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BACKGROUND: Identifying and treating acute and chronic behavioral health conditions is integral to primary care practice, yet primary care nurse practitioner (NP) training models do not meet the demand for integrated behavioral health practices. Simulation offers an effective pedagogical tool for integrating behavioral health training in primary care. METHOD: With support from federal funding and external consultants, new didactic and complementary simulation curricula in integrated behavioral health care were introduced in the primary care and psychiatric mental health NP programs at a school of nursing. Two rounds of this curricular innovation were implemented and evaluated across specialties. RESULTS: Ninety-seven students participated in the training and reported enhanced behavioral-health assessment and hand-off skills, greater confidence in applying core content, and improved communication skills. CONCLUSION: Thoughtfully designed simulation offers an important tool for developing integrated behavioral health competencies that will help prepare future primary care clinicians meet the needs of patients and communities. [J Nurs Educ. 2024;63(2):128-133.].
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Educação de Pós-Graduação em Enfermagem , Profissionais de Enfermagem , Humanos , Profissionais de Enfermagem/educação , Currículo , Pesquisa em Educação em Enfermagem , Competência Clínica , Atenção Primária à SaúdeRESUMO
BACKGROUND: The National Clinician Scholars Program (NCSP) is an interprofessional postdoctoral fellowship for physicians and nurses with a PhD. or DNP focused on health services research, policy, and leadership. PURPOSE: To evaluate 5-year outcomes of nurse postdoctoral scholars in the NCSP. METHODS: We describe the 5-year outcomes of nurse fellows and graduates from six NCSP sites (positions, number of peer-reviewed publications, citations, and h-index). CONCLUSION: There were 53 nurses in the sample (34 alumni, 19 fellows). Approximately half (47%, n = 16) of alumni had tenure-track faculty positions and had bibliometric performance indicators (such as h-indices) 2 to 4 times greater than those previously reported for assistant professors in nursing schools nationally. NCSP nurse scholars and alumni also had an impact on community partnerships, health equity, and health policy DISCUSSION: This study highlights the potential of interprofessional postdoctoral fellowships such as the NCSP to prepare nurse scientists for health care leadership roles.
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Médicos , Pós-Doutorado , Humanos , Pessoal de Saúde , Atenção à Saúde , Serviços de Saúde , Bolsas de EstudoRESUMO
PURPOSE: We undertook a study to examine how stigma influences the uptake of training on medication for opioid use disorder (MOUD) in primary care academic programs. METHODS: We conducted a qualitative study of 23 key stakeholders responsible for implementing MOUD training in their academic primary care training programs that were participants in a learning collaborative in 2018. We assessed barriers to and facilitators of successful program implementation and used an integrated approach to develop a codebook and analyze the data. RESULTS: Participants represented the family medicine, internal medicine, and physician assistant fields, and they included trainees. Most participants described clinician and institutional attitudes, misperceptions, and biases that enabled or hindered MOUD training. Perceptions included concerns that patients with OUD are "manipulative" or "drug seeking." Elements of stigma in the origin domain (ie, beliefs by primary care clinicians or the community that OUD is a choice and not a disease), the enacted domain (eg, hospital bylaws banning MOUD and clinicians declining to obtain an X-Waiver to prescribe MOUD), and the intersectional domain (eg, inadequate attention to patient needs) were perceived as major barriers to MOUD training by most respondents. Participants described strategies that improved the uptake of training, including giving attention to clinician concerns, clarifying the biology of OUD, and ameliorating clinician fears of being ill equipped to provide care for patients. CONCLUSIONS: OUD-related stigma was commonly reported in training programs and impeded the uptake of MOUD training. Potential strategies to address stigma in the training context, beyond providing content on effective evidence-based treatments, include addressing the concerns of primary care clinicians and incorporating the chronic care framework into OUD treatment.
