare disparities. This article gives voice to nine Deaf adults as they describe their lifelong experiences with health care. DATA SOURCES: Qualitative, hermeneutic interviews with nine culturally Deaf adults. Each participant was interviewed three times, aided by a certified American Sign Language interpreter. CONCLUSIONS: Participants recalled childhood memories of painful and frightening procedures to investigate the deafness, which frequently overshadowed emotional needs. Communication barriers between Deaf patients and providers left the patients not understanding the diagnosis or treatment, medication use, or side effects. Descriptions included distressing or embarrassing interactions, and cries for help gone unanswered. Consequently, minimal health promotion occurs and most participants rely on the emergency department for health care. IMPLICATIONS FOR PRACTICE: Deaf patients should be screened for physical, sexual, and emotional abuse at every healthcare encounter. Assessments should include social support and social resources. Specific questions about pain, sleep, appetite changes, suicidal thoughts, and interest may help to identify manifestations of illness and health. Certified interpreters may be useful during the healthcare encounter, but ultimately the Deaf patient is best positioned to identify the most comfortable or meaningful means of communication between patient and healthcare provider.

Who benefits from a psychosocial counselling versus educational intervention to improve psychological quality of life in prostate cancer survivors?

OBJECTIVE: We examined selected survivor characteristics to determine what factors might moderate the response to two psychosocial interventions. DESIGN: Seventy-one prostate cancer survivors (PCSs) were randomly assigned to either a telephone-delivered health education (THE) intervention or a telephone-delivered interpersonal counselling (TIP-C) intervention. MEASURES: Psychological quality of life (QOL) outcomes included depression, negative and positive affect, and perceived stress. RESULTS: For three of the psychological outcomes (depression, negative affect and stress), there were distinct advantages from participating in THE. For example, more favourable depression outcomes occurred when men were older, had lower prostate specific functioning, were in active chemotherapy, had lower social support from friends and lower cancer knowledge. Participating in the TIP-C provided a more favourable outcome for positive affect when men had higher education, prostate specific functioning, social support from friends and cancer knowledge. CONCLUSION: Unique survivor characteristics must be considered when recommending interventions that might improve psychological QOL in PCSs. Future research must examine who benefits most and from what components of psychosocial interventions to enable clinicians to recommend appropriate psychosocial care.

Using American sign language interpreters to facilitate research among deaf adults: lessons learned.

BACKGROUND: Health care providers commonly discuss depressive symptoms with clients, enabling earlier intervention. Such discussions rarely occur between providers and Deaf clients. Most culturally Deaf adults experience early-onset hearing loss, self-identify as part of a unique culture, and communicate in the visual language of American Sign Language (ASL). Communication barriers abound, and depression screening instruments may be unreliable. PURPOSE: To train and use ASL interpreters for a qualitative study describing depressive symptoms among Deaf adults. METHOD: Training included research versus community interpreting. During data collection, interpreters translated to and from voiced English and ASL. RESULTS: Training eliminated potential problems during data collection. Unexpected issues included participants asking for "my interpreter" and worrying about confidentiality or friendship in a small community. CONCLUSIONS: Lessons learned included the value of careful training of interpreters prior to initiating data collection, including resolution of possible role conflicts and ensuring conceptual equivalence in real-time interpreting.

Systematic review of reviews of intervention components associated with increased effectiveness in dietary and physical activity interventions.

