Dennis Keane

Refusing Care to Emergency Department Patients: Evaluation of Published Triage Guidelines

STUDY OBJECTIVE To determine whether a set of published triage guidelines identifies patients who can safely be refused emergency department care. DESIGN Historical cohort study. SETTING A public hospital ED. TYPE OF PARTICIPANTS All patients triaged during a one-week period who were not in the most acute triage category. MEASUREMENTS Two ED nurses, blinded to the study hypothesis, reviewed each triage sheet to determine whether the case met the published guidelines for refusing care. In addition, each ED record was reviewed for appropriateness; a visit was considered appropriate only if predetermined, explicit criteria were met and an emergency physician agreed that a 24-hour delay in care might have worsened the patients outcome. MAIN RESULTS Of the 106 patients who would have been refused care according to the triage guidelines, 35 (33%) had appropriate visits. Four were hospitalized. CONCLUSION When tested in our patient population, the triage guidelines were not sufficiently sensitive to identify patients who needed ED care. Broad application of these guidelines may jeopardize the health of some patients.

The nursing shortage: is it really about image?

EXECUTIVE SUMMARY A poor public “image” of the nurse is believed to contribute to nurse shortages. We surveyed more than 3,000 college students in science and math courses in a seven‐county region of Californias Central Valley to assess their perceptions of a career as a nurse in relation to a career as a physical therapist, a high school teacher, or a physician. Students generally had favorable perceptions of nursing, with two‐thirds agreeing that nursing has good income potential, job security, and interesting work. However, nursing lagged behind the other occupations in perceptions of independence at work and was more likely to be perceived as a “womens” occupation. Our findings suggest that these college students have generally gotten the message that nursing is a financially rewarding and desirable career, although they also perceive nursing to be less attractive on some important occupational characteristics such as job independence. Unless nursing training capacity expands substantially, the projected nurse shortage will occur. With continued aggressive marketing of nursing as a career, there is a risk of engendering a backlash from prospective students frustrated in their effort to find a slot in a nursing training program. Much work remains to be done to alter the image of nursing as a womens occupation and to transform the work environment of nurses to make a career in nursing more attractive.

Name-Based Surveillance and Public Health Interventions for Persons with HIV Infection

