Better Nurse Practitioner Primary Care Practice Environments Reduce Hospitalization Disparities Among Dually-Enrolled Patients.

BACKGROUND: Over 12 million Americans are dually enrolled in Medicare and Medicaid. These individuals experience over twice as many hospitalizations for chronic diseases such as coronary artery disease and diabetes compared with Medicare-only patients. Nurse practitioners (NPs) are well-positioned to address the care needs of dually-enrolled patients, yet NPs often work in unsupportive clinical practice environments. The purpose of this study was to examine the association between the NP primary care practice environment and hospitalization disparities between dually-enrolled and Medicare-only patients with chronic diseases. METHODS: Using secondary cross-sectional data from the Nurse Practitioner Primary Care Organizational Climate Questionnaire and Medicare claims files, we examined 135,648 patients with coronary artery disease and/or diabetes (20.0% dually-eligible, 80.0% Medicare-only), cared for in 450 practices employing NPs across 4 states (PA, NJ, CA, FL) in 2015. We compared dually-enrolled patients' odds of being hospitalized when cared for in practice environments characterized as poor, mixed, and good based on practice-level Nurse Practitioner Primary Care Organizational Climate Questionnaire scores. RESULTS: After adjusting for patient and practice characteristics, dually-enrolled patients in poor practice environments had the highest odds of being hospitalized compared with their Medicare-only counterparts [odds ratio (OR): 1.48, CI: 1.37, 1.60]. In mixed environments, dually-enrolled patients had 27% higher odds of a hospitalization (OR: 1.27, CI: 1.12, 1.45). However, in the best practice environments, hospitalization differences were nonsignificant (OR: 1.02, CI: 0.85, 1.23). CONCLUSIONS: As policymakers look to improve outcomes for dually-enrolled patients, addressing a modifiable aspect of care delivery in NPs' clinical practice environment is a key opportunity to reduce hospitalization disparities.

Nurse Practitioner Care Environments and Racial and Ethnic Disparities in Hospitalization Among Medicare Beneficiaries with Coronary Heart Disease.

BACKGROUND: Nurse practitioners care for patients with cardiovascular disease, particularly those from racial and ethnic minority groups, and can help assure equitable health outcomes. Yet, nurse practitioners practice in challenging care environments, which limits their ability to care for patients. OBJECTIVE: To determine whether primary care nurse practitioner care environments are associated with racial and ethnic disparities in hospitalizations among older adults with coronary heart disease. DESIGN: In this observational study, a cross-sectional survey was conducted among primary care nurse practitioners in 2018-2019 who completed a valid measure of care environment. The data was merged with 2018 Medicare claims data for patients with coronary heart disease. PARTICIPANTS: A total of 1244 primary care nurse practitioners and 180,216 Medicare beneficiaries 65 and older with coronary heart disease were included. MAIN MEASURES: All-cause and ambulatory care sensitive condition hospitalizations in 2018. KEY RESULTS: There were 50,233 hospitalizations, 9068 for ambulatory care sensitive conditions. About 28% of patients had at least one hospitalization. Hospitalizations varied by race, being highest among Black patients (33.5%). Care environment moderated the relationship between race (Black versus White) and hospitalization (OR 0.93; 95% CI, 0.88-0.98). The lowest care environment was associated with greater hospitalization among Black (odds ratio=1.34; 95% CI, 1.20-1.49) compared to White beneficiaries. Practices with the highest care environment had no racial differences in hospitalizations. There was no interaction effect between care environment and race for ambulatory care sensitive condition hospitalizations. Nurse practitioner care environment had a protective effect on these hospitalizations (OR, 0.96; 95% CI, 0.92-0.99) for all beneficiaries. CONCLUSIONS: Unfavorable care environments were associated with higher hospitalization rates among Black than among White beneficiaries with coronary heart disease. Racial disparities in hospitalization rates were not detected in practices with high-quality care environments, suggesting that improving nurse practitioner care environments could reduce racial disparities in hospitalizations.

Acute Care Use Among Patients With Multiple Chronic Conditions Receiving Care From Nurse Practitioner Practices in Health Professional Shortage Areas.

