Training Health Professions preceptors in rural practices: A challenge for Interprofessional practice and education.

The ever-increasing mandate for interprofessional practice and education (IPE) faces challenges in rural settings. Oregon Health & Science University (OHSU) launched a preceptor development program as part of its commitment to training interprofessional student groups in rural settings. The objectives of the program were to (1) encourage preceptors to exemplify team behaviors; (2) characterize contemporary learners and learning styles of trainees; (3) encourage interprofessional precepting skills, and (4) apply practical teaching tools in the clinical setting. This was a qualitative observational project performed at OHSU rural faculty primary care clinics. Subjects were a convenience sample of rural interprofessional preceptors who volunteered to participate. Each educational session was based on a prior interview identifying their specific training needs. Data analysis was based on results from an evaluation survey and comments from providers at these sites. Key factors such as dedicated time for preceptor development, good communication between the rural practices and the academic health center, and concerns about billing revenue were discovered to be critical to the success of the program.

Genetic Diversity and Wolbachia (Rickettsiales: Anaplasmataceae) Prevalence Within a Remnant Population of Regal Fritillary, Argynnis idalia (Lepidoptera: Nymphalidae), in South-Central Pennsylvania.

Eastern populations of the North American regal fritillary, Argynnis idalia Drury (1773), have been largely extirpated over the past half century. Here we report on the last remaining population of eastern regal fritillaries, located within a military installation in south-central Pennsylvania. Samples were obtained from field specimens during two years of annual monitoring, and from females collected for captive rearing over a five year period. Nuclear microsatellite and mitochondrial sequence data do not suggest subdivision within this population, but excess nuclear homozygosity indicates negative impacts on genetic diversity likely due to small population size and potential inbreeding effects. Molecular assays did not detect Wolbachia endosymbionts in field specimens of regal fritillary, but sympatric Argynnis sister species showed high prevalence of Wolbachia infected individuals. Our results inform ongoing conservation and reintroduction projects, designed to protect the last remaining regal fritillary population from extirpation in the eastern United States.

Species traits affect phenological responses to climate change in a butterfly community.

Diverse taxa have undergone phenological shifts in response to anthropogenic climate change. While such shifts generally follow predicted patterns, they are not uniform, and interspecific variation may have important ecological consequences. We evaluated relationships among species' phenological shifts (mean flight date, duration of flight period), ecological traits (larval trophic specialization, larval diet composition, voltinism), and population trends in a butterfly community in Pennsylvania, USA, where the summer growing season has become warmer, wetter, and longer. Data were collected over 7-19 years from 18 species or species groups, including the extremely rare eastern regal fritillary Speyeria idalia idalia. Both the direction and magnitude of phenological change over time was linked to species traits. Polyphagous species advanced and prolonged the duration of their flight period while oligophagous species delayed and shortened theirs. Herb feeders advanced their flight periods while woody feeders delayed theirs. Multivoltine species consistently prolonged flight periods in response to warmer temperatures, while univoltine species were less consistent. Butterflies that shifted to longer flight durations, and those that had polyphagous diets and multivoltine reproductive strategies tended to decline in population. Our results suggest species' traits shape butterfly phenological responses to climate change, and are linked to important community impacts.

Development of the assessment for collaborative environments (ACE-15): A tool to measure perceptions of interprofessional "teamness".

As interprofessional education moves from classroom to clinical settings, assessing clinical training sites for a high level of "teamness" to ensure optimal learning environments is critical but often problematic ahead of student placement. We developed a tool (Assessment for Collaborative Environments, or ACE), suitable for a range of clinical settings and health professionals, that allows rapid assessment of a clinical practice's teamwork qualities. We collected evidence of tool validity including content, response process, internal structure, and convergent validity. Expert review and cognitive interviews allowed reduction of the initial 30-item tool to 15 items (the ACE-15). Data from 192 respondents from 17 clinical professions and varied clinical settings (inpatient, ambulatory, urban, and rural) were used for factor analysis, which resulted in a single factor solution. Internal consistency reliability Cronbach's alpha was high at 0.91. Subgroup analysis of 121 respondents grouped by their clinical teams (n = 16 teams) showed a wide range of intra-team agreement. Data from a subsequent sample of 54 clinicians who completed the ACE-15 and a measure of team cohesion indicated convergent validity, with a correlation of the tools at r = 0.81. We conclude that the ACE-15 has acceptable psychometric properties and promising utility for assessing interprofessional teamness in clinical training sites that are settings for learners, and, in addition may be useful for team development.

There is no "i" in teamwork in the patient-centered medical home: defining teamwork competencies for academic practice.

