Racial Disparities in Lipid Screening Among Patients With Coronary Artery Disease Narrowed in Primary Care Settings Supportive of Nurse Practitioners.

Background: Coronary artery disease (CAD) is the most prevalent heart disease in the United States, and it disproportionately affects Black compared to White patients. Regular primary care and dyslipidemia screening and management are essential for optimal CAD care. Nurse practitioners (NPs) increasingly provide primary care services, though unsupportive practice environments may constrain their ability to do so. Purpose: To examine whether disparities in lipid screening between Black and White patients with CAD were associated with the NP practice environment scores. Methods: Cross-sectional survey data from NPs in primary care practices and Medicare claims were linked to evaluate outcomes among 111,911 CAD patients (94% White, 6% Black) across 456 primary care practices in four states (California, Florida, New Jersey, and Pennsylvania) in 2016. The NP-Primary Care Organizational Climate Questionnaire, which provides a score on the supportiveness of a respondent's practice, was used to evaluate the NP practice environment. Multilevel regression models that accounted for patient and practice characteristics were used to evaluate the study aim. Results: Compared to White patients with CAD, Black patients with CAD less frequently received annual lipid screening (77.0% vs. 70.6%; p < .001). In logistic regression models accounting for patient and practice characteristics, for every standard deviation increase in the practice environment score, Black patients experienced a 5% increase in odds of receiving lipid screening. Conclusion: Investing in the NP practice environment, including increasing NP role visibility and strengthening relationships with physicians and administrators, may narrow racial disparities in CAD management.

Supportive Practice Environments Are Associated With Higher Quality Ratings Among Nurse Practitioners Working in Underserved Areas.

Background: Deployment of nurse practitioners (NPs) to health professional shortage areas (HPSA) may help to address challenges in patient access to care. However, restrictive scope of practice imposed by regulatory and state legislative bodies or unsupportive organizational climates in clinical practice settings may constrain NP care delivery and perpetuate lower assessments of quality of care provided in these underserved communities. Purpose: The purpose of this study was to investigate the associations between state NP scope of practice regulations, NP practice environment, and self-reported ratings of quality of care in primary care practices located in HPSAs. Methods: This was a cross-sectional analysis of data from 1,972 participant NPs practicing across 1,711 primary care practices in six states representing full (Arizona and Washington), reduced (Pennsylvania and New Jersey), and restricted (California and Florida) NP scope of practice regulation. Survey data were merged with the Area Health Resource Files to determine practices located in primary care HPSAs. Logistic regression models estimated the relationship between quality ratings, scope of practice regulations, and practice environment scores while accounting for NP and practice characteristics. Results: Among all included NPs, 95.7% rated their practice as having "excellent," "very good," or "good" quality of care. Practice environments with higher scores had higher ratings of quality of care after accounting for NP and practice characteristics (OR = 3.73, 95% CI: 2.84, 4.89). Conclusion: Unsupportive clinical practice environments were associated with lower ratings of quality of care in HPSAs, suggesting that improvements in working conditions may be necessary adjuncts to greater deployment of NPs to improve primary care in shortage areas.

Engaging Rehabilitation Technicians Through a Career Ladder During a Pandemic.

PURPOSE: Nursing assistant turnover is a growing healthcare concern that negatively impacts healthcare organization work environments and has significant financial implications. The purpose of this study was to implement a career ladder program for rehabilitation nursing technicians-nursing assistants who specialize in performing care duties aligned with therapeutic goals in inpatient rehabilitation. The study evaluated the effect on organizational quality metrics of employee engagement, job satisfaction, and annual turnover of rehabilitation nursing technicians. DESIGN: This pilot study was conducted using a quality improvement approach and a between-subjects pretest-posttest design. METHODS: A three-tier career ladder intervention for rehabilitation nursing technicians in a 76-bed inpatient rehabilitation facility was implemented. Employee engagement and job satisfaction were evaluated in all rehabilitation nursing technicians (n = 44), with a pre-implementation sample size of n = 23 and a post-implementation sample size of n = 21, from January 2020 through December 2020. Twelve rehabilitation nursing technicians participated in the intervention, which consisted of online learning modules, added job responsibilities, and continuing education and were included in the post-implementation sample size. Nondirectional statistical tests were performed with the level of significance set at .05 (two tailed). FINDINGS: A majority of the pre-post intervention sample (n = 44) were female (91%), African American (91%), and aged 30-59 years. Employee engagement increased from 78% favorable in 2019 to 86% favorable in 2020. Overall job satisfaction improved from 74% favorable in 2019 to 86% favorable in 2020. Annual turnover decreased from 35% in 2019 to 31% in 2020. CONCLUSION: In this pilot study, a career ladder program for rehabilitation nursing technicians was effective in increasing and improving employee engagement and job satisfaction while reducing turnover. CLINICAL RELEVANCE: Rehabilitation nursing technicians are crucial members of the interdisciplinary rehabilitation team providing direct bedside care to optimize patient function. Rehabilitation nursing technician career ladders have the capacity to engage an often underrecognized employee population by creating a positive work environment that promotes job growth and retention in the rehabilitation setting.

