Nurse-managed Clinic Research Articles

Characteristics, work environments, and rates of burnout and job dissatisfaction among registered nurses in primary care

BackgroundAlthough more people than ever are seeking primary care, the ratio of primary care providers to the population continues to rapidly decline. As such, registered nurses (RNs) are taking on increasingly central roles in primary care delivery. Yet little is known about their characteristics, their work environments, and the extent to which they experience poor job outcomes such as nurse burnout. PurposeThe purpose of this study was to examine the characteristics of the primary care RN workforce and analyze the association of the nurse work environment with job outcomes in primary care. MethodsCross-sectional analysis of survey data representing N = 463 RNs who worked in 398 primary care practices, including primary care offices, community clinics, retail/urgent care clinics, and nurse-managed clinics. Survey questions included measures of the nurse work environment and levels of burnout, job dissatisfaction, and intent to leave. DiscussionApproximately one-third of primary care RNs were burnt out and dissatisfied with their jobs, with the highest risk of these outcomes among RNs in community clinics. Community clinic RNs were also significantly more likely to be Black or Hispanic/Latino, hold a Bachelor of Science in Nursing, and speak English as a second language (all p < .01). Across all settings, better nurse work environments were significantly associated with lower levels of burnout and job dissatisfaction (both p < .01). ConclusionPrimary care practices must be equipped to support their RN workforce. Adequate nursing resources are especially needed in community clinics, as patients receiving primary care in these settings frequently face structural inequities.

Abstract 15483: A Clinic-based Intervention Achieves Target Doses of Guideline-directed Medical Therapy in Heart Failure

Introduction: Target doses of guideline-directed medical therapy (GDMT) reduce morbidity and mortality, and yet, are challenging to achieve in patients with heart failure and reduced ejection fraction (HFrEF). Long-term, relationship-based approaches are not well described. Methods: We implemented a person-centered approach in a nurse-managed multidisciplinary heart failure clinic. We used repeated measures analysis to prospectively evaluate patient satisfaction, appointment attendance, dose optimization of GDMT for renin-angiotensin inhibitors, beta-blockers (BB), mineralocorticoid antagonists (MRA), and anticoagulation, and ICD placement and cardiac rehab participation at 12 months. GDMT was scored 0-6, with one point for each guideline-indicated therapy. Composite scores were compared using ANOVA at baseline, 6-months, and 12-months. Results: Participants (n=102) were age 68 (± 14.95) years on average, predominantly white (95.1%), male (62.75%), and high school graduates (88.24%). At 12-months, the proportion of patients on ≥50% of target doses improved: renin-antiotensin inhibitors from 27% to 41%, beta-blockers from 46% to 64%, and MRA from 35% to 65%. Cardiac rehab attendance improved from 25% to 84%. Patient satisfaction with care improved; four (3.9%) patients did not attend scheduled follow-up in the 12-month period. Though overall composite scores of GDMT improved (F=51.74, p &lt;0.001), only 12% of patients achieved target doses for all 3 medication classes concomitantly. No participants were readmitted within 30 days of HF-hospitalization; all-cause 30-day readmission was 10.5%. Conclusion: A persistent patient-provider relationship and person-centered approach to HF management may improve GDMT.

Improving SBIRT in a nurse-managed clinic serving homeless patients with substance use disorder.

A nurse-managed clinic in Northeast Tennessee that mainly serves unstably housed patients launched a process improvement project to evaluate Screening, Brief Intervention, and Referral to Treatment (SBIRT) implementation and use. These findings could guide future SBIRT efforts among vulnerable groups.

Exploring Interpersonal Relationships in a Nurse-Managed Clinic and Their Impact on Clinical Outcomes

This study explores the impact of interpersonal relationships on processes and outcomes of care at a nurse-managed, primary care clinic in Southern California serving a vulnerable population. Ten semistructured interviews were conducted with all health care providers in the clinic to explore patient characteristics, types of relationships experienced, and how they may have affected processes and outcomes of care. Themes in interviews were identified through thematic analysis. We found that (a) patients with limited access to health care and resources establish different types of relationships to support their needs, and (b) interpersonal relationships, including those among providers, affect quality of care.

