State policy change and organizational response: Expansion of nurse practitioner scope of practice regulations in New York State.

BACKGROUND: In January of 2015, New York (NY) implemented a new policy, Nurse Practitioners Modernization Act, which removed the required written practice agreement between physicians and experienced nurse practitioners (NPs). PURPOSE: We examined NP work environment in NY before (2012) and after (2018) the implementation of the new policy. METHODS: Cross-sectional survey data on work environments were collected from NPs in NY in 2012 and 2018. Work environment was measured with the Nurse Practitioner Primary Care Organizational Climate Questionnaire. In 2012, 278 and in 2018, 348 NPs completed the tool. Regression analyses were used to examine the relationship between the study year and work environment. FINDINGS: Controlling for individual and organizational characteristics, NPs reported significantly better work environments in 2018. Positive changes were observed both for experienced and less experienced NPs. DISCUSSION: Removing state-level policy restrictions on NPs may promote a better work environment within health care organizations.

Primary care Practice Environment and Burnout among Nurse Practitioners.

Poor practice environments contribute to burnout, but favorable environments containing support, resources, autonomy, and optimal relations with colleagues may prevent burnout. Compared to all nurse practitioners (NPs), 69% of these NPs provide primary care to patients, yet it is unknown whether the practice environment is associated with NP burnout. A study to examine environmental factors related to NP burnout was conducted. Overall, 396 NPs completed the survey and 25.3% were burnt-out. Higher scores on the professional visibility, NP-physician relations, NP-administration relations, independent practice and support subscales were associated with 51%, 51%, 58%, and 56% lower risk of NP burnout, respectively.

Physician-Nurse Practitioner Teamwork in Primary Care Practices in New York: A Cross-Sectional Survey.

BACKGROUND: Primary care practices increasingly rely on the growing workforce of nurse practitioners (NPs) to meet primary care demand. Understanding teamwork between NPs and physicians in primary care practices is critically important. OBJECTIVE: We assessed teamwork between NPs and physicians practicing within the same primary care practice and determined how teamwork affects their job satisfaction, intent to leave their current job, and quality of care. DESIGN: A cross-sectional survey design was used to collect data from both NPs and physicians in New York State in 2017. PARTICIPANTS: 584 participants (398 NPs and 186 physicians) from 476 primary care practices completed the survey yielding a 27% response rate for NPs and 12% for physicians. MAIN MEASURES: The survey tool contained validated measures of teamwork and three outcomes: job satisfaction, intent to leave, and perceived quality of care. Simple and multi-level multivariable regression models were built. KEY RESULTS: Most participants (76%) were either moderately satisfied or very satisfied with their job (NP sample: 75%; physician sample: 77%) and about 10% intended to leave their current job (NP sample: 11%; physician sample: 9%). The average perceived quality of care was the same across NP and physician samples with a mean of 8.5 on a 11 point scale. After controlling for confounders, a higher organizational-level teamwork score was associated with higher job satisfaction (cumulative OR: 3.00; 95% CI: 1.85-4.88), lower odds of intent to leave (OR: 0.25; 95% CI: 0.09-0.74), and higher perceived quality of care (b=1.00; 95% CI: 0.77-1.23). CONCLUSIONS: This study produced evidence about NP-physician teamwork in primary care practices. We found the vast majority of NPs and physicians reported favorable teamwork, and that teamwork affects clinician job satisfaction and intent to leave as well as perceived quality of care in their practices.

Organizational Support for Nurse Practitioners in Primary Care and Workforce Outcomes.

