Policy analysis of Texas Senate Bill 532 and the regulation of nurse practitioners in the convenience care model

Background. Retail clinics, also called convenience care clinics, have become a rapidly growing trend since their initial development in 2000. These clinics are coupled within a larger retail operation and are generally located in "big-box" discount stores such as Wal-mart or Target, grocery stores such as Publix or H-E-B, or in retail pharmacies such as CVS or Walgreen's (Deloitte Center for Health Solutions, 2008). Care is typically provided by nurse practitioners. Research indicates that this new health care delivery system reduces cost, raises quality, and provides a means of access to the uninsured population (e.g., Deloitte Center for Health Solutions, 2008; Convenient Care Association, 2008a, 2008b, 2008c; Hansen-Turton, Miller, Nash, Ryan, Counts, 2007; Salinsky, 2009; Scott, 2006; Ahmed & Fincham, 2010). Some healthcare analysts even suggest that retail clinics offer a feasible solution to the shortage of primary care physicians facing the nation (AHRQ Health Care Innovations Exchange, 2010). ^ The development and performance of retail clinics is heavily dependent upon individual state policies regulating NPs. Texas currently has one of the most highly regulated practice environments for NPs (Stout & Elton, 2007; Hammonds, 2008). In September 2009, Texas passed Senate Bill 532 addressing the scope of practice of nurse practitioners in the convenience care model. In comparison to other states, this law still heavily regulates nurse practitioners. However, little research has been conducted to evaluate the impact of state laws regulating nurse practitioners on the development and performance of retail clinics. ^ Objectives. (1). To describe the potential impact that SB 532 has on retail clinic performance. (2). To discuss the effectiveness, efficiency, and equity of the convenience care model. (3). To describe possible alternatives to Texas' nurse practitioner scope of practice guidelines as delineated in Texas Senate Bill 532. (4). To describe the type of nurse practitioner state regulation (i.e. independent, light, moderate, or heavy) that best promotes the convenience care model. ^ Methods. State regulations governing nurse practitioners can be characterized as independent, light, moderate, and heavy. Four state NP regulatory types and retail clinic performance were compared and contrasted to that of Texas regulations using Dunn and Aday's theoretical models for conducting policy analysis and evaluating healthcare systems. Criteria for measurement included effectiveness, efficiency, and equity. Comparison states were Arizona (Independent), Minnesota (Light), Massachusetts (Moderate), and Florida (Heavy). ^ Results. A comparative states analysis of Texas SB 532 and alternative NP scope of practice guidelines among the four states: Arizona, Florida, Massachusetts, and Minnesota, indicated that SB 532 has minimal potential to affect the shortage of primary care providers in the state. Although SB 532 may increase the number of NPs a physician may supervise, NPs are still heavily restricted in their scope of practice and limited in their ability to act as primary care providers. Arizona's example of independent NP practice provided the best alternative to affect the shortage of PCPs in Texas as evidenced by a lower uninsured rate and less ED visits per 1,000 population. A survey of comparison states suggests that retail clinics thrive in states that more heavily restrict NP scope of practice as opposed to those that are more permissive, with the exception of Arizona. An analysis of effectiveness, efficiency, and equity of the convenience care model indicates that retail clinics perform well in the areas of effectiveness and efficiency; but, fall short in the area of equity. ^ Conclusion. Texas Senate 532 represents an incremental step towards addressing the problem of a shortage of PCPs in the state. A comparative policy analysis of the other four states with varying degrees of NP scope of practice indicate that a more aggressive policy allowing for independent NP practice will be needed to achieve positive changes in health outcomes. Retail clinics pose a temporary solution to the shortage of PCPs and will need to expand their locations to poorer regions and incorporate some chronic care to obtain measurable health outcomes. ^

Assessing the impact of leadership on nurse job satisfaction and the desire for unionization in health care settings

