jenannebeard

Really? I just logged on here after months to see your comment. Course I want my husband to be successful. But I too just want to be as successful when I when to college and paid hard earned money on my education. Can you blame someone to want more for their handwork? Oh and I finally got a hospital job. Thanks.

Sorry so long...please help? ;( So I finally landed a position in acute care at a near by hospital after 3 years of SNF experience. I was so HAPPY when I was offered the job I cried tears of joy. The problem is I have extreme anxiety. Even at the SNF I worked at for 2 years I would experience high anxiety when something/someone would take a turn for the worse. Every day prior to shift my stomach was in knots and I wouldn't be able to sleep the night before and I would lay in bed till it was time to get up to get ready for work. Don't get me wrong, I love nursing...but it only were the days I knew exactly what I needed to do in certain situations I was given at hand. I guess you can say I have high anxiety only in situations where I didn't know what to do. If I do one thing and later come to realize I should have handled it another way I beat myself up for it. I have an extreme type A personality and OCD behaviors. I know I am my own worst enemy/criticizer. I went to my MD last week and mentioned this to him and how I foresee my anxiety levels to be at their highest when I start my new job. He prescribed me Zoloft 25 mg 1 tablet QD X 1 week then 50 mg QD there after. I have been taking it a week and it gives me extreme pressure headaches, nausea, 1 episode of vomiting, and makes me feel spacey/drunk/high all the time. I messaged my MD today and am waiting for a response back. What other medication could possibly work for me? I'm afraid he'll just recommended going to a stress/anxiety management class and I do plan on going to one but I have read/listened and tried many tactics already on my own and they haven't seemed to work for me. I really want to take a medication till I can get back on my own two feet. What medications other than an SSRI has worked for you?

Pfft...probably right. Sure hasn't helped me!! Shall there be a day I hire nurses I'm hiring all those that have worked their asses off going up the ladder!

Wouldn't you essentially need to use studies in an EBP paper if it's an EBP paper?! LOL Otherwise your conducting a plenty lengthy study your self that will takes a while. Just my thought!

We weren't expected to find something that hasn't already been proven, just use different articles/studies to back up the topic.

I did mine on chlorhexidine impregnated patches at central line catheters.

