Allison A. Norful

Primary Care Nurse Practitioner Practice Characteristics: Barriers and Opportunities for Interprofessional Teamwork

Developing team-based care models and expanding nurse practitioner (NP) workforce in primary care are recommended by policy makers to meet demand. Little is known how to promote interprofessional teamwork. Using a mixed-methods design, we analyzed qualitative interview and quantitative survey data from primary care NPs to explore practice characteristics important for teamwork. The Interprofessional Teamwork for Health and Social Care Framework guided the study. We identified NP-physician and NP-administration relationships; organizational support and governance; time and space for teamwork; and regulations and economic impact as important. Practice and policy change addressing these factors is needed for effective interprofessional teamwork.

Organizational structures and outcomes of newly hired and experienced nurse practitioners in New York State

BACKGROUND Given the projected increase in the nurse practitioner (NP) workforce, the number of NPs in health care organizations will grow. However, little is known about the capacity of these organizations to create conducive environments for NP practice. PURPOSE Examine and compare the NP patient panel, job satisfaction, turnover intentions, and organizational structures of NPs with less than three (newly hired) and more than three (experienced) years of experience in their current job. METHODS An online survey of New York State Nurse Practitioner Association members was conducted in 2012; 278 NPs completed measures of NP patient panel, job satisfaction, turnover intentions, and organizational structures. DISCUSSION Both newly hired and experienced NPs faced organizational challenges such as poor relations with administration and lack infrastructure for care. Newly hired NPs were twice more likely to have turnover intentions. CONCLUSION These organizational barriers should be addressed by administrators to assure optimal NP practice.

Primary Care Providers’ Perspectives on Errors of Omission

Background: Despite recent focus on patient safety in primary care, little attention has been paid to errors of omission, which represent significant gaps in care and threaten patient safety in primary care but are not well studied or categorized. The purpose of this study was to develop a typology of errors of omission from the perspectives of primary care providers (PCPs) and understand what factors within practices lead to or prevent these omissions. Methods: A qualitative descriptive design was used to collect data from 26 PCPs, both physicians and nurse practitioners, from the New York State through individual interviews. One researcher conducted all interviews, which were audiotaped, transcribed verbatim, and analyzed in ATLAS.ti, Berlin by 3 researchers using content analysis. They immersed themselves into data, read transcripts independently, and conducted inductive coding. The final codes were linked to each other to develop the typology of errors of omission and the themes. Data saturation was reached at the 26th interview. Results: PCPs reported that omitting patient teaching, patient followup, emotional support, and addressing mental health needs were the main categories of errors of omission. PCPs perceived that time constraints, unplanned patient visits and emergencies, and administrative burden led to these gaps in care. They emphasized that organizational support and infrastructure, effective teamwork and communication, and preparation for the patient encounter were important safeguards to prevent errors of omission within their practices. Discussion: Errors of omission are common in primary care and could threaten patient safety. Efforts to eliminate them should focus on strengthening organizational attributes of practices, improving teamwork and communication, and assigning manageable workload to PCPs. Conclusions: Practice and policy change is necessary to address gaps in care and prevent them before they result in patient harm.

Nurse practitioner–physician comanagement of primary care patients: The promise of a new delivery care model to improve quality of care

Background: The U.S. primary care system is under tremendous strain to deliver care to an increased volume of patients with a concurrent primary care physician shortage. Nurse practitioner (NP)–physician comanagement of primary care patients has been proposed by some policy makers to help alleviate this strain. To date, no collective evidence demonstrates the effects of NP–physician comanagement in primary care. Purpose: This is the first review to synthesize all available studies that compare the effects of NP–physician comanagement to an individual physician managing primary care. Methods: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) framework guided the conduct of this systematic review. Five electronic databases were searched. Titles, abstracts, and full texts were reviewed, and inclusion/exclusion criteria were applied to narrow search results to eligible studies. Quality appraisal was performed using Downs and Black’s quality checklist for randomized and nonrandomized studies. Results: Six studies were identified for synthesis. Three outcome categories emerged: (a) primary care provider adherence to recommended care guidelines, (b) empirical changes in clinical patient outcomes, and (c) patient/caregiver quality of life. Significantly more recommended care guidelines were completed with NP–physician comanagement. There was variability of clinical patient outcomes with some findings favoring the comanagement model. Limited differences in patient quality of life were found. Across all studies, the NP–physician comanagementcare delivery model was determined to produce no detrimental effect on measured outcomes and, in some cases, was more beneficial in reaching practice and clinical targets. Practice Implications: The use of NP–physician comanagement of primary care patients is a promising delivery care model to improve the quality of care delivery and alleviate organizational strain given the current demands of increased patient panel sizes and primary care physician shortages. Future research should focus on NP–physician interactions and processes to isolate the attributes of a successful NP–physician comanagement model.

