Strategies for developing faculty confidence and competencies to mentor quality improvement DNP projects.

DNP faculty who mentor students in quality improvement (QI) DNP projects often lack essential knowledge of QI principles. The purpose of this article is to guide DNP programs in developing confident and competent faculty mentors for QI DNP projects, facilitating DNP student success. At a multi-campus practice- and research-intensive university, strategies employed to teach College of Nursing faculty essential knowledge of QI principles comprise structural and process components. Structural supports standardize faculty workload, promote potential for collaborative scholarship, and provide instructional and resource support for faculty mentors. Organizational processes facilitate identification of practice sites and meaningful projects. A College of Nursing and university Institutional Review Board collaboration established policy to guide human subjects protection regarding DNP project activity, streamlining and standardizing the process. Library support mechanisms, access to ongoing faculty QI training and resources, and faculty feedback processes to improve QI faculty development are ongoing and sustained. Peer coaching provides continued support for faculty development. Initial process outcomes indicate that implemented strategies are well-received by faculty. The transition to competency-based education provides opportunities to create tools to measure multiple student quality and safety competencies highlighted in Domain 5 of The Essentials: Core Competencies for Professional Nursing Education and inform future directions for faculty development essential to support student success.

Why don't all nurse practitioners precept? A comparative study.

BACKGROUND: Preceptors are integral in nurse practitioner (NP) education. A shortage of willing preceptors limits graduations from NP programs. However, little is known about why NPs decide not to precept. PURPOSE: To identify the factors significantly associated with NPs' status as currently, previously, or never precepting, using the Integrated Behavioral Model as the conceptual framework. METHODOLOGY: This was a cross-sectional, comparative, descriptive study of NPs using survey methodology. Our survey was based on published surveys with items added and adapted to reflect our framework. Subscales included personal factors, primary determinants of intent to precept, and external factors. We mailed recruitment postcards, with an online survey link, to all NPs in Arkansas. Data were analyzed using bivariate and stepwise multinomial logistic regression for each subscale. RESULTS: We obtained 261 responses. Participants who had previously and/or never precepted differed from current preceptors on multiple variables on bivariate analysis. Predictive personal factors included experience and hours worked per week. Predictive primary determinants included knowing NPs that precept, support for precepting, recognition of preceptors, and clinical expertise. Predictive external factors included space, liability, having a "gatekeeper," NP program, importance of precepting, and number of requests. CONCLUSIONS: Different factors predict NPs who currently, previously, and have never precepted. However, frequency of requests predicted both nonprecepting groups. Various supports in the clinical setting and program factors predicted one or other nonprecepting group. IMPLICATIONS: Strategies should be developed to ensure all potential preceptors are recruited, increase support for precepting, and ensure educational programs meet preceptors' needs.

Nurse practitioner preceptor resource needs and perceptions of institutional support.

BACKGROUND: Nurse practitioner (NP) preceptors encounter stress when balancing clinical responsibilities with mentoring. Support can decrease role stress and promote preceptor resilience. PURPOSE: Characterize NP preceptor resource needs and their perception of support for the clinical preceptor role. METHODS: A cross-sectional, mixed-methods study used a web-based survey to identify preceptor resource needs. A convenience sample from a large, academic Midwestern university was recruited by email, with reminder emails 1 and 2 weeks after initial invitation. Survey tools included researcher-designed questions about preceptor-desired resources, an adapted Preceptor's Perception of Support Scale, and qualitative questions of preceptor needs. Data were analyzed using descriptive statistics and qualitative thematic analysis. RESULTS: Two hundred thirty-nine of 784 surveys (30.48%) were returned. Preceptors valued free mentoring resources, desired access by "smartphone app," and identified mentoring topics of interest. They perceived adequate role preparation, clearly defined roles, supportive and knowledgeable colleagues, committed supervisors, and appropriate workload. Respondents noted the following insufficiencies: time for normal duties while precepting, preceptor resources, opportunities to share with colleagues, faculty-student time, and faculty assistance to identify student's performance problems. Qualitative data highlighted faculty-preceptor communication and compensation as preceptor concerns. IMPLICATIONS FOR PRACTICE: Preceptors feel a need for specific supports identified in this study. Preceptor insights inform strategies to build clinical preceptor resilience and well-being, strengthen the academic-practice partnership, and facilitate positive education outcomes. Faculty should increase communication-based support individualized to specific student needs. Resources should be developed that more fully support specific competencies and skills within NP student clinical education.

Electronic Health Record Tool to Promote Team Communication and Early Patient Mobility in the Intensive Care Unit.

