Nurse practitioner organizational climate in primary care settings: implications for professional practice

Nurse Practitioner Work Environment and Rural Primary Care for Substance Use

We examined the relationship between the nurse practitioner (NP) work environment and realized access (i.e., utilization) to primary care among rural older adults with substance use disorders (SUD). We analyzed cross-sectional NP survey data merged with Medicare claims and utilized fractional logistic regression. With one unit improvement in NP work environment, the odds of having older adults with SUDs in the practice increased by 20% (adjusted odds ratio=1.20, 95% confidence interval=1.01-1.44, p=0.04). Favorable work environments for NPs, including organizational support, collegiality, and role visibility, are associated with increased realized access to primary care among rural older adults with SUDs.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Nurse practitioners, physician assistants, and trust: A systematic review

BACKGROUND

The use of physician extenders (e.g., nurse practitioners [NPs] and physician assistants [PAs]) has risen in recent years in the U.S. health care domain, yet some scholars have questioned if physician extenders are being fully utilized in the health care field.

PURPOSES

The purpose of this research was to conduct a systematic review to determine if trust in the NP/PA might be influential in the ways these professionals are utilized. We view trust through the lens of Mayer et al. and their model of organizational trust, and we seek to examine how patients, physicians, and NPs/PAs themselves view one another.

METHODS

This systematic review spanned from 1996 to 2022 and applied the Preferred Reporting Items for Systematic Reviews and Meta-Analyses strategy. The final sample consisted of 29 articles.

RESULTS

The findings point to how the antecedents of trust according to Mayer et al.; i.e., trustee's ability, benevolence, and integrity) influence the trusting relationships between patients and NPs/PAs and between physicians and NPs/PAs. Consequences and outcomes of trust are also discussed. Importantly, a trustor's propensity to trust and repeat interactions over time (e.g., feedback loop) is influential to trusting relationships.

PRACTICE IMPLICATIONS

These findings offer health care organizations insight into the mechanisms for building trust as physician extenders become more prominent in the health care field.

Burnout, job satisfaction, and turnover intention among primary care nurse practitioners with their own patient panels

BACKGROUND

Nurse practitioners (NPs) can enhance NP care and improve access to care by autonomously managing their patient panels. Yet, its impact on workforce outcomes such as burnout, job satisfaction, and turnover intention remains unexplored.

PURPOSE

To estimate the impact of NP panel management on workforce outcomes.

METHODS

Structural equation modeling was conducted using survey data from 1,244 primary care NPs. NP panel management was categorized into co-managing patients with other providers, both co-managing and autonomously managing, and fully autonomous management.

DISCUSSION

Fully autonomous management led to more burnout than co-managing (B = 0.089, bias-corrected 95% bootstrap confidence interval [0.028, 0.151]). Work hours partially (27%) mediated this relationship. This findings indicate that greater autonomy in panel management among NPs may lead to increased burnout, partially due to longer work hours.

CONCLUSION

Interventions to reduce work hours could help NPs deliver quality care without burnout.

Practice Environment and Workforce Outcomes of Nurse Practitioners in Community Health Centers

The nurse practitioner (NP) workforce in community health centers (CHCs) increases access to primary care for underserved populations. Working with medically complex patients, high workloads, and low resources in the CHC setting, CHC NPs may be susceptible to poor workforce outcomes. This study uses NP survey data collected from 6 US states to describe and assess the relationship between CHC NP practice environment and burnout, job satisfaction, and turnover intention. CHC NPs rated their practice environments favorably, and more than 89% of CHC NPs reported satisfaction with their job. Better rating of NPs' relationship with CHC administration was associated with improved job satisfaction and decreased turnover intention.

A framework of the institutional policies and practice environments of nurse practitioner primary care models: A cross-case analysis

PURPOSE

The purpose of this article was to compare the implementation of distinct models of nurse practitioner (NP) integration into primary care offices.

DESIGN/METHODOLOGY

A multiple case study design of three NP primary care practice models allowed for in-depth exploration of the management processes supporting the utilization of NPs. At each site, semistructured qualitative interviews, document review, and site tours/observations were conducted and subject to cross-case analysis guided by the NP Primary Care Organizational Framework (NP-PCOF)-developed for this study based on existing theory.

RESULTS

Our case study sites represent three distinct NP primary care models. In the restricted practice model, NPs care for same-day/walk-in acute patients. NPs in the independent practice model have an independent panel of patients and interact collegially as independent coworkers. NPs in the comanagement model function on a team (a physician and two NPs), have a team office space, collectively care for a shared panel of patients, and can earn financial bonuses contingent upon meeting team quality metrics. Our cross-case analysis confirmed differences in physical space design, the relational structure of a workplace, and the capacity for innovation via NP compensation and performance metrics across different NP primary care models.

CONCLUSION

Our findings suggest that NP primary care models are supported by complex management systems and the NP-PCOF is a tool to help understand this complexity.

IMPLICATIONS

The NP-PCOF is a framework to understand the management systems that facilitate the utilization of NPs within primary care organizations.

State responses to COVID-19: Potential benefits of continuing full practice authority for primary care nurse practitioners

BACKGROUND

During the COVID-19 pandemic, federal and state governments removed the scope of practice restrictions on nurse practitioners (NPs), allowing them to deliver care to patients without restrictions.

