Medical Care[JOURNAL]
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200 papers
Conceptualizing the Core Components of Exposure-Informed Care: A Delphi Quality Improvement Study.
Boska RL, Lesnewich LM, Bloeser KJ … +5 more , McAdams MB, Kossoudji AR, Nugent SM, Hunt SC, McAndrew LM
Med Care · 2026 Jan · PMID 41385255 · Full text
BACKGROUND: Environmental exposures are common, may impact health, and may cause concerns. There have been calls to improve clinical care for exposure concerns through an "informed care" approach, which designs care in c...
BACKGROUND: Environmental exposures are common, may impact health, and may cause concerns. There have been calls to improve clinical care for exposure concerns through an "informed care" approach, which designs care in consideration of the patient's experiences with the concern. Understanding Veterans' experiences and concerns about military environmental exposures through an "informed care" approach may help with care; however, there is a need to better define the core components of this model of care. OBJECTIVES: The current project aimed to define the core components of "exposure-informed care" using a modified Delphi quality improvement study. RESEARCH DESIGN: Delphi methodology utilizes expert opinion in a series of rounds and is appropriate to use when there is incomplete knowledge, uncertainty, or lack of evidence on a specific topic. RESULTS: Experts in military environmental exposures (n=35) provided their feedback on the definition of "exposure-informed care." After 4 rounds of rating, 20 statements were agreed upon as core components of exposure-informed care. Accepted statements about the core components of exposure-informed care were coded into a 6-part framework: (1) use concordant communication, (2) build trust, (3) provide resources and support, (4) assess and document, (5) take professional responsibility, and (6) integrate into care. CONCLUSIONS: The 6-part exposure-informed care framework represents experts' definition of the core components of "exposure-informed care." Future implementation of exposure-informed care and the impact of each theme are discussed.
Exposure-Informed Care: Why It's Important and How the Veterans Affairs Does It.
McAndrew LM, Burgo-Black L, Hunt SC … +4 more , Kossoudji A, Mains KC, Shuping E, Llorente MD
Med Care · 2026 Jan · PMID 41385254 · Full text
BACKGROUND: Providing care for individuals with environmental and occupational exposure health concerns is challenging. There is rarely exposure data to allow for verification of dose and duration of exposure, and even w...
BACKGROUND: Providing care for individuals with environmental and occupational exposure health concerns is challenging. There is rarely exposure data to allow for verification of dose and duration of exposure, and even when there is, it is difficult to conclusively determine if or to what degree a health condition is associated with an exposure. This uncertainty can lead to disagreement between patients and providers, lowering trust and satisfaction. To address these issues the Veterans Affairs (VA) has developed, and is implementing, Exposure-Informed Care (EIC). EIC is a model of care that recognizes previous possible or known exposures to environmental factors may impact health and cause concern and seeks to create an environment that at every level is validating, transparent, and proactively addresses environmental exposures. OBJECTIVES: This paper provides a framework for how the VA has implemented the core features of EIC that can be adapted by other health care systems. RESULTS: The VA has implemented EIC through: (1) screening for potential exposures and integration of exposure-related information into clinical care, risk communications, and trust building; (2) trained clinicians to provide evaluations and consultation; (3) surveillance and research; (4) investment and commitment to workforce development by providing education and implementation support and evaluating the impact of these efforts; (5) leadership commitment to standardize institutional policies and create cultural change. DISCUSSION: While this paper focuses on a single health care system, EIC principles can and should be adapted to clinical settings outside of the VA. This is important for Veterans seen in community care as well as civilian populations who are likely to have been exposed to environmental hazards.
Health Care for Military Environmental Exposure Concerns.
McAndrew LM, Bloeser K
Med Care · 2026 Jan · PMID 41385253 · Full text
Abstract loading — click title to view on PubMed.
Health Care for Military Environmental Exposure Concerns.
Med Care · 2026 Jan · PMID 41385252 · Publisher ↗
Abstract loading — click title to view on PubMed.
Long-Term Impact of Medicaid Expansion on Not-for-Profit Hospital Community Benefit Spending in the Southern United States.
Olin S, Owsley K, Stoecker C … +1 more , Santos T
Med Care · 2026 May · PMID 41364613 · Full text
OBJECTIVE: To examine the long-term impact of Medicaid expansion on not-for-profit (NFP) hospital community benefit (CB) spending among hospitals located in Arkansas and Kentucky (9 y postexpansion), Louisiana (7 y poste...