883-P: Diabetes Distress: Provider Perspectives

Purpose: Though many studies focus on patient perspectives of diabetes distress (DD), provider perceptions of DD require further investigation. Defined as diabetes-specific distress related to the emotional and behavioral burden of living with type 2 diabetes (T2DM), DD is a major psychological challenge to diabetes (DM) self-management. The purpose of this qualitative study was to explore how interdisciplinary interprofessional primary care team members identify factors that contribute to a DD future intervention. Methods: A total of 18 providers from three rural nurse-managed clinics located in Northern Virginia participated in the study. Using purposive sampling, providers were interviewed for their perspectives on DD. Face-to-face interviews were conducted, digitally recorded, and transcribed. Two researchers coded the transcripts into themes. Data collection and analysis occurred sequentially using a constructivist grounded theory approach. Results: Provider narratives identified a lack of awareness of DD in their experiences with T2DM-related psychological and emotional challenges in a low-income, immigrant, underserved patient populations. When asked about DD, most participants discussed biomedical aspects of DM management, such as diet, exercise, medications, and blood glucose management. The key facilitator identified by the few participants who recognized DD was the interdisciplinary team practice model. Perceived barriers included: (1) limited knowledge of DD by the healthcare team, (2) under recognition of DD in reported practice, (3) time constraints, and (4) limited clinical experience with treating or referring patients with DD to appropriate mental health services. Conclusions: The American Diabetes Association (ADA) Standards of Medical Care in Diabetes recommends ongoing assessment and monitoring of DD to prevent and delay its progression. Therefore, the challenge is to enhance provider understanding of DD and promote strategies and activities that help reduce DD and improve diabetes outcomes. Disclosure A. John: None.

Healthcare Workers' Perceptions of Services at the Swaziland Wellness Centre

The healthcare workforce in southern Africa is diminished by unprecedented morbidity and mortality as a result of the HIV pandemic. Healthcare workers (HCWs) have been hesitant to access care where facility staff may be unprofessional, stigmatising, or breaching client confidentiality. The Wellness Centre for Health Care Workers opened in 2006 to enhance the health and well-being of HCWs in the Kingdom of Swaziland. The Centre’s nurse-managed model of care – the first of its kind in Africa – delivers HIV and tuberculosis prevention and treatment services through a primary care, community-based clinic. Our mixed-methods study evaluated the first 10 years of the Centre’s operation; a medical record review was complemented with 23 HCW client interviews. This article reports on the qualitative component in which HCWs described their experiences of receiving services at the Centre. The Centre’s service delivery was described as acceptable by HCWs receiving care for physical and psychological conditions. Clients with HIV described a supportive and inspiring environment that lacked the stigma and mistreatment that clients had experienced in other health facilities. Nurses were well-trained, trustworthy clinicians who engaged with their clients in a compassionate manner. The Centre’s unique outreach is effective in engaging HCW clients and their family members in primary care and HIV services. The Centre’s approach may serve as a model for similar nurse-managed clinics in Africa. It is recommended that nurses caring for HCW clients be respectful, communicative, and competent clinicians. Assuring privacy and confidentiality for HCW clients may increase enrolment and retention of clients in care.

