Primary Care Providers' Perspectives on Errors of Omission.

BACKGROUND: Despite recent focus on patient safety in primary care, little attention has been paid to errors of omission, which represent significant gaps in care and threaten patient safety in primary care but are not well studied or categorized. The purpose of this study was to develop a typology of errors of omission from the perspectives of primary care providers (PCPs) and understand what factors within practices lead to or prevent these omissions. METHODS: A qualitative descriptive design was used to collect data from 26 PCPs, both physicians and nurse practitioners, from the New York State through individual interviews. One researcher conducted all interviews, which were audiotaped, transcribed verbatim, and analyzed in ATLAS.ti, Berlin by 3 researchers using content analysis. They immersed themselves into data, read transcripts independently, and conducted inductive coding. The final codes were linked to each other to develop the typology of errors of omission and the themes. Data saturation was reached at the 26th interview. RESULTS: PCPs reported that omitting patient teaching, patient followup, emotional support, and addressing mental health needs were the main categories of errors of omission. PCPs perceived that time constraints, unplanned patient visits and emergencies, and administrative burden led to these gaps in care. They emphasized that organizational support and infrastructure, effective teamwork and communication, and preparation for the patient encounter were important safeguards to prevent errors of omission within their practices. DISCUSSION: Errors of omission are common in primary care and could threaten patient safety. Efforts to eliminate them should focus on strengthening organizational attributes of practices, improving teamwork and communication, and assigning manageable workload to PCPs. CONCLUSIONS: Practice and policy change is necessary to address gaps in care and prevent them before they result in patient harm.

Emergency Preparedness Policy and Practice in Massachusetts Hospitals.

Hospital emergency preparedness has evolved in response to and been challenged by threats of terrorism, meteorological disasters, and public health emergencies. In this case study, the authors examined emergency preparedness policy and practice in Massachusetts hospitals following 9/11/2001, identifying areas of success and opportunities for improvement. Using a qualitative descriptive approach, data analysis included the examination of documents and public health policy. Snowball technique was used to recruit nurses, public health policy makers, and other first responder leaders with historical and present knowledge of emergency preparedness policy and practice. Content analysis identified emerging themes and lessons learned. Key findings included the importance of standardized training, the value of interprofessional collaboration and communication across organizations, and the impact of decreased funding and prior incidents. The lessons learned from this case study contribute to the evolving body of knowledge about emergency preparedness for all hospitals and public health facilities, and their community health partners. Emergency preparedness is a dynamic process, and as it continues to evolve, additional research will be needed to standardize training, encourage collaboration, and facilitate communication so that incident response by hospital professionals, including occupational health nurses, and their public health and community partners is more effective.

Work-Family Conflict, Sleep, and Mental Health of Nursing Assistants Working in Nursing Homes.

Work-family conflict is challenging for workers and may lead to depression, anxiety, and overall poor health. Sleep plays an important role in the maintenance of mental health; however, the role of sleep in the association between work-family conflict and mental health is not well-studied. Questionnaires were collected from 650 nursing assistants in 15 nursing homes. Multivariate linear regression modeling demonstrated that increased work-family conflict was associated with lower mental health scores (ß = -2.56, p < .01). More work-family conflict was correlated with more job demands, less job control, less social support, and longer work hours. Poor sleep quality, but not short sleep duration, mediated the association between work-family conflict and mental health. Workplace interventions to improve nursing assistants' mental health should increase their control over work schedules and responsibilities, provide support to meet their work and family needs, and address healthy sleep practices.

Using a life course model to examine racial disparities in low birth weight during adolescence and young adulthood.

INTRODUCTION: This study examined relationships between health, social, environmental, and economic factors during adolescence and the subsequent risk of giving birth to a low-birth-weight (LBW) infant, to inform strategies for reducing racial disparities in LBW. METHODS: Data were derived from the National Longitudinal Study of Adolescent Health. A sample of 1213 adolescents, reporting on first pregnancies, was created with 35% black, non-Hispanic (black) and 65% white, non-Hispanic (white) participants. Independent variables were from the domains of individual characteristics, health status, access to care, and social environment. The dependent variable was low birth weight. Overall and race-specific logistic regression models were estimated. RESULTS: Black women had 1.9 times the odds of giving birth to an LBW infant as white women. Factors associated with LBW differed between black women and white women. Black women with a history of hypertension were 6 times more likely to have an LBW infant. Intimate partner support during prenatal care was protective for black women. Factors associated with an increased risk of giving birth to an LBW infant for white women included an intergenerational pattern of LBW, low body mass index during adolescence, and smoking during pregnancy. Socioeconomic factors during adolescence did not predict the odds of having an LBW infant for either group, except for white women whose parents had less than a high school education and black women living in medium-poverty neighborhoods. DISCUSSION: Findings suggest that strategies to reduce racial disparities should address the specific needs of the population being served over the life course.

