Sustained impact of an academic-practice partnership

Academic-practice partnerships foster innovation and transition to nursing practice in healthcare systems. The purpose of this paper is to describe the impact of a public-private academic-practice partnership for Doctor of Nursing Practice (DNP) education designed to transform a large healthcare system's nursing workforce and model of care. The conceptual framework is organized around Rogers's (2003) principles of diffusion of innovation in organizations. A logic model illuminates how inputs, activities, outputs and outcomes resulted in sustained impact for graduates, the college and the healthcare organization. Partnership outcomes include education of baccalaureate and master's-prepared employed nurses (n = 95) in a DNP program for advanced practice nursing (APN) roles in the healthcare system; dissemination of scholarship; and revision of the healthcare system's research approval process. Sustained impact includes advancement of DNP-prepared graduates to complex leadership and practice roles; development of new programs and advanced practice roles based on scholarly project findings; expansion of population-specific patient programs; and extension of continuum- and access-to-care models in the healthcare organization. Recommendations include continuing development of academic-practice partnerships for transition to practice and advancement of roles and levels of champions to achieve sustained impact of academic-practice partnerships in healthcare organizations.

An innovative teaching model in an academic-practice partnership for a Doctor of Nursing Practice program

Teaching innovations in Doctor of Nursing Practice (DNP) programs are essential for preparing practitioners for role responsibilities. The purpose of this paper is to describe a teaching model implemented in a public-private academic-practice partnership in which DNP-prepared healthcare organization nursing leaders joined with college of nursing faculty to teach didactic courses in the DNP program. The conceptual framework for this model is organized around Boyer's (1990) principles of the scholarship of teaching, integration, and application, and the American Association of Colleges of Nursing definition of scholarship (2018). A logic model evaluation plan of the teaching model includes a description of inputs, activities, outputs, and outcomes. Outcomes include the attainment of short term goals related to student satisfaction and DNP program completion; faculty and peer satisfaction; and administrator perspectives. Future evaluation will include assessment of long-term impact of the teaching model. The teaching model can be replicated in preparing cohorts of students for advanced practice nursing and cultivating the scholarship of teaching, integration and application.

DNP Practice Improvement Initiative: Staff Nurse Competency Evaluation

This article describes a practice improvement initiative (PII) demonstrating the impact of doctorate of nursing practice (DNP) skills beyond direct patient care. The Donna Wright Competency Assessment Model, AACN DNP Essentials, and National Organization of Nurse Practitioner Faculties nurse practitioner competencies framed the PII. The DNP graduates planned, implemented, and evaluated an assessment of 1,055 staff nurses on shift hand-off, physical assessment, and hand hygiene. Results indicated that 95% of the staff nurses scored 100% on competency assessment. The PII model was adopted for future competency evaluation.

Health Behavior Decision-making in African-American Adults Diagnosed with Schizophrenia

Little is known about the factors that influence health behavior decision-making among people with schizophrenia. The purpose of this qualitative study was to describe the processes used by 10 African-American adults with schizophrenia when making health behavior decisions and identification of perceived barriers and facilitators to health. Three phases of health behavior decision-making were identified: Recognizing Complex Components of Health, Personalizing Components of Health, and Tracking Health Status. Findings may guide clinicians' efforts to improve the health status of patients, as well as influence future research in understanding health behavior decision-making among vulnerable populations.