PURPOSE

To support policy makers' efforts to grant full practice authority to NPs beyond the COVID-19 pandemic, this manuscript summarizes the existing evidence on the benefits of permanently removing state-level scope of practice barriers and outline recommendations for policy, practice, and research.

METHODS

We have conducted a thorough review of the existing literature.

FINDINGS

NP full scope of practice improves access and quality of care and leads to better patient outcomes. It also has the potential to reduce health care cost.

DISCUSSION

The changes to support full practice authority enacted to address COVID-19 are temporary. NP full practice authority could be part of a longer-term plan to address healthcare inequities and deficiencies rather than merely a crisis measure.

Organizational facilitators and barriers to optimal APRN practice: An integrative review

BACKGROUND

The organizational environment can foster or impede full deployment of advance practice registered nurses (APRNs), affecting the quality of care and patient outcomes. Given the critical role APRNs play in health care, it is important to understand organizational factors that promote or hinder APRN practice to maximize the potential of this workforce in health care systems.

PURPOSE

The aim of this study was to synthesize evidence about APRN practice environments, identify organizational facilitators and barriers, and make recommendations for better APRN utilization.

METHODS

A literature search was conducted in CINAHL, PubMed, and PsychInfo, yielding 366 studies. No time or geographic limitations were applied. Study quality was appraised using the National Institutes of Health National Heart, Lung, and Blood Institute Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies and The Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Studies.

RESULTS

Thirty studies conducted in the United States, Canada, and the Netherlands met inclusion criteria. The majority of the studies involved nurse practitioners. Facilitators to optimal practice environment were autonomy/independent practice and positive physician/APRN relations. Barriers included policy restrictions on practice, poor physician relations, poor administrator relations, and others' lack of understanding of the APRN role. Barriers correlate with job dissatisfaction and increased intent to leave job.

PRACTICE IMPLICATIONS

The review highlights the importance of physician and administration relations, organizational-level policies, and colleagues' understanding of the APRN role in promoting effective practice environments. Organizations should align policy reform efforts with factors that foster positive APRN practice environments to efficiently and effectively utilize this increasingly vital workforce. Future research is warranted.

Primary care nurse practitioner burnout and perceptions of quality of care

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Primary care Practice Environment and Burnout among Nurse Practitioners

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

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

As nurse practitioners (NPs) are increasingly relied on to deliver primary care in rural communities, it is critical to understand the contexts in which they work and whether they are characterized by work environments and infrastructures that facilitate the provision of high-quality patient care. This study compares urban and rural NPs using data from a survey of 1,244 primary care NPs in Arizona, California, New Jersey, Pennsylvania, Texas, and Washington. While rural and urban NPs have a number of similarities in terms of demographic characteristics, practice patterns, and job outcomes, they also have noteworthy differences. Rural NPs report higher levels of independent practice, fewer structural capabilities that facilitate quality care, and poorer relationships with physicians. Health care organizations in rural communities may need to invest in work environments and infrastructures that facilitate high-quality care and autonomous practice for NPs.

Role of Nurse Practitioners in Caring for Patients With Complex Health Needs

OBJECTIVE

The objective of this study was to estimate trends in the percentage of Medicare beneficiaries cared for by nurse practitioners from 2012 to 2017, to characterize beneficiaries cared for by nurse practitioners in 2017, and to examine how the percentage of beneficiaries cared for by nurse practitioners varies by practice characteristics.

DESIGN

An observational study of 2012-2017 Medicare fee-for-service beneficiaries' ambulatory visits. We computed the percentage of beneficiaries with 1 or more ambulatory visits from nurse practitioners and the percentage of beneficiaries receiving the plurality of their ambulatory visits from a nurse practitioner versus a physician (ie, predominant provider). We compared beneficiary demographics, clinical characteristics, and utilization by the predominant provider. We then characterized the predominant provider by practice characteristics.

KEY RESULTS

In 2017, 28.9% of beneficiaries received any care from a nurse practitioner and 8.0% utilized nurse practitioners as their predominant provider-an increase from 4.4% in 2012. Among beneficiaries cared for by nurse practitioners in 2017, 25.9% had 3 or more chronic conditions compared with 20.8% of those cared for by physicians. Beneficiaries cared for in practices owned by health systems were more likely to have a nurse practitioner as their predominant provider compared with those attending practices that were independently owned (9.3% vs. 7.0%).

CONCLUSIONS

Nurse practitioners are caring for Medicare beneficiaries with complex needs at rates that match or exceed their physician colleagues. The growing role of nurse practitioners, especially in health care systems, warrants attention as organizations embark on payment and delivery reform.

Optimal staffing in community health centers to improve quality of care

OBJECTIVE

To explore optimal workforce configurations in the production of care quality in community health centers (CHCs), accounting for interactions among occupational categories, as well as contributions to the volume of services.

DATA SOURCES

We linked the Uniform Data System from 2014 to 2016 with Internal Revenue Service nonprofit tax return data. The final database contained 3139 center-year observations from 1178 CHCs.

STUDY DESIGN

We estimated a system of two generalized linear production functions, with quality of care and volume of services as outputs, using the average percent of diabetic patients with controlled A1C level and hypertensive patients with controlled blood pressure as quality measures. To explore the substitutability and complementarity between staffing categories, we estimated a revenue function.

