Racial and ethnic disparities in ED use among older adults with asthma and primary care nurse practitioner work environments.

Background: Nurse practitioners (NPs) increasingly deliver primary care in the United States. Yet, poor working conditions strain NP care. We examined whether racial/ethnic health disparities in ED visits among older adults with asthma are moderated by primary care NP work environments. Methods: Survey data on NP work environments in six states were collected from 1,244 NPs in 2018-2019. 2018 Medicare claims data from 46,658 patients with asthma was merged with survey data to assess the associations of all-cause and ambulatory care sensitive conditions (ACSC) ED visits with NP work environment and race/ethnicity using logistic regression. Results: NP work environment moderated the association of race (Black patients versus White patients) with all-cause (odds ratio [OR]: 0.91; p-value = 0.045) and ACSC (OR: 0.90; p-value = 0.033) ED visits. Conclusions: Disparities in ED visits between Black and White patients with asthma decrease when these patients receive care in care clinics with favorable NP work environments.

"They Did Not Know How to Talk to Us and It Seems That They Didn't Care:" Narratives from Bereaved Family Members of Black Veterans.

Racial disparities in the quality of health care services, including end of life (EOL) care, are well-documented. While several explanations for these inequities have been proposed, few studies have examined the underlying mechanisms. This paper presents the results of the qualitative phase of a concurrent mixed-methods study (QUANT + QUAL) that sought to identify explanations for observed racial differences in quality of EOL care ratings using the Department of Veterans Affairs Bereaved Family Survey (BFS). The objective of the qualitative phase of the study was to understand the specific experiences that contributed to an unfavorable overall EOL quality rating on the BFS among family members of Black Veterans. We used inductive thematic analysis to code BFS open-ended items associated with 165 Black Veterans whose family member rated the overall quality of care received by the Veteran in the last month of life as "poor" or "fair." Four major themes emerged from the BFS narratives, including (1) Positive Aspects of Care, (2) Unmet Care Needs, (3) Lack of Empathy, Dignity, and Respect, and (4) Poor Communication. Additionally, some family members offered recommendations for care improvements. Our discussion includes integrated results from both our qualitative and previously reported quantitative findings that may serve as a foundation for future evidence-based interventions to improve the equitable delivery of high-quality EOL care.

Characteristics, work environments, and rates of burnout and job dissatisfaction among registered nurses in primary care.

BACKGROUND: Although more people than ever are seeking primary care, the ratio of primary care providers to the population continues to rapidly decline. As such, registered nurses (RNs) are taking on increasingly central roles in primary care delivery. Yet little is known about their characteristics, their work environments, and the extent to which they experience poor job outcomes such as nurse burnout. PURPOSE: The purpose of this study was to examine the characteristics of the primary care RN workforce and analyze the association of the nurse work environment with job outcomes in primary care. METHODS: Cross-sectional analysis of survey data representing N = 463 RNs who worked in 398 primary care practices, including primary care offices, community clinics, retail/urgent care clinics, and nurse-managed clinics. Survey questions included measures of the nurse work environment and levels of burnout, job dissatisfaction, and intent to leave. DISCUSSION: Approximately one-third of primary care RNs were burnt out and dissatisfied with their jobs, with the highest risk of these outcomes among RNs in community clinics. Community clinic RNs were also significantly more likely to be Black or Hispanic/Latino, hold a Bachelor of Science in Nursing, and speak English as a second language (all p < .01). Across all settings, better nurse work environments were significantly associated with lower levels of burnout and job dissatisfaction (both p < .01). CONCLUSION: Primary care practices must be equipped to support their RN workforce. Adequate nursing resources are especially needed in community clinics, as patients receiving primary care in these settings frequently face structural inequities.

Perspectives and corrective processes: Evaluating social justice in a nursing PhD program.

Efforts to integrate tenets of social justice into PhD nursing programs are long-standing but have intensified in the past few years in response to civil unrest, threats to human rights, and health inequities exacerbated during the COVID-19 pandemic. In this paper, we present an overview of our School of Nursing's efforts and processes to evaluate and ensure that social justice principles were reflected throughout the PhD program. Components of this initiative included (a) forming a Social Justice Taskforce, (b) conducting listening sessions with alumni and currently enrolled PhD students to understand student experiences, (c) surveying PhD students to aid in prioritization of recommendations for improvement, and (d) convening key stakeholders to connect student priority areas to institutional programs and practices. Lessons learned through these activities highlighted the importance of gaining the perspective of diverse constituents and stakeholders, acknowledging areas for improvement, engaging students in transformative action, and partnering with faculty, staff, and leaders in solution development as we work to eliminate systemic injustices in PhD nursing education.

An integrative review of human-centered design and design thinking for the creation of health interventions.

