Driving high-functioning clinical teams: An advanced practice registered nurse and physician assistant optimization initiative.

The State of Advanced Practice Registered Nursing in Alabama

Independent practice and full practice authority

Moving Forward with Role Recognition for Clinical Nurse Specialists

Previous research has empirically demonstrated that personal resilience and organizational level interventions are important considerations when studying workplace adversity such as burnout and excessive workloads in the context of a pandemic. To explore interest in participating in a wellness initiative program designed specifically for advanced practice registered nurses (APRNs) and physician associates (PAs), with a voluntary option for participation in research. An anonymous, brief, online survey with Likert-response type items and one free-text question was delivered with passive informed consent via email to all APRNs and PAs (N = 312 participants) within one health care system. A positive correlation between likelihood of seeking well-being care and having sufficient time (0.36, p < .01) was found, which indicates that APRNs or PAs who felt they had sufficient time to get counseling were actually more likely to seek counseling services. Results from the path model show that the comfort-level of seeking counseling completely mediates the relationship between fear of negative perceptions of receiving counseling and the likelihood of participating in a wellness program. Well-being strategies are important for organizations to engage in to support their employees; however, confidentiality concerns and competing priorities for time may influence engagement. Interest among APRNs and PAs for participation in research exists if enough information is provided and anonymity can be assured. Organizations should focus on finding innovative ways to integrate wellness into APRN and PA practice that mitigates the belief around the burden of time commitment and seeks ways to provide psychological safety for its employees.

Background: The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm records advance care planning for patients with advanced illness or frailty as actionable medical records. The National POLST Paradigm Task Force recommends that physicians, advanced practice registered nurses (APRNs), and physician assistants (PAs) be permitted to execute POLST forms.Objective: To investigate the percentage of Oregon POLST forms signed by APRNs, and examine the obstacles faced by states attempting to allow APRNs to sign POLST forms.Design: Cross-sectional.Setting/subjects: 226,101 Oregon POLST Registry forms from 2010 to 2015.Measurements: POLST forms in the Oregon Registry were matched with signer type (MD, DO, APRN, PA).Results: 226,101 POLST forms have been added to the Oregon POLST Registry from 2010 to 2015: 85.3% of forms were signed by a physician, 10.9% of forms were signed by an APRN, and 3.8% of forms were signed by a PA. From 2010 to 2015, the overall percentage of POLST forms signed by an APRN has increased from 9.0% in 2010 to 11.9% in 2015. Physicians are authorized signers in all 19 states with endorsed POLST Paradigm programs; 16 of these states also authorize APRN signature, and 3 states (LA, NY, and GA) allow only physicians to sign.Conclusions: More than 10% of Oregon POLST forms are signed by APRNs. Given the need for timely POLST form completion, ideally by a member of the interdisciplinary team who knows the patient's preferences best, these data support authorizing APRNs to complete POLST forms.

BackgroundIn response to the COVID‐19 pandemic, Tennessee's Governor issued executive orders temporarily suspending certain practice restrictions on advanced practice registered nurses (APRN), which expired after 2 months as the pandemic worsened.PurposeThis purpose of this qualitative study was to analyze APRN interview data to evaluate how prepandemic APRN practice barriers, executive orders, and the pandemic affected APRN practice in Tennessee.MethodsFifteen Tennessee APRNs who completed the National APRN Practice and Pandemic study also completed follow‐up interviews via a HIPAA‐compliant Zoom platform. Given the unprecedented circumstances associated with the COVID‐19 pandemic, we conducted a qualitative descriptive study seeking descriptions and unique perspectives of Tennessee APRNs. Consistent with qualitative study design, we conducted an atheoretical study that featured interviews, purposeful sampling with maximum variation sampling, and content analysis.ResultsThe major themes were practice changes, impact of executive orders, and ongoing care barriers. The data revealed that patients, APRNs, and other health care providers were strained in new and profound ways during the pandemic. An underlying theme was Tennessee APRNs' frustration with continued regulatory and other practice barriers despite their state's health and health care disparities and under resourced health care system.ConclusionThese findings indicate the need to improve care access and health outcomes, advocate for full practice authority for APRNs, support telehealth expansion, address transportation deficiencies, and respond to the pandemic‐precipitated mental health crisis.

