Improving Client Outcomes Through Differentiated Practice: A Rural Nursing Center Model

The TriCounty Community Health Center (the Center) was created in 1994 with federal grant monies to increase access and to provide outreach and primary health care services for rural residents. The Center employs a differentiated practice model of nursing care in which all nurses use the nursing process targeted to client systems that match the nurse's level of educational preparation and competence. The model allows nurses to intervene with various client systems, including the individual, family, aggregate, and community. Program outcomes for the Center suggest that using a differentiated nursing practice model for outreach and primary care services appears to have a positive impact on the health of individuals, families, and aggregates in rural settings, using the Omaha Classification System as a framework for evaluation.     

Addressing spiritual leadership: an organizational model

The Joint Commission requires health systems to address spiritual care. Research indicates that spirituality is associated with better physical, psychological, and social health and that culturally diverse populations and individuals at end-of-life often request spiritual care. The authors report the results of a consensus conference of 21 executives representing 10 large faith-based health systems who discussed the input, process, and outcomes of a corporate model for spiritual leadership. Specific initiatives are highlighted.     

Regional health care systems: implications for health care reform

Not only should there be payment reform, but health care delivery should be redesigned to achieve the triple goals of access to services, quality improvement, and cost control. The authors review the forces that have formed multihospital and health care systems in the past, and the seven stages that health care systems traverse toward competency. They briefly discuss the implications of those realities for reform implementation. One premise is that the natural evolution of such health care systems toward competency will take a longer time than most nonproviders expect.     

Health promotion for seniors: what is over the horizon?

The health care industry is experiencing tremendous change in terms of health care delivery systems and fiscal pressure to provide high-quality health care at an affordable cost. A significant step forward in this change process will be the recognition of the value of comprehensive health promotion and disease prevention. The managed care model of health care is an excellent vehicle for a systematic health promotion program to flourish and succeed. This article surveys the literature on the topic of health promotion and its impact on the wellness of Medicare managed care beneficiaries and the senior population. The authors address issues, facilitators, benefits, and barriers within the context of health promotion and its potential to greatly impact both the quality and cost of health care for the rapidly growing senior population in the coming years.     

The impact of nursing care in Latin America and the Carihbean: a focus on outcomes1

A systems model is presented that has the potential to expand understanding of the complex nature of health-related outcomes The horizontal axis is a systems axis of context, process and outcome and the vertical axis consists of the client, provider and setting Examples from outcome research in Latin America and the Caribbean are provided Each section is explored from the perspective of primary health care research and some of the issues of design, measurement and analysis are raised The systems model is offered as a framework for conceptualizing research on the impact of nursing care on client, provider and setting outcomes     

Physicians' Preparedness for Bioterrorism and Other Public Health Priorities

Objectives Potential bioterrorism challenges policy makers to balance competing public health priorities. Earlier surveys showed low physician bioterrorism preparedness but did not assess physicians' general public health preparedness, compare the preparedness of emergency and primary care physicians, or assess temporal trends. Methods This was a national, cross‐sectional, random‐sample survey conducted in 2003. Results Overall, 744 of 1,200 eligible physicians responded (response rate, 62%). Of these, 58% of emergency physician respondents and 48% of primary care physician respondents reported having learned a lot about responding to bioterror since September 11, 2001 (p < 0.01). However, only 43% of emergency physicians and 21% of primary care physicians agreed they are generally “well prepared to play a role in responding to a bioterror attack” (p < 0.001). Beliefs about balancing public health priorities were similar among emergency and primary care respondents. Seventy‐eight percent of respondents believed that local health care systems need to be prepared for bioterrorism, and 92% believed that local health care systems need to be prepared for natural epidemics. By contrast, only 23% and 46% of respondents reported that their local health care systems are well prepared for bioterrorism and natural epidemics, respectively. Meanwhile, 77% agreed that “influenza is a greater threat to public health than bioterrorism,” and 21% reported that bioterrorism preparedness efforts are diverting resources from more important public health problems. Conclusions In 2003, most emergency and primary care physicians reported that they and their local health care systems were not yet well prepared to respond to a bioterror attack, and many believed that more resources should go toward preparing for natural epidemics. These findings highlight the importance of expanding bioterrorism preparedness efforts to improve the public health system more broadly.     