OBJECTIVE: To examine the long-term impact of Medicaid expansion on not-for-profit (NFP) hospital community benefit (CB) spending among hospitals located in Arkansas and Kentucky (9 y postexpansion), Louisiana (7 y postexpansion), and Alabama, Mississippi, Tennessee, and Texas (nonexpansion states). BACKGROUND: To maintain tax-exemption status, NFP hospitals must provide CB, such as charity care and population health initiatives. In the short term, Medicaid expansion has led to decreased charity care and increased Medicaid shortfalls, but no change to other CB categories. Given these early findings and Medicaid expansion's impact on hospital finances, it is important to understand whether hospitals continued to adjust their CB spending. METHODS: We used data on hospital CB spending (2011-2022), for NFP hospitals located in the West South Central and East South Central Census divisions. States that expanded Medicaid formed the treatment group (69 hospitals) and nonexpansion formed the control group (90 hospitals). We used staggered difference-in-differences and event study designs to examine changes in total CB, clinical, and population health spending as a share of operating expenses. RESULTS: We found that Medicaid expansion was associated with a decrease in total CB spending by ∼$782,000 per hospital ( P =0.01). Clinical and population health spending decreased by ∼$759,000 ( P =0.01) and $92,000 per hospital ( P =0.009), respectively. CONCLUSION: Among southern hospitals, Medicaid expansion led to sustained long-term reductions in CB spending. Our findings suggest that states may need to implement CB laws to encourage hospitals to invest more in their communities.
Recommendations for Improving EHR Transitions: Nursing Perspectives From Three Healthcare Systems.
Brunner JA, Amano A, Gauntlett L … +3 more , Sullivan SC, Krein SL, Davila JA
Med Care · 2026 Jan · PMID 41359994 · Full text
BACKGROUND: Transitions from one electronic health record (EHR) to another are increasingly common yet can be enormously disruptive, affecting patient care and health care worker well-being. Nurses are especially impacte...
BACKGROUND: Transitions from one electronic health record (EHR) to another are increasingly common yet can be enormously disruptive, affecting patient care and health care worker well-being. Nurses are especially impacted as the largest group of EHR users, and their perspectives are vital for understanding and improving transitions. OBJECTIVE: To identify actionable recommendations for supporting nurses during EHR transitions by learning from nurse experiences at health care systems that have completed EHR-to-EHR transitions. RESEARCH DESIGN: Semistructured interviews were conducted with nurses from 3 health care systems in the United States between September 2023 and March 2024. We used rapid qualitative analysis to understand the nursing experience and actions taken during the EHR transition and identify recommendations for process improvement. SUBJECTS: We interviewed n=15 participants, including frontline nurses and nurse informaticists across 3 health care systems. RESULTS: We identified ten recommendations across 3 categories: training and support, workflow and usability, and EHR governance. Organizations consistently found that successful transitions required moving beyond vendor-provided support to develop institution-specific guidance, with nurses often taking key roles in developing and disseminating this guidance. Key recommendations included building internal training capacity, staging education to match user readiness, proactively redesigning workflows with nurse input, and establishing shared governance structures for EHR optimization. CONCLUSIONS: EHR transitions are challenging and can have a significant and, in some cases, detrimental impact on nursing staff. Input from nurses is critical for improving the transition process and reducing potential negative effects.
An Innovative Nurse Navigator Approach to Screen For and Address Social Needs in a Veterans Health Administration Women's Health Clinic.
Daus M, Pfeiffer L, Kennedy MA … +12 more , Piazza KM, Cohen AJ, Agnew J, Hinkle P, Igo S, Halladay CW, Leder SM, Mitchell KM, Moy E, Nestman K, Ruggles S, Russell LE
Med Care · 2026 Jan · PMID 41359993 · Full text
BACKGROUND: Women Veterans are the fastest-growing population in the Veterans Health Administration (VHA), but little is known about how to identify and address their social needs. This program evaluation examined the im...
