Public School Nursing Practice in the United States.

School nursing practice has changed dramatically over the past 20 years, yet few nationally representative investigations describing the school nursing workforce have been conducted. The National School Nurse Workforce Study describes the demographic and school nursing practice patterns among self-reported public school nurses and the number and full-time equivalent (FTE) positions of all school nurses in the United States. Using a random sample stratified by public/private, region, school level, and urban/rural status from two large national data sets, we report on weighted survey responses of 1,062 public schools. Additional questions were administered to estimate the school nurse population and FTEs. Findings reported illustrate differences by strata in public school nurse demographics, practice patterns, and nursing activities and tasks. We estimate approximately 132,300 self-identified practicing public and private school nurses and 95,800 FTEs of school nurses in the United States. Research, policy, and school nursing practice implications are discussed.

Interservice Physician Assistant Program: Educators for an Expanding Profession.

PURPOSE: The number of physician assistant (PA) programs has increased exponentially across the past decade, and the demand for PAs will likely remain strong through 2025. Because of this rapid growth, both new and established PA programs face significant challenges in recruiting experienced educators. We describe the value of using PAs trained through the Interservice Physician Assistant Program (IPAP) as civilian PA educators. METHODS: The literature on IPAP and its graduates proved too limited to conduct a formal systematic review. We searched the PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases for works speaking to the value that IPAP-trained PAs may bring to civilian PA training. Those findings were supplemented with informal conversations with IPAP-trained PAs currently employed in the military and those working in civilian PA education. Themes were identified supporting the potential value of IPAP-trained PAs in civilian training. RESULTS: Military PAs work within hierarchical organizations and may transition easily to academic settings. They leave military service not only as highly trained and proficient primary care providers but also as experienced educators. Military PAs must demonstrate professionalism across their entire military careers. They serve as leaders and work in teams, but they are also experienced in negotiating up chains of command. They are trained in and apply the latest innovations in health care delivery and have provided care with a degree of autonomy uncommon in civilian PA practice. CONCLUSIONS: The PAs trained through IPAP leave the service with skills and experiences valuable to civilian PA training. Employing these PAs in civilian education honors their service contributions while addressing emerging PA educator workforce demands.

Implementing an error disclosure coaching model: A multicenter case study.

National guidelines call for health care organizations to provide around-the-clock coaching for medical error disclosure. However, frontline clinicians may not always seek risk managers for coaching. As part of a demonstration project designed to improve patient safety and reduce malpractice liability, we trained multidisciplinary disclosure coaches at 8 health care organizations in Washington State. The training was highly rated by participants, although not all emerged confident in their coaching skill. This multisite intervention can serve as a model for other organizations looking to enhance existing disclosure capabilities. Success likely requires cultural change and repeated practice opportunities for coaches.

Physician Assistant and Nurse Practitioner Malpractice Trends.

Trends in malpractice awards and adverse actions (e.g., revocation of provider license) following an act or omission constituting medical error or negligence were examined. The National Practitioner Data Bank was used to compare rates of malpractice reports and adverse actions for physicians, physician assistants (PAs), and nurse practitioners (NPs). During 2005 through 2014, there ranged from 11.2 to 19.0 malpractice payment reports per 1,000 physicians, 1.4 to 2.4 per 1,000 PAs, and 1.1 to 1.4 per 1,000 NPs. Physician median payments ranged from 1.3 to 2.3 times higher than PAs or NPs. Diagnosis-related malpractice allegations varied by provider type, with physicians having significantly fewer reports (31.9%) than PAs (52.8%) or NPs (40.6%) over the observation period. Trends in malpractice payment reports may reflect policy enactments to decrease liability.

The experiences of risk managers in providing emotional support for health care workers after adverse events.

Risk managers often meet with health care workers who are emotionally traumatized following adverse events. We surveyed members of the American Society for Health care Risk Management (ASHRM) about their training, experience, competence, and comfort with providing emotional support to health care workers. Although risk managers reported feeling comfortable and competent in providing support, nearly all respondents prefer to receive additional training. Risk managers who were comfortable listening to and supporting health care workers were more likely to report prior training. Health care organizations implementing second victim support programs should not rely solely on risk managers to provide support, rather engage and train interested risk managers and provide them with opportunities to practice.

