Genomic Competencies for Nursing Practice: Implications for Nursing Leadership.

Nurses must have appropriate knowledge and skills to provide safe and effective nursing care in recognition of evolving science. Knowledge of genomics is required to ensure appropriate referral and education of patients who would benefit from genetic services. This article describes the process the Veterans Healthcare Administration's (VHA's) Office of Nursing Services used to determine the nursing genomic competencies appropriate for VHA nurses and identify available resources for educating nurses on these nursing competencies and a strategic plan for long-term implementation.

Evidence-based practice: Embracing integration.

BACKGROUND: The Veterans Health Administration's Office of Nursing Services launched several initiatives to support evidence-based practice (EBP) initiatives throughout its system. From evaluation of these initiatives and reflection on discussions with nurse leaders and direct care nurses, our thinking about and approach to EBP has evolved from a project-focused to a practice-focused interpretation. PURPOSE: (a) Offer an expanded view that moves beyond interpreting EBP as process-driven projects to a "way of practicing" where nurses assume ownership for a practice that integrates best available evidence, clinical expertise, and patient preferences, and (b) describe and generate discussion on the educational, cultural, and role modeling implications of this expanded view. METHODS: We illustrate EBP integration using a point-of-care interaction scenario. CONCLUSION: Commitment to EBP is reflected at the point-of-care where each nurse demonstrates the ability to integrate evidence-based interventions, patient preferences, and clinical expertise to arrive at patient-centric health care decisions.

Evaluating the Veterans Health Administration's Staffing Methodology Model: A Reliable Approach.

All Veterans Health Administration facilities have been mandated to use a standardized method of determining appropriate direct-care staffing by nursing personnel. A multi-step process was designed to lead to projection of full-time equivalent employees required for safe and effective care across all inpatient units. These projections were intended to develop appropriate budgets for each facility. While staffing levels can be increased, even in facilities subject to budget and personnel caps, doing so requires considerable commitment at all levels of the facility. This commitment must come from front-line nursing personnel to senior leadership, not only in nursing and patient care services, but throughout the hospital. Learning to interpret and rely on data requires a considerable shift in thinking for many facilities, which have relied on historical levels to budget for staffing, but which does not take into account the dynamic character of nursing units and patient need.

Integrating emerging areas of nursing science into PhD programs.

The Council for the Advancement of Nursing Science aims to "facilitate and recognize life-long nursing science career development" as an important part of its mission. In light of fast-paced advances in science and technology that are inspiring new questions and methods of investigation in the health sciences, the Council for the Advancement of Nursing Science convened the Idea Festival for Nursing Science Education and appointed the Idea Festival Advisory Committee to stimulate dialogue about linking PhD education with a renewed vision for preparation of the next generation of nursing scientists. Building on the 2010 American Association of Colleges of Nursing Position Statement "The Research-Focused Doctoral Program in Nursing: Pathways to Excellence," Idea Festival Advisory Committee members focused on emerging areas of science and technology that impact the ability of research-focused doctoral programs to prepare graduates for competitive and sustained programs of nursing research using scientific advances in emerging areas of science and technology. The purpose of this article is to describe the educational and scientific contexts for the Idea Festival, which will serve as the foundation for recommendations for incorporating emerging areas of science and technology into research-focused doctoral programs in nursing.

Emerging areas of science: Recommendations for Nursing Science Education from the Council for the Advancement of Nursing Science Idea Festival.

The Council for the Advancement of Nursing Science aims to "facilitate and recognize life-long nursing science career development" as an important part of its mission. In light of fast-paced advances in science and technology that are inspiring new questions and methods of investigation in the health sciences, the Council for the Advancement of Nursing Science convened the Idea Festival for Nursing Science Education and appointed the Idea Festival Advisory Committee (IFAC) to stimulate dialogue about linking PhD education with a renewed vision for preparation of the next generation of nursing scientists. Building on the 2005 National Research Council report Advancing The Nation's Health Needs and the 2010 American Association of Colleges of Nursing Position Statement on the Research-Focused Doctorate Pathways to Excellence, the IFAC specifically addressed the capacity of PhD programs to prepare nursing scientists to conduct cutting-edge research in the following key emerging and priority areas of health sciences research: omics and the microbiome; health behavior, behavior change, and biobehavioral science; patient-reported outcomes; big data, e-science, and informatics; quantitative sciences; translation science; and health economics. The purpose of this article is to (a) describe IFAC activities, (b) summarize 2014 discussions hosted as part of the Idea Festival, and (c) present IFAC recommendations for incorporating these emerging areas of science and technology into research-focused doctoral programs committed to preparing graduates for lifelong, competitive careers in nursing science. The recommendations address clearer articulation of program focus areas; inclusion of foundational knowledge in emerging areas of science in core courses on nursing science and research methods; faculty composition; prerequisite student knowledge and skills; and in-depth, interdisciplinary training in supporting area of science content and methods.

