Alice L. March

Medication adherence in a nurse practitioner managed clinic for indigent patients

Purpose:Little is published in the literature about medication adherence rates among patients who are medically indigent and patients receiving primary care from nurse practitioners (NPs). This project examined adherence rates and barriers to adherence among patients at an NP‐managed health clinic (NPMC). Data sources:The setting for this research was an NPMC for uninsured and low‐income patients. A cross‐sectional convenience sample of patients (n = 119) completed surveys eliciting demographic information, self‐report of medication adherence, health literacy, and barriers to adherence. Conclusions:Analysis of subjects demonstrated a vulnerable population, yet the mean adherence rate was surprisingly high (77%), compared to the rate usually cited in published literature. The best predictive model differentiating patients with high adherence from those with low adherence combined the total number of reported barriers, health literacy, and employment status. The barriers most frequently cited by subjects were difficulty paying for medications, and difficulty reading and understanding written prescription labels, which was particularly prevalent among Spanish‐speaking patients. Implications for practice:Clinic efforts to improve patient access to affordable medications may have contributed to subjects’ high rates of adherence. These efforts included helping patients with filling out prescription assistance program paperwork, prescribing generic medications, providing samples, and providing effective patient education.

Can Faith and Hospice Coexist: Is the African American Church the Key to Increased Hospice Utilization for African Americans?

African Americans are twice as likely as Caucasian Americans to choose aggressive hospital treatment when death is imminent. Repeat hospitalizations are traumatic for patients and drain patient and health system resources. Hospice care is a specialized alternative that vastly improves patient quality of life at end-of-life. This study was conducted to determine if hospices partnering with African American churches to disseminate hospice education materials could increase utilization of hospice services by African Americans. Members of two African American churches (N = 34) participated in focus group discussions to elicit beliefs about hospice care. Focus group transcripts were coded and comments were grouped according to theme. Six themes were identified. Lack of knowledge about hospice services and spiritual beliefs emerged as the top two contributing factors for underutilization of hospice services. Study findings support partnerships between hospices and African American churches to provide hospice education to the African American community.

Clinical Judgment During Simulation: A Comparison of Student and Faculty Scores

Abstract This study utilized the Lasater Clinical Judgment Rubric (LCJR) to investigate the relationship between the student’s self-assessment of clinical judgment skills and the faculty’s assessment during a human patient simulation. The study used a quantitative design with baccalaureate nursing students (n = 94) enrolled in an adult health course as participants. The data revealed a positive correlation between evaluator and student scores on the LCJR. The findings support the use of the LCJR in combination with simulation to evaluate nursing students’ clinical judgment skills and to quantify competency levels.

Board #226 - Program Innovation Technology-supported Simulation: A Capstone Event for Interprofessional Education of Rural Primary Care Providers (Submission #8812)

Objectives The US healthcare system utilizes a silo model with each provider caring for one disease. Patients with multiple chronic conditions receive fragmented care affecting cost, safety, effectiveness, quality of life, and mortality.1-2 Providers are not trained to practice in interprofessional (IP) collaborative teams, and may not be aware of the roles and responsibilities of others, thus communication is impaired by stereotypical beliefs. Well-integrated IP teams increase patients’ physical functioning, physical well-being, perceptions of control, self-efficacy, quality of life, satisfaction with services, and reduce healthcare costs.3 A team-based approach to learning stresses shared leadership, fostering growth in the skills needed to be effective drivers of healthcare change. Most IP simulations are face-to-face, and focus on acute care and critical decision-making. The innovation of this course, using technology-supported simulation as a capstone learning experience, provided early IP education to crystalize application of didactic content related to primary care, and the ability for virtual attendance of distance students. The skill set acquired from the course included IP strategies related to Interprofessional Education Collaborative (IPEC) and TeamSTEPPS® for primary care. Description This semester-long IP course included nursing, medicine, nutrition, and social work students. It combined online didactic material, unfolding case studies, and a simulated capstone experience. The format ensured inclusion of communication, values and ethic, roles and responsibilities, teamwork, and embedded four TeamSTEPPS® skills of (leadership, situation monitoring, mutual support, and communication). Critical steps for the success of technology-supported teleconferencing include early communication, advanced planning and practice, and access to proper equipment. Technology support was essential to connect virtual students during simulation and debriefing, and to stream debriefing to overflow rooms. Students used a mobile app to connect to telehealth carts with built-in teleconferencing devices. Test calls were completed in advance to troubleshoot connection issues, ensure call reliability, and assess audio/video quality. Several sessions were needed to establish connections, confirming the importance of advanced planning. To stream the debriefing session into another room, a room with a built-in teleconferencing system served as the base-room. Multiple cameras and microphones covered the room and a telehealth cart connected the audio/visual system to the destination room. Conclusion Thirty students attended the event, and 18 students responded to the non-required survey. The majority of students reported a positive simulation experience and learning expectations were met (88.9%). Students reported that the technology-supported simulation was effective in meeting course objectives, including synthesis of IP collaborative practice concepts (66.7%), enhanced knowledge of professional roles (66.7%), and a better understanding of how working within an IP team improves rural healthcare (66.7%). Specific to IPEC objectives, they reported the event was effective in meeting objectives related to core competencies (88.9%), collaboration (83.3%), professional roles (72.2%), and teamwork (83.3%). This course in general, and the technology-supported simulation event in particular, was developed to help resolve issues related to discipline specific approaches to professional education which limit the breadth of knowledge and skills, as well as the development of positive attitudes to collaboration and patient-centered care.4 These positive findings support continued use of courses and technology-supported simulations that provide both face-to-face and virtual students the opportunity to combine IPEC and TeamSTEPPS® content in early primary care IP training. References 1. Boyd CM, Fortin M. Future of multimorbidity research: How should understanding of multimorbidity inform health system design? Public Health Rev 2011;32:451-474. 2. Parekh AK, Goodman RA, Gordon C, Koh HK. Managing multiple chronic conditions: A strategic framework for improving health outcomes and quality of life. Public Health Rep 2011;126:460-471. 3. Krause CM, Jones CS, Joyce S, Kuhn M, Curtin K, Murphy LP, Lucas DR. The impact of a multidisciplinary approach on improving the health and quality of care for individuals dealing with multiple chronic conditions. Am J Orthopsychiatry 2006;76:109-114. 4. Lapkin S, Levett-Jones T, Gilligan C. A systematic review of the effectiveness of interprofessional education in health professional programs. Nurse Educ Today 2011;33(2):90-102. doi:10.1016/j.nedt.2011.11.006 Disclosures None

