Diverse Care Settings Research Articles

Global Anticoagulant Registry in the Field - Venous Thromboembolism (GARFIELD-VTE). Rationale and design.

Venous thromboembolism (VTE) is a common disorder associated with significant rates of morbidity and mortality. VTE management aims to reduce mortality, the risks of recurrence, and long-term complications. VTE treatment is evolving with the introduction of non-vitamin K antagonist anticoagulants (NOACs). The Global Anticoagulant Registry in the FIELD - Venous Thromboembolism (GARFIELD-VTE) is a prospective, multicentre, observational study that will enrol 10,000 patients treated for acute VTE from ~500 sites in 28 countries. Identified sites reflect the diversity of care settings, including hospital and outpatient settings. Patients will be managed according to local practices and followed for at least three years. The primary objective is to determine the extent to which VTE treatment varies in the real-world setting and to assess the impact of such variability on clinical and economic outcomes. Evolving patterns of care will be captured using two sequential cohorts. The GARFIELD-VTE registry will provide insights into the evolving global treatment patterns for VTE, both deep-vein thrombosis and pulmonary embolism. By enrolling patients from diverse care settings, the registry will provide information on adherence to national and international guidelines, identify good practice as well as treatment deficiencies, and relate patient outcomes to clinical management. The incidence of death, recurrent VTE, bleeding, post-thrombotic syndrome and chronic thromboembolic pulmonary hypertension will be documented. By capturing information during and after anticoagulation treatment, the registry will not only define aspects of the natural history of VTE, but also its economic and societal impact at a regional and global level.

Family Caregiving in Japan: The Influence of Cultural Constructs in the Care of Adults With Cancer.

Caring culture is a concept embodying the perceptions and caring practices of caregivers, acknowledging the unique role of cultural beliefs in shaping behavior. A qualitative descriptive study with 13 caregivers of adult family members with a cancer diagnosis in Japan was conducted to gain insight into perceptions and experiences surrounding caregiving. Several major categories were identified, representing rarely reported cultural constructs of high cultural value for the Japanese: On-repayment for what the patient has given, Caregiving as performing a socially expected role, Enryo/meiwaku-restraint in asking for help, Family decision making reflecting strong bonds, Omoiyari-empathizing with the patient's feelings, and Inori-praying to myriad gods and ancestors. The Japanese cultural construct of ie (the strong relationship to family lineage and spiritual connection to past and future generations) is helpful in understanding these categories. Invisible yet powerful cultural constructs permeated caregiving practices. Insights from Japanese cultural concepts and beliefs may foster sensitivity and individualized care in diverse settings, cultures, and societies.

Prospective Validation of the Objective Prognostic Score for Advanced Cancer Patients in Diverse Palliative Settings

ContextPrognostication is an essential part of palliative care to aid decision making and negotiate goals of care. The Objective Prognostic Score (OPS) is an easy-to-use prognosticating tool to predict survival among far-advanced cancer patients in palliative care units (PCUs) in Korea. ObjectivesThis study aimed to prospectively validate the OPS for advanced cancer patients in the palliative care teams (PCTs), PCUs, and home-based palliative care (HPC) in Japan. MethodsThis was a substudy of a multicenter prospective cohort study that was conducted to validate and compare prognostic tools among advanced cancer patients in Japan. Participants' survival was calculated according to OPS 3 as a cutoff for predicting survival of less than three weeks. Overall accuracy and area under the receiver operator characteristic curves of OPS 3 were calculated for PCT, PCU, and HPC, respectively. ResultsA total of 1146 cases (PCTs 441, PCUs 519, and HPCs 186 cases) were included in final analyses. The overall accuracy of OPS 3 for predicting three-week survival ranged from 0.70 to 0.78 across diverse palliative care settings. The c-statistics ranged from 0.742 to 0.808 across three settings. Participants in the PCT showed the highest overall accuracy and c-statistics for OPS. ConclusionThe OPS can be used for prognostication among advanced cancer patients in PCT, PCU, and HPC settings.

The Patient Outcomes Research To Advance Learning (PORTAL) Network Adult Overweight and Obesity Cohort: Development and Description.

