Influences on advance practice nursing education to prescribe medications for opioid use disorder.

BACKGROUND: Opioid misuse is a major public health concern in the United States. Opioid agonist medications are evidence-based treatments for opioid use disorders (OUD) that can be prescribed by advance practice registered nurses (APRNs) with prescriptive authority and appropriate training. PURPOSE: Article examines factors influencing preparation to provide medications for opioid use disorder (MOUD) in APRN education. METHODS: Data from semi-structured interviews addressing the role of education in preparing APRNs to provide MOUD were grouped into key themes using thematic analysis. Data were collected in a mixed methods study in four states with high opioid overdose deaths whose main findings were previously published. FINDINGS: Two overarching themes emerged: "addressing attitudes" and "curriculum change." Sub-themes include affective barriers to providing OUD treatment; motivation to respond to the OUD crisis; and attitude change through experience with MOUD. DISCUSSION AND CONCLUSION: APRNs can play a key role in reducing the harms caused by OUD. Attention to attitudinal issues, such as stigma, toward people using opioids is important in educating APRNs about providing MOUD.

Repeat hospital transfers among long stay nursing home residents: a mixed methods analysis of age, race, code status and clinical complexity.

BACKGROUND: Nursing home residents are at increased risk for hospital transfers resulting in emergency department visits, observation stays, and hospital admissions; transfers that can also result in adverse resident outcomes. Many nursing home to hospital transfers are potentially avoidable. Residents who experience repeat transfers are particularly vulnerable to adverse outcomes, yet characteristics of nursing home residents who experience repeat transfers are poorly understood. Understanding these characteristics more fully will help identify appropriate intervention efforts needed to reduce repeat transfers. METHODS: This is a mixed-methods study using hospital transfer data, collected between 2017 and 2019, from long-stay nursing home residents residing in 16 Midwestern nursing homes who transferred four or more times within a 12-month timeframe. Data were obtained from an acute care transfer tool used in the Missouri Quality Initiative containing closed- and open-ended questions regarding hospital transfers. The Missouri Quality Initiative was a Centers for Medicare and Medicaid demonstration project focused on reducing avoidable hospital transfers for long stay nursing home residents. The purpose of the analysis presented here is to describe characteristics of residents from that project who experienced repeat transfers including resident age, race, and code status. Clinical, resident/family, and organizational factors that influenced transfers were also described. RESULTS: Findings indicate that younger residents (less than 65 years of age), those who were full-code status, and those who were Black were statistically more likely to experience repeat transfers. Clinical complexity, resident/family requests to transfer, and lack of nursing home resources to manage complex clinical conditions underlie repeat transfers, many of which were considered potentially avoidable. CONCLUSIONS: Improved nursing home resources are needed to manage complex conditions in the NH and to help residents and families set realistic goals of care and plan for end of life thus reducing potentially avoidable transfers.

Rural-urban prescribing patterns by primary care and behavioral health providers in older adults with serious mental illness.

BACKGROUND: Older adults with serious mental illness (SMI) often have multiple comorbidities and complex medication schedules. Shortages of behavioral health specialists (BHSs), especially in rural areas, frequently make primary care providers (PCPs) the only clinician managing this complex population. The aim of this study was to describe rural/urban psychiatric medication prescribing in older adults with SMI by PCPs and BHSs, and by clinician type. METHODS: This retrospective descriptive analysis used 2018 Medicare data to identify individuals with a bipolar, major depression, schizophrenia, or psychosis diagnosis and examined medication claims for antianxiety, antidepressants, antipsychotics, hypnotics, and anticonvulsants. Descriptive statistics summarized percentage of medications provided by PCPs and BHSs stratified by rural and urban areas and by drug class. Additional analyses compared psychiatric prescribing patterns by physicians, advanced practice registered nurses (APRNs), and physician assistants (PAs). RESULTS: In urban areas, PCPs prescribed at least 50% of each psychiatric medication class, except antipsychotics, which was 45.2%. BHSs prescribed 40.7% of antipsychotics and less than 25% of all other classes. In rural areas, percentages of psychiatric medications from PCPs were over 70% for each medication class, except antipsychotics, which was 60.1%. Primary care physicians provided most psychiatric medications, between 36%-57% in urban areas and 47%-65% in rural areas. Primary care APRNs provided up to 13% of prescriptions in rural areas, which was more than the amount prescribed by BHS physicians, expect for antipsychotics. Psychiatric mental health APRNs provided up to 7.5% of antipsychotics in rural areas, but their prescribing contribution among other classes ranged between 1.1%-3.6%. PAs provided 2.5%-3.4% of medications in urban areas and this increased to 3.9%-5.1% in rural areas. CONCLUSIONS: Results highlight the extensive roles of PCPs, including APRNs, in managing psychiatric medications for older adults with SMI.

