Clinican reliability and accuracy in judging appropriate level of care.

Accurately assigning children to the most appropriate level of care is widely recognized as important. Managed care companies conduct utilization reviews in which they monitor the level of care to which clients are assigned using written placement criteria. However, no research has examined the ability of clinicians to perform this task. In the present study, 47 child and adolescent clinical profiles consisting of 48 variables were developed. Eighteen clinicians, trained to use their agency's level of-care guidelines, made level-of-care decisions on these profiles. Their interjudge reliability in assigning a child to an appropriate level of care was close to zero (k?=?.07). There was a small, statistically significant correlation between client placement and actual placement, but chance-corrected agreement between client placement and actual placement was very low (k?=?.09 ) . Implications of these findings for clinical research, practice, policy, and training are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effective treatment relationships for persons with serious psychiatric disorders: The importance of attachment states of mind.

Participants were 54 clients with serious psychiatric disorders and 21 clinical case managers. Clients' serious psychiatric disorders included Axis I diagnoses, such as schizophrenia and bipolar disorder. This study examined how attachment states of mind of both clients and case managers influenced the effectiveness of therapeutic relationships and client functioning. Client and case manager attachment states of mind interacted in predicting the working alliance and client functioning. Specifically, clients who were more deactivating with respect to attachment had better alliances and functioned better with less deactivating case managers, whereas clients who were less deactivating worked better with more deactivating case managers. These findings highlight the importance of clinicians and clients being matched in ways that balance their interpersonal and emotional strategies. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The ECLW Collaborative Study: III. Training and reliability of ICD-10 psychiatric diagnoses in the general hospital setting--an investigation of 220 consultants from 14 European countries. European Consultation Liaison Workgroup

A comprehensive training program for reliable use of the ICD/10 in Consultation-Liaison (C-L) psychiatry was conducted with 220 psychiatrists and psychologists from 14 European countries. The training included rating of written test cases and development of a coding manual to avoid diagnostic pitfalls not addressed in the ICD-10 manual. Following this training, all consultants rated 13 written case histories. One hundred sixty-seven consultants (76%) had a kappa (kappa) of at least 0.70. Only 13 (6%) had a kappa 0.40. The percentage of high reliability raters was evenly distributed among the different countries. Consultants had some problems in the differentiation between adjustment disorders and depressive disorders, and in the classification of disorders where ICD-10 differs from the DSM-III-R system. National biases in diagnostic practice were found with regard to the "case" concept and the role of alcohol in confusional states. Finnish consultants coded "no psychiatric disorder" significantly more often, whereas German and Italian consultants attributed delirious state more often to alcohol than consultants from other European countries. The study demonstrates that it is possible to achieve acceptable interrater reliability in applying the ICD-10 guidelines, through training programs designed for C-L psychiatrists and psychologists. Nevertheless, this first cross-national study shows the importance of addressing differences in national diagnostic practice.     

Undercover careseekers: simulated clients in the study of health provider behavior in developing countries

The simulated client method (SCM) has been used for over 20 years to study health care provider behavior in a first-hand way while minimizing observation bias. In developing countries, it has proven useful in the study of physicians, drug retailers, and family planning services. In SCM, research assistants with fictitious case scenarios (or with stable conditions or a genuine interest in the services) visit providers and request their assistance. Providers are not aware that these clients are involved in research. Simulated clients later report on the events of their visit and these data are analyzed. This paper reviews 23 developing country studies of physician, drug retail, and family planning services in order to draw conclusions about (1) the advantages and limitations of the methods; (2) considerations for design and implementation of a simulated client study; (3) validity and reliability; and (4) ethical concerns. Examples are also drawn from industrialized countries, related methodologies, and non-health fields to illustrate the issues surrounding SCM. Based on this review, we conclude that the information gathered through the use of simulated clients is unique and valuable for managers, intervention planners and evaluators, social scientist, regulators, and others. Areas that need to be explored in future work with this method include: ways to ensure data validity and reliability; research on additional types of providers and health care needs; and adaptation of the technique for routine use.     

Predicting flow at work: Investigating the activities and job characteristics that predict flow states at work.