BackgroundThe Patient-Centered Outcomes Research Institute (PCORI) created a new national network infrastructure to enable large-scale observational comparative effectiveness research across diverse clinical care settings. As part of testing the feasibility of this effort, each clinical data research network (CDRN) was required to construct cohorts of patients, including one of patients with overweight and obesity.ObjectiveThe aim of this paper is to report on the development of the Patient Outcomes Research to Advance Learning (PORTAL) overweight and obese cohort, which includes patients from 10 health plans located across the United States.MethodsInformation was gathered from each plan’s electronic health records (EHR). Eligibility included 18 years of age or older, a valid height and weight in 2012 or 2013, and body mass index (BMI) greater than 22.9 kg/m2. Pre-diabetes and diabetes status was defined using the American Diabetes Association (ADA) criteria, using lab values of glycated hemoglobin (HbA1c) or fasting glucose available in the EHR. Hypertension was identified from the International Classification of Diseases (ICD) diagnosis codes. Individuals were classified into BMI categories: healthy weight (23.0-24.9 kg/m2), overweight (25.0-29.9 kg/m2), obese class 1 (30.0-34.9 kg/m2), obese class 2 (35.0-39.9 kg/m2), obese class 3 (40.0-49.0 kg/m2), and obese class 4 (>50.0 kg/m2).ResultsA cohort of 5,293,458 non-pregnant adults was created. Weight status was 20.39% (1,079,289/5,293,458) healthy weight, 40.40% (2,138,520/5,293,458) overweight, 22.78% (1,205,866/5,293,458) obese class 1, 9.86% (521,872/5,293,458) obese class 2, 5.59% (295,786/5,293,458) obese class 3, and 0.98% (52,125/5,293,458) obese class 4. Race/ethnicity was 49.02% (2,594,776/5,293,458) non-Hispanic white, 22.89% (1,211,677/5,293,458) Hispanic, 10.40% (550,608/5,293,458) Asian, 10.83% (573,506/5,293,458) black, and 6.59% (348,830/5,293,458) other. About 34.33% (1,817,438/5,293,458) met the definition of hypertension, 20.49% (1,660,940/5,293,458) of individuals met the criteria for pre-diabetes, and 14.98% (793,069/5,293,458) met criteria for diabetes. Prevalence of pre-diabetes and diabetes varied across health plans to a greater extent than expected based on hypertension prevalence and BMI status variability.ConclusionsThis large, race, ethnic, and geographically diverse cohort will be useful for future studies of rare exposures or outcomes and differences in health care practices.

Reporting on the Strategies Needed to Implement Proven Interventions: An Example From a “Real-World” Cross-Setting Implementation Study

The objective of this study was to empirically demonstrate the use of a new framework for describing the strategies used to implement quality improvement interventions and provide an example that others may follow. Implementation strategies are the specific approaches, methods, structures, and resources used to introduce and encourage uptake of a given intervention's components. Such strategies have not been regularly reported in descriptions of interventions' effectiveness, or in assessments of how proven interventions are implemented in new settings. This lack of reporting may hinder efforts to successfully translate effective interventions into “real-world” practice. A recently published framework was designed to standardize reporting on implementation strategies in the implementation science literature. We applied this framework to describe the strategies used to implement a single intervention in its original commercial care setting, and when implemented in community health centers from September 2010 through May 2015. Per this framework, the target (clinic staff) and outcome (prescribing rates) remained the same across settings; the actor, action, temporality, and dose were adapted to fit local context. The framework proved helpful in articulating which of the implementation strategies were kept constant and which were tailored to fit diverse settings, and simplified our reporting of their effects. Researchers should consider consistently reporting this information, which could be crucial to the success or failure of implementing proven interventions effectively across diverse care settings. Trial Registrationclinicaltrials.gov Identifier: NCT02299791.

Design and Development of a Sharable Clinical Decision Support System Based on a Semantic Web Service Framework.

