The Role Of Nurse Practitioners In Reinventing Primary Care

Implementing an APRN-Led Integrated Behavioral Health Clinic in a Rural Community

OBJECTIVE

A rural primary care clinic implemented an advance practice providers, including nurse practitioner (APRN)-led integrated behavioral health program to facilitate holistic health care delivery.

METHODS

Implementation was facilitated by Health Resources and Services Administration Grant funding to a state University College of Nursing. The College formed an academic-practice partnership with a Federally Qualified Health Center (FQHC) to implement integrated care in a rural satellite clinic administered by the FQHC. An interdisciplinary team (two family APRNs, a psychiatric APRN, a licensed behavioral health provider, and the Grant Project Director who is a Psychiatric APRN and a licensed Psychologist) provided the integrated care based on the University of Washington's Collaborative Care Model.

RESULTS

This brief report describes the implementation of integrated care during the clinic's first year, services provided, lessons learned, community response, and improvement in anxiety and depressive symptoms for patients who were treated for behavioral health problems. An exemplar illustrates how collaborative care addressed one patient's behavioral health and primary care needs.

CONCLUSIONS

APRN-led collaborative care can expand access to holistic, affordable care in rural areas to improve mental health. Adaptation and flexibility in traditional roles may be necessary and determining post-grant access to funding for services will be necessary for sustainability.

Full practice authority and burnout among primary care nurse practitioners

BACKGROUND

Full practice authority (FPA) improves clinical autonomy for nurse practitioners (NPs). Autonomy may reduce burnout.

PURPOSE

Estimate the effect of changing from reduced or restricted practice authority to FPA on NP burnout.

METHODS

In this quasi-experimental study, we compared NP burnout before (2016) and after (2018) a Veterans Health Administration (VHA) regulation authorized NP FPA. Burnout proportions were estimated for VHA facilities by aggregating responses to the VHA's All Employee Survey from 1,352 primary care NPs.

DISCUSSION

Seventy-seven percent of facilities changed to FPA postregulation. Burnout was six points lower among NPs in facilities that changed to FPA compared to facilities that had FPA prior to the regulation; however, this association was not statistically significant.

CONCLUSION

NPs are increasingly working under independent practice. While changing to FPA did not reduce NP burnout, this association may vary by health care setting or when burnout is measured for individuals or teams.

The Future of Psychiatric-Mental Health Nursing: Observe, Reflect, and Take Action to Empower Knowledge for the Greater Good

The purpose of this article is a call for action to identify areas of concern and promise for the specialty of psychiatric-mental health nursing to flourish in the twenty first century and beyond in the United States. Bits and pieces of this call for action may be relevant to other countries where psychiatric-mental health nursing has had similar trends. However, this paper focuses on the issues, barriers, and politics of education, practice, and research for nurses in the United States who gravitate to psychiatric-mental health and endeavor to rise above the value-laden past that perpetuates the marginalization of not only the specialty, but also the work that PMHN do and for the individuals that they are meant to care for in the new millennial. Much of the history of PMHN knowledge and care is value-laden, biased and riddled in patriarchy, fundamental religious views from centuries ago, and a basic fear of the unknown. It is well over due to sort through the closets and filing cabinets of the specialty's knowledge to clear out the stigma, the myths, the unknown and the "doctor knows best" world view. If PMHN is to survive and truly heal or comfort the suffering that is observed and witnessed first-hand in the twenty first century, a deliberate and purposeful approach is needed.

Estimating the Primary Care Workforce for Medicare Beneficiaries Using an Activity-Based Approach

BACKGROUND

The enumeration of the primary care workforce relies on potentially inaccurate specialty designations sourced from licensure registries and clinician surveys.

OBJECTIVE

To use an activity-based measure of primary care to estimate the number of physicians, nurse practitioners (NPs), and physician assistants (PAs) providing primary care to Medicare beneficiaries.

DESIGN

Observational study using Medicare fee-for-service (FFS) claims data.

SUBJECTS

All clinicians in the US billing Medicare in 2019 and their fee-for-service Medicare patients.

MAIN MEASURES

We construct three measures that together distinguish primary care from specialty clinicians: (1) presence of evaluation and management (E&M) services in a setting consistent with primary care, (2) the dispersion of clinical care across International Classification of Diseases-10 (ICD-10) chapters, and (3) the extent of provided services that are atypical of primary care (e.g., surgical procedure). We apply parameters to the measures to identify the clinicians likely providing primary care and compare the resulting classifications across provider type.

KEY RESULTS

Of physicians with at least 50 Medicare beneficiaries, 19-22% provide primary care. Of medical generalists (i.e., family medicine, internal medicine) with at least 50 beneficiaries, 61-68% provide primary care. We estimate that 40-45% of NPs and 27-30% of PAs meeting the panel size threshold are primary care providers in FFS Medicare.

CONCLUSIONS

Our findings suggest that based on a primary care practice style, the number of primary care physicians in FFS Medicare is likely smaller than conventional estimates. However, compared to prior estimates, the number of primary care NPs is larger and the number of PAs is similar.

Earnings, job satisfaction, and turnover of nurse practitioners across employment settings

Nurse practitioners (NPs) are an important part of the health care workforce. However, little information is available on NP earnings, job satisfaction, or turnover. National survey data from 2018 offer a pre-COVID-19 baseline for ongoing NP workforce monitoring. We found evidence that NPs earned approximately $92 500 annually, ranging from $82 800 in long-term care to $95 600 in hospital settings. Wages increased with tenure in the workforce and varied considerably by geography. Approximately 1 in 5 NPs switched jobs annually, with some net in-flow to ambulatory settings. Both NPs who left their position or considered leaving reported better pay and benefits, burnout, management role, stressful work environment, career advancement, and inadequate staffing as the primary explanations. These findings were augmented by analysis of 2012-2022 Bureau of Labor Statistics data that illustrated substantial growth in the NP workforce. Improving NP job satisfaction has the direct benefit of supporting a critical and growing segment of the health workforce; it has the additional benefit of reducing job turnover and the associated costs, potentially increasing earnings for NPs. Policies that improve working conditions for NPs in different employment settings will not just increase immediate job satisfaction but also ideally strengthen the longer-term labor market to improve patient outcomes.

State Variation in the Utilization of Nurse Practitioner-Provided Home-Based Primary Care: A Medicare Claims Analysis

Nurse practitioners (NPs) provide an increasing proportion of home-based primary care, despite restrictive scope of practice laws in approximately one half of states. We examined the relationship between scope of practice laws and state volume of NP-provided home-based primary care by performing an analysis of 2018 to 2019 Medicare claims. For each state we calculated the proportion of total home-based primary care visits by NPs and the proportion of all NPs providing home-based primary care. We used the 2018 American Association of Nurse Practitioners classification of state practice environment. We performed chi-square tests to assess the significance between volume and practice environment. We found that 42% of home-based primary care is delivered by NPs nationally, but substantial variation exists across states. We did not find a discernible or statistically significant pattern of uptake of NP-provided home-based primary care across full, reduced, or restricted states. [Journal of Gerontological Nursing, 49(5), 11-17.].

