Application of Caring Theory to Nursing Care of Women Experiencing Stillbirth.

PURPOSE: The purpose of this study was to determine the extent to which labor and delivery nurses used the tenets of Swanson's middle-range theory to care for women whose babies were stillborn. STUDY DESIGN AND METHODS: A secondary analysis of qualitative in-depth interview data from 20 labor and delivery nurses obtained during a recent grounded theory study was conducted using the directed content analysis method. The five caring processes as described in Swanson's theory were used as a priori codes to conduct the analysis. RESULTS: Nursing care of a woman experiencing a stillbirth included finding a way to connect with her and to understand what she was experiencing (knowing), spending extra time with her (being with), protecting her and preserving her dignity (doing for), providing information and explanations in a clear and methodical manner (enabling), and ensuring that she did not blame herself to facilitate the grieving/healing process (maintaining belief). CLINICAL IMPLICATIONS: The caring processes outlined in Swanson's theory of caring provide a valuable guide that can be used when caring for women experiencing stillbirth.

Adaptation of Coping Together - a self-directed coping skills intervention for patients and caregivers in an outpatient hematopoietic stem cell transplantation setting: a study protocol.

BACKGROUND: Despite numerous reports of significant distress and burden for hematopoietic stem cell transplantation (HSCT) patients and caregivers (CGs), HSCT-specific coping interventions remain rare. The few in use lack specificity and are often not easily accessible or cost-effective. Whereas the development of new interventions is resource-intensive, theory-informed adaptation of existing evidence-based interventions is promising. To date, no HSCT-specific intervention has relied on a formal adaptation approach. METHODS: Using the Center for Disease Control and Prevention's Map of Adaptation, this two-phase qualitative descriptive study seeks to understand the perceptions of HSCT patients, CGs, individually, and in dyads, and clinicians about Coping Together (CT) for the preliminary adaptation (Phase 1), and then explores perceptions of the modified intervention in additional mixed sample (Phase 2). Six to ten participants including outpatients, CGs and dyads and five to seven HSCT clinician participants will be recruited for Phase 1. For Phase 2, 14 to 16 participants including outpatients, CGs and dyads will be recruited. Individual and dyadic semi-structured interviews will take place between 100 and 130 days post-HSCT. Verbatim transcripts will be analyzed using content analysis. DISCUSSION: It is paramount to have HSCT-specific supportive interventions that address patients' and CGs' multidimensional and complex needs. The timely involvement of key stakeholders throughout the adaptation process is likely to optimize the relevance and uptake of such tailored intervention. TRIAL REGISTRATION: This study is registered on October 6, 2016 in ClinicalTrials.gov at (identifier number NCT02928185 ).

The benefits of respectful interactions: fluid alliancing and inter-occupational information sharing in primary care.

Though inter-occupational interactions in health care have been the focus of increasing attention, we still know little about how such interactions shape information sharing in clinical settings. This is particularly true in primary care where research on teams and collaboration has been based on individual perceptions of work (using surveys and interviews) rather than observing the interactions that directly mediate the inter-occupational flow of information. To explore how interactions shape information sharing, we conducted a secondary analysis of ethnographic data from 27 primary care practices. Ease of information sharing among nurses and doctors is linked to the degree to which practices feature respectful interactions, with practices in the sample falling into one of three categories (those with low, uneven, and high degrees of respectful interactions). Those practices with the highest degree of respectful interactions demonstrate what we describe as fluid-alliancing: flexible interactions between individuals from different occupational groups in which bidirectional information sharing occurs for the benefit of patients and the efficacy of the practice community. We conclude by arguing that this process unlocks the strengths of all practice members, and that leadership should encourage respectful interactions to augment organisational efficacy and the ability of individual practice members to provide quality patient care.

Complex patients and interprofessional relationships: Perceptions of primary care nurse practitioners and primary care physicians.

PURPOSE: The literature describing primary care nurse practitioners (PCNPs) and primary care physicians (PCPs) suggests that PCNPs provide care to patients with less complicated diagnoses than their PCP colleagues. However, other literature suggests the contrary. Therefore, the purpose of this qualitative study was to understand how patients are assigned and cared for by primary care clinicians and how these clinicians relate to one another. Additionally we explore how PCNPs relate to physicians outside the practice. DATA SOURCES: Two nurse investigators conducted in-depth qualitative interviews with a nurse practitioner and a family medicine physician leader in each of 10 primary care practices. A content analysis was used to identify major themes. CONCLUSIONS: The participating PCNPs and PCPs have highly collaborative relationships. PCNPs often function independently, engage in reciprocal consultations with PCPs, and provide care to highly complex patients. In contrast to their relationships with practice colleagues, PCNP relationships with physicians outside the practice are disruptive. IMPLICATIONS FOR PRACTICE: These findings indicate that PCNPs are well positioned to assume responsibility for a diversity of primary care patients, including those with complex diagnoses. To promote the more effective integration of PCNPs, interprofessional barriers must be addressed by healthcare organizations and policy experts.