[Metamorphosis of Nurses: The Development and Breakthroughs of Advanced Practice Registered Nurses].

BACKGROUND: The introduction and development of the advanced practice registered nurse (APRN) is a global trend in nursing. However, the development of APRNs in Taiwan remains uncertain and lacks necessary consensus. PURPOSE: This research study aimed to explore the views and suggestions of nursing experts in industry, government, and academia regarding the development of APRNs (clinical nurse specialists, case managers, certified clinical registered nurse anesthetists, and certified nurse-midwives) in Taiwan. METHODS: Data were collected from March to August 2017. Sixty-four experts participated in one of six focus group discussions held in northern, central, and southern Taiwan. These group discussions were recorded and transcribed verbatim with the consent of the participants. Content analysis was used to analyze the transcribed data. RESULTS: The comments and suggestions raised during the discussions were categorized into four major themes: professional development of necessity, core competencies, accreditation, and future promotion-related issues. Each theme was further divided into several subthemes. CONCLUSIONS / IMPLICATIONS FOR PRACTICE: The opinions of relevant experts regarding the current status of development of the roles, practical scope, and management and suggestions for APRNs were summarized to facilitate the future development of APRNs in Taiwan in terms of education, core competencies, certification, and practical scope. Furthermore, the results may be referenced in the establishment of a nursing consensus model and as a basis for promoting APRNs.

Readiness of Non-Veteran Health Administration Advanced Practice Registered Nurses to Care for Those Who Have Served: A Multimethod Descriptive Study.

Federal, state, and educational policy, as well as public and professional initiatives, should influence how care is delivered to veterans from non-Veteran Health Administration (VHA) advanced practice registered nurses (APRNs) located in civilian health care facilities. Due to the MISSION Act, more veterans are receiving care outside the VHA, but little is known about the readiness of APRNs to address the needs of this population. This mixed-methods study describes the perceptions of 340 non-VHA APRNs concerning practice, clinical needs, and challenges they face while delivering care to veterans. Survey results show only 8% of APRNs consistently asked about military service; less than 1% asked if the patient has a family member with military history; and only 25% applied research by inquiring into military history when patients presented with conditions like chronic pain, interpersonal violence, or insomnia. Technology use via mobile application was minimally reported (<1%). "Missing in Action," the overarching theme from qualitative data, included three subthemes: (a) absence facilitated collaboration with VHA, (b) concerns regarding personal competency in the care of the military person, and (c) lack of recognition of the significance of the need to know about military status. Practice implications proffered include implementation of mandatory inquiry into military service and enactment of APRN veteran-centric nursing competencies. Education actions involve updating graduate nursing programs to include veteran health content and increased policy awareness. Future research should encompass replication of this study in specific APRN roles and consist of ongoing evaluation of veteran care by the civilian sector as the MISSION Act is implemented.

Commentary on Potential Crisis in Nurse Practitioner Preparation in the United States.

Nurse practitioner preparation and education, while evolving, still remains at a crossroads. In a recent article by Mundinger and Carter, a timeline and analysis of the number of Doctor of Nursing Practice (DNP) programs in the United States clearly demonstrated that since inception of the DNP degree, 85% of DNP programs are nonclinical. Many of the nonclinical programs in leadership and administration do not require additional clinical preparation beyond the bachelor's or master's degree in nursing. Thus, registered nurses and advanced practice registered nurses (APRNs) may obtain a DNP degree without additional clinical skill preparation beyond a baccalaureate or master's degree, respectively. Several aspects of the nonclinical DNP are concerning. Among the most challenging issues that nonclinical DNPs present is confusion on the part of other health care providers and the public. The relatively low number of clinically focused DNP programs is also problematic. If we do not prepare APRNs at the clinical doctoral level, then other providers such as physician assistants will meet the health care needs of the community. The future of APRNs could be threatened, especially in primary care.

