A critical analysis of undergraduate students' cultural immersion experiences

PURPOSE

This paper is concerned with the impact of an international health promotion experience on the understanding of culture among university students. Such immersion experiences are often cited as a strategy to prepare nurses for culturally appropriate practice. We describe students' epistemic movements over time with respect to cultural perspectives prior to, during and after a field study in Malawi.

DESIGN

Data were collected at three time points from students in undergraduate nursing (n = 14) and non-nursing (n = 8) programs at a Canadian university. Two essays narrating participants' understanding of culture were submitted by consenting class members. A subgroup of nine participants (four nursing students, five from other disciplines) completed a third narrative following a subsequent field study course in Malawi.

METHOD

Using narrative analysis, themes and structures in the participants' writing were identified and located within a constructivist or essentialist paradigm of cultural understanding.

FINDINGS

Overwhelmingly, students' narratives were initially portrayed and informed by an essentialist understanding of culture. Later narratives demonstrated varying degrees of epistemic movement towards more constructivist viewpoints. Narratives that initially exhibited constructivist characteristics tended to display strengthened convictions in that paradigm.

CONCLUSION

We challenge the claim that an international immersion experience immediately transforms participants into cultural experts; our evidence suggests that students experienced existential growth, but their understanding of culture did not change as a result of their brief stay in a different cultural context. Cultural immersion is a phenomenon that requires more critical analysis and systematic investigation to determine how such experiences contribute to learning about culture among nursing students.

Improving graduate education to support a branching career pipeline: recommendations based on a survey of doctoral students in the basic biomedical sciences

Today's doctoral programs continue to prepare students for a traditional academic career path despite the inadequate supply of research-focused faculty positions. We advocate for a broader doctoral curriculum that prepares trainees for a wide range of science-related career paths. In support of this argument, we describe data from our survey of doctoral students in the basic biomedical sciences at University of California, San Francisco (UCSF). Midway through graduate training, UCSF students are already considering a broad range of career options, with one-third intending to pursue a non-research career path. To better support this branching career pipeline, we recommend that national standards for training and mentoring include emphasis on career planning and professional skills development to ensure the success of PhD-level scientists as they contribute to a broadly defined global scientific enterprise.

Measurement of sleep in critically ill patients

Research to evaluate interventions to promote sleep in critically ill patients has been restricted by the lack of brief, inexpensive outcome measures. This article describes the development and testing of an instrument to measure sleep in critically ill patients. A convenience sample of 70 alert, oriented, critically ill males was studied using polysomnography (PSG), the gold standard for sleep measurement, for one night. In the morning the patients completed the Richards-Campbell Sleep Questionnaire (RCSQ), a five-item visual analog scale. Internal consistency reliability of the RCSQ was .90 and principal components factor analysis revealed a single factor (Eigenvalue = 3.61, percent variance = 72.2). The RCSQ total score accounted for approximately 33% of the variance in the PSG indicator sleep efficiency index (p < .001). The data provide support for the reliability and validity of the RCSQ.

Measuring critical thinking in problem-based learning discourse

BACKGROUND

Critical thinking (CT) is a composite of skills linked to problem-based learning (PBL).

PURPOSES

This study has 3 purposes: (a) to determine if PBL discourse could be coded for CT, (b) to demonstrate reliable coding, and (c) to determine whether a CT ratio would provide a valid measure to compare 2 PBL groups.

METHODS

Using prior research, we refined the code for a content analysis of PBL transcripts. Raters coded 6 hr of transcripts and computed CT ratios for each of the 5 CT stages. Average interrater agreement was 85.5%. CT ratios appeared to differ between 2 PBL groups delivered in 2 modalities.

RESULTS

PBL discourse could be coded following a CT framework. Independent raters reliably applied the code, and the resulting CT ratios detected tenable differences.

CONCLUSIONS

This approach could provide useful information about the effect of case modality.

Modifying a functional obstacle course to test balance and mobility in the community

A previously reported functional obstacle course (FOC) developed to assess elderly persons with and without balance and mobility impairment was used in a hospital-based study of 237 participants. A new modified version of the FOC was developed for use in a community-based study, by placing some obstacles next to walls instead of between parallel bars. These modifications eliminate the need for parallel bars or for extra personnel to interchange the obstacles. We were concerned that the modifications could affect performance scores, because touching or holding onto the now eliminated parallel bars could influence FOC scores under the original scoring system. To determine the effect of these modifications on FOC performance, we tested 36 volunteers, (18 fallers [falls within last year] and 18 non-fallers), on the modified parts of the old and new versions of the FOC. Random testing order and inter-trial rests were used. For both the old and new FOC versions, we summed quality and task completion time scores from the six modified obstacles (artificial turf, carpet, pine bark, sand, up ramp and down ramp) to create scores for quality and time. Our hypothesis was that there would be no performance difference between the original and modified obstacle course. Using a two-factor repeated-measures analysis of variance, we found no difference in quality scores between the two FOC versions and no effect of an interaction between faller status and the course versions. We did find that the time was approximately 2 seconds longer for the new version; however, the time increase was the same for fallers and non-fallers. These data show that fallers and non-fallers have comparable performance on both versions of the FOC; however, to compare the two obstacle courses we recommend an adjustment of 2 seconds in time scores. The obstacle course modifications will facilitate more extensive and efficient use of the obstacle course as a research tool to assess balance and mobility.

