The experiences of internationally educated nurses in the southeastern United States of America.

BACKGROUND: US healthcare facilities have addressed nursing shortages in part by recruiting internationally educated nurses (IENs), and studies suggest IENs may make up a significant percentage of the nursing workforce in urban hospitals. Despite the economic recession of 2008-2012, international nurse migration is expected to continue. Little is known about IENs in the southeastern USA, and no studies have compared their perspectives to those of their US counterparts. OBJECTIVE: The purpose of this study was to gain a deeper understanding about the experiences of IENs compared to those of US registered nurses (RNs) practising in two urban hospitals in southeastern USA. METHODS: This study involved two rounds of semi-structured interviews of 82 IENs and US RNs. Interviews focused on themes relating to education, barriers to practice, intent to stay in nursing and IENs' migration experiences. FINDINGS AND DISCUSSION: Most IENs interviewed migrated to the USA after 1990 to join their family and do not plan to return to their home countries to practise. Most IENs initially received their Associate Degree in Nursing; many have obtained their Bachelor of Science in Nursing degree. IENs and newly licensed US RNs faced similar barriers when they began practising in the USA, but IENs faced additional challenges adjusting to the attitudes of US patients, the perceived lack of respect for nurses and delivering total patient care. CONCLUSIONS: IENs would benefit from orientation regarding the cultural differences in the USA. In other ways, their challenges are similar to those of US RNs; policies regarding education, recruitment and retention could target both groups together.

Dementia family caregiver training: affecting beliefs about caregiving and caregiver outcomes.

OBJECTIVES: Family caregiving is an integral part of the care system for persons with dementing disorders, such as Alzheimer's disease. This study tested role-training intervention as a way to help family caregivers appreciate and assume a more clinical belief set about caregiving and thereby ameliorate the adverse outcomes associated with caregiving. DESIGN: Training effectiveness was tested in a trial in which family care receiver dyads were randomly assigned to training beginning immediately or were placed in a wait-list control group and assigned to receive training in 5 to 6 months, following completion of data collection. SETTING: A community-based 14-hour training program provided in seven weekly 2-hour sessions. The training program curriculum was built on a stress and coping theory base. Recruitment and randomization were ongoing. Programs were begun every 2 months over a two and one half-year period for a total of 16 programs. PARTICIPANTS: Community health and social service agencies referred primary caregivers and at least one other family member of community-dwelling persons with dementia to participate. MEASUREMENTS: Data reported in this paper were gathered from each participating family at entry to the study and 5 months later. Standard measures of beliefs about caregiving, burden, depression, and reaction to care receiver behavior were administered to caregivers. A standard measure of mental status was administered to the person with dementia and standardized instruments were used to gather information from caregivers concerning care receivers' behavior and abilities to perform activities of daily living (ADLs). RESULTS: Data were analyzed from 94 caregiver/care receiver dyads with complete sets of data. Treatment and control caregivers and care receivers were similar at baseline, and care receivers in both groups declined similarly over the 5-month period. Significant within-group improvements occurred with treatment group caregivers on measures of beliefs about caregiving (P = .044) and reaction to behavior (P = .001). When outcomes were compared, treatment group caregivers were significantly different (in the expected direction) from those in the control group on measures of the stress mediator, beliefs (P = .025), and key outcomes, response to behavior (P = .019), depression (P = .040), and burden (P = .051). There was a significant positive association between the strengthened mediator, the caregivers' having less-emotionally enmeshed beliefs about caregiving roles and responsibilities, and the outcome, namely improvements in burden (P = .019) and depression (P = .007). CONCLUSION: A caregiver training intervention focused on the work of caregiving and targeted at knowledge, skills, and beliefs benefits caregivers in important outcome dimensions. The results suggest the benefits of providing information, linkage, and role coaching to dementia family caregivers.

Subjective responses to caregiving for a spouse with dementia.

