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Overuse of urinalysis in older adults to investigate vague changes in condition such as confusion, lethargy, and anorexia, has led to overtreatment of asymptomatic bacteriuria and associated antibiotic resistance.

Advance directives were conceived as a prospective means of empowering patients to direct their own end-of-life care. Unfortunately, these directives have been inadequately incorporated into healthcare decisions due to less-than-optimal execution and implementation. The authors explore challenges to implementing advance directives and propose potential solutions.

This essay focuses on the subset of semiauthoritarian systems that Beatriz Magaloni calls hegemonic-party autocracies. In such autocracies, a single party or coalition holds power without interruption for several decades under semiauthoritarian conditions while conducting regular multiparty elections. Within this category, the experiences of Mexico and the Republic of China (ROC or Taiwan) from the l980s to 2000 are particularly helpful in illuminating the current political dynamics in Malaysia and its prospects (or lack thereof) for democratization.

The past several years have seen explosive growth in the number of doctor of nursing practice (DNP) degree programs offered by colleges of nursing in the United States. Through a process of trial and error since 2005, the faculty at the University of Colorado, College of Nursing, have revised the course structure and procedures related to the DNP capstone project to improve the quality and usefulness of these student projects. Efforts have focused on educating and involving all nursing faculty in the DNP capstone process, distinguishing between competencies for our PhD and DNP projects, clearly aligning the DNP capstone project with quality improvement methods rather than with research, working with our campus institutional review board to clarify regulatory review requirements for quality improvement studies, developing a review committee to oversee DNP students' projects, and structuring our sequential course requirements to encourage students' professional presentations and publications. Our current capstone process reflects 7 years of iterative work, which we summarize in this article in hopes that it will help institutions currently in the process of developing a DNP program.

Comparative effectiveness research (CER) is an important foundation in the development of scientific evidence that can assist patients, clinicians, and policy makers in making decisions that improve patient and system outcomes, including cost. CER is a part of what is now called dissemination and implementation science, which focuses on translating knowledge into practice by facilitating stakeholder access to more interpretable findings. CER has evolved from a rich history that aims to compare the effectiveness of select clinical treatments, approaches, or programs. This article describes the development of CER, approaches to designing and analyzing this research, and resources useful in generating such knowledge by nurse scientists.

Hyponatremia is a common disorder seen in the emergency department and is more prevalent in older adults than in other adult populations (Miller, 2009). Though often discovered by accident, through routine bloodwork, even mild hyponatremia has been shown to have potentially dangerous consequences for older adults, increasing their risks for falls, altered mental status, osteoporosis and fractures, and gastrointestinal disturbances (Soiza and Talbot, 2011). Optimal management of older adults with hyponatremia in the ED involves not only treatment of serum sodium levels and the immediate consequence of the disorder, but exploration and reversal of the causes of the hyponatremia to avoid recurrence. This case study illustrates the clinical presentation, complications and management of hyponatremia in the setting of the emergency department.

Systematic assessment of cardiovascular risk among persons living with HIV (PLWH) has become more important as HIV survival has increased. Since the advent of effective antiretroviral therapy (ART), PLWH often enjoy life expectancies equal to those of the general population. PLWH then share the same comorbidities as the general population, with some increased risks due to HIV and ART. One comorbidity, cardiovascular disease, is the leading cause of death in the United States. As the current population of PLWH ages, reducing cardiovascular risk will become even more important. Before cardiovascular risk reduction can take place, providers must first know the patient's risks. This paper describes the importance of cardiovascular risk assessment for PLWH based on current literature and presents findings from a quality-improvement (QI) initiative designed to implement systematic cardiovascular assessment using the Framingham Risk (FR) for PLWH in an infectious-disease practice.

Transitions between care settings are periods of vulnerability for patients. This is especially true for older adults, for whom comorbidities and functional impairments can increase the complexity of care and the need for multiple caregivers can compromise safety. Poor care transitions can result in costly hospital admissions. For this reason, leading health care organizations have initiated programs to improve the quality of transitions; however, to date, the ambulatory surgical setting has not been a focus of these initiatives. The ambulatory setting serves an increasingly complex patient population and provides the majority of elective surgeries, and adapting some of the transition tools that have been tested in other settings will benefit health care providers and patients in the ambulatory setting. Identifying periods of transition and risk, implementing electronic health records across all phases of patient care, and using evidence-based tools at each transitional stage can optimize the quality and safety of patient care.

Development, Democracy, and Welfare States: Latin America, East Asia, and Eastern Europe. By Stephan Haggard and Robert R. Kaufman. Princeton, NJ: Princeton University Press, 2008. Pp. xxvi + 473. $80.00 cloth, $29.95 paper. Lessons from Pension Reform in the Americas. Edited by Stephen J. Kay and Tapen Sinha. Oxford: Oxford University Press, 2008. Pp. xxiv + 421. $110.00 cloth. Reassembling Social Security: A Survey of Pensions and Healthcare Reforms in Latin America. By Carmelo Mesa-Lago. Oxford: Oxford University Press, 2007. Pp. xi + 453. $150.00 cloth. Measuring Inequality of Opportunities in Latin America and the Caribbean. By Ricardo Paes de Barros, Francisco H. G. Ferreira, Jose R. Molinas Vega, and Jaime Saavedra Chanduvi. Washington, D.C.: Palgrave Macmillan and World Bank/2009. Pp. xxiii + 195. $90.00 paper. Caring for Them from Birth to Death: The Practice of CommunityBased Cuban Medicine. By Christina Perez. New York: Lexington Books, 2008. Pp. xviii + 315. $70.00 cloth.

