Economic evaluation of the Midwifery Initiated Oral Health-Dental Service programme in Australia.

OBJECTIVES: To critically evaluate the cost-effectiveness of the Midwifery Initiated Oral Health-Dental Service (MIOH-DS) designed to improve oral health of pregnant Australian women. Previous efficacy and process evaluations of MIOH-DS showed positive outcomes and improvements across various measures. DESIGN AND SETTING: The evaluation used a cost-utility model based on the initial study design of the MIOH-DS trial in Sydney, Australia from the perspective of public healthcare provider for a duration of 3 months to 4 years. PARTICIPANTS: Data were sourced from pregnant women (n=638), midwives (n=17) and dentists (n=3) involved in the MIOH trial and long-term follow-up. COST MEASURES: Data included in analysis were the cost of the time required by midwives and dentists to deliver the intervention and the cost of dental treatment provided. Costs were measured using data on utilisation and unit price of intervention components and obtained from a micro-costing approach. OUTCOME MEASURES: Utility was measured as the number of Disability Adjusted Life Years (DALYs) from health-benefit components of the intervention. Three cost-effectiveness analyses were undertaken using different comparators, thresholds and time scenarios. RESULTS: Compared with current practice, midwives only intervention meets the Australian threshold (A$50 000) of being cost-effective. The midwives and accessible/affordable dentists joint intervention was only 'cost-effective' in 6 months or beyond scenarios. When the midwife only intervention is the comparator, the midwife/dentist programme was 'cost-effective' in all scenarios except at 3 months scenario. CONCLUSIONS: The midwives' only intervention providing oral health education, assessment and referral to existing dental services was cost-effective, and represents a low cost intervention. Midwives' and dentists' combined interventions were cost-effective when the benefits were considered over longer periods. The findings highlight short and long term economic benefits of the programme and support the need for policymakers to consider adding an oral health component into antenatal care Australia wide. TRIAL REGISTRATION NUMBER: ACTRN12612001271897; Post-results.

Process evaluation of the midwifery initiated oral health-dental service program: Perceptions of dental professionals.

ISSUE ADDRESSED: All pregnant women should have a comprehensive oral health evaluation. Unfortunately, many pregnant women seldom seek dental care and some dentists are hesitant to treat during pregnancy. To address these issues, the Midwifery Initiated Oral Health Dental Service (MIOH-DS) program was developed in Australia. The aim of this study was to undertake a process evaluation and explore the perceptions of dental professionals involved in the program to determine the acceptability, feasibility and effectiveness of the program if it were to be upscaled. METHODS: A qualitative approach using content analysis was conducted on data from two focus groups involving 12 dental professionals. RESULTS: All participants were supportive of the MIOH-DS program. They thought pregnant women were receptive to their care, and reported markedly improved oral health. The provision of free dental care and the involvement of midwives were cited as major factors that improved the uptake of the program. Some of the challenges encountered were the prevailing misconceptions about the safety of dental treatment and pregnancy-related impairments. CONCLUSIONS: Dental professionals found the MIOH-DS to be acceptable, feasible and effective in improving oral health of pregnant women and their uptake of dental services. However, some challenges need to be addressed as the MIOH-DS program is upscaled into a cost-effective model. SO WHAT?: Dental professionals are important stakeholders in the MIOH-DS model. The process evaluation of the successful dental intervention is necessary to understand how and why such interventions work, and is an important step in scaling up to a population-wide intervention.

'Modelling a Secure-Base' for Women with Complex Needs: Attachment-Based Interventions Used by Perinatal and Infant Mental Health Clinicians.

Infant well-being is intrinsically linked to maternal physical and emotional well-being. Internationally health services have implemented policies to identify women at risk of mental health problems and developed effective care pathways. The aim of this paper is to describe how perinatal and infant mental health clinicians perceive their role and the attachment-based interventions they use in their work. The study comes from a larger mixed methods study, which examined two specialist perinatal and infant mental health services in New South Wales (Australia). Two hundred and forty-four medical records were reviewed, and six perinatal and infant mental health clinicians participated in in-depth semi-structured interviews. Data were analysed by content and thematic analysis. One overarching theme, modelling a secure base and three supporting themes, enhancing reflective capacity, enhancing emotional regulation and enhancing empathy emerged from the analysis. These findings demonstrate how perinatal and infant mental health clinicians use attachment theory to inform practice by modelling "holding" and being a secure-base for women. They also provide a clearer understanding of perinatal mental health practice and can be used to inform educational programs for multidisciplinary mental health professionals particularly those working with women and infants.

