Task shifting from general practitioners to other health professionals in out-of-hours primary care - a systematic literature review on content and quality of task shifting

BACKGROUND

Task shifting from general practitioners (GPs) to other health professionals could solve the increased workload, but an overview of the evidence is lacking for out-of-hours primary care (OOH-PC).

OBJECTIVES

To evaluate the content and quality of task shifting from GPs to other health professionals in clinic consultations and home visits in OOH-PC.

METHODS

Four database literature searches were performed on 13 December 2021, and updated in August 2023. We included articles that studied content (patient characteristics, reason for encounter) and/or quality (patient satisfaction, safety, efficiency) of task shifting in face-to-face contacts at OOH-PC. Two authors independently screened articles for inclusion and assessed the methodological quality of included articles using the JBI critical appraisal checklist. Data was extracted and results were synthesised in a narrative summary.

RESULTS

The search identified 1,829 articles, resulting in the final inclusion of seven articles conducted in the UK or the Netherlands. Studies compared GPs with other health professionals (mainly nurses). These other health professionals saw patients with less urgent health problems, younger patients, and patients with less complex health problems than GPs. Most studies concluded that other health professionals provided safe and vastly efficient care corresponding to the level of GPs but findings about productivity were inconclusive.

CONCLUSION

The level of safety and efficiency of care provided by other health professionals in OOH-PC seems like that of GPs, although they mainly see patients presenting with less urgent and less complex health problems.

General practitioner and practice nurses perspectives on implementation of the 75+ health assessment: Implications for dementia care and well-being

BACKGROUND

The uptake of the health assessment for persons aged 75 years and older (75 + HA) remains low. Repeat assessments provide an opportunity to identify areas of change in cognitive function which may mark the onset of dementia. We aimed to explore general practitioner (GP) and practice nurse experiences of implementing the 75 + HA with a focus on clinical considerations for dementia care.

METHODS

An interpretative qualitative study involving interviews with 15 GPs (female = 11, male = 4) and 5 practice nurses (all female). Data were analysed using an inductive thematic approach.

RESULTS

The majority of GPs (n = 11) worked in metropolitan settings and four GPs worked in regional settings across NSW. All participants worked in separate clinics, except for two GPs and one practice nurse who worked within the same metropolitan clinic. Distinct themes emerged regarding participants experiences of implementing the 75 + HA for patients with dementia: (1) negotiating aged care is complex and facilitated by a comprehensive assessment; (2) implementing work practices that support the 75 + HA in patients with cognitive decline; and (3) variations in follow up of findings and implications for care.

DISCUSSION

The 75 + HA provides an opportunity for monitoring and acting on emergent physical and cognitive health changes. Increased engagement and support towards implementing the 75 + HA, particularly in the context of dementia, may facilitate the instigation of interventions. While some participants in this study were confident with identifying and managing cognitive decline, the majority relied on geriatricians to confirm dementia diagnosis and refer to community support services. We suggest the need for greater initiatives and clinical guidelines to assist GPs in the identification and management of cognitive decline.

IMPLICATIONS FOR THE PROFESSION

From a nursing perspective, this study highlights the valuable role of nurses towards assessment and management of issues raised in the health assessment for persons aged 75 years and older. However, more resources are needed to enable nurse time for adequate follow-up care.

A global perspective of advanced practice nursing research: A review of systematic reviews

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.

Advanced practice nursing implementation in France: A mixed-method study

AIM(S)

To describe advanced practice nursing (APN) in the French healthcare landscape and to provide insights on how the role is defined and implemented and how the role is perceived by physicians.

DESIGN

A mixed-method approach incorporating qualitative and quantitative data to offer a global understanding of APN implementation in France was used.

METHODS

Data were collected through questionnaires and interviews with APNs and physicians in diverse healthcare settings in France. The questionnaire assessed the roles, relationships with physicians and patients and the perceived implementation success of APNs. In-depth interviews explored experiences, definitions, challenges and perspectives of APNs. A thematic analysis was applied to the qualitative data to complete the quantitative exploration. Descriptive analyses were performed for quantitative data.

RESULTS

A total of 41 APNs and 12 physicians were involved in this study between December 2022 and March 2023. The findings underscore APN as a pivotal, independent profession integrating advanced clinical expertise and interprofessional skills. The challenges encountered by APNs include role ambiguity, ongoing resistance and the need to address institutional barriers. Despite the fact that 73.2% of APNs reported that their role was well implemented, only 17.1% had clearly defined roles at the outset.

CONCLUSION

This study revealed the dynamic and evolving nature of APN in France, highlighting its challenges and opportunities. Despite facing role ambiguity and resistance, APNs play a crucial role in the healthcare system.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The results highlight the need for specific interventions to tackle challenges and facilitate successful integration of APN. These insights lay a foundation for future research and interventions aimed at boosting the impact and acceptance of APN in France, potentially influencing policy modifications and professional development.

IMPACT

Problem Addressed: The study aimed to enhance comprehension of the implementation and role of advanced practice nursing (APN) in France. It focused on defining APN in the French context, identifying barriers and facilitators to its implementation and evaluating its impact.

MAIN FINDINGS

The study revealed that APN in France is evolving with expanded competencies and clinical autonomy, but faces challenges like role ambiguity and professional resistance. Key findings include the successful integration of APNs in healthcare settings, positive relationships with medical doctors and patient satisfaction. However, the study also highlighted the necessity to resolve role ambiguity and to improve the understanding and acceptance of APN roles among healthcare professionals for successful APN integration. Impact of the research: This research will primarily impact healthcare systems and policy-making in France, guiding the future development and integration of APN roles. It is also relevant for healthcare professionals, particularly nurses and physicians, by providing information about the evolving nature of APN and its benefits in patient care. Globally, the study contributes to the broader discourse on APN, offering insights that could inform APN implementation strategies in other countries facing similar healthcare challenges.

REPORTING METHOD

COREQ-STROBE.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

The effect of consultations performed by specialised nurses or advanced nurse practitioners on patient and organisational outcomes in patients with complex health conditions: An umbrella review

BACKGROUND

Policymakers and researchers often suggest that nurses may play a crucial role in addressing the evolving needs of patients with complex conditions, by taking on advanced roles and providing nursing consultations. Nursing consultations vary widely across settings and countries, and their activities range from complementing to substituting traditional physician-led consultations or usual care.

OBJECTIVE

This study was aimed at describing the effects of nursing consultations with patients with complex conditions in any setting on patient outcomes (quality of life, physical status, psychosocial health, health behaviour, medication adherence, mortality, anthropometric and physiological outcomes, and patient satisfaction) and organisational outcomes (health resource use and costs).

DESIGN

Umbrella review.

METHODS

We followed the Joanna Briggs Institute method for umbrella reviews. We searched PubMed, Embase, Cochrane Database of Systematic Reviews and CINAHL to identify relevant articles published in English, Dutch, French, Spanish or German between January 2013 and February 2023. We included systematic literature reviews, with or without meta-analyses, that included randomised controlled trials conducted in high-income countries. Reviews were eligible if they pertained to consultations led by specialised nurses or advanced nurse practitioners. Article selection, data extraction and quality appraisal were performed independently by at least two reviewers.