The role of restrictive scope-of-practice regulations on the delivery of nurse practitioner-delivered home-based primary care

BACKGROUND

Nurse practitioners (NPs) are the largest group of providers delivering home-based primary care (HBPC) in the U.S. We examined the association of scope-of-practice regulations and NP-HBPC rates.

METHODS

Using the Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Public Use File for 2019, we conducted a state-level analysis to examine the impact of scope-of-practice regulations on the utilization of NP-HBPC. Healthcare Common Procedure Coding System codes were used to identify the HBPC visits in private residences (99341-99,345, 99,347-99,350) and domiciliary settings (99324-99,328, 99,334-99,337). We used linear regression to compare NP-HBPC utilization rates between states of either restricted or reduced scope-of-practice laws to states with full scope-of-practice, adjusting for a number of NP-HBPC providers, state ranking of total assisted living, the proportion of fee-for-service (FFS) Medicare beneficiaries and neighborhood-level socio-economic status and race and ethnicity.

RESULTS

Nearly half of NPs providing HBPC (46%; n = 7151) were in states with a restricted scope of practice regulations. Compared to states with full scope-of-practice, states with restricted or reduced scope-of-practice had higher adjusted rates of NP-HBPC per 1000 FFS Medicare beneficiaries. The average level of the utilization rate of NP-HBPC was 89.9, 63, and 49.1 visits, per 1000 FFS Medicare beneficiaries in states with restricted, reduced, and full- scope-of-practice laws, respectively. The rate of NP-HBPC visits was higher in states with restricted (Beta coefficient = 0.92; 95%CI 0.13-1.72; p = 0.023) and reduced scope-of-practice laws (Beta coefficient = 0.91; 95%CI 0.03-1.79; p = 0.043) compared to states with full scope-of-practice laws.

CONCLUSION

Restricted state NP scope-of-practice regulations were associated with higher rates of FFS Medicare NP-HBPC care delivery compared with full or reduced scope-of-practice. Understanding underlying mechanisms of how scope-of-practice affects NP-HBPC delivery could help to develop scope-of-practice regulations that improve access to HBPC for the underserved homebound population.

A Survey Analysis of Patient Understanding and Preferences for Podiatrists Versus Foot and Ankle Orthopaedic Surgeons

BACKGROUND

Recent studies suggest poorer outcomes and higher costs associated with patients treated by podiatrists, yet no studies have evaluated patient perception and preference for foot and ankle providers. This study aims to determine patient perception of training for podiatrists compared to orthopaedic surgeons and patient preference for type of provider seen.

METHODS

A 20-question survey was administered to new patients seeing either a podiatrist or foot and ankle orthopaedic surgeon. Questions pertained to demographics, patient knowledge of their provider, perception of training requirements, number of years in professional training, and differences in surgical volume during training. Patients were asked their preference for a particular type of foot and ankle provider, and whether they perceived a difference in surgical skillset or a provider's ability to manage different pathology.

RESULTS

In all, 147 podiatry and 115 orthopaedic patients were included in the study. Demographics were similar between groups. Both groups believed orthopedists required more years of education and surgical training. In all, 61.5% of orthopaedic patients believed that orthopedists performed more foot and ankle surgeries and were more skilled as compared to podiatrists, while only about a third of podiatry patients believed this to be true (68.7% vs 38.6%; P < .001). Most patients believed orthopedists were more skilled in treating fractures. In all, 48.7% of orthopaedic patients preferred seeing an orthopedist compared to only 3.5% of podiatry patients.

CONCLUSIONS

Our study demonstrates that patients are knowledgeable about the type of foot and ankle provider they are seeing. Most patients believe orthopaedic surgeons require more years of education and surgical training compared to podiatrists and believe they are more skilled in fracture-related surgery. Fewer podiatry patients expressed a preference for an orthopaedic surgeon. Providers must play an active role in discussing their training background prior to treating foot and ankle patients, especially in the setting of fracture-related pathology.

CLINICAL RELEVANCE

This study demonstrates that most patients seeking care from a podiatrist or foot and ankle orthopaedic surgeon are relatively knowledgeable about the type of provider they are seeing; however, there are some differences. Most patients understand that orthopaedic surgeons require more years of education and surgical training and also believe orthopaedic surgeons are more skilled in fracture work and taking care of arthritic conditions. In general, podiatry patients have less preference for seeing an orthopaedic surgeon; however, many of these patients are seeking care for wounds and infections. With expanding roles and scope of practice among podiatry providers, it is important that providers become more active in explaining their training background and qualifications when treating foot and ankle conditions.

LEVELS OF EVIDENCE

Level II: Prospective.

Factors associated with federally qualified health center financial performance

OBJECTIVES

To understand factors associated with federally qualified health center (FQHC) financial performance.

STUDY DESIGN

We used multivariate linear regression to identify correlates of health center financial performance. We examined six measures of health center financial performance across four domains: margin (operating margin), liquidity (days cash on hand [DCOH], current ratio), solvency (debt-to-equity ratio), and others (net patient accounts receivable days, personnel-related expenses). We examined potential correlates of financial performance, including characteristics of the patient population, health center organization, and location/geography.

DATA SOURCES

We use 2012-2017 Uniform Data System (UDS) files, financial audit data from Capital link, and publicly available data.

DATA COLLECTION/EXTRACTION METHODS

We focused on health centers in the 50 US states and District of Columbia, which reported information to UDS for at least 1 year between 2012 and 2017 and had Capital link financial audit data.

PRINCIPAL FINDINGS

FQHC financial performance generally improved over the study period, especially from 2015 to 2017. In multivariate regression models, a higher percentage of Medicaid patients was associated with better margins (operating margin: 0.06, p < 0.001), liquidity (DCOH: 0.67, p < 0.001; current ratio: 0.28, p = 0.001), and solvency (debt-to equity ratio: -0.08, p = 0.004). Moreover, a staffing mix comprised of more nonphysician providers was associated with better margin (operating margin: 0.21, p = 0.001) and liquidity (current ratio: 1.12, p < 0.001) measures. Patient-centered medical home (PCMH) recognition was also associated with better liquidity (DCOH: 19.01, p < 0.001; current ratio: 4.68, p = 0.014) and solvency (debt-to-equity ratio: -2.03, p < 0.001).

CONCLUSIONS

The financial health of FQHCs improved with provisions of the Affordable Care Act, which included significant Medicaid expansion and direct funding support for health centers. FQHC financial health was also associated with key staffing and operating characteristics of health centers. Maintaining the financial health of FQHCs is critical to their ability to continuously provide affordable and high-quality care in medically underserved areas.

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.

Tendency and foci of nurse practitioners: bibliometric analysis based on the CiteSpaceV†

Objective

Nurse practitioners (NPs) have drawn significant attention recently and played a major role in healthcare. We aim to find the evaluation of NPs through published studies and then visualize the research status and hotspots in this field.

Methods

All data came from the Web of Science Core Collection, and the data were counted and entered into Excel 2016. The key documents nodes were excavated by analyzing the knowledge network map using CiteSpaceV software. In this study, these nodes of “author, country, institution, keyword, co-citation (reference\cited-author\cited-journal), and grant” were harvested for analysis and comparison.

