Misconceptions among nurses about evidence-based practice.

PURPOSE: To delineate the origins and fundamental tenets of evidence-based practice (EBP) and to enhance understanding of this important term. METHODS: A critical review of the literature pertaining to evidence-based practice from the fields of medicine and nursing, including international reports. FINDINGS: The roots of EBP indicate this term is not a synonym for research utilization but rather is the rubric for a set of epistemologic assumptions. Key components of EBP include evidence hierarchies and systematic reviews. Differences were found between the views of EBP presented in papers published by nurses within the US compared to those published by nurses outside the US. CONCLUSIONS: The literature shows incongruity in the interpretation of the basic tenets of the evidence-based paradigm. Additionally, nurses may underestimate implications of the evidence-based movement. These two problems impede nurses' participation as full partners in the advancement of evidence-based practice. They also represent a call to action to achieve a more standardized framework for advancing EBP in nursing.

Lessons learned while collecting ANA indicator data.

Realizing the importance of linking nursing's contribution to quality patient care, a pilot study was conducted to determine whether data regarding the quality indicators proposed by the American Nurses' Association (ANA) could be collected from five acute-care inpatient units at one medical center that is part of a multisite managed care system. Although it was determined that data regarding the ANA quality indicators could be collected at the study site, a variety of unanticipated findings emerged. These findings reflect both discrepancies and congruities between how the investigative team expected the ANA indicators to operate versus what was actually experienced. The lessons learned while collecting ANA indicator data are shared to assist future users and to advance the evolution of the ANA indicators.

Focused obstetrical clinic for active duty junior enlisted service women: model for improved outcomes.

OBJECTIVE: To evaluate the utility of an interdisciplinary clinic in improving perinatal outcomes for all pregnant patients of junior enlisted rank (E4 and below) in response to previous reports that this group is at higher risk for adverse outcomes. METHODS: The study population included all junior enlisted active duty patients (E4 and below) delivering between January 1, 1993, and June 30, 1996. Outcomes for patients receiving care in a focused active duty obstetrical clinic were compared with outcomes in similar cohorts of senior active duty patients (E5 and above) and non-active duty pregnant patients. Evaluation was based on perinatal outcomes, including chorioamnionitis, postpartum hemorrhage, intrauterine growth retardation, cesarean delivery, preterm delivery rates (< 37 weeks), postterm delivery rates (> 41 weeks), postpartum days, mean gestational age at delivery, mean delivery weights, Apgar scores at 1 and 5 minutes, preeclampsia, and premature labor. Variables with potential to confound perinatal outcomes were also studied. Confounding variables included tobacco use, gestational diabetes, chronic hypertension, thyroid disease, history of substance abuse, and alcohol use. Power analysis accomplished before initiation of the study showed adequate sample size (> 240 patients in each group) to demonstrate statistically different rates of preterm delivery. Statistical analysis was done using the chi 2 test for categorical variables and Student's t test for continuous variables. RESULTS: There were no statistical differences between junior active duty patients, senior active duty patients, and non-active duty patients in preterm delivery and other outcome variables. CONCLUSION: The focused obstetrical clinic, conducted for junior enlisted soldiers by a senior nurse practitioner, appears to provide an intervention that ensures perinatal outcomes equal to those of both the non-active duty and the senior active duty population.

Patient satisfaction and loyalty among military healthcare beneficiaries enrolled in a managed care program.

OBJECTIVE: A study was performed to evaluate military beneficiaries' motivation for choosing to change from a civilian managed care system to the military managed care system. BACKGROUND: Concerns about healthcare cost, quality, and access underpin major reform in military healthcare. The military health system (MHS) is implementing managed care through an initiative known as TRICARE. Patient choice and satisfaction are highly relevant to all healthcare delivery systems; they are being explored aggressively in the MHS as TRICARE evolves. METHODS: This descriptive study was conducted using a telephone survey consisting of 63 items derived from four pre-existing instruments as well as five facility-specific questions and demographics. The population of interest targeted military beneficiaries on a TRICARE waiting list who, at the time of enrollment, indicated a desire to receive care at the military facility. RESULTS: Consumers were inclined to return to the military system because of loyalty. Also, this study provided evidence that staff courtesy is important to those who seek healthcare. Good quality and accessibility were verified as essential elements in sustaining a consumer's positive view of and attraction to a particular healthcare system. Cost was proven to be a less substantial factor of consumer decision making. CONCLUSIONS: Surveys such as this give healthcare providers more information about aspects of care, such as patient loyalty and interpersonal dynamics, that attract people to their healthcare delivery systems. For healthcare systems to thrive, consumer influence and the power of patient dissatisfaction must be understood.

A classification scheme for outcome indicators.

PURPOSE: To provide a framework for classifying outcome indicators for a more comprehensive view of outcomes and quality. METHODS: Review of outcomes literature published since 1974 from medicine, nursing, and health services research to identify indicators. Outcome indicators were clustered inductively. FINDINGS: Three groups of outcome indicators were identified: patient-focused, provider-focused, and organization-focused. Although investigators tend to focus on a select few outcome indicators, such as patient satisfaction, quality of life, and mortality, many indicators exist to measure outcomes. CONCLUSIONS: Selecting and integrating a wide array of outcome indicators from the various categories will provide a more balanced view of health care delivery as compared with focusing on a few common indicators or only one category.

