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Background: Larger patient caseloads and increased workplace responsibility for nurse practitioners (NPs) may exacerbate factors leading to compassion fatigue (CF)., Purpose: The purpose of this study is to analyze the rate of burnout in practicing NPs by looking at contributing factors that play a role in CF and compassion satisfaction (CS)., Methods: A NP social media platform was used to distribute a survey to a convenience sample of 208 NPs. Data included the Professional Quality of Life Scale V (ProQOL V) tool, demographic data, and protective factor questions. The data were dissected for CF and protective factors of CS., Results: The relationship of mindfulness practices and levels of CS was statistically significant. The relationship between support from family, coworkers, and administration and levels of CS was also found statistically significant. A large association was found between the correlation of burnout and support from coworkers., Implications for Practice: Findings showed an average to high level of CS with a low-to-average burnout rate among the NPs surveyed. There was a direct impact between the amount of support participants received from individual support systems and their level of CS. These findings could be beneficial for new NP graduates in establishing a sense of community while reducing the risk for burnout., Competing Interests: Competing interests: The authors report no conflicts of interest., (Copyright © 2020 American Association of Nurse Practitioners.)

Purpose of Study: To explore the spiritual dimensions of nurse practitioner consultations in primary care through the lens of availability and vulnerability. Design of Study and Methods Used: A hermeneutic phenomenological enquiry exploring the spiritual dimensions of primary care consultations consisting of two interviews per participant over an 18-month period was conducted with nurse practitioners in the United Kingdom. A purposive sample of eight nurse practitioners were recruited and interviewed. Interviews were fully transcribed and analyzed thematically. Findings: Participants identified that spirituality can be difficult to conceptualize and operationalize in practice. Participants articulated the meaning of spirituality and gave examples of when they had witnessed a spiritual dimension in practice. Key themes included how nurse practitioners conceptualize spirituality, the context for spirituality to be integrated into care, and the importance of spirituality as an aspect of holistic care. The concepts of Availability and Vulnerability were used intentionally as a lens in the study to explore whether these concepts and approaches to practice could enhance integration of spirituality into practice. Conclusion: Knowledge and understanding regarding spirituality in nurse practitioners consultations in primary care has been uncovered. A framework for operationalizing spirituality has been developed.

Academic and health care institutions are charged with improving quality-of-care outcomes by creating culturally educated health care professionals to practice in a global health care environment. International short-term service learning experiences provide nurse practitioner students an opportunity to meet clinical competency skills aligned with course curricula. Faculty can directly observe students' clinical practice, and students broaden diagnostic reasoning skills while earning credit for clinical hours. As project and research ideas are formulated, students develop system-level thinking to implement evidence-based practices and disseminate their knowledge and experience of caring for the underserved. Students who participate in service-learning opportunities foster their awareness of cultural humility, easing transition into practice. Some academic institutions established short-term service-learning opportunities for students, and evidence supports faculty and students' sense of well-being after participation. We describe an example of a short-term, international service-learning opportunity in Haiti where students work with an interprofessional team and experience the effect of social determinants of health on delivering quality care.

The transition between student and new nurse practitioner (NP) can be challenging. Survival guides given to student NPs may help ease the transition and make it a successful one. This study evaluates the effectiveness of survival guides in two student NP cohorts in the fall 2015 and fall 2016 semesters. Students completed a brief online survey at graduation, and three and six months after graduation. Results support the inclusion of survival guides in NP curricula as a creative way to positively support the transition from student to new NP and improve preparation for NP practice.

Social media is increasingly utilized as a resource in healthcare. We sought to identify perceptions of using social media as an educational tool among healthcare practitioners. An electronic survey was distributed to healthcare administrators, nurses, nurse practitioners, pharmacists, physicians, and physician assistants f hospital systems and affiliated health science schools in Georgia, Maryland, South Carolina, and Wisconsin. Survey questions evaluated respondents' use and views of social media for educational purposes and workplace accessibility using a Likert scale (1 = strongly disagree, 5 = strongly agree). Nurses (75%), pharmacists (11%), and administrators (7%) were the most frequent respondents. Facebook® (27%), Pinterest® (17%), and Instagram® (17%) were the most frequently accessed social media platforms. Nearly 85% agreed or strongly agreed that social media can be an effective tool for educational purposes. Among those who had social media platforms, 43.0% use them for educational purposes. Pinterest® (30%), Facebook® (22%), LinkedIn® (16%), and Twitter® (14%) were most frequently used for education. About 50% of respondents had limited or no access to social media at work. Administrators, those with unlimited and limited work access, and respondents aged 20-29 and 30-39 years were more likely to agree that social media is an educational tool (OR: 3.41 (95% CI 1.31 to 8.84), 4.18 (95% CI 2.30 to 7.60), 1.66 (95% CI 1.22 to 2.25), 4.40 (95% CI 2.80 to 6.92), 2.14 (95% CI 1.53 to 3.01) respectively). Residents, physicians, and those with unlimited access were less likely to agree with allowing social media access at work for educational purposes only. Healthcare practitioners frequently utilize social media, and many believe it can be an effective educational tool in healthcare., Competing Interests: The authors have declared that no competing interests exist.

Abstract: Poverty has detrimental effects on health outcomes. Doctorally prepared nurse practitioners are in a position to promote health for patients and communities experiencing poverty. To do so, they must be aware of their own attitudes and to have empathy toward the condition of poverty. Specialized poverty simulations have been successfully used to improve attitudes toward poverty among prelicensure nursing students, but there is a paucity of evidence exploring the effects of poverty simulations among Students in a Doctor of Nurse Practice (DNP) program. The purpose of this study was to evaluate the impact of a poverty simulation for students enrolled in a DNP program on their attitudes toward poverty. A quasi-experimental, pre-test and post-test survey design was used in this curriculum improvement project. A total of 29 DNP students participated in a 1-time, 4-hour Community Action Poverty Simulation© (CAPS). The simulations presented various challenges faced during 1 month of living in poverty. The Attitudes toward Poverty Scale-Short Form (ATPS-SF) was used to measure attitudes toward poverty both before and after the CAPS© experience. Descriptive statistics and paired t-tests were used to describe the participant group and measure the impact of the simulation on attitudes toward poverty. Attitudes toward poverty improved overall on all dimensions of the ATPS-SF after the CAPS© experience as compared to the pre-test, with particular improvement regarding stigmas related to poverty. Statistically significant improvements were detected on four items, and the overall favorable shift in attitudes presents clinically significant results. This poverty simulation experience should be considered for adoption into DNP curricula., Competing Interests: Competing interests: The authors report no conflicts of interest., (Copyright © 2020 American Association of Nurse Practitioners.)

