Nursing Strategic Imperatives: Engaging Nurses in Strategy Development and Execution to Drive Value.

Strategic plans provide a roadmap for value creation by outlining key priorities that, when executed successfully, enhance quality and efficiency. Nurses are uniquely positioned to inform strategic planning because of their understanding of clinical operations and consumer needs. This article describes a multiphase process for engaging nurses, at all levels, in developing, implementing, and revising a nursing strategic plan over a 5-year period.

Health systems and health equity: Advancing the agenda.

Despite a compelling body of evidence and decades of policy recommendations, deep inequities in health persist with historically marginalized groups. Operationalizing strategies to achieve equity in health and health care continues to remain elusive to health systems. We propose several focus areas; attention to semantics and concepts, building knowledge of health inequities, redesigning care and transforming cultures, to advance health equity work by health system nurse leaders and clinical nurses. Health equity frameworks, traditionally applied in population and public health, are also discussed to tackle health equity issues and formulate, implement and evaluate solutions to inequities. Examples illustrate ongoing work in our health system in targeted areas and challenges in advancing health equity work. Future efforts by health system nurse leaders should concentrate on technology for point of care health screening and data acquisition, data-driven decisions, and organizational performance measures to narrow health equity gaps.

Value of Nurse Practitioner Inpatient Hospital Staffing.

BACKGROUND: Evidence indicates hospitals with better registered nurse (RN) staffing have better patient outcomes. Whether involving more nurse practitioners (NPs) in inpatient care produces better outcomes is largely unknown. OBJECTIVE: The objective of this study was to determine whether the presence of more NPs produces better inpatient outcomes net of RN staffing. RESEARCH DESIGN: This was a 2015-2016 cross-sectional data on 579 hospitals linked from: (1) RN4CAST-US nurse surveys; (2) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient surveys; (3) surgical patient discharge abstracts; (4) Medicare Spending per Beneficiary (MSPB) reports; (5) American Hospital Association (AHA) Annual Survey. Hospitals were grouped according to their NP/beds ratios [<1 NP/100 beds (N=132), 1-2.99 NPs/100 beds (N=279), and 3+ NPs/100 beds (N=168)]. SUBJECTS: RNs randomly sampled nurses from licensure lists yielded 22,273 RNs in study hospitals; discharge data for 1.4 million surgical patients; HCAHPS data for 86% of study hospitals. MEASURES: Mortality, readmissions, lengths of stay, MSPB, patient experience, and quality reported by patients and nurses. RESULTS: After adjustments, patients in hospitals with 3+ NPs/100 beds had lower odds than patients in hospitals with <1 NP/100 beds of 30-day mortality [odds ratio (OR)2=0.76; 95% confidence interval (CI)=0.67-0.82; P<0.001] and 7-day readmissions (OR2=0.90; 95% CI=0.86-0.96; P<0.001), shorter average length of stay (incident rate ratio2=0.92; 95% CI=0.88-0.96; P<0.001) and 5.4% lower average MSPB (95% CI=3.8%-7.1%). Patients and nurses in the hospitals with higher NP/bed ratios were significantly more likely to report better care quality and safety, and nurses reported lower burnout, higher job satisfaction, greater intentions of staying in their jobs. CONCLUSIONS: Having more NPs in hospitals has favorable effects on patients, staff nurse satisfaction, and efficiency. NPs add value to existing labor resources.

The Distinguished Nurse Clinician Academy: An Innovative Recognition Program for Frontline Clinicians.

The complexity and growth of healthcare systems provide nurse leaders an opportunity to recognize and facilitate professional development for experienced frontline clinicians and to create formal structures that give expert direct care nurses a stronger voice. The purpose of this article is to describe how one health system developed and implemented an innovative Distinguished Nurse Clinician Academy. This elite academy demonstrates the longitudinal impact of a health systems' Magnet culture.

Moving beyond the measure: Understanding patients' experiences of communication with nurses.

