Collaborative Care: Integrating Behavioral Health Into the Primary Care Setting.

INTRODUCTION: Integrated behavioral health is a model of health care that aims to meet the complex health care needs of patients in primary care settings. Collaborative Care (CC) is an evidence-based model incorporating an interdisciplinary team to improve outcomes for behavioral health disorders commonly seen by primary care providers. AIM: CC was implemented in a nurse-managed health center in a medically underserved community of Chicago with a team of family nurse practitioners, psychiatric mental health nurse practitioners, and a licensed clinical social worker. METHODS: Integration of the CC model required restructuring of the patient visit, the care team, and financial operations. Weekly team meetings were held for interdisciplinary case consultation and training for the primary care team by the psychiatric nurse practitioner. The model includes suggested goals of reducing patient scores of validated depression (Patient Health Questionnaire-9) and anxiety (Generalized Anxiety Disorder-7) screening tools to a score less than 5 points or to less than 50% of original score. RESULTS: During the initial year of implementation, 166 patients received care under the CC model, with 64 patients currently receiving active care. In this cohort, 22% reached suggested goals for depression and 47% for anxiety. CONCLUSIONS: CC has benefits for both patients and providers. Patients receive holistic treatment of both mental and physical health needs and access to psychiatric services for medication initiation and behavioral health modalities when necessary. We observed that the CC model improved collaboration with behavioral health specialists and the competence and confidence of family nurse practitioners.

A Correctional Facility Academic-Practice Partnership: Implementation of a Nurse-Led COVID-19 Initiative.

In 2020, the COVID-19 pandemic resulted in one in five individuals incarcerated in U.S. correctional institutions contracting COVID-19 and 1,700 deaths. Correctional adult transition centers house incarcerated individuals who typically do not have on-site health care access. A COVID-19 outbreak could devastate this population, who live in high-density conditions and have been documented as high risk for poor health outcomes. Owing to a robust practice partnership between a college of nursing and two adult transition centers, a nurse-led COVID-19 initiative was implemented to minimize transmission in the facilities and ensure appropriate health care referral for residents who tested positive for COVID-19. The initiative identified six residents with positive results, who were transferred to a state prison infirmary for management and to minimize risk for other residents.

Breaking Bad News via Telehealth: Simulation Training for Nurse Practitioner Students.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic demonstrated educators must consider students' future practice will involve patient communication via telehealth, including breaking bad news. METHOD: This mixed-methods analysis was conducted among 33 nurse practitioner (NP) students at two universities. Questionnaires were analyzed before and after a simulation training session with standardized patients to determine students' perceptions, learning satisfaction, confidence, and self-rated preparedness for delivering bad news via telehealth. RESULTS: Students' self-rated levels of preparedness for delivering bad news were higher after participating in the simulation. Students found the teaching methods to be effective, enjoyable, motivating, and suitable to individual learning styles. Two themes emerged that described students' perceptions of the experience: valuable simulation processes and multifaceted learning applicable to future NP practice. CONCLUSION: Breaking bad news via virtual platforms is new and challenging. Findings suggest this simulation experience provided a valuable tool for augmenting didactic training for NP students. [J Nurs Educ. 2022;61(9):528-532.].

Leveraging an Academic Practice Partnership to Support a COVID-19 Mass Vaccination Clinic.

BACKGROUND: When the first coronavirus disease 2019 (COVID-19) vaccines received emergency use authorization by the U.S. Food and Drug Administration in December 2020, distribution of the vaccine began within 24 hours. METHOD: Nursing faculty leveraged a long-standing practice partnership with the academic health center (AHC) to lead an innovative effort mobilizing nursing and interprofessional student volunteers to support the COVID-19 mass vaccination program for AHC frontline health care staff, patients, and community members. RESULTS: Student vaccinators administered 98,000 vaccinations and contributed a significant service to the university health system by supporting the swift rollout of the vaccine program. The total number of volunteer vaccinator hours (11,820) resulted in an approximate cost savings of $768,300 to the AHC. CONCLUSION: During a global health crisis, nursing students and faculty demonstrated a strong commitment to the academic-practice partnership and improved access to COVID-19 vaccinations for residents of the health system's underserved communities. [J Nurs Educ. 2022;61(6):308-313.].

