James Plumb

Psychometric properties of an attitude scale measuring physician-nurse collaboration.

This study examined the psychometric properties of an assessment tool for measuring attitudes toward physician-nurse collaboration. A survey addressing areas of responsibility, expectations, shared learning, decision making, authority, and autonomy was administered to first-year medical and nursing students. Factor analysis of the survey indicated that the survey measured four underlying constructs of shared education and collaborative relationships, caring as opposed to curing, nurse’s autonomy, and physician’s authority. A scale was developed in which 15 items of the survey with large factor loadings were included. The alpha reliability estimates of the scale for medical and nursing students were .84 and .85, respectively. The mean of the scale was significantly higher for nursing than medical students. Results supported the construct validity and reliability of the scale. This scale can be used to evaluate the effectiveness of programs developed to foster physician-nurse collaboration, and to study group differences on attitudes toward interpersonal collaboration.

Homelessness: Care, Prevention, and Public Policy

Homelessness, a phenomenon with complex causes and a potential for tragic consequences, is a public health and societal problem in cities, towns, and rural areas across the United States. Homeless men, women, and children make up a growing vulnerable population that has an unacceptably high risk for preventable disease, progressive morbidity, and premature death. Serious questions have been raised about the causes of homelessness and the responsiveness of U.S. society to homelessness. Is homelessness a product of malign neglect [1]? Is it an acceptable price of affluence [2]? Has there been a social construction of homelessness [3] in the United States? It is estimated that 7.4% (13.5 million) of persons living in the United States have been homeless at some point in their lives (that is, sleeping in shelters, the street, abandoned buildings, cars, or bus and train stations) and that 3.1% (5.7 million) were homeless between 1985 and 1990 [4]. Cities across the United States are now preparing for the consequences of the welfare reform bill, officially called the Personal Responsibility and Work Opportunity Reconciliation Act of 1996. This bill creates block grants known as Temporary Assistance to Needy Families and gives states a lump sum equivalent to their 1994 spending on welfare each year for 5 years. As a result of welfare reform, millions of Americans will soon be expected to find adequate jobs in the face of eroding labor markets in many cities. In addition, government officials and providers of care for homeless persons are facing crises caused by cuts in many aid programs, such as the Department of Housing and Urban Developments Homeless Housing program, Aid to Families with Dependent Children, and Mental Health funding for homeless care, as well as the discontinuation of Funding for the Family Self-Sufficiency program. These cuts have left holes in the safety net [5]. Because of Temporary Assistance to Needy Families and these other policy changes, the number of homeless persons in the United States is expected to increase significantly in the coming years. Homelessness and poverty are inextricably linked [6]: The working poor live on a precipice that can tumble them into homelessness any time. An illness, or an unexpected layoff, brings missed paychecks, which leads to skipped utility or rent payments, which snowballs into penalties, which ends in shutoffs or eviction. That leaves a Hobsons choice between no place at all or city-run homeless shelters, which often are dirty, noisy and unsafe. According to the U.S. Bureau of the Census, 36.4 million Americans lived in poverty in 1995 [7]. This growing number can be attributed to eroding labor markets and the declining value and availability of public benefits, such as welfare payments and food stamps [5]. Subgroups of persons who live in poverty run a particularly high risk for becoming homeless. These subgroups include persons with mental disability or post-traumatic stress syndrome associated with war service, persons who have been victimized (especially through domestic violence), persons with drug and alcohol addiction or health problems, and persons who lack sufficient social support to tide them over during potentially long periods of crisis. Other persons at risk are those who are least able to obtain jobs that pay enough to allow them to purchase or rent housing (such as single women with young children and unskilled workers) or those who do not qualify for welfare [1]. According to Wolch and Dear [1], the crisis of homelessness that surfaced in American cities is the 1980s shows little sign of resolution. Indeed, most socioeconomic indicators point to a continuing deterioration continuing high levels of unemployment and under employment; a deepening erosion of the welfare state; the disappearance of the federal governments affordable-housing initiatives; and the socioeconomic polarization that further separates the haves from the have-nots. Chronic disease is seen more frequently in homeless persons, 40% of whom report at least one chronic health problem [8]. These chronic illnesses may be silent until late in their course and, because of limited medical attention, often go unrecognized and untreated. Even if the condition is detected and treated, lack of compliance and consistent follow-up often results in disease progression, disability, morbidity, and premature death [9]. Premature death is the ultimate consequence of the increased vulnerability of homeless persons. Researchers in Atlanta [10] found that the median age at death among homeless persons in their study was 44 years; in a study in San Francisco, the average age at death was 41 years [11]. Hwang and coworkers [12] recently reported an average age at death of 47 years in homeless persons in Boston. This