Supportive Clinical Practice Environments Associated With Patient-Centered Care

Exploring the Roles and Regulatory Challenges of Advanced Practice Nurses in Acute Pain Management: A Scoping Review

AIM

To explore the roles and training of advanced practice nurses specialised in acute pain management, as reported in the current literature.

DESIGN

Scoping review.

DATA SOURCES

We searched PubMed, Scopus and CINAHL in December 2023 to identify relevant studies published from 1996.

METHODS

Relevant literature was identified, screened, and analysed using a structured scoping review process. Two reviewers independently selected and extracted data from eligible studies, with a third reviewer resolving any disagreements.

RESULTS

A total of 1682 records were screened, and 36 studies met the inclusion criteria. Four main themes emerged: job titles, roles, training, and barriers. The review revealed substantial variation in job titles and role descriptions across clinical settings and geographic regions, with more comprehensive role definitions found in countries like the United States and the United Kingdom. Training pathways, including postgraduate qualifications and certification, varied significantly and many low- and middle-income countries lacked structured training frameworks. Barriers identified included regulatory limitations, insufficient educational infrastructure and lack of legal authority to practice.

CONCLUSION

This review highlights significant international variation in the definition, training and regulation of advanced practice nurses in acute pain management. There is an urgent need to develop global standards, including unified competencies and certification pathways, to ensure consistent and effective care.

IMPLICATIONS FOR THE PROFESSION

Standardising competencies and training will support role recognition, improve consistency in clinical practice and promote high-quality care for individuals experiencing acute pain.

IMPACT

This review addresses the global inconsistency in role definition and training of advanced practice nurses in acute pain management. Findings may inform educators, health professionals, policymakers and regulators, particularly in resource-limited settings.

REPORTING METHOD

This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

The Relationship Between the Nurse Practice Environment and Perceived Patient-Centered Care in Intensive Care Units: Nursing Perspective

Introduction

The intensive care unit is a distinct environment that emphasizes the importance of professional and skilled nursing practice.

Purpose

This study aims to assess the relationship between the nurse practice environment and perceived patient-centered care (PCC) among nurses in intensive care units (ICUs) in Palestinian southern West Bank hospitals.

Methods

A cross-sectional, descriptive correlational design was employed for this study. The sample composed of 150 ICUs nurses. Data were collected using scales that assessed the practice environment and PCC.

Results

The practice environment scores ranged from 2.1 to 3.2, with a mean of 2.7 (±0.3), reflecting a moderately favorable environment. The PCC competency scores ranged from a mean 1.9 to 4.1, with of 3.4 (±0.5), indicating a generally high level of competency. A positive correlation was found between the practice environment and PCC competency (r = .397, p = .001). Predictors of PCC included the practice environment (B = .836, p = .001), age (B = .027, p = .006), and educational level (B = .154, p = .015).

Conclusion

The study found a moderately favorable practice environment and a generally high level of competency in PCC among nurses. Additionally, there were significant positive correlations between the practice environment and PCC competency. Age, educational level, and the practice environment were identified as predictors of PCC.

Racial and Ethnic Disparities in Emergency Department Use Among Older Adults With Asthma and Primary Care Nurse Practitioner Work Environments

BACKGROUND

Older adults from specific racial and ethnic minoritized groups experience disproportionately higher asthma prevalence, morbidity, and mortality. They also often use emergency departments (EDs) to manage their asthma. High-quality primary care can improve asthma control and prevent ED use. Nurse practitioners (NPs) provide an increasing proportion of primary care to minoritized patients, yet often, they work in poor work environments that strain NP care.

OBJECTIVES

We examined whether racial and ethnic health disparities in ED visits among older adults with asthma are moderated by the NP work environment in primary care practices.

METHODS

In 2018-2019, we used a cross-sectional design to collect survey data on NP work environments from 1,244 NPs in six geographically diverse states (i.e., Arizona, California, New Jersey, Pennsylvania, Texas, and Washington). We merged the survey data with 2018 Medicare claims data from 46,658 patients with asthma to assess the associations of all-cause and ambulatory care-sensitive conditions, ED visits with NPs' work environment, and race and ethnicity using logistic regression.

RESULTS

More than one third of patients with asthma visited the ED in 1 year, and a quarter of them had an ambulatory care-sensitive condition ED visit. Black and Hispanic patients were more likely than White patients to have all-cause and ambulatory care-sensitive condition ED visits. NP work environment moderated the association of race with all-cause and ambulatory care-sensitive condition ED visits among patients with asthma. Greater standardized NP work environment scores were associated with lower odds of all-cause and ambulatory care-sensitive condition ED visits between Black and White patients.

