Value-added care: a paradigm shift in patient care delivery

Spiraling costs in health care have placed hospitals in a constant state of transition. As a result, nursing practice is now influenced by numerous factors and has remained in a continuous state of flux. Multiple changes within the last 2 decades in nurse/patient ratio and blend of front-line nurses are examples of this transition. To reframe the nursing practice into an economic equation that captures the cost, quality, and service, a paradigm shift in thinking is needed in order to assess work redesign. Nursing productivity must be evaluated in terms of value-added care, a vision that goes beyond direct care activities and includes team collaboration, physician rounding, increased RN-to-aide communication, and patient centeredness; all of which are crucial to the nurse's role and the patient's well-being. The science of appropriating staffing depends on assessment and implementation of systematic changes best illustrated through a "systems theory" framework. A throughput transformation is required to create process changes with input elements (number of front-line nurses) in order to increase time spent in value-added care and to decrease waste activities with an improvement in efficiency, quality, and service. The purpose of this pilot study was two-fold: (a) to gain an understanding of how much time RNs spent in value-added care, and (b) whether increasing the combined level of RNs and unlicensed assistive personnel increased the amount of time spent in value-added care compared to time spent in necessary tasks and waste.     

A model for testing the relationship of nursing care and patient outcomes

Studying patient outcomes alone may not provide enough information to determine the associated factors that must be improved when the desired patient outcomes are not achieved. The purpose of this correlational study was to investigate the effects of perceived quality of nursing care and coordination of care on patients' comfort, satisfaction, and length of hospital stay. The overall model-data fit was good according to four indices: the chi-square value, goodness of fit index, adjusted goodness of fit index, and the Steigers root square error of approximation. The proposed model, effects of care quality on patient outcomes, was tested. The relationship between quality of nursing care and the proposed outcomes was tested. The results provide important information to the nursing profession and policymakers in meeting patient care needs.     

Health care reform: current updates and future initiatives for ambulatory care nursing

While the signing of the Patient Protection and Affordable Care Act was a historical event marking the beginning of health care reform in the United States, it signaled the start of a golden age for ambulatory care nursing. Ambulatory care RNs are well-positioned to fully participate in health care reform initiatives. RNs are well-positioned to lead, facilitate, and/or participate in all patient care medical homes' and accountable care organizations' quality and safety initiatives through enhanced use of major ambulatory care RN role dimensions such as advocacy, telehealth, patient education, care coordination and transitional care, and community outreach. RNs are also well-positioned to provide patient-centered care, coordinate care, and manage transitions across ambulatory care settings. For the golden age of ambulatory care nursing to become a reality, initiatives surrounding competencies, education modules, and leadership must be addressed immediately.     

Ambulatory care nursing: growth as a professional specialty

Ambulatory care nursing has emerged as a distinct professional nursing specialty. Many characteristics differentiate ambulatory care nursing from other specialty practices, including the settings, the characteristics of the patient encounters and the focus upon groups, communities, and populations, as well as individual patients and their families. A conceptual framework for ambulatory care nursing was developed in 1998 and recently revised, through consensus of leaders in the specialty. The key elements of the Ambulatory Care Nursing Conceptual Framework are the patient, the environment (both internal and external), and the nurse, practicing in three major roles.     

Resourcing evidence-based practice in ambulatory care nursing

Ambulatory care nurses may benefit from not only developing knowledge and skills in evidence-based practice (EBP), but also in identifying and providing sufficient resources for EBP to be implemented and sustained. Organizations should select one of the five conceptual models available in the literature to guide development and implementation of EBP. Costs of implementing and sustaining EBP include expert consultation, facilitators, staff time, informatician time, and data management. Benefits of EBP include improvements in patient care quality and safety, as well as regulatory compliance and risk management. Resources supporting EBP include professional literature available via the Internet and databases or agencies, such as ARHQ, professional organizations, and funding through grants.     

Redesigning nursing work in long-term care environments

The authors present a highly statistically oriented argument for examining work attitudes and activities among three groups of caregivers [RNs, RPNs, and HCAs] working in long-term care. The investigators used both work sampling, written surveys, and interviews with a sample of 46 caregivers in a large university-affiliated LTC facility in Toronto, Canada. While RNs stated their strong affinity for direct patient care activities, they perform the lowest percentage of direct care, chiefly due to their accountability for planning and coordinating the care provided by others. The HCAs who provided the bulk of direct patient care "valued it the least," apparently finding little gratification with this aspect of their role. This study suggests that there is a need to examine and clarify work roles and perceptions for all caregivers as part of any work redesign process. A higher level of RN involvement in direct patient care activities, along with "attention to enhancing the importance" of these activities for staff employed in the HCA role, could be beneficial.     

End-of-life care in nursing homes: the high cost of staff turnover

Nursing home staff turnover results in high cost--both economic and personal--and has a negative impact on the quality of care provided to residents at the end of life. Reducing staff turnover in nursing homes would benefit both the cost to the U.S. health care system, and, most importantly, the care residents receive in the vulnerable period leading to death. There is rising pressure on nursing homes to improve their palliative and end-of-life care practices and reduce transfers to hospital for situations and conditions that can be safely managed on site. Nursing care staff deserve an investment in the specific training necessary for them to give the highest quality care to dying residents. This training should be multifaceted and include the physiological, psychological, spiritual, interpersonal, and cultural (including ethnic) aspects of dying. Empowerment with these necessary knowledge, skills, and attitudes will not only result in better care for residents but likely also will reduce the burnout and frustration staff experience in caring for residents near death.     

Expanded role of nursing in ambulatory managed care. Part II: Impact on outcomes of costs, quality, provider and patient satisfaction

This evaluation project used a triangulation of methods and data sources to link the expanded role nurse clinician (NC) to outcomes of costs, quality, and satisfaction in managed care. Results of patient surveys, case studies, cost-benefit analyses, interviews, focus groups, and HMO documents suggest that the impact of the role has benefit far beyond its costs. This article builds on an earlier article (Nursing Economic$, Vol. 17, No. 1). Part I reviewed literature on expanded role nursing in population management, and described the development of the NC role. In Part II, the NC expanded role is linked to organizational outcomes of costs, quality, and satisfaction. Results here could be used by managers and planners to provide rationale for implementing expanded nursing roles in managed care in order to improve ambulatory care processes, recruit and retain nurses, reduce costs, and increase patient and provider satisfaction.     

Restructured patient care delivery: evaluation of the ProAct model

This budget-neutral model uses fewer RNs with increased clinical and nonclinical support and demonstrates potential to improve quality of care, reduce length of stay, and increase revenue.     

The nursing care technologist: an interview with Linda Sims Matessino

To better promote nursing, provide quality patient care, and address long-term problems posed by the nursing shortage, Ochsner Foundation Hospital of New Orleans developed and implemented the role of nursing care technician. In this interview, Linda Sims Matessino, Associate Hospital Director and Director of Nursing Services, details this position and how it has benefitted Ochsner Foundation Hospital.