This dissertation focuses on the leadership styles of managers, the impact these leadership styles have on the job satisfaction of staff nurses, and the proclivity of nurses to consider unionization. The aims of the dissertation include conducting a literature review on topics of leadership style, job satisfaction, and unionization; identifying and elucidating pertinent constructs with respect to shared interrelationships and how they could be measured; and developing a means of assessing if and to what extent transformational and transactional leadership styles affect nurse proclivity to unionize.^ The instrumentation selected includes the Multifactor Leadership Survey, Job Satisfaction Survey, and a newly created Union Preference Survey. Each survey instrument was evaluated as to its appropriateness to administer at a non-consultant level within a health care facility. Options other than self-administering the survey instruments include online access for participants, which provides confidentiality and encourages more responses. ^ The next part of the dissertation is a plan for health care facilities to use the survey tool by administering it themselves. The plan provides a general description of the survey tool, administering the instrument, rating the instrument, and leadership development. Integration of the three surveys is presented in a non-statistical format by coordinating the results of the three survey instrument responses. Recommendations are presented on how to improve leadership development warranted for improvement.^ The conclusions reached are that nurses’ preference for unions is influenced by the leadership style of direct report managers, as rated by staff nurses, and the nurses’ job satisfaction, which is in turn in part dependent on their managers’ leadership style. Thus, changes in leadership style can have a profound impact on nurse job satisfaction and on nurses’ preference for unionization.^

Changes in 911 call volume and type during Hurricane Ike and the implementation and usefulness of the TeleHealth Nurse system for the Houston Fire Department

This study examined both changing call volume and type with resulting effect of TeleHealth Nurse, the Houston Fire Department's (HFD) telephone nurse line, on call burden during Hurricane Ike. On September 13, 2008, Hurricane Ike made landfall in the Galveston area and continued north through Houston resulting in catastrophic damages in infrastructure and posing a public health threat. The overall goal of this study looked at data from Houston Fire Department to obtain a better understanding of the needs of citizens before, during, and after a hurricane. This study looked at four aspects of emergency response from HFD. The first section looked at call volumes surrounding the time of Hurricane Ike in 2008 compared to the same time period in 2007. The data showed a 12% increase in calls surrounding Hurricane Ike compared to previous years with a p value <.001. Next, the study evaluated the types of calls prevalent during Hurricane Ike compared to the same time period in 2007. The data showed a statistically significant increase in chronic health problems such as diabetes and cardiac events, Obstetric calls and an increase in breathing problems, falls, and lacerations during the days following Hurricane Ike. There was also a statistically significant increase in auto med alerts and check patients surrounding Hurricane Ike's landfall. The third section analyzed the change in call volume sent to HFD's Telephone Nurse Line during Hurricane Ike and compares this to earlier time periods while the fourth and final section looks at the types of calls sent to the nurse line during Hurricane Ike. The data showed limited use of the TeleHealth Nurse line before Hurricane Ike, but when the winds were at their strongest and ambulances were unable to leave the station, the nurse line was the only functioning medical help some people were able to receive. These studies bring a better understanding to the number and types of calls that a city might experience during a natural disaster, such as a hurricane. This study also shows the usefulness of an EMS Telephone Nurse Line during a natural disaster.^

Effects of a health advocacy program to promote physical activity and nutrition behaviors among adolescents: An evaluation of the Young Leaders for Healthy Change program

Background. This study was designed to evaluate the effects of the Young Leaders for Healthy Change program, an internet-delivered program in the school setting that emphasized health advocacy skills-development, on nutrition and physical activity behaviors among older adolescents (13–18 years). The program consisted of online curricular modules, training modules, social media, peer and parental support, and a community service project. Module content was developed based on Social Cognitive Theory and known determinants of behavior for older adolescents. ^ Methods. Of the 283 students who participated in the fall 2011 YL program, 38 students participated in at least ten of the 12 weeks and were eligible for this study. This study used a single group-only pretest/posttest evaluation design. Participants were 68% female, 58% white/Caucasian, 74% 10th or 11th graders, and 89% mostly A and/or B students. The primary behavioral outcomes for this analysis were participation in 60-minutes of physical activity per day, 20-minutes of vigorous- or moderate- intensity physical activity (MVPA) participation per day, television and computer time, fruit and vegetable (FV) intake, sugar-sweetened beverage intake, and consumption of breakfast, home-cooked meals, and fast food. Other outcomes included knowledge, beliefs, and attitudes related to healthy eating, physical activity, and advocacy skills. ^ Findings. Among the 38 participants, no significant changes in any variables were observed. However, among those who did not previously meet behavioral goals there was an 89% increase in students who participated in more than 20 minutes of MVPA per day and a 58% increase in students who ate home-cooked meals 5–7 days per week. The majority of participants met program goals related to knowledge, beliefs, and attitudes prior to the start of the program. Participants reported either maintaining or improving to the goal at posttest for all items except FV intake knowledge, taste and affordability of healthy foods, interest in teaching others about being healthy, and ease of finding ways to advocate in the community. ^ Conclusions. The results of this evaluation indicated that promoting healthy behaviors requires different strategies than maintaining healthy behaviors among high school students. In the school setting, programs need to target the promotion and maintenance of health behaviors to engage all students who participate in the program as part of a class or club activity. Tailoring the program using screening and modifying strategies to meet the needs of all students may increase the potential reach of the program. The Transtheoretical Model may provide information on how to develop a tailored program. Additional research on how to utilize the constructs of TTM effectively among high school students needs to be conducted. Further evaluation studies should employ a more expansive evaluation to assess the long-term effectiveness of health advocacy programming.^

