Full text of DOI:10.1177/1084822302014002007

HOME HEALTH CARE MANAGEMENT
& PRACTICE / February 2002
A Model for Using Novel Nursing
Interventions to Meet the Challenges
of Community Health Needs
Julie A. Koehler, RN, PhD
Jennifer Cha, RN, BSN
Carol E. Smith, RN, PhD
The aging population growth, shortened hospital
stays, reduction in home care services reimburse-
ment, and the looming nursing shortage will all
drastically increase community health care needs
and caregiving challenges. Unique and tradi-
tional methods of care delivery provided via inno-
vative interventions can be used to address these
needs. Many research-based nursing interven-
tions can be administered at a distance (e.g.,
video, telehealth, and even robotic “nurses”) or
without the nurse being present through volun-
teers or delegation, thus increasing community-
based care. A model categorizing and guiding use
of these nursing interventions is described herein.
and innovative methods for delivering care can meet
these future challenges (Brennan, 1999).
CAREGIVING AND THE
HEALTH OF CAREGIVERS
Caregivers assist patients with activities ofdaily liv-
ing, technology treatments, and insurance and health
care encounters from 2 to 24 hours a day. Relatives pro-
vide the greatest percentage ofcaregiving, and the
majority ofthese caregivers are also responsible ofr
children. An estimated 14.4 million full- and part-time
workers balance caregiving with job responsibilities
(Metropolitan Life Insurance, 1997).
Geriatric case management has been used to identify
caregivers at high risk for adverse health outcomes and
functional decline (Fillit, Hill, Picariello, & Warburton,
1998). A recent report identified caregiving as a risk
factor for mortality; caregivers had mortality risks that
were 63% higher than those whose spouses were
healthy (Schulz & Beach, 1999). Caregivers were more
likely than their cohorts to rate their own health as poor
and were significantly less likely to rate their health as
good or excellent (Creedon, 1987; George & Gwyther,
1986). They also used prescription drugs for depres-
sion, anxiety, and insomnia more often than the rest of
the population (Gallagher, Rose, Rivera, Lovett, &
ore than 39 million Americans are 65 years
ofage or older; 6.5 million ofthese elderly
M
persons need assistance with activities of
daily living. As our population ages, the number of
elderly needing assistance is projected to double by
2020 (Gutierrez, 2000). There are several factors that
challenge the health care and social services systems to
support family caregivers in new and more substantive
ways. Shortened hospital stays, reduction in home care
services reimbursement, and the looming nursing
shortage are important factors to consider when gar-
nering community health resources for caregivers.
Nursing expertise provided through novel interventions
Key Words: care delivery, caregiving, geragogy, home care,
telehealth
Authors’ Note: The authors would like to acknowledge Jillian Robinson in Family Care Research for her insightful editing of the
manuscript.
Home Health Care Management & Practice / February 2002 / Volume 14, Number 2, 129-136
©2002 Sage Publications
129
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HOME HEALTH CARE MANAGEMENT & PRACTICE / February 2002
Thompson, 1989). Strategies to provide caregivers
with support and maintain their own health need to be
studied.
and resources from nurse expertise at a distance, which
is providing care without being physically present, to
private duty care, which is providing nursing and aide
care up to 24 hours, 7 days per week. The model has
furnished the organizing framework for this article. It
depicts connections between patient age, acuity, and
diagnosis with resources available, and it can guide
nurses for assessing, measuring, and studying clinical
and cost outcomes.
The remainder ofthis article presents a briefdescrip -
tion and the research basis for each of the innovative
nursing interventions. The interventions used geragogy
principles to design programs ofinstruction for elderly
adult learners (Glasner, 1987; Hayes, 1998). Geragogy-
based interventions acknowledge recognition ofthe
elder’s experience with self-care and desire to follow
prescribed care. Guiding principles ofgeragogy include
providing clear, concise, visual delivery oflarge-print
material that is easily readable and specific written
directions to reinforce the verbal information. Elderly
persons need clear information guiding complex home
care, such as identifying medication side effects and
symptom reporting. Patients who monitor themselves
daily and actively use their checklists are more knowl-
edgeable about their illness, report untoward symptoms
quickly, and have fewer rehospitalizations (Girton,
1995).
