The impact of interprofessional collaboration on the effectiveness, significance, and future of advanced practice registered nurses

Interprofessional collaboration was essential for the conduct of research that demonstrated the effectiveness and significance of advanced practice registered nurses (APRNs) in providing care, in reducing health care costs, and in developing innovative models of care for the nation's citizens. If the 2010 Affordable Care Act is to be implemented, APRNs, with their expertise and numbers, are essential to its implementation. Continued interdisciplinary collaboration is needed to expand the scope of APRN state practice regulations, to change reimbursement for APRN services, and to mute opposition to these changes by medical organizations.

Outcomes of an asthma program: Healthy Children, Healthy Homes

PURPOSE

To test the effects of the Healthy Children Healthy Homes program on community perception of susceptibility and severity of asthma, knowledge of common household asthma triggers, misconceptions about asthma, and reported behaviors to control asthma triggers.

DESIGN

Quasi experimental study with pre-post survey conducted in English and Spanish.

LOCATION

Catholic elementary school community in northern Miami, Florida. SELECTION AND SAMPLE: Convenience sample of 15 Asthma Amigo participants, and pre-post survey sample of 100 parents, teachers, and school staff.

INTERVENTION

Program consists of two 90-minute educational sessions with Asthma Amigos, 8-week diffusion of asthma information in the community, educational sessions with 276 school children (grades 1 to 8), and an asthma fair.

FINDINGS

Compared to pre-intervention, post-intervention data indicated significantly greater perceived asthma susceptibility and knowledge about common household triggers and fewer asthma misconceptions.

CONCLUSIONS

Healthy Children Healthy Homes program can be a valuable tool in asthma prevention and management.

The experience of being an Asthma Amigo in a program to decrease asthma episodes in Hispanic children

Asthma is the most common chronic illness among Latino children in urban areas. It is especially problematic for schools serving low-income and minority populations. The purpose of this study was to describe the experience of being an Asthma Amigo, a community-based educator who delivered asthma education to a Hispanic community in a train-the-trainer educational model. Focus group process evaluation was used to assess participant experiences and program strengths and weaknesses. Findings suggested that being an Asthma Amigo helped in gaining entrée into the community and in spreading the message of asthma triggers and prevention.

Women with high-risk pregnancies, problems, and APN interventions

PURPOSE

To (a) describe women's prenatal and postpartum problems and advanced practice nurses (APN) interventions; and (b) determine if problems and APN interventions differed by women's medical diagnosis (diabetes, hypertension, preterm labor).

DESIGN AND METHODS

Content analysis of 85 interaction logs created by APNs during a randomized clinical trial in which half of physician-provided prenatal care was substituted with APN-provided prenatal care in the women's homes. Patients' problems and APN interventions were classified with the Omaha Classification System.

FINDINGS

A total of 212,835 health problems and 212,835 APN interventions were identified. The dominant antenatal problems were physiologic (59.2%) and health-related behaviors (33.3%); postpartum were physiologic (44.0%) and psychosocial problems (31.6%). Antenatally, women with diabetes had significantly more health-related behavior problems; women with preterm labor had more physiologic problems. APN surveillance interventions predominated antenatally (65.6%) and postpartum (66.0%), followed by health teaching, guidance, and counseling both antenatally (25.4%) and postpartum (28.1%). Women with chronic hypertension required significantly more case-management interventions.

CONCLUSIONS

The categories of women's problems were largely similar across medical diagnostic groups. Interventions to address women's problems ranged from assessing maternal and fetal physiologic states to teaching interpersonal relationships and self-care management to assisting with transportation and housing. Data show the range of APN knowledge and skills needed to improve maternal and infant outcomes and ultimately reduce healthcare costs in women with high-risk pregnancies.

Psychometric Properties of Spanish Versions of the FACES II and Dyadic Adjustment Scale

Although Hispanic Americans are one of the fastest growing ethnic populations in the United States, use and psychometric testing of Spanish versions of two instruments commonly used to measure quality of the couple’s relationship and family functioning, the Dyadic Adjustment Scale (DAS) and the FACES II, have not been reported. The purpose of this study was to test the psychometric properties of the newly translated Spanish version of these two instruments. In this bilingual sample of 78 adults, internal consistencies were acceptable (.72 to .77 for the FACES II; .67 to .93 for the DAS) and test-retest correlations were high (.80 to .88 FACES II; .79 to .87 DAS). Correlations between the Spanish and English versions were also high (.87 to .94 FACES II; .91 to .99 DAS). Psychometric findings support the reliability and validity of the Spanish versions of these newly translated measures.