The impact of fluctuating relationships with the Canadian health care system on family management of otitis media with effusion

The analysis of data from a grounded theory study of family interaction when a child has otitis media with effusion (OME) shows that these families are engaged in the process of learning to manage. Their relationship with the health care system, coupled with the effects of the disease on the child and the family lifestyle, has a powerful influence on how this process proceeds. In this paper, the authors discuss the impact of the family's relationship with the Canadian health care system on the development of management skills. Relationships with the health care system fluctuate forward and backward through entrusting, becoming disillusioned, learning the rules and negotiating, as families learn to manage the effects of the disease process on the child and the family. The family perspective of the quality and availability of health care at a time when health care systems throughout the world are under close scrutiny, adds to our understanding of consumer expectations. Some recommendations for improving current relationships between families and the health care system are made.     

Health care relationships: the chronic illness perspective

Most explanations of the relationships between health care providers and health care recipients reflect perspectives and belief systems peculiar to health care professionals. In contrast, this study combined data from two separate qualitative investigations to yield an analysis of these relationships from the perspective of family members involved with chronic illness. Relationships between health care providers and health care recipients are viewed as evolving over time through a process which has identifiable stages. The utility of such a process orientation for nurses and other health care professionals is the insight it provides into the possibilities for negotiating satisfying care.     

Career planning and development for nurses: the time has come

Developments in how the nursing profession is perceived by nurses and by society, along with unparalleled changes in health care systems, have created an environment in which individual nurses must take control of their careers and futures. Educators, employers and professional organizations also have a key role to play in fostering the career planning and development of nurses, usually the largest employee group in most health care organizations. This article provides an overview of what career planning and development is and why it is important for nurses. A career planning and development model is described that provides nurses with a focused strategy to take greater responsibility for engaging in the ongoing planning process that is crucial throughout the major stages of their career. Finally, educators, employers and professional organizations are challenged to collaborate with individual nurses on career-development activities that will enable nurses to continue to provide high-quality care in ever-changing health care systems.     

Health-promoting nursing practice: the demise of the nursing process?

Health promotion is gaining widespread recognition throughout the world as the most efficacious practice in achieving health for all In Canada, the philosophy of health promotion is driving both federal and provincial health initiatives Such a philosophy is derived from a human science paradigm and is in direct opposition to the natural science paradigm from which the biomedical approach to health care emerged There now exists a tension between these contrasting paradigms as health care shifts to embrace a health-promotion perspective The nursing process is based in the natural science paradigm and on a biomedical approach to health care In order for nurses to embrace health promotion fully, they must move away from the philosophy of the natural sciences and adopt a human science perspective Such a shift requires a radical transformation in nursing practice as nurses move away from the'top-down'approach of the nursing process and adopt a'bottom-up'approach to health-promoting nursing practice The purpose of this paper is to compare and contrast the nursing process with the principles of health promotion, and to challenge our use of the nursing process in current nursing practice In particular, a framework for health-promoting nursing practice will be provided     

Integrating health care for women diagnosed with HIV infection, substance abuse, and mental illness in Detroit, Michigan.

This article describes the evolution of Personalized Nursing, a comprehensive nursing practice model of care. Findings from several nursing research studies contributed to the development of Personalized Nursing. The model includes a practice model of the art of nursing care based on nursing theory and a specific nursing process that directs nursing care delivery. The process of care delivery includes location of hard-to-reach clients; linkage to health care providers; integration of care among providers for clients diagnosed with HIV, mental illness, and substance abuse; and strategies to promote retention in health care. Use of Personalized Nursing is designed to assist clients to improve their well-being and increase positive health-related behaviors. Personalized Nursing has been used in urban landscapes to serve multiply diagnosed clients at risk for HIV infection. The model is currently being used in a study targeting multiply diagnosed women who are lost to follow-up from medical care.     