study found that homicide, injuries, and poisoning (most often caused by an overdose of opiates) were the leading causes of death among persons 18 to 24 years of age; the acquired immunodeficiency syndrome (AIDS) was the leading cause of death among persons 25 to 44 years of age; and heart disease and cancer were the leading causes of death among persons 45 to 64 years of age. Other common conditions that are preventable or treatable, such as pneumonia and influenza, were frequently found to cause death in homeless persons in the Boston cohort [12]. Providing effective primary care for homeless persons, who are under the safety net [13], is a formidable task. This is largely because of various internal and external barriers to care [14]. Internal barriers include the denial of health problems by many homeless persons and the pressure to fulfill competing nonfinancial needs, such as those for food, clothing, and shelter. External barriers include unavailable, fragmented, and costly health care services and misconceptions, prejudices, and frustrations on the part of health professionals who care for homeless persons. In addition, according to Gelberg and colleagues [15], as health policy continues to encourage the transfer of the medical care of the poor (including the homeless) into managed care systems gatekeeping mechanisms designed to ration care may lead homeless adults to further avoid seeking care in the early stages of illness if the care-seeking process becomes more arduous or time-consuming. As Hwang and colleagues point out [12], their review of the causes of death in the homeless has significant implications for clinicians and policymakers, particularly with respect to illness and death due to injuries, poisoning, opiate overdose, cancer, heart disease, and human immunodeficiency virus (HIV) infection and AIDS. High-risk sexual behavior and drug use are prevalent in homeless adults [16] and street youth [17]. Preventing HIV infection in homeless persons is difficult, but not impossible, and requires specific targeted programs [16, 17]. Susser and colleagues [18] reported on a program that was used to reduce HIV risk behaviors among homeless, mentally ill men in a New York shelter. The incidence of HIV infection and AIDS in intravenous drug users and prostitutes, who make up an unknown proportion of the homeless, continues to increase. Needle exchange programs that emphasize harm reduction strategies have been shown to be effective in preventing HIV infection in these groups [19]; this service should be made available in locations where homeless persons congregate. Guidelines and protocols for early treatment and management of HIV infection and AIDS are well established [20], but effective use of these services requires access to knowledgeable health care providers, consistent care, and an extensive network of services. These challenges are formidable for homeless persons, who have other priorities [15]. However, when services are provided in a respectful, flexible, and culturally sensitive manner, ongoing primary care for homeless persons with HIV infection is possible [21, 22]. A major problem facing care providers and homeless persons is the cost of, access to, and monitoring of the intensive drug regimens now recommended in the early stages of HIV infection [20]. The feasibility of creating health care services, particularly services focused on treating hypertension and tuberculosis, in places where the homeless congregate is well established [23]. The progressive morbidity and mortality from infection, cancer, and heart disease in homeless persons could be reduced by developing primary care systems that include a common medical record across shelter sites and that offer targeted case management that focuses on influenza and pneumococcal immunization, cancer detection, and reduction of risk factors for premature heart disease. Increasing the availability of adequate low-income housing and violence prevention programs and improving alcohol and drug treatment programs could potentially reduce the risk for death from homicide and the morbidity and mortality associated with cirrhosis, injuries, and drug overdose. Effective disease prevention in homeless persons, however, requires effective prevention of homelessness. With 10% of single adults accounting for half of each years shelter dollars in cities across the United States [6], new approaches that involve shifts in funding from shelters to innovative neighborhood programs have been developed in pilot projects in Philadelphia and New York City. These projects combine stopgap loans with long-term counseling at neighborhood sites. Efforts to decrease morbidity and mortality resulting from preventable disease should focus on identifying individual persons and families at risk and neighborhoods from which a disproportionate number of homeless persons come and on targeting primary care programs to these individual persons, families, and neighborhoods. Whatever the approach to care or prevention, it is imperative that health professionals, the societies to which they belong, and academic health systems now reaffirm their

Obesity and Cancer

Obesity has become the second leading preventable cause of disease and death in the United States, trailing only tobacco use. Weight control, dietary choices, and levels of physical activity are important modifiable determinants of cancer risk. Physicians have a key role in integrating multifactorial approaches to prevention and management into clinical care and advocating for systemic prevention efforts. This article provides an introduction to the epidemiology and magnitude of childhood and adult obesity; the relationship between obesity and cancer and other chronic diseases; potential mechanisms postulated to explain these relationships; a review of recommended obesity treatment and assessment guidelines for adults, adolescents, and children; multilevel prevention strategies; and an approach to obesity management in adults using the Chronic Care Model.