The leadership role of nurse educators in mental health nursing

Leadership behaviors and actions influence others to act, and leadership in clinical practice is an important mediator influencing patient outcomes and staff satisfaction. Indeed, positive clinical leadership has been positioned as a crucial element for transformation of health care services and has led to the development of the Practice Doctorate Movement in the United States. Nurse educators in health care have a vital leadership role as clinical experts, role models, mentors, change agents, and supporters of quality projects. By enacting these leadership attributes, nurse educators ensure a skilled and confident workforce that is focused on optimizing opportunities for students and graduates to integrate theory and practice in the workplace as well as developing more holistic models of care for the consumer. Nurse educators need to be active in supporting staff and students in health care environments and be visible leaders who can drive policy and practice changes and engage in professional forums, research, and scholarship. Although nurse educators have always been a feature of the nursing workplace, there is a paucity of literature on the role of nurse educators as clinical leaders. This discursive article describes the role and attributes of nurse educators with a focus on their role as leaders in mental health nursing. We argue that embracing the leadership role is fundamental to nurse educators and to influencing consumer-focused care in mental health. We also make recommendations for developing the leadership role of nurse educators and provide considerations for further research such as examining the impact of clinical leaders on client, staff, and organizational outcomes.

Challenges of implementing a medication management evidence-based practice in a community mental health setting: results of a qualitative study

The Medication Management Approaches in Psychiatry (MedMAP) is a medication management evidence-based practice (EBP) to guide the use of psychotropic medications in the treatment of schizophrenia. This qualitative study examined facilitators and barriers to implementing MedMAP in community mental health treatment settings. Audio-taped qualitative interviews were conducted with practitioners and administrators involved in a MedMAP implementation project conducted in six community mental health centers. Data analysis was conducted using thematic analysis of transcribed interviews. Findings indicate that facilitators to MedMAP implementation included practitioner recognition of the value of MedMAP, consumer involvement, collaboration, continuity of care, and fidelity assessments. Barriers to MedMAP implementation included problematic technology, work flow issues, lack of flexibility in prescribers' ability to implement MedMAP guidelines, regulatory and financial barriers, and consumer insurance status. Recommendations for improving future implementation efforts of MedMAP emphasize technological readiness, development of innovative models of care delivery, an emphasis on treatment guided by outcomes, and active leadership to promote EBPs within organizations and academic settings.

Organizational fidelity to a medication management evidence-based practice in the treatment of schizophrenia

Organizational support is essential for successful implementation of evidence-based practice (EBP) in clinical settings. This 3-year study used a mixed qualitative and quantitative design to implement a medication management EBP in the treatment of schizophrenia in six community mental health clinics in a south-central state of the United States. Findings from organizational fidelity assessments indicate that support for EBP implementation was moderate. Organizational support was highest for prescriber access to relevant patient information at each medication visit, scheduling flexibility for patients' urgent problems, and availability of medication guidelines. Organizational support was lowest for medication availability and identification of treatment refractory patients. Findings suggest that leadership is essential to support successful implementation. Nurse educators can incorporate implementation research and leadership training into graduate nursing programs to facilitate successful EBP implementation in practice settings.

Prescriber fidelity to a medication management evidence-based practice in the treatment of schizophrenia

OBJECTIVE

Medication Management Approaches in Psychiatry (MedMAP) is an evidence-based practice developed to guide the management and monitoring of psychotropic medications for individuals with schizophrenia. This article reports prescriber fidelity to MedMAP principles in a public mental health service system.

METHODS

This three-year longitudinal intervention study implemented MedMAP in six community mental health centers in Kentucky. Nine psychiatrists and five advanced practice psychiatric nurses with prescriptive authority participated in the study. Prescribers were trained in the use of MedMAP about one month before implementation, and MedMAP principles were reinforced throughout the study. Four posttraining assessments were conducted at each site at approximately four-month intervals over a period of 30 months. An 18-item scale was used to assess baseline and posttraining prescriber fidelity over a period of 30 months in 900 randomly selected medical records.

RESULTS

Average fidelity scores improved significantly over baseline at each of the four postimplementation fidelity assessments. Training effects were most evident at the second posttraining fidelity assessment, but effects persisted over the course of the study. There was considerable variability in scores across items both at baseline and subsequently. Posttraining improvement was greatest in patient education, documentation of illness and medication history, and simplification of medication regimen.

CONCLUSIONS

Implementation and monitoring of MedMAP were feasible in these community mental health settings. Additional implementation projects are crucial for advancing evidence-based practice in clinical settings.

