Chronicling the pursuit for full practice authority in Tennessee: Recommendations for a path forward.

BACKGROUND: The quest for full practice authority (FPA) for Tennessee Advanced Practice Registered Nurses (APRNs) began with promise in the late 1960s. However, progress has stalled in the ensuing time, and prospects for advancing FPA do not look promising. PURPOSE: The purpose of this article is to chronicle the pursuit of FPA in Tennessee, offer reflections on what has transpired to date, and suggest a path forward. METHODS: Various data from various sources were used to chronicle the history of FPA in Tennessee, make the case for its need, and identify better approaches for success. DISCUSSION: As one of a dwindling number of states without FPA, access to primary care health services and the economic vitality of Tennessee communities are of concern. CONCLUSION: The path forward for achieving FPA in Tennessee necessitates changes in approach and players. Specific recommendations are offered.

Evaluating and Addressing the Diversity, Equity, Inclusion, and Belonging Climate in a School of Nursing.

BACKGROUND: There is a critical need to prepare a diverse nursing workforce and address issues of structural racism and health inequities. PROBLEM: A shortage of underrepresented nurse faculty exacerbates the lack of diversity in nursing education. Microaggressions and discrimination experienced by underrepresented nursing students hinder their personal and professional growth. Evaluating diversity, equity, and inclusion (DEI) and belonging within a school of nursing is crucial for progress. APPROACH: An alumni survey and a faculty/staff survey were conducted to assess DEI perceptions, which informed the development of a strategic plan. Goals focused on monitoring the cultural climate, increasing diversity and inclusivity, and enhancing faculty competencies. Educational offerings and initiatives were implemented to support these goals. OUTCOMES: Ongoing evaluation is essential to sustain progress in this critical area. CONCLUSION: These efforts are necessary for sustainable progress and equitable care provision.

Addressing Barriers to APRN Practice: Policy and Regulatory Implications During COVID-19.

Advanced practice registered nurses (APRNs) play a pivotal role in providing healthcare, including preventive care services, to the public. However, barriers to APRN practice exist that impact the provision of vital healthcare services that APRNs are authorized to provide based on their education, training, licensure, and certification. This article provides an overview of APRN barriers to practice, including in the face of the COVID-19 pandemic, and discusses key policy and regulatory implications.

Changes in Telehealth Experienced by Advanced Practice RNs During COVID-19: US Survey Results.

The sudden, expanded need for telehealth during the COVID-19 pandemic added to the challenges advanced practice RNs face in the United States. The purposes of this article are to summarize advanced practice RNs' responses about the use of telehealth before and during the pandemic and to analyze free-text comments about how the use of telehealth changed during the pandemic. A 20-item survey was distributed using convenience sampling to advanced practice RNs from June 1 to September 23, 2020. Analyses of descriptive and open text responses related to telehealth were conducted. Most of the respondents did not use telehealth prior to the pandemic (n = 5441 [73%]), but during the pandemic, half used telehealth at least daily (n = 3682 [49%]). The most common barriers related to telehealth were about the difficulty some populations had in accessing the necessary technology. The most common favorable comments cited by respondents were related to some patients' improved access to care. Telehealth use is unlikely to return to prepandemic levels. As a result, considerations of telehealth-related recommendations provided for advanced practice RN education, policy, and practice are encouraged for the purpose of increasing healthcare access.

Postpartum Hemorrhage: Emergency Management for Uncontrolled Vaginal Bleeding.

Postpartum hemorrhage (PPH) represents total cumulative blood loss in excess of 1,000 ml or blood loss accompanied by signs and/or symptoms of hypovolemia within 24 hr following birth (The American College of Obstetricians and Gynecologists [ACOG], 2017). As a large number of PPHs occur in low-risk women (ACOG, 2019), the emergency nurse practitioner must be prepared to identify and manage this uncommon but life-threatening condition. The etiology, pharmacological management strategies, and other interventions are reviewed in an algorithmic approach. This organized approach not only supports maternal survival during PPH but is also applicable to postprocedural bleeding of obstetric and gynecological etiologies.

Breaking Down Institutional Barriers to Advanced Practice Registered Nurse Practice.

