Katherine Dontje

A Unique Set of Interactions: The MSU Sustained Partnership Model of Nurse Practitioner Primary Care

Purpose To present a unified conceptual model that identifies the integral processes of nurse practitioner (NP) care delivery and that integrates major structural influences and potential outcomes. The model is further characterized to delineate the unique and “value‐added” nature of NP primary care and to describe how this nature may be correlated with specific clinical outcomes. Data Sources Extensive review of the literature, relevant conceptual models, clinical experiences of the authors, and two sets of qualitative data exploring differences between NP practice and other practices. Conclusions The basis of NP primary care is the unique provider‐client relationship that develops within the primary care setting. This relationship is oriented toward (a) helping clients become empowered to more appropriately manage their own care in a way that will best meet their needs, (b) encouraging mutual decision making, (c) ensuring clients’ continuity of care, and (d) providing a holistic approach to primary care. The major structural influences are NP role components, interdisciplinary practice relationships, budget resources and payer mix, and environmental characteristics. The potential outcomes are increased healthpromoting behaviors, improved utilization of care, higher client satisfaction levels, and improved health status. Implications for Practice NPs can use this model to articulate the unique contribution of NP practice and its interrelationships within the broader primary care setting. Practicing NPs can use this framework to better understand the complexities of their current and future primary care practices. Faculty can utilize the concepts to help guide students’ understanding of their prospective roles as advanced practice nurses. Finally, this conceptual framework can inform research about specific NP processes and related outcomes. A clearly delineated model that accurately depicts structures, processes, and outcomes relevant to NP primary care can strengthen NP education, distinguish NP practice, and advance evidenced‐based research linking NP practice and outcomes.

Shared Decision Making Guidance Reminders in Practice (SDM-GRIP)

OBJECTIVE Develop a system of practice tools and procedures to prompt shared decision making in primary care. SDM-GRIP (Shared Decision Making Guidance Reminders in Practice) was developed for suspected stable coronary artery disease (CAD), prior to the percutaneous coronary intervention (PCI) decision. METHODS Program evaluation of SDM-GRIP components: Grand Rounds, provider training (communication skills and clinical evidence), decision aid (DA), patient group visit, encounter decision guide (EDG), SDM provider visit. RESULTS Participation-Physician training=73% (21/29); patient group visits=25% of patients with diagnosis of CAD contacted (43/168). SDM visits=16% (27/168). Among SDM visit pairs, 82% of responding providers reported using the EDG in SDM encounters. Patients valued the SDM-GRIP program, and wanted to discuss comparative effectiveness information with a cardiologist. SDM visits were routinely reimbursed. CONCLUSION Program elements were well received and logistically feasible. However, recruitment to an extra educational group visit was low. Future implementation will move SDM-GRIP to the point of routine ordering of non-emergent stress tests to retain pre-decision timing of PCI and to improve coordination of care, with SDM tools available across primary care and cardiology. PRACTICE IMPLICATIONS Guidance prompts and provider training appear feasible. Implementation at stress testing requires further investigation.

Financially viable nurse-managed centers.

Nurse managed centers play an important role in the health service delivery system; often serving those in greatest need, while struggling to remain financially viable. This article discusses the role of a Financial Advisory Committee (FAC) and the process of financial peer review in academic nurse-managed centers to improve financial outcomes. Advanced practice nurses may find the identified strategies for financial sustainability useful in their own practices.

Mapping evidence-based guidelines to standardized nursing terminologies.

The purpose of this study was to explore how evidence-based practice recommendations for adults with depression were represented in two standardized nursing terminologies. A qualitative concept analysis was used to answer the research question. Concepts were extracted from the recommendations and matched to two standardized nursing terminologies through lexical and semanticconcept mapping techniques. Study findings included variability in the lexical mapping to the standardized terminologies. The ability to map semantically was greater than lexical mapping, but the majority of these were partial matches. Findings also raised concerns about the potential for ambiguity of data retrieved when using standardized terminology.

Establishing a collaborative practice in a comprehensive breast clinic.

BREAST CANCER IN women is a major health concern due to the high prevalence of subtle changes in breast tissue that are difficult to diagnose. Consequently, women require information about benign and malignant breast changes. Nurse practitioners (NPs) can play an important role in helping women with breast concerns by incorporating clinical expertise with teaching and counseling skills. Establishing clinics in which information, screening, and diagnosis of breast cancer are readily available will help decrease womens anxiety and enhance their ability to act as self-advocates within the healthcare system. A comprehensive breast clinic was developed, incorporating NP and physicians in a collaborative model of care. Defining roles within the model was an ongoing process as each provider developed areas of expertise and interest. The NP role emerged as an integral part of the practice, increasing the efficiency, availability, and effectiveness of clinic services.

Nurse-led group visits support shared decision making in stable coronary artery disease.

Objective:The aim of this study was to develop and evaluate a nurse-led educational group visit (GV) as part of a multifaceted intervention, Shared Decision Making (SDM) Guidance Reminders in Practice, to prompt SDM in primary care about angiography in stable coronary artery disease. Methods:A process evaluation designed to test the feasibility of a nurse-led educational GV was conducted. The evaluation used retrospective pre-post surveys. Results:Nurse-led GV was well received and logistically feasible. Patients gained knowledge of options and confidence in doing SDM with providers. However, recruitment at the point of the educational GV was below the threshold of 12 patients per group that would support sustaining this approach in fee-for-service clinical practice. Conclusions:Nurse-led GV can produce gains in knowledge and confidence required for patients to participate in SDM. However, the constraints of time and personnel required to bring groups of patients together require new approaches. Future development will focus on adapting the content of the GV for SDM as an electronic teaching module associated with integrated personal health records.

Refining a brief decision aid in stable CAD: cognitive interviews

BackgroundWe describe the results of cognitive interviews to refine the “Making Choices©” Decision Aid (DA) for shared decision-making (SDM) about stress testing in patients with stable coronary artery disease (CAD).MethodsWe conducted a systematic development process to design a DA consistent with International Patient Decision Aid Standards (IPDAS) focused on Alpha testing criteria. Cognitive interviews were conducted with ten stable CAD patients using the “think aloud” interview technique to assess the clarity, usefulness, and design of each page of the DA.ResultsParticipants identified three main messages: 1) patients have multiple options based on stress tests and they should be discussed with a physician, 2) take care of yourself, 3) the stress test is the gold standard for determining the severity of your heart disease. Revisions corrected the inaccurate assumption of item number three.ConclusionsCognitive interviews proved critical for engaging patients in the development process and highlighted the necessity of clear message development and use of design principles that make decision materials easy to read and easy to use. Cognitive interviews appear to contribute critical information from the patient perspective to the overall systematic development process for designing decision aids.