Educational implications of nurse practitioner students and medical residents' attitudes toward managed care.

The increasing number of individuals enrolled in managed care organizations is a key consideration when planning effective models of education for future health care professionals. This study compares attitudes toward managed care between medical residents (MRs) (n = 431) and advanced practice nursing students (APNSs) (n = 153) in a Midwestern U.S. state, and it reports the results of a factor analysis of the attitude survey. MRs and APNSs completed a 34-item questionnaire. Results show that MRs were more likely than APNSs to believe that cost has priority over quality of care in a managed care setting and that managed care threatens the autonomy of health care providers. APNS were more likely than MRs to believe that managed care encourages preventive health care. Other comparisons related to Medicaid, capitation, practice guidelines, and success factors are discussed. Findings indicate that MRs were more inclined to see managed care as an economic threat to quality of care than APNSs. At the same time, MRs were somewhat less enthusiastic about practice guidelines and patient outcomes as measures of success in managed care settings than APNSs. Educational implications of findings are discussed.     

The influence of managed care on U.S. baccalaureate nursing education programs

The transformation of health care into managed care has raised many issues and concerns for nurse educators. The milieu in which nurses currently practice reflects the restructuring shaped by managed care principles. The shift from acute care to expanded community services has changed the way health care is provided within hospital settings. The organization of nursing programs has been affected by this shift, and the ramifications of these external forces on curriculum structure have altered the way nursing students are educated. This article presents research demonstrating the changes in the structure of the curricula for baccalaureate nursing education in 2001, which were caused by health care reform in effect since 1994.     

Integrating Spirituality into Nurse Practitioner Practice: The Importance of Finding the Time

Is it possible to find the time to incorporate spirituality into nurse practitioner (NP) practice in time-driven managed care? This article reviews how medical schools are increasingly adding spirituality into their curricula, although NP programs and literature may be deficient in the area of spirituality Caring concepts and books on nursing and spirituality are reviewed. Stranahan cites that less than 50% of NPs interviewed incorporate spirituality into practice. Practical suggestions are given to NPs to add spirituality care into their practice and recognize how they can enhance spiritual care by the use of spiritual assessment scales.     

The collaborative nursing care plan: integration of the clinical pathway with the traditional nursing care plan

The nursing care plan is a commonly used teaching tool in nursing education. By developing individualized nursing care plans for specific clients, students practice use of nursing process and making clinical judgments and decisions. However, the system of managed care has impacted current clinical practice, and many health care agencies have shifted their emphasis from requiring the traditional columnar nursing care plans to use of clinical pathways and standards of care. As result of this trend, nursing educators are faced with the problem of preparing students to cope with today's reality in clinical practice. In response to this problem, this article reexamines the practical utility of the traditional nursing care plan in nursing education. The article also introduces a collaborative nursing care plan, the integration of the clinical pathway with the traditional nursing care plan, and its application in teaching.     

Evidence-based nursing: a change dynamic in a managed care system

The emerging evidence‐based decision‐making phenomenon represents a new opportunity for nursing professionals. This opportunity arises because managed care brings about a new motivation to incorporate existing evidence and research skill into the health care delivery process. In order to participate fully in managed care systems nursing research must be uncompromising in its focus on the characteristics of the client group, the processes of intervention and the outcomes of intervention. It is argued that evidence‐based nursing, as a process, needs to consider three questions. How do we know what practice needs to be changed? How do we enable this change in practice? and how do we ensure that change brings about no further harm? The greatest danger in the process of identification and prioritizing by a group is the bias that can occur because of conscious and unconscious habits associated with power relationships within groups. Nominal Group and Delphi techniques are suggested to alleviate this. Action research is proposed as a method of dealing with, the critical issue of risk management.     

The Development and Implementation of a Population-Based Intervention Model for Public Health Nursing Practice

Mandatory enrollment of Medicaid recipients into managed care organizations (MCOs) in 1994 resulted in a major reduction in primary medical care provided by the Peninsula Health District (PHD) in southeastern Virginia. This article describes how the PHD responded proactively by changing from a predominantly primary care clinic practice to a population-based public health practice and changed the role of public health nursing. A participatory planning process involving all PHD employees carefully defined this new direction over several years. As public health care resources were redirected into preventive programs to serve the health needs of the entire community rather then the individual, a new intervention model evolved. The intervention model became the framework for program planning and implementation and has now been in use by the PHD for 3 years. The planning process used by the PHD to devise a population-based intervention model is described in this article.     