BACKGROUND: Patients with multiple chronic conditions often have many care plans, polypharmacy, and unrelieved symptoms that contribute to high emergency department and hospital use. High-quality primary care delivered in practices that employ nurse practitioners can help prevent the need for such acute care services. However, such practices located in primary care health professional shortage areas face challenges caring for these patients because of higher workloads and fewer resources. OBJECTIVE: We examined differences in hospitalization and emergency department use among patients with multiple chronic conditions who receive care from practices that employ nurse practitioners in health professional shortage areas compared to practices that employ nurse practitioners in non-health professional shortage areas. METHODS: We performed an analysis of Medicare claims, merged with Health Resources and Services Administration data on health professional shortage area status in five states. Our sample included 394,424 community-dwelling Medicare beneficiaries aged ≥65 years, with at least two of 15 common chronic conditions who received care in 779 practices that employ nurse practitioners. We used logistic regression to assess the relationship between health professional shortage area status and emergency department visits or hospitalizations. RESULTS: We found a higher likelihood of emergency department visits among patients in health professional shortage areas compared to those in non-health professional shortage areas and no difference in the likelihood of hospitalization. DISCUSSION: Emergency department use differences exist among older adults with multiple chronic conditions receiving care in practices that employ nurse practitioners in health professional shortage areas, compared to those in non-health professional shortage areas. To address this disparity, the health professional shortage area program should invest in recruiting and retaining nurse practitioners to health professional shortage areas to ease workforce shortages.

Exploring the relationships between resilience, burnout, work engagement, and intention to leave among nurses in the context of the COVID-19 pandemic: a cross-sectional study.

BACKGROUND: Nurses have faced significant personal and professional stressors during the COVID-19 pandemic that have contributed to increased rates of burnout, intention to leave, and poorer work engagement. Resilience has been identified as a critical factor influencing job outcomes; however, the dynamics of this association have not yet been investigated within the context of the Thai workforce. The study objective was to determine the associations between resilience and job outcomes, including burnout, intention to leave, and work engagement among nurses working in Thailand during the COVID-19 pandemic. METHODS: This cross-sectional study gathered data from a sample of 394 registered nurses employed across 12 hospitals. The research instruments comprised the Connor-Davidson Resilience Scale (CD-RISC), the Maslach Burnout Inventory-Health Services Survey (MBI-HSS), a questionnaire assessing the intention to leave the job, and the Utrecht Work Engagement Scale (UWES). To determine the associations among the measured variables, multivariate logistic regression analyses were conducted. RESULTS: One-third of nurses experienced emotional exhaustion and depersonalization, and about half experienced reduced personal accomplishment; one-tenth of nurses intended to leave their job. Nurses who exhibited higher levels of resilience were found to have a significantly reduced likelihood of experiencing high emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment. Conversely, these nurses were more likely to report higher levels of work engagement than their less resilience. CONCLUSION: The COVID-19 pandemic offers important lessons learned about promoting the well-being of the nursing workforce and protecting against adverse job outcomes. While we identified resilience as a significant predictor of several nurse outcomes, other work environment factors should be considered. Government and hospital administrations should allocate resources for individual and organizational-level interventions to promote resilience among frontline nurses so that hospitals will be better prepared for the next public health emergency and patient and nurse outcomes can be optimized.

Burnout, job satisfaction, and turnover intention among primary care nurse practitioners with their own patient panels.

BACKGROUND: Nurse practitioners (NPs) can enhance NP care and improve access to care by autonomously managing their patient panels. Yet, its impact on workforce outcomes such as burnout, job satisfaction, and turnover intention remains unexplored. PURPOSE: To estimate the impact of NP panel management on workforce outcomes. METHODS: Structural equation modeling was conducted using survey data from 1,244 primary care NPs. NP panel management was categorized into co-managing patients with other providers, both co-managing and autonomously managing, and fully autonomous management. DISCUSSION: Fully autonomous management led to more burnout than co-managing (B = 0.089, bias-corrected 95% bootstrap confidence interval [0.028, 0.151]). Work hours partially (27%) mediated this relationship. This findings indicate that greater autonomy in panel management among NPs may lead to increased burnout, partially due to longer work hours. CONCLUSION: Interventions to reduce work hours could help NPs deliver quality care without burnout.

