Shared Decision-Making for Patients Using Cannabis for Pain Symptom Management in the United States.

OBJECTIVES: Gaps in research evidence and inconsistent policies regarding use of cannabis for pain and associated symptoms result in confusion for healthcare providers and patients. The objective of this review was to synthesize information on cannabis use for pain with legal and policy implications to create a shared decision-making model that can be used to guide patient care interactions. APPROACH: Current cannabis policies, state laws, research, and patient care practices related to medical and recreational cannabis in the United States were reviewed, along with best practices in shared decision-making. Reviewed literature was then synthesized to create a model that can be used by registered nurses and others to address cannabis use, where legal, for pain and related symptoms. RESULT AND CONCLUSIONS: Cannabis is a legal option for many patients with pain. To minimize harms and optimize benefits, nurses can play a key role when authorized by law in assisting with decision-making surrounding cannabis use.

Nurse practitioner hospitalists: An empowered role.

BACKGROUND: Nurse practitioners (NPs) are increasingly employed by hospital medicine groups and contribute to the care of the hospitalized adult patient. Prior research indicates NP hospitalists are empowered in their role. PURPOSE: This national study describes the work experience of the NP hospitalist workforce. METHOD: A qualitative exploratory study using five focus group sessions with NP hospitalists is described using thematic analysis and synthesis of transcriptions. Inductive coding identified and further refined themes explained by NP hospitalist participants. FINDINGS: Psychological empowerment was reaffirmed as the overarching theme to describe the experience of NP hospitalists. Five subthemes of this empowerment emerged: collegiality, autonomy, role preparation, the road traveled, and pathfinder. DISCUSSION: Three main implications of the study include: the need for educational programs to align with practice; hospital bylaws require updating to support current practice; and the APRN Consensus Model does not fully reflect hospitalist roles.

Swazi Pregnant Women's Knowledge on Consuming Alcoholic Beverages.

Fetal alcohol spectrum disorders (FASD) affect all nations harshly, however, very little is known about the scope of FASD in Swaziland. Alcohol exposure in utero is one of the leading preventable causes of poor fetal birth outcomes. This study assessed the knowledge and practices of pregnant Swazi women, revealing that most participants had knowledge deficit on the effects of consuming alcohol on both the woman (63.3%, n = 19) and her fetus (83.3%, n = 25). The majority (83.0%, n = 25) of the participants reported that they did not drink alcohol, while 16.7% (n = 5) reported that they did consume alcohol. In health facilities, there is a need to intensify health education concerning the effects of alcohol consumption to both the fetus and the pregnant woman. A policy that enforces screening of pregnant women at risk for giving birth to infants with FASD is essential.

The contribution of physicians, physician assistants, and nurse practitioners toward rural primary care: findings from a 13-state survey.

BACKGROUND: Estimates of the relative contributions of physicians, physician assistants (PAs), and nurse practitioners (NPs) toward rural primary care are needed to inform workforce planning activities aimed at reducing rural primary shortages. OBJECTIVES: For each provider group, this study quantifies the average weekly number of outpatient primary care visits and the types of services provided within and beyond the outpatient setting. METHODS: A randomly drawn sample of 788 physicians, 601 PAs, and 918 NPs with rural addresses in 13 US states responded to a mailed questionnaire that measured reported weekly outpatient visits and scope of services provided within and beyond the outpatient setting. Analysis of variance and χ(2) testing were used to test for bivariate associations. Multivariate regression was used to model average weekly outpatient volume adjusting for provider sociodemographics and geographical location. RESULTS: Compared with physicians, average weekly outpatient visit quantity was 8% lower for PAs and 25% lower for NPs (P<0.001). After multivariate adjustment, this gap became negligible for PAs (P=0.56) and decreased to 10% for NPs (P<0.001). Compared with PAs and NPs, primary care physicians were more likely to provide services beyond the outpatient setting, including hospital care, emergency care, childbirth attending deliveries, and after-hours call coverage (all P<0.001). CONCLUSIONS: Although our findings suggest that a greater reliance on PAs and NPs in rural primary settings would have a minor impact on outpatient practice volume, this shift might reduce the availability of services that have more often been traditionally provided by rural primary care physicians beyond the outpatient clinic setting.

