Alliance not compliance: coaching strategies to improve type 2 diabetes outcomes

PURPOSE: To explore strategies for improving patient outcomes in type 2 diabetes. DATA SOURCES: The literature related to type 2 diabetes management, behavior change, communication, diabetes self-management, and coaching. CONCLUSIONS: The strategies currently suggested for improving patient outcomes, e.g., increasing provider adherence to evidence-based management guidelines, streamlining practice systems, and promoting patient lifestyle changes through intensive education, have produced mixed outcomes. Of the many complexities involved in managing type 2 diabetes, motivating patients to change behavior may be the most challenging. A suggestion for improving patient self-management of type 2 diabetes is to use coaching communication within a framework of behavior change in the context of the primary care encounter between nurse practitioners (NPs) and their patients. IMPLICATIONS FOR PRACTICE: Given the varied outcomes of current strategies, coaching by NPs may provide a feasible alternative for improving patient outcomes in type 2 diabetes. Coaching communication can be implemented during office visits as an intervention without cost. To effectively implement this approach, however, practicing NPs and NP students need more formal education in this expected but underdeveloped NP role competency. NPs are called upon to contribute to the body of knowledge needed to validate the merits of coaching for their patients.     

Promoting nurse practitioner practice through research: opportunities, challenges, and lessons

PURPOSE: To discuss the opportunities derived, challenges faced, and lessons learned in the research process, including recruiting and retaining nurse practitioner (NP) participants, obtaining institutional approval, and solving research team issues in a National Institutes of Health/National Institute of Nursing Research (NIH/NINR)-funded study of communication between NPs and their older patients in managed care and non-managed care settings. DATA SOURCES: The video-taped interactions between 30 NPs and 150 patients, research team experiences in conducting the research, and a review of relevant literature. CONCLUSIONS: Key factors in NP study participation included recognizing the importance of research in demonstrating the effectiveness of the NP role and for advancing the profession, having participated in previous research, enjoying the research process, employer incentives, membership in NP professional organizations, relationships with the university and the school of nursing conducting the research, and knowledge of the coinvestigator's work. NP recruitment was facilitated by word of mouth, professional organization assistance, and articles in a widely distributed, free nursing journal. Data collection was significantly delayed by attrition of NP participants, logistical problems with scheduling and travel, and varied approval procedures by Institutional Review Boards (IRBs) at study sites. The pace of nursing research could be much more efficient if IRB processes involved fewer bureaucratic entanglements. Preliminary study findings, however, show positive outcomes for older patients after NP care. IMPLICATIONS FOR PRACTICE: To demonstrate positive patient outcomes and move the NP profession forward, NPs must be willing to commit to participation in research on their effectiveness as providers in today's healthcare environment.     

Intensive care nurse practitioners in Australia: A description of a service model in an adult tertiary intensive care unit

BackgroundAlthough well-established internationally, nurse practitioners (NPs) in Australian adult intensive care units (ICUs) are rare. Australian literature clearly highlights the importance of creating ICU NP roles to meet emerging demands. An ICU NP model of care at a metropolitan hospital in Sydney provides care in four core practice areas: complex case management, vascular access, tracheostomy management, and intrahospital transport of critically ill patients. The ICU NPs also provide training and assessment for ICU nurses and medical officers in these same core practice areas and can efficiently meet service gaps in crisis such as the most recent COVID-19 pandemic.ResultsThe ICU NP program described is an innovative model of care that has demonstrated potential benefits to patients and their families. Potential benefits to the healthcare system including supporting advanced practice nursing development in regional and rural Australia and in addressing future ICU workforce issues are also identified. This model of care provides a clear role and structure for the integration of NPs in the adult ICU. Research to evaluate the impact of the role is required and is underway.ConclusionsThis model is being used to develop a national adult ICU NP fellowship training program for ICU transitional NPs preparing for endorsement or endorsed NPs who require additional ICU-specific training. This immersive clinical training program combined with didactic learning modules offers a framework to support the implementation of the adult ICU NP role as well as a framework for NP fellowship programs in other specialties.     

