Abstract Increased engagement of nurse practitioners (NPs) has been recommended as a way to address care delivery challenges in settings that struggle to attract physicians, such as primary care and rural areas. Nursing homes also face such physician shortages. We evaluated the role of state scope of practice regulations on NP practice in nursing homes in 2012–2019. Using linear probability models, we estimated the proportion of NP-delivered visits to patients in nursing homes as a function of state scope of practice regulations. Control variables included county demographic, socioeconomic, and health care workforce characteristics; state fixed effects; and year indicators. The proportion of nursing home visits conducted by NPs increased from 24% in 2012 to 42% in 2019. Expanded scope of practice regulation was associated with a greater proportion and total volume of nursing home visits conducted by NPs in counties with at least 1 NP visit. These relationships were concentrated among short-stay patients in urban counties. Removing scope of practice restrictions on NPs may address clinician shortages in nursing homes in urban areas where NPs already practice in nursing homes. However, improving access to advanced clinician care for long-term care residents and for patients in rural locations may require additional interventions and resources.
Retail health clinics (RHCs) have been described as a disruptive model of care delivery. We describe RHC market presence in the United States from 2008 to 2016 with a focus on the characteristics of counties where new clinics open. We merge national data on RHC openings and closings from Merchant Medicine with the Area Health Resources File. We examined county-level counts and ownership of RHCs over time. From 2008 to 2016, we found increasing ownership of RHCs by retail pharmacies, and, contrary to earlier predictions, RHCs continue to be located in affluent counties and did not open in underserved or provider shortage areas. Most new clinics opened in counties where RHCs already had a presence, and these counties also had greater primary care physician, nurse practitioner, and physician assistant density per capita (100,000). As RHCs expand and offer more services, they may place new competitive pressures on nearby primary care providers and practices.
Supply of providers by socioeconomic status and health ABSTRACT To identify active providers, those listed in the 2014 National Plan and Provider Enumeration System to Medicare claims were linked. Using practice location and specialty code, the total number of adult primary care physicians (internal medicine, family medicine, and general practice), NPs, and PAs in each US county were identified. Data on county characteristics were gathered from the 2010 US Census, and the presence of a hospital was identified using the Area Health Resource File. Adjusted for county-level differences, the supply of primary care physicians increased across socioeconomic status (P-trend = 0.01). For instance, the number of primary care physicians was 31% higher in the highest income quartile than in the lowest (RR = 1.31 [95% CI: 1.15, 1.48]). The distribution of PAs exhibited a pattern similar to that of primary care physicians. Policies for enhancing access to care for underserved communities should incorporate incentives to encourage providers to locate in areas of greatest need.1 Commentary by Walt Eisenhauer: This research provides a unique mechanism to assess the current system's ability to meet the healthcare needs of rural and underserved populations. The conclusion that a correlation exists between socioeconomic status of a community and the deployment of various primary care provider types is consistent with historic trends. Maldistribution of providers in areas that serve economically disadvantaged populations represents one of the driving forces that precipitated the development of both PA and NP models. One might conclude that NPs have been more successful due to the independent nature of their practice. However, as providers are increasingly employees of large systems, and in light of a corporatized healthcare reimbursement system that is increasingly dependent on volume to maintain operating margins, service becomes secondary to maintaining financial viability. Proposed solutions might include a significant differential in reimbursement for rural and underserved communities or a centralized reimbursement model tasked with assuring primary care access equitably to all socioeconomic classes and geographic regions. REFERENCE Task shifting between physicians and nurses in acute care hospitals ABSTRACT Countries vary in the extent to which they expand scope of practice for advanced practice registered nurses (APRNs). This study analyzed physicians' and APRNs' perceptions of role change and task shifting in nine European countries after APRN scope-of-practice reform. The design was cross-sectional using surveys completed by 1,716 providers treating patients with breast cancer and acute myocardial infarction (AMI) in 161 hospitals. Analyses included descriptions of staff role changes in two country groups: 1) major scope-of-practice reforms (Netherlands, England, Scotland) and 2) no scope-of-practice reform (Czech Republic, Germany, Italy, Norway, Poland, Turkey). From 2010 to 2015, healthcare providers in the first group reported greater provider role changes compared with providers in the second group (breast cancer, 74% versus 38.7%; AMI, 61.7% versus 37.3%), as well as higher independence for APNs (breast cancer, 58.6% versus 24%; AMI, 48.9% versus 