A Rapid Realist Review of Quality Care Process Metrics Implementation in Nursing and Midwifery Practice.

Quality measurement initiatives promote quality improvement in healthcare but can be challenging to implement effectively. This paper presents a Rapid Realist Review (RRR) of published literature on Quality Care-Process Metrics (QCP-M) implementation in nursing and midwifery practice. An RRR informed by RAMESES II standards was conducted as an efficient means to synthesize evidence using an expert panel. The review involved research question development, quality appraisal, data extraction, and evidence synthesis. Six program theories summarised below identify the key characteristics that promote positive outcomes in QCP-M implementation. Program Theory 1: Focuses on the evidence base and accessibility of the QCP-M and their ease of use by nurses and midwives working in busy and complex care environments. Program Theory 2: Examines the influence of external factors on QCP-M implementation. Program Theory 3: Relates to existing cultures and systems within clinical sites. Program Theory 4: Relates to nurses' and midwives' knowledge and beliefs. Program Theory 5: Builds on the staff theme of Programme Theory four, extending the culture of organizational learning, and highlights the meaningful engagement of nurses and midwives in the implementation process as a key characteristic of success. Program Theory 6: Relates to patient needs. The results provide nursing and midwifery policymakers and professionals with evidence-based program theory that can be translated into action-orientated strategies to help guide successful QCP-M implementation.

Enablers and challenges to advanced nursing and midwifery practice roles.

AIM: To describe the enablers and challenges to the development and implementation of advanced nursing and midwifery practice roles in Ireland. BACKGROUND: Leadership strategies need to be put in place to enhance the development and implementation of advanced nursing and midwifery practice roles. METHOD: A descriptive qualitative approach using semi-structured interviews with key stakeholders (n = 15) was undertaken with nurses and midwives working in specialist and advanced practice roles and participants from other areas such as legislative, regulatory, policy, pharmacy, medicine and education. RESULTS: Participant's perspectives on the enablers and challenges to enacting specialist and advanced practice roles resulted in the generation of three themes: organisational factors; collegial, interprofessional and interpersonal support; and role clarity, economic and regulatory contexts. CONCLUSION: Addressing organisational factors, encouraging collegial and interprofessional support and establishing role clarity contribute to the effective development and implementation of the role of advanced practitioners. IMPLICATIONS FOR NURSING AND MIDWIFERY MANAGEMENT: Managers of nursing services need to provide leadership in developing strategies to enhance the enablers and overcome the challenges to advanced practice role development in their own organisation.

Developing and sustaining specialist and advanced practice roles in nursing and midwifery: A discourse on enablers and barriers.

AIMS AND OBJECTIVES: To collate, synthesise and discuss published evidence and expert professional opinion on enablers and barriers to the development and sustainability of specialist and advanced practice roles in nursing and midwifery. BACKGROUND: Expanded practice is a response to population health needs, healthcare costs and practitioners' willingness to expand their scope of practice through enhanced responsibility, accountability and professional autonomy. DESIGN: This discursive paper is based on a rapid review of literature on enablers and barriers to the development and sustainability of specialist and advanced practice roles and is part of a wider policy analysis. METHODS: We analysed and synthesised of 36 research articles, reviews and discussion papers on enablers and barriers in the development and sustainability of expanded practice roles. RESULTS: Several factors enable role expansion, including: role clarity; credentialing and endorsement; availability of education for expanded roles; individual practitioners' dispositions towards role expansion; support from peers, other professionals and the work organisation; and costs. Where limited or absent, these same factors can constrain role expansion. CONCLUSIONS: Enabling nurses and midwives to practice to their full scope of education and expertise is a global challenge for disciplinary leadership, a national challenge for professional regulation and a local challenge for employers and individual clinicians. These challenges need to be addressed through multistakeholder coordinated efforts at these four levels. RELEVANCE TO CLINICAL PRACTICE: This discursive paper synthesises empirical evidence and expert professional opinion on the factors that enable or hinder the development and sustainability of specialist and advanced practice roles. Providing a critical appraisal of current knowledge, it provides a reference source for disciplinary debate and policy development regarding the nursing and midwifery resource and informs clinicians of the myriad issues that can impact on their capacity to expand their scope of practice.