Organizational climate in primary care settings: implications for nurse practitioner practice.

PURPOSE: The purpose of this review is to investigate literature related to organizational climate, define organizational climate, and identify its domains for nurse practitioner (NP) practice in primary care settings. DATA SOURCES: A search was conducted using MEDLINE, PubMed, HealthSTAR/Ovid, ISI Web of Science, and several other health policy and nursingy databases. CONCLUSIONS: In primary care settings, organizational climate for NPs is a set of organizational attributes, which are perceived by NPs about their practice setting, emerge from the way the organization interacts with NPs, and affect NP behaviors and outcomes. Autonomy, NP-physician relations, and professional visibility were identified as organizational climate domains. IMPLICATIONS FOR PRACTICE: NPs should be encouraged to assess organizational climate in their workplace and choose organizations that promote autonomy, collegiality between NPs and physicians, and encourage professional visibility. Organizational and NP awareness of qualities that foster NP practice will be a first step for developing strategies to creating an optimal organizational climate for NPs to deliver high-quality care. More research is needed to develop a comprehensive conceptual framework for organizational climate and develop new instruments to accurately measure organizational climate and link it to NP and patient outcomes.

Patient comprehension of discharge instructions from the emergency department: a literature review.

PURPOSE: To examine research published from 1995 to 2010, evaluating patient comprehension of discharge instructions from emergency department (ED) or urgent care (UC) settings. Specifically, we examined: (a) the interventions utilized to provide discharge instructions, (b) the methods used to assess patient comprehension, and (c) the most effective strategies for assuring patient comprehension of ED discharge instructions. DATA SOURCES: A comprehensive literature review was conducted utilizing the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Reference Center Academic, Medline, Cochrane, and Ovid. English language peer-reviewed articles published between 1995 and 2010 were reviewed. Search terms included patient, comprehension, understanding, discharge instructions, health education, and emergency medicine. CONCLUSIONS: Increases in patient comprehension of ED discharge instructions are identified with alternative teaching interventions (multimedia) in comparison to traditional standardized written discharge instructions (usual care). Literature suggests clinicians seldom clarify patient comprehension in practice, though effective methods are noted in research. Future research is needed to explore innovative teaching interventions and their impact upon patient comprehension and patient outcomes. IMPLICATIONS FOR PRACTICE: To ensure patient comprehension of discharge instructions, the simplification of discharge material is paramount. Nurse practitioners working in ED or UC settings can improve upon "usual care" by exploring more innovative teaching interventions.

Nurse practitioner organizational climate in primary care settings: implications for professional practice.

The expansion of the nurse practitioner (NP) workforce in primary care is key to meeting the increased demand for care. Organizational climates in primary care settings affect NP professional practice and the quality of care. This study investigated organizational climate and its domains affecting NP professional practice in primary care settings. A qualitative descriptive design, with purposive sampling, was used to recruit 16 NPs practicing in primary care settings in Massachusetts. An interview guide was developed and pretested with two NPs and in 1 group interview with 7 NPs. Data collection took place in spring of 2011. Individual interviews lasted from 30-70 minutes, were audio recorded, and transcribed. Data were analyzed using Atlas.ti 6.0 software by 3 researchers. Content analysis was applied. Three previously identified themes, NP-physician relations, independent practice and autonomy, and professional visibility, as well as two new themes, organizational support and resources and NP-administration relations emerged from the analyses. NPs reported collegial relations with physicians, challenges in establishing independent practice, suboptimal relationships with administration, and lack of support. NP contributions to patient care were invisible. Favorable organizational climates should be promoted to support the expanding of NP workforce in primary care and to optimize recruitment and retention efforts.

Development and psychometric testing of the Nurse Practitioner Primary Care Organizational Climate Questionnaire.