UNDERSTANDING NURSE CREATED COGNITIVE ARTIFACTS: PERSONALLY-CREATED-COGNITIVE-ARTIFACTS AS EXTERNAL REPRESENTATIONS OF DISTRIBUTED COGNITION

Manuscript 1: “Conceptual Analysis: Externalizing Nursing Knowledge” We use concept analysis to establish that the report tool nurses prepare, carry, reference, amend, and use as a temporary data repository are examples of cognitive artifacts. This tool, integrally woven throughout the work and practice of nurses, is important to cognition and clinical decision-making. Establishing the tool as a cognitive artifact will support new dimensions of study. Such studies can characterize how this report tool supports cognition, internal representation of knowledge and skills, and external representation of knowledge of the nurse. Manuscript 2: “Research Methods: Exploring Cognitive Work” The purpose of this paper is to describe a complex, cross-sectional, multi-method approach to study of personal cognitive artifacts in the clinical environment. The complex data arrays present in these cognitive artifacts warrant the use of multiple methods of data collection. Use of a less robust research design may result in an incomplete understanding of the meaning, value, content, and relationships between personal cognitive artifacts in the clinical environment and the cognitive work of the user. Manuscript 3: “Making the Cognitive Work of Registered Nurses Visible” Purpose: Knowledge representations and structures are created and used by registered nurses to guide patient care. Understanding is limited regarding how these knowledge representations, or cognitive artifacts, contribute to working memory, prioritization, organization, cognition, and decision-making. The purpose of this study was to identify and characterize the role a specific cognitive artifact knowledge representation and structure as it contributed to the cognitive work of the registered nurse. Methods: Data collection was completed, using qualitative research methods, by shadowing and interviewing 25 registered nurses. Data analysis employed triangulation and iterative analytic processes. Results: Nurse cognitive artifacts support recall, data evaluation, decision-making, organization, and prioritization. These cognitive artifacts demonstrated spatial, longitudinal, chronologic, visual, and personal cues to support the cognitive work of nurses. Conclusions: Nurse cognitive artifacts are an important adjunct to the cognitive work of nurses, and directly support patient care. Nurses need to be able to configure their cognitive artifact in ways that are meaningful and support their internal knowledge representations.

Best practices for school leaders: Implementation of a profesional competence model for school management in Chile

In Chile, during the last three decades there has been a strong decentralization process whose main objective has been to improve the management of schools through the transfer of responsibilities and resources of education and thus improve the outcome of learning, reducing equity gaps between schools and territories. This is how, there has been an evolution of school principals¿ professional profile from an administrative to a management approach, in which principals have become project managers of educational projects. From a competence model for school leaders, based on IPMA guidelines, the present article presents an analysis of best practices for school management, allowing to generate a link between competencies and school management, from the perspective of project management. Results showed that the different competence elements, have relative weights according to the different practice fields, and that this analysis can be considered as a strategic element in educational project planning and development.

Best practices for school leaders: implementation of a professional competence model for school management in Chile

In Chile, during the last three decades there has been a strong decentralization process whose main objective has been to improve the management of schools through the transfer of responsibilities and resources of education and thus improve the outcome of learning, reducing equity gaps between schools and territories. This is how, there has been an evolution of school principals¿ professional profile from an administrative to a management approach, in which principals have become project managers of educational projects. From a competence model for school leaders, based on IPMA guidelines, the present article presents an analysis of best practices for school management, allowing to generate a link between competencies and school management, from the perspective of project management. Results showed that the different competence elements, have relative weights according to the different practice fields, and that this analysis can be considered as a strategic element in educational project planning and development.

