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The purpose of this study was to establish the reliability and validity of the Homeless Satisfaction With Care Scale, a measure of satisfaction with care among homeless clients; and to examine selected predictors of satisfaction with care. A descriptive cross-sectional study was conducted comparing an inductively developed measure of satisfaction with 2 established satisfaction measures in a sample of 168 homeless clients who used a rural or an urban clinic. The inductively developed satisfaction scale had good internal consistency reliability and was significantly related to the established measures of satisfaction, supporting its construct validity. Generally, patient characteristics were not associated with satisfaction level. However, Black clients had significantly lower satisfaction levels than White clients; satisfaction differed between the rural and urban sites. Race and clinical site explained 7% of variance in satisfaction. The inductively developed measure provides a salient and appropriate measure of satisfaction with care for future studies with the unique population of homeless.

Background: The southern Appalachian states show a high prevalence of smoking, with associated high rates of both heart disease and cancer, yet cultural differences raise questions concerning the applicability of the mostfrequently used model for smoking cessation, the transtheoretical model, for smokers from this region of the country. Objective To identify, by examining the applicability of the transtheoretical model for southern Appalachian smokers, the percentage of individuals in each of the five stages of change, the use of the processes of change from the transtheoretical model, and the scores on recognized predictors of smoking cessation including the temptation to smoke, the perceived barriers to cessation, the pros and cons of smoking, and nicotine dependence. Methods: This population-based, descriptive, cross-sectional study used a random sample of 3,800 telephone numbers, which were called up to eight times. The 659 smokers or former smokers who agreed to participate were mailed a written questionnaire consisting of six well-established scales that measure constructs from the transtheoretical model. The final sample consisted of 357 usable questionnaires. Results: The distribution of smokers in northeastern Tennessee differed from national samples across the first three stages of change, with 56% in precontemplation, as compared with previous findings of 40% in national samples. The subjects' scores for the pros of smoking were similar across the stages of change in this sample, and although the scores for the cons differed significantly across the stages in the sample, post hoc analysis indicated that the only significant change occurred between precontemplation and contemplation. The scores for temptation to smoke did not differ significantly across the stages of change in this sample. Discussion: Smokers from Appalachian Tennessee differ from smokers in other parts of the United States, and these findings raise questions about the applicability of the transtheoretical model for this population.

Life in rural America is often idealized, yet rural Americans suffer from mental illness in rates comparable to urban America and require similar types of support and services. However, millions of individuals living in rural areas go without needed mental health services. The dominant care model allows the treatment of mental illness to be delivered by non-mental health professionals with little or no education or training in psychiatric care and who have little desire to provide this type of care, resulting most often in ineffective or inappropriate treatment. Lacking access to appropriate and effective care, rural mentally ill individuals are more often symptomatic than their urban counterparts and may never find relief from the disabling symptoms of treatable mental illnesses. This article will focus on the current state of psychiatric-mental health care in the context of these realities and discuss the impact of the current trend of mental illness being treated by non-mental health professionals. The article will conclude by proposing a model of advanced practice nursing that the authors believe will increase both access and efficacy of treatment for the mentally ill living in rural America. This Integrated Model views the current system of care that completely separates location for traditional physical and mental health care as antithetical to integration and to holism and presents a new model for understanding and provided integrated health care to meet the needs of rural mentally ill individuals and families.

Women who are experiencing crisis situations, including homelessness, are often perceived as passive victims of their social, economic, and personal circumstances. A few studies have challenged the stereotype of homeless women as passive victims and demonstrated that they are active in seeking solutions to their problems (Hodnicki, Horner, & Boyle, 1992; Montgomery, 1994; Thrasher & Mowbray, 1995). This study surveyed women receiving assistance at a nurse-managed clinic that serves a homeless population to determine their health promotion strategies. On the basis of this study's findings, health care providers are encouraged to recognize and build on the strengths of women in crises at both the individual and community levels of care.

This study evaluated the outcomes of a series of health-screening clinics specifically developed to target the homeless population. Problems screened during this study were selected because of the high prevalence of each among the homeless and included hypertension, diabetes, anemia, tuberculosis, and foot problems. Screening clinics were developed and implemented by faculty and senior baccalaureate nursing students. Data were collected with a screening form that focused on risk factors and individual health history and by chart review. Two hundred fourteen clients were screened in 17 different screening clinics. Participation in the clinics ranged from 33 clients at a hypertension-screening clinic to 0 at one of the foot-screening clinics. Abnormalities were identified in 22% of the clients who were screened, and documentation was found that 80% of those with abnormalities received follow-up. Overall, the screening clinics appear to be an effective approach to disease prevention in a homeless population.

