Dissertations / Theses on the topic 'Climatericprimary health care; nursing care'

Health information literacy influences patient health outcomes, yet almost 90% of adults struggle to understand health information. This study explored the impact of an education course in health literacy on healthcare professionals’ methods of providing information to patients in order to increase effective communication and improve patient outcomes. This study drew from an integrated theoretical framework that suggests development and validation of tools to measure health literacy. Access to and understanding of reliable, high-quality health care information equalizes many other variables that impact health outcomes, including age, economic class, and cultural background. This study analyzed survey data collected from 2 doctors, 2 nurse practitioners, and 1 staff nurse selected based on their expertise and experience working with patients. They completed a learner- centered course, in which learners interact and instructors provide feedback. Based on survey responses, the participants strongly supported implementing the proposed education module. Four of the 5 experts agreed that a course in health literacy will help health care workers recognize and address patients with low health literacy. Limited health literacy is associated with poor health outcomes and higher health care costs. This type of literacy requires a complex group of reading, listening, analytical, and decision- making skills, and the ability to apply these skills to health situations. The results of this study may guide educators to effectively communicate with patients, increase health literacy, and improve patient outcomes.

Foster children represent a vulnerable pediatric population with complex health needs including both acute and chronic conditions that require comprehensive health care management. However, years of research has continually demonstrated a poor provision of health care services to this at risk population including gaps in preventative care and poor follow-up with specialty services. Current literature reveals that the health care management for foster children continues to be fragmented and subpar. Several health care delivery models, standards of care, and interventions have been recommended in an effort to improve the outcomes among foster children. However the perspective of foster parents, key caregivers, has been missing in current evidence. This investigation serves as a descriptive study utilizing grounded theory methodology to explore health care management from the Hawaii foster parent's perspective. The purpose of the investigation was two-fold: 1) to describe foster parents' experience obtaining health care for their foster children and 2) to elicit foster parents' opinions about whether or not a health education program designed for foster parents would be helpful. After completing seven individual interviews, which were analyzed using constant comparative analysis, 19 categories were developed describing the foster parent experience related to policy and services, social environment, physical environment, biology, and behavior. The concept of a medical home model was identified as unfeasible for Hawaii foster families, and large variations in health education preparation among foster parents was observed while a significant interest in further education on health-related topics was identified as a necessity. Implications for practice and recommendations for further research were also generated.

Problem: Medical and nursing literature poorly identify primary care providers' (PCP) relationship to care coordination (CC). Primary care providers' education, experience, and perspective, contribute to: (a) assessments of patient's care coordination needs, and (b) variability in behavior to address needs. Dissimilar approaches to CC by PCPs affect work relationships and office flow.

Purpose: To pre-pilot a new tool describing PCPs' knowledge, perception, and behavior regarding CC. Methods: Primary care physicians, nurse practitioners, and physician assistants were surveyed.

Analysis: Frequencies and percentages provided sample characteristics. Descriptive statistics analyzed provider responses within and between groups. Narratives were analyzed for themes. Tool refinement is suggested however, the tool does describe PCPs and CC activities.

Significance: A tool was developed to evaluate areas of CC activity performed by PCPs. Information from surveys of PCPs can illuminate behaviors that lead to improved work flow, efficiency, and patient outcomes. Doctors of Nursing Practice who are PCPs contribute to primary care CC through leadership, experience, and descriptive evidence.

Purpose/problem. Telephone nursing care (TNC) has replaced some home visits to increase efficiency of The Ottawa Hospital Antenatal Home Care Program (AHCP). There is limited published research addressing TNC in similar settings to guide program development. Therefore, chose an evaluation strategy to explore the clients' the researchers and organization perceptions of TNC. Objectives. (1) Perform a systematic literature review of TNC in the high risk antenatal population. (2) Profile high risk antenatal population receiving telephone nursing care. (3) Describe clients' perceptions of telephone nursing care. (4) Explore the feasibility of this methodology for continuous program evaluation and informing development and improvement. Method. A mixed methods approach was used. Two surveys and a semi-structured interview were completed by 13 participants. Data were analyzed using descriptive statistics and constant comparative analysis. Results. Sample was similar to the population in diagnosis, maternal and fetal outcomes. Anxiety scores were high and women identified the highest needs related to high risk pregnancy, psychological and information domains. Four main themes emerged: the experience of being at home, perceptions of the telephone care, perceived benefits, and perceived health systems issues.

Palliative health care is offered to any patient experiencing a life limiting or life changing illness. The palliative approach includes goals of care, expert symptom management, and advance care planning in order to reduce patient suffering. Complex care can be provided by palliative care specialists while primary palliative care can be given by educated staff nurses. However, according to the literature, intensive care unit (ICU) nurses have demonstrated a lack of knowledge in the provision of primary care as well as experiencing moral distress from that lack of knowledge. In this doctor of nursing practice staff education project, the problem of ICU nurses' lack of knowledge was addressed. Framed within Rosswurm and Larrabee's model for evidence-based practice, the purpose of this project was to develop an evidence-based staff education plan. The outcomes included a literature review matrix, an educational curriculum plan, and a pretest and posttest of questions based on the evidence in the curriculum plan. A physician and a master's prepared social worker, both certified in palliative care, and a hospital nurse educator served as content experts. They evaluated the curriculum plan using a dichotomous 6-item format and concluded that the items met the intent of the objectives. They also conducted content validation on each of the pretest/posttest items using a Likert-type scale ranging from 1 (not relevant) to 4 (very relevant). The content validation index was 0.82 indicating that test items were relevant to the educational curriculum objectives. Primary palliative care by educated ICU nurses can result in positive social change by facilitating empowerment of patients and their families in personal goal-directed care and reduction of suffering.

Refugees resettling in the United States face many challenges; especially within the health care setting. The purpose of this research was to add to the increasing body of knowledge about improving health care for the refugee population through investigating providers' lived experience caring for them. This study utilized qualitative research methods with a descriptive phenomenological approach. Five healthcare providers, one Nurse Practitioner, three Pediatricians and one Family Medicine Attending, were interviewed face to face through semi-structured interviews, utilizing twelve questions about their lived experience caring for the refugee population. The data from the five participants interviewed revealed three themes that described their experience: Facing Challenges; Experiencing Satisfaction; and Reframing the System. Although each provider found satisfaction within his or her current positions, there is a critical need for improved allocation of resources for housing, social support, and increased funding to help support refugee families that arrive in the United States.