A conceptual framework for achieving high-quality care in nursing homes

Nursing home care accounts for 12% of healthcare expenditures in the United States, yet serious concerns remain about the quality of care provided in these settings. This article describes a comprehensive systems model that views organizational environments as consisting of four interacting dimensions: organizing arrangements, social factors, technology, and physical setting. This model is then used as a conceptual framework (vis-à-vis an extensive literature review) to identify factors that contribute to poor-quality care in nursing homes and to highlight previous research efforts. The literature review also provides a useful framework to guide nursing home administrators and healthcare quality professionals in their implementation of quality improvement processes and serves to help direct future research in this very important arena.

Nursing documentation versus standardized assessment of cognitive status in hospitalized medical patients

Although the literature discusses the importance of assessing cognitive status, little research has explored the concordance of nurses' documentation of cognitive status and standardized assessment. This study examined nurses documentation of cognitive status in 42 medically hospitalized individuals (mean age 51.9, SD = 10.1 years) using a variety of standardized measures. Although the chart review revealed no documentation of impaired cognitive status, impaired performance in 24 to 67% of the cognitive measures was identified. This study suggests nurses are missing cognitive impairment in hospitalized patients by limiting assessment to orientation. Use of a combination of several brief screening measures, such as the Clock Drawing Test and the standardized Mini-Mental State Examination, would provide timely, effective, and inexpensive assessment of cognitive status.

Balance, mobility, and falls among elderly African American women

OBJECTIVE

To compare balance, mobility, recent falls, and injuries among elderly African American and white women.

DESIGN

This was a nonexperimental study. Participants, who were older than 65 yr of age, able to walk at least 30 ft, not residing in a nursing home, and with no acute medical problems, were recruited from 17 senior citizens' community centers.

RESULTS

Compared with white women (n=180), African American women (n = 118) took fewer medications, had greater body mass indexes, had less muscle strength, and had more medical conditions and neurologic abnormalities. Additionally, these women were less active and had poorer performances on an obstacle course. The two groups had a similar histories of falls and injuries. For both groups, activity level and neurologic findings were predictors of obstacle course performance. For white women, muscle strength was an additional predictor of obstacle course performance. An additional predictor for African American women was range of motion.

CONCLUSION

The poorer balance and mobility of African American women compared with white women may have consequences such as their functional dependence, resulting in their greater use of hospitals and formal and informal health services.

Identifying patterns of disruptive behavior in long-term care residents

OBJECTIVES

To determine the frequency, timing, and pattern of 45 operationalized disruptive behaviors (DB) in older people in long-term care units.

DESIGN

Nursing staff collected prospective descriptive data over 21 consecutive shifts for each patient to document prevalence, frequency, and co-occurrences of DBs.

SETTING

All of the eight long-term care units and one acute/admission unit of a large Veterans Administration Medical Center (VAMC). Each 40-bed unit had patients with varying levels of cognitive impairment and skilled nursing needs.

PARTICIPANTS

The sample consisted of 240 hospitalized VA patients with a mean age of 72.8 (SD = 8.6) years and mean length of stay of 4.02 (SD = 8.6) years. Residents had dementia, a psychiatric diagnosis, or mixed dementia and psychiatric diagnoses.

MEASUREMENTS

The Disruptive Behavior Scale (DBS), an instrument designed for collecting patient-level data on 45 separate DBs.

RESULTS

In a 24-hour period, the average frequency was 3.6 DBs per subject. We found that 41.2% of DB occurred during the day shift, 39.2% during the evening shift, and 19.6% during the night shift. In 32% of observed occurrences, only one DB occurred within the hour. In the remaining 68% of observations, two or more DBs occurred within the same hour. We found two behaviors, Does Not Follow Directions and Excessive Motor Activity, to occur with multiple behaviors in multiple categories. Several characteristic patterns were noted; e.g., physically aggressive behaviors rarely co-occurred with verbal DBs. Physically nonaggressive behaviors seemed to occur most frequently with other physically nonaggressive behaviors and, to a lesser extent, with verbal DBs.

CONCLUSIONS

These findings lend support to the existence of patterns of DBs in long-term care patients, a useful step toward targeting interventions early in the behavioral sequence.

