Guidelines for evaluating tools for clinical decision making.

Managed care is designed to reduce healthcare costs by controlling use of services and by improving quality outcomes. Preparation of nurses to practice in a health management environment mandates clear understanding of this new environment Nursing educators should focus on the spectrum of health services and enhance the nurses'ability to assess patients independently, implement health plans, and be responsible for outcomes. Nurses must understand how clinical decision-making tools facilitate planning care to maximize use of resources. The authors describe the construction and evaluation of a learning strategy that involves the use of guidelines to evaluate clinical decision-making tools. Two examples are presented: evaluating clinical pathways in a case management project and evaluating algorithm (practice guideline) outcome data from a prenatal population case study from a local health maintenance organization.

Therapeutic connection: help seeking on the Internet for persons with implantable cardioverter defibrillators.

PURPOSE: The goal of this study was to understand common themes and shared meanings of help seeking on the Internet for persons with implantable cardioverter defibrillators (ICDs). SETTING: The study took place over an on-line, informal, public, electronic bulletin board for persons with ICDs. SAMPLE: The sample included 469 postings by 75 users during 15 months. RESULTS: Four related themes and 1 constitutive pattern were constructed. Themes included seeking and giving meaningful information; sharing personal perspectives; storytelling as common grounding; and supportive interacting. The constitutive pattern is "therapeutic connection." IMPLICATIONS: Persons with ICDs are proactive, using Internet bulletin boards to seek practical information and support in coping with daily anxieties of living with an ICD. This form of self-directed patient education focuses on common experiences of illness versus information obtained from health care providers.

Native American graduate nursing students' learning experiences.

PURPOSE: To identify learning experiences of Native American graduate nursing students in a university-based nurse practitioner program. DESIGN: The phenomenological approach of Heideggerian hermeneutics. METHOD: A purposive sample of 11 Native American graduate students in a nurse practitioner program were given the choice of participating in a focus group or completing an individual interview to elicit common meanings and shared experiences. FINDINGS: Four themes and two constitutive patterns: (a) Native American students' worldviews reflected unwritten knowledge that served as a background of common understanding, (b) academic environment as a rigid environment with only one way to learn and constant evaluation, (c) faculty-student relationship barriers to establishing a supportive learning environment, and (d) strategies to survive, including a commitment to succeed, conforming to unwritten rules, helping each other, and ultimately changing themselves. Constitutive patterns were: (a) value conflicts when students' values conflicted with academic behavioral values, and (b) on the fringe, when students felt isolation from the main student body, and open to attack (evaluation). Students struggled to be successful in their commitment to complete the degree, but often questioned the applicability of the program in their cultural setting. CONCLUSIONS: A more flexible supportive environment is needed to support students' goals to attain degrees, as well as to encourage dialogue on differing cultural values. Faculty who teach culturally diverse students may need to examine rigid behavioral standards that mandate an assertive practitioner persona and may be a barrier to attainment of goals.

Help seeking in a support group for recipients of implantable cardioverter defibrillators and their support persons.

PURPOSE: To understand shared meanings of help-seeking experiences in support groups of people with implantable cardioverter defibrillator (ICD) and their support persons. SETTING: ICD support group at an urban medical center. SAMPLE: Fifteen individuals with ICD and 9 support persons. RESULTS: Six related themes and 1 constitutive pattern emerged. Themes included hearing and telling stories, help seeking encouraged by triggers, seeking meaningful information, forming a therapeutic friendship through group camaraderie, gaining assistance from the facilitator, and the sharing of a similar view by support persons. The constitutive pattern is coping with the possibility of death. IMPLICATIONS: Health care providers may recommend storytelling as the central mechanism of interactions in support groups that assist in coping with daily anxieties of living with an ICD. Nurses would be appropriate facilitators to guide discussion, to provide technical information, and to promote anticipatory guidance in coping with potential firing events.

Who talks? The social psychology of illness support groups.

More Americans try to change their health behaviors through self-help than through all other forms of professionally designed programs. Mutual support groups, involving little or no cost to participants, have a powerful effect on mental and physical health, yet little is known about patterns of support group participation in health care. What kinds of illness experiences prompt patients to seek each other's company? In an effort to observe social comparison processes with real-world relevance, support group participation was measured for 20 disease categories in 4 metropolitan areas (New York, Chicago, Los Angeles, and Dallas) and on 2 on-line forums. Support seeking was highest for diseases viewed as stigmatizing (e.g., AIDS, alcoholism, breast and prostate cancer) and was lowest for less embarrassing but equally devastating disorders, such as heart disease. The authors discuss implications for social comparison theory and its applications in health care.

Faculty experiences teaching Native Americans in a university setting.

