Using evidence-based practice for managing clinical outcomes in advanced practice nursing.

Preparation of advanced practice nurses to assume leadership positions for clinical decision making requires that traditional ways of solving clinical problems be augmented with information from relevant, research-derived evidence. In this article, the authors describe how one graduate program prepares advanced practice nurses to use the best scientific evidence with clinical expertise to influence patient outcomes. The assignments that students complete in their program provide examples of evidence-based practice that apply quality improvement principles and science-based nursing interventions to create best practices.

A comparative analysis of individuals with spinal cord injury who differ in unplanned utilization of health services.

The purpose of this descriptive study is to describe the profile of individuals with spinal cord injuries (SCI) who frequently use health care services in an unplanned manner so that nursing interventions could be designed to decrease utilization. The medical records of 78 subjects with SCI were reviewed for demographic and injury-related variables, comorbid health conditions, discharge disposition, and health care utilization for five years. Based on the rate of unplanned utilization of health care services, three groups of users were identified: non-user, low-user, and high-user groups. Results indicated that high users, compared to non-users and low users, had a higher substance-use rate, a higher unemployment rate at the time of the most recent health care visit, and more violent causes of their SCI. Findings suggest four clinically meaningful trends that have practical implications for nurses related to marital status, substance use, employment status, and etiology of injury. Results of this study laid the foundation for future research aimed at devising a more in-depth risk profile of high users of health care services in the SCI population.

Are alternative long-term-care programs needed for adults with chronic progressive disability?

Long-term care planning for middle-aged adults with progressive neurological impairment is a largely unexplored area. The purpose of this study was to examine factors that place individuals with progressive disability at risk for institutional placement and identify whether innovative long-term care preferences would be used if available. The sample of 102 clients with a diagnosis of multiple sclerosis (N = 92) or other progressive illnesses (N = 10) was mostly female, married and Caucasian, with an average age of 48 years. The social support network of family and friends was small; most tangible aid was provided by family members. Seventy percent of the participants used community services, the most common being a home-health aide (44%) and professional nursing services (21%). Medicaid insurance, severity of functional disability and lack of social support were associated with greater use of community services. Participants could foresee using long-term care alternatives such as a community residence (65%), adult day healthcare (63%) and family respite (46%), although these services were regarded with some ambivalence. With their knowledge of community resources, nurses are in a key position to make early assessments of clients' present and future care needs and to suggest needed modifications in living arrangements to avoid premature institutionalization.

Relationships among illness uncertainty, stress, coping, and emotional well-being at entry into a clinical drug trial.

The purpose of this cross-sectional study was to examine the relationships among illness uncertainty, stress, coping, and emotional well-being at the time of entry into a clinical drug trial. Hopefulness and mood state were included as indicators of emotional well-being. The sample included 59 clients who participated in a 2-year trial using methotrexate for progressive multiple sclerosis. Results indicated that ambulation status, education, perceived stress, and illness uncertainty were the best correlates of emotional well-being. The results suggest that clients entering a drug trial with high levels of illness uncertainty and stress are likely to experience mood disturbances and feel less hopeful about treatment effectiveness. This information may be used as a foundation for developing nursing interventions designed to foster emotional well-being at the time of entry into drug trials.

From neophyte to expert: the socialization of nursing faculty as researchers.

The concept of socialization provides a useful framework for describing the difficult transition from being a neophyte researcher to becoming an expert. Individuals are often not aware of the complexity of the research process and perceive their struggles and conflicting feelings as unique. Recognition that one's feelings can ease distress and facilitate the development of the researcher and, ultimately, facilitate the advancement of nursing science. The socialization of faculty nurse researchers can be viewed as including four stages: dependence, negative independence, independence and mutuality, and interdependence. Progression through the stages is characterized by the development of a strong sense of self and expertise as a researcher. The individual emerges with feelings of zest and enthusiasm for the role and with competence and integrity as a researcher.

Correlates of the caregiving process in multiple sclerosis.

This study sought to identify predictors of general health, mood, family, and life satisfaction for spousal caregivers of persons with multiple sclerosis. Cross-sectional data were obtained through structured interviews with 34 husbands and 27 wives of the disabled individuals. Results of the hierarchical regression analyses indicated that objective burden, subjective burden, and perceived uncertainty about the illness situation accounted for the largest proportion of variance in caregivers' general health, mood, family and life satisfaction. Perceived social support explained an additional small, but significant proportion in caregivers' general health, mood, and family satisfaction. Contrary to expectation, family coping did not significantly explain any variance in caregiver outcome measures.

Examination of the factor structure of the Ways of Coping Questionnaire with clinical populations.

The purpose of this study was to examine the construct validity of the Ways of Coping Questionnaire in a clinical population. The questionnaire, designed to measure coping behaviors in a community-residing well population, contained eight empirically constructed factors. Confirmatory factor analysis with LISREL was used to validate this original eight-factor model with 655 community-residing adults with multiple sclerosis or a spinal cord injury. The hypothesized model was not a good fit to the data. Subsequent analyses, using both exploratory and confirmatory factor analysis procedures, identified three different coping factors: Cognitive Reframing, Emotional Respite, and Direct Assistance. These factors appeared to have greater applicability to people with chronic conditions. The kinds of coping behaviors used to manage stressful situations by individuals who are well may be quite different from those used by community-residing populations with long-term chronic conditions.

A comparative analysis of coping behaviors in persons with multiple sclerosis or a spinal cord injury.