The Development and Preliminary Validation of a Rubric to Assess Medical Students' Written Summary Statements in Virtual Patient Cases.

PURPOSE: The ability to create a concise summary statement can be assessed as a marker for clinical reasoning. The authors describe the development and preliminary validation of a rubric to assess such summary statements. METHOD: Between November 2011 and June 2014, four researchers independently coded 50 summary statements randomly selected from a large database of medical students' summary statements in virtual patient cases to each create an assessment rubric. Through an iterative process, they created a consensus assessment rubric and applied it to 60 additional summary statements. Cronbach alpha calculations determined the internal consistency of the rubric components, intraclass correlation coefficient (ICC) calculations determined the interrater agreement, and Spearman rank-order correlations determined the correlations between rubric components. Researchers' comments describing their individual rating approaches were analyzed using content analysis. RESULTS: The final rubric included five components: factual accuracy, appropriate narrowing of the differential diagnosis, transformation of information, use of semantic qualifiers, and a global rating. Internal consistency was acceptable (Cronbach alpha 0.771). Interrater reliability for the entire rubric was acceptable (ICC 0.891; 95% confidence interval 0.859-0.917). Spearman calculations revealed a range of correlations across cases. Content analysis of the researchers' comments indicated differences in their application of the assessment rubric. CONCLUSIONS: This rubric has potential as a tool for feedback and assessment. Opportunities for future study include establishing interrater reliability with other raters and on different cases, designing training for raters to use the tool, and assessing how feedback using this rubric affects students' clinical reasoning skills.

A Cross-Sectional Analysis of Publication Types in Quality Improvement Journals.

Despite widespread engagement in quality improvement activities, little is known about the designs of studies currently published in quality improvement journals. This study's goal is to establish the prevalence of the types of research conducted in articles published in journals dedicated to quality improvement. A cross-sectional analysis was performed of 145 research articles published in 11 quality improvement journals in 2011. The majority of study designs were considered pre-experimental (95%), with a small percentage of quasi-experimental and experimental designs. Of the studies that reported the results of an intervention (n = 60), the most common research designs were pre-post studies (33%) and case studies (25%). There were few randomized controlled trials or quasi-experimental study designs (12% of intervention studies). These results suggest that there are opportunities for increased use of quasi-experimental study designs.

Characteristics of nurse practitioners and physician assistants in the United States.

BACKGROUND: Nurse practitioners (NP) and physician assistants (PA) serve as independent or semiautonomous providers and as fundamental members of healthcare teams. PURPOSE: Differentiating roles of health professionals is needed for optimal employment utilization. Clinically practicing PAs and NPs were characterized. METHODOLOGY: Data included wage and workforce projections to 2022.Variables included number practicing, age, gender, race, ethnicity, education, principal employer, practice specialty, and wages. RESULTS: Health delivery establishments employed 88,110 PA and 113,370 NP clinicians in 2013. Both were predominantly female: NPs were older (49 years) on average than PAs (38 years). A significant number of them practiced in physicians' offices or in acute care hospitals. Median wages were at parity. Growth predictions from 2012 to 2022 were 31%-35%. CONCLUSIONS: PAs and NPs constitute 20% of the composite clinician labor force (MD, DO, PA, NP). Labor market analysis suggests they are in demand. A majority of NPs and a third of PAs work in primary care fields. Their collective projected growth suggests a solution to emerging workforce shortages and an ability to help meet healthcare demands. IMPLICATIONS FOR PRACTICE: Adaptability to changing roles, especially in primary care and underserved areas, makes them facile responders to market demands in a continuously evolving healthcare environment.

Rural Versus Suburban/Urban Experiences in a Family Medicine Preceptorship.

