Nurse practitioners as primary care providers with their own patient panels and organizational structures: A cross-sectional study

Practice pathways, education, and regulation influencing nurse practitioners' decision to provide primary care: a rapid scoping review

BACKGROUND/OBJECTIVE

Initially established to improve access to healthcare, particularly for primary care, the full potential of the nurse practitioner role is yet to be realised in most countries. Despite this, most countries are working to meet an ageing population's increasing healthcare needs and reduce healthcare costs and access disparities. Achieving these outcomes requires reform at multiple levels, including nurse practitioner practice pathways, education and regulation, and identifying the barriers and facilitators to optimising their primary care role.

METHODS

A rapid scoping review of nurse practitioner practice pathways, education and regulation inclusive of: (1) a systematic search of Medline and CINAHL for peer-reviewed English language articles, including opinion pieces published between January 2015 and February 2022; and (2) a web-based search of nurse practitioner program entry requirements of International Nurse Regulator Collaborative country members with a protected nurse practitioner title and prescribing rights, plus the Netherlands. The individually summarised search data was integrated and synthesised using Popay's narrative approach.

RESULTS

Emerging evidence from the included nurse practitioner courses (n = 86) and articles (n = 79) suggests nurse practitioners working in primary care provide safe, effective care and improve healthcare efficiencies. However, different regulatory and educational models are required if the primary care nurse practitioner is to meet growing demand.

CONCLUSIONS

International variations in entry criteria, curriculum, and regulation shape the global profile of the nurse practitioner primary care workforce and their practice setting. For countries to grow their primary care nurse practitioner workforce to meet unmet needs, different entry requirements, program content and accredited post-registration transitional programs must be urgently considered.

Burnout, job satisfaction, and turnover intention among primary care nurse practitioners with their own patient panels

BACKGROUND

Nurse practitioners (NPs) can enhance NP care and improve access to care by autonomously managing their patient panels. Yet, its impact on workforce outcomes such as burnout, job satisfaction, and turnover intention remains unexplored.

PURPOSE

To estimate the impact of NP panel management on workforce outcomes.

METHODS

Structural equation modeling was conducted using survey data from 1,244 primary care NPs. NP panel management was categorized into co-managing patients with other providers, both co-managing and autonomously managing, and fully autonomous management.

DISCUSSION

Fully autonomous management led to more burnout than co-managing (B = 0.089, bias-corrected 95% bootstrap confidence interval [0.028, 0.151]). Work hours partially (27%) mediated this relationship. This findings indicate that greater autonomy in panel management among NPs may lead to increased burnout, partially due to longer work hours.

CONCLUSION

Interventions to reduce work hours could help NPs deliver quality care without burnout.

Factors related to motivation, organisational climate and work engagement within the practice environment of nurse practitioners in the Netherlands

AIM

To explore motivation, organisational climate, work engagement and related factors within the practice environment of nurse practitioners.

BACKGROUND

Motivation in the workplace, organisational climate and work engagement are important to motivate nurse practitioners and prevent early exit. However, little is known about related factors.

DESIGN

A cross-sectional design using a digital survey with multiple-choice and open-ended questions. Data were collected from 1 November 2019 to 30 March 2020.

METHODS

The survey contained demographic and job-related data, instruments on motivation in the workplace, organisational climate and work engagement. Three open-ended questions were added to invite respondents to tell about their next career step, (dis)satisfaction with salary and additional comments. Quantitative data were not normally distributed (Kolmogorov-Smirnov test). Kruskal Wallis tests and Mann-Whitney U tests were used to test the relationship between independent and dependent variables. Answers on the open-ended questions were coded and categorised in themes. The STROBE checklist was followed.

RESULTS

In total 586 questionnaires were completed. The majority of the respondents were female (85%), and their mean age was 47 years (range 26-66 years). Aged 45 or over, more work experience, working in nursing homes, experiencing more autonomy, collaboration with other nurse practitioners, a firmly anchored position, satisfaction with salary and developmental opportunities contributed positively to the practice environment. Answers on the open-ended questions supported the quantitative results.

CONCLUSIONS

Work motivation, organisational climate and work engagement are positively related to a large variety of personal and work-related factors. Therefore, policymakers and professional organisations should be aware of the impact of these influencing factors to enhance an inspiring work environment.

RELEVANCE TO CLINICAL PRACTICE

Awareness of factors that influence nurse practitioners' practice environment can be used as a tool to screen and improve the present work environment.

Primary care nurse practitioner work environments and emergency department utilization among older adults with substance use disorders in rural areas

INTRODUCTION

The prevalence of substance use disorders (SUDs) is growing among older adults, and older adults in rural areas face disparities in access to SUD care. Rural older adults with SUDs commonly have comorbid chronic conditions that puts them at risk for frequent acute healthcare utilization. In rural areas, primary care for patients with SUDs are increasingly provided by nurse practitioners (NPs), and quality primary care services may decrease ED visits in this population. Yet, NP-delivered primary care for rural older adults with SUDs may be limited by work environment barriers, which include lack of support, autonomy, and visibility. This study assessed the relationship between the NP work environment and ED utilization among rural older adults with SUDs.

METHODS

This was a secondary analysis of cross-sectional data from a large survey of NPs in six U.S. states merged with Medicare claims. The study measured the NP work environment by the four subscales of the Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ), which measure 1) independent practice and support, 2) NP-physician relations, 3) NP-administration, and 4) professional visibility. Multilevel logistic regression models, adjusted for practice and patient covariates, assess the relationship between the NP work environment and all-cause ED use.

RESULTS

The sample included 1152 older adults with SUDs who received care at 126 rural NP primary care practices. NP independent practice and support at the practice was associated with 49 % lower odds of all-cause ED visits among older adults with SUDs. There were no relationships between the other NP-PCOCQ subscales and all-cause ED visits.

CONCLUSIONS

Organizational support for NP independent practice is associated with lower odds of all-cause ED utilization among rural older adults with SUDs. Practice administrators should ensure that NPs have access to support and resources to enhance their ability to care for rural older adults with SUDs. Ultimately, these practice changes could reduce ED utilization and health disparities in this population.

Evaluating the cost of NP-led vs GP-led primary care in British Columbia

In 2020, British Columbia (BC) opened four pilot Nurse Practitioner Primary Care Clinics (NP-PCCs) to improve primary care access. The aim of this economic evaluation is to compare the average cost of care provided by Nurse Practitioners (NPs) working in BC's NP-PCCs to what it would have cost the government to have physicians provide equivalent care. Comparisons were made to both the Fee-For-Service (FFS) model and BC's new Longitudinal Family Physician (LFP) model. The analyses relied on administrative data, mostly from the Medical Services Plan (MSP) and Chronic Disease Registry (CDR) via BC's Health Data Platform. Results show the cost of NPs providing care in the NP-PCCs is slightly lower than what it would cost to provide similar care in medical clinics staffed by physicians paid through the LFP model. This suggests that the NP-PCC model is an efficient approach to increase accessibility to primary care services in BC and should be considered for expansion across the province.