There is widespread concern that the implementation of the Affordable Care Act will lead to increased health care spending in the United States. One commonly proposed mitigation strategy is the expansion of the scope of practice for advanced practice registered nurses (APRNs). In the November 2013 issue of Health Affairs, several authors discuss using nurse practitioners (NPs) as a way to decrease health care costs (Iglehart, 2013). This is good news. But we need more advanced practice research, especially in the area of emergency department (ED) patient outcomes. Historically, most of the patient outcomes studies with regard to emergency nurse practitioners (ENPs) have been published by ENPs in Australia, Canada, and the United Kingdom (Ducharme, Alder, Pelletier, Murray, & Tepper, 2009; Sandhu, Dale, Stallard, Crouch, & Glucksman, 2009). Only recently have ENPs from the United States offered research contributions with regard to ENPs and patient care outcomes. AUSTRALIAN STUDIES In 2006, ENPs from Australia looked at ENP care and ED patient flow (Considine, Martin, Smit, Winter, & Jenkins, 2006). This study compared ED wait times for patient assessment and management. The study also looked at length of stay (LOS) and treatment times for patients cared for by an ENP candidate as compared with the traditional ED care method with a physician. The authors concluded that there were no significant differences in wait times, LOS, and treatment times. The authors also noted that patient flow outcomes for patients seen by ENPs are comparable with those of patients managed by the physician. That same year Considine (2006) also set out to define the scope of practice of the ENP role in a metropolitan ED in Australia. In 2008, a group of researchers demonstrated shorter wait times and ED LOS associated with the use of ENPs in a major urban ED in Melbourne (Jennings, O'Reilly, Lee, Cameron, Free, & Bailey, 2008). The average wait time for emergency patients seen by the ENP was 12 min compared with 31 min for those seen by a physician. Length of stay in the ED was also significantly lower in the ENP group (94 min) than in the physician group (170 min). Wilson (2008) investigated the effectiveness of ENPs in an adult ED and assessed patient satisfaction for the care received for minor injuries. A majority of patients were satisfied with the treatment received from NPs. The authors also noted that patient flow through the department was significantly improved. CANADIAN STUDIES Carter and Chochinov (2007) performed a systematic review of the literature about the impact of ENPs on cost, quality of care, satisfaction, and wait times in the ED. The researchers focused on four outcome measures: (1) wait times, (2) patient satisfaction, (3) quality of care, and (4) cost-effectiveness. They noted that ENPs decreased wait times while providing quality, comprehensive, and cost-effective ED care, resulting in higher patient satisfaction. A 2008 study of patient satisfaction with NP care in Canadian EDs found that patients were satisfied with NP attentiveness and the comprehensiveness of their care and had a moderate understanding of the ENP role (Thrasher & Purc-Stephenson, 2008). Another Canadian study looked at the impact on patient flow after the integration of NPs and physician assistants (PAs) in six Ontario EDs (Ducharme et al., 2009). That study concluded that the addition of ENPs and PAs to the ED team could improve patient flow in medium-sized community hospital EDs. U.K. STUDIES A 2009 study compared the communication skills and patient satisfaction ratings of ENPs and ED physicians (Sandhu et al., 2009). This study compared the content of, and satisfaction with, consultations made by ENPs and physicians when patients presented to the ED with primary care problems. In the study, the researchers noted that ENPs seemed to focus more on patient education/counseling than did their physician counterparts. The authors noted that there were no statistically significant differences in consultation length. The study also revealed that ENPs had higher levels of self-satisfaction with their consultations than did the ED physicians. U.S. STUDIES In a 2012 study about the effectiveness ED provider in triage (PIT), the authors reported a quality improvement initiative to improve patient flow by redesigning the triage process (Love, Murphy, Lietz, & Jordan, 2012). The ED PIT decreased the time from patient arrival to initial contact with a licensed medical provider from 75 to 25 min. Also, the proportion of patients who left without being seen decreased from 3.6% to 0.9%. Bahena and Andreoni (2013) studied the use of the PIT. They found that using an ENP in triage was a cost-effective method to improve throughput in the ED while providing quality emergency care. Patient satisfaction, quality measures, and financial improvements occurred with the use of a PIT. The authors concluded that an ENP is an excellent ED triage provider option. In addition, the authors noted that by having advanced emergency nursing competencies and decision-making skills, the ENP is a cost-effective provider to improve throughput in the ED while providing quality emergency care. A recent study provided evidence regarding the impact of NPs when compared with physicians. This study addressed the areas of health care quality, safety, and effectiveness from 1990–2009. “A high level of evidence also indicated that patient outcomes on satisfaction with care, health status, functional status, number of ED visits and hospitalizations, blood glucose, blood pressure, and mortality are similar for NPs and MDs” (Stanik-Hutt et al., 2013, p. 492). MORE RESEARCH IS NEEDED We need more quantitative and qualitative studies focusing on patient outcomes when APRNs provide care in the ED. Studies indicate that ENPs can be a valuable resource to manage increased ED service demands, including wait times, LOS, and patient satisfaction. Increased use of ENPs may improve both access to care and patient satisfaction and help make the best use of limited health care resources. Research funding is available from the Centers for Medicare and Medicaid through the National Prevention Partnership Program at www.hhs.gov/ash/nppa-faq.html. For ED quality data, you can also access https://data.medicare.gov/data/hospital-compare/Timely%26&%Effective&20Care (Centers for Medicare & Medicaid Services, 2014). So, let's get researching and get writing. —K. Sue Hoyt, PhD, RN, FNP-BC, CEN, FAEN, FAANP, FAAN Emergency Nurse Practitioner St. Mary Medical Center Long Beach, CA —Jean A. Proehl, RN, MN, CEN, CPEN, FAEN Emergency Clinical Nurse Specialist Proehl PRN, LLC Cornish, NH