BACKGROUND: In the United States, we have a healthcare system crisis with high rates of dissatisfaction among patients and providers. To transform health and healthcare, clinical providers must be proficient in the human-centered approach of design thinking (DT). OBJECTIVE: To synthesize the human-centered design (HCD) and DT literature for the creation of health interventions. METHODS: We performed an integrative literature review focused on how HCD and DT are used in the clinical healthcare setting. Four research databases were searched from inception through November 6, 2020. We analyzed the methodology used, who is using the frameworks, and the DT phases included. RESULTS: Twenty-four articles were included in the final analysis. Of the 24 manuscripts, 6 (25%) were nurse-led and 15 (63%) had interdisciplinary first and last authors (e.g., Nursing and Medicine). Overall, 10/24 (42%) included all DT method. When analyzing the articles by approach or methodology, 12 (50%) stated they were using the HCD approach, 5 (21%) the DT methodology, and 7 (29%) stated they were using both the HCD approach and DT methodology. CONCLUSION: There are inconsistencies in who uses DT and the phases used to create healthcare interventions.

Racial Disparities in Stroke Readmissions Reduced in Hospitals With Better Nurse Staffing.

BACKGROUND: Racial minorities are disproportionately affected by stroke, with Black patients experiencing worse poststroke outcomes than White patients. A modifiable aspect of acute stroke care delivery not yet examined is whether disparities in stroke outcomes are related to hospital nurse staffing levels. OBJECTIVES: The aim of this study was to determine whether 7- and 30-day readmission disparities between Black and White patients were associated with nurse staffing levels. METHODS: We conducted a secondary analysis of 542 hospitals in four states. Risk-adjusted, logistic regression models were used to determine the association of nurse staffing with 7- and 30-day all-cause readmissions for Black and White ischemic stroke patients. RESULTS: Our sample included 98,150 ischemic stroke patients (87% White, 13% Black). Thirty-day readmission rates were 10.4% (12.7% for Black patients, 10.0% for White patients). In models accounting for hospital and patient characteristics, the odds of 30-day readmissions were higher for Black than White patients. A significant interaction was found between race and nurse staffing, with Black patients experiencing higher odds of 30- and 7-day readmissions for each additional patient cared for by a nurse. In the best-staffed hospitals (less than three patients per nurse), Black and White stroke patients' disparities were no longer significant. DISCUSSION: Disparities in readmissions between Black and White stroke patients may be linked to the level of nurse staffing in the hospitals where they receive care. Tailoring nurse staffing levels to meet the needs of Black ischemic stroke patients represents a promising intervention to address systemic inequities linked to readmission disparities among minority stroke patients.

Disparities in Nurse Job Dissatisfaction and Intent to Leave: Implications for Retaining a Diverse Workforce.

OBJECTIVE: To determine if Black nurses are more likely to report job dissatisfaction and whether factors related to dissatisfaction influence differences in intent to leave. BACKGROUND: Minority nurses report higher job dissatisfaction and intent to leave, yet little is known about factors associated with these differences in community settings. METHOD: Cross-sectional analysis of 11 778 nurses working in community-based settings was conducted. Logistic regression was used to estimate the association among race, job satisfaction, and intent to leave. RESULTS: Black nurses were more likely to report job dissatisfaction and intent to leave. Black nurses' intent to leave decreased in adjusted models that accounted for dissatisfaction with aspects of their jobs including salary, advancement opportunities, autonomy, and tuition benefits. CONCLUSION: Nurse administrators may find opportunities to decrease intent to leave among Black nurses through focused efforts to target areas of dissatisfaction.

Supportive Clinical Practice Environments Associated With Patient-Centered Care.

A lack of organizational supports in clinical settings may prevent nurse practitioners from providing patient centered care. Using a cross sectional survey design, data were collected from NPs in 1,571 practices across four states to investigate clinical practice environments and the extent to which they are associated with NP integration of patient preferences. Three-quarters of NPs reported frequent integration of patient preferences into clinical care. Overall, 371 practices (23.6%) were classified as good practice environments; the remaining 76.3% were mixed or poor environments. NPs in good environments were significantly more likely to integrate patient preferences (O.R. = 2.3, p <.001).

Non-psychiatric hospitalization length-of-stay for patients with psychotic disorders: A mixed methods study.