The experience of information sharing among primary care clinicians with cancer survivors and their oncologists.

PURPOSE OF STUDY: Knowledge about information sharing among primary care clinicians, oncologists, and their cancer patients is critical given its importance in facilitating the delivery of quality care to the increasing number of cancer survivors. The purpose of our study was to provide a better understanding of the nature of interactions among primary care clinicians, patients, and oncologists throughout the cancer care continuum to better understand the transition to survivorship. METHOD: Twenty-one qualitative in-depth interviews were conducted with 11 primary care physicians and 10 nurse practitioners. Themes were identified using content analysis. RESULTS: The following themes emerged from the data including: (1) a visit is worth a thousand written reports--primary care clinicians described the importance of patient visits during cancer treatment; (2) community vs. cancer center oncologists--primary care clinicians described differences in information sharing with community oncologists as compared with those in academic centers; (3) correcting for information deficits--primary care clinicians, unable to obtain regular progress reports directly from oncologists, developed indirect strategies to obtain information; (4) the deficiencies in post-treatment follow-up care plans; and (5) the panacea of electronic medical records and survivor care plans. CONCLUSIONS: The themes that emerged from this work describe in detail the absence of systematic information sharing among primary care clinicians, patients, and oncologists that is needed to support quality survivorship care in the primary care setting. The descriptions by primary care clinicians contribute to a deeper understanding of the daily challenges that both interfere and/or support primary care clinicians in their care of survivors of cancer. IMPLICATIONS FOR CANCER SURVIVORS: Managing the complex care of cancer survivors often requires the expertise of a number of skilled providers. Information sharing among these individuals is one of the most fundamental aspects of ensuring effective transitions in care. Our results indicate that systematic information sharing among providers caring for cancer survivors is lacking. Identifying strategies to enhance information sharing among and between providers is essential to facilitating the delivery of high-quality survivor care.

Strategies used and challenges faced by a breast cancer patient navigator in an urban underserved community.

Patient navigation has been widely implemented by cancer care programs across the United States. While activities of navigators have been described elsewhere, little has been documented regarding specific strategies used or challenges experienced by navigators from their own perspectives. We describe the experience of an African American patient navigator who promoted breast cancer screening and facilitated diagnosis and treatment among inner-city mostly African American women in Newark, New Jersey. We conducted qualitative analysis of journal notes, log data, and in-depth interviews with the patient navigator. Strategies used by the patient navigator to develop trust and rapport included: (1) "meet patients where they are" (outreach is best performed in locations women frequent, such as hair salons); (2) being accessible (must be flexible and available by phone or in person to meet patient's needs); and (3) "bring it down, sista" (must have "street credibility" in dress and language). Key challenges included experiencing threats to safety, setting boundaries, and facing and overcoming burnout. The patient navigator responded to these obstacles by creating new community linkages and resources and reaching out for emotional support from her mother and supervisor. Areas that need to be addressed further for future patient navigator programs include promoting safety in potentially dangerous neighborhoods and helping navigators set boundaries and avoid burnout. Further research into experiences of patient navigators in different settings is needed to build upon this preliminary data, and to consider character traits and attributes best suited for a patient navigator, as well as the support needed for this new health care worker.

Organizational culture influences health care workers' influenza immunization behavior.

BACKGROUND AND OBJECTIVES: Low rates of influenza immunization among health care workers (HCWs) pose a potential health risk to patients in primary care practices. Despite previous educational efforts and programs to reduce financial barriers, HCW influenza immunization rates remain low. Variation in practice-level organizational culture may affect immunization rates. To explore this relationship, we examined organizational cultures and HCWs' influenza immunization behaviors in three family medicine practices. METHODS: We used a multi-method comparative case study. A field researcher used participant observation, in-depth interviews, and key informant interviews to collect data in each practice in November-December 2003. A diverse team used grounded theory to analyze text data. RESULTS: Organizational culture varied among practices and differing HCW immunization rates were observed. The most structured and business-like practice achieved immunization of all HCWs, while the other two practices exhibited greater variation in HCW immunization rates. Physicians in the practices characterized as chaotic/disorganized or divided were immunized at higher rates than other members of the practices. CONCLUSIONS: In these practices, organizational culture was associated with varying rates of influenza immunization for HCWs, especially among nonphysicians. Addressing elements of organizational culture such as beliefs regarding influenza immunization and office policies may facilitate the immunization of all staff members.