Nurse Practitioner Work Environment and Rural Primary Care for Substance Use.

We examined the relationship between the nurse practitioner (NP) work environment and realized access (i.e., utilization) to primary care among rural older adults with substance use disorders (SUD). We analyzed cross-sectional NP survey data merged with Medicare claims and utilized fractional logistic regression. With one unit improvement in NP work environment, the odds of having older adults with SUDs in the practice increased by 20% (adjusted odds ratio=1.20, 95% confidence interval=1.01-1.44, p=0.04). Favorable work environments for NPs, including organizational support, collegiality, and role visibility, are associated with increased realized access to primary care among rural older adults with SUDs.

The Impact of Primary Care Practice Structural Capabilities on Nurse Practitioner Burnout, Job Satisfaction, and Intent to Leave.

BACKGROUND: Lack of structure for care delivery (ie, structural capabilities) has been linked to lower quality of care and negative patient outcomes. However, little research examines the relationship between practice structural capabilities and nurse practitioner (NP) job outcomes. OBJECTIVES: We investigated the association between structural capabilities and primary care NP job outcomes (ie, burnout, job dissatisfaction, and intent to leave). RESEARCH DESIGN: Secondary analysis of 2018-2019 cross-sectional data. SUBJECTS: A total of 1110 NPs across 1002 primary care practices in 6 states. MEASURES: We estimated linear probability models to assess the association between structural capabilities and NP job outcomes, controlling for NP work environment, demographics, and practice features. RESULTS: The average structural capabilities score (measured on a scale of 0-1) across practices was 0.6 (higher score indicates more structural capabilities). After controlling for potential confounders, we found that a 10-percentage point increase in the structural capabilities score was associated with a 3-percentage point decrease in burnout ( P <0.001), a 2-percentage point decrease in job dissatisfaction ( P <0.001), and a 3-percentage point decrease in intent to leave ( P <0.001). CONCLUSIONS: Primary care NPs report lower burnout, job dissatisfaction, and intent to leave when working in practices with greater structural capabilities for care delivery. These findings suggest that efforts to improve structural capabilities not only facilitate effective care delivery and benefit patients but they also support NPs and strengthen their workforce participation. Practice leaders should further invest in structural capabilities to improve primary care provider job outcomes.

Primary Care Practice Structural Capabilities and Emergency Department Utilization Among High-Need High-Cost Patients.

BACKGROUND: US primary care practices are actively identifying strategies to improve outcomes and reduce costs among high-need high-cost (HNHC) patients. HNHC patients are adults with high health care utilization who suffer from multiple chronic medical and behavioral health conditions such as depression or substance abuse. HNHC patients with behavioral health conditions face heightened challenges accessing timely primary care and managing their conditions, which is reflected by their high rates of emergency department (ED) utilization and preventable spending. Structural capabilities (i.e., care coordination, chronic disease registries, shared communication systems, and after-hours care) are key attributes of primary care practices which can enhance access and quality of chronic care delivery. OBJECTIVE: The purpose of this study was to analyze the association between structural capabilities and ED utilization among HNHC patients with behavioral health conditions. DESIGN AND MEASURES: We merged cross-sectional survey data on structural capabilities from 240 primary care practices in Arizona and Washington linked with Medicare claims data on 70,182 HNHC patients from 2019. KEY RESULTS: Using multivariable Poisson models, we found shared communication systems were associated with lower rates of all-cause and preventable ED utilization among HNHC patients with alcohol use (all-cause: aRR 0.72, 95% CI: 0.62, 0.84; preventable: aRR 0.5, 95% CI: 0.40, 0.64) and HNHC patients with substance use disorders (all-cause: aRR 0.76, 95% CI: 0.68, 0.85; preventable: aRR 0.61, 95% CI: 0.52, 0.71). Care coordination was also associated with decreased rates of ED utilization among the overall HNHC population and those with alcohol use, but not among HNHC patients with depression or substance use disorders. CONCLUSION: Shared communication systems and care coordination have the potential to increase the effectiveness of primary care delivery for specific HNHC patients.

