Changing Health Care Environment Research Articles

Empowering Nurses with an Online Roadmap for Evidence-Based Practice

ABSTRACT Nurses are involved in an increasingly complex and changing health care environment. To be effective, nurses must have the skills to effectively engage in evidence-based practice (EBP) to improve patient care. In preparing for Magnet reaccreditation, an interdisciplinary team in one academic medical center recognized that there was variability in nurses’ understanding of the EBP process. This left nurses hesitant to engage in the process and resulted in the uneven quality of EBP project outputs. This article details a project lead by a health sciences librarian in collaboration with nurses to create and implement an online resource and reshape EBP instruction. This project aimed to increase the EBP knowledge of bedside nurses, increase overall nurse engagement with EBP, and bring uniformity to the EBP activities of nurses in the organization. The implementation plan, evaluation, and next steps for this project are shared to show the key role health sciences librarians can play in improving EBP in a health care organization.

Compassion Fatigue in Nurses Caring for Medically Complex Children.

The number of children living with chronic, complex medical needs is steadily increasing secondary to advances in clinical technology and disease management. As a result, patient care requirements become multifaceted with the need for specific therapies and treatments that require extensive knowledge and skills. As these children are managed throughout the health care continuum, nurses are challenged to offer specialized care for complex conditions, while meeting the personnel and financial demands of the changing health care environment. It is well established that medically complex children can put a burden on family life, resulting in compassion fatigue for nonclinical caregivers. It is possible that, secondary to frequent and lengthy hospitalizations, nurses may also be affected. Therefore, a review of compassion fatigue or professional burnout in nurses caring for medically complex children was conducted. Appropriate identification of nurses at risk for compassion fatigue is imperative to provide the necessary interventions and support. Reducing compassion fatigue is likely to improve outcomes, including nursing turnover, nursing professional engagement, and job satisfaction, thus improving the care delivery experience for children with complex conditions.

The Brody School of Medicine at East Carolina University.

The Brody School of Medicine at East Carolina University.

Geisinger Commonwealth School of Medicine.

Geisinger Commonwealth School of Medicine.

Cardiology in the COVID-19 Era - The Changing Paradigms

Coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has attained the distinction of a global pandemic, aff ecting more than 185 countries. The impact of COVID-19 in the practice of cardiology extends beyond the clinical Cardiovascular (CV) manifestations of the disease. Many treatment modalities used in the treatment of COVID-19 have direct or indirect eff ects on the CV system. Management of CV disease in patients with proven or suspected COVID-19 infection warrants modifi cation of existing practices and guidelines so as to suit the changed health care environment. The safety of health care personnel becomes an important consideration in the setting of this highly contagious pandemic. Furthermore, long-term cardiovascular consequences of COVID-19 need to be determined for appropriate follow-up of patients recovering from the infection. We review the data available till date on the various aspects of the impact of COVID-19 on the heart and the practice of cardiology.

Reinforcing Telehealth Competence Through Nurse Practitioner Student Clinical Experiences.

Telehealth is becoming increasingly integral in providing improved access to care, especially for patients who reside in frontier and rural areas. Nurse practitioner (NP) faculty are charged with preparing NP students through curriculum and clinical experiences that align with the health care environment and the health care access needs of the populations they serve. To meet this need, NP faculty at a land-grant university located in a frontier and rural midwestern state reinforced NP student telehealth curriculum and competency through application in a clinical environment. Participants included 22 family NP (FNP) students and 19 clinical preceptors. According to the evaluations, the FNP students met seven of the eight competency criteria, and the preceptors met eight of the 13 evaluation criteria. Outcomes indicate telehealth curriculum competency can be reinforced through application in a clinical setting to prepare NP students to meet the needs of patients and changing health care environments. [J Nurs Educ. 2020;59(7):413-417.].

Implementing a New Capstone Leadership Clinical Course.

Nurse educators are challenged to ensure clinical education meets the changing health care environments and needs. New nurses remain unprepared for practice, have insufficient foundational leadership capacities, and lack systems-thinking awareness. Responding to educational gaps, increased enrollment, and scarce clinical placements, faculty used an eclectic education model to develop a new capstone leadership clinical course that included 5 types of experiences. The total acute care clinical hours were reduced, while adding leadership-focused experiences and simulated learning. Stakeholders' evaluations indicate the pilot provided opportunities to strengthen students' leadership capacity, systems thinking, and professional identity while still providing sufficient practice managing care of multiple patients, engaging in teamwork, and applying evidence. The new clinical course addressed students' transition into practice needs and enrollment capacity issues. Thoughtful planning by invested stakeholders, communication among faculty, and clear expectations are necessary to implement eclectic clinical models.

