A qualitative study of persons who are 100% adherent to antiretroviral therapy.

This qualitative study examined the medication-taking behaviors and attitudes of participants determined to be 100% adherers to antiretroviral therapy from a NIH-funded study testing a 12-week telephone adherence intervention. Using open-ended questions, interviewers collected data on a sample of 13 informants, whose medication adherence to a randomly selected antiretroviral medication was 100%, based on a 30-day data collection using electronic event monitoring (EEM). The analysis revealed 'successful medication management' as the core category or main theme. The participants achieved success with medication adherence through managing specific areas (regimen, self and environment). By adopting realistic expectations and pragmatic attitudes, adherence is fostered when medication taking is a priority, when patients believe in the efficacy of their medications and when there is a strong patient/provider relationship. Future research is needed to develop tailored interventions using strategies identified by this population. Further in-depth examination of medication-taking behaviors in 100% adherers may be useful in developing individualized programs to maximize adherence to antiretroviral therapy in the clinical setting.

Problem drinking and medication adherence among persons with HIV infection.

OBJECTIVE: To examine the relation between problem drinking and medication adherence among persons with HIV infection. DESIGN: Cross-sectional survey. SETTING/PARTICIPANTS: Two hundred twelve persons with HIV infection who visited 2 outpatient clinics between December 1997 and February 1998. MEASUREMENTS AND MAIN RESULTS: Nineteen percent of subjects reported problem drinking during the previous month, 14% missed at least 1 dose of medication within the previous 24 hours, and 30% did not take their medications as scheduled during the previous week. Problem drinkers were slightly more likely to report a missed dose (17% vs 12 %, P =.38) and significantly more likely to report taking medicines off schedule (45% vs 26%, P =.02). Among drinking subtypes, taking medications off schedule was significantly associated with both heavy drinking (high quantity/frequency) (adjusted odds ratio [OR], 4.70; 95% confidence interval [95% CI], 1.49 to 14.84; P <.05) and hazardous drinking (adjusted OR, 2.64; 95% CI, 1.07 to 6.53; P <.05). Problem drinkers were more likely to report missing medications because of forgetting (48% vs 35%, P =.10), running out of medications (15% vs 8%, P =.16), and consuming alcohol or drugs (26 % vs 3 %, P <.001). CONCLUSION: Problem drinking is associated with decreased medication adherence, particularly with taking medications off schedule during the previous week. Clinicians should assess for alcohol problems, link alcohol use severity to potential adherence problems, and monitor outcomes in both alcohol consumption and medication adherence.

Moral distress: a pervasive problem.

The shortage of nurses and the flaws within the structure of the current health care system are compromising the nurse's ability to provide competent, compassionate care. Nurses are increasingly disturbed because they see themselves as ineffective advocates for their patients. Nurses, unable to take the appropriate ethical actions, feel paralyzed by their situation. The author's recent conversations with staff nurses about their clinical practice suggest that moral distress has become a very pervasive problem. The purpose of this article is to describe ethical practice, moral distress, the imbalance of power, and the nature of an ethical environment. There is a discussion of potential strategies that will help to create and maintain an ethical environment thereby reducing moral distress such as facilitating dialogue, developing a support system, providing opportunities for professional development, and developing and revising institutional policies.

Medication errors: ethical implications.

Errors in health care are receiving much attention today, although committing such errors is not a new phenomenon. Nurses are taught procedures so that they are less likely to make mistakes. Yet nurses do make errors. Although many types of errors can and do occur in the health care setting, this article focuses on a discussion of medication errors and related ethical implications. Several ethical issues may arise as a result of medication errors: harm to patients, whether to disclose the error, erosion of trust, and impact on quality care. Nurses' appropriate ethical responses to medication errors need to be supported. Changing the health care system will help nurses to promote patient welfare, lessen the chance of harm, and reduce the likelihood of medication errors occurring.

The nursing shortage, patient care, and ethics.

Although nursing shortages are not new, many nurses consider the present shortage to be different from those in the past. Nurses are again questioning whether patients are receiving the quality of care they deserve. Overwhelmed by this nursing shortage, nurses are trying to reconcile how to fulfill their duties to advocate for good patient care and to warn patients about conditions that are possibly detrimental to their welfare. This article discusses two ethical issues that nurses, in the midst of a nursing shortage, face in their clinical practice: lack of control over their practice and potential for harm to patients and themselves. There is also a description of strategies that nurses can use to promote and maintain an environment within the organization that supports providing good patient care.

