A survey-based study of factors that motivate nurses to protect the privacy of electronic medical records.

BACKGROUND: The purpose of this study is to investigate factors that motivate nurses to protect privacy in electronic medical records, based on the Decomposed Theory of Planned Behavior. METHODS: This cross-sectional study used questionnaires to collect data from nurses in a large tertiary care military hospital in Taiwan. RESULTS: The three hundred two (302) valid questionnaires returned resulted in a response rate of 63.7 %. Structural equation modeling identified that the factors of attitude, subjective norm, and perceived behavioral control of the nurses significantly predicted the nurses' intention to protect the privacy of electronic medical records. Further, perceived usefulness and compatibility, peer and superior influence, self-efficacy and facilitating conditions, respectively predicted these three factors. CONCLUSIONS: The results of our study may provide valuable information for education and practice in predicting nurses' intention to protect privacy of electronic medical records.

An Extended Expectation-Confirmation Model for Mobile Nursing Information System Continuance.

Nursing is critical in health care systems and comprises the planning, execution, and documentation of nursing care. To better manage health care information during patient care, the use of a mobile nursing information system (MNIS) provides more time to care for inpatients by reducing time-consuming and redundant paperwork. The purpose of this study was to extend the expectation-confirmation model and explore the roles of nursing professional competency (skill in use), habit (customary use), satisfaction (with use), and frequency of prior use in the context of MNIS continuance usage. We randomly chose 3 hospitals from among 14 hospitals in Taiwan that had indicated they used an MNIS. We conducted a field survey of nurses who had experience using the MNIS. We used a valid sample of 90 nurses to test the research model, using structural equation modeling with the partial least squares method. The results show that habit and frequency of prior use had a significant impact on MNIS continuance usage. Satisfaction and frequency of prior use had a significant impact on habit. Nurses' professional competence is crucial to perceived usefulness and, thus, is relevant in the context of MNIS continuance usage. When habit weakens over time, the continuance intention predicts continuance usage. This study showed that the extended expectation-confirmation model effectively predicts nurses' MNIS continuance usage and provides implications. Academics and practitioners should understand how nurses' habits form and how they affect continued MNIS use. Understanding the antecedents of habits can help nursing managers identify and manipulate habit formation.

How do patients respond to violation of their information privacy?

The introduction of electronic medical records (EMRs) can expose patients to the risk of infringement of their privacy. The purpose of this study was to explore the relationship between patients' concerns about information privacy and their protective responses. A questionnaire survey conducted in a Taiwanese hospital revealed that, regarding information privacy, patients' concerns about the collection of information about themselves, the secondary use of this information and the possibility of errors in the recorded information were associated with their information privacy-protective responses, while concern for unauthorised access to their information by other staff in the medical facility was not. Medical facilities should devote every effort to alleviate patients' concerns about the invasion of their information privacy to avoid eroding the reputation of medical facilities and impeding the promotion of EMRs.

Risk of elevated intraocular pressure and glaucoma in patients with uveitis: results of the multicenter uveitis steroid treatment trial.

