Reflecting on diagnosis: The Metacognitive Diagnostic Reasoning Model©.

BACKGROUND: Diagnostic reasoning is a complex cognitive process that requires intuitive, heuristic processing from knowledge and experience, as well as deliberate and reflective thinking. Evidence on interventions to improve diagnostic reasoning is inconsistent, in part because different terms and models are used to guide research. PURPOSE: To present a model of the factors of diagnostic reasoning in Advanced Practice Registered Nurses (APRNs), based on a review of the literature supporting the Metacognitive Diagnostic Reasoning (MDR) Model©. METHODOLOGY: A review of the literature through systematic database search, historical articles, texts, and documents was conducted from inception through August 2023 (N = 41). RESULTS: The MDR model depicts the following concepts: (1) metacognition is viewed as the driving force of diagnostic reasoning; (2) dual cognitive processing and knowledge representations are used; (3) once a diagnosis, treatment plan, and evaluation are complete, APRNs use metacognition for the next patient encounter, using repetition for improvement of the process. CONCLUSIONS: The model combines key concepts of diagnostic reasoning, providing a framework for researchers to develop and test, and faculty to teach and evaluate this complex process in learners. IMPLICATIONS: The MDR model provides research opportunities to validate its usefulness and effectiveness and a framework to guide educational research, contributing to the body of evidence-based practice in nursing. In addition, it may foster ongoing education and training that could lead to more accurate diagnoses and treatment plans, ultimately improving patient care by reducing diagnostic errors.

The use of electronic health records in advanced practice nursing education: a scoping review.

Electronic health records are integral to the advanced practice registered nurse role, yet access and training during academic preparation are profoundly limited. Lack of exposure to electronic health records prevents students from becoming fully prepared for the responsibilities of clinical practice and potentially impacts quality of care, patient safety, and communication among patients and providers. This scoping review of 20 articles on electronic health record use in advanced practice registered nursing student education shows significant gaps in current research. Nine articles were classified as research. The remaining 11 were non-research reports of teaching innovations describing the use of simulated electronic health records in graduate nursing education or the use of an electronic health record in interprofessional education activities. Most of the limited research did not use valid and reliable instruments or robust designs, employed disparate approaches and tools to study the phenomenon, and measured low-level outcomes such as student navigation and confidence in using electronic health records. The non-research literature draws attention to the deficits in educational resources, including unaffordable electronic health records for academic use. Although rigorous evidence is lacking, a common theme throughout the reviewed literature was the benefit of simulation to develop electronic health record skills.

Effectiveness of Screen-Based Simulation as a Strategy to Improve Nurse Practitioner Students' Access to Electronic Health Records in Clinical Education.

Learning to use electronic health records is essential for family nurse practitioner students to inform practice and clinical decision-making. Limited access to electronic health records during clinical training can lead to suboptimal use. Academic programs often rely on healthcare organizations to provide opportunities for students to learn electronic health record skills. However, clinical experiences are highly individualized, and students may not have access to electronic health records. Alternatives are needed to develop this critical competency. This study compared self-reported ratings regarding comfort and access to electronic health record documentation between students who participated in screen-based simulation and students who completed traditional clinical experiences with a preceptor during the last 70 hours of clinical training in one family nurse practitioner program. There was a significant difference in electronic health record access between students who participated in simulated versus traditional clinical experiences ( P = .002). There were no significant differences in ratings of comfort using electronic health records between groups. Both groups reported limited access to electronic health records in the first 500 hours of clinical experience. However, students who participated in screen-based simulation reported a quarter-fold increase in electronic health record access during their last 70 hours of clinical training.

The Inter Face of Social Media Recruitment and Nursing Education Research.

This study describes using social media in recruiting a large and hard-to-reach national sample of family nurse practitioner students in the United States enrolled in their final clinical course and the impact on survey response targets. Social media recruitment was initiated when sample targets were not met using traditional, direct email invitations. A cross-sectional, observational, complex-samples survey design was used to collect data from students enrolled in accredited programs. When inviting participants via emails to schools of nursing and program administrators was only moderately successful, direct recruitment via social media sites was used. Targeted study advertisements were shown 602 389 times to 77 410 unique Facebook users over 14 months. In the final sample of 3940 study participants, 46% (n = 1811) were recruited through social media. Survey responses for health education research are typically 50% or less of the target. Using Facebook was successful for recruiting a large, geographically disperse and representative student sample necessary to ensure findings were representative and generalizable. This recruitment strategy could be effectively used for a myriad of research in areas where social media use exists to gain access to participants who might otherwise not be accessible.