BACKGROUND: Intensive care unit early mobility programs improve patients' outcomes while reducing costs for both patients and institutions. Inadequate interprofessional communication is a known barrier to achieving good early mobility program outcomes. Electronic health record communication tools promoting interprofessional communication have demonstrated improved patient outcomes, but have not been evaluated for mobility in the intensive care unit. OBJECTIVES: To implement an early mobility collaboration program in an existing early mobility program, consisting of protocol education and an electronic health record tool designed to improve interprofessional communication and collaboration. METHODS: In phase 1, staff members viewed an online educational module, the existing mobility protocol, and the "Mobility Levels" grading scale. In phase 2, an electronic health record communication tool displayed recently recorded mobility levels to all care providers. Staff knowledge of the early mobility program and perceptions of mobility-related communication were assessed by survey; patient outcomes including mobility goals, mechanical ventilation time, length of intensive care unit stay, and cost were assessed by records review. RESULTS: Statistically significant increases were found for staff satisfaction with mobility-related communication (P < .001) and communication frequency (P = .02), but not for staff knowledge (P = .28). Hours to achievement of mobility goal (P = .02) and length of intensive care unit stay (P = .02) decreased significantly. Average ventilation time decreased by 27 hours. Discharge recommendations at higher functional levels increased. Total intensive care unit cost decreased significantly (-39.5%; P = .04). CONCLUSIONS: Interprofessional communication and collaboration can lead to improved outcomes. Combining routine educational reviews and an electronic health record communication tool may improve patient and system outcomes for intensive care unit early mobility program patients.

Medical and pharmacy students shadowing advanced practice nurses to develop interprofessional competencies.

AIM: This article describes a job-shadowing project that partnered second-year medical and third-year pharmacy students with an advanced practice nurse (APN) for a four-hour job- shadowing experience. BACKGROUND: In order to address the Interprofessional Education Collaborative (IPEC) Expert Panel core competencies of interprofessional communication, teamwork, and roles/responsibilities, this project implemented a job-shadowing experience to increase students' knowledge of APN roles and interprofessional collaborative team practices. METHODS: Forty volunteer medical and pharmacy students were paired together and completed the job-shadowing activity with an APN. Assessment of knowledge was measured by pre- and post-project surveys. RESULTS: Pre- and post-job-shadowing differences demonstrated statistical significance in the interprofessional domains of role awareness, collaboration and communication. These results suggest that an APN job-shadowing experience is effective in developing medical and pharmacy students' competencies in interprofessional collaborative practice. CONCLUSION: Specific recommendations include creating enhanced job-shadowing experiences within the curriculums of medicine, pharmacy, and nursing students, and assessing for evidence of enhanced IPEC competencies as a result of these learning experiences.

Interprofessional Collaboration With Pharmacist-Driven Education for Hypertension Control in Federally Qualified Health Center Patients.

INTRODUCTION: Providing collaborative care is essential to decrease cardiovascular complications of hypertension (HTN). Care coordination models, including the Patient Centered Medical Home (PCMH), are advocated to manage chronic diseases. However, they offer no guidance on collaborative strategies to improve patient outcomes. This project enhanced the PCMH model at a Federally Qualified Health Center (FQHC) through application of interprofessional collaboration (IPC) concepts including role optimization, shared decision making, shared power, and care expertise. METHODS: Application of IPC concepts with the key addition of a pharmacist education component was instituted at a Midwestern FQHC over a 60-day period with a single care team. Inclusion criteria included adult patients with a diagnosis of uncontrolled primary HTN (>140/90). Blood pressure, perception of IPC, and patient and care team satisfaction were measured. Descriptive statistics, paired t-test, and unpaired t-test were used for analysis. RESULTS: Twenty-two patients participated in the process change. Mean BP demonstrated a statistically significant decline. Care team perception of IPC improved. Care team members and patients reported satisfaction with the overall process change. CONCLUSION: This project offers support to increase knowledge of how IPC competencies and concepts can be incorporated into an FQHC and the effect it may have on hypertensive patients being treated under a PCMH model.

Strategies used by teens growing up in families with Huntington disease.

The purpose of this study was to identify helpfulness of strategies used by teens growing up in families with Huntington disease (HD). Forty-four participants responded to a mailed HD Family Survey-Teens Strategies. Strategies were those with strong positive correlation between use and perceived helpfulness, and those with negative or inverse relationships. Obtaining information, thinking about or doing something else, and actions on behalf of the parent with HD were rated as highest use and perceived helpfulness. Emotional suppression had high use but low helpfulness. Participants reported using numerous helpful strategies. Social support was often unavailable to help manage teen concerns.

Development of the HD-Teen Inventory.