BACKGROUND: Women Veterans are the fastest-growing population in the Veterans Health Administration (VHA), but little is known about how to identify and address their social needs. This program evaluation examined the implementation of a social screening and referral initiative, Assessing Circumstances and Offering Resources for Needs (ACORN), using nurse navigators in a VHA women's health clinic. OBJECTIVES: (1) Describe the implementation process and outcome measures, (2) assess the prevalence of women Veterans' social needs, (3) characterize nurse navigators' perceptions of ACORN, and (4) document implementation challenges and adaptations. RESEARCH DESIGN: Program evaluation with qualitative and quantitative data collected between March 2023 and November 2024. Descriptive statistics were used to summarize sociodemographic characteristics and social needs of Veterans screened. SUBJECTS: Veterans receiving continuity care at a women's health clinic in a midwestern VHA hospital. RESULTS: Nurse navigators completed ACORN screens with 291 Veterans, with 67% screening positive. The most frequently reported needs were social isolation/loneliness (49%), utilities (17%), transportation (14%), and digital needs (13%). Nurse navigators and the nurse site champion reported that ACORN enhanced their understanding of patients' social needs and their ability to address these needs. They also reported seamless integration of ACORN into existing workflows. CONCLUSIONS: Findings show early insights into women Veterans' unique social needs. An innovative nurse navigator approach to social screening in a VHA women's health clinic was feasible, had high likelihood of sustainment, and improved nurses' ability to care for their patients. This indicates strong potential for expanding nurse navigator roles both within and outside VHA.
Feasibility, Usability, and Satisfaction of a Decision Support Tool to Prevent Community-Acquired Pressure Injuries for Use in the Spinal Cord Injury Clinic.
Burkhart EL, Jacob RL, Bartle B … +8 more , Osteen C, Smith A, Desmond M, Aguina K, Richardson M, LaVela S, Bates-Jensen B, Weaver FM
Med Care · 2026 Jan · PMID 41359992 · Full text
BACKGROUND: Community-acquired pressure injuries (CAPrIs) are common and costly among individuals living with spinal cord injury (SCI). OBJECTIVES: Describe feasibility, usability, and satisfaction of a decision support...
BACKGROUND: Community-acquired pressure injuries (CAPrIs) are common and costly among individuals living with spinal cord injury (SCI). OBJECTIVES: Describe feasibility, usability, and satisfaction of a decision support tool to prevent CAPrIs in individuals with SCI and effect of the Community-Acquired Pressure Injury Prevention-Field Implementation Tool (CAPP-FIT) on CAPrI incidence 6 months post CAPP-FIT implementation. METHODS: Preparation for the pilot included redesigning clinic workflow and training providers using a simulation with a standardized patient. The CAPP-FIT was piloted with community-dwelling veterans with scheduled in-person and telehealth clinic visits. Processes were assessed using contextual inquiry and monthly provider meetings. Feasibility, usability, and satisfaction were assessed using the mobile application rating scale with veterans and focus groups with providers. CAPrI incidence 6 months post CAPP-FIT intervention was assessed using a propensity match of veterans who did not receive the CAPP-FIT intervention. A modified Poisson regression with difference in differences was used to estimate the incidence rate ratio of CAPrIs. RESULTS: Participants included 7 providers (3 registered nurses, 2 nurse practitioners, 2 physicians). Veteran participants (n=103) had a mean age of 64; 50% White, 33% Black; 56% with paraplegia; and 72% with incomplete injury. Veteran participants were satisfied with the CAPP-FIT, agreed questions were relevant, and improved their conversations with providers. Providers felt the CAPP-FIT was easy to use, improved communications, and promoted preventive care. Participants experienced a lower CAPrI incidence rate compared with a propensity-matched sample at the pilot site, with the decrease among CAPP FIT participants being more pronounced than among non-participants. However, the difference in difference was not statistically significant with IRR: 0.23, 95% CI: 0.048-1.066 (P=0.060). CONCLUSIONS: The CAPP-FIT seems to be a useful tool in the SCI Clinic to prevent CAPrIs in veterans with SCI, but further testing is warranted.
Quantifying Risk of Exposure to Workplace Violence in Veterans Affairs (VA) Health Care: The Workplace Behavioral Risk Assessment (WBRA).
Vance K, Hutton S, Zollner S … +1 more , Mohr DC
Med Care · 2026 Jan · PMID 41359991 · Full text
BACKGROUND: Few health care organizations have structured approaches to assimilate and analyze disruptive behavior data. In 2012, Veterans Affairs (VA) developed the Workplace Behavior Risk Assessment (WBRA), a tool that...