Emerging areas of nursing science and PhD education for the 21(st) century: response to commentaries.

We respond to commentaries from the American Academy of Nursing, the American Association of Colleges of Nursing, and the National Institute of Nursing Research on our thoughts about integrating emerging areas of science into nursing PhD programs. We identify areas of agreement and focus our response on cross-cutting issues arising from cautions about the unique focus of nursing science and how best to proceed with incorporation of emerging areas of science into nursing PhD programs.

Genomics for Nursing Education and Practice: Measuring Competency.

BACKGROUND: Nurses lack genome literacy, skill, and self-confidence in applying genomics to health care. Standardized curricula and evaluation tools are needed for wide spread uptake and application of genome science in nursing education, practice, and research. AIM: To determine whether psychometrically robust survey instruments exist to assess knowledge, skills, attitudes, and self-confidence in applying genomic nursing competency among students and registered nurses. DESIGN: Psychometric systematic review. DATA SOURCES: Medline, CINAHL, Academic Search Elite, Web of Science, and ProQuest Dissertations were searched from 1995 to 2014, with an English language restriction. PROCEDURES: Critical analysis of the study elements and psychometric attributes was conducted after data were abstracted into analysis and synthesis tables. The synthesis assessed the design, methods, and measurement properties with a focus on reliability and validity using 16 criteria on a 4-point grading scale. FINDINGS: Twelve studies were included in a detailed review that focused on assessment of genomic nursing core competencies. Six studies met the inclusion criteria. In terms of psychometric quality of the instruments, one study scored high, two moderate, two low, and one very low. LINKING EVIDENCE TO ACTION: Most instruments assess self-perceived rather than objectively assessed competency. The highest quality instrument lacks clinical application. Knowledge-focused test questions based on up-to-date genome science that are relevant to practice need to be developed.

Impact of provider coordination on nurse and physician perceptions of patient care quality.

The objective of this study was to assess the role of provider coordination on nurse manager and physician perceptions of care quality, while controlling for organizational factors. Findings indicated that nurse-nurse coordination was positively associated with nurse manager perceptions of care quality; neither physician-physician nor physician-nurse coordination was associated with physician perceptions. Organizational factors associated with positive perceptions of care quality included facility support of education for nurses and physicians, and the use of multidisciplinary rounding.

Academic practice partnerships: a national dialogue.

Academic-practice partnerships are an important mechanism to strengthen nursing practice and help nurses become well positioned to lead change and advance health. Through implementing such partnerships, both academic institutions and practice settings will formally address the recommendations of the Institute of Medicine Future of Nursing Committee. Effective partnerships will create systems for nurses to achieve educational and career advancement, prepare nurses of the future to practice and lead, provide mechanisms for lifelong learning, and provide a structure for nurse residency programs. This paper details the work of the American Association of Colleges of Nursing-American Organization of Nurse Executives Task Force on Academic-Practice Partnerships that has identified hallmarks of successful partnership and produced tools and shared exemplars to assist nursing leaders in developing and sustaining partnerships for the future.

Nurse staffing and patient care costs in acute inpatient nursing units.

OBJECTIVE: Studies suggest that a business case for improving nurse staffing can be made to increase registered nurse (RN) skill mix without changing total licensed nursing hours. It is unclear whether a business case for increasing RN skill mix can be justified equally among patients of varying health needs. This study evaluated whether nursing hours per patient day (HPPD) and skill mix are associated with higher inpatient care costs within acute medical/surgical inpatient units using data from the Veterans Health Administration. METHODS: Retrospective cross-sectional study, including 139,360 inpatient admissions to 292 acute medical/surgical units at 125 Veterans Health Administration medical centers between February and June 2003, was conducted. Dependent variables were inpatient costs per admission and costs per patient day. RESULTS: The average costs per surgical and medical admission were $18,624 and $6,636, respectively. Costs per admission were positively associated with total nursing HPPD among medical admissions ($164.49 per additional HPPD, P<0.001), but not among surgical admissions. Total nursing HPPD and RN skill mix were associated with higher costs per hospital day for both medical admissions ($79.02 per additional HPPD and $5.64 per 1% point increase in nursing skill mix, both P<0.001) and surgical admissions ($112.47 per additional HPPD and $13.31 per 1% point increase in nursing skill mix, both P<0.001). Patients experiencing complications or transferring to an intensive care unit had higher inpatient costs than other patients. CONCLUSIONS: The association of nurse staffing level with costs per admission differed for medical versus surgical admissions.

The Department of Veterans Affairs Nursing Academy (VANA): forging strategic alliances with schools of nursing to address nursing's workforce needs.