Advanced practice registered nurses (APRNs) significantly contribute to health promotion, disease prevention, and disease management. Yet, barriers to APRN practice exist, including regulatory, state, and institutional barriers, that hinder their ability to practice to the full extent of their education, licensure, and certification. Nurse leaders can play an important role in helping reduce unnecessary institutional barriers to APRN practice.

Results of a National Survey: Ongoing Barriers to APRN Practice in the United States.

Limited information is available on the barriers to practice for advanced practice registered nurses (APRNs) among states with full, restricted, and reduced practice. The purpose of this study is to identify practice barriers in relationship to United States (U.S.) state practice authority, APRN type, area of practice (rural, suburban, urban), and nature of practice (outpatient, inpatient, and both). An electronic survey of a convenience sample of APRNs was conducted to assess barriers to practice. Identified barriers were examined based on state practice environment, APRN role, practice setting, and location. Data were analyzed using thematic analysis for qualitative data and descriptive analysis for quantitative data. Over 7,000 APRNs representing all 50 states participated. Themes that were identified and reported by respondents, included licensure and administrative barriers, therapy restrictions, physician signature requirements, a lack of collegiality, prescribing barriers, uneven reimbursement, physician only procedures, and telehealth issues. Barriers were identified in all states, regardless of the type of practice authority. All four APRN role types identified practice barriers, some of which were more frequent for some roles than others. Restrictions for home health approval and the requirement for a physician signature for durable medical supply orders were identified by over 40% of respondents practicing in rural areas. Barriers to APRN practice continue to restrict aspects of patient care and patient access to care, even in states with full practice authority. Continued efforts to reduce barriers to APRN practice are needed to ensure patient access to care, especially in rural areas.

Bridging Didactic Learning and the Complexity of Practice Through Clinical Immersion: Evaluating the Sexual Assault Nurse Examiner Trainee Experience.

ABSTRACT: In this article, we discuss the development and evaluation of the Vanderbilt Nursing Education Program for Sexual Assault Nurse Examiners (VEP-SANE), a 3-day clinical immersion (CI) program, including the lessons learned and the challenges experienced with the completion of two trainee cohorts. To bridge didactic learning and the complexity of practice, the VEP-SANE team designed an innovative, competency-based CI. Fifteen trainees from Cohort 1 and 19 trainees from Cohort 2 met requirements for CI participation. Trainees in Cohort 1 represented the advanced practice registered nurse specialties of emergency, women's health, and pediatrics. For Cohort 2 recruitment, enrollment was expanded to include family and midwifery advanced practice registered nurse specialties. Trainees were required to complete online training modules before CI participation. Online surveys assessed trainee perceptions about levels of knowledge and confidence related to sexual assault nurse examiner competencies (pre/post CI), each CI session, and the overall CI experience. Separate focused discussions were conducted with trainees and faculty after each CI. Both cohorts rated CI sessions as "excellent" or "very good" over 93% of the time. Perceived levels of knowledge and confidence increased from pre-CI to post-CI for both cohorts. Similar CI strengths were identified across trainees and faculty including speakers, high interactivity, safe environment, reality of cases, and surrogate practice. All trainees indicated readiness for preceptorships and interest in a virtual community of practice. Suggestions included more time for laboratory sessions, documenting photos, and interaction with individuals from the lesbian, gay, bisexual and transgender (LGBT) community and presenters. Future efforts focus on CI conversion to a virtual format because of the impact of COVID-19, increased VEP-SANE community of practice interaction, and expanded engagement with practicing sexual assault nurse examiners.

Impact of COVID-19 pandemic on APRN practice: Results from a national survey.

