Super-Mentors to Train Multiple Neonatal Advanced Practice Providers: Pros and Cons.

BACKGROUND: Despite available training programs for neonatal advanced practice providers (Neo APP), including neonatal nurse practitioners and physician assistants, it is difficult to meet the demand for these providers. There are no publications regarding training models with greater than 1 Neo APP learner per mentor. PURPOSE: To create and measure outcomes of a 12-month program to educate Neo APP "Super-Mentors" able to train 2 Neo APP learners simultaneously. METHODS: Super-Mentors were selected and attended monthly classes to learn mentorship concepts and receive support. Learners received didactic content and support through a Fellowship program. Quantitative data regarding recruitment and retention, as well as Misener Nurse Practitioner Job Satisfaction Scale (MNPJSS) results were compared pre- and postprogram. Qualitative satisfaction measures via survey from 21 stakeholders were analyzed through a phenomenological approach. RESULTS: Six Super-Mentors trained 14 Neo APPs, as compared to 7 in the previous year. One Neo APP left after training. Summative preprogram MNPJSS scores were better (5.1 ± 0.37) than postprogram (4.7 ± 0.47) ( P < .001). The most important preprogram subscale item was "vacation" versus "quality of assistive personnel" postprogram. Both pre- and postprogram scores reflected positive job satisfaction so differences may not be clinically significant. Qualitative program benefits included faster and increased onboarding, stronger relationships, and dedicated time. Challenges included role clarity among other stakeholders, learning culture, and spacial/technological logistics. IMPLICATIONS FOR PRACTICE: Super-Mentors can train twice the number of Neo APP learners, with optimal preparation and support of all stakeholders, adequate space, and appropriate technology.

Advance Practice Provider Transformational Leadership Structure: A Model for Change.

BACKGROUND: The role of the advanced practice provider (APP) is rapidly expanding in healthcare, whereas infrastructure to support it is not keeping pace. A large academic healthcare organization implemented the role of a director of APPs; supported by the C-suite, one who understands scope of practice, revenue models, and compliance and addresses engagement and retention to meet this challenge. This article chronicles the implementation of innovative success strategies, supporting APPs across a large academic health system, employing more than 1000 APPs, which has led to improvements in APP-generated revenue, patient access, engagement, and alignment. METHODS: Emory Healthcare rapidly expanded the number of APPs (nurse practitioners and physician assistants) over the past 10 years. APPs reported to administration or nursing leadership leading to APP dissatisfaction, questions on return on investment (ROI) and productivity, and poor utilization due to lack of role clarity. An APP leadership structure was created so that every APP reported to an APP leader. In alignment with the goals and plan for Emory Healthcare, standardized service line productivity and accountability expectations were developed and implemented, as well as a vision and strategic plan to support APPs. RESULTS: Improvement in productivity was seen across service lines, supported by the increase in full-time equivalent numbers, while improving the ROI for the organization. A roadmap to aligning an APP and organizational strategic plan has been created and implemented. Improvement in APP engagement was realized. CONCLUSIONS: An APP director and leadership structure are vital to the creation of infrastructure to support APPs in this healthcare. Optimization and standardization of APP practice resulted in role clarity and allowed for support of practice development.

Feasibility of an Advance Care Planning Program (ACP) for Korean Community-Dwelling Older Adults and ACP Training of Advance Practice Nurses.

This study aimed to develop a locally suitable advance care planning (ACP) program for older community-dwelling adults and a training program for nurse facilitators in Korea, and to evaluate their feasibility from the facilitators' experiences. This was a mixed methods pilot study that assessed the feasibility of an ACP program by analyzing survey, checklist, and focus group interview data. The ACP program was named CLOSE (Communicating and Listening to Our Seniors' voices about End-of-life care). Home health care nurses (N = 9) participated in this study. The participants reported that CLOSE was applicable to older community-dwelling adults and the training program was useful for increasing facilitator competency. We suggest some lessons from this pilot study that can be used to improve the ACP program and encourage community health nurses to participate in ACP as facilitators.

