The substitution of physician assistants and nurse practitioners for physician residents in teaching hospitals.

This study documents features of clinical departments in teaching hospitals that are using physician assistants (PAs) and nurse practitioners (NPs) to perform some tasks previously done by medical or surgical residents. More than 60 percent of teaching hospital medical directors surveyed reported experience with substitution in their hospitals. The experience overall appears to be positive; one-third of the departments are planning to increase the number of PAs and NPs they use. The results imply that some of the services lost in house-staff reductions called for in many physician workforce reform proposals could be provided by alternative health professionals.

Increasing participation by private physicians in the EPSDT Program in rural North Carolina.

This study evaluated a method to increase physicians' participation in Early and Periodic Screening, Diagnosis and Treatment (EPSDT), a preventive health care program for Medicaid eligible children. Use of EPSDT can improve children's health status and reduce health care costs. Although the potential benefits of EPSDT are clear, the program is underused; low rates of participation by private physicians contribute to underuse. This study targeted a population of 73 primary care physicians in six rural counties in North Carolina where the physician supply, their participation in EPSDT, and use of EPSDT were low. A mailed intervention packet attempted to address barriers to participation perceived by private providers. The packet consisted of a carefully constructed letter, an informative journal article, and an educational pamphlet. Participation in EPSDT screening increased from 15 to 25 private physicians (67 percent), at a cost, on average, of less than $30 per recruited provider. Suggestions are presented for adapting the intervention packet to other settings.

Barriers to the use of preventive health care services for children.

This article describes findings from interviews of parents targeted for outreach efforts that encouraged them to use Medicaid's Early and Periodic Screening, Diagnosis and Treatment(EPSDT) Program. Begun in the 1970s, the EPSDT program held out the promise of ensuring that needy children would receive comprehensive preventive care. With only one-third of eligible children in the United States receiving EPSDT checkups, the program has yet to fulfill its promise. This study sought to understand parents' perceptions of barriers to using EPSDT by interviewing (a) 110 parents who did not schedule EPSDT checkups for their children after being exposed to outreach efforts and (b) 30 parents who did. Although the EPSDT Program is designed to provide health care at no charge and to provide assistance with appointment scheduling and transportation, these low-income parents identified significant barriers to care. Reasons for not using EPSDT services included (a) competing family or personal issues and priorities; (b) perceived or actual barriers in the health care system; and (c) issues related directly to problems with the outreach efforts. Parents who successfully negotiated these barriers and received EPSDT services encountered additional barriers, for example, scheduling and transportation difficulties, long waiting room times, or care that they perceived to be either unresponsive to their medical needs or interpersonally disrespectful. The implications for future outreach efforts and improving access to preventive health care services are discussed.

Consumer perspectives on Medicaid managed care: a comparison between rural and urban enrollees in one selected health plan.

This report presents the findings from a telephone survey of 313 respondents who have family members enrolled in Medicaid managed care in a multicounty region that encompasses both rural and urban counties in Wisconsin. Some demographic differences were noted between the rural and urban families that might affect their impressions of the health care system, their needs for services and their abilities to use those services appropriately. Families in the urban counties had poorer access to health care, as they were more likely to report at least one child not being assigned to a primary care provider. Inadequate preventive health behaviors were found among both rural and urban families, as evidenced by children being overdue for immunizations or health checkups. Yet respondents reported being happy with the care they received. Rural families in particular seemed to fare well in this managed care system.

Communicating research findings to readers of clinical nursing journals: guidance for prospective authors.

The dissemination of research through publication in professional journals is important for the advancement of pediatric nursing practice. Without knowledge of current research, practitioners cannot take actions to apply research to improve the health of the children and families they serve. To ensure that practitioners can make the most appropriate use of quantitative research findings, research publications must adhere to specific scientific standards for the conduct and reporting of research. This article is intended to guide nurse researchers to adhere to these standards and effectively communicate their research findings to nurses in clinical practice.

Nursing drives interdisciplinary health care workforce planning in Wisconsin: one state's experience.