FINDINGS

Primary care physicians and advanced practice clinicians achieve similar quality outcomes (3.2 percent and 3.0 percent improvement in chronic condition management per full-time equivalent (FTE), respectively). Advanced practice clinicians generate less revenue per FTE but are generally less costly to employ.

CONCLUSION

As quality incentives are further integrated into payment systems, CHCs will need to optimize their workforce configuration to improve quality. Given the relative efficiency of advanced practice clinicians in producing quality, further hiring of these professionals is a cost-effective investment for CHCs.

Delegating home visits in general practice: a realist review on the impact on GP workload and patient care

BACKGROUND

UK general practice is being shaped by new ways of working. Traditional GP tasks are being delegated to other staff with the intention of reducing GPs' workload and hospital admissions, and improving patients' access to care. One such task is patient-requested home visits. However, it is unclear what impact delegated home visits may have, who might benefit, and under what circumstances.

AIM

To explore how the process of delegating home visits works, for whom, and in what contexts.

DESIGN AND SETTING

A review of secondary data on home visit delegation processes in UK primary care settings.

METHOD

A realist approach was taken to reviewing data, which aims to provide causal explanations through the generation and articulation of contexts, mechanisms, and outcomes. A range of data has been used including news items, grey literature, and academic articles.

RESULTS

Data were synthesised from 70 documents. GPs may believe that delegating home visits is a risky option unless they have trust and experience with the wider multidisciplinary team. Internal systems such as technological infrastructure might help or hinder the delegation process. Healthcare professionals carrying out delegated home visits might benefit from being integrated into general practice but may feel that their clinical autonomy is limited by the delegation process. Patients report short-term satisfaction when visited by a healthcare professional other than a GP. The impact this has on long-term health outcomes and cost is less clear.

CONCLUSION

The delegation of home visits may require a shift in patient expectation about who undertakes care. Professional expectations may also require a shift, having implications for the balance of staffing between primary and secondary care, and the training of healthcare professionals.

Organizational Support for Nurse Practitioners in Primary Care and Workforce Outcomes

BACKGROUND

Lack of organizational support in healthcare settings has been linked to high levels of clinician stress, burnout, and job dissatisfaction. Little research exists on organizational support for nurse practitioners.

OBJECTIVE

We investigated the relationship between organizational support and nurse practitioner outcomes, including job satisfaction, intent to leave, and quality of care.

METHODS

A cross-sectional survey design was used to collect survey data from nurse practitioners (n = 398) in primary care practices in New York State in 2017. Nurse practitioners completed mail surveys with validated measures of organizational support, job satisfaction, intent to leave, and quality of care. Information on participant demographics and work characteristics was also collected. Multilevel regression models assessed the relationship between organizational-level organizational support and resources measure and job satisfaction, intent to leave, and quality of care.

RESULTS

The organizational-level organizational support and resources measure had a mean of 3.31 on a 4-point scale. Twenty-five percent of the participants were either moderately dissatisfied or very dissatisfied with their jobs, and about 11% intended to leave their current jobs within 1 year. The average quality of care rated by participants was 8.51 out of 10-10 being the best quality of care. After adjusting for covariates, higher organizational-level organizational support and resources measure score was associated with higher job satisfaction category, lower odds of intent to leave, and higher quality of care.

DISCUSSION

Nurse practitioners from primary care practices with higher levels of organizational support are more likely to be satisfied with their jobs, have less intent to leave their jobs, and report better quality of care. Thus, in order to promote nurse practitioner job satisfaction, retain them in clinical positions, and improve quality of care, administrators should take actions to promote organizational support for them. Our findings are consistent with existing literature regarding the relationship between organizational support and clinician outcomes.

Perspectives of Quebec Primary Health Care Nurse Practitioners on Their Role and Challenges in Chronic Disease Management: A Qualitative Study

BACKGROUND

Primary health care nurse practitioners (PHCNPs) can play a key role in chronic disease management. However, little is known about the challenges they face.

PURPOSE

The study aimed to describe PHCNPs' perspectives on their role for patients with chronic health conditions, the barriers they face, and facilitating factors.

METHODS

A qualitative descriptive exploratory study was conducted with 24 PHCNPs in the Canadian province of Quebec.

RESULTS

PHCNPs believe that they are in an optimal position to address the needs of patients with chronic health conditions, especially in providing self-management support. However, PHCNPs reported feeling pressured to practice according to a biomedical model and to constantly defend their role in chronic disease management. They feel that they are frequently being diverted from their role to compensate for the lack of family doctors. PHCNPs made concrete recommendations to optimize their autonomous practice and quality of care: promoting strong interprofessional communication skills, genuine mentoring relationships between PHCNPs and partner physicians, managers upholding the full scope of PHCNPs' practice, and a more flexible legislative framework.

CONCLUSIONS

The original conception of PHCNPs as health professionals with unique characteristics is at stake. The factors that should be targeted to support the autonomy of PHCNPs were identified.

