Client's Condition Research Articles

The concept of readiness to change.

Readiness is associated with change, yet there is little understanding of this construct. The purpose of this study was to examine readiness; its referents, associated factors and the resulting consequences. In the course of nursing five clients living with multiple sclerosis over a 7-month period using a Reflective Practice Model, data were systematically gathered using open-ended and then more focused questioning. Data collected during 42 client encounters (28 face-to-face encounters; 14 telephone contacts) were analysed using Chinn and Kramer's concept analysis technique. Findings. The concept of readiness was inductively derived. Readiness is both a state and a process. Before clients can create change they need to become ready to change. A number of factors trigger readiness. These include when: (a) clients perceive that a health concern is not going to resolve, (b) a change in a client's physical condition takes on new significance, (c) clients feel better able to manage their stress, (d) clients have sufficient energy, (e) clients perceive that they have adequate support in undertaking change. When one or more of these factors is present clients become ready to consider change. The process of readiness involves recognizing the need to change, weighing the costs and benefits and, when benefits outweigh costs, planning for change. The desire to change and to take action determines clients' degree of readiness. When they experience a high degree of readiness they report less anger, less depression, and view their condition in a more positive light. In contrast, when they experience a low degree of readiness they report feeling depressed, afraid and vulnerable in the face of change. Nursing has an important role to play in creating conditions to support change. To fulfil this role, nurses need to be able to assess readiness for change and the factors that enable it and then to intervene in ways that facilitate readiness.

Using classification and regression trees (CART) to support worker decision making

Several approaches can be taken to predict case membership in classes of a dependent variable. Classification and regression trees (CART) analysis has been cited repeatedly as a powerful nonparametric approach in fields where classification or prediction are of concern. To test CART's utility in a social work setting, authors conducted a secondary analysis of data collected in a national study of child protective screening practices to identify factors involved with worker decisions to investigate child maltreatment reports. The CART analysis revealed complex interaction effects previously unobserved in logistic regression. Comparisons of CART with traditional statistical approaches and other tree-based programs are presented. Key words: classification and regression trees; decision trees; decision making; screening; child protective ********** Depending on research question, basic purpose of a classification study is either to produce an accurate classifier or to uncover predictive structure of phenomenon under consideration (Breiman, Friedman, Olshen, & Stone, 1984). For most social work professionals, both objectives are of interest; for example, to target resources, a program planner must be able to identify groups of clients that are likely to benefit from a specific approach and to understand factors that predict likelihood of success given client's presenting conditions. Similarly, when a social worker recommends care alternatives, prediction of outcome given client's condition, available resources, and factors expected to influence rehabilitation are necessary to appropriately assist client and family in their decision making. Yet, many social work professionals are faced with complex decision problems without benefit of a set of rules to organize data. In these situations, most decision makers tend to polarize around only a few variables, potentially missing important aspects of a problem. Although a variety of traditional statistical approaches can be used to predict classification of cases from complex data sets, classification and regression trees (CART) analysis (Breiman et al., 1984) has been cited repeatedly as a powerful nonparametric approach in applied fields where classification or prediction are of concern, such as medicine (for example, Goldman et al., 1998; Mair, Smidt, Lechleitner, Dienstl, & Puschendorf, 1998; Thomssen et al., 1998) and mental health (Barnes, Welte, & Dintcheff, 1991; Boerstler & de Figueiredo, 1991; Craig, Siegel, Hopper, Lin, & Sartorius, 1997). For example, in a study of low-income psychiatric patients, Boerstler and de Figueiredo found client's discharge from inpatient treatment at most recent admission to psychiatric treatment to be the most consistent, most powerful, and only necessary predictor of high use of outpatient psychiatric services (p. 32); an important implication for program administrators. Mair et al. (1995) used CART to develop an algorithm for use in emergency room settings for early diagnosis of heart attack based on clinical symptoms, ECG, and other myocardial measures from 114 patients. The method's ability to predict a diagnosis was as high as that of other statistical methods; however, CART's graphical features, essential for use in clinical training and practice, were cited as a primary advantage over other methods. To demonstrate CART's potential for use in social work settings, this article presents CART technique, its utility in identifying factors involved with decisions to investigate reports of child maitreatment, and comparisons of CART with traditional statistical approaches and other tree-based software programs. BACKGROUND In response to growing discrepancy between number of reports made to child protective (CPS) and number of reports investigated, Children's Bureau funded an on-site study of CPS screening practices in 12 communities from five states to illustrate worker decision-making practices at intake (Wells, Fluke, Downing, & Brown, 1989). …

The Client Encounter Form: conceptual development, reliability analysis, and clinical applications.

