Global trends and issues in APN practice: engage in the change

The advanced practice nursing (APN) movement represents a global vision with similar issues facing APNs across dissimilar countries, disparate political structures, and diverse cultures. As APNs work toward independent practice, they face external challenges from medicine and internal barriers within the domain of nursing. This paper presents reflections on the major practice issues raised at the 7th International Nurse Practitioner/Advanced Practice Nursing Network Conference, a subgroup of the International Council on Nursing (ICN), in London in August, 2012. Major issues addressed at the conference included independent practice, barriers to practice, educational standards, and the APN role in research and evidence-based practice. APNs are best placed to provide and direct an advanced level of quality healthcare. APNs must develop consensus models and present as a more unified force in the quest for independent practice.

Fellow Perceptions of Residency Training in Obstetrics and Gynecology

OBJECTIVE

To evaluate the perceptions of current and former fellows in obstetrics and gynecology (OBG) subspecialties of their readiness for fellowship training.

METHODS

A previously used survey was modified and distributed in 2016 to current and former fellows in gynecologic oncology, maternal-fetal medicine, reproductive endocrinology-infertility, and female pelvic medicine and reconstructive surgery. The survey explored domains of professionalism, independent practice, psychomotor ability, clinical evaluation, and scholarship. A standard Likert scale was employed and domains/responses were tailored to each subspecialty. Standard statistical models were utilized.

RESULTS

A total of 478 fellows responded to the survey. Nearly 75% of fellows from each specialty reported feeling prepared or very prepared for fellowship. More than 65% of fellows from each specialty reported feeling very prepared to perform core surgical procedures. More than 90% of respondents reported having opportunities during residency to independently develop a plan of action for patients on labor and delivery. Fewer respondents reported opportunities to independently manage postoperative complications-40.7% of gynecologic oncology and 44.7% of female pelvic medicine and reconstructive surgery reported having such opportunities, whereas 91.9% of maternal-fetal medicine respondents reported having had such opportunities. While 46.4% of respondents received education on scientific writing during residency, 80% reported writing a manuscript as a resident.

CONCLUSIONS

The majority of current and former fellows in OBG subspecialties report feeling prepared for fellowship in terms of clinical and surgical skills. Their feedback reveals opportunities for improvement of independent practice in gynecologic scenarios, as well as formal education on scientific research, for OBG residencies.

A systematic integrative literature review of the factors influencing the professionalization of midwifery in the last decade (2009-2019)

BACKGROUND

The professionalization of midwifery is not only important for midwives themselves, but for women and society in general since professionalism is associated with high-quality services and moral and ethical standards.

AIM

This systematic integrative literature review seeks to investigate the factors that have affected the professionalization of midwifery in the last decade (2009-2019).

METHODS

Systematic searches were conducted in EBSCO, PubMed, ScienceDirect, SAGE and the Web of Science Core Collection. Critical appraisal was conducted using the Mixed Methods Appraisal Tool (MMAT). The findings were synthesised through a thematic analysis. The PRISMA statement was used to guide the reporting.

FINDINGS

Analysis of the 20 studies included detected two main themes: professionalization barriers and professionalization opportunities. The first theme includes issues concerning power imbalance, social recognition, conflicting perspectives on childbirth, professional autonomy, work characteristics, midwifery associations, and regulation. The second theme includes opportunity issues related to woman-centred care, expansion of professional competency, interprofessional collaboration, and education.

KEY CONCLUSIONS

Over the last decade, the midwifery profession has faced several barriers that seem to be historically entrenched in the professionalization of midwifery, yet changes in the professionalization process are visible in the shift towards elements of the 'new professionalism' that is rising to the surface during this process.

IMPLICATIONS FOR PRACTICE

The findings suggest the socialisation process of midwifery candidates must focus on raising their self-awareness, self-esteem and confidence in their professional role; woman-centred care needs to be further promoted and implemented; and interprofessional collaboration should be addressed in educational programmes for all health professionals.

The Life After Surgical Residency (LASR) Curriculum for Surgical Residents: Addressing the Nonclinical Barriers to Preparedness for Independent Practice

OBJECTIVE

Extrinsic burdens, including new personal and professional responsibilities, may distract from early career success. We sought to assess resident preparedness in nonclinical topics and to utilize this data to design a curriculum to address these content areas.

DESIGN

All residents were surveyed to ascertain their self-reported preparedness on a variety of nonclinical topics (teaching, finances, contract negotiation, real estate, etc.). Using our survey results, a monthly curriculum was designed and implemented for senior residents based on these knowledge gaps.