BACKGROUND: Lack of organizational support in healthcare settings has been linked to high levels of clinician stress, burnout, and job dissatisfaction. Little research exists on organizational support for nurse practitioners. OBJECTIVE: We investigated the relationship between organizational support and nurse practitioner outcomes, including job satisfaction, intent to leave, and quality of care. METHODS: A cross-sectional survey design was used to collect survey data from nurse practitioners (n = 398) in primary care practices in New York State in 2017. Nurse practitioners completed mail surveys with validated measures of organizational support, job satisfaction, intent to leave, and quality of care. Information on participant demographics and work characteristics was also collected. Multilevel regression models assessed the relationship between organizational-level organizational support and resources measure and job satisfaction, intent to leave, and quality of care. RESULTS: The organizational-level organizational support and resources measure had a mean of 3.31 on a 4-point scale. Twenty-five percent of the participants were either moderately dissatisfied or very dissatisfied with their jobs, and about 11% intended to leave their current jobs within 1 year. The average quality of care rated by participants was 8.51 out of 10-10 being the best quality of care. After adjusting for covariates, higher organizational-level organizational support and resources measure score was associated with higher job satisfaction category, lower odds of intent to leave, and higher quality of care. DISCUSSION: Nurse practitioners from primary care practices with higher levels of organizational support are more likely to be satisfied with their jobs, have less intent to leave their jobs, and report better quality of care. Thus, in order to promote nurse practitioner job satisfaction, retain them in clinical positions, and improve quality of care, administrators should take actions to promote organizational support for them. Our findings are consistent with existing literature regarding the relationship between organizational support and clinician outcomes.

A relational perspective on care coordination.

BACKGROUND: Care coordination occurs largely through care coordinators' interactions with patients and community partners to identify and address patients' individual needs. More frequent and higher-quality communication with each may enhance care coordination effectiveness. PURPOSE: The purpose of this study was to understand (a) how care coordinator perceptions of interactions with patients and community partners, respectively, compared to each other group's perceptions of their interactions with care coordinators and (2) whether these dynamics between care coordinators and community partners changed over time. METHODOLOGY: The research context was a comparative case study of provider-based care coordination projects funded through the Texas 1115(a) Medicaid waiver. The Relational Coordination instrument was administered through (a) two waves of in-person interviews with care coordinators (2014-2015 and 2015-2016) at a total of 10 sites across the state, (b) a single 2016 phone survey with 159 patients at nine of those sites, and (c) phone surveys with representatives of the community resources that care coordinators had identified as key partners in 2014-2015 and again in 2015-2016. RESULTS: Care coordinators reported more frequently needing both patients and community partners than either other group reported relative to care coordinators. Frequency of need and mutual influence with community partners increased in the first 2 years of the care coordination programs' implementation. The perceived quality of interactions between care coordinators and both patients and community partners was positive, but with room for improvement. CONCLUSION: Care coordination may entail limited interactions with patients and community partners, especially at program inception. As care coordination programs mature, interactions may become more frequent and influence with partners may expand. PRACTICE IMPLICATIONS: Decision makers should support care coordinators in improving the quality of their communication with both patients and community partners, as well as allow time for these relationships to develop.

Nurse practitioner primary care organizational climate questionnaire: Item response theory and differential item functioning.

AIMS AND OBJECTIVES: To validate Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ) items using item response theory (IRT) models and conduct differential item functioning (DIF) analysis to test the item functioning among nurse practitioners (NPs) practicing in different U.S. states with variable regulations governing NP practice. BACKGROUND: Nurse Practitioner Primary Care Organizational Climate Questionnaire is the only NP-specific tool measuring NP work environment and is being used in different U.S. states with variable NP scope of practice regulations and internationally to produce evidence about NP work environments within their organisations. DESIGN: Cross-sectional survey design was used to collect data from 278 primary care NPs in New York (NY) and 314 NPs in Massachusetts (MA). METHODS: NPs completed the 29-item NP-PCOCQ. Data collection involved an online survey in NY and a mail survey in MA in 2012. We used Samejima's graded response model for IRT and ordinal logistic regression for DIF analysis. A STROBE checklist was completed. RESULTS: IRT models yielded discrimination parameters ranging from 0.98-4.65 in NY and 1.25-6.94 in MA. Item difficulty parameters were within -3 to +3 range, suggesting a fair range of item difficulties exist in the scale. Only five of the 29 items on NP-PCOCQ exhibited DIF, suggesting some other state-related factor besides the measured construct influenced item responses; thus, the items were removed. CONCLUSION: Our findings indicate that a shortened, 24-item NP-PCOCQ is capable of measuring organisational climate of NPs practicing in different U.S. states. NP-PCOCQ can be used in future research to measure NP work environment. RELEVANCE TO CLINICAL PRACTICE: The tool can also be used by practice administrators to assess NP work environment and identify deficiencies to address them. This evidence about NP work environment can be used by practice administrators to promote favourable work environments for NPs to deliver high-quality care.