This research study was conducted to examine changes in cost and service utilization of nurse case managed clients. A secondary analysis was conducted using a pre-test/post-test design. Data for this analysis were collected by Papenhausen (1995) for a study to measure the effect of nurse case management intervention on client outcomes. Cost data for 53 subjects for the periods six months before and six months after nurse case management intervention was initiated were compared. Statistically significant decreases were found in the frequencies of inpatient admissions and emergency visits, as well as in inpatient length of stay and the total cost of services. This cost, including that of nurse case management service, as determined by Huggins (1996), represented a 61% decrease from the total cost before nurse case management was started.

We are trying to bring attention and focus on the important role the nursing profession plays in improving patient’s experience and outcomes. Nurses are best positioned at the center of information exchanges and play critical through their routine interventions. Tasks that are often perceived as simple routine tasks, like: care planning, medication reconciliation, communications with the patient and other professionals, discharge instructions and education, are the very foundation of the successful care coordination intervention.

Health care leaders who lack effective nurse turnover strategies can negatively affect patient quality of care, productivity, and profitability. The purpose of this single case study was to explore strategies health care leaders used to reduce nursing turnover in a health care organization. The conceptual framework for this study was Herzberg's 2-factor theory. Data were collected from semistructured interviews with 4 health care leaders in the West Texas region who had a history of reducing nurse turnover for a minimum of 5 years from the date of hire, and from review of organizational documents related to the strategies to reduce nurse turnover, including policy handbooks and annual reports. Data were analyzed using word frequency and coding to distinguish patterns. Three key themes emerged: leadership support, job satisfaction, and compensation. The results of this study might contribute to social change through an increased understanding of nurse turnover strategies that would improve productivity and the overall quality of patient care to yield organizational success, decreased mortality rates, and improved community health.

Thesis (Ph.D.)--University of California, San Francisco, 2009.
Source: Dissertation Abstracts International, Volume: 70-04, Section: B, page: 2206. Advisers: Mary A. Blegen; Charlene A. Harrington. Includes supplementary digital materials.

I sjuksköterskeprofessionen är omsorg en viktig del. Det används av sjuksköterskor varje dag och är en integral del i det bilaterala förhållandet mellan sjuksköterska och patient. Syftet med denna litteraturgranskning är att undersöka omsorg i omvårdnad samt se om omsorg kan orsaka utbrändhet. Författarna har granskat 11 vetenskapliga studier, gjorda till och med tio år tillbaka runt om i världen. Genom analysering av resultaten identifierades fem huvudteman: patientens syn på god omsorg, patientens syn på dålig omsorg, sjuksköterskans syn på god omsorg, sjuksköterskans syn på dålig omsorg, samt processen och konsekvenserna av utbrändhet.
In the nursing profession, caring is the most essential part. It is used by nurses’ everyday and is an integral part in the responsive nurse-patient relationship. The main aim of this study was to investigate caring in nursing. Furthermore, because of Maslach (1998) statement that close contact within the nurse-patient relationship contributes to burnout in nurses, the authors wanted to investigate studies exploring the cause of burnout in nurses.Additionally, the cause of burnout in nurses is explored. The authors reviewed 11 scientific studies, performed in the past ten years around the world. The results showed that five main themes could be identified. These were: patient’s view of good care, patient’s view of bad care, nurse’s view of good care, nurse’s view of bad care, and the process and consequences of burnout.