BACKGROUND: Few health care organizations have structured approaches to assimilate and analyze disruptive behavior data. In 2012, Veterans Affairs (VA) developed the Workplace Behavior Risk Assessment (WBRA), a tool that collects behavioral threat data from multiple systems, consolidates it, and tailors staff training based on the frequency and type of events. OBJECTIVE: This paper provides an overview of the WBRA and how it can inform nurse training. METHODS: A repeated measures design evaluated trends in workplace violence reporting and event rates across 140 VA health care systems from 2013 to 2024. Data were collected annually using a standardized electronic reporting system and reviewed by multidisciplinary teams. Risk levels were categorized based on the frequency and type of disruptive events, including manual restraint and physical or verbal violence. Descriptive statistics were used to prevalence of incidents and analyze trends, particularly among nursing professionals in high-risk areas. RESULTS: Four VA workplace settings: acute care (psychiatric and medical/surgical), emergency/urgent care, and Community Living Centers (CLC) were consistently classified as high-risk. In FY 2024, nursing staff accounted for over 90% of reports in inpatient and extended care settings and 73% in emergency/urgent care. From FY 2013 to FY 2024, reports involving nurses increased significantly, with the largest rises in CLCs (289%) and Medical/Surgical Units (271%), whereas the proportion of physical violence reports involving nurses rose from 59% to 83%. CONCLUSIONS: The WBRA enables health care systems to analyze behavioral risk data to align training with risk.
Relationship Between Number of Assigned Patients and RN Time to Administer Medications During the Peak-Time Medication Pass.
Eck CS, Knox MK, Mehta PD … +2 more , Yang C, Petersen LA
Med Care · 2026 Jan · PMID 41359990 · Full text
BACKGROUND: Inpatient nurse staffing affects patient outcomes. Less is known about the mechanism of this relationship and how lower overall staffing in a unit affects individual RN activities at the bedside. OBJECTIVES:...
BACKGROUND: Inpatient nurse staffing affects patient outcomes. Less is known about the mechanism of this relationship and how lower overall staffing in a unit affects individual RN activities at the bedside. OBJECTIVES: Estimate the relationship between the number of patients assigned to an RN and time spent on medication administration at the peak-time medication pass (PTM), a common nursing task. RESEARCH DESIGN: Estimate the association using multivariable linear regression to adjust for patient severity and staff and unit fixed effects. SUBJECTS: All 9272 RNs administering medications during the PTM on 243 inpatient units in 113 VHA hospitals in 2019. MEASURES: Number of assigned patients to an RN at PTM; PTM duration. RESULTS: After adjusting for staff and unit fixed effects and average patient severity of illness, the PTM duration for an RN assigned 3 patients is 20.67 (95% CI: 20.31, 21.03) minutes longer than when they are assigned 2 patients. The adjusted difference between 4 and 2 patients is 35.42 (95% CI: 35.01, 35.83). PTM duration per patient declines. Relative to 2 patients, RNs assigned 3 patients spend 0.78 (95% CI: 0.63, 0.93) fewer minutes per patient delivering medications during the PTM (3% reduction), and RNs assigned 4 patients spend 2.52 (95% CI: 2.37, 2.68) fewer minutes (11% reduction). CONCLUSION: Individual nurses spend more time overall delivering medications when assigned more patients. Nurses compensate for the increased patient load by only marginally reducing time spent with each patient, even after controlling for patient severity and other factors.
Using Medication Pass Analysis to Examine Longitudinal Changes in VA Inpatient Nurse Staffing and Workload Before and Through the COVID-19 Pandemic: 2019-2022.
Knox MK, Eck CS, Dorsey L … +3 more , Mehta PD, Yang C, Petersen LA
Med Care · 2026 Jan · PMID 41359989 · Full text
BACKGROUND: The COVID-19 pandemic resulted in extended disruption to the health care system. National-level data-driven comparisons of inpatient nurse staffing and workload before and during the pandemic have been limite...