Aims and Objective: To gain insight into nurse practitioners' (NP) leadership roles in Dutch hospital care, by exploring the perceptions regarding their current leadership role and the differences with their previous role as a registered specialised nurse., Background: To meet today's challenges of the increasing healthcare demands, the employment of NPs is proliferating. NPs have the ideal position to play a pivotal role within healthcare reforms, yet full expansion of their scope of practice and expertise is having limited success. Long-term sustainability of NPs depends on the ability to perform and develop a leading role., Design and Methods: This qualitative descriptive study was conducted in fifteen Dutch hospitals. Data were collected from April-July 2018, and purposive sampling was used for eighteen semi-structured interviews. This study is conducted and reported according to the COREQ checklist., Results: Three main themes concerning NPs' current leadership role emerged, and they were all linked to a successful positioning of NPs. All themes seemed to be of influence on NPs' scope of daily practice. Direct patient care was emphasised, and leadership on other levels appeared to be underused. Most NPs desired to reshape their profession. However, unprofitable use of their leadership skills especially on professional and organisational level and lack of supportive factors seemed to hinder them., Conclusions: An adequate use of leadership is crucial for role development and positioning of NPs. Further development of the NP profession can help to better differentiate between the tasks of registered specialised nurses and NPs., Relevance to Clinical Practice: Leadership in nursing contributes to the improvement of the quality and efficiency of health care. Further positioning of the NP profession depends on a profitable use of leadership competencies. Besides, NPs should collaborate with healthcare organisations, educational institutions and professional associations to value the NP profession in the current healthcare system., (© 2019 John Wiley & Sons Ltd.)

Catherine is an advanced nurse practitioner working in a large general practice in the north of England. She works alongside her medical colleagues and receives and treats patients with undifferentiated complaints. Margaret, a 64 year-old woman, is presenting today with vague symptoms. She is reluctant to come and get help and is fearful of what the consequences might be., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

This third installment of the Disaster Response Series focuses on the need for NPs to be familiar with the information communication technologies used in their geographic areas and be ready to use them when, not if, a disaster strikes.

Background and Purpose: The benefits of professional association membership to individual health care providers are well established. However, not all nurse practitioners (NPs) are members of professional associations. Research is available on factors that influence registered nurses' decisions to join professional associations, but little is known regarding factors influencing the decisions of NPs. The purpose of this study was to identify factors affecting NPs' decisions to join NP associations., Methods: A cross-sectional survey of NPs (N = 537) was conducted electronically in accordance with the Checklist for Reporting Results of Internet E-Surveys guidelines. The Professional Association Membership Questionnaire was used to develop the survey. Three hundred twenty-eight respondents (61.1%) had a current membership in a professional association and 209 (38.9%) were nonmembers. Although both members and nonmembers expressed a desire for professional programs, improvement in the profession, and personal development, current members scored significantly higher in each of these factors (p < .001 to p = .015)., Conclusion: The results suggest that factors influencing NPs' decisions to join professional associations include the desire for professional programs, improvement of the profession, and personal development., Implications for Practice: Professional associations seeking to improve health outcomes by creating more competent, safe NPs and keeping the public's trust should consider focusing on efforts that foster education, professional networking and new ideas, and self-improvement.

Stress is an inevitable part of nursing life. Nurses need to respond to their stressful environment contents to reduce negative consequences. We examined the role of dimensions of emotional intelligence in predicting coping reactions to stress in 201 college nursing practitioners in this cross-sectional study between November 2017 and January 2018. The nurses appraised their own emotions, but they were not sure that appraised others' emotions, regulated their and others' emotions. They could cope with new ideas and faced obstacles. Most of the nurses were moderately stressed. Those nurses were not able to regulate their own emotions were determined to have a higher level of perceived stress. Active coping, positive reframing and acceptance were the most prevalent coping mechanisms. The investigation showed that others' emotion appraisal was a predictor for self-blame reaction, and emotion utilization was the predictor for positive reframing and self-blame.

There has been an increase in student enrollment in advanced practice nurse programs, but limited information regarding attrition and dropout rates in nurse practitioner (NP) programs. Management of NP students includes student evaluations, preceptor guidance and support, student support, and use of reflective practice. Program directors, faculty members, and preceptors must assist NP students with role transitioning and help those who are not meeting the rigors of NP education to leave the program and discover alternative nursing roles.

Acute care nurse practitioners (ACNPs) require special training and educational preparation to meet their role expectations. Using high fidelity simulation with debriefing modalities is considered one of the innovative learning strategies in graduate nursing. No studies have investigated debriefing modalities in nurse practitioner programs specially ACNPs leadership skills. The purpose of this study was to examine the difference in students' knowledge, code team leader skills and self-efficacy using two debriefing modalities. A two group, pretest-posttest quasi-experimental design was used. Students were divided into video-assisted debriefing group vs. verbal debriefing following a simulation scenario of managing emergency codes. There were no significant differences between the two groups in knowledge acquisition/retention, leadership skills, and self-efficacy, but there was a significant difference in self-efficacy in both groups between two-time points. There was a general improvement in teams' performance. Students preferred verbal debriefing over video-assisted debriefing. The debriefing session plays an important role in graduate nursing education. Acute care nurse practitioners are lacking a formal leadership training to meet their advanced role. Nurse Educators, and simulation/debriefing leaders may benefit from our study results to develop a structured, formal curriculum and educational instruction focusing on acute care nurse practitioners' role change especially leading a resuscitation team., Competing Interests: Declaration of competing interest None., (Published by Elsevier Ltd.)

Background and Purpose: Nurse practitioner (NP) faculties are challenged to offer programs that balance didactic knowledge with the clinical experiences required to prepare graduates for the complexities of health care. Students have the stress of extrapolating the information they obtain during these programs and applying it to postgraduation certification examinations. Innovative educational tools are necessary to ease the uncertainty that NP students experience to graduate and pass certification examinations. Tools include academic-clinical partnerships (ACPs) to enhance clinical opportunities and resources to integrate diagnostic readiness tests (DRTs) into curricula., Methods: This was a quasi-experimental one group, pretest/posttest design using a convenience sample of NP students randomly assigned to clinical in ACP or non-ACP clinical placements. They completed the DRTs twice during their final program semesters., Conclusions: The overall DRT group scores for the NP students significantly improved over time. The Wilcoxon signed ranks test showed that the posttest scores were significantly higher than the pretest scores. The Mann-Whitney U test revealed no differences between the ACP and non-ACP students. Students performed the best on assessment, diagnosis, management, and pharmacology domains. This demonstrates support for the integration of DRTs into NP programs., Implications for Practice: Integrating DRTs into NP programs can facilitate transition to the NP role.