Thesis (MCur (Nursing Science))--University of Stellenbosch, 2009.
ENGLISH ABSTRACT: The work environment in critical care units in South Africa is hampered by a profound shortage of nurses, heavy workloads, conflict, high levels of stress, lack of motivation and dissatisfaction among the staff. The task of managing a C.C.U. has therefore become a challenge. It is important that unit managers apply a leadership style that matches these challenges. The aim of this study was to investigate the ideal style of leadership. The objectives set for the study were to identify the ideal leadership style required in the following areas:  administrative functions  education functions  patient care  research An explorative, descriptive research design was applied, with a quantitative approach to determine the ideal leadership style for unit managers in critical care units of private health care institutions. The research sample consisted of all nurses working permanently in eleven private hospitals in the Cape Metropolitan area. A questionnaire consisting of predominantly closed questions was used for the collection of data, which was collected by the researcher in person. Ethical approval was obtained from the Committee of Human Science Research at Stellenbosch University. Permission to conduct the research was obtained from the institutions and informed consent from the participants. A pilot study was conducted to test the questionnaire at a private hospital which did not form part of the study. A 10% sample of the relevant staff, namely 27 participants were involved in this study. The validity and reliability was assured through the pilot study and the use of a statistician as well as experts in nursing and a research methodologist. Data was tabulated and presented in histograms and frequencies. Statistical significant associations were drawn between variables, using the Chi-square test. The Spearman rank (rho) order correlation was used to show the strength of the relationship between two continuous variables. Findings of the study show that participatory leadership style and transformational leadership approach were valued in all four (4) of the objectives. Emphasis was placed on consultation prior to any decisions. Nurses requested an opportunity to give feedback on a regular basis regarding the unit managers conduct (Chi-square test p = 0.025). They also agreed that unit managers should apply the necessary rules and procedures (Chi-square test p = 0.016). A huge request was made for integrity, trust, impartiality, openness, approachability and particularly honesty. The nurses also maintained that the nurse manager’s behaviour should be congruent. Furthermore, the results indicate that nurses would like to be empowered by:  being involved in the scheduling of off-duties  taking the lead in climate meetings  being granted opportunities (to all categories of nurses) to attend managerial meetings. N = 41 (48.2%) of nurses admitted that unit managers would instruct them to cope with insufficient staffing pertaining to ventilated patients, putting them under severe strain and at risk legally. N = 39 (47%) of nurses admitted that unit managers only consider qualifications and experience in the delegation of tasks if the workload in the unit justifies it. Safe patient care is not always a priority. N = 99 (96%) of nurses agreed that autocratic behaviour relating to task delegation exists. Recommendations included the application of transformational leadership and participatory management. The aim to create a healthier, more favourable work environment for critical care nurses will hopefully be attained through applying the ideal leadership style and leadership approach.
AFRIKAANSE OPSOMMING: Die werksverrigtinge in kritieke sorgeenhede in Suid-Afrika word deur ‘n ernstige tekort aan verpleegsters, hoë werklading, konflik, spanning, min motivering en baie ontevredenheid onder verpleeglui gekortwiek. Die leiding en bestuur van ‘n kritieke sorgeenheid is dus nie ‘n maklike taak nie. Dit is dus belangrik dat eenheidsbestuurders ‘n leierskapstyl aan die dag lê wat dié uitdagings doeltreffend aanspreek. Die doel van die studie is dus om ondersoek in te stel na die wenslike leierskapstyl vir kritieke sorgeenhede. Die doelwitte daargestel is dus om die ideale leierskapstyl in elk van die volgende funksies te bepaal:  administrasie  opleiding  pasiënte-sorg  navorsing Die ideale leierskapstyl vir eenheidbestuurders in kritieke sorgeenhede in privaathospitale is bepaal deur ‘n kwantitatiewe benadering met ‘n beskrywende ontwerp toe te pas. Die populasie het alle kritieke sorg verpleeglui ( permanent werksaam by een van elf privaathospitale in die Kaapse Metropool) ingesluit. Instrumentasie het ‘n vraelys behels (met oorwegend geslote vrae) en data is persoonlik deur die navorser ingevorder. Etiese toestemming is vanaf die Etiese Komitee van die Mediese Fakulteit te Universiteit Stellenbosch verkry asook die hoofde van die verskillende privaathospitale waar navorsing plaasgevind het. Ingeligte toestemming is ook van elkeen van die deelnemers verkry. Ten einde die vraelys te toets, is ‘n loodstudie by ‘n privaathospitaal ( wat nie by die studie ingesluit was nie) gedoen. Die loodstudie het N = 27 (10%) van die totale populasie behels. Die betroubaarheid en geldigheid van die studie is deur die loodstudie, die gebruik van ‘n statistikus, verpleegdeskundiges en die navorser-metodoloog versterk. Data is getabuleer en in histogramme en frekwensies voorgestel. Deur die Chi-square- toets te gebruik, is statisties betekenisvolle assosiasies tussen veranderlikes bepaal. Ten einde sterkte van verhoudings tussen twee opeenvolgende veranderlikes te bepaal, is die Spearman rangordekorrelasie (rho) aangewend. Die bevindings van die studie het getoon dat ‘n deelnemende bestuurstyl en transformasie-leierskapbenadering die mees aangewese keuse vir al vier doelwitte is. Die toepassing van veral ‘n deelnemende besluitnemingsproses het groot voorrang geniet, Verpleegkundiges wil daarbenewens ook op ‘n gereelde basis geleentheid hê om terugvoering oor die leierskapgedrag van die eenheidsbestuurder te gee (Chi-square toets p = 0.025). Ook verlang die deelnemers dat eenheidsbestuurders nie reëls en regulasies moet verontagsaam nie (Chi-square toets p = 0.016). ‘n Ernstige versoek is gerig ten opsigte van integriteit met pertinente verwysing na eerlikheid, vertroue, onpartydigheid, deursigtigheid, toeganklikheid en dat die leier se woorde en dade moet ooreenstem. Die resultate het verder getoon dat verpleegsters graag bemagtig wil word deur:  betrokkenheid in die skedulering van afdienste,  leiding in klimaatsvergaderings te wil neem,  geleentheid te hê om bestuurvergaderings by te woon (alle kategorieë van verpleegkundiges).. N = 39 (48.2%) van verpleegkundiges het erken dat hulle gedwonge personeeltekorte ten opsigte van geventileerde pasiënte ervaar en dus aan mediese geregtelike risiko’s en onnodige druk blootgestel word. N 39 (47%) van verpleegkundiges het erken dat eenheidsbestuuders kwalifikasies en ondervinding slegs in ag neem indien die werklading in die eenheid dit toelaat..Veilige pasiëntesorg kry dus nie altyd voorkeur nie. N = 99 (96%) van verpleegkundiges het erken dat outokratiese gedrag ( wat met werkstoewysing verband hou) wel voorkom. ‘n Transformasie leierskapsbenadering en deelnemende bestuurstyl is dus aanbeveel. Die hoop word dus uitgespreek dat deur aan die verpleegkundiges se versoeke ten opsigte van die ideale bestuursbenadering en bestuurstyl te voldoen, die werksatmosfeer binne kritieke sorgeenhede toenemend gesonder en dus aangenamer sal word.

Youth with disabilities and special health care needs (YDSHCN) preparing to exit high schools should receive mandated secondary transition planning. Transition is required to move youth with disabilities smoothly from high school services to postsecondary education and training, work, and adult community participation. Health care transition (HCT) of youth to adult health services is an emerging national focus (Healthy People 2020), but the role of the school nurse in HCT has not been explored. I

n this study, literature is presented on the political, legal, and socio-cultural contexts of the study, the key players for school-based HCT, and a review of relevant research, with emphasis on the role of the school nurse in educational settings and transition services. Review of the literature indicates a lack of research on the roles and responsibilities of the school nurse regarding services to YDSHCN, particularly pertaining to HCT. It is not known what policies and guidance exist for school nurses serving YDSHCN.

This research uses a qualitative single-case study design, through interviews and document reviews, to discover policies and practices that exist for school nurses serving transition-age YDSHCN preparing to exit schools in a school district in a Mid-Atlantic state. Seven district school nurses and three elite informants from the same state were interviewed, and three expert informants, outside of the state, provided information to help inform the study and shape its focus.

The study adresses the overarching research question: What elements of health care transition policies and practices are in place for serving transition-age YDSHCN preparing to exit secondary schools in this one school district? Texts from the interviews and documents were coded and analyzed to gain insight into the policies and practices, and organized using Bronfenbrenner's (1979) ecological framework. The results indicate that no comprehensive policy that includes health care transition policy exists, and that gaps exist at each level of the ecological framework. The study concludes with policy and practice recommendations.

Spirituality and nursing have been intertwined from the beginning of the profession; however, there is little evidence that clearly defines spiritual nursing care and no standardized practices that can be included in the routine preoperative plan of care for patients undergoing invasive surgical procedures. The purpose of this project was to conduct a systematic review of the literature to define spiritual care and identify specific spiritual nursing care interventions. The biopsychosocial model, Narayanasamy's transcultural care practice model, and Watson's theory of human caring provided the theoretical framework for the project. MEDLINE, PubMed, Wiley online library, SCIENCE, WOS, Cochrane, and SciELO databases were searched for the literature review. Keywords and phrases used included spirituality, spiritual nursing care, holistic health practices, inpatient, hospital, and preoperative care. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) II tool was used for data analysis. Interventions found in the literature to be supportive of spirituality included healing presence; providing effective communication; praying with the patient and family or facilitating other religious rituals; using the therapeutic self to be with the patient; listening to and exploring the patients' spiritual perspectives; and showing support and empathy through patient-centered caring, nurturing spirituality, and creating a healing environment. Employing these nursing actions might promote positive social change by contributing to a sense of well-being as patients find meaning and purpose in their illness and life overall, which will promote improved surgical outcomes and better patient satisfaction with care.

