Can Answers to the Health Workforce Crisis Be Found in Equity-Informed Digital Health?

In this paper, we describe current pressures on health human resources (HHRs) in the Canadian context and related factors that impact equity-deserving communities/populations. We explore issues of HHR challenges in rural, remote and urban underserved contexts and explore the associated benefits and challenges of incorporating digital health (DH). We present examples and evidence of integrating hybrid models of care as a means of supporting HHRs via DH in the publicly funded health system.

An economic analysis of a contingency model utilising vaccination for the control of equine influenza in a non-endemic country.

BACKGROUND: Equine influenza (EI) is an infectious respiratory disease of horses that has never been reported in New Zealand (NZ). However, the 2007 EI outbreak in Australia, previously EI free, spurred the NZ government and stakeholders into evaluating alternative EI control strategies in order to economically justify any future decision to eradicate or manage EI. To build on the policy debate, this paper presents an epinomic (epidemiologic and economic) modelling approach to evaluate alternative control strategies. An epidemiologic model to determine how alternative EI control strategies influence the distribution of EI. Model results were then input into a cost-benefit analysis framework, to identify the return and feasibility of alternative EI eradication strategies in NZ. METHODS: The article explores nine alternative eradication scenarios and two baseline strategies. The alternative scenarios consisted of three vaccination strategies (suppressive, protective or targeted) starting at three time points to reflect the commercial breeding-cycle. These alternatives were compared to two breeding-cycle adjusted baselines: movement restriction in the breeding season (August to January) or non-breeding season (February to July). The economic loss parameters were incursion response, impact to the commercial racing industry (breeding, sales and racing), horse morbidity and mortality, and compensation to industry participants. RESULTS AND CONCLUSIONS: Results suggest that the economic viability of the EI eradication programme is dependent on when within the breeding-cycle the EI outbreak occurs. If an outbreak were to occur, the return on each dollar invested for protective or suppressive vaccination strategies would be between NZD$3.67 to NZD$4.89 and between NZD$3.08 to NZD$3.50 in the breeding and non-breeding seasons, respectively. Therefore, protective or suppressive vaccination strategies could be prioritised, regardless of season. As multiple industry stakeholders benefit from these strategies, the study will enable policy development and to better formulate a user-pays eradication programme.

Geographical mapping of advanced practice registered nurses in Louisiana: Leveraging the power of data display.

BACKGROUND AND PURPOSE: Identifying the locations of advanced practice registered nurses (APRNs) in the state is challenging without data readily available, which can adversely affect stakeholder initiatives. The purpose of this project was to develop an online interactive map reflecting distribution of APRNs licensed by the Louisiana State Board of Nursing (LSBN), heightening APRN visibility and improving usability of data for policy, education, practice, and research initiatives. METHODS: A descriptive design with development of a graphical interactive map showing all Louisiana parishes with integrated distribution summaries of APRNs was made. Work proceeded from paper to higher fidelity simulations to the final interactive web page. Compatibility with LSBN's web page and annual data upload were ensured. CONCLUSION: The project was done in collaboration with LSBN, an academic institution, and a privately hired web designer. The principals of Louisiana State Board of Nursing approved the final product. The product meets and exceeds the expectations for mapping. Evaluation of use and usability will be done at the discretion of LSBN. IMPLICATIONS FOR PRACTICE: The outcome of this project will serve to heighten visibility of the distribution of APRNs in the state of Louisiana, enhancing opportunities for APRNs and for patients. Furthermore, those interested in leveraging the information in policy, education, or research initiatives will be served.

Effectiveness of pay-for-performance for chronic kidney disease patients on hemodialysis: a systematic review protocol.

REVIEW QUESTION/OBJECTIVE: The objective of this review is to assess the evidence on the effectiveness of implementation of a pay-for-performance program on clinical outcomes in the adult chronic kidney disease (CKD) patient receiving hemodialysis.The review question is: What is the effectiveness of implementation of a pay-for-performance program on clinical outcomes in the adult CKD patient receiving hemodialysis, as compared to the period immediately before implementation of the program?More specifically, the objectives are to identify.

