Perceived barriers to nurse practitioner practice in rural settings

Enablers and barriers to nurse practitioners working in Australian aged care: A scoping review

OBJECTIVE

To identify evidence reporting on nurse practitioners working in aged care in Australia and to categorise the reported factors found to be barriers or facilitators to operation in terms of establishment, sustainability, and expansion.

INTRODUCTION

Nurse practitioners work in a variety of aged care contexts throughout Australia but are underutilised and uncommon. Despite evidence for their effectiveness, it is unclear what barriers or enabling factors contribute to the successful and sustainable implementation of nurse practitioners working in this sector.

METHODS

Based on an a-priori protocol the JBI methodology for scoping reviews was used and the review reported against the PRISMA extension for scoping reviews (PRISMA-ScR). Databases searched included MEDLINE, Embase, Emcare, Web of Science, and Scopus. Peer reviewed and grey literature describing the role of Australian nurse practitioners in aged care were included.

RESULTS

Of 2968 retrieved sources, 18 were included representing studies of a variety of designs from all Australian states and territories. Residential care and in-home care contexts as well as metropolitan, regional, and remote locations were represented. Overall, 123 individual barriers and facilitators were identified across seven inductively derived categories: staff/individual, organisational, system, operational, resource, data, and consumers/clients/residents. In many cases, factors appeared across both positive (facilitators) and negative (barriers) categories.

CONCLUSIONS

Nurse practitioners can improve the quality of care being provided to older people accessing aged care in Australia. When establishing or maintaining nurse practitioner roles in aged care knowledge users should have a comprehensive understanding of the range of factors potentially contributing to or limiting success or sustainability. As implementation is highly contextual, various types of organisational and sectoral factors as well as individual and overarching factors related to the regulation of nurse practitioners practice should be considered.

Characteristics of Medical Deserts and Approaches to Mitigate Their Health Workforce Issues: A Scoping Review of Empirical Studies in Western Countries

BACKGROUND

Medical deserts are considered a problematic issue for many Western countries which try to employ multitude of policies and initiatives to achieve a better distribution of their health workforce (HWF). The aim of this study was to systematically map research and provide an overview of definitions, characteristics, contributing factors and approaches to mitigate medical deserts within the European Union (EU)-funded project "ROUTE-HWF" (a Roadmap OUT of mEdical deserts into supportive Health WorkForce initiatives and policies).

METHODS

We performed a scoping review to identify knowledge clusters/research gaps in the field of medical deserts focusing on HWF issues. Six databases were searched till June 2021. Studies reporting primary research from Western countries on definitions, characteristics, contributing factors, and approaches were included. Two independent reviewers assessed studies for eligibility, extracted data and clustered studies according to the four defined outcomes.

RESULTS

Two-hundred and forty studies were included (n=116, 48% Australia/New Zealand; n=105, 44% North America; n=20, 8% Europe). All used observational designs except for five quasi-experimental studies. Studies provided definitions (n=171, 71%), characteristics (n=95, 40%), contributing factors (n=112, 47%), and approaches to mitigate medical deserts (n=87, 36%). Most medical deserts were defined by the density of the population in an area. Contributing factors to HWF issues in medical deserts consisted in work-related (n=55, 23%) and lifestyle-related factors (n=33, 14%) of the HWF as well as sociodemographic characteristics (n=79, 33%). Approaches to mitigate them focused on training adapted to the scope of rural practice (n=67, 28%), HWF distribution (n=3, 1%), support/infrastructure (n=8, 3%) and innovative models of care (n=7, 3%).

CONCLUSION

Our study provides the first scoping review that presents and categorizes definitions, characteristics, contributing factors, and approaches to mitigate HWF issues in medical deserts. We identified gaps such as the scarcity of longitudinal studies to investigate the impact of factors contributing to medical deserts, and interventional studies to evaluate the effectiveness of approaches to mitigate HWF issues.

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.

Nurse practitioner led model of after-hours emergency care in an Australian rural urgent care Centre: health service stakeholder perceptions

Background

The challenges of providing and accessing quality health care in rural regions have long been identified. Innovative solutions are not only required but are also vital if effective, timely and equitable access to sustainable health care in rural communities is to be realised. Despite trial implementation of some alternative models of health care delivery, not all have been evaluated and their impacts are not well understood. The aim of this study was to explore the views of staff and stakeholders of a rural health service in relation to the implementation of an after-hours nurse practitioner model of health care delivery in its Urgent Care Centre.