The purpose of this study was to determine the perceptions of residents, family members, and nursing staff regarding quality of care and the physical environment in the nursing home. Relationships among quality of care, the physical environment, and selected organizational characteristics were then described. The Quality of Care Scale (QoCS) and the Environment Description Scale (EDS) were given to a convenience sample of 100 subjects. A significant difference in perceptions of quality of care was found between the nurse assistants and residents. Significant relationships were obtained between perceptions of quality of care and the physical environment for Registered Nurses, Licensed Practical Nurses, and families. Defining quality of care and determining the significance of the physical environment from the consumer perspective may contribute to both quality of life and quality of care in the nursing home.

Many long-term care (LTC) facilities within the United States have replaced the institutional model of care with one that accepts person-centered care (PCC) as the guiding standard of practice. Quality training ensures that direct care staff have the skills and the knowledge in the delivery of quality PCC. However, many nurses and nursing assistants have expressed the desire for further training in PCC practices to effectively deliver quality care. The purpose of this study was to explore the types and length of training and education provided based on the perceptions and experiences of direct care staff related to their implementation of PCC practices. The theoretical framework for this study consisted of Rogers’ PCC approach theory and philosophy. A qualitative interpretative phenomenological design was used to examine the perceptions of training and education of 20 certified nursing assistants using semistructured interviews. Once the interviews were conducted and transcribed, the data were coded into superordinate themes that stemmed from participant responses. Themes of PCC practices, teaching modalities, learner type, length, and introduction of training were identified as a result of the data analysis. The data also revealed that it is important for LTC facilities to be aware of how they are providing PCC education and training to their staff so that they may provide their residents with quality individualized care that emphasizes the whole person. Study findings may inform LTC administrators, leaders, and managers on the deliverance of effective training and educational practices when implementing PCC models within their facilities. The results may also spur national LTC organizations to refocus their core beliefs, values, and culture towards a culture that considers the whole person.

Although predictions for the supply of registered nurses (RNs) is projected to increase to 3,849,000 by 2025, the demand for RNs is projected to grow to 3,509,000. The purpose of this single case study was to explore the strategies some recruiters in a nonprofit health care facility used to recruit RNs. The conceptual lens used for this study was general systems theory. Through a purposeful sample of 3 recruiters at a nonprofit health care facility located in New York, data collection occurred through semistructured interviews, reviewing job boards and the company website, and taking field notes the day of the interviews. Data analysis involved a process of organizing, coding, arranging data into common themes relevant to the research question, and interpreting the data. Member checking was used to enhance the credibility and validity of the data. Through thematic analysis, 4 themes emerged: partnering with colleges, strategies in recruiting RNs, partnering with professional organizations to recruit RNs, and updating the website. Using multiple job boards to promote available RN positions was also identified as a strategy to recruit RNs. Identifying strategies to recruit RNs may assist human resource leaders in a challenging business environment in which the supply of qualified RNs is low. The study findings have implications for positive social change for recruiters in a nonprofit health care facility and in the community. Recruiters in a nonprofit health care facility that recruit qualified RNs may assist with improving the nonprofit mission, identifying sickness or disease, and assisting with proper treatment for patients.

Yearly influenza (flu) immunization rates for hospital healthcare workers (HCW) continue to be lower than those suggested by the Centers for Disease Control and the World Health Organization. Vaccination is considered a valuable step in the process to protect patients against influenza infection. The goal of Healthy People 2020, and most hospital administrators, is that 90% of HCWs are being immunized. The objectives for this systematic literature review were to identify best practice recommendations for improving the vaccine rate among HCWs. The Cochrane methodology framed this systematic review, and Fineout-Overholt's and Melnyk's levels of evidence were used to evaluate the reliability of information and effectiveness of their interventions. Twenty articles that met the inclusion criteria (HCWs with direct patient contact, published between 2009-2016, and written in English) were reviewed. Eight articles met Melnyk's criteria for evidence Levels 5 to 7, 8 articles met the criteria for Levels 3 to 4, 2 articles were Level 2, and 2 articles were systematic reviews of randomized controlled trials (Level 1). The major influences for accepting the flu vaccine was for self-protection; the leading deterrent for receiving the flu vaccine was unbelief and questions about effectiveness. Best practice strategies to increase vaccination rates among HCWs include understanding cultural beliefs, practices, and diversities. Involvement of leadership will direct changes through future policy development. The impact of a progressive flu vaccine campaign can effectively promote social change when health care workers' concerns are addressed and vaccination rates improve. Together, quality of care for patients may also improve.