PURPOSE: Accreditation standards require physician assistant (PA) programs to ensure students receive adequate clinical experiences. During their clinical year of training, PA students complete rotations with multiple clinical preceptors, introducing them to practice and exposing them to a variety of clinical problems. In this article, we examined Typhon Physician Assistant Student Tracking (PAST) system patient encounter logs' value for program evaluation, but also in research to address questions relevant to PA education. Specifically, we explored the MEDEX Northwest Physician Assistant Training Program student experience across rural versus suburban/urban placements in a 4-month family medicine preceptorship. METHODS: Student experience was analyzed from 2 years of collected Typhon PAST encounter data. Encounter characteristics included duration, number of clinical problems, student level of responsibility, and decision type. Patient characteristics included sex, age, race, and clinical problems recorded as ICD-9 codes. RESULTS: Individual student experience varied widely across different preceptors. However, these differences were more specific to the preceptor-student relationship than to whether the site was classified as rural or suburban/urban. Across these settings, significant differences were only noted for percentage of female and 65 or older patient encounters. The most common clinical problems reported across rural versus suburban/urban sites were highly correlated. CONCLUSIONS: Physician Assistant Student Tracking data demonstrated that individual student experience in their family medicine rotation varied widely. However, in general, rural and suburban/urban experiences were more similar than different. This study supports the value of the Typhon PAST logging system for not only tracking student activity but also addressing program evaluation and research questions.

Prolonged Exposure Dermatosis: Reporting High Incidence of an Undiagnosed Facial Dermatosis on a Winter Wilderness Expedition.

OBJECTIVE: Previously unclassified inflammatory skin lesions referred to as sun bumps have been observed throughout the year on participants of wilderness trips; however, the underlying cause and diagnosis remain unclear. The purpose of this prospective observational study was to document the incidence, characteristics, and risk factors associated with these skin lesions as they occurred on a winter wilderness expedition. METHODS: For this study, the lesions were defined as pruritic or erythematous skin lesions occurring while in the wilderness. Seventy-four participants in a wilderness ski touring course in Wyoming fully completed a 44-question written survey concerning occurrence and risk factors for these lesions. Weather information and photographs were collected. RESULTS: Twenty-six percent of participants had similar lesions. The lesions were described as edematous pale papules and plaques with erosions and crusts on an erythematous background. The face was involved in 90% of affected persons. Lesions occurred after an average of 8.7 days in the wilderness and resolved 10.6 days later. Skin that was less prone to sunburn was associated with a decreased incidence (odds ratio 0.44). No association could be found between lesion incidence and history of polymorphous light eruption, sun exposure, ambient temperature, affected contacts, sex, or body mass index. CONCLUSIONS: Overall, the lesions were common among study participants but occurred only after prolonged exposure to wilderness conditions. It was not possible to classify the skin condition as an example of any known diagnosis. We propose the name "prolonged exposure dermatosis" for this condition until further studies better define its etiology, prevention, and treatment.

Interprofessional education and practice guide No. 4: Developing and sustaining interprofessional education at an academic health center.

Increasingly health professions schools and academic health centers are required to include interprofessional education (IPE) as a standard part of their core curricula to maintain accreditation. However, challenges continue to surface as faculty struggle to develop and participate in IPE activities while balancing increasing workloads and limited resources, and also trying to keep current in the changing profession-specific accreditation and standards. This guide shares lessons learned from developing and sustaining IPE activities at the University of Washington (UW) based in the United States. In 2008, the UW Schools of Nursing and Medicine were awarded funds to develop, implement, and evaluate an interprofessional program focused on team communication. This funding supported the creation of two annual large-scale IPE events, provided infrastructure support for the Center for Health Sciences Interprofessional Education, Research and Practice (CHSIERP), and supported numerous interprofessional activities and initiatives in the health professions curricula. Our experiences over the years have yielded several key lessons that are important to consider in any IPE effort. In this guide we report on these lessons learned and provide pragmatic suggestions for designing and implementing IPE in order to maximize long-term success.

Physician assistant wages and employment, 2000-2025.

This study sought to assess physician assistant (PA) wages, make comparisons with other healthcare professionals, and project their earnings to 2025. The Bureau of Labor Statistics PA employment datasets were probed, and 2013 wages were used to explore median wage differences between large employer categories and 14 years of historical data (2000-2013). Median wages of PAs, family physicians and general practitioners, pharmacists, registered nurses, advanced practice nurses, and physical therapists were compared. Linear regression was used to project the PA median wage to 2025. In 2013, the median hourly wage for a PA employed in a clinical role was $44.70. From 2000 to 2013, PA wages increased by 40% compared with the cumulative inflation rate of 35.3%. This suggests that demand exceeds supply, a finding consistent with similar clinicians such as family physicians. A predictive model suggests that PA employment opportunities and remuneration will remain high through 2025.