A Review of Disparities in Outcomes of Hospitalized Patients with Limited English Proficiency: The Importance of Nursing Resources

Language barriers significantly affect communication between patients and health care staff and are associated with receipt of lower-quality care. Registered nurses are well positioned members of the health care team to reduce and eliminate disparities for patients with limited English proficiency (LEP). Current evidence recommends nurses use interpreters or translation devices to overcome language barriers; however, these recommendations fail to recognize that structural system-level factors, such as unsupportive work environments and poor nurse-to-patient staffing ratios, reduce nurses' ability to implement these recommendations. The Quality Health Outcomes Model (QHOM) is a useful framework for understanding relationships between hospital systems, the delivery of care interventions, and patient outcomes. The goal of this manuscript is to use the QHOM and existing empirical evidence to present a new perspective on the long-standing clinical challenge of reducing language-related health outcome disparities by considering the context in which nurses deliver patient care.

A Systematic Review of Outcomes Related to Nurse Practitioner-Delivered Primary Care for Multiple Chronic Conditions

Multiple chronic conditions (MCCs) are more common and costly than any individual health condition in the United States. The growing workforce of nurse practitioners (NPs) plays an active role in providing primary care to this patient population. This study identifies the effect of NP primary care models, compared with models without NP involvement, on cost, quality, and service utilization by patients with MCCs. We conducted a literature search of six databases and performed critical appraisal. Fifteen studies met inclusion criteria (years: 2003-2021). Overall, most studies showed reduced or similar costs, equivalent or better quality, and similar or lower rates of emergency department use and hospitalization associated with NP primary care models for patients with MCCs, compared with models without NP involvement. No studies found them associated with worse outcomes. Thus, NP primary care models, compared with models without NP involvement, have similar or positive impacts on MCC patient outcomes.

Pre-post analysis of the impact of British Columbia nurse practitioner primary care clinics on patient health and care experience

OBJECTIVE

This study aims to evaluate the impact of a primary care nurse practitioner (NP)-led clinic model piloted in British Columbia (Canada) on patients' health and care experience.

DESIGN

The study relies on a quasi-experimental longitudinal design based on a pre-and-post survey of patients receiving care in NP-led clinics. The prerostering survey (T0) was focused on patients' health status and care experiences preceding being rostered to the NP clinic. One year later, patients were asked to complete a similar survey (T1) focused on the care experiences with the NP clinic.

SETTING

To solve recurring problems related to poor primary care accessibility, British Columbia opened four pilot NP-led clinics in 2020. Each clinic has the equivalent of approximately six full-time NPs, four other clinicians plus support staff. Clinics are located in four cities ranging from urban to suburban.

PARTICIPANTS

Recruitment was conducted by the clinic's clerical staff or by their care provider. A total of 437 usable T0 surveys and 254 matched and usable T1 surveys were collected.

PRIMARY OUTCOME MEASURES

The survey instrument was focused on five core dimensions of patients' primary care experience (accessibility, continuity, comprehensiveness, responsiveness and outcomes of care) as well as on the SF-12 Short-form Health Survey.

RESULTS

Scores for all dimensions of patients' primary care experience increased significantly: accessibility (T0=5.9, T1=7.9, p<0.001), continuity (T0=5.5, T1=8.8, p<0.001), comprehensiveness (T0=5.6, T1=8.4, p<0.001), responsiveness (T0=7.2, T1=9.5, p<0.001), outcomes of care (T0=5.0, T1=8.3, p<0.001). SF-12 Physical health T-scores also rose significantly (T0=44.8, T1=47.6, p<0.001) but no changes we found in the mental health T scores (T0=45.8, T1=46.3 p=0.709).

CONCLUSIONS

Our results suggest that the NP-led primary care model studied here likely constitutes an effective approach to improve primary care accessibility and quality.

Nursing Services in the First Level of Care in Colombia. Analysis of the Offer 2002-2020

OBJECTIVES

This work sought to characterize the primary care nursing consultation services reported in the official systemsof health services records in Colombia between 2002 and 2020.

METHODS

This was a descriptive, cross-sectional, retrospective study. Node geographic analysis and descriptive statistics were performed for quantitative data from the Special Registry of Health Providers and the Ministry of Health and Social Protection.

RESULTS

The study identified 6079 nursing services of which 72% are outpatient, 95.05% are assigned to institutions providing health services, 99.75% are of low complexity, and 48.22% of the offer was created in the last five years. The nodes with the highest increase in the offer of services are Caribbean (n = 909) and Pacific (n = 499), while Amazon (n = 48) showed the lowest offer in the last five years.

CONCLUSIONS

Disparity is evident in the availability of services by region and node, in addition to a low liberal exercise to provide nursing care.

Advancement of research on nurse practitioners: Setting a research agenda

BACKGROUND

Primary care delivered by nurse practitioners (NPs) helps to meet the United States' growing demand for care and improves patient outcomes. Yet, barriers impede NP practice. Knowledge of these barriers is limited, hindering opportunities to eliminate them.

PURPOSE

We convened a 1.5-day conference to develop a research agenda to advance evidence on the primary care NP workforce.

METHODS

Thirty experts gathered in New York City for a conference in 2022. The conference included plenary sessions, small group discussions, and a prioritization process to identify areas for future research and research questions.

DISCUSSION

The research agenda includes top-ranked research questions within five categories: (a) policy regulations and implications for care, quality, and access; (b) systems affecting NP practice; (c) health equity and the NP workforce; (d) NP education and workforce dynamics, and (e) international perspectives.

CONCLUSION

The agenda can advance evidence on the NP workforce to guide policy and practice.

An international comparison of student nurse practitioner diagnostic reasoning skills

BACKGROUND

Nurse practitioners (NPs) play a pivotal role in health care provision. Diagnostic reasoning is an important core skill of advanced practice.

PURPOSE

The purpose of this study was to compare diagnostic reasoning skills of NP students. It also identified the variability in clinical teaching components of a sample of international NP curricula.

METHODS

An international group of NP students completed an online survey using a validated diagnostic reasoning scale during the first year of their NP program. Program faculty surveyed provided data on core curricula.

RESULTS

The NP students' ( n = 152) mean diagnostic thinking inventory (DTI) score was 142, flexibility in thinking subscale score mean of 73 with a knowledge structure in memory of 69. The programs surveyed required bioscience courses. Most programs provided opportunities for students to practice diagnostic thinking using individual precepted clinical hours (range 500-950) and objective structured clinical examinations.

CONCLUSION

The lower scores of this group of NP students were similar to other NP students and first-year medical residents. Higher mean scores in the DTI reflect expertise and are developed over time. Courses providing a foundation of biomedical knowledge were identified in each program, with opportunities for the NP students to practice diagnostic thinking using objective structured clinical examinations and clinical practice hours.

IMPLICATIONS

The use of the diagnostic reasoning inventory is a useful tool for evaluating student NP's diagnostic reasoning during their NP program. Nurse practitioner programs should consider the provision of dedicated clinical hours, including supervised clinical practice experiences and objective structured clinical examinations to improve diagnostic reasoning.

Moral Distress, Organizational Climate, and the Risk of Burnout Among Physician Assistants in Oncology

PURPOSE

Moral distress (MD) is the result of barriers or constraints that prevent providers from carrying out what they believe to be ethically appropriate care. This study was initiated to explore associations between MD, burnout, and the organizational climate (OC) for oncology physician assistants (PAs).