Results

A total of 4912 records, which were published between 2007 and 2018 and pertained to NPs, were retrieved from the Web of Science Core Collection database (WoSCC) from a diversity of languages. The total and the annual number of publications and citations of these continually increased over time. Most publications were in 2018 (618 records). This study involved 8241 authors located in 98 countries and 4557 institutions totally. The United States (2737 records) and the University of Michigan (90 records) dominated in publication frequency. There are 902 journals and 2449 articles with funding support that have been analyzed. Most articles were from JAMA: The Journal of the American Medical Association (1386, IF = 47.661), followed by the Journal of Advanced Nursing (1359, IF = 2.267), and The New England Journal of Medicine (1109, IF = 79.258). The reference “The Role of Nurse Practitioners in Reinventing Primary Care” was co-cited most frequently, which revealed it as the highest landmark article in NP. The top-ranked keyword was “Care,” other than “Nurse practitioner,” which has an ultra-high frequency. Some of the high-frequency keywords represent the significant direction of NPs.

Conclusions

NPs are at the crux of health-care delivery and play an important role in providing high-quality nursing. Publications on NPs in WoSCC have increased notably during the recent years, and have appeared in some journals that have a high impact factor. Research frontiers and developmental trends were revealed by the analysis in this study, which can be used to forecast future research developments in NPs and taken as a reference to choose the right directions by subsequent researchers who wish to use these results. However, the grant support from administration or research institutions is still in need of improvement and the scope of research in NPs should be broadened in the future.

Minding the Gap: Adolescent and Parent/Caregiver Reporter Discrepancies on Symptom Presence, Impact of Covariates, and Clinical Implications

INTRODUCTION

Primary care practitioners (PCPs) provide care to adolescents in the context of their families. Supporting parent/caregiver knowledge of symptoms can create opportunities for better recognition of symptoms that can then lead to early identification, intervention, and prevention of poor outcomes.

METHOD

Cross-sectional comparative study of parent/caregiver reported versus adolescent reported symptom presence of anhedonia and depressed mood in the participants of ABCD Study.

RESULTS

Large discrepancies exist between adolescent and parent-reported presence of symptoms.

DISCUSSION

Improving understanding of the etiology, covariates, and patterns of discrepancies may improve primary care assessment, adolescent access to care, and intervention for adolescents and their families. Furthermore, providing education to families about symptom features, working to improve adolescent-caregiver communication, promoting adolescent advocacy, and connecting families to community resources are important attributes of primary care and areas of adolescent and family functioning that primary care providers can strengthen.

A methodology for identifying behavioral health advanced practice registered nurses in administrative claims

OBJECTIVE (STUDY QUESTION)

Advance practice registered nurses (APRNs) play an increased role in mental illness treatment. Health services research that uses claims to study mental health is often limited because behavioral health nurse practitioners (i.e., APRNs who specialize in mental illness also known as psychiatric mental health APRNs) cannot be easily identified in claims data. We describe a methodology to identify behavioral health APRNs in administrative claims. DATA SOURCES/STUDY SETTING (W/ HOSPITAL/INSTITUTION SETTING ANONYMIZED): We use 2010-2018 claims from the traditional Medicare fee-for-service program along with 2010-2019 commercial claims and Medicare Advantage data from the OptumLabs® Data Warehouse (OLDW). Self-reported specialty data from the National Plan & Provider Enumeration System (NPPES) were used for validation.

STUDY DESIGN

For each APRN, we calculated the percentage of visit diagnoses and of prescriptions in each database that were for mental health and classified those with ≥80% as behavioral health APRNs. We validated our definition with NPPES self-reported specialty for Medicare data.

DATA COLLECTION / EXTRACTION METHODS

Not applicable.

PRINCIPAL FINDINGS

Among APRNs with 10+ visits, 10,978 (8.1%) in Medicare and 9829 (11.7%) in commercial claims data met our visit-based criteria as behavioral health APRNs. Among APRNs with 10+ prescriptions, 8160 (6.2%) in Medicare and 16,538 (9.0%) in commercial claims data met our prescription-based criteria as behavioral health APRNs. Among the APRNs who self-reported they were behavioral health APRNs, 92.8% and 90.5% met our visit-based and prescription-based criteria respectively.

CONCLUSIONS

We present and validate two methods of identifying behavioral health APRNs in claims that can be used by other researchers.

A Quality Improvement Initiative: A Nurse Practitioner-Led Interdisciplinary Approach to Reducing Readmissions in the Subacute Population

Background

To decrease the 30-day Subacute Readmissions in an outpatient facility by using an Advanced Practice Nurse (APN) Project Leader while applying evidence based transitional care processes.

Objective

Determine the effects of APN leadership within the Interdisciplinary Team in the subacute setting.

Methods

Immersion of an APN as Project Leader over a 12-week period.

Results

Outcomes were divided into three groups. They were reorganized and analyzed. The new breakdown included patients readmitted plus hospice referrals (n = 5) and those not readmitted (n = 4). A significant difference in the 30-day outcomes as well as the LACE variable comorbidity scores t (4) = 2.95, p = 0.0418 were identified.

Conclusions

The 30-day readmission rates were decreased using hospice as a referral source. Application of the Lippitt’s Model of Planned Change and the use of the LACE Scoring Tool were instrumental to the success of this project.

Implications for Nursing

To improve optimal outcomes it is necessary for the APN/Doctor of Nursing Practice (DNP) and other healthcare professionals to engage in collaborative practices that result in effective policy changes. This quality improvement project restructured the existing Interdisciplinary Team processes to include the APN Project Leader with improved patient-centered outcomes.

Intrinsic motivation in exercise: A concept analysis

AIM

To explore the concept of intrinsic motivation in exercise as it pertains to nursing.

BACKGROUND

Exercise is an integral part of treating and preventing chronic diseases, and yet the vast majority of adults do not adequately meet endorsed exercise recommendations. Evaluating motivation for exercise assists in the effort to promote sustained exercise participation. Intrinsic motivation speaks to the innate drive for an action or behavior. Intrinsic motivation has previously been evaluated in various disciplines including nursing, education, exercise science, medicine, and psychology. The combination of intrinsic motivation and exercise can be applied in the nursing discipline to evaluate, predict, and impact behavior change.

DESIGN

Concept analysis using Walker and Avant (2019) methodology.

DATA SOURCE

PubMed, CINAHL, and PsychINFO. Articles from the years 2011 to 2020 were included.

REVIEW METHODS

Literature from multiple disciplines was synthesized to explore the concept of intrinsic motivation in the context of exercise.

RESULTS

Characteristics of intrinsic motivation, their attributes, antecedents, and consequences were identified. The concept analysis represents a consensus of the identified literature providing a concise description of intrinsic motivation with exercise. Four vital attributes were identified in the literature and became the basis of the concept analysis; self-efficacy, competence, self-determination, and satisfaction.

CONCLUSION

This concept analysis provides a foundation from which to create nursing interventions aimed at fostering intrinsic motivation for exercise. Expansion of our knowledge of intrinsic motivation, in the context of exercise, has the potential to enhance approaches used by nurses and nurse providers to affect healthy behavior changes.