This descriptive correlational study investigated the reliability of a new measure of client-nurse practitioner interaction, the Client Encounter Form (CEF), and used the CEF to describe the domains of client-nurse practitioner interaction that occurred during problem and preventative visits at a primary care clinic. The CEF is based on Cox's Interactional Model of Client Health Behavior. Data were collected from a convenience sample of 41 primary care clinic visits. Descriptive data on all clients and the patterns of use characterized by the CEF were collected using retrospective chart review (n = 60). Reliability testing showed the CEF has high interrater reliability; Cohen's Kappas for its dimensions ranged from 0.78-1.0. The CEF was also shown to be useable in a primary care clinic. Health information, affective support, goal setting, and technical procedures were consistently part of the nurse-client interactions in this sample, demonstrating they are part of the nurse practitioner model of care. Analysis revealed different patterns of interaction for preventative and problem-oriented visits. Preventative visits had higher levels of health promotion information, psychological affective support, and health promotion goal-setting behaviors. Problem visits included more information regarding the client's diagnosis, medications, and treatments, and more affective support related to the client's physical condition.

Managing Chronic Fatigue Syndrome: Overview and Case Study

1. The basic principles of envelope theory are explained. By not overexerting themselves, people with CFS can avoid the setbacks and relapses that commonly occur in response to overexertion while increasing their tolerance to activity. 2. By collecting time series data on fluctuations in energy levels, important clinical observations can be made in respect to a client's unique condition and experience with CFS.

The pinning down of shiatsu, or what i learned from my research experience

Nicola Pooley Shiatsu College Bristol, 46 Station Road, Ashley Down, Bristol BS7 9LB, UK. I can still see the shaft of sunlight playing on the floor as I heard myself say 'I ' l l do it.' This followed a long pause during a Shiatsu Society telephone conference on research. We had found out that the Research Council for Complementary Medicine was inviting applications for a 'First Rung' research award. We all agreed that the Shiatsu Society should apply. We wanted to raise the profile of the Society and give shiatsu more credibility. The awards gave priority to first time researchers who could collaborate with an academic institution. I had last done research as an undergraduate but had support from Philip Harris, a shiatsu practitioner and social researcher from the University of Wales Institute. Originally, I wanted to do some research that proved shiatsu worked but, reluctantly, we decided doing a survey of shiatsu practitioners and clients. I thought I knew what shiatsu practitioners treated. Hadn't I been doing it for years? But what I thought I knew wasn't substantiated by research, so we submitted our proposal 'a survey of illness conditions presenting for shiatsu.' My immediate assumption, based on my own experience of health care and from treating my clients is that shiatsu is mainly used to treat stress and its associated symptoms, such as bad backs and depression. Conventional medicine is my first choice for life-threatening illness and serious physical injury. I prefer shiatsu and complementary health for my physical and emotional aches. When I broke my leg an ambulance and surgery were essential. But when my back gave out, a couple of shiatsu treatments left me pain free, a successful alternative to the 4 weeks bed rest that the doctor recommended. I would see what choices are made by shiatsu clients across the country. The first stage of the research required ten practitioners to volunteer to fill in questionnaires on their clients for 10 weeks. This provided us with guidelines on what should go in a second questionnaire to all practitioners. We soon recruited five women volunteers. We aimed for a demographic spread and so needed some male volunteers. I spent an uncomfortable week cold-calling all the male practitioners in London. I learnt that I didn't enjoy trying to persuade people to do 10 weeks worth of work in the name of research with what might be perceived as little or no reward. It didn't surprise me that women agreed more readily. Then came the hard manual work, processing all the information from the ten practitioners. Answers such as male/female were easily tallied up. Categorizing the conditions required more mental effort. For example, did 'feeling sick due to exams' come under digestive or anxiety? As we were using up to three conditions per client I put this one under both. It may have been hard work, but I enjoyed collecting all the numbers. A disappointment came when all that work and information was edited from the final report; this stage was to be treated merely as a pilot of the second stage of the research. I suppose it was similar to when one of the volunteers had written an interesting essay on one of their client's conditions and I merely recorded this as a tick under 'other'. I found it difficult to reduce people's stories into boxes. We had published our interim report and had started to prepare the second stage of the project when my personal life interfered with our plans. My mother had a serious heart attack and was in hospital. The next 3 months were spent visiting her.

