Research and Practice in Quality Improvement and Implementation Science: The Synergy for Change Model.

BACKGROUND: Nurses play an essential role in the achievement of quality depicted by the Quintuple Aim to improve clinical outcomes, patient experience, equity, provider well-being, and reduction of costs. When quality gaps occur, practice change is required and is facilitated by quality improvement (QI) and implementation science (IS) methods. QI and IS research are required to advance our understanding of the mechanisms that explain how evidence is implemented and improvements are made. PROBLEM: Despite past efforts of the evidence-based practice and QI movements, challenges persist in sustaining practice improvements and translating research findings to direct patient care. APPROACH: The purpose of this article is to describe the Synergy for Change Model that proposes that both QI and IS research and practice be used to accelerate improvements in health care quality. CONCLUSIONS: Recognizing the synergy of QI and IS practice and research will accelerate nursing's contributions to high-quality and safe care.

Safety Competency: Exploring the Impact of Environmental and Personal Factors on the Nurse's Ability to Deliver Safe Care.

BACKGROUND: Patient safety is a priority in health care systems. Nurses' safety competence along with environmental and personal factors plays a role in patient safety. PURPOSE: The purpose of this study was to explore the relationships among safety competency, structural empowerment, systems thinking, level of education, and certification. METHODS: A cross-sectional exploratory design was used to collect data from nurses (n = 163) practicing in a large Midwestern hospital system. RESULTS: There were significant positive correlations between safety competency and ( a ) structural empowerment, ( b ) systems thinking, and ( c ) certification. Systems thinking explained 12.9% of the variance in the knowledge component of safety competency and 6.8% of the variance in the skill component of safety competency. Certification explained 2.4% of the variance in the skill component of safety competency. CONCLUSIONS: Understanding factors that affect safety competency supports the development of effective interventions that may improve safety.

Implementing the nurse practitioner role in Oman: Implications for policymaking.

BACKGROUND: In Oman, limited access to adequately prepared healthcare providers in primary healthcare threatens the provision of quality care to patients and families and access to healthcare services. Nurse practitioners (NP) are in an excellent position to address safety issues and ensure quality healthcare with their advanced nursing skills, knowledge, and acumen for acceptable cultural and religious practices. AIMS: To explain Oman's national strategic plans, processes, challenges, opportunities, and both regional and global implications for the facilitation of NP role implementation and policies. SOURCES OF EVIDENCE: The Nursing and Midwifery Human Resources framework guided the NP implementation project. Guided by the framework, the World Health Organization and the Omani Ministry of Health conducted multiple situational analyses (2004-2016). Later, the NP role was planned and implemented in Oman. During and after implementation, monitoring and evaluation of the NP role implementation were continuously conducted using multiple focus groups, individual interviews, and field visits. DISCUSSION: The NP role implementation revealed multiple challenges and opportunities that either hinder or support NP role implementation. Additionally, the NP implementation project revealed various lessons learned. IMPLICATIONS FOR NURSING AND HEALTH POLICY: National and global nursing leaders and health policymakers should collaborate to discuss NP issues, especially NP role sustainability, legal approval and recognition, prescriptive authority, title protection, practice acts, and professional regulation. CONCLUSION: This paper informs nursing leaders and policymakers in the Middle East and other countries in the global community about Oman's experience regarding NP role implementation.

What are key characteristics of adults with advanced heart failure discharged from ICU?

