Leveraging nursing strengths, listening to nursing needs: A keynote paper from the 2022 Emory University Business Case for Nursing Summit.

This keynote paper is the first installment in the six-part Nursing Outlook special edition based on the 2022 Emory University Business Case for Nursing Summit. The summit, which took place in March 2022, was led by Emory School of Nursing in partnership with Emory School of Business. It convened national nursing, health care, and business leaders to explore possible solutions to nursing workforce crises. Each of the summit's panels authored a paper in this special edition on their respective topic(s). Those topics included the growth, distribution, resilience, and value of the nursing workforce. As on the day of the event, the keynote frames the panelists' discussions by sharing nursing workforce trends, expert workforce insights, and data-informed questions to help promote dialogue in this series and beyond.

Suicide and altitude: A systematic review of global literature.

OBJECTIVE: The purpose of this systematic review was to synthesize the existing global literature examining the relationship between altitude and suicide. METHOD: Using the electronic databases PubMed, CINAHL, EMBASE, and PsychInfo published articles in English that addressed the relationship between altitude and suicide as a primary or secondary aim, and included human subjects, where identified. Studies were assessed for quality based on methodological approach and data relevance on a three-point scale (strong, moderate, or weak). RESULTS: Of the 19 studies related to the purpose and aims, 17 reported evidence of a positive correlation between altitude and increased suicide. Vast design differences were employed within the literature, individual-level suicide data was identified as the preferred level of analysis. DISCUSSION: The relationship between altitude and suicide is an evolving science with a small but growing body of literature suggesting altitude is associated with an increased risk of suicide. This review identifies the need for additional studies examining both individual-level suicide data and improving geographic precision. Public health nurses have a responsibility to carefully examine the quality of studies and the strength of the evidence when addressing variables associated with suicide.

Characteristics of family nurse practitioners and their preparation for practice in rural vs urban employment settings.

BACKGROUND: Policymakers are increasingly interested in using nurse practitioners to provide health care to rural populations, yet little is known about their characteristics and preparation for independent practice. METHODS: We obtained data from the 2018 National Sample Survey of Registered Nurses and compared characteristics of family nurse practitioners (FNPs) employed in rural areas versus those employed in non-rural areas. Regression analysis was used to determine the relationship between the outcome variable of interest, preparation for practice and other covariates. FINDINGS: FNPs practicing in a rural setting felt less prepared for independent practice than their counterparts in non-rural settings except for those prepared with a doctoral degree. DISCUSSION: The majority of FNPs working in rural areas believed they were not as well prepared for independent practice. Because rural FNPs often practice autonomously and without medical back up, nursing educators need to educate FNPs with the skills and knowledge necessary to practice effectively in rural settings.

Value-informed nursing practice: What is it and how to make it a reality.

Nurses make decisions about the use of costly resources in countless care delivery settings 24 hours a day. Consequently, nurses are inseparably connected to not only the quality and safety of care, but to the cost-of-care as well. This article is Part 1 of a 6-part series on value-informed nursing practice. It describes the concept of 'value-informed nursing practice'-practice that focuses not only on outcomes, but also on the cost of care-as a new way to envision nursing practice.

Value-informed nursing practice is needed to make our healthcare systems more environmentally sustainable.

In this 3rd part of our 6-part series on value-informed nursing practice-practice that focuses on both achieving desired patient outcomes and minimizing the use of costly resources to achieve these outcomes-we focus on the importance of nurses in improving environmental outcomes and reducing costly environmental waste. We also propose how nursing education needs to change to prepare the next generation of nurses to effectively address environmental problems through providing value-informed nursing practice.

Part 6. Education for value-informed nursing practice.

With the ongoing transition to value-based health care, a strong command of foundational economic concepts, like cost and value, and the ability to thoughtfully engage in value-informed nursing practice have become essential for the future of the nursing profession. Earlier in this six-part series, we explained value-informed nursing practice, its historical, economic, and ethical foundation, its promise for an environmentally responsible, innovation-driven future health care, and why its adoption requires a reframing of some of the nursing's professional norms and behaviors. This paper concludes the series with one of the most important issues-education for value-informed nursing practice. We begin by setting forth our vision of how nursing students will learn and apply value informed nursing practice, consider challenges that nurse educators will face, and offer some suggestions for engraining value into the consciousness of the nursing profession.