A preliminary evaluation of full practice authority of advance practice registered nurses in the Veterans Health Administration.

BACKGROUND: Responding to National Academy of Medicine and National Council of State Boards of Nursing recommendations, the Department of Veterans Health Affairs (VHA) implemented full practice authority (FPA) for Advanced Practice Registered Nurses in VHA medical centers (VAMCs) in 2017. PURPOSE: To evaluate FPA policy implementation's impact on quality indicators including access to care as measured by new patient appointments in primary, specialty and mental health services. METHODS: Linear growth models compared early (n = 85) vs. late (n = 55) FPA implementing VAMCs on the trajectories of each of the three quality indicators. FINDINGS: Early FPA implementing VAMCs showed greater rates of improvement over time in new patient appointments completed within 30 days of preferred date for primary care (p = .003), specialty care (p = 0.05), and mental health (p = 0.001). DISCUSSION: VAMCs that started implementation of FPA policy early showed greater improvement in access to care for Veterans over time than VAMCs that did not.

Étude exploratoire de la perception des parties prenantes hospitalières vis-à-vis de l'implantation des infirmiers en pratique avancée.

Introduction : One solution proposed by the authorities to address public health issues is to deploy a new category of professionals with a greater range of skills : advanced practice nurses (APNs). The literature identifies the complexity of the deployment projects of these professionals. The PEPPA model approved by the International Council of Nurses is the reference model for the introduction of APNs. The objectives of this study were to explore various stakeholders' perceptions on the introduction of APNs into health institutions, in order to propose recommendations to support the institutions.Method : A multicenter qualitative study was conducted in France's Provence-Alpes-Côte d'Azur region with physicians, managers, nurses, patients, and advanced practice students.Results : APNs are beneficial for patients and the health system, but their introduction into health institutions brings with it risks, primarily linked to their integration. APN introduction projects need to be well planned and should prioritize their integration.Discussion : Results consistent with the PEPPA model identified seven recommendations to facilitate the successful introduction of APNs into hospitals.Conclusion : This work needs to be continued with studies related to the out-of-hospital setting and the evaluation of the successfulness of APNs' introduction.

A chemotherapy privileging process for advanced practice providers at an academic medical center.

PURPOSE: Nurse practitioners, physician assistants, and pharmacists are advanced practice providers who are highly trained and qualified healthcare professionals that can help support traditional demands on oncologists' increased time in direct patient care. The purpose of this study was to detail and assess the creation of a privileging process for this group of medical professionals within an academic medical center. Obtaining the designation of limited oncology practice provider (LOPP) gives the right to modify chemotherapy orders and to order supportive care medications. METHODS: An interdisciplinary team developed a comprehensive training process inclusive of required educational domains, knowledge goals, and educational activities to become an LOPP. In 2018, five years after the implementation of the privileging process, a survey was distributed to assess perceptions of the training process and integration of LOPPs within oncology practice. RESULTS: Most oncologists noted that working with LOPPs is beneficial to oncology practice (94%) and that they make modifying chemotherapy orders more efficient (87%). Greater than 82% of LOPPs also reported that their privileges streamline the chemotherapy process and make them feel valuable. CONCLUSION: The creation of the LOPP designation is an effective way to integrate nurse practitioners, physician assistants, and pharmacists within oncology practice. The inclusion of a focused privileging process ensures the safety of cancer care provided and has created a streamlined process for chemotherapy modifications and supportive care.

The effectiveness of nurse-led interventions for preventing urinary tract infections in older adults in residential aged care facilities: A systematic review.