The effectiveness of interventions designed to reduce medication administration errors: a synthesis of findings from systematic reviews.

AIM: The aim of this overview was to examine the effectiveness of interventions designed to improve patient safety by reducing medication administration errors using data from systematic reviews. BACKGROUND: Medication administration errors remain unacceptably high despite the introduction of a range of interventions aimed at enhancing patient safety. Systematic reviews of strategies designed to improve medication safety report contradictory findings. A critical appraisal and synthesis of these findings are, therefore, warranted. METHODS: A comprehensive three-step search strategy was employed to search across 10 electronic databases. Two reviewers independently examined the methodological rigour and scientific quality of included systematic reviews using the Assessment of Multiple Systematic Reviews protocol. RESULTS: Sixteen systematic reviews were eligible for inclusion. Evidence suggest that multifaceted approaches involving a combination education and risk management strategies and the use of bar code technology are effective in reducing medication errors. CONCLUSION: More research is needed to determine the benefits of routine double-checking of medications during administration by nurses, outcomes of self-administration of medications by capable patients, and associations between interruptions and medications errors. IMPLICATIONS FOR NURSING MANAGEMENT: Medication-related incidents must be captured in a way that facilitates meaningful categorisation including contributing factors, potential and actual/risk of harm and contextual information on the incident.

Reducing Patient Clinical Management Errors Using Structured Content and Electronic Nursing Handover.

We examined whether an integrated nursing handover system-structured content and an electronic tool within the patient clinical information system with bedside delivery-would improve the quality of information delivered at nursing handover and reduce adverse patient outcomes. Using a pre/posttest evaluative design, improvements in the transfer of critical patient information and reductions in nursing clinical management incidents were demonstrated. No changes in falls or medication incident rates were identified.

The evaluation of an oral health education program for midwives in Australia.

BACKGROUND: Antenatal care providers are now recommended to promote oral health during pregnancy and provide dental referrals. However, midwives in Australia are not trained to undertake this role. To address this shortcoming, an online evidence based midwifery initiated oral health (MIOH) education program was systematically developed as a professional development activity. AIM: This study aimed to evaluate the effectiveness of the program in improving the oral health knowledge of midwives and assess their confidence to promote maternal oral health post training. METHODS: The program was evaluated using a pre-post test design involving 50 midwives purposively recruited from two states in Australia. The pre-post questionnaire contained 24 knowledge items previously pilot tested as well as items exploring confidence in promoting oral health and perceptions of the program. FINDINGS: The results showed a significant improvement in the oral health knowledge (↑21.5%, p<0.001) of midwives after completion of the program. The greatest improvement in knowledge occurred in key areas vital in promoting maternal oral health namely the high prevalence of dental problems and its impact on birth and infant outcomes. The majority also reported being confident in introducing oral health into antenatal care (82%) and referring women to dental services (77.6%) after undertaking the education program. CONCLUSION: The MIOH education program is a useful resource to equip midwives with the necessary knowledge and skills to promote oral health during pregnancy. The program is accessible and acceptable to midwives and can potentially be transferable to other antenatal care providers.

The reasons students choose to undertake a nursing degree.

BACKGROUND: Determining the reasons people choose to study nursing may help educators and managers develop student-focussed and enticing nursing programmes. In Australia, little research has been undertaken with students entering nursing programmes and the reasons for their choice. OBJECTIVES: The aim of this study was to determine why new students choose to enter nursing at university. DESIGN: A descriptive survey design. SETTING: An urban university in Sydney, Australia. PARTICIPANTS: Undergraduate nursing students at the beginning of their first year of study. METHOD: An open-ended question relating to the reasons for students' choice of a nursing programme was included in the survey. The transcribed textual data were content analysed for words related to the students' choice. RESULTS: The students' reasons for entering nursing programmes were both personal and career related, with personal being more dominant. The reasons to start nursing were: being able to help and care for people, job security, the ability to enter tertiary education and the enjoyment or love of nursing. CONCLUSIONS: Nursing remains a career of choice for young and mature students entering university. It is seen to provide security, interest and opportunity to help and care for others. Universities must focus on this as they develop programmes for a generation where multiple changes of career appear inevitable during their lifetime. The nursing profession needs to look at career pathways after graduation that provide these challenges within nursing itself.