Pediatric head trauma: parent, parent-child, and family functioning 2 weeks after hospital discharge

OBJECTIVE

To investigate effects of pediatric head trauma on parent mental health, parent-child relationship and family functioning 2 weeks after discharge.

METHODS

Ninety-seven mothers and 37 fathers of 106 preschool children hospitalized with head injury completed Mental Health Inventory (MHI), Parenting Stress Index, Family Adaptability and Cohesion Evaluation Scales II (FACES II) and Multidimensional Scale of Perceived Social Support (MSPSS) 2 weeks after discharge, and perceived injury severity, Parental Concerns Scale (PCS), Parental Stressors Scale: Pediatric Intensive Care Unit (PSS: PICU), and MHI 24-48 h after hospital admission.

RESULTS

Mental health after discharge was related to social support and baseline mental health. Mothers' parental distress was related to perceived injury severity and social support. Greater family cohesion was related to baseline mental health, social support, and being in a two-parent family for mothers, and to social support for fathers.

CONCLUSIONS

Parents' mental health and social support were important for parent mental health and family cohesion after discharge. Perceived injury severity and parent reactions to hospitalization also played a role.

Nurse Dose as a Concept

PURPOSE

To describe the concept of Nurse Dose.

METHODS

The concept of nurse dose has been identified from decades of clinical research as a concept essential in the delivery of safe and high quality health care. The components of nurse dose were conceptualized through review of the literature from nursing, medicine, and health services research.

FINDINGS

Nurse dose is conceptualized as having three equally essential components: dose, nurse, and host and host response. Dose in the macro view includes the number of nurses per patient or per population in cities, states, regions, or countries. Dose in a micro view includes the amount of nurse time and the number of contacts. The nurse component consists of the education, expertise, and experience of the nurse. Host is represented by an organization and its characteristics (culture, autonomy, practice control) in a macro view and by the patient and characteristics (beliefs, values, culture) in a micro view. Host response includes response to the autonomy and acceptability of the nurse.

CONCLUSIONS

Greater nurse dose has been associated with decreases in patient mortality, morbidity, and healthcare costs.

Cross-cultural beliefs, ceremonies, and rituals surrounding death of a loved one

The purpose of this qualitative study was to describe practices surrounding death of a loved one by European, Asian, Caribbean, Central American, and South American families living in the United States. A focus group with 14 masters nursing students from a wide variety of cultural and religious backgrounds was conducted to gain a better understanding of the beliefs, ceremonies, and rituals surrounding death. Many commonalties were found across cultures and religions. A pervasive theme was that beliefs about the soul of the deceased lead families to perform rituals and ceremonies that foster passage to God, the "light," or another life. The stronger their beliefs, the more dedicated the family is in completing the rituals and ceremonies in the way dictated by their religion or culture. Participants had difficulty separating the influence of culture and religion on these practices.

Parents' reactions at 24-48 hrs after a preschool child's head injury

OBJECTIVES

Our objectives were, first, to compare mothers' and fathers' early reactions (stressors, concerns) to the preschool child's head injury, their perceptions of the child's injury severity, and their social support and mental health; second, to compare families with a child in the pediatric intensive care unit (PICU) vs. general care unit (GCU) on these variables; and third, to describe the relationships between parents' early reactions and perceived and objective injury severity, their social support, and mental health.

DESIGN

Analysis of data collected in the hospital 24-48 hrs after the child's admission as part of a longitudinal study of parent and family functioning after a preschool child's head injury.

SETTING

Seven tertiary care centers: three free-standing children's hospitals and four comprehensive hospitals.

PARTICIPANTS

Participants were 182 mothers and 64 fathers of 183 preschool children (ages 3-6) hospitalized for head injury, half in a PICU.

INTERVENTIONS

Data collection.

MEASUREMENTS AND MAIN RESULTS

We measured parents' early reactions (stressors, concerns), influenced by parent mental health, social support, and objective and perceived injury severity. Mothers reported more stress than fathers regarding the child's behavior and emotions, communication with staff, and their parental role. Mothers in the PICU group reported more concern about the child's future and more stress regarding the child's appearance, sights and sounds of the unit, and procedures done to the child than mothers in the GCU group. Fathers in the PICU and GCU groups reported similar levels of stress and concern. Mothers' reactions were influenced by objective and perceived injury severity, social support, and psychological distress. Fathers' reactions were influenced by objective injury severity and psychological distress.

