Search

Physician supervision of nurse practitioners (NPs) was temporarily waived in Massachusetts in response to a state of emergency due to the COVID-19 pandemic. The authors examined the impact of the scope-of-practice changes and pandemic-related demands on psychiatric mental health NPs (PMHNPs) during the state's first COVID-19 surge.A mixed-methods Web-based survey was conducted in May and June of 2020. Fisher's exact test was used to compare associations across certification types, and inductive content analysis was applied to open-ended responses.The survey response rate was 41% (N=389 of 958), consisting of 26 PMHNPs and 363 other NPs. Compared with other NPs, PMHNPs were significantly more likely to work in a telehealth setting (42% vs. 11%, p0.001), to spend more time working during the initial surge (50% vs. 26%, p0.05), and to believe that the waiver improved clinical work (52% vs. 25%, p0.01). Content analysis of PMHNPs' open-ended responses identified four themes: the supervision waiver reduced burden on PMHNPs, collaboration and mentorship models persisted, the pandemic exacerbated the already high demand for psychiatric care, and telehealth helped meet the high demand for such care.PMHNPs may be more sensitive to the scope-of-practice changes and telehealth expansion than other NPs because of the constraints of the psychiatrist shortage and high relative uptake of telehealth in psychiatric care. The interactions of workforce supply, telehealth expansion, and scope-of-practice laws are important to consider in the development of policies to improve access to mental health care.

The Consensus Model specifies distinct education preparations for acute care and primary care nurse practitioners (NP), but incomplete implementation and employer hiring practices risk misalignment of certification and practice.Report the prevalence of acute care certification among NPs working in acute care, investigate the factors associated with alignment, and explore the impact of alignment on nurse outcomes.Using the 2018 National Sample Survey of Registered Nurses, we selected NPs practicing acute care and compared employment, education, and nurse outcomes by certification alignment.A minority of NPs (44.5%) held acute care certification. Controlling for NP characteristics, those practicing in states that restrict a NP's practice to their area of certification had 47% higher odds of acute care certification.Understanding patterns of alignment in the NP workforce and the factors that produce them is critical to an appropriate regulatory framework for advanced practice nursing.

Background Trust occurs when a person feels they can be vulnerable to others because of the sincerity, benevolence, truthfulness and sometimes the competence they perceive. This project examines the various types of trust expressed in written reflections of developing healthcare clinicians. Our goal is to understand the roles trust plays in residents’ self-examination and to offer insight from relationship science to inform the teaching and clinical work for better trust in healthcare. Methods We analyzed 767 reflective writings of 33 residents submitted anonymously, to identify explicit or implicit indicators attention to trust or relationship development. Two authors independently coded the entries based on inductively identified dimensions. Three authors developed a final coding structure that was checked against the entries. These codes were sorted into final dimensions. Results We identified 114 written reflections that contained one or more indicators of trust. These codes were compiled into five code categories: Trust of self/trust as the basis for confidence in decision making; Trust of others in the medical community; Trust of the patient and its effect on clinician; Assessment of the trust of them exhibited by the patient; and Assessment of the effect of the patient’s trust on the patient’s behavior. Discussion Broadly, trust is both relationship-centered and institutionally situated. Trust is a process, built on reciprocity. There is tacit acknowledgement of the interplay among what the residents do is good for the patient, good for themselves, and good for the medical institution. A focus on moments in which trust is experienced or missed, as well as on types of trust, misses this complexity. Conclusion A greater awareness of how trust is present or absent could lead to a greater understanding and healthcare education for beneficial effects on clinicians’ performance, personal and professional satisfaction, and improved quality in patients’ interactions.

In the U.S. healthcare system, telehealth is increasingly present and demands ethical assessment. On the one hand, telehealth increases access to healthcare services for some at-risk populations (e.g., people suffering from mental illness and addictions) and in specific contexts (e.g., rural). On the other hand, telehealth widens the digital divide and can lead to overuse of services. Furthermore, because it is still unclear how telehealth influences trust between patients and primary care clinicians, connecting relationship science and human communication research can inform critical reasoning. Finally, healthcare policy is advancing toward the wide adoption of telehealth. Hence, it is urgent to address these ethical issues and invest in further research.