BACKGROUND: The COVID-19 pandemic resulted in extended disruption to the health care system. National-level data-driven comparisons of inpatient nurse staffing and workload before and during the pandemic have been limited. OBJECTIVES: Assess the extent to which registered nurse (RN) staffing and workload changed from prepandemic levels in a national integrated health care system. RESEARCH DESIGN: Longitudinal descriptive analysis. Medication pass analysis using bar code medication administration data for the peak-time medication pass (PTM) assessing year-over-year changes from 2019 to 2022. To assess significance of year-over-year changes in means we used the Welch 2-sample t test. SUBJECTS: Staff (N=42,999) administering PTM medications on Veterans Health Administration acute-care inpatient units (643 units; 127 facilities) from January 1, 2019, to December 31, 2022 (3,681,802 staff days). MEASURES: Staffing: unique staff, staff days, staff per day, patients per staff (PPS); workload: patient days, medications, medications per patient, medications per RN, PTM duration. RESULTS: RNs administered 93.6% of peak-time medications. Fewer non-RNs administered medications after the onset of the pandemic. The average number of patients per RN (PPS) in 2022 was 3.3 on medical, 3.2 on mixed medical-surgical, 3.3 on surgical, 2.5 on step down, and 1.5 on critical care units. The greatest increase in PPS from 2019 to 2022 occurred on surgical units (+0.20, P<0.0001). Across nearly all unit types and levels of PPS, medications per RN were greater and duration was longer in 2022 than in 2019. CONCLUSIONS: RN staffing and workload fluctuated widely at the onset of the pandemic. In 2022, new patterns began to emerge, showing a higher RN workload than before the pandemic.
Understanding Alternate Work Schedules and Their Potential to Improve Work-Life Well-Being for Veterans Affairs Nurses.
Hysong SJ, Spencer VR, Hoang NV … +3 more , Cruz C, Sloane J, Rollins AL
Med Care · 2026 Jan · PMID 41359988 · Full text
BACKGROUND: The employee experience of clinical personnel, especially nurses, is increasingly vital for health care organizations and is now part of health care's quintuple aim, which includes improving patient experienc...
BACKGROUND: The employee experience of clinical personnel, especially nurses, is increasingly vital for health care organizations and is now part of health care's quintuple aim, which includes improving patient experience, population health, cost, and health equity. Nurse burnout and turnover intentions have heightened since the COVID-19 pandemic, with high workload and inadequate staffing as key organizational drivers. Flexible work schedules, such as 72/80 (where one works three 12-h shifts per week but receives the pay equivalent of 80 h), have been a longstanding countermeasure, but postpandemic data on their impact are limited. OBJECTIVE: This national evaluation investigates the impact of the 72/80 work schedule on Veterans Health Administration (VHA) nurses. We hypothesized that nurses on a 72/80 schedule experience less burnout, higher job satisfaction, greater work engagement, and lower turnover intentions. DESIGN: We conducted a web-based survey including self-reported 72/80 work status and employee experience measures, alongside existing administrative data on employee outcomes. We analyzed the data using Mann-Whitney U tests, mixed effects, and linear regression models. SAMPLE: Eight thousand five hundred forty-five VHA nurses from 170 Veterans Affairs Medical Centers nationwide working in 24/7 bedded units completed the survey. RESULTS: The 72/80 schedule was significantly associated with lower emotional exhaustion and depersonalization, and greater personal accomplishment. In addition, 72/80 status correlated with higher workplace engagement, job satisfaction, organizational satisfaction, and lower turnover intention. CONCLUSIONS: The 72/80 work schedule shows significant potential as a transformative workforce strategy, providing substantial benefits in recruitment, retention, and employee satisfaction.
Higher Proportions of Baccalaureate-Prepared Nurses in Veterans Affairs Medical Centers Associated With Lower Surgical Mortality.
Dick TK, Patrician PA, Dolansky MA … +4 more , Cashy J, Thorpe JM, Sullivan SC, Kutney-Lee A
Med Care · 2026 Jan · PMID 41359987 · Full text
BACKGROUND: Multiple studies have linked higher levels of BSN-prepared nurses to lower odds of postsurgical mortality and failure-to-rescue (FTR; ie, death following the development of a postsurgical complication). OBJEC...
