Care Nurse Practitioners Research Articles

Applying Nurse Practitioner Student Reflections in Design of Telehealth Curricula

Telehealth demand increased precipitously among all populations, particularly Medicare beneficiaries with complex care needs, during the coronavirus disease 2019 pandemic. Current nurse practitioner (NP) graduates require practice readiness in telehealth when transitioning to advanced practice. Competency-based education models integrate progressive, multimodal evaluation of core practice competencies, including telehealth. Self-reflection supports student acquisition of new competencies. Thematic analysis of guided reflections after a pilot gerontologic robot-enabled telehealth simulation identified curricular opportunities in a primary care NP program. NP students’ perceived challenges in communication and adaptation to virtual patient presence were considered in building integrated telehealth curricula in clinical courses applying the 4Ps of Telehealth Education (Planning, Preparing; Providing; and Performance Improvement) framework.

Parent Satisfaction With Pediatric Nurse Practitioner Care in Specialty Services.

This study examined parent satisfaction with care provided to their children by Pediatric Nurse Practitioners (PNPs) in specialty areas at a tertiary care pediatric hospital. A convenience sample of parents of children cared for by 19 PNPs in different specialty settings completed a confidential survey consisting of demographic information and the Parents' Perception of Satisfaction with Care from the Pediatric Nurse Practitioners Instrument (PPSC-PNP). Data were analyzed using SPSS (IBM, Armonk, NY). The overall PPSC-PNP mean score was 129.82/140. Mean subscale scores ranged from 27.15 to 28.51/30. The general satisfaction score showed a mean score of 18.31/20. No statistical difference was found in parental satisfaction when scores were analyzed by the child's age, parent participant, or patient setting. These findings indicate that parents are highly satisfied with the care their children receive from PNPs across various subspecialties regardless of the child's age and clinical setting.

Adult-Gerontology Nurse Practitioners: A Discussion of Scope and Expertise

Adult-gerontology primary care nurse practitioners (NPs) deliver longitudinal primary care in outpatient settings from adolescence to older adulthood, and adult-gerontology acute care NPs provide care to critically ill adults and older adults. Family NP programs vastly outnumber adult-gerontology NP programs nationwide, despite a rapidly aging population. This report discusses the differences in education and scope of practice of adult-gerontology primary care NPs, adult-gerontology acute care NPs, and family NPs and highlights the crucial and unique assets adult-gerontology NPs bring to any health care system or practice. Differences in competencies, certification examinations, and practice settings are discussed in depth.

Scoping review: Diagnostic reasoning as a component of clinical reasoning in the U.S. primary care nurse practitioner education.

Diagnostic Reasoning (DR) is an essential competency requiring mastery for safe, independent Nurse Practitioner (NP) practice, but little is known about DR content included in NP education programs. The aims of this study were to identify whether and how the concept of DR is addressed in NP education. We conducted a scoping review on DR-related content and teaching innovations in U.S. primary care NP education programs, with implications for NP education programs worldwide. Concepts and principles with global applicability include: conducting focused and hypothesis-directed histories and exams, generating the problem statement, formulating the differential diagnosis, appropriate and relevant diagnostic testing, determining the working diagnosis and developing evidence-based, patient-centred management plans. N=1115 articles retrieved from Medline, Embase, PsycINFO, and CINAHL for the period 2005-2021. Forty-one scholarly articles met inclusion/exclusion criteria. Data were extracted, synthesized and grouped by theoretical frameworks, content included, educational interventions and assessment measures. Most articles provided descriptions of approaches for teaching NP clinical or diagnostic reasoning. Ten papers directly referenced the current science and theory of DR. The US NP education literature addressing DR is limited and demonstrates a lack of shared conceptualizations of DR. Whilst numerous components of DR are identifiable in the literature, a robust teaching/learning scholarship for DR has not yet been established in the US NP education literature. Whilst primary care NP education programs are beginning to incorporate DR education into their curricula, little research has been conducted to demonstrate the effectiveness of educational outcomes. Increased integration of DR content into NP education is needed, including increased educational research on teaching DR competencies. No patient or public contribution was included in this review, as the public is generally not familiar with DR or its teaching approaches.