BACKGROUND: Policy makers and healthcare organizations are calling for expansion of the nurse practitioner (NP) workforce in primary care settings to assure timely access and high-quality care for the American public. However, many barriers, including those at the organizational level, exist that may undermine NP workforce expansion and their optimal utilization in primary care. OBJECTIVES: This study developed a new NP-specific survey instrument, Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ), to measure organizational climate in primary care settings and conducted its psychometric testing. METHODS: Using instrument development design, the organizational climate domain pertinent for primary care NPs was identified. Items were generated from the evidence and qualitative data. Face and content validity were established through two expert meetings. Content validity index was computed. The 86-item pool was reduced to 55 items, which was pilot tested with 81 NPs using mailed surveys and then field-tested with 278 NPs in New York State. SPSS 18 and Mplus software were used for item analysis, reliability testing, and maximum likelihood exploratory factor analysis. RESULTS: Nurse Practitioner Primary Care Organizational Climate Questionnaire had face and content validity. The content validity index was .90. Twenty-nine items loaded on four subscale factors: professional visibility, NP-administration relations, NP-physician relations, and independent practice and support. The subscales had high internal consistency reliability. Cronbach's alphas ranged from.87 to .95. DISCUSSION: Having a strong instrument is important to promote future research. Also, administrators can use it to assess organizational climate in their clinics and propose interventions to improve it, thus promoting NP practice and the expansion of NP workforce.

Bedside coaching to improve nurses' recognition of delirium.

Delirium is a widespread complication of hospitalization and is frequently unrecognized by nurses and other healthcare professionals. Patients with neuroscience diagnoses are at increased risk for delirium as compared with other patients. The aims of this quality improvement project were to (1) increase neuroscience nurses' knowledge of delirium, (2) integrate coaching into evidence-based practice, and (3) evaluate the effectiveness of this combined approach to improve nurses' recognition of delirium on a neuroscience unit. Institutional review board approval was obtained. A retrospective chart review of randomly selected patients admitted before the intervention was completed. The (modified) Nurse's Knowledge of Delirium Tool was electronically administered to nursing staff (n = 47), followed within 2 weeks by a didactic presentation on delirium. Bedside coaching was performed over a period of 4 weeks. The (modified) Nurses Knowledge of Delirium Tool was electronically readministered to nurses 4 weeks later to determine the change in aggregate knowledge. A postintervention chart review was conducted. SPSS software was used to analyze descriptive statistics with regard to chart reviews, documentation, and change in questionnaire scores. Findings reveal that neuroscience nurses recognize the absence of delirium 94.4% of the time and the presence of delirium 100% of the time after a didactic session and coaching. The postintervention chart review showed a statistically significant increase (p = .000) in the documentation of delirium screening results. Expert coaching at the bedside may be a reliable method for teaching nurses to use evidence-based screening tools to detect delirium in patients with neuroscience diagnoses.

Revisiting scope of practice facilitators and barriers for primary care nurse practitioners: a qualitative investigation.

Revisiting scope of practice (SOP) policies for nurse practitioners (NPs) is necessary in the evolving primary care environment with goals to provide timely access, improve quality, and contain cost. This study utilized qualitative descriptive design to investigate NP roles and responsibilities as primary care providers (PCPs) in Massachusetts and their perceptions about barriers and facilitators to their SOP. Through purposive sampling, 23 NPs were recruited and they participated in group and individual interviews in spring 2011.The interviews were audio recorded and transcribed. Data were analyzed using Atlas.ti 6.0 software, and content analysis was applied. In addition to NP roles and responsibilities, three themes affecting NP SOP were: regulatory environment; comprehension of NP role; and work environment. NPs take on similar responsibilities as physicians to deliver primary care services; however, the regulatory environment and billing practices, lack of comprehension of the NP role, and challenging work environments limit successful NP practice.

Health reform policy initiatives to promote older women's health.

Currently, women's health care is receiving more attention in health policy discussions. This article reviews aspects of the Patient Protection and Affordable Care Act (PPACA) that seek to improve the health and health care services for older women. Increased access to evidence-based screening assessments for women with Medicare will enhance both the prevention and treatment of acute and chronic diseases. PPACA also contains provisions to expand the gerontological nursing workforce to meet the needs of the rapidly growing population of Medicare-eligible women. Evolving models of care, such as community-based care, shared financial risks, and care coordination, are the current focus of best practice research by the Center of Medicare & Medicaid Innovation. The financing and provision of long-term care is a major issue for women, who represent the majority of adults older than 85. The overarching aim of the new PPACA Medicare changes is to create affordable, quality health care systems that meet the needs of women as they age.

Maternal and newborn outcomes following uterine rupture among women without versus those with a prior cesarean.