Impact of Childhood Vaccine Discussion Format Over Time on Immunization Status.

OBJECTIVE: Presumptive formats to initiate childhood vaccine discussions (eg, "Well, we have to do some shots") have been associated with increased vaccine acceptance after one visit compared to participatory formats (eg, "How do you feel about vaccines?"). We characterize discussion format patterns over time and the impact of their repeated use on vaccine acceptance. METHODS: We conducted a longitudinal prospective cohort study of children of vaccine-hesitant parents enrolled in a Seattle-based integrated health system. After the child's 2-, 4-, and 6-month visits, parents reported the format their child's provider used to begin the vaccine discussion (presumptive, participatory, or other). Our outcome was the percentage of days underimmunized of the child at 8 months old for 6 recommended vaccines. We used linear regression and generalized estimating equations to test the association of discussion format and immunization status. RESULTS: We enrolled 73 parent-child dyads and obtained data from 82%, 73%, and 53% after the 2-, 4-, and 6-month visits, respectively. Overall, 65% of parents received presumptive formats at ≥1 visit and 42% received participatory formats at ≥1 visit. Parental receipt of presumptive formats at 1 and ≥2 visits (vs no receipt) was associated with significantly less underimmunization of the child, while receipt of participatory formats at ≥2 visits was associated with significantly more underimmunization. Visit-specific use of participatory (vs presumptive) formats was associated with a child being 10.1% (95% confidence interval, 0.3, 19.8; P = .04) more days underimmunized (amounting to, on average, 98 more days underimmunized for all 6 vaccines combined). CONCLUSIONS: Presumptive (vs participatory) discussion formats are associated with increased immunization.

An overview of the outcomes and impact of specialist and advanced nursing and midwifery practice, on quality of care, cost and access to services: A narrative review.

OBJECTIVES: This paper presents the results of a systematic rapid review and narrative synthesis of the literature of the outcomes and impact of specialist and advanced nursing and midwifery practice regarding quality of care, cost and access to services. DESIGN: A rapid review was undertaken of the relevant national and international literature, regulatory and policy documents relating to the establishment and definition of nurses' and midwives' specialist and advanced practice roles. DATA SOURCES: A search of the Cumulative Index to the Nursing and Allied Health Literature (CINAHL), PubMed (MEDLINE) was undertaken from 2012 to 2015. The study also included primary data collection on the perceived impact of specialist and advanced practice nursing and midwifery roles and enablers and barriers to these roles using semi-structured interviews. These are not included in this paper. REVIEW METHOD: To facilitate a systematic approach to searching the literature, the PICO framework, was adapted. RESULTS: The database search yielded 437 articles relevant to the analysis of specialist and advanced practice in relation to quality care, cost and access to services with additional articles added in a manual review of reference lists. In the final review a total of 86 articles were included as they fulfilled the eligibility criteria. CONCLUSION: The evidence presented in the 86 articles indicates that nursing and midwifery practitioners continue to be under-utilised despite the evidence that greater reliance on advanced nurse practitioners could improve accessibility of primary care services while also saving on cost. Results point to continued difficulties associated with accurate measurement of the impact of these roles on patient outcomes. This review demonstrates that there is a need for robust measurement of the impact of these roles on patient outcomes.

Improving Outcome of Psychosocial Treatments by Enhancing Memory and Learning.