Patient Experience with an NP-Led Community Wound Care Service

Aim: This study examined patient satisfaction with an NP-Led community wound care program.
 Background: Examining patient experience provides information to guide nurse practitioner (NP) practice regarding patient experience with wound care provided by NPs in Canada.
 Methods: This quantitative study utilized a Likert scale questionnaire to examine patient experience with a 12-week pilot NP-Led wound care service. The population included patients registered to receive community wound management through Southwestern Ontario LHIN.
 Findings: Forty-nine surveys were returned (response rate-42%). Participants reported positive experiences with NP care. Bivariate analysis (ANOVA) found no statistical difference between group means of the independent variables age, education, income level, marital status, and the dependent variable patient experience (p = >.05). Mann-Whitney U demonstrated gender to be statistically significant (p = 0.14); females had higher median scores than males, 4.8 and 4.6 respectively. Linear regression determined that Males were less likely to have a positive experience (F (1, 45) = 7.7, p =.008).
 Conclusion: Patients had a positive experience with the NP-Led wound care service. This study provides information that is useful when designing an NP-Led wound care program.

Implementation of a Standardized National HIV Curriculum in a Primary Care Nurse Practitioner Program.

Although efforts have been made to improve and integrate an HIV curriculum in schools of nursing, little has been done to standardize the integration of competencies related to HIV care in primary care nurse practitioner (NP) programs. The purpose of this study was to understand the effect of integrating the 6 core competencies from the National HIV Curriculum (NHC) on NP students' perceived knowledge about HIV care. This was a quasi-experimental study with a pre/posttest design that measured NP students' self-perceived knowledge of the 6 core competencies from the NHC. A total of 375 student NHC training sessions were implemented across 5 semesters (fall 2019 through fall 2021 academic years). In each of the 3 courses that integrated the NHC, there were statistically significant increases in student knowledge from pre- to posttest for each of the 6 competencies. This project supports using a standardized HIV curriculum as part of primary care NP curricula.

Patient demographics and clinical characteristics influence opioid and nonopioid pain management prescriptions of primary care NPs, PAs, and physicians.

Evidence exists on racial and gender disparities in chronic pain management among veterans. Most literature has described physicians' disparate opioid prescribing patterns, although it is unknown if prescribing disparities exist among nurse practitioners (NPs) and physician assistants (PAs) or among prescription of nonopioid analgesic strategies. To identify patient characteristics associated with opioid and nonopioid prescriptions among Veterans Affairs (VA) chronic pain patients by primary care physicians, NPs, and PAs. We used data from the VA's Survey of Health care Experience of Patients and Corporate Data Warehouse from October 2015 to September 2016. Outcomes included opioid and nonopioid analgesic prescriptions. Patient characteristics included race/ethnicity, gender, education level, age, and clinical characteristics (comorbidities, self-reported health, and self-reported mental health). Logistic regression was performed to test for associations of patient characteristics with outcomes. Patients who were White, male, age 41-64 years, and with no postsecondary education had higher odds of receiving an opioid prescription (all p -values ≤ .01), whereas patients who were Black, female, and <65 years old had higher odds of a nonopioid prescription (all p -values < .01). Having 5+ comorbidities and fair/poor self-reported health increased the odds of opioid and nonopioid prescriptions (all p -values < .01). Disparities in race, gender, and educational level significantly affect how primary care NPs, PAs, and physicians manage chronic pain. NPs and other primary care providers should pursue training opportunities to identify and mitigate potential biases that may affect their practice. Future research should take an intersectional lens in examining the source of chronic pain disparities.

Engaging nurse practitioners and physician assistants to improve patient care and drive productivity in a radiology consult practice at a comprehensive cancer center.