Perinatal Loss: Impacting Family Grieving and Nurse’s Self-fulfillment

C aring for families during the birthing process is one of the most enjoyable privileges nurses can experience during their career. Most cases result in a live and well child, carefully and loving sent home with a family. However, not all pregnancies end with such joy. Vital statistics reveal that pregnancy loss rates are significant. Of pregnancies over 20 and 28 weeks of gestation, the rate of fetal death is 6.4/1000 and 3.2/1000 of live births, respectively. The perinatal loss rate for babies up to 7 days old born after 28 weeks of gestation is 6.9 per 1000. Nurses must be prepared to assist families experiencing expected and unexpected pregnancy loss, and are more effective in facilitating grief when they have examined their own beliefs and are able to experience self-fulfillment. This article presents a model of nurse’s self-fulfillment using a clinical case to illustrate that via therapeutic use of self and interpretation of the event, the nurse impacts the immediate grieving process and finds meaning and self-fulfillment in a time of emotional distress. The case occurred at a rural community hospital where registered nurses were proficient in labor and delivery, postpartum, and newborn care. The nurse involved had 5 years of experience and was competent in caring for families experiencing a fetal or neonatal loss. The case began with the arrival of a couple in labor for their second child. The nurse knew the couple through childbirth education classes and all were excited about working to birth this child. In many cases, the nurse in a community hospital stayed past the end of the shift when the couple was close to delivery. However, this patient’s labor was not going as quickly as expected. The nurse had family commitments that evening and left feeling uncomfortable and sure that something was not right about this situation but was not able to identify the source of the distress. The next day, the nurse was not surprised to learn that an infant with anomalies incompatible with life had been delivered and sent to the tertiary care center for evaluation and stabilization. During that day, the pediatrician and the tertiary care center explored the possibility of transferring the infant back to the community hospital for comfort care. The child was supported by oxygen and although quite anoxic had not been placed on a respirator. The pediatrician held a conference with the parents, who were in favor of having the baby transferred back, but the unit manager declined to take the admission. After the nurse advocated for the couple, the transfer was arranged on the condition that the nurse would provide special care to the family. The nurse was comfortable with death and dying, and had an established relationship with the couple through childbirth education classes and previous care. The baby arrived and was cared for in a private room that had been set up as a special care area at the far end of the unit, affording privacy for the grieving family. The infant was dressed in the clothes that the parents had brought for the trip home. Everyone took turns holding and rocking the baby. The child was very quiet, probably not able to expend energy on crying. However, when placed in the crib, the baby fussed and did not stop until held again. Death came quietly and peacefully at 2 in the morning while the child was held by the mother. The parents expressed gratitude about the nurse staying until such late hours and the nurse felt fulfilled having been able to facilitate this end-of-life care. From the Capstone College of Nursing, University of Alabama, Tuscaloosa, Alabama.