OBJECTIVE: To compare outcomes from uterine ruptures (UR) among women without versus with a prior cesarean. METHOD: This case-control study matched on gestational age +/- 1 week and birth year +/- 2 years using a variable numbers of controls (maximum = 4) for each case. All URs in Massachusetts between 1990 and 1998 were identified using ICD-9 codes from linked hospital discharge and birth/fetal death certificate files and confirmed by medical record review. Complete hospitalization records were abstracted. Maternal outcomes were hysterectomy, transfusion, ICU admission, shock, assisted ventilation, and hospital length of stay. Infant outcomes were 5 min Apgar less than 3 or need for ventilation at birth, death, or poor prognosis at discharge. RESULTS: The UR incidence in women without a prior cesarean was 7 per 100,000 births. Of the 49 women without a prior cesarean and a UR, 36 women met study criteria and were matched to 140 controls. Women without a prior cesarean had more severe maternal morbidity (50% vs. 16%) (adj OR 3.28, 95% CI: 1.70, 6.32) with 47% of cases requiring transfusion and 33% requiring ICU admission. Their hospital stays were nearly two days longer. Among their infants, 14% died or had a poor prognosis at discharge compared to 7% of control infants (OR = 2.42, 95% CI 0.94, 6.28). CONCLUSION: Although UR in a woman without a prior cesarean is uncommon, providers should be prepared for more severe maternal morbidity which may be mitigated by prompt surgical intervention and heightened hemodynamic surveillance.

Singleton preterm birth: risk factors and association with assisted reproductive technology.

The objectives of this study were to determine risk factors for early (less than 34 weeks gestation) and late (34-36 weeks gestation) preterm singleton birth, by assisted reproductive technology (ART) status. We linked data from Massachusetts birth records and ART records representing singleton live births from 1997 through 2004. Using multinomial regression models, we assessed risk factors for early and late preterm birth by ART status. From 1997 to 2004 in Massachusetts, among non-ART births, risk factors for early and late preterm birth were similar and included women <15 and ≥ 35 years of age, those of non-white race or Hispanic ethnicity, those with ≤ 12 years of education, those with chronic diabetes, those with gestational diabetes, those with gestational hypertension, those who smoked during pregnancy, those who used fertility medications, and those who had not had a previous live birth. Among ART births, risk factors for early and late preterm birth differed and odds of early preterm birth were increased among women with ≤ 12 years of education while odds of late preterm birth were increased among women with gestational diabetes. Odds of both early and late preterm birth were increased among women of non-white race or Hispanic ethnicity and among women with gestational hypertension. Among non-ART births, increased risk for preterm birth was more strongly related to socioeconomic factors than among ART births. Medical conditions were associated with an increased risk for preterm birth regardless of women's ART status. Efforts to prevent preterm births should focus on reducing modifiable risk factors.

Neonatal outcomes and mental illness, substance abuse, and intentional injury during pregnancy.

Mental illness (MI), substance abuse (SA), and intentional injury (II) are known individual risk factors for adverse pregnancy outcomes. Their combined association with preterm birth (PTB) and low birth weight (LBW) remains relatively unexplored. We examined hospital utilization for the co-occurrence of II and MI or SA in pregnant women in Massachusetts and assessed their interactive association with PTB and LBW. This retrospective cohort study used ICD-9 and E-codes reported on linked birth and hospital utilization data to identify MI, SA, and II diagnoses during pregnancy for 176,845 Massachusetts resident women who delivered during 2002-2004. Adjusted odds ratios (OR) for the independent and joint associations of MI, SA, and II on PTB and LBW were calculated. Two thousand two hundred and eight women (1.6%) had a prenatal MI visit, 834 (0.5%) a prenatal SA visit, and 847 (0.5%) a prenatal II visit. Among them 163 women had MI and II visits and 69 had SA and II visits. SA, MI, and II were all significant predictors of LBW and PTB. Women with both SA and II had higher odds of PTB (OR 2.7 95% CI 1.3-5.7) and LBW (OR 5.3 95% CI 3.9-7.3) than women with neither diagnosis. Prenatal MI, SA, and II are risk factors for LBW and PTB. Women with SA and II co-diagnoses have greater risk of LBW and PTB than women with neither diagnosis. Screening, timely diagnosis, and treatment of women with co-occurring morbidities, particularly II and SA, should be incorporated into reproductive and perinatal health programs.

Probabilistic linkage of assisted reproductive technology information with vital records, Massachusetts 1997-2000.

To assess the validity of probabilistic linkage (PL) in combining national surveillance data on assisted reproductive technology (ART) with Massachusetts birth and infant death data, for the purpose of monitoring maternal and child health outcomes of ART. A study conducted in 2006 utilized direct identifiers to match Massachusetts birth records with records on ART procedures performed to Massachusetts residents in fertility clinics located in Massachusetts and Rhode Island, achieving a linkage rate of 87.5%. The present study employed PL using the program Link Plus, without access to direct identifiers. The primary linking variables were maternal and infant dates of birth, and plurality. Ancillary variables such as maternal ZIP code and gravidity helped resolve duplicate matches and capture additional matches. PL linked 5,390 (87.8%) of 6,139 deliveries, correctly identifying 96.4% of the matches previously obtained using deterministic linkage methods. PL yielded a high linkage rate with satisfactory validity; this method may be applied in other states to help monitor the maternal and child health outcomes of ART.