DISCUSSION

Disparities in ED visits between Black and White patients with asthma decrease when these patients receive care in care clinics with more favorable NP work environments. Preventing unnecessary ED visits among older adults with asthma is a likely benefit of favorable NP work environments. As the NP workforce grows, creating favorable work environments for NPs in primary care is vital for narrowing the health disparity gap.

Empowering Primary Care Nurse Practitioners: A Multilevel Approach to Combating the Opioid Crisis

AIMS

We offer a literature-driven, empirically informed, and highly warranted recommendation for a multilevel approach tailored to nurse practitioners. This approach aimed to drive change at the individual level (nurse practitioner), dyadic level (nurse-patient therapeutic relationship), and systems level (organisational culture, education, and policy) to strengthen nurse practitioners' capacity to deliver optimal opioid use disorder care.

BACKGROUND

The opioid overdose epidemic is a global public health crisis, with the United States facing the most severe impact. Access to evidence-based treatment for opioid use disorder remains a significant barrier. Primary care nurse practitioners can play a crucial role in expanding access and bridging the treatment gap. Addressing factors influencing access to, quality of, and effectiveness of treatment requires urgent and careful consideration.

DESIGN

This position paper highlights the multilevel barriers that inhibit nurse practitioners in managing opioid use disorder, negatively impacting treatment access and opioid use disorder-related outcomes.

METHOD

The Advanced Practice Provider conceptual model was adapted to guide this paper. This adapted model illustrates the interconnected layers among nurse practitioners, clinical care, education, professional development, and organisational culture and policy in caring for patients with opioid use disorder.

CONCLUSIONS

Equipping primary care nurse practitioners with the necessary tools to both understand opioid addiction and empower patients experiencing it can have a profound impact. This impact benefits the provider and patient and extends to addressing the opioid crisis at multiple levels. Future research should explore nurse practitioners' experiences when working with individuals with opioid use disorder, identify barriers that hinder positive interactions with patients seeking treatment, and pragmatically test and implement multilevel interventions designed to holistically benefit providers and patient outcomes.

IMPACT TO NURSING

This American-based reflection offers valuable insights to nurse practitioners worldwide as they consider effective strategies for addressing opioid use disorder in primary care settings.

Addressing burnout among nurses of color: Key priorities and calls for action

Nursing burnout remains a public health crisis. However, few stakeholders have considered the disproportionate toll of burnout among nurses of color, including nurses identifying as Black, Hispanic/Latino, or Native American. We convened a one-day conference, titled Solutions to Health Inequities and Nurses' Emotional Exhaustion (SHINE), to begin identifying contributing factors and solutions to burnout amongst nurses of color. SHINE included plenaries, small group discussions, and breakout sessions with nearly 40 expert stakeholders from around the country. We employed a deliberative dialogue (DD) methodology to identify key takeaways and implications for research, practice, and policy. High-priority solutions included: improving the work environment and nurse staffing, reducing stigma against nurses seeking mental healthcare, addressing workplace racism as a root cause of nurse burnout, and increasing support for nurses experiencing racism at work. Key priorities identified through SHINE offer a roadmap for nurse leaders to address burnout through an equity-centered lens.

Primary Care Organizational Support for Nurse Practitioner Practice and Emotional Health Care Delivery

OBJECTIVES

Nurse practitioners (NPs) are key to delivery of primary care services. However, poor organizational support for independent NP practice, such as lack of access to clinic resources, may lead to prioritizing patient physical health over emotional health. We investigated the relationship between organizational support for independent NP practice and emotional health care delivery.

METHODS

This was a secondary analysis of cross-sectional survey data collected from 397 NPs in 2017. We measured organizational support for independent NP practice using the independent practice and support subscale of the NP Primary Care Organizational Climate Questionnaire. Emotional health care delivery was measured by asking NPs how frequently they addressed emotional concerns of patients. We utilized multilevel mixed effects linear regression models, adjusting for NP and practice covariates.

RESULTS

Controlling for NP age, gender, marital status, race, and ethnicity, along with practice setting and size, as the independent practice and support score increased, NPs reported addressing emotional concerns of patients more frequently (beta = 0.34, 95% confidence interval = 0.02-0.66, P = 0.04). This indicates that as organizations provided more support for independent NP practice, NPs were able to more frequently address emotional concerns of patients.

