1
|
Grundy Q, Rudner N, Klein T, Ladd E, Hart D, MacIsaac M, Bero L. "I never thought of it as payment": Qualitative evaluation of workshops with advanced practice registered nurses on pharmaceutical industry payment reporting. J Am Assoc Nurse Pract 2024:01741002-990000000-00254. [PMID: 39392645 DOI: 10.1097/jxx.0000000000001077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 09/10/2024] [Indexed: 10/12/2024]
Abstract
BACKGROUND With the expansion of professional autonomy and prescriptive authority of advanced practice registered nurses (APRNs), interactions with industry are under greater scrutiny. As of July 1, 2021, pharmaceutical and medical device companies must publicly report all payments to APRNs through the Centers for Medicare and Medicaid Services' Open Payments website. PURPOSE To gauge APRNs' familiarity with, and perceptions of the Open Payments database and discuss whether and how APRNs should respond. METHODOLOGY Virtual workshops consisting of a didactic presentation and interactive exercises with APRNs recruited through professional networks, associations, and conferences. Transcripts were analyzed using a qualitative interpretive approach, grounded in an everyday ethics theoretical framework. RESULTS Thirty-six APRN clinicians, students, and faculty participated in nine workshops. Seeing sponsored meals reported in Open Payments as "payments" prompted participants to see familiar interactions in a new way. Participants valued the enhanced transparency as a way to identify risks of bias but were concerned that reporting might undermine public trust in APRNs. Emphasizing awareness as a precursor to action, participants desired greater preparation for ensuring independence in practice. CONCLUSIONS The importance of tackling the ethical issues associated with industry interactions is heightened within the context of an existing climate of distrust within health care. However, many participants were concerned about the effects of transparency on public trust rather than how APRNs individually or collectively can be more trustworthy. IMPLICATIONS Open Payments can serve as a useful tool to catalyze broader conversations about ethics, integrity in decision making, and health policy advocacy.
Collapse
Affiliation(s)
- Quinn Grundy
- Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Nancy Rudner
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama
| | - Tracy Klein
- College of Nursing, Washington State University, Vancouver, Washington
| | - Elissa Ladd
- School of Nursing, MGH Institute of Health Professions, Boston, Massachusetts
| | - Dana Hart
- Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Meghan MacIsaac
- Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Lisa Bero
- Center for Bioethics and Humanities, University of Colorado School of Medicine, Aurora, Colorado
| |
Collapse
|
2
|
Kilpatrick K, Savard I, Audet LA, Costanzo G, Khan M, Atallah R, Jabbour M, Zhou W, Wheeler K, Ladd E, Gray DC, Henderson C, Spies LA, McGrath H, Rogers M. A global perspective of advanced practice nursing research: A review of systematic reviews. PLoS One 2024; 19:e0305008. [PMID: 38954675 PMCID: PMC11218965 DOI: 10.1371/journal.pone.0305008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 05/21/2024] [Indexed: 07/04/2024] Open
Abstract
INTRODUCTION The World Health Organization (WHO) called for the expansion of all nursing roles, including advanced practice nurses (APNs), nurse practitioners (NPs) and clinical nurse specialists (CNSs). A clearer understanding of the impact of these roles will inform global priorities for advanced practice nursing education, research, and policy. OBJECTIVE To identify gaps in advanced practice nursing research globally. MATERIALS AND METHODS A review of systematic reviews was conducted. We searched CINAHL, Embase, Global Health, Healthstar, PubMed, Medline, Cochrane Library, DARE, Joanna Briggs Institute EBP, and Web of Science from January 2011 onwards, with no restrictions on jurisdiction or language. Grey literature and hand searches of reference lists were undertaken. Review quality was assessed using the Critical Appraisal Skills Program (CASP). Study selection, data extraction and CASP assessments were done independently by two reviewers. We extracted study characteristics, country and outcome data. Data were summarized using narrative synthesis. RESULTS We screened 5840 articles and retained 117 systematic reviews, representing 38 countries. Most CASP criteria were met. However, study selection by two reviewers was done inconsistently and language and geographical restrictions were applied. We found highly consistent evidence that APN, NP and CNS care was equal or superior to the comparator (e.g., physicians) for 29 indicator categories across a wide range of clinical settings, patient populations and acuity levels. Mixed findings were noted for quality of life, consultations, costs, emergency room visits, and health care service delivery where some studies favoured the control groups. No indicator consistently favoured the control group. There is emerging research related to Artificial Intelligence (AI). CONCLUSION There is a large body of advanced practice nursing research globally, but several WHO regions are underrepresented. Identified research gaps include AI, interprofessional team functioning, workload, and patients and families as partners in healthcare. PROSPERO REGISTRATION NUMBER CRD42021278532.
Collapse
Affiliation(s)
- Kelley Kilpatrick
- Susan E. French Chair in Nursing Research and Innovative Practice, Ingram School of Nursing, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada
- Centre Intégré Universitaire de Santé et de Services sociaux de l’Est-de-l’Île-de-Montréal (CIUSSS-EMTL), Montréal, Québec, Canada
| | - Isabelle Savard
- Ingram School of Nursing, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada
| | - Li-Anne Audet
- Ingram School of Nursing, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada
| | - Gina Costanzo
- Ingram School of Nursing, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada
| | - Mariam Khan
- Ingram School of Nursing, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada
| | - Renée Atallah
- Ingram School of Nursing, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada
| | - Mira Jabbour
- Centre Intégré Universitaire de Santé et de Services sociaux de l’Est-de-l’Île-de-Montréal (CIUSSS-EMTL), Montréal, Québec, Canada
| | - Wentao Zhou
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore; National University Health System, Singapore, Singapore
- Singapore National Neuroscience Institute, Singapore, Singapore
| | - Kathy Wheeler
- College of Nursing, University of Kentucky, Lexington, Kentucky, United States of America
| | - Elissa Ladd
- MGH Institute of Health Professions, School of Nursing, Boston, Massachusetts, United States of America
| | - Deborah C. Gray
- School of Nursing, Old Dominion University, Virginia Beach, Virginia, United States of America
| | - Colette Henderson
- School of Health Sciences, University of Dundee, Dundee, Scotland, United States of America
| | - Lori A. Spies
- Louise Herrington School of Nursing, Baylor University, Dallas, Texas, United States of America
| | - Heather McGrath
- St James Public Health Services, Montego Bay, St James, Jamaica
| | - Melanie Rogers
- Department of Nursing and Midwifery, University of Huddersfield, Queensgate, Huddersfield, United Kingdom
| |
Collapse
|
3
|
De Rosis C, Duconget L, Jovic L, Bourmaud A, Dumas A. The deployment of advanced practice nurses in the French health system: From clinics to professional networks. Int Nurs Rev 2024; 71:362-374. [PMID: 38197737 DOI: 10.1111/inr.12926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 12/13/2023] [Indexed: 01/11/2024]
Abstract
AIM The aim of this study is to contribute to an understanding of the role deployment of advanced practice nurses (APNs) in French healthcare settings. INTRODUCTION The introduction of APNs was formalised in France by the decrees issued on 18 July 2018, which described the areas, activities and training of APNs. BACKGROUND A qualitative study on the role implementation of APNs was conducted between July 2021 and May 2022 following a call for projects launched by the Île-de-France Regional Health Agency to evaluate the deployment of APNs in the area. METHODS Data were collected through field observations and semi-structured interviews in order to explore both the APNs deployment processes in nine healthcare structures and the roles played by APN networks and associations with regard to the deployment of APN activities in their working environments. RESULTS The projects proved to be evolutionary, and their development was marked by various forms of APN isolation and multiple obstacles that were specific to their professional practice settings. Some APNs relied on a variety of forms of mutual assistance and advocacy deployed throughout APN networks and associations. DISCUSSION The deployment of APNs' role was impacted by diverse configurations of professional power relations and the nature of the obstacles that were structural for APNs in primary care. Their experience of isolation derived from the novelty of their role, the challenge they posed to the cohesion of the nursing profession and a lack of supportive policies for their deployment. Their participation in APN networks and associations enabled them to access advocacy and manage the uncertainties and unknowns related to the deployment of their activities. CONCLUSION The results suggest that the formalisation of schemes for mutual assistance among APNs and advocacy should be integrated into the guidelines for the implementation of their role. IMPLICATIONS FOR NURSING POLICY APN policy should strengthen a bottom-up approach, relying in particular on the development of different forms of collaboration and communication between APN networks and associations on the one hand and the public authorities on the other.
Collapse
Affiliation(s)
- Carolina De Rosis
- University of Paris - INSERM ECEVE UMR1123; Université Paris Cité, Inserm, ECEVE, Paris, France
| | - Lisa Duconget
- University of Paris - INSERM ECEVE UMR1123; Université Paris Cité, Inserm, ECEVE, Paris, France
| | - Ljiljana Jovic
- Affiliated Member of the University of Paris - INSERM ECEVE UMR1123; Université Paris Cité, Inserm, ECEVE, Paris, France
| | - Aurélie Bourmaud
- Affiliated Member of the University of Paris - INSERM ECEVE UMR1123; Université Paris Cité, Inserm, ECEVE, Paris, France
- Unité d'Épidémiologie Clinique INSERM CIC 1426 Hôpital Robert Debré, Paris, France
| | - Agnès Dumas
- University of Paris - INSERM ECEVE UMR1123; Université Paris Cité, Inserm, ECEVE, Paris, France
| |
Collapse
|
4
|
Luo Q, Park YH, Chen C, Petterson S. Health care provider movement increased through COVID-19. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae065. [PMID: 38841718 PMCID: PMC11152201 DOI: 10.1093/haschl/qxae065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/29/2024] [Accepted: 05/14/2024] [Indexed: 06/07/2024]
Abstract
COVID-19 placed unprecedented strain on the health workforce, raising concerns of increasing worker turnover and attrition. This study explores the use of 2 publicly available Medicare datasets-Provider Enrollment, Chain, and Ownership System (PECOS) and Doctors and Clinicians-to track provider movement across states and organizations from 2017 to 2023. We found an increase in state-to-state movement of providers post-COVID-19, with an initial spike in physician movement in the first year (April 2020 to March 2021). Movement varied across specialties and professions. Between organizations, we saw an initial increase in movement for family physicians but not internal medicine physicians. Overall, provider movement was generally to larger organizations. Our study finds increasing movement of providers in the post-COVID-19 period through the novel use of 2 publicly available Medicare datasets. Tracking health care workforce movement closer to real time is important to understand a changing workforce-with differences across communities-and to guide policies to ensure sufficient workforce and prevent worsening disparities over time.
Collapse
Affiliation(s)
- Qian Luo
- Department of Health Policy and Management, Fitzhugh Mullan Institute for Health Workforce Equity, Milken Institute School of Public Health, George Washington University, Washington, DC 20037, United States
| | - Yoon Hong Park
- Department of Health Policy and Management, Fitzhugh Mullan Institute for Health Workforce Equity, Milken Institute School of Public Health, George Washington University, Washington, DC 20037, United States
| | - Candice Chen
- Department of Health Policy and Management, Fitzhugh Mullan Institute for Health Workforce Equity, Milken Institute School of Public Health, George Washington University, Washington, DC 20037, United States
| | - Stephen Petterson
- Department of Health Policy and Management, Fitzhugh Mullan Institute for Health Workforce Equity, Milken Institute School of Public Health, George Washington University, Washington, DC 20037, United States
| |
Collapse
|
5
|
Elvidge N, Hobbs M, Fox A, Currie J, Williams S, Theobald K, Rolfe M, Marshall C, Phillips JL. Practice pathways, education, and regulation influencing nurse practitioners' decision to provide primary care: a rapid scoping review. BMC PRIMARY CARE 2024; 25:182. [PMID: 38783189 PMCID: PMC11112961 DOI: 10.1186/s12875-024-02350-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/25/2024] [Indexed: 05/25/2024]
Abstract
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.
