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

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.

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.

Advanced practice nurse capabilities: A mixed methods systematic review

BACKGROUND

Global health challenges demand the optimal use of nurses' professional competence and capability. Competencies related to the roles of advanced practice nurses have been developed, but research on these nurses' capabilities remains limited.

AIM

To summarise and compare the literature on the capabilities of advanced practice nurses and the dimensions of these capabilities.

METHODS

We carried out a mixed methods systematic review, using CINAHL, PubMed, and Scopus to search literature published between 1998 and 2021. The quality of the selected articles was evaluated with the JBI Critical Appraisal Tools. We employed abductive content analysis, including deductive and inductive analysis. The reporting was guided by the standards of the Preferred Reporting Items for Systematic Review and Meta-Analysis Statement.

RESULTS

Eleven articles out of 357 met the inclusion criteria. We identified all five dimensions of Hase and Davis's (1999) capability framework: can apply competencies in familiar as well as unfamiliar situations, is creative, has a high degree of self-efficacy, knows how to learn, and works well in teams. Additionally, we found a new dimension of capability: identifies factors affecting the scope of practice.

LIMITATIONS

This mixed methods systematic review was conducted about a little-studied topic. Because country-specific differences exist and consensus on advanced practice nursing roles is lacking, the concept of advanced practice nurse capabilities cannot be directly generalised.

CONCLUSIONS

Capability is a requirement and a necessity in the performance of advanced practice nurses. Identifying and defining the dimensions of advanced practice nurses' capabilities will lead the way in developing the roles, education, and capability assessments of advanced practice nurses. Identification of advanced practice nurses' capability will facilitate role understanding, visibility, and implementation in health care services. This can improve the quality and accessibility of care and improve the cost-effectiveness of the use of health care professionals.

State Policies and Buprenorphine Prescribing by Nurse Practitioners and Physician Assistants

Nurse practitioner (NP) and physician assistant (PA) prescribing can increase access to buprenorphine treatment for opioid use disorder. In this cross-sectional study, we used deidentified claims from approximately 90% of U.S. retail pharmacies (2017-2018) to examine the association of state policies with the odds of receiving buprenorphine treatment from an NP/PA versus a physician, overall and stratified by urban/rural status. From 2017 to 2018, the percentage of buprenorphine treatment episodes prescribed by NPs/PAs varied widely across states, from 0.4% in Alabama to 57.2% in Montana. Policies associated with greater odds of buprenorphine treatment from an NP/PA included full scope of practice (SOP) for NPs, full SOP for PAs, Medicaid pay parity for NPs (reimbursement at 100% of the fee-for-service physician rate), and Medicaid expansion. Although most findings with respect to policies were similar in urban and rural settings, the association of Medicaid expansion with NP/PA buprenorphine treatment was driven by rural counties.

Impact of state scope-of-practice laws on nurse practitioner-provided home visits

Millions of older Americans receive nurse practitioner (NP)-provided home based primary care (HBPC). Little is known about how state scope-of- practice (SOP) laws may impact use of NP-home visits. Using 2017 Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Public Use File (PUF), we examined the impact of state SOP laws on the use of NP-home visits. The PUF file was merged with the 2017 American Community Survey to assess area-level median income. Over 4.4 million home visits were provided to 1.6 million Medicare beneficiaries. NPs represented the largest share of providers (47.5%). In states with restricted SOP laws, compared to NPs, physicians and physician assistants had higher odds of providing HBPC. In states with reduced SOP laws, compared to NPs, physicians and PAs had decreased odds of providing HBPC. Our study provides evidence that SOP restrictions are associated with decreased utilization of NP-provided HBPC.