Hand hygiene adherence according to World Health Organization Recommendations in a Neonatal Intensive Care Unit / Aderência à higiene das mãos através das recomendações da Organização Mundial de Saúde em uma Unidade de Terapia Intensiva Neonatal

Abstract Objectives: to evaluate the application of hand hygiene technique, according to the World Health Organization (WHO) recommendations, in the neonatal intensive care unit, at a Maternity in Salvador de Bahia, Brazil. Methods: cross-sectional study. Hand hygiene technique by professional category and alcohol solution consumption were systematically registered. For this task an adapted instrument created by the WHO was used and applied using factsheets. The sample was taken from medical physicians, physiotherapists, nurses and nursing technicians. Results: hand hygiene adherence regarding WHO recommendations was deficient in terms of technique and in terms of frequency (adequate technique ranged from 0% to 13.3% between professional categories). Hand hygiene was frequently ignored (27% between physicians and 51.8% between nursing technicians). The moment right after touching surfaces next to patients was the most ignored one. Alcohol gel solution monthly use was only 35% of the expected value for the unit. Conclusions: despite the international investigations and efforts for better results, the adherence and compliance to the hand hygiene guidelines is still deficient and continues to be a major problem.

Resumo Objetivos: avaliar aplicação da técnica de higienização das mãos numa unidade de terapia intensiva neonatal em uma maternidade de Salvador, Bahia, Brasil. Métodos: estudo transversal no qual foi avaliada a técnica de higienização das mãos com água e sabão e álcool gel e o consumo de solução de álcool gel e por categoria profissional. Um instrumento adaptado da OMS foi usado e aplicado usando questionários. A amostra foi composta por médicos, fisioterapeutas, enfermeiros e técnicos de enfermagem. Resultados: a aderência à higienização das mãos foi deficiente em termos de técnica e de frequência (a execução correta da técnica variou de 0 a 13,3% entre as categorias profissionais). A higienização das mãos foi ignorada por 27% dos médicos e 51,8% dos técnicos de enfermagem. Depois de tocar superfícies próximas aos pacientes foi o momento mais ignorado. O uso mensal de álcool gel foi 35% do valor esperado. Conclusões: apesar das investigações internacionais e esforços para melhores resultados, a adesão e o cumprimento das diretrizes de higienização das mãos ainda é deficiente.

Preferred Methods of Learning for Nursing Students in an On-Line Degree Program.

Investigators have demonstrated that on-line courses result in effective learning outcomes, but limited information has been published related to preferred teaching strategies. Delivery of on-line courses requires various teaching methods to facilitate interaction between students, content, and technology. The purposes of this study were to understand student teaching/learning preferences in on-line courses to include (a) differences in preferred teaching/learning methods for on-line nursing students across generations and (b) which teaching strategies students found to be most engaging and effective. Participants were recruited from 2 accredited, private school nursing programs (N=944) that admit students from across the United States and deliver courses on-line. Participants provided implied consent, and 217 (23%) students completed the on-line survey. Thirty-two percent of the students were from the Baby Boomer generation (1946-1964), 48% from Generation X (1965-1980), and 20% from the Millennial Generation (born after 1980). The preferred teaching/learning methods for students were videos or narrated PowerPoint presentations, followed by synchronous Adobe Connect educations sessions, assigned journal article reading, and e-mail dialog with the instructor. The top 2 methods identified by participants as the most energizing/engaging and most effective for learning were videos or narrated PowerPoint presentations and case studies. The teaching/learning method least preferred by participants and that was the least energizing/engaging was group collaborative projects with other students; the method that was the least effective for learning was wikis. Baby Boomers and Generation X participants had a significantly greater preference for discussion board (P<.0167) than millennial students. Millennial students also had a greater preference for simulation than did Baby Boomer and Generation X students and rated on-line games as significantly more energizing/engaging and more effective for learning (P<.0167) than did Baby Boomer and Generation X students. In conclusion, the results of this study demonstrate that there are distinct student preferences and generational differences in preferred teaching/learning methods for on-line students. Faculty need to incorporate various teaching methodologies within on-line courses to include both synchronous and asynchronous activities and interactive and passive methodologies.

Understanding scoping reviews: Definition, purpose, and process.