Collapse
Affiliation(s)
- Norah Elvidge
- Cancer and Palliative Care Outcomes Centre, School of Nursing, Queensland University of Technology, Brisbane, Australia
- School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Megan Hobbs
- Cancer and Palliative Care Outcomes Centre, School of Nursing, Queensland University of Technology, Brisbane, Australia
- School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Amanda Fox
- School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, Australia
- Metro North Health, Redcliffe Hospital, Redcliffe, Australia
| | - Jane Currie
- School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Suzanne Williams
- School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, Australia
- Children's Health Queensland Hospital and Health Service, Brisbane, Australia
| | - Karen Theobald
- School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Melanie Rolfe
- Cancer and Palliative Care Outcomes Centre, School of Nursing, Queensland University of Technology, Brisbane, Australia
- School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Claire Marshall
- Improving Palliative Care Through Clinical Trials (ImPaCCT), Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Jane L Phillips
- Cancer and Palliative Care Outcomes Centre, School of Nursing, Queensland University of Technology, Brisbane, Australia.
- School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, Australia.
- Improving Palliative Care Through Clinical Trials (ImPaCCT), Faculty of Health, University of Technology Sydney, Sydney, Australia.
| |
Collapse
|
6
|
Kosar CM, Thapa BB, Muench U, Santostefano C, Gadbois EA, Oh H, Gozalo PL, Rahman M, White EM. Nurse Practitioner Care, Scope of Practice, and End-of-Life Outcomes for Nursing Home Residents With Dementia. JAMA HEALTH FORUM 2024; 5:e240825. [PMID: 38728021 PMCID: PMC11087831 DOI: 10.1001/jamahealthforum.2024.0825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 03/07/2024] [Indexed: 05/13/2024] Open
Abstract
Importance Nursing home residents with Alzheimer disease and related dementias (ADRD) often receive burdensome care at the end of life. Nurse practitioners (NPs) provide an increasing share of primary care in nursing homes, but how NP care is associated with end-of-life outcomes for this population is unknown. Objectives To examine the association of NP care with end-of-life outcomes for nursing home residents with ADRD and assess whether these associations differ according to state-level NP scope of practice regulations. Design, Setting, and Participants This cohort study using fee-for-service Medicare claims included 334 618 US nursing home residents with ADRD who died between January 1, 2016, and December 31, 2018. Data were analyzed from April 6, 2015, to December 31, 2018. Exposures Share of nursing home primary care visits by NPs, classified as minimal (<10% of visits), moderate (10%-50% of visits), and extensive (>50% of visits). State NP scope of practice regulations were classified as full vs restrictive in 2 domains: practice authority (authorization to practice and prescribe independently) and do-not-resuscitate (DNR) authority (authorization to sign DNR orders). Main Outcomes and Measures Hospitalization within the last 30 days of life and death with hospice. Linear probability models with hospital referral region fixed effects controlling for resident characteristics, visit volume, and geographic factors were used to estimate whether the associations between NP care and outcomes varied across states with different scope of practice regulations. Results Among 334 618 nursing home decedents (mean [SD] age at death, 86.6 [8.2] years; 69.3% female), 40.5% received minimal NP care, 21.4% received moderate NP care, and 38.0% received extensive NP care. Adjusted hospitalization rates were lower for residents with extensive NP care (31.6% [95% CI, 31.4%-31.9%]) vs minimal NP care (32.3% [95% CI, 32.1%-32.6%]), whereas adjusted hospice rates were higher for residents with extensive (55.6% [95% CI, 55.3%-55.9%]) vs minimal (53.6% [95% CI, 53.3%-53.8%]) NP care. However, there was significant variation by state scope of practice. For example, in full practice authority states, adjusted hospice rates were 2.88 percentage points higher (95% CI, 1.99-3.77; P < .001) for residents with extensive vs minimal NP care, but the difference between these same groups was 1.77 percentage points (95% CI, 1.32-2.23; P < .001) in restricted practice states. Hospitalization rates were 1.76 percentage points lower (95% CI, -2.52 to -1.00; P < .001) for decedents with extensive vs minimal NP care in full practice authority states, but the difference between these same groups in restricted practice states was only 0.43 percentage points (95% CI, -0.84 to -0.01; P < .04). Similar patterns were observed in analyses focused on DNR authority. Conclusions and Relevance The findings of this cohort study suggest that NPs appear to be important care providers during the end-of-life period for many nursing home residents with ADRD and that regulations governing NP scope of practice may have implications for end-of-life hospitalizations and hospice use in this population.
Collapse
Affiliation(s)
- Cyrus M. Kosar
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Bishnu B. Thapa
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Ulrike Muench
- Department of Social Behavioral Sciences, University of California at San Francisco School of Nursing, San Francisco
| | - Christopher Santostefano
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Emily A. Gadbois
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Hyesung Oh
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Pedro L. Gozalo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Momotazur Rahman
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Elizabeth M. White
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| |
Collapse
|
7
|
Jounaidi K, Hamdoune M, Daoudi K, Barka N, Gantare A. Advancing Palliative Care through Advanced Nursing Practice: A Rapid Review. Indian J Palliat Care 2024; 30:155-162. [PMID: 38846131 PMCID: PMC11152512 DOI: 10.25259/ijpc_308_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 02/09/2024] [Indexed: 06/09/2024] Open
Abstract
Objectives This study addresses the growing demand for palliative care (PC) by exploring the role of advanced nursing practice (ANP) within the multidisciplinary team. The purpose is to outline the background of ANP in PC, its interest, training needs, and some recommendations for its establishment in the Moroccan healthcare system. Materials and Methods A rapid review of relevant studies was carried out through databases following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards, edition (2020). The inclusion criteria focussed on studies published within the nursing domain between 2012 and 2022, with a preference for the English language. Results Study selection allowed to obtain eight relevant studies. The studies agreed that ANP improves the quality of care provided. It has a major role to play in the multidisciplinary team by mobilising all the knowledge required to offer a complete range of care for patients with needs. Nevertheless, its implementation is fraught with challenges. Conclusion ANP will be able to address the complexity of patient and family needs and serve as cost-effective medical care coordinators for patients and families with both chronic and life-limiting illnesses, to reduce suffering and improve the quality of living and dying across the lifespan. Advanced practice nurses execute assigned authorisations by mobilising the knowledge acquired through university training. The establishment of this cadre in the healthcare system is subject to many challenges that Morocco must anticipate.
Collapse
Affiliation(s)
- Khaoula Jounaidi
- Hassan First University of Settat, Higher Institute of Health Sciences, Laboratory of Health Sciences and Technologies, Settat, Morocco
| | - Meryem Hamdoune
- Hassan First University of Settat, Higher Institute of Health Sciences, Laboratory of Health Sciences and Technologies, Settat, Morocco
| | - Khadija Daoudi
- Hassan First University of Settat, Higher Institute of Health Sciences, Laboratory of Health Sciences and Technologies, Settat, Morocco
| | - Najwa Barka
- Hassan First University of Settat, Higher Institute of Health Sciences, Laboratory of Health Sciences and Technologies, Settat, Morocco
| | - Abdellah Gantare
- Hassan First University of Settat, Higher Institute of Health Sciences, Laboratory of Health Sciences and Technologies, Settat, Morocco
| |
Collapse
|
8
|
Endalamaw A, Khatri RB, Erku D, Zewdie A, Wolka E, Nigatu F, Assefa Y. Barriers and strategies for primary health care workforce development: synthesis of evidence. BMC PRIMARY CARE 2024; 25:99. [PMID: 38539068 PMCID: PMC10967164 DOI: 10.1186/s12875-024-02336-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 03/11/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Having a sufficient and well-functioning health workforce is crucial for reducing the burden of disease and premature death. Health workforce development, focusing on availability, recruitment, retention, and education, is inseparable from acceptability, motivation, burnout, role and responsibility, and performance. Each aspect of workforce development may face several challenges, requiring specific strategies. However, there was little evidence on barriers and strategies towards comprehensive health workforce development. Therefore, this review explored barriers and strategies for health workforce development at the primary health care level around the world. METHODS A scoping review of reviews was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews. The article search was performed in Google Scholar, PubMed, Web of Science, and EMBASE. We used EndNote x9 for managing the collected articles, screening processes, and citation purpose. The scoping review included any kind of review articles on the application of health workforce development concepts, such as availability, recruitment, retention, role and responsibility, education and training, motivation, and burnout, with primary health care and published in English anywhere in the world. Based on the concepts above, barriers and strategies for health workforce development were identified. The findings were synthesized qualitatively based on the building blocks of the health system framework. The analysis involved specific activities such as familiarization, construction of the thematic framework, indexing, charting, and interpretation. The results were presented in texts, tables, and figures. RESULTS The search strategies yielded 7,276 papers were found. Of which, 69 were included in the scoping review. The most frequently cited barriers were financial challenges and issues related to health care delivery, such as workloads. Barriers affecting healthcare providers directly, including lack of training and ineffective teamwork, were also prominent. Other health system and governance barriers include lack of support, unclear responsibility, and inequity. Another notable barrier was the shortage of health care technology, which pertains to both health care supplies and information technology. The most common cited effective strategies were ongoing support and supervision, engaging with communities, establishing appropriate primary care settings, financial incentives, fostering teamwork, and promoting autonomous health care practice. CONCLUSIONS Effective leadership/governance, a robust health financing system, integration of health information and technology, such as mobile health and ensuring a consistent supply of adequate resources are also vital components of primary health care workforce development. The findings highlight the importance of continuous professional development, which includes training new cadres, implementing effective recruitment and retention mechanisms, optimising the skill mix, and promoting workplace wellness. These elements are essential in fostering a well-trained and resilient primary health care workforce.
Collapse
Affiliation(s)
- Aklilu Endalamaw
- School of Public Health, The University of Queensland, Brisbane, Australia.
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia.
| | - Resham B Khatri
- School of Public Health, The University of Queensland, Brisbane, Australia
- Health Social Science and Development Research Institute, Kathmandu, Nepal
| | - Daniel Erku
- School of Public Health, The University of Queensland, Brisbane, Australia
- Centre for Applied Health Economics, School of Medicine, Griffith University, Brisbane, Australia
| | - Anteneh Zewdie
- International Institute for Primary Health Care in Ethiopia, Addis Ababa, Ethiopia
| | - Eskinder Wolka
- International Institute for Primary Health Care in Ethiopia, Addis Ababa, Ethiopia
| | - Frehiwot Nigatu
- International Institute for Primary Health Care in Ethiopia, Addis Ababa, Ethiopia
| | - Yibeltal Assefa
- School of Public Health, The University of Queensland, Brisbane, Australia
| |
Collapse
|
9
|
Ryskina KL, Liang J, Ritter AZ, Spetz J, Barnes H. State scope of practice restrictions and nurse practitioner practice in nursing homes: 2012-2019. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae018. [PMID: 38426081 PMCID: PMC10901290 DOI: 10.1093/haschl/qxae018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 01/26/2024] [Accepted: 02/11/2024] [Indexed: 03/02/2024]
Abstract
Increased engagement of nurse practitioners (NPs) has been recommended as a way to address care delivery challenges in settings that struggle to attract physicians, such as primary care and rural areas. Nursing homes also face such physician shortages. We evaluated the role of state scope of practice regulations on NP practice in nursing homes in 2012-2019. Using linear probability models, we estimated the proportion of NP-delivered visits to patients in nursing homes as a function of state scope of practice regulations. Control variables included county demographic, socioeconomic, and health care workforce characteristics; state fixed effects; and year indicators. The proportion of nursing home visits conducted by NPs increased from 24% in 2012 to 42% in 2019. Expanded scope of practice regulation was associated with a greater proportion and total volume of nursing home visits conducted by NPs in counties with at least 1 NP visit. These relationships were concentrated among short-stay patients in urban counties. Removing scope of practice restrictions on NPs may address clinician shortages in nursing homes in urban areas where NPs already practice in nursing homes. However, improving access to advanced clinician care for long-term care residents and for patients in rural locations may require additional interventions and resources.