BACKGROUND: As the number of people with heart failure and treatment complexity increases, many hospitals are implementing Advanced Heart Failure Intensive Care Units (AHFICU). However, little evidence concerning the clinical characteristics of people admitted to AHFICUs exists. Understanding the clinical characteristics of people admitted to the AHFICU will assist nurses with implementing tailored interventions to ensure high-quality care delivery. AIM: The purpose of this study was to describe the clinical characteristics of people who are admitted to and discharged from an AHFICU. STUDY DESIGN: Baseline data from a longitudinal descriptive study were collected on adults (N = 43) admitted to an AHFICU. Heart failure severity, self-management ability, cognition, sleep quality, and other clinical characteristics were assessed. RESULTS: Most study participants were New York Heart Association functional class IV (n = 24) or class III (n = 14), indicating poor functional capacity. Over half had mild cognitive impairment and poor sleep quality was prevalent (92.7%). Participants had adequate levels of heart failure knowledge, but low levels of heart failure self-management decision-making and ability. CONCLUSIONS: Interventions to address the unique clinical characteristics of AHFICU patients include sleep hygiene, integration of cognitive, sleep, and self-management assessments into the electronic medical record. Addressing the unique clinical needs of people with heart failure will lead to patient-centered, evidence-based, and safe care. RELEVANCE TO CLINICAL PRACTICE: Understanding characteristics of this population addresses this evidence gap and targeted clinical interventions to address unique discharge needs of this population are proposed. Sleep quality education should be done throughout hospitalization on sleep strategies and self-management coaching to facilitate adoption of new sleep routines. Healthcare providers should ensure each patient has care support upon discharge and take cognitive status into consideration during teaching. Addressing self-management readiness should include providing scenarios as part of discharge preparation. Providers must include addressing comorbidities and how they may affect heart failure self-management, such as teaching about sleep apnea device use and encouraging compliance.

Age-Friendly Health Systems: Delivering evidence-based care to older adults.

ABSTRACT: This article discusses the Age-Friendly Health Systems (AFHS) initiative, which aims to provide safe and effective care for older adults by focusing on the 4Ms framework: What Matters, Medication, Mentation, and Mobility. This article also outlines strategies for educating nurses on incorporating the AFHS initiative into their routine care and the potential impact on nursing care for older adults.

Health Literacy, Cognitive Function, and Mortality in Patients With Heart Failure.

BACKGROUND: Health literacy has predicted mortality in heart failure. However, the role of cognitive functioning in this relationship has not been evaluated. We hypothesized that health literacy would predict all-cause mortality but that cognitive functioning would modify the relationship between health literacy and mortality in heart failure. OBJECTIVE: The aim of this study was to examine the association between health literacy, cognitive functioning, and mortality in patients with heart failure. METHODS: This secondary analysis of a larger study included 298 patients with heart failure with reduced ejection fraction (trial identifier: NCT01461629). Health literacy was evaluated using the Rapid Estimate of Adult Literacy in Medicine (REALM) and Medical Term Recognition Test (METER), and cognitive functioning was evaluated using the Modified Mini-Mental Status Examination (3MS). Cox proportional hazards regression was used with time-until-death as the dependent variable. RESULTS: After controlling for age, sex, and race, neither METER nor REALM scores predicted mortality in heart failure (Ps ≥ .37). However, 3MS predicted mortality in models using the METER (Δχ2 = 9.20, P < .01; B = -.07; hazard ratio, 0.94 [95% confidence interval, 0.89-0.98]; P < .01) and REALM (Δχ2 = 9.77, P < .01; B = -0.07; hazard ratio, 0.94 [95% confidence interval, 0.90-0.97]; P < .01). Furthermore, adding the 3MS improved model fit. CONCLUSIONS: Cognitive functioning predicted mortality in heart failure better than health literacy. Results suggest the need to further evaluate the contribution of cognitive functioning to increased risk of mortality in those with heart failure.

A quality improvement approach to develop an educational initiative for an age-friendly health system.

Authors describe a quality improvement approach to develop and pilot test educational materials with an aim to educate MinuteClinic providers in the provision of age-friendly care using the 4Ms Framework: What Matters, Medication, Mentation, Mobility. The team used surveys, focus groups and site visits to develop educational prototypes with Plan-Do-Study-Act iterative cycles to improve the education. Educational materials introduced providers to 4Ms assessment and evidence-based act on strategies for older adults in the convenient care setting. The education activities included an interactive orientation module comparing standard care to 4Ms care, 10 video vignettes with experts addressing gerontological topics, and 12 grand rounds presented monthly on topics applying the 4Ms with older adults. The information gained from the staff aided in the development and the iterative improvement of the materials. This article highlights the benefits of using a quality improvement approach in development of clinician education in provision of age-friendly care.