The demand for health care in the United States is increasing because of an aging population and an increase in the number of individuals insured. This has led to requests to revamp the primary care infrastructure fundamentally. The optimal use of nurse practitioners (NPs) and physician assistants (PAs) is still a subject of debate, but recently, it was reported that for many medical conditions, NP and PA-managed care outcomes are consistent with physician-managed care outcomes. Radiologists' productivity was measured according to relative value units (RVUs)/shift and professional billing changes. Patient care metrics measured were prescribed protocol to patient appointment lead time and number of same-day prescribed imaging protocol changes. The focus was on radiologists' productivity and patient care for three months before and three months after integrating NP and PA into our abdominal radiology consult service. We observed significant increases in the mean RVUs/shift (15.2 ± 0.9 vs. 6.2 ± 1.8; p = .02), studies read per shift (10.1 ± 0.5 vs. 4.4 ± 1.5; p = .003), revenue per shift hour ($756.20 ± 55.40 vs. $335.40 ± 32.60; p = .007), and protocol prescription to patient appointment lead time (39.3 ± 6.7 days vs. 16.3 ± 2.9 days; p = .005) and saw significant decreases in the mean prescribed CT (19.3 ± 0.6 vs. 3.3 ± 0.6; p = .001) and MRI (11.7 ± 0.6 vs. 8.30 ± 0.12; p = .011) same day protocol changes in NP and PA integrated workflow. These findings suggest that NP and PA can be effectively integrated into the abdominal radiology consult service, increasing radiologists' productivity and enhancing clinical care.

Nurse practitioner programs: Selection factors and the student experience.

Nurse practitioner (NP) education has faced numerous challenges related to the changing healthcare landscape, shortages of faculty, and limited resources to meet the needs of NP students. The changes within NP education have impacted students, both positively and negatively. This purpose of this review of the literature is to gain an understanding of the primary care NP student perspective related to selecting a NP program, faculty and peer relationships, program success versus attrition, clinical experiences, and transition to practice. Gaps in the literature encompassing NP education will be reviewed. Finally, recommendations will be given for prospective NP students as well as NP educators.

Physician and Nurse Practitioner Teamwork and Job Satisfaction: Gender and Profession

Designing interprofessional primary care teams composed of physicians and nurse practitioners (NPs) is a national priority. We assessed how profession and gender affect teamwork and job satisfaction among primary care physicians and NPs by using survey data from 186 physicians and 398 NPs practicing in New York State. Our regression models show profession (NP vs physician) moderates the associations of gender with teamwork and job satisfaction. Among NPs, men had higher job satisfaction than women. Among physicians, women had higher job satisfaction than men. Our results can benefit interprofessional primary care teams to optimize their professional and gender mix.

A framework of the institutional policies and practice environments of nurse practitioner primary care models: A cross-case analysis.

The purpose of this article was to compare the implementation of distinct models of nurse practitioner (NP) integration into primary care offices. A multiple case study design of three NP primary care practice models allowed for in-depth exploration of the management processes supporting the utilization of NPs. At each site, semistructured qualitative interviews, document review, and site tours/observations were conducted and subject to cross-case analysis guided by the NP Primary Care Organizational Framework (NP-PCOF)-developed for this study based on existing theory. Our case study sites represent three distinct NP primary care models. In the restricted practice model, NPs care for same-day/walk-in acute patients. NPs in the independent practice model have an independent panel of patients and interact collegially as independent coworkers. NPs in the comanagement model function on a team (a physician and two NPs), have a team office space, collectively care for a shared panel of patients, and can earn financial bonuses contingent upon meeting team quality metrics. Our cross-case analysis confirmed differences in physical space design, the relational structure of a workplace, and the capacity for innovation via NP compensation and performance metrics across different NP primary care models. Our findings suggest that NP primary care models are supported by complex management systems and the NP-PCOF is a tool to help understand this complexity. The NP-PCOF is a framework to understand the management systems that facilitate the utilization of NPs within primary care organizations.

Case-based, asynchronous sleep education outcomes among primary care nurse practitioner students.