Under Medicare's Value-Based Purchasing Program, scores derived from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey are used in the determination of incentive payments and financial penalties for healthcare organizations. Organizations, therefore, invest in approaches to improve the likelihood of positive patient responses. Evidence suggests that nurse communication as measured by HCAHPS influences overall patient satisfaction, yet little is known regarding what patients believe constitutes effective communication with nurses. In this qualitative descriptive study, we conducted phone interviews with 49 recently hospitalized patients to better understand patients' perceptions of their communication with nurses. Our findings indicate that patients perceived their communication with nurses to unfold via nurses' behaviors. Namely, nurses' engagement with patients, anticipation of patients' needs, responsiveness to patients' concerns, and teaching practices positively influence patient satisfaction with communication with nurses. These behaviors resonated most strongly with patients during particularly memorable moments of uncertainty and vulnerability over the course of a hospital stay. These findings suggest that focusing on the development of nurses' behaviors, ensuring processes are in place to support positive behaviors and creating organizational environments that position nurses to consistently apply these behaviors, can improve patients' perceptions of their communication with nurses. These findings also provide a foundation for further research focused on developing and testing specific behavioral interventions and their effect on communication perception.

Partnering With Patients to Improve Care: The Value of Patient and Family Advisory Councils.

Increasingly, healthcare organizations are adopting patient and family advisory councils as a key strategy to create a culture grounded in patient- and family-centered principles and improve the patient experience. In the 1st of a 3-part series, the chief nurse executive and the director of patient- and family-centered care at a Magnet®-designated academic medical center discuss how a stronger patient voice can lead to better care and improved clinical outcomes. The authors examine ways in which the Magnet culture helped drive change and offer tips to establish a successful patient and family advisory council.

Predictors of Nurse Practitioner Prescription of Opioids for Cancer Pain: Quantitative Results.

Background: Nurse practitioners (NPs) have assumed a greater role in the management of pain related to cancer. Several studies have associated adequate management of cancer pain with improved survival. Opioids are an essential treatment for cancer pain management and thus it is important to understand influences on prescribing these substances. However, due to a lack of previous studies on this topic, little is known about the influences on NP prescription of opioids for patients with pain due to cancer. Purpose: Competent decision-making is highly correlated with dominant personality characteristics and dominant decision-making styles in everyday life. The rational approach to decision-making has demonstrated superior performance with different daily tasks, including career-related tasks. However, it is unknown whether dominant personality and/or decision-making style impacts the decisions of medical professionals. Using the Diffusion of Innovations theoretical framework, this study evaluated whether dominant personality, dominant decision style, advanced specialty certification, and/or demographic factors influenced oncology NP opioid prescribing proficiency (termed opioid decision score, or ODS) according to the National Comprehensive Cancer Network (NCCN) Guidelines. Other advanced practice providers (APPs) were excluded from the study due to controlled substance prescribing limitations. Methods: An internet-based descriptive comparative study was performed evaluating the dominant personality characteristic and dominant decision-making style as a predictor of opioid prescribing among NPs working in oncology. Participants were recruited using lists from the Oncology Nursing Society (ONS) and American Association of Nurse Practitioners (AANP). A nationwide convenience sample of NPs working with adult oncology patients was evaluated for opioid prescribing according to recommendations in the NCCN Cancer Pain Guidelines. Results: Univariate linear regression revealed a statistically significant increase in the ODS as the Big Five Inventory (BFI) Openness scale score increased (estimate = 0.36, standard error [SE] = 0.17, 95% confidence interval [CI] = 0.03-0.69). Nurse practitioners reporting advanced specialty certification in oncology and/or hospice or palliative care scored significantly higher on the ODS compared with those with no advanced specialty certification (n = 81, M = 2.86, 2.34, t = -2.75, df = 178, p = .0065). Conclusion: This study provides preliminary findings regarding the decision-making of NPs working with oncology patients and prescribing opioids for cancer pain. Nurse practitioners with a dominant personality characteristic of openness and those reporting an advanced specialty certification in oncology and/or hospice or palliative care were more likely to prescribe opioids for patients with cancer according to NCCN Guidelines. Further investigation is needed to determine additional factors impacting prescribing of controlled sub-stance by NPs and other prescribers.

Policy Evaluation Of The Affordable Care Act Graduate Nurse Education Demonstration.