Marijuana Use and Older Adults' Self-Reported Difficulty Concentrating, Remembering, or Making Decisions.

OBJECTIVE: This study investigated the relationship, in adults 50 years and older, between self-reported past-month marijuana use and difficulty concentrating, remembering, or making decisions (SDCRMD) because of a physical, mental, or emotional condition, using the Behavioral Risk Factor Surveillance System (BRFSS). METHOD: We relied on a sample of 294,000 adults (53.4% female), 50 years and older, from 21 U.S. states and two territories over 4 years (2016-2019). We conducted descriptive analyses to examine the prevalence of past-month marijuana use and SDCRMD and used multivariate logistic regression to examine the association between marijuana use and SDCRMD, controlling for demographic and health-related variables. RESULTS: The overall prevalence of SDCRMD was 11.0%, 95% confidence interval (CI) [10.6%, 11.5%], and the prevalence of self-reported past-month marijuana use was 7.1%, 95% CI [6.7%, 7.5%]. Of those reporting past-month marijuana use, 19.9%, 95% CI [17.8%, 22.1%] reported SDCRMD. Past-month marijuana users were 1.5, 95% CI [1.1, 2.1] times more likely to report SDCRMD than nonusers. Prevalence of past-month marijuana use was higher in states with legalization of both medical and recreational marijuana; however, prevalence of SDCRMD was not. CONCLUSIONS: We found a strong, positive, and statistically significant relationship between past-month marijuana use and SDCRMD. This finding serves as an important first step in identifying the relationship between older adults' self-reported marijuana use and their difficulty concentrating, remembering, and decision-making because of a physical, mental, or emotional condition; however, additional research is needed.

Practice scholarship satisfaction and impact as perceived by DNP-prepared nurses.

BACKGROUND: Today's health systems are complex and are challenged to strive for high-quality care that leads to optimal health outcomes. Doctor of Nursing Practice (DNP)-prepared nurses have the necessary competencies to influence health systems and delivery, that lead to safe and effective practice, by implementing practice scholarship, the translation of science to transform health care delivery, and clinical inquiry to improve practice. PURPOSE: The purpose of this study was to determine DNP-prepared nurses' satisfaction with their frequency of engagement in practice scholarship, and the relationship between the satisfaction and perceived impact of practice scholarship. METHODS: In this cross-sectional study, DNP-prepared nurses (n = 309) were recruited from a U.S. national membership organization and were asked to complete an online survey. RESULTS: Usable data findings (n = 269) revealed that 81% of participants reported feeling very, or moderately, satisfied with time spent engaging in practice scholarship or clinical inquiry in the areas of quality improvement, translation of research, and evidence-based practice; however, 19% expressed minimal satisfaction or dissatisfaction. There was a significant, moderate positive correlation between impact and satisfaction with time spent engaging in practice scholarship. CONCLUSIONS: Unclear roles and the lack of objective data measurement of practice scholarship are hindering the ability of DNP-prepared nurses to work to the full extent of their education and scope of practice. IMPLICATIONS: Further studies to develop processes and tools to measure the value and impact of DNP-prepared nurses on quality and safety, health care policies, systems, and population health are recommended.

Entrustable Professional Activities in Clinical Education: A Practical Approach for Advanced Nursing Education.

BACKGROUND: Competency attainment is foremost in the ethos of this project that provides a practical guide to implementing entrustable professional activities (EPAs) as one approach to competency acquisition in the clinical education component of a health care program. EPAs are units of work that provide evidence of required competencies for the clinical education component of a program of study for educators, preceptors, and students. PROBLEM: The American Association of Colleges of Nursing has raised the importance of competency-based education and need for a practical approach to assess clinical competency challenges (eg, EPAs) in nursing education. APPROACH: The implementation of EPAs in the clinical component of advanced nursing education is detailed as an example in this article. Prioritizing a systematic approach, the Knowledge to Action framework, was chosen to guide the process. CONCLUSION: Nursing must act now to put in place a robust competency acquisition and validation system.

