An Analysis of Lesbian, Gay, Bisexual, Transgender, and Queer Curricula Inclusion: A National Study of Physician Assistant Programs.

INTRODUCTION: The health professions education literature shows an increased focus on inclusion of lesbian, gay, bisexual, transgender, and queer (LGBTQ) content in curricula; however, it does not address hours of content or methods for content delivery. The purpose of this study was to describe the delivery of LGBTQ content in physician assistant (PA) education through a national survey of PA programs. METHODS: In 2021, a national program survey was sent to all US-accredited PA Programs (n = 284) and had a completion rate of 71.8% (n = 204). Descriptive statistics were conducted to describe trends and make comparisons in the delivery of LGBTQ content. RESULTS: Most PA programs are incorporating LGBTQ content into preclinical phases of PA education (81%) and describe that LGBTQ curricula align with institutional values (82%). Most report 1 to 3 hours of preclinical education for all LGBTQ population groups and cite medical interviewing courses as the most frequently used course to address LGTBQ care. Many programs (43%) do not provide instructional hours on LGBTQ content in the clinical phase, and the majority do not offer clinical rotations focused on this care. The results show variability in the level of preparedness that programs report on their students caring for LGBTQ populations. DISCUSSION: Physician assistant programs are generally integrating the content throughout their didactic curricula; however, few offer clinical experiences focused on caring for patients who are LGBTQ. Offering clinical experiences and assessing student competencies are areas of growth in health professions education as related to LGBTQ health.

Nurse practitioner and physician assistant transition to practice: A scoping review of fellowships and onboarding programs.

BACKGROUND: Newly graduated nurse practitioners (NPs) and physician assistants (PAs) benefit from transition-to-practice (TTP) support to move successfully into practice. Transition-to-practice programs (i.e., onboarding programs and fellowships/residencies) hold promise for improving workforce outcomes. PURPOSE: The purpose of this scoping review was to describe the literature regarding NP/PA TTP programs. METHODOLOGY: Using the Joanna Briggs Institute methodology, a specific approach for systematically conducting reviews, publications from January 1990 to May 2022 were included for review if they addressed fellowships/residencies or onboarding programs for NPs or PAs. Final data extraction involved 216 articles. RESULTS: The pace of publication increased over time, with a noticeable increase since 2015. Articles were most commonly about fellowships/residencies, NPs, and programs set in United States nonrural, acute care settings, and academic health centers. CONCLUSIONS/IMPLICATIONS: There is a gap in our understanding of onboarding programs and programs focusing on PAs, as well as TTP support in rural and primary care settings. In addition, there are few articles that assess TTP program outcomes such as benefits and costs. This review describes the need for more published literature in these areas.

NP and PA transition to practice: A scoping review of fellowships and onboarding programs.

OBJECTIVES: Newly graduated NPs and physician associates/assistants (PAs) benefit from transition to practice (TTP) support to move successfully into practice. TTP programs (such as onboarding programs, fellowships, and residencies) hold promise for improving workforce outcomes. The purpose of this scoping review was to describe the literature regarding NP/PA TTP programs. METHODS: Using the Joanna Briggs Institute methodology, a specific approach for systematically conducting reviews, publications from January 1990 to May 2022 were included if they addressed fellowships, residencies, or onboarding programs for NPs or PAs. Final data extraction involved 216 articles. RESULTS: The pace of publication increased over time, with a noticeable increase since 2015. Articles were most commonly about fellowships or residencies, NPs, and programs set in nonrural, acute care US settings and in academic health centers. CONCLUSIONS: A gap exists in our understanding of onboarding programs and programs focusing on PAs, as well as TTP support in rural and primary care settings. In addition, few articles assess TTP program outcomes such as benefits and costs. This review describes the need for more published literature in these areas.

Risk factors of food insecurity among students at diverse post-secondary education institutions: a cross-sectional examination.

