Development of A Patient-Nurse Trust Scale in Underserved Community Setting.

This study developed and evaluated an instrument to measure the patient-nurse trust relationship in a medically underserved community. An exploratory sequential design was employed. In-depth interviews with 20 patients and 15 nurses were conducted to elicit their experiences regarding trust. Interview results were coded, analyzed and formatted into a Likert scale instrument. The instrument was administered to 120 patients. 19 items were retained for the final instrument with item-to-total correlational coefficients greater than 0.5, and a Cronbach's alpha of 0.95. Both construct validity and preliminary criterion validity were confirmed. Psychometric proportions of the instrument were established.

Utilizing a Mobile Health Intervention to Manage Hypertension in an Underserved Community.

This 6-month pilot randomized controlled trial examined the effectiveness of a Mobile Health (mHealth) intervention for hypertension self-monitoring and management in an underserved urban community. The four health outcomes measured included changes in systolic and diastolic blood pressure (BP), BP monitoring adherence, perceived medication adherence self-efficacy, and health-related quality of life. Thirty participants were randomly assigned to the mHealth group or a standard follow-up group; 25 participants completed the study. The mHealth group had statistically significant improvement in systolic BP decrease (p = .01). The mHealth group had better adherence to BP monitoring and improved perceived medication adherence self-efficacy at 6 months, compared with the standard follow-up group. The results suggest that an mHealth intervention has the potential to facilitate hypertension management in underserved urban communities.

Parks as Social and Cultural Spaces Among U.S.- and Foreign-Born Latinas.

Parks provide opportunities for people to engage in activities that can promote physical and emotional well-being. Using focus groups and personal interviews conducted in select neighborhoods of a Northeastern city with a high rate of obesity, we examined perceptions of barriers and facilitators regarding the use of parks and park features that would promote physical activity among Latina women ( N = 39). Foreign-born Latinas emphasized the environmental characteristics of parks and the types of amenities that can support preferred cultural and social activities, while U.S.-born Latinas emphasized the use of parks for physical activity and weight management. Most striking were the different ways in which foreign-born participants conceptualized parks as sociocultural family centers, extending more common conceptualizations centered on exercise or individual health gain. These findings suggest the need for new policies that incorporate culturally specific park programming to promote national goals of increasing levels of physical activity for health.

Uncovering the wisdom hidden between the lines: the Collaborative Reflexive Deliberative Approach.

Background: Meta-analysis and meta-synthesis have been developed to synthesize results across published studies; however, they are still largely grounded in what is already published, missing the tacit 'between the lines' knowledge generated during many research projects that are not intrinsic to the main objectives of studies. Objective: To develop a novel approach to expand and deepen meta-syntheses using researchers' experience, tacit knowledge and relevant unpublished materials. Methods: We established new collaborations among primary health care researchers from different contexts based on common interests in reforming primary care service delivery and a diversity of perspectives. Over 2 years, the team met face-to-face and via tele- and video-conferences to employ the Collaborative Reflexive Deliberative Approach (CRDA) to discuss and reflect on published and unpublished results from participants' studies to identify new patterns and insights. Results: CRDA focuses on uncovering critical insights, interpretations hidden within multiple research contexts. For the process to work, careful attention must be paid to ensure sufficient diversity among participants while also having people who are able to collaborate effectively. Ensuring there are enough studies for contextual variation also matters. It is necessary to balance rigorous facilitation techniques with the creation of safe space for diverse contributions. Conclusions: The CRDA requires large commitments of investigator time, the expense of convening facilitated retreats, considerable coordination, and strong leadership. The process creates an environment where interactions among diverse participants can illuminate hidden information within the contexts of studies, effectively enhancing theory development and generating new research questions and strategies.

Contextual levers for team-based primary care: lessons from reform interventions in five jurisdictions in three countries.

Background: Most Western nations have sought primary care (PC) reform due to the rising costs of health care and the need to manage long-term health conditions. A common reform-the introduction of inter-professional teams into traditional PC settings-has been difficult to implement despite financial investment and enthusiasm. Objective: To synthesize findings across five jurisdictions in three countries to identify common contextual factors influencing the successful implementation of teamwork within PC practices. Methods: An international consortium of researchers met via teleconference and regular face-to-face meetings using a Collaborative Reflexive Deliberative Approach to re-analyse and synthesize their published and unpublished data and their own work experience. Studies were evaluated through reflection and facilitated discussion to identify factors associated with successful teamwork implementation. Matrices were used to summarize interpretations from the studies. Results: Seven common levers influence a jurisdiction's ability to implement PC teams. Team-based PC was promoted when funding extended beyond fee-for-service, where care delivery did not require direct physician involvement and where governance was inclusive of non-physician disciplines. Other external drivers included: the health professional organizations' attitude towards team-oriented PC, the degree of external accountability required of practices, and the extent of their links with the community and medical neighbourhood. Programs involving outreach facilitation, leadership training and financial support for team activities had some effect. Conclusion: The combination of physician dominance and physician aligned fee-for-service payment structures provide a profound barrier to implement team-oriented PC. Policy makers should carefully consider the influence of these and our other identified drivers when implementing team-oriented PC.

