Ruth Ludwick

The use of physical restraints as a safety measure in the care of older people in four rehabilitation wards: findings from an exploratory study

We investigated the prevalence and type of physical restraint used with older persons on four rehabilitation wards in Northern Ireland. A longitudinal observational approach was used. One hundred and two patients were observed on four occasions over a three-day period. Most of the patients (68%) were subjected to some form of physical restraint, side-rails being the most commonly observed method. Those who were restrained were dependent on nursing care to meet their needs and received more drugs than those whose mobility was not restricted. No association was found between restraint use and nursing staffing levels, nor was there any association with the incidence of falls. Nurses rationalised their use of restraint as being linked to wandering and patient protection in cases of confusional type behaviours. An association was found between stroke and the maintenance of positional support through the use of restraints (side-rails and screw-on tabletops). Approximately, one-third of those restrained had this noted in their care plans, with concomitant evidence of patient/family involvement in the restraining decision.

An Improved Methodology for Advancing Nursing Research Factorial Surveys

Clinical judgments and decisions are an integral component of nurse work and nurses are increasingly being challenged to account for their judgments and decisions. Nursing research is needed to help explain judgment and decision making in nursing, but most research in this area is almost exclusively characterized by descriptive studies. This article describes the use of the factorial survey method, which combines the explanatory power of a factorial experiment with the benefits of a sample survey. This hybrid technique is an excellent method for studying judgments and decisions across settings, roles, disciplines, and countries. This article outlines the steps of the method and demonstrates its applicability with an exemplar from a study across nurses from 3 countries.

Humor in hospice care: Who, where, and how much?

Humor has been identified as an intrinsic social phenomenon occurring in all groups throughout human history. It is among the most prevalent forms of human social behavior yet one of the least understood or defined. Although researchers in a number of disciplines have studied the effects of humor on patients, limited work has focused on end-of-life care. The present study investigated social interactions involving humor in hospice settings using nonparticipant observation. Results revealed that humor was present in 85 percent of 132 observed nurse-based hospice visits. Of these, hospice patients initiated humor 70 percent of the time. These findings were consistent regardless of hospice setting. Humor was spontaneous and frequent, and instances of humorous interactions were a prevalent part of everyday hospice work.

Effect of situational and clinical variables on the likelihood of physicians ordering physical restraints.

OBJECTIVES: To model clinical and situational variables that may affect likelihood of physicians to order physical restraints.

Likelihood of Ordering Physical Restraints: Influence of Physician Characteristics

OBJECTIVES: To determine physician knowledge regarding restraint regulations and effectiveness and effect of physician characteristics on likelihood of ordering restraints.

Narrative analysis of the ethics in providing advance care planning

Our objective was to better understand the values and ethical dilemmas surrounding advance care planning through stories told by registered nurses and licensed social workers, who were employed as care managers within Area Agencies on Aging. We conducted eight focus groups in which care managers were invited to tell their stories and answer open-ended questions focusing on their interactions with consumers receiving home-based long-term care. Using narrative analysis to understand how our participants thought through particular experiences and what they valued, we identified seven themes representative of their work with consumers and families: humility, respect, responsibilities, boundaries, empowerment, courage, and veracity.

Validation of the World Health Organization Quality of Life HIV Instrument in a Zambian Sample

&NA; Given the longevity achievable with the current treatment for people living with HIV, quality of life (QOL) has emerged as a significant health outcome measure. The purpose of this study was to test the QOL factor structure in a Zambian sample using the World Health Organization Quality of Life‐HIV (WHOQOL‐HIV) instrument. A cross‐sectional 2 × 2 factorial design was conducted with 160 people living with HIV. Factor analysis yielded 3 new scales: Zambian WHOQOL‐HIV, Zambian WHOHIV Medication Dependence, and Zambian WHOHIV spirituality religion personal beliefs (SRPB), and validated the Overall Quality of Life and General Health Perceptions Scale. The study tested the WHOQOL‐HIV instrument, validated a scale that can be used for regular assessment, and yielded three comprehensive QOL assessment scales to monitor disease progression and response to care. The assessments will lead to the development of holistic nursing interventions based on perception of QOL.