HEALTH CARE SYSTEM SHORTFALLS
The 1997 Balanced Budget Act drastically reduced
reimbursement for home health care, which resulted in
an increase in the demands on family caregivers (Gov-
ernment Accounting Office, 2000). Home health bene-
fits that were reimbursed accounted for 4% of total
Medicare spending in 2000, down 9% from 1997,
which was twice as much savings as was projected.
Therefore, this decrease in reimbursement represents a
shift in costs to families who are, in turn, without for-
mal home care services. Only an estimated 7.2 million
Americans use formal home care services and typically
only ifthey have insurance or Medicare (Pace, 2001).
In the Senate Health, Education, Labor and Pensions
Committee, it was reported that the United States will
need 1.7 million nurses by 2020, but only 600,000 or
35% will be available to care for the public (Reuters
Medical News, 2001). It is expected that by 2010 half
ofthe U.S. counties will be medically underserved. A
cause ofthis shortage is the lack ofnumbers ofyoung
persons choosing nursing and remaining in the field
(U.S. Department ofHealth & Human Services, 2000).
These shortfalls and challenges facing community
health care providers and caregivers need to be
addressed. The implementation ofnovel nursing inter-
ventions to provide new methods ofcare could meet
these challenges and promote better outcomes in
patients and increased support for caregivers.
Nursing Expertise From a Distance
Nurse-developed self-monitoring interventions,
such as guidelines or short checklists for daily care pro-
cedures, can be provided to patients and their care-
givers. Self-monitoring techniques engage both
patients and family members to actively monitor the
prescribed medical therapy without requiring nurse
presence. Any self-monitoring intervention must incor-
porate geragogy techniques into the checklists, work-
books, and diaries. Innovative self-monitoring care has
included the use ofmnemonics (a technique ofimprov -
ing the memory by association, imagination, and
locution) and the repeating ofeasily hummed lyrics to
emphasize specific home care routines.
Nurses are being recruited to develop educational
materials and direct disease management programs for
our aging population’s most costly chronic illnesses,
such as congestive heart failure (CHF), diabetes, and
chronic obstructive pulmonary disease (COPD). Dis-
ease management is a population-based strategy to
proactively manage chronic disease across the life span
ofthe person and over a continuum ofcare, rfom
INNOVATIVE METHODS
OF CARE DELIVERY
Home care nurses throughout history have provided
care in neighborhoods (intermittent skilled care),
expertise at a distance (frontier nurses), substitutes for
nurses (aides, volunteers), or care through nursing inter-
ventions that guide family caregivers such as home care
disease management and self-monitoring of symptoms/
illnesses. Today’s nurses are using novel ways ofdeliv -
ering care, including technological advances such as
robotic nurses, to ensure positive outcomes for elders
and to meet community health care needs.
The Home Care Delivery Model (HCDM) in Figure
1 was used to demonstrate how the interventions have
novel components that gradually increase in intensity
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Koehler et al. / A MODEL FOR USING NOVEL NURSING INTERVENTIONS
131
FIGURE 1
Model of Home Care Delivery
institutionalization to home. These programs are based
on national clinical guidelines and include home care
self-management skills such as (a) self-administering
medication, (b) identifying adverse symptoms to
report, (c) learning how to access a support system, (d)
maintaining prescribed lifestyle changes, and (e) learn-
ing coping strategies.
tions, patients will more likely follow their prescribed
treatments, more readily accept that they have a chronic
illness, and more predictably use their medications
(Havranek, Abrams, Stevens, & Parker, 1999). Overall,
the majority (89%) ofthe 21 patients rated the video -
taped content as motivating, comforting, encouraging,
and realistic because it has mirrored their experiences
with CHF. Patients completed the posttest question-
naires, and all but 2 patients had increased CHF knowl-
edge. Raw scores on quality ofliving with CHF indi -
cated that there was improvement in halfofthe
patients’ self-rated functional status and CHF-related
quality oflife. Scores ofthe other halfofthe patients
remained the same (Koehler, 2000).
Videotape interventions. This nursing care delivery
method consisted ofusing a series offour CHF home
care videotapes developed from the Guidelines for
Evaluation and Care ofHeart Failure Patients created
by the Agency ofHealthcare Research and Quality
(AHRQ). According to AHRQ guidelines, the main
messages and actions suggested were strategically
repeated throughout the videotape using criteria for
successful patient education language (Bernier, 1996).