Is being there enough? Postgraduate nurse practitioner residencies in rural primary care.

PURPOSE: Little research has been conducted on the outcomes of postgraduate nurse practitioner (NP) programs (referred to as residencies), particularly those located in rural communities. This study examined the purpose and characteristics of rural NP residencies that aim to promote the successful recruitment, transition, and retention of NPs in rural primary care practice. METHODS: We compiled a list of rural NP residencies and verified the location of each clinic as rural if it met any of several federal definitions of rurality. We interviewed grant and project administrators, residency program directors, clinic personnel, and former and current NP residents using semistructured guides. FINDINGS: Of 20 rural NP residencies identified, we interviewed 12 program directors or managers; 8 NPs; and 4 clinic personnel. All but 1 program was 12 months long. Three-quarters had federal funding. Each slowly increased residents' patient load and included didactic content and specialty rotations. We identified 2 different program models and 3 administrative models. Some NPs' intentionally chose rural practice, while others opted for a rural residency when unable to secure employment in an urban location. Most programs were new and not yet able to report on residents' subsequent employment locations. CONCLUSIONS: It is premature to conclude definitively that rural NP residencies facilitate and promote NP connectedness to, and investment in, rural communities based on our investigation. Nonetheless, these programs are an option to encourage the recruitment and retention of NPs in rural practice, with further study needed to determine their long-term contribution to rural primary care practice.

The state of evidence-based practice in US nurses: critical implications for nurse leaders and educators.

This descriptive survey assessed the perception of evidence-based practice (EBP) among nurses in the United States. Although evidence-based healthcare results in improved patient outcomes and reduced costs, nurses do not consistently implement evidence-based best practices. A descriptive survey was conducted with a random sample of 1015 RNs who are members of the American Nurses Association. Although nurses believe in evidence-based care, barriers remain prevalent, including resistance from colleagues, nurse leaders, and managers. Differences existed in responses of nurses from Magnet® versus non-Magnet institutions as well as nurses with master's versus nonmaster's degrees. Nurse leaders and educators must provide learning opportunities regarding EBP and facilitate supportive cultures to achieve the Institute of Medicine's 2020 goal that 90% of clinical decisions be evidence-based.

Nurse practitioner practice under the COVID-19 public health emergency: Did policy change persist?

ABSTRACT: The COVID-19 public health emergency (PHE) offers opportunities to study legislative and policy changes to nurse practitioner (NP) practice limitations, including factors that affect persistence. We evaluated states with restricted or reduced practice as identified by the American Association of Nurse Practitioners. This analysis 1) identified and correlated key changes in policy during the PHE with state regulatory, governmental, and practice variables; 2) modeled predictive characteristics that facilitate or impede policy persistence; and 3) explored the lived experience of NPs working in eligible states with policy changes during the PHE. Focus group interviews with NP leaders and bivariate correlations with regression analysis from the 2019 to 2021 legislative sessions were conducted. Nurse practitioner identified three types of persistence during the PHE: the power differential between MDs and NPs; the existing day-to-day environment; and barriers to change. In 2019, significantly more legislation was passed in states with sunset laws (Spearman rho: -0.38; p -value = .046). During 2020, 15 states introduced a total of 22 bills focused on NP practice, although only four passed one bill each. In 2021, states with an independent board structure introduced more NP legislation than did those states with a nonindependent board structure (Spearman rho: -0.406; p -value = .032). Few PHE policies persisted, despite robust predictions that this was likely to occur. Independent board structure and sunset laws were associated with legislation introduction and passage. Policy persistence is complex and based on multiple state and environmental variables. We urge persistence in NP advocacy strategies.

Assessment of Oncology Advanced Practice Professional Willingness to Participate in Medical Aid in Dying.