The use of life review to enhance quality of life of people living with AIDS: a feasibility study.

People living with AIDS (PLWA) are confronted with uncertainty and their own mortality at an earlier than expected age. Life review, an intervention that has the potential to increase life satisfaction in the elderly experiencing transition points in their lives, may have a similar effect when used with PLWA. Therefore, the purpose of this feasibility study was to explore the use of life review in a sample of 20 PLWA through a randomized controlled trial of its effectiveness in decreasing depressive symptoms and in increasing self esteem, quality of life, and purpose in life. Compared to the control group, the treatment group had an improved overall quality of life and self-esteem over 12 months, less depressive symptoms over 12 months, and a greater purpose in life at 3 months. The effects that were seen were mainly small to medium effects. The findings from this feasibility study suggest the potential value of life review to enhance quality of life, purpose in life, and self-esteem, and to decrease depressive symptoms in PLWA. Further research is needed with a larger sample and with other groups such as PLWA experiencing virologic failure.

Transcending the suffering of AIDS.

The overall purpose of this qualitative study was to describe how patients with AIDS (PWAs) transcend the emotional and physical suffering of their illness. Content analysis of the interviews of 5 PWAs resulted in 3 main themes: creating a meaningful life pattern, connectedness, and self-care. The results of this study provide presumptive evidence that PWAs can transcend the suffering associated with a life-threatening illness and live meaningful and productive lives. Nurses who anticipate actual and potential growth in PWAs will be able to validate such experiences and feelings and encourage further development.

Clinical research: what do patients understand?

An increasing amount of clinical research is being conducted to test the efficacy and effectiveness of new medications, therapies, and medical procedures. These studies often require that patients be invited to be subjects. However, what do patients really understand whenever they are asked to participate in clinical research? Are patients aware that research is clearly different from treatment? Are they aware that their participation in research is to benefit future patients? Despite the desire of clinical agencies to support research, there is the concern about how they can best protect the rights of patients who are subjects in this research. The author briefly discusses clinical research, patients as vulnerable subjects, the therapeutic misconception, and informed consent. In addition, recommendations are provided to help assure that the rights of patients who are research subjects are protected.

Adherence in chronic disease.

Nonadherence to treatment regimen is a prevalent problem of patients with chronic disorders. Approximately half of the patients with a chronic disease have problems following their prescribed regimen to the extent that they are unable to obtain optimum clinical benefit. This chapter reviews the state of knowledge regarding adherence to chronic disease regimens across the life span and demonstrates that the extent and nature of the adherence problems are similar across diseases, across regimens, and across age groups. Adherence to the commonly prescribed regimens is addressed, including pharmacological therapies, therapeutic diets, and therapeutic exercise. Randomized, controlled studies focusing on various educational, behavioral, cognitive, and affective interventions to improve adherence are included. Based on this review, further work is needed to better understand and improve adherence. New strategies for analysis and measurement will support these needed advances in the field of adherence.

'Conflicts of interest': an ethical dilemma for the nurse researcher.

More nurse researchers are turning to industry as a possible source of funding to support their scientific work. Corporations may be very interested in particular projects because of the fit that exists between the investigator's interest and the company's product. However, researchers need to be cautious since accepting funding from and entering into a financial relationship with industry may lead to "conflicts of interest." The purpose of this article is to discuss the ethical issues when there are conflicts of interest. The author presents recommendations designed to help nurse researchers avoid and address this potential ethical problem.

When the family asks, 'what happened?'.

Because of the high level of acuity of hospitalized patients, untoward events can and do occur. Very often, nurses develop a caring relationship with the families of these patients. As a result, the family may approach the nurse about this negative turn of events. The questions that the family raises may create an ethical dilemma for the nurse. The nurse may wonder how to respond, feel powerless and "caught in the middle," and experience moral distress because of constraints in the health care system. This article discusses the ethical perspective of caring and the "nurse in the middle" phenomenon. Several strategies to help nurses manage this issue include consulting with a mentor, consulting with the institutional ethics committee, and promoting an ethical climate within the health care setting.

Incentives in research: ethical issues.