Midwives' perspectives of their ability to promote the oral health of pregnant women in Victoria, Australia.

BACKGROUND: Midwives have a potential role in promoting the oral health of pregnant women although they have little formal training in this area. The aim of this study was to explore the perspectives of midwives in Victoria towards incorporating oral health promotion into their antenatal practice after undergoing training through the Midwifery Initiated Oral Health (MIOH) online education program. METHODS: A purposive sample of thirty-nine midwives from maternity services across Victoria, Australia were invited to participate in an online MIOH education program in October 2012. The program included three self-paced modules covering oral health screening, referral processes, and theoretical and practical skill assessments. A mixed methods design was used to capture midwives perspectives. Evaluation questionnaires, completed pre- and post-training, captured knowledge and confidence (confidence likert scale), and also included five opened-ended questions post-training. Open-ended questions, feedback forms and unsolicited emails formed the data for qualitative analysis. Data were analysed using content and thematic analysis and descriptive statistics. RESULTS: Thirty-three midwives completed the MIOH education program and demonstrated a significant increase (51.5%) in their confidence to promote oral health. All participants viewed the program as suitable, acceptable and useful for their practice and were happy to recommend the course to other Victorian midwives. Participants indicated that it would be feasible to incorporate oral health into the first antenatal booking visit and recognised that oral health promotion was within their scope of practice. CONCLUSIONS: This study has shown that the MIOH education program is a valued resource that can assist midwives to increase their confidence and skills to incorporate oral health promotion into their practice. A key barrier identified was time constraints during antenatal care booking visits. However, it is evident that with relevant training it would be feasible and acceptable for Victorian midwives to incorporate oral health promotion within their practice. The current engagement with midwives in Victoria and other parts of Australia provides an opportunity to continue to explore and define the role of antenatal health care professionals in oral health promotion at a state and national level.

Views of pregnant women in South Western Sydney towards dental care and an oral-health program initiated by midwives.

ISSUES ADDRESSED: Oral health during pregnancy is important, yet is often neglected by women. A program is currently being developed for midwives in Australia to promote maternal oral health. The aim of this study was to record the views of pregnant women in Australia towards dental care and midwives promoting oral health. METHODS: Using convenience sampling, a cross-sectional survey was undertaken of 241 pregnant women attending a metropolitan hospital in South Western Sydney in 2010. RESULTS: Only 10% of women received oral-health promotional material during pregnancy. More than 50% reported dental problems, yet only 17% had discussed this with their midwives and less than half (44.6%) had sought dental treatment. The main barriers to obtaining dental care were: lack of awareness, safety concerns about dental treatment and dental costs. Pregnant women were more likely (P<0.05) to see a dentist if they had received information about oral health (odds ratio (OR) 3.25, 95% CI 1.34-7.90) and had private health insurance (OR 2.47, 95% CI 1.26-4.85). Most women (>90%) were receptive to midwives providing oral-health education, assessments and referrals to affordable dental services. CONCLUSION: This study has shown that pregnant women are receiving limited dental advice and are concerned about dental costs. It has also confirmed for the first time in Australia that women are very positive about receiving oral-health advice from midwives during their pregnancy. SO WHAT?: Oral-health promotion programs during pregnancy should consider using midwives to increase dental awareness among women and provide pathways to affordable dental services.

Assessment of the elderly: it's worth covering the risks.

BACKGROUND: Comprehensive assessments provide an invaluable opportunity to identify those at risk of adverse health events, enabling timely access to appropriate health care. AIMS: This study aimed to evaluate the effectiveness of a comprehensive assessment tool, the Adult Patient Assessment Tool (APAT), particularly in relation to early identification of older people at risk of falls, pressure areas, cognitive impairment or delirium, or patients with mental illness or substance abuse. METHODS: Concurrent mixed methods including an initial retrospective medical record audit and focus groups were used. RESULTS: With the introduction of the APAT, assessment of falls risk and mental illness increased. The number of nursing actions relating to pressure areas and falls also increased, indicating a greater awareness of patients' individual needs. Non-clinical information gathered through the APAT enabled a more holistic approach to patient care. CONCLUSION: The use of electronic medical records would alleviate pressures on nurses' time, providing an opportunity to store and retrieve comprehensive nursing assessment and benefit patient health care. IMPLICATIONS FOR NURSING MANAGEMENT: Early assessment results in an increased number of nursing activities related to patient care. Further education relating to mental health and substance abuse screening and cognitive assessment may enhance the completion of these tools.