BACKGROUND: To develop more efficient programmes for promoting dietary and/or physical activity change (in order to prevent type 2 diabetes) it is critical to ensure that the intervention components and characteristics most strongly associated with effectiveness are included. The aim of this systematic review of reviews was to identify intervention components that are associated with increased change in diet and/or physical activity in individuals at risk of type 2 diabetes. METHODS: MEDLINE, EMBASE, CINAHL, PsycInfo, and the Cochrane Library were searched for systematic reviews of interventions targeting diet and/or physical activity in adults at risk of developing type 2 diabetes from 1998 to 2008. Two reviewers independently selected reviews and rated methodological quality. Individual analyses from reviews relating effectiveness to intervention components were extracted, graded for evidence quality and summarised. RESULTS: Of 3856 identified articles, 30 met the inclusion criteria and 129 analyses related intervention components to effectiveness. These included causal analyses (based on randomisation of participants to different intervention conditions) and associative analyses (e.g. meta-regression). Overall, interventions produced clinically meaningful weight loss (3-5 kg at 12 months; 2-3 kg at 36 months) and increased physical activity (30-60 mins/week of moderate activity at 12-18 months). Based on causal analyses, intervention effectiveness was increased by engaging social support, targeting both diet and physical activity, and using well-defined/established behaviour change techniques. Increased effectiveness was also associated with increased contact frequency and using a specific cluster of "self-regulatory" behaviour change techniques (e.g. goal-setting, self-monitoring). No clear relationships were found between effectiveness and intervention setting, delivery mode, study population or delivery provider. Evidence on long-term effectiveness suggested the need for greater consideration of behaviour maintenance strategies. CONCLUSIONS: This comprehensive review of reviews identifies specific components which are associated with increased effectiveness in interventions to promote change in diet and/or physical activity. To maximise the efficiency of programmes for diabetes prevention, practitioners and commissioning organisations should consider including these components.

Psychosocial interventions to improve quality of life in prostate cancer survivors and their intimate or family partners.

PURPOSE: The primary purpose was to test the effectiveness of two telephone-delivered psychosocial interventions for maintaining and improving quality of life (QOL) (psychological, physical, social, and spiritual well-being) among 71 prostate cancer survivors and the 70 intimate or family partners who were supporting them in their recovery. METHODS: This study used a three-wave repeated measures experimental design. Both the interpersonal counseling intervention (TIP-C) and health education attention condition (HEAC) were delivered using the telephone. RESULTS: Improvements in depression, negative affect, stress, fatigue, and spiritual well-being were significantly higher for survivors in the HEAC than for those in the TIP-C condition. Partners in the HEAC condition showed significantly greater improvements in depression, fatigue, social support from family members, social well-being, and spiritual well-being compared to partners in the TIP-C condition. The results revealed superior outcomes for those assigned to the HEAC intervention. CONCLUSIONS: The psychosocial interventions in this study were effective in maintaining or improving the QOL for prostate cancer survivors and their partners. Both the survivor and their intimate partner or family member benefitted from the interventions. Future research is needed to determine the optimal timing and client characteristics for each intervention.

Acute affective responses to prescribed and self-selected exercise intensities in young adolescent boys and girls.

This study examined the patterning of acute affective responses to prescribed and self-selected exercise intensities in a young adolescent population. Twenty-two young adolescents (13.3 +/- .33 years) completed a maximal exercise test to identify ventilatory threshold (VT). Participants then completed two prescribed intensities (one set above and one below the VT) and a self-selected intensity. Pre-, during, and postexercise affective valence was measured. Results revealed that during exercise, affective valence assessed by the Feeling Scale (FS) remained positive in the self-selected and low-intensity conditions but declined in the high-intensity condition. Postexercise FS responses rebounded to preexercise levels, eradicating divergent trends that occurred during exercise.

Prediction of maximal oxygen uptake in sedentary males from a perceptually regulated, sub-maximal graded exercise test.

