Intensive Primary Care Nursing: Exploring the Impact of a Nurse-Led Model for Medically and Social Complex Patients.

Lack of access to primary care contributes to health inequities. Treatment settings that utilize the full experience and training of nurses, both registered nurses (RNs) and advanced practice registered nurses (APRNs), can expand in primary care and successfully address health inequities. This small study describes the implementation of a model of primary care called intensive primary care (IPC), which has eight elements that support the full utilization of a nurse's experience and training. This is a mixed method qualitative study, which reports the observations of the implementation and pre- and post-intervention measures. The IPC model was implemented at a free clinic, which targeted underserved population between 2020 and 2023. Participants were selected as a convenience sample. Participants were to have two or more chronic health problems The participants received primary care using the IPC model, which included setting self-management goals, and meeting with RN or APRN on a monthly basis (face to face, via phone or zoom) to monitor progress toward goals. Twenty-two people were approached, and 19 completed the intervention. Pre- and Post-intervention measures (Patient Assessment of Chronic Illness Care [PACIC]-20); Functional, Communicative, Critical Thinking Health Literacy; Perceived Stress; Patient Activation; Perceived Self Efficacy for Chronic Disease; EuroQo- 5 Dimension (EQ-5D); Trust in Provider; Emotional Support-Patient Reported Outcome Measure Information System (PROMIS); and Patient Health Questionnaire-9) were obtained and analyzed with paired T test (α < .05). Nurses involved meet weekly to share observations recorded in free form notes. These observations were summarized by two of the authors (MD and KF) at the end of the study. All patients had improved physical health outcomes, but more importantly, there were significant improvements in measures known to impact health and health outcomes, specifically, patient activation, self-efficacy for chronic illness, PACIC, and trust in provider. Time spent with patients, both duration and frequency of contact, was observed to have significant impacts.

Perceived impact of faculty practice on nurse practitioner education.

BACKGROUND: Faculty practice is believed to positively affect health education, however limited research exists on the impact of faculty practice on nurse practitioner education. PURPOSE: The purpose was to explore the perceived impact of faculty practice on nurse practitioner education. METHODS: A preliminary mixed methods approach was used to evaluate nurse practitioner student and faculty perspectives on the impact of faculty practice on nurse practitioner education. Student group interviews were conducted and practicing faculty were surveyed. RESULTS: Study findings included student and faculty-perceived benefits and challenges of faculty practice on nurse practitioner education. Specific benefits were increased access to faculty preceptors and clinical sites for nurse practitioner students, influencing faculty-developed education materials, increased number of real-world examples, faculty credibility, applying evidence-based practice, and overall improvement in the quality of teaching. Specific challenges were time, faculty availability to students, managing multiple roles, and clinical sites not conducive to precepting. CONCLUSION: This study provided preliminary information on the perceived impact of faculty practice on nurse practitioner education including the benefits and challenges. Findings support faculty practice as having a positive perceived impact on nurse practitioner education.

The psychometric testing of the functional, communicative, and critical health literacy tool.

OBJECTIVE: The purpose of this study is to assess the validity and reliability of the English version of the FCCHL tool in urban and rural, socioeconomically vulnerable or unstable, chronic comorbid adults in the United States. METHODS: A cross-sectional study measuring both validity and reliability. RESULTS: A total of 276 participants were recruited. Internal consistency was measured using Cronbach's alpha of α = 0.87. External reliability was measured by test-retest methodology. Construct validity was measured using Confirmatory Factor Analysis that showed good fit. Criterion validity was measured by comparing the mean scores of the FCCHL tool sub-scales. Concurrent validity was measured by comparison of means of the FCCHL tool and education level compared to the NVS and s-TOFHLA. CONCLUSION: The results demonstrated that the FCCHL tools is measuring three different concepts. Overall, the FCCHL tool was seen to have good validity and reliability in the identified population. PRACTICE IMPLICATIONS: The FCCHL tool is a 14-item, self-report health literacy tool measuring more than functional health literacy. The tool can be used in practice to improve not only functional health literacy, but also communicative and critical which is highly applicable.

Where are we now? Practice-level utilization of nurse practitioners in comparison with state-level regulations.