Social workers (SW) and community health workers (CHW) have emerged as key workforce personnel in efforts to care for elders in the U.S. However, little is known about the presence and roles of SW and CHW in primary care practices. This paper presents findings from a nationally representative survey of geriatrics and primary care practices. Physician and nurse practitioner clinicians were randomly selected within practices, stratifying by practice staffing and presence/absence of geriatric clinicians; our final sample for this analysis included 341 practices. Key findings include: reported challenges in meeting the social service needs of elders, underutilization of SW, and fuller utilization of social work competencies in practices in which both SW and CHW were present. These findings offer a unique perspective of SW on interprofessional teams and have implications for the future of the profession.

Background: As of 2019, ten jurisdictions in the United States have authorized physicians to prescribe a lethal dose of medication to a terminally ill patient for the purpose of hastening death. Relatively little bioethics scholarship has addressed the question of whether physicians have an obligation to inform qualifying patients about aid-in-dying (AID) in permissive jurisdictions and little is known about providers' actual communication practices with respect to this issue. Methods: One hundred and forty-four in-depth, semi-structured interviews were conducted and analyzed using an inductive analytic approach as part of the Vermont Study on Aid-in-Dying. Results: Seventeen respondents, 14 physicians and 3 nurse practitioners, met the inclusion criteria for this sub-study. Eleven respondents indicated that they at least sometimes inform patients about AID. Respondents described multiple factors that influence whether or not they might initiate discussions of AID, including the importance of informing patients of their options for end-of-life care, worries about undue influence, and worries about the potential effects on the patient-provider relationship. For those providers who do initiate discussion of AID at least some of the time, attention to the particulars of each individual patient's situation and the context of the discussion appear to play a role in shaping communication about AID. Conclusions: While initiating a clinical discussion of AID is undoubtedly challenging, our study provides compelling descriptive evidence that some medical providers who support AID do not unilaterally follow the conventional bioethics wisdom holding that they ought to wait for patients to introduce the topic of AID. Future research should investigate how to approach these discussions so as to minimize ethical worries about undue influence or potential negative consequences.

Abstract: Few nurse practitioner programs integrate education on care of veterans into their curriculum. Because more veterans are seeking health care outside of the Veteran Affairs system, all advanced practice nurses need to be prepared to meet the unique needs of veterans with post-traumatic stress disorder (PTSD). The authors developed an education session on military-to-civilian transition and screening and treatment of veterans with PTSD. The session was provided to a convenience sample of students. Case studies were included to allow student participation and active learning. Students completed pre-education and post-education surveys to measure their comfort level in caring for this specific population and their understanding of PTSD. The participant scores on comfort level with identifying and managing PTSD after the education session were significantly increased. Placing veteran-specific education into nurse practitioner programs enhances the comfort level with identifying and managing PTSD. Adding this veteran-specific education could enhance the overall care for veterans in the civilian sector., Competing Interests: Competing interests: The authors report no conflicts of interest., (Copyright © 2019 American Association of Nurse Practitioners.)

Background: The gap between the expectation and the development of role competency is a dilemma that nurse practitioners (NPs) face in clinical settings., Purpose: This study was designed to explore the perceived importance and actual practice of the role competencies of NPs and to compare the differences between the ideal and practical domains as well as related factors., Methods: This cross-sectional design study used Q-sort to collect data. A 56-item "Nurse Practitioner Role Capacity Questionnaire" was used as the research tool. Two questionnaires: Perceptions of Important Role Competencies and Actual Execution of Role Competencies were distributed to NPs twice, at times that were 2 weeks apart. A total of 40 participants were recruited, including 21(52.5%) internal medicine NPs and 19 (47.5%) surgical medicine NPs., Results: The significant differences that were identified in this study between the perceived importance and actual practice of role competencies were, by domain: medical assistance (t = -5.62, p < .001), clinical research (t = 4.14, p < .001), professional consultation (t = 2.29, p = .027), and direct care (t = 2.21, p = .033). The correlative factors for these differences were: education level (t = -2.17, p = .036) and membership in the Nurse Practitioner Association (t = -2.36, p = .017). NPs with higher levels of education and with membership in the Nurse Practitioner Association earned higher scores for self-expectation in important clinical competency., Conclusions: NPs face discrepancies in their role expectations, in important part due to their role as providers of medical assistance in clinical practical settings. NPs need to learn and demonstrate the roles and functions of advanced nursing practice to enhance nursing professionalism profoundly.

Background: Advanced Practice is recognized by the Royal College of Nursing as a distinctive level of practice encompassing direct care provision, education, research, and management. Advanced Nurse Practitioners (ANP) are educated to MSc level and assessed as competent in their field. A teenage and young adult advanced nurse practitioner (TYA ANP) was introduced in 2015, one of few within the United Kingdom. This service evaluation assesses the impact of the new role on patient and staff experience. Aims/Objectives: To evaluate the impact of TYA ANP role on the experience of TYA oncology patients and the multidisciplinary team (MDT) and to assess perception of quality, safety, and efficiency of this role. Methodology: Retrospective data collection using Australia Nurse Practitioner Study Questionnaire to MDT and patients treated within the TYA unit since the ANP role was introduced. Descriptive statistics were used to analyze outcomes of the data collected. Results: Eighty-six percent of patients and 90% of staff felt they understood the ANP role. While 100% of patients felt the TYA ANP service was a success, met their needs, prescribed correctly, offered holistic and safe care, and had a positive impact on care. Furthermore, 86% of patients felt the TYA ANP service was easy to use and 90% of staff felt the TYA ANP service met the needs of the patients. Discussion/Conclusion: Overall patients and staff reported a positive experience particularly on correct diagnosis, safe prescribing, and having a positive impact on care. Areas for improvement include wider understanding of the role.

Objective: The goal of the study was to assess knowledge gaps and practice patterns of US-based addiction specialists, primary care physicians (PCPs), nurse practitioners (NPs), and physician assistants (PAs) who treat patients with opioid use disorder (OUD)., Design: As part of a prospective study, the authors developed a survey tool consisting of case-vignettes and questions designed to reveal practice patterns and highlight gaps in clinician knowledge., Setting: The primary study setting included clinicians practicing in outpatient care., Participants: The surveys were distributed via email between August and September 2017 to a national sample of addiction specialists, PCPs, and NPs/PAs that see at least one patient per week and at least 1 percent of their patient population had to be diagnosed with OUD., Results: The knowledge assessment results varied among the clinicians surveyed. Addiction specialists saw more patients with OUD than PCPs, NPs, or PAs. They also demonstrated a higher level of understanding and knowledge of the various domains assessed., Conclusions: There are multiple educational intervention strategies that can support the clinicians; including reducing restrictions to access treatment for OUD, care coordination programs for patients to improve early access to treatment and education, and frequent chart audit and feedback programs to support clinician decision making and education., Competing Interests: Sponsored Review