29.2%). Although a higher proportion of APNs from countries with major scope-of-practice reform reported increasingly undertaking more care tasks, most care was performed by both physicians and APNs rather than carried out by one profession. These results suggest that professional boundaries have shifted, but care is still delivered by interdisciplinary groups of providers.1 Commentary by Hilary Barnes: Population changes and policy reform have led to growing patient demand and changes in how healthcare is delivered in the United States. Evolving models of care are increasingly incorporating PAs and NPs, and there is support for full use of these providers in ambulatory settings to mitigate provider shortage concerns and improve patient outcomes.2,3 What this study contributes, however, is new insight and evidence of the growing role of NPs and PAs in hospital-based care.1 The authors show that in countries that favorably reformed PA or NP scope of practice, many care tasks were shifted to PAs and NPs, while others continued to be provided by all three clinician types—potentially reflecting an increase in the use of interdisciplinary, team-based care. This study was conducted in the European Union but the results are relevant to the US healthcare system. At a time when hospitals are seeking ways to improve safety, reduce readmissions, and lower costs, incorporating PAs and NPs into care teams and letting them practice to the top of their education and training is a means to optimize the workforce for the delivery of high-quality and efficient care in hospitals. This will be especially important as value-based payment models become universal. REFERENCES ICU staffing of PAs and NPs in the Netherlands ABSTRACT Literature in Europe about implementing NPs or PAs in ICU is lacking, although some available studies indicate that this concept can improve the quality of care and overcome physician shortages in ICUs. The aim of this study is to provide insight on how a Dutch ICU implemented PAs and NPs, as well as residents, and what this staffing model adds to the care on the ICU. This paper defines the training course and job description of NPs and PAs in a Dutch ICU. It describes the number and quality of invasive interventions performed by PAs, NPs, residents, and intensivists during 2015 and 2016. Salary scales of PAs and NPs and residents are provided to describe potential cost-effectiveness. The tasks of PAs and NPs in the ICU are equal to those of the residents. Analysis of the invasive interventions performed by PAs and NPs showed an incidence of central venous catheter insertion of 20 per full-time equivalent (FTE) compared with 4.3 per FTE for residents in 1 year. For arterial catheters, PAs and NPs inserted 61.7 per FTE and the residents inserted 11.8 per FTE. The complication rate of both groups was in line with recent literature. Regarding salary, after 5 years in service an NP or PA earned more than a starting resident. This is the first European study that describes the role of PAs and NPs in the ICU and shows that practical interventions normally performed by physicians can be performed with equal safety and quality by PAs and NPs.1 Commentary by Harrison Reed: Although this article describes Dutch PAs and NPs in ICUs, the training program and clinical role will be anything but foreign to many US observers. The authors present PAs and NPs as analogous to resident physicians, a designation that might be a compliment for some PAs and an insult to others. In comparing PAs, NPs, and residents, the authors focus on procedural skills and complication rates rather than more holistic outcomes. Although procedural prowess is a selling point of PAs in critical care, the decision to highlight technical skills rather than true clinical decision-making may represent a missed opportunity. After all, Dutch PAs in critical care have proven their broader clinical skills in a head-to-head comparison with residents in the simulation laboratory.2 Distilling the benefit of these clinicians to technical tasks begs the question: are Dutch ICUs—and some of their US counterparts—missing out on the real value of PAs and NPs? Of course, cost-effectiveness is relative. The PAs and NPs presented in this article earn a much lower salary than their colleagues in the United States, making it unlikely that PAs from the United States will flock to the Netherlands, no matter how pretty the tulips. REFERENCES ABSTRACT Can we really reduce burnout without reducing the workload? Appropriate delegation of clinical tasks from primary care providers (PCPs) to other team members may reduce employee burnout in primary care. However, the extent to which delegation occurs within multidisciplinary teams, factors associated with greater delegation, and whether delegation is associated with burnout are unknown. The authors performed a national cross-sectional survey of Veterans Affairs (VA) PCP-nurse dyads in VA primary care clinics, 4 years into the VA's patient-centered medical home initiative. PCPs reported the extent to which they relied on other team members to complete 15 common primary care tasks. A composite score of task delegation/reliance was developed by taking the average of the responses to 15 survey questions relating to delegated tasks. Next, the researchers performed multivariable regression to explore predictors of task delegation and burnout. Among 777 PCP-nurse dyads, PCPs reported delegating tasks less than nurses reported being relied on. About 48% of PCPs and 35% of nurses reported burnout. PCPs who reported more task delegation reported less burnout; nurses