Scope-of-Practice Expansions Associated with Reduced Racial Disparities in Pediatric Mental Health Care.

To examine the association between scope-of-practice (SoP) regulations and racial disparities in pediatric mental health services. We used the National Survey of Children's Health (2016-2020; n = 33,790) to examine racial disparities in unmet mental health care needs and receipt of mental health medication between states with and without SoP expansions for psychologists and nurse practitioners (NP). Our primary outcomes were (1) unmet mental health care needs and (2) receipt of mental health medication. We examined heterogeneous treatment effects of SoP expansion on the outcomes using logistic regression with interaction terms between SoP expansion and race/ethnicity. We estimated population-level racial disparities for both outcomes stratified by SoP expansion to identify differences in racial disparities. The psychologist SoP expansion-associated reduction in unmet need was 15.8 percentage-points (CI= -25.3, -6.2) larger for Other-race children than for White children. The psychologist SoP expansion-associated increase in medication was 5.1%-points (CI=. 0.8, 9.4) larger for Black children and 5.6%-points (CI = 0.5, 10.8) for Other-race children. No differences were found for NP SoP expansion. Racial disparities in both outcomes were lower in psychologist SoP expansion states but varied in NP SoP states. Expanded SoP was generally associated with lower racial disparities in pediatric mental health care access.

Pediatric Mental Health Care and Scope-of-Practice Expansions.

To examine the association between psychologist and nurse practitioner scope-of-practice (SoP) regulations and pediatric mental health service access. A nationally representative sample of children with mental health needs was identified using 5 years of National Survey of Children's Health (2016-2020). Utilization was measured in two ways: (1) unmet mental health care needs and (2) receipt of mental health medication. Expanded SoP for psychologists and nurse practitioners was measured based on the child's state of residence and the year of the survey. The associations between both SoP expansion and both outcomes were assessed using logistic regression models adjusted for multiple covariates. The probability of having unmet mental health needs was 5.4 percentage points lower (95% CI - 0.102, - 0.006) for children living in a state with psychologist SoP expansion; however, there was no significant difference in unmet mental health needs between states with and without NP SoP expansion. The probability of receiving a mental health medication was 2.0 percentage points higher (95% CI 0.007, 0.034) for children living in a state with psychologist SoP expansion. Conversely, the probability of receiving a mental health medication was 1.5 percentage points lower (95% CI - 0.023, - 0.007) for children living in a state with NP SoP expansion. Expanded SoP for psychologists is associated with improved access to pediatric mental health care in terms of both unmet need and receiving medication. Expanded SoP for NPs, however, was not associated with unmet need and lower receipt of medication.

The Perspectives of Advanced Practice Provider Directors on Acute Care Nurse Practitioner Alignment and Hiring.

Demand for acute care is forecasted to grow in the United States. To meet this demand, nurse practitioners (NPs) are increasingly employed in acute care settings. Yet, there is concern about an adequate supply of acute care NPs given demand. Further, professional nursing organizations recommend aligning an NP's role with their education, certification, licensure, and practice. Given workforce constraints and the policy environment, little is known about how hospitals approach hiring NPs for acute care roles. The purpose of this study was to explore advanced practice provider (APP) directors' approaches to hiring NPs within the context of alignment and describe factors that influence hiring decisions. We conducted semi-structured interviews with 17 APP directors in hospitals and health systems. Interviews were recorded, transcribed, and coded using an iterative, hybrid inductive and deductive method. Two themes emerged: (1) local factors that inform aligned hiring and (2) adaptive hiring responses to changing environments. Practices around hiring NPs varied across institutions influenced by organization and state policies and regulations, workforce availability, and institutional culture. Most APP directors recognized trends towards hiring aligned NPs for acute care roles. However, they also identified barriers to fully aligning their NP workforce and described adaptive strategies including hiring physician assistants, building relationships with APP schools, and leveraging hospital resources to develop the APP workforce to meet care delivery demands given the current NP workforce supply. Future research is needed to assess widespread practices around acute care NP alignment and the implications of alignment for patient and organizational outcomes.

Letter to the Editor In Response to: "Referring Provider Opinions of Pediatric Cardiology Evaluations Performed by Nurse Practitioners" (Suh et al. 2022).