OBJECTIVE: Identify the prevalence of food insecurity (FI) and compare sociodemographic, mental, physical, behavioral, and environmental risk factors for FI among students at a private university, community college, and historically black college or university (HBCU). PARTICIPANTS: Adult students attending a private university, community college, or HBCU (n = 4,140) located within the southeastern United States. METHODS: Using an online survey (2017-2019), FI, sociodemographic, mental, physical, behavioral, and environmental data were collected to understand their association with FI. RESULTS: Up to 37.1% of students experienced FI. Identifying as black, other/multi-racial, having poor sleep, federal loans, depressive symptoms, high stress, social isolation, or a chronic condition were associated with FI. These associations varied by institution. CONCLUSIONS: FI is prevalent within diverse post-secondary institutions that serve traditional and nontraditional students with risk factors varying between institutions. The prevalence of FI and risk factors can inform institutional policy responses to ameliorate the effects of FI.

Impact of primary care usual provider type and provider interdependence on outcomes for patients with diabetes: a cohort study.

BACKGROUND: Interprofessional primary care (PC) teams are key to the provision of high-quality care. PC providers often 'share' patients (eg, a patient may see multiple providers in the same clinic), resulting in between-visit interdependence between providers. However, concern remains that PC provider interdependence will reduce quality of care, causing some organisations to hesitate in creating multiple provider teams. If PC provider teams are formalised, the PC usual provider of care (UPC) type (physician, nurse practitioner (NP) or physician assistant/associate (PA)) should be determined for patients with varying levels of medical complexity. OBJECTIVE: To evaluate the impact of PC provider interdependence, UPC type and patient complexity on diabetes-specific outcomes for adult patients with diabetes. DESIGN: Cohort study using electronic health record data from 26 PC practices in central North Carolina, USA. PARTICIPANTS: Adult patients with diabetes (N=10 498) who received PC in 2016 and 2017. OUTCOME: Testing for diabetes control, testing for lipid levels, mean glycated haemoglobin (HbA1c) values and mean low-density lipoprotein (LDL) values in 2017. RESULTS: Receipt of guideline recommended testing was high (72% for HbA1c and 66% for LDL testing), HbA1c values were 7.5% and LDL values were 88.5 mg/dL. When controlling for a range of patient and panel level variables, increases in PC provider interdependence were not significantly associated with diabetes-specific outcomes. Similarly, there were no significant differences in the diabetes outcomes for patients with NP/PA UPCs when compared with physicians. The number and type of a patient's chronic conditions did impact the receipt of testing, but not average values for HbA1c and LDL. CONCLUSIONS: A range of UPC types on PC multiple provider teams can deliver guideline-recommended diabetes care. However, the number and type of a patient's chronic conditions alone impacted the receipt of testing, but not average values for HbA1c and LDL.

Physician assistant and nurse practitioner onboarding in primary care: The participant perspective.

BACKGROUND: Many new graduate primary care physician assistants (PAs) and nurse practitioners (NPs) can experience stress and difficulty as they transition to practice. Feelings of anxiety and role ambiguity are common and can lead to costly turnover, impact care continuity, and place patients at risk for poor clinical outcomes. Onboarding, the process of helping new hires adjust to social and performance aspects of their new job and has the potential to ease transition to practice for PAs and NPs. Recent research has linked PA/NP onboarding programs to increased engagement, decreased turnover, and higher clinical productivity. PURPOSE: To describe new graduate PA and NP perspectives of onboarding programs they completed in their first primary care position. METHODOLOGY: Thirteen semistructured interviews were conducted with new graduate PAs and NPs who participated in onboarding programs. Interviews were transcribed and then analyzed using an inductive coding methodology. RESULTS: Analyses revealed nine thematic concepts that are described within two frameworks. Structural components include improving competence, training on the electronic health record, promoting mentorship, orienting to organizational dynamics, tailoring ramp-up of patient scheduling, clarifying expectations, and providing clear organizational support. Psychosocial factors include creating comfort and building self-confidence. CONCLUSION: Understanding participants' experiences with onboarding programs is essential for ensuring successful transition to practice for new graduate PAs and NPs. IMPLICATIONS: These findings are beneficial to the health care workforce. Administrators can incorporate these findings into existing and future programs, and new graduate PAs and NPs can negotiate for the inclusion of these components in their first position.