Analysis of Emergency Room Visits Reveals a Seriously Mentally Ill, Medically Fragile Population Requiring Strategic Management.

OBJECTIVE: This practice improvement project evaluated the cost of health care services utilized by patients with comorbid mental and physical chronic conditions who were psychiatrically hospitalized but transported for health care services of physical symptoms that developed during their psychiatric hospitalization. METHOD: A retrospective review of invoices to a regional psychiatric hospital for non-psychiatric health services utilized by inpatients revealed high costs of emergency room (ER) visits from July 2016 to June 2017. Medical records for these seriously mentally ill inpatients who visited the ER for evaluation of sudden emergent physical symptoms were reviewed. The collected data were analyzed. RESULTS: ER invoices revealed that 41 visits had been made by 28 patients with a total cost of $308,466.67, of which $258,668.15 was judged to be for the treatment of patients with symptoms of preventable side effect syndromes. This chart review and analysis suggest a need for improved strategic medication management in an integrated model of care. CONCLUSIONS: Polypharmacy was found to be responsible for increased debilitating physical symptoms requiring ER visits for this seriously mentally ill, medically fragile population. An integration of care services for comorbid conditions by advanced practice registered nurses with protocols specifically designed for this population was recommended.

Benefits of Less Restrictive Regulation of Advance Practice Registered Nurses in Florida.

BACKGROUND: Advanced Practice Registered Nurses (APRNs) provide access to cost-effective, high quality care. APRNs are underutilized in states that restrict their practice. Removing restrictions could expand access to quality health care, cost-effectively relieve the physician shortage, and contribute economically. PURPOSE: This study forecasts the health system and economic impacts of reducing practice restrictions for Florida APRNs. METHODS: The analysis utilized a number of data sources and IMPLAN software and estimated changes in APRN supply given less restrictive practice laws, and consequential health system and economic benefits. FINDINGS: Between 2013 and 2025 APRN full time equivalents could increase an additional 11% with less restrictive practice regulations. This could eliminate or reduce the shortage of different types of physicians. Health care cost-savings could be $50 to $493 per resident. There would be a number of general economic benefits. DISCUSSION: A number of health system and economic benefits would ensue from less restrictive APRN regulation.

Answering the call to address chronic pain in military service members and veterans: Progress in improving pain care and restoring health.

Chronic noncancer pain (CNCP) in military and veteran populations mirrors the experience of chronic pain in America; however, these two populations have unique characteristics and comorbid conditions such as traumatic brain injuries, postconcussive syndrome, posttraumatic stress disorder, and behavioral health disorders that complicate the diagnosis and treatment of chronic pain. Military members and veterans may also be stigmatized about their conditions and experience problems with integration back into healthy lifestyles and society as a whole following deployments and after military service. The military and veteran health care systems have made chronic pain a priority and have made substantial strides in addressing this condition through advances in practice, education, research, and health policy. Despite this progress, significant challenges remain in responding to the wide-spread problem of chronic pain. The purpose of this article is to: (a) examine the state of CNCP in military and veteran populations; (b) discuss progress made in pain practice, education, research, and health policy; and (c) examine research, evidence-based practice guidelines, and expert consensus reports that are foundational to advancing pain care and improving health for military service members and veterans with CNCP. In addition, recommendations are proposed to address this widespread health problem through the expanded use of advanced practice registered nurses, the implementation of models of care, and use of national resources to educate health care providers, support practice, and promote effective pain care.

Advanced nursing practice and research contributions to precision medicine.

BACKGROUND: Genomic discoveries in the era of precision medicine hold the promise for tailoring healthcare, symptom management, and research efforts including targeting rare and common diseases through the identification and implementation of genomic-based risk assessment, treatment, and management. However, the translation of these discoveries into tangible benefits for the health of individuals, families, and the public is evolving. PURPOSE: In this article, members of the Genetics Expert Panel identify opportunities for action to increase advanced practice nursing and research contributions toward improving genomic health for all individuals and populations. DISCUSSION: Identified opportunities are within the areas of: bolstering genomic focused advanced practice registered nurse practice, research and education efforts; deriving new knowledge about disease biology, risk assessment, treatment efficacy, drug safety and self-management; improving resources and systems that combine genomic information with other healthcare data; and advocating for patient and family benefits and equitable access to genomic healthcare resources.

