Exploring the effects of change on nursing practice in acute ambulatory care settings : a qualitative study

As a result of the current changes taking place in the delivery of acute care services, the emergence of acute ambulatory care (AAC) settings is expanding. According to a literature review, the volume, acuity, and complexity of patient care in these settings is increasing while the time the patients spend under the care of nurses is decreasing. Two forces, hospital downsizing and advancing technology, are identified as the major contributors to the shift in acute care delivery. The effects that these changes are having on the clinical nursing practice of registered nurses working in AAC settings are not known. Given that AAC settings are rapidly expanding, it can be anticipated that the delivery of nursing care will continue to be compressed into a shorter time frame. Therefore, the following qualitative research question was formulated: What are the problems and issues related to clinical nursing practice in acute ambulatory settings? The purpose of this study was to explore the problems and issues associated with change and clinical nursing practice including the educational needs of nurses working in MC settings. Specific objectives of the study included the following: (a) to explore the problems and issues related to nursing practice in select AAC settings; (b) to explore the similarities and differences in perspectives related to role expectation between nurse managers, nurse educators, and staff nurses; and (c) to develop a conceptual framework that will guide the construction of an instrument needed for further research. This study used semistructured individual interviews and focus group sessions to collect data from the three categories of registered nurses. More specifically, data were collected from one nurse manager, two charge nurses, two nurse educators and fifteen staff nurses, working in three different MC settings of a major teaching hospital. Collected data were separately analyzed by the researcher and an external rater following grounded theory methodology. By using open and axial coding, the problems and issues identified by nurses were grouped into several major and minor themes. In final analysis, by using selective coding, the four core themes (intensification, moderation, frustration, and adaptation) were extracted. Each core theme was presented and discussed in relation to hospital downsizing and advancing technology. The relationships among the four core themes were discussed and depicted in a model termed the "Impact and Consequence Model on Nursing Practice in MC Settings." Implications for further research are discussed and research hypotheses, based on the research findings, are presented.

The association between maternity insurance, residence status and selected perinatal outcomes among Chinese women

Objective: To investigate the impact of maternity insurance and maternal residence on birth outcomes in a Chinese population. Methods: Secondary data was analyzed from a perinatal cohort study conducted in the Beichen District of the city of Tianjin, China. A total of 2364 pregnant women participated in this study at approximately 12-week gestation upon registration for receiving prenatal care services. After accounting for missing information for relevant variables, a total of 2309 women with single birth were included in this analysis. Results: A total of 1190 (51.5%) women reported having maternity insurance, and 629 (27.2%) were rural residents. The abnormal birth outcomes were small for gestational age (SGA, n=217 (9.4%)), large for gestational age (LGA, n=248 (10.7%)), birth defect (n=48 (2.1%)) including congenital heart defect (n=32 (1.4%)). In urban areas, having maternal insurance increased the odds of SGA infants (1.32, 95%CI (0.85, 2.04), NS), but decreased the odds of LGA infants (0.92, 95%CI (0.62, 1.36), NS); also decreased the odds of birth defect (0.93, 95%CI (0.37, 2.33), NS), and congenital heart defect (0.65, 95%CI (0.21, 1.99), NS) after adjustment for covariates. In contrast to urban areas, having maternal insurance in rural areas reduced the odds of SGA infants (0.60, 95%CI (0.13, 2.73), NS); but increased the odds of LGA infants (2.16, 95%CI (0.92, 5.04), NS), birth defects (2.48, 95% CI (0.70, 8.80), NS), and congenital heart defect (2.18, 95%CI (0.48, 10.00), NS) after adjustment for the same covariates. Similar results were obtained from Bootstrap methods except that the odds ratio of LGA infants in rural areas for maternal insurance was significant (95%CI (1.13, 4.37)); urban residence was significantly related with lower odds of birth defect (95%CI (0.23, 0.89)) and congenital heart defect (95%CI (0.19, 0.91)). Conclusions: whether having maternal insurance did have an impact on perinatal outcomes, but the impact of maternal insurance on the perinatal outcomes showed differently between women with urban residence and women with rural residence status. However, it is not clear what are the reason causing the observed differences. Thus, more studies are needed.