Where are we now? Practice-level utilization of nurse practitioners in comparison with state-level regulations

BACKGROUND AND PURPOSE

Full practice authority for nurse practitioners (NPs) is optimal for high-quality, cost-effective health care. However, a complete picture of utilization after states have adopted full practice authority needs to be determined. The purpose of this examination was to review the evidence regarding practice-level utilization (PLU) of NP PLU in comparison to state-level regulations (SLRs).

METHODS

Studies published in English and based on US populations were identified through PubMed, CINAHL, and Scopus (January 1, 1989-December 31, 2018), and bibliographies of retrieved articles. Of the 419 articles identified with these limits, 19 (5%) met all inclusion and exclusion criteria.

CONCLUSIONS

Four categories of PLU were identified: billing practices, level of supervision, privileges, and prescriptive authority. Significant differences were seen between urban versus rural NPs and primary care versus specialty NPs. Thirteen of the 19 studies did not specifically address the SLR of the included sample.

IMPLICATIONS FOR PRACTICE

No studies described the type of NP certification, practice specialty, and utilization, and compared all to the SLR. There is a need for more evidence concerning PLU of NPs across the tiers of SLR. Only then can health care organizations, political leaders, and other stakeholders have the information needed to proceed with beneficial practice-model changes.

Nurse practitioner primary care organizational climate questionnaire: Item response theory and differential item functioning

AIMS AND OBJECTIVES

To validate Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ) items using item response theory (IRT) models and conduct differential item functioning (DIF) analysis to test the item functioning among nurse practitioners (NPs) practicing in different U.S. states with variable regulations governing NP practice.

BACKGROUND

Nurse Practitioner Primary Care Organizational Climate Questionnaire is the only NP-specific tool measuring NP work environment and is being used in different U.S. states with variable NP scope of practice regulations and internationally to produce evidence about NP work environments within their organisations.

DESIGN

Cross-sectional survey design was used to collect data from 278 primary care NPs in New York (NY) and 314 NPs in Massachusetts (MA).

METHODS

NPs completed the 29-item NP-PCOCQ. Data collection involved an online survey in NY and a mail survey in MA in 2012. We used Samejima's graded response model for IRT and ordinal logistic regression for DIF analysis. A STROBE checklist was completed.

RESULTS

IRT models yielded discrimination parameters ranging from 0.98-4.65 in NY and 1.25-6.94 in MA. Item difficulty parameters were within -3 to +3 range, suggesting a fair range of item difficulties exist in the scale. Only five of the 29 items on NP-PCOCQ exhibited DIF, suggesting some other state-related factor besides the measured construct influenced item responses; thus, the items were removed.

CONCLUSION

Our findings indicate that a shortened, 24-item NP-PCOCQ is capable of measuring organisational climate of NPs practicing in different U.S. states. NP-PCOCQ can be used in future research to measure NP work environment.

RELEVANCE TO CLINICAL PRACTICE

The tool can also be used by practice administrators to assess NP work environment and identify deficiencies to address them. This evidence about NP work environment can be used by practice administrators to promote favourable work environments for NPs to deliver high-quality care.

Nurse Practitioner Practice Environments in Primary Care and Quality of Care for Chronic Diseases

BACKGROUND

The chronic disease burden in the United States represents a significant challenge for the primary care system. The nurse practitioner (NP) workforce can help meet the demand for care; however, organizational barriers such as poor practice environments prevent NPs from delivering high quality care.

OBJECTIVES

We investigated the relationship between NP practice environments and quality of care for chronic diseases.

RESEARCH DESIGN

We fit regression models to assess cross-sectional associations between claims-based quality measure performance and survey data on NP practice environments in Massachusetts.

SUBJECTS

We used survey data from 221 primary care NPs from 118 practices. We obtained quality of care data for patients with asthma, diabetes, and cardiovascular disease.

MEASURES

The Nurse Practitioner Primary Care Organizational Climate Questionnaire was used to measure practice environments with its following 4 subscales: NP-Physician Relations, Independent Practice and Support, Professional Visibility, and NP-Administration Relations. Three Healthcare Effectiveness Data and Information Set measures were used to evaluate the quality of care.

RESULTS

A 1-SD increase in the organizational-level NP-Administration Relations subscale score was associated with a near doubling of the odds of receiving medication management for asthma. A 1-SD increase in the organizational-level Independent Practice and Support subscale score was associated with a 60% increase in the odds of receiving recommended screening for cardiovascular disease. There was no impact on diabetes care measure.

CONCLUSIONS

NP practice environment affected the quality of care for 2 chronic conditions. Efforts should be implemented to improve NP practice environment to potentially improve care quality.

An educational intervention to enhance nurse practitioner role transition in the first year of practice

BACKGROUND AND PURPOSE

Role transition is a natural process that occurs when the registered nurse pursues additional education to become a nurse practitioner (NP). Role transition generates feelings of anxiety and insecurity, leading to a longer and more tumultuous adjustment. This study investigated whether an evidence-based role transition webinar would support NP role transition during this critical period.

METHODS

This study was a nonrandomized, pretest-posttest, and single-group study using a convenience sample to address the research question: "Does completion of a role transition webinar enhance the perception of new NPs of their ability to perform well in their role?"

CONCLUSIONS

The educational webinar was shown to have a positive influence on some aspects of the participant's reported perceptions of NP role transition. Having practical and assessable educational interventions to optimize NP role transition and determining factors that contribute to the success of these interventions would be prudent.