Interprofessional teamwork innovations for primary health care practices and practitioners: evidence from a comparison of reform in three countries.

CONTEXT: A key aim of reforms to primary health care (PHC) in many countries has been to enhance interprofessional teamwork. However, the impact of these changes on practitioners has not been well understood. OBJECTIVE: To assess the impact of reform policies and interventions that have aimed to create or enhance teamwork on professional communication relationships, roles, and work satisfaction in PHC practices. DESIGN: Collaborative synthesis of 12 mixed methods studies. SETTING: Primary care practices undergoing transformational change in three countries: Australia, Canada, and the USA, including three Canadian provinces (Alberta, Ontario, and Quebec). METHODS: We conducted a synthesis and secondary analysis of 12 qualitative and quantitative studies conducted by the authors in order to understand the impacts and how they were influenced by local context. RESULTS: There was a diverse range of complex reforms seeking to foster interprofessional teamwork in the care of patients with chronic disease. The impact on communication and relationships between different professional groups, the roles of nursing and allied health services, and the expressed satisfaction of PHC providers with their work varied more within than between jurisdictions. These variations were associated with local contextual factors such as the size, power dynamics, leadership, and physical environment of the practice. Unintended consequences included deterioration of the work satisfaction of some team members and conflict between medical and nonmedical professional groups. CONCLUSION: The variation in impacts can be understood to have arisen from the complexity of interprofessional dynamics at the practice level. The same characteristic could have both positive and negative influence on different aspects (eg, larger practice may have less capacity for adoption but more capacity to support interprofessional practice). Thus, the impacts are not entirely predictable and need to be monitored, and so that interventions can be adapted at the local level.

Coaching strategies for enhancing practice transformation.

BACKGROUND: Current research on primary care practice redesign suggests that outside facilitation can be an important source of support for achieving substantial change. OBJECTIVES: To analyse the specific sequence of strategies used by a successful practice facilitator during the American Academy of Family Physicians' (AAFP) National Demonstration Project (NDP). METHODS: This secondary analysis describes a sequence of strategies used to produce change in family medicine practices attempting to adopt a new model of care. The authors analysed qualitative data generated by one facilitator and six practices by coding facilitator field notes, site visit reports, qualitative summaries, depth interviews and email strings. RESULTS: The facilitator utilized practice member coaching in addition to consulting, negotiating and connecting approaches. Coaching strategies encouraged: (i) expansive, multi-directional, attentive styles of communication; (ii) solving practical problems together; (iii) modelling facilitative leadership and (iv) encouraging an expanded vision of care. Practice members who received consistent coaching reported internal shifts and new ways of conceptualizing work, not just success at implementing model components. They indicated that their facilitator had helped them think and behave in new ways while helping them achieve benchmarks. CONCLUSIONS: It was once believed that the transition from traditional models of family medicine practice to new models of care meant implementing new technological components, suggesting that outside facilitators should act as technological and care delivery consultants. However, coaches may be especially useful in helpful in practices undertake substantial changes.

The transformational role of nursing in health care reform.

Successful health care reform will require more than insuring 32 million additional Americans. It will demand that our expensive, hospital and provider-driven model of care adopt a community-driven wellness model that emphasizes disease prevention. Nursing is perfectly situated to lead this transformation. By educating students in ways that build on nursing's legacy of health promotion and disease prevention, nurse educators can prepare nursing students to partner with underserved communities to offer low-cost, prevention-based services that meet local needs. This article uses preliminary data from the Jordan & Harris Community Health Center in Newark, New Jersey, to demonstrate how nurses can serve as role models in microsystem health care, while still following the Institute of Medicine's recommendations for health care reform.

More black box to explore: how quality improvement collaboratives shape practice change.

BACKGROUND: Quality improvement collaboratives (QICs) are used extensively to promote quality improvement in health care. Evidence of their effectiveness is limited, prompting calls to "open up the black box" to better understand how and why such collaboratives work. METHODS: We selected a cohort of 5 primary care practices that participated in a 6-month intervention study aimed at improving colorectal cancer screening rates. Using an immersion/crystallization technique, we analyzed qualitative data that included audio recordings and field notes of QICs and practice-based team meetings. RESULTS: Three themes emerged from our analysis: (1) practice staff became empowered through and drew on the QICs to advance change efforts in the face of leader/physician resistance; (2) a mix of content and media in the QIC program was important for reaching all participants; (3) resources offered at the QIC did little to spur practice change efforts. CONCLUSION: QICs offer a potentially powerful way of disseminating health care innovations through enhanced strategies for learning and change. Creating collaborative environments in which diverse participants learn, listen, reflect, and share together can enable them to take back to their own organizations key messages and change strategies that benefit them the most.

Meeting the challenge of practice quality improvement: a study of seven family medicine residency training practices.