PURPOSE/OBJECTIVES: (1) Describe the nurse care manager role at a shelter-based clinic for women and children who have experienced domestic violence (DV). (2) Develop an innovative model for nursing care management in this unique setting and discuss implications for its implementation in other shelter-based clinics. (3) Provide historical benchmarking data on the use of health-related community resources and common barriers to obtaining these services among women and children following a nurse care management intervention. PRIMARY PRACTICE SETTING: A clinic-based, nurse care management model was developed and implemented at a not-for-profit emergency residential shelter for women and children who have experienced DV. However, DV victims do not just appear in the community: nurse case managers encounter DV in every healthcare setting from hospitals to physician offices/clinics. FINDINGS/CONCLUSIONS: A shelter-based clinic is a safe, confidential, and easily accessible place for women and children victimized by DV to receive immediate care and ongoing assistance for health-related needs. The nurse care manager, who practices in this setting and utilizes motivational interviewing techniques, has a unique opportunity to empower and support women to make informed decisions regarding the health and well-being of themselves and their children. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Provision of nursing care management services in a shelter-based clinic is an innovative approach to improving outcomes and reducing the burden of suffering among women and children who leave abusive situations. The nurse care manager role and, specifically, the model of care described in this project, which includes motivational interviewing techniques, may be generalized to other shelter-type settings to promote sustained, healthy lifestyle practices for victims of DV. Benchmarks developed in this study serve as an initial approach to evaluating outcomes when applying this nursing care management model in practice. Future studies on the effectiveness of this approach among victims of DV are warranted. Language: en

OBJECTIVES: To determine whether glycemic control contributes to fall risk in frail and nonfrail elderly adults with diabetes mellitus. DESIGN: Retrospective, case-controlled design. SETTING: Health maintenance organization in the Denver, Colorado, metropolitan area. PARTICIPANTS: One hundred eleven community-dwelling adults aged 75 and older who receive care through Kaiser Permanente of Colorado. All subjects had been diagnosed with diabetes mellitus, had at least one hemoglobin A1C (HbA1c) measurement in the previous 12 months, and were using oral hypoglycemic medication or insulin to control their diabetes mellitus. MEASUREMENTS: Measurements of risk factors (Vulnerable Elders Survey (VES-13) with a cutpoint of 3 to determine frailty status, self-reported number of falls over the prior 12-month period, HbA1c, fasting low-density lipoprotein cholesterol, average blood pressure, and other factors related to fall risk) were obtained through telephone interview and medical chart review. The outcome measure was falls. RESULTS: Bivariate analyses to assess correlations between falls and risk factors determined that only HbA1c, frailty, and peripheral neuropathy were significantly associated with falls. A stepwise logistic regression determined that fall risk markedly increased when HbA1c was 7 or below, regardless of frailty status. CONCLUSION: In this retrospective study of a convenience sample of frail older adults with diabetes mellitus, tighter glycemic control was associated with greater risk of falling. Prospective studies that further evaluate the risks and benefits of relaxed glucose control in high-risk older adults are needed to confirm this finding. Language: en

Capitated payment systems have forced healthcare providers to explore new methods of care delivery for frail, older clients who consume a disproportionate amount of time and resources. The authors describe the experiences of frail elders in a community case management program within a managed care setting. The experiences of living with frailty in a changing healthcare system, and perceptions of the case manager's ability to help navigate that system, are described. This article presents the benefits of community case management toward client goals of safety, support, and control.

For the past 15 years, the World Bank (often in cooperation with the International Monetary Fund, and sometimes also with bilateral donors) has tried to encourage policy reforms through conditions attached to structural or sector adjustment loans. In the 1990s, however, such loans are a rapidly dwindling portion of the Bank's disbursements. This article examines major reasons for this shift, including increased flows of private capital, democratization, the changing nature of the reform agenda itself, and growing Bank emphasis on ownership. Reduced direct conditionality is likely to be replaced in part by growing selectivity: the results may well be constructive, but will not ease tensions in the aid relationship.