Methods

This qualitative study included semi-structured individual and group interviews with professional stakeholders of a rural health service in Victoria, Australia and included hospital managers and hospital staff who worked directly or indirectly with the after-hours NPs in addition to local GPs, GP practice nurses, and paramedics. Thematic analysis was used to generate key themes from the data.

Results

Four themes emerged from the data analysis: transition to change; acceptance of the after-hours nurse practitioner role; workforce sustainability; and rural context.

Conclusions

This study suggests that the nurse practitioner-led model is valued by rural health practitioners and could reduce the burden of excessive after-hour on-call duties for rural GPs while improving access to quality health care for community members. As pressure on rural urgent care centres further intensifies with the presence of the COVID-19 pandemic, serious consideration of the nurse practitioner-led model is recommended as a desirable and effective alternative.

Primary healthcare in rural areas: access, organization, and health workforce in an integrative literature review

Primary healthcare is essential for dealing with the iniquities marking rural and remote territories. The concept of rurality is somewhat imprecise, and rural health policies in Brazil are insufficient. A review of the international literature can foster better understanding of the strategies developed in central rural health issues. The article's objective was to identify and analyze the challenges in access, organization of healthcare, and health workforce in primary care in rural areas. An integrative literature review was performed to search for scientific articles published from 2000 to 2019 in the Cochrane and MEDLINE databases and specific rural health journals. The search yielded 69 articles, categorized as addressing access, organization of healthcare, or health workforce. The findings' main themes were analyzed. Articles classified as access presented the following central themes: geographic aspects, patients' needs to travel for care, and access to hospital and specialized services. Articles on organization of healthcare dealt with structure and inputs, functioning of health services, and community-based management. Health workforce featured healthcare workers' profiles and roles and factors for their attraction/retention. Crosscutting issues in strengthening access, organization of healthcare, and health workforce in rural areas were community action, outreach/visiting models, communication/information technologies, access to care, and professional training/development. The review provides a comprehensive understanding of primary care in rural health to promote equity for rural populations.

Nurse practitioner scope of practice and the prevention of foot complications in rural diabetes patients

PURPOSE

Diabetic foot ulcers afflict a quarter of type-2 diabetes mellitus patients and are associated with higher mortality rates among people with diabetes. Routine primary and preventive care is essential to both prevent and treat foot ulcers before they can contribute to further adverse outcomes. One approach for expanding this care to people with diabetes in rural communities is increasing the practice authority of nurse practitioners. This study examines whether the presence of nurse practitioner practice authority is associated with fewer foot ulcer complications in rural populations as measured through the incidence of foot debridement-a common procedure for addressing severe diabetic foot ulcers.

METHODS

This study uses medical claims to estimate the incidence of foot debridement for US counties. A multivariable linear regression was performed to examine the association between nurse practitioner practice authority and the county incidence of foot debridement after adjusting for measures of local health care workforce and sociodemographics.

FINDINGS

Nurse practitioner practice authority was associated with 219.4 fewer foot debridements per 10,000 enrollees (P < .001) in rural counties. Rural health clinics (P < .03) and skilled nursing facilities (P < .03) were also associated with fewer rural debridements. The number of nurse practitioners (P < .69) and primary care physicians (P < .69) per enrollee were not significant. No measure of health care workforce was associated with the incidence of foot debridement in urban counties.

CONCLUSIONS

Expanding nurse practitioner practice authority may be an effective solution for preventing complications from diabetic foot ulcers in rural communities.

A National Survey of RN-to-BSN Programs: Are They Reaching Rural Students?

BACKGROUND

Increased representation of Bachelor of Science in Nursing (BSN)-prepared nurses improves health and reduces costs. Fewer rural U.S. nurses have BSN degrees compared with the national average. RN-to-BSN programs provide an opportunity to increase the number of BSN-prepared rural nurses. However, the number of these programs targeting rural students is unknown.

METHOD

Directors of RN-to-BSN programs were surveyed regarding program characteristics and efforts to target rural learners. Using mail and online return options, the response rate was 31.3%.

RESULTS

Only 38% of programs targeted rural RNs for recruitment. Supports for rural student recruitment and retention, including partnerships with community colleges, rural clinical placements, and online offerings, were limited in number and/or scope.

CONCLUSION

RN-to-BSN programs with the capacity to recruit and retain rural learners may help increase the number of BSN-prepared rural nurses. Increased collaboration among stakeholders will support rural nurses in continuing their education. [J Nurs Educ. 2020;59(10):557-565.].