Researchers have found that after seeing others on vid-
eotape who successfully manage their chronic condi-
Another nurse-developed self-monitoring approach
used without nurse instruction was a videotape titled
“How to Care for Your Vascular Access Catheter” that
won the U.S. 1997 Aurora Award in video instruction
category. Independent testing ofthis videotape indi -
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HOME HEALTH CARE MANAGEMENT & PRACTICE / February 2002
cated that significantly less nurse discharge teaching
time was used with no differences in rehospitalization
during the 6-month follow-up (Katz-Scott et al., 2000).
nection to the National Alzheimer’s Association
(Brennan, 1999). The interactive activities in computer
programs provided information but, more important,
engaged the families in assessing, evaluating, and rec-
ognizing ways to maintain prescribed medical care; fit-
ting caregiving into their everyday lives; and resolving
conflicts about barriers to home care treatment.
Computer-generated problem-solving aids specific
for monitoring daily caregiving have been used to
improve outcomes ofelderly patients with major ill -
nesses including heart disease, cancer, and asthma.
Computer software, which accommodates multidecision
options throughout a computerized algorithm, will be
used for guiding more complex decisions at home—all
presented in step-by-step directions to caregivers
(Gustafson, McTavish, & Hawkins, 1998).
Audiotape with a videotape intervention. An interven-
tion using both audiotape and videotape education was
tested based on the 1995 Centers for Disease Control
scientific guidelines for asepsis management. The
home care infection control intervention consisted of a
13-minute videotape demonstrating correct aseptic pro-
cedures for home parenteral nutrition patients, a pam-
phlet describing infection control principles, and a
checklist for self-monitoring. The practical (clinical)
usefulness of this intervention was established by con-
verting this intervention into a self-guided format (a kit
with audio and videotapes). The long-term outcome
data indicated that patients randomized into the experi-
mental group had significantly fewer rehospitalizations
and episodes of infection at 18-month follow-up when
compared to patients in the control group (Smith &
Curtas, 1999).
Care Delivery Interventions
With Nurse Substitutes
New avenues for care delivery must be developed
and studied to care for the aging population with lim-
ited nurse resources. Nurses can instruct others, such as
peer preceptors, to provide aspects ofcare that may
delay the need for institutional care for the chronically
ill patient.
Therapeutic writing intervention. In this intervention,
nursing expertise was delivered through educating
patients and caregivers about the benefits of managing
depressive symptoms by self-monitoring, therapeutic
writing, and recognizing when to seek professional
help. Patients and caregivers were instructed to write in
the diary daily about emotions they experienced related
to chronic illness and caregiving and describe activities
that enhanced positive moods. They also practiced
identifying depressive symptoms that required imme-
diate medical attention by using the AHRQ guidelines
on depression. Writing about emotions, moods, and
feelings in a journal or diary improved depressive
symptoms ofboth patients and caregivers (Smith,
Holcroft, Rebeck, Thompson, & Werkowitch, 2000).
Stoller, Forster, and Portugal (1993) have modified the
depression diary for elders, using therapeutic writing
guidelines for older adults.
Peer preceptors support programs. Nurse-developed
programs can be used to educate a volunteer force of
laypersons to provide support to chronically ill patients
and their families. Peer preceptors can provide timely
and specific social support (emotional, informational,
or appraisal) by a lay helper in response to patients’ or
caregivers’ immediate concerns without implying a
need to reciprocate. In this program, patients and care-
givers experienced with home technology care volun-
teered to interact by telephone with new caregiving
families. Outcome data from separate studies indicated
that patients who had contact with a trained peer had
significantly greater positive quality of life and lower
reactive depression scores than patients matched on
age, medical diagnosis, severity ofillness, afmily
income, and length oftime on technology but who did
not have contact with a preceptor. The preceptor pro-
gram, modified for the Internet, was available for those
managing chronic illness care at home (Smith et al.,
1998).
Interactive Internet interventions. Another way nursing
expertise can be delivered to patients from a distance is
through the Internet. Even older persons with dexterity
limitations have used computer information systems
successfully. Computer- or Internet-based caregiver
discussion groups have been verified to generate social
support and exchange ofpertinent home care informa -
tion. These Internet discussion groups were frequently
used and evaluated as very helpful, especially the con-
In chronically ill elderly patients, the lack ofsocial
support is associated with depression and withdrawal.
