Reports of three organizations' members about doctor of nursing practice project experiences and outcomes.

BACKGROUND: Holders of the Doctor of Nursing Practice (DNP) degree were envisioned to improve health and health care outcomes by implementing quality improvement initiatives, applying evidence-based practice changes (EBP), and influencing policy. Little is known about the nature of the DNP project experience and its relationship with subsequent experiences of graduates. Filling these knowledge gaps is important because of the investment of time, faculty and student effort, expense, and the projects' potential long-term effects on the organizations in which they were conducted. PURPOSE: (1) Describe the impetus for foci, outcomes and activities of DNP projects and (2) determine the extent to which project foci are a part of post-graduation experiences. METHODS: A cross-sectional descriptive survey design was used and a via mailed paper and online version was sent with return options to graduates of Doctor of Nursing Practice program. The sampling technique was designed to maximize the capture of DNP graduates. Three mailings were sent to 5,830 nurse members of three national organizations with memberships that included advanced practice registered nurses, nurse administrators and nurse educators. The 1,308 DNP prepared respondents were demographically and geographically representative of organizational members. FINDINGS: Most (65.2%) reported the topic of the project was their own idea and they sought out an organization in which to conduct it. Twenty-five percent indicated not all aspects of the reorganization/initiative/policy change were completed by graduation. Five project foci emerged with the majority reporting an EBP initiative or an EBP project involving reorganization in the setting (57.7%) There was also a wide variation in the number, types and combinations of activities reported to be a part of the project. There was wide variation in the relationship of project foci and activities with reports of post-graduation experience by position title. DISCUSSION/CONCLUSION: Findings suggest potential avenues for innovations during the DNP project experience innovations. Long term effects of projects on organizations in which they were conducted and the relationship of project activities with post-graduation roles should be considered.

Providers' Reports of Environmental Conditions and Resources at Births in the United States.

Environmental conditions and resources that may influence provider's behaviors have been investigated in birth environments focusing on location rather than conditions and available resources. Using a descriptive, cross sectional design, we surveyed a random sample of certified nurse-midwives (CNMs), obstetricians, family practice physicians, and certified professional midwives (CPMs) to describe conditions, resources, and workforce present during U.S. births. In all, 1,243 midwives and physicians reported most environmental resources were present at almost 100% of births they attended. Conditions varied: room noise acceptability restriction of phone calls/texts from any source and lighting kept to a minimum. Trainees were present at most births regardless of setting and provider type. The impact of room noise, phone calls/texting, and lighting on outcomes should be determined. The roles and impact of personnel, including trainees, should be described. The extent to which clusters of resources are associated with outcomes might provide new directions for interventions that improve care.

DNPs' labor participation, activities, and reports of degree contributions.

BACKGROUND: There is limited information about the careers, roles and views of doctor of nursing practice (DNP) graduates. METHOD: This study describes the labor participation, post-graduation work activities, and perceptions of 1,308 DNP members of three professional nursing organizations who completed a 2017 survey (32% response rate). FINDINGS: More than 70% of respondents reported substantial improvements in quality improvement, evidenced based practice and leadership abilities. Twenty-two percent of respondents noted the degree was required by their employer and most of these held educational positions. Postgraduate participation in activities associated with DNP education, assessment of personal impact and degree necessity varied by position title and organization membership. DISCUSSION: These differences have implications for nursing associations and professional solidarity.

Nurse Practitioners and Interdisciplinary Teams in Pediatric Critical Care.

OBJECTIVE: To describe the members of pediatric intensive care unit interdisciplinary provider teams and labor inputs, working conditions, and clinical practice of pediatric intensive care unit nurse practitioners. METHODS: A national, quantitative, crosssectional, descriptive postal survey of pediatric intensive care unit medical directors and nurse practitioners was administered to gather information about provider-team members, pediatric intensive care unit nurse practitioner labor inputs, working conditions, and clinical practice. Descriptive statistics, cross-tabulations, and χ2 tests were used. RESULTS: Responses from 97 pediatric intensive care unit medical directors and 59 pediatric intensive care unit nurse practitioners representing 126 institutions were received. Provider-team composition varied between institutions with and without nurse practitioners. Pediatric intensive care units employed an average of 3 full-time nurse practitioners; the average nurse practitioner-to-patient ratio was 1 to 5. The clinical practice reported by medical directors was consistent with practice reported by nurse practitioners. CONCLUSION: Nurse practitioners are integrated into interdisciplinary pediatric intensive care unit teams, but institutional variation in team composition exists. Investigating models of care contributes to the understanding of how models influence positive patient and organizational outcomes and may change future role implementation.