Family members, typically spouses, serve as the primary caregivers for individuals with dementia. While it is recognized that caregivers experience both positive and negative subjective responses to caregiving, relatively little research has been done on the relationship between these types of responses. The objectives of the study were to examine the relationships between and among spouse caregivers' positive and negative subjective responses to caregiving, and increase understanding of the experience of being a spouse caregiver for a person with dementia. Fifty spouse caregivers completed quantitative measures of positive subjective responses (Positive Aspects of Caregiving and Caregiver Competence) and negative subjective responses (Relational Deprivation, Role Captivity, and Loss of Self). Additionally, participants were interviewed concerning their caregiving experiences. Positive Aspects of Caregiving and Caregiving Competence were significantly related to each other (p < .01), as were the three measures of negative subjective responses (p < .01). No significant correlations were found between any measures of a positive and a negative subjective response, suggesting the two types of responses are independent. Duration of caregiving was significantly related to Positive Aspects of Caregiving (p < .05), Caregiver Competence (p < .05), and Relational Deprivation (p < .01). Qualitative interview data revealed that participants simultaneously experienced caregiving as self-affirming, while also enduring losses and difficulties resulting from their caregiving role. Integrating the positive and negative aspects of the whole of caregiving is important to understand the caregiving experience and to design interventions to support caregivers.

Reducing caregiver burden: a randomized psychoeducational intervention for caregivers of persons with dementia.

This 3-year randomized clinical trial tested the effectiveness of an interdisciplinary psychoeducational family group intervention in decreasing the caregivers' perceptions of the frequency and severity of behavioral problems in persons with dementia and their reactions to those problems, and in decreasing caregiver burden and depression. The intervention consisted of seven weekly, 2-hour multimedia training sessions that included education, family support, and skills training for 94 primary caregivers and their families. Repeated measures ANOVA was used to test for significant differences between the intervention and waiting list control groups over a 5-month period. The intervention was successful in reducing caregivers' negative reactions to disruptive behaviors and in reducing caregiver burden over time.

Managed care for older people: a primer for the geriatrician.

Managed care for older people is growing at a very rapid rate. Many geriatricians and primary care providers are interested in this area but have limited sources of information to guide their decision-making about whether to participate in these programs. This review provides a basic overview of managed care for older people, including plan types and roles that geriatricians may choose in participating in these programs. Risk and value are central concepts that impact managed care of this population. Several changes in Medicare Managed Care have occurred with the passage by Congress of the Balanced Budget Act of 1997. Geriatricians are strongly encouraged to participate in managed care as it offers the potential for improved models of care delivery for older adults.

Options, outcomes, values, likelihoods decision-making guide for patients and their families.

When family caregivers are faced with making daily decisions, they may feel burdened, frustrated, and even in conflict with other family members. The OOVL Guide is a tool to help people think about the various aspects of a decision situation and combine them to make a decision. The OOVL Guide supports nurses in their advocacy role because it affirms the importance of the clients' values and preferences. The OOVL Guide provides decision-makers, both professionals and lay people, with a structure and procedure for making choices for themselves or others.

Post-hospital sub-acute care: an example of a managed care model.

OBJECTIVE: This article describes Transitional Care Centers (TCC), an innovative sub-acute care program developed by a large managed care organization (HealthPartners in Minnesota) in partnership with five area nursing homes. The purpose of the TCC is to promote continuity of care for frail older members covered under a TEFRA risk contract. DESIGN: This is a retrospective study of the experiences and outcomes of enrollees who received TCC compared with a like group of enrollees who received customary continuity care through contract services. SETTING: The TCCs are established contractually in five area nursing homes; these facilities keep at least 15 beds available to the health plan for round-the-clock, 7 days per week admissions for sub-acute care. Designated staff from these facilities and designated geriatric nurse practitioners and geriatricians from HealthPartners follow established targeting, admissions, assessment, care planning, and discharge planning procedures to provide team care for these patients at the facilities. PARTICIPANTS: The TCC program is targeted to patients requiring rehabilitation therapy (post-cardiovascular accident, post-fracture/replacement) who are deconditioned, or those with uncomplicated infections (urinary tract infection, pneumonia). A total of 1144 patients participated in the TCC program in the 1-year program under report, and 253 were surveyed in regard to their experience. One hundred HealthPartners physicians were surveyed about the program. RESULTS: Post-acute length of stay in the TCC was substantially lower than that in customary care settings in contract nursing homes (14.3 versus 20.5 days). Rehospitalization rates from these units were comparable to or better than those from other sub-acute units. Patient and primary care physician satisfaction with the units was high. The program provided economic benefit to both partners. The health plan's negotiated rate for the TCC units was 38% less than that paid in noncontractual facilities. CONCLUSION: The TCC partnership provides rehabilitative and geriatric evaluation services in settings more conducive to and less costly than such care usually, and yields improvements in care and utilization outcomes.

