Emerging Adults with Diabetes in Safety-Net Care: Self-Management Influences and Patient-Provider Interactions.

Emerging adults with diabetes, particularly in underserved communities, represent a growing but less studied population whose needs may differ from older adults. This study investigated perspectives of underserved emerging adults regarding diabetes self-management influences and provider interactions. Focus groups and interviews with emerging adults in a safety-net health care setting were conducted to identify perspectives regarding self-management influences and patient-provider interactions. Diabetes was perceived as a psychological burden complicated by busy lifestyles and competing responsibilities. Lack of resources, especially financial barriers, also limited self-management. Participants often perceived diabetes visits as standardized encounters providing access to diabetes supplies but desired additional guidance appropriate to their needs and life-stage. Participants valued encouragement and positive ongoing provider relationships for tailored informational and emotional support and support from family and peers. Providers and health care systems adapting to provide or facilitate this support will be better able to optimize diabetes management at and between visits.

Diabetes Care Provider Perceptions Regarding Emerging Adults' Diabetes Self-Management Influences and Patient-Provider Visit Interactions Within a Safety-Net Hospital.

The increasing number of emerging adults with diabetes (EAWD) being cared for in adult health care settings requires a better understanding of the needs of EAWD and their interactions with adult health care providers (HCPs). This article describes findings from interviews with endocrinologists and diabetes nurses from a safety-net health care system to investigate HCPs' perspectives regarding influences on EAWD self-management and HCP interactions with EAWD. HCPs frequently perceived lower EAWD engagement in diabetes management, which was complicated by barriers such as the emotional burden of diabetes, busy lives and multiple responsibilities, and limited access to resources; however, HCPs valued the role of information and communication at visits in tailoring care for EAWD. Measures to tailor care should address the psychosocial burden related to the life stage goals and priorities of EAWD, identification of resources for EAWD and HCPs, and further elucidation of effective self-management guidance and communication strategies to support EAWD in safety-net settings.

Start Together, Stay Together: Nurse Residencies of the Future.

Consumerism and globalism are driving the demand for new business and education models. Nurse executives in all work environments are facing the need to innovate and implement new service models in a nimble and rapid manner. This article highlights the current and future state of nursing education and clinical practice integration through the lens of an academic-practice partnership, by demonstrating the benefit of a unified approach to nurse residencies. Through adaption and creation of a shared culture, education and service can work effectively together in the development of a pipeline for future nurses in a wide array of nursing roles. As partners, they can demonstrate the nursing profession's ability to meet the health needs of consumers at a local, national, and global level. Agile evolution of the traditional nurse residency model is an imperative for professional nursing practice.

Enacting high reliability principles while caring for people with Ebola Virus Disease.

BACKGROUND: Fear surrounds Ebola Virus Disease (EVD) because it is highly infectious. Yet members of the Serious Communicable Diseases Unit (SCDU) at Emory University Hospital (EUH) had to overcome that fear when caring for patients with EVD. PURPOSE: The analysis reported here illustrates how the members of EUH's SCDU tacitly enacted high reliability (HR) principles while caring for patients with EVD. METHODS: A qualitative study was conducted to describe the experience of members of the EUH SCDU who worked with EVD patients in 2014. We completed 17 semi-structured interviews involving registered nurses, physicians, and support personnel (eg, laboratory technicians). Interview recordings were transcribed and analyzed using conventional content analysis. Exploring HR principles was not among the questions guiding this exploration, but the participants repeatedly described concepts related to HR. RESULTS: The goal of the SCDU team was to save patients' lives while protecting their own lives. Rigorous training and meeting high standards were required to make the team. The fear surrounding EVD set in motion the enactment of HR principles. HR principles served to alleviate failures or breakdowns in infection prevention and control, thus keeping patients and staff safe. CONCLUSIONS: These findings illustrate that it is possible to move HR principles from theory to practice in high-risk situations. HR principles were essential to safety and to infection prevention and control.

Are CNM-Attended Births in Texas Hospitals Underreported?