Background: Neonatal nurse practitioners have become the frontline staff exposed to a myriad of ethical issues that arise in the day-to-day environment of the neonatal intensive care unit. However, ethics competency at the time of graduation and after years of practice has not been described., Research Aim: To examine the ethics knowledge base of neonatal nurse practitioners as this knowledge relates to decision making in the neonatal intensive care unit and to determine whether this knowledge is reflected in attitudes toward ethical dilemmas in the neonatal intensive care unit., Research Design: This was a prospective cohort study that examined decision making at the threshold of viability, life-sustaining therapies for sick neonates, and a ranking of the five most impactful ethical issues., Participants and Research Context: All 47 neonatal nurse practitioners who had an active license in the State of Mississippi were contacted via e-mail. Surveys were completed online using Survey Monkey software., Ethical Considerations: The study was approved by the University of Mississippi Medical Center Institutional Review Board (IRB; #2015-0189)., Findings: Of the neonatal nurse practitioners who completed the survey, 87.5% stated that their religious practices affected their ethical decision making and 76% felt that decisions regarding life-sustaining treatment for a neonate should not involve consultation with the hospital's legal team or risk management. Only 11% indicated that the consent process involved patient understanding of possible procedures. Participating in the continuation or escalation of care for infants at the threshold of viability was the top ethical issue encountered by neonatal nurse practitioners., Discussion: Our findings reflect deficiencies in the neonatal nurse practitioner knowledge base concerning ethical decision making, informed consent/permission, and the continuation/escalation of care., Conclusion: In addition to continuing education highlighting ethics concepts, exploring the influence of religion in making decisions and knowing the most prominent dilemmas faced by neonatal nurse practitioners in the neonatal intensive care unit may lead to insights into potential solutions.

BACKGROUND: There is an increased need for mental health providers to be more attuned to behavioral health needs of racial/ethnic/cultural minorities and the role of social milieus. AIMS: We prioritized training and assessing racial/ethnic and cultural sensitivity among psychiatric mental health nurse practitioner students throughout coursework, clinical practice, and experiences in underserved settings. METHOD: Prior to beginning clinical coursework, students completed a course on culturally competent care where we measured their ( n = 26) perception of their ability to be racially/ethnically sensitive providers at the beginning and end of the semester, demonstrating significant improvement. During clinical coursework, preceptors measured students' racially/ethnically and culturally sensitive clinical behaviors with patients. RESULTS: Sensitivity of students in clinical training significantly improved over a semester of clinical supervision. Our results indicated that placements in underserved settings improved students' racial/ethnic/cultural sensitivity but only among advanced students. At final evaluation, advanced students in underserved settings self-reported significantly higher racial/ethnic and cultural sensitivity than students not in an underserved setting. CONCLUSIONS: Our data suggest that we can produce more racially/ethnically and culturally sensitivity providers through coursework, supervised clinical practice, and experiences in underserved settings. These data are preliminary, and we plan to follow up these results and replicate this work with other cohorts in future semesters.

Aim: With a number of qualified community practitioner nurse prescribers (CPNPs) not prescribing, this research aimed to understand what influences this behaviour., Design: A qualitative research design., Methods: Semi-structured interviews, based on the theoretical domains framework (TDF) were conducted with 20 CPNPs. Data collection took place between March-July 2018 and continued until data saturation was reached., Results: Nine themes inductively explained prescribing behaviour: 1) 'Knowledge and experience'; 2) 'Consultation and communication skills'; 3) 'Professional confidence and identity'; 4) 'Wanting the best outcome'; 5) 'NHS versus patient cost'; 6) 'Emotion-led decisions'; 7) 'Time allocation'; 8) 'Formulary access' and 9) 'Supporting environment for patient-centred care'. Themes were then deductively mapped to the TDF and COM-B., Conclusion: There is an ongoing need to support community practitioner nurse prescribers' 'Capability' to prescribe in terms of knowledge and aquired skills; 'Opportunity' to make prescribing easier, such as access to a wider and up to date nurse formulary alongside effective clinical support; and 'Motivation' to feel confident in prescribing behaviour, highlighting positive patient outcomes while reducing perceived issues such as cost and non-adherence., Impact: Findings show that Capability, Opportunity and Motivation all influence the decision to prescribe. Those responsible for professional regulation and training should ensure community practitioner nurse prescribers have access to the relevant knowledge, skills and formulary to facilitate their prescribing behaviour. Professional confidence and identity as a prescriber should be encouraged, with acknowledgment of influences such as cost and emotion. An environment that allows for patient-centred care and the best outcome should be supported, this may mean increasing time allocated to consultations., (© 2019 John Wiley & Sons Ltd.)

Objective: Job satisfaction and work stress are associated with provider health and patient outcomes. This study aimed to evaluate job satisfaction and workplace stressors in surgical providers (surgeons, physician assistants [PAs], and NPs)., Methods: A survey was distributed to providers within a single surgical department. Job satisfaction and workplace stressors were evaluated by sex, age, profession, career length, and work hours., Results: Providers practicing for 11 to 15 years had greater job satisfaction than those practicing for more than 20 years, with no other differences by demographic group. Females cited supervisory support as a top workplace stressor more than did males (P = .01) and PAs and NPs cited supervisory support (P < .01) and compensation/finances more than surgeons (P = .05). Workplace stressors varied by practice years and work hours., Conclusions: Healthcare organizations should be aware of diversity in perceived workplace stressors. A "one size fits all" approach to provider well-being is likely to be ineffective.

Introduction: African American (AA) women have reported hair maintenance as a barrier to regular exercise; however, to our knowledge, this study is the first to identify primary care provider thoughts, attitudes, beliefs, and knowledge regarding hair as a barrier to increased physical activity among AA females., Methods: A 13-question electronic survey was sent via email to 151 clinicians working within a department of family medicine's 8 ambulatory clinics within a large urban academic medical center., Results: A total of 62 primary care clinicians completed the survey, which is a response rate of 41%. The vast majority of respondents (95%) sometimes/often engage in discussions with AA female patients regarding physical activity. However, 76% of respondents have never included a hairstyling or maintenance assessment in that discussion and only 34% noted being comfortable discussing this topic. Among a list of potential barriers to exercise, hair maintenance/scalp perspiration was rarely endorsed as important by clinicians., Discussion: This study highlights a need for increased education among primary care providers regarding AA hair care and maintenance practices as a barrier to increased physical activity in AA women. If specific barriers to increasing healthy habits among AA women are to be addressed, there must be a baseline knowledge of hair care and maintenance barriers, an understanding of the strong influence of cultural norms and practices as it relates to physical activity and exercise, and an increased comfortability when engaging in difficult cross-cultural conversations to ultimately improve health outcomes in AA females., Competing Interests: Conflict of interest: none declared., (© Copyright 2019 by the American Board of Family Medicine.)

