L. Michele Issel

A review of prenatal home-visiting effectiveness for improving birth outcomes.

OBJECTIVEnTo determine the effectiveness of prenatal home visiting for improving prenatal care utilization and preventing preterm birth and low birth weight.nnnDATA SOURCESnMedline, the Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and Social Work Abstract databases were searched for articles that examined prenatal home-visiting and prenatal care utilization or neonatal outcomes, with additional ascendancy and descendancy searches. Listservs were also used to identify unpublished evaluations.nnnSTUDY SELECTIONnQuantitative studies meeting the following criteria were included in the analyses: published between 1985 and 2009, published in English, reported providing prenatal home visiting, and reported on prenatal care utilization or a neonatal outcome.nnnDATA EXTRACTIONnStudy characteristics and findings related to prenatal care utilization, gestational age, and birth weight were abstracted independently by at least two authors. Study quality was assessed across five domains.nnnDATA SYNTHESISnThe search yielded 28 studies comparing outcomes for women who did and did not receive prenatal home visiting, with 14 (59%) using an RCT design. Five (17%) studies reporting on prenatal care utilization found a statistically significant improvement in use of prenatal care for women with home visiting. Of 24 studies reporting an effect on birth outcomes, five (21%) found a significant positive effect on gestational age, and seven of 17 (41%) found a significant positive effect on birth weight.nnnCONCLUSIONSnMore evidence suggests that prenatal home visiting may improve the use of prenatal care, whereas less evidence exists that it improves neonatal birth weight or gestational age. These findings have implications for implementing Title II of the Affordable Care Act.

The economic value of caring

A heuristic method for monetizing effects of caring is presented. Practitioners caring behaviors have economic value to health care organizations through effects on patient satisfaction, physiology, selfdislosure, and self-esteem, and subsequent use of medications, laboratory tests, and procedures. These effects are monetized as revenues generated, costs avoided, costs reduced, and externalities.

A Public Health Nursing Research Agenda

Public health nurses (PHNs) use many interventions to prevent illness and promote the health of populations. Unfortunately, generating evidence regarding PHN practice is not explicitly identified as a research priority area of the major national funding agencies. Nor has PHN, as a profession, had a strong enough research agenda to drive practice improvement on a population-level and to drive funding to support such areas of research. To further advance the science needed to guide PHN practice, a national conference to set the research agenda was held in October 2010 with grant support from the Agency for Healthcare Research and Quality. The conference was part of a multimethod, participatory, multistage approach taken to generate the final research priority themes and corresponding priority research questions. The process yielded four high priority PHN research themes: PHN intervention models, Quality of population-focused PHN practice, Metrics of/for PHN, and comparative effectiveness and PHN outcomes. As the agenda is adopted by funding agencies, researchers, and practice-based partners, a more focused program of research will produce evidence that can guide population-focused PHN practice.

Developing a Measure of Prenatal Case Management Dosage

Recently, federal funding was designated through the Patient Protection and Affordable Care Act giving states the opportunity to expand their prenatal case management programs (PCM) through home visitation. Studies evaluating the effect of PCM on birth outcomes have shown little or no positive results. One suggested reason for these findings is a lack of attention in the assessment of dosage. The objective of this study is to demonstrate the use of measuring PCM dosage when assessing pregnancy outcomes. A birth cohort (Nxa0=xa04,582) encompassing Medicaid-insured Iowa residents enrolled in PCM who gave birth to a singleton from October 2005 to December 2006 was constructed from linked Iowa birth, Medicaid Claims, and Women’s Health Information Systems datasets. Data was used to create a dosage measure capturing the duration of enrollment, amount of time spent with a case manager, and breadth of interventions. Bivariate analysis and logistic regression were used to assess the relationship between PCM dosage and the birth outcomes. Dosage was significantly associated with LBW (X2xa0=xa031.1, Pxa0<xa00.001) and PTB (X2xa0=xa056.2, Pxa0<xa00.001). After adjustment for potential confounders, the likelihood of LBW and PTB were aOR: 0.47 (95% CI: 0.36–0.63) and aOR: 0.60 (95% CI: 0.44–0.82) for women with medium dosage (compared to low dosage), respectively. For women with high PCM dosage the likelihood of LBW and PTB was aOR 0.40 (95% CI: 0.31–0.51) and aORxa0=xa00.62 (95% CI: 0.48–0.81), respectively. This study showed that PCM dosage was significantly associated with lower odds of an adverse pregnancy outcome occurring.

An Innovative Method to Involve Community Health Workers as Partners in Evaluation Research

OBJECTIVESnWe developed a process through which community outreach workers, whose role is not typically that of a trained researcher, could actively participate in collection of qualitative evaluation data.nnnMETHODSnOutreach workers for a community-based intervention project received training in qualitative research methodology and certification in research ethics. They used a Voice over Internet Protocol phone-in system to provide narrative reports about challenges faced by women they encountered in their outreach activities as well as their own experiences as outreach workers.nnnRESULTSnQualitative data contributed by outreach workers provided insights not otherwise available to the evaluation team, including details about the complex lives of underserved women at risk for poor pregnancy outcomes and the challenges and rewards of the outreach worker role.nnnCONCLUSIONSnLay health workers can be a valuable asset as part of a research team. Training in research ethics and methods can be tailored to their educational level and preferences, and their insights provide important information and perspectives that may not be accessible via other data collection methods. Challenges encountered in the dual roles of researcher and lay health worker can be addressed in training.