PICU Provider Supply and Demand: A National Survey.

OBJECTIVES: To describe physicians' and nurse practitioners' perceptions of the national and local PICU physician and other provider supply in institutions that employ PICU nurse practitioners, assess for differences in perceptions of supply, and evaluate the intent of institutions to hire additional nurse practitioners to work in PICUs. DESIGN: National, quantitative, cross-sectional descriptive study via a postal mail survey from October 2016 to January 2017. SETTING: Institutions (n = 140) identified in the 2015 American Hospital Association Annual Survey with a PICU who employ PICU nurse practitioners. SUBJECTS: PICU physician medical directors and nurse practitioners. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 119 respondents, representing 93 institutions. Responses were received from 60 PICU medical directors (43%) and 59 lead nurse practitioners (42%). More than half (58%) of all respondents reported the national supply of PICU physicians is less than demand and 61% reported the local supply of PICU providers (physicians in all stages of training, nurse practitioners, and physician assistants) is less than demand. Of the respondents from institutions that self-reported a local provider shortage (n = 54), three fourths (78%) reported plans to increase the number of PICU nurse practitioners in the next 3 years and 40% were likely to expand the nurse practitioner's role in patient care. CONCLUSIONS: Most PICU medical directors and lead nurse practitioners in institutions that employ PICU nurse practitioners perceived that national and local supply of providers to be less than the demand. Nurse practitioners are employed in PICUs as part of interdisciplinary models of care being used to address provider demand. The demand for more PICU nurse practitioners with expanded roles in care delivery was reported. Further evaluation of models of care and provider roles in care delivery can contribute to aligning provider supply with demand for care delivery.

Regulation of pediatric intensive care unit nurse practitioner practice: A national survey.

PURPOSE: To describe the extent to which organizational regulation of pediatric intensive care unit (PICU) nurse practitioner (NP) practice and prescriptive authority aligns with state scope-of-practice (SSOP) regulations, to examine differences between PICU medical directors' and NPs' report of regulation, and to describe organizational-level restriction of PICU NP practice. METHODS: A 34-item national, quantitative cross-sectional descriptive survey of US PICU medical directors and NPs included demographic, institutional characteristics, and PICU NP regulation and role-related questions. Invitations to participate were sent between October 2016 and January 2017. RESULTS: Respondents (n = 121, 60 PICU NPs and 61 PICU medical directors) reported that 30% of PICU NPs have additional organizational restrictions beyond their SSOP practice authority and 11% have prescriptive authority regulations that exceed those required by the SSOP regulations. Medical directors and lead NPs showed agreement in reports of NP practice regulation. Variation in organizational-level restrictions of privileging, billing, and reporting structure practices were identified. IMPLICATIONS FOR PRACTICE: As more states move to full SSOP regulatory environments, organizational regulation of NP practice can impede attainment of full practice authority. Future research is needed to determine whether variations in regulation of PICU NP practice influence patient outcomes, interdisciplinary collaboration, and NP role actualization.

Nurses' responses to interruptions during medication tasks: A time and motion study.