BACKGROUND: Multiple studies have linked higher levels of BSN-prepared nurses to lower odds of postsurgical mortality and failure-to-rescue (FTR; ie, death following the development of a postsurgical complication). OBJECTIVE: The purpose of this national evaluation was 2-fold: (1) to assess the proportion of direct care nurses holding a BSN or higher degree in VA Medical Centers; and (2) to examine the association between the proportion of BSN-prepared nurses in VA Medical Centers and the outcomes of hospitalized Veterans undergoing commonly performed surgical procedures. RESULTS: Across our sample of 117 VA Medical Centers nationally, the mean percentage of RNs with a BSN degree or higher in nursing was 55% (SD=16%) and ranged from 9% to 84%. Every 10-point increase in the percentage of nurses with a BSN degree or higher was associated with a 9% decrease in the odds of 30-day mortality and an 8% decrease in the odds of FTR among a cohort of Veterans undergoing commonly performed general, orthopedic, and vascular surgeries. CONCLUSION: Higher proportions of nurses with a BSN or higher in VA Medical Centers is associated with lower postsurgical mortality and FTR among Veterans receiving surgery. These findings confirm within the VA what has been shown in non-VA hospital settings for the last 20 years. Ongoing monitoring and improvements, which are both considered foundational to the tenets of learning health systems and high-reliability organizations, are needed to support staffing with higher proportions of frontline BSN-prepared nurses in VA Medical Centers.
A Landscape of Evidence on RN Transition to Practice Programs: A Systematic Review of Reviews.
Miake-Lye IM, Schlak AE, Thies J … +2 more , Higgins PS, Couig MP
Med Care · 2026 Jan · PMID 41359986 · Full text
BACKGROUND: First-year registered nurses (RNs) have the highest turnover rate of all hospital-based RNs, and often face various challenges during their transition to practice. RN transition-to-practice programs (RNTTPs)...
BACKGROUND: First-year registered nurses (RNs) have the highest turnover rate of all hospital-based RNs, and often face various challenges during their transition to practice. RN transition-to-practice programs (RNTTPs) can potentially alleviate critical RN staffing shortages and support the development of the nursing workforce's future. OBJECTIVES: To (1) capture and critically appraise the landscape of existing synthesis efforts on RNTTPs and (2) synthesize included reviews' findings to assess the potential benefits of RNTTPs for organizational, nursing, and patient outcomes and descriptions of RNTTPs. RESEARCH DESIGN: We conducted a systematic review of reviews to identify published evidence syntheses evaluating RNTTPs for newly graduated RNs. RESULTS: Nineteen evidence reviews were included. Despite having similar scopes, there was little overlap in their included literature, and no single review included the majority of identified original research studies. Two reviews with high methodological rigor and high topical relevance emphasized the methodological issues in the available evidence, which used a mix of methodological approaches, and indicated a connection between RNTTPs and increased critical thinking, competency, and retention. Published reviews suggest program lengths between 6 and 12 months, but evidence for optimal program length was inconclusive or unsupported. CONCLUSIONS: RNTTPs that have been piloted and implemented in recent years deserve more rigorous evaluation to answer critical questions about their role in organizational, nurse, and patient outcomes. However, before best practices can be ascertained to support scaling and sustainment, their potential benefits must first be verified.
Strengthening Rural Health Care: A Scoping Review of Nurse Recruitment and Retention Strategies.
Arredondo K, Witte L, Paterson-Roberts A … +5 more , Caloudas A, Vincenti M, Watts BV, Sutherland B, Touchett H
Med Care · 2026 Jan · PMID 41359985 · Full text
BACKGROUND: Despite nursing being the largest US health profession, only 16% of registered nurses (RNs) practice in rural areas, where health care access is limited. This significantly impacts rural residents, including...
BACKGROUND: Despite nursing being the largest US health profession, only 16% of registered nurses (RNs) practice in rural areas, where health care access is limited. This significantly impacts rural residents, including over 2.7 million rural veterans receiving care at the Veterans Health Administration, leading to compromised health outcomes. Nurses are vital in primary care, improving coordination and management of chronic conditions. OBJECTIVES: Identify recruitment and retention programs for rural nurses (licensed vocational nurses/licensed practical nurses and RNs), including strategy characteristics and location. RESEARCH DESIGN: We conducted a scoping review of published and gray literature. Eligible studies targeted US rural nurse recruitment and retention strategies. MEASURES: Data were extracted for program characteristics, including strategy type (eg, financial incentive), focus (recruitment, retention, or both), and collaboration levels (single or multi-institutional). RESULTS: Of 1179 unique articles identified, only 60 met the inclusion criteria. An additional 42 programs were identified from gray literature, totaling 102 programs. Twenty-two programs used a multipronged approach (2-14 strategies), totaling 180 strategies. Education (n=85) and personal and professional support (n=54) were the most frequently used recruitment and retention strategies. CONCLUSIONS: Of the 102 programs, only 22 used a multipronged approach, with education as the most frequently used strategy. More programs should use a multipronged approach and provide additional incentives and support (eg, financial incentives) to rural nurses beyond education. Only 4 strategies were regulatory, shedding light on the need for more nurse recruitment and retention support at the policy level.