Importance: Many rural and agricultural communities experience hardship from a shortage of clinicians. The aging of the clinician population threatens future supply in these areas. Developing policies to build a sustainable workforce requires the understanding of experiences from those currently in medical practice. Previous research about rural clinicians has primarily sampled non-Latinx white men, and to a lesser extent, non-Latinx white women; to date, no study has examined differences by race/ethnicity, sexual orientation, or gender identity., Objective: To describe the professional experiences of a diverse group of primary care clinicians and clinic directors in an underserved rural and agricultural region of California., Design, Setting, and Participants: In this qualitative study, semistructured in-depth qualitative interviews were performed with clinicians and clinic directors from December 1, 2017, to December 31, 2018, with a present or recent medical practice in the central San Joaquin Valley region of California. Participants (N = 26) consisted of physicians, nurse practitioners, and clinic directors practicing in primary care settings. Settings included solo and group private practice, academic training programs, community health centers, and rural health clinics., Main Outcomes and Measures: Personal experiences as primary care clinicians and clinic directors, and perceived associations with gender, race/ethnicity, sexual orientation, and gender identity., Results: Of 26 primary care clinicians and clinic directors interviewed, 16 (62%) identified as female, 12 (46%) identified as non-Latinx white, and 3 (12%) identified as a member of a sexual and gender minority group. Participants who self-identified as female, nonwhite, and of certain sexual orientation and gender identity minority groups described burnout from bias, harassment, and hostility in their professional relationships with colleagues and health care staff. These experiences intensified their feelings of community isolation and professional isolation. Harassment and institutional discrimination were factors in the decision of participants to change practices or exit the region entirely. Discriminatory acts against members of sexual and gender minority groups were the most severe, including threats to licensure and denial of hospital admitting privileges. In contrast to the minority group participants, the remaining participants expressed little to no awareness of these negative experiences, or the association between these experiences and retention., Conclusions and Relevance: Professional harassment and discrimination may hamper efforts to improve clinician and clinic director recruitment and retention in underserved rural and agricultural areas and may pose barriers to addressing health disparities within those communities. Additional investigation appears to be needed to assess the extent to which professional harassment and discrimination affect clinicians and clinic directors in similar communities across the United States.

The National Organization of Nurse Practitioner Faculties and the American Association of Nurse Practitioners collaborated to develop a document outlining expectations when establishing clinical experiences for nurse practitioner (NP) students. A literature review explored the beliefs of clinical preceptors and NP faculty in relation to the process of the establishment and completion of successful clinical experiences. From the literature, the development of two guidance checklists addressed the expectations and responsibilities of the NP faculty and clinical preceptor during the clinical placement process. In light of challenges to secure clinical sites for NP students, it is imperative that the clinical placement process is standardized and the communicative pathway between the NP faculty and clinical preceptor improved.

New graduate nurse practitioner (NP) postgraduate support programs and interventions have proliferated, sparking controversy. The Institute of Medicine/National Academy of Medicine recommends residency programs for new graduate NPs; however, the NP community debates whether new graduate NPs need additional training and whether such training compromises patient access to care. This systematic review aimed to synthesize evidence regarding the effectiveness of interventions and strategies to promote the professional transition of new graduate NPs. Interventions identified in the current literature included fellowship programs and a webinar. Strategies included mentorship, experiential learning, interprofessional training, and professional socialization. The studies reviewed primarily evaluated NPs' perceptions of the interventions' effects on their professional transitions. The findings from this systematic review highlight challenges in evidencing postgraduate support programs. The small number of available studies underscores a critical problem for the NP community: additional evidence is needed to inform whether and how to support new graduate NPs as they transition to practice., (© 2019 Wiley Periodicals, Inc.)

Background: Preventing burnout and promoting resiliency are important for health professionals' well-being and quality of patient care, as individuals with high levels of burnout are more likely to self-report suboptimal patient interactions. The purpose of this study was to characterize resiliency and burnout among health care professionals in the neurosciences critical care unit (NCCU) at a tertiary care center., Methods: All NCCU clinical staff were invited to participate in a Qualtrics ® electronic survey between November 2016 and August 2017. The survey assessed burnout using the abbreviated Maslach Burnout Inventory (aMBI) and resiliency using the ten-question Connor-Davidson Resilience Scale (CD-RISC 10). Higher scores on each aMBI subsection (range 0-18) indicate higher levels of each characteristic; larger resiliency scores (range 0-40) indicate higher resiliency. Categorical variables were compared using the Chi-square test and continuous variables using the Mann-Whitney U test or independent samples t test., Results: A total of 65 participants (65/70, 93%) were included in the final analysis. Of respondents, 49 (75%) were nurses, 49 (75%) were female, and mean age was 34 years. Median emotional exhaustion, depersonalization, and personal accomplishment scores were as follows: 8 (IQR 6-11), 3 (IQR 0-6), and 15 (IQR 13-16). High emotional exhaustion scores and high depersonalization scores were reported in 45% (n = 29) and 28% (n = 18) of participants, respectively. Longer time working in the NCCU (1-5 years vs. less than 1 year) was independently associated with higher emotional exhaustion scores (p = 0.012). When compared to agnostic/atheist backgrounds, Catholicism was independently associated with higher personal accomplishment scores (p = 0.026). The median resiliency score was 31 (IQR 28-36). Older age was independently associated with higher resiliency scores (p = 0.044)., Conclusions: This study is the first to characterize levels of burnout and resiliency among NCCU providers. A significant minority of participants reported high levels of emotional exhaustion and depersonalization, with those working longer in the NCCU more likely to experience emotional exhaustion. Efforts to improve the current work environments to optimally support the emotional needs of staff are needed to allow care providers to thrive and to promote longevity among NCCU providers.

