Does the standard medical procedure consent process meet the criteria required for informed consent? A concept analysis.

BACKGROUND: Informed consent is a complex process that is legally required before any surgical procedure. PURPOSE: The purpose of this manuscript was to perform a concept analysis of the informed consent process. METHODS: The use of dimensional analysis identified three separate yet related perspectives of the informed consent process: legal, health care, and patients. A database search using the Cumulative Index to Nursing and Allied Health Literature and PubMed were performed. FINDINGS: A total of 27 publications were reviewed. The legal perspective addresses the requirement of informed consent, which starts with the discussion between the health care provider and the patient undergoing the surgical procedure and ends with a signature on a piece of paper. The health care perspective also addresses the legal requirement but incorporates the goals and objectives of the individual initiating the informed consent discussion. The patients' perspectives also incorporate goals and objectives; however, they differ from that of the health care provider in that they go beyond what happens in the operating room or during hospitalization. DISCUSSION: Viewing informed consent through these different yet related perspectives provides insight into this complex process and may enhance the researcher's ability to understand and improve the informed consent process.

Patient Vs. Soldier-Centered Medical Home: Comparing Access, Continuity, and Communication in the U.S. Army.

INTRODUCTION: Over the last 40 years, patient-centered medical home (PCMH) has evolved as the leading primary care practice model, replacing traditional primary care models in the United States and internationally. The goal of PCMH is to improve chronic condition management. In the U.S. Army, the scope of the medical home, which encompasses various care delivery platforms, including PCMH and soldier-centered medical home (SCMH), extends beyond the management of chronic illnesses. These medical home platforms are designed to support the unique health care needs of the U.S. Army's most vital asset-the soldier. The PCMHs and SCMHs within the U.S. Army employ patient-centered care principles while incorporating nationally recognized structural attributes and care processes that work together in a complex adaptive system to improve organizational and patient outcomes. However, U.S. Army policies dictate differences in the structures of PCMHs and SCMHs. Researchers suggest that differences in medical home structures can impact how organizations operationalize care processes, leading to unwanted variance in organizational and patient outcomes. This study aimed to compare 3 care processes (access to care, primary care manager continuity, and patient-centered communication) between PCMHs and SCMHs. MATERIALS AND METHODS: This was a retrospective, cross-sectional, and correlational study. We used a subset of data from the Military Data Repository collected between January 1, 2018, and December 31, 2018. The sample included 266 medical home teams providing care for active duty soldiers. Only active duty soldiers were included in the sample. We reviewed current U.S. Army Medical Department policies to describe the structures and operational functioning of PCMHs and SCMHs. General linear mixed regressions were used to evaluate the associations between medical home type and outcome measures. The U.S. Army Medical Department Center and School Institutional Review Board approved this study. RESULTS: There was no significant difference in access to 24-hour and future appointments or soldiers' perception of access between PCMHs and SCMHs. There was no significant difference in primary care manager continuity. There was a significant difference in medical home team continuity (P < .001), with SCMHs performing better. There was no significant difference in patient-centered communication scores. Our analysis showed that while the PCMH and SCMH models were designed to improve primary care manager continuity, access to care, and communication, medical home teams within the U.S. Army are not consistently meeting the Military Health System standard of care benchmarks for these care processes. CONCLUSIONS: Our findings comparing 3 critical medical home care processes suggest that structural differences may impact continuity but not access to care or communication. There is an opportunity to further explore and improve access to appointments within 24 hours, primary care manager and medical home team continuity, perception of access to care, and the quality of patient-centered communication among soldiers. Knowledge gained from this study is essential to soldier medical readiness.

Predictors of Temporary Profile Days Among U.S. Army Active Duty Soldiers.