The Landscape of Advanced Practice Nursing

Physicians Look to Disrupt Longtime Regulatory Tradition for APRNs

Nurse Practitioners in Emergency Care

Utilization and Timing of Cystoscopy for Hematuria Evaluation by Advanced Practice Providers and Urologists

IN RECENT YEARS, NUMEROUS ALLIED HEALTH PROFESsions have adopted or are planning to adopt clinical or practice doctorates. Although some have transitioned to an entry-level doctorate (eg, pharmacy and physical therapy) and others (eg, nursing) recognize the doctorate as an advanced practice degree, the professions’ goals are the same—to replace the master’s degree with a professionspecific doctoral degree. Allied health care clinicians with these degrees now practice, or will soon practice, as “doctors” alongside their physician colleagues. These clinicians function as competent and effective members of the health care team and had done so before obtaining doctoral degrees. So why make the move to a doctorate? Those in favor argue that a doctorate improves professional image, promotes more autonomous practice, and serves as an appropriate response to advancing technologies and the increasing complexity of health care. Others argue that doctorates may confuse patients, that they represent “degree creep,” and that doctoral degrees are sought largely for professional status rather than for issues related to clinical competence and market demand. The additional tuition costs associated with doctoral degrees and the perception that doctorates are prestigious and will attract students create incentives for universities to offer the degree. The added cost, however, has the potential to adversely affect recruitment of low-income and minority students. In addition, requirements for doctoral degrees lengthen the time in school, vary from program to program, and have not been proven to enhance students’ clinical abilities. At a time when the country is working to keep up with increasing demands of health care, do the perceived benefits of a doctorate justify the additional expense, time, and delay in getting clinicians into the workforce? The physician assistant (PA) profession has said “no.” In March 2009, PA organizations conducted a PA Clinical Doctorate Summit that involved clinically practicing PAs, PA educators, students, army PAs, representatives of other allied health professions, workforce experts, and allopathic and osteopathic physicians. Summit recommendations, which also reflect the views of a majority of surveyed PAs, express opposition to an entry-level PA clinical doctorate and officially endorse the master’s degree as the entrylevel and terminal degree for the profession. The recommendations include support for PAs who choose to pursue postgraduate training beyond the master’s degree but limit this support to non–PA-specific doctoral degrees. Discussions during the PA Clinical Doctorate Summit revolved around a number of issues, including the effects a PA doctorate could have on the profession’s relationship with physicians (eg, would physicians perceive a doctorate as a move toward independent practice?), the additional cost for students, and the potential for the degree to diminish the profession’s diversity. Final justifications for concluding that a PA-specific doctorate is unnecessary were “the length and cost of the current educational model has resulted in a responsive accessible PA workforce . . . and has adapted over 40 years to provide high quality, cost-effective, patientcentered care,” and that “both physicians and PAs practice in the domain of medicine therefore the entry-level doctorate for the practice of medicine is the MD or DO.” Despite the final recommendations, significant pressure for PAs to transition to a doctoral degree persists, especially as other clinicians work to expand their prestige and scope of practice. Some leaders in the PA profession have suggested that the decision not to endorse a clinical doctorate “ . . . may be tantamount to committing professional suicide.” They argue that physicians’ and the public’s perception that nonphysician clinicians with doctoral degrees are better educated, favors nurse practitioners, and will cause PAs to become marginalized, weakening the profession’s status within the health care community. Physicians practicing today may be unaware that physicians established the PA model of education in the 1960s to train individuals with prior health care experience to rapidly meet the needs of medically underserved areas. Currently, most applicants accepted to PA school have a bachelor’s degree, including required coursework in the basic and behavioral sciences, and 3 years of health care experience. PA education, which is modeled on medical education, averages 27 months in length and typically includes a didactic year of instruction in the sciences and clinical medi-