BACKGROUND/PURPOSE: Scoping review design represents a methodology that allows assessment of emerging evidence, as well as a first step in research development. Despite its increasing use, to date no article reflecting use of scoping review methodology has been submitted for review at JAANP. The purpose of this article is to provide detailed information on scoping reviews, including definition, related processes, and uses, and discuss the relationship to nurse practitioner (NP) practice, policy, education, and research. The longer-term goal is that NPs will understand the related techniques, consider the methodology as a viable one for NP scholarship, and bring related reports to the forefront of NP publications. METHODS: This manuscript represents a brief report. Processes to develop the brief include detailed search and review of scoping review literature in CINAHL and PubMed. Both methodologic reports and reviews were included. Definitions and uses of scoping reviews were reviewed. CONCLUSION: The definition and process of scoping review are evolving. Although there is controversy regarding the methodology, there is increasing visibility of scoping review methodology in the published literature since the year 2000, with over 500 published reviews currently available. IMPLICATIONS FOR PRACTICE: A well-executed scoping review has potential to inform NP practice, policy, education, and research.

Cardiovascular Disease and Health Care System Impact on Functionality and Productivity in Argentina: A Secondary Analysis.

OBJECTIVES: To examine the impact of cardiovascular disease (CVD) events on patient functionality and productivity on the basis of patient use of public or social/private institution health care. METHODS: A secondary analysis was conducted of data drawn from records of Argentinian patients, 3 to 15 months posthospitalization after a CVD event, who had originally participated in a multicountry, cross-sectional study assessing the microeconomic impact of a CVD event. Respondents were stratified according to their use of health care institution (public or social/private). Among these groups, pre- and post-CVD event changes in functionality and productivity were compared. RESULTS: Participants' (N = 431) mean age was 56.5 years, and 73.5% were men. Public sector patients reported significantly higher rates of decline in ability to perform moderate activities (P < 0.05), a greater decrease in time spent at work (P < 0.01), a greater limit in the type of work-related activities (P < 0.01), and a higher rate of emotional problems (P < 0.01). Having health insurance (private or social) (odds ratio [OR] = 0.55; 95% confidence interval [CI] 0.35-0.85; P < 0.01) and a higher income (OR = 0.99; 95% CI 0.99-0.99; P < 0.01) were inversely and significantly associated with loss of productivity. Cerebrovascular disease (OR = 2.55; 95% CI 1.42-4.60; P < 0.01) was also significantly associated with productivity loss. CONCLUSIONS: In Argentina, patients receiving care in the public sector experienced a greater impact on functionality and productivity after their hospitalization for a CVD event. Lack of insurance, low income, and cerebrovascular disease event were the major determinants of productivity loss. Further investigation is needed to better understand contributors to these differences.

Student Engagement in Online Nursing Courses.

The purposes of this study were to determine the level of engagement of registered nurse (RN) to Bachelor of Science in Nursing (BSN), Master of Science in Nursing (MSN), and Doctor of Nursing Practice (DNP) nursing students enrolled in online nursing degree programs and to understand whether there are generational differences in level of student engagement. Significant differences were noted for engagement level between generations of students, but no significant difference was noted in the engagement level of students from RN to BSN, MSN, or DNP programs.

The essential SOAP note in an EHR age.

This article reviews the traditional Subjective, Objective, Assessment, and Plan (SOAP) note documentation format. The information in the SOAP note is useful to both providers and students for history taking and physical exam, and highlights the importance of including critical documentation details with or without an electronic health record.

Qualitative evaluation of a text messaging intervention to support patients with active tuberculosis: implementation considerations.

BACKGROUND: Tuberculosis (TB) remains a major global public health problem and mobile health (mHealth) interventions have been identified as a modality to improve TB outcomes. TextTB, an interactive text-based intervention to promote adherence with TB medication, was pilot-tested in Argentina with results supporting the implementation of trials at a larger scale. OBJECTIVE: The objective of this research was to understand issues encountered during pilot-testing in order to inform future implementation in a larger-scale trial. METHODS: A descriptive, observational qualitative design guided by a sociotechnical framework was used. The setting was a clinic within a public pulmonary-specialized hospital in Argentina. Data were collected through workflow observation over 115 days, text messages (n=2286), review of the study log, and stakeholder input. Emerging issues were categorized as organizational, human, technical, or sociotechnical considerations. RESULTS: Issues related to the intervention included workflow issues (eg, human, training, security), technical challenges (eg, data errors, platform shortcomings), and message delivery issues (eg, unintentional sending of multiple messages, auto-confirmation problems). System/contextual issues included variable mobile network coverage, electrical and Internet outages, and medication shortages. CONCLUSIONS: Intervention challenges were largely manageable during pilot-testing, but need to be addressed systematically before proceeding with a larger-scale trial. Potential solutions are outlined. Findings may help others considering implementing an mHealth intervention to anticipate and mitigate certain challenges. Although some of the issues may be context dependent, other issues such as electrical/Internet outages and limited resources are not unique issues to our setting. Release of new software versions did not result in solutions for certain issues, as specific features used were removed. Therefore, other software options will need to be considered before expanding into a larger-scale endeavor. Improved automation of some features will be necessary, however, a goal will be to retain the intervention capability to be interactive, user friendly, and patient focused. Continued collaboration with stakeholders will be required to conduct further research and to understand how such an mHealth intervention can be effectively integrated into larger health systems.