The Relation between Going-Concern Opinions and the Auditor's Loss Function

In this study I explore whether auditor incentives influence the decision to issue a going-concern disclosure to a financially distressed client. Auditor incentives have been suggested as a missing link between the literatures on financial distress prediction and going-concern assessments. While previous research has focused primarily on client financial ratios, I model the auditor's going-concern as a function not only of the client's financial condition and prospects, but also of factors associated with the auditor's loss function, including prospective audit fees, the length of the auditor-client relationship, recent auditor litigation, client losses, and the existence of previously disclosed evidence of goingconcern difficulties.

Quality-of-life issues in home care.

Quality-of-life issues in home care are complex. Nurses not only must help the family consider these factors for the patient at home, but also they must examine the effects of home care on the primary caregiver and the entire family. Nurses use a holistic view in assessment to diagnose the needs of the client and the caregiver. Physiologic, psychologic, cultural, spiritual, and sociologic aspects are all considered. Nurses have an important role in assisting clients and their families to maximize the benefits of home care. They can help them with the provision of care in the current situation and to plan for the future for appropriate levels of care as the client's condition changes. These actions will result in an optimum quality of life for the client and the client's family.

Working with Potentially Assaultive Clients

Social workers and other helping professionals have increasingly become the targets of violence and attack by clients (Guy, Brown, & Polestra, 1990; Star, 1984). It is estimated that all direct-service practitioners, including social workers, are in danger of being assaulted during their careers (Wagner, 1990). It is clear that social work, along with such fields as teaching, nursing, and psychiatry, has become a profession in which the constant risk of assault is part of reality (Risk of Assault, 1989, p. 3). Thus, there is a growing need to increase the abilities of practitioners to predict and control dangerous behavior by clients (Newhill, 1992). This article examines the potentially assaultive or preassaultive client and suggests some ways to minimize the risk of assault by such clients. The data used in this article are derived from the author's 10-year experience in providing social work services on an acute psychiatric ward in a large public medical center. Although the data are limited to one setting, recent studies indicate they may be generalizable to other settings as well (Newhill, 1992). POTENTIALLY ASSAULTIVE CLIENT CONDITIONS Several authors have developed categories to describe clients who may become assaultive or events that may lead to assault (Kaplan & Wheeler, 1983; Madden, 1983). For the purposes of this article, the most serviceable set of categories is that provided by Kronberg (1983), and we have adapted her analysis for use in this discussion. In general, the potentially assaultive client's condition and behavioral cues determine which treatment approaches and therapeutic goals are used. Table 1 outlines some of the most important factors associated with five commonly observed preassaultive conditions, the cues associated with each condition, and the approaches and goals that have been found to be helpful in the management of these conditions (Kronberg, 1983). It should be stressed that these conditions do not represent diagnostic categories but instead signify commonsense definitions of behavioral events frequently encountered in psychiatric settings. Panic Clients can sometimes become so overwhelmed by fear that they lash out in panic at all who attempt to influence their choices or constrain their behavior. Victims of attack can include helping professionals as well as friends or immediate family (Kneisl, 1988). These behaviors are illustrated in the following vignette: A 39-year-old male psychiatric patient became distraught while speaking with the ward social worker about making arrangements to see his estranged wife. His distress grew as the social worker attempted to explore and analyze his feelings until he finally became threatening toward the TABULAR DATA OMITTED worker, claiming he feared that his wife was leaving the state with his infant son and that staff were keeping him from seeing her. The worker quickly exited her office and sought assistance from ward staff. Such clients generally show signs of severe anxiety, such as pressured speech, obsessional thinking, and fears of catastrophe or abandonment. They may exhibit clinging behavior toward staff, in which they claim helplessness and the need to rely on staff for even minimal assistance. Apparent unconcern by staff or even attempts to objectify the client's feelings are often interpreted by the client as indifference and can trigger desperate explosive reactions. The task of calming a severely frightened individual places constraints on the reactions of the helping professional. Because such clients feel as if they are under attack, it is important for the practitioner to avoid any appearance of threatening behavior. Responses to the client should be calm and reassuring, deliberate without haste, with purposeful avoidance of eye contact unless this is sought by the client, because eye contact is often interpreted as a threat. Practitioners should avoid physical closeness unless desired by the client. …

Modeling case management decision-making in a consolidated long-term care program.