CONCLUSIONS

Organizational support for independent NP practice is associated with addressing emotional concerns of patients. To support NP practice, primary care organizations should ensure that NPs manage patients independently and have access to ancillary staff and support for care management.

How Do We Achieve Value-Based, Patient-Centered Care?

I recently saw a new consult for a suspected blood cancer. The patient was accompanied by his wife. Like many of my visits, we reviewed his symptoms, current medications, results of his recent laboratory and imaging studies, and recommended treatment options for his condition. We also discussed social and financial issues he and his wife were worried about. At the end of the 60-minute visit, he and his wife thanked me for the information. As they were walking out the door, his wife turned to me and asked, “How are you able to spend so much time with us today?” I replied that my organization follows the value-based care model, which is the idea of improving patient quality and outcomes. I told them that I have a little more time to spend with new patients, so I can learn about them and assess their needs.

The Social Ecology of Burnout: A framework for research on nurse practitioner burnout

BACKGROUND

The U.S. health system is burdened by rising costs, workforce shortages, and unremitting burnout. Well-being interventions have emerged in response, yet data suggest that the work environment is the problem. Nurse practitioner (NP) burnout is associated with structural and relational factors in the work environment, practice autonomy, and hierarchical leadership.

PURPOSE

We explore the unique social, cultural, and political environment in which NPs work through the lens of social ecology and present the Social Ecology of Burnout (SEB) framework.

METHODS

We review current burnout frameworks in the context of the NP practice environment and discuss the SEB, specifically exploring psychological safety and its influence on burnout.

FINDINGS

Psychological safety, work environment, and policy are presented within the SEB and solutions which empower NPs are considered.

DISCUSSION

Our framework can serve as a guide for future nursing research, practice, and policy.

Facilitators and Barriers to Pediatric Nurse Practitioner Practice in the United States: A Systematic Review

INTRODUCTION

The pediatric nurse practitioner (PNP) workforce was designed to improve child health equity. We aimed to systematically review the evidence on facilitators and barriers to PNP practice.

METHOD

We included empirical studies on PNP practice in the United States and excluded studies with non-identifiable PNP data. We applied Joanna Briggs Institute tools to appraise studies and applied critical interpretive synthesis principles to synthesize.

RESULTS

The final sample is 26 studies, mostly published before 2013 and observational. Prescriptive privileges, training program availability, organizational climate, and telehealth are facilitators. Mandated physician supervision, reduced pediatric curricula, geographically disparate training programs, and poor data infrastructure are barriers. The sample is limited by a moderate to high risk of bias.

DISCUSSION

Evidence suggests modifiable factors impact PNP practice and could have important implications for child health equity. We offer a theoretical model to guide robust research studying the PNP workforce and health equity.

Better Nurse Practitioner Primary Care Practice Environments Reduce Hospitalization Disparities Among Dually-Enrolled Patients

BACKGROUND

Over 12 million Americans are dually enrolled in Medicare and Medicaid. These individuals experience over twice as many hospitalizations for chronic diseases such as coronary artery disease and diabetes compared with Medicare-only patients. Nurse practitioners (NPs) are well-positioned to address the care needs of dually-enrolled patients, yet NPs often work in unsupportive clinical practice environments. The purpose of this study was to examine the association between the NP primary care practice environment and hospitalization disparities between dually-enrolled and Medicare-only patients with chronic diseases.

METHODS

Using secondary cross-sectional data from the Nurse Practitioner Primary Care Organizational Climate Questionnaire and Medicare claims files, we examined 135,648 patients with coronary artery disease and/or diabetes (20.0% dually-eligible, 80.0% Medicare-only), cared for in 450 practices employing NPs across 4 states (PA, NJ, CA, FL) in 2015. We compared dually-enrolled patients' odds of being hospitalized when cared for in practice environments characterized as poor, mixed, and good based on practice-level Nurse Practitioner Primary Care Organizational Climate Questionnaire scores.

RESULTS

After adjusting for patient and practice characteristics, dually-enrolled patients in poor practice environments had the highest odds of being hospitalized compared with their Medicare-only counterparts [odds ratio (OR): 1.48, CI: 1.37, 1.60]. In mixed environments, dually-enrolled patients had 27% higher odds of a hospitalization (OR: 1.27, CI: 1.12, 1.45). However, in the best practice environments, hospitalization differences were nonsignificant (OR: 1.02, CI: 0.85, 1.23).

