Public health nursing data. Building the knowledge base for high-risk prenatal clients.

PURPOSE: To examine and compare referral reason, clinical pathway variance, and intensity of need for care for high-risk prenatal clients of public health nurses. DESIGN: A prospective, descriptive design was used for this pilot study. METHODS: Reasons for referral to the high-risk prenatal home visitation program, variances from a prenatal clinical pathway, and intensity of need for care scores obtained using the Community Health Intensity Rating Scale (CHIRS) were collected at 28 weeks and 38 weeks of gestation from the clinical records of 20 high-risk prenatal clients (age range 16-43 years) visited by five expert public health nurses in one midplains public health nursing department. RESULTS: Findings indicated that the three sources of clinical data provided congruent but not identical data, with each contributing elements needed to specify public health nurses interventions for high-risk prenatal clients. CLINICAL IMPLICATIONS: Collaborative clinical research studies such as this one are useful in advancing evidenced-based practice in clinical agencies. The congruence between the clinical path variance and the intensity of need for care scores reaffirms the importance of the domain of health behavior intervention as a major aspect of public health nurses practice.

Quantifying client need for care in the community: a strategy for managed care.

The Community Health Intensity Rate Scale (CHIRS) is a tool that provides an index of a client's need for care. Emphasis in healthcare has shifted from episodes of illness to covered lives and managed care. CHIRS contains all the elements for holistically determining the intensity of a client's need for care and the environmental, psychosocial, and health behaviors of the client. The CHIRS has been utilized with a variety of community health populations. Each application of CHIRS provided feedback to the researchers for use in revising CHIRS. This article reports the findings of a study which tested the validity and reliability of the refined version of CHIRS. The validity and reliability needed further refinement at the indicator level. The study produced a more practical tool for determining intensity of need for clients in the community.

Patterns of health resource utilization, costs, and intensity of need for primary care clients receiving public health nursing case management.

Case management has been promoted as a managed care strategy that improves quality of care and contains costs. Health resource utilization patterns and associated costs were examined for a generalized primary care population receiving a public health nursing model of case management intervention during a 30-week period. Subjects were referred by providers practicing in an academic health science center and included two client subsamples: chronically ill adults and younger families requiring health maintenance. Health resource utilization patterns and associated costs were examined in relation to intensity of need for care levels as determined by the Community Health Intensity Rating Scale. Results of this pilot study suggest that during public health nursing case management intervention, health resource utilization patterns changed from the preintervention period. Total health resource utilization costs were correlated with care needs related to health management behavior of the chronically ill.

Care paths. A new approach to high-risk maternal-child home visitation.

Care paths for the maternal and infant populations are used to define immediate and long-term outcomes related to care received in the home. This article describes a care path developed by public health nurses for intervention with an at-risk maternal-child population in a city/county health department. A public health nursing care management model provided the framework for developing this care path to foster cost-effective use of limited resources. It is crucial that public health nurses articulate clearly the services provided in the home both for those who may seek service and for policy makers who determine funding structure. The project demonstrated that care paths for home visitation involving high-risk prenatal clients are useful tools that streamline documentation, foster consistency and continuity of care, facilitate quality improvement efforts, and provide outcome data.

The School Health Intensity Rating Scale: establishing reliability for practice.

It is important for school nurses to identify health care needs and nursing resources necessary to achieve desired health outcomes for the school-age population. The purpose of this study was to determine interrater reliability for the School Health Intensity Rating Scale (SHIRS), a tool developed to assess intensity of health care needs of the school-age population. Four school nurses assessed 20 fictitious student records using SHIRS. The SHIRS produced moderate kappa coefficients for more than half of the 15 parameters with 2 additional parameters near the moderate kappa range.

Measuring the need for nursing care in older adults living at home.

The Community Health Intensity Rating Scale (CHIRS) has been found to significantly explain variation in resources consumed by both home health care clients and high-risk public health nurse clients. Secondary analysis of CHIRS scores from two earlier retrospective studies provided insights into basic similarities and differences between older adults served by a home care program (n = 208) and those served by a public health nursing program for frail elderly (n = 47). CHIRS scores for both client groups demonstrated a substantial need for care, with a greater range of CHIRS global scores for home health care clients but significantly higher (CHIRS total scores for the public health nurse clients (t = -5.24, p < .001). These findings suggest that the public health nurse clients experienced needs across multiple areas whereas the home health care clients' needs were more narrowly focused and episodic. Representation of needs by an intensity rating such as CHIRS can foster more focused visit planning and more specific outcome assessment, assist in planning staffing and in-service education, and focus nursing education regarding care of older adults.