Flow (a state of consciousness where people become totally immersed in an activity and enjoy it intensely) has been identified as a desirable state with positive effects for employee well-being and innovation at work. Flow has been studied using both questionnaires and Experience Sampling Method (ESM). In this study, we used a newly developed 9-item flow scale in an ESM study combined with a questionnaire to examine the predictors of flow at two levels: the activities (brainstorming, planning, problem solving and evaluation) associated with transient flow states and the more stable job characteristics (role clarity, influence and cognitive demands). Participants were 58 line managers from two companies in Denmark; a private accountancy firm and a public elder care organization. We found that line managers in elder care experienced flow more often than accountancy line managers, and activities such as planning, problem solving, and evaluation predicted transient flow states. The more stable job characteristics included in this study were not, however, found to predict flow at work. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Guidelines as a strategy for preserving professional autonomy

Practice guidelines are often perceived as a threat to physician autonomy. However, the true challenge to physician autonomy is the rising costs of health care, which in turn is the result of continued progress in medical research. Since, inevitably, choices must be made about how our limited resources are expended, an increasing number of physicians are concluding that health care providers should assume financial risk for providing care--so that providers can make the decisions about which interventions are used for which patients. In this context, groups of physicians are adopting practice guidelines as an important strategy for providing high quality and efficient care under capitation. At least in some areas, practice guidelines are emerging as a critical tool for physicians to assume financial risk, and thereby protect professional autonomy.     

Preparing nurses for the acute care case manager role: educational needs identified by existing case managers

BACKGROUND: There is little in the literature about how best to prepare nurses for case manager roles. METHOD: Twenty acute care case managers were asked to identify skills and knowledge that would be of value to nurses new to case manager roles. RESULTS: Community resources, discharge planning, and third party reimbursement were the top three educational needs identified by all case managers. Baccalaureate prepared case managers identified clinical issues to be of value, such as family coping, patient education, quality of life, and social support, while master's prepared nurses identified only system-related issues. CONCLUSION: Educational programs preparing baccalaureate prepared case managers could focus on both clinical and system issues, while programs preparing master's educated case managers could focus primarily on managing system issues. Staff development professionals may also call on experts inside and outside the institution to assist in teaching about health care finance and reimbursement issues.     

Nursing case management in the NICU: enhanced coordination for discharge planning

A primary goal of health care today is finding alternative ways to provide high-quality, cost-effective care. A model of care that addresses these issues is nursing case management. This article describes the development and implementation of nursing case management in a Level III regional center with the primary goal of enhancing coordination for discharge planning. The model involves development of clinical pathways and utilization of nurse practitioners as case managers. Decreased length of stay, charge per case, and readmission rates are demonstrated following implementation of this program.     

Prechallenge high neutralizing antibodies and long-lasting immune reactivity to gp41 correlate with protection of rhesus monkeys against productive simian immunodeficiency virus infection or disease development

This article aims to explore the ethical issues arising from the sharing of information in the context of interprofessional collaboration. The increased emphasis on interprofessional working has highlighted the need for greater collaboration and sharing of client information. Through the medium of a case study, we identify a number of tensions that arise from collaborative relationships, which are not conducive to supporting interprofessional working in an ethically sound manner. Within this article, it is argued that the way forward within these collaborative relationships is to set clear parameters to the professional-client relationship, paying full regard to the autonomy of both the clients and the professionals involved. We conclude that this approach to working will place the client at the centre of care provision and arguments used for not collaborating that are based on breaches of confidentiality will be negated. Using the approach offered, collaborative working will be not only possible but desirable.     

Reconceptualizing advance care planning from the patient's perspective

BACKGROUND: Traditional academic assumptions about advance care planning (ACP) include the following: (1) the purpose of ACP is preparing for incapacity; (2) ACP is based on the ethical principle of autonomy and the exercise of control; (3) the focus of ACP is completing written advance directive forms; and (4) ACP occurs within the context of the physician-patient relationship. These assumptions about ACP have never been empirically validated. OBJECTIVE: To examine the traditional academic assumptions by exploring ACP from the perspective of patients actively participating in the planning process. METHODS: Forty-eight patients (30 men and 18 women with a mean age of 48.3 years) who were undergoing hemodialysis were interviewed 6 months after receiving an advance directive form. Their experience of ACP was noted in interviews that were audiotaped, transcribed, and analyzed. RESULTS: The participants said that their purpose in ACP was to prepare for death and dying, and their underlying goals included the exercise of control and an attempt to relieve burdens placed on loved ones. Advance care planning was viewed as a social process, and completing a written advance directive form was often regarded as unnecessary. Participants often involved close loved ones, but physicians infrequently. CONCLUSIONS: The traditional academic assumptions are not fully supported from the perspective of patients involved in ACP. The patients we interviewed stated that (1) the purpose of ACP is not only preparing for incapacity but also preparing for death; (2) ACP is not based solely on autonomy and the exercise of control, but also on personal relationships and relieving burdens placed on others; (3) the focus of ACP is not only on completing written advance directive forms but also on the social process; and (4) ACP does not occur solely within the context of the physician-patient relationship but also within relationships with close loved ones.     