OBJECTIVE: Patients with psychotic disorders experience higher rates of chronic and acute non-psychotic diseases and have frequent non-psychiatric hospitalizations which result in both longer and more varied length-of-stay (LoS) than other patients. This study seeks to use a patient-centered perspective to examine LoS. METHODS: This article reports Phase Two of a mixed methods, exploratory sequential study on non-psychiatric hospitalizations for individuals with psychotic disorders. Patients' experiences were used to guide a quantitative analysis of LoS using a general linear model. RESULTS: Medical comorbidities were the patient characteristics which had the largest effect on LoS. Certain processes of care highlighted by patients from Phase One were also associated with longer LoS, including: physical restraints (105%), psychiatric consults (20%) and continuous observation (133%). Only recent in-system outpatient appointments were associated with shorter LoS. Data integration highlighted that factors which were important to patients such as partner support, were not always quantitatively significant, while others like medical comorbidities and use of physical restraints were points of congruence. CONCLUSIONS: Medical comorbidities were highly associated with LoS but processes relating to longer LoS are those that are used to manage symptoms of acute psychosis. Clinicians should develop policies and procedures that address psychosis symptoms effectively during non-psychiatric hospitalizations. Further research is needed to understand which patients with psychotic disorders are at highest risk of extended length-of-stay.

The Untapped Potential of the Nurse Practitioner Workforce in Reducing Health Disparities.

The growing nurse practitioner (NP) workforce represents a significant supply of primary care providers, who if optimally utilized, are well-positioned to improve access to health care for racial and ethnic minorities. However, many barriers affect the optimal utilization of NPs in primary care delivery. These barriers may also prevent NPs from maximally contributing to efforts to reduce racial and ethnic health disparities. Our review of the empirical and health policy literature sought to elucidate factors that affect NPs' potential and ability to narrow or eliminate health disparities. We found that restrictive state scope of practice regulations, disparate reimbursement policies, lack of NP workforce diversity, and poor organizational structures in NP practices may limit NPs' contributions to current efforts to reduce disparities. Our results led to the development of the nurse practitioner health disparities model which identifies barriers to and opportunities for optimal use of NPs in reducing racial and ethnic disparities. State and federal policymakers and administrators in health-care settings should take actions to remove legislative and organizational barriers to enable NPs to deliver high-quality care to racial and ethnic minorities. Researchers can use the nurse practitioner health disparities model to produce empirical evidence to reduce health disparities and improve population health.

Effective Strategies for Achieving Scope of Practice Reform in Pennsylvania.

BACKGROUND: Current regulatory impediments prohibit advanced practice registered nurses from practicing to their full capacity. PURPOSE: To examine the process of successful removal of scope of practice barriers in Pennsylvania under the Rx4PA legislation introduced in 2007. METHOD: We used qualitative research techniques, including purposeful sampling of participants. Twelve stakeholder informed interviews were conducted between October 2013 and May 2014. Participants were closely involved with the development of the Rx4PA legislation. Thematic content analysis was performed to analyze our interviews. DISCUSSION: Interviews identified overarching themes, including the importance of leveraging years of grass roots advocacy, identifying political allies, and recognizing mutually beneficial compromises. CONCLUSIONS: The combination of timing, careful political maneuvering, and compromise were key to scope of practice reform in Pennsylvania and may be useful strategies for other states seeking similar practice changes.

Federal Polices Influence Access to Primary Care and Nurse Practitioner Workforce.

Although most nurse practitioners (NPs) are aware of state-level regulations that influence practice, many are unaware of the ways that federal policies affect NP workforce supply and the delivery of primary care. In this investigation we provide an overview of federal initiatives enacted through the Patient Protection and Affordable Care Act that impact the NP workforce. We explore how the law supports NP workforce supply and settings in which NPs provide care. We then describe challenges that may prevent full utilization of the NP workforce. Examining both federal policies and state-level regulations is essential to achieving an increased NP workforce supply and improved access to care.

The quality of hospital work environments and missed nursing care is linked to heart failure readmissions: a cross-sectional study of US hospitals.

INTRODUCTION: Threats to quality and patient safety may exist when necessary nursing care is omitted. Empirical research is needed to determine how missed nursing care is associated with patient outcomes. AIM: The aim of this study was to examine the relationship between missed nursing care and hospital readmissions. METHODS: Cross-sectional examination, using three linked data sources-(1) nurse survey, (2) patient discharge data from three states (California, New Jersey and Pennsylvania) and (3) administrative hospital data- from 2005 to 2006. We explored the incidence of 30-day readmission for 160 930 patients with heart failure in 419 acute care hospitals in the USA. Logistic regression was used to assess the effect of missed care on the odds of readmission, adjusting for patient and hospital characteristics. RESULTS: The most frequently missed nursing care activities across all hospitals in our sample included talking to and comforting patients (42.0%), developing and updating care plans (35.8%) and educating patients and families (31.5%). For 4 of the 10 studied care activities, each 10 percentage-point increase in the number of nurses reporting having missed the activity was associated with an increase in the odds of readmission by 2-8% after adjusting for patient and hospital characteristics. However, missed nursing care was no longer a significant predictor of readmission once adjusting for the nurse work environment, except in the case of the delivery of treatments and procedures (OR 1.08, 95% CI 1.02 to 1.14). CONCLUSIONS: Missed care is an independent predictor of heart failure readmissions. However, once adjusting for the quality of the nurse work environment, this relationship is attenuated. Improvements in nurses' working conditions may be one strategy to reduce care omissions and improve patient outcomes.