Understanding healing relationships in primary care.

PURPOSE: Clinicians often have an intuitive understanding of how their relationships with patients foster healing. Yet we know little empirically about the experience of healing and how it occurs between clinicians and patients. Our purpose was to create a model that identifies how healing relationships are developed and maintained. METHODS: Primary care clinicians were purposefully selected as exemplar healers. Patients were selected by these clinicians as having experienced healing relationships. In-depth interviews, designed to elicit stories of healing relationships, were conducted with patients and clinicians separately. A multidisciplinary team analyzed the interviews using an iterative process, leading to the development of case studies for each clinician-patient dyad. A comparative analysis across dyads was conducted to identify common components of healing relationships RESULTS: Three key processes emerged as fostering healing relationships: (1) valuing/creating a nonjudgmental emotional bond; (2) appreciating power/consciously managing clinician power in ways that would most benefit the patient; and (3) abiding/displaying a commitment to caring for patients over time. Three relational outcomes result from these processes: trust, hope, and a sense of being known. Clinician competencies that facilitate these processes are self-confidence, emotional self-management, mindfulness, and knowledge. CONCLUSIONS: Healing relationships have an underlying structure and lead to important patient-centered outcomes. This conceptual model of clinician-patient healing relationships may be generalizable to other kinds of healing relationships.

Complementary and alternative medicine in US family medicine practices: a pilot qualitative study.

CONTEXT: The growth of complementary and alternative medicine (CAM) has led some family medicine practices to include CAM. Acupuncture or herbal medicine, for example, may be offered at such practices. When a practice incorporates both CAM and conventional treatments, its goals and values may differ from those found in traditional primary care. Little is known about the development of these integrated practices, which may be expected to become more widespread. OBJECTIVE: To identify some of the concepts and challenges shaping family medicine practices that incorporate CAM. DESIGN: Comparative case study. METHOD: Multi-method assessment process including participant observation, key informant interviews, semi-structured depth interviews, and observation of patient-provider encounters. SETTING: Four family medicine/CAM practices in the mid-Atlantic region of the United States. RESULTS: Key themes that influence these practices' organization include dimensions of health, the selection of therapies used, the practices' approach to evidence, their perspective on the amount of time spent with patients, and their adaptations to financial concerns. Each practice emphasized long patient visits. In each, physicians had expertise that enabled them to draw on both conventional medicine and CAM. CONCLUSION: Successful incorporation of CAM modalities within a family medicine framework requires adaptation not only at the practice level but also by individual physicians.

Variation in electronic prescribing implementation among twelve ambulatory practices.

BACKGROUND: Electronic prescribing has been advocated as an important tool for improving the safety and quality of medication use in ambulatory settings. However, widespread adoption of e-prescribing in ambulatory settings has yet to be realized. The determinants of successful implementation and use in these settings are not well understood. OBJECTIVE: To describe the practice characteristics associated with implementation and use of e-prescribing in ambulatory settings. DESIGN: Multi-method qualitative case study of ambulatory practices before and after e-prescribing implementation. PARTICIPANTS: Sixteen physicians and 31 staff members working in 12 practices scheduled for implementation of an e-prescribing program and purposively sampled to ensure a mix of practice size and physician specialty. MEASUREMENTS: Field researchers used observational and interview techniques to collect data on prescription-related clinical workflow, information technology experience, and expectations. RESULTS: Five practices fully implemented e-prescribing, 3 installed but with only some prescribers or staff members using the program, 2 installed and then discontinued use, 2 failed to install. Compared to practice members in other groups, members of successful practices exhibited greater familiarity with the capabilities of health information technologies and had more modest expectations about the benefits likely to accrue from e-prescribing. Members of unsuccessful practices reported limited understanding of e-prescribing capabilities, expected that the program would increase the speed of clinical care and reported difficulties with technical aspects of the implementation and insufficient technical support. CONCLUSIONS: Practice leaders should plan implementation carefully, ensuring that practice members prepare for the effective integration of this technology into clinical workflow.

Developing a model of social capital: relationships in primary care.

We have developed a model of social capital to enhance relationships within primary care practices that promote organizational success and improve patient care outcomes. The model extends the meaning and the value of social capital by providing dimensions, attributes, and operational definitions that can be used to measure outcomes and guidelines to develop future interventions. Our model brings new insight and logic to understanding relationships to create resources to improve primary care practices. Furthermore, our model provides a preliminary focus on the value of integrating registered nurses into the work of primary care practices and as facilitators of social capital.