The Family Stories Workshop: stories for those who cannot remember.

The Family Stories Workshop (FSW) is a process through which family members and friends of persons with dementing disorders living in nursing homes develop stories of these residents' lives. The stories are meant to help staff members to develop a better, more deeply felt understanding of the lives of the residents, persons who can no longer tell their own stories. The workshop is product-oriented and is not meant as a support group and works best in organizations emphasizing individualized care. This article describes the process of the FSW as well as outcomes from preliminary implementation. It suggests ways of using elements of the process to more broadly accomplish the FSW purposes.

A moving experience: reconfiguring a special care unit for Alzheimer's patients.

Eight years after opening, the patient mix on a 64-bed Special Care Unit (SCU) for Alzheimer's residents had become too diverse to allow the intended programming to be carried out. The unit was carefully reconfigured with residents moving within, to, and from the unit. Successful moves typically involve residents in pre-move planning and preparation activities, but since this isn't feasible with dementia patients, extensive planning, training, and preparation of staff substituted for the involvement of residents. The move met its objectives: resident mix and programming are back to the original intent, and quality of life has improved. Improved discharge policies maintain homogeneity of resident levels on the unit. The change produced unexpected changes, and staff, particularly the Certified Nursing Assistants (CNAs), had to make immediate adjustments. Greater CNA involvement is recommended.

Pet ownership among persons with AIDS in three Florida counties.

Interviews were conducted among 408 adults with acquired immunodeficiency syndrome at three local health departments to determine the proportion who owned pets, their perceived attachment to their pets, and the proportion who were informed about zoonoses. Nearly half (187, or 46%) were living with pets, most commonly dogs (64%), followed by cats (38%), fish (15%), birds (8%), reptiles (3%), and rodents (2%). Most pet owners (81%) reported an attachment to their pet. Only 10% were informed of zoonoses, albeit some incorrectly. Health care providers should recognize the high pet ownership rate among persons infected with human immunodeficiency virus and correctly inform their patients of strategies to sustain a low zoonotic disease incidence.

Ethical and clinical issues with Native-American elders. End-of-life decision making.

This article offers guidance to clinicians for approaching and conducting end-of-life decision-making conversations with Native American elders. The guidelines emphasize the need for flexibility and clarity in communication, avoidance of insistence on formal structures and rigid time frames for decision-making, sensitivity to the cultural and family situation of the elder, and recognition that cultural as well as language interpretation may be necessary. Given the great diversity of the tribes and bands as well as languages among native people and the paucity of empirical work on this topic, the tentative nature of these guidelines is stressed.

Caregivers of frail elderly and medically fragile children: perceptions of ability to continue to provide home health care.

The purposes of this study were to compare the characteristics and support systems of caregivers of frail elderly and medically fragile children and to determine what factors discriminated between caregivers who could (and could not) continue to provide home health care. Caregivers of children were significantly more likely (chi 2 = 52.30)2), p = < .0000) to report that they were managing OK than caregivers of frail elderly. They also reported receiving more support and assistance from formal and informal sources, although in general, less than 30% of the caregivers received any help. Five variables (Mental impairment of the elder, poor physical and mental health of the caregiver, high monthly caregiving-related expenses, and use of paid in-home assistance) explained 35% of the variance between caregivers of frail elderly who were managing OK and those who were unable to continue to manage. Six variables (physical and mental impairment of the child, physical health of the caregiver, feeling like there were no alternative providers, time demand and lack of assistance from others) explained 26.57% of the variance between caregivers of children who were managing OK and those who were unable to continue to manage. The findings suggest that a strong objective stressor, combined with a lack of personal and social resources are associated with caregivers' perceptions that they cannot continue to manage home health care.