Predictors of Inpatient RN Turnover in Rural and Urban VHA Hospitals.
Bay KG, Eck CS, Knox MK … +2 more , Mehta P, Petersen LA
Med Care · 2026 Jan · PMID 41359984 · Full text
BACKGROUND: The rising demand for health care delivery and an aging workforce is of particular concern in rural areas, where health care access depends upon an adequate nursing workforce. To address this shortage and opt...
BACKGROUND: The rising demand for health care delivery and an aging workforce is of particular concern in rural areas, where health care access depends upon an adequate nursing workforce. To address this shortage and optimize care, it is essential to measure when registered nurses (RN) leave inpatient direct care positions (ie, inpatient RN turnover) and identify modifiable factors correlated with RN turnover. OBJECTIVES: Apply a novel method for characterizing inpatient RN turnover to understand factors associated with variation in RNs leaving inpatient positions at rural and urban Veterans Health Administration (VHA) hospitals. PROJECT DESIGN: Retrospective cohort study. SUBJECTS: Direct care RNs working on VHA regular acute care units for at least 15 days across a 60-day period during fiscal year 2022. Measures: outcome: electronic health record (EHR)-derived RN turnover on inpatient medical, surgical, or mixed medical-surgical units; exposure: rurality of hospital location. RESULTS: Among the cohort of 10,415 inpatient RNs in FY22, 3537 RNs left inpatient direct care in FY22 (34.0%). There were 127 inpatient RN turnover events in rural VHA hospitals (42.8% of 297), compared with 3410 in urban (33.7% of 10,118) (P<0.001). However, in the final mixed-effects logistic regression model, individual RN-specific features and care delivery structure, not rurality (P=0.843), were more strongly associated with variation in turnover events. CONCLUSIONS: Inpatient RN turnover was greater in rural versus urban hospitals, but rurality alone was not associated with turnover after multilevel adjustment.
Findings and Recommendations From the State of the Art (SOTA) Conference on Nursing Research to Improve Veteran Outcomes.
Schlak AE, Krein S, Petersen LA … +14 more , Atkins D, Battaglia C, Burkhart E, Colsch R, Daus M, Gilmartin H, Kamdar N, Knox M, Kutney-Lee A, Olney CM, Rugen K, Weistreich T, Sullivan SC, on behalf the Nursing SOTA planning committee
Med Care · 2026 Jan · PMID 41359983 · Full text
The Veterans Health Administration (VHA), the largest employer of nurses in the United States, has more than 120,000 nursing personnel providing care to over 9 million Veterans across diverse settings. Despite nursing's...
The Veterans Health Administration (VHA), the largest employer of nurses in the United States, has more than 120,000 nursing personnel providing care to over 9 million Veterans across diverse settings. Despite nursing's central role in delivering and sustaining care, research on strengthening the nursing workforce and optimizing nursing practice has remained underdeveloped in VHA. To address this gap, VHA's Office of Research and Development, in partnership with the Office of Nursing Services, convened a State of the Art (SOTA) conference in November 2023 focused on nursing. The Nursing SOTA brought together nurses, researchers, operational leaders, and other stakeholders to review current evidence, identify research gaps, and develop recommendations. Five priority areas were identified: pressure injury prevention and treatment, care coordination models, social drivers of health, nurse staffing and care models, and the nursing work environment. Cross-cutting themes included the need for stronger data infrastructure and expanded support for the VHA nursing science workforce. Conference recommendations were incorporated into VHA's 2024 Health Systems Research Priorities and are expected to inform future research, policy, and practice aimed at advancing nursing science and improving care for Veterans.
Advancing Nursing Science in the Veterans Health Administration: Engaging the Nursing Workforce to Improve Veteran Care.
Med Care · 2026 Jan · PMID 41359982 · Publisher ↗
Abstract loading — click title to view on PubMed.