I feel I have done everything by the book my whole life. I didn't have a boyfriend till I was 16, I didn't have my first kiss till I was 16 also, I went to college, I got good grades, I got accepted to nursing school...graduated, got married, and got my bachelor's degree in nursing 2 years later after my associates. I did EXACTLY what I thought I was supposed to do. Except...I didn't attain the career job I thought I'd have by now. And this kills me. I have so much anger and aggression towards those friends and people I know that were able to attain a hospital/acute care nurse job right out of nursing school (might I add..right after receiving their 2 year associate's in nursing). It seems everyone I know that attained an acute care nursing job just got lucky. They didn't know anyone to help them receive their job, but yet they got it. Me, on the other hand, have had at least 2 acute care nursing job interviews in which I KNEW someone that got me an interview...and it didn't help. I know what you're saying right now, "you must have not interviewed very well". I did. I had SEVERAL interviews prior to these two acute care nursing job interviews and I thought both times I NAILED them. I had several interviews else where before them and I thought I was pretty good at selling myself by then. But apparently what I had on paper and how I presented myself in the interview wouldn't have mattered anyhow, they had candidates chosen already in their heads. After all, it is about "who you know". Here's why I think I deserve my career job. My career job is being a registered nurse in a hospital. And I have an interest being a surgical nurse. I was so "awe stricken" when I did my surgical rotation in my associate's nursing program. And I've wondered many times why? Is it because I am attracted to art? Am a creative person that has always been good and steady with my hands? Or maybe it's because I like to see what's behind what our eye's can't interpret from the outside? I don't know, and maybe I won't know till I finally, if ever, become surgical nurse. My real passion in life... However, I would take ANY job as an acute care nurse at a hospital because I feel it's where I will be able to learn the most, and feel like a GOOD nurse. I've worked a little over 2 years in long term/rehabilitation nursing. Once believing I'd NEVER be able to hang in the industry as a charge nurse over 28+ patients, I surprisingly have... but there are some days I feel like a "******" nurse because I didn't do everything to a "T" how I would have done if I had more time. Being scolded if I'm even five minutes on overtime, I sometimes am unable to do a thorough research on all my patients. I LIKE to sit down and read their whole history and physical. I feel equipped and better than ever being their nurse. It's SUCH an awesome feeling to be able to answer ever detail about them in "your" charting. Makes me feel like super woman! Proof to myself I do CARE about my patients, and how I deep down know in myself I would be an awesome nurse in the hospital setting. I sometimes imagine how I would respond after I was offered a job in the acute setting in a personal one-on-one sitting. It made me cry. I HATE how I sometimes regret going into the nursing profession because I've been unhappy with all the nursing jobs I've had. When I was in nursing school I was working as a Radiology transport tech aide for a major hospital in my area, and every nurse I knew in the hospital setting seemed happy, fulfilled, and satisfied. I envied them, I wanted to do exactly what they were doing...one time I even told a nurse something wasn't right about a patient I brought back from Radiology. He actually coded right after I said that and died. Since then, I will always trust my instincts. And so far it's worked out to my advantage every time. Alright, I guess it's apparent that I desperately want an acute care nursing job in a hospital setting... It's my only want in life right now. I feel once I attain it I won't feel as guilty becoming pregnant. Being the girl that "goes by the book", I feel I need to accomplish this goal before I set forth bringing a child into this world. My husband wants children so bad right now and I do too...expect I haven't attained MY career goals like he has... And I hate to say it, but I'm jealous how someone like himself that has NEVER attended college, make more money and has become more successful than myself. After I've spent over 20K on my education!? It's just appalling to me (my husband is a CHP officer making over 100K a year). Can ya blame me?! I'm jealous. I'm of course SO appreciative and happy he's doing something he's always wanted to do, making that kind of income, but I am bitter. I can't even tell you how many nights I've given up on sleep to study through out the night prior to a big test. I'm angry deep inside, because I feel like it didn't matter. WHEN will I be happy and satisfied in my career choice?! If I EVER get my dream job, whether it be in a hospital setting or in another setting I never would have dreamed of, I will always remember to give those like myself in my current situation a fighting CHANCE. I think I would offer the job to every interviewer to just see their reaction. If they react anyway I think how I would react, I would give it to them hands down. You can talk all you want about how much passion you have about something, but your emotion towards your passion doesn't surface to the top...it ain't there.

I'm not a good writer and I stress out turning in writing assignments. If anyone feels so kind to edit, review, and give me any input I'd appreciate it. The question I had to answer was what qualities I would like to develop as a leader and manager.... Many people including myself assume a person in a management must be a leader as that is inherent in the position. Little did I know prior to studying about leadership and management that in actuality they are not the same thing. The two vary differently in characteristics, skills, and personal qualities. Perhaps originally I wasn't able to make a distinction between leaders and managers because I couldn't see how either one of them could not go hand in hand with each other? It seems like a given to me that one would need to develop leadership competencies in order to become a successful manager. As human beings we all want to feel valued and appreciated for the work we do. And allowing staff to be included in the decision-making and planning process is one way to increase staff morale and satisfaction. In addition, a mutually agreed upon value of something creates a natural desire for it, thus encouraging staff to get involved in opportunities to improve. I strongly feel this is one of the most important leadership skill one can learn, and one that all managers' should employ. I often feel managers purposely do not include staff in their decision making in fear that their input may decrease productivity. This is particularly what I'm faced with at my current job. My administrator loads us nurses with several admits a day making it very hard for us to give quality care to our other 25 plus residents/patients. He seems to tune out our concerns and frustrations related to this problem because he doesn't want to find an excuse as to why we shouldn't admit any one of them. Because of his actions and unwillingness to include us nurses in the decision making process he unfortunately has built a bad reputation for himself. As someone that is only driven by dollar signs. With the loss of respect and the unfavorable working conditions he has created for his employees, he now has to deal with a large turn over rate that has occurred at my workplace. If only had he improved the situation to be more effective, by involving staff input as a leader would have done, efficiency could have been maintained at no additional cost. Other leadership qualities I would like to develop are those essentially I wish my current employer had. They include trustworthiness, conscientiousness, adaptability, and empathy. All these qualities are important towards creating a climate full of satisfied staff and patients. They boost staff morale and satisfaction that encourage staff to want to do their best, and subsequently improve the workplace. Recently all my co-workers and I noticed a pay cut on our most recent check. Apparently my administer had made some cut backs that included a deduction in our hourly wages with out notifying us. It made all of us feel cheated and belittled. Needless to say, my administrator's trustworthiness has gone out the door for most of us. He had tried to redeem himself by writing a mass produced apologetic letter but that didn't seem to work for him. He had already created too much damage to his character to be able to redeem him self. If an individual has the audacity to do such a thing like my administrator did, one begins to question what kind of values and principles this kind of individual has. Certainly someone like this isn't going to be viewed as conscientiousness or empathic. It's obviously he didn't take our feelings or well being into account with his actions. And the constant reminders given to him for change with admits from nurses and other staff got no recognition. His unwillingness to accept new ideas to improve demonstrates his lack of value for feedback and resistance toward adaptability. If we continue to be treated like inanimate objects, we'll start to view our job as nothing more than a task to get done to get a check in our hands. Some control must be given up in order to allow staff to participate in some of the decision making and planning process. This is an important task I will remember to apply if I ever become a manager one day. I will encourage feedback and try to implement any changes necessary to help my staff to do their job more effectively. I would hope that staff members on my team would know how important they are to the company as a whole. And by allowing feedback and guidance from my peers they will feel involved and motivated towards improving the organization. Having a mutually agreed upon common goal is what is going to motivate others to include themselves in your vision. I feel teamwork is also best applied when a mutual respect for one another is enforced. That said, honesty and loyalty should be upheld. I find that a person with these qualities can be very influential because trust is adapted. And when trust is developed, power is attained; making a manager become an influential leader others will want to follow.