Mental health delivery in primary care: The perspectives of primary care providers.

PURPOSE: To explore perspectives of primary care providers (PCPs), including physicians and nurse practitioners (NPs), about delivery of mental health care in primary care settings. METHODS: We used a qualitative descriptive designed convenience sample of physicians (N = 12) and NPs (N = 14) through face-to-face interviews in New York State. RESULTS: Three themes emerged: 1) prioritization of patient needs; 2) applicability of mental health care in primary care settings; and 3) physician and NP approaches to mental health care. CONCLUSIONS: PCPs recognized importance of addressing patients' mental health care needs and barriers in primary care practices.

Provision of Pediatric Dental Services by Pediatric Dentists Versus General Dentists: Secondary Dental Analysis of Medical Expenditure Panel Surveys.

Purpose: The purpose of the study was to determine whether visiting only a pediatric dentist (as opposed to visiting only a general dentist) was associated with the provision of preventive dental services for a U.S.-based pediatric population (those 18 years and younger). Methods: This study analyzed pooled Medical Expenditure Panel Survey data from 2018 and 2019 to compare the use of certain preventive dental services (i.e., examination, radiographs, prophylaxis, dental sealant, and fluoride treatment) among those who reported visiting a pediatric dentist versus those who visited a general dentist. Survey procedures were used in Stata 14.0 to perform multivariable logistic regression analyses. Results: Controlling for demographic and insurance variables, children who visited only pediatric dentists had statistically significantly greater odds of receiving radiographs (adjusted odds ratio [AOR] equals 1.22; 95 percent confidence interval [95% CI] equals 1.01 to 1.48; P=0.04), fluoride treatment (AOR equals 1.57; 95% CI equals 1.30 to 1.90; P≤0.001), and sealants (AOR equals 1.63; 95% CI equals 1.24 to 2.16; P=0.001) compared to children who visited only general dentists. There was no statistically significant difference in the provision of periodic examinations and prophylaxis services. Conclusion: Based on the nationally representative data evaluated, pediatric dentists are more likely to provide more optimal preventive services than general dentists (i.e., radiographs, fluoride treatments, and sealants) to children in the United States.

The Multilevel Reliability and Interrater Agreement of the Nurse Practitioner Primary Care Organizational Climate Questionnaire.

Background and Purpose: It is critical to accurately measure and understand the nurse practitioner (NP) work environment in which individual NP information is gathered but decisions or inferences are made at an aggregated, group level. However, there is little research on preconditions of aggregating individual-level data into group level in nursing research. This study was conducted to assess the multilevel reliability and group interrater agreement (IRA) of the Nurse Practitioner Primary Care Organizational Climate Questionnaire. Methods: Secondary data analysis from a cross-sectional survey with 247 NPs in 112 practices across 6 U.S. states in 2018-2019 was used. Results: The generalizability coefficients and values of IRA were acceptable (> .70), and values of ICC(1) were significant (.18-.38). Conclusions: Aggregating individual NP data to a higher group-level work environment construct is acceptable.

Psychometric Testing of Errors of Care Omission Survey: A New Tool on Patient Safety in Primary Care.