PURPOSE: Incorporating quality improvement (QI) into resident education and clinical care is challenging. This report explores key characteristics shaping the relative success or failure of QI efforts in seven primary care practices serving as family medicine residency training sites. METHOD: The authors used data from the 2002-2008 Using Learning Teams for Reflective Adaptation study to conduct a comparative case analysis. This secondary data analysis focused on seven residency training practices' experiences with the reflective adaptive process (RAP), a 12-week intensive QI process. Field notes, meeting notes, and audiotapes of RAP meetings were used to construct case summaries. A matrix comparing key themes across practices was used to rate practices' QI progress during RAP on a scale of 0 to 3. RESULTS: Three practices emerged as unsuccessful (scores of 0-1) and four as successful (scores of 2-3). Larger practices with previous QI experience, faculty with extensive exposure to QI literature, and an office manager, residency director, or medical director who advocated the process made substantial progress during RAP, succeeding at QI. Smaller practices without these characteristics were unable to do so. Successful practices also engaged residents in the QI process and identified serious problems as potential crises; unsuccessful practices did not. CONCLUSIONS: Larger residency training practices are more likely to have the resources and characteristics that permit them to create a QI-supportive culture leading to QI success. The authors suggest, however, that smaller practices may increase their chances of success by adopting a developmental approach to QI.

Evaluation of patient centered medical home practice transformation initiatives.

BACKGROUND: The patient-centered medical home (PCMH) has become a widely cited solution to the deficiencies in primary care delivery in the United States. To achieve the magnitude of change being called for in primary care, quality improvement interventions must focus on whole-system redesign, and not just isolated parts of medical practices. METHODS: Investigators participating in 9 different evaluations of Patient Centered Medical Home implementation shared experiences, methodological strategies, and evaluation challenges for evaluating primary care practice redesign. RESULTS: A year-long iterative process of sharing and reflecting on experiences produced consensus on 7 recommendations for future PCMH evaluations: (1) look critically at models being implemented and identify aspects requiring modification; (2) include embedded qualitative and quantitative data collection to detail the implementation process; (3) capture details concerning how different PCMH components interact with one another over time; (4) understand and describe how and why physician and staff roles do, or do not evolve; (5) identify the effectiveness of individual PCMH components and how they are used; (6) capture how primary care practices interface with other entities such as specialists, hospitals, and referral services; and (7) measure resources required for initiating and sustaining innovations. CONCLUSIONS: Broad-based longitudinal, mixed-methods designs that provide for shared learning among practice participants, program implementers, and evaluators are necessary to evaluate the novelty and promise of the PCMH model. All PCMH evaluations should as comprehensive as possible, and at a minimum should include a combination of brief observations and targeted qualitative interviews along with quantitative measures.

Using Learning Teams for Reflective Adaptation (ULTRA): insights from a team-based change management strategy in primary care.

PURPOSE: The Using Learning Teams for Reflective Adaptation (ULTRA) study used facilitated reflective adaptive process (RAP) teams to enhance communication and decision making in hopes of improving adherence to multiple clinical guidelines; however, the study failed to show significant clinical improvements. The purpose of this study was to examine qualitative data from 25 intervention practices to understand how they engaged in a team-based collaborative change management strategy and the types of issues they addressed. METHODS: We analyzed field notes and interviews from a multimethod practice assessment, as well as field notes and audio-taped recordings from RAP meetings, using an iterative group process and an immersion-crystallization approach. RESULTS: Despite a history of not meeting regularly, 18 of 25 practices successfully convened improvement teams. There was evidence of improved practice-wide communication in 12 of these practices. At follow-up, 8 practices continued RAP meetings and found the process valuable in problem solving and decision making. Seven practices failed to engage in RAP primarily because of key leaders dominating the meeting agenda or staff members hesitating to speak up in meetings. Although the number of improvement targets varied considerably, most RAP teams targeted patient care-related issues or practice-level organizational improvement issues. Not a single practice focused on adherence to clinical care guidelines. CONCLUSION: Primary care practices can successfully engage in facilitated team meetings; however, leaders must be engaged in the process. Additional strategies are needed to engage practice leaders, particularly physicians, and to target issues related to guideline adherence.

'In the Moment': An Analysis of Facilitator Impact During a Quality Improvement Process.

Facilitators frequently act 'in the moment' - deciding if, when and how to intervene into group process discussions. This paper offers a unique look at how facilitators impacted eleven primary care teams engaged in a 12-week quality improvement (QI) process. Participating in a federally funded QI trial, primary care practices in New Jersey and Pennsylvania formed practice-based teams comprised of physicians, nurses, administrative staff, and patients. External facilitators met with each team to help them identify and implement changes aimed at improving the organization, work relationships, office functions, and patient care. Audio-recordings of the meetings and descriptive field notes were collected. These qualitative data provided information on how facilitators acted 'in the moment' and how their interventions impacted group processes over time. Our findings reveal that facilitators impacted groups in multiple ways throughout the QI process, rather than through a linear progression of stages or events. We present five case examples that show what acting 'in the moment' looked like during the QI meetings and how these facilitator actions/interventions impacted the primary care teams. These accounts provide practical lessons learned and insights into effective facilitation that may encourage others in their own facilitation work and offer beneficial strategies to facilitators in other contexts.