RESULTS

We included 50 systematic reviews based on 473 unique trials. For all patient outcomes, nursing consultations achieved effects at least equivalent to those of physician-led consultations or usual care (i.e., non-inferiority). For quality of life, health behaviour, medication adherence, mortality and patient satisfaction, more than half the meta-analyses found statistically significant effects in favour of nursing consultations (i.e., superiority). Cost results must be interpreted with caution, because very few and heterogeneous cost-related data were extracted, and the methodological quality of the cost analyses was questionable. Narrative syntheses confirmed the overall conclusions of the meta-analyses.

CONCLUSIONS

The effects of nursing consultations on patients with complex health conditions across healthcare settings appear to be at least similar to physician-led consultations or usual care. Nursing consultations appear to be more effective than physician-led consultations or usual care in terms of quality of life, health behaviour, mortality, patient satisfaction and medication adherence. Further analysis of the primary data is necessary to determine the patient populations and settings in which nursing consultations are most effective. Moderate study quality, diversity amongst and within systematic reviews, and quality of reporting hamper the strength of the findings.

Scopes of practice for advanced practice nursing and advanced practice midwifery in Kenya: A gap analysis

BACKGROUND

There is increasing global evidence on the impact of advanced nursing and midwifery practitioners, and Kenya's healthcare system has an excellent opportunity to develop scopes of practice and other regulatory frameworks for the integration of these roles.

OBJECTIVE

The primary purpose of this gap analysis was to explore the existing evidence on opportunities and threats toward the integration of the advanced practice nursing (APN) and advanced practice midwifery (APM) roles in Kenya's healthcare system.

METHODS

The study team conducted a structured electronic database search of PubMed, CINAHL, Scopus, EBSCOhost Academic Search Complete, and PsycINFO to retrieve articles and credible websites for reports highlighting the opportunities and threats toward the integration of the APN and APM roles in Kenya's healthcare systems. The retrieved articles were screened for relevance and synthesized for reporting using the traditional literature review approach.

RESULTS

The Kenya Health Policy Framework 2014-2030, growing population needs, and implementation of universal health coverage provide an opportunity to harness and leverage advanced practice roles in nursing and midwifery. There is also momentum to develop advanced practice because of strategic alliances and global evidence showing the contributions and quality of services offered by advanced practice nurses and advanced practice midwives. However, lack of financial support, structural challenges, and lack of national policies, regulations, and legislation continue to obstruct progress.

CONCLUSION AND IMPLICATIONS FOR NURSING POLICY

Developing scopes of practice for APN and APM in Kenya will benefit the professions, the country's healthcare delivery system, and the population. Achieving universal health coverage depends on a health workforce trained and practicing at optimal levels in tandem with education and training to deliver quality care.

APN nurses' core competencies for general clinical health assessment in primary health care. A scoping review

BACKGROUND

The field of Advanced Practice Nursing (APN) has developed over the past six decades. However, the definition of roles and responsibilities of APN nurses seem to be contested due to both a lack of a clear definition of the concept and to institutional and cultural barriers that restrict the nurses' opportunities to practise to the full extent of their competencies.

AIM

The objective of this scoping review was to identify, examine and conceptually map the available literature on APN nurses' core competencies for general health assessment in primary health care.

METHOD

We performed a scoping review, following the methodological guidance for reporting as it is described by the Joanna Briggs Institute (JBI). Furthermore, the PRISMA-ScR statement and checklist for reporting scoping reviews were followed. Guiding the initial process for the search, we used the Population, Concept and Context mnemonic (PCC) to clarify the focus and context of the review.

RESULTS

We found three areas of core competencies on which APN nurse draw in performing general health assessments in primary health care: (1) 'Collaborative, leadership and management skills' (2) 'Person-centred nursing care skills' and (3) 'Academic and educational skills'. Furthermore, we found that the three areas are interrelated, because it is crucial that APN nurses draw on collaborative competencies related to leadership and management to meet the service users' needs and deliver high-quality and person-centred care.

CONCLUSION

There is a need for a more specific investigation into how APN nurses' core competencies play a role during general health assessments of patients in primary care. We suggest an evaluation of what works for whom in what circumstances looking into the interrelation between competencies, skills and knowledge when an APN nurse performs a general health assessment in a primary healthcare setting.

Implementation strategy for advanced practice nursing in Gabon: A multicenter mixed-method study

AIM

To describe the expectations, acceptability, and challenges identified by nurses and key healthcare stakeholders regarding the implementation of advanced practice nursing in Gabon.

BACKGROUND

Advanced practice nursing presents an opportunity to address the epidemiological transition and the shortage of healthcare professionals in Africa. In anticipation of establishing a master's degree program in advanced practice nursing and its subsequent implementation, it is important to understand Gabon's specific needs and characteristics.

DESIGN

This study used a multicenter cross-sectional mixed-method design.

METHODS

From April to May 2022, a total of 187 healthcare professionals were included from two hospitals and two universities in Gabon. Data were collected through questionnaires and complemented by focus group discussions, guided by the existing literature, the PEPPA framework, and Hamric's model.

RESULTS

The implementation of advanced practice nursing was generally well accepted. Factors influencing acceptability included being female, awareness of advanced practice nursing, and supporting the role of advanced practice nurses in diagnosing chronic diseases. Barriers to implementation included the absence of a legal framework for the profession and a lack of recognition of nursing skills by both nurses and doctors. Facilitators included the establishment of a master's degree program, formalization of a legal framework, raising awareness, providing training to medical doctors and other healthcare professionals about advanced practice nursing, and the development of nursing leadership.

IMPLICATIONS FOR NURSING

Advanced practice nursing can play a crucial role in addressing healthcare resource shortages and the dual burden of chronic and infectious diseases in Gabon, as well as in other African countries.

IMPLICATIONS FOR NURSING POLICY

To successfully implement advanced practice nursing in Gabon and French-speaking Africa, it is essential to regulate the nursing and advanced nursing professions by creating a legal framework and establishing nursing councils. An effective implementation strategy for advanced practice nurses should be based on the specific needs of the country.

GUIDELINES

COREQ, STROBE.

Advancing Palliative Care through Advanced Nursing Practice: A Rapid Review

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.

Racial and ethnic disparities in ED use among older adults with asthma and primary care nurse practitioner work environments

Background

Nurse practitioners (NPs) increasingly deliver primary care in the United States. Yet, poor working conditions strain NP care. We examined whether racial/ethnic health disparities in ED visits among older adults with asthma are moderated by primary care NP work environments.

Methods

Survey data on NP work environments in six states were collected from 1,244 NPs in 2018-2019. 2018 Medicare claims data from 46,658 patients with asthma was merged with survey data to assess the associations of all-cause and ambulatory care sensitive conditions (ACSC) ED visits with NP work environment and race/ethnicity using logistic regression.