OBJECTIVE: The aim of the study was to evaluate the psychometric properties of a newly developed survey tool measuring omissions in primary care. METHODS: The Errors of Care Omission Survey (ECOS) is the only known tool to measure critical omissions ("errors") in primary care from the perspectives of primary care providers (PCPs), both physicians and nurse practitioners. The tool has 31 items grouped into the following four subscales: Self-Management Support, Follow-up, Emotional Health Support, and Care Integration. A cross-sectional survey design was used to mail the tool to PCPs and 582 PCPs in one state in the U.S. completed and returned the survey. Exploratory factor analysis with target rotation was carried out. Internal consistency reliability of identified subscales was investigated. RESULTS: Four factors emerged representing domains of omissions in primary care. The original Follow-up and Care Integration subscales were retained. The items on Self-Management Support and Emotional Health Support subscales loaded differently on two factors, which were labeled Patient Self-Management and Family Engagement subscales, suggesting that conceptually PCPs separate patient and family involvement in patient care. Seven poorly performing or redundant items were removed. The remaining 24 items measure patient self-management, family engagement, follow-up, and care integration domains of omissions in primary care. The ECOS subscales have acceptable internal consistency reliability with Cronbach's α ranging from 0.90 to 0.97. CONCLUSIONS: The ECOS can be used in primary care to identify critical omissions, so actions can be taken by clinicians and administrators to prevent them before they result in patient harm. Further testing of the ECOS is recommended with diverse samples.

Primary care nurse practitioner burnout and perceptions of quality of care.

BACKGROUND: Burnout threatens patient care and clinicians are experiencing challenges within the practice environment. Little is known about nurse practitioner (NP) perceptions of burnout and its relationship to care quality and practice environment. We investigate the relationship between primary care NP burnout on perceptions of care quality and if the practice environment moderates the relationship between burnout and care quality. METHODS: This is a secondary analysis of cross-sectional survey data from 396 NPs. Burnout and care quality were measured using a single item, but the practice environment was measured using the Nurse Practitioner Primary Care Organizational Climate Questionnaire. Multi-level proportional odds cumulative logit models were built to test for associations between burnout and care quality and for moderation. RESULTS: Total, 25.3% of NPs reported burnout. Odds of perceiving higher quality of care was 85% less for NPs experiencing burnout compared to those not experiencing burnout. Practice environment did not moderate the relationship between burnout and care quality, but with a one unit increase in the practice environment subscales, the odds of NPs perceiving higher care quality increased anywhere from 3.83 to 7.57 times. CONCLUSION: Burnout is related to lower perceptions of care quality but favorable environments were related to higher perceptions of quality.

Use of multifunctional electronic health records and burnout among primary care nurse practitioners.

BACKGROUND: Prevalence of electronic health records (EHRs) has significantly increased, and EHRs are a known contributor to clinician burnout. However, it is unknown whether the use of multifunctional EHRs is associated with nurse practitioner (NP) burnout in primary care practices. This is a major gap in the literature because 69% of practicing NPs deliver primary care services to patients. PURPOSE: This study aimed to investigate whether the use of multifunctional EHRs is associated with primary care NP burnout. METHOD: This study is a secondary analysis of cross-sectional survey data collected from NPs in two states (Pennsylvania and New Jersey). Nurse practitioners completed surveys measuring burnout, use of multifunctional EHRs, demographics, and characteristics of their practice. Use of multifunctional EHRs was operationalized using two items-computerized capabilities and electronic reminder systems. Burnout was measured using a validated, single item asking NPs to self-report their feelings of burnout. A multilevel cox regression model was built to test for associations between the use of multifunctional EHRs and NP burnout. RESULTS: Of 396 NPs included, 25.3% reported burnout. The use of multifunctional EHRs did not increase primary care NP burnout (risk ratio = 0.30, 95% confidence interval = 0.13-0.71, p = .01). IMPLICATIONS FOR PRACTICE: With 25.3% of NPs burned out, it is imperative to reduce NP burnout. However, computerized capabilities and electronic reminder systems did not contribute to feelings of NP burnout. Future research examining other EHR components is needed to understand which features of the EHR contribute to NP burnout.