State variation in opioid and benzodiazepine prescriptions between independent and nonindependent advanced practice registered nurse prescribing states.

BACKGROUND: Many people lack access to primary care services in the United States. One possible solution is to increase utilization of advanced practice registered nurses (APRNs). A common patient safety concern about independent prescribing by APRNs is that prescribers will increase prescriptions for medications with abuse/dependence potential, such as opioids or benzodiazepines. PURPOSE: The purpose was to investigate the relationship in opioid- and benzodiazepine-prescribing rates between independent vs. nonindependent APRN prescribing states. METHODS: Tertiary analysis of a Centers for Disease Control and Prevention study reporting state variation in prescribing rates of opioids and benzodiazepines using 2012 Intercontinental Marketing Services Health retail prescription data representing 259,000,000 prescriptions. Analyses were performed using different definitions for independent states: (a) states allowing at least one APRN type independent prescribing and (b) states allowing all APRN types independent prescribing. ANOVA tests were used to test for differences in mean number of opioid- and benzodiazepine-prescribing rates per 100 residents. Analysis of Covariance tests were employed controlling for state characteristics previously determined to affect controlled substance-prescribing rates (e.g., Medicare rates, race, socioeconomic status, number of physicians/capita). RESULTS/DISCUSSION: There were significantly higher opioid and benzodiazepine prescriptions in states with nonindependent APRN prescribing laws than those in states with independent APRN prescribing laws and no significant differences in long-acting opioids or high-dose opioids. This study found no evidence to support the argument that independent prescribing increases prescriptions with abuse potential. CONCLUSION: Independent prescriptive authority, only one piece of APRN practice, has been one of the most controversial issues but one with great potential to help ease access to U.S. health care problems. Empirical evidence demonstrating the safety of this practice can help promote this potential.

Doctor of nursing practice by 2015: an examination of nursing schools' decisions to offer a doctor of nursing practice degree.

OBJECTIVES: The American Association of Colleges of Nursing recommends that nursing schools transition their advanced practice registered nurse (APRN) programs to doctor of nursing practice (DNP) programs by 2015. However, most schools have not yet made this full transition. The purpose of this study was to understand schools' decisions regarding the full transition to the DNP. METHODS: Key informant interviews and an online survey of nursing school deans and program directors were performed. DISCUSSION: The vast majority of schools value the DNP in preparing APRNs for the future of the health care system. However, other important factors influence many schools to fully transition or not to the postbaccalaureate DNP, including perceived student and employer demand, issues concerning accreditation and certification, and resource constraints. CONCLUSION: Multiple pathways to becoming an APRN are likely to remain until various factors (e.g., student and employer demand, certification and accreditation issues, and resource constraints) yield a more favorable environment for a full transition to the DNP.

Evaluating an intervention of telehealth education and simulation for advanced practice registered nurse students: A single group comparison study.

As healthcare delivery continues to evolve and expand, nurse educators must prepare advanced practice registered nursing (APRN) students to use telehealth technology safely, effectively, and confidently. The aims of this study were to describe APRN students' beliefs and confidence regarding the delivery of care via telehealth in their future practice. To evaluate these aims, a single group comparison study was conducted. APRN students received an intervention comprised of multimodal telehealth instruction, which involved the simulated application of telehealth with standardized patients. Students' beliefs regarding telehealth did not significantly change between the pre- and post-intervention, in which all areas were rated high pre-intervention. Students reported an increase in their perception and confidence post-intervention. Integration of telehealth into the APRN curriculum is essential to instil knowledge and confidence as healthcare technology advances.

Nurses can be key "REACH" accountable care organization partners to mitigate Medicare inequity.

