Addition of Advanced Practice Providers May Improve ABSITE Scores Through Enhanced Resident Education.

BACKGROUND: Resident work hour restrictions and required protected didactic time limit their ability to perform clinical duties and participate in structured education. Advanced practice providers (APPs) have previoulsy been shown to positively impact patients' outcomes and overall hospital costs. We describe a model in which nurse practitioners (NPs) improve resident education and American Board of Surgery In Training Examination (ABSITE) scores by providing support to our trauma and acute care surgery (ACS) service thereby protecting resident didactic time. MATERIALS AND METHODS: A new educational model aimed to improve ABSITE scores was created, increasing protected resident didactic time. The addition of three full-time NPs to the ACS service allowed implementation of this redesigned academic curriculum to be put into effect without neglecting patient or service-related responsibilities that were previously fulfilled by resident staff. Resident ABSITE results including standard score, percent correct, and percentile were compared before and after the educational changes were instituted. RESULTS: Eleven residents' scores were included. For each ABSITE score, we used a mixed model with time and postgraduate year (PGY) level as fixed effects and subject ID as a random effect. The interaction term between PGY level and time was not significant and removed from the model. A significant main effect of PGY level and of time was then observed. A statistically significant improvement in ABSITE scores after intervention was observed across all the PGY levels. Standard score increased 77.3 points (P-value = 0.001), percent correct increased 5.9% (P-value = 0.002), and percentile increased 23.8 (P-value = 0.02). Following the educational reform, no residents scored below the 35th percentile. CONCLUSIONS: Utilization of NPs on our ACS service provided adequate service coverage, allowing the implementation of an educational reform increasing protected resident education time and improved ABSITE scores.

Nurses as substitutes for doctors in primary care.

BACKGROUND: Current and expected problems such as ageing, increased prevalence of chronic conditions and multi-morbidity, increased emphasis on healthy lifestyle and prevention, and substitution for care from hospitals by care provided in the community encourage countries worldwide to develop new models of primary care delivery. Owing to the fact that many tasks do not necessarily require the knowledge and skills of a doctor, interest in using nurses to expand the capacity of the primary care workforce is increasing. Substitution of nurses for doctors is one strategy used to improve access, efficiency, and quality of care. This is the first update of the Cochrane review published in 2005. OBJECTIVES: Our aim was to investigate the impact of nurses working as substitutes for primary care doctors on:• patient outcomes;• processes of care; and• utilisation, including volume and cost. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), part of the Cochrane Library (www.cochranelibrary.com), as well as MEDLINE, Ovid, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and EbscoHost (searched 20.01.2015). We searched for grey literature in the Grey Literature Report and OpenGrey (21.02.2017), and we searched the International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov trial registries (21.02.2017). We did a cited reference search for relevant studies (searched 27.01 2015) and checked reference lists of all included studies. We reran slightly revised strategies, limited to publication years between 2015 and 2017, for CENTRAL, MEDLINE, and CINAHL, in March 2017, and we have added one trial to 'Studies awaiting classification'. SELECTION CRITERIA: Randomised trials evaluating the outcomes of nurses working as substitutes for doctors. The review is limited to primary healthcare services that provide first contact and ongoing care for patients with all types of health problems, excluding mental health problems. Studies which evaluated nurses supplementing the work of primary care doctors were excluded. DATA COLLECTION AND ANALYSIS: Two review authors independently carried out data extraction and assessment of risk of bias of included studies. When feasible, we combined study results and determined an overall estimate of the effect. We evaluated other outcomes by completing a structured synthesis. MAIN RESULTS: For this review, we identified 18 randomised trials evaluating the impact of nurses working as substitutes for doctors. One study was conducted in a middle-income country, and all other studies in high-income countries. The nursing level was often unclear or varied between and even within studies. The studies looked at nurses involved in first contact care (including urgent care), ongoing care for physical complaints, and follow-up of patients with a particular chronic conditions such as diabetes. In many of the studies, nurses could get additional support or advice from a doctor. Nurse-doctor substitution for preventive services and health education in primary care has been less well studied.Study findings suggest that care delivered by nurses, compared to care delivered by doctors, probably generates similar or better health outcomes for a broad range of patient conditions (low- or moderate-certainty evidence):• Nurse-led primary care may lead to slightly fewer deaths among certain groups of patients, compared to doctor-led care. However, the results vary and it is possible that nurse-led primary care makes little or no difference to the number of deaths (low-certainty evidence).• Blood pressure outcomes are probably slightly improved in nurse-led primary care. Other clinical or health status outcomes are probably similar (moderate-certainty evidence).• Patient satisfaction is probably slightly higher in nurse-led primary care (moderate-certainty evidence). Quality of life may be slightly higher (low-certainty evidence).We are uncertain of the effects of nurse-led care on process of care because the certainty of this evidence was assessed as very low.The effect of nurse-led care on utilisation of care is mixed and depends on the type of outcome. Consultations are probably longer in nurse-led primary care (moderate-certainty evidence), and numbers of attended return visits are slightly higher for nurses than for doctors (high-certainty evidence). We found little or no difference between nurses and doctors in the number of prescriptions and attendance at accident and emergency units (high-certainty evidence). There may be little or no difference in the number of tests and investigations, hospital referrals and hospital admissions between nurses and doctors (low-certainty evidence).We are uncertain of the effects of nurse-led care on the costs of care because the certainty of this evidence was assessed as very low. AUTHORS' CONCLUSIONS: This review shows that for some ongoing and urgent physical complaints and for chronic conditions, trained nurses, such as nurse practitioners, practice nurses, and registered nurses, probably provide equal or possibly even better quality of care compared to primary care doctors, and probably achieve equal or better health outcomes for patients. Nurses probably achieve higher levels of patient satisfaction, compared to primary care doctors. Furthermore, consultation length is probably longer when nurses deliver care and the frequency of attended return visits is probably slightly higher for nurses, compared to doctors. Other utilisation outcomes are probably the same. The effects of nurse-led care on process of care and the costs of care are uncertain, and we also cannot ascertain what level of nursing education leads to the best outcomes when nurses are substituted for doctors.