CONCLUSIONS

As policymakers look to improve outcomes for dually-enrolled patients, addressing a modifiable aspect of care delivery in NPs' clinical practice environment is a key opportunity to reduce hospitalization disparities.

Racial and ethnic disparities in ED use among older adults with asthma and primary care nurse practitioner work environments

Background

Nurse practitioners (NPs) increasingly deliver primary care in the United States. Yet, poor working conditions strain NP care. We examined whether racial/ethnic health disparities in ED visits among older adults with asthma are moderated by primary care NP work environments.

Methods

Survey data on NP work environments in six states were collected from 1,244 NPs in 2018-2019. 2018 Medicare claims data from 46,658 patients with asthma was merged with survey data to assess the associations of all-cause and ambulatory care sensitive conditions (ACSC) ED visits with NP work environment and race/ethnicity using logistic regression.

Results

NP work environment moderated the association of race (Black patients versus White patients) with all-cause (odds ratio [OR]: 0.91; p-value = 0.045) and ACSC (OR: 0.90; p-value = 0.033) ED visits.

Conclusions

Disparities in ED visits between Black and White patients with asthma decrease when these patients receive care in care clinics with favorable NP work environments.

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.

Nurse Practitioner Care Environments and Racial and Ethnic Disparities in Hospitalization Among Medicare Beneficiaries with Coronary Heart Disease

BACKGROUND

Nurse practitioners care for patients with cardiovascular disease, particularly those from racial and ethnic minority groups, and can help assure equitable health outcomes. Yet, nurse practitioners practice in challenging care environments, which limits their ability to care for patients.

OBJECTIVE

To determine whether primary care nurse practitioner care environments are associated with racial and ethnic disparities in hospitalizations among older adults with coronary heart disease.

DESIGN

In this observational study, a cross-sectional survey was conducted among primary care nurse practitioners in 2018-2019 who completed a valid measure of care environment. The data was merged with 2018 Medicare claims data for patients with coronary heart disease.

PARTICIPANTS

A total of 1244 primary care nurse practitioners and 180,216 Medicare beneficiaries 65 and older with coronary heart disease were included.

MAIN MEASURES

All-cause and ambulatory care sensitive condition hospitalizations in 2018.

KEY RESULTS

There were 50,233 hospitalizations, 9068 for ambulatory care sensitive conditions. About 28% of patients had at least one hospitalization. Hospitalizations varied by race, being highest among Black patients (33.5%). Care environment moderated the relationship between race (Black versus White) and hospitalization (OR 0.93; 95% CI, 0.88-0.98). The lowest care environment was associated with greater hospitalization among Black (odds ratio=1.34; 95% CI, 1.20-1.49) compared to White beneficiaries. Practices with the highest care environment had no racial differences in hospitalizations. There was no interaction effect between care environment and race for ambulatory care sensitive condition hospitalizations. Nurse practitioner care environment had a protective effect on these hospitalizations (OR, 0.96; 95% CI, 0.92-0.99) for all beneficiaries.

CONCLUSIONS

Unfavorable care environments were associated with higher hospitalization rates among Black than among White beneficiaries with coronary heart disease. Racial disparities in hospitalization rates were not detected in practices with high-quality care environments, suggesting that improving nurse practitioner care environments could reduce racial disparities in hospitalizations.

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.

"I had become fed up": A qualitative study of Black nurse practitioners' experiences fighting against health inequity, racism, and burnout

BACKGROUND

Increasing diversity in the nurse practitioner (NP) workforce is key to improving outcomes among patients who experience health inequities. However, few studies to date have examined the specific mechanisms by which NPs from diverse backgrounds address inequities in care delivery.

PURPOSE

To explore Black NPs' efforts in addressing inequities, and the facilitators and barriers they face in doing so.

METHODOLOGY

We conducted focus groups and interviews of Black NPs ( N = 16) in the greater Philadelphia area in early 2022, just following the height of the COVID-19 pandemic and the social unrest of the early 2020s. Data were analyzed using thematic analysis.

