Gender differences in use of prescription narcotic medications among living kidney donors.

Prescription narcotic use among living kidney donors is not well described. Using a unique database that integrates national registry identifiers for living kidney donors (1987-2007) in the United States with billing claims from a private health insurer (2000-2007), we identified pharmacy fills for prescription narcotic medications in periods 1-4 and >4 yr post-donation and estimated relative likelihoods of post-donation narcotic use by Cox regression. We also compared narcotic fill rates and medication possession ratios (MPRs, defined as (days of medication supplied)/(days observed)), between donors and age- and sex-matched non-donors. Overall, rates of narcotic medication fills were 32.3 and 32.4 per 100 person-years in periods 1-4 and >4 yr post-donation. After age and race adjustment, women were approximately twice as likely as men to fill a narcotic prescription in years 1-4 (adjusted hazard ratio, aHR, 2.28; 95% confidence interval, CI, 1.86-2.79) and >4 yr (aHR 1.70; 95% CI 1.50-1.93). MPRs in donors were low (<2.5% days exposed), and lower than among age- and sex-matched non-donors. Prescription narcotic medication use is more common among women than men in the intermediate term after live kidney donation. Overall, total narcotic exposure is low, and lower than among non-donors from the general population.

Listening with care: using narrative methods to cultivate nurses' responsive relationships in a home visiting intervention with teen mothers.

Effective public health nursing relies on the development of responsive and collaborative relationships with families. While nurse-family relationships are endorsed by home visitation programs, training nurses to follow visit-to-visit protocols may unintentionally undermine these relationships and may also obscure nurses' clinical understanding and situated knowledge. With these issues in mind, we designed a home-visiting intervention, titled Listening with Care, to cultivate nurses' relationships with teen mothers and nurses' clinical judgment and reasoning. Rather than using protocols, the training for the intervention introduced nurses to narrative methods and therapeutic tools. This mixed-method pilot study included a quasi-experimental design to examine the effect of the intervention on teen mothers' depressive symptoms, self-silencing, repeat pregnancy, and educational progress compared to teens who received usual care. Qualitative data were collected from the nurses to evaluate the feasibility and acceptability of the intervention and therapeutic tools. The nurses endorsed the therapeutic tools and expected to continue using them in their practice. Despite the lack of statistically significant differences in outcomes between groups, findings suggest that further study of the intervention is warranted. Future studies may have implications for strengthening hidden aspects of nursing that make a difference in the lives of teen mothers.

Depression diagnoses after living kidney donation: linking U.S. Registry data and administrative claims.

BACKGROUND: Limited data exist on correlates of psychological outcomes after kidney donation. METHODS: We used a database integrating Organ Procurement and Transplantation Network registrations for 4650 living kidney donors from 1987 to 2007 with administrative data of a U.S. private health insurer (2000-2007 claims) to identify depression diagnoses among prior living donors. The burden and demographic correlates of depression after enrollment in the insurance plan were estimated by Cox regression. Graft failure and death of the donor's recipient were examined as time-varying exposures. RESULTS: After start of insurance benefits, the cumulative frequency of depression diagnosis was 4.2% at 1 year and 11.5% at 5 years, and depression among donors was less common than among age- and gender-matched general insurance beneficiaries (rate ratio, 0.70; 95% confidence intervals [CI], 0.60-0.81). Demographic and clinical correlates of increased likelihood of depression diagnoses among the prior donors included female gender, white race, and some perioperative complications. After adjustment for donor demographic factors, recipient death (adjusted hazard ratio (aHR), 2.23; 95% CI, 1.11-4.48) and death-censored graft failure (aHR, 3.30; 95% CI, 1.49-7.34) were associated with two to three times the relative risk of subsequent depression diagnosis among nonspousal unrelated donors. There were trends toward increased depression diagnoses after recipient death and graft failure among spousal donors but no evidence of associations of these recipient events with the likelihood of depression diagnosis among related donors. CONCLUSIONS: Recipient death and graft loss predict increased depression risk among unrelated living donors in this privately insured sample. Informed consent and postdonation care should consider the potential impact of recipient outcomes on the psychological health of the donor.

The experiences of African-American living kidney donors.