The US is experiencing a shortage of primary care providers, which could be reduced by the addition of nurse practitioners. However, the ability to increase the supply of nurse practitioners is limited by a shortage of clinical preceptors. The Affordable Care Act's Graduate Nurse Education Demonstration provided federal funding to offset the clinical training costs of advanced practice nurses. We used data from the American Association of Colleges of Nursing from academic years 2005-06 through 2017-18 to determine whether the demonstration was associated with increased nurse practitioner enrollment and graduation growth. The demonstration was associated with a significant increase in nurse practitioner enrollments and graduations. A promising model of organizing and implementing funding for graduate nursing education nationally was identified. Findings suggest that modernizing Medicare payments for nursing education to support nurse practitioner clinical training costs is a promising option for increasing primary care providers.

Transparency, Public Reporting, and a Culture of Change to Quality and Safety in Cardiac Surgery.

Academic medical centers have a duty to serve as hospitals of last resort for advanced cardiac surgical care and therefore manage patients at elevated risk of postoperative morbidity and mortality. They must also meet state and professional quality targets devised to protect the public. The tension between these imperatives can be managed by a multidimensional quality improvement program that aims to manage risk, optimize outcomes, and exclude futile operations. We here share our approach to this process, its impact on our institution, and discuss pertinent issues relevant to institutions in a similar situation.

The endocrine tumor summit 2008: appraising therapeutic approaches for acromegaly and carcinoid syndrome.

The Endocrine Tumor Summit convened in December 2008 to address 6 statements prepared by panel members that reflect important questions in the treatment of acromegaly and carcinoid syndrome. Data pertinent to each of the statements were identified through review of pertinent literature by one of the 9-member panel, enabling a critical evaluation of the statements and the evidence supporting or refuting them. Three statements addressed the validity of serum growth hormone (GH) and insulin-like growth factor-I (IGF-I) concentrations as indicators or predictors of disease in acromegaly. Statements regarding the effects of preoperative somatostatin analog use on pituitary surgical outcomes, their effects on hormone and symptom control in carcinoid syndrome, and the efficacy of extended dosing intervals were reviewed. Panel opinions, based on the level of available scientific evidence, were polled. Finally, their views were compared with those of surveyed community-based endocrinologists and neurosurgeons.

Recent Advances in Antiemetics: New Formulations of 5-HT3 Receptor Antagonists in Adults.

BACKGROUND: Despite the availability of effective antiemetic regimens, patients still experience chemotherapy-induced nausea and vomiting (CINV). 5-Hydroxytryptamine 3 (5-HT3) receptor antagonists (RAs) are the mainstay of CINV prevention, and updated antiemetic guidelines include new options. OBJECTIVE: The aim of this study was to highlight advances in CINV management, focusing on new 5-HT3 RA formulations in adults, updated antiemetic guidelines, and the role of nurses. METHODS: MEDLINE searches were conducted for English-language publications for the past 15 years using relevant search terms ("serotonin receptor antagonist," "5-HT3 receptor antagonist," "antiemetic," "chemotherapy-induced nausea and vomiting") in the abstract or title. Abstracts at relevant major congresses for the past 3 years and additional pivotal publications were included. The most informative, relevant, and current publications were included. RESULTS: 5-Hydroxytryptamine 3 RAs are effective in preventing acute (0-24 hours) CINV but less effective in the delayed phase (24-120 hours) given their short half-lives. Updated antiemetic guidelines include fixed-dose intravenous fosnetupitant and palonosetron (IV NEPA) and granisetron extended-release subcutaneous injection, a recently approved 5-HT3 RA formulation providing slow, controlled release of therapeutic granisetron concentrations for 5 days or longer. Nurses play a pivotal role in implementing updated guideline-recommended antiemetic regimens for highly and some moderately emetogenic chemotherapy regimens, comprising a 4- or 3-drug regimen of 5-HT3 RA, neurokinin-1 RA, and dexamethasone, with/without olanzapine. CONCLUSION: Newer antiemetic combinations and formulations provide flexibility for CINV prevention. Granisetron extended-release subcutaneous injection is a convenient subcutaneous granisetron option. IMPLICATIONS FOR PRACTICE: Nurses play a critical role in understanding and using new antiemetic formulations and updated antiemetic guidelines in their practices.