Collapse
Affiliation(s)
- Kira L Ryskina
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Junning Liang
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Ashley Z Ritter
- NewCourtland, Philadelphia, PA 19119, United States
- School of Nursing, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Joanne Spetz
- School of Medicine, Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA 94158, United States
| | - Hilary Barnes
- Widener University School of Nursing, Chester, PA 19013, United States
| |
Collapse
|
10
|
Bae K, Norris C, Shakya S, Timmons E. Advanced Practice Registered Nurse Full Practice Authority, Provider Supply, and Health Outcomes: A Border Analysis. Policy Polit Nurs Pract 2024; 25:6-13. [PMID: 38116640 DOI: 10.1177/15271544231212155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
Due to a growing physician shortage, patients have difficulty accessing primary care. In an effort to expand access and support patient health, many states are reducing barriers for advanced practice registered nurses to provide primary care without physician collaboration. Maryland provides an interesting case study. We leverage Maryland's policy change to explore the effects of full practice authority (FPA), focusing on the number of professionals and health outcomes for patients. Employing a border county comparison between Maryland and Pennsylvania, we estimate the effect of FPA. Our analysis of health outcomes focuses on three county-level health outcomes: poor or fair health, poor mental health days, and preventable hospital stays. We find that FPA is associated with increases in the number of certified nurse midwives by 0.6 per 100,000 residents and nurse practitioners by 22.4 per 100,000 residents. We also find evidence of an association of FPA with reductions in the share of residents who report being in poor or fair health by 2.8 percentage points and poor mental health days per month by 0.354 days per person. Combined, our results provide suggestive evidence that moving to FPA improves access to care and leads to improved health outcomes for Maryland residents. Removing regulatory barriers that prevent certified nurse midwives and nurse practitioners from working to the full extent of their training may increase access to primary care and improve patient outcomes.
Collapse
Affiliation(s)
- Kihwan Bae
- The Knee Center for the Study of Occupational Regulation, Morgantown, WV, USA
- West Virginia University, Morgantown, WV, USA
| | - Conor Norris
- The Knee Center for the Study of Occupational Regulation, Morgantown, WV, USA
| | - Shishir Shakya
- Shippensburg University of Pennsylvania, Shippensburg, PA, USA
| | - Edward Timmons
- The Knee Center for the Study of Occupational Regulation, Morgantown, WV, USA
- West Virginia University, Morgantown, WV, USA
| |
Collapse
|
11
|
Turi E, McMenamin AL, Martsolf G, Hasin D, Han BH, Liu J, Poghosyan L. Primary care nurse practitioner work environments and emergency department utilization among older adults with substance use disorders in rural areas. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 157:209285. [PMID: 38159910 PMCID: PMC10922346 DOI: 10.1016/j.josat.2023.209285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 12/01/2023] [Accepted: 12/20/2023] [Indexed: 01/03/2024]
Abstract
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.
Collapse
Affiliation(s)
- Eleanor Turi
- University of Pennsylvania Perelman School of Medicine, 423 Guardian Drive, Philadelphia, PA 19104, United States of America.
| | - Amy L McMenamin
- Columbia University School of Nursing, 560 West 168th Street, New York, NY 10032, United States of America
| | - Grant Martsolf
- University of Pittsburgh School of Nursing, 3500 Victoria Street, Pittsburgh, PA 15213, United States of America
| | - Deborah Hasin
- Columbia University Department of Psychiatry, 1051 Riverside Drive, New York, NY 10032, United States of America; Columbia University Mailman School of Public Health; 722 West 168th Street, New York, NY 10032, United States of America
| | - Benjamin H Han
- University of California San Diego Department of Medicine, 9500 Gilman Drive, La Jolla, CA 92093, United States of America
| | - Jianfang Liu
- Columbia University School of Nursing, 560 West 168th Street, New York, NY 10032, United States of America
| | - Lusine Poghosyan
- Columbia University School of Nursing, 560 West 168th Street, New York, NY 10032, United States of America; Columbia University Mailman School of Public Health; 722 West 168th Street, New York, NY 10032, United States of America
| |
Collapse
|
12
|
Candon M, Bergman A, Rose A, Song H, David G, Spetz J. The Relationship Between Scope of Practice Laws for Task Delegation and Nurse Turnover in Home Health. J Am Med Dir Assoc 2023; 24:1773-1778.e2. [PMID: 37634547 PMCID: PMC10735229 DOI: 10.1016/j.jamda.2023.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/24/2023] [Accepted: 07/26/2023] [Indexed: 08/29/2023]
Abstract
OBJECTIVE Nurse turnover can compromise the quality and continuity of home health care. Scope of practice laws, which determine the tasks nurses are allowed to perform and delegate, are an important element of autonomy and vary across states. In this study, we used human resource records from a multistate home health organization to examine the relationship between nurse turnover and whether nurses can delegate tasks to unlicensed aides. DESIGN A retrospective, cross-sectional analysis. SETTING AND PARTICIPANTS The study sample included 1820 licensed practical nurses and 3309 registered nurses, who spanned 30 states. The study period was 2016 through 2018. METHODS We used weighted least squares to study the relationship between nurse turnover for registered and licensed practical nurses and task delegation across state-years. We measured task delegation continuously (0-16 tasks) and as a binary variable (14 or more tasks, which indicated the state was in the top half of the distribution). RESULTS Across state-years, the turnover rate was 30.8% for licensed practical nurses and 36.8% for registered nurses. Although there was no significant relationship between task delegation and turnover among registered nurses, we found that states in which nurses could delegate the most tasks had lower turnover rates among licensed practical nurses. CONCLUSION AND IMPLICATIONS The ability to delegate tasks to unlicensed aides was correlated with lower turnover rates among licensed practical nurses, but not among registered nurses. This suggests that the ability to delegate tasks is more likely to affect the workload of licensed practical nurses. This also points to a potential and unexplored element of expanding the scope of practice for nurses: reduced turnover. Given the added work-related hazards associated with home health care, including working in isolation, a lack of social recognition, and inadequate reimbursement, states should consider whether changes in their policy environment could benefit nurses working in home health.
Collapse
Affiliation(s)
- Molly Candon
- Departments of Psychiatry and Health Care Management, Perelman School of Medicine and the Wharton School, University of Pennsylvania, Philadelphia, PA, USA.
| | - Alon Bergman
- Departments of Medical Ethics and Health Policy and Health Care Management, Perelman School of Medicine and the Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - Amber Rose
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA
| | - Hummy Song
- Department of Operations, Information, and Decisions, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - Guy David
- Departments of Medical Ethics and Health Policy and Health Care Management, Perelman School of Medicine and the Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - Joanne Spetz
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA
| |
Collapse
|
13
|
Huynh J, Alim SA, Chan DC, Studdert DM. Inappropriate Prescribing to Older Patients by Nurse Practitioners and Primary Care Physicians. Ann Intern Med 2023; 176:1448-1455. [PMID: 37871318 DOI: 10.7326/m23-0827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND Many U.S. states have legislated to allow nurse practitioners (NPs) to independently prescribe drugs. Critics contend that these moves will adversely affect quality of care. OBJECTIVE To compare rates of inappropriate prescribing among NPs and primary care physicians. DESIGN Rates of inappropriate prescribing were calculated and compared for 23 669 NPs and 50 060 primary care physicians who wrote prescriptions for 100 or more patients per year, with adjustment for practice experience, patient volume and risk, clinical setting, year, and state. SETTING 29 states that had granted NPs prescriptive authority by 2019. PATIENTS Medicare Part D beneficiaries aged 65 years or older in 2013 to 2019. MEASUREMENTS Inappropriate prescriptions, defined as drugs that typically should not be prescribed for adults aged 65 years or older, according to the American Geriatrics Society's Beers Criteria. RESULTS Mean rates of inappropriate prescribing by NPs and primary care physicians were virtually identical (adjusted odds ratio, 0.99 [95% CI, 0.97 to 1.01]; crude rates, 1.63 vs. 1.69 per 100 prescriptions; adjusted rates, 1.66 vs. 1.68). However, NPs were overrepresented among clinicians with the highest and lowest rates of inappropriate prescribing. For both types of practitioners, discrepancies in inappropriate prescribing rates across states tended to be larger than discrepancies between these practitioners within states. LIMITATION The Beers Criteria addresses the appropriateness of a selected subset of drugs and may not be valid in some clinical settings. CONCLUSION Nurse practitioners were no more likely than physicians to prescribe inappropriately to older patients. Broad efforts to improve the performance of all clinicians who prescribe may be more effective than limiting independent prescriptive authority to physicians. PRIMARY FUNDING SOURCE The Robert Wood Johnson Foundation and National Science Foundation.
Collapse
Affiliation(s)
- Johnny Huynh
- Department of Economics, University of California, Los Angeles, Los Angeles, California (J.H.)
| | - Sahil A Alim
- Yale Law School, New Haven, Connecticut (S.A.A.)
| | - David C Chan
- Department of Health Policy, Stanford University School of Medicine, Stanford, California (D.C.C.)
| | - David M Studdert
- Department of Health Policy, Stanford University School of Medicine, and Stanford Law School, Stanford, California (D.M.S.)
| |
Collapse
|
14
|
Tracy C, Russell NG, DePriest K, Knestrick J, D'Aoust R, Slade E. The impact of full practice authority on nurse practitioner compensation, collaboration, and billing. J Am Assoc Nurse Pract 2023; 35:691-698. [PMID: 37602876 DOI: 10.1097/jxx.0000000000000918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/01/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND Although there is a substantial body of evidence regarding full practice authority's (FPA) effects on health care access and quality, very little research has examined how nurse practitioner (NP) licensure laws affect the status of NPs as clinicians, employees, and leaders in health care organizations. PURPOSE This study examined whether states' implementation of FPA leads to higher pay, business ownership, assigned patient panel, and billing transparency for NPs' and whether NPs' gains from FPA increase over time in states where FPA has been in effect longer. METHODOLOGY Data from a nationwide survey of licensed NPs ( N = 5,770) were used to compare NPs' employment conditions between FPA and non-FPA states. After balancing the FPA and non-FPA groups on demographic characteristics (e.g., urbanicity, education), adjusted mean differences in outcomes between the groups were estimated using weighted multivariable regression. RESULTS Compared with NPs in non-FPA states, NPs in FPA states had higher mean earnings ( p < .05), were more likely to be practice owners or shareholders ( p < .01), and billed a greater percentage of their patient visits under their own National Provider Identifier ( p < .001). Having FPA in place for ≥10 years was associated with greater improvements in conditions of employment compared with having FPA <10 years. CONCLUSIONS States' adoption of FPA for NPs is associated with improved conditions of employment among NPs. IMPLICATIONS Untethering NPs from physicians establishes a cascade of modest gains in income and practice ownership that may indicate changes over time. Additional research is needed to determine the trajectory of these increases and if they are consistent.
Collapse
Affiliation(s)
- Christine Tracy
- The American Association of Nurse Practitioners, Austin, Texas
| | - Nancy G Russell
- School of Nursing, Johns Hopkins University, Baltimore, Maryland
| | - Kelli DePriest
- School of Nursing, Johns Hopkins University, Baltimore, Maryland
- RTI International, Research Triangle Park, North Carolina
| | - Joyce Knestrick
- School of Nursing, The George Washington University, Washington, District of Columbia
| | - Rita D'Aoust
- School of Nursing, Johns Hopkins University, Baltimore, Maryland
| | - Eric Slade
- School of Nursing, Johns Hopkins University, Baltimore, Maryland
| |
Collapse
|
15
|
O'Connor AW, Helfrich CD, Nelson KM, Sears JM, Jensen PK, Engstrom C, Wong ES. Full practice authority and burnout among primary care nurse practitioners. Nurs Outlook 2023; 71:102056. [PMID: 37856902 DOI: 10.1016/j.outlook.2023.102056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 09/15/2023] [Accepted: 09/15/2023] [Indexed: 10/21/2023]
Abstract
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.
