Regulation of pediatric intensive care unit nurse practitioner practice: A national survey

A multistate analysis of nurse practitioner delegation regulations

BACKGROUND

Nurse practitioners (NPs) are essential to meeting the demand for primary care and improving quality. Variation in primary care work environment has implications for outcomes. One opportunity to better support NP practice includes increasing NP access to support staff. However, given statutory regulation of NP's ability to delegate to unlicensed personnel, there may be limited effect of these interventions.

PURPOSE

To describe state regulations on NP delegation to unlicensed personnel and consider implications of NP delegation regulations on opportunities to improve NP work environment.

METHODOLOGY

We conducted a cross-sectional, six state policy surveillance of state nursing regulations related to NP delegation to unlicensed personnel. Using an iterative data identification process, we review of documents from six state boards of nursing. Analysis included nominal and textual data.

RESULTS

Five states prohibited NPs from delegating medication administration to unlicensed personnel. One state permitted delegation of mediation administration to unlicensed personnel but only in community settings.

CONCLUSIONS

Delegation limitations prevent NPs from practicing to the full extent of their education. Nurse practitioners must be aware of the delegation regulations when working with unlicensed personnel to prevent disciplinary actions. Nurse practitioner-specific delegation regulations can facilitate greater use of unlicensed personnel in NP-led primary care.

IMPLICATIONS

Boards of Nursing should consider NP delegation regulations that promote public safety, minimize unintended consequences, and increase access to NP-led primary care.

Simulation-Facilitated Education for Pediatric Critical Care Nurse Practitioners' Airway Management Skills: A 10-Year Experience

This study aimed to describe the process of the development and implementation with report of our 10-year experience with a simulation-facilitated airway management curriculum for pediatric acute care nurse practitioners in a large academic pediatric intensive care unit. This is a retrospective observational study. The study was conducted at a single-center quaternary noncardiac pediatric intensive care unit in an urban children's hospital in the United States. A pediatric critical care airway management curriculum for nurse practitioners consisting 4 hours of combined didactic and simulation-facilitated education followed by hands-on experience in the operating room. Tracheal intubations performed by nurse practitioners in the pediatric intensive care unit were tracked by a local quality improvement database, NEAR4KIDS from January 2009 to December 2018. Since curriculum initiation, 39 nurse practitioners completed the program. Nurse practitioners functioned as the first provider to attempt intubation in 473 of 3,128 intubations (15%). Also, 309 of 473 (65%) were successful at first attempt. Implementation of a simulation-facilitated pediatric airway management curriculum successfully supported the ongoing airway management participation and first attempt intubation success by nurse practitioners in the pediatric intensive care unit over the 10-year period.

The Perspectives of Advanced Practice Provider Directors on Acute Care Nurse Practitioner Alignment and Hiring

Demand for acute care is forecasted to grow in the United States. To meet this demand, nurse practitioners (NPs) are increasingly employed in acute care settings. Yet, there is concern about an adequate supply of acute care NPs given demand. Further, professional nursing organizations recommend aligning an NP's role with their education, certification, licensure, and practice. Given workforce constraints and the policy environment, little is known about how hospitals approach hiring NPs for acute care roles. The purpose of this study was to explore advanced practice provider (APP) directors' approaches to hiring NPs within the context of alignment and describe factors that influence hiring decisions. We conducted semi-structured interviews with 17 APP directors in hospitals and health systems. Interviews were recorded, transcribed, and coded using an iterative, hybrid inductive and deductive method. Two themes emerged: (1) local factors that inform aligned hiring and (2) adaptive hiring responses to changing environments. Practices around hiring NPs varied across institutions influenced by organization and state policies and regulations, workforce availability, and institutional culture. Most APP directors recognized trends towards hiring aligned NPs for acute care roles. However, they also identified barriers to fully aligning their NP workforce and described adaptive strategies including hiring physician assistants, building relationships with APP schools, and leveraging hospital resources to develop the APP workforce to meet care delivery demands given the current NP workforce supply. Future research is needed to assess widespread practices around acute care NP alignment and the implications of alignment for patient and organizational outcomes.

Early implementation of full-practice authority: A survey of Massachusetts nurse practitioners

BACKGROUND

In January 2021, Massachusetts granted nurse practitioners (NPs) full-practice authority (FPA). Little is known about how FPA changes the day-to-day work of NPs.

PURPOSE

To examine changes in practice barriers and care delivery in the early stages of FPA.

METHODOLOGY

Descriptive analysis of a web-based survey of clinically active NPs in Massachusetts from October to December 2021, using Fisher exact tests to examine the associations between the perception that FPA improved work and other variables.

RESULTS

Survey response rate was 50.3% ( N = 147). Overall, 79% of NPs believe that clinical work is unchanged by FPA. Practicing outside institutions is a significant predictor of FPA improving work ( p < .05). Larger proportions of respondents feel that efficiency (22%), patient centeredness (20%), and timeliness (20%) are improved by FPA compared with effectiveness (16%), equity (14%), and safety (10%). Almost half of those reporting that FPA improves overall care also report improved efficiency (50%, p < .0001), but only 22% report improved safety ( p < .05). Of those believing that FPA improved work, a minority no longer need physician review of new controlled substance prescriptions (29%, p < .01), a practice agreement (32%, p < .05), or physician signature on clinical documentation (22%, p < .05).

CONCLUSIONS

Almost 1 year after FPA was passed in Massachusetts, the large majority of NPs report no changes in their day-to-day work, suggesting that FPA implementation is slow.

IMPLICATIONS

Concerted efforts by regulators, employers, and individual NPs are needed to ensure that legislated FPA is effectively implemented inside organizations and among payers.