In contemporary Western nursing, the notion of health is considered a basic concept in all nursing theory, yet the many nursing theorists have failed to express unanimity in their various descriptions of health. This situation exists even while the achievement of health is generally identified as the goal or purpose of nursing. In Australia, the requirement that nurses become health-promoting practitioners assumes that nurses understand health in positive ways, which can be translated into nursing practice. Given the myriad definitions of health, confusion among nurses about the nature of health as it is to be promoted appeared possible, even probable.This phenomenological research aimed to illuminate the nature of nurses' understandings of health and the ways such understandings are translated into nursing practice. The purpose of the study was to describe and interpret nurses' experiences of health, and their experiences of giving health care to someone in their care, in order to illuminate the nature of health for nurses and in nursing.The manner in which this research was carried out was informed by the human science approach to phenomenology described by van Manen, which is derived from the traditions of Husserl, Heidegger and Merleau-Ponty. Thus, the inquiry was grounded in the hermeneutic phenomenological philosophical perspective, which began with the work of Husserl who recognised the need to return to the grounding of truths in human experience. The thesis is informed by two views of phenomenology. The first involves the traditional approach to phenomenology advocated by the European phenomenological philosophers while the second approach is referred to by Silverman as arising from 'American continental' philosophy.Data were generated from multiple audiotaped interviews with each of nine participants, and from personal reflection and journalling undertaken by the researcher during the research process. The dual data analyses were guided by the phenomenological approach of van Manen and by that of various nursing scholars who have used phenomenological methodology as it has evolved from American continental philosophy. These analyses included several levels of reflection undertaken by the researcher and each of the participants in the study to illustrate the nature of health in nurses' lives and in nursing.The nature of health, as revealed through the original experience of the participants, was disclosed as manifest in the lives of the participants with most descriptions conveying a sense of contentment that showed as feelings of happiness, feeling alive, complete, energised and optimistic. Health also revealed itself as transient in nature, passing quickly and without notice into and out of the lives of most of the participants. Although obvious in some ways, health simultaneously eluded clear description and, even at the completion of the exploration with each participant, was characterised by an atmosphere of elusiveness. For all the participants, health was an embodied phenomenon with a common element of energy and a sense of wellbeing. These, together with a sense that life was manageable and achievable gave to it a distinctive spirit, even while the spirit simultaneously helped to make life manageable and achievable and thus contributed to health. For all of those who participated, health presented as having the ability to transform their emotional responses to daily life events in such a way that it made those events more acceptable and the tasks of life more achievable.Although health showed as a physical, embodied state which was expressed as vitality and energy, it could not be separated from the mental / emotional state. As it was described, the following leitmotifs of health were lexically revealed: Health: A different encounter for each person, Health described as peace, Health described as feeling good about oneself, Health described as balance, Health as energy, Health as vitality and zest, Health described as happiness and/or contentment, Health described as quality of life, The 'picture of health', Health described as dignity, and Health as the unknown or the inexpressible.The nature of health-focused care in nursing showed as caring, rapport building and support, ever dependent on the social relationship that develops between each nurse-carer and the individual to whom they offer care. However, clear relationships between the meanings of health for the nurses in the study and the way they gave health care could not be elucidated. These relationships have not been identified because of the individualistic nature of health-focused care as these nurses have described it. For this reason, this research makes a strong plea for continued dialogue about the relationships between health and health-focused care in nursing.

Tobacco use among veterans is significantly higher than among members of the general population. The purpose of this quality-improvement project was to increase acute care staff members? knowledge and confidence in using tobacco cessation interventions to increase quit rates among the inpatients of a veterans? hospital in the midwestern region of the United States. An evidence-based, standardized Tobacco Tactics Toolkit was developed and implemented, and a 6 sigma method guided the quality improvement process to define, measure, analyze, improve, and control the tobacco-cessation education initiative. The reach, effectiveness, adoption, implementation, and maintenance framework was used to ensure that evidence-based interventions were applicable to practice. The transtheoretical model was also used to understand the changing behavior of individuals addicted to tobacco and explain the phenomena of nicotine dependence. A convenience sample method was used, and a 10-question pre- and posttest was administered to 12 staff members. Results showed a 60% increase in posttest scores indicating a significant improvement in staff confidence, knowledge, and willingness to implement tobacco-cessation interventions. The Tobacco Tactics Toolkit has the potential to positively impact social change by increasing quit rates, decreasing admissions, and improving quality of life among veterans.

The value-based purchase requirement of the Patient Protection and Affordable Care Act puts pressure on hospital leaders to control cost while improving quality of care. The resource dependency theory was the theoretical framework for this correlational study. Archival data from the Centers for Medicare and Medicaid Services collected from 166 acute care urban hospitals for the Fiscal Year 2016. Multiple linear regression analysis was used to determine the relationship between nursing salaries per patient day, cost of uncompensated care as a percentage of net patient revenue, percentage of net income from patient services, and overall patient satisfaction for quality of care received. The multiple regression analysis results indicated the model as a whole to significantly predict overall patient satisfaction for quality of care for the Fiscal Year 2016, F (3,162) = 13.788, p = .000, and R2 = .203. In the final model, all 3 independent variables significantly predicted overall patient satisfaction for quality of care. Nursing salaries per patient day and percentage of net income from patient services were significant positive predictors of overall patient satisfaction for quality of care. Nursing salaries per patient day (� = .366, t = 5.120, p = .000) accounted for a higher contribution to the model than percentage of net income from patient services (� = .169, t = 2.374, p = .019). The cost of uncompensated care as a percentage of net patient revenue displayed a significant negative relationship with overall patient satisfaction for quality of care (� = .176, t = €2.458, p = .015). The implications of this study for positive social change include the potential to enhance the quality of care for patients while maintaining local hospitals' financial viability.

This study examines the development of nursing as a vocation, in the early twentieth century, within the context of a growing southern city and an evolving health care system. Nursing advanced from a domestic service to a recognized vocation during this era. An extensive survey of historical and nursing literature revealed few studies which focus on nursing and health care in an urban context. Those studies identified gave only brief glimpses of nurses and focus on northern cities. This investigation aims to add a southern chapter to the history of nursing and health care in urban settings. A community systems approach to analyzing changes in the city provides the context for evaluating nursing development, while health care became more accessible and professional. Historical approaches used to support the thesis include analysis of social history, public health, morbidity and mortality statistics, and quantitative collective biography. These methods yield data which depict what it meant to practice nursing during the study period. Much of the actual information about the nurses and their practice had to come from indirect sources in order to draw conclusions from the research. Primary sources used in this research include newspapers, city directories, census reports, probate records, city health reports, student nurse and hospital records, oral histories and medical records. Secondary sources include southern, women's, urban, city, institutional, medical and public health histories. In addition, nationally oriented nursing histories and theses proved useful in the analysis of primary data. The findings of the study demonstrate marked transitions in the maturation of nursing and health care in the city. These changes happened at a different pace when compared to similar events in northern urban areas. Many variables contributed to the differences noted, including the cultural expectations of women and race relations in community life. Nurses functioned in the beginning of the study as occasional domestic servants who were primarily black women. They practiced in a city with limited public health services, one hospital for whites and a pest house for blacks. By 1930, nurses practiced in a city with improved public health services, four hospitals with nurses' training schools, including one for blacks. Nurses enjoyed a professional association and the protection of a state practice act. These women progressed from shadowy figures seldom seen in public, to a group of workers recognized as an asset to the health of the community. PALMM

The foundation of mental health nursing has historically been grounded in an interpersonal, person-centred process of health care, yet recent evidence suggests that the interactional work of mental health nursing is being eroded. Literature emphasises the importance of person-centred care on consumer outcomes, a model reliant upon the intimate engagement of nurses and consumers. Yet, the arrival of medical interventions in psychiatry has diverted nursing work from the therapeutic nursing role to task-based roles delegated by medicine, distancing nurses from consumers. This study used work sampling methodology to observe the proportion of time nurses working in an inpatient mental health setting engage in specific activities. The observations of this study determined that nurses' time is accounted for 31.65% in direct care, 51.63% in indirect care and 16.71% in service related activities.