Closing the gap: Collaborative care addresses social determinants of health.

ABSTRACT: Social determinants of health have a significant impact on individual and community health outcomes. Using an integrated behavioral health model at a primary care clinic-a Federally Qualified Health Center-NPs led an interdisciplinary team to address outcome measures that are influenced by social determinants of health.

Age-based disparities in telehealth use in an urban, underserved population in cancer and pulmonary clinics: A need for policy change.

BACKGROUND: During the COVID-19 pandemic, telehealth rapidly emerged as an essential health care service and became particularly important for patients with cancer and chronic conditions. However, the benefits of telehealth have not been fully realized for some of the most vulnerable populations due to inequitable access to telehealth capable technology. PURPOSE: This study aimed to assess accessibility and satisfaction with telehealth technology by vulnerable patients with cancer and pulmonary disease. METHODOLOGY: A paper survey and internet-based survey were developed and administered to adult (≥18 years) cancer and pulmonary clinic patients (July 1, 2020 to October 30, 2020). RESULTS: Descriptive statistics and Fisher exact test were performed. Two hundred eleven patients completed the survey. Adults ≥50 years old (older) had reduced access to smartphone video capability and internet connection compared with adults less than 50 years old (59% vs. 90%, p < .01). Older adults reported more challenges with telehealth visits compared with younger adults (50.3%, 28.6%; p < .01). No difference in access to technology and preferences for telehealth versus in-person care was found by race, gender, or education level. CONCLUSIONS: Nearly all patients (95%) who had a previous experience with a telehealth visit felt confident in the quality of care they received via telehealth. Younger adults preferred video visits compared with older adults (75% vs. 50.6%, p < .01). Older adults were less likely to have access to smartphones with internet access, have more challenges with telehealth visits, and were less likely to prefer audio-video telehealth visits compared with younger adults. IMPLICATIONS: Ensuring equitable access to all health care delivery modalities by telehealth, including audio-only visits for patients across the age continuum, is paramount.

Identifying contributing factors influencing pediatric nurses' and health professionals' self-reported collaborative practice behaviors.

PURPOSE: In this study, we examined the influence of interprofessional American Heart Association (AHA) resuscitation courses on pediatric health care professionals' (N = 218) self- reported collaborative practice behaviors (CPBs) and examined differences in CPBs between nursing, medicine, and respiratory therapy. DESIGN AND METHODS: A mixed methods explanatory design was utilized with a sample of pediatric nurses, nurse practitioners, physicians, and respiratory therapists. Data were collected using the Interprofessional Collaborative Competency Attainment Survey (ICCAS) and two open-ended questions. Data analysis included: exploratory factor analysis, paired t-tests, mixed effects modeling and directed content analysis. Inferences were made across quantitative and qualitative data. RESULTS: Statistically significant improvement in mean CPB scores was demonstrated by all professions (t (208) = -12.76; ρ < 0.001) immediately after the AHA courses. Qualitative responses indicated physicians identified roles and responsibilities (94%, n = 17) as the most important CPB. Communication was identified by nurses (78%, n = 76), nurse practitioners (100%, n = 11) and respiratory therapists (71%, n = 5) as most important. CONCLUSIONS: Participation in an interprofessional AHA course significantly increased mean self-reported CPB scores. Changes in mean CPB scores were sustained over 6 weeks upon return to clinical practice. PRACTICE IMPLICATIONS: Future research focused on CPBs of front-line health care professionals can provide an accurate portrayal of an interprofessional team and can inform how collaborative practice is established in everyday clinical practice.

Nurse practitioner preceptor resource needs and perceptions of institutional support.