Midwives and oral health care during pregnancy: perceptions of pregnant women in south-western Sydney, Australia.

AIMS AND OBJECTIVE: This study sought to explore the perceptions of pregnant women in Australia towards oral health care during pregnancy and their views regarding midwives providing oral health education, assessment and referrals as part of antenatal care. BACKGROUND: Maintaining oral health during pregnancy is important. Yet, many pregnant women do not access dental services during this time. Antenatal care providers are now recommended to promote maternal oral health, and various countries have adopted this strategy. However, in Australia, a lack of emphasis is placed on maternal oral health especially by antenatal care providers. Currently, a preventive programme is being developed to promote maternal oral health with the help of midwives in Australia. Very little is known about the perceptions of such an approach from pregnant women. DESIGN: Qualitative approach. METHOD: Data were collected via semi-structured telephone interviews with 10 pregnant women residing in south-western Sydney. RESULTS: Thematic analyses of the data suggest a high prevalence of poor oral health among pregnant women, especially those socioeconomically disadvantaged. The findings also highlight various barriers deterring these women from seeking dental care the most significant being lack of dental awareness, high treatment costs and misconceptions about dental treatment during pregnancy. The absence of affordable dental care remains a major barrier in Australia. The proposed preventive programme was well received by women although issues such as education for midwives and referral pathways were highlighted. CONCLUSIONS: The findings suggest that a tailored midwifery-initiated oral health programme has potential in Australia, especially for low-income families as it addresses many existing barriers to dental care. RELEVANCE TO CLINICAL PRACTICE: Antenatal care providers in Australia should provide more information about oral health. These health professionals should be adequately educated to promote oral health. Health services should also consider offering pregnant women affordable and accessible dental services.

How do dental and prenatal care practitioners perceive dental care during pregnancy? Current evidence and implications.

BACKGROUND: Poor maternal oral health may be associated with adverse pregnancy and infant outcomes. However, women seldom seek dental care during pregnancy, and misconceptions by prenatal care practitioners about oral health care during pregnancy may contribute to the problem. The aim of this study was to review current knowledge, attitudes, and behavior of dental and prenatal care practitioners about oral health care during pregnancy. METHODS: This review examined all studies published in English that explored the knowledge, attitude, behavior, and barriers faced by dentists, general practitioners, midwives, and obstetricians/gynecologists with respect to oral health care during pregnancy. RESULTS: Despite acknowledging the importance of maternal oral health, many dentists are uncertain about the safety of dental procedures and are hesitant in treating pregnant women. General practitioners and midwives are poorly informed about the impact of poor maternal oral health and rarely initiate this topic during prenatal care. Many general practitioners also believe that dental procedures are unsafe during pregnancy. Obstetricians/gynecologists are well informed about perinatal oral health and are supportive of dental procedures, but because of lack of training in this area and competing health demands they seldom focus on oral health care during their prenatal care. CONCLUSION: No real consensus exists among dentists and prenatal care practitioners with respect to oral health care during pregnancy. This issue poses a significant deterrent for pregnant women seeking dental care. Practice guidelines in perinatal oral health are needed for health professionals to emphasize this important aspect of prenatal care.

Developing risk management behaviours for nurses through medication incident analysis.

The aim of this study was to define risk management behaviours related to medication safety. Mixed methods were used to analyze 318 nursing related medication incidents reported in an Australian metropolitan hospital. Most incidents did not result in patient harm (93%). Omission of medications was the most frequent often related to patient absences from the unit or nurses failing to sign for medications. Thematic analysis resulted in the Medication Safety Subscales including 29 behavioural statements within three domains-administering medications, storage and management of medications, managing adverse events related to medications. The Medication Safety Subscales can be used by managers, educators and clinicians to reinforce the importance of medication safety. Early action by nurses may reduce patient injury.

The application of Aronson's taxonomy to medication errors in nursing.