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Aprendizagem , Transtornos Relacionados ao Uso de Opioides , Humanos , Estigma Social , Pesquisa Qualitativa , Transtornos Relacionados ao Uso de Opioides/terapia , Atenção Primária à SaúdeRESUMO
A diverse and well-trained, distributed and resourced primary care workforce is essential for advancing health equity. However, few standardized models exist to guide health care professions education (HCPE) on core competencies regarding understanding and effectively addressing social determinants of health, social injustice, structural barriers, and the high burden of health needs in marginalized populations. We propose a framework with domains of policies and incentives, enabling institutional climate, educational content and integration, and community-orientation and community engagement. The framework encompasses inter-disciplinary team-based care and immersive community experiences to equip learners with cognitive skills and knowledge needed to understand and address unmet needs and ensure equitable access to the entire continuum of care. Research is needed to understand barriers and promoters of a health equity-guided HCPE, and standards for theory-driven curricular contents and metrics to evaluate and track progress. Multisector collaborations and demonstration projects may help guide standardized training on advancing health equity.
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Drug overdose death rates from opioid use have risen steadily since 1999 and reached epidemic levels, slowing for the first time in 2018, though not for many forms of opioid use. Yet evidence-based approaches to combating OUD, such as medication-assisted treatment for OUD (MT-OUD), are still inaccessible to many. Primary care providers are well-positioned to offer these services; however, training and education in OUD care remains inadequate. The National Center for Integrated Behavioral Health interviewed the Health Resources Service Administration (HRSA) awardees of federal funding to implement an MT-OUD curriculum in their primary care residency training programs to identify barriers and facilitators to implementation. Awardees were interviewed at program launch and one year later. Results showed the importance of leadership willingness to participate, effective treatment integration into existing workflow, curriculum and clinical flexibility, and supportive interdisciplinary and community partnerships. Recommendations for best practices of MT-OUD training in primary care are identified.
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We read with great interest Mundinger and Carter's exposition of how, in their view, Doctor of Nursing Practice (DNP) education has lost its way and what consequences might result. Mundinger and Carter note that DNP programs are overwhelming focused on nonclinical practice. We share the concern of Mundinger and Carter about the future of nurse practitioner (NP) education within the context of expanding DNP programs. In this commentary, we raise concerns about NP transition to practice and the limited, but concerning, evidence that new NPs struggle in their transition to practice. We note that this concern is magnified as NPs continue to move into specialty roles. Health systems have responded to this concern by developing residency and fellowship programs. Fifteen years after the AACN position statement on the clinical doctorate was issued, the goal of DNP education remains an unfinished project. An important question remains: Can, will, and how should DNP programs deliver?
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Educação de Pós-Graduação em Enfermagem , Profissionais de Enfermagem , Médicos , HumanosRESUMO
PURPOSE: Several studies have identified differences in end-of-life (EOL) care between urban and rural areas, yet little is known about potential differences in care processes or family evaluations of care. The purpose of this study was to examine the relationship between rurality of residence and quality of EOL care within the Veterans Affairs health care system. METHODS: This study was a retrospective, cross-sectional analysis of 126,475 veterans who died from October 2009 through September 2016 in inpatient settings across 151 facilities. Using unadjusted and adjusted logistic regression, we compared quality of EOL care between urban and rural veterans using family evaluations of care and 4 quality of care indicators for receipt of (1) palliative care consult, (2) a chaplain visit, (3) death in an inpatient hospice unit, and (4) bereavement support. FINDINGS: Veterans from rural areas had lower odds of dying in an inpatient hospice unit compared to veterans from urban areas, before and after adjustment (large rural OR 0.73, 95% CI: 0.70-0.77; P < .001, small rural OR 0.81, 95% CI: 0.77-0.86; P < .001, isolated rural OR 0.87, 95% CI: 0.81-0.93; P < .001). Differences in comparisons of other quality of care indicators were small and of mixed significance. No significant differences were found in family ratings of care in fully adjusted models. CONCLUSION: Receipt of some EOL quality indicators differed with urban-rural residence for some comparisons. However, family ratings of care did not. Our findings call for further investigation into unmeasured individual characteristics and facility processes related to rurality.
