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INTRODUCTION: Population health initiatives rely on the availability and skills of an appropriate workforce to meet required goals. One global workforce initiative with demonstrated ability to expand health care services and improve access to care is the development of Advanced Nursing Practice and Advanced Practice Nursing roles. Given the sparse published information about these roles in Low and Lower-Middle-Income countries, this study seeks to describe their development and application in these countries. DESIGN: The researchers developed a descriptive cross-sectional multilingual survey for online distribution to nursing experts within the targeted countries. Survey questions addressed demographic information on the population served, Advanced Nursing Practice and Advanced Practice Nursing titles, the time frame and rationale for creating the title, and how the roles relate to the International Council of Nurses' Advanced Practice Nursing guidelines characteristics of education, practice, and regulation. RESULTS: Of the 167 responses received, only 24 participants met the inclusion criteria. This represented five low-income countries and nineteen lower-middle-income countries from four World Bank regions. Seventy-one roles were identified. Roles emerged predominantly over the last 20 years, focusing on care for underserved populations, with an almost even spread across primary and acute care settings. There were differences in education, practice, and regulation amongst the roles. Roles that required a master's education or higher with practice-related characteristics had a broader scope of practice, which is consistent with international guidelines. CONCLUSION: This paper describes how Advanced Nursing Practice and Advanced Practice Nursing roles from Low and Lower Middle-Income Countries have been implemented to address gaps in service and highlights disparities in education, practice and regulation compared to international guidelines. Maintaining and increasing support from organizations and universities internationally may be required to assist in developing and expanding educational programs for advanced nursing roles in these countries. CLINICAL RELEVANCE: Understanding how these advanced nursing roles are operationalized in relation to education, practice, and regulation in Low and Lower-Middle-Income countries can provide baseline information that will inform workforce development policies to address healthcare needs in similar jurisdictions.

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There is widespread interest in the redesign of primary health care practice models to increase access to quality health care. Registered nurses (RNs) are well positioned to assume direct care and leadership roles based on their understanding of patient, family, and system priorities. This project identified 16 exemplar primary health care practices that used RNs to the full extent of their scope of practice in team-based care. Interviews were conducted with practice representatives. RN activities were performed within three general contexts: episodic and preventive care, chronic disease management, and practice operations. RNs performed nine general functions in these contexts including telephone triage, assessment and documentation of health status, chronic illness case management, hospital transition management, delegated care for episodic illness, health coaching, medication reconciliation, staff supervision, and quality improvement leadership. These functions improved quality and efficiency and decreased cost. Implications for policy, practice, and RN education are considered.

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As nursing academia responds to shifts in nursing education--the emergence of clinically focused doctoral degrees and an emphasis on evidence-based practice, comparative effectiveness, and translational research, nursing scholarship is undergoing transformation. This article outlines guidelines for appointment and promotion that incorporate the academic tripartite and are relevant for all faculty. A clear and equitable pathway for professorial advancement for the both the clinician and research faculty is delineated. Without such clarity and equity, the unique contributions of clinical and research scholars and the synergy that results from these distinctions will not be garnered. Although there is significant overlap in the criteria, there are also distinguishing scholarly activities and outcomes. For each standard at each rank, unique sample criteria of clinical and research scholarship are outlined and the shared scholarly activities that demonstrate the standard. Using an adaptation of Boyer's model, the guidelines incorporate a broadened view of nursing scholarship and offer a framework for nursing academia that recognizes new ways of knowledge. Although recognizing the coexistence of science and practice, these guidelines offer a clear trajectory for advancement in the professorial role that applies an expanded perspective of and provide a framework for nursing scholarship.

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BACKGROUND: Little is known about the hand hygiene practices of surgical patients. Most of the research has been directed at the health care worker, and this may discount the role that hand hygiene of the surgical patient might play in surgical site infections. METHODS: A quasiexperimental, pretest/post-test study was conducted in which patients (n = 72) and nurses (n = 42) were interviewed to examine perceptions and knowledge about patient hand hygiene. Concurrently, observations were conducted to determine whether surgical patients were offered assistance by the nursing staff. Following an initial observation period, nursing staff received an educational session regarding general hand hygiene information and observation results. One month after the education session, patient/nurse dyads were observed for an additional 6 weeks to determine the impact of the educational intervention. RESULTS: Eighty observations, 72 patient interviews, and 42 nurse interviews were completed preintervention, and 83 observations were completed postintervention. In response to the survey, more than half of patients (n = 41, 55%) reported that they were not offered the opportunity to clean their hands, but a majority of the nursing staff reported (n = 25, 60%) that they offered patients the opportunity to clean their hands. Prior to the educational intervention, nursing staff assisted patients in 14 of 81 hand hygiene opportunities. Following the intervention, nursing staff assisted patients 37 out of 83 opportunities (17.3% vs 44.6%, respectively, [χ(2)1 = 13.008, P = .0003]). CONCLUSION: This study suggests that efforts to increase hand hygiene should be directed toward patients as well as health care workers.