Mental disorders are prevalent and can lead to significant impairment. Some progress has been made toward establishing treatments; however, effect sizes are small to moderate, gains may not persist, and many patients derive no benefit. Our goal is to highlight the potential for empirically supported psychosocial treatments to be improved by incorporating insights from cognitive psychology and research on education. Our central question is: If it were possible to improve memory for the content of sessions of psychosocial treatments, would outcome substantially improve? We leverage insights from scientific knowledge on learning and memory to derive strategies for transdiagnostic and transtreatment cognitive support interventions. These strategies can be applied within and between sessions and to interventions delivered via computer, the Internet, and text message. Additional novel pathways to improving memory include improving sleep, engaging in exercise, and using imagery. Given that memory processes change across the lifespan, services to children and older adults may benefit from different types and amounts of cognitive support.

The relationship between parent attitudes about childhood vaccines survey scores and future child immunization status: a validation study.

IMPORTANCE: Acceptance of childhood vaccinations is waning, amplifying interest in developing and testing interventions that address parental barriers to immunization acceptance. OBJECTIVE: To determine the predictive validity and test-retest reliability of the Parent Attitudes About Childhood Vaccines survey (PACV), a recently developed measure of vaccine hesitancy. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort of English-speaking parents of children aged 2 months and born from July 10 through December 10, 2010, who belonged to an integrated health care delivery system based in Seattle and who returned a completed baseline PACV. Parents who completed a follow-up survey 8 weeks later were included in the reliability analysis. Parents who remained continuous members in the delivery system until their child was 19 months old were included in the validity analysis. EXPOSURE: The PACV, scored on a scale of 0 to 100 (100 indicates high vaccine hesitancy). MAIN OUTCOMES AND MEASURES: Child's immunization status as measured by the percentage of days underimmunized from birth to 19 months of age. RESULTS: Four hundred thirty-seven parents completed the baseline PACV (response rate, 50.5%), and 220 (66.5%) completed the follow-up survey. Of the 437 parents who completed a baseline survey, 310 (70.9%) maintained continuous enrollment. Compared with parents who scored less than 50, parents who scored 50 to 69 on the survey had children who were underimmunized for 8.3% (95% CI, 3.6%-12.8%) more days from birth to 19 months of age; those who scored 70 to 100, 46.8% (40.3%-53.3%) more days. Baseline and 8-week follow-up PACV scores were highly concordant (ρ = 0.844). CONCLUSIONS AND RELEVANCE: Scores on the PACV predict childhood immunization status and have high reliability. Our results should be validated in different geographic and demographic samples of parents.

Well-child care visits and risk of ambulatory care-sensitive hospitalizations.

OBJECTIVES: To determine if poor well-child care (WCC) visit adherence is associated with increased risk for Ambulatory Care-Sensitive Hospitalizations (ACSHs) among young children in an integrated healthcare delivery system. STUDY DESIGN: This was a retrospective observational study. METHODS: We used claims and administrative data for children aged 2 months to 3.5 years enrolled at Group Health Cooperative from 1999 to 2006. Our main independent variable was timely WCC visits based on Group Health's 2000 recommended schedule. We used Cox proportional hazard regression models to determine the association between WCC visit adherence and risk for a child's first ACSH. RESULTS: Of the 20,065 children, 797 (4%) had an ACSH. Children with lower WCC visit adherence had increased hazard ratios (HRs) of 1.4-2.0 for ACSH (adherence 0-25%: HR 2.0, 95% confidence interval [CI]: 1.6-2.6, P < .001; adherence 26-50%: HR 1.4, 95% CI: 1.1-1.8, P < .05). Of the 2196 children with > 1 chronic disease, 189 (9%) had an ACSH. Children with > 1 chronic disease and with lower WCC visit adherence also had increased HRs for ACSH (adherence 0-25%: HR 3.2, 95% CI: 1.8-5.6, P < .001; adherence 26-50%: HR 1.9, 95% CI: 1.2-3.2, P < .05). CONCLUSIONS: For young children, poor WCC visit adherence was associated with increased risk for ACSH in this integrated healthcare delivery system.

Integrated personal health record use: association with parent-reported care experiences.