Coping behaviors in individuals with multiple sclerosis (MS) or a spinal cord injury (SCI) were compared. Data were collected on 433 subjects with MS and 257 with SCI. Coping and illness uncertainty were measured by the Ways of Coping Checklist (revised) and the Mishel Uncertainty in Illness Scale. Results of the multivariate analysis of covariance indicated that there was no significant difference between the groups for the use of emotion-focused coping (EFC) or problem-focused coping (PFC). However, there was a significant difference in coping depending on illness uncertainty and the appraisal of life with a disability. Subjects used more EFC at high uncertainty and more PFC at no uncertainty compared to the other levels. When situations were appraised as dangerous, EFC was used more often, and when situations were appraised as an opportunity, PFC was used. The construct of vulnerability emerged as an important antecedent variable. When vulnerability was not included in the analysis, a spurious difference in EFC was found between the groups. Multiple regression results indicated that, for both groups, the choice of coping strategies had no significant effect in explaining emotional well-being while controlling for selected sociodemographic and disability-related variables.

Congruence in uncertainty between individuals with multiple sclerosis and their spouses.

The purpose of this study was to examine differences in the perception of illness uncertainty between husband and wife and to explore how these differences influence emotional well-being. Mood and family satisfaction were used as indicators of emotional well-being. The sample consisted of sixty-one married couples in which one spouse had multiple sclerosis. Results supported that both individual perceptions of illness uncertainty and congruence in perceived uncertainty between spouses may have negative effects on marital partners. For both spouses, those who reported higher levels of uncertainty were more likely to have lower moods and feel more dissatisfied with family life. However, the most crucial factor in determining family satisfaction for spouses with multiple sclerosis was their own perception of illness uncertainty, while for well spouses, it was the congruence between each partner's perception of the illness uncertainty.

Families need help too: group treatment for families of nursing home residents.

Despite long-standing interest in the family as the focal point of nursing care, there are few published reports of clinical interventions with families after they institutionalize an elderly relative. Family members experience loss, guilt, and grief, and report that these emotions continue throughout the time that their older member is in the nursing home. This paper presents the rationale for using a supportive, educational group approach with families of nursing home residents and describes a family group intervention, detailing the role of the geriatric mental health nurse specialist, group goals, and the focus of each session. Evaluations by families and staff are presented, and recommendations for practice are made.

Antidepressant pharmacotherapy of depression associated with multiple sclerosis.

In a double-blind clinical trial involving 28 patients with multiple sclerosis and major depressive disorder, 14 patients were randomly assigned to a 5-week trial of desipramine and individual psychotherapy and 14 to placebo plus psychotherapy. Clinical judgments indicated that patients treated with desipramine improved significantly more than the placebo group. This was confirmed by scores on the Hamilton Rating Scale for Depression but not by Beck Depression Inventory scores. Side effects limited desipramine dosage in half of the treated patients. The authors conclude that desipramine has a modest beneficial effect in serious depression associated with multiple sclerosis but that side effects may be more of a limiting factor than in patients without medical or neurologic disease.

Adaptation to multiple sclerosis: the role of social support, functional disability, and perceived uncertainty.

This study was designed to test a path model depicting the relationships among social support, functional disability, perceived uncertainty, and psychosocial adaptation in 38 men and 80 women with multiple sclerosis, a chronic, unpredictable disease. Results from the regression analyses indicated that 35% of the variance in depression and 33% of the variance in purpose-in-life, respectively, were explained by age, sex, social status, and the perceived supportiveness and unsupportiveness of social network interactions. The path analyses showed that the perceived supportiveness of interactions was directly related to purpose-in-life but not to depression; both the direct path between the perceived unsupportiveness of interactions and adaptation and the indirect one through perceived uncertainty were related to depression and to purpose-in-life; and functional disability had a direct effect on adaptation, but the indirect path through perceived uncertainty was not corroborated.

Multiple sclerosis and affective disorder. Family history, sex, and HLA-DR antigens.

To investigate a possible genetic cause underlying the clinical association between multiple sclerosis (MS) and affective disorder, we studied 56 patients with MS for psychiatric and genetic (family history, sex, and HLA-DR) characteristics. The 2:1 ratio of females to males expected for patients with MS was observed in this sample (40:16), but the excess of females occurred entirely among the 31 MS patients with major affective disorder (27 females and four males). Bipolar probands with MS had significantly more relatives with affective disorder or MS than did unipolar probands with MS. The HLA-DR antigen frequencies in patients with MS categorized by type and family history of affective disorder suggest that it may be possible to validate such clustering of patients. We concluded that sex and other genetic factors are related to the affective symptoms in MS and emphasize the importance of psychiatric evaluation of these patients.

Association between bipolar affective disorder and multiple sclerosis.

Ten patients from Monroe County, N.Y., had both multiple sclerosis and bipolar affective disorder. Epidemiologic data indicate that the expected number would be 5.4. This difference may indicate an association between these disorders.

Obesity: locus of control, body image, weight loss, and age-at-onset.

In a retrospective investigation designed to measure locus of control, body image, and weight loss in Overeaters Anonymous members who had childhood, adolescence, or adulthood onset of obesity, 116 subjects were grouped according to age at onset of obesity and the year they joined OA. A convenience, volunteer sample of OA members completed a demographic data questionnaire, Rotter's Social Reaction. Inventory, and Secord and Jourard's Body Cathexis Scale. Significant overweight percentage differences were not found when the three age-at-onset groups were compared. Significant differences emerged, however, for adolescent-onset group persons who were categorized as "old" members; they had a larger weight loss and were more satisfied with their body image. A positive linear relationship between greater perception of internal control and a good body image was found in the entire adulthood-onset group. Weight loss and good body image of the oldest adolescent-onset group probably was the outcome of their association with a self-help group i.e., OA. Assessment of developmental issues related to the time of initial weight gain may indicate which treatment regime would be most effective.