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This phenomenological study examined the experience of being the father of a child with severe cerebral palsy (CP). Participants were selected using purposive sampling. Two interviews were conducted with 6 English-speaking, biological fathers whose children with CP (ages 5-27 years) were enrolled in a residential and day school in northeastern United States. Audiotaped interviews were transcribed, and thematic analysis was conducted using van Manen's methodology. Themes identified were as follows: Lost in birth; My beautiful unique child; Illness as a way of life…you can't get used to it and after a while it feels like no one cares; Partners-loyalty and commitment; How the world receives my child; Healthcare providers-I'm here; Torn…when your child can't live at home…finding a place to live and grow; and Faith. Clinicians should encourage, value, and include fathers' input during discussions of medical and social problems and when developing long-term care plans. Further research exploring the experiences of fathers of children with CP should be conducted.

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OBJECTIVE: The purposes of this study were to a) estimate the incidence of intensive care units nurses' intention to leave due to working conditions; and b) identify factors predicting this phenomenon. DESIGN: Cross-sectional design. SETTING: Hospitals and critical care units. SUBJECTS: Registered nurses (RNs) employed in adult intensive care units. INTERVENTIONS: Organizational climate, nurse demographics, intention to leave, and reason for intending to leave were collected using a self-report survey. MEASUREMENTS AND MAIN RESULTS: Nurses were categorized into two groups: a) those intending to leave due to working conditions; and b) others (e.g., those not leaving or retirees). The measure of organizational climate had seven subscales: professional practice, staffing/resource adequacy, nurse management, nursing process, nurse/physician collaboration, nurse competence, and positive scheduling climate. Setting characteristics came from American Hospital Association data and a survey of chief nursing officers. RESULTS: A total of 2,323 RNs from 66 hospitals and 110 critical care units were surveyed across the nation. On average, the RN was 39.5 yrs old (SD = 9.40), had 15.6 yrs (SD = 9.20) experience in health care, and had worked in his or her current position for 8.0 yrs (SD = 7.50). Seventeen percent (n = 391) of the respondents indicated intending to leave their position in the coming year. Of those, 52% (n = 202) reported that the reason was due to working conditions. Organizational climate factors that had an independent effect on intensive care unit nurse intention to leave due to working conditions were professional practice, nurse competence, and tenure (p < .05). CONCLUSIONS: Improving professional practice in the work environment and clinical competence of the nurses as well as supporting new hires may reduce turnover and help ensure a stable and qualified workforce.

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The purpose of this phenomenological study was to examine the meaning of being a live liver donor. Six people between ages 27 and 53 years participated. A qualitative, in-depth, semistructured interview format was used to explore donors' thoughts and feelings about being an organ donor. Five themes were identified: (1) no turning back--how do I live without you? (2) roller coaster marathon, (3) donor network, (4) the scar, and (5) reflections--time to think. At the center of the experience was the donor's commitment to the recipient. Once donors began the process, they were determined to see it through. The process was complex, and donors received various levels of support from family, friends, health care professionals, and others. After donation, as donors recovered and were able to resume their usual daily responsibilities, they reflected on the impact of the experience and how it changed their view of life.

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Guidelines recommend that patients with persist- ent seizures not responsive to standard antiepileptic drugs after 1 year be referred to specialized epilepsy centers for evaluation, which may include inpatient video-electroencephalographic monitoring. This 1-year retrospective, limited-focus review of 213 admissions and 3-year postdischarge review of epilepsy surgery referrals sought to determine if admission to an inpatient adult epilepsy monitoring unit resulted in a definitive diagnosis, a change in diagnosis or treatment, and whether referral patterns were consistent with guidelines. The median duration of time since symptom onset prior to admission was 15 years. At discharge, 87.8% of admissions received a definitive diagnosis. Epilepsy was diagnosed in 73.3% and excluded in 21.6%. Admissions without epilepsy had been treated with antiepileptic drugs for a median of 9 years. Admission resulted in change in treatment in 79%. This review documents the diagnostic utility of an epilepsy monitoring unit while highlighting that time since symptom onset to admission exceeded established guidelines.