Primary care nurse practitioners (NPs) receive little sleep education in graduate programs but are often first-line providers for patients presenting with sleep-related symptoms. A pre-/postevaluation study was conducted using asynchronous, case-based sleep education modules in a cohort of primary care NP students enrolled in a single academic institution's nursing master's degree program. Six virtual, case-based modules addressed adult sleep health and disorders, prioritized based on prevalence and primary care presentation. Kirkpatrick Training Evaluation Model guided outcome selection. Descriptive and paired comparative analyses were conducted. Participants were first-year NP students (n = 149; 88% female; 82% ≤ 35 years of age) in an adult primary care program that included psychiatric/mental health track. Participants reacted positively to course delivery methods and content. Insomnia was endorsed by 87% as most relevant to practice with healthy sleep (88%) and obstructive sleep apnea (50%) also frequently endorsed as practice relevant. Posttest knowledge scores significantly improved for all modules (P < .001). Self-rated confidence for future practice application was high. This novel asynchronous, virtual curriculum met Kirkpatrick levels 1 and 2 (positive reaction and knowledge transfer) in NP students who predicted an impact on their practice (Kirkpatrick level 3). Studies are needed to assess the benefits of increasing primary care NP knowledge in sleep medicine on quality of care and access to care (Kirkpatrick level 4). Future use of this novel sleep curriculum in other professional curricula, new-to-sleep clinical researchers, and practicing primary care providers may further potentiate care quality and sleep care access. Sawyer AM, Saconi B, Lyons MM, etal. Case-based, asynchronous sleep education outcomes among primary care nurse practitioner students. J Clin Sleep Med. 2022;18(10):2367-2376.

The Organizational Climate for Nurse Practitioners Working in Primary Health Care in New Zealand: A National Survey

Little is known about the working conditions of nurse practitioners (NPs) in primary health care in New Zealand. Data were collected using an online organizational climate questionnaire from NPs and managers who employed NPs. Nearly two-thirds of all primary health care NPs in the country (n = 136) responded together with a purposive sample of 58 managers. More than 90% of respondents from both groups identified that organizations created an environment where NPs could practice independently and autonomously with collegial support. Other results signaled opportunities for improvement in local and national health policy. This study adds to international evidence on creating positive practice environments for NPs.

0369 Sleep Education for the Nurse Practitioner: Nurse Practitioner Student Focus Group Findings

Abstract Introduction Primary care nurse practitioners (NPs) receive little to no sleep education in graduate programs despite being first-line providers for patients presenting with sleep-related symptoms. Sleep curriculum has been consistently identified as a gap in nursing education and confirmed in recent survey studies of nurses and NPs. Methods Qualitative descriptive study to explore NP students’ reactions to an asynchronous, case-based sleep e-learning program. Data were collected as part of a larger pre-/post-study assessing the program. Six asynchronous online modules were offered to a cohort of primary care NP students in a single academic institution’s master’s degree in primary care nursing program. At the end of the course, students were invited to participate in one-hour, online, focus group sessions. Directed content analysis, guided by the Kirkpatrick training evaluation model, was used to analyze the qualitative data to understand NP students’ experience with the program and elicit their perspectives about sleep education. Results Participants in the course (N=67) were predominantly female (88%) and ≤35 years old (81%). Twenty-four students participated in the focus group sessions. Two overarching themes emerged, including positive reactions to (1) course design and (2) course content. Students reported the case-based scenarios and quizzes enhanced their learning and kept them engaged, noted the user-friendly format, and appreciated that the course was asynchronous. After completing the modules, students recognized they had a previous knowledge gap related to sleep and perceived the information they received to be relevant to their practice/patient population and to their own personal health/wellbeing. Students also discussed their intentions to incorporate sleep assessments into practice. Conclusion Given the increasing sleep health needs of the population and the growing shortages of sleep providers, there is a critical need to ensure NP’s have the proper education to recognize and identify implications of poor and disordered sleep in their patients. In this study, NP students enthusiastically embraced sleep education, identified knowledge gain, and had intentions to apply their learned skills in practice highlighting the feasibility of increasing curricular exposure to sleep medicine. Support (If Any) The work reported herein was supported by National Institutes of Health (R25HL120874 Rosen, PI).

