Medical errors are a continuing issue for healthcare organizations and can lead to patient harm or death. To bring about organizational learning and therefore reduce medical errors, information must successfully flow through an organization. Nurse managers play an essential role as the conduit of information between frontline staff and the organization. The primary purpose of this study is to describe the decision-making process of how nurse managers actively select and transmit information on patient safety concerns. A qualitative constructivist grounded theory approach was used. Nineteen unit-level nurse managers, working full-time in an acute care hospital with a minimum of one-year experience were recruited through professional nursing organizations and snowball recruitment. Semi-structured, conversational, one-on-one interviews were conducted via Zoom or phone call, per the participant's preference. An initial interview guide based on the STOPS framework was used. Participants reported that after they acquired patient safety information, they quickly assessed whether or not the issue was severe and relevant. Then they prioritized the information based on the degree of the severity and relevance, the information source and type, and whether they needed feedback, guidance, or support. The prioritization step determined what mode and how frequently the message was forwarded. Although severity was a consistent consideration on whether to forward information, nurse managers struggled to define the concept. This study suggests that when a patient safety issue is on the extremes of the severity and relevance spectrum the decision-making process is clear. Whether to forward the information that was not on the extremes is less clear and more varied among nurse managers. This part of the decision-making process was inconsistent among nurse managers and has the potential for information to get lost. At the time of the interviews, COVID-19 had created an influx of patients into hospitals, which strained healthcare systems and providers. Nurse managers are in a position where they have insight on how COVID-19 has affected patient safety and can communicate that to their staff and into the organization. Therefore, a secondary thematic analysis of the data was conducted concerning the effects of COVID-19 on patient safety. Nurse managers identified several risks to patient safety that were exacerbated and created by COVID-19. Worsening staffing shortages have negatively affected staff psychological well-being, compelled nurses to work beyond their skill set, and necessitated providing only the mere essentials of nursing care. Burnout and patient isolation have also compounded patient safety concerns. But in the chaos and confusion, nurse managers were able to see some positives that resulted from the pandemic, such as improved teamwork, vigilance, and learning new skills, which can be used to better weather the next pandemic.

Avoidable hospital readmissions continue to be a concerning and costly healthcare issue. While the emphasis on reducing avoidable hospital readmissions persists, incentivization strategies are evolving. Initial strategies prioritized medical care delivery, but recent regulation highlights the value of effective transitional (discharge) care planning, and particularly, patient involvement in that process. This latter aspect of care has a clear indication for the application of shared decision-making. Shared decision-making (SDM) practice in the acute care setting largely represents a gap in the literature; yet understanding patient perceptions of SDM during hospitalization is an important and timely first step in exploring the effectiveness of newly implemented regulation-driven hospital initiatives. The purpose of this study is to examine the relationships between perceptions of SDM during hospitalization, patient experience, and readmissions. This study utilized a prospective cohort design, including participant recruitment and survey distribution upon day of hospital discharge followed by an observation period to monitor for 30-day readmission. The target population was adults who were hospitalized for general medical conditions at a single community hospital. The final sample size was 83. Patient perceptions of SDM were measured using the CollaboRATE Measure of Shared Decision-Making, which was validated as part of this study. Study findings indicated that patients perceive the occurrence of SDM and participation in both care decisions and transitional planning. Most also agreed with their discharge disposition. Perceptions of SDM: varied based on patient, provider, and organizational factors during care decisions; varied based only on nurse communication during transitional care planning; were significantly related to hospital patient experience, as measured by HCAHPS subscales; were not found to be related to 30-day readmissions; however, patient agreement with discharge disposition was predictive of readmission. These findings were largely consistent with the proposed conceptual model and establish a foundation for future related research.

Pediatric palliative care has recently become a priority in the healthcare field and is implemented at the time of diagnosis rather than days or weeks before the child's death. Social constructivism theory in which humans generate meaning from their experiences was utilized as a general framework to determine the impact of pediatric palliative care on close relatives. The purpose of this grounded theory study was to generate a substantive theory that explains how close relatives such as grandparents, aunts, and uncles of a child with cancer experience palliative care. The participants of the study included close relatives of children in palliative care. Semi-structured interviews and journaling were used to collect data. Initial, focused, and selective coding procedures were used to manage the data and a content analysis of the textual data was performed. Findings from the data suggested a process of surrendering to the journey in which close relatives learn to let go of what they cannot control while holding on to what they can control. Social change implications of this study may include improving healthcare programming for close relatives utilizing supportive-expressive measures. This programming may promote mental health of the close relatives who will learn to deal with their adjustment difficulties and improve their coping skills.