Friends and relatives provide support in general terms,
but their contacts and visits are often poorly timed and
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Koehler et al. / A MODEL FOR USING NOVEL NURSING INTERVENTIONS
133
intrusive. Meta-analyses ofsocial support studies
revealed positive outcomes were associated with “con-
text-specific” social support; in other words, the person
who supplied the support was well versed in the inter-
ventions (Smith, Marien, Fernengel, Holcroft, & Ger-
ald, 1994). Findings from a series of National Institute
ofMental Health studies show patients helping others
who have had similar illness experiences consistently
resulted in a sense ofwell-being and mastery, as well as
continued confidence and adherence to recommended
treatments (Toseland & Smith, 1990).
independently and function at their highest levels in
their homes (Carnegie Mellon, 2001).
Technology for Nursing Care Delivery
Advancements in technology continue to afford
nurses more opportunities for innovative ways to
deliver care to patients in their homes. A home
telehealth system was developed by a home health
agency from Kansas, specifically for clinical use with
older adults at risk for institutionalization (Roman,
1996). The home telehealth monitors used were
selected as the lowest cost mode ofdelivery for essen -
tial audiovisual detail and clarity for observing correct
caregiving procedures. The two-way audio-video
telehealth monitor was sensitive enough to identify
abnormal skin color and to read measures on digital
blood pressure and thermometers. Details ofcaregiving
were clearly visible including performing equipment
cleaning and machine maintenance (Smith et al., in
press). The home telehealth camera had freeze frame
and zoom capabilities. For example, a small pressure
ulcer was clearly visible in the televisit, confirmed by
the nurse data collector in the home. Use ofin-home
telehealth with families managing complex care has
had consistent reports of(a) adherence to medical care
regimes, (b) cost effectiveness, and (c) ease of use and
acceptability to older adults (Doolittle et al., 1997;
Rooney, Studenski, & Roman, 1997).
Since 1995, Kansas and many state Medicaid and
Blue Cross/Blue Shield programs have approved reim-
bursement for home telehealth nurse visits for patient
assessment, teaching, counseling, monitoring, refer-
rals, and coordinating services (Rooney et al., 1997).
Several HMOs and case management services also use
home telehealth because ofcost savings from increased
patient adherence to medical regimes for COPD, CHF,
and diabetes mellitus; medication management; and
monitoring ofseveral psychiatric conditions such as
depression and anxiety (Johnston, Wheeler, Deuser, &
Sousa, 2000).
Resource management intervention. Families and care-
givers can gain information about resources in the com-
munity from nurse-developed modules. Strategies for
mobilizing resources according to a curriculum were
tested throughout Kansas with caregivers ofhome -
bound elderly. Home health nurses (N = 77) who have
used the models with families demonstrated signifi-
cantly enhanced competence (t = 5.1, p = .0001)
(Connors & Barr, 1992). Emory University School of
Nursing and Harvard University School ofPublic
Health have incorporated these family self-help mod-
ules in their statewide education and research on
caregiving in frail elderly. Following this intervention,
caregivers indicated they had discovered many more
partners in friends and family and increased recogni-
tion ofhealth proefssionals and community services
resources.
Robotics intervention. The Nursebot, designed to help
the elderly at home, is a prototype robotic assistant.
Mobile robots could play a significant role in changing
the way health care is delivered; using robotics could
give doctors the ability to make house calls long dis-
tance via the Internet and a two-way screen in the
robot’s midsection (Gutierrez, 2000).
This Nursebot uses intelligent reminders for taking
medication and eating meals, connecting patients to
their health care professionals, and collecting and mon-
itoring patient vital signs information such as blood
pressure and heart rate. The robot helps elders by open-
ing jar lids, refrigerator doors, and medication bottles;
following the patient around to help them not get lost;
calling for immediate help in medical emergencies; and
providing social interaction similar to human interac-
tion to lessen feelings of social deprivation. The
Nursebot is helping researchers explore the ways
autonomous mobile robots can help the elderly live
Delivery of Care Through Intermittent
Nursing and Therapy Services
There are increasingly recognized benefits of reha-
bilitation interventions for elders at home to prevent
and treat osteoporosis, hip fractures, osteoarthritis
sequelae, and falls from stroke imbalance (Robinson,
2000). Intervention clinical trials to decrease fragility
injuries were conducted with functionally independent,
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HOME HEALTH CARE MANAGEMENT & PRACTICE / February 2002
community-dwelling elders (older than the age of70)
who were cognitively intact (Rizzo, Baker, McAray, &
Tinetti, 1996). The interventions tested were grounded
on rational, scientifically based risk factors for falling,
orthostasis, polypharmacy, use ofhypnotic sedatives,
or mobility problems. The self-management interven-
tions taught were transfer and gait training, strengthen-
ing and progressive balance exercises, and adjusting
the home environment. There were significant
improvements in stride length, toilet and bathtub trans-
fers from a walker or wheelchair, and balance, with
marginal improvements in orthostasis and decreased
use ofhypnotic sedatives and polypharmacy. The
multidisciplinary interventions in these studies were
provided by nurse practitioners and physical therapists.