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Pacientes Internados/estatística & dados numéricos , População Rural/estatística & dados numéricos , Assistência Terminal/normas , População Urbana/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Distribuição de Qui-Quadrado , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Qualidade da Assistência à Saúde/normas , Qualidade da Assistência à Saúde/estatística & dados numéricos , Estudos Retrospectivos , Assistência Terminal/estatística & dados numéricos , Estados Unidos , United States Department of Veterans Affairs/organização & administração , United States Department of Veterans Affairs/normas , United States Department of Veterans Affairs/estatística & dados numéricos , Veteranos/estatística & dados numéricosAssuntos
Ética em Pesquisa/educação , Disparidades em Assistência à Saúde , Liderança , Características de Residência , Justiça Social , Desenvolvimento de Pessoal , Ensino , Beneficência , Ética Médica , Docentes de Medicina , Disparidades nos Níveis de Saúde , Humanos , Autonomia Pessoal , Avaliação de Programas e Projetos de Saúde , Desenvolvimento de Pessoal/métodos , Desenvolvimento de Pessoal/organização & administração , Desenvolvimento de Pessoal/tendências , Ensino/métodos , Ensino/organização & administração , Ensino/tendências , Estados UnidosRESUMO
BACKGROUND: Although most staff in long-term care services and support (LTSS) are nursing care personnel, a method for measuring the provision of nursing care has not yet been developed. PURPOSE/METHODS: We sought to understand the challenges of measuring nursing care across different types of LTSS using a qualitative approach that included the triangulation of data from three unique sources. RESULTS: Six primary challenges to measuring nursing care across LTSS emerged. These included (a) level of detail about time of day, amount of time, or type of tasks varied by type of nursing and organization; (b) time and tasks were documented across clinical records and administrative databases; (c) data existed in both paper and electronic formats; (d) several sources of information were needed to create the fullest picture of nursing care; (e) data were inconsistently available for contracted providers; and (f) documentation of informal caregiving was unavailable. Differences were observed between assisted living facilities and home- and community-based services compared with nursing homes. Differences were also observed across organizations within a setting. A commonality across settings and organizations was the availability of an electronically stored care plan specifying individual needs, but not necessarily how these would be met. CONCLUSIONS: Findings demonstrate the variability of data availability and specificity across three distinct LTSS settings. This study is an initial step toward establishing a process for measuring the provision of nursing care across LTSS in order to explore the range of nursing care needs of LTSS recipients and how these needs are currently fulfilled.
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Assistência de Longa Duração/métodos , Cuidados de Enfermagem/organização & administração , Recursos Humanos de Enfermagem/estatística & dados numéricos , Garantia da Qualidade dos Cuidados de Saúde/métodos , Apoio Social , Estudos de Tempo e Movimento , Idoso , Moradias Assistidas/normas , Centers for Medicare and Medicaid Services, U.S. , Registros Eletrônicos de Saúde/normas , Serviços de Assistência Domiciliar/normas , Humanos , New Jersey , New York , Cuidados de Enfermagem/normas , Cuidados de Enfermagem/estatística & dados numéricos , Casas de Saúde/normas , Recursos Humanos de Enfermagem/psicologia , Pennsylvania , Pesquisa Qualitativa , Estudos Retrospectivos , Estados Unidos , Recursos HumanosRESUMO
Elderly, chronically ill people experience frequent changes in health status that require transitions among health care providers and settings. This issue brief describes two projects that identified the essential elements of effective care management interventions for this population and the facilitators of translating one such intervention, the Transitional Care Model (TCM), into mainstream practice. Together these projects demonstrate that successful translation of the TCM, which incorporates both in-person contact and a nurse-led, interdisciplinary team approach, can effectively interrupt patterns of frequent rehospitalizations, reduce costs, and improve patient health status. Findings from these projects inform challenges that must be overcome to facilitate the translation of effective care management innovations into mainstream practice.