This dissertation examines the factors that will affect nursing home quality of care using several national data sources on market regulation, county demographic characteristics, market structural and the characteristics of different types of long-term care providers in 2010.

The first study examines how nine different measures of nursing home care quality respond to the greater levels of local market competition from these alternative providers of long-term care, as well as other nursing homes. Findings reveal that faced with greater competition from assisted living facilities, nursing homes are left to care for more disabled, less healthy patients. Although the nursing home's staff-to-bed ratios rise in response, other measures of care quality decline, such as more process- and outcome-based measures. Competition from home health agencies likewise has mixed effects on nursing home care quality, and competition from other nursing homes in a market tends to decrease care quality. These finding suggest that care quality in nursing homes may continue to erode as the market for alternative, community-based long-term care services expands.

The second study examines the Medicare regulation effects on nursing home quality controlling for the whole long-term care market competition structure. In many local markets nursing homes now compete with assisted living facilities for residents, yet most previous studies of the effects of Medicaid nursing home reimbursement policies on care quality have analyzed nursing homes in isolation, ignoring the presence of nearby competitor firms, and how state regulation of assisted living facilities might also affect care quality in nursing homes. This study uses a richer model specification that accounts for a much broader range of state long-term care regulations as well as the structure of a nursing home's local market. Findings reveal that a higher Medicaid reimbursement rate leads to significant improvements in nine different aspects of nursing home quality, while state certificate-of-need programs for nursing homes lead to a decline in several (but not all) dimensions of it. A large presence of assisted living beds in a local market also tends to reduce nursing home quality, and state regulations regarding assisted living facilities indirectly affect nursing home care quality by altering the nature of local market competition. Overall, these results suggest that state laws related to all long-term care providers, not just nursing homes, are important determinants of nursing home care quality.

Purpose: The purpose of this DNP quality improvement project was to increase primary care provider knowledge about indications for adolescent depression screening.

Background: Approximately 13.3% of adolescents experienced depression in the past year. In Oklahoma alone, rates are increasing, with depression totaling 60% of all mental health illness among adolescents. Primary care providers see approximately 75% of adolescents; however, mental health conditions are missed 84% of the time. Current clinical guidelines recommend screening for adolescent depression during wellness visits or when risk factors are present.

Methods: The providers of interest were nurse practitioners, physicians, and physician assistants providing primary care to children between the ages of 12 and 17 in a private pediatric practice group consisting of three clinics. The Model for Improvement guided the process of developing, implementing, and evaluating an educational intervention through use of a pre-test/post-test quantitative design. An email invited participants to complete an anonymous pre-test survey to evaluate knowledge and beliefs surrounding adolescent depression, then view an educational presentation on adolescent depression and screening guidelines, then complete a post-survey to evaluate any changes in knowledge and intention to screen. Results were shared with clinic representatives to help refine the education for future testing cycles and other clinic sites.

Results: Data collection took place over one week. Five providers completed both the pre-test and post-test surveys. Provider knowledge scores significantly increased 29% after participating in the education and self-reported knowledge on screening increased.

Conclusions: DNP quality improvement projects like this help develop strategies to increase best practices, leading to improved patient outcomes. Nurse-led improvement programs like this contribute to healthcare literature and the advancement of the nursing profession by developing patient-centered interventions applicable to a wide variety of providers. Results may be used to develop strategies to increase and align provider practices with best standards to help promote early identification and treatment of adolescents with depression.

This research used a Delphi methodology to solicit challenges that significantly impact the operational success of pediatric long-term care facilities. Further, this study sought to understand the ability of pediatrics administrators to impact, affect, overcome, or resolve these challenges. Round 1 accomplished the desired goal of eliciting a substantial amount of new qualitative information regarding administrative challenges in pediatric long-term care, which previously had been extant in the literature. In Round 2, data were distilled into categories and unique exemplars which in turn were validated by participants. In Round 3, administrators ranked and rated categories and individual challenges in terms of significance and impact.

Findings revealed that the most important challenges for administrators are those of working with an inadequate model that is designed for a geriatric population, inadequate Medicaid funding, and the lack of clinical and administrative indicators in pediatric long-term care. The most important challenges that could be affected by the administrators are related to inadequate model, clinical practice, and the need for diversification. Administrators believe they can strongly impact the rules, regulations, and protocols that are currently geriatric focused, develop pediatric long-term care indicators and evidence-based research, and impact their financial security by diversification.

The Delphi research accomplishes the desired goal of eliciting a substantial amount of new information regarding administrative challenges in pediatric long- term care and contributes to the broader body of knowledge in health services administration. The significant research findings suggest the need for changes in the regulatory and financial models in pediatric long-term care and the need for enhanced clinical practice though evidence-based practice and outcomes.

Background: Nearly 750,000 adolescents and emerging adults with special health care needs (AEA-SHCN) enter into adulthood annually. The linkages to ensure the seamless transfer of care from pediatric to adult care and transition to adulthood for AEA-SHCN have yet to be realized. Purpose: The purpose of this systematic review was to investigate the state of the science of health care transition (HCT) service models as described in quantitative investigations. Methods: A four-tier screening approach was used to obtain reviewed articles published from 2004 to 2013. A total of 17 articles were included in this review. Discussion: Transfer of care was the most prominent intervention feature. Overall, using the Effective Public Health Practice Project criteria, the studies were rated as weak. Limitations included lack of control groups, rigorous designs and methodology, and incomplete intervention descriptions. Conclusion: As the findings indicate, HCT is an emerging field of practice that is largely in the exploratory stage of model development.

While the phenomenon of grief has received considerable attention and has been researched at length, there is a paucity of literature that has focused on health care professionals' experience of grief. The purpose of this study was to investigate the grief experience of pediatric intensive care nurses when their patients die. A phenomenological method was used in this study in order to obtain rich descriptions of nurses' experience of grief within their workplace. The purposive sample consisted of six registered nurses employed in an intensive care unit in a university-teaching pediatric hospital. In-depth, semi-structured interviews were conducted with the study participants in order to generate the data base. The audio-taped interviews were transcribed and analyzed for recurring themes emerging from the data according to the procedure outlined by Colaizzi. These nurses acknowledged they suffered multiple exposures to children's deaths and experienced grief. The interviews revealed eight themes that included one about their grief responses--hurting; two that described the influencing contextual factors--nurse-family unit relationship and dissonance, and five that related to coping strategies employed to manage their feelings of grief--self-expression, self-nurturance, termination of relationship activities, engaging in control taking activities and self-reflection. Further analysis revealed that managing grief effectively was an experiential learning process for the participants. The resultant themes were compared with the broader literature on grieving the loss of a significant other, grief and the health care professional, and the literature that addressed issues of occupational stress in the care of the critically ill, the dying, and the bereaved. The findings of this study could encourage further research that examines interventions designed to enhance the type of education and support needed in relation to the grief experience of nurses.