CONCLUSIONS

Although mother-father couples rated their child's injury severity similarly, mothers experienced more stress than fathers. Social support decreased the stress for mothers but not for fathers. The experience of pediatric head trauma was more stressful for mothers of children in the PICU than mothers of children in the GCU.

Child care use by low-income single mothers of preschoolers born preterm versus those of preschoolers born full term

This study describes prewelfare reform child care use by 64 primarily low-income single mothers (65.6% African American) with preschoolers (half born preterm). Forty percent used child care for more than 75% of their children's lives, 20% did when not employed. Preschool children born preterm were more likely to receive child care from nonrelatives throughout their lives than children born full term. Children with health problems used a greater number of child care arrangements. Findings suggest addressing child care issues with both employed and nonemployed mothers and adequacy of child care for children with special needs.

The cost of prematurity: hospital charges at birth and frequency of rehospitalizations and acute care visits over the first year of life: a comparison by gestational age and birth weight

The proportion of preterm and low-birth-weight infants has been growing steadily for two decades. Most of the more than US 10 billion dollars spent on neonatal care in the United States in 2003 was spent on the 12.3% of infants who were born preterm. Research has shown higher initial hospital costs and a higher rate of acute care visits and rehospitalization for preterm and low-birth-weight infants, but only a limited number of studies of the cost of prematurity that follow infants through the first year of life have been conducted. This study is a secondary analysis of data on a subset of infants drawn from a randomized clinical trial that examined health outcomes and health care costs in women with high-risk pregnancies and their infants. For the current study, a sample of 84 singleton infants was chosen. Forty-three infants (51%) were full term (37 weeks' gestation or more) and 41 (49%) were born preterm (less than 37 weeks' gestation). Fifty-five infants (65.5%) were born at normal birth weights (2,500 g or greater), 24 (28.5%) were born at low birth weights (1,501 to 2,499 g), and five (6%) were born at very low birth weights (less than 1,500 g). Data on the initial hospital charges and the rates of rehospitalization and acute care visits in the first year of life in relation to gestational age and birth weight were collected. The results clearly demonstrated that the charges for initial hospitalizations increased as birth weights and gestational ages decreased. Low-birth-weight infants were less likely to have unscheduled acute care visits than normal-birth-weight infants. Interventions to improve prenatal care targeted to women at high risk for delivering preterm or low-birth-weight infants would reduce health care costs and improve health outcomes of infants as well.

A Comparison of Maternal Attachment between American Adolescent and Adult Mothers of Preschoolers

American adolescent mothers have been viewed as less effective parents than adult mothers. The socioeconomic disadvantages of adolescent mothers should be taken into account. The objectives of this study were to compare maternal attachment between adolescent and adult mothers of preschoolers and to examine changes of adolescents' maternal attachment over time. A secondary analysis of data from a larger study of maternal employment and low birth weight infant outcomes were used. Data were collected through home visits using structured questionnaires at two different time points. Forty-three pairs of adolescent and adult mothers who could be matched on family structure, maternal race, and child's gestational status were compared on maternal attachment. The 7-item Attachment subscale of the Parenting Stress Index was used to measure maternal attachment. Results revealed that the adolescent mothers were not less attached to their preschoolers than the adults. This held true when important confounding factors were taken into account using multiple regression.

South Florida: a national microcosm of diversity and health disparities

South Florida is a microcosm of diversity that reflects a changing national population. The purpose of this paper is to examine some common health status indicators in the four counties that comprise South Florida. The researchers look at birthweight, neonatal and infant death rates, receipt of prenatal care, major causes of death, availability of health care facilities and services, and expenditures for health. Data indicate that, of the four counties, the most affluent has the worst health indicators, and the least affluent--with the highest proportion of minority residents--has some of the best health status indicators. The researchers provide implications for practitioners and future research.

Patient problems, advanced practice nurse (APN) interventions, time and contacts among five patient groups

PURPOSE

To describe patient problems and APN interventions in each of five clinical trials and to establish links among patient problems, APN interventions, APN time and number of contacts, patient outcomes, and health care costs.

DESIGN AND METHODS

Analysis of 333 interaction logs created by APNs during five randomized controlled trials: (a) very low birthweight infants (n = 39); (b) women with unplanned cesarean birth (n = 61), (c) high-risk pregnancy (n = 44), and (d) hysterectomy (n = 53); and (e) elders with cardiac medical and surgical diagnoses (n = 139). Logs containing recordings of all APN interactions with participants, APN time and type of patient contact were content analyzed with the smallest phrase or sentence representing a "unit." These units were then classified using the Omaha Classification System to determine patient problems and APN interventions. Groups were compared concerning total amount of APN time, number of contacts per patient, and mean length of time per APN contact. All studies were conducted in the United States.