RESULTS

Emergent themes included: Strategies Utilized to Address Health Inequities ; Burnout & the Minority Tax ; Risks & Rewards of Taking a Stance ; and Uneven Promises of Organizational Engagement . Nurse practitioners prioritized patient-centered, culturally congruent care, taking additional time to explore community resources and learn about patients' lives to facilitate care planning. Participants advocated to administrators for resources to address inequities while simultaneously navigating organizational dynamics, microaggressions, and racism. Finally, NPs identified organizational-level barriers, leading to emotional exhaustion and several participants' intent to leave their roles.

CONCLUSIONS

Black NPs use a myriad of strategies to improve equity, yet frequently face substantial barriers and emotional exhaustion in doing so with little change to the inequities in care.

IMPLICATIONS

The NP workforce has a critical role to play in reducing health inequities. The strategies outlined by Black NPs in this study offer a roadmap for all clinicians and health care organizations to prioritize equity in care delivery.

Racial Disparities in Lipid Screening Among Patients With Coronary Artery Disease Narrowed in Primary Care Settings Supportive of Nurse Practitioners

Background

Coronary artery disease (CAD) is the most prevalent heart disease in the United States, and it disproportionately affects Black compared to White patients. Regular primary care and dyslipidemia screening and management are essential for optimal CAD care. Nurse practitioners (NPs) increasingly provide primary care services, though unsupportive practice environments may constrain their ability to do so.

Purpose

To examine whether disparities in lipid screening between Black and White patients with CAD were associated with the NP practice environment scores.

Methods

Cross-sectional survey data from NPs in primary care practices and Medicare claims were linked to evaluate outcomes among 111,911 CAD patients (94% White, 6% Black) across 456 primary care practices in four states (California, Florida, New Jersey, and Pennsylvania) in 2016. The NP-Primary Care Organizational Climate Questionnaire, which provides a score on the supportiveness of a respondent's practice, was used to evaluate the NP practice environment. Multilevel regression models that accounted for patient and practice characteristics were used to evaluate the study aim.

Results

Compared to White patients with CAD, Black patients with CAD less frequently received annual lipid screening (77.0% vs. 70.6%; p < .001). In logistic regression models accounting for patient and practice characteristics, for every standard deviation increase in the practice environment score, Black patients experienced a 5% increase in odds of receiving lipid screening.

Conclusion

Investing in the NP practice environment, including increasing NP role visibility and strengthening relationships with physicians and administrators, may narrow racial disparities in CAD management.

Structural capabilities in primary care practices where nurse practitioners care for persons living with dementia

BACKGROUND

Primary care structural capabilities (i.e., electronic health records, care coordination, community integration, and reminder systems) can address the multiple needs of persons living with dementia (PLWD).

OBJECTIVES

This study describes structural capabilities in primary care practices where nurse practitioners (NPs) provide care to PLWD and compares the presence of structural capabilities in practices with a high and low volume of PLWD.

METHODS

We conducted a secondary analysis of cross-sectional data from 293 NPs in 259 practices in California. Logistic regression models were used to determine the association between the volume of PLWD and the presence of structural capabilities.

RESULTS

NPs reported that 96% of practices had electronic health records, 61% had community integration, 55% had reminder systems and 35% had care coordination capabilities. Practices with a high volume of PLWD were less likely to have community integration compared to practices with a low volume of PLWD.

CONCLUSION

Many PLWD-serving practices do not have the essential infrastructure for providing optimal dementia care. Practice managers should focus on implementing the essential structural capabilities to address the complex needs of PLWD.

IMPLICATIONS FOR PRACTICE

Clinicians and practice administrations can use the findings of this study to improve the delivery of care in practices that provide care to PLWD.

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.

The Association between Primary Care Practices' Structural Capabilities and Hospitalizations among Persons Living with Dementia

Background: Persons living with dementia (PLWD) are more likely to be hospitalized than individuals without dementia. Little is known about key features (i.e., structural capabilities) in primary care practices where PLWD receive care. This study assessed the relationship between structural capabilities (i.e., care coordination, community integration, and reminder systems) and hospitalizations among PLWD. Methods: We conducted a secondary analysis of cross-sectional data from 5001 PLWD in 192 practices and used three datasets: nurse practitioner surveys, Medicare claims, and Minimum Data Set. Using generalized estimating equations, we evaluated the association between structural capabilities and hospitalizations. Results: PLWD who received care from practices with care coordination were less likely to have hospitalizations (OR = 0.62, p < .05). No statistically significant associations were observed between community integration and reminder systems and hospitalizations. Conclusion: Primary care practices need to tailor structural capabilities to address the needs of PLWD to reduce hospitalizations.