Evidence suggests that teamwork is essential for safe, reliable practice. Creating health care teams able to function effectively in patient-centered medical homes (PCMHs), practices that organize care around the patient and demonstrate achievement of defined quality care standards, remains challenging. Preparing trainees for practice in interprofessional teams is particularly challenging in academic health centers where health professions curricula are largely siloed. Here, the authors review a well-delineated set of teamwork competencies that are important for high-functioning teams and suggest how these competencies might be useful for interprofessional team training and achievement of PCMH standards. The five competencies are (1) team leadership, the ability to coordinate team members' activities, ensure appropriate task distribution, evaluate effectiveness, and inspire high-level performance, (2) mutual performance monitoring, the ability to develop a shared understanding among team members regarding intentions, roles, and responsibilities so as to accurately monitor one another's performance for collective success, (3) backup behavior, the ability to anticipate the needs of other team members and shift responsibilities during times of variable workload, (4) adaptability, the capability of team members to adjust their strategy for completing tasks on the basis of feedback from the work environment, and (5) team orientation, the tendency to prioritize team goals over individual goals, encourage alternative perspectives, and show respect and regard for each team member. Relating each competency to a vignette from an academic primary care clinic, the authors describe potential strategies for improving teamwork learning and applying the teamwork competences to academic PCMH practices.

Sampling challenges in nursing home research.

BACKGROUND: Research on end-of-life care in nursing homes is hampered by challenges in retaining facilities in samples through study completion. Large-scale longitudinal studies in which data are collected on-site can be particularly challenging. OBJECTIVES: To compare characteristics of nursing homes that dropped from the study to those that completed the study. METHODS: One hundred two nursing homes in a large geographic 2-state area were enrolled in a prospective study of end-of-life care of residents who died in the facility. The focus of the study was the relationship of staff communication, teamwork, and palliative/end-of-life care practices to symptom distress and other care outcomes as perceived by family members. Data were collected from public data bases of nursing homes, clinical staff on site at each facility at 2 points in time, and from decedents' family members in a telephone interview. RESULTS: Seventeen of the 102 nursing homes dropped from the study before completion. These non-completer facilities had significantly more deficiencies and a higher rate of turnover of key personnel compared to completer facilities. A few facilities with a profile typical of non-completers actually did complete the study after an extraordinary investment of retention effort by the research team. CONCLUSION: Nursing homes with a high rate of deficiencies and turnover have much to contribute to the goal of improving end-of-life care, and their loss to study is a significant sampling challenge. Investigators should be prepared to invest extra resources to maximize retention.

End-of-life care in nursing homes: the high cost of staff turnover.

Nursing home staff turnover results in high cost--both economic and personal--and has a negative impact on the quality of care provided to residents at the end of life. Reducing staff turnover in nursing homes would benefit both the cost to the U.S. health care system, and, most importantly, the care residents receive in the vulnerable period leading to death. There is rising pressure on nursing homes to improve their palliative and end-of-life care practices and reduce transfers to hospital for situations and conditions that can be safely managed on site. Nursing care staff deserve an investment in the specific training necessary for them to give the highest quality care to dying residents. This training should be multifaceted and include the physiological, psychological, spiritual, interpersonal, and cultural (including ethnic) aspects of dying. Empowerment with these necessary knowledge, skills, and attitudes will not only result in better care for residents but likely also will reduce the burnout and frustration staff experience in caring for residents near death.

Quality of care and quality of dying in nursing homes: two measurement models.

BACKGROUND: There is consistent evidence of significant variation in the quality of end-of-life care among nursing homes, with many facilities ill-prepared to provide optimal physical and psychological care that is culturally sensitive and respectful of the needs and preferences of residents and their family members. There is continued evidence that what is impeding efforts to improve care is that most measurement tools are hampered by a lack of distinction between quality of care and quality of dying as well as a lack of complete psychometric evaluation. Further, health services researchers cite the need to include "system-level" factors, variables that reflect leadership, culture, or informal practices, all of which influence end-of-life care and can be used to differentiate one setting from another. The purpose of this article is to report advancement in conceptualizing quality end-of-life care in nursing homes and to offer a refined approach to measurement. METHODS: Two latent constructs are tested: quality of care (composed of system-level factors) and quality of dying (comprised of resident/family outcomes). Data obtained from 85 Midwestern nursing homes and 1282 interviews with bereaved family members were used to evaluate both constructs. RESULTS: Confirmatory factor analyses were conducted and evidence of validity and reliability were obtained for both. CONCLUSION: For health services researchers, expanded models that include system-level factors as well as more comprehensive and psychometrically sound models of resident outcomes stand to inform efforts to improve care in this very important area.

A measure of palliative care in nursing homes.

CONTEXT: Efforts to improve care for nursing home residents stand to be enhanced by measures to assess the degree to which staff provide palliative care. As the incidence of death in nursing homes increases with the aging population, the gap in measurement must be addressed. To that end, we report the development and psychometric testing of a nursing home palliative care survey. OBJECTIVES: The purpose of this study was to evaluate the psychometric properties of the Palliative Care Survey (PCS) for use in nursing homes. METHODS: Psychometric evaluation of the instrument was completed in two phases. Phase 1 focused on individual item analyses and subsequent revision or deletion of items, and Phase 2 evaluated evidence for reliability and validity. Phase 1 included 26 nursing homes and staff (n=717), and Phase 2 included 85 nursing homes and staff (n=2779). Data were analyzed using item-total correlations, Cronbach's alpha, confirmatory factor analysis, and analysis of variance. RESULTS: Support was obtained for a 51-item PCS made up of two constructs, Palliative Care Practice and Palliative Care Knowledge. CONCLUSION: The PCS measures the extent to which the nursing home staff engage in palliative care practices and have knowledge consistent with good end-of-life care. Both practice and knowledge are an essential foundation to providing good end-of-life care to nursing home residents. Efforts to improve care for the dying in nursing homes have been slowed by an absence of measurement tools that capture care processes, a gap that the PCS reported here helps fill.