Exploring the Recent Trends in Management of Dementia and Frailty: Focus on Diagnosis and Treatment

Dementia and frailty increase health adversities in older adults, which are topics of growing research interest. Frailty is considered to correspond to a biological syndrome associated with age. Frail patients may ultimately develop multiple dysfunctions across several systems, including stroke, transient ischemic attack, vascular dementia, Parkinson's disease, Alzheimer's disease, frontotemporal dementia, dementia with Lewy bodies, cortico-basal degeneration, multiple system atrophy, amyotrophic lateral sclerosis, and Creutzfeldt-Jakob disease. Patients with dementia and frailty often develop malnutrition and weight loss. Rigorous nutritional, pharmacological, and non-pharmacological interventions generally are required for these patients, which is a challenging issue for healthcare providers. A healthy diet and lifestyle instigated at an early age can reduce the risk of frailty and dementia. For optimal treatment, accurate diagnosis involving clinical evaluation, cognitive screening, essential laboratory evaluation, structural imaging, functional neuroimaging, and neuropsychological testing is necessary. Diagnosis procedures best apply the clinical diagnosis, identifying the cause(s) and the condition(s) appropriate for treatment. The patient's history, caregiver's interview, physical examination, cognitive evaluation, laboratory tests, and structural imaging should best be involved in the diagnostic process. Varying types of physical exercise can aid the treatment of these disorders. Nutrition maintenance is a particularly significant factor, such as exceptionally high-calorie dietary supplements and a Mediterranean diet to support weight gain. The core purpose of this article is to investigate trends in the management of dementia and frailty, focusing on improving diagnosis and treatment. Substantial evidence builds the consensus that a combination of balanced nutrition and good physical activity is an integral part of treatment. Notably, more evidence-based medicine knowledge is required.

Measuring the contribution of clinical rotations to skills confidence in primary care nurse practitioner students

ABSTRACT

Primary care providers (PCPs) are essential components of a health care system, but there are shortages of PCPs. Nurse practitioners (NPs) are essential in meeting the needs of an increased demand for primary care, but there is a wide variety in the training offered to NP students. The purpose of this analysis is to determine student self-reported comfort in a variety of care delivery, covering primary care topics, including knowledge and skills. We conducted a preclinical and postclinical survey. Surveys were obtained before and at the conclusion of two clinical rotations in Baltimore, MD. Students were a part of a Health Resources and Services Administration-funded program to prepare NP students to practice in urban, underserved settings. Seventeen NP students NP students responded to both our pre- and postsurveys. Overall, student comfort increased in many focus areas, but no change was seen in important domains, including interpreting imaging studies, filling out common forms, and interpreting certain diagnostic tests. Further study of student skills and confidence at the conclusion of their study would be beneficial in determining if these gaps persist at entry into NP practice. Given wide variation in NP student training programs, it would be additionally beneficial to understand how these differences impact student skills and confidence during their clinical rotations and on entry to practice. Well rounded, broad-based education is necessary for the development of highly trained PCPs; greater understanding of student confidence, knowledge, and skills can assist educators in assuring that all NPs enter practice as safe and competent providers.

Colorectal Cancer Screening Practices Among Texas Nurse Practitioners and Physician Assistants

The purpose of this study was two-fold: (1) To describe and compare Texas Nurse Practitioners' and Physician Assistants' knowledge and use of current screening guidelines for individuals at varying risk for colorectal cancer and (2) to compare their recommendations for referral for genetic counseling for persons at increased risk for colorectal or endometrial cancer. The study used a descriptive correlational comparative design. A self-administered web-based survey was sent to the members of the Texas Nurse Practitioner Association and the Texas Academy of Physician Assistants. The questionnaire consisted of 44 items categorized in three domains: demographics, knowledge of national guidelines for risk-stratified colorectal cancer (CRC) screening, and referral for genetic counseling and CRC-screening practices. Data were collected from July through October 2014. More than 75% of the survey respondents reported confidence in their knowledge of the lifetime risk of colorectal cancer and the recommendations for screening in the average-risk adult. Fifty-one percent of both groups reported that they were familiar with Lynch syndrome; however, the nurse practitioners had a lower awareness of the lifetime risk of colorectal cancer associated with Lynch syndrome compared to the physician assistants. Only 34.1% of the nurse practitioners and 23.5% of the physician assistants were aware of the lifetime risk of developing endometrial cancer diagnosed before 60 years of age in women with Lynch syndrome, and only 39.6% of the physician assistants and 40% of the nurse practitioners reported performing a three-generation family history of cancer as a risk assessment. Less than 50% of the respondents would refer a patient with a personal or family history of colorectal or endometrial cancer diagnosed before the age of 60 years for genetic counseling. Nurse practitioners and physician assistants in primary care need more formal and continuing education in risk-stratified screening and referral for genetic counseling in adults at increased risk for colorectal cancer. The academic curricula of both disciplines need to include more content on genetic and genomic influences on the pathophysiology of colorectal cancer and the role of this information for screening and personalized treatment.

Drivers of Cost Differences Between Nurse Practitioner and Physician Attributed Medicare Beneficiaries

BACKGROUND

Although recent research suggests that primary care provided by nurse practitioners costs less than primary care provided by physicians, little is known about underlying drivers of these cost differences.

RESEARCH OBJECTIVE

Identify the drivers of cost differences between Medicare beneficiaries attributed to primary care nurse practitioners (PCNPs) and primary care physicians (PCMDs).

STUDY DESIGN

Cross-sectional cost decomposition analysis using 2009-2010 Medicare administrative claims for beneficiaries attributed to PCNPs and PCMDs with risk stratification to control for beneficiary severity. Cost differences between PCNPs and PCMDs were decomposed into payment, service volume, and service mix within low-risk, moderate-risk and high-risk strata.

RESULTS

Overall, the average PCMD cost of care is 34% higher than PCNP care in the low-risk stratum, and 28% and 21% higher in the medium-risk and high-risk stratum. In the low-risk stratum, the difference is comprised of 24% service volume, 6% payment, and 4% service mix. In the high-risk stratum, the difference is composed of 7% service volume, 9% payment, and 4% service mix. The cost difference between PCNP and PCMD attributed beneficiaries is persistent and significant, but narrows as risk increases. Across the strata, PCNPs use fewer and less expensive services than PCMDs. In the low-risk stratum, PCNPs use markedly fewer services than PCMDs.

CONCLUSIONS

There are differences in the costs of primary care of Medicare beneficiaries provided by nurse practitioners and MDs. Especially in low-risk populations, the lower cost of PCNP provided care is primarily driven by lower service volume.

Scope-of-Practice for Nurse Practitioners and Adherence to Medications for Chronic Illness in Primary Care

BACKGROUND

Nonadherence to medications is costly and improving adherence is difficult, requiring multifactorial solutions, including policy solutions.

OBJECTIVE

The purpose of this study is to evaluate the effect of one policy strategy on medication adherence. Specifically, we examine the effect on adherence of expanding scope-of-practice regulations for nurse practitioners (NPs) to practice and prescribe without physician supervision.