A survey of Minnesota home care agencies' perceptions of physician behaviors.

A survey of Minnesota home care agencies assessed perceptions of and satisfaction with the home care practices, knowledge, and skills of Minnesota family physicians and other primary care physicians. We found that physicians did not make many home visits and that agencies were moderately dissatisfied with that practice. Family physicians visited significantly more frequently than other primary care physicians and, in rural areas, received significantly higher satisfaction ratings from agencies. The areas most frequently noted that could benefit from improvement of physician skills/knowledge regarding home care were: better home care clinical skills (38.5% of respondents), knowledge of home care technology and capabilities (37%), and knowledge of reimbursement policies and practice (29%).

The role of physicians in home health care.

Physician involvement in home care has declined markedly over the past 50 years. By contrast, the renaissance in home care in the US over the last decade has created a pressing need for greater physician participation and new roles for physicians as members of the home care team. This article reviews these developments and identifies the need for improved medical education and physician reimbursement if the desired physician involvement in home care is to become a reality.

Development of a quality assurance program in a medical model adult day health care center.

Staff of the Minneapolis VA Medical Center's Adult Day Health Care Center (ADHC), which provides primary medical care to elderly veterans, used a decentralized approach to develop a quality assurance (QA) program that reviews all aspects of care, provides substantive data, and remains flexible to ADHC needs. Staff participated in four one-hour sessions designed to educate them about QA and provide the necessary skills and information for developing and implementing their own QA program. Staff collectively identified important aspects of care, developed indicators, and assigned thresholds. ADHC's QA program has been successfully developed with only a minimum amount of staff and consultative time. Due to its collaborative nature, ADHC's program continues to enjoy high staff support.

Family caregivers for non-Alzheimer's dementia patients.

The extensive literature on dementia (primarily AD) suggests that informal caregiving will play a significant role in patient well-being, will have an impact of some kind on the caregiver, and will benefit from tailored intervention on the part of the clinician. It should be clear from the review of six disorders that dementing conditions emanate from many diseases, affect widely diverse age groups, produce very different symptoms sets, and are a primary or secondary patient management issue for the clinician. In particular, the review points out the need for a comprehensive caregiver assessment and training program. Caregiver assessment needs to consider physical, emotional, social, and financial domains. The assessment should determine the physical demands of caregiving and the exceptional and particular emotional issues of the situation; this should take into account the physical and emotional demands already placed on the caregiver by a pre-existing condition to which the present dementia might be secondary. The assessment should examine the nature and extent of the social isolation of the caregiver, again factoring in the unique isolating effects of concurrent disorders. The clinician should explore what financial resources are available for helping with caregiving and examine the degree to which legal and financial planning have occurred. The assessment should also determine the strengths of the caregiver (skills, personality, physical well-being) as well as his or her information and training needs. This detailed data base will assist the clinician in providing the kind of training and management support that the literature suggests can be most beneficial for sustaining the caregiving situation as well as the caregiver. Within the context of particular disorders, optimal support provides the caregiver with needed information, skill and problem-solving training, opportunity for emotional outlet, attention to the need for social support, acknowledgement of the caregiver's pivotal role, and clinical care as needed.

Helping families cope with Alzheimer's: the physician's role.

The physician's expressed approval of the caregiver's performance has much credibility with the caregiver, thus providing relief. No matter how many hours of devoted care are given, a caregiver almost never hears a "thank you" from a demented loved one. By listening closely to the caregiver, the physician will glean information decisive to the care of both the demented patient and the caregiver. This personal attention also affords the caregiver an outlet for stress.