AIMS AND OBJECTIVES: To explore the effectiveness of nurse-led interventions to prevent urinary tract infections in older adults living in residential aged care facilities. BACKGROUND: While most empirical studies focus on the treatment of urinary tract infections, few studies have examined the effectiveness of nurse-led interventions in preventing urinary tract infections. DESIGN: Systematic review. METHODS: Eight electronic databases were searched for relevant studies published between 2008-2018. The inclusion criteria were as follows: (a) a focus on older adults, (b) evaluation of nurse-led interventions, focusing on prevention of urinary tract infection, (c) implemented in residential aged care facilities, and (d) outcomes reported as incidence or prevalence of urinary tract infection. The selected papers were critically appraised using the Mixed Methods Appraisal Tool. The data were analysed with narrative synthesis, and findings were reported following the PRISMA guidelines. RESULTS: A review of 1,614 titles and abstracts identified four studies that met the inclusion criteria. Three types of nurse-led interventions were identified: (a) the appointment of advanced practice nurses, (b) those focused on a single specific nursing intervention, and (c) implementation of a multicomponent nursing intervention. All included studies reported at least some positive outcomes. However, the included studies were highly heterogeneous and it was impossible to determine the most effective intervention approach. CONCLUSIONS: Nurses are leaders in health care and are well placed to lead prevention of urinary tract infections in residential aged care; however, evidence of the effectiveness of a nurse-led approach is limited. High-quality randomised controlled trials are warranted to address the knowledge gap and advance practice in this area. RELEVANCE TO CLINICAL PRACTICE: When developing an effective nurse-led intervention programme, the programme should be grounded in nurse-led principles and consider the complex staffing factors to ensure that nurse-led programmes are tailored to an effective level.

A survey of oncology advanced practice providers' knowledge and attitudes towards sexual and gender minorities with cancer.

AIMS AND OBJECTIVES: To evaluate the knowledge and attitudes towards sexual and gender minority (SGM) oncology patients' needs among advanced practice providers (APPs). BACKGROUND: SGM individuals experience health disparities, in part due to lack of access to knowledgeable providers. Despite the important role of APPs in cancer care, less is known about their attitudes and knowledge towards SGM cancer patients. DESIGN: Cross-sectional study. METHODS: A survey of APPs at a National Cancer Institute-Designated Comprehensive Cancer Center assessed self-reported demographics, attitudes, knowledge and postsurvey confidence in knowledge of SGM oncology patient needs. Reporting of this study adheres to STROBE guidelines. RESULTS: Knowledge of health needs was low with an average of 2.56 (SD = 1.27) items answered correctly out of 6. The majority of APPs self-reported being comfortable treating SGM patients (93.6% and 87.2%, respectively), but less confident in knowledge of their health needs (68.0% and 53.8%, respectively). Although less than half of APPs believed education should be mandatory (44.9%), 79.5% were interested in education about SGMs' unique health needs. Political affiliation, medical specialty, licensure, and having SGM friends or family were associated with various attitude items, but not knowledge. Moderation analyses indicated that APPs who had greater overall knowledge scores were more likely to agree, on average, that knowing sexual orientation, gender identity and sex assigned at birth are important to providing quality oncology care. CONCLUSION: APPs report being comfortable providing care for SGMs with cancer, but knowledge gaps remain that may inhibit the quality of care provided. Given the interest in education, results would support the development of SGM-related healthcare training for oncology APPs. RELEVANCE TO CLINICAL PRACTICE: Targeted education for providers during training and continuing education is likely to improve the provision of quality care for SGMs with cancer.

Advanced practice registered nurses' work environment perceptions in hospitals: A cross-sectional survey.

AIM: To examine work environment differences between hospital certified nurse practitioners (CNPs) and certified registered nurse anaesthetists (CRNAs). BACKGROUND: Nurse work environments impact patient and nurse outcomes. How differing advanced practice nurse (APRN) roles influence work environments is unknown. METHODS: Multi-level cross-sectional survey design. APRNs (n = 490) completed the APRN Organizational Climate Questionnaire and Psychological Ownership Questionnaire. Nurse executives (N = 24) reported on Scope of Practice and Institutional Voice. Descriptive, t test, chi-square and linear and mixed-effects regression statistical analyses were employed. RESULTS: CNPs reported better organisational climate and job ownership than CRNAs. The largest effects involved relationships with physicians, control over practice and independent practice. Among CNPs, a significant positive relationship was observed between relations with physicians and work engagement. In CRNAs, a similar positive relationship between physician relations and work engagement was only observed for those working in higher scope of practice settings, not for those working in more restrictive settings. CONCLUSIONS: Significant differences exist in the perceived work environments between CNPs and CRNAs that may be related to differences in job design and historical relations with physician colleagues. IMPLICATIONS FOR NURSING MANAGEMENT: Efforts to improve APRN work environments in hospital settings should consider differing CRNA and CNP perspectives.