A Crisis in the Health System and Quality of Healthcare in Economically Developed Countries

A health crisis caused by a pandemic tested the effectiveness of national healthcare systems by testing both financing and organizational and technical performance of patient care. At that time, the structural flaws in healthcare systems and inequalities in the level of healthcare in its different dimensions and countries due to resource constraints were highlighted. Therefore, the paper concentrates on investigating how the crisis in the health system affects the quality of healthcare services as a result of changes in the availability of financial, material, and human resources belonging to this system. The quantitative data, in terms of healthcare characterizing the OECD countries and selected non-member economies, treated as an example of economically developed regions, were chosen for the analysis. The study included five areas of resources, i.e., demographic, financial, human, technical, and the delivery of basic services in healthcare. T-test method for dependent samples, supplemented with Hedge's g statistics, was applied to test the differences between the mean values of individual indicators. The results indicate the occurrence of changes in some areas of the healthcare system due to a crisis. Identifying areas that are particularly vulnerable to sudden changes in the healthcare system helps to understand which resource areas need to be strategically managed first, as shifts in levels respond to deteriorating healthcare quality outcomes.

Supportive Practice Environments Are Associated With Higher Quality Ratings Among Nurse Practitioners Working in Underserved Areas

Background

Deployment of nurse practitioners (NPs) to health professional shortage areas (HPSA) may help to address challenges in patient access to care. However, restrictive scope of practice imposed by regulatory and state legislative bodies or unsupportive organizational climates in clinical practice settings may constrain NP care delivery and perpetuate lower assessments of quality of care provided in these underserved communities.

Purpose

The purpose of this study was to investigate the associations between state NP scope of practice regulations, NP practice environment, and self-reported ratings of quality of care in primary care practices located in HPSAs.

Methods

This was a cross-sectional analysis of data from 1,972 participant NPs practicing across 1,711 primary care practices in six states representing full (Arizona and Washington), reduced (Pennsylvania and New Jersey), and restricted (California and Florida) NP scope of practice regulation. Survey data were merged with the Area Health Resource Files to determine practices located in primary care HPSAs. Logistic regression models estimated the relationship between quality ratings, scope of practice regulations, and practice environment scores while accounting for NP and practice characteristics.

Results

Among all included NPs, 95.7% rated their practice as having "excellent," "very good," or "good" quality of care. Practice environments with higher scores had higher ratings of quality of care after accounting for NP and practice characteristics (OR = 3.73, 95% CI: 2.84, 4.89).

Conclusion

Unsupportive clinical practice environments were associated with lower ratings of quality of care in HPSAs, suggesting that improvements in working conditions may be necessary adjuncts to greater deployment of NPs to improve primary care in shortage areas.

Advanced practice nurse work environments and job satisfaction and intent to leave: Six-state cross sectional and observational study

AIMS

To explore the relationship between nurse practitioner work environment and nurse practitioner outcomes (job satisfaction and intent to leave) in the United States.

DESIGN

The study used a cross-sectional survey design to collect survey data from primary care nurse practitioners in six states in the United States.

METHODS

We sent mail surveys to 5689 eligible nurse practitioners in Arizona, New Jersey, Washington, Pennsylvania, California and Texas. The mail also contained an online link. Participants could complete either the paper or online questionnaire. In total, 1244 participants completed the survey in 2018-2019. The work environment was measured using the Nurse Practitioner-Primary Care Organizational Climate Questionnaire comprised of four subscales: Nurse Practitioner-Administration Relations, Nurse Practitioner-Physician Relations, Independent Practice and Support and Professional Visibility. Global items measured job satisfaction and intent to leave. We used mixed-effect proportional-odds cumulative logit models to assess the association between work environment and job satisfaction and intent to leave.

RESULTS

Overall, 90% of participants were either very satisfied or somewhat satisfied with their job and 22% reported intent to leave their job in 1 year. With a one-unit increase in the organizational-level Nurse Practitioner-Administration Relations score, the odds of having a higher job satisfaction level increased by about four times and the odds of intent to leave job decreased by about 60%. A higher organizational-level Nurse Practitioner-Physician Relations score was significantly associated with higher job satisfaction and lower odds of intent to leave.

CONCLUSION

Improvements in work environments may improve nurse practitioner job satisfaction and retention.

IMPACT

This study examined the relationship between work environment, job satisfaction and turnover intention of nurse practitioners. Better work environment is associated with higher job satisfaction and lower turnover intention. Findings have implications for clinical leadership who can take actions to create better work environments to increase the nurse practitioner workforce capacity.