The Consortium for Primary Care in Wisconsin convened a forum to develop an interdisciplinary primary care workforce plan to address issues related to the supply of and demand for primary health care providers in Wisconsin. Nursing leaders played a pivotal role in making this effort successful and in ensuring that the focus would be on all primary health care professionals, not just physicians. This process used a primary care workforce planning tool (IRM) developed by the Bureau of Health Professions, U.S. Public Health Service which allowed Wisconsin to (1) examine its own workforce needs with data produced in Wisconsin, (2) compare the state's situation with national trends, and (3) include these data and projections in a cooperative process for state-level planning for interdisciplinary workforce development. The Bureau has encouraged other states and organizations to adopt a similar strategy through a series of IRM workshops in which the Wisconsin process serves as a model for training materials developed for these workshops. The Wisconsin planning process is an innovative model for other states to follow in facilitating workforce development and serves to encourage other states to share their experiences in the academic literature.

Master's degree-level community health nursing educational needs: a national survey of leaders in service and education.

This study identified the core components of the curriculum for master's degree-level community health nurses (CHNs) and assessed whether existing educational programs provide this knowledge base. According to 588 leaders in community health nursing (CHN) service and education, all master's degree-prepared CHNs require skills in the administrative role. Interdisciplinary core content areas needed to fulfill role responsibilities include a practicum experience; epidemiology; community health assessment and diagnosis; administration and management, including program planning and evaluation, financial management, budgeting, and quality assurance; research methods and biostatistics; health promotion and disease prevention; interventions at the aggregate level; and leadership theory. There were notable discrepancies between what was considered essential and what actually was included in CHN education. This article provides suggestions and possible alternatives for initiating change to ensure adequate educational preparation for graduate-level CHN practice.

Evaluation of sampling methods in research reported in selected clinical nursing journals: implications for nursing practice.

This article summarizes standards relating to sampling methodology, identifies deviations from these standards in research studies reported in selected clinical nursing journals, and provides suggestions for improving sampling methods to enhance the applicability of research for nursing practice. A random sample of 30 research reports published in 1986 in five clinical nursing journals was examined. Nearly 97 per cent of the published studies contained at least one major deficiency in sampling methodology. More than two thirds failed to describe the sampling frame, sample size, or number of refusals, withdrawals, and/or cases lost. Thirteen per cent did not report sampling methods. More than half made generalizations that were inappropriate for the sampling method used; 43 per cent did not acknowledge any limitations of their sample. Sample sizes were small, and statistical power to detect significant differences was low. These deficiencies in sampling procedures could detract from the value of the research that nurses are encouraged to use as a basis for practice. This article provides specific recommendations for remedying these deficiencies to help ensure the scientific merit of the research published for nursing practice.

Reporting of instrument validity and reliability in selected clinical nursing journals, 1989.

Before research findings are applied to practice, the quality of the research must be assessed so that flawed research does not lead inadvertently to flawed practice. Two critical indicators of research quality are the validity and reliability of the data collection instruments. This article summarizes the principles of instrument validity and reliability and identifies deviations from these principles in a random sample of 55 research studies published in 1989 in five refereed nursing journals targeted toward practicing clinicians. Using a valid and reliable instrument, the investigators found that even with a policy of giving authors "the benefit of the doubt," 47% of the research studies contained no evidence of validity for any data collection instruments and 36% had no evidence of reliability; 29% had no evidence of either validity or reliability. Content validity, a basic requirement for all research instruments, was addressed in only 27% of the studies. This article provides documentation, justification, and suggestions for nursing educators, journal editors, and researchers to take action to improve the reporting of instrument validity and reliability to help ensure the quality of the research on which nursing practice is based.

Easing the burden on health departments: a cost-effective method for public health nurses to increase private sector participation in the early and periodic screening, diagnosis, and treatment program.

Federal legislation requires states to increase use of the early and periodic screening, diagnosis, and treatment (EPSDT) program. The program provides comprehensive health services to children from low-income families on Medicaid and has been shown to improve health and reduce health care costs. Health departments and public health nurses (PHNs) bear a major burden conducting EPSDT screenings because many private physicians choose not to provide these services. Given scarce resources, health departments alone may be unable to meet the mandate for increased EPSDT services. Thus PHNs concerned about children's access to health care may have to encourage provision of EPSDT through the private sector. This project, phase I of the federally funded Healthy Kids Project to increase EPSDT use in rural areas of North Carolina, established the cost-effectiveness of a mailed intervention to recruit private physicians to do EPSDT screens that exceeded the capacity of health departments. The intervention, consisting of a personal letter, journal article, and pamphlet, was sent to all 73 primary care physicians in six rural counties. Before the mailing, 15 (21%) of the 73 physicians were willing to provide EPSDT screenings; after the mailing the number rose to 25 (34%). The one-time cost to recruit each provider was less than the estimated annual cost savings associated with each child in the EPSDT program.