Evaluation of the effectiveness of Project Trust: an elementary school-based victimization prevention strategy.

This study employed a Posttest-Only Control Group Design to assess the effects of a victimization prevention program, Project TRUST, on elementary school students' knowledge of general prevention concepts, knowledge of difficult-to-acquire prevention concepts, anxiety, and reporting of abuse. A selected subgroup of experimental subjects was also assessed for retention of acquired concepts over time. Students exposed to Project TRUST demonstrated significantly greater knowledge of maltreatment prevention information, as well as difficult-to-acquire concepts, than control group students. A 3-month delayed reassessment of the experimental subgroup showed no loss in acquired prevention information. No differences in anxiety scores existed between experimental and control groups. First-time student abuse disclosures were greater in the experimental than in the control group. These findings support the effectiveness of Project TRUST as a strategy to increase prevention knowledge and generate abuse disclosures without creating student anxiety.

Characteristics of clients who receive home health aide service.

Nurses who plan and supervise home health aide service must have a good understanding of the amount and intensity of nursing care and the amount of home health aide service that individual clients will need. However, there is little in the nursing literature that describes how clients who receive both RN and home health aide services differ from clients who receive only RN care. Indeed, there have been few reports on how need for home health aide service relates to the amount of nursing care received. Secondary analysis of data from a study on resource consumption in home care revealed that clients who receive home health aide service: 1) are older; 2) are more likely to be women; 3) have a higher rating using the Community Health Intensity Rating Scale; and 4) are discharged from the caseload due to death or institutionalization at a higher rate than those who receive only RN care. Clients who received both home health aide services and RN care needed assistance with activities of daily living, but they also required more RN care than did clients who received only RN care. These data hold implications for nurses in addressing agency staffing, focusing home health aide training, and advocating for resources to address service needs of this segment of their care population.

Fostering expertise in occupational health nursing: levels of skill development.

1. Levels of nursing expertise described by Benner--novice, advanced beginner, competent, proficient, and expert--hold potential for fostering improved practice among occupational health nurses. 2. Lacking a clear understanding of the full potential of the role of the occupational health nurse, employers may not reward the development of clinical expertise that incorporates employee advocacy within the context of written standards and guidelines. 3. Expertise in occupational health nursing can be fostered by job descriptions that incorporate a broader view of nursing (one that stresses judgment and advocacy), retention and longevity, innovative strategies for consultation and collegial interaction to foster mentoring, and distance learning strategies.

Measuring the essence of nursing: a guide for future practice.

Today's changing health care environment presents nursing with the opportunity to expand its role in the health care system. With this opportunity, issues of appropriate education, delegation of supplemental activities to nonprofessionals, and cost of nursing services become significant. Satisfactory resolution of these issues will require a clearly articulated language for what nursing does so that services can be well defined in some way other than a medical model. Once there are clear definitions, competencies for education can be established, decisions regarding delegation of activities can be made, and costs can be assigned. This article describes the use of the Community Health Intensity Rating Scale (CHIRS) as a beginning point for resolving these issues. The CHIRS is a reliable and valid patient classification tool developed to measure the needs of clients of community health nurses as a basis for projecting agency resources required to address those needs. Data elements in CHIRS offer a nursing perspective that incorporates environmental, psychosocial, and health management concerns; more specific definitions of the content and context of care; and an expanded basis for defining resource consumption.

Nursing intensity as a predictor of resource consumption in public health nursing.

The community Health Intensity Rating Scale (CHIRS) has been found to explain variations in resource consumption by home health care clients. The purposes of this study were to determine the amount of variance in nursing resource consumption among public health nursing (PHN) clients explained by CHIRS and to assess whether the four CHIRS domains accurately represent its underlying structure. The sample included 133 PHN clients from three programs: frail older adult, high-risk prenatal, and high-risk infant. CHIRS total score significantly predicted variation in nursing resource consumption in two of the three PHN programs when a composite measure of resource consumption, referred to as nursing effort, was used as the criterion variable. A principal components factor analysis of CHIRS produced a three-factor solution, two of which were reliable enough for use as subscales. A contextual/behavioral subscale and a physiological subscale increased the variance in nursing resource consumption explained in two of the three PHN programs.

Linking quality and cost effectiveness: case management by an advanced practice nurse.