A Multivariate Analysis of Pain and Distress in Adults Undergoing BMAB.

Clinicians routinely perform bone marrow aspiration and biopsy (BMAB) to diagnose cancer and evaluate disease status; however, few studies address pain and distress with BMAB. A prospective descriptive-correlational design examined patients' (N = 152) ratings of pain intensity (numeric rating scale, 0-10) and distress (distress thermometer) at baseline and 5 min and 1 hr postprocedure. Data were analyzed using descriptive statistics, chi-square, and linear regression models. Mean postprocedure pain intensity at 5 min was moderate, 5.56 (SD = 3.03), and opioid use was associated with decreased pain at 1 hr (p < .001). Preprocedure administration of anxiolytics had no significant effect on distress reduction (p = .88). Being female, first-time biopsy, and increased preprocedure pain were significant predictors of postprocedure distress (p < .001). Treating anxiety alone may not be sufficient to lessen pain and distress. Individualized plans of care should be based on patient risk and response to procedure.

Breast, colorectal and prostate cancer screening for cancer survivors and non-cancer patients in community practices.

BACKGROUND: Cancer survivors have cancer surveillance and preventive screening needs that require monitoring. Little is known regarding their patterns of care in community primary care practices. METHODS: Secondary analysis of 750 baseline patient surveys and medical record audits for patients ages 50+ years in 25 community-based primary care practices (N = 109 survivors and 641 noncancer patients). RESULTS: Patient self-reported screening rates for breast cancer (72%), colorectal cancer (81%) and prostate cancer (77%) were higher for cancer survivors compared to noncancer patients (69%, 67%, 53%, respectively). Screening rates documented in the primary care records were lower for all cancers. Cancer survivors were more likely than others to report having been screened for colorectal cancer (P = 0.002) even after excluding colorectal cancer survivors from the analysis (P = 0.034). Male cancer survivors were more likely to report being screened for prostate cancer than those without cancer (P < 0.001), even after excluding prostate cancer survivors (P = 0.020). There were no significant differences in either self-reported or medical record report of breast cancer screening rates among cancer survivors and noncancer patients. CONCLUSIONS: Cancer survivors were more likely to self-report receipt of cancer screening than noncancer patients. Medical record reports of cancer screening were lower than self-reports for cancer survivors and noncancer patients. Identifying factors that affect cancer screening among cancer survivors is important and has implications for intervention design.

Breast cancer survivors: information and support after treatment.

Women living with and beyond breast cancer have special health care needs. Persistent physical and psychological symptoms such as fatigue, pain, sleep disturbances, and fear of recurrence as well as quality-of-life outcomes have been described in women during and after breast cancer. Much less information exists on the experience of women completing treatment. This study describes the information and support needs of women following breast cancer treatment. A semistructured interview guide designed by the research team was used to gather data. Major findings indicate that women continue to experience a variety of physical and psychological symptoms and have concrete information and support needs following therapy, including the need for information on persistent treatment effects, emotional distress, and lifestyle changes. Findings illustrate that there is need to provide comprehensive information and support to help women transition from breast cancer therapy. Additional research is needed to optimize approaches to providing posttreatment care.

The role of low-molecular-weight heparins as supportive care therapy in cancer-associated thrombosis.

Venous thromboembolism (VTE) is a common complication of malignant disease, affecting approximately 1 in 200 cancer patients. Oncology nurses are instrumental in identifying patients with cancer at high risk of venous thromboembolism. Risk factors include: stage of disease, chemotherapy, the patient's degree of immobility, a history of recent surgery, and the presence of a central venous catheter. The treatment of venous thromboembolism in patients with cancer usually involves a sequential combination of unfractionated heparin or low-molecular-weight heparin (LMWH), followed by oral warfarin or LMWH. LMWHs are an alternative to warfarin for secondary prophylaxis and long-term treatment. LMWH is given by subcutaneous injection, does not require hospitalization for administration or routine laboratory monitoring. Recent clinical trial results have shown that LMWH use is associated with improved survival in cancer patients with relatively good prognoses. Patients receiving any anticoagulant therapy should be monitored for signs of pulmonary embolism or bleeding and intravenous sites (if present) should be monitored for oozing. Appropriate patient selection, a carefully constructed treatment plan, extensive patient education, and regular patient contact are integral elements for the nursing care of patients with cancer-associated thrombosis treated in the outpatient setting.