Primary care provider confidence in addressing opioid use disorder: A concept analysis.

Primary care providers (PCPs) are well-positioned to provide care for opioid use disorder (OUD), yet very few address OUD regularly. One contributing factor may be PCPs' lack of confidence in their ability to effectively treat OUD. Evidence demonstrates that clinician confidence in home care and hospital settings is associated with improved care delivery and patient outcomes. However, a conceptual definition of PCP confidence in addressing OUD has yet to be established. The aim of this concept analysis is to enhance conceptual understanding of PCP confidence in addressing OUD and inform future measurement strategies. Following Walker and Avant's method of concept analysis, PubMed, PsycINFO, and Google Scholar were searched in October 2021. Manuscripts were included if they referenced confidence in relation to PCPs who provide care to adult patients with OUD. Studies conducted outside the US and not published in English were excluded. The search resulted in 18 studies which were synthesized to conceptualize PCP confidence in addressing OUD. Defining attributes include self-efficacy, experience, and readiness to address OUD. These attributes may be influenced by organizational culture, training, support, and resources. Consequences of PCP confidence addressing OUD may include improved patient outcomes, improved delivery of and access to OUD care, and PCP attitude changes. This concept analysis-which grounds the concept of PCP confidence in addressing OUD in the theoretical and empirical literature-lays the framework for future measurement of the concept. This represents a critical first step towards developing strategies to enhance PCP confidence in addressing OUD.

Using machine-learning methods to predict in-hospital mortality through the Elixhauser index: A Medicare data analysis.

Accurate in-hospital mortality prediction can reflect the prognosis of patients, help guide allocation of clinical resources, and help clinicians make the right care decisions. There are limitations to using traditional logistic regression models when assessing the model performance of comorbidity measures to predict in-hospital mortality. Meanwhile, the use of novel machine-learning methods is growing rapidly. In 2021, the Agency for Healthcare Research and Quality published new guidelines for using the Present-on-Admission (POA) indicator from the International Classification of Diseases, Tenth Revision, for coding comorbidities to predict in-hospital mortality from the Elixhauser's comorbidity measurement method. We compared the model performance of logistic regression, elastic net model, and artificial neural network (ANN) to predict in-hospital mortality from Elixhauser's measures under the updated POA guidelines. In this retrospective analysis, 1,810,106 adult Medicare inpatient admissions from six US states admitted after September 23, 2017, and discharged before April 11, 2019 were extracted from the Centers for Medicare and Medicaid Services data warehouse. The POA indicator was used to distinguish pre-existing comorbidities from complications that occurred during hospitalization. All models performed well (C-statistics >0.77). Elastic net method generated a parsimonious model, in which there were five fewer comorbidities selected to predict in-hospital mortality with similar predictive power compared to the logistic regression model. ANN had the highest C-statistics compared to the other two models (0.800 vs. 0.791 and 0.791). Elastic net model and AAN can be applied successfully to predict in-hospital mortality.

The relationship between nurse burnout, missed nursing care, and care quality following COVID-19 pandemic.

OBJECTIVES: To determine the relationship between nurse burnout, missed nursing care, and care quality following the COVID-19 pandemic. BACKGROUND: Quality of care and missed nursing care can be consequences of nurse burnout. Little is known about how these factors related to nurse burnout following the COVID-19 pandemic. DESIGN: This study used a cross-sectional correlational design and was conducted in 12 general hospitals across Thailand from August to October 2022. METHODS: 394 nurses providing direct nursing care to patients during the COVID-19 pandemic completed the survey. The Emotional Exhaustion (EE) subscale of the Maslach Burnout Inventory-Human Services Survey (MBI-HSS), MISSCARE survey, and quality of care reported by nurses were used to collect data. Descriptive statistics and logistic regression models were used to analyse the data. RESULTS: Approximately thirty-six percent of nurses had burnout following the COVID-19 pandemic. Missed nursing care was higher among nurses with burnout. Most participants reported illness/symptoms such as anxiety, fatigue, a lack of concentration, and sleeping problems. After adjusting for demographic characteristics, every additional unit of emotional exhaustion was associated with 1.61 times higher odds of missed nursing care, 3.37 times higher odds of poor quality of nurse care, and 2.62 times higher odds of poor quality of care for the overall unit. CONCLUSION: The study findings demonstrate that burnout is associated with missed nursing care and poor quality of care following the COVID-19 pandemic. RELEVANCE TO CLINICAL PRACTICE: Policymakers, hospital administrators, and nurse managers should invest in strategies to reduce nurse burnout, which can increase patient safety and quality of care.