Obstacle course performance and risk of falling in community-dwelling elderly persons

OBJECTIVE

To determine the efficacy of obstacle course performance scores in predicting persons at risk for falls, after adjusting for age, sociodemographic, health-status, and physiologic variables.

DESIGN

Correlational descriptive study design utilizing a logistic regression model.

SETTING

Community setting.

PATIENTS OR PARTICIPANTS

A convenience sample of 352 community-dwelling elderly individuals at sites in a metropolitan area. MAIN CRITERION MEASURE: Number of falls reported prospectively during a 2-year follow-up period.

RESULTS

Obstacle course performance, fall history, symptoms of balance dysfunction, and activity level distinguished those who fell and those who did not 12 and 18 months later. At 24 months, range of motion and number of medications also were significant. In multivariate logistic regression, only history of a fall was a significant predictor of future falling at 12 and 18 months; at 24 months, the presence of balance dysfunction symptoms was the significant predictor of those who fell.

CONCLUSIONS

The obstacle course, as a predictor of future falls, is not superior to the question of whether or not an individual has fallen in the previous year, and is not recommended to predict future falls. The obstacle course may be better as a short-term indicator of response to a rehabilitation program for balance and mobility.

Comparison of a functional obstacle course with an index of clinical gait and balance and postural sway

BACKGROUND

Older adults commonly experience falls because of balance and mobility problems. Better assessment methods are needed to understand and correct balance and mobility disorders.

METHODS

We used a low technology, functional obstacle course (FOC) to measure balance and mobility in 352 community-dwelling elderly participants. To establish concurrent validity of the FOC, we compared performance on the FOC with two established measures of balance and mobility: performance on the Tinetti Index (TI) and postural sway area measured on a force platform.

RESULTS

Bivariate correlation analyses revealed significant inverse correlations between FOC completion time, the TI balance and gait subscores, and the TI total score (r = -.73 to -.78). The FOC quality scores and TI balance and subscores gait and TI total scores (r = .76 to .82) were significantly positively correlated. FOC time had significant, but small, positive correlations with sway area with eyes open (r = .18) and closed (r = .17) and nonsignificant correlation with sway area with visual feedback. FOC quality also had significant, but smaller, inverse correlations with sway area with eyes open (r = -.024) and closed (r = -.015), and nonsignificant correlation with sway area with visual feedback. Regression analysis showed that TI gait and balance measures accounted for most of the variance found in FOC performance.

CONCLUSIONS

Our findings support the position that the FOC and the TI measure dynamic balance, whereas postural sway measures a different aspect of balance. Advantages of the FOC include the evaluation of environmentally influenced falls and balance problems.

Students' educational activities during clerkship

PURPOSE

To quantify the educational activities and types of teachers that medical students had in third-year clerkships at community-based teaching hospitals.

METHOD

In October-November 1992, 201 students in third-year medical clerkships at nine community-based hospitals completed a log that recorded the primary activity, site, and educator and method of education (for teaching or supervised activities) for each 15-minute interval of a 24-hour day. Each hospital offered at least three of the clerkships studied: medicine, obstetrics-gynecology (ob-gyn), pediatrics, psychiatry, and surgery. Statistical comparisons of the clerkships were done with chi-square analysis and one-way analysis of variance.

RESULTS

The students received 6.5 hours a day of teaching with an instructor and committed an additional 4.9 hours to clerkship-related learning. Nearly 75% of the teaching fell to full-time faculty members and residents. In just over half of their educational activities the students participated with other learners, such as residents. The clerkships did not differ significantly in the amounts of formal teaching given; however, medicine did significantly more informal teaching, and surgery and ob-gyn did significantly more supervised practice.

CONCLUSION

This preliminary study quantified medical students' educational activities in 1992 during third-year clerkships and provides baseline data describing these activities and the educators involved. Some findings may not be replicable, however, with the increasing demands of full-time faculty members in inpatient and outpatient settings and the shifting emphases in how and where residents provide instruction. Another study such as this one would help assess the effects on medical education of changes in the health care environment.

Do internists and emergency physicians agree on the appropriateness of emergency department visits?

The purpose of this study was to determine the levels of agreement between three methods of assessing appropriateness of emergency department (ED) visits. In particular, we tested the agreement between internists and emergency physicians reviewing the ED nurses' triage notes, containing information that might be available by telephone to an internist. For 892 adult patient ED visits reviewed, we found only moderate agreement (kappa = 0.47) between these groups. In cases of disagreement, emergency physicians were 10.3 times more likely than internists to classify those with minor discharge diagnoses as appropriate for ED care. As managed care grows, the determination of ED appropriateness may depend on open discussions between physician groups, as well as on access to timely care in office settings.