The Role of School Nurses, Challenges, and Reactions to Delegation Legislation: A Qualitative Approach.

Passage of new laws, national standards regarding delegation, and the recommendation for at least one full-time nurse in every school have provided more visibility to the role of school nurses. Recent legislative amendments in Kentucky presented an opportunity to examine how the role of the school nurse is changing. Aims were to describe the (1) role of school nurses in Kentucky, (2) impact of school nurses, (3) challenges faced by school nurses, and (4) impact of budget cuts and legislation. Three focus groups were conducted. School nurses faced challenges of limited time and resources, communication barriers, and multiple documentation requirements. Nurses' greatest impacts were their availability, recognition of psychosocial problems and health concerns, and connection with resources. Nurses had not yet encountered many changes due to new legislation that expanded delegation of diabetes-related tasks to unlicensed school personnel, but some had concerns about possible negative effects while others expressed support.

The consequences of task delegation for the process of care: Female patients seem to benefit more.

The shift of tasks from primary care physicians to practice nurses and the continuing incease in the numbers of women involved in medical care may have consequences for the provision of health care and communication. The aim of the present study was to examine potential differences in female practice nurses' application of communication skills, practice guidelines, and motivational interviewing skills during consultations with female and male patients. Nineteen female practice nurses and their patients (n = 181) agreed to have their consultations videotaped (during 2010-2011). The videotaped consultations were rated using two validated instruments: the Maas-Global (to assess generic communication skills and practice guidelines) and the Behaviour Change Counselling Index (to assess motivational interviewing skills). Multilevel linear and logistic regression analyses were performed. Female practice nurses provided significantly more comprehensive information during consultations with female patients (p = .03) and talked more about management with male patients (p = .04). Furthermore, nurses applied motivational interviewing skills more clearly during consultations with female than with male patients (p < .01). The shift in tasks from primary care physicians toward practice nurses may have implications for clinical and patient outcomes as patients will no longer be counseled by male professionals. Conceivably, female patients are motivated more by nurses to change their behavior, while male patients receive more concrete management information or advice.

Medication Assistant-Certification Program in Washington State: Barriers to implementation.

Medication assistants (MAs) are a legal alternative that enables licensed nurses to safely delegate medication administration to stable residents in non-acute settings. The purpose of this study was to query the beliefs and understanding of skilled nursing facility staff regarding the Washington State Medication Assistant Endorsement Program (MAEP). A 15-item survey was developed and administered to a convenience sample of 218 nursing staff from five eastern Washington nursing homes. Most believed that MAs would not change the cost of care, nor would they enhance or reduce the quality of care provided to residents in skilled nursing facilities. The relatively few Licensed Practical Nurses surveyed (n = 19) were the least in favor of MAs, possibly fearing job loss with the addition of MAs to the staffing mix at their facilities. These factors in combination may reflect why MAEP has not yet been embraced by providers in Washington State.

Teamwork and delegation in medical homes: primary care staff perspectives in the Veterans Health Administration.