Introduction: Up to 87% of trafficking victims encounter a health care provider while being trafficked but are not recognized as victims. Most health care providers receive little or no training, and awareness remains low. To describe the knowledge, beliefs, and attitudes of pediatric advanced practice registered nurses about human trafficking., Method: A survey of the National Association of Pediatric Nurse Practitioners membership (n = 8,647) before the intervention measured knowledge, beliefs, and experience regarding child trafficking. An awareness campaign was implemented with continuing education, national media presence, Train the Trainer programs, and creation of a nonprofit organization to direct strategic initiatives., Results: Overall, 799 (9%) NAPNAP members completed the survey. Although 87% believed it possible that they might encounter a victim of trafficking in their practice, 35% were unsure if they had provided care for a victim. Only 24% reported confidence in their ability to identify a child at risk for trafficking., Discussion: These survey findings indicate the need for clinical practice guidelines to identify potential and actual victims of human trafficking. Pediatric advanced practice registered nurses are ideally equipped and situated to intervene on behalf of vulnerable children with health disparities in a myriad of care settings, advocating for prevention and optimization of equitable health outcomes., (Copyright © 2019 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: An obstacle to clinical implementation of precision medicine is the absence of easily accessible peer-reviewed, comprehensive clinical practice guidelines. Therefore, an easily accessible format is needed to propel the adoption of these guidelines by healthcare providers. An understanding of the process providers take to prescribe medications will inform development of clinical decision support tools, specifically related to precision medicine. Successful use of mobile applications will depend on the buy-in from healthcare providers. The purpose of this study was to assess perceptions of trustworthiness surrounding clinical decision support tools and mobile applications through interviews with nurse practitioners., Methods: A descriptive, qualitative research design was used. A sample of 10 nurse practitioners who actively prescribe medication was used within the study., Conclusions: The participants mentioned both negative and positive attitudes regarding these prescribing techniques. Overall four themes emerged from this thematic analysis: the use of pharmacists to help with current prescribing practices, reliance on the EMR as a clinical decision support tool, lack of mobile app use in clinical practice, but the desire to have these resources if they were affordable and reliable., Implications for Practice: The participants were aware of the use of mobile apps for clinical decision support, but the adoption of these tools was limited due to the perceived lack of affordability and reliability. Therefore, to overcome these barriers to adoption of a mobile app related to precision medicine, affordability and transparent construction of an app grounded in credible sources must be developed.

Executive Summary: This prospective study focuses on professional satisfaction among advanced practice providers (APPs) in primary care. We aimed to determine whether incorporating specialty care clinics within primary care practices increases professional satisfaction. We administered the validated Misener Nurse Practitioner Job Satisfaction Scale and a self-developed demographic questionnaire to all primary care APPs before and one year after implementation of a gynecology practice within the primary care setting. APPs practicing in a dual-role specialty practice reported higher overall professional satisfaction; professional growth; intrapractice partnership/collegiality; professional, social, and community interaction; and benefits than their primary care-only counterparts. We concluded that professional satisfaction among APPs may contribute to staff retention.

Importance: Many believe a major cause of the epidemic of clinician burnout is poorly designed electronic health records (EHRs)., Objectives: To determine which EHR design and use factors are associated with clinician stress and burnout and to identify other sources that contribute to this problem., Design, Setting, and Participants: This survey study of 282 ambulatory primary care and subspecialty clinicians from 3 institutions measured stress and burnout, opinions on EHR design and use factors, and helpful coping strategies. Linear and logistic regressions were used to estimate associations of work conditions with stress on a continuous scale and burnout as a binary outcome from an ordered categorical scale. The survey was conducted between August 2016 and July 2017, with data analyzed from January 2019 to May 2019., Main Outcomes and Measures: Clinician stress and burnout as measured with validated questions, the EHR design and use factors identified by clinicians as most associated with stress and burnout, and measures of clinician working conditions., Results: Of 640 clinicians, 282 (44.1%) responded. Of these, 241 (85.5%) were physicians, 160 (56.7%) were women, and 193 (68.4%) worked in primary care. The most prevalent concerns about EHR design and use were excessive data entry requirements (245 [86.9%]), long cut-and-pasted notes (212 [75.2%]), inaccessibility of information from multiple institutions (206 [73.1%]), notes geared toward billing (206 [73.1%]), interference with work-life balance (178 [63.1%]), and problems with posture (144 [51.1%]) and pain (134 [47.5%]) attributed to the use of EHRs. Overall, EHR design and use factors accounted for 12.5% of variance in measures of stress and 6.8% of variance in measures of burnout. Work conditions, including EHR use and design factors, accounted for 58.1% of variance in stress; key work conditions were office atmospheres (β̂ = 1.26; P < .001), control of workload (for optimal control: β̂ = -7.86; P < .001), and physical symptoms attributed to EHR use (β̂ = 1.29; P < .001). Work conditions accounted for 36.2% of variance in burnout, where challenges included chaos (adjusted odds ratio, 1.39; 95% CI, 1.10-1.75; P = .006) and physical symptoms perceived to be from EHR use (adjusted odds ratio, 2.01; 95% CI, 1.48-2.74; P < .001). Coping strategies were associated with only 2.4% of the variability in stress and 1.7% of the variability in burnout., Conclusions and Relevance: Although EHR design and use factors are associated with clinician stress and burnout, other challenges, such as chaotic clinic atmospheres and workload control, explain considerably more of the variance in these adverse clinician outcomes.

NPs in primary care settings are well positioned to treat substance use disorders (SUDs). SUDs affect patients across the age spectrum and may be diagnosed and treated by NPs using brief interventions and pharmacologic therapies, or patients may be referred to specialty services. This article provides guidelines for screening, brief interventions, and pharmacologic therapies.

Background: Alcohol use during pregnancy can have a variety of harmful consequences on the fetus. Lifelong effects include growth restriction, characteristic facial anomalies, and neurobehavioral dysfunction. This range of effects is known as fetal alcohol spectrum disorders (FASD). There is no amount, pattern, or timing of alcohol use during pregnancy proven safe for a developing embryo or fetus. Therefore, it is important to screen patients for alcohol use, inform them about alcohol's potential effects during pregnancy, encourage abstinence, and refer for intervention if necessary. However, how and how often nurses and midwives inquire about alcohol drinking during pregnancy or use recommended screening tools and barriers they perceive to alcohol screening has not been well established., Methods: This survey was sent to about 6,000 American midwives, nurse practitioners, and nurses who provide prenatal care about their knowledge of the effects of prenatal alcohol exposure, the prevalence of alcohol use during pregnancy, and practices for screening patients' alcohol use. Participants were recruited by e-mail from the entire membership roster of the American College of Nurse-Midwives., Results: There were 578 valid surveys returned (about 9.6%). Analyses showed that 37.7% of the respondents believe drinking alcohol is safe during at least one trimester of pregnancy. Only 35.2% of respondents reported screening to assess patient alcohol use. Only 23.3% reported using a specific screening tool, and few of those were validated screens recommended for use in pregnant women. Respondents who believe alcohol is safe at some point in pregnancy were significantly less likely to screen their patients., Conclusions: Respondents who reported that pregnancy alcohol use is unsafe felt more prepared to educate and intervene with patients regarding alcohol use during pregnancy and FASD than respondents who reported drinking in pregnancy was safe. Perceived alcohol safety and perceived barriers to screening appeared to influence screening practices. Improving prenatal care provider knowledge about the effects of prenatal alcohol exposure and the availability of valid alcohol screening tools will improve detection of drinking during pregnancy, provide more opportunities for meaningful intervention, and ultimately reduce the incidence of FASD., (© 2019 The Authors Alcoholism: Clinical & Experimental Research published by Wiley Periodicals, Inc. on behalf of Research Society on Alcoholism.)