Advanced practice nurses' experiences and well-being: Baseline demographics from a cohort study.

AIMS: To create a cohort of advanced practice nurses from across the UK and to report the initial questionnaire including demographics, work experiences and well-being. BACKGROUND: In the UK, advanced nursing practice is not regulated. This has led to the concern that advanced nurses are working in very different ways with different levels of autonomy and support. METHODS: Participants were recruited via university and Royal College of Nursing mailing lists, and social media adverts. They completed the initial questionnaire about their background and workplace, work experiences, credentialing and well-being. RESULTS: A total of 143 nurses were recruited to the cohort and 86 completed the survey. Over 40 job titles were reported, across five pay bands. Job title was not correlated with pay band (p = .988). Participant well-being was not significantly different from the UK general population, but they reported high rates of work-related stress (44.2%) compared with the National Health Service national average (37.9%). CONCLUSION: There is a wide disparity in pay, which is not reflected in title or setting. The high levels of work-related stress require further exploration. IMPLICATIONS FOR NURSING MANAGEMENT: The range of experiences reported here should encourage managers to evaluate whether title, pay and support mechanisms for Advanced Practice Nurses in their organisations align with suggested national standards set by Royal Colleges and government departments.

Advanced Practice Provider-Led Strategies to Improve Patient Discharge Timeliness.

Hospitals are under increased pressure to address both financial and capacity constraints to improve their clinical operations. Effective capacity management programs have become a key driver of clinical operations for managing the flow of patients into and out of the hospital. Many high-functioning medical centers have developed capacity management programs to strategically address patient throughput. Discharging patients from the hospital is one fundamental, but complex, patient flow initiative for efficient patient throughput. Despite advances in optimizing patient flow, there is a lack of understanding associated with the structure and processes to efficiently discharge patients. This article outlines a discharge timeliness project where advanced practice providers are principal leaders of designing a safe and efficient patient discharge prototype. Design thinking was used to develop a patient discharge prototype that included 6 key areas that led to improved discharge times on a cardiac surgery step-down unit. High tech solutions were incorporated into the electronic medical record system to enhance communication across phases of care and inform the interdisciplinary team of patient progress.

Leveraging Advanced Practice Nursing in Complex Health Care Systems.

The US health care system has seen unprecedented growth in health care cost with only a mediocre return on investment. Achieving sustained quality improvement will require innovation that is effectively integrated into complex systems of care. Complexity leadership has the ability to place value on traditional quality improvement processes, with less focus on rigid structure and more attention on the potential for flexibility and creativity at the point of care. Clinical team leaders, such as nurse practitioners, must nurture adaptability to the constantly changing clinical environment while balancing structured thinking of team members. Nurse practitioners operating in interdisciplinary teams are well positioned to foster adaptive change through rapid cycle improvements at the point of care. As a learning approach to quality improvement, the PDSA (plan-do-study-act) method should be seen as a useful tool for organizations to create an emergent quality improvement process. This article discusses the significance of nurse practitioner leadership using the PDSA method informed by complexity leadership theory and the impact for clinical practice.

A predictive model for fall risk in hospitalized adults: A case-control study.