The authors present a Letter to the Editor in response to the recently published article: "Referring Provider Opinions of Pediatric Cardiology Evaluations Performed by Nurse Practitioners" by Suh et al. (Pediatr Cardiol, https://doi.org/10.1007/s00246-022-02959-0 , 2022).

Describing the male registered nursing workforce toward increasing male representation in professional nursing.

BACKGROUND: Men are significantly underrepresented in nursing and increasing their numbers should be a priority. PURPOSE: To describe the male nursing workforce in terms of size, demographics, education, and work settings. METHODS: Using data from the 2018 National Sample Survey of Registered Nurses, we performed a secondary descriptive analysis. FINDINGS: We find that 9.6% of registered nurses are men. Men are more likely than women to hold an associate degree and clinical doctorates, be nurse anesthetists and supervisors, and work in emergency settings but less likely than females to participate in teaching. DISCUSSION: To increase male representation in nursing we must simultaneously rearticulate what it means for a job to be "female" while also showing that nursing incorporates many skills and interests traditionally coded as "male." We can also show men that nursing offers appealing employment that can lead to a deeply fulfilling personal and professional life.

Advancement of research on nurse practitioners: Setting a research agenda.

BACKGROUND: Primary care delivered by nurse practitioners (NPs) helps to meet the United States' growing demand for care and improves patient outcomes. Yet, barriers impede NP practice. Knowledge of these barriers is limited, hindering opportunities to eliminate them. PURPOSE: We convened a 1.5-day conference to develop a research agenda to advance evidence on the primary care NP workforce. METHODS: Thirty experts gathered in New York City for a conference in 2022. The conference included plenary sessions, small group discussions, and a prioritization process to identify areas for future research and research questions. DISCUSSION: The research agenda includes top-ranked research questions within five categories: (a) policy regulations and implications for care, quality, and access; (b) systems affecting NP practice; (c) health equity and the NP workforce; (d) NP education and workforce dynamics, and (e) international perspectives. CONCLUSION: The agenda can advance evidence on the NP workforce to guide policy and practice.

Advanced Practice Provider-inclusive Staffing Models and Patient Outcomes in Pediatric Critical Care.

BACKGROUND: Pediatric intensive care units (PICUs) are increasingly staffed with advanced practice providers (APPs), supplementing traditional physician staffing models. OBJECTIVES: We evaluate the effect of APP-inclusive staffing models on clinical outcomes and resource utilization in US PICUs. RESEARCH DESIGN: Retrospective cohort study of children admitted to PICUs in 9 states in 2016 using the Healthcare Cost and Utilization Project's State Inpatient Databases. PICU staffing models were assessed using a contemporaneous staffing survey. We used multivariate regression to examine associations between staffing models with and without APPs and outcomes. MEASURES: The primary outcome was in-hospital mortality. Secondary outcomes included odds of hospital acquired conditions and ICU and hospital lengths of stay. RESULTS: The sample included 38,788 children in 40 PICUs. Patients admitted to PICUs with APP-inclusive staffing were younger (6.1±5.9 vs. 7.1±6.2 y) and more likely to have complex chronic conditions (64% vs. 43%) and organ failure on admission (25% vs. 22%), compared with patients in PICUs with physician-only staffing. There was no difference in mortality between PICU types [adjusted odds ratio (AOR): 1.23, 95% confidence interval (CI): 0.83-1.81, P=0.30]. Patients in PICUs with APP-inclusive staffing had lower odds of central line-associated blood stream infections (AOR: 0.76, 95% CI: 0.59-0.98, P=0.03) and catheter-associated urinary tract infections (AOR: 0.73, 95% CI: 0.61-0.86, P<0.001). There were no differences in lengths of stay. CONCLUSIONS: Despite being younger and sicker, children admitted to PICUs with APP-inclusive staffing had no increased odds of mortality and lower odds of some hospital acquired conditions compared with those in PICUs with physician-only staffing. Further research can inform APP integration strategies which optimize outcomes.

Implications of State Scope-of-Practice Regulations for Pediatric Intensive Care Unit Nurse Practitioner Roles.