COVID-19 on New Primary Care Nurse Practitioners: A Qualitative Exploration.

New nurse practitioners (NPs) struggle with the transition to practice and feelings of uncertainty concerning roles and responsibilities. COVID-19 has added a new layer of stress. This pilot study used a qualitative case study design featuring semistructured interviews of 10 newly graduated primary care NPs. Data analysis revealed 2 main themes: (1) emotional burden, and (2) coping and support. Emerging themes highlight the resiliency of NPs, who cope and seek support when faced with emotional burdens. This study informs educators and employers on the needs of new NPs during a global pandemic in order to better support the future workforce.

Impact of Practice Scholarship as Perceived by Nurses Holding a DNP Degree.

OBJECTIVE: The aim of this study was to explore the perceived impact of practice scholarship among DNP-prepared nurses and the relationship of impact to primary work role and years since graduation. BACKGROUND: Healthcare organizations continuously seek ways to improve health outcomes and reduce cost. Doctor of Nursing Practice-prepared nurses are educated with essential competencies to lead healthcare reform initiatives based on their practice scholarship contribution. METHODS: A cross-sectional design was used to administer a self-report online survey to a convenience sample of 306 DNP graduates currently in practice. RESULTS: The highest impact of practice scholarship was perceived on patients, populations, quality of care, and the profession. The impact on policy, cost, and cost savings was significantly lower. No significant difference was found on practice scholarship impact based on role or between years of experience since graduation. CONCLUSION: Doctor of Nursing Practice competencies support practice scholarship outcomes. Organizational resources are needed to support the impact of practice scholarship.

Facilitators and challenges to military undergraduate nursing student success.

BACKGROUND: Understanding the broader community of educators and programs involved in the education of military nursing students (MNSs) is needed to develop best practices that support their academic success. PURPOSE: The purpose of this study was to 1) identify factors nursing faculty perceived would facilitate and/or challenge the success of MNSs when transitioning to and progressing through baccalaureate nursing programs, and 2) ascertain successful strategies used in teaching and working with these students. METHODS: A descriptive survey research design was used to collect data from faculty at 26 schools of nursing that received federal funding to support the transition of veterans to a career in nursing. Quantitative and qualitative data were collected, analyzed, and integrated via descriptive statistics and content analysis. RESULTS: The survey was completed by 88 faculty from 19 of the 26 schools. The top four categories for both the facilitators and challenges, based on Jeffreys' (2015) NURS Model, were student affective characteristics, student profile characteristics, professional integration factors, and environmental factors. Programmatic factors were the most commonly cited success strategies, including having culturally competent, knowledgeable, and designated faculty and staff for MNSs. CONCLUSION: Developing evidence-based strategies to use in teaching and advising MNSs ideally will ensure their academic success.

Practice scholarship engagement as reported by nurses holding a doctor of nursing practice degree.

BACKGROUND: Nearly 15 years after the introduction of the doctor of nursing practice (DNP) degree, stakeholders anticipate practice scholarship outcomes from graduates. PURPOSE: To examine the frequency of engagement in practice scholarship, the relationship between the knowledge gained in DNP programs and the frequency of engagement in practice scholarship and the relationship between engagement in practice scholarship, work role, and years since graduation with a DNP degree, as reported by practicing nurses. METHODOLOGY: This cross-sectional study recruited 306 practicing DNP graduates via a national organization and employed an electronic survey. Descriptive and inferential statistics, correlational analysis, and a one-way analysis of variance were conducted on demographics and outcome variables for 269 completed surveys. RESULTS: The practice scholarship activity reported most frequently was evaluation of current clinical evidence and least frequently was dissemination of policy papers. Reported knowledge gained from DNP programs and frequency of engagement in practice scholarship indicate a weak positive correlation. There was a significant difference in the direct care work role and practice scholarship engagement compared with other roles, and between those practicing greater than 10 years and those with less experience. CONCLUSIONS: Results highlight the underutilization of knowledge gained in DNP programs and engagement in practice scholarship. The study emphasizes the complexity of realizing practice scholarship outcomes of DNP-prepared nurses to influence patients, populations, systems, and policy as well as the advancement of the nursing profession. IMPLICATIONS: This is a call to action for DNP graduates, academia, practice, and the nursing profession to support and value practice scholarship.

