Purpose Previous research suggests an association between depression and poorer clinical outcomes for heart failure patients. Administrative ICD-9 coding is used extensively in health services research to capture variables of interest for outcomes studies, such as mental health issues. However, there is limited evidence of the accuracy of administrative ICD-9 coding for identifying patient-level mental health issues. The purpose of this study was to determine the agreement between ICD-9 coding and ‘gold standard’ clinician documentation in a patient’s History & Physical, consult notes and/or discharge summary of a mental health issue, as part of a larger study examining predictors of readmission for hospitalized heart failure patients. Methods Study sample (n=504) was randomly chosen from the population of all unique patients (n=3770) hospitalized with a heart failure primary diagnosis from 2009-2012 at one of four Sharp HealthCare (a large community based health system) hospitals with complete electronic records. A mental health issue was defined as any ICD-9 code between 290-319 in any discharge diagnosis position from 1-30. Study sample patient records were manually reviewed to identify mental health issue documentation in the dictated History & Physical, discharge summary, and/or consult notes. Three reviewers copied text suggesting any mental health issue into a data spreadsheet and recorded where text was found. Documented text was reviewed by all three reviewers and consensus reached to indicate a mental health issue. Reviewers were blinded to administrative coding data. Agreement was calculated using the Kappa statistic for non-random agreement. Results Thirty four percent (n=1285) of the total HF population were coded for a mental health issue, and 33% of the study sample (n=164). Agreement between coding and chart review to identify mental health issue was 89%, with a 4% false positive and 10% false negative rate. Positive predictive value was 87% and negative predictive value was 85%. The Kappa statistic was .69: CI .61-.79, interpreted as substantial agreement. There was no significant difference in rates of mental health categories between manual chart review and ICD-9 coding for anxiety/depression, 31% vs. 29% (p=.59); dementia, 25% vs. 18% (p=.10); and alcohol/drug abuse, 14% vs. 18% (p=.39). Conclusion ICD-9 coding appears to be a reliable method for identifying mental health issues for patients hospitalized with heart failure. To our knowledge this is the first study to determine agreement between coding and clinician documentation of mental health issues/categories for hospitalized heart failure patients.

Thomas Bender’s 2009 essay “Can National History Be De-Provincialized? U.S. History Textbook Controversies in the 1940s and 1990s,” originally published in Contexts: The Journal of Educational Media, Memory, and Society, asks the important question of how a nation-specific curriculum in history—that is, how “American” history itself—can be taught with the least influence of political factions and the least interference of commercial factors, in light of the fact that both elements, the political and the commercial, have played a role in the construction of the US history textbook. Bender’s essay demonstrates the complexity of the problem as multiple stakeholders seek to control, limit, or promote particular elements of the narratives of US history. Professional historians, Bender argues, like history itself, have “no responsibility to supply comfort”—that is, no role in promoting nationalism or American exceptionalism—yet he also warns that, due to changes in the textbook industry, they also may have little role in determining what is finally published. Bender’s essay, which specifically discusses the impact of political conditions—World War II, for example—on the daily practice of teaching and writing about history, serves as an insightful reminder of the complexity and vulnerability of a nation’s memory.

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Numerous policy bodies have identified the clinical nurse leader (CNL) as an innovative new role for meeting higher health care quality standards. Although there is growing evidence of improved care environment and patient safety and quality outcomes after redesigning care delivery microsystems to integrate CNL practice, significant variation in CNL implementation has been noted across reports, making it difficult to causally link CNL practice to reported outcomes. This variability reflects the overall absence in the literature of a well-defined CNL theoretical framework to help guide standardized application in practice. To address this knowledge gap, an interpretive synthesis with a grounded theory analysis of CNL narratives was conducted to develop a theoretical model for CNL practice. The model clarifies CNL practice domains and proposes mechanisms by which CNL-integrated care delivery microsystems improve health care quality. The model highlights the need for a systematic approach to CNL implementation including a well-thought out strategy for care delivery redesign; a consistent, competency-based CNL workflow; and sustained macro-to-micro system leadership support. CNL practice can be considered an effective approach to organizing nursing care that maximizes the scope of nursing to influence the ways care is delivered by all professions within a clinical microsystem.

Yrast states in 34P were investigated using the 18O(18O,pn) reaction at energies of 20, 24, 25, 30, and 44 MeV at Florida State University and at Lawrence Berkeley National Laboratory. The level scheme was expanded, ray angular distributions were measured, and lifetimes were inferred with the Doppler-shift attenuation method by detecting decay protons in coincidence with one or more rays. The results provide a clearer picture of the evolution of structure approaching the \Island of Inversion", particularly how the 1 and 2 particle-hole (ph) states fall in energy with increasing neutro number approaching inversion. However, the agreement of the lowest few states with pure sd shell model predictions shows that the level scheme of 34P is not itself inverted. Rather, the accumulated evidence indicates that the 1-ph states start at 2.3 MeV. A good candidate for the lowest 2-ph state lies at 6236 keV, just below the neutron separation energy of 6291 keV. Shell model calculations made using a small modification of the WBP interaction reproduce the negative-parity, 1-ph states rather well.

Jacqueline Fawcett's nursing metaparadigm-the domains of person, health, environment, and nursing-remains popular in nursing curricula, despite having been repeatedly challenged as a logical philosophy of nursing. Fawcett appropriated the word "metaparadigm" (indirectly) from Margaret Masterman and Thomas Kuhn as a devise that allowed her to organize then-current areas of nursing interest into a philosophical "hierarchy of knowledge," and thereby claim nursing inquiry and practice as rigorously "scientific." Scholars have consistently rejected the logic of Fawcett's metaparadigm, but have not yet proposed a substantially agreed-upon alternative. Through an analysis of articles introducing and critiquing Fawcett's metaparadigm, I argue for a re-conceptualized metaparadigm that articulates nursing's ontology. What exists for the nursing discipline are not already-demarcated metaparadigm domains, but rather interdependent, dynamic relations that constitute people, including nurses, in their health/environment circumstance. The nursing discipline aims to skillfully access this dynamic relationality as the basis for action and reflection to produce both positive health trajectories and knowledge that facilitates future action and reflection. Further inquiry into the onto-epistemology of nursing will produce a more robust understanding of nursing practice, science, and philosophy, and clarify its unique contribution to health and healthcare.

Background

The Institute of Medicine's Future of Nursing report identifies the clinical nurse leader as an innovative new role for meeting higher health-care quality standards. However, specific clinical nurse leader practices influencing documented quality outcomes remain unclear. Lack of practice clarity limits the ability to articulate, implement and measure clinical nurse leader-specific practice and quality outcomes.

Purpose and methods

Interpretive synthesis design and grounded theory analysis were used to develop a theoretical understanding of clinical nurse leader practice that can facilitate systematic and replicable implementation across health-care settings.

Results

The core phenomenon of clinical nurse leader practice is continuous clinical leadership, which involves four fundamental activities: facilitating effective ongoing communication; strengthening intra and interprofessional relationships; building and sustaining teams; and supporting staff engagement.

Conclusion

Clinical nurse leaders continuously communicate and develop relationships within and across professions to promote and sustain information exchange, engagement, teamwork and effective care processes at the microsystem level.

Implication for nursing management

Clinical nurse leader-integrated care delivery systems highlight the benefits of nurse-led models of care for transforming health-care quality. Managers can use this study's findings to frame an implementation strategy that addresses theoretical domains of clinical nurse leader practice to help ensure practice success.