Purchasing Versus Providing Care at the VHA: Quality Differences in Follow-Up After Psychiatric Hospitalization.
Nieser KJ, Chen C, Harris AHS … +2 more , Wagner TH, Schmidt EM
Med Care · 2026 Feb · PMID 41359449 · Publisher ↗
BACKGROUND: The Veterans Health Administration (VHA) greatly expanded the proportion of health care services it purchases from community providers over the last decade, which could impact the quality of care and create c...
BACKGROUND: The Veterans Health Administration (VHA) greatly expanded the proportion of health care services it purchases from community providers over the last decade, which could impact the quality of care and create care fragmentation. Continuity of care between inpatient and outpatient care delivery systems is critical for high-quality mental health care. OBJECTIVE: To compare rates of outpatient follow-up visits between VHA-purchased and VHA-delivered psychiatric hospitalizations, overall and by VHA facility. METHODS: Using VHA electronic medical records and community care claims data, we compared 7-day and 30-day outpatient follow-up rates across VHA-purchased and VHA-delivered settings. We estimated follow-up rates and comparisons overall as well as separately for 4 diagnosis groups and separately across VHA facilities. RESULTS: Our sample included 64,784 hospitalizations; more than 30% were VHA-purchased as opposed to VHA-delivered. Compared with VHA-delivered hospitalizations, follow-up rates were 30.1 (95% CI: 27.8-32.5) percentage points lower at 7 days and 22.5 (95% CI: 20.8-24.1) percentage points lower at 30 days for VHA-purchased hospitalizations. Lower follow-up rates occurred for neurocognitive disorder discharges for both VHA-purchased and delivered care. Follow-up rates at 30 days were significantly lower for VHA-purchased hospitalizations at 121 out of 128 facilities and significantly higher at no facility. CONCLUSIONS: VHA enrollees seeking mental health care and VHA program managers could benefit from data on psychiatric care quality differences between community providers and VHA providers. From a system perspective, VHA-purchased care quality reports and value-based purchasing contracts could include outpatient follow-up quality measures to incentivize higher quality care.
Health Insurance and Access to Care After Unemployment in Medicaid Expansion Versus Nonexpansion States During COVID-19.
Campbell JM, Escarce JJ, Rünger D … +2 more , Eisenman DP, Huckfeldt PJ
Med Care · 2026 Jan · PMID 41359418 · Publisher ↗
BACKGROUND: Prior work has shown that Medicaid coverage offset reductions in employer-sponsored insurance after COVID-19-related job loss in Medicaid expansion states. However, the effect of Medicaid expansion on health...
BACKGROUND: Prior work has shown that Medicaid coverage offset reductions in employer-sponsored insurance after COVID-19-related job loss in Medicaid expansion states. However, the effect of Medicaid expansion on health care access is not fully understood. OBJECTIVE: To estimate the association of unemployment during COVID-19 with health insurance coverage and health care access in Medicaid expansion versus nonexpansion states. STUDY DESIGN: We used restricted, longitudinal National Health Interview Survey (NHIS) data from 2019 to 2020, focusing on working-age adults (N=5156). Using triple-difference models, we estimated changes in outcomes for respondents becoming unemployed between 2019 and 2020 (after COVID-19) relative to continuously employed respondents, in Medicaid expansion versus nonexpansion states. PRINCIPAL FINDINGS: Compared with continuously employed respondents, there was a statistically significant increase in Medicaid coverage among the newly unemployed in expansion states (6.1 percentage points (pp), 95% CI: 1.0 to 11.3, P=0.019) but not in nonexpansion states (3.9 pp, 95% CI: -3.9 to 11.8, P=0.324); however, the triple difference was nonsignificant. Uninsurance increased among the newly unemployed in expansion states by only 4.9 pp (95% CI: 0.9 to 8.9, P=0.016) versus 12.4 pp in nonexpansion states (95% CI: 0.2 to 24.6, P=0.047), but the triple difference was statistically nonsignificant. There was a significant increase in delaying or skipping medical care among newly unemployed respondents in nonexpansion states, but not in expansion states and the triple difference was statistically significant (-15.5 pp, 95% CI: -26.9 to -4.0, P=0.008). CONCLUSION: Our results suggest that Medicaid expansion prevented disruptions in health care access for the newly unemployed during COVID-19.
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