The experiences of internationally educated nurses in the southeastern United States of America.

BACKGROUND: US healthcare facilities have addressed nursing shortages in part by recruiting internationally educated nurses (IENs), and studies suggest IENs may make up a significant percentage of the nursing workforce in urban hospitals. Despite the economic recession of 2008-2012, international nurse migration is expected to continue. Little is known about IENs in the southeastern USA, and no studies have compared their perspectives to those of their US counterparts. OBJECTIVE: The purpose of this study was to gain a deeper understanding about the experiences of IENs compared to those of US registered nurses (RNs) practising in two urban hospitals in southeastern USA. METHODS: This study involved two rounds of semi-structured interviews of 82 IENs and US RNs. Interviews focused on themes relating to education, barriers to practice, intent to stay in nursing and IENs' migration experiences. FINDINGS AND DISCUSSION: Most IENs interviewed migrated to the USA after 1990 to join their family and do not plan to return to their home countries to practise. Most IENs initially received their Associate Degree in Nursing; many have obtained their Bachelor of Science in Nursing degree. IENs and newly licensed US RNs faced similar barriers when they began practising in the USA, but IENs faced additional challenges adjusting to the attitudes of US patients, the perceived lack of respect for nurses and delivering total patient care. CONCLUSIONS: IENs would benefit from orientation regarding the cultural differences in the USA. In other ways, their challenges are similar to those of US RNs; policies regarding education, recruitment and retention could target both groups together.

Managed care for older people: a primer for the geriatrician.

Managed care for older people is growing at a very rapid rate. Many geriatricians and primary care providers are interested in this area but have limited sources of information to guide their decision-making about whether to participate in these programs. This review provides a basic overview of managed care for older people, including plan types and roles that geriatricians may choose in participating in these programs. Risk and value are central concepts that impact managed care of this population. Several changes in Medicare Managed Care have occurred with the passage by Congress of the Balanced Budget Act of 1997. Geriatricians are strongly encouraged to participate in managed care as it offers the potential for improved models of care delivery for older adults.

Dementia family caregiver training: affecting beliefs about caregiving and caregiver outcomes.

OBJECTIVES: Family caregiving is an integral part of the care system for persons with dementing disorders, such as Alzheimer's disease. This study tested role-training intervention as a way to help family caregivers appreciate and assume a more clinical belief set about caregiving and thereby ameliorate the adverse outcomes associated with caregiving. DESIGN: Training effectiveness was tested in a trial in which family care receiver dyads were randomly assigned to training beginning immediately or were placed in a wait-list control group and assigned to receive training in 5 to 6 months, following completion of data collection. SETTING: A community-based 14-hour training program provided in seven weekly 2-hour sessions. The training program curriculum was built on a stress and coping theory base. Recruitment and randomization were ongoing. Programs were begun every 2 months over a two and one half-year period for a total of 16 programs. PARTICIPANTS: Community health and social service agencies referred primary caregivers and at least one other family member of community-dwelling persons with dementia to participate. MEASUREMENTS: Data reported in this paper were gathered from each participating family at entry to the study and 5 months later. Standard measures of beliefs about caregiving, burden, depression, and reaction to care receiver behavior were administered to caregivers. A standard measure of mental status was administered to the person with dementia and standardized instruments were used to gather information from caregivers concerning care receivers' behavior and abilities to perform activities of daily living (ADLs). RESULTS: Data were analyzed from 94 caregiver/care receiver dyads with complete sets of data. Treatment and control caregivers and care receivers were similar at baseline, and care receivers in both groups declined similarly over the 5-month period. Significant within-group improvements occurred with treatment group caregivers on measures of beliefs about caregiving (P = .044) and reaction to behavior (P = .001). When outcomes were compared, treatment group caregivers were significantly different (in the expected direction) from those in the control group on measures of the stress mediator, beliefs (P = .025), and key outcomes, response to behavior (P = .019), depression (P = .040), and burden (P = .051). There was a significant positive association between the strengthened mediator, the caregivers' having less-emotionally enmeshed beliefs about caregiving roles and responsibilities, and the outcome, namely improvements in burden (P = .019) and depression (P = .007). CONCLUSION: A caregiver training intervention focused on the work of caregiving and targeted at knowledge, skills, and beliefs benefits caregivers in important outcome dimensions. The results suggest the benefits of providing information, linkage, and role coaching to dementia family caregivers.