Importance: In 2021, New Mexico passed legislation allowing nurse practitioners and physician assistants (referred to herein as advanced practice professionals [APPs]) to prescribe medications for medical aid in dying (MAID). Other US states with existing MAID laws (eg, Washington) are also considering expanding MAID prescribing authority to APPs. There is a lack of research exploring APP knowledge of, willingness to, and comfort with acting as a prescribing or consulting clinician for MAID. Objective: To assess perspectives of oncology APPs regarding MAID, including their willingness to prescribe and/or consult for MAID and factors associated with willingness. Design, Setting, and Participants: This cross-sectional, self-report survey study used data collected from APPs working at a comprehensive cancer center in Washington State in fall 2021. Main Outcomes and Measures: The primary survey question was whether APPs would be willing to participate in death with dignity, the term used for MAID in Washington. Survey questions evaluated how influential specific factors were on APP views on MAID as well as respondents' knowledge of and comfort with aspects of the MAID process. Results: Of 167 eligible APPs, 77 (46.1%) responded to the survey. Most respondents (68 [88.3%]) reported their race and ethnicity as White; 72 (93.5%) identified as a woman. Medical oncology (28 [36.4%]) was the most common field of practice, and 21 respondents (27.3%) reported having practiced as an APP for 6 to 10 years. Of all respondents, 61 (79.2%) reported having at least 1 patient who inquired about MAID; depending on the question, less than a third of respondents (5.0%-27.0%) endorsed feeling knowledgeable or very knowledgeable about any aspect of the MAID process. In this study, 39 APPs (50.6%) endorsed being willing to participate in MAID either as a consulting or prescribing clinician, whereas 31 (40.3%) were uncertain of whether they would participate. Willingness to participate was associated with having had more patients pursue MAID (33 of the 39 willing participants [84.6%] vs 15 of the 31 unsure participants [48.4%] reported having 1 or more patients pursue MAID). Higher knowledge and comfort scores were both significantly associated with increased odds of being willing to participate (odds ratio, 1.14 per 1-point score increase [95% CI, 1.03-1.27]; P = .01) vs unsure (1.18 [95% CI, 1.07-1.30; P = .001). Conclusions and Relevance: The results of this survey study suggest that oncology APPs may require preparation for the addition of MAID to their scope of practice. This study also raises questions for future research regarding support for APPs who may be considering participation in MAID but question their role or want physician involvement.

CRNA prescribing practices: the Washington State experience.

One year after implementation of a 2005 Washington State law that granted Certified Registered Nurse Anesthetists (CRNAs) authority to prescribe schedule II through IV controlled substances, only 30% of CRNAs held prescriptive authority. The purpose of this study was to describe Washington State CRNA prescribing practices and workforce and practice characteristics. A questionnaire was mailed in 2006 to CRNAs licensed in Washington with addresses in Washington, Oregon, and Idaho. A typical respondent was 51 years old, white, and equally likely to be male or female, with 19 years of experience. More than half (52.2%) of the CRNAs were employed by hospitals, and 22% were in solo practice. Forty-one percent of the sample had prescriptive authority; however, 11% had prescriptive authority without Drug Enforcement Administration (DEA) registration. Respondents without prescriptive authority used the Nurse Practice Act provision to "select, order and administer" as the foundation for practice. Of CRNAs with prescriptive authority, 94.7% prescribed anesthetics, 60% prescribed nonsteroidal anti-inflammatory medications, and just 53.3% prescribed narcotic analgesics. Professional and policy controversies about autonomous prescribing for CRNAs are discussed. Further research is needed to determine the factors that limit CRNA prescribing and the transition to a new scope of practice.

Advocating for Washington state ARNP payment parity.

Workforce and reimbursement data were collected from a 2018 survey of Washington state advanced registered nurse practitioners (ARNPs). Survey results will be used to improve workforce planning and advocate for payment parity legislation requiring health plans to pay ARNPs the same as physicians for the same service.

Characteristics and perceptions of the US nurse practitioner hospitalist workforce.