Building administrative support for your research: a neglected key for turning a research plan into a funded project.

There is more to grantsmanship than writing a good proposal. Planning, building, and negotiating administrative support may make the difference in a successful research effort.

Specialty roles in community health nursing: a national survey of educational needs.

This study identified population groups, health conditions, and employment settings considered appropriate for graduate-level community health nursing (CHN) practice and employment, and described the relative importance of each of these areas as assessed by CHN leaders. According to 588 leaders in CHN service and education, (1) the population groups most in need of graduate-prepared CHNs are the elderly, persons of low socioeconomic status, the homeless, adolescents, and the unemployed; and (2) the health conditions most in need of CHN services are AIDS, pregnancy and prenatal problems, low birth weight and infant mortality, stress-related illness, and Alzheimer's and other chronic diseases of the elderly. Among the many employment settings rated as having a great need for CHNs are state and local health departments and home health agencies. The findings provide the direction and justification for developing specialty options within CHN that correspond to these identified and changing needs. This article provides suggestions and possible alternatives for initiating educational change to prepare graduate-level CHNs for these various specialties and for the settings in which the specialties will be applied.

Improving EPSDT use: development and application of a practice-based model for public health nursing research.

The purposes of this article are to describe the process of adapting an existing model to create a framework suitable for public health nursing (PHN) practice and to demonstrate how the resulting model can guide research for PHN practice. Using the PRECEDE (predisposing, reinforcing, and enabling causes in educational diagnosis and evaluation) model as a base, we synthesized concepts of health behavior, health education, health promotion/disease prevention, and program evaluation to develop a model for planning and evaluating aggregate-level PHN interventions to improve the use of the Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT) in rural North Carolina. The model provided the framework for identifying variables relevant to EPSDT use, designing interventions to improve use, and planning a research evaluation of the effectiveness, efficacy, and cost effectiveness of the interventions. This model, and the process used in adapting it for PHN practice, should be helpful for others investigating methods of reaching and bringing effective health-promotion/disease-prevention information to underserved, low-education members of minority groups.

Core curriculum for master's-level community health nursing education: a comparison of the views of leaders in service and education.

This study identified core components of the curriculum for master's-level community health nurses (CHNs) and assessed whether leaders in service agreed with leaders in education on the importance of these components. Through a mailed survey, 588 leaders in CHN service and education identified the following as the most important to include in the core CHN curriculum: a practicum experience; epidemiology; community health assessment and diagnosis; administration and management, including public health administration, management theory, program planning and evaluation, financial management and budgeting, and quality assurance; research methods and biostatistics; health promotion and disease prevention; intervention at the aggregate level; and leadership theory. These leaders also indicated that skills in both administration and direct care are essential for CHN practice. While there was remarkable agreement between service and education leaders in many areas, notable disagreements were seen in the importance accorded administrative skills. Service leaders rated these skills much more highly than did leaders in education.

Public health nursing interventions to improve the use of a health service: using a pilot study to guide research.

This article demonstrates how a pilot study can provide useful direction for a research project. In planning a study to improve the use of the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program for Medicaid-eligible children, we tested our research methods and interventions (mailed pamphlets, telephone calls, home visits) on a small scale (N = 100) prior to implementing a large-scale (N greater than 2000) project. The issues and obstacles included obtaining cooperation from many agencies involved in administering the Medicaid program, addressing informed consent, assessing feasibility of methods for random sampling and random assignment, identifying sources of Medicaid data, designing and assessing validity and reliability of research tools, and testing the feasibility of implementing interventions in the field. Our experience may be particularly helpful for public health nurses who plan to investigate approaches to improve the use of services in federally mandated health programs where cooperation from federal, state, and local agencies is required.