Risk managers' descriptions of programs to support second victims after adverse events.

Guidelines call for healthcare organizations to provide emotional support for clinicians involved in adverse events, but little is known about how these organizations seek to meet this need. We surveyed US members of the American Society for Healthcare Risk Management (ASHRM) about the presence, features, and perceived efficacy of their organization's provider support program. The majority reported that their organization had a support program, but features varied widely and there are substantial opportunities to improve services. Provider support programs should enhance referral mechanisms and peer support, critically appraise the role of employee assistance programs, and demonstrate their value to institutional leaders.

Physician assistants and the disclosure of medical error.

Evolving state law, professional societies, and national guidelines, including those of the American Medical Association and Joint Commission, recommend that patients receive transparent communication when a medical error occurs. Recommendations for error disclosure typically consist of an explanation that an error has occurred, delivery of an explicit apology, an explanation of the facts around the event, its medical ramifications and how care will be managed, and a description of how similar errors will be prevented in the future. Although error disclosure is widely endorsed in the medical and nursing literature, there is little discussion of the unique role that the physician assistant (PA) might play in these interactions. PAs are trained in the medical model and technically practice under the supervision of a physician. They are also commonly integrated into interprofessional health care teams in surgical and urgent care settings. PA practice is characterized by widely varying degrees of provider autonomy. How PAs should collaborate with physicians in sensitive error disclosure conversations with patients is unclear. With the number of practicing PAs growing rapidly in nearly all domains of medicine, their role in the error disclosure process warrants exploration. The authors call for educational societies and accrediting agencies to support policy to establish guidelines for PA disclosure of error. They encourage medical and PA researchers to explore and report best-practice disclosure roles for PAs. Finally, they recommend that PA educational programs implement trainings in disclosure skills, and hospitals and supervising physicians provide and support training for practicing PAs.

Expanding assessments of translational research programs: supplementing metrics with value judgments.

The University of Washington (UW) Institute for Translational Health Sciences (ITHS), funded by a Clinical and Translational Sciences Award program, has supplemented its initial Kellogg Logic Model-based program evaluation with the eight judgment-based evaluative elements of the World Health Organization's (WHO) Health Services Assessment Model. This article describes the relationship between the two models, the rationale for the decision to supplement the evaluation with WHO evaluative elements, the value-added results of the WHO evaluative elements, and plans for further developing the WHO assessments.

Internists' attitudes about assessing and maintaining clinical competence.

BACKGROUND: Important changes are occurring in how the medical profession approaches assessing and maintaining competence. Physician support for such changes will be essential for their success. OBJECTIVE: To describe physician attitudes towards assessing and maintaining competence. DESIGN: Cross-sectional internet survey. PARTICIPANTS: Random sample of 1,000 American College of Physicians members who were eligible to participate in the American Board of Internal Medicine Maintenance of Certification program. MAIN MEASURES: Questions assessed physicians' attitudes and experiences regarding: 1) self-regulation, 2) feedback on knowledge and clinical care, 3) demonstrating knowledge and clinical competence, 4) frequency of use and effectiveness of methods to assess or improve clinical care, and 5) transparency. KEY RESULTS: Surveys were completed by 446 of 943 eligible respondents (47%). Eighty percent reported it was important (somewhat/very) to receive feedback on their knowledge, and 94% considered it important (somewhat/very) to get feedback on their quality of care. However, only 24% reported that they receive useful feedback on their knowledge most/all of the time, and 27% reported receiving useful feedback on their clinical care most/all of the time. Seventy-five percent agreed that participating in programs to assess their knowledge is important to staying up-to-date, yet only 52% reported participating in such programs within the last 3 years. The majority (58%) believed physicians should be required to demonstrate their knowledge via a secure examination every 9-10 years. Support was low for Specialty Certification Boards making information about physician competence publically available, with respondents expressing concern about patients misinterpreting information about their Board Certification activities. CONCLUSIONS: A gap exists between physicians' interest in feedback on their competence and existing programs' ability to provide such feedback. Educating physicians about the importance of regularly assessing their knowledge and quality of care, coupled with enhanced systems to provide such feedback, is needed to close this gap.