A provocative look at performance measurement.

A fascinating web of issues can be spun from the notion of performance measurement. After a brief discussion about the background of performance measurement, this article puts performance measurement into a fresh light by examining three major issues: the concept of quality and its application to performance measurement, the power of the patient and the transition of focus to customers within health care organizations, and deliberations about data and concomitant implications for information systems of the future.

The language of outcomes.

Outcomes are a topic of great interest. Their potential is considerable as a mechanism to evaluate quality, improve effectiveness, and link practice to professional accountability. Greater clarity and precision in the use of outcomes terminology will allow this potential to be realized. This article identifies the current confusion in outcomes terminology, begins an outcomes lexicon, and issues a call to action for further clarification in the language of outcomes.

Quality health outcomes model. American Academy of Nursing Expert Panel on Quality Health Care.

PURPOSE: Donabedian's 1966 framework of structure, process, and outcome has guided three decades of study in the United States of the elements needed to evaluate and compare medical care quality. Donabedian's perspective was essentially linear, assuming that structures affect processes, which in turn affect outcomes. Patient characteristics are sometimes considered as mediating outcomes and clinical interventions are considered to be processes. A model is presented in the following article that relates multiple factors affecting quality of care to desired outcomes. It extends previous models by positing dynamic relationships with indicators that not only act upon, but reciprocally affect the various components. SCOPE AND SOURCES: The proposed model was derived from a synthesis of the authors' experience in quality of care practice and research, as well as selected previous theories. CONCLUSIONS: The quality health outcomes model is sufficiently broad (a) to guide development of databases for quality improvement and outcomes management, (b) to suggest key variables in clinical intervention research, and (c) to provide a framework for outcomes research and outcomes management that compares not only treatment options, but organizational or system level interventions. The model also has several policy implications.

Policy issues associated with analyzing outcomes of care.

Policy questions associated with the conduct of outcomes studies are addressed and outcomes management and outcomes research are differentiated. Multiple outcomes initiatives are being undertaken in the United States, from the institutional to national and international levels. Nurses have had limited involvement, thus far-although the array of outcomes being examined is considerable. Members of an American Academy of Nursing expert panel on quality health care discuss the environmental context and multiple focuses of outcomes analysis. They provide an overview of current activities, present the challenges confronting nursing in its pursuit of a quality assessment agenda, and make recommendations for increasing nurses' participation in quality initiatives.

Utilization of supplemental agency nurses in an Army medical center.

The purpose of this study was to describe the perceived impact of supplemental agency nurses upon the quality of patient care, unit cohesiveness, and morale of permanently assigned personnel at an Army medical center. The study population consisted of 28 agency nurses and 138 permanently assigned nursing staff. The study was descriptive and exploratory in nature, utilizing the method of content analysis. Major themes that emerged from data analysis included economic, professional nursing, and patient care issues. Perceptions were that agency nurses provided the institution with necessary labor, but that the agency nurses had greater flexibility of hours and control over their practice. Permanently assigned nursing staff reported that the use of agency services hindered continuity of patient care, at times reduced the quality of care, negatively affected morale among personnel, and impacted adversely upon the time available for mission-related training.

Outcomes: two directions--research and management.

Outcomes research took hold in the late 1980s. Because of the rising costs of health care, policymakers demanded an objective analysis of treatments and interventions as demonstrated by cost-effective patient outcomes. More recently, outcomes management programs have surfaced. In contrast to outcomes research, which is concerned with effectiveness, outcomes management is concerned with efficiency. Therefore, this one concept, outcomes, has moved in two related but different directions. Understanding outcomes from both the research and management perspectives is a challenge facing the nursing profession.

A critical analysis of hardiness.

Hardiness is a construct with widespread appeal to nurse researchers. Of 97 papers reviewed, 35 were written by nurses. Because of its popularity, there is a pressing need to analyze hardiness carefully. This critical analysis of hardiness describes Kobasa's work as the foundation of hardiness research, provides a review of hardiness in the nursing literature, and recommends future hardiness research.

Clinical case management in the Army medical department.

Clinical case management is a system that has the potential to improve the efficiency and effectiveness of health care delivery. Given this potential, the Army Medical Department (AMEDD) is examining this process as a means to achieve goals of quality care and cost effectiveness. In this article, the authors describe the concept of case management, the AMEDD system of clinical case management, the implementation of clinical case management in the AMEDD, and the role of the case manager.

Nursing implications of the Department of Defense Coordinated Care Program.

As the Department of Defense implements the Coordinated Care Program (CCP), it is essential to examine the implications of such a change for nursing. The nursing aspects of a CCP must be designed with consideration of nursing's contribution to patient care and hence the relationship of nursing to quality, access, and cost containment goals. In this paper, following an overview of the CCP, three major nursing implications of the CCP are identified and addressed. These are: (a) the cost of nursing, (b) the structure of nursing, and (c) the role of nurses.

The health care environment: issues and questions for nurses.

We must understand today's health care environment to ensure that the future of health care accommodates the needs of patients as well as health care providers in general and nurses in particular. To that end, five concepts from the macroenvironment--awareness, cost, quality, access, and policymaking--and three concepts from the microenvironment--patients, clinicians, and administrators--are examined in this paper. Although the number of questions raised exceeds the number of answers posed, identifying critical questions is a necessary first step in searching for solutions to health care challenges.