INTRODUCTION: More than 40,000 soldiers cannot deploy every year, which undermines readiness. The medical readiness of soldiers is a critical component of the overall operational readiness of the U.S. Army. Acute musculoskeletal injuries (MSIs) are the greatest threat to medical readiness. Medical providers place soldiers on temporary profiles to facilitate treatment and recovery of acute MSIs. Poorly managed temporary profiles negatively impact a soldier's work attendance, resulting in the loss or limitation of over 25 million workdays annually. Upgrading the electronic profile system and implementing the Army Medical Home has led to improvements in managing temporary profiles over the last decade. The Army Medical Home encompasses care delivery platforms, including the Patient-Centered Medical Home (PCMH) and Soldier-Centered Medical Home (SCMH). The structure of U.S. Army PCMHs and SCMHs differ in ways that may affect care processes and patient outcomes. Temporary profile management is an important soldier health outcome that has not been studied in relation to the U.S. Army's PCMH and SCMH structures or care processes. Access to care, continuity, and communication are three care processes that have been described as essential factors in reducing lost workdays and functional limitations in workers after an acute injury. Understanding the impact of the medical home on temporary profile days is vital to medical readiness. This study aimed to (1) compare temporary profile days between the U.S. Army PCMHs and SCMHs and (2) determine the influence of medical home structures and care processes on temporary profile days among active duty U.S. Army soldiers receiving care for MSIs. MATERIALS AND METHODS: This was a retrospective, cross-sectional, and correlational study guided by Donabedian's conceptual framework. We used secondary data from the Military Data Repository collected in 2018. The sample included 27,214 temporary profile records of active duty U.S. Army soldiers and 266 U.S. Army PCMH and SCMH teams. We evaluated bivariate and multivariate associations between outcomes and predictors using general and generalized linear mixed regression models. The U.S. Army Medical Department Center and School Institutional Review Board approved this study. RESULTS: Total temporary profile days ranged from 1 to 357, with a mean of 37 days (95% CI [36.2, 37.0]). There was a significant difference in mean temporary profile days between PCMHs (43) and SCMHs (35) (P < 0.001). Soldiers in PCMHs were more likely to have temporary profiles over 90 days (OR = 1.54, 95% CI [1.17, 2.03]). Soldiers in the heavy physical demand category had fewer temporary profile days (P < 0.001) than those in the moderate physical demand category. Age, sex, rank level, physical demand category, profile severity, medical home type, the "explain things" communication subscale, and primary care manager continuity were significant predictors of temporary profile days. CONCLUSIONS: Excessive temporary profile days threaten medical readiness and overall soldier health. Aspects of the medical home structure and care processes were predictors of temporary profile days for musculoskeletal conditions. This work supports continued efforts to improve MSI-related outcomes among soldiers. Knowledge gained from this study can guide future research questions and help the U.S. Army better meet soldier needs.

Ambulatory Care Nurse-Sensitive Indicators: A Scoping Review of the Literature 2006-2021.

BACKGROUND/PURPOSE: Meeting recommendations that nurses should partner in leading health care change is hampered by the lack of ambulatory care nurse-sensitive indicators (ACNSIs). This scoping review was conducted to identify evidence regarding ACNSI identification, development, implementation, and benchmarking. METHODS: Following the PRISMA-ScR reporting guide, we performed PubMed/MEDLINE, CINAHL, and Cochrane Library searches for the period January 2006 to March 2021. RESULTS: Twelve of the 1984 articles from 6 countries met inclusion criteria. All focused on identifying, developing/pilot testing indicators, and included structure, process, and outcome indicators. Seven articles were level II and all were at least grade B quality. Leverage points involved leadership support, automated data extraction infrastructure, and validating links between nurses' roles/actions and patient outcomes. CONCLUSIONS: While high-quality work is ongoing to identify clinically meaningful and feasible ACNSIs, knowledge in this field remains underdeveloped. Prioritizing this work is imperative to address gaps and facilitate national strategic health care goals.

Improving 9.5 Million Lives: Pilot Testing Ambulatory Care Nurse-Sensitive Quality Indicators.