BACKGROUND: The impact of the COVID-19 pandemic on Advanced Practice Registered Nurse (APRN) practice is not well known. PURPOSE: This study aimed to describe state practice barriers and explore the effects of the COVID-19 pandemic on APRN practice. METHODS: A descriptive study design used a 20-item web-based survey open from June 1 through September 23, 2020. FINDINGS: A total of 7,467 APRNs responded from all 50 states, including nurse practitioners (n = 6,478, 86.8%), certified registered nurse anesthetists (n = 592, 7.9%), certified nurse-midwives (n = 278, 3.7%), and clinical nurse specialists (n = 242, 3.2%). A number of barriers to practice prior to the pandemic were identified. Most respondents (n = 6334, 84.8%) identified that practice barriers limited the ability of APRNs to provide care during the pandemic. DISCUSSION: Barriers to APRN practice continue to restrict aspects of patient care and patient access to care, even in states with Full Practice Authority (FPA), during the COVID-19 pandemic and with state executive orders waiving practice restrictions. The study findings can be used to advocate for policy changes to support APRN practice authority.

Engaging the community through a longitudinal, interprofessional, interinstitutional experiential learning collaboration.

Background Interprofessional education (IPE) and training in community settings is not commonly described in the literature. Studies primarily focus on clinical education of interprofessional teams in clinical practice and primary care. This is a description of a longitudinal, collaborative interinstitutional IPE project that engages community partners (CP) while delivering core IPE competencies. Interprofessional Education Activity: Twenty-seven students from five universities representing ten healthcare academic programs participated in the project. Participating CP were non-profit agencies developed to meet the needs of specific vulnerable, underserved populations. Students were divided into teams and then paired with CP. This was a six-month project, with students committing to 30 hours over two semesters. At the end of the project, students presented project deliverables to CP, faculty collaborative and other students. Interprofessional education collaborative (IPEC) domains were qualitatively assessed and students completed the Interprofessional Socialization and Valuing Scale (ISVS) at the beginning and conclusion of the project. Students provided written reflections at the conclusion of the project. Faculty completed the Team Observed Structured Clinical Encounter (TOSCE). Discussion" Twenty-seven students (100%) students completed the project and twenty-one students (77.8%) completed the evaluation tools. Students demonstrated a statistically significant difference between pre- and post-project ISVS total scores (5.81 +/- 0.64 vs. 6.51 +/- 0.37). Teamwork, communication skills, and increased comfort with those from other professions were common themes in the student reflections. Implications: Community-based IPE provides a venue for healthcare professionals to engage and partner with community organizations. This project demonstrates an effective inter-institutional, interprofessional method of delivering IPE.

A Summer Professional Immersion in Nursing Program for Underrepresented Minority Undergraduate Students.

BACKGROUND: By 2044, more than 50% of the U.S. population will consist of ethnic/racial minorities. To facilitate optimal health, the projected nursing workforce should mirror this statistic. This pilot study examined the effects of a Summer Professional Immersion in Nursing Program (SPIN) on confidence in career decision making of under-represented minority undergraduate students. The 4-week program exposed participants to various nursing experiences. METHOD: The Career Decision Self-Efficacy Scale was administered pre- and post-SPIN to measure level of confidence in career decision making. RESULTS: The sample included eight women, with an average age of 19.63 years (SD = 0.52). Comparative analysis was performed using a reliable change index. The pre- to post-SPIN change was 0.38, indicating a meaningful significant increase in confidence. CONCLUSION: SPIN is an example for nursing programs interested in attracting undergraduate underrepresented minority students. The program positively influenced self-efficacy toward career selection and may positively influence enrollment of underrepresented nurses in the future. [J Nurs Educ. 2020;59(11):631-636.].

Development and Pilot Testing of a Multidimensional Learning Environment Survey.

BACKGROUND: Multiple, complex factors comprise the learning environment and influence student learning outcomes, yet comprehensive evaluation of the learning environment in nursing schools is limited. PURPOSE: The Learning Environment Survey (LES) was developed to facilitate nursing students' report of perceptions of the complex learning environment in nursing education. METHODS: Systematic exploration of the literature, conceptual operationalization of the learning environment, and development of an item pool were completed. Content validity was established with expert assessment, student testing for clarity, and calculation of scale-content validity index/average (S-CVI/Ave). Pilot testing was completed at 1 school of nursing with baccalaureate-equivalent prelicensure and advanced practice master's level students, and doctor of nursing practice students. RESULTS: The CVI (S-CVI/Ave) was 0.92. Domain scores demonstrated Cronbach's α reliabilities of 0.67 or higher with most being > 0.85. CONCLUSION: The LES establishes a mechanism for eliciting comprehensive learning environment data for systematic assessment and national comparison of multiple nursing learning environments.