Nurse staffing and postsurgical outcomes in black adults.

OBJECTIVES: To determine the association between nurse staffing and postsurgical outcomes for older black adults, including 30-day mortality and failure to rescue. DESIGN: A cross-sectional study of University of Pennsylvania Multi-State Nursing Care and Patient Safety Survey data, linked to 2006-2007 administrative patient discharge data from four states (CA, PA, NJ, FL), American Hospital Association Annual Survey data, and a U.S. Census-derived measure of socioeconomic status (SES). Risk-adjusted logistic regression models with correction for clustering were used for the analysis. SETTING: Five hundred ninety-nine adult nonfederal acute care hospitals in California, Pennsylvania, New Jersey, and Florida PARTICIPANTS: Five hundred forty-eight thousand three hundred ninety-seven individuals ages 65 and older undergoing general, orthopedic, or vascular surgery (94% white, 6% black). MEASUREMENTS: Thirty-day mortality and failure to rescue (death after a complication). RESULTS: In models adjusting for sex and age, 30-day mortality was significantly higher for black than white participants (odds ratio (OR) = 1.42, 95% confidence interval (CI) = 1.32-1.52). In fully adjusted models that accounted for SES, surgery type, and comorbidities, as well as hospital characteristics, including nurse staffing, the odds of 30-day mortality were not significantly different for black and white participants. In the fully adjusted models, one additional patient in the average nurse's workload was associated with higher odds of 30-day mortality for all patients (OR = 1.03, 95% CI = 1.01-1.05). A significant interaction was found between race and nurse staffing for 30-day mortality, such that blacks experienced higher odds of death with each additional patient per nurse (OR = 1.10, 95% CI = 1.03-1.18) compared to whites (OR = 1.03, 95% CI = 1.01-1.06). Similar patterns were detected in failure-to-rescue models. CONCLUSION: Older surgical patients experience poorer postsurgical outcomes, including mortality and failure to rescue, when cared for by nurses with higher workloads. The effect of nurse staffing inadequacies is more significant in older black individuals.

Life and death in Philadelphia's black belt: a tale of an urban tuberculosis campaign, 1900-1930.

The poor health status of black Americans was a widely recognized fact during the first third of the twentieth century. Excess mortality in black communities was frequently linked to the infectious disease tuberculosis, which was particularly menacing in densely populated urban settings. As health authorities in large cities struggled to keep pace with the needs of citizens, private charities worked to launch community-oriented attacks against the deadly disease. In 1914 a novel experiment to address excess mortality among blacks was launched in Philadelphia. The success of the health promotion campaign initiated by the Henry Phipps Institute and the Whittier Centre, two private charitable associations, has been attributed primarily to the presence of black clinicians, in particular public health nurse Elizabeth Tyler. This study suggests that community health efforts also rest on partnerships between like-minded organizations and coalition building.

Lost in translation: student perceptions of cultural competence in undergraduate and graduate nursing curricula.

The rapidly changing demographics of the United States require nurses who are equipped with knowledge and skills to meet the needs of an increasingly diverse patient population. Nurse educators seek to meet this challenge through integrating cultural competence into nursing course curricula. Few studies have examined student perceptions of the integration of this material. As part of a larger school-wide assessment, this qualitative descriptive study used focus groups of doctoral and bachelor of science in nursing students to evaluate their perceptions of the integration of cultural competence in the nursing curriculum. We sought to answer two questions: (a) what the students' perceptions were and (b) what recommendations they had for improvement. The results of the focus groups yielded three themes: (a) broadening definitions, (b) integrating cultural competence, and (c) missed opportunities. Student suggestions and recommendations for enhancing cultural competence in the curricula are provided.

Medicare readmissions policies and racial and ethnic health disparities: a cautionary tale.

Beginning in 2009, the Centers for Medicare & Medicaid Services started publicly reporting hospital readmission rates as part of the Hospital Compare website. Hospitals will begin having payments reduced if their readmission rates are higher than expected starting in fiscal year 2013. Value-based purchasing initiatives including public reporting and pay-for-performance incentives have the potential to increase quality of care. There is concern, however, that hospitals providing service to minority communities may be disproportionately penalized as a result of these policies due to higher rates of readmissions among racial and ethnic minority groups. Using 2008 Medicare data, we assess the risk for readmission for minorities and discuss implications for minority-serving institutions.