Nursing faculty told their stories about the beginnings of a Native American Family Nurse Practitioner Recruitment Program. Through hermeneutical analysis, the authors' findings reveal a strong academic worldview, active in maintaining professional standards. This traditional view tends to override efforts to provide individualized programs that are culturally relevant to the Native American worldviews. By understanding the value conflicts active in this study, nursing faculty can begin dialogue to create new learning experiences that are more culturally relevant.

Active learning strategies to teach case management.

Changes in healthcare delivery require a new understanding of the concepts of case management in managed care. The authors describe the construction and evaluation of a learning module that encourages active engagement and skill development. Students develop an understanding of how to plan for care of populations in an effort to meet managed care demands. This approach to teaching case management can be effective in an educational setting and possibly in clinical settings as well.

Cardiac spouses' help-seeking experiences.

The purpose of this study was to investigate the phenomenon of help seeking by spouses of cardiac rehabilitation patients by eliciting their verbal description of the experience. A phenomenological approach was used to collect data that consisted of individual interviews and focus group interviews. The exhaustive description of the phenomenon of help seeking described how the spouses' views of the illness affected initiation of help seeking. Spouses' stories revealed three time periods when spouses needed help: diagnosis, a time of uncertainty and loss of control; hospitalization, a time of information seeking and vigilance; and homecoming, a time of active help seeking because control is regained. To manage the uncertainty, spouses sought meaningful information to contend with difficulties. Spouses told of the individuals who assisted most, of barriers to seeking help, and availability of resources for support. This study increases health care providers' understanding of spouses' experiences, which may facilitate design of interviews that maximize supports for spouses. Assisting spouses will subsequently improve patients' recovery and facilitate lifestyle changes.

Shared experiences and meanings of military nurse veterans.

OBJECTIVE: To determine the shared perceptions, feelings, and experiences of U.S. military nurse veterans. DESIGN: Phenomenological based on Heideggerian philosophy. POPULATION, SAMPLE, SETTING: The population was of military nurse veterans in the U.S.A. from World War II, Korea, Vietnam, and Operation Desert Storm. The convenience sample was 22 nurses recruited from local and national veterans' groups who volunteered to be interviewed. METHODS: Transcribed interviews with team members producing written interpretations; the team produced consensus about themes. Each interview was summarized and validation from the research team and respondents was sought. CONCLUSIONS: Five common themes or shared meanings emerged: reacting personally to the war experience, living in the military, the meaning of nursing in the military, the social context of war, and images and sensations of war. CLINICAL IMPLICATIONS: A coherent review of wartime nursing.

Images and sensations of war: a common theme in the history of military nursing.

We analyzed interviews with 22 military nurses who had served in wars or conflicts since World War II, up to and including Operation Desert Storm. Using a method of hermeneutic phenomenology, we found several common themes in the interviews. In this article, we report on the theme Images and Sensations of War. Within that theme, the subcategories sights, sounds, and other sensations (climate and weather, taste, smell, and comfort) were discovered. We categorized the images and sensations as pleasant, unpleasant, and horrible. The findings from this analysis may be useful to professionals who recruit military nurses, provide ongoing military training, help military nurses return to civilian life, and treat posttraumatic stress syndrome. Furthermore, the findings could be used as a basis for future quantitative studies to determine how widespread this theme is in larger groups of military nurses.

Focus groups: nursing staff's experiences using restraints.

A phenomenological approach was used to examine nursing staff's experiences using physical restraints. A total of 12 nurses from a tertiary hospital participated in one of three focus groups. Exploring the attitudes of nurses can contribute to a better understanding of how decisions are made concerning restraints. An analysis of the focus group data resulted in a description of the lived experiences of nurses using restraints. Seven themes emerged from the data, one of which reflected that the nurses felt ambiguous about restraints, yet they made judgments and justified their decisions after assessing patient characteristics, environmental safety, and unit traditions. Nurse clinicians could use the focus group method to sensitize themselves to the staff's needs and to allow staff the opportunity to share ideas and to dispel misconceptions about restraints.

Support needs of spouses of cardiac patients.

A focus group approach was used to determine the perceived support needs of cardiac patients' significant others. Data were gathered during four focus groups of 2-6 people for a total of 13 informants. Two open-ended questions guided the discussion: (a) What was it like for a person to have someone close have a sudden heart problem? (b) What kind of support is needed during the experience? Informants included spouses of cardiac patients who were newly enrolled in a cardiac rehabilitation program. Discussion sessions were tape recorded. Transcripts were analyzed by using grounded theory. Results revealed three core categories: perceptions, needs, and strategies. Categories differed according to three phases of the illness: finding out, hospitalization, and recovery. The model differs in perceptions, needs, and strategies for support in each phase. Nurses can use this model to understand the needs of significant others and plan support interventions.