Evidence-based practice and the advanced practice nurse: a curriculum for the future.

The concept of evidence-based practice has gained increased attention throughout the 1990s as a strategy for linking the best scientific findings with clinical judgment to improve health outcomes. Because the concept implies finding, evaluating, summarizing, and using research results, a high level of clinical reasoning skills is required. Effective evidence-based practice also requires the incorporation of new practices into clinical and organizational settings, thereby demanding advanced leadership skills. Competencies in clinical reasoning, leadership, and clinical practice are critical for advanced practice nurses. This article describes a master's-level curriculum supportive of evidence-based practice and includes recommendations for developing curricula of this type.

Evaluation of variances in patient outcomes.

New knowledge and understanding about improving the quality and reducing the costs of care will come from careful scrutiny of the variations in the outcomes of nursing interventions. Nurses need to systematically identify and measure outcomes, understanding the probabilistic nature of these patient responses to the care received. Using a formative evaluation process, nurses should measure degrees of patient outcomes over time to ascertain the effects of nursing care and analyze the variances in these observed outcomes from what was expected. Critical pathways are valuable tools for guiding evaluations of nursing care along a timeline and can lead to improvements in nursing care.

Living arrangements, visit patterns, and health problems in a nurse-managed clinic for the homeless.

The purpose of this article is to describe living arrangements, clinic visit patterns, and health problems of clients by age and gender in a nurse-managed clinic serving the homeless. The conceptual framework for this project was derived from a nursing perspective of community health. The problem classification scheme used included four domains of community health practice: environmental, psychosocial, physiological, and health-related behavior. Data were collected during each visit to a nurse-managed health clinic for the homeless for 18 months. The findings indicate that living arrangements and visit patterns vary by age and gender. Health problems associated with integument and income were identified as primary and secondary problems across all age groups. Six other health problems were shared across all age and gender groups as either primary or secondary: circulation, respiration, pain, nutrition, communication, and prescription medication. Substance misuse was not a primary problem noted by clients, but was commonly a secondary problem. Genitourinary problems were noted primarily to be problems of younger women. Implications for planning nursing services for the homeless are discussed.

Dietary calcium intakes of elderly Korean Americans.

Dietary calcium intake among elderly Korean Americans was examined. Results of this study indicate that calcium intakes of the women were considerably lower than the Recommended Dietary Allowance partly because of their lower consumption of dairy products and lower energy intakes. For the same reasons, nonparticipants in a nutrition program for the elderly were less likely than participants to consume adequate amounts of calcium. A number of other factors may have influenced low calcium intake by some subjects. The examination of their food habits revealed that the subjects rarely consumed their preferred calcium-rich Korean foods because of the high cost and limited availability of the foods and their own difficulty in chewing. Consumption of calcium-rich foods in the United States diet also was limited. The subjects disliked calcium-rich foods in the United States diet, with the exception of milk and ice cream. Although a majority of the subjects liked and consumed milk daily, the amount was not sufficient to meet the calcium requirements in their diets. Furthermore, a substantial proportion of the subjects disliked and seldom consumed milk. In addition to dairy products, grains, fruits, and vegetables were major sources of calcium in diets of the subjects. However, individuals did not consume enough of the calcium-rich foods from these food groups to meet the calcium requirements.

Nurses' propensity to risk.

Risk taking by 53 nurses and 22 non-nurses was investigated in nursing and nonnursing situations in a laboratory study to assess nurses' propensity to risk and to gain information about how nurses make decisions. Games involving loss and gain of money were used. Subjects received money won from the games, but debts incurred by subjects were canceled. The study indicated that unwillingness to accept risk is not characteristic of all nurses. A nurse's propensity to risk appeared to depend on the situation and on the nurse's educational level. Study findings, though restricted by the mode of investigation, have implications for practice and future research.

Decision making about patient care.

Written descriptions of four patient situations and a table of nursing actions and outcomes were presented to 47 registered nurses to investigate quantification of 185 nursing decisions about patient care. The nurses ranked the actions according to that which they considered best for the patient described, gave probabilities of the occurrence of outcomes, and assigned values to outcomes. The probability of an outcome's occurring, multiplied by the value of that outcome, and added for all outcomes of an action constituted the expected value (EV) of an action in achieving a goal. Significant agreements between the EVs and ranking of actions were obtained. The preferred action had the highest EV for 109 of the 185 decisions studied. Most decisions were justifiable in that chosen actions were desirable for achieving goals, were consistent with the nurses' knowledge of the probability of the outcomes' occurring, and were in keeping with the nurses' values for the outcomes. The findings indicated that decision theory is applicable to nursing practice, that nursing decisions can be adapted to analytical models, and that nurses can order outcomes of their actions according to their desirability and likelihood of occurrence.