Home healthcare nursing in the managed care environment. Part II. The impact on clients and professional nurses.

Part I, published in last month's issue of Home Healthcare Nurse, provided information about managed care and health maintenance organizations (HMOs). This article, Part II, presents an overview of the history of home healthcare nursing, the results of a purposeful sample, and interviews of home care nurses. Interviews were conducted to determine how nurses perceived the impact of managed care on their clients and nursing practice. Conclusions are presented in terms of emergent categories gleaned from the interviews. Recommendations for the continued growth and advancement of professional nursing in the context of managed care are given.

Home healthcare nursing in the managed care environment. Part I. Managed care: and overview.

Dramatic changes in the provision of healthcare from fee-for-service to managed care have had a definitive impact on consumers as well as providers. As providers and recipients of healthcare, home care nurses must be knowledgeable about managed care and Health Maintenance Organizations (HMOs): This article, part 1 of a two-part series, discusses the tenets of managed care and the different types of HMOs. Part 2, in next month's issue, discusses the historic background of home care and home care nurses perceptions of the impact that managed care has on clients and the practice of home care nursing.

Recognizing and assisting the impaired nurse: recommendations for nurse managers.

The impaired nurse places the client, her/himself, and all members of the healthcare community at risk. As members of the nursing profession, the priority of all nurses is to protect clients and adhere to professional standards of practice. In light of the statistics validating increased abuse by nursing professionals, the author believes that Peer Assistance Programs and Employee Assistance Programs are necessary and should be supported. To do less is to continue a "conspiracy of silence".

Epithelial sheet movement: effects of tunicamycin on migration and glycoprotein synthesis.

Corneas with central epithelial wounds, 3 mm in diameter, were organ cultured in the presence of tunicamycin (TM) (1 microgram/ml), an antibiotic that inhibits glycosylation of asparagine-linked glycoproteins. Compared with control corneas, which healed in 22 hr, corneas cultured in the presence of TM for the entire culture time or for only the first 6 hr displayed a progressively slower epithelial healing rate that essentially dropped to zero by 24 hr of culture time. At 24 hr, approximately 75% of the wound was covered. After repeated washings with TM-free culture media (6X, 10 min each), this effect could consistently be reversed in corneas exposed to TM for 6 hr. Incorporation of [3H]glucosamine into trichloroacetic acid-precipitable proteins of migrating epithelial sheets was reduced to 14% that of controls after 12 hr of culture with TM, whereas [14C]leucine incorporation was not significantly affected. The decreased glycosylation was reflected on the cell surface after 12 and 20 hr culture in the presence of TM: apical cell membranes of the first six cells of the leading edge of the migrating sheet bound significantly fewer ferritin-concanavalin A particles per micrometer of membrane than did controls. These results indicate that synthesis of asparagine-linked glycoproteins is required for continued migration of corneal epithelial sheets. The asparagine-linked glycoproteins that are required for migration probably include cell-surface glycoproteins.

Hemidesmosome formation in vitro.

Intact, viable sheets of adult rabbit corneal epithelium, 9 mm in diameter, were prepared by the Dispase II method (Gipson, I. K., and S. M. Grill, 1982, Invest. Ophthalmol. Vis. Sci. 23:269-273). The sheets, freed of the basal lamina, retained their desmosomes and stratified epithelial characteristics, but lacked hemidesmosomes (HD). Epithelial sheets were placed on fresh segments of corneal stroma with denuded basal laminae and incubated in serum-free media for 1, 3, 6, 18, or 24 h. Tissue was processed for electron microscopy, and the number of HD/micron membrane, the number of HDs with anchoring fibrils directly across the lamina densa from them, and the number of anchoring fibrils not associated with HDs were counted. After 6 h in culture, the number of newly formed HD was 82% of controls (normal rabbit corneas), and by 24 h the number had reached 95% of controls. At all time periods studied, 80-86% of HDs had anchoring fibrils directly across the lamina densa from them. Anchoring fibrils not associated with HDs decreased with culture time. These data indicate that the sites where anchoring fibrils insert into the lamina densa may be nucleation sites for new HD formation. Corneal epithelial sheets placed on two other ocular basal laminae, Descemet's membrane and lens capsule, had not formed HDs after 24 h in culture. These two laminae do not have anchoring fibrils associated with them. Rabbit epithelial sheets placed on the denuded epithelial basal lamina of rat and human corneas formed new HDs. Thus, at least in these mammalian species, HD formation may involve some of the same molecular components.