Addressing the National League for Nursing critical-thinking outcome

The National League for Nursing outcome-oriented accreditation process challenges nursing faculty to think about teaching and evaluating critical thinking. In a survey of schools of nursing, the authors found that programs are using standardized measures and individualized assessments to address the criterion. Their greatest difficulty involves decisions about measuring critical thinking. School administrators identified a variety of approaches effective for helping faculty. The authors provide insight and ideas for nursing faculty involved with critical thinking in the curricula.

Assessing substance abuse among health care students and the efficacy of educational interventions

Approximately 10 per cent of nurses are chemically dependent, and, for many, substance abuse begins while attending nursing school. Faculty must be able to assess the extent of the problem, understand the contributing factors, recognize signs and symptoms, and use educational interventions in identifying and preventing chemical dependency in nurses. Beginning in 1989, the authors sampled all entering students in four colleges on a health science campus using the Standardized Substance Abuse Attitude Survey and obtained resurvey data from two of the colleges' 1989 entering classes in fall 1991. Each college developed educational interventions. Some clear differences between nursing and pharmacy students emerged and indicated that a greater emphasis on drug and alcohol education can pay dividends. Establishing a data base over a period of more than 2 years provides a foundation to evaluate further interventions.

Rehabilitation of elderly fallers: pilot study of a low to moderate intensity exercise program

OBJECTIVE

The role of exercise in the prevention of falls and fall-related injuries among elderly persons is unclear. The objective of this study was to assess the response to an exercise-based rehabilitation program intended to improve balance and mobility and reduce or prevent falls.

DESIGN

Pretest-posttest experimental design with repeated measures at baseline, immediately postintervention, and 6 months postintervention. To assess the effect of repeated exposure to our main outcome measure (the obstacle course), half of the participants (randomly selected) were allowed to practice on the obstacle course.

SETTING

A veterans affairs medical center.

PARTICIPANTS

Elderly, ambulatory, community-dwelling volunteers recruited from among local outpatients at our medical center.

INTERVENTION

Sixty-five volunteers completed a 6-week supervised low to moderate intensity program of stretching, postural control, endurance walking, and coordination exercises designed to improve balance and mobility. Participants were divided into 2 groups: 34 participants who did not practice on the obstacle course during their exercise program and 31 participants who practiced on the obstacle course in addition to their otherwise identical exercise program.

MAIN OUTCOME MEASURES

Performance on a functionally oriented obstacle course and self-reported falls and fall-related injuries.

RESULTS

No significant performance differences were found between the two groups. After intervention, mean qualitative obstacle course scores improved modestly (5%) and mean obstacle course completion time decreased by 15% from baseline. These postintervention pairwise performance differences were clinically important but not statistically significant. Relative to baseline levels, postintervention falls and injuries did not change significantly.

CONCLUSIONS

Our exercise intervention may have the potential to improve functional performance. However, some modifications are necessary to enhance efficacy. The obstacle course may be a useful tool in the evaluation of elderly persons with balance and mobility impairment in the rehabilitation setting.

Use of an obstacle course to assess balance and mobility in the elderly. A validation study

An obstacle course, consisting of a series of 12 simulated functional tasks, has been developed to aid in the evaluation of rehabilitation interventions for elderly individuals with balance and mobility dysfunction. The validity of the obstacle course as a measure of balance and functional mobility was tested by comparing obstacle course performance scores of a sample of 237 community-dwelling veterans, aged 67 to 93 yr, with clinical indicators of balance and mobility including age, history of falls, symptoms of balance dysfunction, medication use, orthostatic blood pressure changes, neurologic examination abnormalities, muscle strength, joint range of motion, self-reported activity level, and functional status. Significant correlations were found between obstacle course scores and all clinical indicators except blood pressure changes and age. Multiple regression analysis of selected variables showed that activity level and neurologic abnormalities best determined both qualitative and quantitative obstacle course performance. Non-fallers performed significantly better on the obstacle course than fallers. These results suggest that the obstacle course is valid and has potential as a useful tool in the evaluation of older persons with balance and mobility impairment.

"Inappropriate" emergency department use: a comparison of three methodologies for identification

OBJECTIVE

To determine the level of agreement between the rates of "inappropriate" ED visits assigned to a cohort of ambulatory patients based on three methods of defining ED use appropriateness.

METHODS

Ambulatory adult patients seen at one urban, university-based teaching hospital ED between 8 AM and midnight during select days from April to June 1994 were assessed regarding the appropriateness of their ED visits. Patients triaged to acute resuscitation rooms in the ED were excluded. Eligible patients were asked to complete a 90-question survey including demographics and health service use (response rate 81%). The appropriateness of ED use was assessed for consenting respondents by 1) application of a list of 51 non-emergent complaints that have been used by managed care providers and previously published (TRIAGE), 2) use of ten explicit criteria (e.g., need for parenteral medication) from prior publications (EXPLICIT), and 3) the consensus of two emergency physicians (EPs) reviewing the records of ED patients (PHYS). All three methods were applied at the time of retrospective chart review. The agreement between methods was evaluated using kappa scores.