The interprofessional Veterans Affairs Quality Scholars program pre- and postdoctoral nurse fellow outcomes.

BACKGROUND: The Department of Veterans Affairs (VA) Quality Scholars (VAQS) program, an interprofessional fellowship that includes pre- and postdoctoral nurses, aims to inspire practice change leaders. Fellows participate in a national curriculum, lead improvement/research teams, and establish professional development plans with expert mentor guidance. PURPOSE: To describe the distinctive elements of the VAQS program, nurse fellow outcomes, and accomplishments of nurse alumni as leaders, researchers, and educators. METHODS: Data were reviewed and aggregated from past and current fellow surveys. FINDINGS: Nurse fellows completed research and improvement projects that benefitted both the VA and the local health systems. Scholarly outcomes include publications, conference presentations, grant submissions, teaching/leading quality improvement, and research initiatives. Graduates transition to positions as nurse scientists, academic faculty, and operational leaders. DISCUSSION: Fellows contribute to the strategic priorities of local and national VA and external health care organizations providing a pipeline of health system expert leaders, educators, and researchers. CONCLUSION: Doctoral nursing fellowship experiences build human capital for enhancing the science of improvement and implementation, interprofessional collaboration, and leadership.

The interprofessional VA quality scholars program: Promoting predoctoral nursing scientists and their career trajectories.

BACKGROUND: The VA Quality Scholars (VAQS) program is an interprofessional fellowship that provides a unique opportunity for predoctoral nurse scientists to embed their work in quality improvement learning "laboratories" to inform their scholarship, science, and research. PURPOSE: To describe the VAQS program in relation to promoting nursing science and predoctoral nurse scientist (PhD) career trajectories, and to propose policy implications. METHOD: Data were collected on all predoctoral (PhD, DNP) nurses who entered and completed the VAQS program nationally. FINDINGS: A total of 17 predoctoral nurses (11 PhD and 6 DNP) have completed the VAQS program. Ten predoctoral PhD nurses (91%) completed their degree while in the program. Nine predoctoral PhD nurses (82%) entered a postdoctoral fellowship, and many obtained positions as faculty at research-intensive universities postfellowship. DISCUSSION: The knowledge, skills, and experiences gained by predoctoral nurse scientists from the VAQS's program contribute to their nursing research and professional career growth.

Pre-Implementation of the Age-Friendly Health Systems Evidence-Based 4Ms Framework in a Multi-State Convenient Care Practice.

BACKGROUND: Quality issues in the delivery of healthcare services to older adults and changes in societal demographics call for a social movement to improve the care of older adults in a variety of healthcare settings, including ambulatory care and convenient care clinics. AIMS: To describe the pre-implementation phase to integrate the Age-Friendly Health Systems (AFHS) 4Ms (i.e., What Matters, Medication, Mentation, and Mobility) Framework in 1,100 MinuteClinics (the retail medical clinic of CVS Health) using the Consolidated Framework for Implementation Research (CFIR) and RE-AIM (an evaluation implementation framework). METHODS: The CFIR and RE-AIM models guided data collection. Data were collected from all stakeholders (patients, healthcare providers, managers, educators, informatics staff, communications staff, and implementation consultants) via observations, surveys, interviews, focus groups, organizational readiness assessment, stakeholder assessment, and workflow mapping during a 15-month period to identify potential barriers, facilitators, and other opportunities for implementation. RESULTS: The CFIR and RE-AIM implementation frameworks provided a comprehensive approach to guide the pre-implementation phase of the AFHS 4Ms Framework at the MinuteClinic. The baseline assessments guided by the CFIR revealed important insights in the choice of implementation strategies that were developed and tested in the pre-implementation phase, and the RE-AIM guided meaningful components to the development of the logic model. LINKING ACTION TO EVIDENCE: As more healthcare systems integrate the AFHS 4Ms Framework, the approach reported in this quality improvement project can be used in other settings to facilitate a comprehensive implementation.

Development and Validation of the Systems Thinking Scale.