Oh my god, I feel like I'm reading a post I wrote when I first started LTC. Yes you WILL get faster! I've been a LTC for about a year now and I struggle at times. Best advise, just be consistent! It doesn't matter how slow you are, as long as you're doing your job right and providing the necessary care your patients deserve, that is all that matters! You will pick up the pace. You'll start to find what best works for you, what patients you should give medication to first, and how to managed your time wisely. LTC was the only job I was able to get right how of nursing school. I cried every day after work and sometimes at work! I finally found a place that I love and that's because of the people I work with! No one makes me feel like I'm stupid for not knowing how to do something. Everyone is so helpful. As long as you have a good support system at work, you'll do just fine. It's only temporary how you feel. Once you've been doing it for about 6 months or so it'll all become second nature. I learned something knew EVERY day and I learn from my mistakes too. Do NOT beat yourself up by a mistake you've made. EVERYONE has made a mistake. I about quit being a nurse forever because I accidentally gave someone somebody else's medications (thank god it was just mostly vitamins). Just admit to your mistakes and take ownership in it. Now a days organizations and hospitals are steering away from the "blame and shame" attitude to an educational learning tool of what you could of done differently to prevent this. I only mention this because making a mistake most likely will be in your future and I don't want you to react how I did. It could have changed my life entirely if I had decided to quit nursing. Now I'm in school again getting my bachelors. As this point, I don't care if I ever work in a hospital like I use to want to. I just want to be happy with what ever type of nursing I do. LTC is HARD, and when I ask many of my friends who work at hospitals if they would ever do LTC most say they wouldn't because it's too stressful. Imagine how much we have overcome and learned from taking on such a high patient load! We might be freakin ALL STARS in the acute care system if we get a job at a hospital. I'm looking forward to endless possibilities nursing has in store for me.

This is the only question I have to address in a group oral presentation and I'm so frustrated trying to get a straight answer! I wanted to see what government actions has been implemented after the report "To Err Is Human" by the Institute of Medicine was released in 1999. I've been researching all day and all the agencies involved is just confusing me further. I just need a website or resource that lists the strategies that have EVOLVED in the health care system. I don't understand why this is so hard to find. I found FDA's way to eliminate medical errors, but I was trying to find a general list of what most hospitals are doing to elminate medical errors. Any tips. PLEASE!!! Thank you!

Hey all, I have to answer a question and I can't seem to find a good resource for information. The question is... How does current health care financing influence the lives of older adults? I've been trying to search how the cost of health care impacts older adults but all I can find is how older adults are a large part of medical expenses. Any have any good links? Thanks!