Results

NP work environment moderated the association of race (Black patients versus White patients) with all-cause (odds ratio [OR]: 0.91; p-value = 0.045) and ACSC (OR: 0.90; p-value = 0.033) ED visits.

Conclusions

Disparities in ED visits between Black and White patients with asthma decrease when these patients receive care in care clinics with favorable NP work environments.

Advanced Practice Registered Nurse Full Practice Authority, Provider Supply, and Health Outcomes: A Border Analysis

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.

Can an advanced practice nursing framework address workforce shortages? A case study of a regional health service

BACKGROUND

Across the globe, shortages of nurses and midwives in rural regions persist. Advanced practice nursing has been found to address workforce shortages through career progression aimed at retention. A regional health service sought to consult with staff about developing an advanced practice nursing framework.

AIMS

This study aimed to explore the perspectives of nurses and midwives at a regional health service on (i) how their roles aligned with the modified Advanced Practice Role Delineation (APRD) tool and (ii) the potential for implementation of such a framework at their service.

DESIGN

A case study conducted at Goulburn Valley Health (GVH) in southeast Australia used a mixed method design with a survey of all nursing and midwifery staff and focus groups with senior staff.

METHODS

All nurses and midwives were asked to complete a validated modified ARPD questionnaire and those in Grades 3-6 were asked to participate in a focus group.

RESULTS

From 183 questionnaires and 38 participants in the focus group discussions, findings concurred that nurses and midwives at GVH reported spending most time on direct patient care and minimal time on research activities, publication and/or leadership. While education was strongly embraced and advanced practice usually supported, senior staff cited the lack of resources, the culture and staff shortages as restricting opportunities for education, career development and implementation of an advanced practice framework.

CONCLUSIONS

While an advanced practice framework could address staff shortages at this health service, implementation of such a framework is constrained by the lack of resources and workforce shortages common in rural health services. A national strategy that embeds advanced practice roles and resources implementation of advanced practice nursing and midwifery frameworks in areas of need is recommended.

Evaluating the success of an inpatient PA and NP program through trends in ED consults

OBJECTIVE

We investigated the effect of an inpatient physician associate/assistant (PA) and NP program on consult volume, length of stay (LOS), and ED returns.

METHODS

A retrospective observational study of 4,118 orthopedic ED consults was conducted from January 2017 to March 2022. Univariate statistics were used to evaluate outcomes between cohorts and multivariate regression to evaluate the odds of an LOS of less than 24 hours.

RESULTS

After implementation of the PA and NP program, surgeon consults steadily declined and orthopedic consults increased markedly. Statistically significant differences were found in LOS of less than 24 hours and ED arrival-to-discharge time. Adjusting for case mix, patients were 47% more likely to be discharged within 24 hours. Survey results noted that more than 80% of surgeons felt on-call workload, disruptions to clinic and surgical schedules decreased, and quality of care increased.

CONCLUSIONS

Implementation of an inpatient PA and NP program reduced orthopedic surgeon consults and hospital LOS while improving surgeon satisfaction with on-call workload, schedule disruptions, and quality of care.

Nurse Practitioner Care Environments and Racial and Ethnic Disparities in Hospitalization Among Medicare Beneficiaries with Coronary Heart Disease

BACKGROUND

Nurse practitioners care for patients with cardiovascular disease, particularly those from racial and ethnic minority groups, and can help assure equitable health outcomes. Yet, nurse practitioners practice in challenging care environments, which limits their ability to care for patients.

OBJECTIVE

To determine whether primary care nurse practitioner care environments are associated with racial and ethnic disparities in hospitalizations among older adults with coronary heart disease.

DESIGN

In this observational study, a cross-sectional survey was conducted among primary care nurse practitioners in 2018-2019 who completed a valid measure of care environment. The data was merged with 2018 Medicare claims data for patients with coronary heart disease.

PARTICIPANTS

A total of 1244 primary care nurse practitioners and 180,216 Medicare beneficiaries 65 and older with coronary heart disease were included.

MAIN MEASURES

All-cause and ambulatory care sensitive condition hospitalizations in 2018.

KEY RESULTS

There were 50,233 hospitalizations, 9068 for ambulatory care sensitive conditions. About 28% of patients had at least one hospitalization. Hospitalizations varied by race, being highest among Black patients (33.5%). Care environment moderated the relationship between race (Black versus White) and hospitalization (OR 0.93; 95% CI, 0.88-0.98). The lowest care environment was associated with greater hospitalization among Black (odds ratio=1.34; 95% CI, 1.20-1.49) compared to White beneficiaries. Practices with the highest care environment had no racial differences in hospitalizations. There was no interaction effect between care environment and race for ambulatory care sensitive condition hospitalizations. Nurse practitioner care environment had a protective effect on these hospitalizations (OR, 0.96; 95% CI, 0.92-0.99) for all beneficiaries.

CONCLUSIONS

Unfavorable care environments were associated with higher hospitalization rates among Black than among White beneficiaries with coronary heart disease. Racial disparities in hospitalization rates were not detected in practices with high-quality care environments, suggesting that improving nurse practitioner care environments could reduce racial disparities in hospitalizations.

Clinical and Organizational Nursing Innovations in Primary Care: Findings From a Stakeholders' Symposium

Nursing innovations in primary care, based on interprofessional care models, could be better identified, recognized, and deployed. This article presents the results of a symposium discussing the implementation of nursing innovations in primary care in Quebec, Canada, in partnership with researchers and stakeholders. Built on the appreciative inquiry approach, 9 nursing innovations were described. To support the implementation of such nursing innovations responding to current primary care issues and population needs, 4 recommendations emerged: the need to implement strategies to achieve optimal scope of practice for primary care nurses; the importance to develop funding and organizational models that support primary care nursing innovation; the need to enhance a collaborative and democratic governance open to innovation; and the opportunity to create partnerships with the research community and teaching institutions.

A Systematic Review of Outcomes Related to Nurse Practitioner-Delivered Primary Care for Multiple Chronic Conditions

Multiple chronic conditions (MCCs) are more common and costly than any individual health condition in the United States. The growing workforce of nurse practitioners (NPs) plays an active role in providing primary care to this patient population. This study identifies the effect of NP primary care models, compared with models without NP involvement, on cost, quality, and service utilization by patients with MCCs. We conducted a literature search of six databases and performed critical appraisal. Fifteen studies met inclusion criteria (years: 2003-2021). Overall, most studies showed reduced or similar costs, equivalent or better quality, and similar or lower rates of emergency department use and hospitalization associated with NP primary care models for patients with MCCs, compared with models without NP involvement. No studies found them associated with worse outcomes. Thus, NP primary care models, compared with models without NP involvement, have similar or positive impacts on MCC patient outcomes.