Effect of Practice Environment on Nurse Reported Quality and Patient Safety: The Mediation Role of Person-Centeredness

This study aims to explore the potential mediation role of person-centeredness between the effects of the work environment and nurse reported quality and patient safety. A quantitative cross-sectional survey collected data from 1055 nurses, working in medical and surgical units, in twelve Malaysian private hospitals. The data collection used structured questionnaires. The Hayes macro explored the mediation effect of person-centeredness between the associations of work environment dimensions and care outcomes, controlling nurses’ demographics and practice characteristics. A total of 652 nurses responded completely to the survey (61.8% response rate). About 47.7% of nurses worked 7-h shifts, and 37.0% were assigned more than 15 patients. Higher workload was associated with unfavorable outcomes. Nurses working in 12-h shifts reported a lower work environment rating (3.46 ± 0.41, p < 0.01) and person-centered care (3.55 ± 0.35, p < 0.01). Nurses assigned to more than 15 patients were less likely to report a favorable practice environment (3.53 ± 0.41, p < 0.05), perceived lower person-centered care (3.61 ± 0.36, p < 0.01), and rated lower patient safety (3.54 ± 0.62, p < 0.05). Person-centeredness mediates the effect of nurse work environment dimensions on quality and patient safety. Medical and surgical nurses, working in a healthy environment, had a high level of person-centeredness, which, in turn, positively affected the reported outcomes. The function of person-centeredness was to complement the effects of the nurse work environment on care outcomes. Improving the nurse work environment (task-oriented) with a high level of person-centeredness (patient-oriented) was a mechanism through which future initiatives could improve nursing care and prevent patient harm.

Primary care nurse practitioner burnout and perceptions of quality of care

BACKGROUND

Burnout threatens patient care and clinicians are experiencing challenges within the practice environment. Little is known about nurse practitioner (NP) perceptions of burnout and its relationship to care quality and practice environment. We investigate the relationship between primary care NP burnout on perceptions of care quality and if the practice environment moderates the relationship between burnout and care quality.

METHODS

This is a secondary analysis of cross-sectional survey data from 396 NPs. Burnout and care quality were measured using a single item, but the practice environment was measured using the Nurse Practitioner Primary Care Organizational Climate Questionnaire. Multi-level proportional odds cumulative logit models were built to test for associations between burnout and care quality and for moderation.

RESULTS

Total, 25.3% of NPs reported burnout. Odds of perceiving higher quality of care was 85% less for NPs experiencing burnout compared to those not experiencing burnout. Practice environment did not moderate the relationship between burnout and care quality, but with a one unit increase in the practice environment subscales, the odds of NPs perceiving higher care quality increased anywhere from 3.83 to 7.57 times.

CONCLUSION

Burnout is related to lower perceptions of care quality but favorable environments were related to higher perceptions of quality.

Methodology for a six-state survey of primary care nurse practitioners

BACKGROUND

Primary care practices employing nurse practitioners (NPs) can play an important role in improving access to high quality health care services. However, most studies on the NP role in health care use administrative data, which have many limitations.

PURPOSE

In this paper, we report the methods of the largest survey of primary care NPs to date.

METHODS

To overcome the limitations of administrative data, we fielded a cross-sectional, mixed-mode (mail/online) survey of primary care NPs in six states to collect data directly from NPs on their clinical roles and practice environments.

FINDINGS

While we were able to collect data from over 1,200 NPs, we encountered several challenges with our sampling frame, including provider turnover and challenges with identification of NP specialty.

DISCUSSION

In future surveys, researchers can employ strategies to avoid the issues we encountered with the sampling frame and enhance large scale survey data collection from NPs.

Primary care Practice Environment and Burnout among Nurse Practitioners

Poor practice environments contribute to burnout, but favorable environments containing support, resources, autonomy, and optimal relations with colleagues may prevent burnout. Compared to all nurse practitioners (NPs), 69% of these NPs provide primary care to patients, yet it is unknown whether the practice environment is associated with NP burnout. A study to examine environmental factors related to NP burnout was conducted. Overall, 396 NPs completed the survey and 25.3% were burnt-out. Higher scores on the professional visibility, NP-physician relations, NP-administration relations, independent practice and support subscales were associated with 51%, 51%, 58%, and 56% lower risk of NP burnout, respectively.

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.