Clinical decision support (CDS) systems provide clinicians and other health care stakeholders with patient-specific assessments or recommendations to aid in the clinical decision-making process. Despite their demonstrated potential for improving health care quality, the widespread availability of CDS systems has been limited mainly by the difficulty and cost of sharing CDS knowledge among heterogeneous healthcare information systems. The purpose of this study was to design and develop a sharable clinical decision support (S-CDS) system that meets this challenge. The fundamental knowledge base consists of independent and reusable knowledge modules (KMs) to meet core CDS needs, wherein each KM is semantically well defined based on the standard information model, terminologies, and representation formalisms. A semantic web service framework was developed to identify, access, and leverage these KMs across diverse CDS applications and care settings. The S-CDS system has been validated in two distinct client CDS applications. Model-level evaluation results confirmed coherent knowledge representation. Application-level evaluation results reached an overall accuracy of 98.66 % and a completeness of 96.98 %. The evaluation results demonstrated the technical feasibility and application prospect of our approach. Compared with other CDS engineering efforts, our approach facilitates system development and implementation and improves system maintainability, scalability and efficiency, which contribute to the widespread adoption of effective CDS within the healthcare domain.

What does ePrescribing mean for patients? A case study of the perspectives of hospital renal patients

BackgroundHospital ePrescribing systems are expected to improve quality of care for patients, yet the perspectives of patients themselves have seldom been explored in the context of ePrescribing deployments.ObjectiveWe sought to...

Verbal and nonverbal indicators of quality of communication between care staff and residents in ethnoculturally and linguistically diverse long-term care settings.

Linguistic and ethnocultural diversity in long-term residential care is a growing trend in many urban settings. When long-term care staff and residents do not share the same language or ethnocultural background, the quality of their communication and care are jeopardized. There is very little research addressing how staff and residents communicate when they experience a mismatch in their language and ethnocultural backgrounds. Thus, the goals of the present study were to 1) document the verbal and nonverbal behaviours used by staff and residents in diverse interactions, and 2) identify and account for behaviours that either promoted or detracted from positive communication by drawing on principles from 'Communication Accommodation Theory'. Two long-term care facilities in British Columbia Canada were selected due to the diverse linguistic and ethnocultural backgrounds of their staff and residents. Twenty-seven staff and 27 residents consented to being video-recorded during routine activities (e.g., mealtimes, recreational activities). The recorded observations were transcribed, translated, and coded using qualitative descriptive and interpretive analyses. A number of verbal and nonverbal behaviours were identified and interpreted in relation to whether they promoted or detracted from positive communication. The findings point to considering a variety of proactive strategies that staff and administrators could employ to effectively accommodate to language and ethnocultural diversity in long-term care practice.

“It was like reading a detective novel”: Using PAR to work together for culture change

Participatory action research (PAR), with its focus on engagement and collaboration, is uniquely suited to enhancing culture change initiatives in dementia care. Yet, there is limited literature of its application to culture change approaches in care settings, and even less in dementia specific care contexts. To address these gaps in the literature, the purpose of this paper is to examine the complexities of a PAR project aimed at changing the culture of dementia care in two diverse dementia care settings, including a long term care (LTC) and community care setting. Drawing from data gathered throughout the PAR process, we unpack the challenges experienced by participants working together to guide culture change within their respective care settings. These challenges include: overextending selves through culture change participation; fluctuating group membership; feeling uncertainty, confusion and apprehension about the process; frustratingly slow process; and seeking diverse group representation in decision making. We also highlight the potential for appreciative inquiry (AI) to be integrated with PAR to guide a process whereby participants involved in culture change initiatives can develop strategies to mitigate challenges they experience. We view the challenges and strategies shared here as being constructive to would-be culture change agents and hope this paper will move others to consider the use of PAR when engaging in culture change initiatives.

Trends in observation-prone emergency department visits among Michigan children, 2007-2011.