Conflict coaching training for nurse managers: a case study of a two-hospital health system

brinkert r . (2011) Journal of Nursing Management 19, 80–91
Conflict coaching training for nurse managers: a case study of a two-hospital health system Aim This study evaluated the application of the Comprehensive Conflict Coaching model in a hospital environment. Background Conflict coaching involves a coach working with a client to improve the client’s conflict understanding, interaction strategies and/or interaction skills. The training of nurse managers as conflict coaches is an innovative continuing education programme that partially addresses conflict-related concerns in nursing. Method Twenty nurse managers trained as conflict coaches and each coached a supervisee. Qualitative data were gathered from nurse managers, supervisees and senior nursing leaders over an 8-month period and organized using standard programme evaluation themes. Results Benefits included supervisor conflict coaching competency and enhanced conflict communication competency for nurse managers and supervisees facing specific conflict situations. Challenges included the management of programme tensions. Additional benefits and challenges are discussed, along with study limitations. Conclusion Conflict coaching was a practical and effective means of developing the conflict communication competencies of nurse managers and supervisees. Additional research is needed. Implications for nursing management Conflict is common in nursing. Conflict coaching is a new conflict communication and supervision intervention that demonstrates initial promise. Conflict coaching seems to work best when supported by a positive conflict culture and integrated with other conflict intervention processes.     

Clinical Coaching – An innovative role to improve marginal nursing students' clinical practice

In order for undergraduate nursing students to demonstrate their ability to achieve the required level of competency with practice they must be able to integrate both the clinical skills and knowledge that are pivotal to safe and competent nursing practice. In response to ongoing concerns about students' level of competency expressed by the supervising clinical staff, one School of Nursing and Midwifery created a Clinical Coach (CC) role. The purpose of this paper is to present the data collected including outcomes achieved and the coaching strategies used when a CC role was implemented to support and develop nursing practice for the marginal performer or ‘at risk’ student. A literature review of the application of coaching to nursing, a detailed analysis and discussion of the outcomes identified from auditing of collected data and the specific coaching strategies that resulted in successful outcomes for students is presented. This model of Clinical Coaching for nursing students could readily be adopted by other Schools of Nursing and Midwifery. This account of the regime of coaching practices may also offer a transferable, adaptable and flexible approach for other health professions who require their undergraduate students to complete clinical placements in preparation for professional practice.     

Coaching patients to self-care: a primary responsibility of nursing

Aim.  To explore the process nurses use to guide and support patients to actively re-establish self-care.
Background.  The movement of hospitalized patients from less to more independence is primarily a nursing responsibility. Studies of nursing practice in inpatient rehabilitation settings have begun to shed some light on this, but as yet there is limited understanding of the actual skills nurses use to support patients to re-establish self-care.
Method.  This study used grounded theory. Microanalysis and constant comparative analysis of data collected during interviews with, and observation of, registered and enrolled nurses during everyday nursing practice in five inpatient rehabilitation units facilitated open, axial and selective coding. Relevant literature was woven into the final theory.
Findings.  To facilitate patient transition from the role of acute care patient to rehabilitation patient actively reclaiming self-care, nurses engaged in a three-phase process known as coaching patients to self-care. The three phases were: easing patients into rehabilitation, maximizing patient effort and providing graduated assistance.
Conclusion.  Coaching patients to self-care is a primary activity and technology of rehabilitation nursing.
Relevance to clinical practice.  Patients in a variety of settings would benefit from nurses incorporating coaching skills into their nurse–patient interactions.     

Challenges of outcomes research for nurse practitioners

PURPOSE: To describe the numerous methodological challenges nurse practitioners (NPs) face in designing and conducting outcomes research and provide practical tips to implement an outcomes study within an institution. DATA SOURCES: Review of world wide scientific literature on outcomes research. CONCLUSIONS: Nurse practitioners must be aware of the challenges of conducting outcomes research. Challenges associated with variable definition, designing outcomes studies, use of data sets, and instrument development and selection must be understood prior to undertaking an outcome study. IMPLICATIONS FOR PRACTICE: Valuable studies have laid a foundation for evidence of quality care provision by NPs. Now is the time to measure patient outcomes of the NP care longitudinally over significant periods of time.     