BACKGROUND: Nurse practitioner (NP) preceptors encounter stress when balancing clinical responsibilities with mentoring. Support can decrease role stress and promote preceptor resilience. PURPOSE: Characterize NP preceptor resource needs and their perception of support for the clinical preceptor role. METHODS: A cross-sectional, mixed-methods study used a web-based survey to identify preceptor resource needs. A convenience sample from a large, academic Midwestern university was recruited by email, with reminder emails 1 and 2 weeks after initial invitation. Survey tools included researcher-designed questions about preceptor-desired resources, an adapted Preceptor's Perception of Support Scale, and qualitative questions of preceptor needs. Data were analyzed using descriptive statistics and qualitative thematic analysis. RESULTS: Two hundred thirty-nine of 784 surveys (30.48%) were returned. Preceptors valued free mentoring resources, desired access by "smartphone app," and identified mentoring topics of interest. They perceived adequate role preparation, clearly defined roles, supportive and knowledgeable colleagues, committed supervisors, and appropriate workload. Respondents noted the following insufficiencies: time for normal duties while precepting, preceptor resources, opportunities to share with colleagues, faculty-student time, and faculty assistance to identify student's performance problems. Qualitative data highlighted faculty-preceptor communication and compensation as preceptor concerns. IMPLICATIONS FOR PRACTICE: Preceptors feel a need for specific supports identified in this study. Preceptor insights inform strategies to build clinical preceptor resilience and well-being, strengthen the academic-practice partnership, and facilitate positive education outcomes. Faculty should increase communication-based support individualized to specific student needs. Resources should be developed that more fully support specific competencies and skills within NP student clinical education.

Diagnostic reasoning: relationships among expertise, accuracy, and ways that nurse practitioner students self-explain.

OBJECTIVES: To improve diagnostic ability, educators should employ multifocal strategies. One promising strategy is self-explanation, the purposeful technique of generating self-directed explanations during problem-solving. Students self-explain information in ways that range from simple restatements to multidimensional thoughts. Successful problem-solvers frequently use specific, high-quality self-explanation types. In a previous phase of research, unique ways that family nurse practitioner (NP) students self-explain during diagnostic reasoning were identified and described. This study aims to (a) explore relationships between ways of self-explaining and diagnostic accuracy levels and (b) compare differences between students of varying expertise in terms of ways of self-explaining and diagnostic accuracy levels. Identifying high-quality diagnostic reasoning self-explanation types may facilitate development of more refined self-explanation educational strategies. METHODS: Thirty-seven family NP students enrolled in the Doctor of Nursing Practice program at a large, Midwestern university diagnosed three written case studies while self-explaining. During the quantitative phase of a content analysis, associational and comparative data analysis techniques were applied. RESULTS: Expert students voiced significantly more clinical and biological inference self-explanations than did novice students. Diagnostic accuracy scores were significantly associated with biological inference scores. Clinical and biological inference scores accounted for 27% of the variance in diagnostic accuracy scores, with biological inference scores significantly influencing diagnostic accuracy scores. CONCLUSIONS: Not only were biologically focused self-explanations associated with diagnostic accuracy, but also their spoken frequency influenced levels of diagnostic accuracy. Educational curricula should support students to view patient presentations in terms of underlying biology from the onset of their education.

Ways that nurse practitioner students self-explain during diagnostic reasoning.

OBJECTIVES: An important step in mitigating the burden of diagnostic errors is strengthening diagnostic reasoning among health care providers. A promising way forward is through self-explanation, the purposeful technique of generating self-directed explanations to process novel information while problem-solving. Self-explanation actively improves knowledge structures within learners' memories, facilitating problem-solving accuracy and acquisition of knowledge. When students self-explain, they make sense of information in a variety of unique ways, ranging from simple restatements to multidimensional thoughts. Successful problem-solvers frequently use specific, high-quality self-explanation types. The unique types of self-explanation present among nurse practitioner (NP) student diagnosticians have yet to be explored. This study explores the question: How do NP students self-explain during diagnostic reasoning? METHODS: Thirty-seven Family NP students enrolled in the Doctor of Nursing Practice program at a large, Midwestern U.S. university diagnosed three written case studies while self-explaining. Dual methodology content analyses facilitated both deductive and qualitative descriptive analysis. RESULTS: Categories emerged describing the unique ways that NP student diagnosticians self-explain. Nine categories of inference self-explanations included clinical and biological foci. Eight categories of non-inference self-explanations monitored students' understanding of clinical data and reflect shallow information processing. CONCLUSIONS: Findings extend the understanding of self-explanation use during diagnostic reasoning by affording a glimpse into fine-grained knowledge structures of NP students. NP students apply both clinical and biological knowledge, actively improving immature knowledge structures. Future research should examine relationships between categories of self-explanation and markers of diagnostic success, a step in developing prompted self-explanation learning interventions.