OBJECTIVE: To examine integrated personal health record (PHR) use patterns among parents of children with chronic disease and compare ratings of care experiences between integrated PHR users and nonusers. METHODS: A survey was mailed to 600 randomly selected parents of children with chronic disease ≤ 5 years old and enrolled at Group Health for ≥ 1 year. Respondents reported integrated PHR use in the past 12 months, types of services used, or reasons for nonuse. We measured parent ratings of care experiences by using Consumer Assessments of Healthcare Providers and Systems (CAHPS) composite measures: Attention to Growth and Development, Attention to Safety and Health, Getting Care Quickly, Getting Needed Care, Prescription Medications, and Care Coordination. We used multivariate logistic regression to test the association between integrated PHR use and each CAHPS composite measure dichotomized by using the top box score method. RESULTS: Of 256 respondents (43% eligible response rate), 166 (65%) were integrated PHR users and 90 (35%) were nonusers. The top integrated PHR services used were viewing immunization records, viewing medical records, secured messaging, and scheduling appointments. The top reasons for not using the integrated PHR were "too busy," "forgot login/password," and "my child does not have health care needs." Adjusted logistic regression did not reveal any significant differences between users and nonusers. CONCLUSIONS: Parents of children with chronic disease appear willing to use an integrated PHR to address health care needs for their child. Integrated PHR use was not associated with higher scores on CAHPS composite measures in this health plan.

Clinical inquiry. What is the most effective way to treat recurrent canker sores?

Amlexanox appears to be most effective overall. Amlexanox 5% paste reduces ulcer size, pain duration, and healing time.

The Children's Health Insurance Program Reauthorization Act quality measures initiatives: moving forward to improve measurement, care, and child and adolescent outcomes.

In 2009, a publicly transparent evidence-informed process responded to the requirement of the Children's Health Insurance Program Reauthorization Act (CHIPRA) legislation to identify an initial core set of recommended children's health care quality measures for voluntary use by Medicaid and the Children's Health Insurance Program, which together cover almost 40 million of America's children and adolescents. Future efforts under CHIPRA will be used to improve and strengthen the initial core set, develop new measures as needed, and post improved core measure sets annually beginning in January 2013. This supplement aims to make available useful information about issues surrounding the initial core set and key concepts for moving forward toward improvement of children's health care quality measures, children's health care quality, and children's health outcomes. The set of articles in this supplement includes a detailed description of how the identification of a balanced, grounded, and parsimonious core set of children's health care quality measures was accomplished by means of an open, public process combined with an evidence-informed evaluation methodology. Additional articles note that Medicaid and Children's Health Insurance Program (CHIP) officials put a high priority on children's health care quality and desire better measures; that publicly insured children are more likely than privately insured children to experience severe, complex chronic conditions and experience poorer quality in some respects; and that some key CHIPRA topics did not yet have valid, feasible measures (eg, availability of services, duration of enrollment and coverage, most integrated health care settings, and some aspects of family experiences of care). Key stakeholders and observers provide commentary noting the unprecedented scope and nature of the CHIPRA legislation as well as noting areas in which the nation still needs to move to improve health care quality, including its measurement. These areas include greater engagement of families and health care providers in the quality measurement and improvement enterprises, collaboration across federal agencies, more emphasis on clinical effectiveness research to enhance the validity of children's health care services and quality measures, and a need to maintain an emphasis on children as the nation expands health care coverage and attention to quality for all populations. This overview also notes areas of future priorities for measure enhancement and development, including inpatient specialty, health outcomes, and a focus on inequity. We and others contributing to this supplement consider the identification of the initial core set to be a significant initial accomplishment under CHIPRA. With sufficient attention to making the measures feasible for use across Medicaid and CHIP programs, and with technical assistance, voluntary use should be facilitated. However, the initial core set is but one step on the road toward improved quality for children. The identification of future challenges and opportunities for measure enhancement will be helpful in setting and implementing a future pediatric quality research agenda.