Winning policy change to promote community health workers: lessons from massachusetts in the health reform era.

There is a national movement among community health workers (CHWs) to improve compensation, working conditions, and recognition for the workforce through organizing for policy change. As some of the key advocates involved, we describe the development in Massachusetts of an authentic collaboration between strong CHW leaders of a growing statewide CHW association and their public health allies. Collaborators worked toward CHW workforce and public health objectives through alliance building and organizing, legislative advocacy, and education in the context of opportunities afforded by health care reform. This narrative of the path to policy achievements can inform other collaborative efforts attempting to promote a policy agenda for the CHW workforce across the nation.

Rates of hospital visits for assault during pregnancy and the year postpartum: timing matters.

OBJECTIVE: To clarify the risk of violence for women during pregnancy and the first year postpartum, we examined the timing of hospital visits for assault among a population cohort of women in Massachusetts. METHODS: Using linked natality and hospital data from 2001 through 2007 for Massachusetts, we examined the timing of hospital (i.e., emergency, inpatient, and observation) visits for maternal assault during seven time periods: the three prenatal trimesters and four three-month postpartum periods. To describe the risk of assault for each of the time periods, we calculated the rate as the number of such visits per 100,000 person-weeks. We used the denominator of 100,000 person-weeks to adjust for variable lengths of gestation and for postpartum periods shortened by subsequent pregnancies. RESULTS: Rates of hospital visits for maternal assault were highest in the first trimester and lowest in the third trimester, with rates of 16.0 and 5.8 per 100,000 person-weeks, respectively. The four postpartum period rates were higher than the third trimester rate but never reached the levels observed in the first and second trimesters. CONCLUSIONS: These findings suggest a changing rate for assault visits during each prenatal trimester and postpartum period. In addition, the importance of violence prevention strategies as part of women's health care across the life span and the need for preconception care initiatives are reaffirmed.

The future of gerontological nursing.

Spring 2010 marked the passage of the Patient Protection and Affordable Care Act; however, soon after this landmark legislation passed, legal and political challenges ensued to change key features of the law. In this environment of proposed changes to transform the U.S. health care system, the Institute of Medicine released its report titled The Future of Nursing: Leading Change, Advancing Health in October 2010. The groundbreaking consensus report calls for a transformation of nursing at practice, education, and leadership levels. This article briefly summarizes findings and key recommendations with an emphasis on areas most relevant to the future of gerontological nursing. In addition, various implementation actions promoted through the Robert Wood Johnson Foundation's Future of Nursing Campaign and the AARP Center to Champion Nursing are discussed to encourage gerontological nurses to participate in current and future debates.

Risk factors for uterine rupture among women who attempt a vaginal birth after a previous cesarean: a case-control study.

OBJECTIVE: To identify risk factors associated with uterine rupture among term pregnancies attempting a vaginal birth after a previous cesarean. STUDY DESIGN: A case-control study was done of 348 uterine ruptures in Massachusetts between 1991 and 1998, initially screened by ICD-9 code and confirmed by medical record review, with 424 control women with a trial of labor randomly selected proportional to cases on year of delivery. Multivariable regression was used to estimate odds ratios and 95% confidence intervals. RESULTS: Successful previous vaginal birth decreased risk for uterine rupture, and gestation > 40 weeks and macrosomia increased risk. Oxytocin for induction increased risk, with a slightly lower effect when used for augmentation. Prostaglandin use in conjunction with oxytocin did not have an additive uterine rupture risk. Women using epidural analgesia have an increased uterine rupture risk. CONCLUSION: Certain labor management practices increase the risk for uterine rupture 2-3 times, although the absolute increase is small from a baseline uterine rupture rate of 0.5% to 1.0-1.5%. The association between epidural analgesia and uterine rupture deserves further study.

Translating evidence from systematic reviews for policy makers.

Gerontological nurses who have received education and have experience in conducting systematic reviews may assume a key role in interpreting systematic reviews for policy makers. Systematic reviews offer evidence to determine the best policy and program solutions to a problem. To be successful in translating evidence from systematic reviews, gerontological nurses need to (a) understand the steps of the policy making process and where different kinds of reviews may be used, (b) assess the "technical" literacy and level of interest in gerontological issues of the intended policy maker, and (c) develop and practice skills in policy writing that distill information in policy briefs as well as shorter formats. Gerontological nurses can be powerful advocates for older adults using the systematic review of the literature as an instrument to educate policy makers.