Purpose: Medical errors occur at high rates in intensive care units (ICUs) and have great consequences. The impact of errors on healthcare professionals is rarely discussed. We hypothesized that issues regarding blame and guilt following errors in the ICU exist and may be dependent on type of practitioner, level of experience, and error type., Materials and Methods: An online survey was conducted of members of a large critical care medical society addressing three clinical scenarios of procedural, diagnostic and treatment errors., Results: Nine hundred one practitioners responded. In all scenarios, negative feeling after medical errors occurred in all practitioners regardless of experience or field. Surgeons and anesthesiologists showed higher negative responses after procedural errors while internal medicine and emergency medicine practitioners had higher negative responses after diagnostic errors. Survey respondents identified multiple ways to address these adverse feelings, including debriefing with the medical team (68%), talking with colleagues (68%) and discussing with patients and families (36%)., Conclusions: In critical care, blame and guilt after medical errors are common and affect all providers. Critical care practitioners have identified methods which may help mitigate adverse feeling after medical errors, including debriefing and talking with colleagues. Hospitals may benefit from developing these types of strategies after medical errors., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Members of the sexual and gender minority (SGM) community face complex barriers to accessing quality healthcare. NPs have a responsibility to create welcoming care settings where patients can share a trusting provider-patient relationship to disclose their SGM status, an event shown to improve patient outcomes.

Aims and Objectives: To explore the ways in which Irish and Australian Nurse Practitioners (NPs) implement leadership and research in their roles and whether there is a difference in how leadership and research are demonstrated between NPs in Ireland and Australia., Background: The original concept of the NP role was to expand nursing practice in order to provide high-quality, accessible health care to patients. This placed NPs at the crux of changes to healthcare delivery. Implementing these changes requires leadership. Research demonstrates the effects of these changes to healthcare delivery and contributes to healthcare knowledge from the nursing profession., Design: In the qualitative phase of a mixed methods study, an interpretative descriptive approach was used to draw on participant experiences., Methods: Thirty-eight respondents agreed to be interviewed following an online survey. Ten interviews were recorded and transcribed verbatim. Data were analysed using Braun and Clarke thematic analysis method. The research complied with the consolidated criteria for reporting qualitative research, COREQ., Results: Ten participants, five NPs from Ireland and five from Australia were interviewed. Four themes emerged from the analysis: (a) Innovative leadership, which included the categories of leadership activities, the work of NPs and trailblazers; (b) Optimism, incorporating pride in achievements, the future outlook for the role and continued innovation of NPs over time; (c) Research, which included the NP research role, research challenges, support and research leadership; and (d) Resilience, which included overcoming resistance, isolation and seeking positive support systems., Conclusion: Nurse Practitioners are clinical leaders focused on improving healthcare delivery for patient populations. There is a lack of understanding of the NP role. Nurse Practitioners lack confidence to be independently research active. Research by NPs requires support from nurses in academia. There is no difference in the role in Ireland and Australia., Relevance to Clinical Practice: Nurse Practitioners are engaged in healthcare transformation. Nurse Practitioners require support from research experts in academia to make a significant contribution to nursing knowledge in healthcare delivery., (© 2019 John Wiley & Sons Ltd.)

Globally, from America to Europe and beyond, the need for the expansion of the role of nurse practitioners has been recognized within the healthcare professions. However, little emphasis has been placed on assessing the views of clients, and within the addiction services, the voice of clients can be additionally marginalized as a result of treatment philosophies, stigma, and resource constraints. The aims of this study were to establish from clients their nursing needs and to use these findings alongside an objective measurement of clients' health, to inform the development of a nurse-led treatment model.A cross-sectional survey with open-ended questions on client nursing needs was conducted in 2017 within a representative sample of six clinics in Dublin, Ireland. A convenience sample of 131 clients were interviewed. Interviews were analyzed using thematic analysis.Findings were both as expected and surprising. Clients articulated the role of the nurse in their physical care; however, unexpectedly, clients identified nurses as an essential source of psychological support and expressed the wish for the role to be expanded in terms of managing methadone treatment and accessing additional services and resources.Results contributed to the formation of the nurse-led, client mental-health-focused, Healthy Addiction Treatment Recovery Model for addiction nursing services. In terms of national policies, findings provided new evidence articulated by service users on their desire for the expansion of nurse prescribing in addiction services and an expansion of the role to more adequately address client needs.

Burnout is characterized by 3 facets: the presence of emotional exhaustion, depersonalization, and a lack of sense of personal accomplishment. It arises when stress becomes so severe relative to a person's own resources that he or she loses motivation to perform, and it is associated with many negative outcomes. Emergency medicine (EM) physicians ranked highest in a study of burnout rates among physician subspecialties. However, there is an overall lack of robust research examining the work-related psychological states in advanced practice providers (APPs). Because the utilization of APPs in emergency departments (EDs) is steadily increasing, we aimed to describe burnout in this understudied group. A sample of APPs employed in a large urban academic hospital was surveyed using 3 well-established questionnaires measuring burnout, resilience, and mindfulness. Responses were compared with a normative group of health care workers (HCWs). The respondents reported a significantly greater sense of personal accomplishment than other HCWs. This was greater with a perceived control over their work environment and if they self-identified as being nonjudgmental. The sense of accomplishment was less in the respondents of older age and for those with children. This group also reported an increased sense of depersonalization. Mindfulness traits of acting with awareness and having trust in their instincts were identified as potential protective factors against depersonalization. Although the respondents were not more emotionally exhausted than other HCWs, being more emotionally "reactive" did predict greater emotional exhaustion. This is an important finding for APPs working in affect-laden work environments such as EDs. These findings suggest that increasing control over the work environment, fostering trust of instincts, and reducing emotional reactiveness are prudent interventional targets for EM-APP leaders to prevent and reduce burnout in the workforce.