PA and NP onboarding in primary care: The participant perspective.

OBJECTIVE: To describe new graduate physician associate/assistant (PA) and NP perspectives of onboarding programs in their first primary care position. METHODS: Thirteen semistructured interviews were conducted with new graduate PAs and NPs who participated in onboarding programs. Interviews were transcribed and then analyzed using an inductive coding methodology. RESULTS: Analyses revealed nine thematic concepts that are described in two frameworks. Structural components are improving competence, training on the electronic health record (EHR), promoting mentorship, orienting to organizational dynamics, tailoring ramp-up of patient scheduling, clarifying expectations, and providing clear organizational support. Psychosocial factors are creating comfort and building self-confidence. DISCUSSION: The results describe and delineate important components for onboarding that administrators can incorporate into existing and future programs. CONCLUSION: Understanding participants' experiences with onboarding programs is essential for ensuring successful transition to practice for new graduate PAs and NPs.

Transition-to-practice programs for newly graduated advanced practice registered nurses and physician assistants: a scoping review protocol.

OBJECTIVE: The objective of this scoping review is to map the evidence on transition-to-practice programs for newly graduated advanced practice registered nurses and physician assistants, and describe how they differ. Additional objectives include summarizing what outcomes are evaluated and what gaps remain within the literature. By consolidating this information, health care administrators may more easily reference transition-to-practice methods to enhance their own programs for advanced practice registered nurses and physician assistants.z. INTRODUCTION: Transition to practice involves 2 program types: onboarding and postgraduate training. However, no existing reviews describe the state of the literature regarding these program types, and how they compare with regard to location, setting, and outcomes. Because transition-to-practice programs may improve workforce outcomes, understanding how these programs differ, and what gaps exist, is needed to help these programs grow. INCLUSION CRITERIA: This review will include articles describing transition to practice for advanced practice registered nurses and/or physician assistants, including onboarding and fellowship/residency programs. Articles will be included regardless of geographic location if they take place within a professional, clinical setting. METHODS: The scoping review will follow the JBI approach. Databases to be searched include MEDLINE (PubMed), CINAHL, Cochrane Central Register of Controlled Trials, Embase, ProQuest Dissertations and Theses, Scopus, and Web of Science. All included manuscripts will be screened by two reviewers and relevant data will be extracted. These data will summarize what transition to practice programs are used, how they differ, and what gaps exist.

National Implementation of a Group-Based Program Promoting Patient Engagement and Peer Support in the Veterans Health Administration: A Multi-Methods Evaluation.

Evidence-based approaches promoting patient engagement and chronic illness self-management include peer support, shared decision-making, and education. Designed based on these components, Taking Charge of My Life and Health (TCMLH) is a group-based, 'Whole Person' care program promoting mental and physical self-care and patient empowerment. Despite evidence of effectiveness, little is known about implementation for TCMLH and similar programs. In this first-of-its-kind, multi-methods evaluation conducted between 2015-2020, we report on implementation strategies and intervention adaptations with a contextual analysis to describe TCMLH translational efforts in Veterans Health Administration (VHA) facilities across the United States. Quantitative and qualitative data were collected via listening sessions with TCMLH facilitators, open-ended survey responses from facilitators, and quarterly reports from clinical implementation sites. We used the Consolidated Framework for Implementation Research (CFIR) to analyze, interpret, and organize qualitative findings, and descriptive statistics to analyze quantitative data. Most TCMLH programs (58%) were adapted from the original format, including changes to the modality, duration, or frequency of sessions. Findings suggest these adaptations occurred in response to barriers including space, staffing constraints, and participant recruitment. Overall, findings highlight practical insights for improving the implementation of TCMLH, including recommendations for additional adaptations and tailored implementation strategies to promote its reach.

Implementation of social needs screening in primary care: a qualitative study using the health equity implementation framework.