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Doença Crônica/enfermagem , Continuidade da Assistência ao Paciente/organização & administração , Cuidados Críticos/organização & administração , Serviços de Saúde para Idosos/organização & administração , Serviços de Assistência Domiciliar/organização & administração , Administração dos Cuidados ao Paciente/organização & administração , Transferência de Pacientes/organização & administração , Idoso , Cuidadores/educação , Doença Crônica/terapia , Humanos , Cobertura do Seguro , Seguro Saúde , Medicare , Equipe de Assistência ao Paciente , Alta do Paciente , Educação de Pacientes como Assunto , Participação do Paciente , Relações Profissional-Paciente , Estados UnidosRESUMO
BACKGROUND: Comparing disease management programs and their effects is difficult because of wide variability in program intensity and complexity. The purpose of this effort was to develop an instrument that can be used to describe the intensity and complexity of heart failure (HF) disease management programs. METHODS AND RESULTS: Specific composition criteria were taken from the American Heart Association (AHA) taxonomy of disease management and hierarchically scored to allow users to describe the intensity and complexity of the domains and subdomains of HF disease management programs. The HF Disease Management Scoring Instrument (HF-DMSI) incorporates 6 of the 8 domains from the taxonomy: recipient, intervention content, delivery personnel, method of communication, intensity/complexity, and environment. The 3 intervention content subdomains (education/counseling, medication management, and peer support) are described separately. In this first test of the HF-DMSI, overall intensity (measured as duration) and complexity were rated using an ordinal scoring system. Possible scores reflect a clinical rationale and differ by category, with zero given only if the element could potentially be missing (eg, surveillance by remote monitoring). Content validity was evident as the instrument matches the existing AHA taxonomy. After revision and refinement, 2 authors obtained an inter-rater reliability intraclass correlation coefficient score of 0.918 (confidence interval, 0.880 to 0.944, P<0.001) in their rating of 12 studies. The areas with most variability among programs were delivery personnel and method of communication. CONCLUSIONS: The HF-DMSI is useful for describing the intensity and complexity of HF disease management programs.
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Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/terapia , Guias de Prática Clínica como Assunto , Avaliação de Programas e Projetos de Saúde/métodos , Projetos de Pesquisa , American Heart Association , Gerenciamento Clínico , Progressão da Doença , Estudos de Viabilidade , Pessoal de Saúde , Insuficiência Cardíaca/classificação , Insuficiência Cardíaca/fisiopatologia , Humanos , Variações Dependentes do Observador , Cooperação do Paciente , Educação de Pacientes como Assunto , Avaliação de Programas e Projetos de Saúde/normas , Índice de Gravidade de Doença , Estados UnidosRESUMO
Industry-wide health sector reforms in the United States, Canada, and Europe have provided a unique opportunity to examine the effects of hospital restructuring on inpatient nursing care and patient outcomes across an array of settings. Seven interdisciplinary research teams--1 each in Alberta, British Columbia, England, Germany, Ontario, Scotland, and the United States--have formed an international consortium whose aim is to study the effects of such restructuring. Each site has enrolled large numbers of hospitals and nurses to explicate the role that organization of nursing care, a target of hospital restructuring, plays in differential patient outcomes. The study seeks to understand more fully the influence of both nurse staffing and the nursing practice environment on patient outcomes. Discussion of the theoretical foundation, study design, and process of developing the study instruments and measures illustrates the process to date, as well as the feasibility of and opportunities inherent in such an international endeavour.
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BACKGROUND: The study of how the quality of pediatric end-of-life care varies across systems of health care delivery and financing is hampered by lack of methods to adjust for the probability of death in populations of ill children. OBJECTIVE: To develop a prognostication models using administratively available data to predict the probability of in-hospital and 1-year postdischarge death. METHODS: Retrospective cohort study of 0-21 year old patients admitted to Pennsylvania hospitals from 1994-2001 and followed for 1-year postdischarge mortality, assessing logistic regression models ability to predict in-hospital and 1-year postdischarge deaths. RESULTS: Among 678,365 subjects there were 2,202 deaths that occurred during the hospitalization (0.32% of cohort) and 860 deaths that occurred 365 days or less after hospital discharge (0.13% of cohort). The model predicting hospitalization deaths exhibited a C statistic of 0.91, with sensitivity of 65.9% and specificity of 92.9% at the 99th percentile cutpoint; while the model predicting 1-year postdischarge deaths exhibited a C statistic of 0.92, with sensitivity of 56.1% and specificity of 98.4% at the 99th percentile cutpoint. CONCLUSIONS: Population-level mortality prognostication of hospitalized children using administratively available data is feasible, assisting the comparison of health care services delivered to children with the highest probability of dying during and after a hospital admission.