METHODS

A national survey of oncology PAs was conducted to explore the associations between MD, OC, and burnout. The Nurse Practitioner-Primary Care OC Questionnaire was revised for oncology PAs to assess OC for PA practice. MD and burnout were assessed using the Measure of MD-Healthcare Professionals (MMD-HP) and the Maslach Burnout Inventory.

RESULTS

One hundred forty-six oncology PAs are included in the analysis. PAs were mostly female (90%), White/Caucasian (84%), married/partnered (78%), and in medical oncology (73%), with mean age 41.0 years. The mean MMD-HP score for oncology PAs was 71.5 and there was no difference in MD scores on the basis of oncology subspecialty, practice setting, practice type, or hours worked per week. PAs currently considering leaving their position because of MD had significantly higher mean scores on the MMD-HP compared with those not considering leaving their position (108.2 v 64.8; P = .001). PAs with burnout also had significantly higher mean scores for MD compared with PAs without burnout (97.6 v 54.3; P < .001). A negative relationship between OC for PA practice and MD was only found for the PA-administration relations subscale, whereas all subscales were negatively associated with burnout.

CONCLUSION

This study demonstrates that the risk of professional burnout increases significantly with increasing levels of MD. Additional research exploring the relationship between MD and burnout is needed.

Perception, perceived scope, and potential barriers towards developing nurse practitioners cadre among health care providers and beneficiaries: A pilot study from Northern India

BACKGROUND

The role of nurse practitioner (NP) emerged in early 1965 when general practitioners began working with nurses. Evidence across the world highlights the benefits achieved by the NP role. The Indian Nursing Council (INC) implemented a country-wide NP in critical care (NPCC) program with the approval of the ministry of health and family welfare (MoHFW) in 2017. The NP role is in its infancy in India. Hence, there is a need to assess the perception among beneficiaries and healthcare personnel. This study was conducted to assess the perception, perceived scope, and potential barriers for developing the role of NPs in India among beneficiaries and healthcare providers.

MATERIAL AND METHODS

A descriptive, cross-sectional pilot study was conducted at AIIMS Rishikesh, Uttarakhand, India, among 205 participants (84 beneficiaries, 78 nurses, and 43 physicians) using a proportionate stratified random sampling technique. Likert scales and socio-demographic sheets were used to assess the perception, perceived scope of practice, and potential barriers in developing a NP cadre in India. Descriptive and inferential statistics were used for analyzing data.

RESULTS

The mean age of beneficiaries was 37.98, nurses was 27.58, and physicians was 28.13 years, respectively. 121 (61%) of participants were highly favored, and 77 (38%) were in favor of developing NP cadre in India. They considered it to be necessary, feasible, and acceptable in India. The feasibility and necessity of the perception domain were highly significant (P < 0.001 and P < 0.003, respectively). Nurses (mean ± SD: 35.36 ± 3.55) considered that NPs could have a wide range of practice followed by beneficiaries (mean ± SD: 38.17 ± 3.68) than physicians (mean ± SD: 34.75 ± 5.95). Lack of awareness, the nonexistence of cadre structure, lack of acceptance of the role of physicians, and lack of clear policy were the key potential barriers to develop an NP cadre in India.

CONCLUSIONS

In this study, participants had favorable views on employing NPs in India; thus, this role will improve healthcare access for beneficiaries. NPs can carry out a wide range of practices.However, a lack of awareness, no cadre structure, and a lack of a clear policy may hinder the development of the NP cadre in India.

Connecting unattached patients to comprehensive primary care: a rapid review

INTRODUCTION

Lack of access to primary care providers (PCPs) is a significant hurdle to receiving high-quality comprehensive health care and creates greater reliance on emergency departments and walk-in clinics.

METHODS

We conducted a rapid review and analysis of the literature that discusses approaches to increasing access to continuous care for patients with no PCP ('unattached patients').

RESULTS

Five distinct themes across 38 resources were identified: financial incentives for patients and providers, health care organization, policy intervention, virtual care and health information technology (HIT), and medical education. Approaches that increased attachment were primary care models that combined two or more of these and reflected the Patient's Medical Home (PMH) model.

CONCLUSIONS

Although there are individual initiatives that could allow for temporary relief, long-term and community-wide success lies in designing models of primary care that use multiple tools, meet the needs of the community, and are supported by regional, provincial, and national policies.

Organisation-level and individual-level predictors of nurse-reported quality of care in primary care: A multilevel study in China

OBJECTIVES

Knowledge of the predictors of nursing quality and safety remains a gap in global primary care research. This study examines organisational-level and nurse-level predictors of nurse-reported quality of care from a management perspective.

METHODS

We recruited 175 primary care nurses in 38 community health centres (CHCs) varying by size and ownership in Jinan, Tianjin, Shenzhen and Shanghai. Guided by the Systems Engineering Initiative for Patient Safety model, the organisation-level predictors comprised organisational structure, organisational culture, psychological safety and organisational support, while the nurse-level predictors included organisational commitment and organisational citizenship behaviour. Nurse-reported quality of care was measured by two questions: "How do you rate the quality of care that you provide?" and "Do you often receive complaints from patients or their family members at work?" Multilevel linear regression models were used to examine the predictors of nurse-reported quality of care.

RESULTS

Among the four organisation-level predictors, organisational structure, psychological safety and organisational support were positive predictors of nurse-reported quality of care. Nurses working in CHCs with highly hierarchical organisational structures (Coef. = 0.196, p = 0.000), a high level of organisational support (Coef. = 0.158, p = 0.017) and a high level of psychological safety (Coef. = 0.159, p = 0.035) were more likely to report high quality of care or less likely to receive medical complaints. In terms of nurse-level predictors, nurses willing to increase their knowledge through continuous education were more likely to report good quality of care (Coef. = 0.107, p = 0.049) and less likely to receive medical complaints from patients (Coef. = 0.165, p = 0.041).

CONCLUSIONS

Potential management levers to improve quality of nursing care include formalised organisational structures, strong organisational support and a psychologically safe environment as well as the provision of training to facilitate continuous education. Implementing these recommendations is likely to enhance the nursing quality in primary care.

Autonomous competences and quality of professional life of paediatric nurses in primary care, their relationship and associated factors: A cross-sectional study

AIMS AND OBJECTIVES

To identify the autonomous competences and quality of professional life of paediatric nurses in primary care, their relationship and possible associated factors.

BACKGROUND

The autonomous competences of paediatric nurses vary among healthcare providers in Catalonia, Spain. Autonomy is related to quality of professional life, but little is known about autonomous competences and other factors contributing to paediatric nurses' quality of professional life.

DESIGN

A cross-sectional study following the STROBE statement.

METHODS

Data from 206 paediatric primary care nurses were analysed. A self-administered survey consisting of an ad hoc questionnaire and a validated instrument to measure quality of professional life (QPL-35 questionnaire) was conducted. Descriptive, bivariate and general multivariate regression analyses were used to identify the relationship between autonomous competences and quality of professional life, and its predicting factors.

RESULTS

47.6% nurses reported a medium level of autonomous competences, 46.6% a high level, and 5.8% a low level. Quality of professional life was medium-high for the domains perception of managerial support and global perception of workload and for the item disconnect from work after work shift, and very high and high values for the domain intrinsic motivation and for the item quality of work life, respectively. Autonomous competences and perceived autonomy were factors associated with quality of professional life. Other associated factors were academic background, specific training and being a paediatric nurse specialist.