OBJECTIVE: To report the 2-year incidence of raised intraocular pressure (IOP) and glaucomatous optic nerve damage in patients with uveitis randomized to either fluocinolone acetonide (FA) implants or systemic therapy. Secondarily, we sought to explore patient and eye characteristics associated with IOP elevation or nerve damage. DESIGN: A randomized, partially masked trial in which patients were randomized to either FA implants or systemic therapy. PARTICIPANTS: Patients aged ≥ 13 years with noninfectious intermediate, posterior, or panuveitis active within the prior 60 days for which systemic corticosteroids were indicated were eligible. METHODS: Visual fields were obtained at baseline and every 12 months using the Humphrey 24-2 Swedish interactive threshold algorithm (SITA) fast protocol. Stereoscopic optic nerve photos were taken at baseline and at 3-, 6-, 12-, and 24-month follow-up visits. Masked examiners measured IOP at every study visit. MAIN OUTCOME MEASURES: Glaucoma was diagnosed based on an increase in optic nerve cup-to-disc ratio with visual field worsening or increased cup-to-disc ratio alone, for cases where visual field change was not evaluable, because of missing data or severe visual field loss at baseline. RESULTS: Most patients were treated as assigned; among those evaluated for glaucoma, 97% and 10% of patients assigned to implant and systemic treatment, respectively, received implants. More patients (65%) assigned to implants experienced an IOP elevation of ≥ 10 mmHg versus 24% assigned to systemic treatment (P<0.001). Similarly, 69% of patients assigned to the implant required IOP-lowering therapy versus 26% in the systemic group (P<0.001). Glaucomatous optic nerve damage developed in 23% versus 6% (P<0.001) of implant and systemic patients, respectively. In addition to treatment assignment, black race, use of IOP-lowering medications, and uveitis activity at baseline were associated with incident glaucoma (P<0.05). CONCLUSIONS: Implant-assigned eyes had about a 4-fold risk of developing IOP elevation of ≥ 10 mmHg and incident glaucomatous optic neuropathy over the first 2 years compared with those assigned to systemic therapy. Central visual acuity was unaffected. Aggressive IOP monitoring with early treatment (often including early filtration surgery) is needed to avoid glaucoma when vision-threatening inflammation requires implant therapy. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Retinopathy and chronic kidney disease in the Chronic Renal Insufficiency Cohort (CRIC) study.

OBJECTIVE: To investigate the association between retinopathy and chronic kidney disease. METHODS: In this observational, cross-sectional study, 2605 patients of the Chronic Renal Insufficiency Cohort (CRIC) study, a multicenter study of chronic kidney disease, were offered participation. Nonmydriatic fundus photographs of the disc and macula in both eyes were obtained in 1936 of these subjects. The photographs were reviewed in a masked fashion at a central photograph reading center using standard protocols. Presence and severity of retinopathy (diabetic, hypertensive, or other) and vessel diameter caliber were assessed by trained graders and a retinal specialist using protocols developed for large epidemiologic studies. Kidney function measurements and information on traditional and nontraditional risk factors for decreased kidney function were obtained from the CRIC study. RESULTS: Greater severity of retinopathy was associated with lower estimated glomerular filtration rate after adjustment for traditional and nontraditional risk factors. The presence of vascular abnormalities usually associated with hypertension was also associated with lower estimated glomerular filtration rate. We found no strong direct relationship between estimated glomerular filtration rate and average arteriolar or venular calibers. CONCLUSIONS: Our findings show a strong association between severity of retinopathy and its features and level of kidney function after adjustment for traditional and nontraditional risk factors for chronic kidney disease, suggesting that retinovascular pathology reflects renal disease.

Nursing perception of patient transitions from hospitals to home with home health.

PURPOSE OF THE STUDY: The study's purpose was to determine nurses' opinions of sending patients from the hospital to home with home health services. PRIMARY PRACTICE SETTING: The study occurred in the Charleston, South Carolina, Tricounty area (Berkeley, Charleston, and Dorchester counties). Home health agencies and hospitals were invited to participate. METHODOLOGY AND SAMPLE: The study used a survey design to gather information on nursing perceptions of current practices and needed changes to improve transition of patients. The population was nurses (licensed practical nurses (LPNs) and registered nurses (RNs)) employed at inpatient hospitals or home health agencies in the area. Thirty-four RNs responded with no LPNs respondents. Agency administrators/chief nursing officers agreed for their agencies to participate and distributed the survey using a Research Electronic Data Capture (REDCap) Internet-based survey tool. Using the survey results and information from a literature review, the study developed a list of propositions, which participating administrators reviewed, for improving transitions to home. RESULTS: Both home health and hospital nurses reported a need to improve the process of sending patients from hospital to home with home health services. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: This study provides hospitals and home health agencies with propositions to facilitate the establishment of a process to communicate effectively patients care needs and streamline the discharging patients from the hospital to home health care; thus, improving patient transition. Case managers and discharge planners will need interagency collaboration along with evidence-based interventions to transition patients from the hospital to home with home health services with various populations. Direct patient care nurses in both hospital and home health settings should share the same accountability as case managers to ensure successful transitions.