Listening to Those at the Frontline: Patient and Healthcare Personnel Perspectives on Tuberculosis Treatment Barriers and Facilitators in High TB Burden Regions of Argentina.

Purpose. In Argentina, tuberculosis (TB) control measures have not achieved key treatment targets. The purpose of this study was to identify modes of treatment delivery and explore patient and healthcare personnel perceptions of barriers and facilitators to treatment success. Methods. We used semistructured group and individual interviews for this descriptive qualitative study. Eight high burden municipalities were purposively selected. Patients in treatment for active TB (n = 16), multidisciplinary TB team members (n = 26), and TB program directors (n = 12) at local, municipal, regional, and national levels were interviewed. Interviews were recorded, transcribed verbatim, and analyzed using thematic analysis. Results. Modes of treatment delivery varied across municipalities and types of healthcare facility and were highly negotiated with patients. Self-administration of treatment was common in hospital-based and some community clinics. Barriers to TB treatment success were concentrated at the system level. This level relied heavily on individual personal commitment, and many system facilitators were operating in isolation or in limited settings. Conclusions. We outline experiences and perspectives of the facilitating and challenging factors at the individual, structural, social, and organizational levels. Establishing strong patient-healthcare personnel relationships, responding to patient needs, capitalizing on community resources, and maximizing established decentralized system could mitigate some of the barriers.

Research methods for graduate students: a practical framework to guide teachers and learners.

PURPOSE: The purpose of this article is to present the Arrow Framework for Research Design, an organizing framework that facilitates teaching and learning of research methods, providing logical organization of interrelationships between concepts, content, and context of research methods, and practice application. The Arrow Framework was designed for teaching and learning research methods to facilitate progression of knowledge acquisition through synthesis. DATA SOURCES: The framework was developed over several years and used successfully to teach masters, DNP, and PhD nursing students across five universities. The framework is presented with incremental graphics and narrative for teaching. CONCLUSION: The Arrow Framework provides user-friendly information, in an organized and systematic approach demonstrated as successful for teaching and learning the foundational language of research, facilitating synthesis and application in scholarly endeavors. IMPLICATIONS FOR PRACTICE: The Arrow Framework will be useful for educators and students in teaching and learning research language, relationships, and application of methods. The materials are easily adaptable to slide or paper presentation, and meet learner needs for narrative and visual presentation. Teaching research design to graduate students is critical to meet the expectation that students are to understand the scientific underpinnings of nursing science and appropriate use of evidence that are essential for well-educated practitioners.

MHEALTH INTERVENTION DEVELOPMENT TO SUPPORT PATIENTS WITH ACTIVE TUBERCULOSIS.

BACKGROUND: Mobile Health (mHealth) based interventions have been increasingly used to improve a broad range of health outcomes. However, few researchers have reported on the process or the application of theory to guide the development of mHealth based interventions, or specifically for tuberculosis (TB) treatment management. AIMS: To describe the steps, process, and considerations in developing a text messaging-based intervention to promote treatment adherence and provide support to patients with active TB. METHODS: Traditional qualitative techniques, including semi-structured interviews, field notes, content analysis, iterative coding, and thematic analysis, were used to design and document the intervention development with a multidisciplinary team of researchers, clinicians, administrators, and patients who were in active TB treatment. The Information-Motivation-Behavioral Skills (IMB) model was used to guide the coding scheme for content analysis of patient-directed TB educational material and intervention development. RESULTS: The development steps included: a) establishing intervention components, including justifications, considerations, timing and frequency of components; b) developing educational messages, including cultural adaption, text or short message service (SMS) formatting, and prioritizing message delivery order; and c) determining implementation protocol. A set of 16 IMB-based messages were developed for the educational component. Final intervention development was achieved in 3 months. CONCLUSION: A collaborative approach and application of a theory to guide the intervention design and development is supported. Although a collaborative approach was more time consuming, it resulted in a more responsive, culturally appropriate, and comprehensive intervention. Considerations for developing a text messaging based intervention are provided and may serve as a guide for similar interventions. Further empirical evidence is needed for applying the IMB model for adherence-promotion in TB efforts.

