Communication and collaboration: it's about the pharmacists, as well as the physicians and nurses.

OBJECTIVE: Collaboration and communication as dimensions of patient safety climate have been measured in acute care hospital units, and discrepant viewpoints have been documented between different professional groups, particularly between physicians and nurses. In the ambulatory care setting, these groups often work more closely together throughout the day than in acute care settings, thereby enhancing effective collaboration and communication. This study sought to determine if the communication differences that are known to impact patient safety, which are found in acute care, also exist in ambulatory care. METHODS: The Safety Attitudes Questionnaire, a 77-item survey of collaboration, communication and safety attitudes, was administered to the primary care staff at four Midwestern military ambulatory care clinics. RESULTS: There were 107 participants consisting of nurses (n=46), nurse practitioners (n=12), pharmacists (n=10) and physicians (n=39), yielding an overall response rate of 65%. All groups rated their peer group higher than other professional groups. The ratings of nurses and physicians were very similar: 85.0% of nurses rated physicians, and 85.7% of physicians rated nurses as high or very high in communication and collaboration. Pharmacists were rated the lowest by each of the other professional groups. Only 60% of pharmacists rated physicians as high or very high. CONCLUSIONS: Collaboration and communication ratings among physicians and nurses appear to be higher in the ambulatory care setting than in the acute care. However, interactions with pharmacists are more problematic, perceived as adversarial. Teamwork training that focuses on specific interactions among professional groups should target these concerns.

On nursing theories and evidence.

PURPOSE: To expand the understanding of what constitutes evidence for theory-guided, evidence-based nursing practice from a narrow focus on empirics to a more comprehensive focus on diverse patterns of knowing. ORGANIZING CONSTRUCT: Carper's four fundamental patterns of knowing in nursing--empirical, ethical, personal, and aesthetic--are required for nursing practice. A different mode of inquiry is required to develop knowledge about and evidence for each pattern. CONCLUSIONS: Theory, inquiry, and evidence are inextricably linked. Each pattern of knowing can be considered a type of theory, and the modes of inquiry appropriate to the generation and testing of each type of theory provide diverse sources of data for evidence-based nursing practice. Different kinds of nursing theories provide different lenses for critiquing and interpreting the different kinds of evidence essential for theory-guided, evidence-based holistic nursing practice.

Costs of interdisciplinary practice in a school-based health center.

In the context of market-driven health care reform, interest in cost and quality outcomes has increased. Quality, as defined by Donabedian, includes assessment of structure, process, and outcomes. However, the definition of quality in health care must be expanded to include the expectations and opinions of patients, their representatives, and society. The purpose of this article is to examine the outcome variable of costs in a specific nursing practice setting. Cost is frequently defined as the judicious use of resources consumed by structures and processes of care. This article presents activity-based costing methodology and results of a cost study of primary care and mental health services provided by advanced practice nurses (APNs) in a school-based health center. The application of the methods and outcomes of this pilot study has significant implications for the delivery of health care by APNs in a variety of settings, including community nursing centers, freestanding birthing centers, and rural and urban neighborhood centers. Because much of the health care delivered by APNs in these community-based settings includes health promotion, screening, counseling, and anticipatory guidance, it is important to explore methods such as activity-based costing to identify actual costs of care (versus charges) in emerging community-based practices where primary care is delivered by APNs.

The University of Rochester experience.

To establish a school-based health center, it is more important than ever to plan for financial support for building a practice. It is difficult to get to and stay at the target enrollment for this population since it is ever-changing group of students. Plan for increased numbers of initial assessments since every year at least one-fourth of the enrollees in the program change. Work closely with primary care providers and make it clear in verbal and written communication that there is no intent to disrupt the relationship with the student. Assess risk of the population and attempt to predict utilization of services (number and type of encounters) and determine costs of care. It is also important to find ways to track hospitalizations, emergency room visits and other unscheduled access to care. Since adolescents frequently seek confidential care, parents and providers may be uninformed regarding the actual cost of management of covered lives in a managed care environment.

Merger motorway. Giving staff the tools to reengineer.

Mergers and health care agencies' response to mergers dominate current conversations in this evolving managed care environment. Hospitals are rapidly learning to adjust to declining occupancy rates and deceased utilization of resources. A business model to guide mergers was adapted to assist staff with the people, structural, cultural and political issues of organizational change. Creating successful new work environments, moving from a "We-they" mentality to unity and decreasing use of resources are outcomes described in this article.

School-based care: clinical challenges and research opportunities.

PURPOSE: To explore clinical challenges and research opportunities in one school-based clinic in a faculty practice model of health care delivery CLIENT POPULATION: Ninth-through twelfth-graders at an Eastern urban high school, 80% of the students are from ethnic minorities CONCLUSIONS: Clinical, administrative, and research challenges need to be addressed on a larger scale through practice-based research networks across the country in order to have an impact on policy PRACTICE IMPLICATIONS: School-based care required integration of primary care and management of psychosocial and developmental needs. Practice in this setting includes primary, secondary, and tertiary prevention as intervention.

Exploring cost and quality: community-based versus traditional hospital delivery systems.

This article presents two approaches for comparison studies of cost and quality outcomes between community-based and traditional hospital systems of care. Two methodologies are used specifically to compare midwifery practice in a free-standing birth center to traditional obstetric practice with hospital deliveries. Findings from both studies reinforce the potential cost savings of community-based care without compromising quality. The methodologies used here can be applied to other settings. These approaches are also relevant for comparison studies of cost and quality outcomes between physicians and other nonphysician providers such as physician assistants and nurse practitioners, who frequently staff emerging models of community-based care. Issues related to obtaining comparable clinical and cost data versus reimbursement for both community-based and hospital care will be highlighted.

Cost-effectiveness analysis: birth center vs. hospital care.

Increasingly nursing will need to prove the cost effectiveness of alternative models of care. A cost-effectiveness analysis, using a decision analysis format, compared a birthing center to a hospital for low-risk deliveries. Results indicate that a birth center is a cost-effective model of nursing care.