DESIGN

We conducted three difference-in-difference multivariable analyses of commercial insurance claims.

PARTICIPANTS

Patients who filled at least two prescriptions in one of three chronic therapeutic medications: anti-diabetics (n = 514,255), renin angiotensin system antagonists (RASA) (n = 1,679,957), and anti-lipidemics (n = 1,613,692).

MAIN MEASURES

Medication adherence was measured as the proportion of days covered (PDC). We used one continuous (PDC 0-1) and one binary outcome (PDC of > .8), the latter indicating good adherence.

KEY RESULTS

Patients taking anti-diabetic medications had a 1.9 percentage point higher medication adherence rate (p < 0.05) and a 2.7 percentage point higher probability of good adherence (p < 0.001) in states that expanded NP scope-of-practice. Medication adherence for patients taking RASA was higher by 2.3 percentage points (p < 0.001) and 3.4 percentage points (p < 0.01) for both measures, respectively. Patients taking anti-lipidemics saw a smaller, but statistically insignificant, improvement in adherence.

CONCLUSIONS

Results indicate that scope-of-practice regulations that allow NPs to practice and prescribe without physician oversight are associated with improved medication adherence. We postulate that the mechanism for this effect is increased access to health care services, which in turn increases access to prescriptions. Our results suggest that policies allowing NPs to maximally use their skills can be beneficial to patients.

Study of the Strengths and Weaknesses of Nursing Work Environments in Primary Care in Spain

Background: Nursing work environments are defined as the characteristics of the workplace that promote or hinder the provision of professional care by nurses. Positive work environments lead to better health outcomes. Our study aims to identify the strengths and weaknesses of primary health care settings in Spain. Methods: Cross-sectional study carried out from 2018 to 2019. We used the Practice Environment Scale of the Nursing Work Index and the TOP10 Questionnaire of Assessment of Environments in Primary Health Care for data collection. The associations between sociodemographic and professional variables were analyzed. Results: In total, 702 primary care nurses participated in the study. Responses were obtained from 14 out of the 17 Spanish Autonomous Communities. Nursing foundation for quality of care, management and leadership of head nurse and nurse–physician relationship were identified as strengths, whereas nurse participation in center affairs and adequate human resources to ensure quality of care were identified as weaknesses of the nursing work environment in primary health care. Older nurses and those educated to doctoral level were the most critical in the nursing work environments. Variables Age, Level of Education and Managerial Role showed a significant relation with global score in the questionnaire. Conclusion: Interventions by nurse managers in primary health care should focus on improving identified weaknesses to improve quality of care and health outcomes.

Integrating nurse practitioners into primary care: policy considerations from a Canadian province

Background

The integration of nurse practitioners (NPs) into primary care health teams has been an object of interest for policy makers seeking to achieve the goals of improving care, increasing access, and lowering cost. The province of Alberta in Canada recently introduced a policy aimed at integrating NPs into existing primary care delivery structures. This qualitative research sought to understand how that policy – the NP Support Program (NPSP) – was viewed by key stakeholders and to draw out policy lessons.

Methods

Fifteen semi-structured interviews with NPs and other stakeholders in Alberta’s primary care system were conducted, recorded, transcribed and analyzed using the interpretive description method.

Results

Stakeholders predominantly felt the NPSP would not change the status quo of limited practice opportunities and the resulting underutilization of primary care NPs in the province. Participants attributed low levels of NP integration into the primary care system to: 1) financial viability issues that directly impacted NPs, physicians, and primary care networks (PCNs); 2) policy issues related to the NPSP’s reliance on PCNs as employers, and a requirement that NPs panel patients; and 3) governance issues in which NPs are not afforded sufficient authority over their role or how the key concept of ‘care team’ is defined and operationalized.

Conclusions

In general, stakeholders did not see the NPSP as a long-term solution for increasing NP integration into the province’s primary care system. Policy adjustments that enable NPs to access funding not only from within but also outside PCNs, and modifications to allow greater NP input into how their role is utilized would likely improve the NPSP’s ability to reach its goals.

Use of a State Registry to Compare Practices of Physicians and Nurse Practitioners in Completing Physician Orders for Life-Sustaining Treatment Forms

Background: Understanding the role of nonphysicians in Physician Orders for Life-Sustaining Treatment (POLST) completion is limited. Objectives: To examine the role that nurse practitioners (NPs) play in POLST completion and differences between NPs and physicians in POLST orders. Design: Retrospective observational study. Setting/Subjects: A total of 3829 POLST forms submitted to the West Virginia (WV) e-Directive Registry between July 1, 2018 and June 30, 2019, which was completed by 98 NPs and 511 physicians. Measurements: POLST forms completed and orders in POLST Section A and Section B by all physicians and NPs according to practice (primary care, palliative care, hospital, and nursing home) and by palliative care physicians and NPs only. Results: NPs completed almost twice as many forms on average as physicians (9.54 ± 20.82 vs. 5.66 ± 17.18, p = 0.0064). NPs constituted 16.10% (98/609) of the clinicians writing POLST forms but completed 24.40% (935/3829) of the forms (p < 0.001). Compared with physicians' orders, a greater percentage of NP's orders was for do-not-resuscitate in Section A (87.20% vs. 72.60%, p < 0.001) and comfort measures in Section B (42.90% vs. 33.10%, p < 0.001). There was a greater percentage of NPs in palliative care practice than physicians (23.50% vs. 6.07%, p < 0.001), and palliative care NPs completed 64.20% (600/935) of the forms submitted by NPs compared with palliative care physicians who completed 17.90% (517/2894) of the forms submitted by physicians (p < 0.001). Conclusions: In WV, physician and NP POLST completion differs based on practice. NPs completed significantly more POLST forms on average and more often ordered comfort measures. NPs can play a significant role in POLST completion.

Pathways to Enable Primary Healthcare Nurses in Providing Comprehensive Primary Healthcare to Rural, Tribal Communities in Rajasthan, India

Background: Emerging health needs and uneven distribution of human resources of health have led to poor access to quality healthcare in rural areas. Rural pathways provide an approach to plan and evaluate strategies for ensuring availability, retention, motivation, and performance of human resources for health in rural areas. While effectiveness of primary healthcare (PHC) nurses to deliver primary health care is established, there is not enough evidence on ways to ensure their availability, retention, motivation, and performance. The paper draws on the program experience and evidence from a primary healthcare network (AMRIT Clinics), in which nurses play a central role in delivering primary healthcare in rural tribal areas of Rajasthan, India, to bridge this gap. Methods: Rural, tribal areas of Rajasthan have limited access to functional healthcare facilities, despite having a high burden of diseases. We used the rural pathway approach to describe factors that contributed to the performance of the nurses in AMRIT Clinics. We analyzed information from the human resource information system and health management information system; and supplemented it with semi-structured interviews with nurses, conducted by an independent organization. Results: Most nurses were sourced from rural and tribal communities that the clinics serve; nurses from these communities were likely to have a higher retention than those from urban areas. Sourcing from rural and tribal communities, on-going training in clinical and social skills, a non-hierarchical work environment, and individualized mentoring appear to be responsible for high motivation of the primary healthcare nurses in AMRIT Clinics. Task redistribution with due credentialing, intensive and on-going training, and access to tele-consultation helped in sustaining high performance. However, family expectations to perform gendered roles and pull of government jobs affect their retention. Conclusion: Rural and remote areas with healthcare needs and scarcity of health provisions need to optimize the health workforce by adopting a multi-pronged pathway in its design and implementation. At the same time, there is a need to focus on structural factors that affect retention of workforce within the pathway. Our experience highlights a pathway of up-skilling PHC nurses in providing comprehensive primary healthcare in rural and remote communities in Low and Middle-Income Countries (LMICs).

