Preparing nurse scientists for health services and policy research: Five-year outcomes of interprofessional postdoctoral training in the National Clinician Scholars Program.

BACKGROUND: The National Clinician Scholars Program (NCSP) is an interprofessional postdoctoral fellowship for physicians and nurses with a PhD. or DNP focused on health services research, policy, and leadership. PURPOSE: To evaluate 5-year outcomes of nurse postdoctoral scholars in the NCSP. METHODS: We describe the 5-year outcomes of nurse fellows and graduates from six NCSP sites (positions, number of peer-reviewed publications, citations, and h-index). CONCLUSION: There were 53 nurses in the sample (34 alumni, 19 fellows). Approximately half (47%, n = 16) of alumni had tenure-track faculty positions and had bibliometric performance indicators (such as h-indices) 2 to 4 times greater than those previously reported for assistant professors in nursing schools nationally. NCSP nurse scholars and alumni also had an impact on community partnerships, health equity, and health policy DISCUSSION: This study highlights the potential of interprofessional postdoctoral fellowships such as the NCSP to prepare nurse scientists for health care leadership roles.

A Framework for Transforming Primary Care Health Care Professions Education and Training to Promote Health Equity.

A diverse and well-trained, distributed and resourced primary care workforce is essential for advancing health equity. However, few standardized models exist to guide health care professions education (HCPE) on core competencies regarding understanding and effectively addressing social determinants of health, social injustice, structural barriers, and the high burden of health needs in marginalized populations. We propose a framework with domains of policies and incentives, enabling institutional climate, educational content and integration, and community-orientation and community engagement. The framework encompasses inter-disciplinary team-based care and immersive community experiences to equip learners with cognitive skills and knowledge needed to understand and address unmet needs and ensure equitable access to the entire continuum of care. Research is needed to understand barriers and promoters of a health equity-guided HCPE, and standards for theory-driven curricular contents and metrics to evaluate and track progress. Multisector collaborations and demonstration projects may help guide standardized training on advancing health equity.

Treatment for Opioid Use Disorder in Primary Care: Opportunities and Challenges for Sustainable Training Programs.

Drug overdose death rates from opioid use have risen steadily since 1999 and reached epidemic levels, slowing for the first time in 2018, though not for many forms of opioid use. Yet evidence-based approaches to combating OUD, such as medication-assisted treatment for OUD (MT-OUD), are still inaccessible to many. Primary care providers are well-positioned to offer these services; however, training and education in OUD care remains inadequate. The National Center for Integrated Behavioral Health interviewed the Health Resources Service Administration (HRSA) awardees of federal funding to implement an MT-OUD curriculum in their primary care residency training programs to identify barriers and facilitators to implementation. Awardees were interviewed at program launch and one year later. Results showed the importance of leadership willingness to participate, effective treatment integration into existing workflow, curriculum and clinical flexibility, and supportive interdisciplinary and community partnerships. Recommendations for best practices of MT-OUD training in primary care are identified.

Does Quality of End-of-Life Care Differ by Urban-Rural Location? A Comparison of Processes and Family Evaluations of Care in the VA.

PURPOSE: Several studies have identified differences in end-of-life (EOL) care between urban and rural areas, yet little is known about potential differences in care processes or family evaluations of care. The purpose of this study was to examine the relationship between rurality of residence and quality of EOL care within the Veterans Affairs health care system. METHODS: This study was a retrospective, cross-sectional analysis of 126,475 veterans who died from October 2009 through September 2016 in inpatient settings across 151 facilities. Using unadjusted and adjusted logistic regression, we compared quality of EOL care between urban and rural veterans using family evaluations of care and 4 quality of care indicators for receipt of (1) palliative care consult, (2) a chaplain visit, (3) death in an inpatient hospice unit, and (4) bereavement support. FINDINGS: Veterans from rural areas had lower odds of dying in an inpatient hospice unit compared to veterans from urban areas, before and after adjustment (large rural OR 0.73, 95% CI: 0.70-0.77; P < .001, small rural OR 0.81, 95% CI: 0.77-0.86; P < .001, isolated rural OR 0.87, 95% CI: 0.81-0.93; P < .001). Differences in comparisons of other quality of care indicators were small and of mixed significance. No significant differences were found in family ratings of care in fully adjusted models. CONCLUSION: Receipt of some EOL quality indicators differed with urban-rural residence for some comparisons. However, family ratings of care did not. Our findings call for further investigation into unmeasured individual characteristics and facility processes related to rurality.

Scaling up: bringing the transitional care model into the mainstream.

Elderly, chronically ill people experience frequent changes in health status that require transitions among health care providers and settings. This issue brief describes two projects that identified the essential elements of effective care management interventions for this population and the facilitators of translating one such intervention, the Transitional Care Model (TCM), into mainstream practice. Together these projects demonstrate that successful translation of the TCM, which incorporates both in-person contact and a nurse-led, interdisciplinary team approach, can effectively interrupt patterns of frequent rehospitalizations, reduce costs, and improve patient health status. Findings from these projects inform challenges that must be overcome to facilitate the translation of effective care management innovations into mainstream practice.

The association between nursing factors and patient mortality in the Veterans Health Administration: the view from the nursing unit level.