Creating complex health improvement programs as mindful organizations: From theory to action

PURPOSEnThe purpose of this paper is to identify ways for organizationally complex, community-based health improvement initiatives to avoid failures with regard to client outcomes.nnnDESIGN/METHODOLOGY/APPROACHnOrganizational research on errors, failures and high reliability organizations led Weick and Sutcliffe to articulate five strategies for organizational mindfulness: preoccupation with failure, reluctance to simplify, sensitivity to operations, commitment to resilience, and deference to expertise. Using this framework, one US federally funded health initiative to reduce infant mortality and pre-term birth and a corresponding locally implemented program are analyzed. Experience with both over a five year period is the basis for this case study.nnnFINDINGSnMindlessness actions were found to occur at both the federal and local levels, despite the possibility of enacting mindfulness strategies at federal and local levels.nnnPRACTICE IMPLICATIONSnTo create health care initiatives and programs in ways that prevent disastrous outcomes, such as infant death and preterm births, can be achieved through application of the mindfulness strategies.nnnORIGINALITY/VALUEnThe evidence-based approach of organizational mindfulness previously has not been applied to health programs. Yet, this analysis demonstrates its usefulness in identifying ways in which these semi-autonomous organizations could avoid failures for their program clients.

Measuring Dosage: A Key Factor When Assessing the Relationship Between Prenatal Case Management and Birth Outcomes

To assess whether a measure of prenatal case management (PCM) dosage is more sensitive than a dichotomous PCM exposure measure when evaluating the effect of PCM on low birthweight (LBW) and preterm birth (PTB). We constructed a retrospective cohort study (Nxa0=xa016,657) of Iowa Medicaid-insured women who had a singleton live birth from October 2005 to December 2006; 28xa0% of women received PCM. A PCM dosage measure was created to capture duration of enrollment, total time with a case manager, and intervention breadth. Propensity score (PS)-adjusted odds ratios (ORs), and 95xa0% confidence intervals (95xa0% CIs) were calculated to assess the risk of each outcome by PCM dosage and the dichotomous PCM exposure measure. PS-adjusted ORs of PTB were 0.88 (95xa0% CI 0.70–1.11), 0.58 (95xa0% CI 0.47–0.72), and 1.43 (95xa0% CI 1.23–1.67) for high, medium, and low PCM dosage, respectively. For LBW, the PS-adjusted ORs were 0.76 (95xa0% CI 0.57–1.00), 0.64 (95xa0% CI 0.50–0.82), and 1.36 (95xa0% CI 1.14–1.63), for high, medium, and low PCM dosage, respectively. The PCM dichotomous participation measure was not significantly associated with LBW (ORxa0=xa00.95, 95xa0% CI 0.82–1.09) or PTB (0.97, 95xa0% CI 0.87–1.10). The reference group in each analysis is No PCM. PCM was associated with a reduced risk of adverse pregnancy outcomes for Medicaid-insured women in Iowa. PCM dosage appeared to be a more sensitive measure than the dichotomous measure of PCM participation.

Three Population‐Patient Care Outcome Indicators for Public Health Nursing: Results of a Consensus Project

OBJECTIVESnDifficulties in recruiting nurses into public health settings threaten the publics health. Gaps in existing data make determining the health impact of workforce changes numbers difficult to perform. Public health practice leaders are left to make difficult staffing and program decisions without knowing how the health of their vulnerable populations will be affected. The objective of this study was to identify indicators that could be used to document the effect of the shortage of public health nurses (PHNs) on the health of a population.nnnDESIGN AND SAMPLEnA consensus-building process was used. Nursing directors from 6 local health departments (LHDs) in 2 states participated along with 3 public health system researchers.nnnRESULTSnThe findings from this collaborative process suggest that it is possible to identify outcome indicators across states and multiple LHDs that may be sensitive to PHN staffing levels and interventions. Possible connections between PHN staffing and each population-patient care indicator (rates of Chlamydia, first trimester prenatal care, early childhood immunization) are presented.nnnCONCLUSIONSnThe process used here in identifying these indicators and the proposed nursing-sensitive population outcome indicators themselves provide a template for the development and analysis of additional outcome indicators sensitive to the quality of nursing and other health care.

Safe practice of population-focused nursing care: Development of a public health nursing concept

Patient safety, a cornerstone of quality nursing care in most healthcare organizations, has not received attention in the specialty of public health nursing, owing to the conceptual challenges of applying this individual level concept to populations. Public health nurses (PHNs), by definition, provide population-focused care. Safe practice of population-focused nursing care involves preventing errors that would affect the health of entire populations and communities. The purpose of this article is to conceptually develop the public health nursing concept of safe practice of population-focused care and calls for related research. Key literature on patient safety is reviewed. Concepts applying to population-focused care are organized based on Donabedians Framework. Structural, operational and system failures and process errors of omission and commission can occur at the population level of practice and potentially influence outcomes for population-patients. Practice, research and policy implications are discussed. Safe PHN population-focused practice deserves attention.

Creating a brand image for public health nursing.

Public health nurses (PHNs) have declined as a proportion of both the nursing and the public health workforces in the past 2 decades. This decline comes as 30 states report public health nursing as the sector most affected in the overall public health shortage. Taken together, these data point to a need for renewed recruitment efforts. However, the current public images of nurses are primarily those of professionals employed in hospital settings. Therefore, this paper describes the development of a marketable image aimed at increasing the visibility and public awareness of PHNs and their work. Such a brand image was seen as a precursor to increasing applications for PHN positions. A multimethod qualitative sequential approach guided the branding endeavor. From the thoughts of public health nursing students, faculty, and practitioners came artists renditions of four award-winning posters. These posters portray public health nursing-incorporating its image, location of practice, and levels of protection afforded the community. Since their initial unveiling, these posters have been distributed by request throughout the United States and Canada. The overwhelming response serves to underline the previous void of current professional images of public health nursing and the need for brand images to aid with recruitment.