Collapse
Affiliation(s)
- Allyson W O'Connor
- Department of Health Systems and Population Health, University of Washington, Seattle, WA.
| | - Christian D Helfrich
- Department of Health Systems and Population Health, University of Washington, Seattle, WA; Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA
| | - Karin M Nelson
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA; Department of Medicine, University of Washington, Seattle, WA
| | - Jeanne M Sears
- Department of Health Systems and Population Health, University of Washington, Seattle, WA; Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, WA; Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
| | - Penny Kaye Jensen
- Office of Nursing Service, Department of Veterans Affairs, Washington, DC
| | - Christine Engstrom
- Office of Nursing Service, Department of Veterans Affairs, Washington, DC
| | - Edwin S Wong
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA
| |
Collapse
|
16
|
Leslie K, Bourgeault IL, Carlton AL, Balasubramanian M, Mirshahi R, Short SD, Carè J, Cometto G, Lin V. Design, delivery and effectiveness of health practitioner regulation systems: an integrative review. HUMAN RESOURCES FOR HEALTH 2023; 21:72. [PMID: 37667368 PMCID: PMC10478314 DOI: 10.1186/s12960-023-00848-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 07/23/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Health practitioner regulation (HPR) systems are increasingly recognized as playing an important role in supporting health workforce availability, accessibility, quality, and sustainability, while promoting patient safety. This review aimed to identify evidence on the design, delivery and effectiveness of HPR to inform policy decisions. METHODS We conducted an integrative analysis of literature published between 2010 and 2021. Fourteen databases were systematically searched, with data extracted and synthesized based on a modified Donabedian framework. FINDINGS This large-scale review synthesized evidence from a range of academic (n = 410) and grey literature (n = 426) relevant to HPR. We identified key themes and findings for a series of HPR topics organized according to our structures-processes-outcomes conceptual framework. Governance reforms in HPR are shifting towards multi-profession regulators, enhanced accountability, and risk-based approaches; however, comparisons between HPR models were complicated by a lack of a standardized HPR typology. HPR can support government workforce strategies, despite persisting challenges in cross-border recognition of qualifications and portability of registration. Scope of practice reform adapted to modern health systems can improve access and quality. Alternatives to statutory registration for lower-risk health occupations can improve services and protect the public, while standardized evaluation frameworks can aid regulatory strengthening. Knowledge gaps remain around the outcomes and effectiveness of HPR processes, including continuing professional development models, national licensing examinations, accreditation of health practitioner education programs, mandatory reporting obligations, remediation programs, and statutory registration of traditional and complementary medicine practitioners. CONCLUSION We identified key themes, issues, and evidence gaps valuable for governments, regulators, and health system leaders. We also identified evidence base limitations that warrant caution when interpreting and generalizing the results across jurisdictions and professions. Themes and findings reflect interests and concerns in high-income Anglophone countries where most literature originated. Most studies were descriptive, resulting in a low certainty of evidence. To inform regulatory design and reform, research funders and governments should prioritize evidence on regulatory outcomes, including innovative approaches we identified in our review. Additionally, a systematic approach is needed to track and evaluate the impact of regulatory interventions and innovations on achieving health workforce and health systems goals.
Collapse
Affiliation(s)
- Kathleen Leslie
- Athabasca University, Athabasca, Canada.
- Canadian Health Workforce Network, Ottawa, Canada.
| | - Ivy Lynn Bourgeault
- University of Ottawa, Ottawa, Canada
- Canadian Health Workforce Network, Ottawa, Canada
| | - Anne-Louise Carlton
- Royal Melbourne Institute of Technology (RMIT) University, Melbourne, Australia
| | - Madhan Balasubramanian
- College of Business, Government and Law, Flinders University, Adelaide, Australia
- Menzies Centre for Health Policy and Economics, The University of Sydney, Sydney, Australia
| | - Raha Mirshahi
- University of Ottawa, Ottawa, Canada
- Canadian Health Workforce Network, Ottawa, Canada
| | | | - Jenny Carè
- University of Technology Sydney, Sydney, Australia
| | | | - Vivian Lin
- University of Hong Kong, Hong Kong, China
| |
Collapse
|
17
|
Pelzl CE, Rula EY, Duszak R, Christensen EW. Trends in Diagnostic Imaging by Nonphysician Practitioners and Associations With Urbanicity and Scope-of-Practice Authority. Curr Probl Diagn Radiol 2023; 52:315-321. [PMID: 37455202 DOI: 10.1067/j.cpradiol.2023.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 06/28/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE We aimed to assess the changing share of diagnostic imaging billed by NPPs and how such changes differ by urbanicity within the context of scope-of-practice (SOP) regulations and legislation. METHODS This retrospective cohort study used patient claims for diagnostic imaging studies spanning 2016-2020 from Optum Clinformatics Datamart datasets. Multivariable modeling determined the odds of patients receiving NPP-interpreted vs physician-interpreted imaging. Imaging rates and trends in proportions of NPP-billed claims were assessed by urbanicity and relative to other factors including SOP, imaging modality, and place of service. RESULTS Of all identified imaging claims, 3,348,881 (3.0%) were attributed to NPPs, with the highest rates of NPP interpretations per 10,000 images occurring in rural and small-town areas. From 2016 to 2020, the rate of NPP-billed imaging increased from 257 to 331 claims per 10,000 beneficiaries (P = 0.004), observed across both metropolitan (240 to 315, P = 0.001) and micropolitan (367 to 436, P = 0.020) settings. Although rates in rural and small-town areas rose, the increase was not significant (330 to 392, P = 0.363). Rises in NPP imaging in metropolitan settings occurred in states with moderately restrictive (307 to 358, P = 0.008) and least restrictive (289 to 419, P = 0.004) SOP legislation. DISCUSSION Rates of diagnostic imaging interpretation by NPPs are rising. Growth in recent years appears driven by metropolitan areas in states with less restrictive SOP regulations. Future work is necessary to assess the quality of and downstream costs related to increasing NPP-interpreted imaging.
Collapse
Affiliation(s)
- Casey E Pelzl
- The Harvey L. Neiman Health Policy Institute, Reston, VA.
| | | | - Richard Duszak
- Department of Radiology, University of Mississippi Medical Center, Jackson, MS
| | - Eric W Christensen
- The Harvey L. Neiman Health Policy Institute, Reston, VA; Health Services Management, University of Minnesota, St. Paul, MN
| |
Collapse
|
18
|
O'Reilly-Jacob M, Perloff J, Srinivasan M, Alvarez M, Hoyt A. State Variation in the Utilization of Nurse Practitioner-Provided Home-Based Primary Care: A Medicare Claims Analysis. J Gerontol Nurs 2023; 49:11-17. [PMID: 37126015 DOI: 10.3928/00989134-20230414-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
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.].
Collapse
|
19
|
Evaluating the Impact of Executive Orders Lifting Restrictions on Advanced Practice Registered Nurses During the COVID-19 Pandemic. JOURNAL OF NURSING REGULATION 2023; 14:50-58. [PMID: 37035773 PMCID: PMC10074069 DOI: 10.1016/s2155-8256(23)00068-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
Background In the early stages of the COVID-19 pandemic, strains on the healthcare system forced many U.S. states to revisit long-standing statutory limitations on the care coordinated by advanced practice registered nurses (APRNs). This was done by issuing waivers via executive, legislative, or board of nursing orders. Purpose To identify the impact of temporary practice waivers on APRNs’ direct patient care during the COVID-19 pandemic. Methods This cross-sectional study utilized a two-phased approach. First, a confidential online survey was conducted of APRNs practicing across 27 U.S. states. Second, comprehensive APRN discipline data from 2019 to 2021 were retrieved from the National Council of State Boards of Nursing's Nursys database and reviewed. Univariable and multivariable binary logistic regression models were used to determine the significance of observed trends. Results A total of 16,699 APRNs responded to the survey for a response rate of 14.2%. APRNs practicing in private outpatient clinics, in rural areas, and in health provider shortage areas were more likely to report a positive effect of the practice waiver (all p < .05). Providers noted that the waivers allowed them more time with their current patients and expanded the geographic boundaries of their direct patient care to take on new patients. Furthermore, despite the changing profile of APRN care during the early stages of the pandemic, including a pronounced increase in telehealth usage, the current review found no evidence of an uptick in discipline cases brought against APRNs in 2021. Conclusion Full practice authority for APRNs benefits patients by promoting expanded access to care and increasing the resiliency of our healthcare system without compromising patient safety. It is time for states and organizations that employ APRNs to recognize that permanently removing barriers to APRN practice is essential to the health of our nation.
Collapse
|
20
|
Kodi SM, Sharma SK, Basu S. Perception, perceived scope, and potential barriers towards developing nurse practitioners cadre among health care providers and beneficiaries: A pilot study from Northern India. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2023; 12:92. [PMID: 37288389 PMCID: PMC10243426 DOI: 10.4103/jehp.jehp_1200_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 10/03/2022] [Indexed: 06/09/2023]
Abstract
BACKGROUND The role of nurse practitioner (NP) emerged in early 1965 when general practitioners began working with nurses. Evidence across the world highlights the benefits achieved by the NP role. The Indian Nursing Council (INC) implemented a country-wide NP in critical care (NPCC) program with the approval of the ministry of health and family welfare (MoHFW) in 2017. The NP role is in its infancy in India. Hence, there is a need to assess the perception among beneficiaries and healthcare personnel. This study was conducted to assess the perception, perceived scope, and potential barriers for developing the role of NPs in India among beneficiaries and healthcare providers. MATERIAL AND METHODS A descriptive, cross-sectional pilot study was conducted at AIIMS Rishikesh, Uttarakhand, India, among 205 participants (84 beneficiaries, 78 nurses, and 43 physicians) using a proportionate stratified random sampling technique. Likert scales and socio-demographic sheets were used to assess the perception, perceived scope of practice, and potential barriers in developing a NP cadre in India. Descriptive and inferential statistics were used for analyzing data. RESULTS The mean age of beneficiaries was 37.98, nurses was 27.58, and physicians was 28.13 years, respectively. 121 (61%) of participants were highly favored, and 77 (38%) were in favor of developing NP cadre in India. They considered it to be necessary, feasible, and acceptable in India. The feasibility and necessity of the perception domain were highly significant (P < 0.001 and P < 0.003, respectively). Nurses (mean ± SD: 35.36 ± 3.55) considered that NPs could have a wide range of practice followed by beneficiaries (mean ± SD: 38.17 ± 3.68) than physicians (mean ± SD: 34.75 ± 5.95). Lack of awareness, the nonexistence of cadre structure, lack of acceptance of the role of physicians, and lack of clear policy were the key potential barriers to develop an NP cadre in India. CONCLUSIONS In this study, participants had favorable views on employing NPs in India; thus, this role will improve healthcare access for beneficiaries. NPs can carry out a wide range of practices.However, a lack of awareness, no cadre structure, and a lack of a clear policy may hinder the development of the NP cadre in India.
Collapse
Affiliation(s)
- S Malar Kodi
- College of Nursing, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Suresh K. Sharma
- College of Nursing, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Somprakas Basu
- Department of Surgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| |
Collapse
|
21
|
Katz PR, Smith BJ, Gilberstadt NJ, Rust C, Rosasco R. Physician Practice Characteristics Influencing Nurse Practitioner and Physician Assistant Care in Nursing Homes: A Scoping Review. J Am Med Dir Assoc 2023; 24:599-608. [PMID: 36958373 DOI: 10.1016/j.jamda.2023.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/26/2023] [Accepted: 02/11/2023] [Indexed: 03/25/2023]
Abstract
OBJECTIVES Physicians, nurse practitioners (NPs), and physician assistants (PAs) are key to the effective delivery of medical care in nursing homes (NHs). Although several studies have reported on the relationship between the care delivered by a given discipline and specific clinical outcomes, the mediating effect of physician practice characteristics is unknown. A scoping review was conducted to determine whether studies examining the impact of NP and PA care in NHs have accounted for both the collaborative relationship between themselves and physicians as well as physician practice size and type. DESIGN Scoping review. SETTINGS AND PARTICIPANTS NH and NH residents. METHODS Papers eligible for review included peer-reviewed studies written in English and that were quantitative in nature. Inclusion criteria required that more than 1 NH and more than a single NP or PA be included for the analysis. Further, the size of the NH studied must have equaled or exceeded 100 residents and more than 1 clinical outcome reported. Databases searched included Ovid MEDLINE, Cochrane Library, Web of Science; CINAHL, and AgeLine. RESULTS A total of 1878 studies underwent abstract review of which 1719 were excluded. A full-text review of the remaining articles was completed (n = 157, as 2 articles could not be retrieved), of which 16 met eligibility criteria. The study designs were generally retrospective and quasi-experimental in nature. No randomized controlled studies were identified. Physician practice variables such as number of physicians, total practice case load, case mix, and the nature of the collaborative practice between NP/PA and MD were infrequently specified. In no reports was the type of physician practice characterized and no physician practice variables were adjusted for with regard to outcomes. CONCLUSIONS None of the studies included in the review were found to have incorporated any physician variables into their outcome analyses. Before purporting equivalency between medical provider disciplines in NHs, future studies must, at the very least, consider the mediating effect of physician practice characteristics.