The conclusion is that when nursing interventions are
combined with environmental improvement interven-
tions then functional outcomes are positive for the com-
munity-based elderly population (Berg & Intrator,
1998). Another important rehabilitation intervention
that greatly benefits caregivers and patients alike is
adult day care (ADC).
psychological well-being (Gottlieb & Johnson, 1995;
Zarit, Stephens, Townsend, & Greene, 1998).
Private Duty Care Delivery
As the condition ofthe elderly person at home grows
worse and his or her needs grow more complex, more
resources are necessary to provide care in the home to
prevent or delay institutionalization. Families and care-
givers may need from 4 to 24 hours of nursing or per-
sonal care assistance daily. Agencies can be contracted
to provide this care. Social agencies and churches often
compile lists ofvolunteers who may be recruited to
help the family and offset the financial costs of continu-
ous care. This level ofcare delivery can be a financial
burden or impossibility for many. Policy makers must
look at ways to provide comprehensive care to patients
at home rather than the more expensive institutional,
long-term care. This is an area where nursing has the
opportunity to create new ways to supervise bedside
and continuous care delivery to patients in their homes.
FUTURE DEVELOPMENT OF
INNOVATIVE CARE DELIVERY MODELS
Adult day care. Often, the ill elderly can receive care
and socialization in a setting away from home that
allows their caregivers respite or the ability to continue
full-time employment. Caregivers to persons with con-
ditions such as Alzheimer’s disease or other dementias,
Parkinson’s disease, heart failure, strokes, hip frac-
tures, or diabetes mellitus benefit from respite and care
assistance from ADC centers managed by nurses.
These centers provide a stimulating environment that
offers socialization, skilled nursing interventions, ther-
apy services, social work services, nutrition consulting,
hot meals, and transportation up to five times per week.
Studies have shown that ADC programs have
resulted in postponing many inevitable nursing home
placements. Forty-six percent ofparticipants dis -
charged from ADC were discharged to nursing home
care, 15% were discharged due to death, and 18% were
discharged to the hospital or home health (Travis,
Steele, & Long, 2001). Recent changes in interpretation
to the homebound criteria for home health eligibility
have enabled patients to receive both services simulta-
neously, thereby providing the additional services
needed to keep elders at home and provide respite for
the caregivers. Using ADC programs affected care-
givers’ appraisals ofprimary stressors, resulting in
lower feelings of overload and worry/strain and better
In 2000, there were 12 million self-help groups giv-
ing people advice about their health in the United
States; very few of these groups were facilitated by
nurses. This is certainly a different, yet efficient way to
deliver health prevention, health promotion, and
self-care strategies to the consumer. Nanotechnological
applications will give nurses opportunities and new
venues for the education of patients about chronic ill-
ness care. At Stanford University, researchers are
studying a computer chip implanted in patients to mon-
itor glucose level, alert them to problems, and prompt
them about appropriate self-care interventions (O’Neil,
2001). These are examples ofopportunities for nursing
to provide health care in new and different ways.
Nurses must be ready to change the traditional models
ofcare delivery to meet the changing needs ofour
aging, yet increasingly knowledgeable consumer.
Nurses will have opportunities to interface with the
new technologies available in health care to reach peo-
ple more efficiently and effectively.
SUMMARY
With the implementation ofthe Balanced Budget
Act of1997 and the looming nursing shortage, methods
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Koehler et al. / A MODEL FOR USING NOVEL NURSING INTERVENTIONS
135
George, L., & Gwyther, L. (1986). Caregiver well-being: A multidimen-
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must be considered to provide nursing care with none
or minimal nurse presence. The HCDM (see Figure 1)
depicts the various levels ofcare required to keep
chronically ill or disabled persons at home longer.