Electronic medical records and diabetes quality of care: results from a sample of family medicine practices.

PURPOSE: Care of patients with diabetes requires management of complex clinical information, which may be improved by the use of an electronic medical record (EMR); however, the actual relationship between EMR usage and diabetes care quality in primary care settings is not well understood. We assessed the relationship between EMR usage and diabetes care quality in a sample of family medicine practices. METHODS: We conducted cross-sectional analyses of baseline data from 50 practices participating in a practice improvement study. Between April 2003 and December 2004 chart auditors reviewed a random sample of medical records from patients with diabetes in each practice for adherence to guidelines for diabetes processes of care, treatment, and achievement of intermediate outcomes. Practice leaders provided medical record system information. We conducted multivariate analyses of the relationship between EMR usage and diabetes care adjusting for potential practice- and patient-level confounders and practice-level clustering. RESULTS: Diabetes care quality in all practices showed room for improvement; however, after adjustment, patient care in the 37 practices not using an EMR was more likely to meet guidelines for process (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.42-3.57) treatment (OR, 1.67; 95% CI, 1.07-2.60), and intermediate outcomes (OR, 2.68; 95% CI, 1.49-4.82) than in the 13 practices using an EMR. CONCLUSIONS: The use of an EMR in primary care practices is insufficient for insuring high-quality diabetes care. Efforts to expand EMR use should focus not only on improving technology but also on developing methods for implementing and integrating this technology into practice reality.

The qualitative research interview.

BACKGROUND: Interviews are among the most familiar strategies for collecting qualitative data. The different qualitative interviewing strategies in common use emerged from diverse disciplinary perspectives resulting in a wide variation among interviewing approaches. Unlike the highly structured survey interviews and questionnaires used in epidemiology and most health services research, we examine less structured interview strategies in which the person interviewed is more a participant in meaning making than a conduit from which information is retrieved. PURPOSE: In this article we briefly review the more common qualitative interview methods and then focus on the widely used individual face-to-face in-depth interview, which seeks to foster learning about individual experiences and perspectives on a given set of issues. We discuss methods for conducting in-depth interviews and consider relevant ethical issues with particular regard to the rights and protection of the participants.

Delivery of clinical preventive services in family medicine offices.

BACKGROUND: This study aimed to elucidate how clinical preventive services are delivered in family practices and how this information might inform improvement efforts. METHODS: We used a comparative case study design to observe clinical preventive service delivery in 18 purposefully selected Midwestern family medicine offices from 1997 to 1999. Medical records, observation of outpatient encounters, and patient exit cards were used to calculate practice-level rates of delivery of clinical preventive services. Field notes from direct observation of clinical encounters and prolonged observation of the practice and transcripts from in-depth interviews of practice staff and physicians were systematically examined to identify approaches to delivering clinical preventive services recommended by the US Preventive Services Task Force. RESULTS: Practices developed individualized approaches for delivering clinical preventive services, with no one approach being successful across practices. Clinicians acknowledged a 3-fold mission of providing acute care, managing chronic problems, and prevention, but only some made prevention a priority. The clinical encounter was a central focus for preventive service delivery in all practices. Preventive services delivery rates often appeared to be influenced by competing demands within the clinical encounter (including between different preventive services), having a physician champion who prioritized prevention, and economic concerns. CONCLUSIONS: Practice quality improvement efforts that assume there is an optimal approach for delivering clinical preventive services fail to account for practices' propensity to optimize care processes to meet local contexts. Interventions to enhance clinical preventive service delivery should be tailored to meet the local needs of practices and their patient populations.

Social network analysis as an analytic tool for interaction patterns in primary care practices.

PURPOSE: Social network analysis (SNA) provides a way of quantitatively analyzing relationships among people or other information-processing agents. Using 2 practices as illustrations, we describe how SNA can be used to characterize and compare communication patterns in primary care practices. METHODS: Based on data from ethnographic field notes, we constructed matrices identifying how practice members interact when practice-level decisions are made. SNA software (UCINet and KrackPlot) calculates quantitative measures of network structure including density, centralization, hierarchy and clustering coefficient. The software also generates a visual representation of networks through network diagrams. RESULTS: The 2 examples show clear distinctions between practices for all the SNA measures. Potential uses of these measures for analysis of primary care practices are described. CONCLUSIONS: SNA can be useful for quantitative analysis of interaction patterns that can distinguish differences among primary care practices.