OBJECTIVE: The aim of this study was to evaluate scientific acceptability, feasibility, utility, and value of ambulatory care nurse-sensitive quality indicators (ACNSIs) in military outpatient clinics. BACKGROUND: Optimizing healthcare quality and cost requires scientifically sound metrics. However, ACNSI development and measurement have lagged behind inpatient nurse-sensitive indicators. Validated and reliable ACNSIs are urgently needed to maximize nurses' efforts to improve healthcare quality. METHODS: Two staffing and 4 patient-centered ACNSIs were pilot tested in 5 military clinics over a 6-month period using a mixed-methods design. RESULTS: Reliability and validity were generally acceptable. Most ACNSIs demonstrated feasibility, utility, and value for performance measurement. Challenges to using ACNSIs include absence of standardized administrative and clinical processes, infrastructure, and leadership and technological support. CONCLUSIONS: These ACNSIs show promise as valid performance metrics. Provider- and nurse-level metrics may synergistically improve practice, enhancing the team approach so critical to ambulatory care.

Comparing the Nurse Work Environment, Job Satisfaction, and Intent to Leave Among Military, Magnet®, Magnet-Aspiring, and Non-Magnet Civilian Hospitals.

OBJECTIVE: This study aimed to compare the nurse work environment, job satisfaction, and intent to leave (ITL) among military, Magnet®, Magnet-aspiring, and non-Magnet civilian hospitals. BACKGROUND: The professional nurse work environment is an important, modifiable, organizational trait associated with positive nurse and patient outcomes; creating and maintaining a favorable work environment should be imperative for nursing leaders. METHODS: Secondary data from the Army Nurse Corps and the National Database of Nursing Quality Indicators included the Practice Environment Scale of the Nursing Work Index (PES-NWI) and single-item measures of job satisfaction and ITL. RESULTS: Magnet and military hospitals had identical PES-NWI composite scores; however, statistically significant differences existed among the subscales. Military nurses were the most satisfied among all groups, although this difference was not statistically significant, yet their ITL was highest. CONCLUSIONS: Favorable work environments may exist in other organizational forms besides Magnet; however, the specific components must be considered.

Identifying Potentially Preventable Reasons Nurses Intend to Leave a Job.

OBJECTIVE: The aim of this study was to describe the relationships between intent to leave, reasons nurses intend to leave, and the nursing work environment in military hospitals. BACKGROUND: Intention to leave is a precursor of nurse turnover. The reasons nurses intend to leave may be influenced by leader interventions and potentially preventable. METHODS: This descriptive, correlational secondary analysis included 724 nurse survey responses from 23 US Army hospitals. Bivariate correlations and predictive modeling techniques were used. RESULTS: Forty-nine percent of nurses indicated they intended to leave, 44% for potentially preventable reasons. Dissatisfaction with management and the nursing work environment were the top potentially preventable reasons to leave. Nurses who intended to leave for potentially preventable reasons scored aspects of the nursing work environment significantly lower than those intending to leave for nonpreventable reasons. CONCLUSIONS: Identifying potentially preventable reasons in conjunction with intent to leave can provide leaders opportunities to intervene and influence turnover intention.

The Value of the Patient-Centered Medical Home in Getting Adults Suffering From Acute Conditions Back to Work: An Integrative Literature Review.

Acute conditions are the leading cause of work restrictions and missed workdays, contributing to over $27 billion in lost productivity each year and negatively impacting workers' health and quality of life. Primary care services, specifically patient-centered medical homes (PCMHs), play an essential role in supporting timely acute illness or injury recovery for working adults. The purpose of this review is to synthesize the evidence on the relationship between PCMH implementation, care processes, and outcomes. In addition, we discuss the empirical connection between this evidence and return-to-work outcomes, as well as the need for further research.

Nurse Burnout Predicts Self-Reported Medication Administration Errors in Acute Care Hospitals.