Lack of pediatric mental health clinical experiences among FNP students.

BACKGROUND: Mental health disorders accounted for approximately 5% of outpatient child and adolescent visits between 2008 and 2011, and 34.8% of these children were seen by a primary care provider. As primary care providers, family nurse practitioners (FNP) are positioned to address mental health issues across the lifespan; however, they require appropriate training and experience. AIM: The study examined pediatric mental health assessment clinical experiences in a national survey of FNP students. METHODS: A secondary analysis was performed on a data set of FNP students (N = 3940). Frequencies and chi-square analyses were performed to examine pediatric mental health assessment clinical experiences. RESULTS: Nearly 30% (n = 1118) of FNP students reported experiencing two or fewer pediatric mental health assessments during their clinical rotations. More than half (53%) of these students were required to set up their own preceptors and clinical sites. CONCLUSION: Despite the growing need for mental health care in the U.S, students reported lacking pediatric mental health assessment clinical opportunities. Moreover, students who set up their own clinical sites and preceptors were even less likely to assess pediatric patients' mental health. FNP educators and programs are encouraged to provide students with the support and opportunity for adequate pediatric practice, including mental health assessment.

Drivers for seeking the doctor of nursing practice degree and competencies acquired as reported by nurses in practice.

BACKGROUND: The American Association of Colleges of Nursing introduced the Doctor of Nursing Practice (DNP) degree in 2004. To date, few publications examine the competencies and impact of nurses with practice doctorates. PURPOSE: The purpose of this study was to examine reasons for seeking a DNP degree, assess knowledge and competencies acquired from DNP programs, and to inform stakeholders about the skills acquired by nurses with practice doctorates. METHODS: A cross-sectional design was used to administer a self-report survey to a convenience sample of DNP-prepared nurses in practice, recruited from a national membership organization. The electronic survey was designed using constructs developed from the literature, national organization position statements, and standards of doctoral nursing education. RESULTS: A total of 306 participants responded to the survey, 270 were used after data review. The majority of respondents did not seek a DNP degree because it was required for a job, to gain additional supervised practice, or to receive additional training with a specialty population. The majority strongly agreed that they gained competency in translating and synthesizing research evidence into practice, designing and implementing quality improvement, and identifying, measuring, and evaluating outcomes. CONCLUSIONS: Primary reasons for seeking a DNP degree were seeking knowledge, skills, competencies, confidence, and job opportunities. IMPLICATIONS FOR PRACTICE: Doctor of Nursing Practice-prepared nurses hold unique, advanced knowledge, competencies and skills to affect health care across multiple settings. Study results suggest that highly skilled DNP-prepared nurses are equipped to lead quality improvement, engage in practice scholarship, and improve clinical outcomes.

Competency frameworks for nurse practitioner residency and fellowship programs: Comparison, analysis, and recommendations.

ABSTRACT: Nurse practitioner (NP) education has followed the pattern of other health professions in recent years to place an emphasis on competency-based education. In recent years, postgraduate NP residency/fellowship programs to achieve competence and successful transition to practice have emerged and flourished. Currently, there is no standard competency framework in use for NP residency/fellowship programs in the United States, despite numerous published frameworks available. This article aimed to provide a comprehensive analysis of competency frameworks for NP education and to summarize and compare the competency frameworks used in NP education and residency/fellowship programs. Recommendations were sought for standardization of these competencies to create consistent evaluation and outcome measurements. Seven competency frameworks used across NP education and residency/fellowship programs were reviewed and compared in table format. Commonalities, differences, and themes were extracted from this comparison. There were more similarities than differences between the competency frameworks; however, common themes emerged as the emphasis on patient-centered, evidence-based practice, systems-based and quality improvement, and interprofessional practice and teamwork. The American Association of Colleges of Nursing Common Advanced Practice Registered Nurse Doctoral-Level Competencies, published in 2017, provided the most current, inclusive, comprehensive, and complete set of competencies for NPs at the time of graduation; however, they have not defined a progression indicator for postgraduate NP competency evaluation. This review of the competencies emphasizes (a) the need for consistent and consensus-based standards and (b) areas that NP education and residency/fellowship programs can strengthen to assess their ability to describe observable, measurable competencies. Instruments to evaluate competencies are recommended.