A new conceptualization of the related activities QA, RM, and UR may allow an organization to ensure appropriate, proficient, and satisfactory care and to ameliorate the consequences of bad outcomes. Three processes incorporated into the conceptualization are essential to ensuring excellence, as are specific attributes of the care process. The difference in initiation of activities (reactive versus proactive) is part of the model; relationships among the essential activities and processes and between reactive and proactive activities are suggested; and viewing data sources or collection as separate from the processes and activities is suggested. Areas for development and research within the conceptualization that are inadequately understood include data sources and analysis methods useful for the processes needed, evaluation of the consequences of different reactive activities, and the usefulness of TQI activities for setting goals or standards and for changing behavior. Implementing such an approach to ensuring excellence would be a challenge. It is hoped that this formulation will assist in communication among those working to ensure excellence; promote analysis of whether current organizational structures for ensuring excellence and for cost containment are creating redundance, competition, or gaps in needed activities; broaden the perception of the possible and/or appropriate scope of some activities, such as the inclusion of proactive preventive care and the provision of special high-risk programs; and assist in the identification of areas of needed research and development.

Satisfaction with a self-care intervention program was evaluated through this quantitative study of arthritis clients at home. The results indicate that the clients were highly satisfied with the intervention. In this era of consumer satisfaction with their care, nurse administrator's knowledge of which interventions are satisfying is important for staff development and case management in the community.

Objectives: To identify a typology for high system users among a rural Medicaid population that could assist policy makers and providers in better and more efficiently serving this population. Design and Sample: Exploratory secondary data analysis of a large integrated Medicaid database in a western state. Five hundred and thirty-nine Medicaid recipients receiving 2 or more state services and receiving 10 or more unique medications. Measures: Data analysis examining health care use, medication use, and demographic characteristics using SAS to identify patterns of use of services in the population. Results were confirmed with a statewide sample of 2,287 Medicaid users. Results: 3 characteristics—(1) use of 36 or more health care services in a year; (2) no gap in health care service use over the entire year; and (3) use of >12 health care services in 1 month—describe high-risk groups of Medicaid users. Conclusions: Public health nurses, particularly as case managers and program planners, can look at service use patterns through client histories and their own agency records, in order to identify high-risk groups who may benefit the most from programs that address their support, education, and coordination of health care needs.

Purpose: The purpose of this study was to evaluate the perceived preparedness of nurse practitioners (NPs) for practice after completing their basic NP educational programs and to evaluate NPs’ perceived preparedness in and their perceived importance of select clinical content areas basic to NP education. Data sources: This cross-sectional descriptive study used a written questionnaire consisting of 32 items, two of which contained 25 subitems. Subjects were asked to rate their overall level of preparedness when they completed their NP program and both their level of preparation in and the importance of 25 clinical content areas. The questionnaires were administered to attendees at two large national NP conferences in 2004; a total of 562 questionnaires were completed and used in the analysis. Conclusions: Ten percent of the sample perceived that they were very well prepared for practice as an NP after completing their basic NP education. Fifty-one percent perceived that they were only somewhat or minimally prepared. Current age, years since graduation from an NP program, and age when attending the NP program did not differ significantly for those who felt prepared versus those who did not. For a number of content areas, subjects did not perceive that they were well prepared in the same areas that they perceived were very important. Implications for practice: Our results indicate that formal NP education is not preparing new NPs to feel ready for practice and suggests several areas where NP educational programs need to be strengthened. Practicing NPs are the basis of the NP profession, and their views need to be sought, listened to, and reflected upon as we advance toward expanded preparation at the doctoral level.

This study evaluated the accomplishment of the Nursing Outcomes Classification (NOC) outcome "Health Seeking Behavior" in 5 nurse-managed clinics. Nurse practitioners and registered nurses rated patients on 11 indicators of health seeking behaviors, and recorded their level of knowledge of the patient. A total of 556 evaluations were collected. Health seeking behavior scores were lowest in a rural county school-based clinic and highest in a federally qualified health center. Ratings increased with nurses' knowledge of patients and for older patients.

Research on continuous lateral rotational therapy (CLRT) has demonstrated mixed results, but there have been definite benefits described in its use for the prevention and treatment of nosocomial and ventilator-acquired pneumonia. Several studies have shown decreased hospital and intensive care unit costs and lengths of stay, and ventilator days when used appropriately. The intent of this study was to develop a protocol for initiating and discontinuing CLRT and to determine if the protocol would result in more effective and efficient use of this therapy.

This article explores homeless individuals' experiences of satisfaction with health care, and explores the interrelationship among experiences of being homeless, health perceptions of participants, and experiences of satisfaction with health care. It presents the findings of a phenomenological study that was conducted using participants selected from five sites in one southeastern state. Participant interviews were conducted at a nurse-managed primary health care clinic for homeless, at a night time soup-kitchen, and at three private, not-for-profit, homeless shelters in two different towns. The study was part of a larger study designed to develop and validate a reliable measure of client satisfaction with primary health care among homeless individuals. Face-to-face in-depth interviews with 17 homeless individuals were conducted, with the semistructured interview constituting the primary data source. Common themes were identified and the interrelationship of theme clusters was explored. Analysis of the data yielded five distinct themes that represent the lived experiences of satisfaction with health care. These themes were mediated and directly informed by five themes of homelessness and three themes of health identified in the shared experiences of the participants. The themes identified suggest that satisfaction with health care for homeless persons differs from currently identified dimensions of satisfaction with care, and that some aspects of homelessness are seen by participants as positive and health promoting.