Part 4: Value-informed nursing practice depends on nursing innovation.

With the adoption of value-based payments which tie reimbursement to patient outcomes and costs, days when nursing is viewed primarily as a cost to hospitals will soon be over. Already the backbone of high-quality care delivery and patient outcomes, nurses are becoming key drivers of health care organizations' financial outcomes, too. The first three articles published in this 6-part series on value-informed nursing practice-practice that considers both the outcomes and the cost of producing the outcomes-described what value-informed nursing practice means, its economic, policy, and ethical impetuses, and how value-informed nursing practice helps improve environmental sustainability of health systems. Here, in Part 4, we focus on the importance of nursing innovation in implementing value-informed nursing practice. We begin by discussing how innovation is connected to value and then examine the false dichotomy, perceived by many, between innovation and evidence-based care. Following this, we examine how health care organizations and systems can support nursing innovation, before concluding with recommendations for nursing educators.

Drivers of Cost Differences Between Nurse Practitioner and Physician Attributed Medicare Beneficiaries.

BACKGROUND: Although recent research suggests that primary care provided by nurse practitioners costs less than primary care provided by physicians, little is known about underlying drivers of these cost differences. RESEARCH OBJECTIVE: Identify the drivers of cost differences between Medicare beneficiaries attributed to primary care nurse practitioners (PCNPs) and primary care physicians (PCMDs). STUDY DESIGN: Cross-sectional cost decomposition analysis using 2009-2010 Medicare administrative claims for beneficiaries attributed to PCNPs and PCMDs with risk stratification to control for beneficiary severity. Cost differences between PCNPs and PCMDs were decomposed into payment, service volume, and service mix within low-risk, moderate-risk and high-risk strata. RESULTS: Overall, the average PCMD cost of care is 34% higher than PCNP care in the low-risk stratum, and 28% and 21% higher in the medium-risk and high-risk stratum. In the low-risk stratum, the difference is comprised of 24% service volume, 6% payment, and 4% service mix. In the high-risk stratum, the difference is composed of 7% service volume, 9% payment, and 4% service mix. The cost difference between PCNP and PCMD attributed beneficiaries is persistent and significant, but narrows as risk increases. Across the strata, PCNPs use fewer and less expensive services than PCMDs. In the low-risk stratum, PCNPs use markedly fewer services than PCMDs. CONCLUSIONS: There are differences in the costs of primary care of Medicare beneficiaries provided by nurse practitioners and MDs. Especially in low-risk populations, the lower cost of PCNP provided care is primarily driven by lower service volume.

The roles and clinical activities of registered nurses and nurse practitioners in practices caring for older adults.

BACKGROUND: Population aging and physician shortages have motivated recommendations of increased use of registered nurses in care provision; little is known about RN and NP employment in primary care and geriatric practices or service types each provide. PURPOSE: Determine current RN and NP employment frequency in practices in the U.S., identify services provided by RNs, and whether NP presence in practice is associated with the types and frequency of services provided by RNs. METHODS: National survey of 410 primary care and geriatric clinicians. FINDINGS: Only half of practices employed RNs. RNs most frequently provide teaching or education for chronic disease management. RNs provide significantly more primary care and geriatric services when practices employed a NP. DISCUSSION: Reasons for RN underuse in practices should be identified, clinical placements in such practices should increase, and NP education programs should include care models using RNs to their full scope of practice.

Top priorities for the next decade of nursing health services research.

BACKGROUND: The U.S. health care system faces increasing pressures for reform. The importance of nurses in addressing health care delivery challenges cannot be overstated. PURPOSE: To present a Nursing Health Services Research (NHSR) agenda for the 2020s. METHOD: A meeting of an interdisciplinary group of 38 health services researchers to discuss five key challenges facing health care delivery (behavioral health, primary care, maternal/neonatal outcomes, the aging population, health care spending) and identify the most pressing and feasible research questions for NHSR in the coming decade. FINDINGS: Guided by a list of inputs affecting health care delivery (health information technology, workforce, delivery systems, payment, social determinants of health), meeting participants identified 5 to 6 research questions for each challenge. Also, eight cross-cutting themes illuminating the opportunities and barriers facing NHSR emerged. DISCUSSION: The Agenda can act as a foundation for new NHSR - which is more important than ever - in the 2020s.