PURPOSE: Systems thinking is the ability to recognize and synthesize patterns, interactions, and interdependencies in a set of activities and is a key component in quality and safety. A measure of systems thinking is needed to advance our understanding of the mechanisms that contribute to improvement efforts. The purpose of this study was to develop and conduct psychometric testing of a systems thinking scale (STS). METHODS: The development of the STS included obtaining national quality and safety experts' conceptual domains of systems thinking and the generation of a provisional set of items. Further psychometric analyses were conducted with interprofessional healthcare faculty (N = 342) and students (N = 224) engaged in quality improvement initiatives and education. RESULTS: Of the 26 items identified in the development phase, factor analyses indicated three factors: (1) system thinking (20 items), (2) personal effort (2 items), and (3) reliance on authority (4 items). The six items from factors 2 and 3 were omitted due to low factor loadings. Test-retest reliability of the 20-item STS was performed on 36 healthcare professionals and a correlation of 0.74 was found. Internal consistency testing on a sample of 342 healthcare professionals using Cronbach's alpha showed a coefficient of 0.89. Discriminant validity was confirmed with three groups of healthcare professions students (N = 102) who received high, low, or no dose levels of systems thinking education in the context of process improvement. CONCLUSIONS: The 20-item STS is a valid and reliable instrument that is easy to administer and takes less than 10 min to complete. Further research using the STS has the potential to advance the science and education of quality improvement in two main ways: (1) increase understanding of a critical mechanism by which quality improvement processes achieve results, and (2) evaluate the effectiveness of our education to improve systems thinking.

Impact of Instrumental Activities of Daily Living Limitations on Hospital Readmission: an Observational Study Using Machine Learning.

BACKGROUND: Limitations in instrumental activities of daily living (IADL) hinder a person's ability to live independently in the community and self-manage their conditions, but its impact on hospital readmission has not been firmly established. OBJECTIVE: To test the importance of IADL dependency as a predictor of 30-day readmissions and quantify its impact relative to other morbidities. DESIGN: A retrospective cohort study of the population-based Health and Retirement Study linked to Medicare claims data. Random forest was used to rank each predictor variable in terms of its ability to predict readmission. Classification and regression tree (CART) was used to identify complex multimorbidity combinations associated with high or low risk of readmission. Generalized linear regression was used to estimate the adjusted relative risk of readmission for IADL limitations. SUBJECTS: Hospitalizations of adults age 65 and older (n = 20,007), from 6617 unique subjects. MAIN MEASURES: The main outcome was 30-day all-cause unplanned readmission. The main predictor of interest was self-reported IADL limitation. Other key predictors were self-reported complex multimorbidity including chronic diseases, geriatric syndromes, and activities of daily living (ADL) limitations, along with demographic, socioeconomic, and behavioral factors. KEY RESULTS: The overall 30-day readmission rate in the study was 16.4%. Random forest analysis ranked ADLs and IADL limitations as the two most important predictors of 30-day readmission. CART identified hospitalizations of patients with IADL limitations and diabetes as a subgroup at the highest risk of readmission (26% readmitted). Multivariable regression analyses showed that ADL limitations were associated with 1.17 (1.06-1.29) times higher risk of readmission even after adjusting for other patient covariates. Risk prediction was modest though for even the best model (AUC = 0.612). CONCLUSIONS: IADL limitations are key predictors of 30-day readmission as demonstrated using several machine learning methods. Routine assessment of functional abilities in hospital settings could help identify those most at risk.

Integrating a Reflective Learning Activity to Ensure Quality Improvement Project Success.

This article describes a brief learning activity that provided reflective time to identify barriers, facilitators, and action steps to ensure quality improvement (QI) project success. Learners from our program participated in an interactive 90-minute session that used Liberating Structures to reflect on current barriers to implementation of their QI projects. Analysis of the individual reflective cards identified 10 barriers to QI success. Facilitators were grouped into 16 themes. Action steps were placed into six categories. Integration of reflection promotes important identification of QI project barriers, facilitators, and the creation of action steps.

Patient reported symptom outcomes during medication titration for adult heart failure management.