Impact of a heart failure nurse practitioner service on rehospitalizations, emergency presentations, and survival in patients hospitalized with acute heart failure

AIMS

Heart failure nurse practitioners (HF NPs) are an emerging component of the heart failure (HF) specialist workforce but their impact in an inpatient setting is untested. The aim of this paper is to explore the impact of an inpatient HF NP service on 12-month all-cause rehospitalizations, emergency department (ED) presentations, and mortality in patients hospitalized with HF compared with usual hospital care.

METHODS AND RESULTS

Retrospective, two-group comparative design involving patients (n = 408) admitted via ED with acute HF to a metropolitan quaternary hospital between January 2013 and August 2017. Doubly robust estimation with augmented inverse probability weighting (DR-AIPW) was used to account for the non-random allocation of patients to usual hospital care or the HF NP service in addition to usual in-hospital care. Among 408 patients (186 usual care and 222 HF NP service) admitted with acute HF, the mean age was 76.5 [standard deviation (SD) 12.0] years and 56.4% (n = 230) were male. After IPW adjustment, patients seen by the HF NP service had a lower risk of 12-month rehospitalization (61.3 vs. 78.3% usual care; difference -16.9%, 95% CI: -26.4%, -6.6%) and ED presentations (12.6 vs. 22.0%; difference -9.4%, 95% CI: -17.3%, -1.4%) with no difference in 6- or 12-month mortality. The HF NP service improved referrals to a home visiting programme that was available to HF patients (64.4 vs. 45.4%; difference 19%, 95% CI: 8.8%, 28.8%).

CONCLUSION

Additional support by an inpatient HF NP service has the potential to significantly reduce rehospitalizations and ED presentations over 12 months. Further evidence from a multicentre randomized control trial is warranted.

Identifying indicators sensitive to primary healthcare nurse practitioner practice: A review of systematic reviews

AIM

To identify indicators sensitive to the practice of primary healthcare nurse practitioners (PHCNPs).

MATERIALS AND METHODS

A review of systematic reviews was undertaken to identify indicators sensitive to PHCNP practice. Published and grey literature was searched from January 1, 2010 to December 2, 2022. Titles/abstracts (n = 4251) and full texts (n = 365) were screened independently by two reviewers, with a third acting as a tie-breaker. Reference lists of relevant publications were reviewed. Risk of bias was examined independently by two reviewers using AMSTAR-2. Data were extracted by one reviewer and verified by a second reviewer to describe study characteristics, indicators, and results. Indicators were recoded into categories. Findings were summarized using narrative synthesis.

RESULTS

Forty-four systematic reviews were retained including 271 indicators that were recoded into 26 indicator categories at the patient, provider and health system levels. Nineteen reviews were assessed to be at low risk of bias. Patient indicator categories included activities of daily living, adaptation to health conditions, clinical conditions, diagnosis, education-patient, mortality, patient adherence, quality of life, satisfaction, and signs and symptoms. Provider indicator categories included adherence to best practice-providers, education-providers, illness prevention, interprofessional team functioning, and prescribing. Health system indicator categories included access to care, consultations, costs, emergency room visits, healthcare service delivery, hospitalizations, length of stay, patient safety, quality of care, scope of practice, and wait times.

DISCUSSION

Equal to improved care for almost all indicators was found consistently for the PHCNP group. Very few indicators favoured the control group. No indicator was identified for high/low fidelity simulation, cultural safety and cultural sensitivity with people in vulnerable situations or Indigenous Peoples.

CONCLUSION

This review of systematic reviews identified patient, provider and health system indicators sensitive to PHCNP practice. The findings help clarify how PHCNPs contribute to care outcomes.

PROSPERO REGISTRATION NUMBER

CRD42020198182.

Examining nursing processes in primary care settings using the Chronic Care Model: an umbrella review

BACKGROUND

While there is clear evidence that nurses can play a significant role in responding to the needs of populations with chronic conditions, there is a lack of consistency between and within primary care settings in the implementation of nursing processes for chronic disease management. Previous reviews have focused either on a specific model of care, populations with a single health condition, or a specific type of nurses. Since primary care nurses are involved in a wide range of services, a comprehensive perspective of effective nursing processes across primary care settings and chronic health conditions could allow for a better understanding of how to support them in a broader way across the primary care continuum. This systematic overview aims to provide a picture of the nursing processes and their characteristics in chronic disease management as reported in empirical studies, using the Chronic Care Model (CCM) conceptual approach.

METHODS

We conducted an umbrella review of systematic reviews published between 2005 and 2021 based on the recommendations of the Joanna Briggs Institute. The methodological quality was assessed independently by two reviewers using the AMSTAR 2 tool.

RESULTS

Twenty-six systematic reviews and meta-analyses were included, covering 394 primary studies. The methodological quality of most reviews was moderate. Self-care support processes show the most consistent positive outcomes across different conditions and primary care settings. Case management and nurse-led care show inconsistent outcomes. Most reviews report on the clinical components of the Chronic Care Model, with little mention of the decision support and clinical information systems components.

CONCLUSIONS

Placing greater emphasis on decision support and clinical information systems could improve the implementation of nursing processes. While the need for an interdisciplinary approach to primary care is widely promoted, it is important that this approach not be viewed solely from a clinical perspective. The organization of care and resources need to be designed to support contributions from all providers to optimize the full range of services available to patients with chronic conditions.

PROSPERO REGISTRATION

CRD42021220004.

"Low-value" glycemic outcomes among older adults with diabetes cared for by primary care nurse practitioners or physicians: A retrospective cohort study

BACKGROUND

"Low-value" healthcare is care without benefit to patients. Overly intensive glycemic control (i.e., HgbA1C < 7 %) can cause harm to patients at high risk of hypoglycemia, particularly among older adults with co-morbidities. It is unknown whether overly intensive glycemic control differs among patients with diabetes and at high-risk of hypoglycemia cared for by primary care nurse practitioners versus physicians.

OBJECTIVE

This study examined patients with diabetes at high risk of hypoglycemia receiving primary care between Jan 2010 and Jan 2012, comparing patients reassigned to nurse practitioners to those reassigned to physicians after their previous physician separated from practice in an integrated United States health system.

DESIGN

This was a retrospective cohort study. Study outcomes were collected at two years after reassignment to a new primary care provider. Outcomes were predicted probabilities of HgbA1C < 7 % using two-stage residual inclusion instrumental variable models, controlling for baseline confounders.

SETTING

Primary care clinics within the United States Veterans Health Administration.

PARTICIPANTS

38,543 patients with diabetes at increased risk for hypoglycemia (age ≥ 65 years with renal disease, dementia, or cognitive impairment), who had their primary care physician leave the Veterans Health Administration and who were reassigned to a new primary care provider in the following year.

RESULTS

Cohort patients were on average 76 years and 99 % men. Of these, 33,700 were reassigned to physicians and 4843 to nurse practitioners. After two years with their new provider, in adjusted models, patients reassigned to nurse practitioners had a -20.4 percentage-point [95 % CI -37.9 to -2.8] lower probability of two-year HgbA1C < 7 %.