Embracing quality and safety education for the 21st century: building interprofessional education.

The education of health professions students is rooted historically in time-honored and silo-bound traditions of pedagogy and content not easily influenced by outside forces. However, the quality chasm work of the Institute of Medicine, Institute of Healthcare Improvement, Quality and Safety Education for Nurses, and other groups has led to a remarkable willingness to change at one academic health sciences university. This article describes one university's strategies, challenges, and successes in delivering interprofessional educational programs. Four interprofessional learning activities, developed using a plan-do-study-act model and focused on teamwork, quality, and safety, are presented. Challenges and successes encountered are described as well as a curricular framework to enhance sustainability.

Policy issues in end-of-life care.

The purpose of this policy brief is to bring attention to the urgent systems-level matters that impede progress in improving end-of-life care in the United States. Despite advances in care of the dying over the last 20 years, many recalcitrant system-level barriers prevent high-quality end-of-life care that is consistent with clinical and ethical standards and reasonably adheres to patient and family wishes for care and compassion. A major barrier is the orientation of health care toward rescue medicine despite the fact that most deaths today result from long-standing chronic disease. Recommendations for policy changes are suggested, and nursing's role in advocating for policy change is explored.

Symptom experiences of residents dying in assisted living.

OBJECTIVES: To identify the end-of-life symptom experiences of residents who died in assisted living, to describe family satisfaction with the end-of-life care, and to compare end-of-life symptom distress across 4 settings: assisted living, private home, nursing home, and hospital. DESIGN: In-person interviews with family members of people aged 65 or older who had died 2 to 4 months earlier in an assisted-living facility. Symptom distress reports were compared with data from prior studies in other settings. SETTING: A mixed urban-rural community in the Northwest. PARTICIPANTS: Twenty-five family members who self-identified as closely involved in the care or decision making for a relative who died in an assisted-living facility. MEASUREMENTS: A 28-item interview guide composed of demographic questions, the modified Family Memorial Symptom Assessment Scale-Global Distress Index (FMSAS-GDI), and open-ended items describing the decedent's last days and family satisfaction with care and symptom management. RESULTS: Symptoms experienced by at least 75% of decedents were lack of energy, loss of appetite, dry mouth, drowsiness, and pain. Symptom experiences in assisted living were comparable to those in other settings. Families overall were satisfied with end-of-life care in assisted living, but had concerns about communication among providers, inadequate monitoring of their decedent, and lack of staff knowledge specific to symptom management. CONCLUSION: Residents dying in assisted-living settings have similar symptom distress experiences as people dying in other, more studied settings. As residents and families alike overwhelmingly support resident deaths in their assisted living "home," policies, structures, and processes are needed to ensure that end-of-life care needs are met.

Men as caregivers at the end of life.

BACKGROUND: Few studies have focused on men as caregivers at the end-of-life. The objective of this secondary data analysis was to examine the experiences of men involved in end-of-life caregiving, focusing on caregiver strain. METHODS: We used a random sample of Oregon death certificates to telephone survey family caregivers of Oregonians who had died 2 to 5 months earlier in private homes, nursing homes, and other community-based settings. Measurements included single-item indicators and embedded scales to measure caregiver strain and perceived decedent symptom distress. For the 25 husbands, sons, wives, and daughters who reported the highest levels of strain, we also analyzed caregivers' description of the decedent's last few days of life. RESULTS: The sample included 1384 caregiver interviews from a pool of 3048 death certificates. Men constituted 29% of the caregivers, including 15% sons, 9% husbands, and 5% others. In a linear regression model, male gender was a significant predictor of lower caregiver strain (p < 0.001). The strongest predictor of high end-of-life caregiver strain was the severity of the decedents' symptom distress. The qualitative analysis revealed that men used fewer words than women did to describe their experiences, and, despite subsequently reporting the highest levels of caregiving strain, only 15% of men spontaneously mentioned their own struggles. CONCLUSIONS: As caregivers at the end of life, men are less common and less likely to report caregiver strain and decedent symptom distress. Health care professionals should actively ask men about these issues and listen carefully, as their responses may be brief and understated.

Building high-impact science: the dean as innovator.

If funding level is accepted as an empirical referent of research productivity, the nursing profession's relatively low volume of funded research puts its capacity to influence practice and policy based on scientific evidence at a disadvantage. For the profession to effectively compete with other "high-impact," health-related disciplines, nursing leaders must find ways for a greater proportion of nursing faculty to excel as scientists, producing sufficient volume and quality of work in their careers to have a major influence on health care. In addition, if nursing leaders are to enhance nurses' interest in scientific development and use, the academic environment needs to foster greater connectivity of students at all levels of education with the scientific enterprise.