BACKGROUND: Screening in primary care for unmet individual social needs (e.g., housing instability, food insecurity, unemployment, social isolation) is critical to addressing their deleterious effects on patients' health outcomes. To our knowledge, this is the first study to apply an implementation science framework to identify implementation factors and best practices for social needs screening and response. METHODS: Guided by the Health Equity Implementation Framework (HEIF), we collected qualitative data from clinicians and patients to evaluate barriers and facilitators to implementing the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE), a standardized social needs screening and response protocol, in a federally qualified health center. Eligible patients who received the PRAPARE as a standard of care were invited to participate in semi-structured interviews. We also obtained front-line clinician perspectives in a semi-structured focus group. HEIF domains informed a directed content analysis. RESULTS: Patients and clinicians (i.e., case managers) reported implementation barriers and facilitators across multiple domains (e.g., clinical encounters, patient and provider factors, inner context, outer context, and societal influence). Implementation barriers included structural and policy level determinants related to resource availability, discrimination, and administrative burden. Facilitators included evidence-based clinical techniques for shared decision making (e.g., motivational interviewing), team-based staffing models, and beliefs related to alignment of the PRAPARE with patient-centered care. We found high levels of patient acceptability and opportunities for adaptation to increase equitable adoption and reach. CONCLUSION: Our results provide practical insight into the implementation of the PRAPARE or similar social needs screening and response protocols in primary care at the individual encounter, organizational, community, and societal levels. Future research should focus on developing discrete implementation strategies to promote social needs screening and response, and associated multisector care coordination to improve health outcomes and equity for vulnerable and marginalized patient populations.

An open trial of app-assisted acceptance and commitment therapy (iACT) for eating disorders in type 1 diabetes.

BACKGROUND: Eating disorders (EDs) among individuals with type 1 diabetes (T1D) increase the risk of early and severe diabetes-related medical complications and premature death. Conventional eating disorder (ED) treatments have been largely ineffective for T1D patients, indicating the need to tailor treatments to this patient population and the unique conditions under which ED symptoms emerge (in the context of a chronic illness with unrelenting demands to control blood glucose, diet and exercise). The current study was a pilot open trial of iACT, a novel intervention for EDs in T1D grounded in Acceptance and Commitment Therapy (ACT). iACT was based on the premise that ED symptoms emerge as individuals attempt to cope with T1D and related emotional distress. iACT taught acceptance and mindfulness as an alternative to maladaptive avoidance and control, and leveraged personal values to increase willingness to engage in T1D management, even when it was upsetting (e.g., after overeating). A tailored mobile application ("app") was used in between sessions to facilitate the application of ACT skills in the moment that individuals are making decisions about their diabetes management. METHODS: Adults with T1D who met criteria for an ED completed 12 sessions of iACT (with three optional tapering sessions). In addition to examining whether treatment was acceptable and feasible (the primary aim of the study), the study also examined whether iACT was associated with increased psychological flexibility (i.e., the ability to have distressing thoughts/feelings about diabetes while pursuing personally meaningful values), and improvements in ED symptoms, diabetes management and diabetes distress. RESULTS: Treatment was acceptable to T1D patients with EDs and feasible to implement. Participants reported increased psychological flexibility with diabetes-related thoughts/feelings, and less obstruction and greater progress in pursuing personal values. There were large effects for change in ED symptoms, diabetes self-management and diabetes distress from baseline to end-of-treatment (Cohen's d = .90-1.79). Hemoglobin A1c also improved, but the p-value did not reach statistical significance, p = .08. CONCLUSIONS: Findings provide preliminary evidence for iACT to improve outcomes for T1D patients with EDs and support further evaluation of this approach in a controlled trial. TRIAL REGISTRATION: NCT02980627 . Registered 8 July 2016.

Academic-Practice Partnership for Caregiver Training and Support: The Duke Elder Family/Caregiver Training (DEFT) Center.