Collapse
Affiliation(s)
- Paul R Katz
- Florida State University, Tallahassee, FL, USA.
| | | | | | - Casey Rust
- Florida State University, Tallahassee, FL, USA
| | | |
Collapse
|
22
|
O'Reilly-Jacob M, Tierney M, Freeman P, Perloff J. Emergency Removal of Supervision Requirements for Psychiatric Mental Health Nurse Practitioners: A Mixed-Methods Survey. Psychiatr Serv 2023; 74:127-133. [PMID: 36004434 DOI: 10.1176/appi.ps.202100725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Physician supervision of nurse practitioners (NPs) was temporarily waived in Massachusetts in response to a state of emergency due to the COVID-19 pandemic. The authors examined the impact of the scope-of-practice changes and pandemic-related demands on psychiatric mental health NPs (PMHNPs) during the state's first COVID-19 surge. METHODS A mixed-methods Web-based survey was conducted in May and June of 2020. Fisher's exact test was used to compare associations across certification types, and inductive content analysis was applied to open-ended responses. RESULTS The survey response rate was 41% (N=389 of 958), consisting of 26 PMHNPs and 363 other NPs. Compared with other NPs, PMHNPs were significantly more likely to work in a telehealth setting (42% vs. 11%, p<0.001), to spend more time working during the initial surge (50% vs. 26%, p<0.05), and to believe that the waiver improved clinical work (52% vs. 25%, p<0.01). Content analysis of PMHNPs' open-ended responses identified four themes: the supervision waiver reduced burden on PMHNPs, collaboration and mentorship models persisted, the pandemic exacerbated the already high demand for psychiatric care, and telehealth helped meet the high demand for such care. CONCLUSIONS PMHNPs may be more sensitive to the scope-of-practice changes and telehealth expansion than other NPs because of the constraints of the psychiatrist shortage and high relative uptake of telehealth in psychiatric care. The interactions of workforce supply, telehealth expansion, and scope-of-practice laws are important to consider in the development of policies to improve access to mental health care.
Collapse
Affiliation(s)
- Monica O'Reilly-Jacob
- Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts (O'Reilly-Jacob, Freeman); School of Nursing, University of California, San Francisco, San Francisco (Tierney); Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (Perloff)
| | - Matthew Tierney
- Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts (O'Reilly-Jacob, Freeman); School of Nursing, University of California, San Francisco, San Francisco (Tierney); Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (Perloff)
| | - Patricia Freeman
- Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts (O'Reilly-Jacob, Freeman); School of Nursing, University of California, San Francisco, San Francisco (Tierney); Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (Perloff)
| | - Jennifer Perloff
- Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts (O'Reilly-Jacob, Freeman); School of Nursing, University of California, San Francisco, San Francisco (Tierney); Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (Perloff)
| |
Collapse
|
23
|
Plemmons A, Shakya S, Cato K, Sadarangani T, Poghosyan L, Timmons E. Exploring the Relationship between Nurse Practitioner Full Practice Authority, Nurse Practitioner Workforce Diversity, and Disparate Primary Care Access. Policy Polit Nurs Pract 2023; 24:26-35. [PMID: 36482692 DOI: 10.1177/15271544221138047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In this study, we examine how full nurse practitioner (NP) practice authority affects racial and ethnic diversity of the NP workforce. Specifically, the purpose of our research is to understand the relationship between the racial and ethnic composition of the NP workforce, NP level of practice authority, and the communities they service. In this paper, we compare the ethnic and racial composition of the NP workforce to the composition of the state's population, and then observe if there are any noticeable differences in the patients served by NPs when we compare full practice authority (FPA) and non-FPA states. We also estimate how FPA affects the race and ethnicity of Medicare patients served by NPs.
Collapse
Affiliation(s)
- Alicia Plemmons
- West Virginia University John Chambers College of Business and Economics
| | | | | | | | | | - Edward Timmons
- West Virginia University John Chambers College of Business and Economics
| |
Collapse
|
24
|
Martsolf GR, Kandrack R, Ferrara SA, Poghosyan L. The Impact of the New York Nurse Practitioner Modernization Act on the Employment of Nurse Practitioners in Primary Care. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2023; 60:469580231171333. [PMID: 37139742 PMCID: PMC10161305 DOI: 10.1177/00469580231171333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Expanding scope of practice (SOP) for nurse practitioners (NPs) may increase NP employment in primary care practices which can help meet the growing demand in primary care. We examined the impact of enacting less restrictive NP practice restrictions-NP Modernization Act-in New York State (NYS) on the overall employment of primary care NPs and specifically in underserved areas. We used longitudinal data from the SK&A outpatient database (2012-2018) to identify primary care practices in NYS and in the comparison states (Pennsylvania [PA] and New Jersey [NJ]). Using a difference-in-differences design with an event study specification, we compared changes in (1) the presence and (2) total counts of NPs in primary care practices in NYS and neighboring comparison states (ie, PA and NJ) before and after the policy change. The NP Modernization Act was associated with a 1.3 percentage point lower probability of a practice employing at least one NP on average across each of the 3 post-periods (95% CI: -.024, -.002). NP Modernization Act was associated with 0.065 fewer NPs on average across the post-period (95% CI: -.119, -.011). Results were similar in underserved areas. NP employment in primary care practices in NYS was lower after the NP Modernization Act than would have been expected based counterfactual of comparison states. The negative relationship may be explained by gains in provider efficiency which leads to reduced NP hiring in primary care. More research is needed to understand the relationship between SOP regulations, NP supply, and access to care.
Collapse
|
25
|
Posada EL, Lauck KC, Tran T, Krause KJ, Nelson KC. Educational Interventions to Support Primary Care Provider Performance of Diagnostic Skin Cancer Examinations: A Systematic Literature Review. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2022; 37:1579-1588. [PMID: 35040018 PMCID: PMC8763425 DOI: 10.1007/s13187-021-02118-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/15/2021] [Indexed: 06/14/2023]
Abstract
To our knowledge, there is no available standardized educational curriculum designed to promote the incorporation of skin cancer examinations and procedures into general practice. To explore the contemporary training landscape, we conducted a systematic review of educational interventions designed to support skin cancer diagnostic examinations by primary care providers (PCPs). Our review uniquely encompasses all PCPs, including practicing physicians, residents, and advanced practice practitioners (APPs). The objective of this study is to review and synthesize worldwide data on educational interventions addressing PCP performance of skin cancer diagnostic examinations. A systematic review was performed in MEDLINE, Cochrane, EMBASE, and Scopus for English language articles worldwide published from 2000 onwards. Articles were screened for eligibility, and possibly overlapping datasets were resolved. Data extracted included curriculum content, delivery format, and educational outcomes. This review followed the PRISMA guidelines. A total of 63 studies were selected for data inclusion with one addressing training for resident physicians, 4 for APPs, and the remainder for practicing physicians. Educational interventions included in this review reflect the pre-SARS-CoV-2 pandemic educational environment: half provided live/synchronous instruction of about 5-h duration on average, and a quarter featured interactive components. Less than a quarter of interventions included practice change as a specific reported outcome. Without sustainable practice change, the anticipated long-term benefits of early cancer detection in patients remain limited. Previous and existing educational interventions designed to support skin cancer detection by PCPs demonstrate heterogeneous curriculum content, delivery methods, and educational outcomes. An ideal intervention would teach consensus-derived clinical competencies, provide meaningful learner feedback, and measure outcomes, such as knowledge/competency, confidence/attitudes, and practice change, using validated instruments.
Collapse
Affiliation(s)
- Eliza L Posada
- The University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kyle C Lauck
- Department of Internal Medicine, The University of Texas Health Science Center, Houston, TX, USA
| | - Tiffaney Tran
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kate J Krause
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kelly C Nelson
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| |
Collapse
|
26
|
Christensen EW, Liu CM, Duszak R, Hirsch JA, Swan TL, Rula EY. Association of State Share of Nonphysician Practitioners With Diagnostic Imaging Ordering Among Emergency Department Visits for Medicare Beneficiaries. JAMA Netw Open 2022; 5:e2241297. [PMID: 36355374 PMCID: PMC9650604 DOI: 10.1001/jamanetworkopen.2022.41297] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
IMPORTANCE The use of nonphysician practitioners (NPPs) in the emergency department (ED) continues to expand, yet little is known about associations between NPPs and ED imaging use. OBJECTIVE To investigate whether the state share of ED visits for which an NPP was the clinician of record is associated with imaging studies ordered, given that state NPP share is associated with state-level NPP scopes of practice. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study compared diagnostic imaging ordering patterns associated with ED visits based on 2005-2020 Medicare claims for a nationally representative 5% sample of fee-for-service beneficiaries. For all 50 states and the District of Columbia, the state NPP share of ED visits by year was used to represent state-specific practice patterns for NPPs and physicians and how those patterns have evolved over time. The analysis controlled for patient demographic characteristics, Charlson Comorbidity Index scores, ED visit severity, year, and principal diagnosis. EXPOSURES The share of ED visits in each state in each year (state share) for which an NPP was the evaluation and management clinician. MAIN OUTCOMES AND MEASURES The main outcomes were the number and modality of imaging studies associated with ED visits. Analyses were by logistic regression and generalized linear model with γ-distribution and log-link function. RESULTS Among 16 922 274 ED visits, 60.0% involved women, and patients' mean (SD) age was 70.3 (16.1) years. The share of all ED visits with an NPP as the clinician increased from 6.1% in 2005 to 16.6% in 2020. Compared with no NPPs, the presence of NPPs in the ED was associated with 5.3% (95% CI, 5.1%-5.5%) more imaging studies per ED visit, including a 3.4% (95% CI, 3.2%-3.5%) greater likelihood of any imaging order per ED visit and 2.2% (95% CI, 2.0%-2.3%) more imaging studies ordered per visit involving imaging. CONCLUSIONS AND RELEVANCE In this study, use of NPPs in the ED was associated with higher imaging use compared with the use of only physicians in the ED. Although expanded use of NPPs in the ED may improve patient access, the costs and radiation exposure associated with more imaging warrants additional study.