Racial and ethnic minorities in the United States have higher rates of hypertension than European Americans. In this ethnographic study, 30 Nigerian immigrant health care workers with hypertension described their self-efficacy management of the disease to ascertain the relationship between health-related hardiness, individual attitudes on compliance, and medication adherence self-efficacy. Using a mixed methods designs comprised of survey tools and focus-group questionnaires, the research questions were focused on understanding attitudes and health practices within Nigerian culture that support self-efficacy management. The theoretical framework for this study is the social learning theory and the social cognitive theory postulated by Bandura. Content analysis of the focus group transcript revealed that all participants agreed that culture directly influences their self-efficacy practices. Interview responses generated 4 major themes in which the study participants expressed positive attitude towards adopted values including culture practices, faith, enculturation, and fear of medication effects. Cross tabulations of data from the survey tools showed no relationship between self-care management, attitude, and medication adherence. Factor analysis of the Health Related Hardiness (HRH) scale identified 6 constructs with a cumulative variance of 64.9%. Implication for positive social change include culturally specific health intervention programs that focus on the impact of culture on hypertension self-efficacy practices and self-care management.

Hypertension affects as many as 50-70 million Americans; early and consistent compliance to hypertension guidelines is important to prevent heart attack and stroke, both leading causes of death in the United States. Despite the advances in medicine and health-care technology, the effectiveness with which hypertension is managed at the individual and community level is less than optimal. The research questions in this study addressed the lack of physician compliance to hypertension guidelines and why patients fail to follow guidelines. Improving hypertension management depends on bridging the gap between physician awareness of evidence-based guidelines and patient compliance. Grounded theory was used to understand and integrate the perspectives of a purposeful selection of nine physicians and seven patients regarding barriers to hypertension guidelines compliance. Theoretical perspectives used to frame this research were self-efficacy and the health-belief model for the patient and awareness to adherence and the dissemination model for the physician. Data analysis strategies included open/axial and in-vivo coding to assign and refine themes and discover key concepts. Themes for both physician and patient participants related to methods of compliance, the physician/patient relationship, awareness of theoretical models by both groups, and issues related to patient non-compliance. Eight key recommendations were developed, including: evidence and theory must coexist to increase compliance, health insurance practices must be reformed, and collaboration and communication between physicians and patients must improve. Implications for positive social change included reduced health care costs and improved outcomes for hypertensive patients.

The Bureau of Substance Abuse Treatment Recovery and Prevention, which oversees drug intervention services for Detroit residents, has found the city's illegal drug use among teens to mirror national rates. Illegal drug use is associated with addiction, major health problems, and stigma. Incorporating evidence-based screening during all teen health care visits would decrease missed opportunities to identify at-risk behaviors, the number of teens that do not receive intervention, and the stigma associated with screening. The purpose of this project was to develop evidence-based policy and practice guidelines for teen screening services for illegal drug use. The Plan-Do-Study-Act (PDSA) model was used to guide the project. An interdisciplinary team of direct service and administrative staff selected questions based on 6 key words---car, relax, alone, forget, friends, and trouble (CRAFFT)---to screen teens for illegal drug use. The interdisciplinary team also developed a teen screening policy along with practice guidelines for the screening policy, implementation plan, and project evaluation. A review of the literature provided support for the project methods. Two experts in the field of substance abuse provided content validity for the policy and practice guidelines, and concluded that the CRAFFT screening questions were valid for evidence-based screening for illegal drug use among teens, that the PDSA model was effective to guide the project, and that an interdisciplinary team approach was effective to address the issue. These findings may improve identification of at-risk teens, decrease missed screening opportunities, decrease stigma, and align the Bureau with current trends in substance abuse treatment.

Children with special health care needs (CSHCN) generally have physical, mental, or emotional conditions that require a broader range and greater quantity of health and related services compared to typical children. Care coordination (CC) and family-centered care (FCC) are necessary in the quality of health care for CSHCN. A gap exists in the literature regarding the impact of CC and FCC on children's functional ability (FA). Previous researchers have focused on met and unmet health care needs, but not on health outcomes or functionality. The purpose of this study was to determine if there was an association between CC, FCC, and FA in CSHCN. The design of this study was a secondary analysis of data from the 2005--2006 National Survey of CSHCN. The study was guided by an adapted socioecological multilevel conceptual framework. Statistical methods included univariate, bivariate, and multiple logistic regression analysis. Results indicated that CC was associated with FA in CSHCN. CSHCN that did not receive CC had a 53% increased risk (OR =1.53, 95%CI 1.21--1.94, p < 0.001) for a limitation in FA compared to CSHCN that received CC, controlling for age, gender, number of conditions, household poverty level, parental educational level, and health insurance. FCC was not associated with a limitation in FA in CSHCN ( p = 0.61). Findings from this study were consistent with the socioecological multilevel framework and the literature on care coordination. This study contributed to positive social change by providing information that can be used by public health officials, health care providers and policy makers in developing policies to assure that care coordination is provided to CSHCN and their families in order to improve their health outcomes and functionality.