CONTEXT: Nurse staffing is not the same across an entire hospital. Nursing care is delivered in geographically-based units, with wide variation in staffing levels. In particular, staffing in intensive care is much richer than in nonintensive care acute units. OBJECTIVE: To evaluate the association of in-hospital patient mortality with registered nurse staffing and skill mix comparing hospital and unit level analysis using data from the Veterans Health Administration (VHA). DESIGN, SETTINGS, AND PATIENTS: A retrospective observational study using administrative data from 129,579 patients from 453 nursing units (171 ICU and 282 non-ICU) in 123 VHA hospitals. METHODS: We used hierarchical multilevel regression models to adjust for patient, unit, and hospital characteristics, stratifying by whether or not patients had an ICU stay during admission. MAIN OUTCOME MEASURE: In-hospital mortality. RESULTS: : Of the 129,579 patients, mortality was 2.9% overall: 6.7% for patients with an ICU stay compared with 1.6% for those without. Whether the analysis was done at the hospital or unit level affected findings. RN staffing was not significantly associated with in-hospital mortality for patients with an ICU stay (OR, 1.02; 95% CI, 0.99-1.03). For non-ICU patients, increased RN staffing was significantly associated with decreased mortality risk (OR, 0.91; 95% CI, 0.86-0.96). RN education was not significantly associated with mortality. CONCLUSIONS: Our findings suggest that the association between RN staffing and skill mix and in-hospital patient mortality depends on whether the analysis is conducted at the hospital or unit level. Variable staffing on non-ICU units may significantly contribute to in-hospital mortality risk.

Managed care and hospital cost containment.

This study assesses the ability of managed care to contain hospital costs since the managed care backlash, using data from California's Office of Statewide Health Planning and Development for all acute-care hospitals in the state for the period 1991-2001. The analysis employs a long-differences design to examine cost growth before and after the managed care backlash. Results from the early 1990s are consistent with prior evidence that the combination of more competitive markets and high managed care penetration held down costs. Post-backlash, high managed care penetration no longer was associated with lower cost growth in the most competitive markets, indicating that the synergistic effects between managed care and hospital competition no longer may exist.

International nurse migration: lessons from the Philippines.

Developed countries facing nursing shortages have increasingly turned to aggressive foreign nurse recruitment, primarily from developing nations, to offset their lagging domestic nurse supplies and meet growing health care demands. Few donor nations are prepared to manage the loss of their nurse workforce to migration. The sole country with an explicit nurse export policy and the world's leading donor of nurse labor - the Philippines - is itself facing serious provider maldistribution and countrywide health disparities. Examining the historical roots of Philippines nurse migration provides lessons from which other nurse exporting countries may learn. The authors discuss factors that have predicated nurse migration and policies that have eased the way. Furthermore, the authors analyze how various stakeholders influence migratory patterns, the implications of migration for nurses and the public in their care, and the challenges that future social policy and political systems face in addressing global health issues engendered by unfettered recruitment of nurses and other health workers.

The migration of nurses: trends and policies.

This paper examines the policy context of the rise in the international mobility and migration of nurses. It describes the profile of the migration of nurses and the policy context governing the international recruitment of nurses to five countries: Australia, Ireland, Norway, the United Kingdom, and the United States. We also examine the policy challenges for workforce planning and the design of health systems infrastructure. Data are derived from registries of professional nurses, censuses, interviews with key informants, case studies in source and destination countries, focus groups, and empirical modelling to examine the patterns and implications of the movement of nurses across borders. The flow of nurses to these destination countries has risen, in some cases quite substantially. Recruitment from lower-middle income countries and low-income countries, as defined by The World Bank, dominate trends in nurse migration to the United Kingdom, Ireland, and the United States, while Norway and Australia, primarily register nurses from other high-income countries. Inadequate data systems in many countries prevent effective monitoring of these workforce flows. Policy options to manage nurse migration include: improving working conditions in both source and destination countries, instituting multilateral agreements to manage the flow more effectively, and developing compensation arrangements between source and destination countries. Recommendations for enhancements to workforce data systems are provided.

Imported care: recruiting foreign nurses to U.S. health care facilities.

As U.S. health care facilities struggle to fill current registered nurse staffing vacancies, a more critical nurse undersupply is predicted over the next twenty years. In response, many institutions are doubling their efforts to attract and retain nurses. To that end, foreign nurses are increasingly being sought, creating a lucrative business for new recruiting agencies both at home and abroad. This paper examines past and current foreign nurse use as a response to nurse shortages and its implications for domestic and global nurse workforce policies.

Nursing shortage redux: turning the corner on an enduring problem.

Projections of a substantial nursing workforce imbalance in the coming decade have galvanized policymakers, providers, private foundations, nurses, and others to proffer aggressive and sustainable strategies to ameliorate the looming shortage. The solutions are largely ones that seek to increase supply. Analysis of the 1992-2000 National Sample Surveys of Registered Nurses shows that increasing losses from the active workforce, stagnant wages, and low levels of job satisfaction pose major impediments to bolstering supply. Strategies focused on working conditions and retention should occupy a central position in any nursing workforce revitalization plan.