Practice environment, independence, and roles among DNP- and MSN-prepared primary care nurse practitioners.

BACKGROUND: Many nursing schools are adopting the Doctor of Nursing Practice (DNP) as the preferred model of nurse practitioner (NP) education and eliminating Master of Science in Nursing (MSN) programs. To date, no studies have explored the relationship between DNP preparation and NP practice environment, independence, and roles. PURPOSE: The purpos of this study is to compare practice environment, independence, and roles among DNP- and MSN-prepared primary care NPs. METHODS: This study used a cross-sectional design and observational regression analysis of survey data. FINDINGS: DNP-prepared NPs reported: 1) more favorable NP-Physician Relationships, 2) fewer clinical hours, and 3) more practice leadership. These differences were, however, small and not significant at 0.05 level. DISCUSSION: We found no major differences in practice environment, independence, and roles among DNP- and MSN-prepared primary care NPs. As more nursing schools establish DNP programs and more DNP-prepared NPs enter the field, it is especially important to continue to study the impact of DNP preparation on the NP workforce.

Value of Nurse Practitioner Inpatient Hospital Staffing.

BACKGROUND: Evidence indicates hospitals with better registered nurse (RN) staffing have better patient outcomes. Whether involving more nurse practitioners (NPs) in inpatient care produces better outcomes is largely unknown. OBJECTIVE: The objective of this study was to determine whether the presence of more NPs produces better inpatient outcomes net of RN staffing. RESEARCH DESIGN: This was a 2015-2016 cross-sectional data on 579 hospitals linked from: (1) RN4CAST-US nurse surveys; (2) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient surveys; (3) surgical patient discharge abstracts; (4) Medicare Spending per Beneficiary (MSPB) reports; (5) American Hospital Association (AHA) Annual Survey. Hospitals were grouped according to their NP/beds ratios [<1 NP/100 beds (N=132), 1-2.99 NPs/100 beds (N=279), and 3+ NPs/100 beds (N=168)]. SUBJECTS: RNs randomly sampled nurses from licensure lists yielded 22,273 RNs in study hospitals; discharge data for 1.4 million surgical patients; HCAHPS data for 86% of study hospitals. MEASURES: Mortality, readmissions, lengths of stay, MSPB, patient experience, and quality reported by patients and nurses. RESULTS: After adjustments, patients in hospitals with 3+ NPs/100 beds had lower odds than patients in hospitals with <1 NP/100 beds of 30-day mortality [odds ratio (OR)2=0.76; 95% confidence interval (CI)=0.67-0.82; P<0.001] and 7-day readmissions (OR2=0.90; 95% CI=0.86-0.96; P<0.001), shorter average length of stay (incident rate ratio2=0.92; 95% CI=0.88-0.96; P<0.001) and 5.4% lower average MSPB (95% CI=3.8%-7.1%). Patients and nurses in the hospitals with higher NP/bed ratios were significantly more likely to report better care quality and safety, and nurses reported lower burnout, higher job satisfaction, greater intentions of staying in their jobs. CONCLUSIONS: Having more NPs in hospitals has favorable effects on patients, staff nurse satisfaction, and efficiency. NPs add value to existing labor resources.

Relationship between rural hospital closures and the supply of nurse practitioners and certified registered nurse anesthetists.

BACKGROUND: Reductions in primary care and specialist physicians follow rural hospital closures. As the supply of physicians declines, rural healthcare systems increasingly rely on nurse practitioners (NPs) and certified registered nurse anesthetists (CRNAs) to deliver care. PURPOSE: We sought to examine the extent to which rural hospital closures are associated with changes in the NP and CRNA workforce. METHOD: Using Area Health Resources Files (AHRF) data from 2010-2017, we used an event-study design to estimate the relationship between rural hospital closures and changes in the supply of NPs and CRNAs. FINDINGS: Among 1,544 rural counties, we observed 151 hospital closures. After controlling for local market characteristics, we did not find a significant relationship between hospital closure and the supply of NPs and CRNAs. DISCUSSION: We do not find evidence that NPs and CRNAs respond to rural hospital closures by leaving the healthcare market.

Dual-eligible beneficiaries and inadequate access to primary care.