Association between retinopathy and cardiovascular disease in patients with chronic kidney disease (from the Chronic Renal Insufficiency Cohort [CRIC] Study).

Patients with chronic kidney disease experience co-morbid illnesses, including cardiovascular disease (CVD) and retinopathy. The purpose of the present study was to assess the association between retinopathy and self-reported CVD in a subgroup of the participants in the Chronic Renal Insufficiency Cohort study. For this observational, ancillary investigation, 2,605 Chronic Renal Insufficiency Cohort participants were invited to participate in the present study, and nonmydriatic fundus photographs in both eyes were obtained for 1,936 subjects. The photographs were reviewed in a masked fashion at a central photograph reading center. The presence and severity of retinopathy (diabetic, hypertensive, or other) and vessel diameter caliber were assessed using standard protocols by trained graders who were masked to the information about the study participants. A history of self-reported CVD was obtained using a medical history questionnaire. Kidney function measurements and traditional and nontraditional risk factors for CVD were obtained from the Chronic Renal Insufficiency Cohort study. A greater severity of retinopathy was associated with a greater prevalence of any CVD, and this association persisted after adjustment for the traditional risk factors for CVD. The presence of vascular abnormalities usually associated with hypertension was also associated with increased prevalence of CVD. We found a direct relation between CVD prevalence and mean venular caliber. In conclusion, the presence of retinopathy was associated with CVD, suggesting that retinovascular pathology might indicate macrovascular disease, even after adjustment for renal dysfunction and traditional CVD risk factors. This would make the assessment of retinal morphology a valuable tool in CKD studies of CVD outcomes.

Photographic assessment of baseline fundus morphologic features in the Comparison of Age-Related Macular Degeneration Treatments Trials.

OBJECTIVE: To describe the methods used for assessment of baseline fundus characteristics from color photography and fluorescein angiography (FA) in the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT) and to describe the relationship between these characteristics and visual acuity. DESIGN: Randomized, masked, multicenter trial. PARTICIPANTS: This investigation included 1185 participants of the CATT study. METHODS: Baseline stereoscopic color fundus photographs and FAs of participants in the CATT study were assessed at a central fundus photograph reading center by masked readers. Replicate assessments of random samples of photographs were performed to assess intragrader and intergrader agreements. The association of the lesion characteristics with baseline visual acuity was assessed using analyses of variance and correlation coefficients. MAIN OUTCOME MEASURES: Intragrader and intergrader reproducibility, visual acuity, and lesion characteristics. RESULTS: Intragrader and intergrader reproducibility showed agreements ranging from 75% to 100% and weighted κ values ranging from 0.48 to 1.0 for qualitative determinations. The intraclass correlation coefficients were 0.96 to 0.97 for quantitative measurements of choroidal neovascularization (CNV) area and total area of CNV lesion. The mean visual acuity varied by the type of pathologic features in the foveal center: 64.5 letters (standard error, 0.7 letters) for fluid only, 59.0 letters (standard error, 0.5 letters) for CNV, and 58.7 letters (standard error, 1.3 letters) for hemorrhage (P<0.001). Fibrotic or atrophic scar present in the lesion, but not under the center of the fovea, also was associated with a markedly reduced visual acuity of 48.4 letters (standard error, 2.2 letters; P<0.0001). Although total area of CNV lesion was correlated weakly with visual acuity when all participants were assessed (Spearman correlation coefficient, ρ = -0.16; P<0.001), the correlation was stronger within patients with predominantly classic lesions (ρ = -0.42; P<0.001). CONCLUSIONS: These results show that the methodology used for grading CATT fundus images has good reproducibility. As expected, larger total CNV lesion area and pathologic findings such as hemorrhage, fibrosis, and atrophy at baseline are associated with decreased visual acuity.