Speaking of weight: how patients and primary care clinicians initiate weight loss counseling.

BACKGROUND: Obesity is epidemic in the US and other industrialized countries and contributes significantly to population morbidity and mortality. Primary care physicians see a substantial portion of the obese population, yet rarely counsel patients to lose weight. METHODS: Descriptive field notes of outpatient visits collected as part of a multimethod comparative case study were used to study patterns of physician-patient communication around weight control in 633 encounters in family practices in a Midwestern state. RESULTS: Sixty-eight percent of adults and 35% of children were overweight. Excess weight was mentioned in 17% of encounters with overweight patients, while weight loss counseling occurred with 11% of overweight adults and 8% of overweight children. In weight loss counseling encounters, patients formulated weight as a problem by making it a reason for visit or explicitly or implicitly asking for help with weight loss. Clinicians did so by framing weight as a medical problem in itself or as an exacerbating factor for another medical problem. CONCLUSIONS: Strategies that increase the likelihood of patients identifying weight as a problem, or that provide clinicians with a way to "medicalize" the patient's obesity, are likely to increase the frequency of weight loss counseling in primary care visits.

Opportunistic approaches for delivering preventive care in illness visits.

OBJECTIVE: To describe how clinicians create opportunities to deliver preventive care in illness visits and assess the impact this has on preventive service delivery. METHOD: Detailed and descriptive fieldnotes were collected from 18 purposefully selected family practices, including direct observations of 53 primary care clinicians and 1620 patient encounters. Conversation analysis was used to examine the conversational techniques employed to deliver four preventive services (smoking counseling, immunization delivery, mammography, and cervical cancer screening) in illness visits. Qualitative data was coded and analyzed to assess impact on preventive service delivery rates. RESULTS: Two methods for opportunistic preventive service delivery were observed. In the first, clinicians used the close of the medical encounter to make arrangement for follow-up preventive care. In the second approach, clinicians use a stepwise conversational device to exit talk about the patient's presenting problem and enter into relevant health habit advice. Quantitative analyses show that opportunistic methods are rarely used to deliver preventive services in illness visits. The stepwise technique was the most frequently used method. Patients treated by clinicians who used opportunistic techniques to deliver preventive care in illness visits were more likely to be up-to-date on smoking counseling and cervical cancer screening than those patients who were treated by clinicians who did not use opportunistic approaches. CONCLUSIONS: Opportunistic preventive service delivery in illness visits can be an efficient and effective way to deliver preventive care. Although infrequently used, quantitative data suggest that the use of opportunistic approaches to deliver preventive services during illness visits can enhance preventive care rates. Interventions aimed at helping clinicians develop effective strategies for offering preventive care during illness visits may be an important complement to existing mechanical interventions that might, by themselves, be insufficient to improve preventive care.

The racial and gendered experiences of immigrant nurses from Kerala, India.

The purpose of this article is to describe the experience of a group of immigrant women nurses regarding their life and work in a culture other than their own. Semistructured, in-depth interviews were conducted with nurses who were born in Kerala, India, educated in India, and are actively employed as nurses in the United States. The participants told stories that were about (a) the challenges of living between two cultures and countries, (b) the racism they experience, and (c) their marginalization as female nurses of color. This study underscores the continuing inequities of our health care system. Our challenge is to establish a more just and effective environment for those who provide care as well as those who receive it.

Home care nurses: a study of the occurrence of culturally competent care.

The purpose of this study is to describe how home care nurses orient to and manage cultural issues during patient visits. Fourteen home care nurse-patient dyads were observed. Interviews were then conducted with nurses. Nurses and the home care agencies for which they worked engaged in practices aimed at minimizing patients' cultural practices and beliefs. A correspondence with how nurses oriented to patients' cultures and how cultural issues were managed during encounters was observed. Overwhelmingly, nurses and home care agencies used strategies to avoid dealing with patients' "different" cultural backgrounds. Work needs to be done to begin integrating theory and practice regarding culturally competent health care.

Assessing diversity and quality in primary care through the multimethod assessment process (MAP).

The U.S. health care system serves a diverse population, often resulting in significant disparities in delivery and quality of care. Nevertheless, most quality improvement efforts fail to systematically assess diversity and associated disparities. This article describes application of the multimethod assessment process (MAP) for understanding disparities in relation to diversity, cultural competence, and quality improvement in clinical practice. MAP is an innovative quality improvement methodology that integrates quantitative and qualitative techniques and produces a system level understanding of organizations to guide quality improvement interventions. A demonstration project in a primary care practice illustrates the utility of MAP for assessing diversity.