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.

Nurse Practitioner Autonomy and Satisfaction in Rural Settings

Rural primary care shortages may be alleviated if more nurse practitioners (NPs) practiced there. This study compares urban and rural primary care NPs (classified by practice location in urban, large rural, small rural, or isolated small rural areas) using descriptive analysis of the 2012 National Sample Survey of NPs. A higher share of rural NPs worked in states without physician oversight requirements, had a DEA (drug enforcement administration) number, hospital admitting privileges, and billed using their own provider identifier. Rural NPs more often reported they were fully using their NP skills, practicing to the fullest extent of the legal scope of practice, satisfied with their work, and planning to stay in their jobs. We found lower per capita NP supply in rural areas, but the proportion in primary care increased with rurality. To meet rural primary care needs, states should support rural NP practice, in concert with support for rural physician practice.

The Role of the Advanced Practice Nurse in the Academic Setting

OBJECTIVES

To explore how advanced practice nurses implement practice change in academic medical centers to support optimal patient and staff outcomes.

DATA SOURCES

Published peer reviewed literature, web-based resources, and professional society materials.

CONCLUSION

Cancer care is rapidly evolving and advanced practice nurses can shape the future of how care is delivered as well as the setting it is delivered in.

IMPLICATIONS FOR NURSING PRACTICE

Advanced practice oncology nurses (Nurse Practitioners and Clinical Nurse Specialists) have an opportunity to significantly shape the patient experience by implementing programmatic changes across the continuum of care by engaging stakeholders in project design. Knowledge of change management and implementation science is critical to success.

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

The expansion of the nurse practitioner (NP) workforce in primary care is key to meeting the increased demand for care. Organizational climates in primary care settings affect NP professional practice and the quality of care. This study investigated organizational climate and its domains affecting NP professional practice in primary care settings. A qualitative descriptive design, with purposive sampling, was used to recruit 16 NPs practicing in primary care settings in Massachusetts. An interview guide was developed and pretested with two NPs and in 1 group interview with 7 NPs. Data collection took place in spring of 2011. Individual interviews lasted from 30-70 minutes, were audio recorded, and transcribed. Data were analyzed using Atlas.ti 6.0 software by 3 researchers. Content analysis was applied. Three previously identified themes, NP-physician relations, independent practice and autonomy, and professional visibility, as well as two new themes, organizational support and resources and NP-administration relations emerged from the analyses. NPs reported collegial relations with physicians, challenges in establishing independent practice, suboptimal relationships with administration, and lack of support. NP contributions to patient care were invisible. Favorable organizational climates should be promoted to support the expanding of NP workforce in primary care and to optimize recruitment and retention efforts.

An examination of barriers to nurse practitioner endorsement in senior rural drug and alcohol nurses in New South Wales

INTRODUCTION AND AIMS

To examine barriers senior rural nurses in New South Wales drug and alcohol clinical settings perceive when considering endorsement to Nurse Practitioner (NP).

DESIGN AND METHODS

A survey was designed to record views of senior alcohol and drug nurses in rural New South Wales about becoming a NP. Participants were identified by Area Health Service Directors of Drug and Alcohol Services for each Area Health Service in NSW excluding metropolitan Sydney. Forty eight surveys were distributed, with 17 (35%) completed surveys included in the results.

RESULTS

Of the 17 participants, 12 (70.6%) expressed interest in becoming a NP. The majority (12, 70.6%) were unaware or unsure of endorsement processes. Lack of clarity about the NP role and processes and benefits to becoming a NP was found to be of most concern to all participants. Only 6 participants (35%) indicated they would consider seeking endorsement to NP.

DISCUSSION AND CONCLUSION

Despite agreeing that NP positions in alcohol and drug settings would improve patient access to treatment and care, senior nurses working in these settings in regional areas are unfamiliar with pathways to becoming endorsed. Barriers, such as a lack of internal support from management and colleagues, as well as the fact that respondents reported no foreseeable financial gain in endorsement, also need to be addressed, before more nurses will consider endorsement. Further evaluation of the views of senior nurses in metropolitan alcohol and other drug settings in the process to NP endorsement is needed before clients will benefit from the expertise and enhanced care that NP's may provide.