Influence of Managed Care on Professional Nursing Practice

To explore how nurses in one U.S. state perceived that managed care influenced professional nursing in that state. The nursing community is challenged to move with haste in demonstrating, through research, the clinical and economic value that nurses add to cost-effective outcomes.

Design:

A Delphi survey in 1996 of a convenience sample of 84 clinical nurse specialists (CNSs) and nurse practitioners (NPs) in California.

Methods:

CNSs and NPs contributed to the list of managed care influences on nursing practice. Fifty-seven (68%) completed the third and final round.

Findings:

Panelist agreement was the highest for (a) exploring new approaches to providing quality care more cost-effectively, (b) expanding nurse practitioners' rote in primary care, and (c) more effectively partnering with clients in helping them assume greater self-responsibility for their health. Greatest threats were perceived to be hassles involved in seeking authorization for care and responding to payment denials; the tenuous job market for nurses; and encroachment on nursing practice by others.

Conclusions:

The findings can assist nurses in states with low managed-care concentration to create their preferred future within health care delivery. A more highly educated nurse workforce will be needed for 21st century health systems in which more care is likely to be delivered outside hospitals.     

An innovative professional nursing practice model.

Nursing, as with health care delivery, is changing to meet the greater challenges brought about by managed care and the accompanying external forces in the marketplace. Nurses, with their vast resources of knowledge and experience, are crucial in achieving optimal quality care. Given the opportunity to redefine and strengthen the impact of nursing practice at Piedmont Medical Center in Atlanta, Georgia, a group of advanced practice nurses began developing a unique practice model. The resulting Professional Nursing Practice Model--a theoretical framework created for nurses by nurses--presents a common vision of human beings, health, and nursing in accordance with the values and beliefs of nursing. This model demonstrates the importance of a person-centered, value-driven nursing practice across the continuum of health from birth to death.     

Shaping advanced nursing practice in the new millennium

OBJECTIVES: To provide a review of converging themes and trends that are shaping advanced practice nursing roles in oncology nursing. DATA SOURCES: Review and research articles, text-books, and organization documents. CONCLUSIONS: The current managed care environment provides many opportunities and challenges for oncology advanced practice nurses. Advanced practice nurses have both clinical and organization competencies that enable them to mediate the clinical needs of patients and organization goals within the health care system. IMPLICATIONS FOR NURSING PRACTICE: Advanced practice nurses can help shape their roles and practice by active participation in the development of systems to support access to clinical and financial information for effective decision making, collaboration among disciplines, and incorporating evidence-based care in their clinical practices.     

Surviving managed care: the effect on job satisfaction in hospital-based nursing.

Major changes brought about by managed care have redefined the nursing profession. Current trends such as case management, downsizing, restructuring of the workforce, and changes in the patient profile have had numerous effects, particularly on job satisfaction among hospital-based nurses. Strategies to improve job satisfaction during this era of increased managed care penetration include enhanced communication mechanisms, support from hospital administration, implementation of care models that promote professional nursing practice, adequate staffing, and competitive salaries and benefits.     

Application of King's theory of goal attainment and the Carondelet St. Mary's case management model

The promulgation of managed care has become the catalyst for nursing leaders to creatively develop new approaches for the effective and efficient utilization of resources. The transition into a capitated environment has heightened the need for theory-based practice to new levels. The application of King's theory of goal attainment and the Carondelet St. Mary's case management model offers hope for a practical approach to the actualization of discipline development.     

PSYCHIATRIC-MENTAL HEALTH NURSING AT THE INTERFACE: REVISIONING EDUCATION FOR THE SPECIALTY

In the emerging health care environment, families and communities are facing a broad range of conditions that require more integrated views of wellness and illness, mind and body, and the biomedical and the behavioral. This also calls for an enhanced care delivery system. Three interfacing areas of practice have particular significance for the psychiatric-mental health nursing workforce: enhanced primary care, public health or population-focused health interventions, and managed care. This paper addresses the broad range of knowledge, skills, and competencies that are required for the future of advanced practice psychiatric-mental health nursing and describes interactive learning experiences and new pedagogies to deliver them.     

