Determining the elements of sustainability in academic nursing clinical practices

Abstract

Demand for healthcare resources have exploded as baby-boomers age-in to Medicare, seniors live longer, and chronic conditions proliferate. Millions of new patients, many with complex health-care needs, will enter the health-care system as Medicare and Medicaid expand under the Accountable Care Act. Additionally, shortages of primary care physicians and clinic closures have severely diminished access to healthcare services. Reimbursement rates are low and administrative barriers considerable. The pressure is increasing to determine sound and reliable programs/systems that will improve patient health and ensure sustainability. For over a century Academic Nursing Clinical Practices (ANCPs) and nurse-managed health clinics/centers have provided comprehensive high-quality primary care to populations in rural, urban, and suburban communities. An alarming number of these practices have closed while others struggle to remain viable. A complete array of the elements impacting sustainability have not been examined empirically. This study analyzed and determined elements that contributed to the sustainability of academic nursing clinical practices to inform the continuance of these vital primary care health centers. No suitable established analytical instrumentation corresponded to the specific purpose and evaluative needs of this study. Therefore, themes and data from clinical and social science arenas were extracted to guide the creation of a valid and reliable tool to measure sustainability in academic nursing clinical practices (Aim 1). The original study instrument consisted of two hundred and fifty elements and employed a three-phase survey design. This instrument was substantiated by seven academic clinical practice nursing experts. Instrument construct validity, content validity, and instrument reliability were established. Recommendations were made to replace the laborious finance questions with the Institute of Nursing Center's (INC) most recent study results. Seventy-seven elements achieved eighty percent or greater agreement required for retention. The final instrument elements were segmented into four Aims/Domains - Academic Infrastructure, Clinical Practice Leadership and Planning, the Academic Clinical Practice Site, and Academic Practice Finance - and converted to an on-line instrument. A field-test was conducted with a sample of fifty-two participating ANCPs associated with fourteen Schools/Colleges of Nursing (SoNs) across the United States. Study participants entered data for each designated practice and rated their impression of each practice's sustainability using a defined likert scale (1-9). A non-normal distribution was determined by Kruskal-Wallis analyses and revealed multiple significant elements of sustainability associated with these 52 clinical practices within each primary domain. These included: Aim 2 - Academic Infrastructure - Mission and Vision are addressed in Promotion and Tenure Documents; Aim 3 - Practice Leadership and Planning demonstrated five significant elements (when analyzed together) including: Faculty may Opt Out of the Practice Plan when no contract is available; A formal planning structure exists to grow practices; Faculty are involved in practice design; the Practice Champion credentials; and Minimum Service allocation for practice workload. Two element sets were significant when evaluated together for Aim 4 - the Clinical Practice Site and Total Hours Practiced each week for all faculty. However, a combination of elements - Students + Providers + Staff - when evaluated with financial Gross charges, produced a negative inverse relationship regarding sustainability. Achieving sustainability is a dynamic, rigorous, and purposeful process. These foundational elements facilitate analysis and intervention of new and existing clinical practices before they are threatened with closure. The knowledge acquired from this study will assist in forming and sustaining these vital clinical practices and in turn, deliver continuation of healthcare to those in need.