RESULTS

Of the 892 eligible respondents, 64% were white, 54% were employed, 50% were female, and 29% were uninsured. Of the respondents, 26% had no regular source of ambulatory care and 25% considered the ED their regular source of care. The assigned rates of "inappropriate" visits using the three definitions were TRIAGE, 58%; PHYS, 47%; and EXPLICIT, 42%. Of those deemed "inappropriate" by the EXPLICIT criteria, 81% also were judged as "inappropriate" by the TRIAGE criteria, and 72%, by the PHYS criteria. Of those patients deemed "inappropriate" by the TRIAGE criteria, 59% also were judged as "inappropriate" by the EXPLICIT criteria, and 66%, by the PHYS criteria. Levels of agreement (kappas) were TRIAGE/EXPLICIT, 0.39; TRIAGE/PHYS, 0.42; and EXPLICIT/PHYS, 0.42.

CONCLUSION

There is only moderate agreement between different methods of determining appropriateness of ED use. Until further refinement is made in triage assessment, managed care organizations and EPs should remain cautious when implementing a protocol that defines and restricts "inappropriate" ED visits.

Evaluating medical residents' literature-appraisal skills

BACKGROUND

Measuring critical-appraisal skills is a key step in assessing physicians' abilities to engage in self-directed learning. The authors developed an instrument to evaluate the abilities of residents to critically appraise a journal article.

METHOD

In 1991, 62 residents in the categorical internal medicine program at the New England Medical Center were asked to respond to a questionnaire, evaluate a sample article, and complete a self-assessment of competence in evaluation of research. Critical-appraisal skill was determined by calculating the resident's deviations from a "gold standard" critique developed through a modified Delphi technique, using a panel of five physicians. Spearman correlation coefficients were used to compare the residents' actual and self-perceived abilities.

RESULTS

Twenty-eight residents returned the questionnaire, for a response rate of 45%. The composite score for the residents' objective assessments was 63% of the gold standard, and was not significantly correlated with post-graduate year, prior journal club experience, or self-assessed critical-appraisal skill.

CONCLUSION

After further validation in other settings, the assessment instrument in this study may be used to objectively assess critical-reading skills. It may also provide feedback and measure outcomes for interventions designed to improve critical reading.

Changes in the pattern of drug overdoses

OBJECTIVE

To describe changes in the pattern of patients with drug overdoses hospitalized over the past two decades.

DESIGN

Retrospective data review.

SETTING

A 719-bed university-affiliated hospital.

PATIENTS

All adults admitted to the hospital with drug overdoses in 1968, 1979, and 1989.

PRIMARY OUTCOME MEASURES

Changes in demographics, drugs used, and discharge disposition.

RESULTS

A majority of patients admitted with drug overdoses have had previous suicide attempts; and while women predominate, they make up a decreasing proportion of admissions over time (76% in 1968 to 52% in 1989 (p = 0.003). Benzodiazepines were the drugs most commonly used in 1979 and 1989, and cocaine has shown a marked increase in use over time, while barbiturate overdoses have progressively decreased. The use of two or more drugs is common and has been consistent over time, as has been the concomitant use of alcohol. The mortality rate has remained low at 1%, but mean length of stay has decreased dramatically from 6.6 days in 1979 to 3.2 days in 1989 (p < 0.001) and discharge disposition has shifted from out-patient to inpatient psychiatric care.

CONCLUSIONS

The majority of patients admitted to a general acute care hospital following a drug overdose have a history of previous suicide attempts and are followed by a mental health professional. The changing pattern of drugs used over two decades reflects trends in drugs used in the community in general and by patients with mental illness in particular. Discharge disposition has changed over time and is related to patients' insurance status.

Gestational diabetes: predictors of subsequent disordered glucose metabolism

OBJECTIVE

We tested the hypothesis that the development of abnormal glucose metabolism after gestational diabetes can be predicted readily by means of available clinical variables.

STUDY DESIGN

Three hundred fifty nonpregnant former gestational diabetic women delivered during the previous 10 years underwent glucose tolerance tests. Variables including body mass index before the index pregnancy, pregnancy glucose tolerance test values, gestational diabetes treatment, complications, gestational age at diagnosis of gestational diabetes, and time elapsed since pregnancy were analyzed with logistic regression.

RESULTS

Variables that distinguished subjects who later developed diabetes or impaired glucose tolerance included prepregnancy body mass index (28.5 +/- 7 versus 25 +/- 5 kg/m2, p < 0.001) and fasting glucose on the pregnant oral glucose tolerance test (109 +/- 20 vs 92 +/- 15 mg/dl, p < 0.001). Logistic results with these two variables plus time since the index pregnancy predict subsequent glucose tolerance test abnormality by the following equation: estimated risk = 1/[1 + e-(-10.37 + 0.04 (fasting plasma glucose) + 0.08 (body mass index) + 0.03 (months since delivery))].