Evaluation of Nurse Practitioners' Professional Competence and Comparison of Assessments Using Multiple Methods: Self-Assessment, Peer Assessment, and Supervisor Assessment

PURPOSE

Nurse practitioners (NPs) are increasingly important in healthcare as they play a key role in leading advanced nursing practices. Assessing their professional competence is essential. The aim of this study was to evaluate NPs' professional competencies based on at a collaborative model around NP self and compare different methods of assessment.

METHODS

This is a cross-sectional study, and a purposive sample of 211 participants in the teaching hospital was used. Methods used were self-assessment (nurse practitioners), peer assessment (physicians and nurses) and supervisor assessment (head nurses).

RESULTS

The competence of nurse practitioners was rated as moderate (mean score = 3.45 of a possible 5; SD = 0.59). However, each method resulted in differences in competence for total scores and dimensions. The highest competence was in direct patient care (mean = 3.55, SD = 0.53), and the lowest score was in monitoring the quality of patient care (mean = 3.30, SD = 0.82). post hoc analysis shown that supervisor assessment rated professional competence significantly lower than the method of self-assessment and peer assessment (F = 10.07, p < .001).

CONCLUSION

NPs require an increased effort to continuous learning for enhancing professional competencies. Moreover, using multiple methods for assessment to obtain a more comprehensive and accurate evaluation of NPs' professional competence.

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.

Does Telemedicine Reduce Emergency Room Congestion? Evidence from New York State

Overcrowding in emergency rooms (ERs) is a common yet nagging problem. It not only is costly for hospitals but also compromises care quality and patient experience. Our paper provides solid evidence that telemedicine can significantly improve ER care delivery, especially in the presence of demand and supply fluctuations. We believe such findings are critical for ERs, due to the special setting of unscheduled arrivals leading to high unpredictability of patient traffic. Additional evidence suggests that the efficiency gained from telemedicine does not come at the expense of lower care quality or higher medical expenditure, which points to telemedicine as a feasible solution to the ER overcrowding problem. For healthcare practitioners, our paper highlights the general applicability of telemedicine through the “hub and spoke” architecture. Besides increasing patients’ access to more immediate care from specialists who were not available otherwise, telemedicine enables flexible resource allocation for any hospitals, regardless of where hospitals are located. Our research also provides ground for policymakers to incentivize hospitals to adopt telemedicine in ER, which we believe is critical given the relatively low adoption rate, the lack of direct evidence on its effectiveness, and the current inflexibility of reimbursement policies regarding the application of ER telemedicine.

Differences in patient population and service provision between nurse practitioner and general practitioner consultations in Swiss primary care: a case study

Background

Primary care systems around the world have implemented nurse practitioners (NPs) to ensure access to high quality care in times of general practitioner (GP) shortages and changing health care needs of a multimorbid, ageing population. In Switzerland, NPs are currently being introduced, and their exact role is yet to be determined. The aim of this study was to get insight into patient characteristics and services provided in NP consultations compared to GP consultations in Swiss primary care.

Methods

This case study used retrospective observational data from electronic medical records of a family practice with one NP and two GPs. Data on patient-provider encounters were collected between August 2017 and December 2018. We used logistic regression to assess associations between the assignment of the patients to the NP or GP and patient characteristics and delivered services respectively.

Results

Data from 5210 patients participating in 27,811 consultations were analyzed. The average patient age was 44.3 years (SD 22.6), 47.1% of the patients were female and 19.4% multimorbid. 1613 (5.8%) consultations were with the NP, and 26,198 (94.2%) with the two GPs. Patients in NP consultations were more often aged 85+ (OR 3.43; 95%-CI 2.70–4.36), multimorbid (OR 1.37; 95%-CI 1.24–1.51; p < 0.001) and polypharmaceutical (OR 1.28; 95%-CI 1.15–1.42; p < 0.001) in comparison to GP consultations. In NP consultations, vital signs (OR 3.05; 95%-CI 2.72–3.42; p < 0.001) and anthropometric data (OR 1.33; 95%-CI 1.09–1.63; p 0.005) were measured more frequently, and lab tests (OR 1.16; 95%-CI 1.04–1.30; p 0.008) were ordered more often compared to GP consultations, independent of patient characteristics. By contrast, medications (OR 0.35; 95%-CI 0.30–0.41; p < 0.001) were prescribed or changed less frequently in NP consultations.

Conclusions

Quantitative data from pilot projects provide valuable insights into NP tasks and activities in Swiss primary care. Our results provide first indications that NPs might have a focus on and could offer care to the growing number of multimorbid, polypharmaceutical elderly in Swiss primary care.

The outcomes of nurse practitioner (NP)-Provided home visits: A systematic review

Background

With the shortage of primary care providers to provide home-based care to the growing number of homebound older adults in the U.S. Nurse Practitioners (NPs) are increasingly utilized to meet the growing demand for home-based care and are now the largest type of primary care providers delivering home-visits.

Purpose

The purpose of this study was to systematically examine the current state of the evidence on health and healthcare utilization outcomes associated with NP-home visits.

Method

Five Databases (PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature and the Cochrane Library) were systematically searched to identify studies examining NP-home visits. The search focused on English language studies that were published before April 2019 and sought to describe the outcomes associated with NP-home visits. We included experimental and observational studies.  Quality appraisal was performed with the Kmet, Lee & Cook tool, and results summarized qualitatively. The impact of NP-home visits on clinical (functional status, quality of life [QOL]), and healthcare utilization (hospitalization, Emergency department(ED) visits) outcomes was evaluated.

Results/Discussion

A total of 566 citations were identified; 7 met eligibility criteria and were included in the review. The most commonly reported outcomes were emergency department (ED) visits and readmissions. Given the limited number of articles generated by our search and wide variation in intervention and outcomes measures. NP-home visits were associated with reductions in ED visits in 2 out of 3 studies and with reduction in readmissions in 2 out of 4 studies.

Conclusion

Published studies evaluating the outcomes associated with NP-home visits are limited and of mixed quality. Limitations include small sample size, and variation in duration and frequency of NP-home visits. Future studies should investigate the independent effect of NP-home visits on the health outcomes of older adults using large and nationally representative data with more rigorous study design.