BACKGROUND: Every one out of 10 nurses reported suffering from high levels of burnout worldwide. It is unclear if burnout affects job performance, and in turn, impairs patient safety, including medication safety. The purpose of this study is to determine whether nurse burnout predicts self-reported medication administration errors (MAEs). METHODS: A cross-sectional study using electronic surveys was conducted from July 2018 through January 2019, using the Copenhagen Burnout Inventory. Staff registered nurses (N = 928) in acute care Alabama hospitals (N = 42) were included in this study. Descriptive statistics, correlational, and multilevel mixed-modeling analyses were examined. RESULTS: All burnout dimensions (Personal, Work-related, and Client-related Burnout) were significantly correlated with age (r = -0.17 to -0.21), years in nursing (r = -0.10 to -0.17), years of hospital work (r = -0.07 to -0.10), and work environment (r = -0.24 to -0.57). The average number of self-reported MAEs in the last 3 months was 2.13. Each burnout dimension was a statistically significant predictor of self-reported MAEs (p < .05). CONCLUSIONS: Nurse burnout is a significant factor in predicting MAEs. This study provides important baseline data for actionable interventions to improve nursing care delivery, and ultimately health care, for Alabamians.

An Exploratory Study of the Influence of Perceived Organizational Support, Coworker Social Support, the Nursing Practice Environment, and Nurse Demographics on Burnout in Palliative Care Nurses.

Burnout, a condition characterized by emotional exhaustion, depersonalization, and decreased personal accomplishment, has been studied in many disciplines in health care, including nursing, medicine, and social work. The purpose of this study was to examine the relationship between perceived organizational support, coworker social support, the nursing practice environment, and nurse demographics (age, years of nursing experience, education level, marital status, and sex) on burnout in a national sample of palliative care nurses. The study aims were (1) to examine the relationship between perceived organizational support, coworker social support, and nursing practice environment on burnout in palliative care nurses; (2) to examine the relationship between age, years of nursing experience, education level, marital status, and sex on burnout in palliative care nurses; and (3) to examine potential moderators (perceived organizational support and coworker social support) on the relationship between demographic characteristics and palliative care nurse burnout. A convenience sample of 73 Hospice and Palliative Nurses Association registered nurses who were bedside caregivers was recruited from Hospice and Palliative Nurses Association's membership. Data were analyzed using Pearson correlation and regression modeling. Findings indicated palliative care nurses had moderate to high levels of burnout. There was a negative correlation between burnout and perceived organizational support, and between burnout and coworker social support. The nursing practice environment of palliative care nurses was favorable; perceived organizational support and coworker social support were not moderators for demographics of age and years of experience and their relationship to burnout.

Parental Self-Efficacy in New Mothers Predicts Infant Growth Trajectories.

The purpose of this study was to examine whether parental self-efficacy (PSE) is associated with change in infant weight-for-length z score (WLZ) from age 3 to 12 months. Data were drawn from the Infant Care, Feeding, and Risk of Obesity study, conducted with low-income, African American mother-infant dyads (n = 127). PSE was measured at infant age of 3 months. Infant anthropometrics were measured at infant age of 3 and 12 months, WLZ change between these time points was calculated, and infants stratified into WLZ change categories (expected, excessive, or slow). To analyze the data, ANCOVA, multiple regression, and post hoc techniques were used. Controlling for infant birthweight, PSE at 3 months was associated with infant WLZ change (η2 = 0.05, p = .04). Mothers of infants who exhibited excessive growth had higher PSE than mothers of infants who exhibited slow growth (Tukey-adjusted p = .03). This finding suggests that infants of mothers with high PSE may have increased obesity risk, but more research is needed.

A concept analysis of health literacy.

AIM: To propose a conceptual definition of health literacy incorporating system demands, burdens, and complexities that are a critical part of patients' level of health literacy. BACKGROUND: Health literacy is used frequently in health care and often is confused with patients' reading and comprehension levels. DESIGN: Walker and Avant's concept analysis method was used. DATA SOURCE: Cochrane Library, Cumulative Index of Nursing and Health Literature, OVID, PubMed, EBSCO Host databases, and Google Scholar. REVIEW METHOD: The primary Search terms and MeSH terms used were health literacy, patient education, patient engagement, patient activation, health communication, health promotion, and nursing. Empirical and nonempirical articles published in English were reviewed. Ten systematic literature reviews were included. RESULTS: A new definition of health literacy is provided based on four components that include: system demands, burdens, and complexities; measurable components, processes and outcomes; the dynamic nature of health literacy; and demonstration of the direct relationship of informed decisions to informed actions. Defining attributes, antecedents, and consequences are identified. Implications for nursing practice, education, and research are given. CONCLUSIONS: Because health literacy is a dynamic and quickly changing concept, further exploration and evolution of the concept is warranted as empirical research and theoretical literature emerge.