Models of care delivery in mental health nursing practice: a mixed method study

The aim of this study was to identify the conceptual models that underpin mental health nursing care in clinical settings. This study is a modification of a previous study which evaluated the influence of implicit models of mental disorder on processes of decision making within community-based teams. Participants completed questionnaires in response to a scenario. A range of explanatory conceptual models were identified in respect to aetiology, treatment and recovery. In a forced choice the participants ranked a medical model of care above other models as underpinning care delivery. The content analysis found that the participants used a psychodynamic framework for understanding the causes of mental distress but described the nursing interventions in terms of supporting a medical model of care. Nursing care is dominated by a medical model which constrains mental health nursing. This potentially creates tension between what nurses believe to be the problem and the responses available for nurses in their clinical setting. A range of psychosocial approaches to mental health care delivery have been developed, but there seems to be problems with their implementation in practice. Further research is required to explore how broader therapeutic interventions can be implemented by nurses within multidisciplinary systems of mental health care delivery.     

Primary Health Care and Public Health: Foundations of Universal Health Systems

The aim of this review is to advocate for more integrated and universally accessible health systems, built on a foundation of primary health care and public health. The perspective outlined identified health systems as the frame of reference, clarified terminology and examined complementary perspectives on health. It explored the prospects for universal and integrated health systems from a global perspective, the role of healthy public policy in achieving population health and the value of the social-ecological model in guiding how best to align the components of an integrated health service. The importance of an ethical private sector in partnership with the public sector is recognized. Most health systems around the world, still heavily focused on illness, are doing relatively little to optimize health and minimize illness burdens, especially for vulnerable groups. This failure to improve the underlying conditions for health is compounded by insufficient allocation of resources to address priority needs with equity (universality, accessibility and affordability). Finally, public health and primary health care are the cornerstones of sustainable health systems, and this should be reflected in the health policies and professional education systems of all nations wishing to achieve a health system that is effective, equitable, efficient and affordable.Key Words: Health systems, Primary health care, Public health, Universality, Program integration, Social-ecological model, Professional education, Policy, Planning, Human resources     

Developing standards for an integrated approach to workplace facilitation for interprofessional teams in health and social care contexts: a Delphi study

Integration of health and social care forms part of health and social care policy in many countries worldwide in response to changing health and social care needs. The World Health Organization’s appeal for systems to manage the global epidemiologic transition advocates for provision of care that crosses boundaries between primary, community, hospital, and social care. However, the focus on structural and process changes has not yielded the full benefit of expected advances in care delivery. Facilitating practice in the workplace is a widely recognised cornerstone for developments in the delivery of health and social care as collaborative and inclusive relationships enable frontline staff to develop effective workplace cultures that influence whether transformational change is achieved and maintained. Workplace facilitation embraces a number of different purposes which may not independently lead to better quality of care or improved patient outcomes. Holistic workplace facilitation of learning, development, and improvement supports the integration remit across health and social care systems and avoids duplication of effort and waste of valuable resources. To date, no standards to guide the quality and effectiveness of integrated facilitation have been published. This study aimed to identify key elements constitute standards for an integrated approach to facilitating work-based learning, development, improvement, inquiry, knowledge translation, and innovation in health and social care contexts using a three rounds Delphi survey of facilitation experts from 10 countries. Consensus about priority elements was determined in the final round, following an iteration process that involved modifications to validate content. The findings helped to identify key qualities and skills facilitators need to support interprofessional teams to flourish and optimise performance. Further research could evaluate the impact of skilled integrated facilitation on health and social care outcomes and the well-being of frontline interprofessional teams.     

CA8-01: Can the HMORN Transform Itself into a Learning Health Care Network?