The hospitalization of one's infant is a stressful situation that can lead to decreased bonding and poor health outcomes. This longitudinal comparative design study examined the effects of neonatal palliative care (PC) consultation on stress levels and satisfaction scores of parents of neonatal intensive care unit (NICU) infants. Clinical data was abstracted from the medical record. Demographic data, stress scores, and satisfaction reports were obtained via self-report.

Mean stress scores indicated most parents experienced moderate stress due to NICU hospitalization. Some parents met diagnostic criteria for acute stress disorder. While all parents expressed satisfaction with care received; PC parents were extremely satisfied with care. No statistically significant differences in stress or satisfaction scores were noted between parents who received PC consultation and those who did not. Study conclusions validate previous research regarding NICU parent stress and show that additional quantitative and qualitative research regarding NICU palliative care is warranted.

A trend toward non-institutionalization of the elderly, in conjunction with the increasing size of the elderly population has resulted in the development of a variety of community programs and services to help meet their complex and diverse health care needs in the community setting. Although there is substantial documentation pertaining to the needs of the elderly in the community and the available services (Lifton, 1989; Padula, 1983; Starrett, 1986; Wallace, 1987), this documentation has been generated primarily by health care professionals and agencies, rather than from the perspectives of the elderly themselves. Adult Day Care [ADC] programs were established in the late 1960s as one means of attempting to meet the needs of the frail elderly in the community (Padula, 1983). On the surface, these programs appear to be effective in meeting the needs of clients through the provision of nursing services and a wide variety of therapeutic programs and social activities. This exploratory descriptive study was based on the premise that there exists a need to gain insight into the clients' perspectives regarding the ways in which ADC services are instrumental in meeting their perceived needs. Data were collected and analyzed to identify the self-perceived needs of ADC clients and their perceptions of how the ADC nursing services were instrumental in assisting them to meet these needs. Two interviews were conducted with each of the 11 ADC participants comprising the sample, using a semi-structured interview guide developed by the researcher. The two needs most commonly identified by participants included the need to cope with a range of concurrent and/or successive losses, and the need to establish new support systems. Participants identified the most significant components of the nursing role as those of the provision of emotional support through counselling, and the provision of health monitoring services. Participants viewed the overall ADC program as important in assisting them to meet their needs by providing access to social outings, individualized care, emotional support, and the opportunity to enhance their self-esteem, confidence, and feelings of belongingness.
Applied Science, Faculty of
Nursing, School of
Graduate

When patients present with complaints of anxiety or depression, providers in the primary care setting often prescribe anxiolytics or antidepressants without conducting an early emotional trauma or adverse childhood experiences assessment. Several studies demonstrate the link between early emotional trauma (EET) or adverse childhood experiences (ACEs) and the increased risk of anxiety or depression as adults. This Clinical Scholarly Project (CSP) implemented the use of the Adverse Childhood Experience (ACE) Questionnaire with patients who had a diagnosis of anxiety or depression in the primary care setting to increase patient access to resources and align clinical practice with practice guidelines. Participants included eight primary care providers, 30 patients and 21 chart review patients. The CSP utilized a quasi-experimental design to determine if the use of the ACE Questionnaire by patients with anxiety or depression would result in patients receiving more community resources (to include counseling), strengthen the provider-patient relationship, increase provider comfort in discussing ACEs with their patients and result in patients receiving care that was evidence based. Patient sample participants received significantly more resources (M = 8.27, SD = 2.27) than the chart audit sample (M = 0.90, SD = 0.30). Patient sample members received an average of eight resources (M = 8.27) and utilized an average of five resources (M = 5.07). Use of the ACE Questionnaire resulted in more trust in provider-patient relationship by patients (80.0%) and the majority of the provider sample more comfortable discussing ACEs after the project (85.7%).

Blood transfusions occur in all areas of a hospital with nurses at the point-of-care responsible for specimen collection, blood administration, patient surveillance, and adverse event reporting. Unfortunately there is a paucity of nursing research on blood transfusions. The purpose of this study was to describe the state of the science of medical-surgical acute care nurses' practices with blood transfusion therapy. Seven research questions addressed the comprehensive scope of nurses' involvement with blood transfusions. Data was collected via a valid and reliable web-based survey, Nurses' Practices with Blood Transfusions: Medical-Surgical Acute Care. A random selection of U.S. hospitals with a nurse executive who was a member of the American Organization of Nurse Executives was recruited via postal letter. One survey was completed per hospital with 148 hospitals responding (18.3% response rate).

Nurses' practices in transfusion processes are similar across the country. The hospital's transfusion policy was the most influential source of information for nurses because it specified nurses' transfusion practices. Limitations in surveillance of the medical-surgical patient with a blood transfusion were due to the lack of current information on transfusion reaction symptoms included in the education programs, delegation of transfusion vital signs to non-licensed staff that were not educated on symptoms of a transfusion reaction and transportation of patients with blood infusing to tests and procedures. Hospitals were in the process of adopting electronic technologies to reduce or eliminate wrong-blood-in-tube errors or wrong blood administered mistransfusion errors. Nurses need to collaborate with the transfusion service to update the transfusion policy and the blood transfusion education programs; include non-licensed staff in compulsory blood transfusion education; and closely evaluate the capabilities of an electronic documentation system to truly match the patient to the blood product. This descriptive study is a foundation for future research of nurses with blood transfusions.