Adolescents, who have a parent with Huntington Disease (HD), not only are at genetic risk for HD but also are witness to its onset and devastating clinical progression as their parent declines. To date, no mechanism has been developed to direct health care providers to the atypical adolescent experiences of these teens. The purpose of this report is to describe the process of developing the HD-Teen Inventory clinical assessment tool. Forty-eight teens and young adults from 19 U.S. states participated in the evaluation of the HD-Teen Inventory tool. Following item analysis, the number of items was reduced and item frequency and reaction scales were combined, based on the strong correlation (r = .94). The resultant tool contains 15 inventory and 2 open-ended response items. The HD-Teen Inventory emerged as a more compact and efficient tool for identifying the most salient concerns of at-risk teens in HD families in research and/or clinical practice.

Patient and family issues regarding genetic testing for cystic fibrosis: a review of prenatal carrier testing and newborn screening.

Cystic fibrosis (CF) is a potentially life-shortening autosomal recessive genetic condition resulting in chronic progressive respiratory involvement, malnutrition, electrolyte imbalance, and male infertility It is the most common autosomal inherited condition in the white population, and its presence is recorded with varying prevalence across ethnicities. Since the 1989 discovery of the genetic variant F508del, the most common cystic fibrosis transmembrane conductance regulator (CFTR) mutation, more than 1900 CF mutations have been identified. The 1997 National Institutes of Health (NIH) Consensus Statement on Cystic Fibrosis, along with 2001 and 2005 recommendations from the American College of Obstetricians and Gynecologists (ACOG), provide the basis for population CF carrier screening in the prenatal setting. Recommendations for newborn screening (NBS) for cystic fibrosis were released in 2004, with NBS programs in the United States initiated thereafter. With the wide variety of CFTR mutations and mutation combinations, there is not a clear understanding of the genotype-phenotype correlations or of the anticipated clinical trajectory for an individual who has identified CFTR mutations. This ambiguity creates challenges for patients and families in decision making related to CFTR carrier screening during the prenatal period, understanding the results of newborn screening for CF, or coping with the new genetic knowledge obtained. This literature review examines research regarding genetic testing for CF as it related to population screening. Patient and family issues from both the prenatal period and newborn testing are reviewed. Opportunities for future nursing research and implication for nursing practice are discussed.

Caregiving by teens for family members with Huntington disease.

The purpose of this report is to describe caregiving by teens for family members with Huntington disease (HD). Thirty-two teens in HD families in the United States and Canada participated in focus groups from 2002 to 2005 in a study to identify concerns and strategies to manage concerns. An unexpected finding was 24 (77%) described caregiving activities. Descriptive analysis of caregiving statements identified themes of Tasks and Responsibilities, Subjective Burden, Caregiving in Context of Personal Risk for HD, and Decisional Responsibility. Teens took an active part in nearly all aspects of care with the exception of contacting health care providers and attending doctors' appointments. Some described emotional distress, and many provided care knowing they had the potential to develop HD. Teens recognized the need for decisions but lacked the authority to make these decisions. Findings may be relevant for other teens who strive to meet caregiver and student roles and developmental tasks.

Pregnancy as foreground in cystic fibrosis carrier testing decisions in primary care.

Cystic fibrosis carrier testing (CFCT) is among the first of the DNA tests offered prenatally in primary care settings. This paper from a descriptive qualitative study describes the influence of pregnancy in CFCT decisions by women receiving community-based prenatal care. Twenty-seven women receiving prenatal care in Midwestern U.S. primary care clinics completed semistructured interviews. Audiotaped interviews were analyzed using content analysis. Participants described decision-making influences and strategies from the perspective of "being pregnant." Patterns of attitudes and beliefs include (1) dealing with emotions, (2) pregnancy is natural, and (3) thinking about the baby. Strategies in the decision-making process included (1) reducing stress, (2) choosing what is relevant, (3) doing everything right, (4) wanting to be prepared, (5) delaying information, and (6) trusting God. While other factors were mentioned by some women, major themes reflect the influence of currently being pregnant on the decision-making process. These findings suggest that pregnancy is a powerful influence on the decision-making process and may not be the optimal time to make fully informed decisions regarding genetic carrier testing. Further understanding of factors influencing the genetic testing decision-making process is needed. Offering CFCT prior to conception is advocated.

Experiences of teens living in the shadow of Huntington Disease.