BACKGROUND: The use of nurse practitioners (NPs) as hospitalists has grown over the last two decades. Based on current educational preparation, certification, and scope of practice, the acute care NP is considered by professional standards the best prepared to care for the needs of acutely and critically ill patients. Little is known about this sector of the NP workforce. PURPOSE: The study was designed to identify the NP hospitalist workforce's characteristics and describe the NP hospitalist workforce's perception of the work environment. METHODS: We deployed five questions in the 2019 American Association of Nurse Practitioners National NP Sample Survey. Of 880 respondents working in an eligible inpatient setting, 366 responded that they work as hospitalists caring for adult patients. RESULTS: Most respondents (n = 275, 74.7%) were certified in primary care. On-the-job training was the most common qualification to be an NP hospitalist (n = 274, 75%). The majority (n = 252, 68.9%) had a collaborative relationship with a physician at their site. Job satisfaction was significantly correlated with full utilization of one's education and practicing to the fullest extent of the state's scope of practice with an r(360) = .719, p = .00 (two-tailed). IMPLICATIONS FOR PRACTICE: The prevalence of on-the-job training as the most common preparation for the hospitalist role suggests a need to evaluate the effectiveness and outcomes of NPs not initially educated as acute care NPs who work as hospitalists. Nurse practitioner educators should address the evolving workforce needs of both primary and acute care practice when planning and implementing educational programs.

Factors That Encourage and Support Advanced Practice Registered Nurses to Work in Rural and Safety-Net Settings.

Advanced practice registered nurses (APRNs) provide vital care in rural and safety-net settings. Research regarding effective strategies for recruiting and retaining rural or safety-net providers often focuses on physicians or combinations of health care professionals. We conducted a scoping review using MEDLINE and CINAHL to identify effective strategies and research gaps specific to recruiting and retaining APRNs in rural and safety-net settings. We found 13 articles published between 1990 and 2019. Educational experiences and loan repayment obligations influenced APRNs to seek employment in both types of settings. Rural connectedness or satisfaction with the community, having a mentor and supportive work environment, and salary and benefits influenced retention in rural practice. Post-graduate NP residency and an NP-physician team-based care model influenced retention in safety-net settings. We found a limited quantity of evidence for strategies that encourage a strong rural and safety-net APRN workforce, indicating need for additional research.

Knowledge, Practices, and Attitudes of Washington State Health Care Professionals Regarding Medical Cannabis.

Introduction: Health care providers in Washington State practice in a unique environment where both medical and recreational cannabis use are legal. Five types of health care providers can authorize medical cannabis. State-certified medical cannabis consultants may advise patients in a cannabis retail store regarding use and consumption. Washington State's health care professionals' perspectives about medical cannabis can inform policy-makers nationwide who are navigating challenges posed by legalization of medical and recreational cannabis. Materials and Methods: A cross-sectional mixed-mode survey using a 26-item questionnaire was administered to a random sample of actively licensed health care professionals legally permitted to provide medical cannabis authorizations in Washington State. We describe participant demographics and summarize responses to survey questions. We report comparisons across provider types using Fisher's exact tests with a level of significance of p<0.01. Results: Among the 1440 health care professionals invited to participate in the study, 310 respondents met eligibility criteria (response rate 24%). Only 57 respondents (18.4%) indicated having ever issued a medical cannabis authorization. Among them, 6, all naturopaths, had provided more than 500. Over half (58%) reported that they did not feel they had the knowledge and skills necessary to provide authorizations. Depending on the condition, 29-93% of respondents correctly identified conditions that qualified a patient to receive a medical cannabis authorization. Very few knew that employers are not required to provide accommodations for medical cannabis. Health care professionals (64.8%) served as the most frequent source of information regarding cannabis risks and benefits. Over half (62%) strongly or somewhat agreed that the Drug Enforcement Agency should reschedule cannabis to make it legal at the federal level. Conclusion: A wide range of knowledge was exhibited within our sample of health care professionals regarding qualifying conditions for medical cannabis. As more states adopt comprehensive medical cannabis laws, health care professionals must be prepared to provide information to patients regarding the effects, risks, and benefits of cannabis. Standardized education could ensure that health care professionals are prepared to responsibly promote the use of cannabis when indicated for medically appropriate symptoms and conditions. A rational approach to medical cannabis is needed to assure that unforeseen consequences are mitigated.

NP program efforts promoting transition to rural practice.

This article presents the results of a study that identifies, describes, and compares the approaches of rural-oriented NP education programs to facilitate the NP transition from education to practice in rural settings. Preparing NP students effectively during their education may be key to their success in rural practice.