To examine nurse practitioner (NP) and physician assistant (PA) practice in nursing homes (NHs) during 2000-2010. Data were derived from the Online Survey Certification and Reporting system and Medicare Part B claims (20 percent sample). NP/PA state average employment, visit per bed year (VPBY), and providers per NH were examined. State fixed-effect models examined the association between state regulations and NP/PA use. NHs using any NPs/PAs increased from 20.4 to 35.0 percent during 2000-2010. Average NP/PA VPBY increased from 1.0/0.3 to 3.0/0.6 during 2000-2010. Average number of NPs/PAs per NH increased from 0.2/0.09 to 0.5/0.14 during 2000-2010. The impact of state scope-of-practice regulations was mixed. NP and PA scope-of-practice regulations impact their practice in NHs, not always as intended.

The imperative to integrate primary palliative care (PPC) into primary health care provides a compelling rationale for U.S.-based educational initiatives to prepare frontline health providers to deliver PPC across settings. Physicians, advanced practice registered nurses (APRNs), and physician assistants (PAs) are positioned as autonomous decision-makers. Therefore, their education should include PPC fundamentals critical to high-quality serious illness care. To conduct an integrative review of best teaching practices in PPC education for medical, APRN, and PA students preparing for frontline provider roles in the United States. A systematic search of peer-reviewed literature published between 2011 and 2025 was conducted. Studies describing PPC educational interventions or curricula for medical, APRN, or PA students were included. Data extraction and thematic synthesis were guided by the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care and Kirkpatrick's model of assessing educational outcomes. A total of 1691 articles were identified. After screening 1256 titles and abstracts and reviewing 292 full-text articles, 64 studies met inclusion criteria. Most studies focused on medical students (94%), with fewer addressing APRN (13%), PA (2%), or interprofessional cohorts (16%). A majority were descriptive or nonempirical (88%) and focused on structural and process-oriented components of PPC education (89%). Eighty-four percent employed multifaceted teaching approaches. Five consensus themes emerged as best practices: (1) multifaceted teaching strategies, (2) interprofessional education, (3) reflective and/or humanities-based experiences, (4) early and repeated exposure, and (5) availability of teaching resources. While the literature supports improvements in learners' knowledge, skills, and attitudes, few studies evaluate higher-level outcomes such as long-term skill retention or impact on patient and system-level care. This review provides lessons learned and evidence-informed recommendations to guide curricular development and identifies key gaps to inform future educational research to better prepare frontline health professions students in delivering high-quality PPC.

The purpose of this article is to describe the development of a professional practice model (PPM) for advanced practice registered nurses (APRNs). A literature review was conducted on PPMs. Simultaneous review of authoritative resources, including The National Organization of Nurse Practitioner Faculties (NONPF) and the Licensure, Accreditation, Certification and Education (LACE) Consensus Model, was performed. An expert panel was established to validate the transformational advanced professional practice (TAPP) model. APRNs are relied upon by organizations to provide leadership in the delivery of high-quality, cost-effective health care while improving access and eliminating preventable morbidities. Existing models fail to fully capture the professional scope of practice for APRNs. The TAPP model serves as a framework to guide professional development and mentorship of APRNs in seven domains of professional practice (DOPP). To meet the Institute of Medicine's recommendations for the future of nursing, APRNs should practice to the fullest extent of their education and training. Providing clarification regarding the DOPP of the APRN role is needed to standardized professional practice. The TAPP model is an inspiring blueprint that allows APRNs to model the way by delivering comprehensive health care in seven DOPP.