BACKGROUND: The patient-centered medical home (PCMH) relies on a team approach to patient care. For organizations engaged in transitioning to a PCMH model, identifying and providing the resources needed to promote team functioning is essential. OBJECTIVE: To describe team-level resources required to support PCMH team functioning within the Veterans Health Administration (VHA), and provide insight into how the presence or absence of these resources facilitates or impedes within-team delegation. DESIGN: Semi-structured interviews with members of pilot teams engaged in PCMH implementation in 77 primary care clinics serving over 300,000 patients across two VHA regions covering the Mid-Atlantic and Midwest United States. PARTICIPANTS: A purposive sample of 101 core members of pilot teams, including 32 primary care providers, 42 registered nurse care managers, 15 clinical associates, and 12 clerical associates. APPROACH: Investigators from two evaluation sites interviewed frontline primary care staff separately, and then collaborated on joint analysis of parallel data to develop a broad, comprehensive understanding of global themes impacting team functioning and within-team delegation. KEY RESULTS: We describe four themes key to understanding how resources at the team level supported ability of primary care staff to work as effective, engaged teams. Team-based task delegation was facilitated by demarcated boundaries and collective identity; shared goals and sense of purpose; mature and open communication characterized by psychological safety; and ongoing, intentional role negotiation. CONCLUSIONS: Our findings provide a framework for organizations to identify assets already in place to support team functioning, as well as areas in need of improvement. For teams struggling to make practice changes, our results indicate key areas where they may benefit from future support. In addition, this research sheds light on how variation in medical home implementation and outcomes may be associated with variation in team-based task delegation.

Policy and programmatic implications of task shifting in Uganda: a case study.

BACKGROUND: Uganda has a severe health worker shortage and a high demand for health care services. This study aimed to assess the policy and programmatic implications of task shifting in Uganda. METHODS: This was a qualitative, descriptive study through 34 key informant interviews and eight (8) focus group discussions, with participants from various levels of the health system. RESULTS: Policy makers understood task shifting, but front-line health workers had misconceptions on the meaning and intention(s) of task shifting. Examples were cited of task shifting within the Ugandan health system, some formalized (e.g. psychiatric clinical officers), and some informal ones (e.g. nurses inserting IV lines and initiating treatment). There was apparently high acceptance of task shifting in HIV/AIDS service delivery, with involvement of community health workers (CHW) and PLWHA in care and support of AIDS patients.There was no written policy or guidelines on task shifting, but the policy environment was reportedly conducive with plans to develop a policy and guidelines on task shifting.Factors favouring task shifting included successful examples of task shifting, proper referral channels, the need for services, scarcity of skills and focused initiatives such as home based management of fever. Barriers to task shifting included reluctance to change, protection of professional turf, professional boundaries and regulations, heavy workload and high disease burden, poor planning, lack of a task shifting champion, lack of guidelines, the name task shifting itself, and unemployed health professionals.There were both positive and negative views on task shifting: the positive ones cast task shifting as one of the solutions to the dual problem of lack of skills and high demand for service, and as something that is already happening; while negative ones saw it as a quick fix intended for the poor, a threat to quality care and likely to compromise the health system. CONCLUSION: There were widespread examples of task in Uganda, and task shifting was mainly attributed to HRH shortages coupled with the high demand for healthcare services. There is need for clear policy and guidelines to regulate task shifting and protect those who undertake delegated tasks.

Is work beneficial to good health?

Unemployment and insecurity at work are a source of stress and may create a threat to individual physical and psychological health. The purpose of this study was to examine the connection between personal, functional, and professional variables and reports of how the health of hospital patients is impacted by financial status in Israel. One hundred and forty three hospitalized patients completed demographic, health-functional, and financial status questionnaires. Of the respondents, 32.9% reported a correlation between financial status and health. Significant connections were found between family status, lack of work, a change in partner's employment status, job insecurity, and financial commitments and reports of a correlation between financial status and health. The multivariate model predicting reports of a correlation between financial status and health was statistically significant. Discussion and implications focus on the need to create special preparation among health care professionals, in the community and in hospitals, to identify and treat people suffering from financial stress.

Experiences of the new role of advanced practice nurses in Swedish primary health care--a qualitative study.

Experiences of the new role of advanced practice nurses in Swedish primary health care-A qualitative study The aim of this study was to investigate and describe the experiences of the first advanced practice nurses (APNs), a new profession for Swedish health care, and of their supervising general practitioners (GPs), regarding the new role and scope of practice of APNs in primary health care. Individual interviews were conducted with the four first APNs and one focus group interview was conducted with five supervising physicians. The material was transcribed verbatim and analysed using latent content analysis. The respondents expressed confidence and trust in the new role of APNs. Some opposition to this new role from the GPs and other colleagues was observed, but was nonetheless overcome. The experiences of the APN role indicate that the new role is clearly demarcated from the role of physicians. The APNs were considered an extra resource for both the GPs and other nurses, which contributed to an increased availability of care for patients. The APN role requires an explicit definition and demarcation in relation to responsibility and roles among colleagues. Further development of the APN role presupposes the right to prescribe medication and order treatments, as well as an evaluation of patient, organizational and inter-professional perspectives on the matter.