The Family Stories Workshop: stories for those who cannot remember.

The Family Stories Workshop (FSW) is a process through which family members and friends of persons with dementing disorders living in nursing homes develop stories of these residents' lives. The stories are meant to help staff members to develop a better, more deeply felt understanding of the lives of the residents, persons who can no longer tell their own stories. The workshop is product-oriented and is not meant as a support group and works best in organizations emphasizing individualized care. This article describes the process of the FSW as well as outcomes from preliminary implementation. It suggests ways of using elements of the process to more broadly accomplish the FSW purposes.

Reducing caregiver burden: a randomized psychoeducational intervention for caregivers of persons with dementia.

This 3-year randomized clinical trial tested the effectiveness of an interdisciplinary psychoeducational family group intervention in decreasing the caregivers' perceptions of the frequency and severity of behavioral problems in persons with dementia and their reactions to those problems, and in decreasing caregiver burden and depression. The intervention consisted of seven weekly, 2-hour multimedia training sessions that included education, family support, and skills training for 94 primary caregivers and their families. Repeated measures ANOVA was used to test for significant differences between the intervention and waiting list control groups over a 5-month period. The intervention was successful in reducing caregivers' negative reactions to disruptive behaviors and in reducing caregiver burden over time.

The role of physicians in home health care.

Physician involvement in home care has declined markedly over the past 50 years. By contrast, the renaissance in home care in the US over the last decade has created a pressing need for greater physician participation and new roles for physicians as members of the home care team. This article reviews these developments and identifies the need for improved medical education and physician reimbursement if the desired physician involvement in home care is to become a reality.

Family caregivers for non-Alzheimer's dementia patients.

The extensive literature on dementia (primarily AD) suggests that informal caregiving will play a significant role in patient well-being, will have an impact of some kind on the caregiver, and will benefit from tailored intervention on the part of the clinician. It should be clear from the review of six disorders that dementing conditions emanate from many diseases, affect widely diverse age groups, produce very different symptoms sets, and are a primary or secondary patient management issue for the clinician. In particular, the review points out the need for a comprehensive caregiver assessment and training program. Caregiver assessment needs to consider physical, emotional, social, and financial domains. The assessment should determine the physical demands of caregiving and the exceptional and particular emotional issues of the situation; this should take into account the physical and emotional demands already placed on the caregiver by a pre-existing condition to which the present dementia might be secondary. The assessment should examine the nature and extent of the social isolation of the caregiver, again factoring in the unique isolating effects of concurrent disorders. The clinician should explore what financial resources are available for helping with caregiving and examine the degree to which legal and financial planning have occurred. The assessment should also determine the strengths of the caregiver (skills, personality, physical well-being) as well as his or her information and training needs. This detailed data base will assist the clinician in providing the kind of training and management support that the literature suggests can be most beneficial for sustaining the caregiving situation as well as the caregiver. Within the context of particular disorders, optimal support provides the caregiver with needed information, skill and problem-solving training, opportunity for emotional outlet, attention to the need for social support, acknowledgement of the caregiver's pivotal role, and clinical care as needed.

A survey of Minnesota home care agencies' perceptions of physician behaviors.

A survey of Minnesota home care agencies assessed perceptions of and satisfaction with the home care practices, knowledge, and skills of Minnesota family physicians and other primary care physicians. We found that physicians did not make many home visits and that agencies were moderately dissatisfied with that practice. Family physicians visited significantly more frequently than other primary care physicians and, in rural areas, received significantly higher satisfaction ratings from agencies. The areas most frequently noted that could benefit from improvement of physician skills/knowledge regarding home care were: better home care clinical skills (38.5% of respondents), knowledge of home care technology and capabilities (37%), and knowledge of reimbursement policies and practice (29%).