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Mortalidade , Alta do Paciente , Pediatria , Prognóstico , Adolescente , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Mortalidade Hospitalar , Humanos , Lactente , Recém-Nascido , Modelos Logísticos , Masculino , Modelos Teóricos , Pennsylvania/epidemiologia , Estudos Retrospectivos , Adulto JovemRESUMO
The evidence base of what works in chronic care management programs is underdeveloped. To fill the gap, we pooled and reanalyzed data from ten randomized clinical trials of heart failure care management programs to discern how program delivery methods contribute to patient outcomes. We found that patients enrolled in programs using multi-disciplinary teams and in programs using in-person communication had significantly fewer hospital readmissions and readmission days than routine care patients had. Our study offers policymakers and health plan administrators important guideposts for developing an evidence base on which to build effective policy and programmatic initiatives for chronic care management.
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Insuficiência Cardíaca/terapia , Avaliação de Programas e Projetos de Saúde , Idoso , Idoso de 80 Anos ou mais , Doença Crônica/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Qualidade da Assistência à Saúde , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
CONTEXT: Nurse staffing is not the same across an entire hospital. Nursing care is delivered in geographically-based units, with wide variation in staffing levels. In particular, staffing in intensive care is much richer than in nonintensive care acute units. OBJECTIVE: To evaluate the association of in-hospital patient mortality with registered nurse staffing and skill mix comparing hospital and unit level analysis using data from the Veterans Health Administration (VHA). DESIGN, SETTINGS, AND PATIENTS: A retrospective observational study using administrative data from 129,579 patients from 453 nursing units (171 ICU and 282 non-ICU) in 123 VHA hospitals. METHODS: We used hierarchical multilevel regression models to adjust for patient, unit, and hospital characteristics, stratifying by whether or not patients had an ICU stay during admission. MAIN OUTCOME MEASURE: In-hospital mortality. RESULTS: : Of the 129,579 patients, mortality was 2.9% overall: 6.7% for patients with an ICU stay compared with 1.6% for those without. Whether the analysis was done at the hospital or unit level affected findings. RN staffing was not significantly associated with in-hospital mortality for patients with an ICU stay (OR, 1.02; 95% CI, 0.99-1.03). For non-ICU patients, increased RN staffing was significantly associated with decreased mortality risk (OR, 0.91; 95% CI, 0.86-0.96). RN education was not significantly associated with mortality. CONCLUSIONS: Our findings suggest that the association between RN staffing and skill mix and in-hospital patient mortality depends on whether the analysis is conducted at the hospital or unit level. Variable staffing on non-ICU units may significantly contribute to in-hospital mortality risk.
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Mortalidade Hospitalar , Hospitais de Veteranos/estatística & dados numéricos , Recursos Humanos de Enfermagem Hospitalar/provisão & distribuição , Idoso , Competência Clínica/estatística & dados numéricos , Grupos Diagnósticos Relacionados/estatística & dados numéricos , Bacharelado em Enfermagem/estatística & dados numéricos , Feminino , Hemorragia Gastrointestinal/mortalidade , Humanos , Unidades de Terapia Intensiva , Masculino , Análise Multivariada , Recursos Humanos de Enfermagem Hospitalar/educação , Razão de Chances , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Pneumonia/mortalidade , Probabilidade , Estudos Retrospectivos , Risco , Sepse/mortalidade , Choque/mortalidade , Análise de Sobrevida , Estados Unidos , Trombose Venosa/mortalidade , Recursos HumanosRESUMO
BACKGROUND: Mandatory hospital nurse staffing ratios are under consideration in a number of states without strong empirical evidence of the optimal ratio. OBJECTIVE: To determine whether increases in medical-surgical licensed nurse staffing levels are associated with improvements in patient outcomes for hospitals having different baseline staffing levels. RESEARCH DESIGN: Cross-sectional and fixed-effects regression analyses using a 1993-2001 panel of patient and hospital data from California. Splines define 4 staffing ratios. SUBJECTS: Adult acute myocardial infarction (AMI) (n = 348,720) and surgical failure to rescue (FTR) (n = 109,066) patients discharged between 1993 and 2001 from 343 California acute care general hospitals. MEASURES: Patient outcomes are 30-day AMI mortality and surgical FTR; 4 baseline staffing levels-4 to 7 patients per licensed nurse [registered nurses (RN) and licensed vocational nurses (LVN)]. RESULTS: Significant cross-sectional associations between higher nurse staffing and AMI mortality are reduced in the fixed-effects analyses. Improvements in outcomes were smaller in hospitals with higher baseline staffing: for each RN and RN + LVN increase, respectively, AMI mortality declined by 0.71 (P < 0.05) and by 2.75 percentage points for hospitals with more than 7 patients per nurse compared with 0.19 (P = NS) and 0.28 percentage points (P < 0.05) in hospitals with more than 4 patients per nurse. Significant cross-sectional associations between higher nurse staffing and FTR were not found in the fixed-effects analyses. CONCLUSIONS: Strong diminishing returns to nurse staffing improvements and lack of significant evidence that staffing uniformly increases improve outcomes raise questions about the likely cost-effectiveness of implementing state-wide mandatory nurse staffing ratios.