FINDINGS

Groups with greater mean APN time and contacts per patient had greater improvements in patients' outcomes and greater health care cost savings. Of the 150,131 APN interventions, surveillance was the predominant APN function in all five patient groups. Health teaching, guidance, and counseling was the second most frequent category of APN intervention in four of the five groups. In all five groups, treatments and procedures accounted for < 1% of total APN interventions. Distribution of patient problems (N = 150,131) differed across groups reflecting the health care problems common to the group.

CONCLUSIONS

Dose of APN time and contacts makes a difference in improving patient outcomes and reducing health care costs. Skills needed by APNs in providing transitional care include well-developed skills in assessing, teaching, counseling, communicating, collaborating, knowing health behaviors, negotiating systems, and having condition-specific knowledge about different patient problems.

High-risk pregnancy: postpartum rehospitalization

OBJECTIVE

Examine frequency, timing, and reasons for maternal postpartum rehospitalizations and acute care visits 1 year postpartum after a high-risk pregnancy.

STUDY DESIGN

Secondary analysis of data collected during a randomized clinical trial of advanced practice nurses gives transitional care for women with high-risk pregnancies. The 171 women were primarily African American, never married, Medicaid eligible, diagnosed with pregestational diabetes (20), gestational diabetes (23), either diagnosed (48) or at risk (44) for preterm labor, and chronic hypertension (36).

RESULTS

Of the total rehospitalizations (17%) and acute care visits (32%), over one third occurred in the first 8 weeks postpartum. Chronic hypertensives and gestational diabetics had the highest rate of rehospitalization and proportion of acute care visits. Six women were rehospitalized for subsequent pregnancies.

CONCLUSION

Women with high-risk pregnancies have continued high health care resource use over the first postpartum year demonstrating the need for more intensive patient education and follow-up to improve outcomes and reduce resource use.

Institutional research responsibilities and needed infrastructure

PURPOSE

To describe research grantee institutions' responsibilities to the funding agencies, research participants, and investigators, and the infrastructure and resources necessary for successful completion of funded research projects.

ORGANIZING FRAMEWORK

Grants management includes investigator access to institutional and school infrastructure and resources, oversight and monitoring of the implementation of the research, and strategies to maximize research yield while stretching research dollars.

CONCLUSIONS

Grantee institutions are responsible for overseeing the conduct of research, protecting rights of research participants, safety of study personnel, monitoring conflict of interest, fiscal management, access to data, and disseminating study findings. Central and school departments that provide needed services are important infrastructure supports. In addition to research space and investigator time, senior research mentors and research administrators are the most valuable resources for research success.

Identification of sleep-disordered breathing in children: variation with event definition

STUDY OBJECTIVES

To determine the effect of varying approaches to the measurement of the respiratory disturbance index (RDI) on identification of sleep disordered breathing (SDB) in children.

DESIGN

Cross-sectional study of SDB in a well-characterized birth cohort (stratified for term and preterm birth) participating in longitudinal studies of cognition and behavior.

SETTING

Community-based; overnight studies conducted in participant's homes.

PARTICIPANTS

433 children, ages 8-11 years, un-referred for clinical assessment of SDB.

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

Participants underwent unattended overnight in-home recording of respiratory inductance plethysmography, pulse oximetry, body position, and heart rate. The relationships among RDIs derived from various definitions of apnea and hypopneas and thresholds for frequency of events were assessed. Median RDI varied by more than 20-fold for definitions using the more liberal criteria for event definition (all respiratory events; i.e., central or obstructive events and hypopneas with no requirement for associated desaturation) to the most conservative definition (using obstructive apneas only or obstructive apnea and hypopneas requiring a 5% associated desaturation). Prevalence estimates for SDB based on RDIs that included central apneas were 40% to 140% higher than those that excluded central apneas.

CONCLUSIONS

Different approaches for quantifying RDI contribute to substantial variability in identification and classification of SDB in children and will lead to discrepant estimates of its presence and severity.

Lessons learned from testing the quality cost model of Advanced Practice Nursing (APN) transitional care

PURPOSE

To describe the development, testing, modification, and results of the Quality Cost Model of Advanced Practice Nurses (APNs) Transitional Care on patient outcomes and health care costs in the United States over 22 years, and to delineate what has been learned for nursing education, practice, and further research.

ORGANIZING CONSTRUCT

The Quality Cost Model of APN Transitional Care.