Nurse Practitioner Involvement in Medicare Accountable Care Organizations: Association With Quality of Care

The objective was to examine trend and care quality outcomes associated with nurse practitioner (NP) involvement in Accountable Care Organizations (ACOs) via a cross-sectional study of 521 Medicare Shared Savings Program ACOs during 2014 to 2016. Data include ACO provider/beneficiary files, Medicare claims, and ACO performance data with a focus on Medicare beneficiaries with diabetes, chronic obstructive pulmonary disease, or heart failure. ACO care quality measures were stratified by NP involvement and adjusted for patient, provider, and ACO factors. NP involvement was highest in larger ACOs, states that allow NPs full scope of practice, and rural areas. Greater involvement was associated with fewer readmissions and higher scores on measures of preventive care but not chronic disease and medication management. Greater NP involvement in ACOs was associated with improvement in some care quality measures. With NPs' increasing involvement in ACOs, more research is needed to understand the NP role in processes and outcomes of care.

Examining variable nurse practitioner independence across jurisdictions: A case study of the United States

BACKGROUND

Nurse Practitioners have the potential to reduce primary care shortages for underserved populations. Yet, scopes of practice in some political jurisdictions (e.g. states, provinces) are more restrictive than others, and prevent Nurse Practitioners from working to the full extent of their training. The research is limited as to which intrastate or interstate characteristics contribute to understanding why scope of practice differences exist.

OBJECTIVES

To estimate associations between intrastate/interstate characteristics and US state-level Nurse Practitioner Scope of Practice policy.

RESEARCH DESIGN

Retrospective study of state-level factors influencing Nurse Practitioner Scopes of Practice.

SUBJECTS

U.S. states from 2001 to 2015.

MEASURES

Our dependent variable is state-level Scope of Practice policy, indicating the extent to which Nurse Practitioners are autonomous in a state (Independent, Collaboration or Supervision). The intrastate characteristics that we include are numbers of Nurse Practitioners, Primary Care Physicians and rural hospitals per capita, state Board of Medicine governance and Nursing License Compact membership. We also measure the number of border-states that adopt specific policies in order to indicate the extent to which interstate characteristics influence focal states to adopt similar policies.

RESULTS

Among intrastate characteristics, we found that rural hospital concentrations (Odds Ratio=0.78; 95% Confidence Interval: 0.71-0.85) and Nursing License Compact membership (Odds Ratio=0.23; 95% Confidence Interval: 0.0-0.60) were associated with lower levels of restrictions, while Board of Medicine governance (Odds Ratio=27.36; 95% Confidence Interval: 5.75-130.20) was associated with increased levels of restrictions. Among interstate characteristics, higher numbers of border-states adopting Nursing License Compact membership (Odds Ratio=0.51; 95% Confidence Interval: 0.32-0.80) was associated with lower levels of restrictions.

CONCLUSIONS

Barriers to Nurse Practitioner independence are largely attributable to unfavorable governance arrangements and non-participation in reciprocal licensing networks. Achieving Nurse Practitioner independence will require cooperation between nursing, medicine and policy makers. We offer some suggestions as to where parties interested in seeing increased Nurse Practitioner independence should focus their efforts when attempting to remove restrictions on Nurse Practitioner practice.

Comparing quality of care in medical specialties between nurse practitioners and physicians

BACKGROUND

The American health care system is facing a growing health care provider shortage in primary and specialty care settings. Research has established that nurse practitioners (NPs) match or exceed their physician colleagues in providing quality care in primary care settings.

OBJECTIVE

This systematic review aimed to compare the quality of NP versus physician-led care in outpatient specialty care setting for clinical outcomes patient satisfaction.

DATA SOURCES

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guided the literature search (CINAHL, PubMed, and Cochrane Library) and interpretation of findings. Of the 228 articles that met the inclusion/exclusion criteria, 11 were selected for further review.

CONCLUSIONS

Studies were conducted from 1995 to 2016 across four countries and spanned 10 distinct medical specialties. As a whole, these studies demonstrated that NPs in specialty settings perform as well as physicians terms of clinical safety and positive patient outcomes. Nurse practitioners matched or exceeded their physician counterparts in patient education and satisfaction.

IMPLICATIONS FOR PRACTICE

Nurse practitioners are a feasible option for addressing specialty care shortages. Further research should investigate whether NPs and physicians are equally prepared to provide equivalent care immediately following their respective postbaccalaureate programs. If not, studies should explore specific training duration and elements NPs require to provide equivalent care.

A concept analysis of nurse practitioner autonomy

BACKGROUND

Nurse practitioner (NP) autonomy is often misunderstood and misconstrued. These misconceptions cause a confusing interplay of words that impedes advocating for policy change and ultimately hinders the profession.

OBJECTIVE

To develop a clear definition of NP autonomy to describe the professional role.

DATA SOURCES

Walker and Avant's method of concept analysis was used to undertake a concept analysis of NP autonomy. The terms used to search for possible uses and definitions of NP autonomy in electronic databases included NP, autonomy, and concept analysis. In addition, the websites for nursing organizations, Google, Google Scholar, and the Merriam-Webster dictionary were searched and included in this analysis. This search yielded 29 articles, consisting of literature reviews, meta-synthesis, position papers, and qualitative and quantitative studies.

CONCLUSIONS

Nurse practitioner autonomy should be defined as the NP's use of their experience, clinical judgment, and responsibility to practice without restriction in professional collaboration with other health care professionals. Autonomy allows NPs to practice to the maximum extent of their advanced education, participate in productive and voluntarily collaborations, and continue to positively influence health care discrepancies throughout the United States.

IMPLICATIONS FOR PRACTICE

This concept analysis provides a clear definition of NP autonomy. In addition, it explains the difference between the concepts of NP autonomy and full practice authority. Clear definitions of the concepts of NP autonomy and full practice authority will be beneficial in advocating and advancing policy on behalf of NPs.

Advanced practice nurses' and general practitioners' first experiences with introducing the advanced practice nurse role to Swiss primary care: a qualitative study

BACKGROUND

Primary care is facing a multimorbid, ageing population and a lack of general practitioners (GPs), especially in rural areas. In many countries, advanced practice nurses (APNs) may be a potential solution for these challenges. Switzerland, however, is in the early stages of APN role development with a handful of pilot projects that are unresearched. Our aim was to explore the experiences of APNs and GPs involved in introducing the APN role to Swiss primary care.

METHODS

We organised two focus group discussions with APNs (n = 9) engaged in primary care across German-speaking Switzerland and individual interviews with APNs (n = 2) and GPs (n = 4) from two pilot projects in remote areas. Data analysis followed an exploratory hybrid approach of thematic analysis and was guided by the PEPPA Plus framework.

RESULTS

The analysis resulted in five main themes: The participants considered themselves pioneers developing a new model in primary care, seeking to shape and improve future health care ((1) pioneering spirit). Both nurses and doctors agreed on the additional value of the APN role, a role seen as having more time for and a different approach to patient care, bringing higher quality of care and flexibility to the practice ((2) added value from the APN role). Participants also emphasized the importance of asking for advice when unsure about diagnostic steps or appropriate treatment ((3) awareness of limited knowledge and skills). The main barriers identified included the impression that Swiss doctors have little knowledge about nurses in advanced roles ((4) GP's lack of knowledge regarding the APN role), and that further regulations will be important to foster role clarity and accountability ((5) political and legal obstacles in introducing the APN role).