Physician and nurse practitioner roles in emergency, trauma, critical, and intensive care.

BACKGROUND: The delivery of emergency, trauma, critical, and intensive care services requires coordination among all members of the care team. Perceived teamwork and role clarity may vary among physicians (MDs) and nurse practitioners (NPs). PURPOSE: To examine differences in perceived roles and responsibilities of NPs and MDs practicing in emergency, trauma, critical, and intensive care. METHODS: Secondary Analysis of the National Survey of Emergency, Intensive, and Critical Care Nurse Practitioners and Physicians, a cross-sectional national survey of clinicians. Mail survey of randomly selected stratified cross-sectional samples of MDs and NPs drawn from national lists of clinicians in eligible specialties working in emergency, trauma, intensive, and critical care units in the United States. 814 clinicians (351 NPs and 463 MDs) were recruited from national by postal mail survey. Our initial sample included n = 2,063 clinicians, n = 1,031 NPs and n = 1,032 MDs in eligible specialties. Of these, 63.5% of NPs and 70.1% of MDs completed and returned the survey excluding those who were ineligible due to lack of current practice in a relevant specialty. FINDINGS: NPs in ICU/CCU are more likely to be female and report working fewer hours than do MDs and provide direct care to more patients. 55% of NPs and 82% of MDs agree that their individual role in their unit is clear (p < .001); 34% of MDs and 42% of NPs agree that their unit is an example of excellent team work among professionals (p = 0.021); 41% of MD and 37% of NP clinicians (p = 0.061) agree that their teams are "prepared to provide outstanding care in a crisis or disaster." Perceived role clarity was significantly associated with increased perceptions of excellent teamwork and disaster preparedness. DISCUSSION: At the time of this survey, and majority of NPs and MDs working in emergency, critical and intensive care did not agree that their teams were prepared for a crisis or disaster. Leaders of health organizations should encourage teamwork and professional role clarity to assist units to perform effectively in emergency and disaster preparedness.

Developing a Workforce for Health in North Carolina: Planning for the Future.

Among the many trends influencing health and health care delivery over the next decade, three are particularly important: the transition to value-based care and increased focus on population health; the shift of care from acute to community-based settings; and addressing the vulnerability of rural health care systems in North Carolina.

The Association of Nurse Practitioner Scope-of-Practice Laws With Emergency Department Use: Evidence From Medicaid Expansion.

BACKGROUND: Overuse and inappropriate use of emergency departments (EDs) remains an important issue in health policy. After implementation of Medicaid expansion, many states experienced an increase in ED use, but the magnitude varied. Differential access to primary care might explain such variation. OBJECTIVE: To determine whether the increase in ED use among Medicaid enrollees following Medicaid expansion was smaller in states that allowed greater access to primary care providers by permitting nurse practitioners (NPs) to practice without physician oversight. RESEARCH DESIGN: Examining data on ED use by Medicaid beneficiaries, we estimated random effects models to examine changes in ED visits. Models for 8 different clinical conditions were estimated, with each model including a linear time trend, indicators for Medicaid expansion and for the absence of physician oversight requirements, and an interaction between these 2 indicators. RESULTS: States requiring physician oversight of NPs had a 28% increase in ED visits relative to the preexpansion period, while states allowing NP practice without physician oversight had only a 7% increase. The increase in the share of visits covered by Medicaid in no-oversight states was 40% of the size of the increase in oversight states. CONCLUSIONS: Allowing NPs to practice without physician oversight was associated with a reduction in the magnitude of increase in ED use following Medicaid expansion. States that restrict NP practice should weigh the costs of maintaining these restrictions against the potential benefits of lower ED use. States considering Medicaid expansion should also consider relaxing NP scope-of-practice laws.

Individual Nurse Productivity in Preparing Patients for Discharge Is Associated With Patient Likelihood of 30-Day Return to Hospital.