This retrospective chart review examined relationships among case management by an advanced practice nurse (APN), patient acuity, and length of hospital stay among 35 case-managed and 43 non-case-managed patients with colon resection. Patients case managed by the APN had a mean (+/- SD) acuity level of 8.36 +/- 3.98 and mean length of stay (LOS) of 11.51 +/- 4.28 days; non-case-managed patients had a mean acuity of 7.78 +/- 3.55 and mean LOS of 12.35 +/- 7.30 days. These differences were not statistically significant. In separate group regressions, acuity significantly predicted LOS for the non-case-managed group (R2 = 0.137, p = 0.0145) but not for the case-managed group (R2 = 0.0351, p = 0.2812). APN case-managed patients showed a trend toward higher acuity and shorter LOS. It appears that APN involvement in care negated acuity as a predictor of LOS. Patterns of association between APN case management and patient outcomes warrant further investigation.

Determining intensity of need of high-risk maternal and infant clients.

Sound funding decisions by policymakers require data that relate health care services to both client need and client outcome. However, client need for care is not easy to express quantitatively, particularly in the realm of preventive and health promotion services. Application of the Community Health Intensity Rating Scale (CHIRS) with high-risk infants and prenatal clients revealed that differences in intensity of need, particularly in contextual and behavioral domains, helped to explain variation in amount of care received. The CHIRS holds promise of providing the language and measurement with which to articulate client need as the basis for cost-effective multidisciplinary care.

School nursing in the 21st century: prediction and readiness.

The complex health and education needs of today's students are prompting schools to develop more responsive school health programs. School nurses' preparation for roles in these emerging programs requires both a vision of future practice and a clear recognition of present skill levels. This study compared the vision of practice in the twenty-first century held by school nurses in a rural, mid-plains state with the vision of a national expert school nurse panel. The findings have implications for role evolution and educational preparation.

Informatics issues for nursing's future.

Automated clinical databases are crucial to the future of nursing but presently are not meeting the needs of clinicians, administrators, educators, or researchers. This article examines theoretical, empirical, and practical issues relating to the development of automated nursing clinical databases that will foster safe, effective practice and further nursing's knowledgebase. A series of key questions are identified relevant to each issue. These issues must be resolved if nurses are to take full advantage of the possibilities inherent in the evolving information technology.

The new paradigm: concepts and application in community health nursing.

The central role of community health nursing in future health care delivery systems is undisputed. The abilities and characteristics of nurses who will practice in those systems depends to a large extent on their learning experiences in basic nursing programs. Educators are being asked to prepare skilled, compassionate scholar-clinicians to provide care for the complex needs of clients, despite already packed curricula. The curricular changes cannot be additive; learning must be designed to empower students to become nurses who are both skilled and compassionate. Certain faculty attitudes and behaviors are essential to this new educational paradigm and student activities and assignments must foster confident effective practice.

Nursing care requirements and resource consumption in home health care.

Nursing care requirements provide the rationale for nursing practice. Two representations of nursing care requirements are nursing intensity and nursing diagnoses. In the present study, these two indicators each significantly explained variation in nursing resource consumption in home health care. Further study is needed to refine a measure of nursing intensity that has construct validity and a base in nursing theory. In addition, techniques are needed for grouping and weighting the various nursing diagnoses to reflect their contribution in explaining the amount of care provided to patients.

The kappa statistic for establishing interrater reliability in the secondary analysis of qualitative clinical data.

Analysis of extant clinical records is receiving increased emphasis in nursing investigations. Appropriate use of this approach to patient research requires careful attention to data management, including assessment of reliability. Percent agreement, phi, and Kappa all serve as estimates of interrater reliability in the analysis of data. Kappa has particular merit as a measure of interrater reliability; it also has some peculiar problems in implementation and interpretation. The nature and computation of Kappa and its application in analysis of clinical data are discussed.

Multiple delivery methods for an interdisciplinary audience: assessing effectiveness.

Recent federal legislation has provided guidelines for intervention services for infants and toddlers with handicaps, birth to age three, and their families. Many disciplines, including nursing, will be involved in providing these services. Serving on an interdisciplinary team or acting as a consultant requires appropriate preparation. Many professionals are not comfortable with their roles in serving this new population, due in part to the limited emphasis on the handicapped infant and toddler in most basic preservice professional education programs. The project described here was useful in helping an interdisciplinary audience develop knowledge and skills needed for intervention services for infants and toddlers.