IMPLICATIONS FOR PRACTICE

This is the first quantitative study to investigate the positive association between an online educational intervention and NP role transition. A timelier and less tumultuous transition would allow NPs to perform more effectively in their new role.

Transformational leadership to promote nurse practitioner practice in primary care

AIM

This study investigated transformational leadership from the perspectives of primary care nurse practitioners.

BACKGROUND

The growing workforce of nurse practitioners in the United States could play a critical role in meeting the increasing demand for primary care. Little is known about how leadership within primary care practices could promote nurse-practitioner care. Transformational leadership is a widely recognized leadership style that affects clinician practice and outcomes.

METHOD

A cross-sectional survey design was used to collect data from nurse practitioners in New York state in 2012. The online survey containing measures of nurse practitioners and leadership relationships was completed by 278 nurse practitioners.

RESULTS

The four factors of transformational leadership-idealized influence, inspirational motivation, intellectual stimulation, and individual consideration-were recognized by nurse practitioners. Almost half of nurse practitioners reported that leadership did not share information equally between nurse practitioners and physicians (idealized influence), and 45.9% reported that nurse practitioners were not represented on important organisational committees (intellectual stimulation).

CONCLUSION

Transformational leadership can be applied to promote nurse practitioner practice in primary care. Future research should explore how transformational leadership affects nurse practitioner care and outcomes.

IMPLICATIONS FOR NURSING MANAGEMENT

Leaders in primary care practices should consider applying transformational leadership principles to promote nurse practitioner practice.

Nurse Practitioners and Interdisciplinary Teams in Pediatric Critical Care

Objective:

To describe the members of pediatric intensive care unit interdisciplinary provider teams and labor inputs, working conditions, and clinical practice of pediatric intensive care unit nurse practitioners.

Methods:

A national, quantitative, crosssectional, descriptive postal survey of pediatric intensive care unit medical directors and nurse practitioners was administered to gather information about provider-team members, pediatric intensive care unit nurse practitioner labor inputs, working conditions, and clinical practice. Descriptive statistics, cross-tabulations, and χ2 tests were used.

Results:

Responses from 97 pediatric intensive care unit medical directors and 59 pediatric intensive care unit nurse practitioners representing 126 institutions were received. Provider-team composition varied between institutions with and without nurse practitioners. Pediatric intensive care units employed an average of 3 full-time nurse practitioners; the average nurse practitioner-to-patient ratio was 1 to 5. The clinical practice reported by medical directors was consistent with practice reported by nurse practitioners.

Conclusion:

Nurse practitioners are integrated into interdisciplinary pediatric intensive care unit teams, but institutional variation in team composition exists. Investigating models of care contributes to the understanding of how models influence positive patient and organizational outcomes and may change future role implementation.

Skill mix change between general practitioners, nurse practitioners, physician assistants and nurses in primary healthcare for older people: a qualitative study

Background

More and more older adults desire to and are enabled to grow old in their own home, regardless of their physical and mental capabilities. This change, together with the growing number of older adults, increases the demand for general practitioners (GPs). However, care for older people lacks prestige among medical students and few medical students are interested in a career in care for older people. Innovative solutions are needed to reduce the demand for GPs, to guarantee quality of healthcare and to contain costs. A solution might be found in skill mix change by introducing nurse practitioners (NPs), physician assistants (PAs) or registered nurses (RNs). The aim of this study was to describe how skill mix change is organised in daily practice, what influences it and what the effects are of introducing NPs, PAs or RNs into primary healthcare for older people.

Methods

In total, 34 care providers working in primary healthcare in the Netherlands were interviewed: GPs (n = 9), NPs (n = 10), PAs (n = 5) and RNs (n = 10). Five focus groups and 14 individual interviews were conducted. Analysis consisted of open coding, creating categories and abstraction.

Results

In most cases, healthcare for older people was only a small part of the tasks of NPs, PAs and RNs; they did not solely focus on older people. The tasks they performed and their responsibilities in healthcare for older people differed between, as well as within, professions. Although the interviewees debated the usefulness of proactive structural screening on frailty in the older population, when implemented, it was also unclear who should perform the geriatric assessment. Interviewees considered NPs, PAs and RNs an added value, and it was stated that the role of the GP changed with the introduction of NPs, PAs or RNs.

Conclusions

The roles and responsibilities of NPs, PAs and RNs for the care of older people living at home are still not established. Nonetheless, these examples show the potential of these professionals. The establishment of a clear vision on primary healthcare for older people, including the organisation of proactive healthcare, is necessary to optimise the impact of skill mix change.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0746-1) contains supplementary material, which is available to authorized users.

NP and PA Privileging in Acute Care Settings: Do Scope of Practice Laws Matter?

As hospitals’ interest in nurse practitioners (NPs) and physician assistants (PAs) grows, their leadership is eager to know how their medical staffing privileging policies for these professionals compare to peer hospitals. This study assesses the extent of variation of these policies in four clinical areas and examines whether the differences are associated with state scope of practice laws for NPs and PAs. We also examine the relationship of NP and PA privileging policies to each other. Our analysis finds no evidence that hospital privileging is associated with state scope of practice, and indeed within-state variation is more significant than cross-state variation. We also find a strong correlation between NP and PA privileging in all four clinical areas. These results suggest the need for additional research to understand the institutional-level variables and human dynamics at the level of medical staffing committees that may explain the dramatic variation in privileging policies and, ultimately, the effects of different privileging levels on costs and quality.