AIMS AND OBJECTIVES: This project used the Patient Reported Outcomes Measurement Information System (PROMIS) tools to evaluate heart failure patient's experiences of dyspnea, fatigue, and physical mobility during initiation and up titration of drugs in an outpatient setting. BACKGROUND: Investigating patient reported outcome may improve adherence to GDMT. Theoretical support for this study is found in the University of California, Theory of Symptom Management. DESIGN: Exploratory, repeated measures design. METHODS: Patients (n = 21) completed three PROMIS questionnaires for dyspnea, fatigue and physical mobility when GDMT was started or up titrated, and again at a follow up appointment within 30 days (+/- 14 days) of the baseline measures. Patients were asked open- ended queries regarding the usefulness of these questionnaires in identifying and managing symptoms. Provider input was sought on usefulness of the tools in clinical practice and decision making. RESULTS: Dyspnea change scores significantly decreased (p = .001), physical mobility scores significantly increased (p = .017), and fatigue scores did not change (p = .319). Duration of HF diagnosis was associated with dyspnea change scores. Patients reported PROMIS tools were easy to use, while providers felt the tools were easy for patients to use but were too long and time intensive for usual office practice. CONCLUSIONS: Dyspnea and physical mobility improved with up titration of GDMT but fatigue did not change. RELEVANCE TO CLINICAL PRACTICE: PROMIS tools could be helpful in tracking selected symptom changes during GDMT HF medication initiation or up titration for HF management if reformulated into shorter format.

The Contribution of Living Arrangements, Social Support, and Self-efficacy to Self-management Behaviors Among Individuals With Heart Failure: A Path Analysis.

BACKGROUND: Living arrangements, social support, and self-efficacy have significant implications for self-management science. Despite the theoretical linkages among the 3 concepts, there is limited empirical evidence about their interplay and the subsequent influence on heart failure (HF) self-management. OBJECTIVE: The aim of this study was to validate components of the Individual and Family Self-management Theory among individuals with HF. METHODS: This is a secondary analysis of cross-sectional data generated from a sample of 370 individuals with HF. A path analysis was conducted to examine the indirect and direct associations among social environment (living arrangements), social facilitation (social support) and belief (self-efficacy) processes, and self-management behaviors (HF self-care maintenance) while accounting for individual and condition-specific factors (age, sex, race, and HF disease severity). RESULTS: Three contextual factors (living arrangements, age, and HF disease severity) had direct associations with perceived social support and self-efficacy, which in turn were positively associated with HF self-management behaviors. Living alone (ß = -.164, P = .001) was associated with lower perceived social support, whereas being an older person (ß = .145, P = .004) was associated with better support. Moderate to severe HF status (ß = -.145, P = .004) or higher levels of perceived social support (ß = .153, P = .003) were associated with self-efficacy. CONCLUSIONS: Our results support the Individual and Family Self-management Theory, highlighting the importance of social support and self-efficacy to foster self-management behaviors for individuals with HF. Future research is needed to further explore relationships among living arrangements, perceived and received social support, self-efficacy, and HF self-management.

Prioritizing Functional Capacity as a Principal End Point for Therapies Oriented to Older Adults With Cardiovascular Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association.

Adults are living longer, and cardiovascular disease is endemic in the growing population of older adults who are surviving into old age. Functional capacity is a key metric in this population, both for the perspective it provides on aggregate health and as a vital goal of care. Whereas cardiorespiratory function has long been applied by cardiologists as a measure of function that depended primarily on cardiac physiology, multiple other factors also contribute, usually with increasing bearing as age advances. Comorbidity, inflammation, mitochondrial metabolism, cognition, balance, and sleep are among the constellation of factors that bear on cardiorespiratory function and that become intricately entwined with cardiovascular health in old age. This statement reviews the essential physiology underlying functional capacity on systemic, organ, and cellular levels, as well as critical clinical skills to measure multiple realms of function (eg, aerobic, strength, balance, and even cognition) that are particularly relevant for older patients. Clinical therapeutic perspectives and patient perspectives are enumerated to clarify challenges and opportunities across the caregiving spectrum, including patients who are hospitalized, those managed in routine office settings, and those in skilled nursing facilities. Overall, this scientific statement provides practical recommendations and vital conceptual insights.