CONCLUSIONS

Paediatric nurses in primary care have a medium-high level of autonomous competences and they perceive a high level of autonomy. Autonomous competences and level of perceived autonomy are predictors of quality of professional life.

RELEVANCE TO CLINICAL PRACTICE

Enhancing paediatric nurses' autonomous competences and academic background, receiving specific training and being paediatric nurse specialists might improve their quality of professional life, healthcare quality and outcomes for the child population.

Daily practices of advanced practice nurses within a multi-professional primary care practice in Switzerland: a qualitative analysis

BACKGROUND

The rising global population of older persons with chronic conditions demands new primary care models. Advanced practice nurses (APNs) can help meet that need. In Switzerland, APNs have only recently been introduced in primary care and little is known about their daily practice. This study aims to describe APNs' activities and general roles at four sites with multi-professional primary care practices in the Swiss cantons of Bern and Solothurn.

METHODS

To study the practices of APNs at the study sites, we adopted a social constructivist perspective, lending methods from ethnographic field research. We interviewed, observed and accompanied participants over five months, generating rich data on their daily practices. The analysis followed Braun and Clarke's six-step thematic analysis process.

RESULTS

The APNs' daily practices cover three main themes. Their core activities are working with expanded clinical skills and being on-site specialists for patients and their relatives. These practices are surrounded by net activities, i.e., taking care of patients in tandem with the physicians and regular visits in residential long-term care facilities. The outer activity layer consists of cohesive activities, with which APNs anchor and facilitate their role and catalyze further development of the care model. APNs tailor their expanded medical knowledge and nursing practice to maximize the value they provide in patient care.

CONCLUSIONS

This study extends our knowledge of APNs' daily practice within a Swiss multi-professional primary care practice. Our results indicate competencies that need to be integrated in APN education and point out the high potential of APN integration in such primary care practices.

A framework of the institutional policies and practice environments of nurse practitioner primary care models: A cross-case analysis

PURPOSE

The purpose of this article was to compare the implementation of distinct models of nurse practitioner (NP) integration into primary care offices.

DESIGN/METHODOLOGY

A multiple case study design of three NP primary care practice models allowed for in-depth exploration of the management processes supporting the utilization of NPs. At each site, semistructured qualitative interviews, document review, and site tours/observations were conducted and subject to cross-case analysis guided by the NP Primary Care Organizational Framework (NP-PCOF)-developed for this study based on existing theory.

RESULTS

Our case study sites represent three distinct NP primary care models. In the restricted practice model, NPs care for same-day/walk-in acute patients. NPs in the independent practice model have an independent panel of patients and interact collegially as independent coworkers. NPs in the comanagement model function on a team (a physician and two NPs), have a team office space, collectively care for a shared panel of patients, and can earn financial bonuses contingent upon meeting team quality metrics. Our cross-case analysis confirmed differences in physical space design, the relational structure of a workplace, and the capacity for innovation via NP compensation and performance metrics across different NP primary care models.

CONCLUSION

Our findings suggest that NP primary care models are supported by complex management systems and the NP-PCOF is a tool to help understand this complexity.

IMPLICATIONS

The NP-PCOF is a framework to understand the management systems that facilitate the utilization of NPs within primary care organizations.

Analysis of the Effect of Rational Emotional Intervention Combined with Hierarchical Management Mode on Improving the Psychological Stress of Emergency Nurses and Trainee Nurses

Purpose

To explore the effect of rational emotional intervention combined with hierarchical management mode on improving the psychological stress of emergency nurses and trainee nurses.

Methods

50 emergency nurses who worked or practiced in our hospital from June 2019 to May 2021 were selected as the research object. From June 2019 to May 2020, our hospital adopted the traditional management mode. From June 2020 to May 2021, our hospital adopted the rational emotional intervention combined with hierarchical management mode. The psychological state, work stress, stress response, job burnout, and sleep quality of emergency nurses were compared before and after intervention.

Results

Compared with before intervention, the scores of self-rating anxiety scale and self-rating depression scale, the work stress scores, the Maslach burnout inventory score, the Pittsburgh sleep quality index score of emergency nurses decreased after intervention (P < 0.05). Compared with before intervention, the stress coping scores of emergency nurses increased after intervention (P < 0.05).

Conclusion

The rational emotional intervention combined with hierarchical management mode can improve the psychological pressure of emergency nurses and trainee nurses, reduce job burnout, improve stress coping ability, and improve sleep quality.

Analysis of Variation in Organizational Definitions of Primary Care Panels: A Systematic Review

IMPORTANCE

Primary care panel size plays an increasing role in measuring primary care provider (ie, physicians and advanced practice providers, which include nurse practitioners and physician assistants) workload, setting practice capacity, and determining pay and can influence quality of care, access, and burnout. However, reported panel sizes vary widely.

OBJECTIVE

To identify how panels are defined, the degree of variation in these definitions, the consequences of different definitions of panel size, and research on strengths of different approaches.

EVIDENCE REVIEW

Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, MEDLINE, Web of Science, Embase, and Dissertations and Theses Global databases were searched from inception to April 28, 2021, for subject headings and text words to capture concepts of primary care panel size. Article review and data abstraction were performed independently by 2 reviewers. Main outcomes reported included rules for adding or removing patients from panels, rules for measuring primary care provider resources, consequences of different rules on reported panel size, and research on advantages and disadvantages of different rules.

FINDINGS

The literature search yielded 1687 articles, with 294 potentially relevant articles and 74 containing relevant data. Specific practices were identified from 29 health care systems and 5 empanelment implementation guides. Patients were most commonly empaneled after 1 primary care visit (24 of 34 [70.6%]), but some were empaneled only after several visits (5 [14.8%]), enrollment in a health plan (4 [11.8%]) or any visit to the health care system (1 [3.0%]). Patients were removed when no visit had occurred in a specified look-back period, which varied from 12 to 42 months. Regarding primary care provider resources, half of organizations assigned advanced practice providers independent panels and half had them share panels with a physician, increasing the physician's panel by 50% to 100%. Analyses demonstrated that changes in individual rules for adding patients, removing patients, or estimating primary care provider resources could increase reported panel size from 20% to 100%, without change in actual primary care provider workload. No research was found investigating advantages of different definitions.

CONCLUSIONS AND RELEVANCE

Much variation exists in how panels are defined, and this variation can have substantial consequences on reported panel size. Research is needed on how to define primary care panels to best identify active patients, which could contribute to a widely accepted standard approach to panel definition.

The level of quality care nurse practitioners provide compared with their physician colleagues in the primary care setting: A systematic review

BACKGROUND

There is an increasing demand for high-quality primary care providers without adequate supply to meet the need. Nurse practitioners (NPs) are uniquely positioned to fill this demand but influence on regulatory practice authority from concerned groups regarding patient safety and quality of care has delayed this as an effective solution.

OBJECTIVES

The objective was to address concerns abovt NP-led care by examining evidence regarding patient safety, clinical outcomes, cost, and patient satisfaction that reflect on the ability of NPs to provide high-quality care within the primary care setting and to compare their ability with standard models of care led by physicians.