Collapse
Affiliation(s)
- Eric W. Christensen
- Harvey L. Neiman Health Policy Institute, Reston, Virginia
- Health Services Management, University of Minnesota, St Paul
| | - Chi-Mei Liu
- Harvey L. Neiman Health Policy Institute, Reston, Virginia
| | - Richard Duszak
- Department of Radiology, University of Mississippi Medical Center, Jackson
| | - Joshua A. Hirsch
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | |
Collapse
|
27
|
Hassmiller SB, Wakefield MK. The Future of Nursing 2020-2030: Charting a path to achieve health equity. Nurs Outlook 2022; 70:S1-S9. [PMID: 36446536 DOI: 10.1016/j.outlook.2022.05.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 05/27/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Susan B Hassmiller
- Rober Wood Johnson Foundation Senior Advisor for Nursing Emerita, Princeton, N.J., USA.
| | - Mary K Wakefield
- University of Texas School of Nursing at Austin, Austin, Texas, USA.
| |
Collapse
|
28
|
Amin-Esmaeili M, Gribble A, Johnson RM, Alinsky RH, Oyedele N, Parnham T, Byregowda H, Schneider KE, Park JN, Goddard L, Susukida R. Unsolicited reporting notifications (URNs) through Maryland's prescription drug monitoring program (PDMP): Characteristics of providers. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 5:100111. [PMID: 36844159 PMCID: PMC9948924 DOI: 10.1016/j.dadr.2022.100111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/27/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022]
Abstract
Objectives Unsolicited reporting is the activity of analyzing Prescription Drug Monitoring Program (PDMP) data and then sending unsolicited reporting notifications (URNs) to prescribers to notify them of their outlier prescribing behavior. We aimed to describe information about prescribers who were issued URNs. Methods A retrospective study of Maryland's PDMP data from Jan.2018-Apr.2021. All providers who were issued ≥ one URN were included in analyses. We summarized data on types of URNs issued by provider type and years in practice using basic descriptive measures. We also performed logistic regression analysis to provide odds ratio and estimated marginal probability of issuing ≥ one URN to providers in the Maryland health care workforce in comparison with physicians as reference group. Results A total of 4,446 URNs were issued to 2,750 unique providers. Odds ratio (OR) and the population estimated probability of issuing URNs were higher among nurse practitioners [OR: 1.42, 95% Confidence Interval (CI): 1.26-1.59] followed by physician assistants [OR: 1.87, 95% CI: 1.69-2.08], compared to physicians. Physicians and dentists with >10 years in practice comprised the majority of providers who were issued URNs (65.1% and 62.6%, respectively), while majority of nurse practitioners had been in practice for <10 years (75.8%). Conclusion Findings indicate a higher probability of issuing URN for Maryland's physician assistants and nurse practitioners, compared to physicians, and an overrepresentation of physicians and dentists with longer and nurse practitioners with shorter practice experience. The study suggests education programs on safer prescribing practices and management of opioids should target certain types of providers.
Collapse
Affiliation(s)
- Masoumeh Amin-Esmaeili
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University,Corresponding author at: Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624 N. Broadway Room 763, Baltimore, MD 21205, United States
| | - Anna Gribble
- Maryland Department of Health (MDH), Office of Provider Engagement and Regulation (OPER)
| | - Renee M. Johnson
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University
| | - Rachel H Alinsky
- Division of Adolescent/Young Adult Medicine, Johns Hopkins University School of Medicine
| | - Natasha Oyedele
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University
| | - Taylor Parnham
- Department of Health Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University
| | - Himani Byregowda
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University
| | - Kristin E. Schneider
- Department of Health Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University
| | | | - Lindsey Goddard
- Maryland Department of Health (MDH), Office of Provider Engagement and Regulation (OPER)
| | - Ryoko Susukida
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University
| |
Collapse
|
29
|
Poghosyan L, Stein JH, Liu J, Spetz J, Osakwe ZT, Martsolf G. State-level scope of practice regulations for nurse practitioners impact work environments: Six state investigation. Res Nurs Health 2022; 45:516-524. [PMID: 35852444 PMCID: PMC9534177 DOI: 10.1002/nur.22253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/02/2022] [Accepted: 06/18/2022] [Indexed: 11/12/2022]
Abstract
Nurse practitioner (NP) scope of practice (SOP) policies are different across the United States. Little is known about their impact on NP work environment in healthcare organizations. We investigated the association between SOP policies and organizational-level work environment of NPs. Through a cross-sectional survey design, data were collected from 1244 NPs in six states with variable SOP regulations (Arizona, New Jersey, Washington, Pennsylvania, Texas, and California) in 2018-2019. Arizona and Washington had full SOP-NPs had full authority to deliver care. New Jersey and Pennsylvania had reduced SOP with physician collaboration requirement; California and Texas had restricted SOP with physician supervision requirement. NPs completed mail or online surveys containing the Nurse Practitioner Primary Care Organizational Climate Questionnaire, which has these subscales: NP-Administration Relations (NP-AR), NP-Physician Relations (NP-PR), Independent Practice and Support (IPS), and Professional Visibility (PV). Regression models assessed the relationship between state-level SOP and practice-level NP work environment. NP-AR scores were higher in full SOP states compared to reduced (β = 0.22, p < 0.01) and restricted (β = 0.15, p < 0.01) SOP states. Similarly, IPS scores were higher in full SOP states. The PV scores were also higher in full SOP states compared to reduced (β = 0.16, p < 0.001) and restricted (β = 0.12, p < 0.05) SOP states. There was no relationship between SOP and NP-PR score. State-level policies affect NP work environment. In states with more favorable policies, NPs have better relationships with administration and report more role visibility and support. Efforts should be made to remove unnecessary SOP restrictions.
Collapse
Affiliation(s)
| | - Jordan H. Stein
- School of Nursing, Columbia University, New York, New York, USA
| | - Jianfang Liu
- School of Nursing, Columbia University, New York, New York, USA
| | - Joanne Spetz
- School of Nursing, University of California, San Francisco, California, USA
| | - Zainab T. Osakwe
- College of Nursing and Public Health, Adelphi University, Garden City, New York, USA
| | - Grant Martsolf
- School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
30
|
Kodi MS, Sharma SK, Basu S. Perceptions of Implementing Nurse Practitioner Role in India. J Nurse Pract 2022. [DOI: 10.1016/j.nurpra.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
31
|
Devictor J, Burnet E, Henriot T, Leclercq A, Ganne‐Carrie N, Kilpatrick K, Jovic L. Implementing advanced practice nursing in France: A country-wide survey 2 years after its introduction. Nurs Open 2022; 10:1437-1448. [PMID: 36168185 PMCID: PMC9912409 DOI: 10.1002/nop2.1394] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 07/09/2022] [Accepted: 09/14/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES To examine the characteristics of the first Advanced Practice Nurses in France and to compare the French model to international standards. BACKGROUND Common barriers and facilitators to their integration in healthcare provision have been identified internationally. In France, the legislative framework was introduced in 2016, and the first graduates entered the workforce in 2019. METHODS The French model was examined in comparison with Hamric's conceptual framework and to the International Council of Nurses' guidelines and definitions. A cross-sectional survey was also conducted, using three self-administered online questionnaires. Two were distributed to 2019 and 2020 graduates and a third to the accredited programme directors. The characteristics of advanced practice nursing graduates were described and compared based on employment status and field of practice (primary vs secondary/tertiary care). RESULTS Although the French model of advanced practice nursing meets Hamric's primary criteria and core competencies, it does not differentiate between Nurse Practitioner and Clinical Nurse Specialist roles. Of the 320 students enrolled in one of the 11 accredited training programmes 165 participated in the survey. Mean age was 40, and mean prior nursing experience was 15 years. By February 2021, 30% of respondents were still employed as Registered Nurses. Barriers to practice included insufficient income generation (primary care), the lack of position creation (secondary/tertiary care), the physician-dependent patient referral process and delays in prescription credentials approval. CONCLUSIONS The implementation of advanced practice nursing in France faces several barriers. Legislative adjustments and greater financial incentives to practice seem warranted. RELEVANCE TO CLINICAL PRACTICE as in other countries, France introduced advanced practice nursing to respond to the Public Health challenge of improving access to quality health care in the context of increasing chronic disease prevalence and limited resource allocation. Facilitating its integration in the healthcare provision landscape seems paramount.
Collapse
Affiliation(s)
- Julie Devictor
- Hepatology Department, DMU DIGEST, Beaujon HospitalAP‐HP.Nord ‐ Université de Paris, INSERM UMRS 1123, ECEVEClichyFrance
| | - Espérie Burnet
- Respiratory Medicine DepartmentDMU Thorax, ORL et Sommeil, Cochin Hospital, APHP.Centre ‐ Université de ParisParisFrance
| | | | - Anne Leclercq
- Direction des Soins, Beaujon HospitalAP‐HP.Nord ‐ Université de ParisClichyFrance
| | - Nathalie Ganne‐Carrie
- Hepatology DepartmentDMU NARVAL, Avicenne Hospital, AP‐HP Hôpitaux Universitaires Paris Seine‐Saint‐Denis, Université Sorbonne Paris Nord, INSERM UMR 1138, Centre de Recherche des Cordeliers, Sorbonne UniversitéBobignyFrance
| | - Kelley Kilpatrick
- Susan E. French Chair in Nursing Research and Innovative Practice, Ingram School of Nursing, Faculty of MedicineMcGill UniversityMontrealQuebecCanada
| | - Ljiljana Jovic
- Université de Paris, INSERM, UMRS 1123, ECEVEParisFrance
| |
Collapse
|
32
|
Optimizing the productivity and placement of nurse practitioners and physician assistants in outpatient primary care sites. J Am Assoc Nurse Pract 2022; 34:1022-1032. [PMID: 36330553 DOI: 10.1097/jxx.0000000000000733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 04/12/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND It is increasingly imperative that organizational leaders continually assess nurse practitioners' (NPs) and physician assistants' (PAs) productivity, turnover, and vacancies. Optimizing the feasibility, impact, strategic placement, and monitoring increases patient access, improves wait times and affordability, and increases revenue. LOCAL PROBLEM A healthcare system needed a systematic, data-driven approach aimed at optimizing productivity and placement of NPs and PAs in outpatient primary care sites. METHOD Results from this project are reported using the Revised Standards for Quality Improvement Reporting Excellence framework. After formation of a QI team, a gap analysis, and action plans were developed and implemented. INTERVENTION/RESULTS Priority areas requiring action included the development of an integrated position justification algorithm and tracking form addressing NPs' and PAs' placement, establishing consistent patient contact hours, setting workload expectations, and consistently communicating these via an organization-specific situation background, assessment, and recommendation communication tool. CONCLUSION Health care leaders should leverage the talents of NPs and PAs meeting organizational benchmarks and goals as well as the needs of patients. Nurse practitioner and PA leaders should focus on benchmarking performance and analyzing barriers to optimization. These efforts are most beneficial when multidisciplinary in nature.
Collapse
|
33
|
Zaletel CL, Madura B, Metzel JM, Lancaster RJ. Optimizing the productivity and placement of NPs and PAs in outpatient primary care sites. JAAPA 2022; 35:41-49. [PMID: 35881717 DOI: 10.1097/01.jaa.0000840496.00307.5b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Organizational leaders must continually assess the productivity, turnover, and vacancies of physician assistants (PAs) and NPs. Optimizing the feasibility, effect, strategic placement, and monitoring increases patient access, improves wait times and affordability, and increases revenue. This quality improvement project sought to develop a systematic, data-driven approach to optimize productivity and placement of NPs and PAs in outpatient primary care sites. METHODS Results from this project are reported using the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE) framework. Postformation of a quality improvement team, a gap analysis, and action plans were developed and implemented. RESULTS Priority areas requiring action included the development of an integrated position justification algorithm and tracking form addressing NP and PA placement, establishing consistent patient contact hours, setting workload expectations, and consistently communicating these via an organization-specific situation, background, assessment, and recommendation communication tool. CONCLUSIONS Healthcare leaders should leverage the talents of NPs and PAs meeting organizational benchmarks and goals as well as the needs of patients. NP and PA leaders should focus on benchmarking performance and analyzing barriers to optimization. These efforts are most beneficial when multidisciplinary in nature.