In the United States, each state has the authority to require disease reporting. Although all states mandate that persons with AIDS be reported by name to public health departments, reporting HIV-infected adults by name remains controversial. This policy has been adopted by 31 states but by only 5 of the 10 states with the highest incidence of reported AIDS cases. Effective new antiretroviral treatments for HIV infection have decreased the incidence of AIDS and increased interest in using an HIV reporting policy to monitor the epidemic. Effective treatments also provide a stronger rationale for early diagnosis and treatment of HIV infection. Name-based surveillance is now under consideration in the states that do not have it, but it remains a subject of debate. The policy debate about name-based surveillance has focused on the potential for benefit or harm in three areas: epidemic monitoring, HIV testing behavior and timely medical care, and interventions by public health personnel who follow up on name reports of persons with newly identified infections (1-3). Name-based surveillance could be harmful if confidentiality is breached or if concern about confidentiality deters high-risk persons from being tested or, if they test positive for HIV, from seeking care. The potential benefits of name-based reporting include improved surveillance of the epidemic [which can, in turn, help allocate funding and target public health services] and use of public health interventions to assist newly infected persons after follow-up. Two types of public health interventions have been offered: 1) assistance with health education and access to treatment and 2) notification of at-risk sex and needle-sharing partners. Name-based surveillance can be conducted without these interventions, and some states provide them without name-based surveillance (for example, by offering partner notification at anonymous HIV test sites). Although the theoretical benefits of health department intervention are easily described, studies of the results of intervention have usually lacked comparison data on the consequences of no intervention (4-10). Name-based surveillance linked with partner notification has long been a feature of sexually transmitted disease programs. Its effectiveness has been controversial in the control of bacterial sexually transmitted diseases, such as syphilis and gonorrhea (for which treatment prevents transmission), and is even more controversial in control of HIV infection (for which preventive treatment has not been available) (11, 12). The Multistate Evaluation of Surveillance for HIV Project The Multistate Evaluation of Surveillance for HIV (MESH) project, which was funded by the Centers for Disease Control and Prevention (CDC) to evaluate HIV surveillance systems, was carried out as a collaboration among nine state health departments, the University of California, and the CDC. Two surveys, one of persons at high risk for HIV infection and one of persons who had recently received a diagnosis of AIDS, were carried out in 1995 and 1996 in these nine states, which had different laws for reporting HIV infection (13, 14). In addition, the policy of reporting HIV infection by using a system of non-name unique identifiers was evaluated in two of the states (15). Potential avoidance or delay of HIV testing among high-risk persons has been the greatest concern surrounding name-based surveillance of HIV infection. In the MESH project survey of persons at risk for HIV infection, 2370 HIV-negative or untested persons were interviewed. This sample was made up of nearly equal numbers of men who had sex with men, persons who used injection drugs, and heterosexual persons attending sexually transmitted disease clinics. Most respondents delayed or avoided HIV testing out of fear of learning that they were infected or out of a belief that they were not at risk (14). Of the 25% of the sample who had never been tested for HIV, 19% cited fear of having their name reported as a reason and 2% gave it as the main reason. Among untested men who had sex with men, 28% gave fear of having their name reported as a reason for delaying testing; in states with name reporting, 35% gave it as a reason and 3% gave it as the main reason; and in states without name reporting, 11% gave it as a reason and 7% gave it as the main reason. The level of concern was lower than many opponents of name-based surveillance had expected, but it was also clear that confidentiality was a greater concern among men who had sex with men than among other high-risk populations. The AIDS patient survey done by the MESH Study Group was designed to examine, in a population-based sample, the effect of type of HIV test and type of HIV surveillance on the timeliness of testing and receipt of medical care and on notification of partners (13). A probability sample of recently reported patients with AIDS was drawn from eight states. Five of the states had name-reporting policies for HIV infection (Arizona, Colorado, Mississippi, Missouri, and North Carolina) and three of the states did not (Texas, Oregon, and New Mexico; New Mexico adopted name-based surveillance after the MESH Study was completed). Researchers conducting the survey sought to interview, in each state, all persons or a stratified probability sample of persons whose new diagnosis of AIDS was reported from May 1995 through December 1996, who were alive at the time of report, who were living in the state, who were at least 18 years of age, who received the AIDS diagnosis within 12 months of the report date, who spoke English or Spanish, and who were healthy enough to consent to and complete an interview. The date of the first AIDS diagnosis was extracted from the AIDS surveillance database and was combined with the interview data for analysis; no patient identifiers were sent to the University of California or to the CDC. Interviews were completed with 1913 persons (completion rate, 68.3%). Because almost all HIV-infected persons eventually progress to AIDS (16), this survey provided a population-based sample of the experience of HIV-infected persons that may avoid potential biases caused by use of venue-based samples. Participants self-reported the month and year of their first positive HIV test result and their first receipt of HIV-related care. The number of sex and needle-sharing partners notified was the sum of the number of partners that participants notified personally and the number of partners that participants asked public health personnel to notify (however, it is not known whether public health personnel carried out this notification). A validity check of self-reported contact with the health department was done in Colorado, where state contact records were compared with self-reports for a random 10% of interviewed participants. Records agreed with self-reports in 25 of 28 cases (89.3%). Type of HIV test was classified as anonymous or confidential on the basis of whether the participant reported giving a number or a name to receive the HIV test result. Participants who said that they gave a false name were excluded from analysis (n=55). Anonymous tests are usually associated with numbers, and confidential tests are usually associated with names. From a public health perspective, the key difference is that confidential HIV tests are recorded in a patients medical record or chart but anonymous tests are not. State public health laws for such activities as surveillance or follow-up of persons affect the information contained in patient records. The effect of reporting policies on HIV testing behavior must be considered in conjunction with the effect of the availability of options for anonymous and confidential testing. In the AIDS patient survey, four of the five states that practiced name-based surveillance also offered an anonymous HIV testing option. Previous analysis of data from the MESH AIDS patient survey found that, among persons who had sought HIV testing, those who were tested anonymously were tested and received care earlier in the course of HIV disease than those who were tested confidentially (13). The availability of anonymous testing was an important option, particularly for men who had sex with men, who were more likely to have concerns about confidentiality. Delayed Medical Care after a Positive HIV Test Result Most participants began medical care soon after receiving a positive HIV test result (47% began when they learned of their HIV infection, 66% began within 2 months, 76% began within 6 months, 83% began within 1 year, and 94% began within 3 years). The proportion seeking timely care in states with and without name-based surveillance of HIV infection differed only slightly (66% compared with 67% at 2 months and 81% compared with 86% at 1 year, respectively). The experience of survey participants in the five states with name reporting was examined to evaluate public health interventions from February 1990 (after all five states had name-based surveillance laws in effect) through the survey period. During that period, 441 persons had a positive result on an HIV test before their AIDS diagnosis; 388 of these persons (88%) were tested confidentially and could have been contacted by public health personnel and assisted with information and access to medical care. Of these 388 persons, 75% reported contact with the health department (range, 46% to 89% across the five states). Contact with the health department was not associated with receiving more timely care. The percentage of persons who received care within 3 months of the positive test result was 67% among those contacted and 69% among those not contacted (Table). The variables most strongly associated with seeking care early were having symptoms at the time of the HIV-positive test result or having a regular source of care (Table). Persons who were contacted by health departments were more likely to have a regular source of medical care tha