CONCLUSIONS

Aligned with prior studies on care quality, rates of overly intensive glycemic control may be appropriately lower among older patients with diabetes at high-risk of hypoglycemia, cared for by nurse practitioners than physicians.

TWEETABLE ABSTRACT

Primary care nurse practitioners deliver equivalent or better rates of low-value diabetes care for older patients, compared to physicians.

Enhancing the education of paediatric nurses: A positive step towards achieving sustainable development goals

AIM

The aim of this discursive paper was to describe and expound on how paediatric nurses will be able to address the needs of children and adolescents through the lens of selected Sustainable Development Goals (SDGs) in Rwanda.

DESIGN

A discursive analysis of SDGs relating to the roles of paediatric nurses in the context of Rwanda.

METHODS

A discursive method using SDGs as a guiding framework is used in this paper. We drew on our own experiences and supported them with the available literature.

RESULTS

A collection of contextually relevant examples of how paediatric nurses will be able to address the needs of children and adolescents through the lens of selected SDGs in Rwanda was discussed. The selected SDGs expounded on were: no poverty, good health and well-being, quality of education, decent work and economic growth, reduced inequalities, and partnerships for the goals.

CONCLUSIONS

There is no doubt that the paediatric nurses in Rwanda play undeniable key roles in attaining SDGs and their targets. Thus, there is a need to train more paediatric nurses with the support of the interdisciplinary partners. Collaboratively, this is possible in the bid to ensure equitable and accessible care to the current and future generations.

PUBLIC CONTRIBUTION

This discursive paper is intended to inform the different stakeholders in nursing practice, research, education and policy to support and invest in the advanced education of paediatric nurses for attainment of the SDGs.

The Effects of an Educational Intervention on Exercise Advice Behaviors of Thai Oncology Nurses

OBJECTIVE

To evaluate an educational intervention based on the Theory of Planned Behavior to increase oncology nurses' exercise advice behaviors.

METHODS

A single-group, quasi-experimental repeated measures design study was used with 124 oncology nurses in a Thai cancer institute. The educational intervention included preeducation self-directed activities for 1 hour, a 2-hour group education session, and posteducation outreach contact 1 week later. The outcome measures, including the Theory of Planned Behavior constructs, exercise knowledge, and self-reported exercise prescription behaviors, were collected at three time points: Time 1 (2 weeks preintervention), Time 2 (immediately preintervention), and Time 3 (2 weeks after the intervention).

CONCLUSION

Results indicated a statistically significant increase in scores after the intervention for all outcomes, including the Theory of Planned Behavior constructs (overall P value <.001), exercise knowledge (β = 2.99, P < .001), and exercise prescription behaviors: asking (odds ratio [OR] = 12.98, P < .001), assessing (OR = 6.20, P < .001), referring (OR = 4.10, P < .001), and writing exercise advice (OR = 11.52, P < .001). Additionally, verbal counseling behavior was performed by all participants, and therefore, the odds for verbal counseling were not reported. Structural equation modeling analysis demonstrated that attitudes and perceived behavioral control explained 41% of the variance in exercise advice intention. Perceived behavioral control and intention also explained 20% of the variance in self-reported exercise advice behaviors.

IMPLICATIONS FOR NURSING PRACTICE

Attitudinal and perceived behavioral control constructs should be a focus of attention to improve health care professionals' exercise advice behaviors. More focused research is required to examine whether patients engage in and follow the exercise advice provided by oncology nurses.

The effectiveness of nurse practitioner care for patients with mental health conditions in primary care settings: A systematic review

BACKGROUND

The nurse practitioner (NP) workforce is key to meeting the demand for mental health services in primary care settings.

PURPOSE

The purpose of this study is to synthesize the evidence focused on the effectiveness of NP care for patients with mental health conditions in primary care settings, particularly focused on primary care NPs and psychiatric mental health NPs and patients with anxiety, depression, and substance use disorders.

METHODS

Studies published since 2014 in the United States studying NP care of patients with anxiety, depression, or substance use disorders in primary care settings were included.

FINDINGS

Seventeen studies were included. Four high-quality studies showed that NP evidence-based care and prescribing were comparable to that of physicians. Seven low-quality studies suggest that NP-led collaborative care is associated with reduced symptoms.

DISCUSSION

More high-quality evidence is needed to determine the effectiveness of NP care for patients with mental health conditions in primary care settings.

Evaluation of the Nurse Practitioner Offsite Model

Rural older adults residing in assisted living (AL) (herein referred to as residents) have limited access to health care for urgent and chronic management of diseases. The current project aimed to assess rural residents, families, and staff satisfaction with the Nurse Practitioner (NP) Offsite Visit Program. Residents and their families were asked to complete the NP Satisfaction Survey. The survey comprised three subscales (satisfaction, communication, and accessibility) and measured residents' and families' satisfaction. AL staff attended a 1-hour focus interview. Mean survey scores were 81.5 for satisfaction, 26.4 for communication, and 16.9 for accessibility subscales. Focus interview themes included Care Coordination, Prevention of Acute Care Utilization, and Access to Care. Findings suggest that residents, families, and site staff believe the NP Offsite Visit Program was beneficial and improved care coordination between residents and the provider team. The next step is to evaluate the program's impact on residents' health outcomes and further evaluate the Offsite team membership. [Journal of Gerontological Nursing, 49(7), 25-30.].

From Revolution to Evolution: Early Experience with Virtual-First, Outcomes-Based Primary Care

Primary care is foundational to health systems and a common good. The workforce is threatened by outdated approaches to organizing work, payment, and technology. Primary care work should be restructured to support a team-based model, optimized to efficiently achieve the best population health outcomes. In a virtual-first, outcomes-based primary care model, a majority of professional time for primary care team members is protected for virtual, asynchronous patient interactions, collaboration across clinical disciplines, and real-time management of patients with acute and complex concerns. Payments must be re-structured to cover the cost of, and reward the value created by, this advanced model. Technology investments should shift from legacy electronic health records to patient relationship management systems, built to support continuous, outcome-based care. These changes enable primary care team members to focus on building engaged, trusting relationships with patients and their families and collaborating on complex management decisions, and reconnecting team members with joy in clinical practice.

DNP preparation of primary care nurse practitioners and clinical outcomes for patients with chronic conditions

BACKGROUND

Many professional nursing organizations have proposed that the Doctor of Nursing Practice (DNP) is the most appropriate entry-level degree for nurse practitioners (NPs). There have been no studies to date examining the impact of DNP preparation on quality of care or patient outcomes.

PURPOSE

To examine differences in emergency department utilization and hospitalizations among patients with chronic conditions cared for by Master of Science in Nursing (MSN)- and DNP-prepared primary care NPs.

METHODS

We use survey data from over 1,000 primary care NPs in 6 states linked to Medicare claims data. Using regression models, we controlled for various patient, NP, and practice characteristics that might confound the relationship.

RESULS

We find that patient outcomes are not statistically different between patients attributed to MSN- and DNP-prepared primary care NPs.