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Programas Obrigatórios/legislação & jurisprudência , Recursos Humanos de Enfermagem Hospitalar/provisão & distribuição , Avaliação de Resultados em Cuidados de Saúde , Admissão e Escalonamento de Pessoal/legislação & jurisprudência , Garantia da Qualidade dos Cuidados de Saúde , California , Estudos Transversais , Humanos , Risco AjustadoRESUMO
BACKGROUND: Mandated minimum nurse-to-patient staffing ratio legislation was passed in California in 1999 and implemented January 1, 2004. Nurse staffing legislation is being considered in at least 25 other states. OBJECTIVES: The objectives of this study were: (1) to evaluate nurse staffing trends in California from 1993 to 2004, (2) to identify types of hospitals below minimum staffing ratios and staffing changes in 2004, the first year post-implementation; and (3) to discuss possible implications of nurse staffing on hospitalists and their hospital-based initiatives. DESIGN, SETTING, PATIENTS: We analyzed data from the medical-surgical units of all short-term acute-care general hospitals in California from 1993 to 2004. The annual hospital staffing ratio is composed of the combined hours of registered nurses and licensed vocational nurses and total number of patient days on medical-surgical units. RESULTS: Nurse staffing ratios were relatively unchanged from 1993 to 1999 and then increased significantly from 1999 to 2004, with the largest increase in 2004, the year the nurse staffing ratio was implemented. Types of hospitals more likely to be below minimum ratios had a high Medicaid/uninsured patient population and were government owned, nonteaching, urban, and in more competitive markets. Most hospitals below ratios were considered part of the health care "safety net." CONCLUSIONS: Nurse staffing legislation may increase nurse staffing. However, mandated nurse staffing ratios without mechanisms to help achieve ratios may force hospitals, especially safety-net hospitals, to make tradeoffs in other services or investments with unintended negative consequences for patients. Nurse staffing likely influences the outcomes of hospitalist-led quality initiatives, but these effects need to be explored further.
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Médicos Hospitalares , Recursos Humanos de Enfermagem Hospitalar/organização & administração , Admissão e Escalonamento de Pessoal , Carga de Trabalho , California , Pesquisa sobre Serviços de Saúde , Humanos , Recursos Humanos de Enfermagem Hospitalar/legislação & jurisprudência , Garantia da Qualidade dos Cuidados de SaúdeRESUMO
This study assesses the ability of managed care to contain hospital costs since the managed care backlash, using data from California's Office of Statewide Health Planning and Development for all acute-care hospitals in the state for the period 1991-2001. The analysis employs a long-differences design to examine cost growth before and after the managed care backlash. Results from the early 1990s are consistent with prior evidence that the combination of more competitive markets and high managed care penetration held down costs. Post-backlash, high managed care penetration no longer was associated with lower cost growth in the most competitive markets, indicating that the synergistic effects between managed care and hospital competition no longer may exist.