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.

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.

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.

Recruitment and retention of primary care nurse practitioners in underserved areas: A scoping review.

BACKGROUND: The growing nurse practitioner (NP) workforce plays a critical role in primary care delivery in the United States. However, better recruitment and retention of the robust NP workforce in underserved areas are needed; evidence to inform such effort is limited. PURPOSE: This scoping review aimed to examine the findings, scope, and knowledge gaps of available literature on factors associated with NP recruitment and retention in underserved areas. METHODS: This review was guided by Joanna Briggs' Scoping Review Methodology and PRISMA-SCR reporting standards. Literature search for peer-reviewed and gray literature was conducted in six databases. FINDINGS: A total of 22 studies met inclusion criteria. Factors associated with NP recruitment and retention in underserved areas were mapped into five themes, including factors related to: the individual NP, NP education programs/financial aid, organizations employing NPs, the communities NPs work in, and autonomous practice. Majority of the included studies were published before 2010; few used rigorous study designs and analysis methods; and few exclusively studied NPs and unique challenges facing the NP workforce. DISCUSSION: Available studies demonstrate that NP recruitment and retention can be addressed by various stakeholders (e.g., educators, policy makers); however, up-to-date, methodologically rigorous, and NP-focused studies are needed.

Nurse staffing, missed care, quality of care and adverse events: A cross-sectional study.

AIM: This study aimed to illustrate the relationship between nurse staffing and missed care, and how missed care affects quality of care and adverse events in Thai hospitals. BACKGROUND: Quality and safety are major priorities for health care system. Nurse staffing and missed care are associated with low quality of care and adverse events. However, examination of this relationship is limited in Thailand. METHODS: This cross-sectional study collected data from 1188 nurses in five university hospitals across Thailand. The participants completed questionnaires that assessed the patient-to-nurse ratio, adequacy of staffing, missed care, quality of care and adverse events. Logistic regression models were used to estimate associations. RESULTS: Higher patient-to-nurse ratio, poor staffing and lack of resource adequacy were significantly associated with higher odds of reporting missed care. Higher nurse-reported missed care was significantly associated with higher odds of adverse events and poor quality of care. CONCLUSIONS: Poor nurse staffing was associated with missed care, and missed care was associated with adverse events and lower quality of care in Thai university hospitals. IMPLICATIONS FOR NURSING MANAGEMENT: Improving nurse staffing and assuring adequate resources are recommended to reduce missed care and adverse events and increase quality of care.

A Systematic Review of Primary Care and Payment Models on Emergency Department Use in Patients Classified as High Need, High Cost.

INTRODUCTION: Reducing costly and harmful ED use by patients classified as high need, high cost is a priority across health care systems. The purpose of this systematic review was to evaluate the impact of various primary care and payment models on ED use and overall costs in patients classified as high need, high cost. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a search was performed from January 2000 to March 2020 in 3 databases. Two reviewers independently appraised articles for quality. Studies were eligible if they evaluated models implemented in the primary care setting and in patients classified as high need, high cost in the United States. Outcomes included all-cause and preventable ED use and overall health care costs. RESULTS: In the 21 articles included, 4 models were evaluated: care coordination (n = 8), care management (n = 7), intensive primary care (n = 4), and alternative payment models (n = 2). Statistically significant reductions in all-cause ED use were reported in 10 studies through care coordination, alternative payment models, and intensive primary care. Significant reductions in overall costs were reported in 5 studies, and 1 reported a significant increase. Care management and care coordination models had mixed effects on ED use and overall costs. DISCUSSION: Studies that significantly reduced ED use had shared features, including frequent follow-up, multidisciplinary team-based care, enhanced access, and care coordination. Identifying primary care models that effectively enhance access to care and improve ongoing chronic disease management is imperative to reduce costly and harmful ED use in patients classified as high need, high cost.

Self-Directed Home and Community-Based Services Improve Outcomes for Family Caregivers: A Systematic Review.

BACKGROUND AND OBJECTIVES: Self-direction is an approach that allows older adults and people with disabilities to determine the home and community-based services they receive, including the ability to hire caregivers of their choice. Self-direction has been shown to improve outcomes for the service recipients. The promotion of choice and control in self-direction may also affect family caregivers. We conducted a systematic review examining the impact of self-direction on a broad range of caregiver outcomes. RESEARCH DESIGN AND METHODS: We conducted a systematic review guided by PRISMA guidelines. Literature search was conducted in 8 databases. We appraised risk of bias using the Joanna Briggs Institute critical appraisal checklists and assessed certainty of evidence using the GRADE framework. RESULTS: Sixteen studies meeting inclusion criteria were included. We found, with moderate certainty, that self-direction is associated with improved caregivers' personal and social wellbeing. Caregivers also reported reduced unmet needs and increased access to care for the care recipients under self-direction. Self-direction did not appear to reduce caregiving hours. With less certainty, self-direction was also positively associated with increased respite care use, perception of choice, and intention to continue caregiving by caregivers. DISCUSSION AND IMPLICATIONS: Beyond delivering person-centered services that improve recipient outcomes, self-direction may also improve the outcomes of family caregivers.

Practice Environment and Workforce Outcomes of Nurse Practitioners in Community Health Centers.

The nurse practitioner (NP) workforce in community health centers (CHCs) increases access to primary care for underserved populations. Working with medically complex patients, high workloads, and low resources in the CHC setting, CHC NPs may be susceptible to poor workforce outcomes. This study uses NP survey data collected from 6 US states to describe and assess the relationship between CHC NP practice environment and burnout, job satisfaction, and turnover intention. CHC NPs rated their practice environments favorably, and more than 89% of CHC NPs reported satisfaction with their job. Better rating of NPs' relationship with CHC administration was associated with improved job satisfaction and decreased turnover intention.

The Association between Health Professional Shortage Area (HPSA) Status, Work Environment, and Nurse Practitioner Burnout and Job Dissatisfaction.

Clinicians in health professional shortage areas (HPSAs) often work in practices with fewer resources and higher workloads, challenging recruitment and retention efforts. Nurse practitioners (NPs) frequently care for underserved patients in HPSAs. As a result, HPSA NPs may be susceptible to poor workforce outcomes, including burnout and job dissatisfaction. Using multiple logistic regression, our study assessed the relationship between the work environment and the odds of burnout and job dissatisfaction, and whether HPSA status moderated the relationship between a good work environment and lower odds of these negative outcomes. Consistent with prior research, we found that better work environments significantly decreased the odds of burnout and job dissatisfaction. Working in an HPSA was not associated with NP burnout or job dissatisfaction, nor did HPSA moderate the relationship between the work environment and NP job outcomes. Thus, improving work environments holds promise for reducing negative NP workforce outcomes regardless of HPSA designation.

The Cure for the Racist Patient?

In health care, appeasement tends to be the norm. That may be changing.