The purpose of this study was to assess the validity of predicting the maximal oxygen uptake (VO2(max)) of sedentary men from sub-maximal VO2 values obtained during a perceptually regulated exercise test. Thirteen healthy, sedentary males aged 29-52 years completed five graded exercise tests on a cycle ergometer. The first and fifth test involved a graded exercise test to determine VO2(max). The two maximal graded exercise tests were separated by three sub-maximal graded exercise tests, perceptually regulated at 3-min RPE intensities of 9, 11, 13, 15, and 17 on the Borg ratings of perceived exertion (RPE) scale, in that order. After confirmation that individual linear regression models provided the most appropriate fit to the data, the regression lines for the perceptual ranges 9-17, 9-15, and 11-17 were extrapolated to RPE 20 to predict VO2(max). There were no significant differences between VO2(max) values from the graded exercise tests (mean 43.9 ml x kg(-1) x min(-1), s = 6.3) and predicted VO2(max) values for the perceptual ranges 9-17 (40.7 ml x kg(-1) x min(-1), s = 2.2) and RPE 11-17 (42.5 ml x kg(-1) x min(-1), s = 2.3) across the three trials. The predicted VO2(max) from the perceptual range 9-15 was significantly lower (P < 0.05) (37.7 ml x kg(-1) x min(-1), s = 2.3). The intra-class correlation coefficients between actual and predicted VO2(max) for RPE 9-17 and RPE 11-17 across trials ranged from 0.80 to 0.87. Limits of agreement analysis on actual and predicted VO2 values (bias +/- 1.96 x S(diff)) were 3.4 ml x kg(-1) x min(-1) (+/- 10.7), 2.4 ml x kg(-1) x min(-1) (+/- 9.9), and 3.7 ml x kg(-1) x min(-1) (+/- 12.8) (trials 1, 2, and 3, respectively) of RPE range 9-17. Results suggest that a sub-maximal, perceptually guided graded exercise test provides acceptable estimates of VO2(max) in young to middle-aged sedentary males.

Toward creating family-friendly work environments in pediatrics: baseline data from pediatric department chairs and pediatric program directors.

OBJECTIVE: The objective was to determine baseline characteristics of pediatric residency training programs and academic departments in regard to family-friendly work environments as outlined in the Report of the Task Force on Women in Pediatrics. METHODS: We conducted Web-based anonymous surveys of 147 pediatric department chairs and 203 pediatric program directors. The chair's questionnaire asked about child care, lactation facilities, family leave policies, work-life balance, and tenure and promotion policies. The program director's questionnaire asked about family leave, parenting, work-life balance, and perceptions of "family-friendliness." RESULTS: The response rate was 52% for program directors and 51% for chairs. Nearly 60% of chairs reported some access to child care or provided assistance locating child care; however, in half of these departments, demand almost always exceeded supply. Lactation facilities were available to breastfeeding faculty in 74% of departments, although only 57% provided access to breast pumps. A total of 78% of chairs and 90% of program directors reported written maternity leave policies with slightly fewer reporting paternity leave policies. The majority (83%) of chairs reported availability of part-time employment, whereas only 27% of program directors offered part-time residency options. Most departments offered some flexibility in promotion and tenure. CONCLUSIONS: Although progress has been made, change still is needed in many areas in pediatric departments and training programs, including better accessibility to quality child care; improved lactation facilities for breastfeeding mothers; clear, written parental leave policies; and flexible work schedules to accommodate changing demands of family life.

The patient experience of treatment for hepatitis C.

This study has used qualitative hermeneutics to explore the patient's experience of treatment for hepatitis C. Hepatitis C treatment may pose numerous physical and emotional challenges. There is a need to understand the experience from a holistic nursing perspective in order to facilitate the patient's well-being. Individuals undergoing combination treatment for hepatitis C participated in a hermeneutic dialogue, which provided the investigators with an emic perspective. Dialogue content, reflection, and preunderstanding were hermeneutically analyzed. Similar treatment experiences elicited four common emotions (sadness, anger, fear, and frustration). Analyzing the similar experiences led to two emerging themes: (1) "That is not who I am," connoted by rejecting the notion of being a "typical" patient, seeing treatment as not so bad, being "different" during treatment, and feeling abandoned because of treatment; and (2) "looking beyond the experience" was noted by looking for faith beyond traditional healthcare and looking for understanding. The hepatitis C treatment experience was seen as a process: having a start, a middle, and an end, without being all-consuming. Implications for holistic nursing care are presented.