Continuum of nursing education and practice: Time to close the chasm between academia and practice.

Nurses play a key role in the health of Americans. Unfortunately, the nation is expected to experience an increasing nursing shortage due to nurses retiring or leaving the profession and growing healthcare needs. In this context, it is important to prepare nursing students to be practice-ready graduates.

Development of an academic-practice partnership model to anchor care coordination and population health.

The National Academy of Medicine's The Future of Nursing 2020-2030 recommends the expansion of the role of nurses throughout the continuum of health care in an effort to improve the health of the nation while decreasing costs. To accomplish this goal, nursing students and nurses must be well prepared to perform at their highest capacity to meet health care demands. Currently the U.

Nonlinear association of nurse staffing and readmissions uncovered in machine learning analysis.

Objective: Several studies of nurse staffing and patient outcomes found a curvilinear or U-shaped relationship, with benefits from additional nurse staffing diminishing or reversing at high staffing levels. This study examined potential diminishing returns to nurse staffing and the existence of a "tipping point" or the level of staffing after which higher nurse staffing no longer improves and may worsen readmissions.

Data Sources/study Setting: The Readiness Evaluation And Discharge Interventions (READI) study database of over 130,000 adult (18+) inpatient discharges from 62 medical, surgical, and medical-surgical (noncritical care) units from 31 United States (US) hospitals during October 2014-March 2017.

Effectiveness of home health care in reducing return to hospital: Evidence from a multi-hospital study in the US.

Background: Home health care, a commonly used bridge strategy for transitioning from hospital to home-based care, is expected to contribute to readmission avoidance efforts. However, in studies using disease-specific samples, evidence about the effectiveness of home health care in reducing readmissions is mixed.

Objective: To examine the effectiveness of home health care in reducing return to hospital across a diverse sample of patients discharged home following acute care hospitalization.

Development of a DNP measurement grid to increase the rigor of doctor of nursing practice students' data collection and analysis methods.

A key component of the DNP project rigor is the collection and analysis of data or measurement. A Steering Committee at the University of Maryland formed to improve the quality of DNP projects established a workgroup to evaluate the current measurement content in four DNP core courses with the goal of establishing DNP project measurement criteria across the curriculum. The steps included: Step 1: Identify QI Measurement Methods and Tools.

Clinical nurses' perspectives on discharge practice changes from participating in a translational research study.

Aim: To describe clinical nurses' experiences with practice change associated with participation in a multi-site nursing translational research study implementing new protocols for hospital discharge readiness assessment.

Background: Nurses' participation in translational research studies provides an opportunity to evaluate how implementation of new nursing interventions affects care processes within a local context. These insights can provide information that leads to successful adoption and sustainability of the intervention.

Using the consolidated framework for implementation research to evaluate clinical trials: An example from multisite nursing research.

Background: The Consolidated Framework for Implementation Research (CFIR) is a comprehensive guide for determining the factors that affect successful implementation of complex interventions embedded in real-time clinical practice.

Purpose: The study aim was to understand implementation constructs in a multi-site translational research study on readiness for hospital discharge that distinguished study sites with low versus high implementation fidelity.

Methods: In this descriptive study, site Principal Investigator interviews (from 8 highest and 8 lowest fidelity sites) were framed with questions from 20 relevant CFIR constructs.

Nurse Continuity at Discharge and Return to Hospital.

Background: Promoting continuity of nurse assignment during discharge care has the potential to increase patient readiness for discharge-which has been associated with fewer readmissions and emergency department visits. The few studies that examined nurse continuity during acute care hospitalizations did not focus on discharge or postdischarge outcomes.

Objectives: The aim of this research was to examine the association of continuity in nurse assignment to patients prior to hospital discharge with return to hospital (readmission and emergency department or observation visits), including exploration of the mediating pathway through patient readiness for discharge and moderating effects of unit environment and unit nurse characteristics.

Individual Nurse Productivity in Preparing Patients for Discharge Is Associated With Patient Likelihood of 30-Day Return to Hospital.

Objective: Applied to value-based health care, the economic term "individual productivity" refers to the quality of an outcome attributable through a care process to an individual clinician. This study aimed to (1) estimate and describe the discharge preparation productivities of individual acute care nurses and (2) examine the association between the discharge preparation productivity of the discharging nurse and the patient's likelihood of a 30-day return to hospital [readmission and emergency department (ED) visits].