Perceptions of Sexual and Gender Minority Content in Graduate Nursing Curricula.

AIM: The aim of the study was to evaluate how faculty and nursing students perceive the importance of including sexual and gender minority (SGM) content in graduate curricula. BACKGROUND: Nurses in education and practice must be culturally sensitive to the unique populations we serve and to the diversity represented in all health care environments. METHOD: Online secure web-based surveys were distributed to graduate nursing faculty and students in 2015 and 2017 employing a triangulated methodology. RESULTS: Faculty and students responded that basic content and knowledge of clinical care for SGM populations are important. Thematic analysis of open-ended questions provided suggestions for improvement in curricula and within the learning environment. CONCLUSION: Continued development of faculty knowledge and application of SGM content in nursing curricula must meet student expectations and health needs of SGM populations.

Development of an interprofessional clinical learning environment report card.

Multiple factors in the learning environment can encourage or impede student learning. Unanswered questions regarding the shared learning environment for graduate nursing and medical education and the desire for an ongoing improvement process drove creation of an interprofessional collaborative and development of an Interprofessional Clinical Learning Environment Report Card (I-CLERC) at one U.S. academic medical center. The I-CLERC offers a process and a product for institutionalizing a shared assessment tool to inform improvement efforts, track progress and promote accountability. In addition, it enhances interprofessional collaboration, with students and faculty from both nursing and medicine working together to define excellence, monitor performance, and identify areas for improvement in the shared clinical learning environment. The purpose of this manuscript is to describe development and implementation of an interdisciplinary, institutional collaborative for ongoing evaluation of the shared clinical learning environment.

Providers' Reports of Environmental Conditions and Resources at Births in the United States.

Environmental conditions and resources that may influence provider's behaviors have been investigated in birth environments focusing on location rather than conditions and available resources. Using a descriptive, cross sectional design, we surveyed a random sample of certified nurse-midwives (CNMs), obstetricians, family practice physicians, and certified professional midwives (CPMs) to describe conditions, resources, and workforce present during U.S. births. In all, 1,243 midwives and physicians reported most environmental resources were present at almost 100% of births they attended. Conditions varied: room noise acceptability restriction of phone calls/texts from any source and lighting kept to a minimum. Trainees were present at most births regardless of setting and provider type. The impact of room noise, phone calls/texting, and lighting on outcomes should be determined. The roles and impact of personnel, including trainees, should be described. The extent to which clusters of resources are associated with outcomes might provide new directions for interventions that improve care.

Variables That Influence US Midwife and Physician Management of the Third Stage of Labor.

INTRODUCTION: Midwives and physicians incorporate their knowledge, experiences, and other variables in making clinical decisions. Variations in the management of the third stage of labor may be a result of variables that influence providers' decision making. The purpose of this study was to describe variables that influence US midwives' and physicians' management of the third stage of labor. METHODS: A randomly selected national sample of certified nurse-midwives and certified midwives, certified professional midwives, obstetricians, and family physicians was surveyed about the extent to which maternal characteristics, maternal history, and current birth characteristics influence their third-stage management. The extent of influence was defined in terms of always to never altering management. Descriptive summaries, group comparisons, and partial correlations were used to determine differences in influences between midwives and physicians. One free-text question was analyzed using qualitative methods. RESULTS: A total of 1243 clinicians responded. There was considerable variability in the response patterns in that the same variable was reported to always alter management during the third stage of labor for some participants yet did not influence the management practices of others at all. Differences between responses from midwives and physicians were explored as a possible explanation for some of the variability. In response to the free-text inquiry about variables that most influenced changes in participants' usual management of the third stage, the participants most often included active bleeding, current recommendations or guidelines, and maternal or family preferences. DISCUSSION: This study identifies variables reported as influencing clinical decision making during the third stage of labor. Therefore, these variables are important to consider when evaluating interventions and outcomes related to management of the third stage of labor and any attempts to design new interventions. The findings are descriptive of practice; they are not intended to guide changes in practice.