DNP preparation of primary care nurse practitioners and clinical outcomes for patients with chronic conditions.

BACKGROUND: Many professional nursing organizations have proposed that the Doctor of Nursing Practice (DNP) is the most appropriate entry-level degree for nurse practitioners (NPs). There have been no studies to date examining the impact of DNP preparation on quality of care or patient outcomes. PURPOSE: To examine differences in emergency department utilization and hospitalizations among patients with chronic conditions cared for by Master of Science in Nursing (MSN)- and DNP-prepared primary care NPs. METHODS: We use survey data from over 1,000 primary care NPs in 6 states linked to Medicare claims data. Using regression models, we controlled for various patient, NP, and practice characteristics that might confound the relationship. RESULS: We find that patient outcomes are not statistically different between patients attributed to MSN- and DNP-prepared primary care NPs. DISCUSSION: These findings suggest that there remains little evidence that DNP education has led to significant improvements in patient outcomes. CONCLUSIONS: Further empirical analysis related to the clinical outcomes other than health care utilization of the DNP degree is warranted. Future studies might consider examining (a) NPs in settings other than primary care, (b) practice-wide or system-wide outcomes, (c) other measures of care quality, and (d) impact of DNP program content.

The effectiveness of nurse practitioner care for patients with mental health conditions in primary care settings: A systematic review.

BACKGROUND: The nurse practitioner (NP) workforce is key to meeting the demand for mental health services in primary care settings. PURPOSE: The purpose of this study is to synthesize the evidence focused on the effectiveness of NP care for patients with mental health conditions in primary care settings, particularly focused on primary care NPs and psychiatric mental health NPs and patients with anxiety, depression, and substance use disorders. METHODS: Studies published since 2014 in the United States studying NP care of patients with anxiety, depression, or substance use disorders in primary care settings were included. FINDINGS: Seventeen studies were included. Four high-quality studies showed that NP evidence-based care and prescribing were comparable to that of physicians. Seven low-quality studies suggest that NP-led collaborative care is associated with reduced symptoms. DISCUSSION: More high-quality evidence is needed to determine the effectiveness of NP care for patients with mental health conditions in primary care settings.

Advancement of research on nurse practitioners: Setting a research agenda.

BACKGROUND: Primary care delivered by nurse practitioners (NPs) helps to meet the United States' growing demand for care and improves patient outcomes. Yet, barriers impede NP practice. Knowledge of these barriers is limited, hindering opportunities to eliminate them. PURPOSE: We convened a 1.5-day conference to develop a research agenda to advance evidence on the primary care NP workforce. METHODS: Thirty experts gathered in New York City for a conference in 2022. The conference included plenary sessions, small group discussions, and a prioritization process to identify areas for future research and research questions. DISCUSSION: The research agenda includes top-ranked research questions within five categories: (a) policy regulations and implications for care, quality, and access; (b) systems affecting NP practice; (c) health equity and the NP workforce; (d) NP education and workforce dynamics, and (e) international perspectives. CONCLUSION: The agenda can advance evidence on the NP workforce to guide policy and practice.

A qualitative study exploring nursing home care environments where nurse practitioners work.