We were given an article and I have to answer a few simple questions. But I want to see if anyone else see anything I've missed. Any help is much appreciated! Thanks! Here's the article... CHICO-A nursing home has been ordered to pay a $100,000 fine in connection with the death of an elderly resident. The fine was levied against Twin Oaks Health and Rehabilitation Center by the state Department of Public Health. Jason Smith, a spokesman for Evergreen Healthcare Management, which owns the Chico nursing home, said he couldn't comment on the citation because of rules that protect residents' privacy. A document from the Department of Public Health indicated Evergreen is appealing the citation. The resident who died, a 98-year-old woman, slipped out of her wheelchair and was strangled by a belt that was supposed to keep her in the chair, according to documents from the Department of Public Health. The woman, who had to use a wheelchair, moved into Twin Oaks in February of last year. She'd been diagnosed with Alzheimer's, anxiety, depression, weakness and psychosis, according to state documents. Often, she would slip down in her wheelchair. Staff members had to watch her and pull her up when that happened, the documents said. For a time, a device called a pummel cushion was used to help keep her in the chair, but for some reason its use was discontinued. A restraint called a "soft waist belt" was used to help prevent her from falling out of the chair. During supper on Dec. 7, the woman kept sliding down in her wheelchair. It happened so many times that two certified nurse assistants (CNAs) who were working in the dining room decided to put her to bed immediately, documents stated. The two CNAs, who weren't regular staff members but had been hired through a registry to work temporarily, were taking the woman to her room when they were stopped by a family member of another resident, who asked them to put that resident to bed first. According to documents, the two CNAs said they thought the woman in the wheelchair would be all right by herself for a little while, so they left her in the doorway of her room and attended to the other resident. Twenty to 30 minutes later, the documents said, the two CNAs came out into the hall and noticed that the door was closed to the room of the woman in the wheelchair. They opened the door and saw the woman on the floor with the waist belt pressed against her neck and chest, the documents stated. She wasn't breathing. The nurse assistants began performing CPR, but a nurse who had been called told them to stop because the woman had left instructions that she was not to be resuscitated, the documents said. Twin Oaks reported the incident to the Department of Public Health, which investigated. The nursing home was issued a Class AA citation for failing to keep the resident safe and not providing adequate supervision. Class AA citations are the most serious the state issues. They carry a fine of between $25,000 and $100,000. The nursing home was required to develop what's called a plan of correction. In its plan, the Twin Oaks administration said the entire staff, including employees hired through registries, would be instructed that residents' safety must take priority over all other concerns. What is/are the problem(s) that you recognize? (For each identify the population of interest: patient, staff, agency, etc.) Possible lack of appropriate nursing staff to resident ratios - Agency Inadequate training of nursing staff - Agency Lack of proper documentation for discontinued use of pummel cushion - Staff Abandonment - Staff (Should I just state Alzeheimers as the problem and patient as the population, I'm confused what problem I can relate to the patient population) What information (or type) do you need to address each of these problems? (Be specific and justify your response) Possible lack of appropriate nursing staff to resident ratios - Agency I'm thinking I need to look up California's requirement of nurse to patient ratio for nursing homes [*]Inadequate training of nursing staff - Agency Maybe find a study done that tells me the outcome/results of injuries that occur related to staff incompetence? [*]Lack of proper documentation for discontinued use of pummel cushion - Staff No idea! [*]Abandonment - Staff No idea! What information would be helpful to know for each problem, even if it may not be easily available? (Explain) Uhhhh..... Identify at least 2 specific sources of information for each of these problems (e.g. websites with a brief description about what information can be obtained). I will do this later, not that hard. Provide a brief description of the overall problem(s) and your recommendations to the director to address this issue. Remember that you are not solving the problems but setting up a method to address the issues. I will be able to do this once I am able to identify all possible problems. STRESSED OUT!

Thanks guys. I knew I was right about who the subjects were at least. But I wanted to be sure so I didn't blow my entire midterm if I so happened to be wrong. Greatly appreciate it.

I'm currently in an Evidence-Based Nursing Practice class and I have a simple question I think I know the answer to already but want to get confirmation that I'm right. What question is who are the subjects of this study? I believe it is just the mothers of the hospitalized children (ages 1-12 years of age). Here is the scenario: As a member of an IRB (Institutional Review Board) of a local hospital, you have been asked to review a research proposal submitted by several nurses practicing on a pediatric unit at your facility. With the rising concern regarding child abuse, these nurses propose to conduct a selfcompleted 2-page survey of all mothers of hospitalized children (ages 1-12 years of age) admitted during the month of January 2010. The survey will specifically address parental views on disciplinary methods appropriated for this age range of children. Also, from what I gather it is the nurses filling out the survey. Am I right? Not the mothers. Any input will set my anxiety at ease! THANK YOU!!!