Background/Aims The national case for learning healthcare systems was made in a 2006 Institute of Medicine (IOM) workshop. The IOM's vision was healthcare systems where "the process of generating and applying the best evidence will be natural and seamless components of the process of care itself." HMORN members have the potential to model this future, but few of them have yet achieved the necessary levels of integration with their affiliated care and insurance organizations and none fulfill the IOM vision. The Mental Health Research Network (MHRN) proposes to build such integrated relationships with each of its partner organizations and knit them together into a learning healthcare network for mental health in hopes of becoming a model for a future HMORN learning network. Methods Phase I: a lead at each MHRN research group identifies appropriate leaders among their organizational partners and builds bidirectional relationships while identifying their mental health improvement priorities, researchable problems, and questions. Phase II: these new partnerships are formalized through periodic meetings and small projects while developing partnership grant proposals that address operational leaders' priorities. Phase III: we demonstrate the seamless generation and application of evidence within each organization desired by the IOM. Phase IV: we collaborate across MHRN members as a learning network and a template for the HMORN to become a learning healthcare network. Results We are just beginning, building the relationships and trust that will turn into more formal structures in Phase II and shared projects and studies. Each site has a person to coordinate this effort and a list of important mental health affiliated leadership positions. The level of partnership varies from regular meetings at some sites to just beginning conversations at others. This presentation will quantify our progress, describe barriers encountered, and provide concrete examples. Discussion MHRN and HMORN have an opportunity to be leaders in transforming health care by organizing and modeling learning through strategic bidirectional partnerships. If anyone can achieve the IOM vision, it should be us, but the path is unclear and the cultural and historical barriers are many.     

Care transitions: integrating transition theory and complexity science concepts

Care transitions, defined as hospital discharge or movement from one health care setting to another, are currently a major concern of health care providers and policy makers. Extensive empirical research has been conducted on care transitions, but the theoretical foundations are rarely made explicit. We propose that integrating concepts on complex adaptive systems from complexity science with classic theory on transitions in nursing provides a powerful new lens through which to study care transitions and improve transition outcomes. We summarize concepts from both theoretical approaches, propose an expanded model of transitions, and apply the model to the transition from hospital to home.     

A nurse coach quality improvement intervention: feasibility and treatment fidelity

As the U.S. population ages and chronic illness prevalence increases, new approaches to care are needed. Although large health systems have begun to respond to this challenge, most Americans seek care from practitioners functioning in small office settings. Implementing systematic sustainable changes for quality improvement in this setting remains an unresolved challenge. In this study, trained Nurse Coaches (NCs) were employed to assist practices in adopting a new model of patient care called Virtual Integrated Practice (VIP). The feasibility and treatment fidelity of this approach were assessed through process measures and interviews in three practices. Findings document high acceptance of the NC approach and consistent delivery of the intervention. Enactment of the VIP model took place across practices, although to a variable degree. The study suggests that NCs may be an effective delivery method for quality and organizational improvements in small primary care practices.     

Point of View Managed Outcomes: A Strategy to Improve the Nation's Health

Current health care delivery systems in the United States have led to high cost, uneven quality, less than universal coverage, undue emphasis on a medical/clinical model, and scant attention to primary care and prevention. In the context of health care reform, a new strategy is introduced that reverses present trends and incentives, called managed outcomes. This strategy is not specific to any particular health care delivery system. Managed outcomes encourages experimentation and flexibility in the design of health care systems and fosters primary care, health promotion, and disease prevention models. It links purchasing decisions to established specific and measurable goals that can provide quality and cost-effective services to improve health.     

CALM©:: A Customized Advanced Leader Model for Enhancing Career and Well-Being

Advanced nurse leader roles are key to the transformation of health care systems. In today’s challenging health care environments, there is a need for leaders to focus their development on the current and future role skill sets for success. This Customized Advanced Leader Model (CALM) provides a practical guide for leadership development and personal well-being. The model is based on identification of current and future role competencies, encourages reflective inquiry, and provides a process for the development of a customized plan that can be updated for each career stage or job change.