OBJECTIVES: To determine whether enough primary care providers are in close proximity to where dual-eligible beneficiaries live to provide the capacity needed for integrated care models. STUDY DESIGN: Secondary data analysis using dual-eligible enrollment data and health care workforce data. METHODS: We determined the density of dual-eligible beneficiaries per 1000 population in 2017 for each of 3142 US counties. County-level supply of primary care physicians (PCPs), primary care nurse practitioners, and physician assistants was determined. RESULTS: One-third of the 791 counties with the highest density of dual-eligible beneficiaries had PCP shortages. Counties with the highest density of dual-eligible beneficiaries and the fewest primary care clinicians of any type were concentrated in Southeastern states. These areas also had some of the highest coronavirus disease 2019 outbreaks within their states. CONCLUSIONS: States in the Southeastern region of the United States with some of the most restrictive scope-of-practice laws have an inadequate supply of primary care providers to serve a high concentration of dual-eligible beneficiaries. The fragmented care of the dually eligible population leads to extremely high costs, prompting policy makers to consider integrated delivery models that emphasize primary care. However, primary care workforce shortages will be an enduring challenge without scope-of-practice reforms.

The Role of Advanced Practice Providers in Urology.

The nation's undersupply of urology services disproportionately affects Medicare beneficiaries compared to the general population. Advanced Practice Providers (APPs), most commonly nurse practitioners and physician assistants may be a vehicle to meet this need. The increased use of APPs in urology is hampered by physician discomfort with delegating responsibility to APPs. This discomfort may be compounded by complexities with billing issues and interstate variation in scope of practice regulations. To expand access to urological services while simultaneously ensuring service quality, it is imperative that urologists engage with APPs individually and as a specialty.

Methodology for a six-state survey of primary care nurse practitioners.

BACKGROUND: Primary care practices employing nurse practitioners (NPs) can play an important role in improving access to high quality health care services. However, most studies on the NP role in health care use administrative data, which have many limitations. PURPOSE: In this paper, we report the methods of the largest survey of primary care NPs to date. METHODS: To overcome the limitations of administrative data, we fielded a cross-sectional, mixed-mode (mail/online) survey of primary care NPs in six states to collect data directly from NPs on their clinical roles and practice environments. FINDINGS: While we were able to collect data from over 1,200 NPs, we encountered several challenges with our sampling frame, including provider turnover and challenges with identification of NP specialty. DISCUSSION: In future surveys, researchers can employ strategies to avoid the issues we encountered with the sampling frame and enhance large scale survey data collection from NPs.

Do nurse practitioner-led medical homes differ from physician-led medical homes?

BACKGROUND/PURPOSE: The patient-centered medical home (PCMH) is an enhanced model of primary care. This study examined to what extent nurse practitioner (NP)-led PCMHs differed from traditional physician-led PCMHs. METHODS: We tested for differences between 391 NP-led PCMHs and 11,479 physician-led PCMHs, as well as across two distinct clusters identified by the Two-Step cluster analysis procedure using a sample of 136 practices. FINDINGS: NP-led PCMHs were more likely to serve vulnerable populations in rural and underserved areas than physician-led PCMHs. NP-led PCMHs tended to be more responsive to population health needs in the areas during the recognition process, while physician-led PCMHs emphasized practice improvements through enhanced access to care and management of patient information data. DISCUSSION: The findings suggest possible differences in capabilities, priorities and needs of the population served across practices. This is an important guide as policymakers track the adoption of PCMHs.

The influence of nurse practitioner staffing on intensive care unit mortality.

BACKGROUND: In Taiwan, nurse practitioners (NPs) have taken on expanded clinical roles in the intensive care unit (ICU) due to insufficient staffing of attending physicians and resident physicians. LOCAL PROBLEM: The objective of this study was to investigate the influence of NP staffing on the quality of patient care in ICUs. METHODS: This is a retrospective study that selected patients from the ICUs of three hospitals during 2015. The mortality risks among the three hospitals were compared after adjusting variables using the Cox regression model. The care qualities of the three hospitals were analyzed using the standardized mortality ratio. INTERVENTIONS: Hospital A consisted of attending physicians and resident physicians. Hospital B consisted of attending physicians and NPs. Hospital C consisted of attending physicians, NPs, and resident physicians. RESULTS: Outcomes were assessed for 2,932 patients. The patients in hospital A had a lower mortality risk than hospital B or C. Septic shock patients received better care quality in hospital B than in hospital A or hospital C. CONCLUSIONS: In regional hospitals with lower NP-to-patient ratios, increasing that ratio could reduce the risk of mortality in the ICU and increase the quality of care.

Projected Contributions of Nurse Practitioners and Physicians Assistant to Buprenorphine Treatment Services for Opioid Use Disorder in Rural Areas.

