Predictors of Patient Activation Among Underserved Patients in a Nurse-managed Health Center: A Pilot Study

The concept of patient activation has gained traction as the term referring to patients who understand their role in the care process and have “the knowledge, skills and confidence” necessary to manage their illness over time (Hibbard & Mahoney, 2010). Improving health outcomes for vulnerable and underserved populations who bear a disproportionate burden of health disparities presents unique challenges for nurse practitioners who provide primary care in nurse-managed health centers. Evidence that activation improves patient self-management is prompting the search for theory-based self-management support interventions to activate patients for self-management, improve health outcomes, and sustain long-term gains. Yet, no previous studies investigated the relationship between Self-determination Theory (SDT; Deci & Ryan, 2000) and activation. The major purpose of this study, guided by the Triple Aim (Berwick, Nolan, & Whittington, 2008) and nested in the Chronic Care Model (Wagner et al., 2001), was to examine the degree to which two constructs– Autonomy Support and Autonomous Motivation– independently predicted Patient Activation, controlling for covariates. For this study, 130 nurse-managed health center patients completed an on-line 38-item survey onsite. The two independent measures were the 6-item Modified Health Care Climate Questionnaire (mHCCQ; Williams, McGregor, King, Nelson, & Glasgow, 2005; Cronbach’s alpha =0.89) and the 8-item adapted Treatment Self-Regulation Questionnaire (TSRQ; Williams, Freedman, & Deci, 1998; Cronbach’s alpha = 0.80). The Patient Activation Measure (PAM-13; Hibbard, Mahoney, Stock, & Tusler, 2005; Cronbach’s alpha = 0.89) was the dependent measure. Autonomy Support was the only significant predictor, explaining 19.1% of the variance in patient activation. Five of six autonomy support survey items regressed on activation were significant, illustrating autonomy supportive communication styles contributing to activation. These results suggest theory-based patient, provider, and system level interventions to enhance self-management in primary care and educational and professional development curricula. Future investigations should examine additional sources of autonomy support and different measurements of autonomous motivation to improve the predictive power of the model. Longitudinal analyses should be conducted to further understand the relationship between autonomy support and autonomous motivation with patient activation, based on the premise that patient activation will sustain behavior change.

REDUCING TEACHER ATTRITION: THE ROLES AND RESPONSIBILITIES OF BUILDING PRINCIPALS IN A LARGE URBAN DISTRICT TO SUPPORT TEACHER RETENTION

The high rate of teacher attrition in urban schools is well documented. While this does not seem like a problem in Carter County, this equates to hundreds of teachers that need to be replaced annually. Since school year (SY) 2007-08, Carter County has lost over 7,100 teachers, approximately half of (50.1%) of whom resigned, often going to neighboring, higher-paying jurisdictions as suggested by exit survey data (SY2016-2020 Strategic Plan). Included in this study is a range of practices principals use to retain teachers. While the role of the principal is recognized as a critical element in teacher retention, few studies explore the specific practices principals implement to retain teachers and how they use their time to accomplish this task. Through interviews, observations, document analysis and reflective notes, the study identifies the practices four elementary school principals of high and relatively low attrition schools use to support teacher retention. In doing so, the study uses a qualitative cross-case analysis approach. The researcher examined the following leadership practices of the principal and their impact on teacher retention: (a) providing leadership, (b) supporting new teachers, (c) training and mentoring teaching staff, (d) creating opportunities for collaboration, (d) creating a positive school climate, and (e) promoting teacher autonomy. The following research questions served as a foundational guide for the development and implementation of this study: 1. How do principals prioritize addressing teacher attrition or retention relative to all of their other responsibilities? How do they allocate their time to this challenge? 2. What do principals in schools with low attrition rates do to promote retention that principals in high attrition schools do not? What specific practices or interventions are principals in these two types of schools utilizing to retain teachers? Is there evidence to support their use of the practices? The findings that emerge from the data revealed the various practices principals use to influence and support teachers do not differ between the four schools.