Collapse
Affiliation(s)
- Cynthia L Zaletel
- At Advocate Aurora Medical Group in Downers Grove, Ill., Cynthia L. Zaletel is a family NP and professional development specialist in the Office of Advanced Practice Clinicians, Brenda Madura is director of advanced practice clinicians for Illinois, and Julie Miyamasu Metzel is a family NP and advanced practice clinician consultant in primary care in the Office of Advanced Practice Clinicians. Rachelle J. Lancaster is nursing research manager and a nurse scientist in the Center for Nursing Research and Practice at Advocate Aurora Health. The author has disclosed no potential conflicts of interest, financial or otherwise
| | | | | | | |
Collapse
|
34
|
Schlunegger MC, Aeschlimann S, Palm R, Zumstein-Shaha M. Competencies of nurse practitioners in family practices: A scoping review. J Clin Nurs 2022; 32:2521-2532. [PMID: 35642084 DOI: 10.1111/jocn.16382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/04/2022] [Accepted: 05/16/2022] [Indexed: 12/01/2022]
Abstract
AIMS AND OBJECTIVE To explore the existing literature related to nurse practitioner (NP) competencies in family practices and to examine the evidence and develop a list of competencies. BACKGROUND The integration of NPs into the healthcare system is at different stages of progress around the world. Therefore, an overview and clarification of competencies are important to ensure successful implementation of new roles in existing healthcare systems. However, detailed knowledge is lacking about the competencies of NPs in adult care in family practices. DESIGN AND METHODS We conducted a scoping review in accordance with the JBI methodology for scoping reviews and the PRISMA-ScR guidelines. We considered studies published in English, German or French from 1965 to the present. Databases searched included MEDLINE, CINAHL, Web of Science and PsycINFO. Sources of grey literature that were searched included ProQuest Dissertations and Theses, OpenGrey and websites of national NP organisations. Two reviewers retrieved full-text studies and extracted data independently. We described the competencies using Hamric's model of advanced practice nursing. RESULTS We included 23 publications. Competencies in direct clinical practice were described most often particularly pertaining to nursing or medical tasks. Indirect care activities were frequently mentioned. Less information was found regarding competencies in leadership, ethical decision-making and evidence-based practice. We found elementary and extended competencies required to perform the role in family practices. Depending on the country, the role was either emerging or already well-established. CONCLUSIONS AND RELEVANCE TO CLINICAL PRACTICE This review provides insight into current knowledge about competencies of NP in family practices. The identified competencies can be used to develop job descriptions or to conceptualise professional development programmes in countries where such roles are just recently emerging. A list of competencies will promote a common understanding of the NP role and to help clarify interprofessional collaboration in clinical practice.
Collapse
Affiliation(s)
- Margarithe Charlotte Schlunegger
- Department of Health Professions, Applied Research & Development in Nursing, Bern University of Applied Sciences, Bern, Switzerland.,School of Nursing Science, Faculty of Health, Department of Nursing Science, Witten/Herdecke University, Witten, Germany
| | - Simona Aeschlimann
- Tilia Köniz, Tilia Foundation for Long-Term Care, Ostermundigen, Switzerland
| | - Rebecca Palm
- School of Nursing Science, Faculty of Health, Department of Nursing Science, Witten/Herdecke University, Witten, Germany.,German Center for Neurodegenerative Diseases (DZNE), Witten, Germany
| | - Maya Zumstein-Shaha
- Department of Health Professions, Applied Research & Development in Nursing, Bern University of Applied Sciences, Bern, Switzerland.,School of Nursing Science, Faculty of Health, Department of Nursing Science, Witten/Herdecke University, Witten, Germany
| |
Collapse
|
35
|
Jones DD. Examining the Unconscious Racial Biases and Attitudes of Physicians, Nurses, and the Public: Implications for Future Health Care Education and Practice. Health Equity 2022; 6:375-381. [PMID: 35651358 PMCID: PMC9148656 DOI: 10.1089/heq.2021.0141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 11/12/2022] Open
|
36
|
Carthon MB, Brom H, Nikpour J, Todd B, Aiken L, Poghosyan L. Supportive Practice Environments Are Associated With Higher Quality Ratings Among Nurse Practitioners Working in Underserved Areas. JOURNAL OF NURSING REGULATION 2022; 13:5-12. [PMID: 36249162 PMCID: PMC9555817 DOI: 10.1016/s2155-8256(22)00028-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background Deployment of nurse practitioners (NPs) to health professional shortage areas (HPSA) may help to address challenges in patient access to care. However, restrictive scope of practice imposed by regulatory and state legislative bodies or unsupportive organizational climates in clinical practice settings may constrain NP care delivery and perpetuate lower assessments of quality of care provided in these underserved communities. Purpose The purpose of this study was to investigate the associations between state NP scope of practice regulations, NP practice environment, and self-reported ratings of quality of care in primary care practices located in HPSAs. Methods This was a cross-sectional analysis of data from 1,972 participant NPs practicing across 1,711 primary care practices in six states representing full (Arizona and Washington), reduced (Pennsylvania and New Jersey), and restricted (California and Florida) NP scope of practice regulation. Survey data were merged with the Area Health Resource Files to determine practices located in primary care HPSAs. Logistic regression models estimated the relationship between quality ratings, scope of practice regulations, and practice environment scores while accounting for NP and practice characteristics. Results Among all included NPs, 95.7% rated their practice as having "excellent," "very good," or "good" quality of care. Practice environments with higher scores had higher ratings of quality of care after accounting for NP and practice characteristics (OR = 3.73, 95% CI: 2.84, 4.89). Conclusion Unsupportive clinical practice environments were associated with lower ratings of quality of care in HPSAs, suggesting that improvements in working conditions may be necessary adjuncts to greater deployment of NPs to improve primary care in shortage areas.
Collapse
Affiliation(s)
- Margo Brooks Carthon
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia
| | - Heather Brom
- Villanova (Pennsylvania) University School of Nursing
| | - Jacqueline Nikpour
- Center for Health Outcomes & Policy Research, University of Pennsylvania School of Nursing
| | - Barbara Todd
- Advanced Practice and Education Hospital of the University of Pennsylvania, Philadelphia
| | - Linda Aiken
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing
| | - Lusine Poghosyan
- Center for Healthcare Delivery Research & Innovations, and the Elise D. Fish Professor of Nursing and Professor of Health Policy and Management, Columbia School of Nursing, New York, New York
| |
Collapse
|
37
|
Santavicca S, Hughes DR, Rosenkrantz AB, Rubin E, Duszak R. Radiology Practices Employing Nurse Practitioners and Physician Assistants: Characteristics and Trends From 2017 Through 2019. J Am Coll Radiol 2022; 19:746-753. [DOI: 10.1016/j.jacr.2022.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 01/21/2023]
|
38
|
Recruitment and retention of primary care nurse practitioners in underserved areas: A scoping review. Nurs Outlook 2022; 70:401-416. [PMID: 35183357 PMCID: PMC9232900 DOI: 10.1016/j.outlook.2021.12.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 12/06/2021] [Accepted: 12/19/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND The growing nurse practitioner (NP) workforce plays a critical role in primary care delivery in the United States. However, better recruitment and retention of the robust NP workforce in underserved areas are needed; evidence to inform such effort is limited. PURPOSE This scoping review aimed to examine the findings, scope, and knowledge gaps of available literature on factors associated with NP recruitment and retention in underserved areas. METHODS This review was guided by Joanna Briggs' Scoping Review Methodology and PRISMA-SCR reporting standards. Literature search for peer-reviewed and gray literature was conducted in six databases. FINDINGS A total of 22 studies met inclusion criteria. Factors associated with NP recruitment and retention in underserved areas were mapped into five themes, including factors related to: the individual NP, NP education programs/financial aid, organizations employing NPs, the communities NPs work in, and autonomous practice. Majority of the included studies were published before 2010; few used rigorous study designs and analysis methods; and few exclusively studied NPs and unique challenges facing the NP workforce. DISCUSSION Available studies demonstrate that NP recruitment and retention can be addressed by various stakeholders (e.g., educators, policy makers); however, up-to-date, methodologically rigorous, and NP-focused studies are needed.
Collapse
|
39
|
DesRoches C, Chang Y, Kim J, Mukunda S, Norman L, Dittus RS, Donelan K. Who wants to work in geriatrics: Findings from a national survey of physicians and nurse practitioners. Nurs Outlook 2022; 70:309-314. [DOI: 10.1016/j.outlook.2021.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 09/22/2021] [Accepted: 10/23/2021] [Indexed: 11/15/2022]
|
40
|
Barnes H, Richards MR, Martsolf GR, Nikpay SS, McHugh MD. Association between physician practice Medicaid acceptance and employing nurse practitioners and physician assistants: A longitudinal analysis. Health Care Manage Rev 2022; 47:21-27. [PMID: 33181552 PMCID: PMC8110602 DOI: 10.1097/hmr.0000000000000291] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Access to care is often a challenge for Medicaid beneficiaries due to low practice participation. As demand increases, practices will likely look for ways to see Medicaid patients while keeping costs low. Employing nurse practitioners (NPs) and physician assistants (PAs) is one low-cost and effective means to achieve this. However, there are no longitudinal studies examining the relationship between practice Medicaid acceptance and NP/PA employment. PURPOSE The purpose of this study was to examine the association of practice Medicaid acceptance with NP/PA employment over time. METHODS Using SK&A data (2009-2015), we constructed a panel of 102,453 unique physician practices to assess for changes in Medicaid acceptance after newly employing NPs and PAs. We employed practice-level fixed effects linear regressions. RESULTS Our results showed that, among practices employing both NPs and PAs, there was a roughly 2% increase in the likelihood of Medicaid participation over time. When stratifying our sample by practice size and specialty, the positive correlation localized to small primary care and medical practices. When both NPs and PAs were present, small primary care practices had a 3.3% increase and small medical practices had a 6.9% increase in the likelihood of accepting Medicaid. CONCLUSION NP and PA employment was positively associated with increases in Medicaid participation. PRACTICE IMPLICATIONS As more individuals gain coverage under Medicaid, organizations will need to decide how to adapt to greater patient demand. Our results suggest that hiring NPs and PAs may be a potential lower cost strategy to accommodate new Medicaid patients.
Collapse
Affiliation(s)
- Hilary Barnes
- Assistant Professor, University of Delaware School of Nursing, Newark
| | - Michael R. Richards
- Associate Professor, Department of Economics, Hankamer School of Business, Baylor University, Waco, Texas
| | - Grant R. Martsolf
- Professor, Department of Acute and Tertiary Care, University of Pittsburgh School Nursing, and Adjunct Policy Researcher, RAND Corporation, Pittsburgh, Pennsylvania
| | - Sayeh S. Nikpay
- Assistant Professor, Department of Health Policy, Vanderbilt University, Nashville, Tennessee
| | - Matthew D. McHugh
- Independence Chair for Nursing Education, Professor of Nursing, Associate Director, Center for Health Outcomes & Policy Research, University of Pennsylvania School of Nursing, and Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| |
Collapse
|
41
|
CLARKE LORCAN, ANDERSON MICHAEL, ANDERSON ROB, KLAUSEN MORTENBONDE, FORMAN REBECCA, KERNS JENNA, RABE ADRIAN, KRISTENSEN SØRENRUD, THEODORAKIS PAVLOS, VALDERAS JOSE, KLUGE HANS, MOSSIALOS ELIAS. Economic Aspects of Delivering Primary Care Services: An Evidence Synthesis to Inform Policy and Research Priorities. Milbank Q 2021; 99:974-1023. [PMID: 34472653 PMCID: PMC8718591 DOI: 10.1111/1468-0009.12536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Policy Points The 2018 Declaration of Astana reemphasized the importance of primary health care and its role in achieving universal health coverage. While there is a large amount of literature on the economic aspects of delivering primary care services, there is a need for more comprehensive overviews of this evidence. In this article, we offer such an overview. Evidence suggests that there are several strategies involving coverage, financing, service delivery, and governance arrangements which can, if implemented, have positive economic impacts on the delivery of primary care services. These include arrangements such as worker task-shifting and telemedicine. The implementation of any such arrangements, based on positive economic evidence, should carefully account for potential impacts on overall health care access and quality. There are many opportunities for further research, with notable gaps in evidence on the impacts of increasing primary care funding or the overall supply of primary care services. CONTEXT The 2018 Declaration of Astana reemphasized the importance of primary health care and its role in achieving universal health coverage. To strengthen primary health care, policymakers need guidance on how to allocate resources in a manner that maximizes its economic benefits. METHODS We collated and synthesized published systematic reviews of evidence on the economic aspects of different models of delivering primary care services. Building on previous efforts, we adapted existing taxonomies of primary care components to classify our results according to four categories: coverage, financing, service delivery, and governance. FINDINGS We identified and classified 109 reviews that met our inclusion criteria according to our taxonomy of primary care components: coverage, financing, service delivery, and governance arrangements. A significant body of evidence suggests that several specific primary care arrangements, such as health workers' task shifting and telemedicine, can have positive economic impacts (such as lower overall health care costs). Notably absent were reviews on the impact of increasing primary care funding or the overall supply of primary care services. CONCLUSIONS There is a great opportunity for further research to systematically examine the broader economic impacts of investing in primary care services. Despite progress over the last decade, significant evidence gaps on the economic implications of different models of primary care services remain, which could help inform the basis of future research efforts.