Prescriber fidelity to a medication management evidence-based practice in the treatment of schizophrenia

OBJECTIVE

Medication Management Approaches in Psychiatry (MedMAP) is an evidence-based practice developed to guide the management and monitoring of psychotropic medications for individuals with schizophrenia. This article reports prescriber fidelity to MedMAP principles in a public mental health service system.

METHODS

This three-year longitudinal intervention study implemented MedMAP in six community mental health centers in Kentucky. Nine psychiatrists and five advanced practice psychiatric nurses with prescriptive authority participated in the study. Prescribers were trained in the use of MedMAP about one month before implementation, and MedMAP principles were reinforced throughout the study. Four posttraining assessments were conducted at each site at approximately four-month intervals over a period of 30 months. An 18-item scale was used to assess baseline and posttraining prescriber fidelity over a period of 30 months in 900 randomly selected medical records.

RESULTS

Average fidelity scores improved significantly over baseline at each of the four postimplementation fidelity assessments. Training effects were most evident at the second posttraining fidelity assessment, but effects persisted over the course of the study. There was considerable variability in scores across items both at baseline and subsequently. Posttraining improvement was greatest in patient education, documentation of illness and medication history, and simplification of medication regimen.

CONCLUSIONS

Implementation and monitoring of MedMAP were feasible in these community mental health settings. Additional implementation projects are crucial for advancing evidence-based practice in clinical settings.

Scales to evaluate quality of medication management: development and psychometric properties

This paper describes the psychometric properties of two fidelity scales created as part of the Substance Abuse and Mental Health Services Administration (SAMHSA) sponsored medication management toolkit and their metric properties when used in 26 public mental health clinics with 50 prescribers. A 23-item scale, based on chart reviews, was developed to assess whether prescribers are following good medication practices, in conjunction with a 17-item scale to assess organizational support for and evaluation of prescriber adherence to recommended medication-related practices. Fundamental gaps in routine practice, including poor documentation of medication history and infrequent monitoring of symptoms and side effects were found.

The care and outcomes management plan and Kardex. A design for improving documentation of nursing plan of care and patient outcomes

The gradual transition from paper records to electronic records presents challenges for nurses. In particular, split paper/electronic records can interfere with staff communication during shift change reports. A project was implemented to facilitate documentation of individualized care plans and improve staff communication during shift change report. The hospital's critical pathway was incorporated into Kardex to create a single electronic medical record for use during shift change report. This combined electronic outcomes plan and Kardex improved access to patient information during shift report and facilitated nurses' ability to update the care plan with the most current patient information. Future strategies will include collaboration with the hospital's information systems staff to make the COMPdex compatible with the hospital's electronic documentation system, so that pertinent patient data will populate from the current electronic chart into the COMPdex forms for printing and to include patient outcome data in the electronic medical record.

Assessment and management of hospitalized suicidal patients

Suicide in inpatient psychiatric settings is a critical problem. A comprehensive literature review was performed to determine risk factors for inpatient suicide, instruments for assessing suicide, and treatment of hospitalized suicidal patients. Findings suggested that root causes of inpatient suicide were factors related to the treatment environment, failure to assess patient behavioral characteristics, and staff reliance on no-suicide contracts. Recommendations include assessing suicide risk regularly throughout hospitalization, including on admission, during changes in a patient's mental or physical status, after a change in observation level, and before discharge. Orientation and inservice education for all staff and additional research on the psychometric properties of available suicide assessment instruments are also essential.

Predictors of satisfaction among adult recipients of medicaid mental health services

This study measured service satisfaction, perceptions of service quality and general health, and overall quality of care among 787 adult recipients of Medicaid mental health services. Methods included cross-sectional retrospective design and stratified random sampling technique. Respondents were satisfied with consumer-provider relationships and were dissatisfied with functional outcomes resulting from treatment. Satisfaction was positively correlated with ratings of mental health care and the mental health component score of the SF-12. Predictors of satisfaction included ratings of mental health care and overall health. Recommendations include coordination of services that promote patient functioning and measurement of consumer satisfaction as an indicator of quality.

