By completing all the steps to Rodgers' (2000a) evolutionary view of concept analysis, a working definition and clarification of the concept in its current use has been achieved. This provides a solid conceptual foundation for further study.

To date, a number of studies evaluating service developments, education, expert practice and leadership have been carried out. However although a number of studies have assessed perceived impact of the consultant role, no measure of actual benefit has been published to date. Studies that evaluate the cost benefit/outcomes of these roles in relation to both activity and quality of service are required.

PURPOSE Out-of-pocket cost sharing for health care expenses is a growing burden. Prior research has emphasized the medical consequences of cost sharing. This study investigates the range of social, medical, fi nancial, and sometimes legal disruptions from high out-of-pocket health expenses.METHODS We conducted open-ended, semistructured interviews with 33 insured patients (two-thirds covered by Medicare). All had chronic illnesses and sought philanthropic fi nancial assistance. RESULTSWe found that high levels of cost sharing precipitated considerable anxiety and substantial debt problems, as well as disruptions of medical care. Participants described various borrowing strategies (eg, credit cards), legal problems (eg, debt collections), and threats to their nonmedical household budgets (eg, food, housing). Participants described explicit and rank-ordered strategies for coping with new medical expenses. Participants understood their health benefi ts with exceptional detail but described considerable anxiety about changes to those benefi ts that could easily disrupt carefully managed household budgets. Benefi t designs that resulted in large a variations in fi nancial liability from month to month (eg, large deductibles or coverage gaps) imposed considerable fi nancial challenges.CONCLUSIONS As health care cost sharing grows, policy makers will need to consider the consequences of high cost sharing for families facing strained household budgets. Although the generosity of health insurance is important, continuity of benefi ts and month-to-month stability of fi nancial liability are also important and may be undervalued in policy discussions. Ann Fam Med 2013;11:37-42. doi:10.1370/afm.1444. INTRODUCTIONA merican families are contributing a growing fraction of their personal income to health care. [1][2][3] From 1999 to 2007, health insurance premiums increased more than 4 times faster than wages. 4,5 Benefi ts also have become less comprehensive. 1,4,[6][7][8] These cost pressures lead families to make fi nancial trade-offs within their household budgets in response to health care needs. Little is known about the choices families make and how they make them. In this study, we investigate the range of social, medical, fi nancial, and sometimes legal disruptions from high out-of-pocket health expenses. We refer to these broad effects as life disruptions.The literature examining fi nancial burden from health care focuses on 2 major areas. First, several studies have examined trends in the numbers of individuals and families facing a great fi nancial burden from health care. These studies generally have shown that a large and growing percentage of Americans are experiencing fi nancial challenges attributable to health care. 1,2,7,9 Second, other studies have examined the extent to which high levels of cost sharing and fi nancial burdens translate into decreased use of 38 LIFE DISRUP T IONS FRO M HIGH HE A LT H E X PENDIT UR ESnecessary health services, such as ambulatory visits or prescription drugs. [10][11...