This research sought to ascertain the extent to which providing public sponsored health insurance (PSHI) to previously uninsured Mexican-American Hispanics improves health outcomes among those requiring ongoing treatment to control diabetes. Prior research utilizing insurance access theory; access, equity, and health outcome interrelationship theory; health affordability theory; and financial and resource burden theory suggests the uninsured receive less care than the insured, with delayed treatment, leading to chronic conditions. This research tested each of those major theoretical constructs into a blended conceptual framework based on the notion that providing health insurance helps alleviate the disabling effects of diabetes among this population. This study used an unobtrusive, longitudinal, one group pretest-posttest design. Research questions were designed to measure the strength of the relationship between PSHI and patient health outcomes using physical examination data, laboratory results, and diagnosis of 712 diabetic patients with 5,300 medical visits over 3 years before and after enrolling for PSHI. Logistic regression was used to analyze data related to age, gender, time enrolled in PSHI, and service location relative to health outcomes. Findings support the theories that accessibility increases with the provision of health insurance but also show that health outcomes do not improve after enrollment in a PSHI. This study contributes to the body of knowledge in public health policy and administration by quantifying the strength and significance of the relationship between health insurance and health outcomes and effects positive social change by measuring the effectiveness of legislation providing the uninsured with health insurance in order to improve health outcomes.

<p><strong>Abstract</strong></p> <p>Health care practice environments are central to the safety and quality of patient care. Hospitals often develop and implement a professional practice model (PPM) to improve practice environments. In the United States, magnet hospital designation is a driving force in PPM implementation. In Ontario, Canada, despite the lack of magnet hospital designation, many hospitals have implemented PPMs. There appear to be differences in how PPMs are implemented in Ontario.</p> <p>This phenomenographic study examined professional practice experts’ conceptions of PPM implementation and use in Ontario acute care hospitals. The findings indicate that PPM implementation is a dynamic and emergent phenomenon that occurs in cyclical phases of growth and reduced activity.</p> <p>Seven categories of PPM use are described (a) creating alignment/consistency, (b) supporting evidence-based practice, (c) enabling interprofessional practice, (d) enhancing professional accountability, (e) enabling patient-centred care, (f) creating/ strengthening linkages, and (g) strategic positioning of professional practice. Categories exhibited hierarchical relationships, with more foundational uses providing support for higher level uses.</p> <p>Three structural themes are identified (a) model design/structure, (b) professional practice leadership, and (c) organizational support. These themes work individually and synergistically, within and across the categories to influence use and potential impact of the PPM. Progressively fuller and more complex use of the PPM appears to occur under increasingly intense influence of the structural themes.</p> <p>The analysis provides unique information about relationships within and among categories of PPM use. This provides insight regarding how organizations might maximize return on investment with PPM implementation. Seven recommendations are identified.</p> / Master of Science (MSc)

For several decades, the cost of medical care in the United States has increased exponentially. Congress enacted the Patient Protection and Affordable Care Act (PPACA) of 2010 to ensure affordable healthcare to the citizens of the United States. The purpose of this case study was to explore physicians' perspectives regarding physician-centric business models evolving under the requirements of PPACA legislation. Complex adaptive systems formed the conceptual framework for this study. Data were gathered through face-to-face, semistructured interviews and e-mail questionnaires with a purposeful sample of 20 participants across 14 medical specialties within Northeast Texas. Participant perceptions were elicited regarding opinions of PPACA legislation and the viability of business models under the PPACA. In addition, a word cloud was used to identify 3 prevalent or universal themes that emerged from participant interviews and questionnaires, including (a) use of mid-level practitioners, (b) changes to provider practices, and (c) lack of business education. The implications for positive social change include the potential to develop innovative models for the delivery of medical care that will improve the health of the aggregate population. Healthcare leaders may use the findings to advance the evolution of physician business models that meet the needs of healthcare stakeholders. These findings may also inform healthcare leaders of the need to develop cost-effective and innovative organizational models that are distinct to individual patient populations.