BACKGROUND: The majority of interruption research has focused on the undesirable effects of interruptions, especially related to errors during medication tasks. However, there may be times when interruptions result in positive effects by providing new information to a situation or preventing an error. The study of nurses' responses to interruptions is limited. Since interruptions cannot (and possibly should not) be avoided, a reasonable method for handling interruptions might be to learn how best to prepare for and manage interruption-prone situations. OBJECTIVES: The purpose of this study was to examine nurses' responses to interruptions and explore contextual factors that influence interruption management during medication tasks. This is a secondary analysis of an original study aimed at describing interruptions and nurses' responses to interruptions during routine nursing work on medical-surgical units. DESIGN AND SETTING: This descriptive study was conducted in 5 medical and/or surgical units at 2 acute care facilities in the southern United States, during weekday shifts. PARTICIPANTS: Twenty registered nurses participated in the study. METHODS: The researcher observed nurse participants for at least 4.5 h during routine nursing work. Observation data were collected using time and motion software. Questionnaires were used to collect organizational, unit, and nurse level data. Interruptions during medication tasks were isolated and described as a secondary analysis. RESULTS: Approximately 39% of medication tasks were interrupted. Following an interruption, nurses were more likely to suspend the medication task to attend to the interruption task (51.1%) or multitask (40.3%) than delay responding to the interruption until the medication task was complete (12.6%). Several characteristics of the interruption task, including task type, source, method, and communication intent were associated with nurses' responses at the level of statistical significance. CONCLUSIONS: The findings of this study reveal that nurses are interrupted frequently during medication tasks. The range of nurses' responses to interruptions was surprising in relation to the frequency with which nurses accepted the interruption task and the infrequency of delay responses. Additional study of nurses' responses to interruptions during medication tasks and the effect of different responses on patient safety outcomes is indicated.

Variables That Influence US Midwife and Physician Management of the Third Stage of Labor.

INTRODUCTION: Midwives and physicians incorporate their knowledge, experiences, and other variables in making clinical decisions. Variations in the management of the third stage of labor may be a result of variables that influence providers' decision making. The purpose of this study was to describe variables that influence US midwives' and physicians' management of the third stage of labor. METHODS: A randomly selected national sample of certified nurse-midwives and certified midwives, certified professional midwives, obstetricians, and family physicians was surveyed about the extent to which maternal characteristics, maternal history, and current birth characteristics influence their third-stage management. The extent of influence was defined in terms of always to never altering management. Descriptive summaries, group comparisons, and partial correlations were used to determine differences in influences between midwives and physicians. One free-text question was analyzed using qualitative methods. RESULTS: A total of 1243 clinicians responded. There was considerable variability in the response patterns in that the same variable was reported to always alter management during the third stage of labor for some participants yet did not influence the management practices of others at all. Differences between responses from midwives and physicians were explored as a possible explanation for some of the variability. In response to the free-text inquiry about variables that most influenced changes in participants' usual management of the third stage, the participants most often included active bleeding, current recommendations or guidelines, and maternal or family preferences. DISCUSSION: This study identifies variables reported as influencing clinical decision making during the third stage of labor. Therefore, these variables are important to consider when evaluating interventions and outcomes related to management of the third stage of labor and any attempts to design new interventions. The findings are descriptive of practice; they are not intended to guide changes in practice.

US Physician and Midwife Adherence to Active Management of the Third Stage of Labor International Recommendations.

INTRODUCTION: The prevalence of postpartum hemorrhage has increased in the United States despite the international promotion of active management of the third stage of labor. Adherence to the international recommendations in the United States is unclear. It is also not known how the components of active management are related to other practices that may be used during the third stage of labor. The purpose of this study was to determine routine practice patterns for managing the third stage of labor in the United States. METHODS: A randomized national survey was conducted of certified nurse-midwives/certified midwives, certified professional midwives, obstetricians, and family physicians who self-reported third-stage practices. Descriptive analyses and partial correlations were used to determine differences in practice patterns between midwives and physicians. A 2-step clustering algorithm was used to identify clusters of third-stage practices. RESULTS: A total of 1243 clinicians responded. Uterine massage after placenta expulsion was reportedly used at almost every birth by all provider types. Median use of cord traction and oxytocin administration by all provider types was 80% and 90% of births, respectively. Cluster analysis of these and other interventions used during the third stage of labor revealed 4 distinct clusters of practices ranging from primarily a hands-off at one extreme to high-intervention approaches at the other extreme. The other 2 clusters were defined by practices that fell between those extremes. DISCUSSION: Determination of how, and under what conditions, clinicians decide when to use particular techniques to manage the third stage of labor and how these techniques influence the incidence of postpartum hemorrhage, is necessary. The clusters of practice combinations that emerged in this study suggest that there are extreme variations in clinician practices during management of the third stage of labor.