The United States is experiencing an opioid use disorder epidemic. The Comprehensive Addiction and Recovery Act allows nurse practitioners (NPs) and physician assistants (PAs) to obtain a Drug Enforcement Administration waiver to prescribe medication-assisted treatment (MAT) for opioid use disorder. This study projected the potential increase in MAT availability provided by NPs and PAs for rural patients. Using workforce and survey data, and state scope of practice regulations, the number of treatment slots that could be provided by NPs and PAs was estimated for rural areas. NPs and PAs are projected to increase the number of rural patients treated with buprenorphine by 10,777 (15.2%). Census Divisions varied substantially in the number of projected new treatment slots per 10,000 population (0.8-10.6). The New England and East South Central Census Divisions are projected to have the largest population-adjusted increase. NPs and PAs have considerable potential to reduce substantial MAT access disparities.

The nurse practitioner workforce: One rural state's experience of comparing state data with national trends.

BACKGROUND: There is a great need for primary care across the country especially in rural and underserved areas. Nurse practitioners (NPs) are filling these access gaps by providing high-quality, cost-effective primary care. However, one rural midwestern state does not address NP workforce data separately from other types of nursing data. In addition, these data are not included in the state's overall primary care workforce. Therefore, the data cannot be compared to the state's needs or national workforce trends. PURPOSE: The purpose of this investigation was to describe North Dakota's (NDs) NP workforce and compare this with national data. METHODS: A cross-sectional descriptive design was used to collect and analyze NP workforce data from several sources. State Board of Nursing licensure data were used for description of the NDs current NP workforce. Six other data sources or reports were used to complete the data picture. State information was then compared with national NP survey results. RESULTS: Both ND and national data sources reported the largest percentage of NPs certified in either primary care or adult care and practice primary care at either an outpatient or inpatient setting. North Dakota has a higher percentage of NPs working in primary care as compared with the national numbers. However, inconsistent categories are used in ND's NP workforce data and national surveys making comparisons difficult. IMPLICATIONS FOR PRACTICE: Accurate inclusion of NP workforce data in the overall health care workforce data will better guide state and national policy makers on necessary changes to decrease provider shortages and promote increased access to rural primary care services.

The Distribution of Advanced Practice Nurses Within the Psychiatric Workforce.

OBJECTIVE: To examine the size and distribution of the advanced practice psychiatric nurse workforce relative to the total psychiatry workforce to determine whether nurses are predominantly working in areas with higher or lower levels of behavioral health specialists. METHODS: State-level data for psychiatric nurses were obtained from the American Nurses Credentialing Center, and included mental health psychiatric nurse practitioners, adult psychiatric nurse practitioners, child psychiatric clinical nurse specialists, and adult psychiatric clinical nurse specialists. Supply estimates of the full psychiatry workforce were calculated for comparison purposes. State population estimates were obtained from U.S. Census Bureau data. State workforce estimates were converted to a 1:100,000 provider-to-population ratio to analyze the density of providers across states. RESULTS: In 2018, the psychiatric workforce supply was estimated to be composed of 66,740 providers, including psychiatrists (n = 47,046; 71%), psychiatric nurses (n = 17,534; 26%), physician assistants (n = 1,164; 2%), and psychiatric pharmacists (n = 966; 1%). Overall, psychiatric providers appeared to be most densely concentrated in the northeast region of the United States. A dearth of providers was most pronounced within areas in the 12-state Midwest region, southern states, California, and Nevada. The average concentration of psychiatric workers was 22.61 per 100,000 population. CONCLUSIONS: The findings of this study find inconsistent pattern of how psychiatric nurses are distributed relative to the rest of the workforce, but reinforce the idea that they are essential in addressing care needs in areas with low concentrations of psychiatry specialists-especially if they are authorized to work to the full extent of their training/education.

Provision of Resident-Centered Care by Nurse Practitioners in Saskatchewan Long-Term Care Facilities: Qualitative Findings From a Mixed Methods Study.

With their education and skill set, nurse practitioners (NPs) are ideally situated to provide primary care to long-term care (LTC) residents, and this is a timely development as physician presence in LTC has been decreasing. A sequential follow-up explanatory mixed methods design was used for the current study, which focused on the interviews that followed the initial survey. The sample included seven NPs who work with LTC residents in urban and rural settings in a western Canadian province. The interviews provided an opportunity for in-depth discussion regarding survey results. Interpretive description guided the data analysis. NPs provide timely access to primary care, address medication reconciliation, decrease transfers to hospitals, and take part in collaborative practice. NPs promote the health care goals of LTC residents. Departments of health would benefit from the inclusion of a wider range of health providers, including NPs, to provide timely access to quality care in LTC facilities. [Research in Gerontological Nursing, 13(2), 73-81.].