Research on families with Huntington Disease (HD) has primarily focused on adult decision-making surrounding predictive genetic testing and caregiver stress. Little is known about the experiences of teens living in these families. This qualitative study explored the experiences of 32 teens living in families with HD. Six focus groups were conducted across the U.S. and Canada. Data were analyzed using descriptive qualitative analysis. Huntington disease appeared to cast a shadow over the experiences described by teens. Four themes were identified: watching and waiting; alone in the midst of others; family life is kind of hard; and having to be like an adult. These experiences highlight the need for genetic counselors, health care providers, and school personnel to be aware of issues facing teens living in families with HD. Recognizing patterns of teen experiences may help health care providers develop strategies to support coping by teens in HD families.

"No one else sees the difference: "family members' perceptions of changes in persons with preclinical Huntington disease.

Manifestations of Huntington disease (HD) prior to clinical diagnosis are not well understood. This study documents adult family members' perceptions of changes and their attempts to manage these changes in persons who had received a positive predictive molecular HD test prior to clinical diagnosis. Data were obtained from 19 adult family members in six focus groups in the US and Canada and one individual interview in the US. Changes reported by family members included problems in cognition and behavior, which are consistent with prior reports. In addition, family members observed changes in motor functioning, the ability to complete usual activities at work or at home, and interpersonal relationships with family and friends. Family members attempted to manage these changes by taking on new responsibilities and preparing for future caregiving. Lack of information about preclinical HD, difficulty in understanding changes that may represent early stages of HD, and efforts to maintain secrecy of the preclinical HD situation contribute to compromising the abilities of family members to respond to changes in the person with preclinical HD. Findings provide insights into alterations in cognition, behavior, and functioning observed by the family members prior to clinical diagnosis. Findings further support the need for a more comprehensive assessment and management of early HD symptoms as well as support for family members.

Hospital readmission from a transitional care unit.

The purpose of this project was to characterize patients readmitted to the hospital during a stay in a transitional care unit (TCUT). Typically, readmitted patients were females, widowed, with 8 medical diagnoses, and taking 12 different medications. Readmission from the TCU occurred within 7 days as a result of a newly developed problem. Most patients did not return home after readmission from the TCU. Understanding high-risk patients' characteristics that lead to costly hospital readmission during a stay in the TCU can assist clinicians and healthcare providers to plan and implement timely and effective interventions, and help facility personnel in fiscal and resource management issues.

Abuse-related post-traumatic stress during the childbearing year.

BACKGROUND: Women with abuse-related post-traumatic stress who are pregnant experience symptoms that nurses and midwives may not recognize or know how to respond to. AIM: The purpose of this article is to increase familiarity with the post-traumatic stress disorder diagnostic framework by illustrating the symptom categories and associated features with women's descriptions of the symptoms from qualitative interviews. METHODS: A secondary analysis was performed with data from a qualitative interview study of the maternity care experiences of 15 American women who had abuse-related post-traumatic stress during pregnancy. Content analysis was used to extract all participant statements describing how post-traumatic stress disorder symptoms and associated features manifested in pregnancy. These were then juxtaposed with the post-traumatic stress disorder diagnostic framework. RESULTS: Participants' interviews included a range of descriptions of the intrusive re-experiencing, avoidance and numbing, and hyperarousal core symptoms of post-traumatic stress disorder, as well as associated psychological features such as somatization, dissociation and interpersonal sensitivity, and associated behavioural features such as substance abuse, disordered eating, high-risk sexual behaviours, suicidality, and revictimization. CONCLUSIONS: Limitations of this study include that it is a secondary analysis, using a small North American sample, and focusing only on abuse-related post-traumatic stress disorder. Descriptive information from this qualitative study may bridge the gaps between psychiatric technical language, women's subjective experiences, and clinicians' perceptions of a woman's post-traumatic stress reactions.

Abuse-related posttraumatic stress and desired maternity care practices: women's perspectives.

Qualitative research participants who self-identified as having a history of childhood sexual abuse and abuse-related posttraumatic stress during the childbearing year were interviewed for the purpose of determining what these women perceive as optimal maternity care. Using a process of narrative analysis, desired care practices were identified. With the exception of one woman, all of the study participants wanted their maternity care provider to be competent to address trauma-related needs. Three groups emerged from the data, providing a useful structure for informing providers on how best to respond to diverse abuse-survivor clients: 1) women far along in recovery, 2) women who were not safe, and 3) women who were not ready to "know." The first group had the best trauma-related and maternity outcomes and the best childbearing experiences. For these women, having a provider who was a "collaborative ally" seemed beneficial. The second group had safety needs that required a "compassionate authority figure" who offered referral and follow-up care. Women in the third group were not ready to address trauma-related symptoms or issues overtly and appeared to need a provider who was a "therapeutic mentor." Four assessment factors help providers determine how to respond.