Comorbid medical illnesses and perceived general health among adult recipients of Medicaid Mental Health Services

The purpose of this retrospective, cross-sectional, descriptive study was to measure self-reported frequencies of medical problems, overall health, and health-related quality of life among mental health consumers. The sample included 787 adults who had received a mental health service paid for by Medicaid over a one-year period. The self-administered questionnaire included the 12-item Medical Outcomes Study (MOS) Short-Form (SF) Physical and Mental Health Summary Scales, and items about physical health problems and health-related quality of life. The majority of respondents (83.3%) reported that their general health was poor or fair. Frequently reported medical problems included arthritis, migraines, and high blood pressure. Knowledge of physical problems in persons with mental illness is essential for advanced practice nurses.

Consumer perspectives on quality of inpatient mental health services

This study, conducted at two public-sector psychiatric hospitals in a south-eastern state, investigated satisfaction with inpatient services and treatment outcomes among 204 hospitalized mental health consumers. A simple survey design with nonrandom sampling technique was used; instruments included the KY-CSI, the 21-item MHSIP Consumer Survey, and the CSQ-8. Respondents reported satisfaction with time available to be with other patients, staff availability, and their degree of comfort talking to staff. Areas of dissatisfaction included lack of client input into treatment planning, lack of family involvement, and lack of medication education. Providers are encouraged to include clients in all phases of treatment planning and to continue to evaluate consumer perspectives of quality services.

Training Consumers to Collect Data in Mental Health Service System Evaluation Research

Consumer satisfaction with services is an outcome measure. This report describes The Consumer Satisfaction Research Associate Training Program, which was designed for the education and supervision of recovered consumers who collected data during four studies at three psychiatric hospitals. The educational program had didactic and laboratory components. Consumer research associates collected quantitative and qualitative data using a survey tool for face-to-face interviews. Participant recruitment and management of confidential records were included in the role. Data collected by research associates from consumers who are in treatment can enhance the validity and trustworthiness of satisfaction surveys. Nurses can play an important role in the research process by serving as staff resources for consumers who collect data in various service system settings.

Consumer satisfaction with services in a regional psychiatric hospital: a collaborative research project in Kentucky

Consumer satisfaction with mental health services is a dimension of outcome. This report is on a university and state mental health department research project that involved development of the Kentucky Consumer Satisfaction Instrument (KY-CSI) and a retrospective, cross-sectional study designed to measure consumer satisfaction with services at a regional psychiatric hospital. Triangulation of methods guided the survey of participants (N = 189) near discharge from the hospital during a 6-month period. Research associates, who were former consumers of mental health services, collected data during face-to-face interviews. Most participants were unemployed White men. Factor analysis indicated the 19-item instrument was unidimensional; Cronbach's alpha was 0.90. Multiple regression indicated predictors of satisfaction were levels of education and diagnosis. As education increased, satisfaction decreased; participants with a diagnosis of bipolar disorder tended to be more satisfied than those with other diagnoses. Analysis of qualitative data combined with standardized summary of KY-CSI items indicated participants were most satisfied with opportunities to talk with other patients and least satisfied about lack of involvement of people with whom they lived in discharge planning. Study findings guided recommendations for quality of care and additional studies at other hospital sites.

Evidence-based practice and the advanced practice nurse: a curriculum for the future

The concept of evidence-based practice has gained increased attention throughout the 1990s as a strategy for linking the best scientific findings with clinical judgment to improve health outcomes. Because the concept implies finding, evaluating, summarizing, and using research results, a high level of clinical reasoning skills is required. Effective evidence-based practice also requires the incorporation of new practices into clinical and organizational settings, thereby demanding advanced leadership skills. Competencies in clinical reasoning, leadership, and clinical practice are critical for advanced practice nurses. This article describes a master's-level curriculum supportive of evidence-based practice and includes recommendations for developing curricula of this type.