In many cases, optimal treatment for end stage renal disease (ESRD) is living kidney donation. African Americans are of interest because of high incidence of ESRD, documented disparities regarding kidney transplantation, and under-representation in living kidney donor research. An interpretive qualitative study was conducted among African Americans to improve understanding of living donation to genetically or emotionally related recipients. Two major themes emerged - context of living kidney donation and work of living kidney donors. Specially noted are the influence of spiritual and religious practices, and experiences of participants with history of substance abuse. Research recommendations and clinical implications are presented.

Writing therapeutic letters in undergraduate nursing education: promoting relational skill development.

Although therapeutic letters (TLs) have been included in graduate nursing programs, studies have not examined the impact of TLs on the clinical learning of undergraduate students. This qualitative study was part of a larger project that introduced TLs into already established undergraduate clinical courses. Instructors prepared students for writing TLs by discussing their purpose and by providing a relevant article and examples. In all, 74 students participated in 12 focus group interviews. Interviews were audiotaped, professionally transcribed, and analyzed using qualitative description. Results suggest that TLs cultivate rapport building and the development of students' relational skills. Although the assignment promoted clinical learning and reflection on helping relationships for the vast majority of students, a few students treated TLs as an instrumental activity. Implications for educating health professionals are described.

Therapeutic letters in undergraduate nursing education: Ideas for clinical nurse educators.

Therapeutic letter writing (TLW) is a well-known intervention in family nursing practice but it has been overlooked as a strategy in nursing education to promote relationship-building. This article reviews what is known about TLW and presents what was learned by adding a TLW assignment to undergraduate clinical nursing courses. This paper adds to the evidence supporting TLW as an effective clinical teaching strategy to promote students relational skills and to recognize patients' strengths. TLW has benefits for students, patients and faculty.

Re/Affirming and re/conceptualizing disciplinary knowledge as the foundation for doctoral education.

Global shortages of nurses, limited resources, and increasing transnational crises mandate changes in healthcare planning and delivery. Disciplinary knowledge is integral to the development of nurse practitioners and researchers who can provide leadership role in addressing critical healthcare problems. This collaborative meditation examines how critical reflection about disciplinary knowledge in the context of nursing doctoral education facilitates this endeavor. Factors that constrain the development of disciplinary knowledge are discussed. Suggestions for further development of disciplinary knowledge are offered.

Moving upstream: Becoming a public health nurse, part 2.

This article extends the argument in Part 1 that stand- ards, protocols, textbook knowledge, and other external guidelines, while important for beginners, must yield to the "real world" of practice. Additional narratives document how the development of practical reasoning, perceptual skills, and responsiveness to clients supplants the beginner's reliance on external guidelines and promotes a situated understanding of practice. This growth in understanding and clinical know-how, cultivated by frontline experience with individuals and families, fosters a perceptual grasp of the "big picture" and makes it possible for the nurse to learn the community through the eyes of clients. Experiences from home visiting and community-based activities provide critical lessons that inform and inspire nurses to act and think upstream. This interpretation provides additional evidence for legitimizing clinical practice as a rich source of situated knowledge and clinical reasoning.

Getting your feet wet: becoming a public health nurse, part 1.

While the competencies and theory relevant to public health nursing (PHN) practice continue to be described, much less attention has been given to the knowledge derived from practice (clinical know-how) and the development of PHN expertise. A study was designed to address this gap by recruiting nurses with varied levels of experience and from various practice sites. A convenience sample of 28 public health nurses and seven administrators/supervisors were interviewed. A subsample, comprised of less-experienced public health nurses, were followed longitudinally over an 18-month period. Data included more than 130 clinical episodes and approximately 900 pages of transcripts and field notes. A series of interpretive sessions focused on identifying salient aspects of the text and comparing and contrasting what showed up as compelling, puzzling, and meaningful in public health nurses' descriptions. This interpretive analysis revealed changes in understanding of practice and captured the development of clinical know-how. In Part 1, we describe the sample, study design, and two aspects of clinical knowledge development--grappling with the unfamiliar and learning relational skills--that surfaced in nurses' descriptions of early clinical practice. In Part 2, which is to be published in the next issue of Public Health Nursing (SmithBattle, Diekemper, & Leander, 2004), we explore gradual shifts in public health nurses' understanding of practice that led to their engagement in upstream, population-focused activities. Implications of these findings for supporting the clinical learning of public health nurses and the development of expertise are described.