Implementing and evaluating a community-based, inter-institutional, interprofessional education pilot programme.

Many health professions programmes have begun integrating interprofessional learning into their curricula; however, community-based interprofessional education (IPE) initiatives are relatively scarce. The Meharry-Vanderbilt Alliance IPE Faculty Collaborative, comprised of faculty from five institutions, developed a community-based IPE programme that allowed students to engage in meaningful interprofessional activities while exposing them to social determinants of health. Thirty students from ten professions were divided into six teams and paired with three community organisations. Each team engaged community organisation staff and clients to develop practical solutions to their priorities. Teams participated in debriefings and team-building exercises to further support interprofessional learning. Students' comfort working with others (CWO), value in working with others (VWO), and self-perceived ability (SPA) to work with others were assessed using the Interprofessional Socialisation and Valuing Scale (ISVS). Mean rank scores in all three subcategories increased significantly from baseline (CWO: z = -4.11, p < 0.0001; VWO: z = -3.41. p = 0.001; SPA: z = -2.79, p = 0.005). In addition, programme evaluations suggest the programme improved students' understanding of social determinants of health. Our findings align with those of two other community-based IPE initiatives and support the expansion of IPE efforts beyond traditional settings.

US Physician and Midwife Adherence to Active Management of the Third Stage of Labor International Recommendations.

INTRODUCTION: The prevalence of postpartum hemorrhage has increased in the United States despite the international promotion of active management of the third stage of labor. Adherence to the international recommendations in the United States is unclear. It is also not known how the components of active management are related to other practices that may be used during the third stage of labor. The purpose of this study was to determine routine practice patterns for managing the third stage of labor in the United States. METHODS: A randomized national survey was conducted of certified nurse-midwives/certified midwives, certified professional midwives, obstetricians, and family physicians who self-reported third-stage practices. Descriptive analyses and partial correlations were used to determine differences in practice patterns between midwives and physicians. A 2-step clustering algorithm was used to identify clusters of third-stage practices. RESULTS: A total of 1243 clinicians responded. Uterine massage after placenta expulsion was reportedly used at almost every birth by all provider types. Median use of cord traction and oxytocin administration by all provider types was 80% and 90% of births, respectively. Cluster analysis of these and other interventions used during the third stage of labor revealed 4 distinct clusters of practices ranging from primarily a hands-off at one extreme to high-intervention approaches at the other extreme. The other 2 clusters were defined by practices that fell between those extremes. DISCUSSION: Determination of how, and under what conditions, clinicians decide when to use particular techniques to manage the third stage of labor and how these techniques influence the incidence of postpartum hemorrhage, is necessary. The clusters of practice combinations that emerged in this study suggest that there are extreme variations in clinician practices during management of the third stage of labor.

Facilitators of prenatal care in an exemplar urban clinic.

BACKGROUND: Perinatal outcomes have complex causes that include biologic, maternal, structural, and societal components. We studied one urban nurse-led clinic serving women at risk for poor perinatal outcomes with superior pre-term birth rates (4%) when compared with the surrounding county (11.2%). AIM: To explore women's perspectives of their interface with the clinic, staff, and providers to understand this exemplary model. METHODS: A qualitative descriptive approach with semi-structured interviews as the primary data source. Participants (n=50) were recruited from an urban clinic in the Southeast United States designed to serve women of low socio-economic status or who are recent immigrants. FINDINGS: Women greatly valued a personal connection with the nurse-midwives and staff, and felt this resulted in high-quality care. Convenient appointment times and the lack of wait for initial or subsequent appointments made care accessible. Participants reported the relaxed and helpful approach and attitudes of the office staff were essential components of their positive experience. Women valued unrushed visits to ask questions and receive information. In addition, participants felt that clinic staff were easy to reach. CONCLUSION: While qualitative data cannot demonstrate causation, this study provides support that a compassionate and personalized approach to care motivates women to access needed services in pregnancy. Clinic staff are an essential component of the access process. Women overcame barriers to obtain personalized, culturally appropriate care provided by kind, competent practitioners. Clinic staff and practitioners should develop a connection with each woman by providing care that meets her physical, cultural, and personal needs.