Physicians’ Perception About Primary Care Nurse Practitioners in Saudi Arabia

The purpose of this study was to explore physicians’ perception about the supply and demand of nurse practitioners (NPs) in primary care settings. We used a cross-sectional design and the National Survey of Primary Care Physicians and Nurse Practitioners to recruit physicians working in Saudi Arabia. Most participants agreed that the numbers of primary care physicians and NPs are less than the demand and increasing the NP supply would improve health care access and quality. Statistically significant differences were found between physicians based on demographic characteristics. Physicians support the development of the primary care NP role in Saudi Arabia to optimize health care access and quality.

Inclusion of physical activity in nurse practitioner programs: A national perspective.

Physical activity (PA) provides a multitude of health benefits, creating an avenue for disease prevention and management. Health care providers play a crucial role in helping patients become more active, yet little is known about the preparation of primary care nurse practitioners (NPs) to aid in this effort. To examine the amount and type of PA training offered in primary care NP programs in the United States. A cross-sectional study design was used. Eligible programs' websites were reviewed, and an online survey of program leaders assessed details regarding the inclusion of PA training, barriers, and future plans. Data extracted from 1,067 NP program websites revealed that 81.7% of websites (n = 264) with course descriptions contained one or more general health promotion keywords, whereas only 0.6% (n = 2) included a PA-specific keyword. Two-hundred institutions (53.2%) completed the program leader survey, of which 45.0% reported no inclusion of PA training. Among institutions providing PA training, 82.2% (n = 88) and 55.1% (n = 59) reported the inclusion of aerobic activity and strength training recommendations, respectively. Forty-one institutions (46.1%) felt that their institution prepared students to effectively counsel patients on starting a PA program. Although some NP programs include PA content, most provide no or less-than-adequate PA training. The current state of PA training in NP programs may hinder health promotion and disease prevention efforts. Programs should dedicate sufficient time and attention to preparing future NPs to promote PA behaviors. A multifaceted, multistakeholder approach is needed to facilitate widespread adoption of PA inclusion.

Nurse practitioner experiences providing nutrition counseling to adult patients in primary care.

Poor nutrition is one of the leading risk factors for preventable chronic diseases in the United States. Nutrition counseling has been shown to improve clinical outcomes in the adult primary care setting. Nurse practitioners (NPs) can help fill the critical need for nutrition counseling, yet little is known about their role providing nutrition counseling. To describe the primary care NP's experience in providing nutrition counseling to adult patients in primary care practice. Qualitative descriptive study design. Data were collected through virtual semi-structured interviews with 18 board-certified primary care NPs. Interviews were audio-recorded, de-identified, transcribed verbatim, and analyzed. Data collection and analysis took place concurrently and continued until data saturation was achieved. Five themes emerged from NPs' descriptions of their experiences in providing nutrition counseling to adult patients in primary care practice: (1) role of nutrition counseling in NP primary care practice; (2) developing NP self-efficacy in nutrition counseling; (3) nutrition counseling is more than the provision of information; (4) emotional aspect of nutrition; and (5) barriers to behavior change. Findings suggest that although NPs understand the importance of nutrition counseling in primary care practice and provide it in some capacity, its continuance is limited by multiple barriers. Future research should evaluate ways to enhance NPs' preparedness to provide nutrition counseling, assess specific resources and tools to aid in nutrition counseling, and determine best practices for communication when delivering nutrition counseling. Future interventions have the potential to positively affect patients' dietary practices and improve clinical outcomes.