Transition of Nurse Practitioner Faculty Practice and Student Clinicals to Telehealth: Response to the COVID-19 Pandemic.

The COVID-19 pandemic forced the US health care system to evaluate alternative care delivery strategies to reduce the risk of coronavirus transmission to patients and health care providers. Telehealth modalities are a safe and effective alternative to face-to-face visits for primary and psychiatric care. Federal policy makers approved changes to telehealth reimbursement coverage and allowed flexibility of location for patients and providers. This article describes the transition of patient visits to telehealth by nurse practitioner faculty at an academic medical center to maintain continuity of care of underserved patient populations. This pivot facilitated resumption of clinical learning experiences for nurse practitioner students.

Health Literacy Assessment of Detained Individuals and Correctional Officers Within a Large Urban Jail: Optimizing Health Education.

BACKGROUND: Little research has been done to address the health literacy level of detained individuals and correctional officers. PURPOSE: The aim of this pilot project was to describe the health literacy of individuals detained or working within a large urban jail to inform their health education. METHODS: Health literacy assessments were conducted using the Rapid Estimate of Adult Literacy in Medicine-Short Form (REALM-SF) and the Newest Vital Sign (NVS) tools. RESULTS: Of the 48 participants, 17% (n = 8) exhibited low health literacy on the REALM-SF, whereas 38% (n = 18) demonstrated the need for improved health literacy when assessed with the NVS. Detained individuals from the women's tiers were more likely to have lower health literacy than the detained veterans or correctional officers. CONCLUSIONS: Results indicate that tailored health education programming, using evidence-based health literacy improvement techniques, should be offered to the individuals detained or working within a correctional facility.

Home Oxygen Therapy for Patients With COPD: Time for a Reboot.

Just over 100 years ago, John Scott Haldane published a seminal report about the therapeutic potential of supplemental oxygen to treat hypoxemia. In the 1980s, a pair of clinical trials confirmed the benefit of long-term oxygen therapy in improving survival in patients with COPD associated with severe resting hypoxemia. This review provides a summary of evidence supporting long-term and short-term oxygen therapy, as well as the various types of oxygen equipment commonly used in homes to deliver supplemental oxygen. Because the majority of orders for home oxygen occur at hospital discharge following acute illness, a typical conversation between a patient and their pulmonologist following a COPD exacerbation is presented. The SHERLOCK Consortium, a multi-stakeholder group established following the publication of the COPD National Action Plan in 2017 is also detailed. Interim results of the SHERLOCK Consortium, which suggest a chain of care involving 9 steps to ensure that patients are successfully initiated on home oxygen therapy during transitions from hospital to home, are presented. Recommendations to support evidence-based policies in this high-risk population are provided.

Facilitating faculty knowledge of DNP quality improvement projects: Key elements to promote strong practice partnerships.

Enrollment in Doctor of Nursing Practice (DNP) programs is growing rapidly. This poses a challenge to faculty because there is a gap in knowledge about evidence-based practice and quality improvement DNP projects. Challenged by the growing unavailability of preceptors and mentors in the practice setting, solutions are needed to help students meet the essentials of the degree and competencies for practice. Faculty knowledge of key DNP quality improvement project elements, measuring, monitoring, and sustaining improvement outcomes, may help students design projects to provide value to practice partners. A literature review was conducted to identify gaps in faculty knowledge of potential practice partners' value-added elements of DNP quality improvement projects (measuring, monitoring, and sustainability) to make recommendations for faculty development to improve DNP project mentoring. There is evidence in the literature that faculty feel ill-prepared to mentor DNP projects. Quality improvement content is available for faculty development in the nursing and other health sciences literature. Optimizing faculty knowledge regarding evidence-based practice, quality improvement processes, and mentoring of sustainable DNP projects that improve health care provides value to practice partners and may advance long-term partnerships. Adding structures to support faculty knowledge in these areas contributes to solutions to the challenges of rapidly expanding DNP programs.