Pharmacy benefit management, cost-effectiveness analysis and drug formulary decisions

Ten years ago, a review of U.S. center-based infant and toddler care found that not even one state met federally recommended standards of quality with regard to group composition, staff training, and program of care. The present analysis indicates that little progress has been made since then. While most states currently require centers to follow appropriate practice guidelines, standards for staff training were rated as unacceptable in almost all states. Findings are discussed in terms of the interrelation of quality dimensions and the ongoing importance of improved state-level infant and toddler child-care regulation.     

Antibiotic sensitivity of hospital strains of Staphylococcus

1. Changing trends in health care reflect increasing involvement with clients and families in the development of treatment plans, such as self medication planning. 2. Acting as an advocate for the client, the nurse, in consultation with the client and the multidisciplinary team, developed a consumer-centered program, which allowed the client to master a complicated medication regime prior to discharge. 3. Discharge planning, follow-up, and evaluation of medication compliance, ensured continuity of care, successful outcomes, and reduced use of in-hospital health care dollars.     

Sexual health for people with learning disabilities

This article is based on work into the sexual health needs of people with learning disabilities, carried out by a working group of the RCN Family Planning Forum. Literature searches were conducted, and local initiatives, specialist services and information sources for training and education for clients and staff were identified. The authors' aim in this article is to increase awareness among those involved in the care of people with learning disabilities and those providing family planning and sexual health services, so that these services are appropriate, accessible and sensitive to the needs of this vulnerable client group.     

An exploratory survey on empirically supported treatments: Implications for internship training.

Is training in empirically supported treatments (ESTs) necessary for internship? Are all internship sites embracing EST training equally? An exploratory survey reports training practices and attitudes toward use of ESTs in internship sites accredited by the American Psychological Association. Training practices during an internship year varied across type of setting, but only 28% reported offering more than 15 hr of training. Lack of managed care demands, flexibility in session limits, and perceived mismatch between client needs and treatment options were reasons endorsed for not doing more training and supervision with ESTs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Guidelines for clinical practice

Clinical practice guidelines are systematically developed statements that are intended to support medical decision making in well-defined clinical situations. Essentially, their object is to reduce the variability in medical practice, to improve quality, and to make appropriated control of the financial resources possible. Internationally, ever more organisations, associations, and institutions are concerned with the development of guidelines in many different areas of care. Making implicit knowledge explicit is one of the associated advantages of guidelines: they have a potential utility in training, in process evaluation, and in the reevaluation of outcome studies. In liability issues, their existence has a double effect: they can be used to justify medical behaviour, and they constitute a generally accepted reference point. A derivative problem is the legal liability of the compilers of the guidelines. The principle of the guideline approach can be challenged academically: science cannot give a definition of optimal care with absolute certainty. What is called objectivity often rests on methodologically disputable analyses; also the opinion of opinion leaders is not always a guarantee for scientific soundness. Moreover, patients are not all identical: biological variability, situational factors, patient expectations, and other elements play a role in this differentiation. Clinicians are often hesitant with respect to clinical guidelines: they are afraid of cookbook medicine and curtailment of their professional autonomy. Patients fear reduction of individualization of care and the use of guidelines as a rationing instrument. The effects of the introduction of clinical practice guidelines on medical practice, on the results and on the cost of care vary but are generally considered to be favourable. The choice of appropriate strategies in development, dissemination, and implementation turns out to be of critical importance. The article ends with concrete suggestions for the various steps in the development of guidelines and their actual compilation.     

Effect of caffeine ingestion on perception of effort and subsequent work production

The chief nurse officer brings the value-adding contribution of client partner to the executive management team. The nurse executive contributes professional nursing's client-centered, health-enabling approach to care delivery to assist organizations in developing new client and community services. The single most important leadership-challenge presented to nurse administrators, leaders, and managers is the ability to articulate a vision of client-centered care, demonstrate the costs and benefits of service innovations, and effectively shape organizational cultures to achieve innovations in service delivery.     

An ego/object relations approach to treating childhood sexual abuse survivors.

Examines intrapsychic considerations for clients with a history of childhood sexual abuse and recommends a model for treatment planning based on client level of ego development. With neurotic-level clients, the preponderant therapeutic error is often avoidance of the traumatic material, whereas with borderline-level Ss therapeutic error tends toward the use of inappropriate techniques. Recommended treatment guidelines are based on a holistic ego/object relations approach to therapy. The case example of a 26 yr-old female with borderline personality organization is included. (PsycINFO Database Record (c) 2010 APA, all rights reserved)