DATA SOURCES

A systematic review was completed using PubMed, CINHAL Complete, and Scopus. Using PRISMA guidelines to critique literature and the John's Hopkins Research Evidence Appraisal tool, articles were analyzed comparing the quality of care between NP and physician providers in the primary care setting.

CONCLUSIONS

A total of 11 articles met the criteria and reveal that NPs provide equal or better quality of care for all outcomes outcomes when compared with their physician colleagues.

IMPLICATIONS FOR PRACTICE

Quality patient care provided by NPs in the primary care setting is equal to, and in several cases superior to, that of physicians. Concerns for patient safety and quality care outcomes seem unsupported by data, and state legislatures should continue to grant full practice authority. as an effective source of providing high-quality primary health care.

Organizational facilitators and barriers to optimal APRN practice: An integrative review

BACKGROUND

The organizational environment can foster or impede full deployment of advance practice registered nurses (APRNs), affecting the quality of care and patient outcomes. Given the critical role APRNs play in health care, it is important to understand organizational factors that promote or hinder APRN practice to maximize the potential of this workforce in health care systems.

PURPOSE

The aim of this study was to synthesize evidence about APRN practice environments, identify organizational facilitators and barriers, and make recommendations for better APRN utilization.

METHODS

A literature search was conducted in CINAHL, PubMed, and PsychInfo, yielding 366 studies. No time or geographic limitations were applied. Study quality was appraised using the National Institutes of Health National Heart, Lung, and Blood Institute Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies and The Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Studies.

RESULTS

Thirty studies conducted in the United States, Canada, and the Netherlands met inclusion criteria. The majority of the studies involved nurse practitioners. Facilitators to optimal practice environment were autonomy/independent practice and positive physician/APRN relations. Barriers included policy restrictions on practice, poor physician relations, poor administrator relations, and others' lack of understanding of the APRN role. Barriers correlate with job dissatisfaction and increased intent to leave job.

PRACTICE IMPLICATIONS

The review highlights the importance of physician and administration relations, organizational-level policies, and colleagues' understanding of the APRN role in promoting effective practice environments. Organizations should align policy reform efforts with factors that foster positive APRN practice environments to efficiently and effectively utilize this increasingly vital workforce. Future research is warranted.

Quality of professional life of primary healthcare nurses: A systematic review

AIMS

To identify and critically appraise the available evidence on the overall quality of professional life of primary care nurses worldwide and its main influencing factors.

BACKGROUND

Quality of professional life of healthcare workers is a keystone that influences the quality of healthcare services provided by healthcare organisations. Nurses have a key role as healthcare services providers given the growing shortage of doctors in primary care.

DESIGN

A systematic review design in accordance with the PRISMA statement.

METHODS

The search was conducted through MEDLINE (PubMed), CINAHL, SCOPUS, Scientific Electronic Library Online (SciELO) and Web of Science databases. The grey literature was reviewed at OpenGrey. The search was limited to human studies published from April 2010-April 2020. No limit of original language publication was applied. Three independent reviewers analysed the methodological quality of the studies.

RESULTS

Ten studies were included from five countries. Five studies reported nurses were satisfied with their quality of professional life and the influencing factors identified were Workload, Job autonomy, Demographic variables, Management support, Recognition, Intrinsic motivation, Interpersonal relations, Compassion fatigue, Burnout, Turnover intention, and work was reported as a component of Quality of life.

CONCLUSION

Primary healthcare nurses reported a high level of quality of professional life, but the scarce studies found do not provide solid consistency to assess the overall quality of professional life. Perception of high workload was the most frequently identified factor to negatively influence the quality of professional life of nurses.

RELEVANCE TO CLINICAL PRACTICE

Quality of professional life of primary care nurses is a key issue because of nurses' important relation with patient's care and satisfaction. Healthcare organisations should strive to address primary care nurses' quality of professional life to enhance their well-being and consequently patients' safety and high-quality healthcare services.

Patient and family views of team functioning in primary healthcare teams with nurse practitioners: a survey of patient-reported experience and outcomes

BACKGROUND

Nurse practitioners (NPs) have been added to primary healthcare teams to improve access to care. Team processes, including communication and decision-making, explicate how patients and families view team functioning. Yet, important gaps exist in our understanding of patient-reported experience and outcomes at the level of the healthcare team. We aimed to examine the influence of individual, team, and organizational characteristics, and role clarity on outcomes of care mediated by team processes in primary healthcare teams that include NPs.

METHODS

A cross-sectional survey across six sites representing practices with NPs in Québec, Canada, was conducted between March 2018 and April 2019 as part of a multiple-case study. Patients and families (n = 485; response rate: 53%) completed a validated questionnaire, which included a patient-reported experience measure (PREM) and a patient-reported outcome measure (PROM) of team functioning (Cronbach alpha: 0.771 (PROM) to 0.877 (PREM)). We performed logistic regression and mediation analyses to examine relationships between the individual, team, and organizational characteristics, role clarity, and outcomes of care mediated by team processes.

RESULTS

Patients and families expressed positive perceptions of team functioning (mean 4.97/6 [SD 0.68]) and outcomes of care (5.08/6 [0.74]). Also, high team processes (adjusted odds ratio [AOR] 14.92 [95% CI 8.11 to 27.44]) was a significant predictor of high outcomes of care. Role clarity (indirect effect coefficient ab = 6.48 [95% CI 3.79 to 9.56]), living in an urban area (-1.32 [-2.59 to -0.13]), patient as respondent (-1.43 [-2.80 to -0.14]), and income (1.73 [0.14 to 3.45]) were significant predictors of outcomes of care mediated by team processes.

CONCLUSIONS

This study provides key insights on how primary healthcare teams with NPs contribute to team functioning, using a validated instrument consistent with a conceptual framework. Results highlight that high role clarity, living in a non urban area, family as respondent, and adequate income were significant predictors of high outcomes of care mediated by high team processes. Additional research is needed to compare teams with and without NPs in different settings, to further explicate the relationships identified in our study.

Care received by patients from nurse practitioners and physicians in U.S. primary care settings

OBJECTIVE

Nurse practitioners (NPs) and physicians serve in both usual source of care (USC) and supplement roles to each other in the provision of primary care to patients. Yet little is known about the care that patients receive from providers in these roles. This study examined the care individuals received when NPs and physicians served in USC and supplemental roles.

DATA SOURCES

Pooled data from the Household Component of the Medical Expenditure Panel Survey 2002-2013.

STUDY DESIGN

Cross-sectional, secondary data analysis using propensity score matching and multinomial logistic regression.

DATA COLLECTION

Data were collected from a national subsample of households.

PRINCIPAL FINDINGS

Regardless of provider role, patients reported receiving more therapeutic or preventive care from NPs but more diagnostic care and biomedical treatments from physicians. Patients reported having similar diagnoses when seen by NPs and physicians serving in USC roles, but different diagnoses when NPs and physicians served in supplemental roles.

CONCLUSIONS

NPs and physicians providing different care when serving in the same role. Findings can inform policy-makers as they develop policies for serving patients and utilizing the relevant expertise of NPs and physicians.

Paediatric nursing clinical competences in primary healthcare: A systematic review

AIMS

To identify and critically appraise the available evidence on paediatric nurses' clinical competencies performed autonomously regarding disease prevention and health promotion activities for children and adolescents in primary healthcare worldwide.