Practice environments and job satisfaction and turnover intentions of nurse practitioners: Implications for primary care workforce capacity

BACKGROUND

Health care professionals, organizations, and policy makers are calling for expansion of the nurse practitioner (NP) workforce in primary care to assure timely access and high-quality care. However, most efforts promoting NP practice have been focused on state level scope of practice regulations, with limited attention to the organizational structures.

PURPOSE

We examined NP practice environments in primary care organizations and the extent to which they were associated with NP retention measures.

METHODOLOGY

Data were collected through mail survey of NPs practicing in 163 primary care organizations in Massachusetts in 2012. NP practice environment was measured by the Nurse Practitioner Primary Care Organizational Climate Questionnaire, which has four subscales: Professional Visibility, NP-Administration Relations, NP-Physician Relations, and Independent Practice and Support. Two global items measured job satisfaction and NPs' intent to leave their job. We aggregated NP level data to organization level to attain measures of practice environments. Multilevel logistic regression models were used.

FINDINGS

NPs rated the relationship between NPs and physicians favorably, contrary to the relationship between NPs and administrators. All subscales measuring NP practice environment had similar influence on the outcome variables. With every unit increase in each standardized subscale score, the odds of job satisfaction factors increased about 20% whereas the odds of intention of turnover decreased about 20%. NPs from organizations with higher mean scores on the NP-Administration subscale had higher satisfaction with their jobs (OR = 1.24, 95% CI [1.12, 1.39]) and had lower intent to leave (OR = 0.79, 95% CI [0.70, 0.90]).

PRACTICE IMPLICATIONS

NPs were more likely to be satisfied with their jobs and less likely to report intent to leave if their organizations support NP practice, favorable relations with physicians and administration, and clear role visibility. Creating productive practice environments that can retain NPs is a potential strategy for increasing the primary care workforce capacity.

Collaboration in teams with nurse practitioners and general practitioners during out-of-hours and implications for patient care; a qualitative study

BACKGROUND

Increasingly, nurse practitioners (NPs) are deployed in teams along with general practitioners (GPs) to help meet the demand for out-of-hours care. The purpose of this study was to explore factors influencing collaboration between GPs and NPs in teams working out-of-hours.

METHODS

A descriptive qualitative study was done using a total of 27 semi-structured interviews and two focus group discussions. Data was collected between June, 2014 and October, 2015 at an out-of-hours primary care organisation in the Netherlands. Overall, 38 health professionals (GPs, NPs, and support staff) participated in the study. The interviews were audio-taped and transcribed verbatim. Two researchers conducted an inductive content analysis, involving the identification of relevant items in a first phase and clustering into themes in a second phase.

RESULTS

The following four themes emerged from the data: clarity of NP role and regulation, shared caseload and use of skills, communication concerning professional roles, trust and support in NP practice. Main factors influencing collaboration between GPs and NPs included a lack of knowledge regarding the NPs' scope of practice and regulations governing NP role; differences in teams in sharing caseload and using each other's skills effectively; varying support of GPs for the NP role; and limited communication between GPs and NPs regarding professional roles during the shift. Lack of collaboration was perceived to result in an increased risk of delay for patients who needed treatment from a GP, especially in teams with more NPs. Collaboration was not perceived to improve over time as teams varied across shifts.

CONCLUSION

In out-of-hours primary care teams constantly change and team members are often unfamiliar with each other or other's competences. In this environment, knowledge and communication about team members' roles is continuously at stake. Especially in teams with more NPs, team members need to use each other's skills to deliver care to all patients on time.

Nurse practitioners as primary care providers with their own patient panels and organizational structures: A cross-sectional study

BACKGROUND

Health care systems globally are facing challenges of meeting the growing demand for primary care services due to a shortage of primary care physicians. Policy makers and administrators are searching for solutions to increase the primary care capacity. The effective utilization of nurse practitioners (NPs) has been proposed as a solution. However, organizations utilize NPs in variable capacities. In some settings, NPs serve as primary care providers delivering ongoing continuous care to their patients, referred to as patient panels, whereas in other settings they deliver episodic care. Little is known about why organizations deploy NPs differently.

OBJECTIVES

Investigate the NP role in care delivery-primary care providers with the own patient panels or delivering episodic care-within their organizations and understand how work environments affect their role.

DESIGN

A cross-sectional survey design was used to collect data from primary care NPs.

SETTINGS

The study was conducted in one state in the United States (Massachusetts). Data from 163 primary care organizations was obtained, which employed between one to 12 NPs.

PARTICIPANTS

807 NPs recruited from the Massachusetts Provider Database received mail surveys; 314 completed and returned the survey, yielding a response rate of 40%.

METHODS

The survey contained measures of NP role in care delivery and work environment. NP role was measured by an item asking NPs to report if they deliver ongoing continuous care to their patient panel or if they do not have patient panel. The work environment was measured with the Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ). The multilevel Cox regression models investigated the influence of organization-level work environment on NP role in care delivery.