Knowledge and attitudes of primary care physicians toward the nurse practitioner role in the Kingdom of Bahrain

PURPOSE

The Kingdom of Bahrain is facing a number of challenges, including an escalating cost of health services, increasing incidence of chronic diseases, and shortage of primary care physicians (PCPs). Introducing the nurse practitioner (NP) specialty in the primary care setting is one way to meet these challenges. The purpose of this quasi-experimental study was to examine the knowledge and attitudes of PCPs about the NP role prior to and following an educational intervention.

DATA SOURCES

The modified Northern Emergency Nurse Practitioner Staff Survey was used to measure the PCPs' attitudes and knowledge. A total of 90 PCPs completed the pretest and posttest.

CONCLUSIONS

The study findings showed that PCPs had poor understanding of the NP role. Their knowledge and attitudes changed significantly after the educational intervention. Also, posttest data indicated a positive correlation between knowledge and attitudes toward the NP role.

IMPLICATIONS FOR PRACTICE

More educational preparation and orientation to the NP role for PCPs and other healthcare professionals are needed before the implementation of the role in the primary care setting in Bahrain. There is a need for the role to be clearly defined prior to implementation to help gain understanding and acceptance.

Clients' understanding of the role of nurse practitioners

Nurse practitioners (NPs) have an emerging role in the Australian health care system. However, there remains a dearth of data about public understanding of the NP role. The aim of this study was to evaluate clients' understanding of the role of the NP and their satisfaction with education received, quality of care and NP knowledge and skill. All authorised NPs working in a designated NP position in Western Australia and those working in three area health services in New South Wales were invited to recruit five consecutive clients to complete the self-administered survey. Thirty-two NPs (NP response rate 93%) recruited 129 clients (client response rate 90%). Two-thirds of clients (63%) were aware they were consulting an NP. The majority rated the following NP-related outcomes as 'excellent' or 'very good': education provided (89%); quality of care (95%); and knowledge and skill (93%). Less than half reported an understanding that NPs could prescribe medications (40.5%) or interpret X-rays (33.6%). Clients of NPs practising in a rural or remote setting were more likely than those in an urban setting to have previously consulted an NP (P = 0.005), and where applicable would to prefer to see an NP rather than a doctor (P = 0.022). Successful implementation and expansion of the NP role requires NP visibility in the community. Despite high levels of satisfaction, more awareness of the scope of the NP role is required.

Predicting medical students' intentions to take up rural practice after graduation

OBJECTIVES

Using a novel longitudinal tracking project, this study develops and evaluates the performance of a predictive model and index of rural medical practice intention based on the characteristics of incoming medical students.

METHODS

Medical school entry survey data were obtained from the Medical Schools Outcome Database (MSOD) project implemented in all Australian and New Zealand medical schools and coordinated through Medical Deans Australia and New Zealand, the representative body for the Deans of 18 Australian and two New Zealand medical schools and faculties. The medical school commencement survey collects data on students' education and family background, including rural upbringing, personal circumstances and scholarships, and on their practice intentions in terms of location and specialty. The MSOD will also allow tracking of medical graduates after graduation. Logistic regression modelling was used to develop a predictive model of rural practice intention. Split-sample validation was used to gain some insight into the stability of performance of the model.

RESULTS

Response rates to the MSOD survey exceeded 90% on average. The model findings confirm and extend previous research examining the association of medical student characteristics with intention to take up rural medical practice. The statistically significant independent factors in the model included students' rural backgrounds, financial arrangements and intentions regarding specialist versus generalist practice upon graduation. Model performance was good, with an area under the receiver-operator characteristics curve of 0.86, and reproducible, with an area in a validation sample of 0.83.

CONCLUSIONS

The model and related index provide important insights into individual factors associated with rural practice intention among students commencing medical studies. The model can also provide a means for optimising the use of scarce medical programme resources, thereby helping to improve the supply of rural medical practitioners. This study illustrates the power and potential of a robust, consistent, systematic longitudinal tracking project.

Exploring the expanded practice roles of community mental health nurses

Significant changes to the delivery of mental health services have resulted in the expansion of the community mental health nursing role. This qualitative study was undertaken to explore the extent to which community mental health nurses are currently engaged in expanded forms of practice. Focus groups were undertaken with community mental health nurses (n = 27) from metropolitan and rural Victoria, Australia. Thematic analysis identified the following major themes: reported practice, consumers as beneficiaries of expanded practice, risk of harm and litigation, and barriers to expanded practice. The findings emphasize the need for significant changes in current legislation if expanded practice for nurses is to become a reality.