INTRODUCTION: Accurate data on the number of births attended by certified nurse-midwives and certified midwives (CNMs/CMs) are required to establish the public health benefits attributed to the midwifery model of care and the role of CNMs/CMs in the US health care system. However, the number of CNM/CM-attended births may be underreported in birth certificate data. The purpose of this project was to estimate the number of births CNM practices attended in Texas hospitals in 2014 and to describe Texas CNMs' knowledge about their hospitals' policies on naming CNMs as birth attendants. METHODS: CNMs from Texas practices employing CNMs completed a survey. Descriptive statistics were used to summarize respondent data. These results were used to impute data for practices that did not respond to the survey so that total estimates for the state could be calculated. RESULTS: CNM-attended hospital births in Texas in 2014 may be underreported by 65%. Most CNMs (90%) keep records of births attended, but only 19% of practices receive facility reports with the births CNMs in the practice attended. DISCUSSION: CNMs/CMs need to regularly verify that they are being named as the provider on birth certificates for births they attend and work with advocacy groups, hospital administrators, physicians, legislators, and policy makers to improve the accuracy of birth certificate data.

The Effect of a Youth-Centered Sexual Risk Event History Calendar (SREHC) Assessment on Sexual Risk Attitudes, Intentions, and Behavior.

INTRODUCTION: The purpose of this study was to examine the effect of a youth-centered assessment, the Sexual Risk Event History Calendar (SREHC), compared with the Guidelines for Adolescent Preventive Services (GAPS) assessment, on sexual risk attitudes, intentions, and behaviors. METHODS: The Interaction Model of Client Health Behavior guided this participatory research-based randomized control trial. Youth participants recruited from university and community clinics in the Midwestern United States were randomized to a health care provider visit using either the SREHC or GAPS and completed surveys at baseline, postintervention, and 3, 6, and 12 months. RESULTS: Participants included 181 youth (15-25 years old) and nine providers. Findings showed that youth in the SREHC group reported stronger intentions to use condoms compared with those in the GAPS group. Age and race were also significant predictors of sexual experience. DISCUSSION: This study highlights the importance of using a youth-centered, systematic approach in the assessment of sexual risk behaviors.

Patient-Centered Participatory Research in Three Health Clinics: Benefits, Challenges, and Lessons Learned.

Research informed by individuals' lived experiences is a critical component of participatory research and nursing interventions for health promotion. Yet, few examples of participatory research in primary care settings with adolescents and young adults exist, especially with respect to their sexual health and health-risk behaviors. Therefore, we implemented a validated patient-centered clinical assessment tool to improve the quality of communication between youth patients and providers, sexual risk assessment, and youths' health-risk perception to promote sexual health and reduce health-risk behaviors among adolescents and young adults in three community health clinic settings, consistent with national recommendations as best practices in adolescent health care. We describe guiding principles, benefits, challenges, and lessons learned from our experience. Improving clinical translation of participatory research requires consideration of the needs and desires of key stakeholders (e.g., providers, patients, and researchers) while retaining flexibility to successfully navigate imperfect, real-world conditions.

Strategic modeling of the neonatal nurse practitioner workforce.

BACKGROUND: Neonatal nurse practitioners (NNPs) play a vital role in the medical care of newborns and infants. There is expected to be a shortage of NNPs in the near future. PURPOSE: To assess the present NNP workforce and study the impact of potential policy changes to alleviate forecasted shortages. METHODS: We modeled the education and workforce system for NNPs. Forecasting models were combined with optimal decision-making to derive best-case scenario admission levels for graduate and undergraduate programs. DISCUSSION: Under the best-case scenario for the current system, the shortage of NNPs is expected to last 10 years. We analyzed the impact of improving the certification examination passing rate, increasing the annual growth rate of master's programs, and reducing the workforce annual attrition rate. We found that policy changes may reduce the forecasted shortage to 4 years. CONCLUSION: Present forecasts of demand for NNPs indicate that the existing workforce and education system will be unable to satisfy the growing demand. Policy changes may reduce the expected shortage and potentially improve access to care for newborns and infants.

What are we missing? Risk behaviors among Arab-American adolescents and emerging adults.