Contemporary research highlights the serious mental health issues facing physicians and allied health professionals. Yet to date, much of this research has focused on these occupational groups in isolation. Drawing upon data collected from medical staff in a neonatal intensive care unit (N = 222), we address this gap by contrasting the mental health and workplace experiences of four groups of healthcare workers: physicians, nurse practitioners, registered nurses, and respiratory therapists. We find evidence that higher status healthcare workers-physicians and nurse practitioners-are more likely than their colleagues to report work-life conflict, irregular work hours, and heavy work pressure. These stressors explain an appreciable amount of the higher levels of burnout found among physicians and nurse practitioners. Collectively, results lend support to "the stress of higher status" hypothesis and provide insights into the job demands and mental health issues confronted by today's medical workforce., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Evidence has continued to accumulate regarding the potential risks of treating chronic pain with long-term opioid therapy (LTOT). Clinical practice guidelines now encourage clinicians to implement practices designed to reduce opioid-related risks. Yet how clinicians implement these guidelines within the context of the patient encounter has received little attention., Objective: This secondary analysis aimed to identify and describe clinicians' strategies for managing prescription opioid misuse and aberrant behaviors among patients prescribed LTOT for chronic pain., Design: Individual interviews guided by a semi-structured interview protocol probed: (1) methods clinicians utilize to reduce prescription opioid misuse and address aberrant opioid-related behaviors; (2) how clinicians respond to misuse; and (3) resources and constraints faced in managing and treating misuse among their patients., Participants: Interviews were conducted with 24 physicians and nurse practitioners, representing 22 Veterans Health Administration (VA) facilities across the USA, who had one or more patients in their clinical panels who were prescribed LTOT for the treatment of chronic non-cancer pain., Approach: Qualitative content analysis was the analytic approach utilized. A codebook was developed iteratively following group coding and discussion. All transcripts were coded with the finalized codebook. Quotes pertaining to key themes were retrieved and, following careful review, sorted into themes, which were then further categorized into sub-themes. Quotes that exemplified key sub-themes were selected for inclusion., Key Results: We detail the challenges clinicians describe in navigating conversations with patients around prescription opioid misuse, which include patient objection as well as clinician ambivalence. We identify verbal heuristics as one strategy clinicians utilize to structure these difficult conversations, and describe four heuristics: setting expectations, following orders, safety, and standardization., Conclusion: Clinicians frequently use verbal heuristics to routinize and increase the efficiency of care management discussions related to opioid prescribing, redirect responsibility, and defuse the potential emotional charge of the encounter.

Current research on NPs' use of the American Academy of Pediatrics (AAP) Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents is limited. This cross-sectional survey examined 89 NPs in Upstate New York regarding self-reported practice behaviors based on the guideline. Most NPs followed at least 50% of the AAP guideline for diagnosis and treatment. However, use of all criteria was less than optimal.

Background and Purpose: To evaluate the ability of the Well-Being Index (WBI) to stratify distress and well-being (high quality of life [QOL]) in nurse practitioners and physician assistants (NPs and PAs) and identify those whose degree of distress place them at an increased risk for medical error or turnover., Methods: A national sample of NPs and PAs completed a survey that included the WBI and instruments to measure QOL, fatigue, burnout, recent suicidal ideation, medical error, and intent to leave the current job., Conclusions: Overall, 1,576 of 4,106 (38.4%) NPs and PAs completed the survey. Those NPs and PAs with low mental QOL, extreme fatigue, recent suicidal ideation, or burnout had less favorable WBI scores (all p < .0001). Using a prevalence of low overall QOL among APPs of 14.4% as the pretest probability, the WBI score can reduce the posttest probability of low QOL to 2% or increase it to 64.7%. As the WBI score worsened, the posttest probability of high overall QOL decreased from 73% to 8.2%. Also, WBI score stratified the NPs and PAs likelihood of reporting recent medical errors and intent to leave his or her current job., Implications for Practice: The WBI is a useful screening tool to stratify distress and well-being in APPs across a variety of domains and identify those NPs and PAs whose degree of distress may increase the risk of medical error or turnover.

Purpose: In this study we identified the essential elements of adolescent-friendly care in school-based health centers (SBHCs) from the perspectives of the nurse practitioners (NPs) providing care to adolescents and the adolescents, as the consumers of these services., Design and Methods: Complex adaptive systems provided the philosophical and theoretical foundation for this study. An explanatory sequential mixed methods study was conducted. A Delphi technique (strand one) was conducted with an expert panel of NPs (N = 21) to identify the essential elements of adolescent-friendly care in SBHCs. The second strand, a focus group study with adolescents (N = 30), elaborated on the Delphi results. Data from the two strands were then mixed., Results: This study generated expert opinion regarding the essential elements of adolescent-friendly health care in SBHCs. After four Delphi rounds, consensus was reached on 98-items (49% of the original 200; consensus level of 0.75). The results clustered into 6 essential elements: Confidentiality/Privacy (n = 8; 8.2%), Accessibility, (n = 15; 15.3%), Clinician/Staff (n = 51; 52%), SBHC Clinical Services (n = 12; 12.2%), SBHC Environment (n = 4; 4.1%), and Relationship between the School and SBHC (n = 8; 8.2%). The adolescent focus groups confirmed the essential elements identified in the Delphi and added two overarching themes: Comfortable and Trusted Relationship., Conclusions: These findings contribute to a greater understanding of essential characteristics needed in adolescent friendly care., Practice Implications: SBHCs, as an important community resource for addressing the health care needs of adolescents, should incorporate these characteristics., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To assess the level of job satisfaction and associated factors among nurses in Bahir Dar city, Northwest Ethiopia, 2017., Results: The overall proportion of nurses' job satisfaction was 43.6%. From motivational factors, advancement (AOR = 2.64; 95% CI [1.17, 5.96]) and recognition (AOR = 2.56; 95% CI [1.08, 6.08]) were the main determinants of nurses' job satisfaction. Among hygienic factors, work security (AOR = 4.88; 95% CI [1.13, 21.03]) was positively associated with nurses' job satisfaction. In conclusion, the nurses' job satisfaction was low in this study setting. Modifiable factors such as advancement, recognition and work security positively affect job satisfaction of nurses. Therefore, the current study recommended that the health care system administers should work on improvement of advancement, security, and recognition in the facilities.

Background and Purpose: Little is known about the facilitators and barriers to the workforce transition of novice nurse practitioners (NPs) in primary care. This research aimed to identify factors contributing and detracting from a successful initial workforce transition for novice NPs in the primary care setting., Methods: A descriptive, cross-sectional study was conducted via online survey administered to a national sample of 177 NPs who graduated from an accredited NP program and were practicing in a primary care setting for 3-12 months. Open-ended responses were analyzed using the Krippendorff content analysis method., Conclusions: This study demonstrated that facilitators of the novice NP transition are the presence of mentorship and social support, finding meaning in their work, job satisfaction, and work-life balance. Barriers to the novice NP transition are lack of support and respect, role ambiguity, and workload., Implications for Practice: More mentorship, support, role clarity, and respect are needed to facilitate the novice NP workforce transition. More research is needed on interventions that can be implemented by health care organizations to improve the facilitators of role transition identified in this study.