Aligning for Heroes: Partnership for Veteran Care in New Hampshire.

A growing number of veterans and service members ("veterans" refers to both veterans and eligible service members) are returning home and may be living with mental health conditions related to their military service. For a variety of reasons, the majority of US veterans receive their health care outside the Veterans Administration or the military health system. Nurse leaders and citizen-soldiers were among a number of concerned government officials, health care professionals, service providers, and military leaders in New Hampshire (NH) who joined forces to explore NH veterans' mental health needs and manage provider service capacity. This article describes the formation and efforts of a permanent legislative commission, the NH Commission on PTSD and TBI (COPT), composed of interdisciplinary, multiorganizational, and cross-governmental leaders aligned to address the issues of stigma, military cultural awareness, and integration of care. Commission participants were asked to share their perspectives on the gaps and challenges to veterans' care, opportunities for collaboration, and measurable outcomes. Key challenges included interagency communication and care integration issues, veteran and provider knowledge gaps about needs and system problems. Favorable timing, available funding, and the collaborative environment of the commission were identified as potential opportunities. While still a work in progress, the COPT has begun making an impact. We identify early outcomes and lessons learned. The COPT is a model for leveraging interdisciplinary professional collaboration to improve access to care for veterans.

Going beyond patient classification systems to create an evidence-based staffing methodology.

The Department of Veterans Affairs developed a nationally standardized nurse staffing methodology, using an evidence-based process. We present an overview, linking an integrative review of recent literature on patient classification systems, interdisciplinary expert panel consultation, operational feasibility assessment, and frontline manager involvement. This resulted in 7 candidate indicators for inclusion in unit-specific staffing models. Adaptable to all healthcare settings, this process goes beyond traditional patient classification systems.

Predisposing characteristics, enabling resources and need as predictors of utilization and clinical outcomes for veterans receiving mental health services.

BACKGROUND: Though demand for mental health services (MHS) among US veterans is increasing, MHS utilization per veteran is decreasing. With health and social service needs competing for limited resources, it is important to understand the association between patient factors, MHS utilization, and clinical outcomes. OBJECTIVES: We use a framework based on Andersen's behavioral model of health service utilization to examine predisposing characteristics, enabling resources, and clinical need as predictors of MHS utilization and clinical outcomes. METHODS: This was a prospective observational study of veterans receiving inpatient or outpatient MHS through Veterans Administration programs. Clinician ratings (Global Assessment of Functioning [GAF]) and self-report assessments (Behavior and Symptom Identification Scale-24) were completed for 421 veterans at enrollment and 3 months later. Linear and logistic regression analyses were conducted to examine: (1) predisposing characteristics, enabling resources, and need as predictors of MHS inpatient, residential, and outpatient utilization and (2) the association between individual characteristics, utilization, and clinical outcomes. RESULTS: Being older, female, having greater clinical need, lack of enabling resources (employment, stable housing, and social support), and easy access to treatment significantly predicted greater MHS utilization at 3-month follow-up. Less clinical need and no inpatient psychiatric hospitalization predicted better GAF and Behavior and Symptom Identification Scale-24 scores. White race and residential treatment also predicted better GAF scores. Neither enabling resources, nor number of outpatient mental health visits predicted clinical outcomes. CONCLUSIONS: This application of Andersen's behavioral model of health service utilization confirmed associations between some predisposing characteristics, need, and enabling resources on MHS utilization but only predisposing characteristics, need, and utilization were associated with clinical outcomes.

Results of an integrative review of patient classification systems.

This chapter presents the findings of an integrative review of the literature to identify current practices related to patient classification systems (PCSs). We sought to determine if there was a "gold standard" PCS that could be adopted or adapted for use by nurse leaders in practice. Sixty-three articles reporting studies related to PCS, Patient Acuity Systems or Workload Management Systems from 1983 to 2010 and applicable for inpatient medical/surgical settings were reviewed. Generally, we found that many of the criticisms of earlier PCSs are still evident: (1) difficulties with measuring workload remain an overarching theme throughout the literature; (2) definitions and descriptions of nursing work continue to be deemed inadequate; (3) there is insufficient evidence of reliability and validity testing of PCSs; and (4) there is still a need to identify nursing sensitive performance indicators and outcomes. We identified characteristics of promising PCSs, but concluded that no consensus exists about PCSs. We suggest that any approach to predicting staffing should seek to be parsimonious, minimize additional workload, be based on expert nurse judgment, be a true reflection of nursing work, and include indicators that measure patient complexity, required nursing care, available resources, and relevant organizational attributes.

The culture of nursing engagement: a historical perspective.

Work engagement is key to organizational efforts to retain nurses and mitigate future nursing shortages. In their dual role as caregivers and organization "keepers," nurses may already have the key to creating a culture of engagement. The characteristics and benefits of "engaging" work environments are captured in nursing professional practice models, as evidenced by a quarter century of research on Magnet hospitals and professional practice. An inflection point, providing an opportunity for transformational change in the nursing work environment, may be generated by a critical need for nurses and a call for healthcare delivery system redesign. This article explores this opportunity for change by (1) examining history and nursing's deep roots in professional practice and its journey as an evolving profession and (2) mapping the growth of hospitals and the advancement of nursing's role in the United States, in the context of organizational theory. Finally, it examines the relationship and alignment of goals between the Institute of Medicine's call for system redesign and professional practice model elements, as the potential infrastructure for change. Focusing on the past and today provides us with a beginning framework from which to move expeditiously toward creating a culture of nursing engagement now.

Measuring the influence of professional nursing practice on global hospital performance in an organizational context.

The purpose of this study was to measure the influence of professional nursing practice (PNP) on global hospital performance (GHP). Evidence links PNP and positive outcomes for patients and nurses, however, little is known about PNP influence on GHP measures used for patient decision-making and hospital management resource allocation decisions. A quantitative study using multiple regression analysis to predict a composite measure of GHP was conducted. Two survey instruments measuring perspectives of the PNP environment were completed by 1815 (31.3%) Registered Nurses (RN) and 28 (100%) Senior Nurse Executives (SNE) at 28 northeastern US hospitals. Secondary data provided organizational attributes. The degree of PNP was consistently reported by RNs and SNEs. When regressed with organizational factors, PNP was not a significant predictor of GHP. Better GHP was associated with lower lengths of stay, lower profitability, less admission growth, and non-health system affiliation. Further research is needed to define a nursing-sensitive GHP measure.