Junior research track faculty in U.S. schools of nursing: Resources and expectations.

BACKGROUND: Concerns about U.S. nursing research workforce preparation and success in the research arena require information about support mechanisms and readiness because the first research position is key to researcher retention and success. PURPOSE: The purpose was to describe the state of junior nursing research faculty recruitment terms, nursing programs' support during the first 2 years of employment, and administrators' views about strengths and weaknesses of the junior nursing research faculty pool and adequacy of the support provided. METHODS: Survey administrators in all U.S. nursing programs offering research doctorates (n = 125; response rate: 52%). DISCUSSION: Resource availability varied widely across institutions. Most respondents reported resources were adequate regardless of the actual level provided. Administrators' teaching and research expectations of these faculty also varied widely. Administrators identified readiness to perform as an issue of concern. CONCLUSION: As consumers of nursing research program graduates and as administrators responsible for the nursing research enterprise, deans need to take collective as well as individual actions.

Relationships of Maternal Stress with Milk Immune Components in African American Mothers of Healthy Term Infants.

BACKGROUND: In the United States, African American infants experience the highest mortality, and their mothers report the lowest breastfeeding rates. Science reports decreased infant mortality among breastfed infants and suggests that milk immune component (MIC) levels are associated with maternal stressors. Little is known about these relationships among African Americans; therefore the aim was to explore the relationships of African American mothers' stressors and MICs 1-14 days postdelivery. MATERIALS AND METHODS: Mothers meeting eligibility requirements were approached for consent 48-72 hours postdelivery of a healthy term infant and given instructions to collect milk (Days 3, 9, and 14) and saliva (Day 9), as well as complete three Perceived Stress Scale questionnaires (Days 3, 9, and 14) and a survey of pregnancy stressors experiences. Pearson correlations and linear regressions were performed to assess the relationships of maternal stressors with MICs. RESULTS: There was at least one statistically significant correlation of a maternal stressor with nine of the 10 MICs (effect sizes ranging from r = 0.22 to 0.38) on Days 3 and 9. Of all MICs, epidermal growth factor had the most associations with maternal stress indicators. No mediational relationship of cortisol with MICs was observed. CONCLUSIONS: Many of the MIC changes observed could potentially impact the health of term and preterm infants. Further research is warranted.

Preinjury Physical Function and Frailty in Injured Older Adults: Self- Versus Proxy Responses.

OBJECTIVES: To determine the extent to which proxy respondents can provide reliable reports. DESIGN: Prospective cohort study. SETTING: Level I trauma center. PARTICIPANTS: Seventy-seven older adults (≥65, median 73.0, interquartile range 67-80; 53% female) admitted to three services (trauma, geriatrics, orthopedics) with primary injury diagnoses over a 6-month period and their proxies (43% spouses, 44% children, 5% siblings, 8% friends or other relatives). MEASUREMENTS: Three brief screening instruments (Vulnerable Elders Survey-13 (VES-13), modified Barthel Index (mBI), Life Space Assessment (LSA)) for physical function and frailty were administered to older adults and their proxies within 48 hours of admission. Data analysis included frequencies, percentages, intraclass correlations, and Kappa statistics. RESULTS: Approximately 47% (n = 36) of the proxies lived with the older adults. Perfect agreement and 90% agreement between older adults and proxies: There was perfect agreement for 39 (51%) dyads and a difference of 1 or less (range 1-10) for 66 (86%) on the VES-13, perfect agreement for 48 (62%) and a difference of two or less (range 0-20) for 69 (89%) on the mBI, and perfect agreement for 27 (35%) and a difference of 12 or less (range 0-120) for 55 (71%) on the LSA. CONCLUSION: Proxy reports of older adults' preinjury physical function and frailty are in an acceptable range of agreement with those of the older adults. Using proxy reports when people cannot provide information on themselves may facilitate care management and goal setting.