DISCUSSION

These findings suggest that there remains little evidence that DNP education has led to significant improvements in patient outcomes.

CONCLUSIONS

Further empirical analysis related to the clinical outcomes other than health care utilization of the DNP degree is warranted. Future studies might consider examining (a) NPs in settings other than primary care, (b) practice-wide or system-wide outcomes, (c) other measures of care quality, and (d) impact of DNP program content.

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

BACKGROUND

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

PURPOSE

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

METHODOLOGY

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS

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

Contributions of Advanced Practice Nursing to Primary Health Care: A Scoping Review

Objective: To map the contributions and strategies to implement advanced practice nursing in primary health care. Materials and methods: This scoping review was carried out following the guidelines of the Joanna Briggs Institute in six databases, namely: LILACS, MEDLINE, WoS, Embase, CINAHL, and Scopus, in addition to a bibliographic repository. A total of 3,076 studies were found, from which 12 were selected. Results: The contributions mentioned by the studies regarding advanced practice nursing were divided into three subcategories, as follows: care, educational or management, and preventive practices. They concern autonomy, specialized clinical skills, therapeutic counseling, and patient-centered interaction. Some strategies to implement advanced practice are related to continuing education, practice management, self-care, and disease management. Conclusions: There is a need to improve strategies for advanced practice nursing, especially in primary care, to address gaps in specialized care, the development of indicators, and therapeutic objectives.

Self-reported factors contributing to delay in ALS diagnosis among primary care providers in a large Ohio-based US healthcare network

OBJECTIVE

This study's primary objective is to identify self-reported factors that contribute to diagnostic delay in ALS among Primary Care Providers (PCPs).

METHODS

A de novo email-based survey was deployed to Ohio-based PCPs in the Cleveland Clinic Health System.

RESULTS

Of the 77 PCP participants [including 30 Advance Practice Providers (APPs)] only: (a) 18% of physicians, and 3% of APPs were very confident or confident with recognizing signs and symptoms of ALS, (b) 13% of physicians, and 21% of APP s felt very confident or confident with distinguishing between a neurologic cause of dysfunction from other possible causes, and (c) 23% of physicians, and 11% of APPs felt very confident or confident with distinguishing between upper and lower motor neuron signs. If presented with a weak patient without a specific diagnosis, PCPs most frequently ordered electrodiagnostic testing, brain MRI, cervical or thoracic spine MRI, and serum creatine kinase. PCPs identified top reasons for delayed ALS diagnosis as: (a) patient's delay in seeking medical help, (b) diagnostic uncertainty (c) waiting time for neurology/neuromuscular medicine (NM) consultation. The most desired strategies to shorten diagnostic delay involved: (a) educating PCPs and other non-neurologist "gatekeeper" providers, (b) improving access to specialist neurology care, and (c) developing a reliable diagnostic test for ALS.

DISCUSSION

Self-reported factors that increase ALS diagnostic delay among PCPs primarily comprise gaps in clinical knowledge and skills required to detect key symptoms and signs, and suboptimal referral access to a neurology/NM provider. These areas represent important opportunities for targeted improvement efforts.

Emergency Removal of Supervision Requirements for Psychiatric Mental Health Nurse Practitioners: A Mixed-Methods Survey

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.

The Impact of the New York Nurse Practitioner Modernization Act on the Employment of Nurse Practitioners in Primary Care

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.

The advanced nurse practitioner in context: Systemic processes

BACKGROUND

Healthcare systems are becoming increasingly complex. Systems thinking can help us to understand this complexity and how to apply that understanding to design and evaluate interventions that improve health outcomes. With the current emphasis on developing advanced nursing practice, it is timely to examine systemic processes that characterize ANP systems and their interactions with wider healthcare systems, and how these processes enable and constrain the role.

OBJECTIVE

To make explicit the systemic processes that characterize the Advanced Nurse Practitioner (ANP) system and how they enable and constrain the role.

DESIGN

An interpretive descriptive study.

SETTING

The study was conducted in a large Hospital Group, consisting of eleven acute hospitals, within the Irish Healthcare System.

PARTICIPANTS

Twenty nine participants, including ANPs, nurses, nurse managers, medics and allied health professionals, participated in the study.

METHODS

Data were collected through seven in-depth interviews and four focus groups. Data were analyzed using the Organic Systems Framework (OSF), where attention was on language indicative of the processes of individuation, integration, differentiation and homogenization.

RESULTS

Participants emphasize how ANP systems exert power by individuating and differentiating; however, restrictive regulations and medical control constrain this power. Integration and homogenization are expressed as ANPs encourage and engage in collaborative practice towards common purposes. When hierarchical structures and professional self-interest dominate, however, these processes are submerged, resulting in unbalanced systems.

CONCLUSION

ANP systems realize their power through increased autonomy by individuating and differentiating. Hierarchical structures positioning ANPs in subservient roles should be challenged. Processes of integration and homogenization are expressed in collaborative practices. We recommend that ANPs realize and articulate the value and diversity that they bring to health systems to strengthen their contribution to them.

CLINICAL RELEVANCE

Lack of awareness of the systemic processes that enable and constrain the ANP role affects the role's potential contribution to the healthcare system. Systems thinking and employing the OSF as an analysis framework can help us to understand these processes and their implications, and how to apply that understanding to design and evaluate interventions that improve health outcomes.

Perspectives on Collaboration between Physicians and Nurse Practitioners in Japan: A Cross-Sectional Study

BACKGROUND

Nurse practitioners (NPs) are known as effective healthcare providers worldwide. In Japan, nurse practitioner adoption is considered to be in a shaky period. Although nurse practitioners were introduced approximately 10 years ago at the initiative of educational institutions in Japan, the full extent of this trend is not known. Therefore, we have clarified the whole picture of nurse practitioners from two directions: the perception of nurse practitioners in Japan and the perception of physicians who work with nurse practitioners. This will inform discussions regarding the recruitment of nurse practitioners at the national level in Japan.

METHODS

From 18 June to 24 July 2021, we administered a nationwide cross-sectional survey of NPs and physicians working in the same clinical settings as NPs in Japan. The domains of the survey included "scope and content of work", "perceptions of NPs' clinical practice", and "individual clinical practice characteristics". The survey was distributed and collected digitally.

RESULTS

The total number of respondents to the survey was 281, including 169 NPs and 112 physicians; the percentage of NPs who responded was 50.5%. The number of valid responses was 164 NPs and 111 physicians, for a total of 275 respondents. Approximately 60% of NPs are concentrated in Tokyo, the capital of Japan, and the three prefectures adjacent to Tokyo. They also worked fewer hours per week, cared for fewer patients per day, and earned less money than physicians. More physicians than NPs indicated that "more NPs would improve the quality of care". A total of 90.1% of physicians and 82.3% of NPs agreed that "Nurse practitioners should practice to the full extent of their education and training," and 73.9% of physicians and 81.7% of NPs agreed that "Nurse practitioners' scope of practice should be uniformly defined at a national level".