I'm so confused with reasearch language! What is this question actually asking me to find in this article? 1. Is a theoretical/conceptual framework specified? And what is it? I'm having a hard to identify it. The article is lengthy so I apologize but obviously you don't have to read the whole thing. I know once I find it I'll be able to move on to answering my other questions correctly. I just need some help with identifying it. Thanks for your help! Impoverished children with asthma: a pilot study of urban healthcare access. By Klinnert, Mary Publication: Journal for Specialists in Pediatric Nursing Thursday, April 1 2004 inShare Share ISSUES AND PURPOSE. Using Andersen's Behavioral Model of Health Care Use, this pilot study was conducted to better understand the experiences of children with asthma as they access an urban healthcare system. DESIGN AND METHODS. This descriptive study used a convenience sample of 34 families of pediatric asthma patients who participated in semistructured interviews and closed medical record review. RESULTS. Only one patient reported having a written exacerbation management plan. Beliefs regarding medication addiction and side effects were frequently reported as barriers to medication adherence, and children seeking asthma care in primary care settings saw many care providers. PRACTICE IMPLICATIONS. Exploring how expanded nursing roles can help address both family and system factors serving as barriers to health care ought to be a key priority for nursing. Search terms: Accessibility, asthma, health beliefs, health services ********** Asthma is the most common childhood illness and, despite advances in asthma management, morbidity and mortality rates are rising (Centers for Disease Control and Prevention, 1998; Tartasky, 1999). Latest estimates project asthma expenditures of at least $12.7 billion annually (Public Health Policy Advisory Board, 2002). Many factors seem to contribute to asthma morbidly, including race and ethnicity, socioeconomic status, urban dwelling, severe disease, prior emergency room visits, psychological problems, and treatment nonadherence. Urban, impoverished, minority children contribute disproportionately to the trend of increasing asthma morbidity and mortality (Aligne, Auinger, Byrd, & Weitzman, 2000; Bartlett et al., 2001; Miller, 2000). Urban impoverished children with asthma, regardless of payor source, access costly emergency services more frequently than do their nonurban counterparts (Halfron & Newacheck, 1993; Lozano, Connell, & Koepsell, 1995; Ortega et al., 2001). Children with Medicaid are likely to report a usual source of routine care but are less likely to receive care in a primary care office or to have continuity between care sources (Crain, Kercsmer, Weiss, Mitchell, & Lynn, 1998; Halfron & Newacheck; Kattan et al., 1997). In a recent study, 75.4% of parents of urban asthmatic children cited the emergency department (ED) as their usual source of care (Crain et al.). This reliance on emergency care services appears to play a role in rising asthma morbidity among urban children because those frequently accessing emergency care also have fewer visits to primary care providers and are less likely to fill prescriptions for inhaled anti-inflammatories (Ortega et al.). Having previous emergency room visits for asthma care also is a predictor of more emergency room visits in the future (Emerman, Cydulka, & Rim, 1999; Wasilewski et al., 1996). Conceptual Framework Andersen's Behavioral Model of Health Services Use well-established framework for understanding the determinants of healthcare access (Aday & Andersen, 1974; Andersen, 1995) and continues to be a relevant and evolving model in health services research. The model "provides a framework to describe those factors that inhibit or facilitate entrance to the health care delivery system as well as ... how these inhibiting (and facilitating) factors operate to affect admittance" (Aday, Andersen, & Fleming, 1980, p. 36). Andersen's model lends structure to the concept of healthcare utilization by identifying and organizing the characteristics involved in how individuals access resources. The model suggests culture, social structure, individual characteristics, healthcare system organization, and need for services influence individual healthcare utilization (Aday & Andersen; Andersen). Andersen's predisposing and enabling attributes appear to have particular significance for urban children with asthma. Key elements specific to Anderson's model are presented in Figure 1. [FIGURE 1 OMITTED] Predisposing Attributes In Andersen's model, demographics, social structure, health beliefs, and psychosocial characteristics predispose a person's access to care (Andersen, 1995). Among children with Medicaid, race and ethnicity are associated with higher resource utilization for asthma (Apter et al., 1997; Joseph, Havstad, Ownby, Johnson, & Tilley, 1998; Liu et al., 2000). This is also evident in a managed care setting in which African-American patients filled controller medications, such as inhaled anti-inflammatory agents, less frequently than their white counterparts did (Zoratti et al., 1998). Increases in hospitalization rates appear to be