A description of U.S. post-graduation nurse residency programs.

BACKGROUND: Concern regarding newly licensed registered nurses' abilities to cope with the increasing complexity of care has led to the development of a variety of nurse residency program (NRP) initiatives. The unknowns are the extent to which and how various program elements are implemented across NRPs. Without understanding the extent to which NRPs deliver the same program, determination of their impact on care is limited. The purpose of this study was to describe U.S. NRPs and thereby identify the extent of treatment fidelity across programs. METHODS: Program attributes were measured using a 24-item survey based on the outcomes production conceptual framework. The survey was sent to known NRP directors or chief nursing officers at the 1,011 U.S. hospitals having 250 or more inpatient beds; 203 surveys (a 20% response rate) were returned. RESULTS: Almost half (48%) of hospitals reported operating an NRP. NRP models included University HealthSystems Consortium (22%), facility based (54%), and "other" (24%). Significant (p < .01) differences were noted among and within program model types in terms of career planning, project requirements and types, and mentoring. CONCLUSIONS: The extent of differences within and across program types indicates a lack of treatment fidelity needed to detect objectively the impact of the NRP as a discrete intervention on patient outcomes. NRP expansion may be limited by the number of hospitals of a size most likely able to support such programs.

How self-care education in ventricular assist device programs is organized and provided: a national study.

OBJECTIVE: To describe the care delivery structure and elements used for patient self-care education in ventricular assist device (VAD) programs. BACKGROUND: Use of VADs as destination therapy and to sustain organ function until cardiac transplantation has increased 517% since 2007. Elements of VAD-specific self-care education have not been described. METHODS: A 26-item survey measuring VAD self-care education resource use, organizational, employment, behavioral and labor variables was sent to VAD coordinators at all US VAD centers (N = 111) in 2011. Two subsequent mailings yielded a 63% (n = 71) return rate. Analysis included descriptive statistics and cluster analysis. RESULTS: Element use varied across programs. Reliance on single educational and evaluation methods, and lack of return demonstration were noted. VAD coordinators reported extensive caregiver, hospital provider, and community educational responsibilities in addition to patient self-care education. CONCLUSIONS: VAD self-care education programs varied by hospital. Future research is needed to determine if specific care delivery structures or elements used in self-care education improve VAD patient outcomes.

Defining and describing capacity issues in U.S. Doctor of Nursing Practice programs.

Recent calls to expand the number of U.S. Doctors of Nursing Practice (DNPs) raises questions about programs' capacities, content and requirements, and their ability to expand. This paper aims to describe (1) key aspects of DNP program capacities that may provide direction for DNP program expansion plans, the timing of such expansion and program QI efforts; and (2) the impact of the DNP on faculty resources for research doctoral programs. A survey of all U.S. DNP programs (n = 130; response rate 72%) was conducted in 2011 based on previously tested items. Reviews of Web sites of nonresponding schools provided some data from all programs. Ratios of students to faculty active in advanced practice (AP) and in QI (QI) were high (AP 11.0:1, SD 10.1; QI 20.2:1, SD 17.0 respectively). There was wide variation in scholarly requirements (0-4: 50% of program had none) and program committee composition (1-5; mode=2). Almost all responding schools that offered PhD and DNP programs reported assigning research-active or potentially research-active faculty in both programs. The ability to expand programs while maintaining quality may be compromised by capacity issues. Addressing demand issues through the alignment of program requirements with societal and employment requirements may provide directions for addressing current DNP capacity issues.

Operating room team members' views of workload, case difficulty, and nonroutine events.