BACKGROUND AND PURPOSE: Research on Arab-Americans as a distinct ethnic group is limited, especially when considering the health of Arab-American youth. This study describes health risk (substance use, violence); health promotive behaviors (hope, spirituality); and sexual activity (oral, vaginal, anal sex) of Arab-American adolescents and emerging adults (aged 15-23) within their life context, as well as the association between these behaviors. METHODS: A secondary analysis of data on a subset of Arab-American participants obtained from a randomized-control trial was utilized to conduct mixed methods analyses. Qualitative analyses completed on the open-ended questions used the constant comparative method for a subsample (n = 24) of participants. Descriptive quantitative analyses of survey data utilized bivariate analyses and stepwise logistic regression to explore the relation between risk behaviors and sexual activity among the full sample (n = 57). CONCLUSIONS: Qualitative analyses revealed two groups of participants: (a) multiple risk behaviors and negative life-events, and (b) minimal risk behaviors and positive life-events. Quantitative analyses indicated older youth, smokers, and those with higher hope pathways were more likely to report vaginal sex. IMPLICATIONS FOR PRACTICE: The unique cultural and social contexts of Arab-American youth provide a framework for recommendations for the prevention of risk behaviors.

Capacity of, and Demand for, Pediatric Nurse Practitioner Educational Programs: A Missing Piece of the Workforce Puzzle.

BACKGROUND: In contrast to family nurse practitioners and other adult nurse practitioners, the percentage of new pediatric nurse practitioners (PNPs) graduating each year has not increased. PURPOSE: The aim of this study was to determine whether the marginal increase in the pipeline for PNPs is related to a limit in the capacity of educational programs or whether unfilled student openings exist. METHODS: Self-administered survey of program directors at all recognized PNP educational programs in the United States. RESULTS: Approximately 10% of PNP programs in the United States were either closed, put on hold, or did not have new graduates in the last 3 years. Even with these closures, over 25% of active programs did not fill all available positions for the class entering in 2012. CONCLUSION: Despite evidence that demonstrates plans by employers to hire a greater number of PNPs in a variety of clinical venues including pediatric hospitals, primary care and subspecialty pediatric practices, the PNP pipeline has remained relatively stagnant. More than one third of program directors do not believe that their PNP program is currently at capacity, indicating that underutilized capacity to educate PNPs is a hindrance to meeting the current and future demands for these professionals.

Capacity of, and Demand for, Neonatal Nurse Practitioner Educational Programs: A Missing Piece of the Workforce Puzzle.

BACKGROUND: Studies have demonstrated a dramatic increase in the number of new nurse practitioners (NPs) overall completing NP education each year. However, NPs who provide specialized care to children have not experienced increases in their pipeline at all. This has resulted in shortages of neonatal nurse practitioners (NNPs). PURPOSE: The aim of this study was to gain a greater understanding of the NNP pipeline and potential for increasing the number of new NNPs graduating each year. METHODS: Telephone survey of all NNP educational programs. DISCUSSION: Approximately one fourth of all NNP education programs had closed over the past several years. This is despite a strong job market, planned increases in hiring NNPs, and a seemingly growing shortage of NNPs. CONCLUSION: Problems with the NNP pipeline are not due to a lack of capacity of existing programs, but rather to difficulties in increasing the enrollment demand.

Strategic modeling of the pediatric nurse practitioner workforce.

OBJECTIVE: To assess the current pediatric nurse practitioner (PNP) workforce and to investigate the impact of potential policy changes to address forecasted shortages. METHODS: We modeled the admission of students into nursing bachelor's programs and followed them through advanced clinical programs. Prediction models were combined with optimal decision-making to determine best-case scenario admission levels. We computed 2 measures: (1) the absolute shortage and (2) the expected number of years until the PNP workforce will be able to fully satisfy PNP demand (ie, self-sufficiency). RESULTS: There is a forecasted shortage of PNPs in the workforce over the next 13 years. Under the best-case scenario, it would take at least 13 years for the workforce to fully satisfy demand. Our analysis of potential policy changes revealed that increasing the specialization rate for PNPs by 4% would decrease the number of years required until there are enough PNPs from 13 years to 5 years. Increasing the certification examination passing rate to 96% from the current average of 86.9% would lead to self-sufficiency in 11 years. In addition, increasing the annual growth rate of master's programs to 36% from the current maximum of 10.7% would result in self-sufficiency in 5 years. CONCLUSIONS: Current forecasts of demand for PNPs indicate that the current workforce will be incapable of satisfying the growing demand. Policy changes can result in a reduction in the expected shortage and potentially improve access to care for pediatric patients.