associated with greater numbers of nonwhite residents and lower levels of education (Gottlieb, Beiser, & O'Connor, 1995); however, rates of ED use do not decline with increased income for African-American children (Miller, 2000). The mental health of children and caretakers, as well as family functional status, are predictive factors in asthma morbidity (Bartlett et al., 2001; Klinnert, McQuaid, & Gavin, 1997; Weil et al., 1999). Caregiver problem-solving skills and positive expectations are associated with higher functional status among urban children with asthma (Wade, Holden, Lynn, Mitchell, & Ewart, 2000). Asthma itself does not appear to expose children or caretakers to increased risk of mental health difficulties (Bender et al., 2000). Many studies suggest urban children underutilize efficacious inhaled anti-inflammatory agents (Butz, Eggleston, Huss, Kolodner, & Rand, 2000; Diaz et al., 2000; Warman, Silver, McCourt, & Stein, 1999). A lack of caretaker confidence in asthma medications is linked to ED visits (Wasilewski et al., 1996), suggesting medication beliefs play a part in morbidity and utilization. Mansour, Lanphear, and DeWitt (2000) found that health beliefs inherent to urban caretakers, such as competing demands and prioritization, serve as significant barriers to asthma care. Enabling Attributes Enabling attributes are those resources allowing individuals to access the healthcare system. Simply possessing health insurance and knowing where to obtain health services do not determine healthcare access for urban children with asthma (Mansour et al., 2000). Lack of understanding about asthma medications, exacerbation management, and decision-making skills regarding emergency care access may be evidence of ineffective family education by urban care providers (Warman et al., 1999; Wasilewski et al., 1996). The availability of appropriate care delivered by urban providers is an enabling characteristic according to Andersen's model. Despite the availability of evidence-based guidelines, healthcare providers do not consistently administer evidence-based care to urban children (Diaz et al., 2000; Taylor, Auble, Calhoun, & Mosesso, 1999). They do not prescribe inhaled anti-inflammatory agents appropriately, do not provide effective medication information, and inconsistently provide exacerbation management plans outlining asthma medications, asthma symptoms, and what parents should do during an asthma exacerbation (Hartert, Windom, Peebles, Freidhoff, & Togias, 1996). Table 1 shows readily available resources for asthma management plans and guidelines. While some studies have investigated the urban asthma "epidemic" in terms of characteristics found in individual families and access barriers, few have subjectively compared data given by families against medical record review. Additional research is needed to assess family beliefs about asthma, sources of asthma disease knowledge deficits, and ineffective aspects of healthcare provided to this population in order to understand how each affects urban asthma morbidity among impoverished children. The purpose of this descriptive study, using a behavioral model of healthcare use, is to explore the asthma care provided to urban children. Methods A descriptive study was conducted in an integrated urban healthcare system. Consenting patients participated in an interview assessing beliefs and knowledge along with current exacerbation management practices. A closed medical record review exploring the number of primary care providers involved in asthma management, prescribed medications, emergency visits, and hospitalizations also was used to assess care quality and resource utilization. The study was approved by the University of Colorado Institutional Review Board for human subject research. The registered nurse (RN) case manager interviewed patients and families referred by physicians and nurses working in the urgent care clinic, intensive care unit, inpatient unit, and a community clinic over a 1-year period. Included were families of children up to 18 years of age with a diagnosis of asthma who had at least one previous urgent care contact and/or hospital admission for asthma. Non-English-speaking families were excluded. Family Knowledge and Management The Family Asthma Management Symptom Scale (FAMSS), developed to evaluate the complex nature of family asthma management and shown to have good reliability and validity measures (Klinnert & Bender, 2002; Klinnert et al., 1997), was adapted and used by the RN case manager. The 40-minute FAMSS interview was shortened to a 20-minute format in order to conduct the interview during limited clinical time. National Inner-City Asthma Study questions were added (Mitchell et al., 1997) to assess asthma medication barriers and beliefs. The interview was examined for content validity by an expert asthma researcher. The psychometrics of the adapted tool were not measured due to the descriptive, exploratory nature of the study. Table 2 shows sample interview questions. The RN case manager used predetermined criteria to judge written transcripts for elements associated with successful asthma management including general asthma knowledge, symptom perception, symptom