We propose that Advanced Practice Registered Nurses (APRNs) can be key Accountable Care Organization (ACO) partners in mitigating Medicare inequity due to a shortage of primary care physicians. This shortage particularly impacts minority Medicare beneficiaries residing in urban and rural Health Professional Shortage Areas. In order to expand the primary care workforce to open the gateway to our health care system for these beneficiaries, we propose that APRNs provide primary care in a Medicare Neighborhood Clinic, as key partners of a modified "REACH" (Realizing Equity, Access, and Community Health) ACO model. We review the long history of ineffective efforts to alleviate the physician primary care shortage. After highlighting a report emphasizing the importance of nurses in achieving health equity, we describe the APRN role in a Medicare Neighborhood Clinic, and its potential for alleviating the primary care shortage. This clinic, as part of the modified "REACH" strategy, provides nurses with a key role in achieving Medicare equity. We contend that this strategy, as a means of APRNs providing value-based care to all Medicare beneficiaries while restraining the Medicare budget, contributes to transforming primary care for Medicare equity.

We propose that Advanced Practice Registered Nurses (APRNs) can transform primary care as key Accountable Care Organization (ACO) partners for Medicare equity. They can relieve a shortage of primary care physicians, which impacts minority Medicare beneficiaries residing in Health Professional Shortage Areas. APRNs would be instructed as certified specialty practitioners. An ACO is a health care organization that ties provider reimbursement to quality and to reductions in cost of care. In order to expand the primary care workforce to open the gateway to our health care system for all Medicare beneficiaries, we propose that APRNs provide primary care in a Medicare Neighborhood Clinic, as key partners of a modified "REACH" (Realizing Equity, Access, and Community Health) ACO model. We review the long history of ineffective efforts to alleviate the physician primary care shortage and describe the APRN role in the Medicare Neighborhood Clinic in alleviating this primary care shortage. This clinic, as part of a modified "REACH" ACO strategy, provides nurses with the opportunity to assume a key role in Medicare equity. We contend that this strategy, as a means of providing value-based care to all Medicare beneficiaries while restraining the Medicare budget, contributes to a primary care transition for Medicare equity.

Developing Nurse Practitioners for Hospitalist Roles: Lessons Learned From an Academic Practice Partnership.

Background: There are numerous benefits to academic practice partnerships. While there is great emphasis on the new graduate nurse transition to practice, there is less intention placed on the new nurse practitioner (NP) role transition. In a rural teaching hospital, leadership perceived a need for more support to successfully transition NPs into hospitalist practice roles. Objective: One academic practice partnership developed and implemented a grant-funded program to support advanced practice registered nurses (APRNs) transition to practice at a rural teaching hospital. Methods: Informed by the results of a needs assessment, faculty and practice partners delivered lecture content in a face-to-face setting during scheduled hours. Results: Although the content was well received, attendance to and engagement with the program were suboptimal. Conclusions: Upon reflection, the program team gained valuable lessons regarding role expectations, intentional interdisciplinary collaboration, timing, alignment, delivery format, and the need for a dedicated program coordinator. Implications for nursing: APRN transition programs can provide much-needed support with dedicated structure, clear communication, and individualized content. It can also be a recruitment and retention strategy for healthcare organizations.

Addressing Barriers to APRN Practice: Policy and Regulatory Implications During COVID-19.

Advanced practice registered nurses (APRNs) play a pivotal role in providing healthcare, including preventive care services, to the public. However, barriers to APRN practice exist that impact the provision of vital healthcare services that APRNs are authorized to provide based on their education, training, licensure, and certification. This article provides an overview of APRN barriers to practice, including in the face of the COVID-19 pandemic, and discusses key policy and regulatory implications.

Earnings, job satisfaction, and turnover of nurse practitioners across employment settings.

Nurse practitioners (NPs) are an important part of the health care workforce. However, little information is available on NP earnings, job satisfaction, or turnover. National survey data from 2018 offer a pre-COVID-19 baseline for ongoing NP workforce monitoring. We found evidence that NPs earned approximately $92 500 annually, ranging from $82 800 in long-term care to $95 600 in hospital settings. Wages increased with tenure in the workforce and varied considerably by geography. Approximately 1 in 5 NPs switched jobs annually, with some net in-flow to ambulatory settings. Both NPs who left their position or considered leaving reported better pay and benefits, burnout, management role, stressful work environment, career advancement, and inadequate staffing as the primary explanations. These findings were augmented by analysis of 2012-2022 Bureau of Labor Statistics data that illustrated substantial growth in the NP workforce. Improving NP job satisfaction has the direct benefit of supporting a critical and growing segment of the health workforce; it has the additional benefit of reducing job turnover and the associated costs, potentially increasing earnings for NPs. Policies that improve working conditions for NPs in different employment settings will not just increase immediate job satisfaction but also ideally strengthen the longer-term labor market to improve patient outcomes.