A latent class analysis of prolonged mechanical ventilation patients at a long-term acute care hospital: Subtype differences in clinical outcomes.

RATIONALE: Patients on prolonged mechanical ventilation (PMV) at Long-Term Acute Care Hospital's (LTACHs) are clinically heterogeneous making it difficult to manage care and predict clinical outcomes. OBJECTIVES: Identify and describe subgroups of patients on PMV at LTACHs and examine for group differences. METHODS: Latent class analysis was completed on data obtained during medical record review at Midwestern LTACH. MAIN RESULTS: A three-class solution was identified. Class 1 contained young, obese patients with low clinical and co-morbid burden; Class 2 contained the oldest patients with low clinical burden but multiple co-morbid conditions; Class 3 contained patients with multiple clinical and co-morbid burdens. There were no differences in LTACH length of stay [F(2,246) = 2.243, p = 0.108] or number of ventilator days [F(2,246) = 0.641, p = 0.528]. Class 3 patients were less likely to wean from mechanical ventilation [χ2(2, N = 249) = 25.48, p < 0.001] and more likely to die [χ2(2, N = 249) = 23.68, p < 0.001]. CONCLUSION: Patient subgroups can be described that predict clinical outcomes. Class 3 patients are at higher risk for poor clinical outcomes when compared to patients in Class 1 or Class 2.

Electronic Health Record Tool to Promote Team Communication and Early Patient Mobility in the Intensive Care Unit.

BACKGROUND: Intensive care unit early mobility programs improve patients' outcomes while reducing costs for both patients and institutions. Inadequate interprofessional communication is a known barrier to achieving good early mobility program outcomes. Electronic health record communication tools promoting interprofessional communication have demonstrated improved patient outcomes, but have not been evaluated for mobility in the intensive care unit. OBJECTIVES: To implement an early mobility collaboration program in an existing early mobility program, consisting of protocol education and an electronic health record tool designed to improve interprofessional communication and collaboration. METHODS: In phase 1, staff members viewed an online educational module, the existing mobility protocol, and the "Mobility Levels" grading scale. In phase 2, an electronic health record communication tool displayed recently recorded mobility levels to all care providers. Staff knowledge of the early mobility program and perceptions of mobility-related communication were assessed by survey; patient outcomes including mobility goals, mechanical ventilation time, length of intensive care unit stay, and cost were assessed by records review. RESULTS: Statistically significant increases were found for staff satisfaction with mobility-related communication (P < .001) and communication frequency (P = .02), but not for staff knowledge (P = .28). Hours to achievement of mobility goal (P = .02) and length of intensive care unit stay (P = .02) decreased significantly. Average ventilation time decreased by 27 hours. Discharge recommendations at higher functional levels increased. Total intensive care unit cost decreased significantly (-39.5%; P = .04). CONCLUSIONS: Interprofessional communication and collaboration can lead to improved outcomes. Combining routine educational reviews and an electronic health record communication tool may improve patient and system outcomes for intensive care unit early mobility program patients.

Teaching Diagnostic Reasoning: A Review of Evidence-Based Interventions.

Problem/Background: The ability to accurately diagnose patients based on symptom profiles is a vital yet challenging skill that Nurse Practitioners (NPs) undertake frequently. PURPOSE: This integrative literature review highlights a variety of evidence based, practical educational strategies that foster the development of diagnostic reasoning. METHODS: An integrative literature review was conducted in order to identify original research focusing on diagnostic reasoning educational interventions. RESULTS: Eighteen primary sources met inclusion and exclusion criteria. Results are synthesized in terms of sample and setting, methodological features, interventions, and outcomes. Interventions broadly fit into five educational themes: testing strategies, cognitive biases, simulation programs, course formats, and instructional approaches. DISCUSSION: Interventions are simple and can be implemented in multiple educational settings. Future research should occur in populations of NP students. Validated, easy-to-use measurement tools as well as more precise diagnostic reasoning concept development should occur.