Evaluation of a Nurse-managed Wellness Centre for Healthcare Workers in Swaziland

Southern Africa is experiencing unprecedented levels of morbidity and mortality as a result of the HIV pandemic. Healthcare workers (HCWs) living with HIV infection may be at risk from illness and death, but may not access needed services within their workplace facility. The Swaziland Wellness Centre for Health Care Workersâ was designed to enhance the health and well-being of HCWs through a nurse-managed, community-based clinic. The purpose of the parent mixed-methods study was to describe the enrolment of clients into care over the first 10 years of the clinic’s operation and assess the HCWs’ perceptions of the Centre and its services. This report describes the findings from a retrospective review of medical records used to describe the characteristics of the clients, enrolment patterns, and services delivered. The Centre enrolled HCWs (n = 2,562) and their dependents (n = 2,571) into primary care. The HCW clients represented a variety of cadres across the health sector; nurses (29%) were the largest single cadre enrolled. The Centre nurses initiate antiretroviral and/or antitubercular treatments and provide ongoing monitoring. The database was not designed for evaluation purposes and written documentation of client care was often incomplete or illegible. The enrolment and treatment patterns suggest that nurse-managed clinics can successfully integrate HIV and tuberculosis care with primary care services for HCWs in southern Africa. Recommendations include improving the written documentation and electronic management of services provided to support ongoing evaluations.

Diabetes Distress—Provider Perspectives

Purpose: Though many studies focus on patient perspectives of diabetes distress (DD), provider perceptions of DD require further investigation. Defined as the diabetes-specific distress related to the emotional and behavioral burden of living with type 2 diabetes (T2DM), DD is a major psychological challenge to self-management. The purpose of this qualitative study was to explore how primary care team members identify factors that contribute to DD future intervention. Methods: Eighteen care providers from three rural nurse-managed interprofessional clinics located in Northern Virginia participated in the study. Using purposive sampling, providers were interviewed to obtain perspectives on DD in the management of T2DM. Face-to-face interviews were conducted, digitally recorded, and transcribed. Two researchers coded the transcripts into themes. Data collection and analysis occurred sequentially using a constructivist grounded approach. Results: Provider narratives identified a lack of awareness of DD in their experiences with T2DM-related psychological and emotional challenges in a low-income, immigrant, underserved patient population. When asked about DD, most participants discussed the biomedical aspects of diabetes management, such as diet, exercise, medications, and blood glucose management. The key facilitator identified by the few participants who recognized DD was the interdisciplinary team practice model. Perceived barriers included: 1.) limited knowledge of DD by the healthcare team, 2.) under recognition of DD in reported practice, 3.) time constraints, and 4.) limited clinical experience with treating or referring patients with DD to appropriate mental health services. Conclusions: The American Diabetes Association (ADA) Standards of Medical Care in Diabetes recommends ongoing assessment and monitoring of DD to prevent and delay its progression. Therefore, the challenge is to enhance provider understanding of DD and promote strategies and activities that help reduce DD and improve diabetes outcomes. Disclosure A. John: None.

The Emerging Role of APRNs in Hospital Nursing Practice: Perspectives From a Survey of Chief Nursing Officers

The number of and demand for advance practice registered nurses (APRNs)—including nurse practitioners, certified nurse-midwives, clinical nurse specialists, and certified registered nurse anesthetists—continue to grow. Although the majority of APRNs work in physician practices, community health centers, nurse-managed clinics, schools, or other similar venues, APRNs are increasingly employed by acute care hospitals in a variety of roles. With the changing and expanding of APRN roles comes a need for a better understanding of current practice and how APRNs can be supported in order to maximize the use of their skills and knowledge, especially within the acute care setting. The number of and demand for advance practice registered nurses (APRNs)—including nurse practitioners, certified nurse-midwives, clinical nurse specialists, and certified registered nurse anesthetists—continue to grow. Although the majority of APRNs work in physician practices, community health centers, nurse-managed clinics, schools, or other similar venues, APRNs are increasingly employed by acute care hospitals in a variety of roles. With the changing and expanding of APRN roles comes a need for a better understanding of current practice and how APRNs can be supported in order to maximize the use of their skills and knowledge, especially within the acute care setting.

Increasing Colorectal Cancer Screening Using a Quality Improvement Approach in a Nurse-Managed Primary Care Clinic.