Does HIV reporting by name deter testing

ObjectiveName-based HIV reporting is controversial in the United States because of concerns that it may deter high-risk persons from being tested. We sought to determine whether persons at risk of HIV infection knew their states HIV reporting policy and whether they had delayed or avoided testing because of it. DesignA cross-sectional anonymous survey. MethodsWe interviewed 2404 participants in one of three high-risk groups: men who have sex with men (MSM), heterosexuals attending a sexually transmitted disease (STD) clinic, and street-recruited injection drug users (IDU). Participants were asked standardized questions about their knowledge of reporting policies and reasons for having delayed or avoided testing. We recruited in eight US states: four with name-based reporting and four without; all offered anonymous testing at certain sites. ResultsFewer than 25% correctly identified their states HIV reporting policy. Over 50% stated they did not know whether their state used name-based reporting. Of the total, 480 participants (20%) had never been tested. Of these, 17% from states with name-based reporting selected concern about reporting as a reason for not testing compared with 14% from states without name-based reporting (P = 0.5). Comparing previously tested participants from states with name-based reporting to those from states without, concern about HIV reporting was given as a reason for delaying testing by 26% compared with 13% of IDU (P < 0.001), and for 26% compared with 19% of MSM (P = 0.06). ConclusionMost participants did not know their states HIV reporting policy. Name-based reporting policies were not associated with avoiding HIV testing because of worry about reporting, although they may have contributed to delays in testing among some IDU.

Hospital RN job satisfaction and nurse unions.

The objective of the study was to examine whether unionization is associated with job satisfaction among RNs in the United States using nationally representative surveys of RNs. Factors that predict job satisfaction for RNs in healthcare continue to be of great concern to nurse administrators and managers because job satisfaction remains an important aspect of nurse retention. In addition, the notion of having unions for RNs has also gained prominence on the national stage. The relationship between RN job satisfaction and having an RN union has rarely been studied, but in 2 studies, a paradox was found; hospitals with RN unions had higher job dissatisfaction but greater retention. This study will test the relationship between having an RN union and job satisfaction with data that are both more recent and nationally representative. We analyze the public-use data from the 2004 and 2008 National Sample Surveys of Registered Nurses. In both 2004 and 2008, union representation was negatively associated with job satisfaction, although this relationship was not statistically significant in 2008. Some nurse administrators and executives would not be surprised by this finding. However, although union nurses may express more dissatisfaction, they may also be more vocal and less fearful about voicing concerns. If managers can harness this ability of the nurses to be articulate and outspoken, working with unions and union nurses can be productive and satisfying.

Measuring Attributes of Success of College Students in Nursing Programs: A Psychometric Analysis

Because of the most recent nurse shortage it has become important to determine retention factors of nursing students in the context of various aspects of college nursing programs and institutional systems. The purpose of this article is to describe the psychometric properties of a new measure that could be useful in examining nursing student retention related to the educational institution characteristics, educational processes, and individual student characteristics. The measurement instrument was conceptually designed around 4 constructs and was administered to a test group and a validation group. The dispositional construct loaded differently for each group (test group: math and science ability, confidence in the future, and confidence in ability; validation group: math and science ability, confidence in the future, self-expectation, and confidence in ability). The situational construct factored on 4 subscales (financial issues, social support, missed classes, and work issues); the institutional construct on 4 factors (peer, overall experience, diversity, and faculty); the career values construct on 5 factors (job characteristics, autonomy, caring, flexibility, and work style). Based on the results of the factor analyses and alpha reliability, evidence supported using the dispositional subscales of math and science ability, the career values subscales of job characteristics and work style, the situational subscales of work issues and financial issues, and the institutional subscales of diversity and faculty. The other potential subscales need further refinement and testing.