BACKGROUND AND PURPOSE: Full practice authority for nurse practitioners (NPs) is optimal for high-quality, cost-effective health care. However, a complete picture of utilization after states have adopted full practice authority needs to be determined. The purpose of this examination was to review the evidence regarding practice-level utilization (PLU) of NP PLU in comparison to state-level regulations (SLRs). METHODS: Studies published in English and based on US populations were identified through PubMed, CINAHL, and Scopus (January 1, 1989-December 31, 2018), and bibliographies of retrieved articles. Of the 419 articles identified with these limits, 19 (5%) met all inclusion and exclusion criteria. CONCLUSIONS: Four categories of PLU were identified: billing practices, level of supervision, privileges, and prescriptive authority. Significant differences were seen between urban versus rural NPs and primary care versus specialty NPs. Thirteen of the 19 studies did not specifically address the SLR of the included sample. IMPLICATIONS FOR PRACTICE: No studies described the type of NP certification, practice specialty, and utilization, and compared all to the SLR. There is a need for more evidence concerning PLU of NPs across the tiers of SLR. Only then can health care organizations, political leaders, and other stakeholders have the information needed to proceed with beneficial practice-model changes.

Federally qualified health center use of the Nebraska Tobacco Quitline.

INTRODUCTION: Promoting cessation services like quitlines is important to reduce tobacco-related morbidity and mortality. A critical need exists to improve clinical staff's awareness of tobacco quitlines and reduce barriers in recommending and referring tobacco-using patients. The purpose was to obtain information on the use of the Nebraska Tobacco Quitline (NTQ) by Federally Qualified Health Center (FQHC) clinical staff at FQHC settings with tobacco-using patients. Specific aims were: 1) identify FQHC clinical staff and setting characteristics that influence current tobacco cessation assessment and interventions, and 2) identify barriers and facilitators that influence future use of NTQ by FQHC clinical staff and settings. METHODS: This study recruited participants from seven FQHC settings. All FQHC provider and non-provider clinical staff were recruited to complete a Clinical Staff Survey. The Medical Director, Associate Medical Director, or Nurse Manager at each FQHC was asked to provide setting information through the Setting Survey. Descriptive statistics were used to report percentages and qualitative data were analyzed using pattern coding. RESULTS: The main findings include insufficient awareness and insufficient perceived effectiveness of NTQ, non-providers reporting a limited role in tobacco cessation efforts beyond assessment of tobacco use, and the lack of supportive setting processes for intervention use. CONCLUSIONS: Targeted efforts are needed to increase awareness and perceived effectiveness of NTQ, for role expansion for non-providers, and to add Electronic Health Record (EHR) prompts and e-referral capability to increase cessation interventions including NTQ referrals. Future research is suggested to better understand patient-specific barriers in using NTQ.

Educating Integrated Family/Psychiatric-Mental Health Nurse Practitioners: Program Development and Evaluation.

BACKGROUND: This article describes the development, implementation, and outcomes of an integrated family nurse practitioner/psychiatric-mental health nurse practitioner (FNP/PMH-NP) program. The program was designed to help alleviate health professional shortages in rural areas. METHOD: Faculty from both specialties developed a 3-year integrated curriculum, with attention to course sequencing and removing redundancies. Students completed all FNP and PMH-NP specialty courses and 855 clinical hours. Specialty integration occurred during the final semester through faculty-facilitated integrated case studies and clinical preceptorships with dual-certified rural nurse practitioners. RESULTS: Thirteen students completed the program between 2006 and 2014. A survey of graduates (75% response rate) demonstrated that most were dual certified, and less than half practiced in rural areas. All were very satisfied with their nurse practitioner role. CONCLUSION: The program successfully prepared graduates to care for patients across the mind-body spectrum in integrated mental health-primary care positions. More work may be needed to market the integrated role and rural practice.

Medication adherence in a nurse practitioner managed clinic for indigent patients.

PURPOSE: Little is published in the literature about medication adherence rates among patients who are medically indigent and patients receiving primary care from nurse practitioners (NPs). This project examined adherence rates and barriers to adherence among patients at an NP-managed health clinic (NPMC). DATA SOURCES: The setting for this research was an NPMC for uninsured and low-income patients. A cross-sectional convenience sample of patients (n = 119) completed surveys eliciting demographic information, self-report of medication adherence, health literacy, and barriers to adherence. CONCLUSIONS: Analysis of subjects demonstrated a vulnerable population, yet the mean adherence rate was surprisingly high (77%), compared to the rate usually cited in published literature. The best predictive model differentiating patients with high adherence from those with low adherence combined the total number of reported barriers, health literacy, and employment status. The barriers most frequently cited by subjects were difficulty paying for medications, and difficulty reading and understanding written prescription labels, which was particularly prevalent among Spanish-speaking patients. IMPLICATIONS FOR PRACTICE: Clinic efforts to improve patient access to affordable medications may have contributed to subjects' high rates of adherence. These efforts included helping patients with filling out prescription assistance program paperwork, prescribing generic medications, providing samples, and providing effective patient education.