Research Design: Secondary analysis of patient-nurse data from a cluster-randomized multisite study of patient discharge readiness and readmission.

Effect of Implementing Discharge Readiness Assessment in Adult Medical-Surgical Units on 30-Day Return to Hospital: The READI Randomized Clinical Trial.

Importance: The downward trend in readmissions has recently slowed. New enhancements to hospital readmission reduction efforts are needed. Structured assessment of patient readiness for discharge has been recommended as an addition to discharge preparation standards of care to assist with tailoring of risk-mitigating actions.

Post-Hospital Medication Discrepancies at Home: Risk Factor for 90-Day Return to Emergency Department.

The purpose of this study was to evaluate the occurrence of medication discrepancies during transitional care home visits and the association with emergency department (ED) visits. Using secondary data analysis, the relationships between in-home medication discrepancies and 30- and 90-day ED utilization were examined. For every in-home medication discrepancy, the odds of being admitted to the ED within 90 days increased by 31%.

A Model for Hospital Discharge Preparation: From Case Management to Care Transition.

There has been a proliferation of initiatives to improve discharge processes and outcomes for the transition from hospital to home and community-based care. Operationalization of these processes has varied widely as hospitals have customized discharge care into innovative roles and functions. This article presents a model for conceptualizing the components of hospital discharge preparation to ensure attention to the full range of processes needed for a comprehensive strategy for hospital discharge.

Models of Discharge Care in Magnet® Hospitals.

Objective: The aim of this article is to describe how the discharge preparation process is operationalized in Magnet® hospitals.

Background: Nationally, there are intensive efforts toward improving discharge transitions and reducing readmissions. Discharge preparation is a core hospital function, yet there are few reports of operational models.

Validation of patient and nurse short forms of the Readiness for Hospital Discharge Scale and their relationship to return to the hospital.

Objective: To validate patient and nurse short forms for discharge readiness assessment and their associations with 30-day readmissions and emergency department (ED) visits.

Data Sources/study Setting: A total of 254 adult medical-surgical patients and their discharging nurses from an Eastern US tertiary hospital between May and November, 2011.

Study Design: Prospective longitudinal design, multinomial logistic regression analysis.

Improving assessment of cardiovascular disease risk by using family history: an integrative literature review.

Background: Cardiovascular disease (CVD) is the number one killer in the United States. Although the causes of CVD are multifactorial, including genetic and environmental influences, it is largely a preventable disease. The cornerstone of CVD prevention is accuracy in risk prediction to identify patients who will benefit from interventions aimed at reducing risk.

Using appreciative inquiry during care transitions: an exploratory study.

The purpose of the study was to evaluate the effectiveness of a transitional care coaching intervention offered to chronically ill medical patients during the transition from hospital to home. This 2-arm randomized pilot study uses a coaching framework based on appreciative inquiry theory. This article reviews the appreciative inquiry literature and identifies the characteristics of patients who participated in appreciative inquiry coaching.

Facilitators and challenges to conducting interdisciplinary research.

Background: Complex, interconnected issues challenge the United States health care system and the patients and families it serves. System fragmentation, limited resources, rigid disciplinary boundaries, institutional culture, ineffective communication, and uncertainty surrounding health policy legislation are contributing to suboptimal care delivery and patient outcomes.

Methods: These problems are too complex to be solved by a single discipline.

Nurse-pharmacist collaboration on medication reconciliation prevents potential harm.

Background: Medication reconciliation can prevent some adverse drug events (ADEs). Our prospective study explored whether an easily replicable nurse-pharmacist led medication reconciliation process could efficiently and inexpensively prevent potential ADEs.

Methods: Nurses at a 1000 bed urban, tertiary care hospital developed the home medication list (HML) through patient interview.

Challenges in posthospital care: nurses as coaches for medication management.

The purpose of this study was to evaluate a transitional care intervention posthospital discharge for chronically ill medical patients managing complex medication regimens. This descriptive pilot study tested 2 interventions: telephone follow-up and a home visit. Registered nurses delivered the interventions with consulting pharmacist support.