According to the American Cancer Society, 1 in 23 Americans will be diagnosed with colorectal cancer (CRC) in their lifetime. Screening for CRC is an effective, yet underused preventive approach. This is especially true in rural areas, where only 35% of patients were found to be up to date on their screenings in 2014. Increasing CRC screening can produce positive patient outcomes by early recognition and removal of precancerous polyps. The purpose of this project was to use quality improvement (QI) interventions to increase CRC screening rates at a nurse-managed clinic in rural Indiana. Using Deming's Plan-Do-Study-Act QI model, multiple interventions were implemented which resulted in a 37% increase in the number of screenings ordered on eligible patients and an overall increase of 28% in the completion of the screenings. This project contributes to healthcare quality knowledge by also suggesting that the fundamental principles of encouraging staff feedback to gain buy-in, improving processes informed by patient data, and valuing frequent performance feedback to staff, strengthened this QI project and ensured adoption and sustainability of these results.

Abstract A22: Programmatic implementation of hepatocellular carcinoma prevention through hepatitis C testing, secondary prevention, and treatment for a medically and minority underserved population

Abstract This study assessed the programmatic implementation of a multi-disciplinary program to prevent hepatocellular carcinoma through hepatitis C (HCV) testing, secondary prevention among diagnosed individuals (defined as interventions that prevent further progression of liver disease), and treatment within a medically and minority underserved clinic. The Lewis Cancer &amp; Research Pavilion (LCRP) at St. Joseph's/Candler Health System is a Community Cancer Center and regional destination for cancer care in coastal Georgia. LCRP disparities efforts focus on cancer prevention, screening, and facilitating access to cancer care at two clinics for underserved and uninsured, low-income, predominately African American and Hispanic populations. Because the primary cause of hepatocellular carcinoma is cirrhosis from chronic hepatitis infection, in 2014 the LCRP began implementing Centers for Disease Control and Prevention (CDC) recommendations for HCV testing as a cancer prevention activity at the clinics. As HCV patients were identified, it became clear that disease specific protocols needed to be developed in order to improve nurse practitioners' clinical practice. Barriers identified and addressed during program implementation included: 1) perception that expensive HCV treatment is inaccessible for uninsured patients, 2) lack of knowledge of CDC clinical testing guidelines resulting in inaccurate HCV diagnosis 3) lack of knowledge of secondary prevention and treatment leading to inappropriate clinical care for HCV+ patients, and 4) under-utilization of Electronic Medical Record (EMR) and other data tracking tools to enhance clinical care. The LCRP and clinical team identified available community and statewide resources, physician champions, and education resources. A multi-disciplinary team developed protocols for secondary prevention activities while a clinical team implemented clinical testing and treatment algorithms using CDC, American Association for the Study of Liver Diseases (AASLD), and Infectious Diseases Society of American (IDSA) guidelines. These initiatives are consistent with CDC efforts to move HCV management to community-based health-care providers within primary care with supportive training and supervision by HCV care specialists. The clinic conducted a baseline chart audit of patients with HCV documented in their medical record. At baseline, CDC testing algorithms to confirm diagnosis were followed in 14% of patients who received the initial HCV+ antibody test. Six months after implementation of testing algorithms and other clinical and programmatic improvements, 44% of birth cohort patients (patients born between 1945 and 1964) were screened in compliance with CDC guidelines. Average age of HCV+ patients was 51, 58% were African American, 41% Caucasian, 62% female, and 38% male. Secondary prevention activities including hepatitis A &amp; B vaccines, referral for alcohol and/or substance abuse counseling, depression and mental health screening, and identification of prevention and/or treatment barriers were initiated during the first six months of 2014 with 34% of HCV+ patients. Prevention activities conducted concurrently with treatment planning. Nurse practitioners at the clinic obtained co-management HCV treatment support from an internal medicine and primary care physician. This cancer prevention program demonstrated improvement in HCV testing, prevention, and treatment within a primary-care nurse-managed community clinic. The inter-disciplinary approach outlined in this model utilized evidence based guidelines and diagnostic algorithms. Application of secondary prevention activities and effective data tracking increased overall programmatic success, and ultimately contributes to the prevention of hepatocellular carcinoma among disparate populations. Citation Format: Sarah E. Dobra, Nidsa Baker, Lesley Miller, Lauren Stokes. Programmatic implementation of hepatocellular carcinoma prevention through hepatitis C testing, secondary prevention, and treatment for a medically and minority underserved population. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr A22.