Utility of digital stereo images for optic disc evaluation.

PURPOSE: To assess the suitability of digital stereo images for optic disc evaluations in glaucoma. METHODS: Stereo color optic disc images in both digital and 35-mm slide film formats were acquired contemporaneously from 29 subjects with various cup-to-disc ratios (range, 0.26-0.76; median, 0.475). Using a grading scale designed to assess image quality, the ease of visualizing optic disc features important for glaucoma diagnosis, and the comparative diameters of the optic disc cup, experienced observers separately compared the primary digital stereo images to each subject's 35-mm slides, to scanned images of the same 35-mm slides, and to grayscale conversions of the digital images. Statistical analysis accounted for multiple gradings and comparisons and also assessed image formats under monoscopic viewing. RESULTS: Overall, the quality of primary digital color images was judged superior to that of 35-mm slides (P < 0.001), including improved stereo (P < 0.001), but the primary digital color images were mostly equivalent to the scanned digitized images of the same slides. Color seemingly added little to grayscale optic disc images, except that peripapillary atrophy was best seen in color (P < 0.0001); both the nerve fiber layer (P < 0.0001) and the paths of blood vessels on the optic disc (P < 0.0001) were best seen in grayscale. The preference for digital over film images was maintained under monoscopic viewing conditions. CONCLUSIONS: Digital stereo optic disc images are useful for evaluating the optic disc in glaucoma and allow the application of advanced image processing applications. Grayscale images, by providing luminance distinct from color, may be informative for assessing certain features.

Prevalence of ocular fundus pathology in patients with chronic kidney disease.

BACKGROUND AND OBJECTIVES: The objective of this study was to describe the prevalence of ocular fundus pathology in the Chronic Renal Insufficiency Cohort (CRIC) study, a multicenter, longitudinal study of individuals with varying stages of chronic kidney disease (CKD). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In this cross-sectional study, 45 degree digital photos of the disc and macula in both eyes were obtained by nonophthalmologic personnel using a nonmydriatic Canon CR-DGI fundus camera in 1936 individuals who participated in the CRIC study. Photographs were assessed in a masked manner by graders and a retinal specialist at a central photograph reading center. The purpose of this review was to inform participants quickly of conditions that warranted a complete eye examination by an ophthalmologist. RESULTS: Among the 1936 participants who were photographed, 1904 (98%) had assessable photographs in at least one eye. Eye pathologies that required a follow-up examination by an ophthalmologist were identified in 864 (45%) of these 1904 participants. These eye pathologies included, among others, retinopathy (diabetic and/or hypertensive), a finding that was observed in 482 (25%) of these 1904 participants. Three percent (65 participants) of the 1904 participants had serious eye conditions that required urgent follow-up and treatment. Lower estimated GFR and cardiovascular disease were associated with greater eye pathology. Estimated GFR <30 ml/min per 1.73 m(2) was associated with a three times higher risk for retinopathy. CONCLUSIONS: We found a high prevalence of fundus pathology in participants with CKD. This finding supports recommendations for regular complete eye examinations in the CKD population.

Description of the Age-Related Eye Disease Study 9-step severity scale applied to participants in the Complications of Age-related Macular Degeneration Prevention Trial.

OBJECTIVE: To describe characteristics of the Age-Related Eye Disease Study (AREDS) 9-step severity scale applied to participants in the Complications of Age-related Macular Degeneration Prevention Trial (CAPT). METHODS: Eligibility criteria for CAPT required 10 or more large (>or=125 microm) drusen in each eye. Readers graded baseline photographs from all participants and all follow-up photographs from 402 untreated eyes. Drusen and pigment characteristics were used to assign the AREDS scale score. Choroidal neovascularization was identified from fluorescein angiograms. Geographic atrophy involving the macular center was identified from color photographs. RESULTS: Among 1001 untreated eyes, 90% were at steps 5 to 7 at baseline. The 5-year incidence of advanced age-related macular degeneration (AMD) increased with each step from 8% (step 4) to 40% (steps 8 and 9 combined). These rates were similar to those reported in AREDS. Among 261 eyes with all 5 annual photograph gradings available and without progression to advanced AMD, 55% of eyes had scores that indicated improvement at least once. Before progression to advanced AMD, only 32% of 141 eyes either went through step 8 or 9 or had an increase of 2 or more steps from baseline. CONCLUSIONS: The AREDS 9-step severity scale was predictive of development of advanced AMD. The AREDS scale has deficiencies as a surrogate outcome for progression to advanced AMD.