Policy Evaluation Of The Affordable Care Act Graduate Nurse Education Demonstration.

The US is experiencing a shortage of primary care providers, which could be reduced by the addition of nurse practitioners. However, the ability to increase the supply of nurse practitioners is limited by a shortage of clinical preceptors. The Affordable Care Act's Graduate Nurse Education Demonstration provided federal funding to offset the clinical training costs of advanced practice nurses. We used data from the American Association of Colleges of Nursing from academic years 2005-06 through 2017-18 to determine whether the demonstration was associated with increased nurse practitioner enrollment and graduation growth. The demonstration was associated with a significant increase in nurse practitioner enrollments and graduations. A promising model of organizing and implementing funding for graduate nursing education nationally was identified. Findings suggest that modernizing Medicare payments for nursing education to support nurse practitioner clinical training costs is a promising option for increasing primary care providers.

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

BACKGROUND: During the COVID-19 pandemic, federal and state governments removed the scope of practice restrictions on nurse practitioners (NPs), allowing them to deliver care to patients without restrictions. PURPOSE: To support policy makers' efforts to grant full practice authority to NPs beyond the COVID-19 pandemic, this manuscript summarizes the existing evidence on the benefits of permanently removing state-level scope of practice barriers and outline recommendations for policy, practice, and research. METHODS: We have conducted a thorough review of the existing literature. FINDINGS: NP full scope of practice improves access and quality of care and leads to better patient outcomes. It also has the potential to reduce health care cost. DISCUSSION: The changes to support full practice authority enacted to address COVID-19 are temporary. NP full practice authority could be part of a longer-term plan to address healthcare inequities and deficiencies rather than merely a crisis measure.

Value of Nurse Practitioner Inpatient Hospital Staffing.

BACKGROUND: Evidence indicates hospitals with better registered nurse (RN) staffing have better patient outcomes. Whether involving more nurse practitioners (NPs) in inpatient care produces better outcomes is largely unknown. OBJECTIVE: The objective of this study was to determine whether the presence of more NPs produces better inpatient outcomes net of RN staffing. RESEARCH DESIGN: This was a 2015-2016 cross-sectional data on 579 hospitals linked from: (1) RN4CAST-US nurse surveys; (2) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient surveys; (3) surgical patient discharge abstracts; (4) Medicare Spending per Beneficiary (MSPB) reports; (5) American Hospital Association (AHA) Annual Survey. Hospitals were grouped according to their NP/beds ratios [<1 NP/100 beds (N=132), 1-2.99 NPs/100 beds (N=279), and 3+ NPs/100 beds (N=168)]. SUBJECTS: RNs randomly sampled nurses from licensure lists yielded 22,273 RNs in study hospitals; discharge data for 1.4 million surgical patients; HCAHPS data for 86% of study hospitals. MEASURES: Mortality, readmissions, lengths of stay, MSPB, patient experience, and quality reported by patients and nurses. RESULTS: After adjustments, patients in hospitals with 3+ NPs/100 beds had lower odds than patients in hospitals with <1 NP/100 beds of 30-day mortality [odds ratio (OR)2=0.76; 95% confidence interval (CI)=0.67-0.82; P<0.001] and 7-day readmissions (OR2=0.90; 95% CI=0.86-0.96; P<0.001), shorter average length of stay (incident rate ratio2=0.92; 95% CI=0.88-0.96; P<0.001) and 5.4% lower average MSPB (95% CI=3.8%-7.1%). Patients and nurses in the hospitals with higher NP/bed ratios were significantly more likely to report better care quality and safety, and nurses reported lower burnout, higher job satisfaction, greater intentions of staying in their jobs. CONCLUSIONS: Having more NPs in hospitals has favorable effects on patients, staff nurse satisfaction, and efficiency. NPs add value to existing labor resources.