METHODS

Review of published results of seven randomized clinical trials with very low birth-weight (VLBW) infants; women with unplanned cesarean births, high risk pregnancies, and hysterectomy surgery; elders with cardiac medical and surgical diagnoses and common diagnostic related groups (DRGs); and women with high risk pregnancies in which half of physician prenatal care was substituted with APN care. Ongoing work with the model is linking the process of APN care with the outcomes and costs of care.

FINDINGS

APN intervention has consistently resulted in improved patient outcomes and reduced health care costs across groups. Groups with APN providers were rehospitalized for less time at less cost, reflecting early detection and intervention. Optimal number and timing of postdischarge home visits and telephone contacts by the APNs and patterns of rehospitalizations and acute care visits varied by group.

CONCLUSIONS

To keep people well over time, APNs must have depth of knowledge and excellent clinical and interpersonal skills that are the hallmark of specialist practice, an in-depth understanding of systems and how to work within them, and sufficient patient contact to effect positive outcomes at low cost.

Evidence-based nursing practice: why is it important?

Evidence-based practice has gained momentum in nursing, and definitions vary widely. Research findings, knowledge from basic science, clinical knowledge, and expert opinion are all considered "evidence"; however, practices based on research findings are more likely to result in the desired patient outcomes across various settings and geographic locations. The impetus for evidence-based practice comes from payor and healthcare facility pressures for cost containment, greater availability of information, and greater consumer savvy about treatment and care options. Evidence-based practice demands changes in education of students, more practice-relevant research, and closer working relationships between clinicians and researchers. Evidence-based practice also provides opportunities for nursing care to be more individualized, more effective, streamlined, and dynamic, and to maximize effects of clinical judgment. When evidence is used to define best practices rather than to support existing practices, nursing care keeps pace with the latest technological advances and takes advantage of new knowledge developments.

A randomized trial of nurse specialist home care for women with high-risk pregnancies: outcomes and costs

OBJECTIVE

To examine prenatal, maternal, and infant outcomes and costs through 1 year after delivery using a model of prenatal care for women at high risk of delivering low-birth-weight infants in which half of the prenatal care was provided in women's homes by nurse specialists with master's degrees.

STUDY DESIGN

Randomized clinical trial.

PATIENTS AND METHODS

A sample of 173 women (and 194 infants) with high-risk pregnancies (gestational or pregestational diabetes mellitus, chronic hypertension, preterm labor, or high risk of preterm labor) were randomly assigned to the intervention group (85 women and 94 infants) or the control group (88 women and 100 infants). Control women received usual prenatal care. Intervention women received half of their prenatal care in their homes, with teaching, counseling, telephone outreach, daily telephone availability, and a postpartum home visit by nurse specialists with physician backup.

RESULTS

For the full sample, mean maternal age was 27 years; 85.5% of women were single mothers, 36.4% had less than a high school education, 93.6% were African American, and 93.6% had public health insurance, with no differences between groups on these variables. The intervention group had lower fetal/infant mortality vs the control group (2 vs 9), 11 fewer preterm infants, more twin pregnancies carried to term (77.7% vs 33.3%), fewer prenatal hospitalizations (41 vs 49), fewer infant rehospitalizations (18 vs 24), and a savings of more than 750 total hospital days and $2,496,145 [corrected].

CONCLUSION

This model of care provides a reasoned solution to improving pregnancy and infant outcomes while reducing healthcare costs.

Effects of maternal employment and prematurity on child outcomes in single parent families

BACKGROUND

Effects of maternal employment for preschool children vary based on specific characteristics of the mother's employment, the family's economic status, and the mother's attitudes about employment. However, there is limited research on a growing group of children at developmental risk-those born prematurely and living in a single-parent family.

OBJECTIVE

To examine the effects of maternal employment and prematurity on child cognition and behavior in single-parent families.

METHODS

Sixty preterm and 61 full-term preschool children were recruited through NICU admission records and birth records. Data were collected with the Kaufmann Assessment Battery for Children, Peabody Picture Vocabulary Test, Child Behavior Checklist, Parenting Stress Index, and the Life History Calendar.

RESULTS

Greater hours employed was related to higher achievement and mental processing scores only. Less discrepancy between actual and desired employment was related to higher achievement, mental processing, and language scores and lower behavior scores. Prematurity was not related to child cognitive and behavioral performance. Only the relationship between discrepancy and language remained after statistical control.

CONCLUSIONS

The concerns about negative effects of maternal employment on young children may be overstated, especially in low-income, single-mother families. These findings are especially important in the context of welfare reform.