The Development and Acceptability of a Mobile Application for Tracking Symptoms of Heart Failure Among Older Adults.

PURPOSE: Heart failure (HF) is common in older adults. With increases in technology use among older adults, mobile applications may provide a solution for older adults to self-manage symptoms of HF. This article discusses the development and acceptability of a HF symptom-tracking mobile application (HF app). METHODOLOGY: The HF app was developed to allow patients to track their symptoms of HF. Thirty (N = 30) older adults completed an acceptability survey after using the mobile app. The survey used Likert items and open-ended feedback questions. RESULTS: Overall, the acceptability feedback from users was positive with participants indicating that the HF app was both easy to use and understand. Participants identified recommendations for improvement including additional symptoms to track and the inclusion of instructions and reminders. CONCLUSION: HF is common in older adults, and acceptability of mobile apps is of key importance. The HF app is an acceptable tool for older patients with HF to self-manage their symptoms, identify patterns, and changes in symptoms, and ultimately prevent HF readmission.

Entrustable professional activities for quality and patient safety.

BACKGROUND: Further efforts are warranted to identify innovative approaches to best implement competencies in nursing education. To bridge the gap between competency-based education, practice, and implementation of knowledge, skills, and attitudes, one emerging approach is entrustable professional activities (EPAs). PURPOSE: The objective of this study was to introduce the concept of EPAs as a framework for curriculum and assessment in graduate nursing education and training. METHODS: Seven steps are provided to develop EPAs for nurses through the example of a quality and safety EPA. The example incorporates the Quality and Safety Education for Nurses (QSEN) patient safety competencies and evidence-based literature. FINDINGS: EPAs provide a practical approach to integrating competencies in nursing as quality and safety are the cornerstones of nursing practice, education, and research. DISCUSSION: Introducing the EPA concept in nursing is timely as we look to identify opportunities to enhance nurse practitioner (NP) training models and implement nurse residency programs.

Nurse Practitioner residents' perceptions of competency development during a year-long immersion in Veterans Affairs primary care.

BACKGROUND: Nurse Practitioner (NP) Postgraduate Residency programs are rapidly expanding. Currently, little is known about trainees' self-perceptions during these experiences. PURPOSE: Describe NP residents' perceptions of their strengths, areas for improvement, and goals while participating in the Veterans Affairs Centers of Excellence in Primary Care Education NP Residency program. METHODS: NP residents responded to open-ended questions at three time points across their training year. Responses were analyzed using inductive and deductive approaches. FINDINGS: NP residents self-reported strengths in patient-centered care and interprofessional teamwork. They identified clinical skill acquisition as the major area for improvement. Their short- and long-term goals focused on personal and professional growth. DISCUSSION: These results suggest NPs prioritize clinical skill acquisition during a primary care residency. In contrast, leadership and performance improvement skills did not capture their attention. When aggregated at the programmatic level, assessments identified opportunities to improve the NP Residency program curriculum.

Evaluation of Veterans Affairs primary care nurse practitioner residency: Achievement of competencies.

BACKGROUND: The Institute of Medicine has recommended the establishment of residency programs for advanced practice nursing graduates. Currently, the evidence about program effectiveness is limited. PURPOSE: To describe the nurse practitioner (NP) resident outcomes on seven competency domains established by the VA Centers of Excellence in Primary Care Education (VA CoEPCE). METHODS: We evaluated mean NP resident competency self-ratings and mean mentor ratings over the 12-month program across NP residency programs at five sites. Highest and lowest rated items and differences between NP resident self-ratings and mentor ratings were analyzed. RESULTS: Mean NP resident self-ratings and mean mentor ratings demonstrated statistically significant improvement in all domains (p < .0001). At 12 months, NP residents were rated by their mentors as able to practice without supervision in all competency domains. At 1 and 12 months, clinical, leadership and quality improvement/population management competencies were the lowest scored domains while patient-centered care, interprofessional team collaboration, shared decision-making and sustained relationships competencies were highest. CONCLUSIONS: These results provide initial evidence for the effectiveness of VA CoEPCE NP residency programs and also highlight areas of needed improvement.