Research is needed to support the growing nurse practitioner workforce to assure higher quality care for older adults in nursing homes. Nursing homes with optimal care environments that support nurse practitioner roles, increased visibility, independence, and relationships are better positioned to support care of older adults. This study reports findings of thirteen qualitative interviews with nurse practitioners to explore facets of nursing home care environments and adapt a tool to measure care environments. Our team incorporated deductive and inductive coding to identify three major emerging themes impacting care environments: 1) nurse practitioner practice in nursing homes, 2) overall goals of practice, 3) workplace challenges. Themes were derived from seven overarching categories and 33 codes describing aspects of NH care environment important to nurse practitioners. Some of the most highly important survey items measured nurse practitioner and physician relationships. Less important items measured relationships between nurse practitioners and administration.

Exploring the Relationship between Nurse Practitioner Full Practice Authority, Nurse Practitioner Workforce Diversity, and Disparate Primary Care Access.

In this study, we examine how full nurse practitioner (NP) practice authority affects racial and ethnic diversity of the NP workforce. Specifically, the purpose of our research is to understand the relationship between the racial and ethnic composition of the NP workforce, NP level of practice authority, and the communities they service. In this paper, we compare the ethnic and racial composition of the NP workforce to the composition of the state's population, and then observe if there are any noticeable differences in the patients served by NPs when we compare full practice authority (FPA) and non-FPA states. We also estimate how FPA affects the race and ethnicity of Medicare patients served by NPs.

Primary Care Nurse Practitioner Work Environments and Hospitalizations and ED Use Among Chronically Ill Medicare Beneficiaries.

BACKGROUND: Nurse practitioners (NPs) play a critical role in delivering primary care, particularly to chronically ill elderly. Yet, many NPs practice in poor work environments which may affect patient outcomes. OBJECTIVE: We investigated the relationship between NP work environments in primary care practices and hospitalizations and emergency department (ED) use among chronically ill elderly. RESEARCH DESIGN: We used a cross-sectional design to collect survey data from NPs about their practices. The survey data were merged with Medicare claims data. SUBJECTS: In total, 979 primary care practices employing NPs and delivering care to chronically ill Medicare beneficiaries (n=452,931) from 6 US states were included. MEASURES: NPs completed the Nurse Practitioner-Primary Care Organizational Climate Questionnaire-a valid and reliable measure for work environment. Data on hospitalizations and ED use was obtained from Medicare claims. We used Cox regression models to estimate risk ratios. RESULTS: After controlling for covariates, we found statistically significant associations between practice-level NP work environment and 3 outcomes: Ambulatory Care Sensitive (ACS) ED visits, all-cause ED visits, and all-cause hospitalizations. With a 1-unit increase in the work environment score, the risk of an ACS-ED visit decreased by 4.4% [risk ratio (RR)=0.956; 99% confidence interval (CI): 0.918-0.995; P=0.004], an ED visit by 3.5% (RR=0.965; 99% CI: 0.933-0.997; P=0.005), and a hospitalization by 4.0% (RR=0.960;99% CI: 0.928-0.993; P=0.002). There was no relationship between NP work environment and ACS hospitalizations. CONCLUSION: Favorable NP work environments are associated with lower hospital and ED utilization. Practice managers should focus on NP work environments in quality improvement strategies.

Prevalence of lifetime nonmedical opioid use among U.S. Health Center Patients aged 45 years and older with psychiatric disorders.

OBJECTIVE: Despite recent concerns over the increase in opioid misuse among aging adults, little is known about the prevalence of lifetime nonmedical opioid use in underserved, vulnerable middle-aged and older patients with psychiatric disorders. This study aims to determine the lifetime prevalence of nonmedical opioid use among underserved, vulnerable U.S. adults aged ≥45 years with psychiatric disorders. METHOD: A nationally representative sample (n = 3,294) was obtained from the 2014 Health Center Patient Survey which collects data on psychiatric disorders, opioid use, and other health information from underserved, vulnerable U.S. primary care populations. Predictor variables included self-reported panic disorder, generalized anxiety disorder, schizophrenia, or bipolar disorder. The outcome variable was self-reported lifetime nonmedical opioid use. Frequencies, counts, and unadjusted and adjusted logistic regression models were conducted with the cross-sectional survey dataset. RESULTS: Patients with bipolar disorder had the highest lifetime nonmedical opioid use rate (20.8%), followed by schizophrenia (19.3%), panic disorder (16.5%), and generalized anxiety disorder (14.5%). Nonmedical opioid use was significantly associated with bipolar disorder (OR 3.46, 95% CI [1.33, 8.99]) and generalized anxiety disorder (OR 2.03 95% CI [1.08, 3.83]). CONCLUSION: Our findings demonstrate a high prevalence of lifetime nonmedical opioid use in underserved, vulnerable middle-aged and older health center patients with psychiatric disorders. Given the prevalence, health center professionals should monitor, prevent, and treat new or reoccurring signs and symptoms of nonmedical opioid use in this high-risk group of aging patients with psychiatric disorders.