Medication administration is a frequent nursing activity that is prone to error. In this study of 318 self-reported medication incidents (including near misses), very few resulted in patient harm-7% required intervention or prolonged hospitalization or caused temporary harm. Aronson's classification system provided an excellent framework for analysis of the incidents with a close connection between the type of error and the change strategy to minimize medication incidents. Taking a behavioral approach to medication error classification has provided helpful strategies for nurses such as nurse-call cards on patient lockers when patients are absent and checking of medication sign-off by outgoing and incoming staff at handover.

Interdisciplinary communication in general medical and surgical wards using two different models of nursing care delivery.

AIM: To compare two models of care on nurses' perception of interdisciplinary communication in general medical and surgical wards. BACKGROUND: Effective interdisciplinary collaboration remains the cornerstone of efficient and successful functioning of health care teams and contributes substantially to patient safety. METHODS: In May 2007, participants were recruited from a tertiary teaching hospital in Australia. The multifaceted Shared Care in Nursing (SCN) model of nursing care involved team work, leadership and professional development. In the Patient Allocation (PA) model one nurse was responsible for the care of a discrete group of patients. Differences in interdisciplinary communication were assessed at the 6-month follow-up. RESULTS: Completed questionnaires were returned by 125 participants. At the 6-month follow-up, there was a significant reduction in scores in the SCN group in the subscales relating to communication openness (P = 0.03) and communication accuracy (P = 0.02) when compared with baseline values. There were no significant differences in the two groups at the 6-month follow-up in any of the other subscales. CONCLUSIONS: There is a need for effective training programmes to assist nurses in working together within a nursing team and an interdisciplinary ward team. The SCN and the PA models of care have been found by nurses to support most aspects of interdisciplinary and intradisciplinary communication. The applicability of both models of care to wards with a varying skill mix of nurses is suggested. Further studies of larger samples with varying compositions of skill mix and varying models of care are required. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers can use varying models of care to support interdisciplinary communication and enhance patient safety.

Personality, gender and medico-legal matters in medical practice.

OBJECTIVES: The aim of this paper was to explore the relationship between the personality traits of Australian General Practitioners (GPs) and their gender, work practice arrangements, and history of medico-legal matters. METHODS: A cross-sectional self report survey was mailed to 1239 GPs. There were 566 respondents (45.7% response rate to survey). The survey assessed personality traits (using the Eysenck Personality Questionnaire), demographic and practice information, and history of medico-legal matters with any medical defence organization. The number and type of medico-legal matters was also extracted from the UNITED Medical Protection database. RESULTS: Male respondents had significantly higher psychoticism scores than females (p<0.001), and females had significantly higher neuroticism scores than males (p<0.01), as in community samples. However, for GPs who worked more than 48 hours per week, there were no gender differences in personality trait scores. Solo practitioners and non-solo practitioners did not differ on personality scores. Proceduralists and non-proceduralists did not differ on personality scores. However, a higher proportion of proceduralists experienced a medico-legal matter than non-proceduralists (p<0.001). There was a positive correlation between extraversion scores and doctors who attended peer review (p<0.001). There was no difference in the numbers of medico-legal matters for doctors who attended peer review. Males who self reported a medico-legal matter had higher neuroticism scores than the males who did not report medico-legal matters. This was not the case for females. For males, this pattern was not replicated when considering data from UNITED. CONCLUSIONS: The known demographic and practice factors that differ for doctors having a medico-legal matter are replicated here--being male, a proceduralist and working longer hours. There is not a consistent pattern regarding personality traits and medico-legal matters.

A survey of the risk-management behaviours of Australian general practitioners.

BACKGROUND: To assist general practitioners (GPs) in minimising their risk of medical error, the education unit of a medical insurer developed a survey that assessed the risk-management behaviours of GPs. OBJECTIVE: This study describes the risk-management behaviours of Australian GPs and how they vary by age, sex and workload intensity. METHOD: A cross-sectional survey of 572 practising GPs, from a random selection of 1657 insured GPs, formed the data for analysis. GPs self-reported their behaviour using the valid and reliable Know your Risk - GP-Non-procedural Scale. RESULTS: GPs reported performing risk-management behaviours frequently in six key areas: practitioner communication, facilitating patient responses, managing adverse outcomes, practice setting, diagnosis, and prescribing/treatment. Risk-management behaviours varied little by age, sex or workload, with 'facilitating patient responses' being a key domain in age, sex and workload differences (older GPs and women self-reported higher performance) later found to be not significant when the interaction of age, sex and workload was examined. CONCLUSION: Most GPs were actively engaged in general risk-management behaviours. This self-assessment tool and education strategy identified areas for improvement for individual GPs. The initiative prompted GPs to seek additional education including practice reviews. This risk-management strategy would be applicable to sole practices, group practices and divisions of general practice. Workload intensity may be a major consideration in the focus and extent of participation in risk-management behaviours, and research using varying levels of workload intensity is recommended.