In 1978, Primary Health Care (PHC) was formally recognised, in the Declaration of Alma-Ata, as the key to achieving the World Health Organisation's goal of 'Health For All by the Year 2000' (HFA). PHC was seen as the solution to the inadequate illness management systems that had developed throughout the world. It was hoped that PHC would address some of the major inequalities in health observed both within and between countries by its balanced system of treatment and disease prevention. The WHO envisaged that PHC would take place as close as possible to where people live and work and be the first element of a continuing health care process. Additionally, health service collaboration and multi-professional partnerships were expected to replace professional boundaries and competition. Shortly after the Declaration of Alma-Ata, the World Health Organisation, supported by national and international nursing bodies, proposed that nurses would be the driving force behind the HFA movement as active partners in inter-professional teams, leaders in health care and resources to people rather than resources to other health professionals. In the ensuing years, although community health nurses were acknowledged by the government and the nursing profession as key players in PHC in Australia, practice nurses (nurses who are employed in general medical practices) were not identified within this group. Hence, it appeared as though these practice nurses were 'invisible', not considered important to PHC in Australia, or simply overlooked as a major influence on population health. The purpose of this study was to describe the current role of these nurses and to identify and analyse the factors that influenced their scope of practice and hence their contribution to PHC. The research was conducted as a case study of practice nurses in one Division of General Practice in southeast Queensland. The study was influenced by the constructivist paradigm of inquiry and utilised a complementary sequence of quantitative methods followed by qualitative investigation. The first stage of the study comprised a telephone followed by mail survey of general practitioners and practice nurses employed within the Division. This was followed by a second stage, which involved group and individual interviews of key informants and was supported by document review and observation. The study revealed that the practice nurse role is essentially one of assistant to the general practitioner wherein the nurse undertakes basic assessment procedures to aid the medical diagnosis, carries out delegated therapeutic procedures, and contributes to the administrative functioning of the practice. Autonomous nursing initiatives, which appear to be largely opportunistic and incidental to delegated activities, include physical and emotional support of patients, clarification and reinforcement of medical instructions, and the provision of health education. The practice nurse's role, and hence contribution to PHC, was found to be constrained by a number of factors. These factors include the current funding arrangements for general practice, the view that practice nurses are an option rather than a necessity, the general practitioners' control of the practice setting, the appropriation of nursing work to medical receptionists, the lack of professional development opportunities, and the practice nurses' passive acceptance of their circumstances. However, both general practitioners and practice nurses appreciate the value of nursing services in general practice and GPs would sanction the employment of more nurses, if given financial incentives, especially for the purpose of preventive care. The majority of practice nurses believe their role should be expanded to include autonomous functioning while most of the GPs were amenable to some extension of nursing practice but reticent or opposed to any independent interventions. There appears a need in Queensland for courses to prepare practice nurses for advanced practice if they want to expand their role in PHC beyond that of assistants to GPs. It would also seem to be in the nurses' interests to initiate a professional association of practice nurses as a vehicle to explore other issues relevant to their professional development. In addition, if PNs want to expand their role they will need to demonstrate improved patient outcomes and cost effectiveness.

Healthcare industry owners who have unsatisfactory customer care services may experience a financial risk and create dissatisfied patients. The purpose of this case study was to explore customer care strategies that managers of urgent care businesses used to improve customer care services and patient satisfaction. The target population consisted of 1 urgent care manager from 3 separate urgent care clinics with the highest customer satisfaction ratings in Alabama. The urgent care managers were knowledgeable about effective customer care strategies that improved customer care services and patient satisfaction. Customer loyalty theory with emphases on customer behavior, customer attitude, repeat patronage, and loyalty was the conceptual framework for the study. Semistructured interviews and patient survey forms were the data sources. Data were analyzed using thematic analysis which identified similar codes, patterns, and themes. The 3 primary themes that emerged from thematic analysis were patient-focused care, social media outreach, and employee engagement. The implications of this study for positive social change include the potential to enhance the quality of healthcare experiences, which may empower individuals to seek medical care. The patients might become trusting of healthcare providers and become collaborators in responding to medical care requests by medical staff to improve their quality of life.

Concerns have been well documented about deteriorating patients being missed and that care has not been of a sufficient standard to maintain their safety. This 'failure to rescue' remains despite changes in training and critical care experts working with ward staff. little is known about what influences decision-making at the point a patient deteriorates and prior to referring on to an expert. The aim of this study was to understand how nurses reach their clinical decisions while caring for a deteriorating patient and to identify the contextual factors that influence that decision-making process. Using grounded theory methodology the study comprised fieldwork, semi-structured interviews and a focus group; participants were 22 nurses and 2 physiotherapists working in general medical and surgical wards. A pragmatist philosophical tradition informing symbolic interaction guided the interpretive analytical framework of the study. The simultaneous collection, memoing, dimensional analysis of the data and constant comparison of the findings with the body of literature, built an emerging theory of clinical reasoning in acute care situations. Findings suggested that acute care nurses practice in one of 3 modes. They are: • 'Ward routine', where normal ward work takes place and nurses use protocols to deliver care. • 'Crescendo of care' where searching, information gathering, checking findings and efforts to gain control over the clinical situation took place. Nurses' reasoning in this mode was abductive and focused on building a believable case prior to referral. • 'Management of crisis' where the nurse was sure of their concerns, made the referral and continues to seek to confirm concerns. Through the three modes nurses reasoned and made sense of the clinical information they picked up. They spent lime marshalling this data until it served them a believable credible case with which to refer to another professional. This involved negotiating and bargaining to elicit action. The goals in these actions and interactions were to keep the patient and themselves safe. This was underpinned and motivated by their personal and professional beliefs. Throughout the whole decision-making process nurses accounted for every decision and judgement they made until they were convinced and confident in what they believed was happening. Then they made a referral to a more senior professional. This was conceptualised as the theory of mind accounting in clinical reasoning 'Which emerged as the explanation for how nurses clinically reason and make decisions when caring for a patient whose condition is declining. The emerging theory offers an alternative explanation of the way nurses assess and intervene when concerned about a patient. This is significant because timely accurate decision-making is fundamental to providing quality care.

This research study was designed to improve the quality of health care received by the Hispanic population in northeast Tennessee. After reviewing past research, it is evident that the Hispanic population reports a lower level of health care satisfaction and a greater number of health disparities. Although attempts to reconcile this problem have included implementing regulations and guidelines on the cultural competency of and the provision of language services by health care providers, no measurable improvement has been noted. To positively impact this pervasive problem, the focus must shift away from how health care agencies can affect health care for Hispanics, and toward how health care providers can improve patient care. It is the responsibility of health care providers to provide quality care to all patients, regardless of their culture, race, or language. By interviewing three primary care nurse practitioners who serve a large Hispanic population in northeast Tennessee, it became evident that even with a language aide present, barriers to caring for this population still exist, although these barriers are not unsurmountable. Through years of experience, these providers have developed skills that have improved communication with, and health-related outcomes of, Hispanic patients, but this type of care should not be impacted by nurse practitioner turnover. Each provider agreed that nursing students’ education and opportunities to work with diverse populations while in basic nursing education programs must be improved, so that when students graduate, they can become part of the solution to this ongoing problem.