Reproducibility of gradings of retinal photographs in eyes with subfoveal choroidal neovascularization and age-related macular degeneration in the macular photocoagulation study.

PURPOSE: To assess the reproducibility of the evaluation of color photographs and fluorescein angiograms of the macula of each eye for patients enrolled in the Macular Photocoagulation Study (MPS) trials of laser photocoagulation of subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration. METHODS: A total of 65 pre-enrollment and 26 posttreatment sets of photographs were regraded. The two gradings were compared on selected items judged to be of primary importance with respect to the role of the MPS Reading Center. RESULTS: Agreement on eligibility of the neovascular lesion for an MPS trial was 88% (kappa statistic = 0.59); agreement on the size of the lesion was 86% (kappa statistic = 0.80); agreement on whether the lesion was covered by heavy treatment was 69% (kappa statistic = 0.35); and agreement on whether the treatment was in compliance with the study protocol was 73% (kappa statistic = 0.06). CONCLUSIONS: Interpretation of photographs of eyes with CNV secondary to age-related macular degeneration for eligibility and size of the lesion was reproducible in the MPS. However, adequacy of laser photocoagulation treatment could not be determined reliably from photographs.

Characteristics of choroidal neovascularization in the complications of age-related macular degeneration prevention trial.

OBJECTIVE: To describe the characteristics of incident choroidal neovascularization (CNV) in observed and treated eyes in the Complications of Age-related Macular Degeneration Prevention Trial (CAPT). DESIGN: Cross-sectional descriptive study within a multicenter, randomized clinical trial. PARTICIPANTS: Patients who developed CNV during CAPT follow-up. METHODS: Inclusion criteria for CAPT specified bilateral large drusen (>or=10 drusen at least 125 micro), visual acuity >or=20/40 in each eye, and age >or=50. Exclusion criteria included CNV and geographic atrophy >1 Macular Photocoagulation Study (MPS) disc area or within 500 micro of the foveal center. One eye of each person was selected randomly for low-intensity laser treatment and the contralateral eye was observed. Fluorescein angiography was performed at baseline, annually for >or=5 years, and whenever there were symptoms of CNV. Trained readers at the CAPT Photograph Reading Center assessed color stereo photographs and angiogram negatives to identify CNV. MAIN OUTCOME MEASURES: Choroidal neovascularization was classified by type (predominantly classic CNV, minimally classic CNV, occult only CNV, or scar), location, and area. Visual acuity was measured by certified examiners. Symmetry of characteristics between eyes of bilaterally affected patients was examined. RESULTS: Choroidal neovascularization developed in 282 eyes of 225 patients. At the time of detection, 192 (68%) of the lesions were occult only, 153 (54%) were subfoveal, and 157 (56%) were or=20/40 in 123 (69%) of 179 eyes with visual acuity measured at the time of detection. Choroidal neovascularization developed in both eyes in 57 patients (25%) during CAPT follow-up. Lesions in eyes of bilaterally affected patients were no more similar to each other than affected eyes in 2 different patients. CONCLUSIONS: When patients are monitored closely, many CNV lesions can be detected outside of the fovea and when they are relatively small. Early detection may lead to improved long-term visual acuity.

Prerequisites to providing culturally competent care to Mexican migrant farmworkers: a Delphi study.