Assessment of Leadership Knowledge and Practice among Nurse Managers

Background: Leadership has become an important aspect of management practice in the changing health care environment. Globally, leadership has important implications for all stakeholders in healthcare disciplines with responsibility for maintaining high standards of care. Aim: This study aimed at assessing the leadership knowledge and practice among nurse managers. Design: Descriptive research design was used. Setting: This study conducted at Aswan University Hospital. Subjects: Total study subjects included 40 nurse managers. Tools of data collection: two data collection tools were used namely; nurse manager‟s knowledge questionnaire sheet and leadership practice scale. Results: The lowest leadership knowledge and practice level was found among nurse managers. Conclusion: Nurse Managers had satisfactory low level of total leadership knowledge. Recommendations: Establishing more leadership development programs. Creating different strategies for promotion based on competences and performance.

Exploring the needs and experiences of educators in facilitating use of the Bass Model of Holistic Reflection

Health professionals are required to reflect on practice to evaluate and improve care in rapidly changing health care environments. This study explored the professional development needs of educators facilitating development of reflective capacity in midwifery students using the Bass Model of Holistic Reflection. Thirteen midwifery academics at two Australian universities took part in the study conducted in three phases. Phase 1 identified the learning needs of educators described as ‘understanding the building blocks of reflection’; ‘practical application of the model, and ‘assessment of reflective capacity’. Phase 2 involved an Intervention including development of a reflective practice tool kit and delivery of a two-day workshop. Phase 3 evaluated the experience of educators using the resources and four themes emerged: 1) ‘Educators value a reflective practice toolkit’; 2) ‘A toolkit builds confidence and trust in the model through promotion of deep personal reflection’; 3) ‘Effective use of the model is key to achieving consistency in application by educators; and 4) ‘Deeper understanding of the model promotes transformation of practice’. This paper confirms the importance of developing resources for educators, that support reflective pedagogy when implementing models of reflection into curricula.

Leading Innovative Practice: Leadership Attributes in LEAP Practices.

Over the past several decades, health care in the United States has undergone substantial and rapid change. At the heart of this change is an assumption that a more robust primary care infrastructure helps achieve the quadruple aim of improved care, better patient experience, reduced cost, and improved work life of health care providers. Practice-level leadership is essential to succeed in this rapidly changing environment. Complex adaptive systems theory offers a lens for understanding important leadership attributes. A review of the literature on leadership from a complex adaptive system perspective identified nine leadership attributes hypothesized to support practice change: motivating others to engage in change, managing abuse of power and social influence, assuring psychological safety, enhancing communication and information sharing, generating a learning organization, instilling a collective mind, cultivating teamwork, fostering emergent leaders, and encouraging boundary spanning. Through a secondary qualitative analysis, we applied these attributes to nine practices ranking high on both a practice learning and leadership scale from the Learning from Effective Ambulatory Practice (LEAP) project to see if and how these attributes manifest in high-performing innovative practices. We found all nine attributes identified from the literature were evident and seemed important during a time of change and innovation. We identified two additional attributes-anticipating the future and developing formal processes-that we found to be important. Complexity science suggests a hypothesized developmental model in which some attributes are foundational and necessary for the emergence of others. Successful primary care practices exhibit a diversity of strong local leadership attributes. To meet the realities of a rapidly changing health care environment, training of current and future primary care leaders needs to be more comprehensive and move beyond motivating others and developing effective teams.