Aims and objectives To evaluate constructs from the theory of planned behavior (TPB, Ajzen 2002) – attitudes, sense of control, subjective norms and intentions – as predictors of accuracy in blood pressure monitoring. Background Despite numerous initiatives aimed at teaching blood pressure measurement techniques, many healthcare providers measure blood pressures incorrectly. Design Descriptive, cohort design. Methods Medical assistants and licensed practical nurses were asked to complete a questionnaire on TPB variables. These nursing staff's patients had their blood pressures measured and completed a survey about techniques used to measure their blood pressure. We correlated nursing staff's responses on the TBP questionnaire with their intention to measure an accurate blood pressure and with the difference between their actual blood pressure measurement and a second measurement taken by a researcher immediately after the clinic visit. Patients' perceptions of MAs' and LPNs' blood pressure measurement techniques were examined descriptively. Results Perceived control and social norm predicted intention to measure an accurate blood pressure, with a negative relationship between knowledge and intention. Consistent with the TPB, intention was the only significant predictor of blood pressure measurement accuracy. Conclusions Theory of planned behavior constructs predicted the healthcare providers' intention to measure blood pressure accurately and intention predicted the actual accuracy of systolic blood pressure measurement. However, participants' knowledge about blood pressure measurement had an unexpected negative relationship with their intentions. Relevance to clinical practice These findings have important implications for nursing education departments and organisations which traditionally invest significant time and effort in annual competency training focused on knowledge enhancement by staff. This study suggests that a better strategy might involve efforts to enhance providers' intention to change, particularly by changing social norms or increasing perceived control of the behaviour by nursing staff.

Joan M. Nelson is senior associate at the Overseas Development Council in Washington, D.C. The editor most recently of A Precarious Balance: Democracy and Economic Reforms in Eastern Europe and A Precarious Balance: Democracy and Economic Reforms in Latin America (two-volume set, 1994), she consults for various international organizations on problems of governance and the politics of economic adjustment. In the past dozen years, new elected governments in much of Latin America and (more recently) all of Eastern Europe have confronted urgent problems associated with economic reform. In both of these regions, the collapse of prior military or communist regimes was partly a result of long-festering economic difficulties. In both, the adoption and the implementation of programs to stabilize and more fundamentally reform economies have posed formidable political challenges. And in both, the ultimate success or failure of those programs is widely viewed as having a significant influence on the fate of democratic political systems. This essay examines some of the major interactions between political opening and economic reform in countries where these have occurred more or less simultaneously. 1 It argues that the economic reform agenda changes significantly between the launch phase and later phases. The character of politics, moreover, also tends to change in partly predictable ways as the early posttransition period yields to more structured (but not necessarily more democratic) patterns. As both economic and political reforms evolve over the course of the posttransition period, the interactions between them change. The essay begins with a discussion of the various aspects of democratic transitions and the immediate posttransition period that either encourage or impede the launching of economic reforms. The focus then changes to the later stages of economic reform, with an examination of

This study examined the value and effectiveness of a patient navigation program in terms of timeliness of access to cancer care, resolution of barriers, and satisfaction in 55 patients over a six-month period. Although not statistically significant, the time interval between diagnostic biopsy to first consultation with a cancer specialist after program implementation was reduced from an average of 14.6 days to 12.8 days. The time interval between diagnostic biopsy to initiation of cancer treatment also was reduced from 30 days to 26.2 days (not statistically significant). In addition, 71% of patient barriers were resolved by the time treatment was initiated. Overall, patients were highly satisfied with their navigated care experience. Consistent evaluation and monitoring of quality-of-care indicators are critical to further develop the program and to direct resource allocation. Oncology nurses participating in patient navigation programs should be encouraged to evaluate their importance and impact in this developing concept. Nurses should seek roles that allow them to optimize the effective use of their specialized knowledge and skills to the benefit of patients along the cancer care continuum.

Two sets of Third World nations can shed light on the politics of economic transformation in Eastern Europe. First, there are nations that pursued particularly vigorous reforms in the 1980s. They shared three key political features: popular consensus that basic reforms were imperative; antireform groups largely in disarray or suppressed; and substantial executive autonomy in economic management. The first of these features is clearly present in Eastern Europe; the second is questionable; and the third is present but precarious and probably temporary. Second and also relevant to Eastern Europe is the growing group of Third World nations seeking to consolidate political openings simultaneously with major economic reforms. Economic and political liberalization conflict with, yet are crucial for, each other. Proposals that they be sequenced are unrealistic. In Eastern Europe as in the Third World, a crucial dilemma is reconciling public demands for access to decision making with sufficient executive autonomy for coherent economic management.

Clinical ladders, or career advancement systems, were designed to enhance professional development, provide a reward system for quality clinical performance, promote quality nursing practice, and improve job satisfaction among nurses. Most of the literature on RN clinical ladder programs is related to the acute care setting, where these programs originated; not much is known about their effectiveness in the ambulatory care environment. The RN Career Ladder at Kaiser Permanente of Colorado was begun by a Labor Management Partnership Committee in 2003, and awards financial incentives to RNs who demonstrate a commitment to continuing education, leadership activities, and program development on a local and regional level. In this study significantly more involvement in leadership, interdisciplinary, and quality improvement activities were found among career ladder nurses than non-career ladder nurses, regardless of their job role. It is not clear whether nursing leaders gravitate toward a career ladder or whether career ladder participation encourages increased participation in leadership activities.

Organized labor is usually viewed as an obstacle to labor market adjustment. But unions' responses to adjustment programs in fact range from militant opposition to acquiescence or even explicit cooperation. Three sets of variables shape these responses: the strength and characteristics of the union movement itself; economic cycles; and political institutions and their ties to unions. This article discusses in detail these variables and their effects.