Primary Care Expectations in an Underserved Population

The purpose of this study was to examine the association between insurance status, primary care utilization and expectations of an underserved population. Two hundred thirty men and women participated. Having Medicaid increased the use of primary care services in a population that would otherwise be uninsured (p=0.01). Health status was not related to utilization of care. New practice models, such as nurse-managed health clinics, are well suited to fill the gaps of the primary care infrastructure in underserved urban areas. Nurse practitioners are in unique positions to lead and manage these new emerging practice models.

Effects of dance on upper extremity activities in underserved adults.

This secondary analysis examined the immediate and maintaining effects of a 12-week line-dancing intervention on upper and lower extremity activities in underserved adults who receive care from a nurse-managed clinic (NMC). This one-group, repeated measures, feasibility study consisted of 40 participants recruited from an urban apartment complex that housed a NMC. Of the 40 participants, 21 participants completed the 12-week line-dancing intervention. Physical function of the upper and lower extremities was measured with the Late Life Function and Disability Instrument at baseline, 12, and 18 weeks to determine the maintaining effects. Age ranged from 45 to 87 years (M = 63; SD = 7.8), body mass index (BMI) was 33.4 (SD = 7.8), 92% were female, and 75% were African American. At baseline, participants showed limitations in all aspects of physical function. Significant improvements in upper and lower extremity activities were noted at 12 weeks and maintained at 18 weeks. Although line-dancing mainly involves the lower body, there were significant improvements in upper extremity activities at 12 weeks, which were maintained at 18 weeks. The maintaining effects support line-dancing as an intervention to improve upper and lower extremity activities needed for independent living. NMCs are important settings for health promotion interventions in underserved adults.

Bridge Care Nurse-managed Clinics Fill the Gap in Health Care

Nurse-managed health clinics (NMHCs) play a critical role in expanding access to health care for the low-income, uninsured, and underserved populations. In addition, they offer opportunities to educate future nurse practitioners, improve practice, and increase the primary care workforce. In this brief report, we describe an innovative Bridge Care model for a nurse-led clinic that is connected to an academic school of nursing. This model is unique in that it is not a permanent medical home model but rather bridges the gap between entry into the health care system and a permanent medical home. It unites the disciplines of nursing, psychology, social work, medicine, and nutrition to provide interprofessional education and health care in a sustainable nurse-managed health clinic model built on community partnerships. It is where national and local health policy meets the “real life” of individuals with limited resources. The Affordable Care Act improves access to primary care and offers nurses the opportunity to play a key role in transforming the health care system and improving patient care, and the Bridge Care clinic model is an innovative approach that improves access to quality primary care and prepares future nurse practitioners to be leaders in the health care system.

Leadership for the Integration of Comprehensive Care and Interprofessional Collaboration

The clinically prepared Doctor of Nursing Practice (DNP) professional is uniquely prepared to integrate the concepts of comprehensive care with interprofessional collaboration. Leadership skills and team-based competencies can shift the academic paradigm from educating in silos to interprofessional education, thereby addressing the problems originating from a fragmented health care system. A successful nurse-managed clinic accredited as a Level 2 patient-centered medical home, under the leadership of a DNP professional, is described. Interprofessional team training in comprehensive care is then described in a piloted program known as the Deans’ Honors Colloquium.