The experience of fathers of adult children with schizophrenia

The purpose of this study was to describe the lived experience of fathers of adult children with schizophrenia by exploring the extent to which they engaged in caregiving. Cross-sectional data were gathered from 12 fathers over a 2-year period using naturalistic inquiry. Two instruments guided in-depth explorations of caregiving experiences, theme extrapolation, and theme refinement. Data were collected during taped interviews using the constant-comparative method. Findings indicated that the caregiving event was prolonged. Three themes explained the extent to which these fathers engaged in caregiving: involvement in care, unresolved issues, and severity of the event. Recommendations include similar studies with ethnic groups and use of chronic sorrow as a framework for studies about parental care for adult children with severe mental illness. practice implications include immediate assessment of fathers, supportive listening, and brief therapy.

Keratometry, ultrasonic biometry, and prediction of intraocular lens power in the feline eye

OBJECTIVE

To determine ocular dimensions (using A-scan ultrasound biometry) and corneal curvature (using keratometry) in the feline eye and to calculate the appropriate dioptric power for a prototype posterior chamber intraocular lens (IOL) necessary to achieve emmetropia in the eyes of cats undergoing lens extraction.

ANIMALS

25 clinically normal adult mixed-breed cats and 10 eyes from 10 clinically normal adult mixed-breed cat cadavers.

PROCEDURE

A-scan ultrasonic biometry was performed on both eyes of each live cat. Cats were tranquilized, and keratometry was performed on each eye. Biometry was performed on the cadaver eyes. Five of the cadaver eyes had the lens extracted and an IOL, designed for use in dogs, was implanted. Biometry was repeated to estimate postoperative IOL position. Using 3 theoretical IOL formulas, data from biometry, keratometry, and postoperative IOL position were used to predict IOL strength required to achieve emmetropia after lens extraction in cats.

RESULTS

Mean axial length of eyes in live cats was 20.91 +/- 0.53 mm. Mean preoperative anterior chamber depth (ACD) was 5.07 +/- 0.36 mm, and mean lens thickness was 7.77 +/- 0.23 mm. Predicted postoperative ACD was calculated to be 10.84 mm. Measured postoperative ACD in the 5 cadaver eyes was 8.28 mm. Required IOL strength calculated, using the predicted postoperative ACD, was 73 to 76 diopters. The required IOL strength calculated, using the measured postoperative ACD, was 53 to 55 diopters.

CONCLUSIONS AND CLINICAL RELEVANCE

An IOL of substantially higher diopter strength than that needed in dogs is required to achieve emmetropia after lens extraction in average cats; an IOL strength of approximately 53 to 55 diopters will likely be required.

Advanced practice psychiatric nursing: a national profile

The results of a national survey of Advanced Practice Psychiatric Nurses (APPN) are presented. Results are based on the Society for Education and Research in Psychiatric/Mental Health Nursing's (SERPN) Primary Mental Health and Advanced Practice Psychiatric Nursing monograph. Characteristics of the nurses, the clients they serve, and their practice patterns are described. Documenting the cost-effectiveness of these practitioners and increasing the number of younger APPNs is recommended.

Constraints to advanced psychiatric-mental health nursing practice

Constraints and barriers to advanced practice psychiatric nursing were reported by respondents of the Primary Mental Health and Advanced Practice Psychiatric Nursing survey of certified psychiatric clinical nurse specialists. Primary data (N = 507) were the qualitative responses to a survey item about constraints and secondary data were the literature and theoretical memos. Methodology was based on principles of qualitative data analysis and procedures for manifest and latent content analysis. Findings resulted in eight themes that explained both constraints and barriers to advanced practice: (1) reimbursement, (2) prescriptive authority, (3) admitting privileges, (4) bureaucracy, (5) practice environment, (6) colleagues, (7) image, and (8) personal. Themes were interpreted within the context of regulatory, market-based, and inter/intraprofessional constraints and barriers that led to suggestions for organizational and individual strategies for action. The survey was funded by the Society for Education and Research in Psychiatric-Mental Health Nursing with technical support from the Center for Mental Health Services.