IMPORTANT BUT INCOMPLETE: PLAN B AS AN AVENUE FOR POST-ASSAULT CARE.

Many survivors of rape do not seek post-assault care. The recent change in status of emergency contraception (EC), such as Plan B, to an over-the-counter (OTC) product may be further changing post-assault care-seeking. This descriptive study will quantify OTC EC use in the post-assault period and elicit survivors' desires for care. Data were collected from women purchasing OTC EC at university pharmacies (n=55) and students in an undergraduate university class (n=165). Quantitative results indicate annual prevalence rates of post-assault OTC EC use as 5.4%-7.3%. Qualitative analyses indicate OTC EC is an important but incomplete form of post-assault care. Future work should focus on intervention development to provide all OTC EC users with information about post-assault resources to prevent long-term sequelae.

Urban American Indian Adolescent Girls: Framing Sexual Risk Behavior.

PURPOSE: The purpose of this study was to explore factors that influence urban adolescent American Indian (AI) girls' sexual risk behavior. DESIGN: A qualitative study was conducted with grounded theory methodology to reveal factors and processes that influence sexual risk behavior. METHOD: Talking circles, individual interviews, and event history calendars were used with 20 urban AI 15- to 19-year-old girls to explore influences on sexual risk behavior. RESULTS: The generated theory-framing sexual risk behavior-describes social and structural factors and processes that influenced the girls' sexual risk behavior. The theory extends Bronfenbrenner's ecological model by identifying microsystem, mesosystem, and macrosystem influences on sexual risk behavior. DISCUSSION: Urban AI girls reported similar social and structural influences on sexual risk behavior as urban adolescents from other racial and ethnic groups. However, differences were noted in the family structure, cultural heritage, and unique history of AIs. IMPLICATIONS: This theory can be used in culturally responsive practice with urban AI girls.

Urban Dwelling American Indian Adolescent Girls' Beliefs Regarding Health Care Access and Trust.

Indigenous people, specifically American Indians (AI), have historically had a greater mistrust of the medical system compared to their White counterparts. The purpose of this paper is to explore the perceptions of AI adolescent girls living in an urban, Midwest area about health care providers, health care systems, and access to health care as related to sexual health care. Using grounded theory methodology, twenty 15-19 year old AI girls participated in talking circles and individual interviews. Two distinct themes emerged related to sexual health care: 1) AI adolescent girls trust their health care providers and the health care system; and 2) Access to health care is critical to practicing safe sex and obtaining information about healthy sexual practices. These findings are unique and may help health care providers and social workers providing care and support to the urban adolescent AI girl.

The Rapid Assessment for Adolescent Preventive Services (RAAPS): providers' assessment of its usefulness in their clinical practice settings.

INTRODUCTION: The purpose of this study was to evaluate health providers' use of the Rapid Assessment for Adolescent Preventive Services (RAAPS) screening tool to identify adolescent high-risk behaviors, its ease of use and efficiency, and its impact on provider/patient discussions of sensitive risk behaviors. METHOD: This mixed methods descriptive study used an online survey to assess providers' use of the RAAPS and their perspectives on its implementation and effect on adolescent-provider communication. The survey was completed by providers from a variety of settings across the United States (N = 201). RESULTS: Quantitative and qualitative analyses indicated that the RAAPS facilitated identification of risk behaviors and risk discussions and provided efficient and consistent assessments; 86% of providers believed that the RAAPS positively influenced their practice. DISCUSSION: Adoption of the RAAPS in practice settings could lead to more effective adolescent preventive services by giving providers a tool to systematically assess and identify adolescents at risk. Implementation of RAAPS offers health providers an efficient, consistent, and "adolescent friendly" way to identify risky behaviors and open the discussion needed to tailor interventions to meet their needs.

Modifiable influences on female HPV vaccine uptake at the clinic encounter level: a literature review.