Practice Patterns, Work Environments, and Job Outcomes of Rural and Urban Primary Care Nurse Practitioners.

As nurse practitioners (NPs) are increasingly relied on to deliver primary care in rural communities, it is critical to understand the contexts in which they work and whether they are characterized by work environments and infrastructures that facilitate the provision of high-quality patient care. This study compares urban and rural NPs using data from a survey of 1,244 primary care NPs in Arizona, California, New Jersey, Pennsylvania, Texas, and Washington. While rural and urban NPs have a number of similarities in terms of demographic characteristics, practice patterns, and job outcomes, they also have noteworthy differences. Rural NPs report higher levels of independent practice, fewer structural capabilities that facilitate quality care, and poorer relationships with physicians. Health care organizations in rural communities may need to invest in work environments and infrastructures that facilitate high-quality care and autonomous practice for NPs.

A methodology for identifying behavioral health advanced practice registered nurses in administrative claims.

OBJECTIVE (STUDY QUESTION): Advanced practice registered nurses (APRNs) play an increased role in mental illness treatment. Health services research that uses claims to study mental health is often limited because behavioral health nurse practitioners (i.e., APRNs who specialize in mental illness, also known as psychiatric mental health APRNs) cannot be easily identified in claims data. We describe two methodologies to identify behavioral health APRNs in administrative claims. DATA SOURCES/STUDY SETTING (W/ HOSPITAL/INSTITUTION SETTING ANONYMIZED): We use 2010-2018 claims from the traditional Medicare fee-for-service program along with 2010-2019 commercial claims and Medicare Advantage data from the OptumLabs Data Warehouse (OLDW). Self-reported specialty data from the National Plan & Provider Enumeration System (NPPES) were used for validation. STUDY DESIGN: For each APRN, we calculated the percentage of visit diagnoses and of prescriptions in each database that were for mental health and classified those with ≥80% as behavioral health APRNs. We validated our definition with NPPES self-reported specialty for Medicare data. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: Among APRNs with 10+ visits, 10,978 (8.1%) in Medicare and 9829 (11.7%) in commercial claims data met our visit-based criteria as behavioral health APRNs. Among APRNs with 10+ prescriptions, 8160 (6.2%) in Medicare and 16,538 (9.0%) in commercial claims data met our prescription-based criteria as behavioral health APRNs. Among the APRNs who self-reported they were behavioral health APRNs, 92.8% and 90.5% met our visit-based and prescription-based criteria, respectively. CONCLUSIONS: We present and validate two methods of identifying behavioral health APRNs in claims that can be used by other researchers.

Blueprint for a Palliative Advanced Practice Registered Nurse Fellowship.

Opportunities for advanced practice registered nurses (APRNs) to train for specialty palliative care practice are insufficient to meet workforce needs. Graduate nursing programs in the United States do not have uniform or required curricula in palliative and end-of-life care of the seriously ill. In clinical practice, APRNs acquire palliative care skills by a mix of on-the-job experience, self-study, and continuing education. While physician colleagues can pursue post-residency training in one of 156 accredited hospice and palliative medicine fellowships, there are fewer than a dozen fellowships for APRNs, each training between one and three nurse fellows for specialty palliative care practice. This disparity slows the pipeline of palliative nursing experts and leaders, taxes employers with significant training duties, and results in an APRN workforce without uniform training. There are grass roots initiatives-often by non-nursing educators-to adapt existing physician and interprofessional fellowships for nurse learners, both in palliative care and other specialties. While these efforts help meet staffing needs and promote interprofessionalism, these programs are built upon medical curricula and competencies rather than grounding from a nursing framework. Nursing fellowship directors may not have the same administrative support, protected nonclinical time, funding, or access to nursing mentors and faculty afforded to their medical counterparts. This article provides a blueprint for clinician educators from nursing or non-nursing disciplines, who want to develop or refine training programs for APRNs that adhere to palliative nursing standards and offer a curriculum integrated with supervised practice and mentorship.