CONCLUSIONS

This study clarified the present working conditions of NPs from NPs' and physicians' perspectives in Japanese contexts. Japanese NPs may be able to work effectively in collaboration with physicians. Therefore, the implementation of NPs in Japanese medical conditions should be discussed further for better healthcare.

The Disparity in the Management of Polycystic Ovary Syndrome between Obstetrician-Gynecologists in Different-Level Hospitals under the Hierarchical Medical System

Background

PCOS is a prevalent endocrine and metabolic disorder in women characterized by abnormal blood glucose, dyslipidemia, and abnormal mental health. To improve patient care, the goal of our study is to find out if there are differences in how PCOS patients are treated at different hospital levels within the hierarchical medical system.

Methods

Obstetricians and gynecologists from primary, secondary, and tertiary hospitals were the participants in the survey. The responses provided and collected were analyzed using various statistical techniques like the chi-square test, Fisher exact test, and logistic regression with multiple variables.

Results

The investigation examined 2298 survey replies (13.1% primary hospitals, 52.4% secondary hospitals, and 34.5% tertiary hospitals). As hospital grade increases, more participants inquire about a patient's history of unfavorable pregnancies concerning hormone evaluation; the better the hospital's grade, the greater the number of participants who would undergo AMH and androgen-related tests. The higher the hospital level, the more participants would pick the oral glucose tolerance test (OGTT) to determine insulin resistance, the BMI Asian criteria for defining obesity, and blood lipids. Participants in primary (odds ratio (OR) = 0.383, 95% confidence interval (CI) 0.282-0.520) and secondary (OR = 0.607, 95% confidence interval (CI) 0.481-0.765) hospitals were significantly less likely to select OGTT than those in tertiary hospitals. Comparatively, fewer primary hospitals chose to do lipid profiling than tertiary hospitals (OR 0.689, 95% CI 0.523-0.909). With the increase in hospital level, participants were more knowledgeable about the multiple efficacies and dose alternatives of metformin and selected letrozole and assisted reproduction more frequently.

Conclusion

Our study uncovered differences in the endocrine evaluation, metabolic screening, and management of PCOS patients across obstetrics and gynecology at various hospital levels. Simultaneously, it underlines the need to improve the hierarchical medical system and close the knowledge gap across hospitals.

Parent Satisfaction With Pediatric Nurse Practitioner Care in Specialty Services

INTRODUCTION

This study examined parent satisfaction with care provided to their children by Pediatric Nurse Practitioners (PNPs) in specialty areas at a tertiary care pediatric hospital.

METHOD

A convenience sample of parents of children cared for by 19 PNPs in different specialty settings completed a confidential survey consisting of demographic information and the Parents' Perception of Satisfaction with Care from the Pediatric Nurse Practitioners Instrument (PPSC-PNP). Data were analyzed using SPSS (IBM, Armonk, NY).

RESULTS

The overall PPSC-PNP mean score was 129.82/140. Mean subscale scores ranged from 27.15 to 28.51/30. The general satisfaction score showed a mean score of 18.31/20. No statistical difference was found in parental satisfaction when scores were analyzed by the child's age, parent participant, or patient setting.

DISCUSSION

These findings indicate that parents are highly satisfied with the care their children receive from PNPs across various subspecialties regardless of the child's age and clinical setting.

Optimizing the productivity and placement of nurse practitioners and physician assistants in outpatient primary care sites

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.

Optimizing the productivity and placement of NPs and PAs in outpatient primary care sites

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.

Advanced practice nursing roles in Arab countries in the Eastern Mediterranean region: a scoping review

OBJECTIVE

The objectives of this review were to map and summarize evidence regarding advanced practice nursing roles in Arab countries located in the Eastern Mediterranean region.

INTRODUCTION

Many countries have reported an increase in the number and types of advanced practice nursing roles as research demonstrating their positive impact on patient and health system outcomes continues to accumulate. There is international evidence that the achievement of these outcomes depends on the effective implementation of advanced practice nursing roles at the organizational and country levels. A comprehensive review of the status of advanced practice nursing role implementation in Arab countries in the Eastern Mediterranean region has not been conducted.

INCLUSION CRITERIA

Eligible studies included advanced practice nursing roles (including, but not limited to, nurse practitioners and clinical nurse specialists) in Arab countries in the Eastern Mediterranean region. Studies were considered if they focused on role development, titles, entry-level education, regulation and scope of practice, and facilitators and barriers to role implementation.

METHODS

A comprehensive systematic search was completed for both published and non-published literature. The databases searched included CINAHL, PubMed, PsycINFO, Embase, Nursing and Allied Health Database, and Scopus. Gray literature was searched using websites such as Google Scholar, ProQuest Dissertations and Theses, International Council of Nurses, World Health Organization regional office for the Eastern Mediterranean region, and websites of nursing associations and Ministries of Health in Arab countries. The search included literature published in Arabic and English from the inception of the databases to August 2020.

RESULTS

A total of 35 articles were included, the majority (n = 24) of which were published from 2010 onward. Ten of the included studies were empirical research papers that used qualitative and quantitative research designs. Advanced practice nursing role development is still in its infancy in most of the Arab countries in the Eastern Mediterranean region and can be described as slowly and steadily evolving. The main driving forces for the implementation of the roles in this region included a shortage of physicians both in number and specialties, the emergence of chronic diseases due to lifestyle changes, the desire to have more cost-effective primary care, and to advance nursing as a profession. Clinical nurse specialists and nurse practitioners are the most common titles for the advanced nursing roles practiced in the region. Some advanced practice nursing roles stipulated a master's degree as a minimum requirement, while others required a 12-month in-house training program. Oman is the only Arab country that authorizes nurse practitioners to prescribe pre-set medications. The common barriers to advanced practice nursing role implementation included a lack of recognition of roles at national levels, role ambiguity, lack of clear scope of practice, resistance from male physicians, low involvement of nurses in policy-making, and low status of nursing as a profession.

CONCLUSION

The successful implementation and sustainment of advanced practice nursing roles in Arab countries in the Eastern Mediterranean region requires foundational work, including development of definitions, educational standards, regulations, and a clear scope of practice.

SCOPING REVIEW REGISTRATION NUMBER

Open Science Framework: https://osf.io/wyj8a.

A realist evaluation case study of the implementation of advanced nurse practitioner roles in primary care in Scotland

Aim

To evaluate Advanced Nurse Practitioner (ANP) role implementation in primary care across Scotland in contributing to primary care transformation, and establish what works, for whom, why and in what context.

Design

A realist evaluation using multiple case studies.

Methods

Two phases, conducted March 2017 to May 2018: (1) multiple case studies of ANP implementation in 15 health boards across Scotland, deductive thematic analysis of interviews, documentary analysis; (2) in‐depth case studies of five health boards, framework analysis of interviews and focus groups.