BACKGROUND After a hospital stay, many older adults rely on their caregivers for assistance at home. Empirical evidence demonstrates that caregiver support programs in hospital-to-home transitions are associated with favorable caregiver and patient outcomes. We tested the feasibility of implementing the Duke Elder Family/Caregiver Training (DEFT) program in an academic medical center.METHODS: We recruited adult caregivers of homebound patients who were aged 55 years or older from Duke University Hospital in Durham, North Carolina. Caregivers attended a face-to-face caregiver training and received two telephone checks after hospital discharge with DEFT services ending at 14 days of hospital discharge. We used a one-item survey to measure overall DEFT satisfaction. We also monitored 30-day readmissions of patients whose caregivers completed the DEFT program.RESULTS: The DEFT Center received 104 consult orders in six months. Of these, 61 agreed to participate but nine caregivers were unable to schedule the DEFT training and three decided to eventually withdraw from participation. Forty-nine caregivers received the DEFT training, 12 of whom were ineligible to continue because of change in patients' disposition plan. Of the remaining 37 caregivers, 15 completed the full program and reported high satisfaction; one patient was readmitted within 30 days of discharge.LIMITATIONS: The DEFT implementation was based on academic-medical partnership and relied on electronic medical records for consult and documentation. Replicability and generalizability of findings are limited to settings with similar capabilities and resources.CONCLUSION: The implementation of a caregiver training and support program in an academic medical center was feasible and was associated with favorable preliminary outcomes.

Time of Day When Type 1 Diabetes Patients With Eating Disorder Symptoms Most Commonly Restrict Insulin.

OBJECTIVE: Restricting insulin to lose weight is a significant problem in the clinical management of type 1 diabetes (T1D). Little is known about this behavior or how to effectively intervene. Identifying when insulin restriction occurs could allow clinicians to target typical high-risk times or formulate hypotheses regarding factors that influence this behavior. The current study investigated the frequency of insulin restriction by time of day. METHODS: Fifty-nine adults with T1D and eating disorder symptoms completed 72 hours of real-time reporting of eating and insulin dosing with continuous glucose monitoring. We used a generalized estimating equation model to test the global hypothesis that frequency of insulin restriction (defined as not taking enough insulin to cover food consumed) varied by time of day, and examined frequency of insulin restriction by hour. We also examined whether patterns of insulin restriction for 72 hours corresponded with patients' interview reports of insulin restriction for the past 28 days. RESULTS: Frequency of insulin restriction varied as a function of time (p = .016). Insulin restriction was the least likely in the morning hours (6:00-8:59 AM), averaging 6% of the meals/snacks consumed. Insulin restriction was more common in the late afternoon (3:00-5:59 PM), peaking at 29%. Insulin was restricted for 32% of the meals/snacks eaten overnight (excluding for hypoglycemia); however, overnight eating was rare. Insulin restriction was associated with higher 120-minute postprandial blood glucose (difference = 44.4 mg/dL, 95% confidence interval = 22.7-68.5, p < .001) and overall poorer metabolic control (r = 0.43-0.62, p's < .01). Patients reported restricting insulin for a greater percentage of meals and snacks for the past 28 days than during the 72 hour real-time assessment; however, the reports were correlated (Spearman's ρ = 0.46, p < .001) and accounted for similar variance in HbA1c (34% versus 35%, respectively). CONCLUSIONS: Findings suggest that insulin restriction may be less likely in the morning, and that late afternoon is a potentially important time for additional therapeutic support. Results also suggest that systematic clinical assessment and treatment of overnight eating might improve T1D management.

Measuring teacher dispositions using the DAATS battery: a multifaceted Rasch analysis of rater effect.

The purpose of this study was to examine the extent to which raters' subjectivity impacts measures of teacher dispositions using the Dispositions Assessments Aligned with Teacher Standards (DAATS) battery. This is an important component of the collection of evidence of validity and reliability of inferences made using the scale. It also provides needed support for the use of subjective affective measures in teacher training and other professional preparation programs, since these measures are often feared to be unreliable because of rater effect. It demonstrates the advantages of using the Multi-Faceted Rasch Model as a better alternative to the typical methods used in preparation programs, such as Cohen's Kappa. DAATS instruments require subjective scoring using a six-point rating scale derived from the affective taxonomy as defined by Krathwohl, Bloom, and Masia (1956). Rater effect is a serious challenge and can worsen or drift over time. Errors in rater judgment can impact the accuracy of ratings, and these effects are common, but can be lessened through training of raters and monitoring of their efforts. This effort uses the multifaceted Rasch measurement models (MFRM) to detect and understand the nature of these effects.