Self-assessment of medico-legal risk by doctors: the Know Your Risk Version 1 - Short Form.

An instrument to measure medico-legal risk-management behaviours among medical practitioners was developed and tested. A cross-sectional survey was posted to 962 UNITED Medical Protection members receiving premium support. A final sample of 757 currently working medical practitioners responded, including general practitioners (21.9%), surgeons (29.9%), obstetricians and gynaecologists (12.7%), and others (35.5%). The Know Your Risk Version 1 - Short Form and other tools developed by this team are available for use by group practices, hospital administrators and practitioners. These tools have the potential to assist regulators and insurers to identify, monitor or screen individual medico-legal risk behaviours.

Causal modeling of self-concept, job satisfaction, and retention of nurses.

BACKGROUND: The critical shortage of nurses experienced throughout the western world has prompted researchers to examine one major component of this complex problem - the impact of nurses' professional identity and job satisfaction on retention. DESIGN: A descriptive correlational design with a longitudinal element was used to examine a causal model of nurses' self-concept, job satisfaction, and retention plans in 2002. METHOD: A random sample of 2000 registered nurses was selected from the state registering authority listing. A postal survey assessing multiple dimensions of nurses' self-concept (measured by the nurse self-concept questionnaire), job satisfaction (measured by the index of work satisfaction) was undertaken at Time 1 (n=528) and 8 months later at Time 2 (n=332) (including retention plans (measured by the Nurse Retention Index). Using confirmatory factor analysis, correlation matrices and path analysis, measurement and structural models were examined on matching pairs of data from T1 and T2 (total sample N=332). FINDINGS: Nurses' self-concept was found to have a stronger association with nurses' retention plans (B=.45) than job satisfaction (B=.28). Aspects of pay and task were not significantly related to retention plans, however, professional status (r=.51), and to a lesser extent, organizational policies (r=.27) were significant factors. Nurses' general self-concept was strongly related (r=.57) to retention plans. CONCLUSIONS: Strategies or interventions requiring implementation and evaluation include: counseling to improve nurse general self-concept, education programs and competencies in health communication between health professionals, reporting of nurse-initiated programs with substantial patient benefit, nurse-friendly organizational policies, common health team learning opportunities, and autonomous practice models.

Nursing research priorities for Ireland.

PURPOSE: The purpose of the study was to identify and rate clinical, managerial, and educational nursing research priorities in Ireland. DESIGN: The study design was a three-round, decision Delphi survey to identify and rate the importance of clinical, managerial, and educational research issues. A discussion group workshop was also undertaken to identify timeframes within which research on the issues identified should be conducted. A total of 1,695 nurses from all divisions of the nursing register in Ireland were initially surveyed. Response rates varied over the three rounds of the Delphi survey. A total of 122 nurses attended the discussion group workshop. This is the largest known survey of nurses to identify research priorities reported in the literature. RESULTS: Twenty-four nursing research priorities were identified. The five highest priorities were three clinical issues: outcomes of care delivery, staffing issues in practice, communication in clinical practice; and two managerial issues: recruitment and retention of nurses, and nursing input into health policy and decision-making. CONCLUSIONS: These research priorities identified for nursing in Ireland indicate, to an extent, the nursing research priorities identified in other European countries and in North America. The research priorities identified in this survey indicate that outcomes of care and the need to make nursing visible are attaining a higher priority than seen in previous studies. Also evident is that nursing shortages and increasing skill-mix in the clinical area have indicated a need for research into nurse recruitment, staff turnover, and staffing levels and how these issues affect patient outcomes. The priorities suggest research programmes that target the health service concerns identified in the national health agenda, such as the need to identify protocols and procedures that improve patient and client care outcomes and to examine and test solutions to workforce problems.