Self-efficacy, infant feeding practices, and infant weight gain: An integrative review.

It has been suggested that self-efficacy specific to parenting or feeding may influence the decisions parents make regarding infant feeding; however, a review of this topic has not been conducted. The purpose of this integrative review is to synthesize the literature regarding the potential role of self-efficacy in infant feeding practices or infant weight gain. A total of 40 articles were used to guide this review, which were classified into three categories examining an association with self-efficacy (1) breastfeeding; (2) infant feeding practices such as parental feeding style and dietary quality; and (3) infant weight gain. Evidence regarding breastfeeding self-efficacy (BFSE) and breastfeeding is extensive; mothers with a higher sense of BFSE more often initiate breastfeeding and breastfeed for longer durations. The evidence regarding self-efficacy and the association with infant feeding practices other than breastfeeding is sparse. However, several studies report that mothers who have a higher sense of self-efficacy are more likely to follow infant feeding practices which align with recommendations. The authors have speculated an association between self-efficacy and infant weight gain; yet, to date, no study has found a significant association. More research is needed on the topic, particularly in diverse populations and with fathers and mothers.

Relationships between Army nursing practice environments and patient outcomes.

Favorable nursing practice environments have been associated with lower patient mortality, failure to rescue, nurse-administered medication errors, infections, patient complaints, and patient falls. Favorable environments have also been associated with higher nurse-reported care quality and patient satisfaction in civilian hospitals. However, limited information exists on the relationship between favorable nursing practice environments and positive outcomes in military facilities. Using 4 years of secondary data collected from 45 units in 10 Army hospitals, generalized estimating equations were used to test the associations between nurses' scores on the Practice Environment Scale of the Nursing Work Index (PES-NWI) and patient outcomes of falls with and without injury, medication administration errors with and without harm, and patient experience. Four significant associations were found between the PES-NWI subscales and the patient outcomes under study. The Staffing and Resource Adequacy subscale was significantly associated with patient falls, the Collegial Nurse Physician Relations subscale was significantly associated with the rate of nurse-administered medication errors, and the Nursing Foundations for Quality Care and Collegial Nurse Physician Relations subscales were both significantly associated with patient experience with nursing care. As in civilian hospitals, favorable nursing practice environment was associated with improved patient outcomes within these military nursing units.

Health Literacy: Essential for a Culture of Health.

BACKGROUND: A culture of health requires a commitment from all-individuals, families, communities, organizations, and municipalities-to value health and make decisions reflective of a healthy society. At the individual level, health literacy is a necessary precursor to assist individuals in achieving a higher level of health. METHOD: One method for ensuring that staff members are routinely assessing and promoting health literacy is using competencies and practices previously identified for all health professions. RESULTS: Cross-walking these competencies with the Health Literacy Tapestry model can be extremely helpful in framing assessment, action steps, and outcomes for nurses. CONCLUSION: Professional development nurse leaders have the challenge of ensuring that nurses are addressing patient health literacy as a fundamental nursing activity in every nursing-patient-family interaction. Assuming health literacy deficits as a "universal approach" to care is one method of ensuring health literacy needs are routinely addressed by staff. J Contin Educ Nurs. 2018;49(2):73-78.

Twenty years of staffing, practice environment, and outcomes research in military nursing.

BACKGROUND: Two decades ago, findings from an Institute of Medicine (IOM) report sparked the urgent need for evidence supporting relationships between nurse staffing and patient outcomes. PURPOSE: This article provides an overview of nurse staffing, practice environment, and patient outcomes research, with an emphasis on findings from military studies. Lessons learned also are enumerated. METHOD: This study is a review of the entire Military Nursing Outcomes Database (MilNOD) program of research. DISCUSSION: The MilNOD, in combination with evidence from other health care studies, provides nurses and leaders with information about the associations between staffing, patient outcomes, and the professional practice environment of nursing in the military. Leaders, therefore, have useful empirical evidence to make data-driven decisions. The MilNOD studies are the basis for the current Army nursing dashboard, and care delivery framework, called the Patent CaringTouch System. CONCLUSION: Future research is needed to identify ideal staffing based on workload demands, and provide leaders with factors to consider when operationalizing staffing recommendations.