Ways to substitute for the nurse to promote self-care
must be looked at more closely to ensure fewer unnec-
essary physician and emergent care visits and to
improve self-care to maintain patients in their homes
longer and prevent early nursing home placement.
Telehealth is a method to improve access to care when
distance prevents the direct, real-time contact with a
nurse or other health professional.
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This article reports a series ofstudies on nursing
interventions for home care that can be targeted to
aging caregivers and their problems. All interventions
were designed to be used concurrently with medical
treatment. Intervention components have demonstrated
efficacy in studies with older adults and of care delivery
via home telehealth and Internet computer reminders to
robot home care technology. Research in home
caregiving for older adults is needed to provide unique
ways ofhealth care delivery as we are afcing acute
nursing shortages and the aging ofthe American
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patients. Her previous research activities have included cost effec-
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sis in nurses’ perceptions of the work unit, evaluation of the effect of
organizational context on clinical practice, and the comparison of
work satisfaction and burnout in community hospital nurses.
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caregiver health effect study. Journal of the American Medical Association,
282, 2215-2219.
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Jennifer Cha, RN, BSN, is the informatics nurse for family care
research at the University of Kansas School of Nursing in Kansas
City. The research is dedicated to adherence to continuous positive
airway pressure (CPAP) for patients who are diagnosed with
obstructive sleep apnea. Previously, she was a coordinator for fam-
ily care where research was conducted with TPN patients. She has
also been an analyst for information services at a large hospital sys-
tem in Kansas City, Missouri. At this institution, she implemented a
home health billing and patient care system. She has recently
coauthored an article discussing the feasibility of telehealth in con-
ducting nursing research. She has also authored an article that
focused on utilizing research for complex home care.
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patient teaching. Nutrition, 15(2), 99.
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Werkowitch, M., & Rosenthal, H. (1998). Patient as peer preceptors for
orthopedic oncology rehabilitation patients. Rehabilitation Nursing Research,
23(2), 78-83.
Smith, C., Holcroft, C., Rebeck, S., Thompson, N., & Werkowitz, M. (2000).
Journal writing as a complementary therapy for reactive depression: A reha-
bilitation teaching program. Rehabilitation Nursing Research, 25(5), 170.
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Meta-analysis ofthe associations between social support and health out -
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Carol E. Smith, RN, PhD, is a professor at the University of Kansas
School of Nursing, Kansas City. She is currently funded by the
National Institute of Nursing Research, National Institutes of
Health (NIH), for “Technological Home Care: Costs & Quality of
Life” and “Rural Dwelling Older Adults: CPAP Telehealth-
Internet Support.” Dr. Smith has had a textbook on patient education
for the past 10 years and has developed patient Internet material for
patients and families. Her research activities include assisting
patients and their family caregivers who manage chronic illnesses
and highly technical care in the home. Interventions being tested
include CPAP adherence support via in-home telehealth, computer
systems that guide symptom monitoring, use of algorithm guides for
daily technology care and interactive patient education on the
Internet for adherence to CPAP, reducing infusion catheter sepsis,
dealing with depression, and monitoring economic and human
resources of the family. Other clinical interventions she has tested
include caregivers’ mobilizing assistance, patient-to-patient (peer)
support, high tough for high technology, and the use of Internet and
telehealth in homes. Cost-benefit analysis for differing interven-
tions is studied. In 2000, Dr. Smith presented data at NIH to the
Health Care Financing Administration on home ventilation and
protecting the most vulnerable to Medicaid/HMO–managed care
shortfalls.
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toms by older people: A health diary study ofillness behavior. Medical
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professional and peer helpers for family caregivers of the elderly. Psychol-
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state. Nursing Economics, 19(2), 62-67.
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It all starts with quality professionals. In Communications Staff (Eds.),
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53B(5), S267-S277.
Julie A. Koehler, RN, PhD, is an assistant professor at the Univer-
sity of Kansas School of Nursing in Kansas City. She has had more
than 25 years of experience in home and community health care in
Colorado, Georgia, Kansas, Missouri, and New York. Dr.
Koehler’s research focuses on the relationships of nurse staffing,
nurse expertise, and care delivery systems (including emerging
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