DESIGN

A systematic review design in accordance with the Preferred Reporting Items Systematic Reviews and Meta-Analyses statement.

DATA SOURCES

The search was conducted through MEDLINE (PubMed), Cumulative Index to Nursing and Allied Health Literature, SCOPUS, The Cochrane Library, Scientific Electronic Library Online, Web of Science and The Joanna Briggs Institute EBP (Ovid) databases. The grey literature was reviewed at OpenGrey. Additional studies were located through a references list of selected studies identified on first search.

REVIEW METHODS

Database search employed MeSH terms: (paediatric nursing) AND (primary healthcare) AND ((clinical skills) OR (clinical competences)). Studies published from inception to October 2019 exploring paediatric nurses' clinical competencies in primary healthcare were eligible for inclusion. No language restrictions were applied in the main search. Selection was made by two reviewers independently. Three independent reviewers assessed the methodological quality of included studies.

RESULTS

Eighteen studies were included from six countries. The most common nursing competencies independently performed identified and described in studies were Health education and advice, Child and adolescent health and development assessment, Immunizations and Child health checks.

CONCLUSION

Studies describe clinical competencies of nurses in children care. No consistent scientific evidence is available about clinical competencies of paediatric nurses performed autonomously in primary care.

IMPACT

Few scientific studies identifying and assessing nurses' child primary healthcare skills were found and therefore recorded. Studies describe nurses' clinical skills in childhood, but results do not show firm consistency assessing their practice scope. Health policy-makers should encourage the development of nurses' competencies if they wish to preserve quality and equity of healthcare services to children. Therefore, the first step is to identify the autonomous competencies of paediatric nurses in primary care.

Measures of Organizational Culture and Climate in Primary Care: a Systematic Review

BACKGROUND

Primary care is increasingly contributing to improving the quality of patient care. This has imposed significant demands on clinicians with rising needs and limited resources. Organizational culture and climate have been found to be crucial in improving workforce well-being and hence quality of care. The objectives of this study are to identify organizational culture and climate measures used in primary care from 2008 to 2019 and evaluate their psychometric properties.

METHODS

Data sources include PubMed, PsycINFO, HAPI, CINAHL, and Mental Measurements Yearbook. Bibliographies of relevant articles were reviewed and a cited reference search in Scopus was performed. Eligibility criteria include primary health care professionals, primary care settings, and use of measures representing the general concept of organizational culture and climate. Consensus-Based Standards for the selection of health Measurement Instruments (COSMIN) guidelines were followed to evaluate individual studies for methodological quality, rate results of measurement properties, qualitatively pool studies by measure, and grade evidence.

RESULTS

Of 1745 initial studies, 42 studies met key study inclusion criteria, with 27 measures available for review (16 for organizational culture, 11 for organizational climate). There was considerable variability in measures, both conceptually and in psychometric quality. Many reported limited or no psychometric information.

DISCUSSION

Notable measures selected for frequent use and strength and applicability of measurement properties include the Culture Questionnaire adapted for health care settings, Practice Culture Assessment, and Medical Group Practice Culture Assessment for organizational culture. Notable climate measures include the Nurse Practitioner Primary Care Organizational Climate Questionnaire, Practice Climate Survey, and Task and Relational Climate Scale. This synthesis and appraisal of organizational culture and climate measures can help investigators make informed decisions in choosing a measure or deciding to develop a new one. In terms of limitations, ratings should be considered conservative due to adaptations of the COSMIN protocol for clinician populations.

PROSPERO REGISTRATION NUMBER

CRD 42019133117.

A preliminary evaluation of full practice authority of advance practice registered nurses in the Veterans Health Administration

BACKGROUND

Responding to National Academy of Medicine and National Council of State Boards of Nursing recommendations, the Department of Veterans Health Affairs (VHA) implemented full practice authority (FPA) for Advanced Practice Registered Nurses in VHA medical centers (VAMCs) in 2017.

PURPOSE

To evaluate FPA policy implementation's impact on quality indicators including access to care as measured by new patient appointments in primary, specialty and mental health services.

METHODS

Linear growth models compared early (n = 85) vs. late (n = 55) FPA implementing VAMCs on the trajectories of each of the three quality indicators.

FINDINGS

Early FPA implementing VAMCs showed greater rates of improvement over time in new patient appointments completed within 30 days of preferred date for primary care (p = .003), specialty care (p = 0.05), and mental health (p = 0.001).

DISCUSSION

VAMCs that started implementation of FPA policy early showed greater improvement in access to care for Veterans over time than VAMCs that did not.

Changing nursing practice within primary health care innovations: the case of advanced access model

BACKGROUND

The advanced access (AA) model has attracted much interest across Canada and worldwide as a means of ensuring timely access to health care. While nurses contribute significantly to improving access in primary healthcare, little is known about the practice changes involved in this innovative model. This study explores the experience of nurse practitioners and registered nurses with implementation of the AA model, and identifies factors that facilitate or impede change.

METHODS

We used a longitudinal qualitative approach, nested within a multiple case study conducted in four university family medicine groups in Quebec that were early adopters of AA. We conducted semi-structured interviews with two types of purposively selected nurses: nurse practitioners (NPs) (n = 6) and registered nurses (RNs) (n = 5). Each nurse was interviewed twice over a 14-month period. One NP was replaced by another during the second interviews. Data were analyzed using thematic analysis based on two principles of AA and the Niezen & Mathijssen Network Model (2014).

RESULTS

Over time, RNs were not able to review the appointment system according to the AA philosophy. Half of NPs managed to operate according to AA. Regarding collaborative practice, RNs were still struggling to participate in team-based care. NPs were providing independent and collaborative patient care in both consultative and joint practice, and were assuming leadership in managing patients with acute and chronic diseases. Thematic analysis revealed influential factors at the institutional, organizational, professional, individual and patient level, which acted mainly as facilitators for NPs and barriers for RNs. These factors were: 1) policy and legislation; 2) organizational policy support (leadership and strategies to support nurses' practice change); facility and employment arrangements (supply and availability of human resources); Inter-professional collegiality; 3) professional boundaries; 4) knowledge and capabilities; and 5) patient perceptions.

CONCLUSIONS

Our findings suggest that healthcare decision-makers and organizations need to redefine the boundaries of each category of nursing practice within AA, and create an optimal professional and organizational context that supports practice transformation. They highlight the need to structure teamwork efficiently, and integrate and maximize nurses' capacities within the team throughout AA implementation in order to reduce waiting times.

Practice Patterns, Work Environments, and Job Outcomes of Rural and Urban Primary Care Nurse Practitioners

As nurse practitioners (NPs) are increasingly relied on to deliver primary care in rural communities, it is critical to understand the contexts in which they work and whether they are characterized by work environments and infrastructures that facilitate the provision of high-quality patient care. This study compares urban and rural NPs using data from a survey of 1,244 primary care NPs in Arizona, California, New Jersey, Pennsylvania, Texas, and Washington. While rural and urban NPs have a number of similarities in terms of demographic characteristics, practice patterns, and job outcomes, they also have noteworthy differences. Rural NPs report higher levels of independent practice, fewer structural capabilities that facilitate quality care, and poorer relationships with physicians. Health care organizations in rural communities may need to invest in work environments and infrastructures that facilitate high-quality care and autonomous practice for NPs.