Climate and grazing control nurse effects in an Ecuadorian dry shrubby community

Positive plant interactions have strong effects on plant diversity at several spatial scales, expanding species distribution under stressful conditions. We evaluated the joint effect of climate and grazing on the nurse effect of Croton wagneri, by monitoring several community attributes at two spatial scales: microhabitat and plant community. Two very close locations that only differed in grazing intensity were surveyed in an Ecuadorian dry scrub ecosystem. At each location, two 30 × 30-m plots were established at four altitudinal levels (1500, 2630, 1959 and 2100 m asl) and 40 microsites were surveyed in each plot. Croton wagneri acted as community hubs, increasing species richness and plant cover at both scales. Beneath nurses mean richness and cover values were 3.4 and 21.9%, and in open areas 2.3 and 4.5%, respectively. Magnitude of nurse effect was dependent on climate and grazing conditions. In ungrazed locations, cover increased and diversity reduced with altitude, while grazed locations showed the opposite trend. In ungrazed plots the interactions shifted from positive to negative with altitude, in grazed locations interactions remained positive. We conclude that the nurse effect is a key mechanism regulating community properties not only at microsite but also at the entire community scale.

Eventual election of multiple leaders for solving consensus in anonymous systems

In classical distributed systems, each process has a unique identity. Today, new distributed systems have emerged where a unique identity is not always possible to be assigned to each process. For example, in many sensor networks a unique identity is not possible to be included in each device due to its small storage capacity, reduced computational power, or the huge number of devices to be identified. In these cases, we have to work with anonymous distributed systems where processes cannot be identified. Consensus cannot be solved in classical and anonymous asynchronous distributed systems where processes can crash. To bypass this impossibility result, failure detectors are added to these systems. It is known that ? is the weakest failure detector class for solving consensus in classical asynchronous systems when amajority of processes never crashes. Although A? was introduced as an anonymous version of ?, to find the weakest failure detector in anonymous systems to solve consensus when amajority of processes never crashes is nowadays an open question. Furthermore, A? has the important drawback that it is not implementable. Very recently, A? has been introduced as a counterpart of ? for anonymous systems. In this paper, we show that the A? failure detector class is strictly weaker than A? (i.e., A? provides less information about process crashes than A?). We also present in this paper the first implementation of A? (hence, we also show that A? is implementable), and, finally, we include the first implementation of consensus in anonymous asynchronous systems augmented with A? and where a majority of processes does not crash.

The Thought Leaders Roundtable Discussion about Race Relations in Missouri

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Somatic hypermutation of the new antigen receptor gene (NAR) in the nurse shark does not generate the repertoire: Possible role in antigen-driven reactions in the absence of germinal centers

The new antigen receptor (NAR) gene in the nurse shark diversifies extensively by somatic hypermutation. It is not known, however, whether NAR somatic hypermutation generates the primary repertoire (like in the sheep) or rather is used in antigen-driven immune responses. To address this issue, the sequences of NAR transmembrane (Tm) and secretory (Sec) forms, presumed to represent the primary and secondary repertoires, respectively, were examined from the peripheral blood lymphocytes of three adult nurse sharks. More than 40% of the Sec clones but fewer than 11% of Tm clones contained five mutations or more. Furthermore, more than 75% of the Tm clones had few or no mutations. Mutations in the Sec clones occurred mostly in the complementarity-determining regions (CDR) with a significant bias toward replacement substitutions in CDR1; in Tm clones there was no significant bias toward replacements and only a low level of targeting to the CDRs. Unlike the Tm clones where the replacement mutational pattern was similar to that seen for synonymous changes, Sec replacements displayed a distinct pattern of mutations. The types of mutations in NAR were similar to those found in mouse Ig genes rather than to the unusual pattern reported for shark and Xenopus Ig. Finally, an oligoclonal family of Sec clones revealed a striking trend toward acquisition of glutamic/aspartic acid, suggesting some degree of selection. These data strongly suggest that hypermutation of NAR does not generate the repertoire, but instead is involved in antigen-driven immune responses.