SETTING

University-based general surgery residency program.

PARTICIPANTS

All general surgery residents.

RESULTS

Residents reported low levels of preparedness on the topics of contract negotiation and practice management and high levels of preparedness on the topics of teaching and money management. Following curriculum implementation, statistically significant improvement was noted in the topics of contract negotiation and academic pursuits.

CONCLUSIONS

Residents report low levels of preparedness in many nonclinical topics that may represent potentially modifiable stressors that can impact career success. Implementation of a directed curriculum improves sense of preparedness and may promote wellness among surgical trainees.

How well are Swiss French physicians prepared for future practice in primary care?

BACKGROUND

Moving from postgraduate training into independent practice represents a major transition in physicians' professional life. Little is known about how Swiss primary care graduates experience such a transition. The aim of this study was to explore the extent to which primary care physicians who recently set up private practice felt prepared to work as independent practitioners.

METHODS

We conducted 7 focus groups among recently established (≤ 5 years) primary care physicians in Switzerland. Questions focused on positive and negative aspects of setting up a practice, and degree of preparedness. Transcripts were analysed according to organisational socialisation and work role transition frameworks.

RESULTS

Participants felt relatively well prepared for most medical tasks except for some rheumatologic, minor traumatology, ENR, skin and psychiatric aspects. They felt unprepared for non clinical tasks such as office, insurance and medico-legal management issues and did not anticipate that the professional networking outside the hospital would be so important to their daily work. They faced dilemmas opposing professional values to the reality of practice which forced them to clarify their professional roles and expectations. Adjustment strategies were mainly informal.

CONCLUSION

Although the postgraduate primary care curriculum is longer in Switzerland than in most European countries, it remains insufficiently connected with the reality of transitioning into independent practice, especially regarding role development and management tasks. A greater proportion of postgraduate training, with special emphasis on these issues, should take place directly in primary care.

[Rights and duties of liberal professions]

BACKGROUND

The medical profession is categorized as a liberal profession. But what does this mean specifically for members of the profession?

OBJECTIVES

What rights and obligations apply to a physician as a member of a liberal profession-and does this apply to all physicians? Or is membership of the liberal professions influenced by employment status?

MATERIALS AND METHODS

Legislative and normative texts that shape the concept of liberal professions and its consequences are examined.

RESULTS

The rights and obligations are not laid down jointly, but result from an interplay of various regulations and may vary for different professional groups. They are reflected in particular in professional law.

CONCLUSION

Characteristics, rights, and duties of a liberal profession cannot be considered separately, but are mutually dependent.

Urology Group Compensation and Ancillary Service Models in an Era of Value-based Care

Changes involving the health care economic landscape have affected physicians' workflow, productivity, compensation structures, and culture. Ongoing Federal legislation regarding regulatory documentation and imminent payment-changing methodologies have encouraged physician consolidation into larger practices, creating affiliations with hospitals, multidisciplinary medical specialties, and integrated delivery networks. As subspecialization and evolution of care models have accelerated, independent medical groups have broadened ancillary service lines by investing in enterprises that compete with hospital-based (academic and nonacademic) entities, as well as non-physician- owned multispecialty enterprises, for both outpatient and inpatient services. The looming and dramatic shift from volume- to value-based health care compensation will assuredly affect urology group compensation arrangements and productivity formulae. For groups that can implement change rapidly, efficiently, and harmoniously, there will be opportunities to achieve the Triple Aim goals of the Patient Protection and Affordable Care Act, while maintaining a successful medical-financial practice. In summary, implementing new payment algorithms alongside comprehensive care coordination will assist urology groups in addressing the health economic cost and quality challenges that have been historically encountered with fee-for-service systems. Urology group leadership and stakeholders will need to adjust internal processes, methods of care coordination, cultural dependency, and organizational structures in order to create better systems of care and management. In response, ancillary services and patient throughput will need to evolve in order to adequately align quality measurement and reporting systems across provider footprints and patient populations.

Transition to practice curriculum for general internal medicine physicians: scoping review and Canadian national survey

BACKGROUND

There remains a paucity of evidence for curricula for the transition to practice (TTP) stage of Competence by Design internal medicine (IM) training programs. Current entrustable professional activities are based on expert consensus rather than robust subspecialty-specific needs assessment.