An investigation of the role nurses play in Norwegian home care.

Registered nurses' (RNs') role in Norwegian home care services exists in a state of flux owing to the early discharge of patients from hospitals, more time-consuming and complex care for young patients, and a growing number of older care recipients. The aim of this study was to investigate the RN role through an integrative research review, with a focus on nursing activities and competence. This study found that RNs and assistant nurses often perform the same tasks, providing assistance with personal hygiene, medication and wound management. The change towards more medicalized and complex home care entails that requirements pertaining to RNs' competence, the allocation of RNs' time and skills to those in most need of nursing care, and the assignment of assistant nurses to lower care levels activities must be delineated. Norwegian home care must examine how care activities can be better allocated between RNs, social educators, assistant nurses, and informal care-givers.

Nurse practitioners substituting for general practitioners: randomized controlled trial.

AIM: This paper is a report of a study conducted to evaluate process and outcomes of care provided to patients with common complaints by general practitioners or specially trained nurse practitioners as first point of contact. BACKGROUND: Studies in the United States of America and Great Britain show that substituting nurse practitioners for general practitioners results in higher patient satisfaction and higher quality of care. As the American and British healthcare system and settings differ from that in The Netherlands, a Dutch trial was conducted. METHODS: A total of 1501 patients in 15 general practices were randomized to consultation by a general practitioner or a nurse practitioner. Data were collected over a 6-month period in 2006 by means of questionnaires, extracting medical records from practice computer systems and recording the length of consultations. FINDINGS: In both groups, the patients highly appreciated the quality of care. No statistically significant differences were found in health status, medical resource consumption and compliance of practical guidelines in primary care in The Netherlands. Patients in the NP intervention group were more often invited to re-attend, had more follow-up consultations and their consultations took statistically significantly longer. CONCLUSION: Nurse practitioners and general practitioners provide comparable care. Our findings support an increased involvement of specially trained nurse practitioners in the Dutch primary care and contribute to knowledge of the effectiveness of care provision by nurse practitioners from a national and international perspective.

Defining, analyzing, and quantifying work complexity.

Advances in science have transformed the provision of nursing care with processes that require extremely sophisticated technology to manage scenarios that were not possible until recently. Patients and patients' families are increasingly savvy about interventions and outcomes, and they articulate their expectations about both in their desire for individualized care. But the environments in which this very complex care is provided are often not modified to keep pace with the principle that form follows function. This article reviews the definition of complexity in the context of nursing care, discusses how complexity can be analyzed, and demonstrates the use of work complexity analysis to determine the skill mix needed for specific care environments.

How do contextual factors influence quality and safety work in the Norwegian home care and nursing home settings? A qualitative study about managers' experiences.

OBJECTIVE: Although many contextual factors can facilitate or impede primary care managers' work with quality and safety, research on how these factors influences the managers' continuous improvement efforts is scarce. This study explored how primary care managers experience the impact of a variety of contextual factors on their daily quality and safety work. DESIGN: The study has a qualitative design. Nine semistructured qualitative interviews were conducted at the participants' workplaces. Systematic text condensation was used for analysis. SETTING: Five nursing homes and three home care services in Norway. PARTICIPANTS: Female primary care managers at different levels, working in different units and municipalities varying in size and location. RESULTS: The participants cited the lack of time and money as a significant impediment to quality and safety, and these resources had to be carefully allocated. They emphasised the importance of networks and competence for their quality and safety work. Delegation of responsibility among employees helped create engagement, improved competence and ensured that new knowledge reached all employees. External guidelines and demands helped them to systematise their work and explain the necessity of quality and safety work to their employees, if they were compliant with daily clinical practice in the organisation. CONCLUSIONS: Numerous contextual factors influence the managers by determining the leeway that they have in quality and safety work, by setting the budgetary constraints and defining available competence, networks and regulation. At first glance, these factors appear fixed, but our findings underscore the importance of primary care managers acting on and negotiating the environment in which they conduct their daily quality and safety work. More research is needed to understand how these managers strategise to overcome the impediments to quality and safety.

Staffing and Service Availability in Assisted Living: The Importance of Nurse Delegation Policies.