A program evaluation of the Patient CaringTouch System: A pre- and postimplementation assessment.

BACKGROUND: The Patient CaringTouch System (PCTS) is an innovative, strategic and patient-centric framework developed by the Army Nurse Corps for nursing care delivery that is designed to reduce nursing care variation and improve patient and nurse outcomes. PURPOSE: This manuscript describes a program evaluation of the PCTS. METHODS: A pre and post design was used to describe changes in patient and nursing measures following PCTS implementation. DISCUSSION: Overall there was a good uptake of the PCTS; however, concurrent with initiation of the PCTS, declines in staffing levels and increases in patient acuity were noted. Medication administration error rates declined, but fall with injury rates increased. Pain reassessment following pain medication administration improved, as did several aspects of the nursing practice environment. Nurses' job dissatisfaction and intent to leave increased; however, potentially preventable losses decreased. CONCLUSIONS: The program evaluation results will be used to target areas for improvement so that the PCTS may be sustained.

The Practice Environment Scale of the Nursing Work Index: An updated review and recommendations for use.

OBJECTIVES: The Practice Environment Scale of the Nursing Work Index (PES-NWI) is an instrument, which measures the nursing practice environment - defined as factors that enhance or attenuate a nurse's ability to practice nursing skillfully and deliver high quality care. The purpose of this paper is to provide an updated review of the Practice Environment Scale of the Nursing Work Index's use to date and provide recommendations that may be helpful to nursing leaders and researchers who plan to use this instrument. DESIGN: A narrative review of quantitative studies. DATA SOURCES: PubMed, EMBASE, and the Cumulative Index to Nursing & Allied Health Literature were searched to identify relevant literature using the search terms, Practice Environment Scale of the Nursing Work Index and PES-NWI. REVIEW METHODS: Studies were included if they were published in English between 2010 and 2016 and focused on the relationship between the Practice Environment Scale of the Nursing Work Index and patient, nurse, or organizational outcomes. Data extraction focused on the reported survey scores and the significance and strength of the reported associations. RESULTS: Forty-six articles, from 28 countries, were included in this review. The majority reported significant findings between the nursing practice environment and outcomes. Although some modifications have been made, the instrument has remained primarily unchanged since its development. Most often, the scores regarding staffing and resource adequacy remained the lowest. CONCLUSION: The frequency of use of this instrument has remained high. Many researchers advocate for a move beyond the study of the connection between the Practice Environment Scale and nurse, patient, and organizational outcomes. Research should shift toward identifying interventions that improve the environment in which nurses practice and determining if changing the environment results in improved care quality.

The Value of Nursing Care: A Concept Analysis.

AIM: To report an analysis of the concept of value of nursing care. BACKGROUND: Value-based health care delivery and reimbursement models are focused on value as a product of quality and cost. Nursing care provides tangible and intangible contributions to patient and organizational outcomes. The nursing profession must be able to proactively and effectively communicate the value of nursing care. DESIGN: Concept analysis. DATA SOURCES: Thirty-five separate sources were chosen from database searches of CINAHL Complete and ABI/INFORM Complete. Key terms utilized for the search were "nursing value" OR "nursing care value" OR "value of nursing". METHODS: Caron and Bowers' (2000) dimensional analysis method was used as a guide for the project. RESULTS: Dimensions identified from this concept analysis included: (a) economic, (b) relational, and (c) societal. CONCLUSION: Direct care nurses experience the relational and societal dimensions of the value of nursing care. Patients and/or families experience the relational dimension of value in nursing care. Health care administrators, third-party payers, and nurse researchers interpret value from the economic dimension. Future nursing research should better quantify the economic value of nursing care. Qualitative research which focuses on how patients and families experience the value of nursing care would also contribute to further refinement of this concept.