Psychiatric Mental Health Nurse Practitioners Meeting Rural Mental Health Challenges.

OBJECTIVE: To describe the current rural mental health system crisis in the United States and how psychiatric mental health nurse practitioners (PMHNPs) can holistically mitigate this systemic issue. METHOD: Respective to the objective, relevant literature is reviewed. RESULTS: PMHNPs have successfully increased access to care in underserved rural communities by practicing at the fullest extent of their scope without mandated supervision, utilizing telepsychiatry practice, while expanding PMHNP rural mental health education and research to meet and absolve pressing rural mental health challenges. CONCLUSIONS: Current evidence supports that rural mental health care improves when PMHNPs have full scope of practice, utilize telepsychiatry, engage in related scholarly activity, and have formalized education and training for rural health care delivery, which collectively answer the professional and moral call serving the underserved rural population with mental illness.

In Rural Areas, Buprenorphine Waiver Adoption Since 2017 Driven By Nurse Practitioners And Physician Assistants.

Few patients with opioid use disorder receive medication for addiction treatment. In 2017 the Comprehensive Addiction and Recovery Act enabled nurse practitioners (NPs) and physician assistants (PAs) to obtain federal waivers allowing them to prescribe buprenorphine, a key medication for opioid use disorder. The waiver expansion was intended to increase patients' access to opioid use treatment, which was particularly important for rural areas with few physicians. However, little is known about the adoption of these waivers by NPs or PAs in rural areas. Using federal data, we examined waiver adoption in rural areas and its association with scope-of-practice regulations, which set the extent to which NPs or PAs can prescribe medication. From 2016 to 2019 the number of waivered clinicians per 100,000 population in rural areas increased by 111 percent. NPs and PAs accounted for more than half of this increase and were the first waivered clinicians in 285 rural counties with 5.7 million residents. In rural areas, broad scope-of-practice regulations were associated with twice as many waivered NPs per 100,000 population as restricted scopes of practice were. The rapid growth in the numbers of NPs and PAs with buprenorphine waivers is a promising development in improving access to addiction treatment in rural areas.

Establishing nurse practitioner clinical practicums: Addressing fiscal realities.

As demand expands for nurse practitioner clinical practicum sites, the supply of preceptors is decreasing. The traditional model of in-kind clinical training is losing its foothold for a variety of reasons. A looming question is how quickly a "pay to precept" norm will grow and what will be the costs. The pay for precepting movement is discussed including current trends, costs, and emerging compensation models. To adapt to this trend, alternative ways of drawing the precepting value proposition are suggested, particularly decreasing preceptor and site demands while increasing students' readiness to enter clinical practicum and tapping into faculty expertise to add value to the partnership. The authors provide suggestions on building a strategy for rethinking the structure of student precepting arrangements and compensation models.

Nurse Practitioners and Physician Assistants: An Underestimated Workforce for Older Adults with Cancer.

OBJECTIVES: To describe the composition of the US provider workforce for adults with cancer older than 65 years and to determine whether there were differences in patients who received care from different providers (eg, nurse practitioners [NPs], physician assistants [PAs], and specialty physicians). DESIGN: Observational, cross-sectional study. SETTING: Adults within the 2013 Surveillance, Epidemiology, and End Results cancer registries linked to the Medicare claims database. PARTICIPANTS: Medicare beneficiaries who received ambulatory care for any solid or hematologic malignancies. MEASUREMENTS: International Classification of Diseases, Ninth Revision (ICD-9), diagnosis codes were used to identify Medicare patient claims for malignancies in older adults. Providers for those ambulatory claims were identified using taxonomy codes associated with their National Provider Identifier number. RESULTS: A total of 2.5 million malignancy claims were identified for 201, 237 patients, with 15, 227 providers linked to claims. NPs comprised the largest group (31.5%; n = 4,806), followed by hematology/oncology physicians (27.7%; n = 4,222), PAs (24.7%; n = 3767), medical oncologists (10.9%; n = 661), gynecological oncologists (2.6%; n = 403), and hematologists (2.4%; n = 368). Rural cancer patients were more likely to receive care from NPs (odds ratio [OR] = 1.84; 95% confidence interval [CI] = 1.65-2.05) or PAs (OR = 1.57; 95% CI = 1.40-1.77) than from physicians. Patients in the South were more likely to receive care from NPs (OR = 1.36; 95% CI = 1.24-1.49). CONCLUSIONS: A large proportion of older adults with cancer receive care from NPs and PAs, particularly those who reside in rural settings and in the southern United States. Workforce strategies need to integrate these provider groups to effectively respond to the rising need for cancer care within the older adult population.