The purpose of this study was to identify prerequisites to providing culturally competent care to Mexican migrant farmworkers. A national sample of nurse experts who worked with Mexican migrant farmworkers (N = 93 [50.2%] in round 1; and N = 142 [54.8%] in round 2) participated during the period of August 1998 to April 1999. Using a two-round modified Delphi method, a list of 89 items was generated. The nurse experts agreed that the 89 items identified were prerequisites to cultural competence, showing consensus rates of 85.4% in round 1 and 88.8% in round 2. The prerequisites to culturally competent care identified by participants encompassed caring, cultural sensitivity, cultural knowledge (general/specific), cultural abilities/skills, and others (bi-cultural status; cultural and learning experiences).

Sheriff's deputies and nursing students: service-learning partnership.

An innovative community health experience was provided through a collaborative partnership between the Richland County Sheriff's Department and the University of South Carolina College of Nursing. The authors discuss this unique experience.

Correlation among client satisfaction, nursing perception of outcomes, and organizational variables.

Client satisfaction as an outcome measure provides useful information to home healthcare managers. After a review of client satisfaction instruments in home healthcare, a study of 38 home health sites indicated that clients had a high level of satisfaction with nursing care. A correlational descriptive study compared the client satisfaction to the Community Health Nursing Outcomes Inventory. Findings suggest that client satisfaction was higher when nurses perceive meeting clients' psychosocial needs, when nurses and supervisors maintain a good working relationship, and when nurses use guidelines to direct nursing practice.

Workplace variables and their relationship to quality client outcomes in home health.

The purpose of the study was to investigate the relationship of workplace variables and client outcomes, and to propose a model of the fit between the workplace variable dimensions of nursing technology (NT) and organizational structure (OS) to predict client outcomes in home health. The researchers used a correlational, predictive, descriptive design to measure NT, OS, nurses' role clarity, client outcomes, and client satisfaction. A convenience sample consisted of 43 home health sites with 205 nurses and 325 clients completing surveys. Nurses perceived that clients had better outcomes when the three dimensions of NT fit the three dimensions of OS: (1) when clients' conditions were unstable, nurses interacted with peers; (2) when care was complex, nurses consulted with supervisors; and (3) when clients' needs varied, nurses used rules to guide clinical decisions. Findings suggested that nurses' understanding of their roles correlated to OS. Nurse managers in home health care settings can use the model constructed as a result of the research to adjust the dimensions of OS to improve client outcomes.

The age-related macular degeneration radiotherapy trial (AMDRT): one year results from a pilot study.

PURPOSE: To assess the short-term safety and efficacy of treating subfoveal choroidal neovascularization (CNV) with external beam radiation delivered in 5 x 4 Gy fractions among patients having age-related macular degeneration (AMD). DESIGN: A multicenter prospective randomized controlled pilot study. METHODS: Eighty-eight patients were enrolled through 10 sites and were randomized to radiotherapy (20 Gy delivered in 5 daily fractions of 4 Gy each; 6 MV [N = 41]) or no radiotherapy (sham radiotherapy [N = 22] or observation [N = 25]). Eligibility criteria included visual acuity of at least 20/320 and subfoveal CNV not amenable to treatment. Randomization was stratified by lesion type (new or recurrent CNV) and blood (<50% or >/=50% of the lesion [N = 13]). The primary outcome measure was loss of >/=3 lines of visual acuity. Secondary outcome measures were angiographic response and side effects. RESULTS: At baseline, patient and ocular characteristics were similar between treatment groups. At six months, 9 radiated eyes (26%) and 17 eyes not radiated (49%) lost >/=3 lines of visual acuity (P = .04; stratified chi(2) test). At 12 months, 13 radiated eyes (42%) and 9 observed eyes (49%) lost >/=3 visual acuity lines (P = .60). The radiated group demonstrated smaller lesions and less fibrosis than the nonradiated group (P = .05 and .004, respectively) at 12 months. Radiation-induced complications were not observed except for one radiated eye with numerous cotton wool spots and possible radiation retinopathy. CONCLUSIONS: External beam radiation at 5 x 4 Gy may have a modest and short-lived (six month) benefit in preserving visual acuity.