Role of Nurse Practitioners in Caring for Patients With Complex Health Needs

OBJECTIVE

The objective of this study was to estimate trends in the percentage of Medicare beneficiaries cared for by nurse practitioners from 2012 to 2017, to characterize beneficiaries cared for by nurse practitioners in 2017, and to examine how the percentage of beneficiaries cared for by nurse practitioners varies by practice characteristics.

DESIGN

An observational study of 2012-2017 Medicare fee-for-service beneficiaries' ambulatory visits. We computed the percentage of beneficiaries with 1 or more ambulatory visits from nurse practitioners and the percentage of beneficiaries receiving the plurality of their ambulatory visits from a nurse practitioner versus a physician (ie, predominant provider). We compared beneficiary demographics, clinical characteristics, and utilization by the predominant provider. We then characterized the predominant provider by practice characteristics.

KEY RESULTS

In 2017, 28.9% of beneficiaries received any care from a nurse practitioner and 8.0% utilized nurse practitioners as their predominant provider-an increase from 4.4% in 2012. Among beneficiaries cared for by nurse practitioners in 2017, 25.9% had 3 or more chronic conditions compared with 20.8% of those cared for by physicians. Beneficiaries cared for in practices owned by health systems were more likely to have a nurse practitioner as their predominant provider compared with those attending practices that were independently owned (9.3% vs. 7.0%).

CONCLUSIONS

Nurse practitioners are caring for Medicare beneficiaries with complex needs at rates that match or exceed their physician colleagues. The growing role of nurse practitioners, especially in health care systems, warrants attention as organizations embark on payment and delivery reform.

An evaluation of the impact of advanced nurse practitioner triage and clinical intervention for medically expected patients referred to an acute National Health Service hospital

AIMS AND OBJECTIVES

To evaluate the impact of advanced nurse practitioner triage on the management of medically expected patients referred to an acute National Health Service hospital. The objectives of the study were to determine whether advanced nurse practitioner triage reduced waiting times and hospital admissions and expedited essential investigations and treatments.

BACKGROUND

The effectiveness of employing advanced nurse practitioners to meet service demands has been widely studied in emergency departments and critical care units. However, no studies have evaluated the impact advanced nurse practitioners can have on the management of medically expected patients, who have been referred to hospital because they are acutely unwell and require immediate medical intervention.

DESIGN

A pre- and postimplementation evaluation.

METHOD

The Revised Standards for Quality Improvement Reporting Excellence guidelines were used as a framework to guide the triaging role of advanced nurse practitioners. The charts of patients attending before and after the implementation of the advanced nurse practitioner triage role were retrospectively analysed.

RESULTS

The implementation of advanced nurse practitioner triage for medically expected patients saw a statistically significant reduction in the length of time patients have to wait to be seen. There were also significant improvements in timings to diagnosis and treatment of patients presenting with conditions such as sepsis or community-acquired pneumonia. Additionally, patient admissions to hospital were reduced, as advanced nurse practitioners instead streamed a number of patients to ambulatory care for same day treatment and/or medical follow-up.

CONCLUSIONS

Advanced nurse practitioner triage has made significant improvements to the efficiency and effectiveness of care and management of medically expected patients who were referred to acute hospital settings.

RELEVANCE TO PRACTICE

Utilisation of advanced nurse practitioner triage in the ambulatory care setting is an effective method by which to streamline and improve the management of medically expected patients.

Service Value Activities by Nurse Practitioners in Ambulatory Specialty Care

The increase in nurse practitioners (NPs) in ambulatory medical and surgical specialty settings has prompted inquiry into their role and contribution to patient care. We explored the role and contribution of NPs in ambulatory specialty care through their activities outside of direct care and billable visits (referred to as service value activities), and how NPs perceive these activities enhance quality and efficiency of care, for both patients and the health care institution. This qualitative thematic analysis examined interviews from 16 NPs at a large academic medical center about their role and contribution to patient care quality and departmental efficiency beyond billable visits. Five categories of NP contribution were identified: promoting patient care continuity, promoting departmental continuity, promoting institutional historical and insider knowledge, addressing time-sensitive issues, and participating in leadership and quality improvement activities. As the role of NPs in specialty care grows and health care systems emphasize quality of care, it is appropriate to explore the quality- and efficiency-enhancing activities NPs perform in specialty care beyond direct patient care.

Advanced practice registered nurses' work environment perceptions in hospitals: A cross-sectional survey

AIM

To examine work environment differences between hospital certified nurse practitioners (CNPs) and certified registered nurse anaesthetists (CRNAs).

BACKGROUND

Nurse work environments impact patient and nurse outcomes. How differing advanced practice nurse (APRN) roles influence work environments is unknown.

METHODS

Multi-level cross-sectional survey design. APRNs (n = 490) completed the APRN Organizational Climate Questionnaire and Psychological Ownership Questionnaire. Nurse executives (N = 24) reported on Scope of Practice and Institutional Voice. Descriptive, t test, chi-square and linear and mixed-effects regression statistical analyses were employed.

RESULTS

CNPs reported better organisational climate and job ownership than CRNAs. The largest effects involved relationships with physicians, control over practice and independent practice. Among CNPs, a significant positive relationship was observed between relations with physicians and work engagement. In CRNAs, a similar positive relationship between physician relations and work engagement was only observed for those working in higher scope of practice settings, not for those working in more restrictive settings.

CONCLUSIONS

Significant differences exist in the perceived work environments between CNPs and CRNAs that may be related to differences in job design and historical relations with physician colleagues.

IMPLICATIONS FOR NURSING MANAGEMENT

Efforts to improve APRN work environments in hospital settings should consider differing CRNA and CNP perspectives.

Supportive Clinical Practice Environments Associated With Patient-Centered Care

A lack of organizational supports in clinical settings may prevent nurse practitioners from providing patient centered care. Using a cross sectional survey design, data were collected from NPs in 1,571 practices across four states to investigate clinical practice environments and the extent to which they are associated with NP integration of patient preferences. Three-quarters of NPs reported frequent integration of patient preferences into clinical care. Overall, 371 practices (23.6%) were classified as good practice environments; the remaining 76.3% were mixed or poor environments. NPs in good environments were significantly more likely to integrate patient preferences (O.R. = 2.3, p <.001).

New understanding of primary health care nurse practitioner role optimisation: the dynamic relationship between the context and work meaning

BACKGROUND

Optimising health professionals' contribution is an essential step in effective and efficient health human resources utilisation. However, despite the considerable efforts made to implement advanced practice nursing roles, including those in primary care settings (PHCNP), the optimisation of these roles remains variable. In this investigation, we report on the subjective work experience of a group of PHCNPs in the province of Quebec (Canada).

METHODS

We used Giddens' structuration theory to guide our study given its' facilitation of the understanding of the dynamic between structural constraints and actors' actions. Using a qualitative descriptive study design, and specifically both individual and focus group interviews, we conducted our investigation within three health care regions in Quebec during 2016-2017.