Editorial: Advancing the advance care planning process

How many of us have heard an older person say, ‘I never thought I’d end up like this?’ Or have you listened to older persons with chronic diseases lament they are tired of living with unrelieved pain, under or over-treated physical problems, or overlooked psychological or social problems? Maybe you have heard both older persons and their loved ones voice feeling overwhelmed, confused or disempowered about treatments and their options? Perhaps in these circumstances, you have thought ‘I would not want to live like that?’ The purpose of this editorial is to revisit advance care planning (ACP) and inspect our own actions and beliefs about ACP in order to identify as individuals and care providers how we can advance ACP in the lives of older persons. Advance care planning is often narrowly defined in terms of end of life care or advance directives. The terms are not synonymous and while often used interchangeably, the slippery slope of terminology has led to many misconceptions. Though ACP was chosen purposefully in the early 1990s to imply a process (Curd, 1999) many older persons and their loved ones, as well as many health practitioners, continue to associate ACP solely with completing legal documents. Advanced directives are most often completed when death is imminent, a crisis occurs in a chronic illness trajectory or on admission to a hospice programme. There is, however, much variation globally. The USA is commonly cited for its early legislation. Since 1991, all adults on admission to hospitals are asked if they have made their wishes known about advance directives to be in compliance with the Patient Self-Determination Act (U.S.P.L. 101–508). In other countries across the world, laws vary. Vezzoni (2005) surveyed 70 countries regarding advance directives legislation and grouped the findings into three country categories: those where there was unambiguous support, those that had informed consent but the laws on advance directives were more ambiguous, and the last contained one country that did not recognise informed consent. Legal documents in the form of advance directives are considered the cornerstone of ACP and informed consent is the basis for ACP, but ACP as a process is much more dynamic. ACP includes education about prognosis and common clinical and functional disease trajectories and associated treatment plans. Patients and their loved ones help shape plans of care based on their values and beliefs as their health changes due to the dynamic nature of chronic diseases (Davison, 2008). However, legal documents may be a logical starting point for starting the process of ACP (Sudore et al., 2008). But laws are changing as noted by Jeong et al. (2010) and ACP is evolving to reflect its fluid nature. In the USA, for example, Oregon developed a protocol for persons with serious chronic diseases called the Physician Orders for LifeSustaining Treatment (POLST). The protocol involves a process in which a modifiable portable ACP document is shared across settings and physicians. Sabatino (2010) writes: ‘POLST is not an advance directive; it is an ACP tool that reflects the patient’s here-and-now goals for medical decisions that, considering the patient’s current condition, could confront him or her in the immediate future’ (p. 229). For a complete look at the use of the protocol across States visit the POLST website (http:// www.ohsu.edu/polst/). Advance care planning is perhaps more obvious at the life junctures of older persons noted above, but more recently, attention has been given to ACP in serious chronic conditions like congestive heart failure, dementia (e.g. Alzheimer’s), and chronic obstructive pulmonary disease and with healthy older adults over the age of 85. Other work has been progressing to make ACP normative, that is to make it routine and part of expected health care. An example of this is seen in the ‘Respecting Choices’ ACP programme that was developed in La Crosse, Wisconsin, over 15 years ago so that patients’ choices are assessed and reassessed regularly and those choices are honoured (Hammes et al., 2010). Further work is showing the positive impact of using ACP in settings besides in-patient institutions like home care, primary care and outpatient clinics. Kass-Bartelmes and Hughes (2003) in a written report for The Agency for Healthcare Research and Quality cite numerous studies that show individuals are not involved effectively in ACP and that healthcare professionals themselves are often misinformed about ACP. In several studies dying patients (as well as their families) cited communication as a major problem indicating there were misunderstandings about treatment plans, the disease itself and its trajectory, and the decisions that were needed about care. More recent studies on advance directives show an increase in use (Silveira et al., 2010). However, the issue remains that advance directives are not the whole answer and we must reach older persons sooner in their disease processes. As the number of frail elders continues to increase around the world, fostering ACP is crucial given the emotional and financial costs that come with redundant, avoidable, unwanted or unnecessary, or disputed medical treatments associated with the unfolding of serious chronic illnesses in older persons. As authors we believe that the word process should routinely be added to the current term, ACP, to remind and inform older persons and professionals of the dynamic nature of the advance care planning process (ACPP). To reach more people and ensure consistent and ongoing access to the ACPP each of us has a role in (i) working with older persons sooner in their disease processes and (ii) being politically active within our governments and

Outcomes of a community-based three-year breast and cervical cancer screening program for medically underserved, low income women.

Purpose To evaluate a community level three‐year breast and cervical cancer screening program for medically underserved, low income women. Data Sources Descriptive data on 128 women gathered from five semiannual screening programs held between 1995 and 1997 were analyzed. Conclusions Poor and medically under served women often face barriers that may discourage or prevent screening activity and measures for early detection of breast and cervical cancer. Besides success in recruiting women to the program, community collaborative partnerships were established that continue to sustain this program. Implications for Practice The results from this project provide an example of how advance practice nurses (APNs) can demonstrate meaningful and competitive health care services for underserved women and how APNs can actively evaluate programs they offer that affect the health practices of communities in need.

Results of a factorial survey investigating the health information seeking behaviors of older adults

This paper presents the results of research of an experimental research method, the factorial survey, investigating the health information seeking preferences of older adults (60 years and older). Volunteer subjects from rural, urban, and suburban areas in Ohio participated in this study; 450 subjects responded to health information seeking vignettes (the key feature of factorial surveys) and provided demographic data. Using regression analysis and ANOVA, findings from this study address preferences for the format of materials, information on particular health topics, and, preferences for receiving assistance from information providers such as librarians, nurses, pharmacists, and, doctors.