CONCLUSION

The risk for subsequent glucose abnormality among individuals with previous gestational diabetes is quantifiable based on prepregnant body mass index and fasting plasma glucose during pregnancy.

Limits of patient autonomy. Physician attitudes and practices regarding life-sustaining treatments and euthanasia

BACKGROUND

In making decisions about life-sustaining medical interventions, respect for patient autonomy has been widely advocated, yet little is known about what variables may compete with a physician's ability to honor patient requests in clinical situations. We investigated physician attitudes and behaviors about end-of-life decisions by means of a questionnaire that posed five hypothetical scenarios in which an elderly, competent, terminally ill patient made a request that, if agreed to by the physician, could result in the patient's death.

METHODS

We surveyed 392 physicians in Rhode Island and asked them to decide (1) whether or not they would comply with a specific patient request, (2) the justifications they used in making their decision, and (3) whether they had been approached with such a request in their clinical practices.

RESULTS

Two hundred fifty-six physicians (65%) responded. Of the respondents, 98% agreed not to intubate the patient in the face of worsening respiratory failure. Eighty-six percent agreed to give the patient a dose of narcotics that could cause respiratory compromise and death to treat his pain adequately. Fifty-nine percent agreed, once the patient was intubated without hope of coming off the respirator, to turn the respirator off. Nine percent agreed to give the patient a prescription for an amount of sleeping pills that would be lethal if taken all at once. Only 1% agreed to give the patient a lethal injection. When they complied with patient requests, physicians cited patient autonomy as the principle most important to their decision making. Physicians who would not comply with patient requests also, paradoxically, often cited this principle but agreed with it less strongly; others cited concerns about the ethical nature of the request, legal questions, and the perception that they were "killing the patient." Sixty-five percent of respondents had been asked by patients to turn off a respirator, and 12% had been asked to administer lethal injections. Twenty-eight percent of respondents indicated that they would comply with requests for lethal injection more frequently if such an action were legal.

CONCLUSIONS

Difficult clinical decisions regarding potentially life-prolonging measures are commonly heard in clinical practice. Physicians value the concept of patient autonomy but place it in the context of other ethical and legal concerns and do not always accept specific actions derived from this principle.

Utilization of medical services by drug abusers in detoxification

To establish the extent of health services, including inpatient, emergency room, and outpatient care utilized by illicit drug users during the previous year, we surveyed 77 drug abusers, who were not known to be HIV-positive, entering a detoxification unit and a comparison group of 70 drug nonusers. Over the previous year, drug abusers had a greater number of visits to their usual source of care, to emergency rooms, and to other sites than drug nonusers. Drug abusers were significantly more likely to have been hospitalized during the past year. Using a logistic model including sociodemographic factors, drug abusers were 2.3 times as likely to use an emergency room and 6.7 times as likely to be hospitalized as drug nonusers. We conclude that drug abusers are heavy users of health services compared to a group of drug nonusers.

Ambulatory-based residency education: improving the congruence of teaching, learning, and patient care

Residency education in internal medicine should be based in the ambulatory setting. The challenge in ambulatory education lies not only in the unique opportunities afforded by the setting but also in the careful implementation of a program based on sound educational principles. We have designed a new ambulatory-based model of internal medicine residency that adheres to the principles of adult learning theory. Four aspects of the proposed residency model are discussed: the setting, the teaching-learning model, the curriculum, and the schedule. Potential barriers to implementation of the model are reviewed, and solutions are suggested. Residency programs in internal medicine are at an important crossroad. Either we can substantially change the programs' content and focus, or we can risk the continued unpopularity and "second-class" status of the programs among medical students. Internal medicine needs to be recognized and accepted as a fundamental primary care discipline to justify continued public support in an era of overspecialization.

Alumni perspectives comparing a general internal medicine program and a traditional medicine program

OBJECTIVE

To evaluate a primary care internal medicine curriculum, the authors surveyed four years (1983-1986) of graduates of the primary care and traditional internal medicine residency programs at their institution concerning the graduates' preparation.

DESIGN

Mailed survey of alumni of a residency training program.

SETTING

Teaching hospital alumni.

SUBJECTS/METHODS

Of 91 alumni of an internal medicine training program for whom addresses had been found, 82 (90%) of the residents (20 primary care and 62 traditional) rated on a five-point Likert scale 82 items for both adequacy of preparation for practice and importance of training. These items were divided into five groups: traditional medical disciplines (e.g., cardiology), allied disciplines (e.g., orthopedics), areas related to medical practice (e.g., patient education), basic skills and knowledge (e.g., history and physical), and technical procedures.