Nurse practitioner (NP) advocacy efforts often focus on attaining full practice authority. While the effects of full practice authority in primary care are well described, implications for hospital-based NPs are less clear and may differ because of hospitals' team-based care and administrative structure. This study examines associations between state scope-of-practice (SSOP) and clinical roles of hospital-based pediatric intensive care unit (PICU) NPs. We conducted a national survey to assess clinical roles of PICU NPs including daily patient care, procedural, and consultation responsibilities as well as hospital-level administrative oversight practices. We classified SSOP as full or limited (reduced or restricted SSOP) practice. We present descriptive statistics and evaluate differences in clinical roles and hospital-level administrative oversight based on SSOP. The final sample included 55 medical directors and 58 lead (senior or supervisory) NPs from 93 of the 140 (66.4%) PICUs with NPs. There were no significant differences in daily patient care, procedural, or consultation responsibilities based on SSOP (p > .05). However, NPs in full practice authority states were more likely to bill for care than those in limited practice states (66.7% vs. 31.8%, p = .003), while those in limited practice states were more likely to report to advanced practice managers (36.7% vs. 13%, p = .03). For PICU NPs, SSOP was not associated with variation in clinical responsibilities; conversely, there were differences in billing and reporting practices. Future work is needed to understand implications of variation in hospital-level administrative oversight.

Economic Analysis of Mandated Protocolized Sepsis Care in New York Hospitals.

OBJECTIVES: Initial evidence suggests that state-level regulatory mandates for sepsis quality improvement are associated with decreased sepsis mortality. However, sepsis mandates require financial investments on the part of hospitals and may lead to increased spending. We evaluated the effects of the 2013 New York State sepsis regulations on the costs of care for patients hospitalized with sepsis. DESIGN: Retrospective cohort study using state discharge data from the U.S. Healthcare Costs and Utilization Project and a comparative interrupted time series analytic approach. Costs were calculated from admission-level charge data using hospital-specific cost-to-charge ratios. SETTING: General, short stay, acute care hospitals in New York, and four control states: Florida, Massachusetts, Maryland, and New Jersey. PATIENTS: All patients hospitalized with sepsis between January 1, 2011, and September 30, 2015. INTERVENTIONS: The 2013 New York mandate that all hospitals develop and implement protocols for sepsis identification and treatment, educate staff, and report performance data to the state. MEASUREMENTS AND MAIN RESULTS: The analysis included 1,026,664 admissions in 520 hospitals. Mean unadjusted costs per hospitalization in New York State were $42,036 ± $60,940 in the pre-regulation period and $39,719 ± $59,063 in the post-regulation period, compared with $34,642 ± $52,403 pre-regulation and $31,414 ± $48,155 post-regulation in control states. In the comparative interrupted time series analysis, the regulations were not associated with a significant difference in risk-adjusted mean cost per hospitalization (p = 0.12) or risk-adjusted mean cost per hospital day (p = 0.44). For example, in the 10th quarter after implementation of the regulations, risk-adjusted mean cost per hospitalization was $3,627 (95% CI, -$681 to $7,934) more than expected in New York State relative to control states. CONCLUSIONS: Mandated protocolized sepsis care was not associated with significant changes in hospital costs in patients hospitalized with sepsis in New York State.

Misalignment of specialty nurse practitioners and the Consensus Model.

Nurse practitioner (NP) employment in specialty practice areas, such as subspecialty ambulatory practices and inpatient units is growing substantially. The Consensus Model provides guidelines to help states aligning NP education and certification with specialty practice area. Despite expansion of the Consensus Model, significant misalignment exists between specialty NPs' education, certification, and practice location. Therefore, further implementation of the Consensus Model across states could have significant impact on health systems and NPs working in specialty settings. More than 10 years after its introduction, it is time to evaluate the policy and practice implications of the Consensus Model. Important next steps include examination of the impact of the Consensus Model and how to help health systems with alignment when and if the Model is more widely implemented.

PICU Provider Supply and Demand: A National Survey.