Collapse
Affiliation(s)
- LORCAN CLARKE
- London School of Economics and Political Science
- Trinity College Dublin
| | | | | | | | | | - JENNA KERNS
- London School of Economics and Political Science
| | | | | | | | | | - HANS KLUGE
- World Health Organization Regional Office for Europe (WHO/Europe)
| | - ELIAS MOSSIALOS
- London School of Economics and Political Science
- Imperial College London
| |
Collapse
|
42
|
Martsolf GR, Kim DK, Germack HD, Harrison JM, Poghosyan L. Determinants of nurse practitioner independent panel management in primary care. J Nurse Pract 2021. [DOI: 10.1016/j.nurpra.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
43
|
Cuccovia BA, Heelan-Fancher L, Aronowitz T. A policy analysis of nurse practitioner scope of practice in Massachusetts. J Am Assoc Nurse Pract 2021; 34:410-417. [PMID: 34652300 DOI: 10.1097/jxx.0000000000000657] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 08/20/2021] [Indexed: 11/27/2022]
Abstract
ABSTRACT Nurse practitioner (NP) practice has evolved since inception of the role in 1965. Educational requirements have been standardized requiring a master's degree, yet variation in NPs scope of practice exists across the United States. As the population ages and more Americans have health insurance coverage, the demand for health care continues to increase. Shortages of clinical providers and changes in hospital models of care continue to burden the health care system. Nurse practitioners have been found to provide safe, high-quality patient care and are a potential solution to ease the burden on our health care system. Nurse practitioner scope of practice restrictions limit the ability for NPs to practice independently. The purpose of this article was to analyze the advanced practice registered nurse's (APRNs) scope of practice policy in Massachusetts (MA) where APRNs just recently obtained full practice authority. Legislation to remove NP scope of practice restrictions in MA had been presented several times but was met with resistance from physician advocacy groups stating that NPs lack the education requirements to practice independently. A recent report from the MA Health Policy Commission demonstrates the impact that NPs have on lowering health care costs and servicing individuals in underserved areas of the state. During the pandemic, restrictions on NP scope of practice in MA were temporarily removed. It was realized that if NPs can practice independently during a pandemic, then they certainly are competent to practice independently at other times. A reassessment of NP scope of practice to allow for full authority should be completed nationally.
Collapse
Affiliation(s)
| | | | - Teri Aronowitz
- UMass Medical School, Tan Chingfen Graduate School of Nursing, Boston, MA
| |
Collapse
|
44
|
Pittman P, Chen C, Erikson C, Salsberg E, Luo Q, Vichare A, Batra S, Burke G. Health Workforce for Health Equity. Med Care 2021; 59:S405-S408. [PMID: 34524235 PMCID: PMC8428843 DOI: 10.1097/mlr.0000000000001609] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Patricia Pittman
- Fitzhugh Mullan Institute for Health Workforce Equity, Milken Institute School of Public Health
| | - Candice Chen
- Fitzhugh Mullan Institute for Health Workforce Equity, Milken Institute School of Public Health
| | - Clese Erikson
- Fitzhugh Mullan Institute for Health Workforce Equity, Milken Institute School of Public Health
| | - Edward Salsberg
- Fitzhugh Mullan Institute for Health Workforce Equity, Milken Institute School of Public Health
| | - Qian Luo
- Fitzhugh Mullan Institute for Health Workforce Equity, Milken Institute School of Public Health
| | - Anushree Vichare
- Fitzhugh Mullan Institute for Health Workforce Equity, Milken Institute School of Public Health
| | - Sonal Batra
- Fitzhugh Mullan Institute for Health Workforce Equity, School of Medicine and Health Sciences, George Washington University, Washington, DC
| | - Guenevere Burke
- Fitzhugh Mullan Institute for Health Workforce Equity, School of Medicine and Health Sciences, George Washington University, Washington, DC
| |
Collapse
|
45
|
Geller DE, Swan BA. Recent evidence of nurse practitioner outcomes in a variety of care settings. J Am Assoc Nurse Pract 2021; 33:771-775. [PMID: 32649383 DOI: 10.1097/jxx.0000000000000451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/20/2020] [Indexed: 11/26/2022]
Abstract
ABSTRACT When nurse practitioners (NPs) work to expand their scope of practice through state legislatures, the opposing lobbying groups are often physician-led organizations. The main argument against NP independence and limited scope of practice is that NP care is inherently inferior to that of physicians. However, more than three decades of research demonstrates quality and cost outcomes to be equal to or better than that of physicians. This article reviews a wide range of evidence documenting NP competency, satisfaction, and safety, as well as the challenges and consequences when limiting NP scope of practice. The evidence is clear and has not changed in over 30 years, NPs provide access to effective primary care in a variety of settings, equal in quality outcomes, safety, and cost-effectiveness compared with physicians.
Collapse
Affiliation(s)
- Daniel E Geller
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | | |
Collapse
|
46
|
Liu DH, Ge M, Smith SS, Park C, Ference EH. Geographic Distribution of Otolaryngology Advance Practice Providers and Physicians. Otolaryngol Head Neck Surg 2021; 167:48-55. [PMID: 34428088 DOI: 10.1177/01945998211040408] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Advanced practice providers (APPs), namely physician assistants (PAs) and nurse practitioners (NPs), play an increasing role in meeting growing demands for otolaryngologic services, particularly in rural communities. This study analyzes the geographic distribution of otolaryngology providers, which is essential to addressing future demands. STUDY DESIGN Cross-sectional study. SETTING Medicare Provider Utilization and Payment Data for 2017. METHODS Current Procedural Terminology codes were used to identify APPs providing 10 common otolaryngologic services. Geographic distribution was evaluated by calculating densities of APPs and otolaryngologists per 100,000 persons in urban versus rural counties as defined by the National Center for Health Statistics Urban-Rural Classification Scheme. RESULTS We identified cohorts of 8573 otolaryngologists, 1148 NPs, and 895 PAs. There were significantly higher population-controlled densities of otolaryngologists and APPs in urban counties as compared with rural counties. The majority of otolaryngologists (92.1%) and APPs (83.3%) were in urban counties. However, the proportion of APPs (16.7%) in rural counties was significantly higher than the proportion of otolaryngologists (7.9%) in rural counties (P < .01). A significant majority of rural counties (72.2%) had zero identified providers, and a greater proportion of rural counties (5.0%) were served exclusively by APPs as compared with urban counties (3.2%). CONCLUSIONS Although otolaryngologists and APPs mostly practiced in urban counties, a relatively higher proportion of APPs practiced in rural counties when compared with otolaryngology physicians. The majority of rural counties did not have any otolaryngologic providers. Given the expected shortages of otolaryngology physicians, APPs may play a critical role in addressing these gaps in access.
Collapse
Affiliation(s)
- Derek H Liu
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Marshall Ge
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Stephanie Shintani Smith
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Christine Park
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Elisabeth H Ference
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| |
Collapse
|
47
|
Gigli KH, Martsolf GR. Implications of State Scope-of-Practice Regulations for Pediatric Intensive Care Unit Nurse Practitioner Roles. Policy Polit Nurs Pract 2021; 22:221-229. [PMID: 34129414 PMCID: PMC10024928 DOI: 10.1177/15271544211021049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
Collapse
Affiliation(s)
- Kristin H. Gigli
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, United States
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Grant R. Martsolf
- Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, United States
- RAND Corporation, Pittsburgh, Pennsylvania, United States
| |
Collapse
|
48
|
Alignment of Nurse Practitioner Educational Preparation and Scope of Practice in United States Emergency Departments: A Systematic Review of the Literature. J Emerg Nurs 2021; 47:563-581. [PMID: 34275527 DOI: 10.1016/j.jen.2021.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/19/2021] [Accepted: 04/21/2021] [Indexed: 11/20/2022]
Abstract
INTRODUCTION National debate persists surrounding the expanded use of nurse practitioners in the emergency department. Current understanding of the alignment of nurse practitioner educational preparation and practice parameters in United States emergency departments is inchoate. The objective of this review was to seek evidence to support that nurse practitioner education and training align with current practices in the emergency department. METHODS A Preferred Reporting Items for Systematic Reviews and Meta-Analyses guided systematic review of the existing literature was conducted of 4 relevant databases. Level of evidence and quality assignments were made for each article using Grading of Recommendations, Assessment, Development, and Evaluation or Confidence in Evidence from Reviews of Qualitative Research as appropriate. RESULTS Nurse practitioners are increasingly staffing emergency departments, providing care to both patients classified as high-acuity and low-acuity. Reports of nurse practitioner scope of practice vary widely. No studies evaluated alignment of educational preparation and training for actual clinical practice. DISCUSSION This review of the literature was inconclusive, and the review team we was unable to find evidence that supports the alignment of nurse practitioner educational preparation and training with scope of clinical practice in United States emergency departments. Future research should seek to articulate the landscape of nurse practitioner academic preparation for specialty practice in the emergency department and to specifically examine the alignment of educational preparation with scope of practice and impact on clinical outcomes of patients seen in the emergency department.
Collapse
|
49
|
Timmons EJ, Norris C, Martsolf G, Poghosyan L. Estimating the Effect of the New York State Nurse Practitioners Modernization Act on Care Received by Medicaid Patients. Policy Polit Nurs Pract 2021; 22:212-220. [PMID: 33990171 DOI: 10.1177/15271544211018152] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The demand for primary care services may surpass the supply of primary care providers, exacerbating challenges with access, quality, and cost in the U.S. health care system. Expanding the supply of, and access to, nurse practitioner (NP) care has been proposed as one method to alleviate these challenges. New York State (NYS) changed its regulatory environment for NPs in 2015. We estimate the impact of expanded NP scope of practice (SOP) regulations in NYS on total care days received by Medicaid beneficiaries from 2015 to 2018 using a model derived from national historical data from 1999 to 2011. We used a longitudinal data policy analysis framework and a generalized difference-in-differences model to identify the effect of changes in NP SOP regulations on total care days. The model included controls for state income and unemployment rates. Our results suggest that the policy change increased total care days provided to patients, but that this difference was not statistically significant and became negligible after computing the number of days per beneficiary. In addition, our results suggest that had NYS moved to a full practice environment, more care days could have been provided to Medicaid patients, and this difference was found to be statistically significant. Our results suggest that states should adopt full NP SOP practice environments to realize measurable benefits of expanded NP SOP.
Collapse
Affiliation(s)
- Edward Joseph Timmons
- Department of Business Administration, Saint Francis University, Loretto, Pennsylvania, United States
| | - Conor Norris
- Department of Business Administration, Saint Francis University, Loretto, Pennsylvania, United States
| | - Grant Martsolf
- School of Nursing, University of Pittsburgh, Pennsylvania, United States
| | - Lusine Poghosyan
- School of Nursing, Columbia University, New York, New York, United States
| |
Collapse
|
50
|
Kodi S M, Sharma SK. Realities, scope, challenges, and facilitators for implementation of nurse practitioner's role in India: A review. Int J Nurs Sci 2021; 8:237-242. [PMID: 33997140 PMCID: PMC8105548 DOI: 10.1016/j.ijnss.2021.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 03/01/2021] [Accepted: 03/03/2021] [Indexed: 11/29/2022] Open
Abstract
India is in dire need of an alternative to general medical practitioners to overcome a severe shortage of doctors, especially in rural and underprivileged regions. Empowering nurses through nurse practitioner (NP) role is the superlative solution to provide quality health care in primary care setting. Based on conceptions and research findings of the NP’ s role, we analyzed and examined the realities, scope, and barriers for implementing the NP’ s role in India and propose future strategies to create a NP cadre.
Collapse
Affiliation(s)
- Malar Kodi S
- Department of Nursing, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Suresh K Sharma
- Department of Nursing, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| |
Collapse
|