To the best of the authors' knowledge, admission of children under observation status in community hospitals has not been examined. The hypothesis of this study was that there has been an increase in observation charge code use over time and variations in the application of observation charge codes across hospital types. This was a cross-sectional analysis of 5 years (2007 through 2011) of administrative claims data from Michigan residents enrolled in Medicaid, Blue Cross/Blue Shield of Michigan preferred provider organization, and Blue Cross Network health maintenance organization compiled into a single data set. Emergency department (ED) visits to facilities in Michigan made by children (younger than 18 years) were selected. Observation-prone ED visits were identified based on the presence of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Counts of observation-prone ED visits were determined and descriptive statistics were calculated. Changes over time in the proportion of visits with observation charge codes by hospital type were assessed with chi-square analysis. The observation-prone ICD-9-CM codes were identified in 881,622 ED visits made by children to 142 Michigan facilities during the 5-year study period. Overall, the vast majority of visits (n = 646,499; 91.0%) with the selected ICD-9-CM codes resulted in discharge from the ED without associated observation or inpatient charge codes. Among the 64,288 visits that resulted in admission for observation or inpatient care, observation charge codes without inpatient charge codes were applied to 22,933 (35.7%) admissions, observation and inpatient charge codes were applied to 4,756 (7.4%) admissions, and inpatient charge codes without observation charge codes were applied to 36,599 (56.9%) admissions. Hospitals with pediatric ED and inpatient services (Type 1 and Type 2 hospitals) had higher proportions of ED visits that went on to admission for observation or inpatient care (15.9 and 10.7%) than hospitals without pediatric ED services (Type 3 and Type 4 hospitals; 7.2 and 3.7%). The proportion of admissions that had observation charge codes for all hospital types increased over time, most prominently among Type 1 and Type 2 hospitals. The application of observation charge codes to Michigan children with observation-prone conditions has increased over time across all hospital types. There is a need to evaluate pediatric observation care in diverse settings to compare the effectiveness of different models.

Psychometric evaluation of the Swedish language Person-centred Climate Questionnaire-family version.

In a holistic view of care, the family is important for the patient as well as for the staff and integration of family members in health care is a growing trend. Yet, family participation in the care is sparsely investigated and valid assessment instruments are needed. Data were collected from 200 family members participating in an intervention study at an emergency department (ED) in Sweden. The Person-centred Climate Questionnaire-Family (PCQ-F) is a measure for how family members perceive the psychosocial climate. PCQ-F is a self-report instrument that contains 17 items assessing safety, everydayness and hospitality--three subscale dimensions that mirror the Swedish patient version of the questionnaire, the PCQ-P. The aim of this study was to evaluate the psychometric properties of the Swedish version of the PCQ-F in an ED context. The psychometric properties of the PCQ-F were evaluated using statistical estimates of validity and reliability and showed high content validity and internal consistency. Cronbach's Alpha was >0.7 and item-total correlations were >0.3 and <0.7. In terms of psychometrics, the findings in this study indicate that the PCQ-F can be used with satisfactory validity and reliability to explore to what degree family members perceive ED settings as being person-centred, safe, welcoming and hospitable within an everyday and decorated physical environment. As the PCQ already exists in a valid and reliable patient (PCQ-P) and staff (PCQ-S) version, this new family member version is a significant addition to the literature as it enables further comparative studies of how diverse care settings are perceived by different stakeholders.

CNE Quiz

The disability associated with late life depression makes it an important target for screening. Identifying clinically significant depression symptoms in older adults who have known risk factors provides an important opportunity for early evaluation and treatment. Screening that leads to evaluation and treatment is critical to both preventing depression, and reducing the associated disability, symptom burden, and costs of major depressive disorders (MDD). The guideline described here recommends the 9-item Patient Health Questionnaire (PHQ-9) for screening because it is based on diagnostic criteria for MDD and has the advantages of being brief, self-administered, easily scored and interpreted, and reliable and valid in diverse populations and care settings. Nurses and allied health professionals who provide care to older adults across the continuum of care are uniquely positioned to identify at risk older adults, use depression screening scales, make needed referrals for evaluation and treatment, and monitor outcomes across time.

Management of the alcohol withdrawal syndrome at Canberra Hospital Alcohol and Drug Service: a best practice implementation project