This study identifies the informational factors and judgment processes involved in making two case management decisions within a consolidated long-term care program: evaluating risk of nursing home placement and choosing a care plan. A multidisciplinary case management team formulated these decisions for hypothetical clients described in vignettes (N = 1,507). The team used information about the client's condition and the program's available resources in judging risk of institutionalization, but only client-related information in selecting a care plan.

An empirical analysis of Hong Kong bankers' perceptions of auditor ability to resist management pressure in an audit conflict situation

This study investigates the effects of financial condition of client, size of audit fees and audit tendering on bankers' perceptions of auditors' ability to resist management pressure in an audit conflict situation. Empirical evidence on auditor independence in recently developed countries (RDCs) such as Hong Kong is needed for two reasons. First, there is a dearth of evidence regarding perceptions of auditor independence in these RDCs and applying the results of studies in developed countries to these RDCs is unsatisfactory. Second, such evidence can enhance our understanding of the role of auditors in different cultural and economic settings and also provide some input into attempts at international harmonization of auditing standards. The results of this study showed that financial condition of the client and size of audit fees were important variables that affected lending officers' perceptions of auditors' ability to resist management pressure. In particular, the results showed that when the client's financial condition was good and when the size of the audit fees was significant, lending officers had less confidence in auditors' ability to resist management pressure.

Discussion of Conservatism and Auditor-Client Negotiations

ation process. A number of points were raised during the discussion of the paper. These points were concerned primarily with modeling the auditing game of interest. These and other points are discussed below. 1. Issues Involving the Sequence of Actions Some of the discussion concerned the assumed time sequence in the model. In the model there are two players: a client and an auditor. The client is required to issue an audited financial statement. At the start of the game, the client and auditor share common beliefs about the client's financial condition. The client then receives a signal which provides additional, but imperfect, information about the firm's financial condition. The uninformed auditor moves first by providing a standard audit which reveals that the client's true income is uniformly distributed in the interval [7r - r, 7r + r]. Because the auditor is uninformed about the client's financial condition at the time that the audit is designed, this standard audit does not vary

Quality of Care in Occupational Health through Nursing Diagnosis

Nursing diagnosis as a part of nursing is not a new activity, but rather one that has been more clearly delineated and structured. Nursing diagnosis is the natural outcome following nursing assessment, and directs the establishment of care goals. Nursing diagnosis promotes quality of care by providing a common framework for the description of client needs, by delineating the areas of nursing responsibility, and by providing criteria to measure the comprehensiveness of the care provided. Consistency in terminology and structure is important for the effectiveness of nursing diagnosis. The use of a widely accepted diagnostic label promotes a clear understanding of the nurse's intended statement of the client's condition. Although consistency and standardization are features of the taxonomy of nursing diagnosis, the concept is flexible enough to be used in a variety of care settings. In occupational health nursing, this flexibility is provided through use of group data, through the diagnostic category of health maintenance, and by the identification of potential nursing diagnoses.

Over-reports of recent alcohol consumption in a clinical population: A validity study

Decisions concerning appropriate treatment in alcoholism programs are often based on the self-reports of the clients. However, few programs have incorporated validation procedures (such as breath tests) since it is generally assumed that alcoholics will deny the extent of their drinking and their subsequent alcohol problems. The self-reports of recent alcohol consumption of sixty-five new entrants to an alcoholism treatment program were validated with breath tests. Five estimates of blood alcohol concentrations were derived by varying elimination rates. For all five estimates, over-reporters comprised a substantial proportion of the total sample (23%–57%) and exceeded the percentage of consistent reporters for those people who had a positive breath test. Correlations between self-reports and breath tests were not significant which indicates that the amount of alcohol consumed does not necessarily relate to reporting behavior. It is concluded that despite the widely held notion that alcoholics deny the extent of their drinking, errors in the direction of over-reporting should be taken seriously and examined more closely. On an individual level, overpresentation of a client's condition may be related to subsequent behavior in a treatment program; on an aggregate level, over-reports may bias the findings of evaluation studies by inflating success rates.