An integrated model for teaching, research, and practice within a nurse-managed clinic is presented to guide faculty and administration in implementing these three roles. The concepts and relationships in the model are described theoretically, and a real clinical setting is used to illustrate the practical application of the model.

Various educational programs have been developed and found to be effective in the self-management of arthritis. This study reexamined the effectiveness of one such program, "Bone Up On Arthritis" (BUOA), when the program was delivered by a community-based service organization to a sample of persons (N = 154) who differed widely in disease type and demographic characteristics. Arthritis Foundation staff implemented BUOA at four national sites; data were collected and analyzed by University of Michigan nurse researchers. Investigators found improved scores on all outcome measures (self-care behavior, helplessness, pain, dysfunction, and depression). These findings suggest that "Bone Up" is an effective nursing intervention in multiple organizational and community environments and for diverse patient populations.

This study examined the ability of two specific measures of stressors associated with smoking cessation to act as predictors of progress through the stages of smoking cessation as described by Prochaska and DiClemente (1983). Specifically, a 19-item scale measuring barriers to smoking cessation and a 14-item scale measuring smoking cessation self-efficacy were completed by 127 smokers and self-quitters at three time points over a six-month period. Subjects who made progress through the stages of smoking cessation had lower barriers scores initially and had significant changes in their self-efficacy and barriers scores over the six-month period. In contrast, non-progressors had no significant changes in either their self-efficacy or barriers scores over the time period. These results suggest that the two scales may provide clinically useful data to public health nurses working with smokers.

Despite the concern with medical malpractice suits and research about them, little is known about why some perceived injuries lead to claims of malpractice while other similar injuries do not. This paper presents a conceptualization and hypotheses regarding the determinants of an injury or perceived injury leading to suit. The conceptualization and hypotheses are tested using information collected from 113 medical malpractice plaintiffs' attorneys in three states. A series of proposed concepts prove useful in explaining patient willingness to pursue a suit as well as the plaintiff's success and award size. These are concepts of anger, reluctance to sue, patient and provider worthiness, affinity, economic burden and potential for compensation. Specific attributes of the injury, the patient, the provider, and the doctor-patient relationship relate to these concepts. Injury and doctor-patient relationship attributes prove more important than patient or provider attributes. However, the reported impact of the attributes of the patient and physician on plaintiff success and award is high and suggests that the impact of "non-relevant" variables in the medical malpractice process. Doctor-patient relationship variables hypothesized to reflect affinity are reported to be important in reducing patient willingness to pursue a case; and, certain populations, such as minorities, elderly, foreign-born, are perceived to have a reluctance to sue. The effect of specific characteristics of the patient, the doctor, the injury and the patient-doctor relationship on patient reaction and on disposition is reported, as well as evidence that relates to the validity of the overall conceptualization.

The purpose of this research was to develop and test a measure of barriers to smoking cessation. Barriers, reconceptualized within the Transactional Model of Stress (Lazarus, 1966), reflect specific stressors associated with smoking cessation. The measure consists of a 19-item scale, which has been tested in three studies. Cronbach's alpha coefficients ranged from .81 to .87. Construct validity was demonstrated by correlations between barriers scores and scores on the Daily Hassles Scale (DeLongis, Folkman, & Lazarus, 1988). Predictive validity was demonstrated by findings that barriers scores significantly contributed to classification of abstainers versus relapsers 8 weeks after smoking cessation group participants quit smoking.

The purpose of this study was to examine the perceived well-being of persons who are smokers, nonsmokers, or are quitting smoking. The sample included 74 nonsmokers, 74 smokers, and 92 self-defined quitters. Subjects' well-being was examined controlling for the effects of daily hassles and selected demographic differences. Measures of well-being included general health, morale, physical, and psychological symptoms. Scores for intensity of daily hassles were significantly higher, and well-being scores lower, for persons quitting smoking compared to smokers and nonsmokers. Further, even after controlling for the effects of daily hassles on well-being, persons quitting smoking had significantly lower levels of well-being than did smokers or nonsmokers.

Research on the effects of smoking, alcohol, and caffeine on the outcomes of pregnancy is reviewed. The strength of the evidence on the effects of these substances is varied, ranging from some clear and consistent findings for smoking to inconsistent findings for caffeine. Evidence regarding alcohol is strong in some areas and less consistent in others. The implications for clinical practice, particularly that effects vary with both the timing and the amount of the substances used, are discussed.

Balanced nutrition and weight gain during pregnancy, and the relationship between these variables and pregnancy outcomes were examined. Data were collected from 510 pregnant women and from their prenatal, hospital, and infants' health records. Despite a common assumption in the prenatal literature that weight gain during pregnancy reflects nutritional adequacy, nutrition and weight gain were only weakly related in this sample. Further, nutritional balance did not significantly contribute to additional explained variance in mother's weight gain when gestation, body mass index, and edema were controlled. Moreover, it was weight gain, not nutrition, that contributed to variance in baby's birth weight. These results suggest that while weight gain during pregnancy influences fetal outcomes, weight gain may not be a valid measure of nutrition.