Supportive Clinical Practice Environments Associated With Patient-Centered Care.

A lack of organizational supports in clinical settings may prevent nurse practitioners from providing patient centered care. Using a cross sectional survey design, data were collected from NPs in 1,571 practices across four states to investigate clinical practice environments and the extent to which they are associated with NP integration of patient preferences. Three-quarters of NPs reported frequent integration of patient preferences into clinical care. Overall, 371 practices (23.6%) were classified as good practice environments; the remaining 76.3% were mixed or poor environments. NPs in good environments were significantly more likely to integrate patient preferences (O.R. = 2.3, p <.001).

Nurse practitioner student clinical placement processes: A national survey of nurse practitioner programs.

BACKGROUND: Providing quality clinical sites and preceptors is one of the greatest challenges for nurse practitioner programs. PURPOSE: To conduct a national survey of nurse practitioner (NP) program directors to better understand the complex process for clinical site placement in the United States. METHODS: In 2018, a web-based survey was sent to program directors to ascertain the faculty and staff effort allocation and processes related to NP student placements, the number of required clinical rotations, the total hour requirement, and preceptor incentives and barriers. FINDINGS: There was a 47% survey response rate. Variation in processes was found across NP programs. Almost 14% of respondents said that students were required to find sites entirely on their own. Ten percent of faculty reported devoting 90% to 100% of their effort to finding preceptors. Preceptors and sites were rarely paid, but other incentives were common. DISCUSSION: It is vital for NP programs to streamline clinical placement processes, to foster academic-practice partnerships, and to advocate for federal funding to train the future NP workforce.

Precepting nurse practitioner students in the graduate nurse education demonstration: A cross-sectional analysis of the preceptor experience.

BACKGROUND: The Graduate Nurse Education (GNE) Demonstration seeks to increase the number of advanced practice registered nurses (APRNs) in clinical practice. With the overall increase in APRN programs and, particularly, enrollment in nurse practitioner (NP) programs, there is growing competition among students to secure quality clinical precepting experiences. PURPOSE: This study describes NPs' and physicians' experiences with precepting APRN students within the Greater Philadelphia GNE Consortium. METHODS: This was a cross-sectional descriptive survey of 1,021 NP and physician preceptors who provided clinical practicum experiences for at least one of the nine Greater Philadelphia GNE Consortium schools. RESULTS: Differences between NP and physician precepting experiences regarding the importance of various factors in their decisions to precept were explored. Both NP and physician preceptors provide clinical practicum experiences to APRN students because they enjoy doing so. However, they differ regarding what they find important in their decisions to precept such as having protected time to precept and educational opportunities. IMPLICATIONS FOR PRACTICE: As universities work to recruit quality preceptors, they should consider tailoring their approach based on the preceptor's clinical role. In addition, schools located within the same region should consider streamlining administrative processes to form sustaining and productive clinical partnerships.

Physician Assistant and Nurse Practitioner Utilization in Academic Medical Centers.

The purpose of this study was to collect information on the utilization of physician assistants (PAs) and nurse practitioners (NPs) in academic health centers. Data were gathered from a national sample of University HealthSystem Consortium member academic medical centers (AMCs). PAs and NPs have been integrated into most services of respondent AMCs, where they are positively rated for the value they bring to these organizations. The primary reason cited by most AMCs for employing PAs and NPs was Accreditation Council for Graduate Medical Education resident duty hour restrictions (26.9%). Secondary reasons for employing PAs and NPs include increasing patient throughput (88%), increasing patient access (77%), improving patient safety/quality (77%), reducing length of stay (73%), and improving continuity of care (73%). However, 69% of AMCs report they have not successfully documented the financial impact of PA/NP practice or outcomes associated with individual PA or NP care.

Advanced Practice Providers' Perceptions of Patient Workload: Results of a Multi-Institutional Survey.