Nurse practitioners and managed care: patient satisfaction and intention to adhere to nurse practitioner plan of care

PURPOSE: To explore patient satisfaction, intention to adhere to nurse practitioner (NP) plan of care, and the impact of managed care on NPs' patients in multiple settings, the final phase of a three-part study of NPs and managed care. DATA SOURCES: Postvisit questionnaires and narrative comments about patient satisfaction with NP communication, overall satisfaction with visit, recall of plan of care, intention to adhere to NP's recommendations, and impact of managed care on ease of obtaining healthcare resources. CONCLUSIONS: Patients were very satisfied with NP communication and with their healthcare visit. They mostly intended to adhere to the NP-recommended plan of care but less so to recommended lifestyle changes. Patients trusted their NPs, valued their expertise, were confident in the NPs' care, and believed that the NPs considered their best interests. They appreciated that the NPs took time to listen to their concerns and helped them to obtain healthcare resources. Most patients were not greatly impacted by managed care and obtained needed healthcare resources with little difficulty. IMPLICATIONS FOR PRACTICE: Although the first two phases of this study found that many NPs had strong negative attitudes toward managed care, these attitudes were not conveyed toward patients in this sample. NPs, however, will continue to face new challenges as third-party payers attempt to reduce healthcare costs, further testing NP adaptability and resourcefulness.     

Family satisfaction with care provided by nurse practitioners to nursing home residents with dementia at the end of life

The purpose of this study was to examine family satisfaction with care provided by nurse practitioners (NP) to nursing home (NH) residents with dementia. A survey was mailed to 239 family members of nursing home residents who died with dementia. One open-ended question was added to provide comment about the care provided by the NP. A total of 131 surveys were returned (response rate 55%). The study revealed that 98% of family members agreed that they were satisfied with the end-of-life care provided by the NP. Survey responses were used to analyze the associations of communication, comfort, and satisfaction with NPs to total satisfaction with end-of-life care. Pearson's correlations demonstrated that overall satisfaction was significantly associated with NP-family communication, resident comfort, and satisfaction with NP care. Findings suggested that NPs using a model of care that emphasizes advance care planning, communication, and comfort results in high satisfaction of family members.     

Budd-Chiari syndrome from an advanced practice nurse perspective

PURPOSE: To provide nurse practitioners (NPs) with a case study and literature review of Budd-Chiari syndrome (BCS). This rare liver disease has a multitude of clinical presentations that NPs may encounter in the primary care setting. DATA SOURCE: A literature search was conducted in Pub-Med and CINAHL using key search words. Information for the case study was obtained from a patient and his gastroenterology specialist, who is a foremost expert in this field. CONCLUSION: BCS is complex and may be difficult to diagnose because of its atypical clinical presentation. Delayed diagnosis can affect the quality and quantity of a patient's life. Increasing NPs' awareness about this rare condition through a case presentation and review of the literature emphasizes the major factors for accurate diagnosis. IMPLICATIONS FOR PRACTICE: Knowledge of BCS can assist the NP in identifying this syndrome and making prompt, appropriate referrals.     

Reconceptualizing the core of nurse practitioner education and practice

Purpose: The movement to the doctor of nursing practice (DNP) is progressing rapidly with new programs emerging and curricular documents being developed. We argue that the implementation of the DNP is a good move for nursing, provided that we use the opportunity to reconceptualize the core of advanced practice nursing, especially nurse practitioner (NP) practice.
Data sources: Theory and research articles from nursing focused on advanced practice nursing, NPs, and doctoral education.
Conclusions: The foundation of NP education is currently based essentially on borrowed or shared content in assessment, pharmacology, and pathophysiology. We argue that the heart and soul of nursing is in health promotion, both in healthy persons and in those dealing with chronic illness. Current master's programs do not prepare NPs to assume high-level practice focused on health promotion and disease management using the latest theoretical developments in health behavior change, behavioral sciences, exercise physiology, nutrition, and medical anthropology. Although these are touched upon in most NP programs, they do not represent the core science of NP education and need to be a critical part of any DNP program.
Implications for practice: Ultimately, our vision is for NP care to be consistently "different," yet just as essential as physician care, leading to positive outcomes in health promotion and disease management.     