Interventions such as mandatory "time-outs" have contributed to intraoperative safety but improvements are still necessary. We present data provided by 3 professions always present in the intraoperative setting that suggest next steps in the quest for improvements. We describe the differences and similarities in operating room (OR) nurses', anesthesia providers', and surgeons' beliefs about team function, case difficulty, nonroutine event (NRE), and error causation using a qualitative design at 3 Veterans' Administration hospitals. Intraoperative errors are costly in lives, suffering, and dollars. A quality improvement tenet states that workers are a rich information source regarding the context within which quality can be improved. Identifying and describing OR providers' beliefs are necessary steps in devising novel approaches to quality improvement. Intraoperative NRE and error prevention opportunities exist within and outside of the OR. There may be "cascade" and "perfect storm conditions" before and during operative procedures that increase the likelihood of NREs. Confirmation of these phenomena could improve prediction and prevention of NREs. Exploration of differences in team definition and team performance ratings by provider type may also identify avenues for improvement.

Leadership in doctoral nursing research programs.

The expansion of U.S. doctoral nursing research programs and transitions based on demographic distribution of the nursing academic workforce raises questions about the preparation for leadership transition planning. The purpose of this study was to describe the program leaders, job conditions, and status of transition efforts. A survey of U.S. nursing research doctoral programs (N = 105) was conducted in 2008. The response rate was 84.8%. A Web search of nonresponding schools provided some data from all programs. Most research doctoral program leaders hold additional responsibilities (mean = 4.2). The mean budgeted leadership time was 32.9% (SD = 21.4). Among programs in which the director's age was at least 60 years, 59% had no succession plan. Continuing improvement of the quality of doctoral nursing research programs could be compromised by leadership transition issues. To produce research-competitive graduates, continued support and attention to leadership of these programs is essential.

Defining and describing capacity issues in US doctoral nursing research programs.

The expansion of US doctoral research programs raises questions about mentorship capacity, program quality, and decisions about future expansion. To describe capacity issues and, when possible, compare findings to those of an earlier study, a survey of US nursing research doctoral programs (n = 105) was conducted in 2008. The response rate was 84.8%. The Web sites of non-responding schools were reviewed providing some data from all programs. The mean ratio of students per current externally funded grant was 6.9 (SD 7.5) to 1. The mean ratio of student to ever-funded faculty was 8.3 (SD 8.3) to 1. The mean number of research activities required (out of 5 possible) was 1.8 (SD 1.4), and the most common was a research practica (77%), followed by attendance at a research meeting external to the school (37%), and submitting an article for publication (32%). The quality of many programs may be compromised by capacity issues. Attention to existing programs' requirements and capacities and determination of the roles of these variables in producing research competitive graduates is needed.

Nurse labor data: the collection and interpretation of nurse-to-patient ratios.

Nurse labor has been shown to be related to some patient outcomes, but varying definitions and measurement approaches have resulted in conflicting findings about the nature of the relationship. Nurse administrators and researchers need to know rates of missing data and error in labor data to better inform decision making. The authors compare the degree of completeness and the agreement between these approaches (nurse survey and nurse-to-patient ratio staffing plans) to obtain patient-to-nurse ratios at the unit level.

The design of adult acute care units in U.S. hospitals.

PURPOSE: To describe the current state of design characteristics determined to be desirable by the Agency for Health Research and Quality (AHRQ) in U.S. adult medical, surgical, and intensive care units (ICUs). DESIGN: Descriptive study of patient visibility; distance to hygiene, toileting, charting, and supplies; unit configuration; percentage of private rooms; and presence or absence of carpeting in 56 ICUs and 81 medical-surgical units in six metropolitan areas. METHODS: Data were collected via observation, measurement, and interviews. Unit configurations were classified via an iterative process. Descriptive data were analyzed according to ICU and non-ICU status using SPSS (Version 15). FINDINGS: Analysis of unit configurations indicated eight unit designs. Statistical analysis showed inter- and intrahospital variation in unit configurations, percentage private rooms, carpeting, visibility, and distance to supplies and charting. Few units met the AHRQ designated design elements studied. CONCLUSIONS: A wide gap exists between desirable characteristics in ICUs and medical-surgical units. Future research is needed to explore operationalization of unit design elements as risk adjustments, how design elements contribute to patient outcomes, and how design elements influence one another. CLINICAL RELEVANCE: There is room for improvement on almost every design variable, particularly on medical-surgical units. Future planning should take into consideration the interaction of bed capacity and unit configuration.