Community pharmacists expand point-of-care testing

Point-of-care testing (POCT) in pharmacies has grown from A1C and cholesterol screenings to testing for infectious diseases such as hepatitis C virus. POCT by pharmacists for influenza and streptococcal pharyngitis infection has been especially well received, along with the ability of pharmacists in certain states to dispense needed medications when those tests come back positive. Because of ease of access, the community pharmacy is an ideal choice to provide this service. An example of how POCT can be implemented in the community pharmacy is demonstrated by eTrueNorth. This Texas-based company has partnered with numerous community pharmacies to help expand clinical services through Clinical Laboratory Improvement Amendments (CLIA)–waived POCT, wellness screenings, and preventive health services. The cofounders—Michael McEntee, a clinical laboratory professional, and Coral May, a registered nurse with health plan experience—used their vision of leveraging the most accessible health professional, pharmacists, to provide clinical services for patients. “Pharmacists’ education, training, and clinical knowledge are invaluable assets, and when combined with patient access, makes them uniquely positioned to meet the needs of a changing health care environment,” said May. POCT assays are waived under CLIA of 1988, and pharmacists who offer POCT must register with CMS as a CLIA-waived laboratory. More than 120 tests are considered CLIA waived. “CLIA-waived POCT allows pharmacists to provide patients with clinical information on the efficacy of their medications (e.g. statins, antihypertensives) as well as screening for undiagnosed conditions,” May added. The model is twofold. The first part focuses on working with pharmacy partners to help them establish CLIA-waived laboratories within the pharmacy. The second part focuses on contracting with organizations whose employees can benefit from clinical services provided in a pharmacy setting. Establishment within the pharmacy setting requires meeting regulatory compliance with national, state, and county (in California) requirements. May noted that her company provides guidance on the application process for a CLIA Certificate of Waiver, state laboratory license (if required), laboratory director requirements, and testing personnel requirements. “CLIA-waived POCT allows pharmacists to provide patients with clinical information on the efficacy of their medications as well as screening for undiagnosed conditions.” In addition, training is provided on all aspects of waived testing, from analyzer use to quality control requirements. Pharmacists have access to support via telephone from trained laboratory professionals if a question should arise while working in the pharmacy. Numerous organizations have partnered with eTrueNorth to offer their employees an alternative site for wellness screening. It is estimated that approximately 35% of eligible employees are unable to participate in a screening offered at their employer location and seek alternative testing sites. An organization’s employees can enter their zip code on the eTrueNorth website to search for participating pharmacies in their area that provide the list of services they need, such as a lipid profile, glucose, and administration of flu shots or common vaccines. After selecting their preferred location, the patient receives a voucher with details on the location they selected and any pretest instructions. The voucher allows for convenient access and payment to a pharmacy providing services. Upon completion and documentation of the services, eTrueNorth bills the organization and reimburses the pharmacy partner for services provided. This model eliminates many of a pharmacy’s billing and reimbursement challenges. In the second half of 2020, eTrueNoth expects to launch programs to health plan members who have gaps in their recommendations for evidence-based care. For example, a plan member who has diabetes may not have had an A1C test to monitor their glycemic control or may need to have a dilated retinal exam to screen for retinopathy. “Working with the health plan and pharmacy partners, we’re able to catch the patient at the pharmacy counter and provide services to meet their needs,” said May. By working with the payer, the plan can improve the patient’s quality scores, provide the patient’s physician with information for clinical follow-up, and strengthen the role of the pharmacist as a critical member of the health care team. Expanded clinical services in the retail setting allow conversations between pharmacists and patients to be further enhanced by focusing on all aspects of health, from preventive medicine to medication adherence to improved clinical outcomes.

Comparing Opinions on Meaningful Recognition: Do Views of Trauma Nursing Leaders and Staff Align?

With increased demand for registered nurses (RN), due to increasing shortage and turnover rate, the role of meaningful recognition becomes of paramount importance. We hypothesized that RNs and leaders value forms of recognition differently, due to generational gap and changing health care environment. This study included 46 RN/support staff (RN/SS group) and 10 nurse leaders (leaders group) from a Level 1 trauma center. Mean values from 5-point Likert scale survey on 31 forms of recognition (grouped into 6 categories) and demographics (age, nursing experience, and gender) were compared. All participants were separated into groups: 35 years of age and younger (millennials; n = 29) and older than 35 years (Gen X/boomers; n = 27). Majority of RN/SS were 26-35 years of age (43.5%) and 50.0% had less than 3 years of nursing experience. Half of the leaders were 36-45 years of age (p = .01 vs. RN/SS), and 70.0% had 16 years of experience or greater (p = .001). There was 9:1 female-to-male ratio in both groups (p = .8). The RN/SS rated "salary increase" highest and leaders rated "celebration for years of service" highest (both means: 4.4). When categorized, "monetary rewards" ranked highest both by RN/SS and leaders (means: 4.4 and 4.1). Overall, there was no statistically significant difference between mean values. The Gen X/boomers rated statistically significantly higher 9 forms and 3 categories (written/public acknowledgment and private verbal feedback) than millennials. Mean values for forms/categories of recognition were lower for RN/SS than for leaders, but differences were not statistical. Age drove the most difference in most meaningful forms, as preference for monetary rewards stems from the younger generations' focus on work-life balance.