RESULTS

About 45% of NPs served as primary care providers with their own patient panel. Organization-level Independent Practice and Support subscale, an NP-PCOCQ subscale, had a significant positive effect on NP role (risk ratio=2.33; 95% CI: 1.06-5.13); with a one unit increase on this subscale, the incidence of the NPs serving as primary care providers with their own patient panel doubled.

CONCLUSIONS

NPs can help meet the increasing demand for primary care by taking responsibilities as primary care providers, and organizations can assign NPs their own patient panels. Supporting NP independent practice within organizations promotes NP role as primary care providers. Policy and organizational change focused on promoting NP work environments so NPs can practice as primary care providers can be an effective strategy to increase the primary care capacity.

Does the Regulatory Environment Affect Nurse Practitioners' Patterns of Practice or Quality of Care in Health Centers?

OBJECTIVE

To examine the impact of state-granted nurse practitioner (NP) independence on patient-level quality, service utilization, and referrals.

DATA SOURCES/STUDY SETTING

The National Ambulatory Medical Care Survey's community health center (HC) subsample (2006-2011). Primary analyses included approximately 6,500 patient visits to 350 NPs in 220 HCs.

STUDY DESIGN

Propensity score matching and multivariate regression analysis were used to estimate the impact of state-granted NP independence on each outcome, separately. Estimates were adjusted for sampling weights and NAMCS's complex design.

DATA COLLECTION/EXTRACTION METHODS

Every "NP-patient visit unit" was isolated using practitioner and patient visit codes and, using geographic identifiers, assigned to its state-year and that state-year's level of NP independence based on scope of practice policies. Nine outcomes were specified using ICD-9 codes, standardized drug classification codes, and NAMCS survey items.

PRINCIPAL FINDINGS

After matching, no statistically significant differences in quality were detected by states' independence status, although NP visits in states with prescriptive independence received more educational services (aIRR 1.66; 95 percent CI 1.09-2.53; p = .02) and medications (aIRR 1.26; 95 percent CI 1.04-1.53; p = .02), and NP visits in states with practice independence had a higher odds of receiving physician referrals (AOR 1.88; 95 percent CI 1.10-3.22; p = .02) than those in restricted states.

CONCLUSIONS

Findings do not support a quality-scope of practice relationship.

The Untapped Potential of the Nurse Practitioner Workforce in Reducing Health Disparities

The growing nurse practitioner (NP) workforce represents a significant supply of primary care providers, who if optimally utilized, are well-positioned to improve access to health care for racial and ethnic minorities. However, many barriers affect the optimal utilization of NPs in primary care delivery. These barriers may also prevent NPs from maximally contributing to efforts to reduce racial and ethnic health disparities. Our review of the empirical and health policy literature sought to elucidate factors that affect NPs' potential and ability to narrow or eliminate health disparities. We found that restrictive state scope of practice regulations, disparate reimbursement policies, lack of NP workforce diversity, and poor organizational structures in NP practices may limit NPs' contributions to current efforts to reduce disparities. Our results led to the development of the nurse practitioner health disparities model which identifies barriers to and opportunities for optimal use of NPs in reducing racial and ethnic disparities. State and federal policymakers and administrators in health-care settings should take actions to remove legislative and organizational barriers to enable NPs to deliver high-quality care to racial and ethnic minorities. Researchers can use the nurse practitioner health disparities model to produce empirical evidence to reduce health disparities and improve population health.

Maximizing nurse practitioners' contributions to primary care through organizational changes

The nurse practitioner (NP) workforce represents a considerable supply of primary care providers able to contribute to meeting a growing demand for care. However, organizational barriers hinder their optimal use. This article presents reports from 592 NPs on their roles, organizational support available to them, relationships between NPs and administration, their job satisfaction, and intentions of leaving their jobs. Nurse practitioners reported deficits in organizational context of care, problematic deployment of resources, and unfavorable working relationships with administrators. Addressing these challenges and creating work environments conducive to NP practice are necessary to fully exploit the capacity of the NP workforce.

Experiences of nurse practitioners and medical practitioners working in collaborative practice models in primary healthcare in Australia - a multiple case study using mixed methods

Background

In 2010 policy changes were introduced to the Australian healthcare system that granted nurse practitioners access to the public health insurance scheme (Medicare) subject to a collaborative arrangement with a medical practitioner. These changes facilitated nurse practitioner practice in primary healthcare settings. This study investigated the experiences and perceptions of nurse practitioners and medical practitioners who worked together under the new policies and aimed to identify enablers of collaborative practice models.

Methods

A multiple case study of five primary healthcare sites was undertaken, applying mixed methods research. Six nurse practitioners, 13 medical practitioners and three practice managers participated in the study. Data were collected through direct observations, documents and semi-structured interviews as well as questionnaires including validated scales to measure the level of collaboration, satisfaction with collaboration and beliefs in the benefits of collaboration. Thematic analysis was undertaken for qualitative data from interviews, observations and documents, followed by deductive analysis whereby thematic categories were compared to two theoretical models of collaboration. Questionnaire responses were summarised using descriptive statistics.