Therapeutic options for the treatment of cancer-associated thrombosis.

OBJECTIVE: To provide oncology nurses with an understanding of therapeutic options for cancer-associated thrombosis, strategies to prevent recurrence, and practical issues in patient management. DATA SOURCES: Primary and tertiary literature and the author's clinical experience. CONCLUSION: Oncology nurses monitor patients throughout the care continuum for signs and symptoms indicating vascular thromboembolism and need to know the steps to take to expedite an accurate diagnosis and ensure prompt treatment. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses must keep informed about the evolving evidence that leads to practice changes. They should be able to teach patients about therapeutic options and their potential for improving outcomes.

Complex patients and interprofessional relationships: Perceptions of primary care nurse practitioners and primary care physicians.

PURPOSE: The literature describing primary care nurse practitioners (PCNPs) and primary care physicians (PCPs) suggests that PCNPs provide care to patients with less complicated diagnoses than their PCP colleagues. However, other literature suggests the contrary. Therefore, the purpose of this qualitative study was to understand how patients are assigned and cared for by primary care clinicians and how these clinicians relate to one another. Additionally we explore how PCNPs relate to physicians outside the practice. DATA SOURCES: Two nurse investigators conducted in-depth qualitative interviews with a nurse practitioner and a family medicine physician leader in each of 10 primary care practices. A content analysis was used to identify major themes. CONCLUSIONS: The participating PCNPs and PCPs have highly collaborative relationships. PCNPs often function independently, engage in reciprocal consultations with PCPs, and provide care to highly complex patients. In contrast to their relationships with practice colleagues, PCNP relationships with physicians outside the practice are disruptive. IMPLICATIONS FOR PRACTICE: These findings indicate that PCNPs are well positioned to assume responsibility for a diversity of primary care patients, including those with complex diagnoses. To promote the more effective integration of PCNPs, interprofessional barriers must be addressed by healthcare organizations and policy experts.

Anemia in the oncology patient: cognitive function and cancer.

Cancer-related anemia often develops from the infiltration of marrow by malignant cells, impaired hemoglobin (Hb) production related to chemotherapy or radiation therapy, iron deficiency, or low endogenous erythropoietin levels. Patients with cancer-related anemia may experience cognitive dysfunction including decreased mental alertness, poor concentration, and memory problems. Anemia-mediated cerebral hypoxia may cause symptoms such as headache, vertigo, tinnitus, and dizziness. These symptoms often are exacerbated in the elderly patient with cancer and related to underlying low Hb concentrations. Restoring Hb levels via the administration of iron supplements, blood transfusions, or, more recently, erythropoiesis-stimulating therapy (epoetin alfa) results in significant improvement of cognitive function. The use of epoetin alfa as a treatment option for patients with chemotherapy-associated anemia and an Hb concentration less than 10 g/dL has been recommended by the American Society of Clinical Oncology and the American Society of Hematology. Erythropoiesis-stimulating therapies are a promising treatment option for cancer-related anemia that may improve cognitive function and quality of life for patients with cancer.

Telephone calls postdischarge from hospital to home: a literature review.

The oncology population is particularly affected by hospital readmissions because hospitalized patients with cancer often have complex needs. The complexity and diversity of care requirements create substantial challenges in planning for appropriate postdischarge support. Implementing postdischarge telephone calls in the population of patients with cancer could offer a low-cost intervention to address the complex needs of patients during the transition from hospital to home. The goal of the current literature review is to provide an understanding about postdischarge telephone calls in patients with cancer. Findings from this review support the notion that discharge phone calls could improve care continuity for patients transitioning from hospital to home. The literature review outlines information related to telephone call content, timing, and structure for healthcare systems that want to use a postdischarge telephone intervention for patients with cancer. However, additional research is needed to develop and test cancer-specific protocols.