RESULTS

Forty-one PHCNPs participated. Their descriptions of their experience fell into two general categories. The first of these, their perception of others' inadequate understanding and valuing of their role, included the influence of certain work conditions, perceived restrictions on professional autonomy and the feeling of being caught between two professional paradigms. The second category, the PHCNPs' sense of engagement in their work, included perspectives associated with the specific conditions in which their work is situated, for example, the fragility of the role depending on the particular clinic/s in which they work or on the individuals with whom they work. This fragility was also linked with certain health care reforms that had been implemented in Quebec (e.g., legislation requiring greater physician productivity).

CONCLUSION

Several new insights emerged, for example, the sense of role fragility being experienced by PHCNPs. The findings suggest an overarching link between the work context, the meaning attributed by PHCNPs to their work and their engagement. The optimisation of their role at the patient care level appears to be influenced by elements at the organisational and health system context levels. It appears that role optimisation must include the establishment of work environments and congruent health context structures that favour the implementation and deployment of new professional roles, work engagement, effective collaboration in interprofessional teams, and opportunities to exercise agency. Further research is necessary to evaluate initiatives that endeavour to achieve these objectives.

Team Functioning And Beliefs About Team Effectiveness In Inter-Professional Teams: Questionnaire Development And Validation

Purpose

Few validated instruments are available to measure team functioning in acute and primary care teams. To address this, we developed a questionnaire measuring healthcare provider perceptions of team effectiveness (Provider-PTE) and assessed its psychometric properties.

Patients and methods

Empirical evidence and a conceptual model were used for item generation. The 41-item self-completed questionnaire was developed. A cross-sectional survey of healthcare providers (n=283) across a range of settings was performed. Psychometric properties were assessed for French and English language questionnaires using Cronbach alpha (α) for reliability, the feedback form for face validity, expert opinion for content validity, and the known-group technique for construct validity. Responsiveness was examined by comparing scores in high and low functioning teams.

Results

The mean time needed to complete the questionnaire was less than 9 mins. Respondents were typically female (84%), and employed full time (80%) in urban settings (82%). Cronbach α values were as follows: Team Processes = 0.88; PTE-Overall = 0.91; Outcomes = 0.72. Significant differences were found by professional group (p = 0.017), length of time in the team (p = 0.025), and presence of nurse practitioners. Responses to Outcomes varied by employment status (p = 0.017). Differences were identified in high and low functioning teams (p<0.001). Feedback indicated that two questions related to team meetings needed to be added.

Conclusion

The study produced evidence of validity for English and French language Provider-PTE questionnaires. The revised 43-item instrument represents an important contribution by providing a validated questionnaire to measure team functioning across a range of settings that is consistent with a conceptual framework.

Where are we now? Practice-level utilization of nurse practitioners in comparison with state-level regulations

BACKGROUND AND PURPOSE

Full practice authority for nurse practitioners (NPs) is optimal for high-quality, cost-effective health care. However, a complete picture of utilization after states have adopted full practice authority needs to be determined. The purpose of this examination was to review the evidence regarding practice-level utilization (PLU) of NP PLU in comparison to state-level regulations (SLRs).

METHODS

Studies published in English and based on US populations were identified through PubMed, CINAHL, and Scopus (January 1, 1989-December 31, 2018), and bibliographies of retrieved articles. Of the 419 articles identified with these limits, 19 (5%) met all inclusion and exclusion criteria.

CONCLUSIONS

Four categories of PLU were identified: billing practices, level of supervision, privileges, and prescriptive authority. Significant differences were seen between urban versus rural NPs and primary care versus specialty NPs. Thirteen of the 19 studies did not specifically address the SLR of the included sample.

IMPLICATIONS FOR PRACTICE

No studies described the type of NP certification, practice specialty, and utilization, and compared all to the SLR. There is a need for more evidence concerning PLU of NPs across the tiers of SLR. Only then can health care organizations, political leaders, and other stakeholders have the information needed to proceed with beneficial practice-model changes.

Systematic review addressing nurse practitioner reimbursement policy: Part one of a four-part series on critical topics identified by the 2015 nurse practitioner research agenda

BACKGROUND AND PURPOSE

The growth and sustainability of nurse practitioners (NPs) requires transparent, fair and equitable reimbursement policies. Complicating this issue is variation in reimbursement policy within and across federal, state, and other payers. Even with explicit regulations, there remain questions on how reimbursement policies are covertly operationalized in practice. This systematic review aims to identify knowledge gaps related to reimbursement policy issues and outlines recommendations for further research.

METHODS

Eight major databases were searched using terms including "nurse practitioner," "reimbursement," "policy," and "research," limited to the United States and inclusive of December 2006-September 2017. Articles meeting the inclusion criteria were analyzed for themes and gaps.

CONCLUSION

The final review includes 17 articles identifying themes including state-determined Medicaid reimbursement and scope of practice legislation shapes NP clinical practice; NPs as identified primary care providers: credentialing and contracting; reimbursement parity; and "incident to" billing. Moreover, there is evidence of discriminatory policies that disadvantage NPs and limit their access to patients, direct billing, and direct reimbursement.

IMPLICATIONS FOR PRACTICE

Future research needs to focus on outcomes of discriminatory, as well as supportive, reimbursement policies in organizations, and their influence on patient access and quality care.

Development of an Innovative Endocrinology Training Program for Nurse Practitioners

BACKGROUND

Nurse practitioners (NPs) have a critical role in meeting the growing demand for health care in the current complex health care system. The use of NPs in both primary care and specialty settings is expected to rise significantly by 2025 in response to increased demands and a shortage of physician providers.

METHOD

The Duke University School of Nursing, with funding from the Health Resource Services Administration, has implemented the first endocrinology specialty training program for primary care NP students.

RESULTS

The first in the country, this innovative, hybrid training program prepares primary care NP students to manage complex diabetes mellitus and general endocrine conditions.

CONCLUSION

Well-trained NPs can help meet the increased demands in primary care. This subspecialty certificate program provides a framework for other graduate nursing schools that are considering adding specialty content as a supplement to primary care training. [J Nurs Educ. 2018;57(8):506-509.].

Formalisation and subordination: a contingency theory approach to optimising primary care teams

OBJECTIVE

While there is consensus on the need to strengthen primary care capacities to improve healthcare systems' performance and sustainability, there is only limited evidence on the best way to organise primary care teams. In this article, we use a conceptual framework derived from contingency theory to analyse the structures and process optimisation of multiprofessional primary care teams.

DESIGN

We focus specifically on inter-relationships between three dimensions: team size, formalisation of care processes and nurse autonomy. Interview-based qualitative data for each of these three dimensions were converted into ordinal scores. Data came from eight pilot sites in Quebec (Canada).

RESULTS

We found a positive association between team size and formalisation (correlation score 0.55) and a negative covariation (correlation score -0.64) between care process formalisation and nurses' autonomy/subordination. Despite the study being exploratory in nature, such relationships validate the idea that these dimensions should be analysed conjointly and are coherent with our suggestion that using a framework derived from a contingency approach makes sense.

CONCLUSIONS

The results provide insights about the structural design of nurse-intensive primary care teams. Non-physicians' professional autonomy is likely to be higher in smaller teams. Likewise, a primary care team that aims to increase nurses' and other non-physicians' professional autonomy should be careful about the extent to which it formalises its processes.