METHODS

A scoping review was completed to identify studies with TTP focus. A national survey was conducted to identify transition experiences for general internal medicine physicians. Results were assessed by grounded theory analysis to identify core topics for TTP curricula.

RESULTS

Neither scoping review nor national survey identified TTP topics related to the CanMEDS Medical Expert role. Scoping Review: 41 relevant studies were identified. Most (97.6%) were from North America. The most common study types were observational (survey) or curriculum (13/41 31.7% for each). Only two studies were exclusively in IM, and the most common subspecialty studied was surgical (13/41, 31.7%). The most common TTP topics were mentorship, billing and coding, practice management, negotiating contract and job, and financial aspects of practice. National Survey: There were 44 respondents, with the majority (25/44, 56.8%) having completed an IM subspecialty fellowship. Most (38/44) completed medical school in Canada, and most were from academic practice settings (33/44, 75.0%). The most common TTP topics were billing and coding, personal financial planning, practice management, work-life balance and mentorship. Grounded Theory Analysis: There were six themes that encompassed all TTP topics from the scoping review and national survey, being (i) building a career, (ii) continuing professional development, (iii) expectations of the profession, (iv) practice management, (v) Life, health and well-being and (vi) clinical skills. Curriculum competencies and resources for curriculum development were provided.

CONCLUSIONS

This study identifies topics critical for curricula development for IM transition to practice. Further research is required to evaluate effectiveness of curricula including topics and themes developed from this scoping review and national survey.

Thrown into the world of independent practice: from unexpected uncertainty to new identities

One of the most exciting yet stressful times in a physician's life is transitioning from supervised training into independent practice. The majority of literature devoted to this topic has focused upon a perceived gap between clinical and non-clinical skills and interventions taken to address it. Building upon recent streams of scholarship in identity formation and adaptation to new contexts, this work uses a Heideggerian perspective to frame an autoethnographical exploration of the author's transition into independent paediatric practice. An archive of reflective journal entries and personal communications was assembled from the author's first 3 years of practice in four different contexts and analyzed using Heidegger's linked existentials of understanding, attunement and discourse. Insights from his journey suggest this period is a time of anxiety and vulnerability when one questions one's competence and very identity as a medical professional. At the same time, it illustrates the inseparable link between practitioners and the network of relationships in which they are bound, how these relationships contextually vary and how recognizing and tuning to these differences may allow for a more seamless transition. While this work is the experience of one person, its insights support the ideas that change is a constant in professional practice and competence is contextual. As a result, developing educational content that inculcates contextual flexibility and an increased comfort level with uncertainty may prepare our trainees not just to navigate the unavoidable novelty of transition, but lay the groundwork for professional identities attuned to engage more broadly with change itself.

Comfort Level of US Radiation Oncology Graduates: Assessment of Transition to Independent Clinical Practice

Radiation training programs are designed to prepare graduates for independent practice, with metrics in place to assess appropriateness of clinical decision-making. Here, we investigated the self-assessed preparedness of US graduates during the transition to independent practice.An anonymous, Internet-based survey was distributed to recent graduates of radiation oncology residencies (2016-2017). A Likert scale was used to assess comfort with various aspects of practice, as well as "time" to development of comfort in independent practice.Responses were obtained from 70/210 (33%), the majority reported training in programs with 5-8 residents (n = 35). Most (77%) reported designing between 500 and 900 treatment plans during training (n = 54). Only 41% of respondents reported the opportunity to review treatment plans and make decisions about safety/adequacy without attending input > 50% of the time (n = 29). Thirty percent of residents reported being responsible for seeing/managing on-treatment visits (OTVs) ≤ 75% of the time. Aspects with which practitioners reported the least comfort were understanding of billing/application to practice (2.43, IQR 2-3), orthovoltage (superficial radiation) setup and field design (2.57, IQR 1-4), and planning/delivery of prostate implants (2.82, IQR 2-4). Increased mean comfort levels were reported by those designing > 700 treatment plans in training as well as those reporting an opportunity to evaluate plans and make clinical decisions prior to attending input > 50% of the time during residency. Comfort with the delivery of stereotactic body radiation (SBRT) correlated with caseload for liver, spine, prostate, and CNS disease sites but not lung.Variations in training experiences exist across institutions. Here, a lower than expected number of residents reported seeing/managing OTVs as well as reviewing treatment plans prior to attending input during training. Overall comfort was correlated with case volume and opportunities to independently review treatment plans prior to attending input. These data highlight areas of opportunity for improving resident education with implications for ease of transition to independent clinical practice.