Nurse Practitioner–Physician Comanagement: A Theoretical Model to Alleviate Primary Care Strain

PURPOSE Various models of care delivery have been investigated to meet the increasing demands in primary care. One proposed model is comanagement of patients by more than 1 primary care clinician. Comanagement has been investigated in acute care with surgical teams and in outpatient settings with primary care physicians and specialists. Because nurse practitioners are increasingly managing patient care as independent clinicians, our study objective was to propose a model of nurse practitioner–physician comanagement. METHODS We conducted a literature search using the following key words: comanagement; primary care; nurse practitioner OR advanced practice nurse. From 156 studies, we extracted information about nurse practitioner–physician comanagement antecedents, attributes, and consequences. A systematic review of the findings helped determine effects of nurse practitioner–physician comanagement on patient care. Then, we performed 26 interviews with nurse practitioners and physicians to obtain their perspectives on nurse practitioner–physician comanagement. Results were compiled to create our conceptual nurse practitioner–physician comanagement model. RESULTS Our model of nurse practitioner–physician comanagement has 3 elements: effective communication; mutual respect and trust; and clinical alignment/shared philosophy of care. Interviews indicated that successful comanagement can alleviate individual workload, prevent burnout, improve patient care quality, and lead to increased patient access to care. Legal and organizational barriers, however, inhibit the ability of nurse practitioners to practice autonomously or with equal care management resources as primary care physicians. CONCLUSIONS Future research should focus on developing instruments to measure and further assess nurse practitioner–physician comanagement in the primary care practice setting.

Nurse practitioners as primary care providers with their own patient panels and organizational structures: A cross-sectional study

BACKGROUND Health care systems globally are facing challenges of meeting the growing demand for primary care services due to a shortage of primary care physicians. Policy makers and administrators are searching for solutions to increase the primary care capacity. The effective utilization of nurse practitioners (NPs) has been proposed as a solution. However, organizations utilize NPs in variable capacities. In some settings, NPs serve as primary care providers delivering ongoing continuous care to their patients, referred to as patient panels, whereas in other settings they deliver episodic care. Little is known about why organizations deploy NPs differently. OBJECTIVES Investigate the NP role in care delivery-primary care providers with the own patient panels or delivering episodic care-within their organizations and understand how work environments affect their role. DESIGN A cross-sectional survey design was used to collect data from primary care NPs. SETTINGS The study was conducted in one state in the United States (Massachusetts). Data from 163 primary care organizations was obtained, which employed between one to 12 NPs. PARTICIPANTS 807 NPs recruited from the Massachusetts Provider Database received mail surveys; 314 completed and returned the survey, yielding a response rate of 40%. METHODS The survey contained measures of NP role in care delivery and work environment. NP role was measured by an item asking NPs to report if they deliver ongoing continuous care to their patient panel or if they do not have patient panel. The work environment was measured with the Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ). The multilevel Cox regression models investigated the influence of organization-level work environment on NP role in care delivery. RESULTS About 45% of NPs served as primary care providers with their own patient panel. Organization-level Independent Practice and Support subscale, an NP-PCOCQ subscale, had a significant positive effect on NP role (risk ratio=2.33; 95% CI: 1.06-5.13); with a one unit increase on this subscale, the incidence of the NPs serving as primary care providers with their own patient panel doubled. CONCLUSIONS NPs can help meet the increasing demand for primary care by taking responsibilities as primary care providers, and organizations can assign NPs their own patient panels. Supporting NP independent practice within organizations promotes NP role as primary care providers. Policy and organizational change focused on promoting NP work environments so NPs can practice as primary care providers can be an effective strategy to increase the primary care capacity.