PURPOSE: A review of the literature to identify modifiable influences on female human papillomavirus (HPV) vaccine uptake relevant to clinical practice in order to support nurse practitioners (NPs) in the prevention of cervical cancer. DATA SOURCES: PubMed, CINAHL, reference lists of publications that surfaced in the electronic search. CONCLUSIONS: Six influences are modifiable and potentially amenable to being addressed at the clinic encounter level: (a) cost and insurance coverage, (b) provider recommendation, (c) vaccination opportunity, (d) HPV and HPV vaccine knowledge, (e) vaccine safety concerns, and (f) HPV risk. IMPLICATIONS FOR PRACTICE: NPs have an important role in improving HPV vaccine uptake and research suggests several areas they can address to increase vaccination during clinic visits.

Inter-Rater Reliability of the Measure of Patient-Centered Communication in Health Promotion Clinic Visits with Youth.

Patient-centered communication during clinic visits is critical for a patient and provider to establish a relationship that explores the patient's needs and desires and tailors health care accordingly. However, there are currently limitations to measuring patient-centered communication within the clinic visit. This study will examine the inter-rater reliability of a modified version of the Measure of Patient-Centered Communication (MPCC) for use with youth in health promotion clinic visits. Transcripts from actual patient-provider interactions (n=11) with 17-23 year old participants and providers (n=6; NPs and MDs) were analyzed for inter-rater reliability of a modified version of the MPCC. The MPCC demonstrated satisfactory inter-rater reliability among the five components of patient-centered communication (kappa=0.78) and good mean inter-rater reliability among the five provider responses (percent agreement=87.5%). Measuring patient-centered communication presents challenges. This study demonstrated that the MPCC could be a potential tool in this endeavor; however, adjustments are needed for it to be a reliable measure of patient-centered communication during clinic visits with youth. In order to provide patient-centered communication and care we must be able to accurately measure the communication and techniques being implemented in all patient visits.

Patient-centered communication and health assessment with youth.

BACKGROUND: Patient-centered communication is fundamental to individualizing healthcare, but there has been limited evaluation of provider communication with youth. OBJECTIVES: The aim was to compare communication outcomes after use of an event history calendar (EHC) and Guidelines for Adolescent Preventive Services (GAPS) to structure interactions during a clinic visit. Patient and provider descriptions of EHC and GAPS communication experiences were also obtained. METHODS: This is a secondary analysis of data obtained during a randomized controlled trial. A sequential explanatory mixed-methods approach was used. A split-plot design with one between factor (EHC, GAPS) and one within factor (pretest, posttest) was used for the quantitative portion. Qualitative data were collected from open-ended questions, audiotaped visits, and exit interviews. Providers (n = 9) at three clinics were assigned at random and trained to implement either the EHC or GAPS protocol. Male and female youth (n = 186) were randomly assigned to the EHC or GAPS intervention. Before their clinic visit, youth completed assessments of past communication experiences with healthcare providers (pretest); communication during the current visit was assessed immediately after the visit (posttest). RESULTS: Communication outcomes from pretest to posttest improved for youth in both the EHC and GAPS groups. Post hoc subgroup analysis suggested that men and Arab Americans derived more benefit from the EHC intervention in some aspects of communication. Qualitatively, the EHC group identified improved outcomes in validating patient perspective, being viewed in context, reaching a shared understanding of needs and preferences, and being helped to share power in the healthcare interaction. DISCUSSION: EHC and GAPS provided effective frameworks for structuring communication during a clinic visit. Compared with GAPS, the integrated time-linked assessment captured by the EHC enhanced patient-centered communication in select groups.

Exploring eating and activity behaviors with parent-child dyads using event history calendars.

Despite advances in science, the prevalence of childhood obesity persists and outcomes remain inconsistent. An event history calendar (EHC) is a tool to facilitate understanding of family life dynamics influencing eating and activity choices. This tool uses reflection to assess temporally linked behavior in the context of life events so that choices related to eating and activity are more explicit. Fourteen parent-child (6-14 years) dyads completed an EHC and interview 2 months following a healthy eating/activity intervention. Phenomenological analysis revealed themes including "awareness" of activity/eating behaviors, "healthy lessons," "family time," and "barriers" to change. The EHC facilitated participant communication and understanding by making connections between behaviors, habits, and events in family context, so that eating and activity behaviors could be realistically reviewed. This tool has potential to guide development of individualized interventions through barrier identification and goal establishment in research and clinical settings to help counteract childhood obesity over time.