Advanced practice nurse work environments and job satisfaction and intent to leave: Six-state cross sectional and observational study.

AIMS: To explore the relationship between nurse practitioner work environment and nurse practitioner outcomes (job satisfaction and intent to leave) in the United States. DESIGN: The study used a cross-sectional survey design to collect survey data from primary care nurse practitioners in six states in the United States. METHODS: We sent mail surveys to 5689 eligible nurse practitioners in Arizona, New Jersey, Washington, Pennsylvania, California and Texas. The mail also contained an online link. Participants could complete either the paper or online questionnaire. In total, 1244 participants completed the survey in 2018-2019. The work environment was measured using the Nurse Practitioner-Primary Care Organizational Climate Questionnaire comprised of four subscales: Nurse Practitioner-Administration Relations, Nurse Practitioner-Physician Relations, Independent Practice and Support and Professional Visibility. Global items measured job satisfaction and intent to leave. We used mixed-effect proportional-odds cumulative logit models to assess the association between work environment and job satisfaction and intent to leave. RESULTS: Overall, 90% of participants were either very satisfied or somewhat satisfied with their job and 22% reported intent to leave their job in 1 year. With a one-unit increase in the organizational-level Nurse Practitioner-Administration Relations score, the odds of having a higher job satisfaction level increased by about four times and the odds of intent to leave job decreased by about 60%. A higher organizational-level Nurse Practitioner-Physician Relations score was significantly associated with higher job satisfaction and lower odds of intent to leave. CONCLUSION: Improvements in work environments may improve nurse practitioner job satisfaction and retention. IMPACT: This study examined the relationship between work environment, job satisfaction and turnover intention of nurse practitioners. Better work environment is associated with higher job satisfaction and lower turnover intention. Findings have implications for clinical leadership who can take actions to create better work environments to increase the nurse practitioner workforce capacity.

State-level scope of practice regulations for nurse practitioners impact work environments: Six state investigation.

Nurse practitioner (NP) scope of practice (SOP) policies are different across the United States. Little is known about their impact on NP work environment in healthcare organizations. We investigated the association between SOP policies and organizational-level work environment of NPs. Through a cross-sectional survey design, data were collected from 1244 NPs in six states with variable SOP regulations (Arizona, New Jersey, Washington, Pennsylvania, Texas, and California) in 2018-2019. Arizona and Washington had full SOP-NPs had full authority to deliver care. New Jersey and Pennsylvania had reduced SOP with physician collaboration requirement; California and Texas had restricted SOP with physician supervision requirement. NPs completed mail or online surveys containing the Nurse Practitioner Primary Care Organizational Climate Questionnaire, which has these subscales: NP-Administration Relations (NP-AR), NP-Physician Relations (NP-PR), Independent Practice and Support (IPS), and Professional Visibility (PV). Regression models assessed the relationship between state-level SOP and practice-level NP work environment. NP-AR scores were higher in full SOP states compared to reduced (ß = 0.22, p < 0.01) and restricted (ß = 0.15, p < 0.01) SOP states. Similarly, IPS scores were higher in full SOP states. The PV scores were also higher in full SOP states compared to reduced (ß = 0.16, p < 0.001) and restricted (ß = 0.12, p < 0.05) SOP states. There was no relationship between SOP and NP-PR score. State-level policies affect NP work environment. In states with more favorable policies, NPs have better relationships with administration and report more role visibility and support. Efforts should be made to remove unnecessary SOP restrictions.