Attitudes toward physician-nurse alliance: comparisons of medical and nursing students.

No abstract available.

Modifiable cardiovascular risk factors among individuals in low socioeconomic communities and homeless shelters.

To understand cardiovascular health in low socioeconomic populations, we analyzed the data from 426 low socioeconomic community-dwelling males and females and 287 homeless males in Philadelphia. Despite higher prevalence of smoking and hypertension, the proportion of homeless participants at increased risk for coronary heart disease was comparable with that of low socioeconomic community-dwelling participants. Among various characteristics, emotional stress was significantly associated with coronary heart disease risk in low socioeconomic community-dwelling participants only, suggestive of a differential psychosocial effect of stress. Our findings suggest that low socioeconomic populations are heterogeneous with respect to their risk factors and needs for interventions.

COLLABORATIVE CARE BETWEEN NURSE PRACTITIONERS AND PRIMARY CARE PHYSICIANS

Primary care practices are looking at methods of providing quality care for an increasing number of patients, and one method of achieving this goal is the development of a collaborative agreement with a physician(s) and nurse practitioner(s). There is a need for information about the role of the nurse practitioner and the advantages of collaboration. This article reviews the history of the nurse practitioner movement, practice standards, and the scope of practice for nurse practitioners. Models of collaborative practice and the advantages of these models are discussed. Considerations for entering into collaborative practice are addressed also.

A primary care-public health partnership addressing homelessness, serious mental illness, and health disparities.

Background: People with histories of homelessness and serious mental illness experience profound health disparities. Housing First is an evidenced-based practice that is working to end homelessness for these individuals through a combination of permanent housing and community-based supports. Methods: The Jefferson Department of Family and Community Medicine and a Housing First agency, Pathways to Housing-PA, has formed a partnership to address multiple levels of health care needs for this group. We present a preliminary program evaluation of this partnership using the framework of the patient-centered medical home and the “10 Essential Public Health Services.” Results: Preliminary program evaluation results suggest that this partnership is evolving to function as an integrated person-centered health home and an effective local public health monitoring system. Conclusion: The Pathways to Housing-PA/Jefferson Department of Family and Community Medicine partnership represents a community of solution, and multiple measures provide preliminary evidence that this model is feasible and can address the “grand challenges” of integrated community health services.

Cultural factors in preventive care: African-Americans.

In summary, the implications for healthcare practitioners in caring for African American patients in a culturally sensitive manner include: Gaining trust, and understanding the historical distrust of the health care system Understanding and employing the kinship web in decisions regarding screening and treatment Involving the church in developing and delivering prevention and care messages Asking patients about the meaning of words or phrases Asking patients about the use of alternative medicines and herbs Tailoring messages about prevention to depictions of real life situations Paying attention to body language and other nonverbal communication.

Stage of change and other predictors of participant retention in a behavioral weight management program in primary care.

High attrition often limits the efficacy of weight management programs, particularly those that serve primary care patients. We investigated stage of change and other predictors of retention in a behavioral intervention program that enrolled adult obese patients at three primary care sites. The program included practice improvements and provider training, as well as individual lifestyle counseling and educational group classes for participants. We analyzed predictors of whether participants returned for counseling visits and whether they attended group classes. The 461 participants were mainly women (84%) and minorities (87%), and most of them were in the preparation stage for dietary and physical activity changes. A total of 134 (29%) participants returned for at least one follow-up visit with their counselor and 85 (18%) attended at least one class. Baseline stage of change was not significantly associated with either return visits or class attendance (p = .875 and .182, respectively). Men and participants with children in the household were less likely to return for subsequent counseling sessions (p = .012 and .027, respectively). Age and employment were associated with class attendance (p = .099 and .034, respectively). Focus groups with participants confirmed that reasons for dropout included physical limitations or health issues, family issues, stress, and lack of social support. We conclude that prescreening of patients for readiness to participate and attention to personal barriers related to family and work might improve program retention. More frequent contacts between visits and stronger provider engagement might also strengthen the intervention.

A COLLABORATIVE COMMUNITY APPROACH TO HOMELESS CARE

Homelessness is a social, economic, and public health problem of increasing magnitude in the United States. The past methods and approaches to delivering health care to those without homes have been inadequate because of the many complex problems faced by homeless persons today. To facilitate a discussion of a collaborative community approach to homeless care, it is helpful to include a definition of homelessness, describe the homeless population and the health status of homeless individuals, and explain what is meant by health care for the homeless.