Health Services Research & Development

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Research Highlight

The VA Office of Nursing Services (ONS), along with the Quality Enhancement Research Initiative (QUERI), established a Partnered Evaluation Initiative (PEI) with a team of researchers from the Ann Arbor Center for Clinical Management Research in 2014. The purpose of the PEI is to improve Veteran care by informing the QUERI program and ONS about: 1) the ability of strategic initiatives to maintain, modify, and expand nursing programs; and 2) the implementation of strategic initiatives, including variations in implementation across sites. The ONS/Ann Arbor PEI conducted evaluations of the: 1) Staffing Methodology (SM) directive; 2) RN Transition-To-Practice (RNTTP) program; and 3) Full Practice Authority (FPA) regulation.

Using nurse staffing data from 123 VHA facilities between fiscal year 2009 and 2015, we assessed: 1) the effect of the Staffing Methodology (SM) directive on changes in nurse staffing (defined as nursing hours per patient day [NHPPD]); and 2) the association between changes in nurse staffing and central-line associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) rates. We modeled the monthly change in infection rates associated with staffing levels in the postimplementation period, compared to the pre-implementation period, using an interrupted time series/segmented regression analysis and adjusting for serial correlations. We found a modest, but significant increase in NHPPD trends post-SM directive implementation, relative to pre-implementation. Additionally, in the post-implementation period, an increase of one NHPPD was significantly associated with a decrease of .26 and .09 in the number of infections per 1,000 device days on average, relative to the effect of staffing on the pre-implementation infection rates for CAUTI and CLABSI respectively. In conjunction with other co-occurring hospital infection prevention initiatives, our findings suggest that changes in nurse staffing processes, as required by the staffing directive, are associated with reduced hospital-associated infections.

To assess implementation of the RN Transition-To-Practice (RNTTP) program, we conducted semi-structured telephone interviews with Chief Nurse Executives, RNTTP Coordinators, and their teams at 19 medical centers between June 2015 and February 2016. Factors commonly mentioned as affecting implementation fell into four primary domains: materials and support from ONS, facility-level dynamics and resources, program-specific requirements, and program outcomes. Interviewees generally felt that curriculum resources, evaluation tools, and other program materials provided by ONS were helpful, but electronically stored in places and on platforms that were difficult to access and navigate. While interviewees described RNTTP as a powerful recruiting tool, coordinators were challenged by aligning the schedules of trainees with mentors and preceptors, and protecting trainee time for educational components. Our findings confirm that implementing RNTTP requires significant time and coordination by program staff and nursing leadership. ONS leadership is aware of this, and are providing national guidance and support to ensure new graduates are able to transition effectively from entrylevel to competent professionals. RNs are the largest single component of the VHA workforce, and their recruitment and retention are essential to ensuring access to patient care.

To understand and describe the models of anesthesia care in VHA, we analyzed retrospective surgical data from 125 VHA facilities for an 18-month period (October 1, 2013-March 31, 2015). We identified three models of anesthesia care based on the documented principal anesthetist and supervising anesthetist (if present): Model 1: physician anesthesiologist supervising a certified registered nurse anesthetist (CRNA); Model 2: physician anesthesiologist practicing independently or supervising an anesthesiology resident; and Model 3: CRNA without a supervising anesthesiologist. We determined case volume and anesthesia care models by assessing the surgical case complexity, patient health status, and facility complexity. Over half (57 percent) of all surgical cases indicated a model of physician anesthesiologist collaborating with or supervising CRNA (Model 1), whereas 32 percent of cases were categorized as having a physician-driven model (Model 2), and 12 percent of cases indicated a CRNA without physician collaboration/ supervision model (Model 3). Model 2 represented a higher proportion of highly complex cases (39 percent) compared to Model 3 (6 percent). Over half of surgical cases in the largest, most complex facilities used a collaborative/supervisory approach to anesthesia care (Model 1), while we found that the CRNA without collaboration/ supervision model (Model 3) occurred almost exclusively among surgical cases in smaller facilities with lower complexity. These facilities are also in states in which the nursing practice act permits independent CRNA practice.

Our findings, which are descriptive only, indicate that anesthesia care is delivered primarily by physician anesthesiologists collaborating with or supervising CRNAs. Utilization of CRNAs in VHA may be influenced by case- and facility-level factors and by availability of physician anesthesiologists at facilities. CRNA practice without collaboration/supervision may be one approach to ensuring access to surgical services in VHA, particularly at smaller, rural facilities.

The partnership between ONS and our evaluation center is an excellent example of strong collaboration between an important program office responsible for policy and practice in the field, and health services research and development.

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