Customization of electronic medical record templates to improve end-user satisfaction.

Since 2004, increasing importance has been placed on the adoption of electronic medical records by healthcare providers for documentation of patient care. Recent federal regulations have shifted the focus from adoption alone to meaningful use of an electronic medical record system. As proposed by the Technology Acceptance Model, the behavioral intention to use technology is determined by the person's attitude toward usage. The purpose of this quality improvement project was to devise and implement customized templates into an existent electronic medical record system in a single clinic and measure the satisfaction of the clinic providers with the system before and after implementation. Provider satisfaction with the electronic medical record system was evaluated prior to and following template implementation using the current version 7.0 of the Questionnaire for User Interaction Satisfaction tool. Provider comments and improvement in the Questionnaire for User Interaction Satisfaction levels of rankings following template implementation indicated a positive perspective by the providers in regard to the templates and customization of the system.

TextTB: A Mixed Method Pilot Study Evaluating Acceptance, Feasibility, and Exploring Initial Efficacy of a Text Messaging Intervention to Support TB Treatment Adherence.

Objective. To assess a text messaging intervention to promote tuberculosis (TB) treatment adherence. Methods. A mixed-methods pilot study was conducted within a public pulmonary-specialized hospital in Argentina. Patients newly diagnosed with TB who were 18 or older, and had mobile phone access were recruited and randomized to usual care plus either medication calendar (n = 19) or text messaging intervention (n = 18) for the first two months of treatment. Primary outcomes were feasibility and acceptability; secondary outcomes explored initial efficacy. Results. Feasibility was evidenced by high access to mobile phones, familiarity with texting, most phones limited to basic features, a low rate of participant refusal, and many describing suboptimal TB understanding. Acceptability was evidenced by participants indicating feeling cared for, supported, responsible for their treatment, and many self-reporting adherence without a reminder. Participants in the texting group self-reported adherence on average 77% of the days whereas only 53% in calendar group returned diaries. Exploring initial efficacy, microscopy testing was low and treatment outcomes were similar in both groups. Conclusion. The texting intervention was well accepted and feasible with greater reporting of adherence using text messaging than the diary. Further evaluation of the texting intervention is warranted.

Effects of mindfulness-based cognitive therapy on mental disorders: a systematic review and meta-analysis of randomised controlled trials.

OBJECTIVE: Mindfulness-based cognitive therapy (MBCT) is a programme developed to prevent depression relapse, but has been applied for other disorders. Our objective was to systematically review and meta-analyse the evidence on the effectiveness and safety of MBCT for the treatment of mental disorders. METHODS: Searches were completed in CENTRAL, MEDLINE, EMBASE, LILACS, PsychINFO, and PsycEXTRA in March 2011 using a search strategy with the terms 'mindfulness-based cognitive therapy', 'mindfulness', and 'randomised controlled trials' without time restrictions. Selection criteria of having a randomised controlled trial design, including patients diagnosed with mental disorders, using MBCT according to the authors who developed MBCT and providing outcomes that included changes in mental health were used to assess 608 reports. Two reviewers applied the pre-determined selection criteria and extracted the data into structured tables. Meta-analyses and sensitivity analyses were completed. RESULTS: Eleven studies were included. Most of them evaluated depression and compared additive MBCT against usual treatment. After 1 year of follow-up MBCT reduced the rate of relapse in patients with three or more previous episodes of depression by 40% (5 studies, relative risk [95% confidence interval]: 0.61 [0.48, 0.79]). Other meta-analysed outcomes were depression and anxiety, both with significant results but unstable in sensitivity analyses. Methodological quality of the reports was moderate. CONCLUSION: Based on this review and meta-analyses, MBCT is an effective intervention for patients with three or more previous episodes of major depression.