who reported being relied on more reported more burnout. Strategies to improve work life in primary care by increasing PCP task delegation must take into account the effect on nurses.1 Commentary by Bettie Coplan: This cross-sectional study of VA primary care teams revealed that PCP (physician, NP, or PA) task delegation to nurses was associated with less burnout for providers but more burnout for nurses. In other words, shifting the work may merely shift the burnout. Although factors related to how healthcare professionals work, for example—with little autonomy, a lack of social support, or in teams with poor leadership—are known to contribute to burnout, workload alone has a significant effect.2-5 Tasks that are perceived as unrewarding, such as the administrative aspects of healthcare delivery that have increased with the computerization of order entry and documentation, particularly affect job satisfaction.5 Despite lofty goals to shift the focus of healthcare from quantity to quality, fee-for-service payment methods continue to dominate.6 Research suggests that work demands on healthcare professionals are associated with burnout period.3,5 Although efficient team processes, such as appropriate task delegation, certainly have the potential to improve job satisfaction, relying on team members to reduce burnout may be a solution for some that simply shifts the burden to others.7 REFERENCES
ADVERTISEMENT RETURN TO ISSUEPREVArticleNEXTIn Reply to a Statement made by Dr. R. Cohen in a Paper on the Theory of the Transition Cell of the Third KindH. T. BarnesH. T. BarnesMore by H. T. BarnesCite this: J. Phys. Chem. 1900, 4, 4, 306Publication Date (Print):April 1, 1900Publication History Published online1 May 2002Published inissue 1 April 1900https://doi.org/10.1021/j150022a005RIGHTS & PERMISSIONSArticle Views15Altmetric-Citations1LEARN ABOUT THESE METRICSArticle Views are the COUNTER-compliant sum of full text article downloads since November 2008 (both PDF and HTML) across all institutions and individuals. These metrics are regularly updated to reflect usage leading up to the last few days.Citations are the number of other articles citing this article, calculated by Crossref and updated daily. Find more information about Crossref citation counts.The Altmetric Attention Score is a quantitative measure of the attention that a research article has received online. Clicking on the donut icon will load a page at altmetric.com with additional details about the score and the social media presence for the given article. Find more information on the Altmetric Attention Score and how the score is calculated. Share Add toView InAdd Full Text with ReferenceAdd Description ExportRISCitationCitation and abstractCitation and referencesMore Options Share onFacebookTwitterWechatLinked InReddit PDF (78 KB) Get e-Alerts
Barnes Aim A concept analysis of nurse practitioner (NP) role transition. Background The Affordable Care Act is expected to provide 32 million Americans with health insurance, and NPs are gaining attention in addressing this increasing demand for healthcare providers. However, there is limited analysis of the transition from registered nurse to NP. Oftentimes, during this transition, there is a shift from an experienced, expert status to an inexperienced, novice status, with a subsequent loss of confidence in one's ability and competence. This can hinder successful role development and affect employment continuity within the first year of practice. Methods and Sources NP role transition was examined using Walker and Avant's method of concept analysis. Electronic databases were searched using the terms role transition and nurse practitioner. Thirty articles from nursing, psychology, and business were included. Findings and Conclusions The four defining attributes of NP role transition are absorption of the role, the shift from provider of care to prescriber of care, straddling two identities, and mixed emotions. Personal and environmental antecedents and consequences of the concept are identified. The development of empirical knowledge on NP role transition through further research is important in order for new-to-practice NPs to become high-quality, full-functioning providers.
ABSTRACT Background: Newly graduated nurse practitioners (NPs) and physician assistants (PAs) benefit from transition-to-practice (TTP) support to move successfully into practice. Transition-to-practice programs (i.e., onboarding programs and fellowships/residencies) hold promise for improving workforce outcomes. Purpose: The purpose of this scoping review was to describe the literature regarding NP/PA TTP programs. Methodology: Using the Joanna Briggs Institute methodology, a specific approach for systematically conducting reviews, publications from January 1990 to May 2022 were included for review if they addressed fellowships/residencies or onboarding programs for NPs or PAs. Final data extraction involved 216 articles. Results: The pace of publication increased over time, with a noticeable increase since 2015. Articles were most commonly about fellowships/residencies, NPs, and programs set in United States nonrural, acute care settings, and academic health centers. Conclusions/Implications: There is a gap in our understanding of onboarding programs and programs focusing on PAs, as well as TTP support in rural and primary care settings. In addition, there are few articles that assess TTP program outcomes such as benefits and costs. This review describes the need for more published literature in these areas.
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