response, primary care provider (PCP) planning, environmental control, medication compliance, and adherence complications. Utilization and Access Medical record review examined inhaled steroid prescription rates and asthma specialty clinic use. Data were collected reflecting utilization of acute care, emergency care, and asthma-related primary care services. The number of PCPs involved in asthma care also was considered. Results Sample Characteristics Thirty-five children in 34 families participated for 1 year. According to current National Heart Lung and Blood Institute guidelines (National Institutes of Health, 2002), all 35 participants met criteria for persistent asthma. The average age was 7.9 years (range 18 months to 16 years). Twelve children were female (34%). Eight children (23%) were African American, 21 (60%) Hispanic, and 6 (17%) white (non-Hispanic). Of those reporting, 21 (62%) mothers were single, 8 (24%) were married, and 4 (12%) were grandmothers who served as guardians. The children had a mean 34.2 (0-75) months of asthma management records in the healthcare system. Twenty-eight percent of participants had no insurance coverage, while Medicaid HMO covered 26% and Medicaid covered 23%. Ten percent had S-CHIP, 10% had private insurance, and 3% were covered by an indigent care grant. Family Knowledge and Management Interview results indicated that, although many parents (82%) included "difficulties with breathing" in their definition of asthma, fewer (58%) freely associated the lungs with their definition of asthma. Most parents and children (97%) could identify at least one symptom indicating an asthma exacerbation, most often coughing and wheezing, but fewer (36%) could name signs of an impending exacerbation. Only 64% could distinguish between severe exacerbation symptoms and less severe symptoms. Retractions, posturing, and lethargy were listed as symptoms parents first recognized. Many (76%) identified a seasonal asthma symptom pattern; however, fewer (55%) identified a daily symptom pattern to their child's asthma. Most families (76%) could name symptoms requiring treatment, but fewer (12%) could name symptoms, such as onset of a cold or exposure to environmental triggers, requiring proactive treatment. With asthma exacerbations, 55% of families did not include assessment of the child's condition, 58% did not identify symptoms necessitating emergency treatment, and 88% did not identify symptoms necessitating contact with their primary care providers. Only one family indicated it had a written plan outlining home asthma care. Most families had a nebulizer (91%) and medications (73%) at home, and most parents could name their children's medications (73%). Questions targeting asthma medication beliefs suggest the majority of families believe beta-agonists (90%) and oral steroids (90%) help asthma. However, of those prescribed inhaled steroids, 29% believed they did not help or were unsure about efficacy. Several parents (26%) stated cost was a barrier to providing asthma medications, 35% expressed fear of medication addiction, and 42% expressed fear of medication side effects. Parents did not prefer alternative treatments, or feared giving the incorrect dose (4%). Some families indicated as reasons for nonadherence a lack of availability of asthma medications at the pharmacy (19%), a lack of transportation to the pharmacy (19%), difficulty following the medication schedule (13%), and the desire to stop medication before the prescription was finished (16%). However, more parents indicated that difficulty giving medications (42%) and not having the medication at home when needed (45%) were more likely reasons for not giving asthma medications. Utilization and Access Sixty percent of patients were prescribed an inhaled steroid, and 43% had consulted with a pediatric allergist. Children were likely to see multiple providers in community clinics for asthma care. The number of providers correlates to both number of visits made to community health clinics for asthma care ([r.sub.s] = 0.741, p [less than or equal to] 0.05) and with the length of time children are enrolled in the system ([r.sub.s] = 0.561, p Discussion Episodic asthma care and low level of medication adherence by urban children with asthma has been reported. We observed in our cohort of children with persistent asthma that significant deficits exist in disease understanding and care management. Only one patient reported having a written exacerbation management plan. Beliefs regarding medication addiction and side effects were frequently reported as barriers to medication adherence. Children seeking asthma care in primary care settings are likely to see multiple care providers. This appears to be related to poor problem solving around asthma exacerbations. These results indicate that family and system factors--or predisposing and enabling attributes--appear to serve as access barriers for these urban children with asthma. Exacerbation Management Inadequate caretaker understanding regarding exacerbation management is a factor in increased utilization (Warman et al., 1999), and our results are similar in this regard. Parents denied having written exacerbation management plans, an issue