CONCLUSIONS

The early phase of introducing APNs to Swiss primary care is characterised by heterogeneous, small-scale projects of pioneering GPs and APNs recognising the added value and limits of APNs despite a lack of governance and knowledge regarding the APN role among GPs. Experiences gained from ongoing projects provide elements of good practice for political discussions and regulations.

Effectiveness of interprofessional oral health program for pediatric nurse practitioner students at Northeastern University, United States

Background

Interprofessional education (IPE) is an important part of the landscape of modern education. However, there is a significant deficiency of studies that evaluate IPE in dentistry. The aim of this article is to evaluate the effects of an oral health educational program on the dental knowledge, awareness, attitude, confidence, and behavior of pediatric nurse practitioner (PNP) students and to emphasize the importance of IPE for PNP.

Methods

First-year pediatric nurse practitioners from Northeastern University participated in an IPE oral health education seminal and practical session as a pilot study. Several tests were used to evaluate the effectiveness of the educational program. The post-test assessed the knowledge, awareness, attitude, confidence, and behavior of the students immediately after attending the lecture; again immediately after hands on experience; and finally at a follow-up approximately a month after attending the training module. The training module consists of prevention and anticipatory guidance; caries process and management; trauma and dental emergencies. Differences in score items were evaluated between 4 time points. Friedman’s, Wilcoxon signed-rank and McNemar’s tests were used to analyze the results.

Results

Knowledge score was determined based on the number of correct responses to seven questions, while awareness score was based on the median of eight questions. Fifteen confidence, attitude, and behavior questions were used. The total sample size was 16 students with a mean age 33.31 ± 7.52. The majority were females (87.5%). Significant improvement was seen in all subjects’ overall knowledge of oral health topics. The confidence, attitude, and behavior scores were differed by time of test (P < 0.01). It was the highest after post-test and the lowest in pre-test.

Conclusion

Our study suggests that introducing an Interprofessional education program for pediatric nurse practitioner students can provide them with adequate knowledge, awareness, confidence, and attitude regarding oral health issues. It also can help them in changing behavior, prevention and ongoing dental surveillance.

From education to practice: What we can learn about the workforce from a survey of new nurse practitioners

BACKGROUND AND PURPOSE

To understand the posttraining plans and job market for new nurse practitioners (NPs), a survey was conducted of new family NPs (FNPs) in 2017. The survey was also designed to test the logistics and feasibility of conducting such a survey on a national scale and the usefulness of data gathered.

METHODS

A descriptive, cross-sectional study was conducted through an online survey administered to a national sample of 159 FNPs who graduated from an accredited NP program.

CONCLUSIONS

Many new NPs are not willing or interested in moving out of their local community even if there are limited opportunities locally. There are high numbers of NPs going into private practice compared with community health or federally qualified health centers. Many new NPs have extensive previous work experience as registered nurses in hospitals; the career progression to NP shifts their work setting from inpatient to outpatient settings.

IMPLICATIONS FOR PRACTICE

Although the job market for new NPs is generally good, with the rapid increase in NP graduates combined with the unwillingness or inability of many new NPs to move, some areas may have surpluses of NPs and limited job opportunities for new NPs, whereas other areas may have shortages upcoming. The survey of new NP graduates is a useful tool to monitor the experience of new NPs and provides valuable information to NP programs and prospective students. Future research should ensure a representative sample of new graduate NPs to accurately reflect the experience of new NPs.

Pathways to Independent Primary Care Clinical Practice: How Tall Is the Shortest Giant?

Patients can be treated by a physician, a nurse practitioner (NP), or a physician assistant (PA) despite marked differences in the education and training for these three professions. This natural experiment allows examination of a critical question: What is the minimum education and training required to practice primary care? In other words, how tall is the shortest giant? State licensing requirements, not educational bodies, legislate minimum training. The current minimum is 6 years, which includes 27.5 weeks of supervised clinical experience (SCE), for NPs. In comparison, PAs train for 6 years with 45 weeks of SCE, and physicians for at least 8 years with 110 weeks of SCE. Initial, flawed studies show equivalent patient outcomes among the professions. If rigorous follow-up studies confirm equivalence, the content and length of medical education for primary care physicians should be reconsidered. Unmatched medical school graduates, with 7 years of training and 65 weeks of SCE, more than the required minimum for NPs, deserve to practice independently. So do PAs. If equivalence is not confirmed, the minimum requirements for NPs and/or PAs should be raised, including considering a required residency (currently optional). Alternatively, the scope of practice for the three professions could be defined to reflect differences in training. There is an urgent need to set aside preconceived notions and turf battles, conduct rigorous independent studies, and generate meaningful data on practice patterns and patient outcomes. This should inform optimal training, scope of practice, and workforce development for each invaluable primary care clinical practitioner.

Just what the nurse practitioner ordered: Independent prescriptive authority and population mental health

We examine whether relaxing occupational licensing to allow nurse practitioners (NPs)-registered nurses with advanced degrees-to prescribe medication without physician oversight improves population mental health. Exploiting time-series variation in independent prescriptive authority for NPs from 1990 to 2014, we find that broadening prescriptive authority leads to improvements in self-reported mental health and decreases in mental health-related mortality. These improvements are concentrated in areas that are underserved by physicians and among populations that have difficulty accessing physician-provided care. Our results demonstrate that extending independent prescriptive authority to NPs can help mitigate physician shortages and extend care to disadvantaged populations.

Primary Care Appointments for Medicaid Beneficiaries With Advanced Practitioners

Primary care access in Medicaid improved after the Patient Protection and Affordable Care Act despite millions of new beneficiaries. One possible explanation is that practices are scheduling more appointments with advanced practitioners. To test this theory, we used data from a secret shopper study in which callers simulated new Medicaid patients and requested appointments with 3,742 randomly selected primary care practices in 10 states. Conditional on scheduling an appointment, simulated patients asked whether the practitioner was a physician or advanced practitioner. From 2012 through 2016, the proportion of appointments scheduled with advanced practitioners increased from 7.7% to 12.9% (P <.001) across the 10 states.

Specializing Nurses as An Indirect Education Program for Stoma Patients

Education programs are beneficial for patients with different chronic conditions. Prior studies have examined direct education, where information is transferred directly to patients. In contrast, in this program, information is transferred directly to nurses who become specialists and transfer education individually to patients. Hence, this paper evaluates the impact of having specialist nurses for stoma patients at hospitals, as those nurses provide healthcare to patients but also inform and educate patients about their condition and needs. The analysis uses an observational study with ostomized patients in Spain at hospitals with and without specialist nurses, and measures health service utilization and health-related quality of life (HRQL), besides performing a cost analysis and a cost-effectiveness analysis at both types of hospitals. The results show that patients with access to specialist nurses self-manage better, present lower adverse events and a better evolution of HRQL, and significantly demand more consultations with specialist nurses and less to A&E, primary care or specialists, resulting in important savings for the health system. Consequently, specializing or hiring nurses to provide indirect education to stoma patients is cost-effective and highly beneficial for patients. This type of indirect education strategy might be considered for specific conditions with low incidence or difficulties in identifying target patients or delivering information directly to them.