In 2007, the Department of Veterans Affairs (VA) established the VA Nursing Academy (VANA), a 5-year, $60-million pilot program funding 15 partnerships between schools of nursing and local VA health care facilities nationwide, to expand nursing faculty, enhance clinical faculty development, increase nursing student enrollment, and promote educational innovations. VA is an ideal setting for educating nursing students owing to a well-educated registered nurse staff, an array of traditional and nontraditional settings, a state-of-the-art computerized electronic health record system, and a unique patient population. Challenges related to the complex nature of VANA partnerships, conceptualized as strategic alliances created between disparate subunits, each embedded in a larger organization, require careful governance to ensure smooth implementation. To ensure the program's aims are met, a 6-year national evaluation has been funded to help identify which strategies best achieve VANA's goals. The speed of economic recovery and the resulting changes in the nursing workforce are important determinants of VANA's future.

Adding a Nursing Information Technology Subscale to the Practice Environment Scale of the Nursing Work Index.

In the past decade, the use of information technology (IT) to support healthcare delivery has greatly expanded. Introducing new clinical information systems and updating existing systems require continued learning and training among registered nurses (RNs) and other clinicians. Consequently, a 5-item measure was designed as a subscale to the Practice Environment Scale of the Nursing Work Index. This new subscale, the Nursing Information Technology Subscale (NITS) measures RNs' perception of the extent to which IT in their practice environment supports patient care delivery. A psychometric evaluation of the NITS was conducted at 8 Veterans Affairs hospitals. The findings demonstrated that this brief subscale has acceptable reliability as well as convergent and discriminant validity.

The association between nursing factors and patient mortality in the Veterans Health Administration: the view from the nursing unit level.

CONTEXT: Nurse staffing is not the same across an entire hospital. Nursing care is delivered in geographically-based units, with wide variation in staffing levels. In particular, staffing in intensive care is much richer than in nonintensive care acute units. OBJECTIVE: To evaluate the association of in-hospital patient mortality with registered nurse staffing and skill mix comparing hospital and unit level analysis using data from the Veterans Health Administration (VHA). DESIGN, SETTINGS, AND PATIENTS: A retrospective observational study using administrative data from 129,579 patients from 453 nursing units (171 ICU and 282 non-ICU) in 123 VHA hospitals. METHODS: We used hierarchical multilevel regression models to adjust for patient, unit, and hospital characteristics, stratifying by whether or not patients had an ICU stay during admission. MAIN OUTCOME MEASURE: In-hospital mortality. RESULTS: : Of the 129,579 patients, mortality was 2.9% overall: 6.7% for patients with an ICU stay compared with 1.6% for those without. Whether the analysis was done at the hospital or unit level affected findings. RN staffing was not significantly associated with in-hospital mortality for patients with an ICU stay (OR, 1.02; 95% CI, 0.99-1.03). For non-ICU patients, increased RN staffing was significantly associated with decreased mortality risk (OR, 0.91; 95% CI, 0.86-0.96). RN education was not significantly associated with mortality. CONCLUSIONS: Our findings suggest that the association between RN staffing and skill mix and in-hospital patient mortality depends on whether the analysis is conducted at the hospital or unit level. Variable staffing on non-ICU units may significantly contribute to in-hospital mortality risk.

The Department of Veterans Affairs pre- and post-doctoral nurse fellowships: diverse opportunities for research.

The purpose of this article is to explicate research funding and training opportunities available through the Department of Veterans Affairs to nurses seeking advanced preparation at the pre- and post-doctoral levels. A brief discussion of the available resources including student stipend and health insurance, workspace, and research support is presented. Additionally, articulation of the benefits and challenges associated with these types of fellowships is delineated from the perspective of a fellow, Department of Veterans Affairs (VA) site preceptor, and dissertation faculty. Discussion of the post-doctoral fellowship and the extensive resources of the VA related to overall research career development are also addressed.

Promoting respect for persons: developing a brochure for research participants.

The Institute of Medicine report Responsible Research: A Systems Approach to Protecting Research Participants noted that research participants require educational materials and ongoing interactions with investigators and healthcare professionals to have sufficient information to make a choice and be empowered to ask questions regarding their research participation. One of the ethical principles outlined in the Belmont Report, Respect for Persons, provided the framework for developing a brochure for research participants specific to the Department of Veterans Affairs (VA). The intent was to provide veterans and their families information about research in the VA and a list of basic questions to guide them through the complex decision making about their rights as research participants.

Addressing nurses' ethical concerns about research in critical care settings.

Clinical research with critically ill patients presents numerous ethical issues affecting patients' well-being, research integrity, and nursing practice. Key findings from a survey of critical care nurses' perceptions about research ethical issues in these settings indicated that nurses encounter ethical issues about which they have limited knowledge and they may not seek guidance from the most appropriate resources. The results suggest that nurses, as well as researchers, need not only training about the responsible conduct of research but also visible and highly functional organizational structures to support and oversee clinical research in research-oriented medical centers.