Strategies to promote the professional transition of new graduate nurse practitioners: A systematic review

New graduate nurse practitioner (NP) postgraduate support programs and interventions have proliferated, sparking controversy. The Institute of Medicine/National Academy of Medicine recommends residency programs for new graduate NPs; however, the NP community debates whether new graduate NPs need additional training and whether such training compromises patient access to care. This systematic review aimed to synthesize evidence regarding the effectiveness of interventions and strategies to promote the professional transition of new graduate NPs. Interventions identified in the current literature included fellowship programs and a webinar. Strategies included mentorship, experiential learning, interprofessional training, and professional socialization. The studies reviewed primarily evaluated NPs’ perceptions of the interventions’ effects on their professional transitions. The findings from this systematic review highlight challenges in evidencing postgraduate support programs. The small number of available studies underscores a critical problem for the NP community: additional evidence is needed to inform whether and how to support new graduate NPs as they transition to practice.     

DNP preparation of primary care nurse practitioners and clinical outcomes for patients with chronic conditions

BackgroundMany professional nursing organizations have proposed that the Doctor of Nursing Practice (DNP) is the most appropriate entry-level degree for nurse practitioners (NPs). There have been no studies to date examining the impact of DNP preparation on quality of care or patient outcomes.PurposeTo examine differences in emergency department utilization and hospitalizations among patients with chronic conditions cared for by Master of Science in Nursing (MSN)- and DNP-prepared primary care NPs.MethodsWe use survey data from over 1,000 primary care NPs in 6 states linked to Medicare claims data. Using regression models, we controlled for various patient, NP, and practice characteristics that might confound the relationship.ResulsWe find that patient outcomes are not statistically different between patients attributed to MSN- and DNP-prepared primary care NPs.DiscussionThese findings suggest that there remains little evidence that DNP education has led to significant improvements in patient outcomes.ConclusionsFurther empirical analysis related to the clinical outcomes other than health care utilization of the DNP degree is warranted. Future studies might consider examining (a) NPs in settings other than primary care, (b) practice-wide or system-wide outcomes, (c) other measures of care quality, and (d) impact of DNP program content.     

EverCare nurse practitioner practice activities: similarities and differences across five sites

PURPOSE: To examine the similarities and differences in the performance and frequency of performance of EverCare nurse practitioner (NP) practice activities at demonstration sites in five states. This study builds upon a previous study in which the development and testing of the EverCare Nurse Practitioner Role and Activity Scale (ENPRAS) was conducted. DATA SOURCES: A Background Data Sheet and the ENPRAS, a 99-item tool that encompasses six role subscales-Collaborator, Clinician, Care Manager/Coordinator, Counselor, Communicator/Cheerleader, and Coach/Educator, were completed by 127 EverCare NPs at demonstration sites in five states (Georgia, Maryland, Massachusetts, Colorado, and Florida). CONCLUSIONS: Performance of NP activities across the demonstration sites in five states was generally consistent, with significant differences only in the amount of time spent on activities associated with the Collaborator and Coach/Educator roles. Overall, EverCare NPs spent more time on Clinician and Communicator/Cheerleader role activities than on activities associated with the other roles. EverCare NP patient caseload was positively related to frequency of performance of the Clinician and Care Manager/Coordinator roles. IMPLICATIONS FOR PRACTICE: EverCare NPs provide proactive primary care to long-stay nursing home residents. The observed consistency reflects a strong centrally directed practice model. The identified roles and activities of the EverCare NP are consistent with previous studies and reports focused on the roles and activities of NPs who provide care to nursing home residents in other models of care delivery. Policy makers, healthcare providers, and the public should take these findings into account when considering a national model of care for this population. Future studies should examine the effect of variations in performance of activities on resident-specific and setting-specific outcomes.     

Prevention in the inpatient setting

PURPOSE: To review the literature on and describe approaches to implementing health promotion and disease prevention practices in the inpatient setting. DATA SOURCES: Comprehensive review of nursing and medical literature, clinical practice guidelines, and U.S. government documents. CONCLUSIONS: Preventive screening has been shown to reduce morbidity and mortality from many diseases. Health promotion and disease prevention activities form the foundation of practice for many nurse practitioners (NPs). As increasing numbers of NPs begin to practice in the acute care setting, it is important they incorporate prevention into the inpatient setting. IMPLICATIONS FOR PRACTICE: Because there are many barriers that impact appropriate preventive screening, health care providers must take advantage of every patient encounter including those in the inpatient setting. Although it may not be feasible to actually perform certain screening exams while a patient is hospitalized, it is feasible in many cases to take a few minutes to review recommended preventive screening.