OBJECTIVES: To describe physicians' and nurse practitioners' perceptions of the national and local PICU physician and other provider supply in institutions that employ PICU nurse practitioners, assess for differences in perceptions of supply, and evaluate the intent of institutions to hire additional nurse practitioners to work in PICUs. DESIGN: National, quantitative, cross-sectional descriptive study via a postal mail survey from October 2016 to January 2017. SETTING: Institutions (n = 140) identified in the 2015 American Hospital Association Annual Survey with a PICU who employ PICU nurse practitioners. SUBJECTS: PICU physician medical directors and nurse practitioners. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 119 respondents, representing 93 institutions. Responses were received from 60 PICU medical directors (43%) and 59 lead nurse practitioners (42%). More than half (58%) of all respondents reported the national supply of PICU physicians is less than demand and 61% reported the local supply of PICU providers (physicians in all stages of training, nurse practitioners, and physician assistants) is less than demand. Of the respondents from institutions that self-reported a local provider shortage (n = 54), three fourths (78%) reported plans to increase the number of PICU nurse practitioners in the next 3 years and 40% were likely to expand the nurse practitioner's role in patient care. CONCLUSIONS: Most PICU medical directors and lead nurse practitioners in institutions that employ PICU nurse practitioners perceived that national and local supply of providers to be less than the demand. Nurse practitioners are employed in PICUs as part of interdisciplinary models of care being used to address provider demand. The demand for more PICU nurse practitioners with expanded roles in care delivery was reported. Further evaluation of models of care and provider roles in care delivery can contribute to aligning provider supply with demand for care delivery.

Experiences of Workplace Violence in Graduate Nursing Clinical Education.

BACKGROUND: Exposure to workplace violence (WPV) is common in health care, and little is known about nurse practitioner (NP) students' experiences during graduate nursing clinical education. PURPOSE: This study described experiences of WPV among NP students during their clinical education. METHODS: We conducted a cross-sectional, quantitative survey of a random sample of NPs licensed in Texas examining graduate nursing education experiences. RESULTS: A total of 334 NPs responded, a 12% response rate. More than a quarter (27%) experienced WPV during their graduate nursing clinical experience. Preceptors were the most reported perpetrators (44%). Most NPs remained in their clinical site after their WPV experience (55%); a majority felt they had no alternative clinical placement option. CONCLUSIONS: Nurse practitioner students experience WPV, and there may be implications for educational persistence and their careers. Future work should attempt to reduce the frequency of student WPV experiences and examine implications for NP careers.

Opportunities to Diversify the Pediatric Nursing Workforce: A Focus on Male Nurses.

INTRODUCTION: Pediatric nursing has been a profession dominated by women, but patients benefit from representation of both men and women. We describe characteristics associated with male pediatric nurses and consider potential pathways to greater male pediatric nurse workforce participation. METHOD: We used data from the 2018 National Sample Survey of Registered Nurses, a nationally representative survey of nurses that estimates characteristics of the workforce. We present summary statistics to describe demographic, work setting and work environment characteristics of male and pediatric nurse workforces. Analyses accounted for complex survey design and weighting. RESULTS: Only 7% (N = 108,752) of the pediatric registered nurse workforce and 3% (N = 779) of the pediatric nurse practitioner workforces were male. Notable demographic and educational difference exist among compared workforces. DISCUSSION: Males are significantly underrepresented in pediatric nursing. Much effort and intention need to be directed towards increasing male representation in pediatric nursing.

Facilitators and Barriers to Pediatric Nurse Practitioner Practice in the United States: A Systematic Review.

INTRODUCTION: The pediatric nurse practitioner (PNP) workforce was designed to improve child health equity. We aimed to systematically review the evidence on facilitators and barriers to PNP practice. METHOD: We included empirical studies on PNP practice in the United States and excluded studies with non-identifiable PNP data. We applied Joanna Briggs Institute tools to appraise studies and applied critical interpretive synthesis principles to synthesize. RESULTS: The final sample is 26 studies, mostly published before 2013 and observational. Prescriptive privileges, training program availability, organizational climate, and telehealth are facilitators. Mandated physician supervision, reduced pediatric curricula, geographically disparate training programs, and poor data infrastructure are barriers. The sample is limited by a moderate to high risk of bias. DISCUSSION: Evidence suggests modifiable factors impact PNP practice and could have important implications for child health equity. We offer a theoretical model to guide robust research studying the PNP workforce and health equity.