MAIN RESULTS

Primary care residents were more likely to see themselves as primary care physicians versus subspecialists (84% versus 45%). The primary care graduates felt significantly better prepared in the allied disciplines and in areas related to medical practice (p less than 0.01). There was no significant difference overall in perceptions of preparation in the traditional medical disciplines, basic skills and knowledge, and procedures. The same results were obtained when the authors looked only at graduates from the two programs who spent more than 50% of their time as primary care physicians versus subspecialists. There was no significant difference between the two groups in the perceived importance of these areas to current practice.

CONCLUSIONS

These results suggest that the primary care curriculum has prepared residents in areas particularly relevant to primary care practice. Additionally, these individuals feel as well prepared as do their colleagues in the traditional medical disciplines, basic skills and knowledge, and procedural skills.

Hyperosmolarity and acidosis in diabetes mellitus: a three-year experience in Rhode Island

OBJECTIVES

Diabetic acidosis (DA) and the diabetic hyperosmolar state (DHS) are generally considered to be two distinct clinical entities. However, clinical experience and the literature suggest that there may be some overlap. The purposes of this study were 1) to establish the proportion of overlap cases, 2) to identify any occurrence of DHS in diabetic patients under the age of 30 years (likely type I) and any occurrence of DA in diabetic patients over the age of 60 years (likely type II), 3) to describe clinical factors associated with the development of DA and DHS, and 4) to identify factors that influence the prognosis of DHS.

PATIENTS AND METHODS

613 cases were identified by retrospective chart review, using discharge information from all 15 Rhode Island community hospitals during 1986, 1987, and part of 1988. DA alone [serum glucose (glu) greater than 300 mg/dL, bicarbonate (HCO3) less than 15mEq/L, calculated total serum osmolarity (osm) less than or equal to 320 mOsm/L] was the diagnosis for 134 subjects (22%), DHS alone (glu greater than 600 mg/dL, HCO3 greater than or equal to 15mEq/L, osm greater than 320 mOsm/L), for 278 subjects (45%), and a mixed case (glu greater than 600 mg/dL, HCO3 less than 15 mEq/L, osm greater than 320 mOsm/L), for 200 subjects (33%). Information about serum or urinary ketones was available for 109 subjects who had DA alone [103 had diabetic ketoacidosis (DKA)] and 144 subjects who had mixed DA and DHS (131 had mixed DKA and DHS). All the data were also analyzed using the effective osmolarity and a cutoff of 310 mOsm/L for this alternative case definition.

RESULTS

Patients with DA alone were younger (mean age 33 years) and patients with DHS alone were older (mean age 63 years). However, 28 (10%) of the 278 cases of DHS alone and 72 (36%) of the 200 cases of mixed DA and DHS occurred in patients under the age of 30. Eighteen cases (13%) of DA alone and 62 cases (31%) of mixed DA and DHS occurred in patients over the age of 60. The results were not substantially changed when effective osmolarity greater than 310 mOsm/L was used to define hyperosmolarity and when only cases with documented DKA were included. An infection was the most common precipitating factor of DA (30%), DHS (27%), and mixed cases (32%). Other common associated factors included noncompliance with treatment (20% for DA, 12% for DHS, and 22% for mixed cases) and previously undiagnosed diabetes (24% for DA, 18% for DHS, and 10% for mixed cases). Nursing home residents accounted for 0.7% of DA cases, 18% of DHS cases, and 4.5% of mixed cases. Mortality was 4% for DA, 12% for DHS, and 9% for mixed cases. The mortality for DHS is the lowest reported in the literature, continuing a downward trend that began in the 1970s. Nonsurvival was associated with older age, higher osmolarity, and nursing home residence. Survival was associated with the presence of an infection.

CONCLUSIONS

1) many patients experience mixed DA (DKA) and DHS rather than either condition alone, 2) both DA (DKA) and DHS occur in young and old diabetic persons, 3) infection is the most common predisposing factor for either condition, and 4) higher osmolarity, older age, and nursing home residence are associated with nonsurvival in DHS.

HIV-positive women: reasons they are tested for HIV and their clinical characteristics on entry into the health care system

STUDY OBJECTIVE

To describe the reasons for the HIV testing of HIV-positive women and their clinical presentation and to make specific laboratory comparisons between women intravenous drug users (IVDUs) and non-IVDUs who were heterosexually infected (HTs).

DESIGN

Consecutive case series.

SETTING

Four primary care sites associated with the Brown University AIDS Program.

PARTICIPANTS

140 consecutive HIV-seropositive women.