noted by others (Yoos et al., 1997) and a factor in increased ED use (Wasilewski et al., 1996). According to Andersen's model, education regarding what to do and where to go during an asthma exacerbation would be a factor enabling a person to appropriately access healthcare services. The lack of exacerbation management information may increase this population's use of emergency resources. Medication Beliefs Low caretaker confidence in asthma medications is a risk factor for ED use (Wasilewski et al., 1996). One recent study found that health beliefs and other social stressors intrinsic to urban caretakers were found to be more significant barriers to asthma care than were availability of services, cost, or insurance status (Mansour et al., 2000). Our results also suggest that beliefs inherent to urban caregivers, or predisposing attributes, may be equally important as cost barriers. Past research has repeatedly reported a low level of adherence with asthma medication regimens, particularly in urban populations (Butz et al., 2000; Diaz et al., 2000; Warman et al., 1999). Lack of understanding about the use of inhaled steroids during asymptomatic periods may contribute to their underuse, but concern about side effects is a commonly cited reason for nonadherence (Chambers, Markson, Diamond, Lasch, & Berger, 1999). Although the uninsured composed the largest percent of study participants (28%), we found that many families named a fear of side effects and addiction as reasons for potential non-adherence. A lack of education targeting beliefs about medications and the persistence of asthma may have an impact on how children with asthma living in urban poverty access services differently. In addition, the role of Andersen's predisposing and enabling attributes in access to healthcare services, or the hypothesis of a link among medication beliefs, misinformation, misuse, and resource utilization, appears to be supported by findings in this study. Continuity of Care Children seeking primary care appear to experience a lack of continuity, with its associated use of emergency services and hospitalizations (Christakis, Mell, Koepsell, Zimmerman, & Connell, 2001). Children receiving asthma care by a PCP who could be reached by telephone, who had received a written asthma plan (Warman et al., 2001), and who perceive themselves as active participants in their care management (Chambers et al., 1999) are more likely to use controller therapy. Focus group interviews of urban minority caretakers suggest the theme of inconsistent care and messages given by providers is important (Yoos et al., 1997). For our sample, the healthcare system, poised to act as an enabling attribute to appropriately accessing healthcare services, may instead be contributing to these children's reliance on emergency services. Limitations and Implications This study's small sample size and exclusion of monolingual Spanish-speaking participants are limitations. However, results suggest the need for further research into how beliefs and system factors affect use of primary care and medication adherence. How the characteristics of urban healthcare systems affect quality patient care should be considered when creating consistent, quality health-education programs. Studies incorporating larger samples that circumvent language barriers may better investigate the reasons for urban children to suffer a disparate asthma burden. Expanded nursing roles, such as case management and health educators offering continuity and comprehensive teaching, may help better serve impoverished urban children with asthma. Table 1. Asthma Resources The following Web sites provide information on asthma management guidelines and exacerbation management guidelines: nationaljewish.org / pdf / asthma_action_plan.pdf http://www.nhlbi.nih.gov / guidelines / asthma / asthgdln.htm http://www.aaaai.org / members / resources / initiatives / pediatricasthma.stm Table 2. Sample Questions From Semistructured Interview * Tell me your understanding of what asthma is. * How do you tell your child is having breathing problems? * What things cause your child to wheeze? * Tell me, step-by-step, using as much detail as you can, what you do when your child has trouble with his/her asthma. * What has your doctor told you to do if your child has an asthma attack? Has a plan ever been written out for you? * Can you tell me the names and doses of your child's medications? * When does your child have the most trouble with his/her asthma? Is there a time of year or a time of day? * Do you think oral steroids (give example of medication) help your child's breathing problems? * Do you think inhaled steroids (give example of medication) help your child's breathing problems? * People have many reasons why they might not be able to give their child his/her asthma medicines. Can you tell me if any of the following have caused you not to be able to give your child his/her asthma medicines? --Hard to get to the pharmacy --Medicines cost too much --Ran out or wasn't prepared --Afraid of child becoming addicted --Side effects --Use alternative treatment --Trouble getting child to take medication --Afraid of wrong dosage --Schedule or prescription hard to follow