Psychiatric-mental health nursing at the interface: revisioning education for the specialty

In the emerging health care environment, families and communities are facing a broad range of conditions that require more integrated views of wellness and illness, mind and body, and the biomedical and the behavioral. This also calls for an enhanced care delivery system. Three interfacing areas of practice have particular significance for the psychiatric-mental health nursing workforce: enhanced primary care, public health or population-focused health interventions, and managed care. This paper addresses the broad range of knowledge, skills, and competencies that are required for the future of advanced practice psychiatric-mental health nursing and describes interactive learning experiences and new pedagogies to deliver them.     

Enabling care: working through obscurity and uncertainty a basic social process used in selected acute care settings.

Using grounded theory methodology this study explored the process that nurses used to determine, deliver, and communicate patient care in acute care hospital settings and to assess whether or not this was congruent with the nursing process structure (O'Connell, 1998). Data were obtained from semi-structured interviews, participant field observations and in-depth audits of patient records. Textual data were managed using NUD*IST and analysed using the constant comparative method. The findings of this study revealed a number of factors that hindered nurses from using the nursing process in its current form. Instead, nurses used a basic social process termed: Enabling Care: Working through obscurity and uncertainty. This paper describes a basic social process used in selected acute care settings and discusses its implications for nursing practice. An understanding of this process will assist the profession to critique some nursing theories and to construct ideas of nursing practice based on current clinical realities.     

Shifting patterns of practice: nurse practitioners in a managed care environment

The purpose of this qualitative study was to uncover patterns across nurse practitioner (NP) experiences that contribute to understanding their perceptions of managed care, how it affects daily practice, and how NPs respond to a changing managed care workplace. In-depth interviews were conducted with 14 NPs representing primary care, specialty, and independent practices. Over an 18-month period, data collection and analysis occurred simultaneously using standard methods of purposive sampling, constant comparison, memoing, and member checks. This study illuminates the tension NPs experience between a business and a professional ethic and the strategies they use to reconcile this difference with core nursing values. Type of setting, workplace dynamics, and length of time in practice contributed to variation in NP perspectives.     

A nurse-managed inpatient program for patients with chronic mental disorders

The deinstitutionalization movement has left a legacy of need for appropriate care for inpatients with chronic refractory mental illness. This article describes a nurse managed program for such patients based on the principles of a therapeutic milieu. The program was formally defined for a 6-month period with an effort to include outcome measures for program evaluation. Multidisciplinary treatment team planning with a psychiatric nursing clinical specialist as team leader provided a format for putting therapeutic concepts into practice. The nurse clinical specialist and two nurse practitioners served as case managers as well as primary care providers. Program evaluation showed that cost-effective quality care could be achieved with a reduction in polypharmacy and overall neuroleptic usage. The notion of a restraint appropriate environment, with the goal of minimizing restraint use, was introduced and put into practice.     

Communication. Improving RNs' organizational and professional identification in managed care hospitals

Nurse administrators are searching for an expanded repertoire of strategies to attract and retain qualified nursing staff in today's managed care environment. This study examined hospital registered nurses' interpretations of managed care and the effects of those views on nurses' identification with their employing organization and the nursing profession. Findings show that nurses held greater identification with their occupation than their organization. Significant factors influencing nurses' attachment to both of these reference groups included uncertainty about managed care changes, information received about managed care changes, and effects of managed care on the nursing role. Communication principles and strategies are presented to nurse leaders for use in fostering a stronger organizational affiliation among staff nurses while maintaining a strong identification with the nursing profession.     

What to do when the end is near: ethical issues in home health care nursing

As managed care shortens the length of hospital stays, home settings for the practice of nursing will become increasingly important. In spite of community health nursing's long tradition of family-centered care delivered in the home, many discussions of the nurse/patient relationship in the medical ethics literature assume the hospital setting for the practice of nursing and seem to neglect the impact of family and significant others for the nurse/patient relationship. Through a case-based analysis, this article highlights the special ethical and legal issues encountered in caring for patients who are dying at home. This analysis demonstrates that traditional frameworks for the nurse/patient relationship are inadequate for capturing the richness of the relationship the home health care nurse has with both patient and family. By developing a new framework for the nurse/patient/family relationship that (a) recognizes the patient's decision-making authority and autonomy, (b) allows the exercise of the nurse's moral rights, and (c) recognizes the patient's relationships to significant others, the authors attempt to resolve some challenging legal and ethical questions concerning who should be allowed to decide what to do when the end is near. The discussion details the implications of this framework for nursing assessment in the home care setting.