October's "Hopkins Nursing News and Research Briefs" covers the resilience of children with chronic medical conditions, moral distress among nurses, web-based care models, and reducing health disparities.
Children with Chronic Medical Conditions More Resilient than Expected
A recent study by Johns Hopkins University School of Nursing (JHUSON) faculty member Susan Immelt, PhD, RN has produced results that run counter to commonly held assumptions about children with chronic medical conditions. In an article published this month in the Journal of Pediatric Nursing, Immelt shows that children in her study-ranging from ages 7 to 11 and diagnosed with conditions such as diabetes mellitus, moderate or severe persistent asthma, cystic fibrosis, and sickle cell disease-were no more anxious or depressed than healthy children. Although most are expected to be at higher risk for behavioral and emotional problems, in the article "Psychological Adjustment in Young Children with Chronic Medical Conditions," Immelt reveals that the depression and anxiety scores of the children in the study were comparable to those of healthy children with no psychological symptoms. Condition-related factors such as days missed from school, days of reduced activity, and difficulties related to managing children's pain, medications, and diet had a minimal effect on their outlook. However, she underscores the importance of both maternal and child perceptions and notes that maternal worry and maternal perception of the impact of disease on the family were strong influences on the children's psychological adjustment.
Web-Based, Collaborative Geriatric "Guided Care" Model Offers Superior Quality, Lower Costs
Eight community practices in Baltimore, MD and Washington, DC are now evaluating a model of care for older Americans that in a recent pilot test proved superior to "usual care" in both quality and cost of chronic care. "Guided Care," an innovative medical model developed by JHUSON's Rosemarie Brager, CRNP, PhD and other researchers, combines contemporary primary care with state-of-the-art information technology and innovations in chronic care to address major challenges in the treatment of older patients, many of whom suffer from multiple chronic medical conditions. In a poster presentation this month at the National Gerontological Nursing Association's 21st Annual Convention, Brager and colleagues described how the newly designed system-based in the primary care office and equipped with secure, web-accessible information technology-succeeds through the collaboration of a "Guided Care Nurse" (GCN) with two to four physicians to provide care to 50 to 60 older patients. The role of the GCN is to assess the patient's status and work with a team comprised of the patient, physician, and family to create an evidence-based care guide that incorporates the patient's preferences. The nurse then monitors the patient's chronic conditions, and works with the team to facilitate future care, family support, and transitions to community-based services.
Treatment Conflicts Can Cause "Moral Distress," Impact Care, Create Nursing Turnover
In her article "Defining and Addressing Moral Distress" appearing in a recent issue of Advanced Critical Care, JHUSON Associate Professor Cynda Hylton Rushton, PhD, RN explores the issue of "moral distress" experienced by many nurses, including those treating critically ill patients. Rushton, who also holds a joint appointment with the JHU Phoebe R. Berman Bioethics Institute, defines this reaction as "when clinicians are unable to translate their moral choices into ethically appropriate action." She adds that "Moral distress is a critical, frequently ignored problem in health care work environments. Unaddressed, it restricts nurses' ability to provide optimum patient care and to find job satisfaction..." In one study Rushton cites, half the nurses surveyed reported experiencing moral distress as a result of acting against their consciences in over or under treating terminally ill persons. Rushton notes that the costs of this unrelieved moral distress can be high. "Some nurses leave their positions and even the profession." She urges health care environments to confront moral distress when it arises and take steps to address it, including following the American Association of Critical Care Nurses Association's (AACN) "4 A's Model to Rise Above Moral Distress" - Ask, Affirm, Assess, and Act. This process, coupled with implementing AACN's "Standards for a Healthy Work Environment,", can begin to create a workplace where nurses can practice with integrity while providing quality, safe care.
New Approaches Needed to Reduce Health Disparities, Provide Health Care to Poor
Numerous JHUSON faculty and researchers are addressing the compelling issues surrounding today's delivery of health care services to minorities and other underserved populations. In "Health Care for the Poor and Underserved," a chapter in the recently published Current Issues in Nursing (Mosby, 7th Edition, 2006), faculty member Sara Groves, DrPH, APRN notes that in 2000, the United States was ranked 37th in health care by the World Health Organization; a low ranking not reflective of how much is spent on health care ($1.4 trillion in 2001) but rather that it is not spent in a fair and equitable manner. As a result, poor and underserved populations in the U.S. are disenfranchised and do not receive the same level and quality of care as those with higher socioeconomic status. Groves outlines efforts to address that problem dating from the era of Franklin D. Roosevelt to policies currently being promoted at the state level such as the "Health Care for All" legislative campaign. She concludes that ensuring adequate medical care for all will not in itself lead to dramatic overall improvements in the nation's health and observes that to make such strides, the nation must alleviate the adverse socioeconomic conditions that for too many poor and underserved families and communities are obstacles to a healthy lifestyle.
At a National Institutes of Health (NIH) Conference later this month, JHUSON professor Fannie Gaston-Johansson, PhD, RN, FAAN and a team of co-researchers will present new information drawn from the focus group data compiled by the Institute of Medicine and originally released in the 2002 report Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. The study, "Perspectives on Disparities in Healthcare from African American, Hispanic, Mandarin and Native American Samples: Secondary Analysis of Institute of Medicine Focus Group Data," explores the responses of the focus group participants regarding improving processes of care, including varied educational experiences for providers regarding populations served; settings and treatment to increase cultural competency; processes for patients to make informed choices about service providers; and promotion of patient self-advocacy and monitoring systems. Gaston-Johansson notes that these recommendations will be especially valuable in providing the patients' perspectives and serving as a basis for developing health disparities interventions.