Changes in Use and Access to Care for Children and Youth With Special Health Care Needs During the COVID-19 Pandemic.

INTRODUCTION: Children and youth with special health care needs (CYSHCN) are vulnerable to health care disruption, and policies were adopted to mitigate COVID-19-related disruptions. We compare CYSHCN use of and access to care in 2019 to 2020. METHOD: Using the National Survey of Children's Health, we identified CYSHCN and assessed differences in health care use, unmet health care needs, frustrations accessing care, and barriers to care using multivariable logistic regression analysis. RESULTS: The final sample included 17,065 CYSHCN. In the fully adjusted analysis, there was a significant decrease in odds of accessing preventive dental care (adjusted odds ratio [AOR], 0.63; 95%confidence interval [CI], 0.51-0.77) and increased odds of unmet mental health care needs (AOR,1.34; 95% CI, 1.02-1.77). The inability to obtain an appointment was a barrier that increased during the study period (AOR, 2.77; 95% CI, 1.71-4.46). DISCUSSION: Novel pandemic related policies may have mitigated negative impacts on health care access for CYSHCN.

Career Choices and Experiences in Role Transition: A Multistate Survey of Pediatric-Focused Hospital-Based Nurse Practitioners.

INTRODUCTION: We examined factors influencing pediatric hospital-based APPs' career decisions and described the transition to practice experiences. METHOD: We conducted a cross-sectional, descriptive electronic survey using a novel instrument to examine APP career decisions and transition to practice experiences among APPs in four Southeastern children's hospitals. RESULTS: There were 158 respondents composed of family nurse practitioners (NPs) (30%), primary care pediatric NPs (24%), and acute care pediatric NPs (18%). APPs chose their career to further their education (46%) and because of interest in pediatrics (18%). Most APPs had experience in pediatrics on APP graduation and were well prepared for the role (47%) and to care for pediatric patients (56%). Nearly two-thirds of APPs had an orientation. DISCUSSION: Early exposure to pediatrics influenced APP career choices and increased career preparedness. Although most APPs had an orientation, future studies should assess the impact of orientation on patient, professional, and organizational outcomes.

Pediatric Organ Donation and Transplantation: Across the Care Continuum.

This policy statement aims to enhance comfort and increase knowledge of pediatric organ donation and transplantation to the general pediatric community, specifically focusing on the pediatric health care professional and the medical home. The pediatric health care professional will care for neonates, infants, children, and adolescents who may become donors or transplant recipients and, thus, is a crucial member of the pediatric patient's care team. Understanding donation, transplantation, and follow-up care are important to primary care engagement. Furthermore, the pediatric health care professional may play a role in shaping public policies related to the process of organ donation and access to organ transplantation.

Care coordination and unmet need for specialised health services among children with special healthcare needs in the USA: results from a cross-sectional analysis of the national survey of children with special healthcare needs.

OBJECTIVE: To report rates of need and unmet need for specialised health services (occupational and speech therapies, durable medical equipment, home healthcare, and mobility and communication aids) from the National Survey of Children with Special Health Care Needs (CSHCN) (2009/2010) and assess the role of care coordination in having needs met. We distinguish between CSHCN with and without emotional, behavioural and developmental disorders (EBDPs) in the USA. DESIGN: A cross sectional cohort study of a nationally representative sample of CSHCN from the National Survey of CSHCN for 2009/2010 used logistic regression to assess the relationship between EBDPs and need and unmet need for specialised services. It also estimates the association of care coordination with unmet need for all services, for CSHCN with and without EBDPs. SETTING: A nationally representative sample of CSHCN in the USA. PARTICIPANTS: Children ages 0-17 years of age. RESULTS: Across all specialised health services, rates of unmet need were at or below 25%. Need and unmet need for most services was higher among CSHCN with EBDPs than those without. For CSHCN with and without EBDPs, adequate care coordination was associated with greater probability of having needs for therapy, home health and communication aids met. CONCLUSION: Care coordination is essential to reducing barriers to a wide range of healthcare services for CSCHN. Policies requiring adequate insurance coverage for care coordination may play a critical role in ensuring access to specialised health services.