THE MAKING OF A PHYSICIAN: A PERSON-CENTERED APPROACH

The subject “The Making of a Physician: A Person-Centered Approach” is important today because of the current changing health care environment, where the practice of medicine is being increasingly influenced by growth in science, technology, high cost, rising expectations of the people, and other powerful market forces emerging from the globalization process, which have put medical practice at cross roads. The essence of medicine lies in the therapeutic relationship between the doctor and the patient and our attitude to our patients. It is the person in totality that we are interested in both in health and disease. In reality, the relief of suffering and the cure of a person must be seen as twin obligations of the profession, and true dedication to the cure of the sick. The cure of disease is influenced by our scientific knowledge and growth of science, while the relief of suffering is guided by our compassion to the patient and sharing of patients’ suffering and feelings.

Patients' Experiences With a Digital Primary Health Care Concept Using Written Dialogues: A Pilot Study.

Background: The changing health care environment promotes the adoption of new information technologies to connect patients and health care providers. However, individuals greatly vary in their ability to use new digital systems, and in their feelings regarding integrity and validation. Caregivers in southern Sweden plan to implement a new digital primary health care (DPHC) service, and patients’ experiences must be studied to guide the best possible implementation of this service. Purpose: To examine the patients’ experiences with DPHC using written dialogues. Method: Patients were consecutively recruited from June 2018 to April 2019. This prospective pilot study used questionnaires with fixed response options, summarized as index values (IV, 0-1.0) in the following domains: communication, technical functionality, and general experience of DPHC. Results: Participants included 286 patients with a mean age of 40 ± 15 years. The response rate was 49% (n = 140), including 40 men (29%) and 100 women (71%). Communication using DPHC was experienced as fairly good (IV, 0.58), technical functionality was experienced as good (IV, 0.80), and the general experience of DPHC was positive with an IV of 0.76. The overall experience of the concept (IV, 0.71), corresponds to a median satisfaction value of 8.0 (interquartile range, 6-9). The patients felt well-prepared and experienced reasonable time aspects. Of the responding patients, 81% would recommend DPHC to others, and a notable reason for satisfaction was availability. However, patients expressed some uncertainty regarding the physician’s ability to assess correct care needs. Conclusion: The patients in our pilot study described their satisfaction and expressed good experiences with the concept of DPHC using written dialogues.

Paulinian Nurses in Clinical Practice as Blueprint towards Development of Paulinian Nurses’ Residency Program

New nursing graduates are expected to adapt well in the changing health care environment especially having gone through ASEAN standardization and a shift to outcomes-based education, this study sought to describe the lived experiences of Paulinian Nurse in the Clinical Practice to develop a blueprint for new Paulinian nurses that will enable to facilitate their entry into the health care industry. Fifteen Paulinian nurses from batches 2013 to 2017 were interviewed to surface their initial clinical experiences as they transitioned from nursing students to staff nurses. After a textual analysis integrated within a descriptive phenomenological research design, the study revealed four (4) themes and nine (9) subthemes. The themes were crossing the roughest road, acclimatizing in the midst of transition, echoing Paulinian Education in the workplace and finding one’s niche in the clinical nursing. Voices of clinical instructors were cross-referenced with said themes prior to the development of blueprint which was presented to three Nursing Administrators. Concluding to present this study is the Pre Post Graduate Residency Blueprint towards development of Paulinian Nurse Residency Program, which starts with Clinical Intensive Program, Post-Graduate Clinical Preparatory Seminar-Workshop, On-boarding Clinical Transition Program finally reaching to their destination, being the Paulinian Professional Nurse.

Formal leadership training for orthopedic surgeons: Limited opportunities amongst growing demand.