OBJECTIVES: To examine the health services provided in residential care and assisted living (RC/AL), the staff providing these services, and the degree to which the services relate to state-level nurse delegation policies and other correlates of service provision. DESIGN: This cross-sectional study descriptively examined the relationships among RC/AL characteristics, services, staffing, and nurse delegation regulations/policies. SETTING: RC/AL settings (N=245) in 8 U.S. states (CA, FL, IL, KS, NC, NH, NJ, OR). PARTICIPANTS: Administrators and healthcare supervisors (individuals overseeing health care and services provided to residents). MEASUREMENTS: Using a telephone survey, we examined how delegation policies related to staffing and the availability of 26 health services. RESULTS: Significantly more services were available in RC/AL settings that permit delegation (delegation states) than states that do not permit delegation (nondelegation states) (19.7 vs 18.1, p < .001). Delegation states also had more medication technicians administering, assisting with, or observing self-administration of prescribed and as-needed medications (p < .001), whereas nondelegation states had staff with fewer qualifications handling medications (p < .001). In 2-way comparisons of categories of nurse staffing (none, licensed practical nurses (LPNs) and licensed vocational nurses (LVNs) only, registered nurses (RNs) only, LPN/LVNs and RNs), RC/AL communities with no nurse staffing offered significantly fewer services than all other categories. Those with RNs only also offered a significantly fewer services than those with LPN/LVNs only. CONCLUSION: This study is a first step in identifying how staffing and availability of services in RC/AL are related to statewide nurse delegation practices, forming the basis for further exploration of how these characteristics may relate to quality of care. J Am Geriatr Soc 66:2158-2166, 2018.

Supplementary prescribing: relationships between nurses and psychiatrists on hospital psychiatric wards.

The purpose of this study was to explore some of the issues for the implementation of supplementary prescribing for acute hospital care. The study design was the use of focus group methodology. In total, 19 nurses and 7 psychiatrists joined 1 of 6 focus groups held on the psychiatric unit. The data were analyzed using a modified grounded theory technique. In the study to be reported here, nurses and psychiatrists described the potential for different ways of working to emerge on acute psychiatric wards. Two major themes were identified: supplementary prescribing bringing about different ways of influencing decisions and controlling professional work; nurses and psychiatrists developing different types of relationships. Findings suggest an overall positive acceptance for supplementary prescribing, but for greater attention to be placed on the nature of relationships between nurses and psychiatrists. Implications for practice include the impact on new roles for nurses and psychiatrists and how this new form of relationship can best serve patients.

Registered nurses and unlicensed assistive personnel: an uneasy alliance.

To meet challenges of continuing change in the health care industry and maintain organizational viability in increasingly competitive markets, the use of the registered nurse--unlicensed assistive personnel model is an undeniable reality that fills the void created by the current shortage of nurses and decreases the costs of providing patient care. Although much has been published about the need for nurses to delegate and supervise patient care-related activities, little has been written about the skills needed to do this effectively or how these skills may be learned. Academic and clinical educators must find ways to facilitate the development of delegation and supervision abilities as nurses increasingly work with nonprofessional staff. Continuing education is an effective way for nurses to learn the skills required by changing models of patient care delivery and evolving professional roles.

Can a CRNA be medically directed and be an independent contractor for tax purposes at the same time?

Employee or independent contractor designation has significant tax implications for the Certified Registered Nurse Anesthetist (CRNA). On superficial view, it appears that a CRNA who is medically directed would be under a number of controls that would force the CRNA to be in an employee status. However, on analysis, it seems that for tax purposes a CRNA can be medically directed while also being an independent contractor. But when looking closer at all of the controversy in the legal system and the protections available to an employee that are not available to an independent contractor, a CRNA may find the employee status a better option.

Factors influencing effective independent nurse prescribing.

AIM: To identify some of the factors influencing effective independent nurse prescribing within a surgical high-dependency unit. METHOD: An audit methodology was used to record the personal prescribing practice of a critical care nurse following the completion of a course in independent and supplementary prescribing. RESULTS: The main factors influencing effective independent nurse prescribing were identified as limitations of the Nurse Prescribers' Formulary; lack of depth and breadth of experience in clinical and diagnostic reasoning; insufficient opportunities to enable reflection in practice and case-based learning; and variation in prescribing practice among individual clinicians. CONCLUSION: In the acute setting, the limitations imposed by the Nurse Prescribers' Formulory reduced the number of medicines that would otherwise have been prescribed, amended or discontinued. The recommendation from the Committee on Safety of Medicines that suitably qualified and trained nurses should be able to prescribe any medicine from the BNF is therefore wholly welcomed.