OBJECTIVE: Applied to value-based health care, the economic term "individual productivity" refers to the quality of an outcome attributable through a care process to an individual clinician. This study aimed to (1) estimate and describe the discharge preparation productivities of individual acute care nurses and (2) examine the association between the discharge preparation productivity of the discharging nurse and the patient's likelihood of a 30-day return to hospital [readmission and emergency department (ED) visits]. RESEARCH DESIGN: Secondary analysis of patient-nurse data from a cluster-randomized multisite study of patient discharge readiness and readmission. Patients reported discharge readiness scores; postdischarge outcomes and other variables were extracted from electronic health records. Using the structure-process-outcomes model, we viewed patient readiness for hospital discharge as a proximal outcome of the discharge preparation process and used it to measure nurse productivity in discharge preparation. We viewed hospital return as a distal outcome sensitive to discharge preparation care. Multilevel regression analyses used a split-sample approach and adjusted for patient characteristics. SUBJECTS: A total 522 nurses and 29,986 adult (18+ y) patients discharged to home from 31 geographically diverse medical-surgical units between June 15, 2015 and November 30, 2016. MEASURES: Patient discharge readiness was measured using the 8-item short form of Readiness for Hospital Discharge Scale (RHDS). A 30-day hospital return was a categorical variable for an inpatient readmission or an ED visit, versus no hospital return. RESULTS: Variability in individual nurse productivity explained 9.07% of variance in patient discharge readiness scores. Nurse productivity was negatively associated with the likelihood of a readmission (-0.48 absolute percentage points, P<0.001) and an ED visit (-0.29 absolute percentage points, P=0.042). CONCLUSIONS: Variability in individual clinician productivity can have implications for acute care quality patient outcomes.

Comparing the rates of low-value back images ordered by physicians and nurse practitioners for Medicare beneficiaries in primary care.

BACKGROUND: Little is known about the extent of ordering low-value services by. PURPOSE: To compare the rates of low-value back images ordered by primary care physicians (PCMDs) and primary care nurse practitioners (PCNPs). METHOD: We used 2012 and 2013 Medicare Part B claims for all beneficiaries in 18 hospital referral ̱regions (HRRs) and a measure of low-value back imaging from Choosing Wisely. Models included random clinician effect and fixed effects for beneficiary age, disability, Elixhauser comorbidities, clinician sex, the emergency department setting, back pain visit volume, organization, and region (HRR). FINDINGS: PCNPs (N = 231) and PCMDs (N = 4,779) order low-value back images at similar rates (NP: all images: 26.5%; MRI/CT: 8.4%; MD: all images: 24.5%; MRI/CT: 7.7%), with no detectable significant difference when controlling for covariates. DISCUSSION: PCNPs and PCMDs order low-value back images at an effectively similar rate.

Quality of Primary Care Provided to Medicare Beneficiaries by Nurse Practitioners and Physicians.

OBJECTIVE: To examine differences in the quality of care provided by primary care nurse practitioners (PCNPs), primary care physicians (PCMDs), or both clinicians. DATA SOURCES: Medicare part A and part B claims during 2012-2013. STUDY DESIGN: Retrospective cohort design using standard risk-adjustment methodologies and propensity score weighting assessing 16 claims-based quality measures grouped into 4 domains of primary care: chronic disease management, preventable hospitalizations, adverse outcomes, and cancer screening. EXTRACTION METHODS: Continuously enrolled aged, disabled, and dual eligible beneficiaries who received at least 25% of their primary care services from a random sample of PCMDs, PCNPs, or both clinicians. PRINCIPAL FINDINGS: Beneficiaries attributed to PCNPs had lower hospital admissions, readmissions, inappropriate emergency department use, and low-value imaging for low back pain. Beneficiaries attributed to PCMDs were more likely than those attributed to PCNPs to receive chronic disease management and cancer screenings. Quality of care for beneficiaries jointly attributed to both clinicians generally scored in the middle of the PCNP and PCMD attributed beneficiaries with the exception of cancer screening. CONCLUSIONS: The quality of primary care varies by clinician type, with different strengths for PCNPs and PCMDs. These comparative advantages should be considered when determining how to organize primary care to Medicare beneficiaries.