Leadership skills are important to all orthopedic surgeons, regardless of practice or location, as interactions with patients, staff, and other physicians necessitate professionalism and leadership. Leadership skills are best developed through formal training and experiential opportunities. Several programs emphasizing leadership skills for orthopedic surgeons exist; however, the number of programs is not adequate to meet the demand. It is difficult for orthopedic surgeons to take advantage of these opportunities, given clinical and professional responsibilities. To appropriately adapt to the changing healthcare environment and ensure advancement of the orthopedic field, formal leadership skills development should be widely integrated into orthopedic training.

Understanding primary care-oncology relationships within a changing healthcare environment

BackgroundManagement of care transitions from primary care into and out of oncology is critical for optimal care of cancer patients and cancer survivors. There is limited understanding of existing primary care-oncology relationships within the context of the changing health care environment.MethodsThrough a comparative case study of 14 innovative primary care practices throughout the United States (U.S.), we examined relationships between primary care and oncology settings to identify attributes contributing to strengthened relationships in diverse settings. Field researchers observed practices for 10–12 days, recording fieldnotes and conducting interviews. We created a reduced dataset of all text related to primary care-oncology relationships, and collaboratively identified patterns to characterize these relationships through an inductive “immersion/crystallization” analysis process.ResultsNine of the 14 practices discussed having either formal or informal primary care-oncology relationships. Nearly all formal primary care-oncology relationships were embedded within healthcare systems. The majority of private, independent practices had more informal relationships between individual primary care physicians and specific oncologists. Practices with formal relationships noted health system infrastructure that facilitates transfer of patient information and timely referrals. Practices with informal relationships described shared commitment, trust, and rapport with specific oncologists. Regardless of relationship type, challenges reported by primary care settings included lack of clarity about roles and responsibilities during cancer treatment and beyond.ConclusionsWith the rapid transformation of U.S. healthcare towards system ownership of primary care practices, efforts are needed to integrate strengths of informal primary care-oncology relationships in addition to formal system driven relationships.

Value-Based Care for Musculoskeletal Pain: Are Physical Therapists Ready to Deliver?

Early physical therapy models hold great promise for delivering high-value care for individuals with musculoskeletal pain. However, existing physical therapist practice and research standards are misaligned with value-based principles, which limits the potential for growth and sustainability of these models. This Perspective describes how the value proposition of early physical therapy can be improved by redefining harm, embracing a prognostic approach to clinical decision making, and advocating for system-wide guideline-adherent pain care. It also outlines the need to adopt a common language to describe these models and embrace new, rigorous study designs and analytical approaches to better understand where and how early physical therapy delivers value. The goal is to define a clear path forward to ensure physical therapists are aligned within health care systems to deliver on the American Physical Therapy Association's vision of high-value care in a rapidly changing health care environment.

Nurse Practitioner Job Satisfaction and the Healthy Work Environment.

Nurse Practitioner Job Satisfaction and the Healthy Work Environment.

Laboratory Test Utilization in an Expanding Regional Laboratory Network: Past Successes and Future Opportunities

Abstract Introduction The University of Rochester Medical Center developed a reference test utilization program implemented in 2011 to tackle increasing test volumes and costs. There was an initial >7,000 decrease in test volumes, which equated to >$1,000,000.00 in savings by year end 2012. Despite this, by the end of 2018, testing volumes had increased 34% and the cost had climbed 36%. Here we would like to discuss the methods implemented for initial success, potential reasons for continued increases in volumes and costs, and ideas to mitigate this trend in the future. Methods In 2010, the University of Rochester formed a laboratory diagnostics committee, which successfully decreased reference testing volumes and costs in both the inpatient and outpatient settings. They did this by developing a formulary for reference tests, which was divided into three tiers based on clinical utility and cost: tier 1 tests, unrestricted and available to all providers to order; tier 2 tests, restricted with only board-certified, subspecialty-trained physicians able to order; and tier 3 tests, off formulary and not available to order. The resident physician staff was also no longer allowed to order any reference testing on inpatients. Despite initial gains costs and volumes have climbed >36% and 34%, respectively, since implementation. Possible explanations for this include the addition of regional affiliate hospitals and reference clients that are not following these protocols, increased testing volumes, and increasing use of molecular testing. Conclusion Despite successful implementation of a reference test utilization program, close monitoring and adaptations are necessary in our continuously changing health care environment to remain effective. Implementation of the program at the regional affiliate hospitals and a more robust molecular testing menu in-house are potential options to control rising costs while providing high-quality patient care.