Results

Sixty‐eight informants were interviewed, and 72 documents were reviewed across both phases. ANP roles involved substitution for elements of the GP role for minor illness and injuries, across all ages. In rural areas ANPs undertook multiple nursing roles, were more autonomous and managed greater complexity. Mechanisms that facilitated implementation included: the national ANP definition; GP, primary care team and public engagement; funding for ANP education; and experienced GP supervisors. Contexts that affected mechanisms were national and local leadership; remote, rural and island communities; and workload challenges. Small‐scale evaluations indicated that ANPs: make appropriate decisions; improve patient access and experience.

Conclusions

At the time of the evaluation, the implementation of ANP roles in primary care in Scotland was in early stages. Capacity to train ANPs in a service already under pressure was challenging. Shifting elements of GPs workload to ANPs freed up GPs but did little to transform primary care. Local evaluations provided some evidence that ANPs were delivering high‐quality primary care services and enhanced primary care services to nursing homes or home visits.

Impact

ANP roles can be implemented with greater success and have more potential to transform primary care when the mechanisms include leadership at all levels, ANP roles that value advanced nursing knowledge, and appropriate education programmes delivered in the context of multidisciplinary collaboration.

Inequal distribution of nursing personnel: a subnational analysis of the distribution of nurses across 58 countries

BACKGROUND

Nursing personnel are critical for enabling access to health service in primary health care. However, the State of the World's Nursing 2020 report showed important inequalities in nurse availability between countries.

METHODS

The purpose of this study/analysis was to describe the differences in nurse-to-population density in 58 countries from six regional areas and the relationship between differences in access to nurses and other indicators of health equity.

RESULTS

All countries and income groups showed subnational inequalities in the distribution of nursing personnel with Gini coefficients ranging from 1 to 39. The latter indicated situation such as 13% of the population having access to 45% of nurses in a country. The average max-to-min ratio was on average of 11-fold. In our sample, the African region had the highest level of subnational inequalities with the average Gini coefficient of 19.6. The European Region had the lowest level of within-country inequalities with the average Gini coefficient being 5.6. A multivariate analysis showed a clustering of countries in three groups: (1) high Gini coefficients comprised mainly African countries; (2) moderate Gini coefficients comprised mainly South-East Asian, Central and South American countries; (3) low Gini coefficients comprised mainly Western countries, Japan, and Korea. The analysis also showed that inequality in distribution of nurses was correlated with other indices of health and inequality such as the Human Development Index, maternal mortality, and life expectancy.

CONCLUSIONS

This study showed that there is a high level of geographic inequality in the distribution of nurses at subnational level. Inequalities in nursing distribution are multifactorial, to improve access to nurses, policies should be bundled, tailored to the local context and tackle the various root causes for inequalities.

Role dimensions of practice nurses and interest in introducing advanced nurse practitioners in general practice in Ireland

Background

Internationally many countries have implemented strategies to enhance primary care, to strengthen their health systems to cope with an aging population, the rise of chronic conditions, and increased costs. Primary care has the potential to address these challenges, however, general practitioners are increasingly struggling to meet patient demand resulting from a growing and aging population. Expanding the role of general practice nurses to advanced nurse practitioner (ANP) level has worked internationally and could equally be a solution to the Irish context. However, their current role must first be established as well as their level of interest in becoming an ANP.

Aim

To explore the role of general practice nurses and their interest in becoming an ANP.

Design

A survey design.

Method

A purposeful sample of general practice nurses (n = 40) was undertaken between April and June 2019. Data were analyzed using the Statistical Package for Social Science (SPSS V 25.0; IBM).

Results

General practice nurses appear to have an agenda in relation to activities associated with wound care, immunizations, respiratory and cardiovascular issues. Just over half of the respondents were not interested in becoming an ANP. Their perceived challenges associated with the implementation of the role include a lack of support from general practitioners, a lack of resources, insurance issues, and a lack of understanding of the role. Challenges were associated with undertaking further training and their experience of having more work transferred to general practice without concomitant reallocation of resources.

Conclusion

General practice nurses have extensive clinical experience to deliver major improvements in primary care. Educational opportunities need to be provided for upskilling existing general practice nurses to advanced practice level. Greater understanding of the role and the potential contribution of the role in general practice is required among medical colleagues and the public.

Recruitment and retention of primary care nurse practitioners in underserved areas: A scoping review

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.

Nurse practitioners' perception of temporary full practice authority during a COVID-19 surge: A qualitative study

BACKGROUND

At the beginning of the COVID-19 pandemic in the United States, 22 state governors temporarily waived physician supervision of nurse practitioners to expand access to health care during the state of emergency.

OBJECTIVE

We examined the nurse practitioner perception of the simultaneous scope of practice changes and the exigent pandemic demands during the initial COVID-19 surge in Massachusetts.

METHODS

Qualitative descriptive design using content analysis of open-ended responses to a web-based survey of Massachusetts nurse practitioners conducted in May & June 2020.

RESULTS

Survey response rate was 40.6 percent (N = 389). Content analysis identified four themes including: 1) State waivers enabled more control over practice and more expedited care, 2) State waiver did not change practice either because of pre-established independence or employers not changing policy, 3) Perception of nurse practitioner role as both versatile and disposable and 4) Telehealth increased access to care and created an autonomous setting.

CONCLUSIONS

Although findings suggest fewer barriers in some areas, the temporary removal of state-level restrictions alone is not sufficient to achieve immediate full scope of practice for nurse practitioners. There is a need for regulatory frameworks that optimize the capacity of the advanced practice nursing workforce to respond to global health emergencies. US-based policymakers and healthcare organizations should revise outdated scope of practice policies and capitalize on telehealth technology to utilize the full extent of nurse practitioners. Likewise, nursing leaders should be a voice for nurse practitioners to more effectively and safely maximize the nurse practitioner contribution during emergency responses. In countries where the role is under development, regulators can leverage these findings to establish modernized nurse practitioner scope of practice policies from the outset.

The effect of nurse practitioner scope of practice laws on primary care delivery

Nurse practitioners (NPs) are an increasingly integral part of the primary care workforce. NPs' authority to practice without physician oversight is regulated by state-level scope of practice (SOP) restrictions. To the extent that SOP restrictions prevent NPs from practicing to their full abilities and capacity, they could create inefficiencies and restrict access to health care. In this paper, I study what happens at primary care practices when states relax their SOP laws. Using a novel dataset of claims and electronic health records paired with a difference-in-differences research design, I quantify the effects of relaxing SOP laws on: (1) NPs' autonomy in their day-to-day jobs; (2) total workload and patient allocation between NPs and physicians; and (3) the provision of low-value services at primary care practices. I find some evidence that NPs practice more autonomously following SOP changes, but I find no evidence that relaxing SOP laws changes the volume nor allocation of patients to NPs, nor the provision of low-value services. Given the lower reimbursement that NPs typically receive, these findings suggest that allowing NPs to practice without physician oversight could reduce health care spending, without harming patients.

Economic Aspects of Delivering Primary Care Services: An Evidence Synthesis to Inform Policy and Research Priorities

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.