Quality indicators for primary mental health within managed care: a public health focus

Primary mental health is an orientation to care that addresses mental health needs of consumers on point of first contact with caregivers. Core values, and principles drawn from a public health perspective serve as the foundation for indicators of quality within managed primary mental health. A model, illustrating the key components for quality indicators, includes stakeholder groups (consumers, families, providers, and payers), quality concerns (access, appropriateness, outcomes, and prevention), and the spectrum of clinical processes (assessment, treatment, rehabilitation, and support). Responsibility for monitoring quality is vested in these stakeholder groups. To enable them to fulfill their responsibilities, indicators are proposed in the form of checklists. The checklists assist stakeholders in evaluating the plans and services offered by managed care entities.

Reservoir competence of the rice rat (Rodentia: Cricetidae) for Borrelia burgdorferi

The reservoir competence of the rice rat, Oryzomys palustris, for Borrelia burgdorferi is described. Infected Ixodes scapularis Say (I. dammini, Spielman, Clifford, Piesman & Corwin) nymphs were used to infect animals. Borrelia infection was diagnosed by xenodiagnostic feeding of noninfected I. scapularis larvae and by reisolation of the spirochetes from blood and other tissues. Rice rats acquired B. burgdorferi and maintained spirochete infection for 5-9 wk. B. burgdorferi were cultured from samples of skin and urinary bladders from all animals killed on day 21 (three rats), 35 (three rats), or 56 (three rats) after infection. The spirochetes were also detected in blood samples obtained 1 and 2 wk after exposure. Spirochetes that persisted for 5 wk in rice rats did not lose their infectivity for golden Syrian hamsters. The prepatent period for infecting xenodiagnostic ticks was 1 wk. Overall, 75.6% of I. scapularis larvae (n = 694) that fed on infected rice rats acquired B. burgdorferi. Prevalence of infection reached 83% in ticks that fed on tick-exposed animals during the 2nd-4th wk, 68% during the 5th wk, and 17.4% during the 9th wk. The duration of rice rat infectivity for ticks exceeded 2 mo. I. scapularis nymphs infected as larvae on rice rats transmitted B. burgdorferi. Taken together, these studies confirm the reservoir competence of the rice rat for B. burgdorferi.

Lifelong maternal caregiving for children with schizophrenia

Maternal caregiving for adult children with schizophrenia is described using a lifespan perspective. Principles of naturalistic inquiry and a grounded-theory design guided field work methods. Nineteen in-depth interviews with ten participants averaged 4 hours each. Data analysis involved coding and classifying themes, constant comparison, and saturating theme categories. A model depicts findings including stages of learning in the experience. The stages are as follows: (1) perceiving a problem; (2) searching for solutions; (3) enduring the situation; and (4) surviving the experience. Implications include use of the model in developing intervention and education models.

An anti-EnaTS detected in the serum of an MiI homozygote

The serum of EH reacted with all red cells (RBCs) except her own, ficin- or trypsin-treated red cells, and En(a-) red cells. This reactivity defined an anti-EnaTS specificity. The red cells of the proposita typed as M-N+S-S+, Vw+Mur-Hil-Hut-Anek-Lane-, Wr(a-b+), EnaKT+. Red cells of five relatives were Vw+ and positive with her serum. Titration studies suggest that EH is genetically an MiI homozygote and that her Vw+ relatives are MiI heterozygotes. There is no history of consanguinity. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis and immunoblotting studies have agreed with the serologic observations. A variant sialoglycoprotein of faster mobility than normal glycoprotein A, but no normal glycoprotein A, was detected on her red cells. Treatment with N-glycanase did not alter the mobility, which indicated that there was no N-glycosylation of residue 26. These findings are in agreement with the reported properties of the Mi.I-specific glycoprotein A. The relatives' Vw+ red cells showed the variant sialoglycoprotein and normal glycoprotein A. EH appears to be the first reported MiI homozygote.