Effectiveness of intensive physician training in upfront agenda setting.

BACKGROUND: Patients want all their concerns heard, but physicians fear losing control of time and interrupt patients before all concerns are raised. OBJECTIVE: We hypothesized that when physicians were trained to use collaborative upfront agenda setting, visits would be no longer, more concerns would be identified, fewer concerns would surface late in the visit, and patients would report greater satisfaction and improved functional status. DESIGN AND PARTICIPANTS: Post-only randomized controlled trial using qualitative and quantitative methods. Six months after training (March 2004-March 2005) physician-patient encounters in two large primary care organizations were audio taped and patients (1460) and physicians (48) were surveyed. INTERVENTION: Experimental physicians received training in upfront agenda setting through the Establishing Focus Protocol, including two hours of training and two hours of coaching per week for four consecutive weeks. MAIN MEASURES: Outcomes included agenda setting behaviors demonstrated during the early, middle, and late encounter phases, visit length, number of raised concerns, patient and physician satisfaction, trust and functional status. KEY RESULTS: Experimental physicians were more likely to make additional elicitations (p < 0.01) and their patients were more likely to indicate agenda completion in the early phase of the encounter (p < 0.01). Experimental group patients and physicians raised fewer concerns in the late encounter phase (p < 0.01). There were no significant differences in visit length, total concerns addressed, patient or provider satisfaction, or patient trust and functional status CONCLUSION: Collaborative upfront agenda setting did not increase visit length or the number of problems addressed per visit but may reduce the likelihood of "oh by the way" concerns surfacing late in the encounter. However, upfront agenda setting is not sufficient to enhance patient satisfaction, trust or functional status. Training focused on physicians instead of teams and without regular reinforcement may have limited impact in changing visit content and time use.

The feasibility of a multi-format Web-based assessment of physicians' communication skills.

OBJECTIVE: Little is known about the best approaches and format for measuring physicians' communication skills in an online environment. This study examines the reliability and validity of scores from two Web-based communication skill assessment formats. METHODS: We created two online communication skill assessment formats: (a) MCQ (multiple-choice questions) consisting of video-based multiple-choice questions; (b) multi-format including video-based multiple-choice questions with rationales, Likert-type scales, and free text responses of what physicians would say to a patient. We randomized 100 general internists to each test format. Peer and patient ratings collected via the American Board of Internal Medicine (ABIM) served as validity sources. RESULTS: Seventy-seven internists completed the tests (MCQ: 38; multi-format: 39). The adjusted reliability was 0.74 for both formats. Excellent communicators, as based on their peer and patient ratings, performed slightly better on both tests than adequate communicators, though this difference was not statistically significant. Physicians in both groups rated test format innovative (4.2 out of 5.0). CONCLUSION: The acceptable reliability and participants' overall positive experiences point to the value of ongoing research into rigorous Web-based communication skills assessment. PRACTICE IMPLICATIONS: With efficient and reliable scoring, the Web offers an important way to measure and potentially enhance physicians' communication skills.

The physician assistant profession and military veterans.

The physician assistant (PA) profession originated to train former medics and corpsmen for a new civilian health care career. However, baccalaureate degree prerequisites to training present barriers to discharged personnel seeking to enter this profession. A survey was administered (2006-2007) to all MEDEX Northwest PA program graduates who had entered with military experience. The survey addressed attitudes toward the profession, PA education, and practice and how military experience influenced their education and careers. The response rate was 46.4%, spanning all branches of the military. Respondents reported military experience positively impacting ability to handle stress and work in health care teams and that patients and colleagues viewed their military background positively. Most (75.5%) respondents did not hold a bachelor's degree at matriculation. Veterans bring substantial health care training to the PA profession. However, program prerequisites increasingly present barriers to entry. Veterans' contributions to health care and the consequences of losing this resource are discussed.