OBJECTIVE: This study examines data collected from a survey of advanced practice providers' (APPs') perceptions of reasonable versus actual APP-to-patient ratios and other factors that affect workload burden in both inpatient and outpatient clinical settings. BACKGROUND: Advanced practice providers provide accessible, cost-effective, and quality care in a growing number of specialty practices across multiple patient care settings. They are caring for higher volumes of patients and assuming more responsibilities while continuing to navigate highly complex healthcare systems. Limited evidence or benchmark data exist that would assist in determining optimal workload and staffing models that include APPs. METHODS: A group of advanced practice leaders developed and distributed a 43-question survey of workload factors to a highly diverse APP workforce. RESULTS: There were 1466 APPs across 37 areas of practice who responded to the survey distributed in 14 separate organizations. The perceived reasonable workload was lower than the actual workload for 22 specialty practice areas. The analysis included years of experience as an APP, work hours, on-call commitment, nonclinical responsibilities, and time spent in documentation, direct patient care, and performing procedures. CONCLUSIONS: There is a consensus among APPs, within their practice area, about what constitutes a reasonable patient assignment, despite the variability in APP experience, organizational culture, processes, and patient acuity.

Physician assistant and nurse practitioner utilization in academic medical centers.

The purpose of this study was to collect information on the utilization of physician assistants (PAs) and nurse practitioners (NPs) in academic health centers. Data were gathered from a national sample of University HealthSystem Consortium member academic medical centers (AMCs). PAs and NPs have been integrated into most services of respondent AMCs, where they are positively rated for the value they bring to these organizations. The primary reason cited by most AMCs for employing PAs and NPs was Accreditation Council for Graduate Medical Education resident duty hour restrictions (26.9%). Secondary reasons for employing PAs and NPs include increasing patient throughput (88%), increasing patient access (77%), improving patient safety/quality (77%), reducing length of stay (73%), and improving continuity of care (73%). However, 69% of AMCs report they have not successfully documented the financial impact of PA/NP practice or outcomes associated with individual PA or NP care.

How do surgical residents and non-physician practitioners play together in the sandbox?

INTRODUCTION: The reduction of resident work hours due to the 80-hour workweek has created pressure on academic health-care systems to find "replacement residents." At the authors' institution, a group of nurse practitioners (NPs) and physician assistants (PAs), collectively referred to as non-physician practitioners (NPPs), were hired as these reinforcements, such that the number of NPPs (56) was almost twice the number of clinical categorical surgery residents (37). An experienced leader with national credibility was hired to run the NPP program. On each service, the call system was changed to a night float system, whereby residents were pulled from traditional resident teams to serve as nighttime residents during the week. A total of 1-3 NPPs were hired for each team, but whether NPPs worked for the team as a whole, or were assigned to individual attendings, was left to the discretion of the division chiefs. One year after the start of this program, the authors wanted to study the effects it has had on both surgery resident education and NPP job satisfaction. METHODS: An electronic, anonymous survey was conducted during a monthly surgery resident meeting, and out of 72 categorical and preliminary surgery residents, 50% submitted answers to 12 questions. A similar electronic survey was administered to all 56 NPPs, with 45% responding. RESULTS: Overall, 63% of residents believed that lines of communication between surgery team members were clear, and 58% of residents and 71% of NPPs believed that attendings, residents, and NPPs worked together effectively. A total of 91% of residents believed that the addition of NPPs to the teams was positive overall, and 80% of NPPs were satisfied with their positions. Overall, 60% of residents and 50% of NPPs felt that educational goals were being met. DISCUSSION: Implementation of the 80-hour workweek and introduction of NPs and PAs onto the inpatient surgical services has altered resident education at the authors' institution. Although overall most residents view the addition of NPPs to the clinical services as positive, there are concerns about the program. Although hired to fill the void left by decreasing labor hours of residents, NPPs do not necessarily have the same goals as surgery residents and there is confusion about how NPPs fit into the hierarchy of the traditional surgical team.

Sexual health services in school: a project in a multi-agency drop-in.

This article describes how sexual health services for young people can be successfully offered through a multi-agency drop-in session at a secondary school. Funding from the local Teenage Pregnancy Unit's Co-ordinator to the Reproductive Health Department led to training family planning nurses and school nurses to develop drop-in sessions in high schools and deliver sexual health to young people.