RESULTS

The most common reason for HIV testing in both groups was self-perception of risk. Presenting T-helper lymphocyte counts, leukocyte counts, and hematocrits did not differ significantly between the groups. Intravenous drug users were significantly more likely than HTs to have evidence of hepatitis B virus exposure (p less than 0.0001) and to report the history of a sexually transmitted disease (p = 0.005). Twenty percent of HTs versus 10% of IVDUs were tested only after they had HIV-related symptoms. The most frequent clinical presentation for both groups was Centers for Disease Control Group IV/A constitutional symptoms.

CONCLUSIONS

Many HIV-seropositive women do not enter the health care system until they are symptomatic, but those infected heterosexually and those using parenteral drugs have similar laboratory indices at presentation. AIDS education strategies toward all women at risk must include information about manifestations of HIV disease in women, as well as preventive measures, to ensure early access to the health care system.

Patient characteristics associated with the use of mechanical restraints

STUDY OBJECTIVE

To compare the characteristics of restrained patients with those of unrestrained patients by assessing a number of medical, behavioral, and cognitive variables including a disruptive-behavior inventory.

DESIGN

Case-control study.

SETTING

A 719-bed university-affiliated teaching hospital.

PATIENTS

The 80 cases were patients identified by the nursing staff as having had a restraint applied within the last 24 hours prior to entry in the study. The 80 unrestrained controls were selected from the rooms adjacent to the cases' in order to match for proximity to the nursing station and nurse staffing.

MEASUREMENTS AND MAIN RESULTS

Demographic data, data on diagnoses and treatments, results of the Folstein Mini-Mental State (MMS) test and an eight-item disruptive-behavior inventory, and outcome information were obtained for each patient using a standardized procedure. Three important patient characteristics were significantly associated with restraint use in a multiple logistic regression model: disruptive behaviors, nursing assessment of risk of falling, and cognitive impairment. Cases were older than controls, but age was not an independent characteristic associated with restraint use when controlling for cognitive impairment, risk of falling, and disruptive behaviors.

CONCLUSIONS

Restraint use was more likely in patients with disruptive behaviors, at risk of falling, and with cognitive impairment. Attention to these factors and alternative strategies for dealing with them may reduce the use of physical restraints.

The service/education conflict in residency programs: a model for resolution

Residency programs consist of a range of activities involving service to patients and education of residents. The observation that a conflict exists between the service and education components of residency is widespread and has been used to explain many of the problems afflicting such programs today. The authors believe that the service/education conflict is a significant barrier to change in residency programs. A model is presented for residency education that reorganizes the service and education components. First, they present a broad overview of the conflict. Then they provide a brief historical perspective and comment on some of the current recommendations for residency programs. Next, they discuss how principles of adult learning relate to residency and propose a new model of residency that adheres more closely to these principles. Finally, the proposed model is presented in some detail and its implications are discussed. Only if the service and education components of residency are carefully delineated can residency programs adapt to the changing and growing needs of postgraduate medical education.

Effects of route of fluid administration on severity of side effects with post-metrizamide myelogram

The effect of route of hydration on the severity of side effects of nausea, vomiting, and headaches for 13 patients receiving a metrizamide myelogram was studied. Six patients were hydrated by mouth only and seven by mouth and intravenously. Severity was measured 24 hours postmyelogram with a visual analogue scale for each side effect. Controlling for the volume of all fluid received, significantly more severe headaches were reported by patients hydrated only orally. For this small sample, no significant differences were found for severity of nausea or vomiting. The study and its implications for nursing are described.

Comparison of medical, surgical and oncology patients' descriptions of pain and nurses' documentation of pain assessments

Eighty-four nurse-patient dyads were studied to obtain descriptions of pain from medical, surgical and oncology patients experiencing pain. These descriptions were compared with the documentation of pain assessment recorded by the nurses providing care to these patients. Neither the descriptions of pain nor the amount of information documented about that pain differed significantly across the three groups. For each group, nurses documented significantly less than 50% of what the patients described. Inadequate documentation of pain assessment has legal and continuity of patient care implications.

Assessing pediatric clerkship evaluations using generalizability theory

Evaluation of pediatric clerkship ratings using generalizability theory is demonstrated. Ratings collected during an academic year are analyzed in a generalizability study, with emphasis placed upon the nature of the designs used to collect ratings. Since decisions regarding students' performances are made with these data, decision-study type analyses were carried out using the generalizability study results. Recommendations are made as to the type of designs that could be used in order to obtain generalizable results.

Mildly mentally retarded and nonretarded children's learned helplessness

The relationship among four measures identified as operational definitions of learned helplessness was assessed in 44 mildly mentally retarded and 44 nonretarded children of equivalent mental age. Assessment of perseverance, response initiation, teacher perception of helplessness, and attributions for positive and negative achievement outcomes revealed an absence of corroboration in the two subgroups. The findings suggest that ability grouping and instrumentation are meaningful variables when evaluating learned helplessness in retarded and nonretarded students.