PH Roundtable: Disparities in PH

PH Roundtable: Disparities in PH

Supportive Practice Environments Are Associated With Higher Quality Ratings Among Nurse Practitioners Working in Underserved Areas

Deployment of nurse practitioners (NPs) to health professional shortage areas (HPSA) may help to address challenges in patient access to care. However, restrictive scope of practice imposed by regulatory and state legislative bodies or unsupportive organizational climates in clinical practice settings may constrain NP care delivery and perpetuate lower assessments of quality of care provided in these underserved communities. The purpose of this study was to investigate the associations between state NP scope of practice regulations, NP practice environment, and self-reported ratings of quality of care in primary care practices located in HPSAs. This was a cross-sectional analysis of data from 1,972 participant NPs practicing across 1,711 primary care practices in six states representing full (Arizona and Washington), reduced (Pennsylvania and New Jersey), and restricted (California and Florida) NP scope of practice regulation. Survey data were merged with the Area Health Resource Files to determine practices located in primary care HPSAs. Logistic regression models estimated the relationship between quality ratings, scope of practice regulations, and practice environment scores while accounting for NP and practice characteristics. Among all included NPs, 95.7% rated their practice as having "excellent," "very good," or "good" quality of care. Practice environments with higher scores had higher ratings of quality of care after accounting for NP and practice characteristics (OR = 3.73, 95% CI: 2.84, 4.89). Unsupportive clinical practice environments were associated with lower ratings of quality of care in HPSAs, suggesting that improvements in working conditions may be necessary adjuncts to greater deployment of NPs to improve primary care in shortage areas.

Impact of a Head and Neck Cancer Chemoradiation (HNC CRT) Nurse Practitioner (NP) on Patient Outcomes

<h3>Purpose/Objective(s)</h3> In addition to chemotherapy toxicities, most HNC patients receiving CRT experience moderate to severe radiation-induced pharyngitis. Management includes escalating analgesics, dietary modification, supplemental hydration, and feeding tubes for nutritional support as needed. Uncontrolled symptoms can interrupt or truncate curative intent treatment, impacting both quality of life and cancer outcomes. In 2014, a fulltime NP role dedicated to symptom management during and immediately post-CRT was initiated at our center. We assessed the impact on patient Emergency Department (ER) visits, hospitalizations and deaths. <h3>Materials/Methods</h3> Patients receiving definitive primary CRT with curative intent were identified during 12 month periods prior to (April 2012-March 2013) and three years after (April 2017-March 2018) initiation of the NP from records of H&N MDT case conferences. We hypothesized that ER visits and hospitalizations would be reduced with NP care. Effects on treatment delivery were secondary outcomes. Patient demographic, tumor, treatment, ER visit, hospital admission, and mortality data were extracted retrospectively from the electronic medical record. Unadjusted comparisons were done using the chi-square test for categorical variables and t-test for continuous variables with p<0.05 considered of significance. This project was approved by the institutional REB. <h3>Results</h3> 105 and 120 patients were identified in the pre-NP and post-NP cohorts, respectively. Post-NP patients were younger (mean age 63.2 vs 67.3 years), more often had oropharyngeal cancer (81.5% vs 56.2%), did not receive weekly carboplatin (0.0% vs 8.6%), and received cisplatin scheduled q3weekly less often (45.0% vs 71.4%) and weekly more often (48.3% vs 16.2%). Patients received a mean of 3.6 visits and 4.3 phone calls with the NP. There was no difference in ER visits within 42 days of treatment between cohorts (55.2% vs 55.8%). However, hospital admissions were reduced (60.0% vs 45.8%, p=0.034). Length of stay was similar, and there was no difference in 90-day mortality (2.9% vs 2.5%). <h3>Conclusion</h3> This before-and-after study showed a 23.7% reduction in hospitalizations after introduction of the NP role, consistent with the findings of others (Terzo 2017). Over 50% of patients visited the ER at least once and 1 in 40 died in both cohorts. Time trends included a 14.3% increase in the number of patients receiving CRT; and shifts in patient age, cancer type and cisplatin schedule consistent with an increasing incidence of HPV-related oropharyngeal cancer. We cannot rule out effects of these trends or other interventions on our results. Additional limitations include inability to harmonize staging between cohorts and lack of quality of life and cost effectiveness data. Nevertheless, these data support the value of a NP role focused on HNC patients receiving CRT to optimize outcomes.