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OBJECTIVE: The purposes of this study were to a) estimate the incidence of intensive care units nurses' intention to leave due to working conditions; and b) identify factors predicting this phenomenon. DESIGN: Cross-sectional design. SETTING: Hospitals and critical care units. SUBJECTS: Registered nurses (RNs) employed in adult intensive care units. INTERVENTIONS: Organizational climate, nurse demographics, intention to leave, and reason for intending to leave were collected using a self-report survey. MEASUREMENTS AND MAIN RESULTS: Nurses were categorized into two groups: a) those intending to leave due to working conditions; and b) others (e.g., those not leaving or retirees). The measure of organizational climate had seven subscales: professional practice, staffing/resource adequacy, nurse management, nursing process, nurse/physician collaboration, nurse competence, and positive scheduling climate. Setting characteristics came from American Hospital Association data and a survey of chief nursing officers. RESULTS: A total of 2,323 RNs from 66 hospitals and 110 critical care units were surveyed across the nation. On average, the RN was 39.5 yrs old (SD = 9.40), had 15.6 yrs (SD = 9.20) experience in health care, and had worked in his or her current position for 8.0 yrs (SD = 7.50). Seventeen percent (n = 391) of the respondents indicated intending to leave their position in the coming year. Of those, 52% (n = 202) reported that the reason was due to working conditions. Organizational climate factors that had an independent effect on intensive care unit nurse intention to leave due to working conditions were professional practice, nurse competence, and tenure (p < .05). CONCLUSIONS: Improving professional practice in the work environment and clinical competence of the nurses as well as supporting new hires may reduce turnover and help ensure a stable and qualified workforce.

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BACKGROUND: Although there is consistent evidence of a link between antibiotic use and increasing antimicrobial resistance in the community, inappropriate use of antimicrobials continues to be a global problem. OBJECTIVE: To describe knowledge, attitudes, and practices of Latino community members in upper Manhattan regarding use of antibiotics. METHODS: Written questionnaires and eight focus groups comprised of Hispanic community members (three groups), bodega employees, and healthcare providers (one group) in a Latino neighborhood in New York City. RESULTS: There were major knowledge deficits regarding use of antibiotics. Informants reported taking antibiotics for pain or other conditions as well as for symptoms of infection. Antibiotics were frequently obtained from bodegas without prescription, but generally only for adults, not for children. DISCUSSION: Interventions to improve antibiotic use that are focused on the formal healthcare system (e.g., clinicians, pharmacists, persons with health insurance) are unlikely to be effective with recently immigrated Latino community members. Successful interventions for this population should include targeted messages to bodega employees, community organizations, and children and their parents.

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Access to affordable health care has become a national crisis. The uninsured have many faces and many reasons for being uninsured. The nation cannot afford to sustain this broken system; not in terms of resources, nor in terms of the deteriorating health of the public. Universal coverage could offer a promising opportunity to begin to ameliorate the unsustainable use of expensive illness care now substituting for effective low-cost prevention and early detection. A proposal for essential health care coverage, a balance between cost and choice to maximize use of beneficial care, is presented.

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PURPOSE: The purpose of this study was to compare selected diabetes care processes and outcomes of nurse practitioners (NPs) and physicians (MDs) in the primary care of adults with type 2 diabetes. METHODS: Adults with type 2 diabetes and no regular source of primary care were enrolled from the emergency room and randomized to an NP or MD practice. Chart reviews were conducted to assess processes of care; patient interviews and hemoglobin A1C (A1C) testing were performed to measure patient outcomes. RESULTS: NPs were more likely than MDs to document provision of general diabetes education and education about nutrition, weight, exercise, and medications. They were more likely to document patient height, urinalyses results, and A1C values. No differences were found in documenting current medications; alcohol, illicit drug, or tobacco use; depression; weight and blood pressure; foot and cardiovascular exams; blood glucose and creatinine testing; or referral to ophthalmologists. No differences were found in patient outcomes. CONCLUSIONS: This study provides preliminary evidence of interdisciplinary differences in the processes of care employed by primary care NPs and MDs in caring for patients with type 2 diabetes. NPs documented the provision of diabetes education and selected monitoring tests more frequently than MDs; however, these differences were not reflected in 6-month patient outcomes.

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