Results

Using the scale measurements, nurse practitioners and medical practitioners reported high levels of collaboration, were highly satisfied with their collaborative relationship and strongly believed that collaboration benefited the patient. The three themes developed from qualitative data showed a more complex and nuanced picture: 1) Structures such as government policy requirements and local infrastructure disadvantaged nurse practitioners financially and professionally in collaborative practice models; 2) Participants experienced the influence and consequences of individual role enactment through the co-existence of overlapping, complementary, traditional and emerging roles, which blurred perceptions of legal liability and reimbursement for shared patient care; 3) Nurse practitioners’ and medical practitioners’ adjustment to new routines and facilitating the collaborative work relied on the willingness and personal commitment of individuals.

Conclusions

Findings of this study suggest that the willingness of practitioners and their individual relationships partially overcame the effect of system restrictions. However, strategic support from healthcare reform decision-makers is needed to strengthen nurse practitioner positions and ensure the sustainability of collaborative practice models in primary healthcare.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0503-2) contains supplementary material, which is available to authorized users.

Nurse Practitioner Autonomy and Relationships with Leadership Affect Teamwork in Primary Care Practices: a Cross-Sectional Survey

BACKGROUND

The Nurse Practitioner (NP) workforce represents a substantial supply of primary care providers able to contribute to meeting a growing demand for care. However, controversy exists regarding the expanding role of NPs in primary care in terms of challenging the teamwork between NPs and physicians. To date, no empirical evidence exists regarding how to promote teamwork in primary care between NPs and physicians.

OBJECTIVE

We investigated whether NP autonomy within primary care practices and the relationships they have with leadership affect teamwork between NPs and physicians.

DESIGN

Using a cross-sectional survey design, data was collected from 163 primary care practices in Massachusetts.

PARTICIPANTS

Three hundred and fourteen primary care NPs completed and returned the mail survey yielding a response rate of 40 %.

MAIN MEASURES

The Autonomy and Independent Practice (AIP) and NP-Administration Relations (NP-AR) scales were used to measure NP independent practice and the relationships with leadership, respectively. These measures were aggregated to the practice level. Teamwork between NPs and physicians was measured at the individual NP level using the Teamwork (TW) scale.

KEY RESULTS

The multilevel linear regression models investigated the influence of practice-level NP autonomy and the relationship between NPs and leadership on teamwork. With every unit increase on the practice-level mean score of AIP centered at the grand mean, the mean TW score increased by 0.271 units (p < 0.0001). With every unit increase of NP-AR centered at the grand mean, the mean TW score increased by 0.375 (p < 0.001). Over one-third (41.3 %) of the variance in teamwork could be explained by the final model.

CONCLUSION

The study findings demonstrate that NP autonomy and favorable relationships with leadership improve teamwork. Policy and organizational change should focus on promoting NP autonomy and improving the relationship between NPs and leadership to improve teamwork and consequently improve patient care and outcomes.

Describing team development within a novel GP-led urgent care centre model: a qualitative study

OBJECTIVE

Urgent care centres (UCCs) co-located within an emergency department were developed to reduce the numbers of inappropriate emergency department admissions. Since then various UCC models have developed, including a novel general practitioner (GP)-led UCC that incorporates both GPs and emergency nurse practitioners (ENPs). Traditionally these two groups do not work alongside each other within an emergency setting. Although good teamwork is crucial to better patient outcomes, there is little within the literature about the development of a team consisting of different healthcare professionals in a novel healthcare setting. Our aim was therefore to describe staff members' perspectives of team development within the GP-led UCC model.

DESIGN

Open-ended semistructured interviews, analysed using thematic content analysis.

SETTING

GP-led urgent care centres in two academic teaching hospitals in London.

PARTICIPANTS

15 UCC staff members including six GPs, four ENPs, two receptionists and three managers.

RESULTS

Overall participants were positive about the interprofessional team that had developed and recognised that this process had taken time. Hierarchy within the UCC setting has diminished with time, although some residual hierarchical beliefs do appear to remain. Staff appreciated interdisciplinary collaboration was likely to improve patient care. Eight key facilitating factors for the team were identified: appointment of leaders, perception of fair workload, education on roles/skill sets and development of these, shared professional understanding, interdisciplinary working, ED collaboration, clinical guidelines and social interactions.

CONCLUSIONS

A strong interprofessional team has evolved within the GP-led UCCs over time, breaking down traditional professional divides. Future implementation of UCC models should pro-actively incorporate the eight facilitating factors identified from the outset, to enable effective teams to develop more quickly.

Optimizing full scope of practice for nurse practitioners in primary care: A proposed conceptual model

BACKGROUND

Nurse practitioners (NPs), if utilized to their optimal potential, could play a key role in meeting the growing demand for primary care.

PURPOSE

The purpose of this study was to propose a comprehensive model for maximizing NP contributions to primary care which includes the factors affecting NP care and patient outcomes and explains their interrelated impact.

METHOD

We synthesized the results of the published literature to develop a model, which emphasizes NP scope of practice regulations, institutional policies, NP practice environment, and NP workforce outcomes as determinants of NP care and patient outcomes.

DISCUSSION

Our model provides a framework to help explain how variations in scope of practice regulations at the state-level and institutional policies within organizations directly and indirectly influence the practice environment of NPs, NP workforce outcomes, and patient care and outcomes.

CONCLUSION

Aligning policy change, organizational innovations, and future research are critical to NP optimal utilization and patient care and outcomes.