AIM: To develop and validate a predictive model for falls in hospitalized adult clinical and surgical patients, assessing intrinsic (i.e. patient-related) and extrinsic factors (i.e. care process-related). BACKGROUND: To identify factors predictive of falls and enable appropriate management of fall risk it is necessary to understand patient and environmental factors, along with care delivery processes. DESIGN: A matched case-control study. METHODS: This study was conducted in the medical and surgical wards of a Brazilian teaching hospital. The sample included 536 patients, with data collected in 2013-2014. Data analysis included descriptive statistics and conditional logistic regression. Cases of patients aged 18 years or older who fell while hospitalized were included. One patient who did not fall during hospitalization, matched by sex, ward and admission date, was selected as a control for each included case. RESULTS: The SAK Fall Scale (Severo-Almeida-Kuchenbecker) was developed and validated. The scale includes seven variables: disorientation/confusion, frequent urination, walking limitations, lack of caregiver, postoperative status, previous falls and number of medications administered within 72 hr prior to the fall. This scale showed acceptable predictive accuracy. CONCLUSIONS: The newly developed SAK Fall Scale includes five intrinsic and two extrinsic variables and differs from other predictive scales for falls. The findings of this study are broad and the scale, which is easy to apply, can be used worldwide by nurses in health services. In advanced practice, the testing of a new model for fall risk contributes to preventive interventions and thus has an impact on patient safety.

Practice patterns and role perception of advanced practice nurses: A nationwide cross-sectional study.

AIMS: To provide an overview of the practice patterns of advanced practice nurses and to explore their perceptions of their role in Singapore. BACKGROUND: Role expansion of advanced practice nurses is increasingly popular in healthcare systems. However, their practice patterns remain variable, thereby introducing role ambiguity. Uncertainty revolves around how advanced practice nurses perceive their practice, competency and readiness for role expansion. METHODS: A nationwide survey of advanced practice nurses was conducted in Singapore. Statistical analyses of closed-ended responses and content analysis of open-ended responses were undertaken. RESULTS: A total of 87 participants were surveyed (42.8% response rate). Significant discrepancies existed between current practices and their expectations. Readiness for and acceptance of role expansion were discerned but multiple barriers to practice have remained. CONCLUSION: This pioneering study in Asia provides important evidence to support the call for greater clarity in the role of APNs and for review of existing institutional practice restrictions. It provides insights into healthcare systems in similar developmental stages of advanced practice nursing. IMPLICATIONS FOR NURSING MANAGEMENT: When outlining the goals and role priorities of advanced practice nurses APNs, nurse administrators can consider their best contributions in practice. This allows for long-term sustainability of their role.

Evidence-Based Prescribing in Mental Health Nursing.

Since Sackett et al.'s epic throw down of the gauntlet in 1996, the hallmark of quality health care practice has been evidence-based clinical decision making. But what does it mean to base one's practice on evidence, and what are the barriers to evidence-based prescribing? The current article addresses these questions and offers suggestions to improve one's evidence-based practice. [Journal of Psychosocial Nursing and Mental Health Services, 57(6), 9-13.].

Engagement in Psychotherapy Improves Outcomes for Veterans.

The longstanding partnership between the Birmingham Veterans Affairs Medical Center (BVAMC) and the University of Alabama at Birmingham School of Nursing inspired the establishment of one of the country's first psychiatric-mental health nurse practitioner (PMHNP) residencies and subsequent formation of a Resident Continuity Clinic (RCC). Within the RCC, PMHNP residents deliver evidence-based care that is informed by measurement-based care (MBC) to improve patient outcomes and reduce time to recovery. Determined by the BVAMC Institutional Review Board to be a quality improvement project, PMHNP residents administered the Patient Stress Questionnaire (PSQ), a MBC tool that uses four independently validated screening tools to measure the behavioral health symptoms of depression, anxiety, trauma, and alcohol use. Additional clinical variables of interest included patient use of illicit substances, participation in psychotherapy, and use of psychotropic medications. PSQ scores were reviewed retrospectively via descriptive statistics and nonparametric tests. Analysis demonstrated statistically significant improvements in depression and anxiety. Data also revealed that patients engaged in psychotherapy demonstrated greater improvements on all PSQ screening tools compared to patients not involved in psychotherapy. The results reinforce the value of MBC in psychiatric care and highlight the importance of engaging Veterans in psychotherapy to improve outcomes. [Journal of Psychosocial Nursing and Mental Health Services, 57(6), 30-38.].