Implementation of the Nurse Practitioner as Most Responsible Provider model of care in a Specialised Mental Health setting in Canada

Globally, mental health systems have failed to adequately respond to the growing demands of mental health services resulting in a disparity between the need and provision of treatment. Paucity of mental health care providers contributes to the aforementioned disparity. This can be addressed by engaging Nurse Practitioners (NPs) in an integrated model within healthcare teams. This paper describes the implementation of NPs as Most Responsible Provider (MRP) care of model in a specialised mental health hospital in Ontario, Canada. Guided by the participatory, evidence-based, patient-focused process for advanced practise nursing (APN) role development, implementation, and evaluation (PEPPA) framework, authors developed a model of care and implemented the first seven steps of the PEPPA framework - (a) define the population and describe the current model of care, (b) identify stakeholders, (c) determine the need for a new model of care (d) identify priority areas and goals of improvement, (e) define the new model of care, and (f) plan and implement the NP as MRP model of care. Within these steps, different strategies were implemented: (a) revising policies and procedures (b) harmonising reporting structures, (c) developing and implementing a collaborative practise structure for NPs, (d) standardised and transparent compensation (e) performance standards and monitoring (f) Self-Assessment Competency frameworks, education, and development opportunities. This paper contributes to the state of the knowledge by implementing NPs as MRP model of care in a specialised mental health care setting in Ontario, Canada; and advocates the need for incorporating mental health programmes within the Ontario nursing curriculum.

Implications of State Scope-of-Practice Regulations for Pediatric Intensive Care Unit Nurse Practitioner Roles

Nurse practitioner (NP) advocacy efforts often focus on attaining full practice authority. While the effects of full practice authority in primary care are well described, implications for hospital-based NPs are less clear and may differ because of hospitals' team-based care and administrative structure. This study examines associations between state scope-of-practice (SSOP) and clinical roles of hospital-based pediatric intensive care unit (PICU) NPs. We conducted a national survey to assess clinical roles of PICU NPs including daily patient care, procedural, and consultation responsibilities as well as hospital-level administrative oversight practices. We classified SSOP as full or limited (reduced or restricted SSOP) practice. We present descriptive statistics and evaluate differences in clinical roles and hospital-level administrative oversight based on SSOP. The final sample included 55 medical directors and 58 lead (senior or supervisory) NPs from 93 of the 140 (66.4%) PICUs with NPs. There were no significant differences in daily patient care, procedural, or consultation responsibilities based on SSOP (p > .05). However, NPs in full practice authority states were more likely to bill for care than those in limited practice states (66.7% vs. 31.8%, p = .003), while those in limited practice states were more likely to report to advanced practice managers (36.7% vs. 13%, p = .03). For PICU NPs, SSOP was not associated with variation in clinical responsibilities; conversely, there were differences in billing and reporting practices. Future work is needed to understand implications of variation in hospital-level administrative oversight.

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.

Regulation of the Nurse Practitioner Workforce: Implications for Care Across Settings

Introduction

The current shortage of physicians in the United States has potential to dramatically limit access to healthcare. Nurse practitioners (NPs) can provide a cost-effective solution to the shortage, yet few states allow NPs to practice independently.

Purpose

The purpose of this study was to provide an up-to-date description of the NP workforce and to identify the professional and organizational factors associated with NP care quality.

Methods

Cross-sectional survey data from a sample of NPs actively employed in four states with reduced or restricted practice (California, Florida, New Jersey, and Pennsylvania) was used. NPs were categorized into acute and primary care. Regression models were fit to estimate the odds of three measures of care quality: overall quality of patient care, NP confidence that patients and their caregivers can manage their care at home, and whether NPs would recommend their practice facility to family and friends.

Results

Receiving support from administrative staff and physicians was associated with an increase in the three measures of quality. The greatest effects were seen in primary care settings.

Conclusion

It is imperative that legislators and healthcare administrators implement policies that provide NPs with an environment that supports clinical practice and enhances care delivery.

PICU Provider Supply and Demand: A National Survey

OBJECTIVES

To describe physicians' and nurse practitioners' perceptions of the national and local PICU physician and other provider supply in institutions that employ PICU nurse practitioners, assess for differences in perceptions of supply, and evaluate the intent of institutions to hire additional nurse practitioners to work in PICUs.

DESIGN

National, quantitative, cross-sectional descriptive study via a postal mail survey from October 2016 to January 2017.

SETTING

Institutions (n = 140) identified in the 2015 American Hospital Association Annual Survey with a PICU who employ PICU nurse practitioners.

SUBJECTS

PICU physician medical directors and nurse practitioners.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were 119 respondents, representing 93 institutions. Responses were received from 60 PICU medical directors (43%) and 59 lead nurse practitioners (42%). More than half (58%) of all respondents reported the national supply of PICU physicians is less than demand and 61% reported the local supply of PICU providers (physicians in all stages of training, nurse practitioners, and physician assistants) is less than demand. Of the respondents from institutions that self-reported a local provider shortage (n = 54), three fourths (78%) reported plans to increase the number of PICU nurse practitioners in the next 3 years and 40% were likely to expand the nurse practitioner's role in patient care.

CONCLUSIONS

Most PICU medical directors and lead nurse practitioners in institutions that employ PICU nurse practitioners perceived that national and local supply of providers to be less than the demand. Nurse practitioners are employed in PICUs as part of interdisciplinary models of care being used to address provider demand. The demand for more PICU nurse practitioners with expanded roles in care delivery was reported. Further evaluation of models of care and provider roles in care delivery can contribute to aligning provider supply with demand for care delivery.