PURPOSE Previous studies suggest that the highest-risk patients value accessible, coordinated primary care that they perceive to be of high technical quality. We have limited understanding, however, of how low-income, chronically ill patients and the staff who care for them experience each individual step in the primary care process. METHODSWe conducted qualitative interviews with uninsured or Medicaid patients with chronic illnesses, as well as with primary care staff. We interviewed 21 patients and 30 staff members with a variety of job titles from 3 primary care practices (1 federally qualified health center and 2 academically affiliated clinics). RESULTSThe interviews revealed 3 major issues that were present at all stages of a primary care episode: (1) information flow throughout an episode of care is a frequent challenge, despite systems that are intended to improve communication; (2) misaligned goals and expectations among patients, clinicians, and staff members are often an impediment to providing and obtaining care; and (3) personal relationships are highly valued by both patients and staff.CONCLUSIONS Vulnerable populations and the primary care staff who work with them perceive some of the same challenges throughout the primary care process. Improving information flow, aligning goals and expectations, and developing personal relationships may improve the experience of both patients and staff. INTRODUCTIONH igh-quality primary care is important for prevention and treatment of chronic diseases such as diabetes and hypertension, 1 which disproportionately affect minorities and those of low socioeconomic status.2 Inadequate access to high-quality, patient-centered care 3 can have detrimental effects including poor outcomes, 4 use of emergency services for nonurgent conditions, 5,6 or forgoing care altogether. 7,8 Patient experience, the measure of patient-centeredness, has become increasingly important in assessments of primary care quality. 9Patient experience surveys, however, have been used primarily with Medicare and privately insured populations, leaving the voices of patients in the lowest socioeconomic status underrepresented. 10 Qualitative studies suggest that vulnerable patients place a high value on access to care, care coordination, and continuity, 11,12 but may perceive primary care to be less accessible and of lower technical quality than hospital care. 6Patient experience is rarely compared with clinician experience, despite the fact that job satisfaction of both primary care clinicians and support staff has been correlated with patient satisfaction.13 Studies directly comparing patient and physician experience of insomnia and depression treatment in primary care have shown that disease understanding and expectations for treatment can affect the experience for both parties.14,15 A qualitative study of patients, physicians, nurses, and administrative staff showed widespread agreement that communication and tailored "whole-person" care was essential to patient-centered care, Elizabeth...

Aim: This study aims to explore the proposed concept of "nurse-sensitive environmental indicators" among nursing and non-nursing leaders of environmental stewardship who work with nurses.Background: Aligned with the Sustainable Development Goals, nurses are obligated to "practice in a manner that advances environmental safety and health." Little is known about environmental impacts in acute-care nursing.Methods: Nursing and non-nursing leaders of environmental stewardship across the United States (N = 9) were interviewed to explore the concept of acute-care nursesensitive environmental indicators. Transcripts were examined using qualitative descriptive analysis.Results: Thematic analysis revealed that nurses are in key positions to influence environmental change, need more education and awareness to be effective, and need leadership support and role-modelling. Issues related to waste were highly nurse sensitive; issues related to food, chemicals, and transportation were moderately nurse sensitive; issues related to energy and water were minimally nurse sensitive. Conclusion: Preliminary consensus on nurse-sensitive environmental indicators was confirmed by leader participants in this study. Implications for Nursing Management: To help meet environmentally focused Sustainable Development Goals, nursing leaders can use the concept of nurse-sensitive environmental indicators in planning, education, resource allocation, and leadership to improve environmental stewardship in acute care nursing.

Healthcare contributes significant pollution to the natural environment. Nurses are obligated by professional commitment, to avoid causing harm in their care processes and decisions, including environmental harm. Nurse awareness of healthcare-generated pollution is growing but nurses may lack an understanding of how nursing contributes specifically to this pollution and what nurses can do within their scope and span to address it. This chapter introduces the concept “Nurse-Sensitive Environmental Indicators” as a proposal to identify, measure, and reduce the unintended harm of nursing practice that contributes to healthcare-generated pollution. It discusses the environmental problem, environmental health, and healthcare. The chapter explains what environmental stewardship has to do with nursing and describes nurse sensitive indicators. As has been the case with other quality outcomes measures, identifying agreed-upon environmental outcomes measures may give the nursing profession tools to measure and then address environmental impacts arising from nursing practice.

To explore perceptions of high-risk patients and their practice staff on the patient-centered medical home, we conducted a multisite qualitative study with chronically ill, low-income patients and their primary care practice staff (N = 51). There were 3 key findings. Both patients and staff described a trade-off: timely care from an unfamiliar provider versus delayed access to their personal physician. Staff were enthusiastic about enhancing access through strategies such as online communication, yet high-risk patients viewed these as access barriers. Practices lacked capacity to manage high-risk patients and therefore frequently referred them to the emergency room.

No abstract