Ethical Reasoning in Prescribing and Monitoring Psychotropic Medications.

Traditionally, schools of nursing teach legal and ethical responsibilities at the pre-licensure and advanced practice levels, with emphasis on legal duties and ethical principles. However, involving clinicians in the process of ethical reasoning, a process similar to the scientific method and nursing process, is much less common. The current article describes and demonstrates the steps in ethical reasoning in common situations faced by prescribing advanced practice RNs and psychiatric-mental health nurses. [Journal of Psychosocial Nursing and Mental Health Services, 57(1), 7-10.].

Report on the APNA National Psychiatric Mental Health Advanced Practice Registered Nurse Survey.

BACKGROUND: Further exploration of the practice roles of psychiatric mental health (PMH) advanced practice registered nurses (APRNs) is warranted. OBJECTIVE: In March of 2016, the American Psychiatric Nurses Association (APNA) conducted a national survey to gather data on the demographics, practice roles, and activities of certified PMH APRNs. DESIGN: The e-mail survey contained 46 questions consistent with minimum data set requirements of the Forum of State Nursing Workforce Centers. RESULTS: The data indicate that PMH APRNs are a clinically active workforce; the majority deliver a wide variety of mental health services including diagnosis and management of both acute and chronic mental illness, prescribing, and providing psychotherapy. CONCLUSION: PMH APRNs are delivering care to clients dealing with a range of serious mental illnesses across the life span in a variety of roles. It will be critical to monitor the activities and outcomes of this expanding behavioral health care workforce.

Intersecting Evidence-Based Practice With a Lean Improvement Model.

In our journey from Magnet designation to a Lean hospital, a team of advanced practice nurses, a nurse scientist, and Lean specialists developed a crosswalk of evidence-based practice (EBP) with Lean to explicitly embed the use of evidence in our organization's 4-step problem-solving method. Once finalized, the blended Lean-EBP model now guides improvement work as highlighted in the example of updating our practice for frequency of changing peripheral intravenous catheters.

[Advanced nurse triage for emergency department]. / Le triage infirmier avancé aux Urgences.

To cope with overcrowding, a consequence of their constant growth, emergency departments have implemented operational strategies based on triage systems. Despite its interest, nurse triage has been limited by several hindrances, and new strategies are emerging. Among those, advanced nurse triage, allowing a nurse to initiate the diagnostic process just after categorization of the patient, seems to be promising. A study on advanced nurse triage for patients presenting with chest pain has been conducted in the emergency department of the CHU of Liège. The encouraging results obtained following this new system demonstrate a reduction of the delay to management of patients, and a reduction of the total length of stay in the emergency unit mainly during overcrowding periods. Advanced nurse triage, in addition to a conventional triage during overcrowding periods, improves management of patients in terms of time and reduces the total time spent in the emergency department.

Confronté au problème de surpopulation, conséquence de leur fréquentation sans cesse croissante, les services d'urgence ont mis en place des stratégies opérationnelles basées sur des filières de soins organisées au départ de systèmes de triage des patients. Pareils outils ont démontré leur intérêt, mais s'avèrent aujourd'hui insuffisants, raison pour laquelle de nouvelles stratégies voient le jour. L'une d'elles, le triage infirmier avancé, permettant à un infirmier d'initier la démarche diagnostique juste après la catégorisation du patient, semble être une promesse d'avenir. Une étude portant sur un triage infirmier avancé pour les patients se présentant pour une douleur thoracique a été menée récemment au CHU de Liège. Les résultats encourageants de cette étude révèlent un gain de temps dans la prise en charge des patients en faveur de ce nouveau système et une durée totale de séjour aux urgences réduite, principalement en période de surpopulation. Il se confirme donc que le triage infirmier avancé, couplé à un triage classique, particulièrement en période de surpopulation, améliore la prise en charge des patients en termes de temps et réduit le temps total de séjour aux urgences, tout en garantissant la qualité, combattant, par là, la surpopulation.