A DNP Nurse-Managed Hepatitis C Clinic, Improving Quality of Life for Those in a Rural Area

Hepatitis C virus is quickly becoming a national threat, involving 2% of the nation’s population, ranking this as the 11 th most prevalent disease in the world. Traditionally, treatment for hepatitis C has been conducted in tertiary care settings, limiting access to care for those residing in rural areas. Improving access to care through the development of a Doctor of Nursing Practice (DNP) nurse-managed clinic in a rural setting will improve health outcomes and quality of life for those treated outside the traditional setting. Caring for those living in less densely populated areas requires an understanding of rural culture. This paper will discuss the development and implementation of a DNP Model of Care for rural patients being treated for hepatitis C. The model of care starts with identifying the hepatitis C, treating the patient following established medical guidelines, using the nursing model to monitor clinical progress and managing side-effects caused by the treatment medications. Using the DNP Model of Care, a patient-focused clinic can successfully treat rural patients utilizing the principles of the Effect Theory for management and the Process Theory for ongoing evaluation. Collaboration with other key resources, utilizing a multidisciplinary approach allows the DNP nurse to care for those requiring treatment for chronic hepatitis C, where they live and work with the assistance of family and social support. Key Words: Hepatitis C, Rural nursing, Nurse-managed clinics

Perceptions of Pediatric Nurse Practitioners and How a Pulmonary Function Printout Influenced Practice

The rate of asthma in the pediatric population has risen over the last two decades and is now considered to be the most common serious chronic disease in children and adolescents as well as a serious public health concern. In one suburban, Pennsylvania nurse-managed clinic, a group of pediatric nurse practitioners (PNPs), noted an increase in the number of children with asthma and purchased a pulmonary function machine (Spirometer). The purpose of this paper is to discuss how the integration of a pulmonary function measurement printout influenced a small group of PNPs visit satisfaction, their delivery of nursing care, and the response of the families. As the incidence of asthma increases in the pediatric population, nurse practitioners and other healthcare professionals can take a leading role in patient teaching and provision of care by augmenting their practice with new technology combined with continued education for the client and family.

Quality of health care provided at a pediatric nurse‐managed clinic

The purpose of this study is to assimilate evidence regarding quality of care received at nurse-managed clinics (NMCs), particularly a pediatric NMC that provides health care for the underserved pediatric population. A nonexperimental design was used in this study. Quality of care data were collected at Trinity Nursing Center for Child Health (TNCCH), a pediatric NMC. Evidence included whether a pediatric NMC met selected national benchmark pediatric Healthcare Effectiveness and Data Information Set (HEDIS) quality indicators as well as HEDIS targets set by the Office of Medicaid Policy and Planning (OMPP) in Indiana. Findings suggest that TNCCH met or exceeded national HEDIS benchmark standards of care and targets set by OMPP. This study offers further evidence that NMCs provide a high quality of care. Benefits of addressing the research question in this study include the preservation of the nurse-managed healthcare safety net, increased access to health care for the medically underserved population resulting in improved health outcomes, and evidence to suggest that NMCs can assist private practice physicians to support this population of patients.

Integrated Physical and Mental Health Care at a Nurse-Managed Clinic: Report from the Trenches

Integrated Physical and Mental Health Care at a Nurse-Managed Clinic: Report from the Trenches

Integrated Physical and Mental Health Care at a Nurse-Managed Clinic: Report from the Trenches

The Health and Wellness Center (HWC), located in Joliet, Illinois, is a nurse-managed universally accessible primary health care center funded by a grant from the Health Resources and Services Administration. The goals of the HWC are to improve access to quality primary health care services for all patients, including those who are uninsured and underserved, and to develop and implement a model of nurse-managed primary health care that integrates both physical and mental health assessment and treatment. After 5 years of developing and using this model, it is clear that integration requires strategic supports from the financial, political, and professional sectors to be considered a cost-effective model of health care delivery. Recommendations for policy and practice change are offered based on the author's experiences of providing integrated health care at the HWC and the health care industry's responses to uninsured or underinsured patients' needs.