Developing and Implementing the Family Nurse Practitioner Role in Eswatini: Implications for Education, Practice, and Policy.

Introduction: Eswatini, a small, largely rural country in Southern Africa, has a high burden of morbidity/mortality in the setting of a critical shortage of human resources for health. To help achieve universal access to healthcare across the lifespan, the advanced practice family nurse practitioner (FNP) role was proposed and is in the process of being implemented. Methods/Approach: The PEPPA framework (Participatory, Evidence-based, Patient focused Process for Advanced practice nursing) illustrates the steps in the process of developing and implementing the FNP role in a country. These steps include: determining the need for the role, deciding on a model of care, developing/implementing the curriculum, relevant policies, and scope of practice (SOP), and integrating the role into relevant nursing regulations and Ministry of Health (MOH) guidelines and documents. Outcomes: The assessment has been completed, a locally tailored competency-based FNP curriculum has been developed, revised, and implemented, the FNP SOP has been approved and MOH guidelines are being updated to reflect current evidence-based practice and to integrate the FNP role. Continuous cycles of improvement/revision were needed to adapt the curriculum and SOP to meet local needs. Clinical placements were challenging since this is a new health cadre, but most challenges were overcome and many resulted in important opportunities for interdisciplinary collaboration. Summary: Outcomes from this quality improvement initiative demonstrate that it is feasible to develop and implement a locally responsive, competency-based FNP program in a low resource setting and enroll students, despite time and financial constraints. Adapting the curriculum and SOP from western countries can provide a foundation for program development but revision to assure that the program is responsive to local context is then needed. There is general acceptance of the role among Eswatini communities and professional stakeholders with emphasis on the need for FNP graduates to be clinically competent and able to function independently. Policy work related to deploying new graduates is ongoing.

Doctor of Nursing Practice program evaluation and beyond: capturing the profession's transition to the DNP.

The Doctor of Nursing Practice (DNP) educational preparation for advanced practice nursing and DNP role development are innovations that require intense scrutiny through formative and summative evaluation. It is imperative to move beyond standard curriculum evaluation approaches to capture the transformation of advanced nursing practice and the profession. The University of Washington School of Nursing designed a comprehensive DNP evaluation plan that focuses on both program effectiveness and the experience of transition as described by faculty and students. The evaluation plan is outlined, and lessons learned regarding data collection, student and faculty participation, and institutional review board approval are discussed. Examples of instruments are included.

An evaluation of Washington's Medicaid disease-management program.

In 2002, Washington State Medicaid implemented a disease-management program for clients with diagnoses of asthma, chronic obstructive pulmonary disease, heart failure, and diabetes. The program represented a unique attempt to manage disabled clients in a fee-for-services environment, and at its onset, was one of the first statewide programs in the United States. This article reviews the effectiveness of the program based on the results from two independent evaluations. Results of cost-savings measurements and health outcomes are presented for each of the conditions. These results were used to make program changes, which began in 2007.

The Washington State Nurse Anesthetist Workforce: a case study.

The purposes of this study were to describe the Washington State Certified Registered Nurse Anesthetist (CRNA) workforce and analyze selected dimensions of their clinical practice. We developed the 31-item CRNA Practice Questionnaire. After receiving institutional review board approval, the questionnaire was mailed in 2003 to CRNAs licensed in Washington with an address in Washington, Oregon, and Idaho. Statistical analysis included descriptive statistics for all variables and was performed by University of Washington Center for Health Workforce Studies staff. Results indicate that the typical Washington State CRNA is 50.7 years old, white, and equally likely to be a man or woman. More than half of the Washington State CRNAs are master's educated and have an average of 19 years of CRNA experience. Most work at least 40 hours a week, take call, and earn more than 100,000 dollars per year. Almost all have hospital privileges, but only 30% believe they are equal colleagues with physicians. A chi2 analysis comparing urban and rural respondents yielded few differences except that rural CRNAs reported seeking significantly less consultation and were more likely to take call. Workforce data may assist CRNAs when negotiating with employers and institutions and in resolving interprofessional conflicts and can have implications for scope of practice, policy, and legislative issues.