The participation of some subjects in research may be association with their receiving some compensation for their time and effort. Is the use of monetary or other nonmonetary incentives ethical? Do incentives make a study so enticing that it is difficult to resist being a participant? The authors discuss some relevant ethical questions that a researcher needs to address when providing stipends to study subjects. Additionally, there is a discussion of implications for nurses such as acquiring knowledge of research and ethics, creating an environment in which the patient's questions and any issues can be discussed, advocating for the patient who is being asked to participate, and the nurse's responsibilities when asked to help with recruitment efforts.

Adherence to combination therapy in persons living with HIV: balancing the hardships and the blessings.

Evidence from clinical trials demonstrates the benefits of combination therapy in persons living with HIV (PLWHIV); however, there is little information about the patient's experience when taking a complex regimen. Thus, the primary purpose of this preliminary study was to describe the everyday experience of PLWHIV who were prescribed combination therapy in order to identify a potential intervention to enhance adherence to this regimen. The secondary purpose was to examine the association between adherence to combination therapy and quality of life. The researchers purposively sampled six PLWHIV (two women and four men) to reflect the diverse demographic characteristics of the population of PLWHIV. The themes that evolved were decision making, difficulties, problem solving, and quality of life. Clinical indicators provide only one measure of the effectiveness of combination therapy. When the informants described the outcome of this therapy as "having their life back," they spoke of having quality in their lives that they viewed as more than their physical health.

The patient no one liked.

Despite professional admonitions to treat patients with dignity and to promote their well being, there are some patients who are unpopular with or not liked by nurses. Caring for these patients presents an ethical challenge for nurses. The purposes of this article are to explore the issue of bias and the use of labels, as well as the subsequent ethical concerns of respecting the uniqueness of the patient and preventing harm when nurses have a negative bias toward and label particular patients. The authors discuss several implications for nursing practice, including engaging in introspection, understanding the "problem" patient, actively involving patients in their care, and evaluating strategies used to eliminate negative bias and labeling.

What does it mean to blow the whistle?

Whistle blowing causes people to pay attention. An alarm has been sounded drawing attention to a particular set of circumstances. When nurses blow the whistle because of unethical or incompetent colleagues, they are going public with this information. Yet, even though nurses are able to provide an ethical justification for the action, not all will look favorably on what has been done. This article examines the concept of whistle blowing, its relationship to advocacy, and some consequences of whistle blowing. This article provides recommendations for educators, health care agencies, and nurses as ways to support nurses who choose to blow the whistle.

Psychometric properties of the Index of Homophobia Scale in registered nurses.

The psychometric properties of the Index of Homophobia Scale (IHS; Bouton et al., 1987) were examined in a sample of registered nurses (n = 95). Scores on the IHS may range from 0 (no homophobia) to 28 (highly homophobic). This sample had relatively low total scores on the IHS (M = 7.99, SD = 5.41), indicating that subjects were predominantly not homophobic. Internal consistency as estimated by Cronbach's alpha was .88. The average item mean was 1.14 (SD = 0.29) ranging from .77 to 1.48. Corrected item-to-total scale correlations were satisfactory, ranging from .58 to .75. Inter-item correlations ranged from .35 to .67 indicating some redundancy in content sampling. The 7-item IHS indicates promise for future use with registered nurses, and perhaps also with other health care professionals in adequately and accurately measuring homophobia.

Treatment decision making: who should decide?

Why is someone other than a competent adult patient considered to be the person to make important treatment decisions? Since one's values influence decision making, who other than the patient should make these significant decisions? The author argues that competent adult patients should make treatment decisions because of the moral nature of these decisions. Recommendations for facilitating the patient's active involvement include increasing one's understanding of values, autonomy, and decision making; identifying personal values; creating a supportive environment; educating patients about their role in decision making; and advocating for patient involvement in treatment decisions.

Multicultural issues and ethical concerns in the delivery of nursing care interventions.

Nurses are beginning to recognize the importance of understanding the values, beliefs, and health practices of different cultures in order to provide care that is appropriate and culturally relevant to diverse patient populations. Individuals from other cultures may have different languages and customs. These cultural factors are important to the nurse's understanding of the specifics of health care practice. Culture and ethnicity may influence one's physical development and exposure to health compromising environments and conditions. This article uses a case study to describe a process that health care providers can use when faced with ethical dilemmas that arise when caring for patients from different cultures. Nursing strategies to promote culturally sensitive care are discussed, and include cultural assessment, heightening sensitivity to ethical issues in cultural diversity, and the role of continuing education in providing culturally competent care.