Background While optimal utilization of the nurse practitioner (NP) workforce is an increasingly popular proposal to alleviate the growing primary care shortage, federal, state, and organizational scope of practice policies inhibit NPs from practicing to the full extent of their license and training. In March of 2020, NP state-specific supervisory requirements were temporarily waived to meet the demands of the coronavirus disease 2019 (COVID-19) pandemic in Massachusetts. Objective The objective of this study was to examine the impact of temporarily waived state practice restrictions on NP perception of care delivery during the initial surge of the COVID-19 pandemic in Massachusetts. Research design Mixed methods descriptive analysis of a web-based survey of Massachusetts NPs (N=391), conducted in May and June 2020. Results The vast majority (75%) of NPs believed the temporary removal of practice restriction did not perceptibly improve clinical work. Psychiatric mental health NPs were significantly more likely than other NP specialties to believe the waiver improved clinical work (odds ratio=6.68, P=0.001). NPs that experienced an increase in working hours during the pandemic surge were also more likely to report a positive effect of the waiver (odds ratio=2.56, P=0.000). Conclusions Temporary removal of state-level practice barriers alone is not sufficient to achieve immediate full scope of practice for NPs. The successful implementation of modernized scope of practice laws may require a collective effort to revise organizational and payer policies accordingly.

Digital health advances offer a multitude of possibilities to improve public health and individual wellbeing. Little attention has been paid, however, to digital health's potential to create low-value care - the reduction of which is increasingly appreciated as a policy priority. This commentary provides a framework to illustrate the potential for consumer-facing digital health to generate three distinct categories of low-value care; 1) ineffective care because it is underdeveloped, 2) inefficient care because it supplements rather than substitutes, or 3) unwanted care because it is not aligned with clinician and patient preferences. We offer specific policy recommendations to reduce each type of low-value care.

Objective: The objective of this study was to estimate trends in the percentage of Medicare beneficiaries cared for by nurse practitioners from 2012 to 2017, to characterize beneficiaries cared for by nurse practitioners in 2017, and to examine how the percentage of beneficiaries cared for by nurse practitioners varies by practice characteristics. Design: An observational study of 2012–2017 Medicare feefor-service beneficiaries’ ambulatory visits. We computed the percentage of beneficiaries with 1 or more ambulatory visits from nurse practitioners and the percentage of beneficiaries receiving the plurality of their ambulatory visits from a nurse practitioner versus a physician (ie, predominant provider). We compared beneficiary demographics, clinical characteristics, and utilization by the predominant provider. We then characterized the predominant provider by practice characteristics. Key Results: In 2017, 28.9% of beneficiaries received any care from a nurse practitioner and 8.0% utilized nurse practitioners as their predominant provider—an increase from 4.4% in 2012. Among beneficiaries cared for by nurse practitioners in 2017, 25.9% had 3 or more chronic conditions compared with 20.8% of those cared for by physicians. Beneficiaries cared for in practices owned by health systems were more likely to have a nurse practitioner as their predominant provider compared with those attending practices that were independently owned (9.3% vs. 7.0%). Conclusions: Nurse practitioners are caring for Medicare beneficiaries with complex needs at rates that match or exceed their physician colleagues. The growing role of nurse practitioners, especially in health care systems, warrants attention as organizations embark on payment and delivery reform.

To examine differences in the quality of care provided by primary care nurse practitioners (PCNPs), primary care physicians (PCMDs), or both clinicians.Medicare part A and part B claims during 2012-2013.Retrospective cohort design using standard risk-adjustment methodologies and propensity score weighting assessing 16 claims-based quality measures grouped into 4 domains of primary care: chronic disease management, preventable hospitalizations, adverse outcomes, and cancer screening.Continuously enrolled aged, disabled, and dual eligible beneficiaries who received at least 25% of their primary care services from a random sample of PCMDs, PCNPs, or both clinicians.Beneficiaries attributed to PCNPs had lower hospital admissions, readmissions, inappropriate emergency department use, and low-value imaging for low back pain. Beneficiaries attributed to PCMDs were more likely than those attributed to PCNPs to receive chronic disease management and cancer screenings. Quality of care for beneficiaries jointly attributed to both clinicians generally scored in the middle of the PCNP and PCMD attributed beneficiaries with the exception of cancer screening.The quality of primary care varies by clinician type, with different strengths for PCNPs and PCMDs. These comparative advantages should be considered when determining how to organize primary care to Medicare beneficiaries.