BACKGROUND Within specialist withdrawal units, alcohol withdrawal syndrome is easily predicted, assessed, monitored and treated as it is the principle reason for admission. In the acute care setting it may be the primary or secondary reason for admission, and may initially go undetected and untreated until the withdrawal syndrome becomes severe. This clinical audit project commenced in October 2013 and was completed in March 2014 in acute care settings in the Canberra Hospital, by the Alcohol and Drug Consultation Liaison Service. OBJECTIVES The aim of this project was to ensure accurate management of alcohol withdrawal syndrome, across two diverse acute care settings, promoting best practice symptom triggered pharmacotherapy administration. An audit of alcohol withdrawal management documentation to ensure best practice standards was completed. An adjunct to this was to increase awareness of appropriate referral processes to Consultation Liaison Alcohol and Drug Service from the acute care setting. METHODS The project utilized the Joanna Briggs Institute’s Practical Application of Clinical Evidence System and Getting Research into Practice online audit tool for promoting change in health practice. Data collection was prolonged due to requiring training to access electronic patient records. Training was completed and 20 electronic patient clinical files, addressing alcohol withdrawal management, were reviewed against 5 audit criteria. This baseline audit was conducted across two diverse clinical areas. Planned education sessions, discussion with clinical leaders and a streamlined referral form were implemented in an attempt to improve practice and reduce patient risk of a more complicated withdrawal syndrome. Follow-up clinical audit reviewing 20 different patient files was conducted to assess for improved practice and adherence to procedure. RESULTS The follow-up audit demonstrated a variation in compliance across the two clinical areas. Clinical area A had a lower baseline, but showed the greatest improvement in compliance for the most part of the audit criteria. Clinical area B had a higher baseline but showed poorer compliance in the follow up audit. CONCLUSIONS This project has demonstrated that providing a best practice framework for alcohol withdrawal syndrome in the form of standard operating procedures is vital in acute care settings. There is variation in clinician knowledge of this issue and further difficulties arise when the syndrome is unexpected. The alcohol withdrawal syndrome is self-limiting, and an understanding of this and of the alcohol withdrawal scale is vital in guiding medical management and preventing further complications. The ongoing priority is to ensure clinicians know how to refer to Alcohol and Drug Consultation and Liaison Service, as an early referral reduces risk.

The Seniors' Outdoor Survey: An Observational Tool for Assessing Outdoor Environments at Long-Term Care Settings.

To describe the development and psychometric testing of the Seniors' Outdoor Survey (SOS), an instrument for evaluating how well the outdoor space in a long-term care setting supports the preferences and outdoor usage of residents. Content validity of the main SOS items initially was based on relevant literature and preliminary studies in diverse long-term care settings. After conducting a multiregional pilot study with 152 outdoor spaces at 68 assisted living facilities, the instrument was substantially revised and tested for interrater and test-retest reliability with 22 outdoor spaces at 12 long-term care settings, using 2 raters. Validity was examined using content analysis of resident survey responses (N = 1,128) from the multiregional study and specific item validation by subject matter experts (N = 53). The final instrument contains 60 ratable items organized in 5 domains: access to nature (14 items), outdoor comfort and safety (15 items), walking and outdoor activities (14 items), indoor-outdoor connection (11 items), and connection to the world (6 items). Intraclass correlation coefficient (ICC) estimates of interrater reliability were .91 for the overall instrument, ranging from .83 to .98 for the 5 domains. Interrater reliability (ICC) was above .70 for more than 79% of individual items. Test-retest reliability (ICC) was .92, ranging from .81 to .98 for domains. The SOS tool fills a gap in the available environmental assessment instruments, providing a reliable way for researchers, providers, and designers to evaluate and compare the supportive potential of outdoor spaces for long-term care residents.

Lieberman Sees Promising Future for Psychiatrists, Patients

Lieberman Sees Promising Future for Psychiatrists, Patients

Developing a data infrastructure for a learning health system: the PORTAL network.

The Kaiser Permanente & Strategic Partners Patient Outcomes Research To Advance Learning (PORTAL) network engages four healthcare delivery systems (Kaiser Permanente, Group Health Cooperative, HealthPartners, and Denver Health) and their affiliated research centers to create a new national network infrastructure that builds on existing relationships among these institutions. PORTAL is enhancing its current capabilities by expanding the scope of the common data model, paying particular attention to incorporating patient-reported data more systematically, implementing new multi-site data governance procedures, and integrating the PCORnet PopMedNet platform across our research centers. PORTAL is partnering with clinical research and patient experts to create cohorts of patients with a common diagnosis (colorectal cancer), a rare diagnosis (adolescents and adults with severe congenital heart disease), and adults who are overweight or obese, including those with pre-diabetes or diabetes, to conduct large-scale observational comparative effectiveness research and pragmatic clinical trials across diverse clinical care settings.

Practical challenges in integrating genomic data into the electronic health record

Genetic testing has had limited impact on routine clinical care. Widespread adoption of electronic health records presents a promising means of disseminating genetic testing into diverse care settings. Practical challenges to integration of genomic data into electronic health records include size and complexity of genetic test results, inadequate use of standards for clinical and genetic data, and limitations in electronic health record capacity to store and analyze genetic data. Related challenges include uncertainty in the interpretation of regulatory requirements for return of results, and privacy concerns specific to genetic testing. Successful integration of genomic data may require significant redesign of existing electronic health record systems.

Health information exchange system usage patterns in three communities: Practice sites, users, patients, and data

ObjectivesPublic and private organizations are implementing systems for query-based health information exchange (HIE), the electronic aggregation of patient data from multiple institutions. However, existing studies of query-based HIE system usage have addressed a limited number of settings. Our goal was to quantify the breadth and depth of usage of a query-based HIE system implemented across multiple communities with diverse care settings and patient populations. MethodsWe performed a cross-sectional study in three communities in New York State using system access log files from January 2009 to May 2011 to measure usage patterns of a query-based HIE web portal system with respect to practice sites, users, patients, and data. ResultsSystem access occurred from 60% (n=200) of practice sites registered to use the system in Community A, 59% (n=156) in Community B, and 82% (n=28) in Community C. In Communities A and B, users were primarily non-clinical staff in outpatient settings, while in Community C inpatient physicians were the main users. Across communities, proportions of patients whose data were accessed varied with 5% (n=11,263) in Community A, 60% (n=212,586) in Community B, and 1% (n=1107) in Community C. In Community B, users updated patient consent through the HIE portal, whereas in the other communities, users updated patient consent through a separate system. Across communities, users most frequently accessed only patient summary data displayed by default followed by detailed laboratory and radiology data. ConclusionsThis study is among the first to illustrate large-scale usage of a query-based HIE system implemented across multiple communities. Patient summary data displayed by default may be an important feature of query-based HIE systems. User role, practice site type, and patient consent workflow may affect patterns of query-based HIE web portal system usage in the communities studied and elsewhere.

The Diverse Landscape of Palliative Care Clinics

Many health care organizations are interested in instituting a palliative care clinic. However, there are insufficient published data regarding existing practices to inform the development of new programs. Our objective was to obtain in-depth information about palliative care clinics. We conducted a cross-sectional survey of 20 outpatient palliative care practices in diverse care settings. The survey included both closed- and open-ended questions regarding practice size, utilization of services, staffing, referrals, services offered, funding, impetus for starting, and challenges. Twenty of 21 (95%) practices responded. Practices self-identified as: hospital-based (n=7), within an oncology division/cancer center (n=5), part of an integrated health system (n=6), and hospice-based (n=2). The majority of referred patients had a cancer diagnosis. Additional common diagnoses included chronic obstructive pulmonary disease, neurologic disorders, and congestive heart failure. All practices ranked "pain management" and "determining goals of care" as the most common reasons for referrals. Twelve practices staffed fewer than 5 half-days of clinic per week, with 7 operating only one half-day per week. Practices were staffed by a mixture of physicians, advanced practice nurses or nurse practitioners, nurses, or social workers. Eighteen practices expected their practice to grow within the next year. Eleven practices noted a staffing shortage and 8 had a wait time of a week or more for a new patient appointment. Only 12 practices provide 24/7 coverage. Billing and institutional support were the most common funding sources. Most practices described starting because inpatient palliative providers perceived poor quality outpatient care in the outpatient setting. The most common challenges included: funding for staffing (11) and being overwhelmed with referrals (8). Once established, outpatient palliative care practices anticipate rapid growth. In this context, outpatient practices must plan for increased staffing and develop a sustainable financial model.

Medical Student Attitudes Toward Patients in Diverse Care Settings: The Impact of a Patient Evaluation Course

Background: First-year medical students typically have limited exposure to patients in diverse care settings, such as rehabilitation facilities and nursing homes. Purpose: It is unknown whether students bring predetermined attitudes toward these patients, or whether attitudes are influenced by early exposure. We studied this in a new course that provides opportunities for students to interact with patients of various ages and disabilities. Methods: We conducted surveys of 1st-year medical students at the University of Rochester in the year prior to the new course and during its initial year. We used factor analysis to derive underlying dimensions of students’ responses. We also investigated the impact that the course had on their perceptions. Results: In both years, we found that students conceptualize patient care along 2 affective dimensions (comfort and pleasure) and 2 attitudinal dimensions (bias and pessimism), rather than by type of disability. Conclusions: This 10-week course improved their affect toward these patient groups but had little effect on their general attitudes toward the value of caring for them.