Characteristics of risk in patients of nurse practitioner safety net practices.

PURPOSE: The purpose of this article is to describe the characteristics of vulnerability in patients at safety net practices where nurse practitioners (NPs) provide the majority of the health care and to discuss the implications regarding patient data collection for all NPs who provide safety net care. DATA SOURCES: Data were collected from patients at four safety net practices: a rural health clinic, a rural nurse-managed health clinic, an urban nurse-managed health clinic, and an urban Indian health clinic. CONCLUSIONS: The users of these practices reflected a significant degree of risk for poor health outcomes based on characteristics of risk identified in the literature. Patients seen in nurse-managed health clinics without federal subsidies had more risk that those in federally supported clinics. IMPLICATIONS FOR PRACTICE: Given the increasing evidence of the impact of social and environment factors on poor health outcomes, the importance of assessing and describing the characteristics of risk is discussed. These data are essential for supporting the value of these NP-provided safety net services to healthcare insurers and federal health policy makers.

Toward a national nurse-managed health center data set: findings and lessons learned over 3 years.

Although primary care nurse-managed health centers (NMHCs) have gained increasing recognition, there are limited standardized clinical and financial data on these centers. The purpose of this paper is to present the process, benefits, and challenges in collecting standardized national data based on a consensus process from NMHCs over 3 consecutive years. The Institute for Nursing Centers (INC) NMHC Survey focuses on demographic, clinical, and financial data. A detailed codebook accompanied the INC NMHC Survey. A total of 42 NMHCs responded in at least 1 of the 3 years. Despite the challenges in collecting some of the data, especially for the first survey year, data quality improved remarkably when the INC NMHC Survey was repeated. Financial data seemed to be more easily reported than demographic or clinical data. NMHCs increase access to care, often for vulnerable populations, yet to date there are limited standardized clinical and financial data on these centers. The INC NHMC Survey and data described in this paper begins to address that gap.

Quality and safety in graduate nursing education: Cross-mapping QSEN graduate competencies with NONPF's NP core and practice doctorate competencies.

To ensure that nurse practitioners are prepared to deliver safe, high-quality health care, the National Organization of Nurse Practitioner Faculties (NONPF) publishes documents that outline the expected competencies for nurse practitioner (NP) practice (Domains and Core Competencies of Nurse Practitioner Practice and Practice Doctorate Nurse Practitioner Entry-Level Competencies). Having participated in the development of the Quality and Safety Education for Nurses (QSEN) competencies for graduate education, NONPF convened a task force to compare NONPF competencies with QSEN competencies for graduate education. This paper reports the first step of that cross-mapping process, comparing NONPF competencies with the QSEN knowledge objectives. Overall findings indicate close congruence across the 2 sets of competencies; however there are areas in which gaps are noted or for which clarification is required.

The effects of motivational interviewing on physiological outcomes.

This study examined the effects of a motivational interviewing (MI) intervention on physiological outcomes among hyperlipidemic persons randomly assigned to an MI (n = 12) or an attention-control (AC; n = 12) group. Lipid and cardiorespiratory fitness levels were measured pre- and postintervention. The MI intervention was significant in reducing total cholesterol and low-density-lipoprotein cholesterol but not in increasing VO(2max) when compared with the AC group. Contrary to what was expected, the MI intervention significantly reduced high-density-lipoprotein cholesterol. Although this study was limited by a small sample size, findings suggested that an MI telephone session can have a positive effect on lipid profiles and fitness levels.

National consensus on data elements for nurse managed health centers.

This report presents a summary of the findings from the National Network for Nurse Managed Health Centers Data Consensus Conference. Nationally, nurse-managed health centers are increasingly offering communities another option for access to high-quality primary care. The lack of agreed upon, standardized data elements for these centers has limited the ability to present clear information about their contributions as well as to inform policy related to their support and development. Fifty-three national invitees came to consensus in Washington, DC on the critical data elements for a national database for nurse-managed health centers. This database includes both clinical and financial/business practices elements. Consensus was not reached around some clinical areas. These areas are briefly discussed as well as the plans for next stages of data collection.

Identifying clinical scholarship guidelines for faculty practice.

Clear descriptors of faculty practice and scholarly activities are essential to precisely demonstrate that the faculty practice role meets the standards of academic advancement and to influence academic policy. A description of scholarly clinical activities (1) justifies the benefits of faculty practice by means other than fiscal, (2) provides data for research regarding faculty practice, and (3) provides data to support the nursing profession's political, social, and health care agendas. Guidelines for clinical scholarship are described in this article. A review of relevant literature demonstrates that these guidelines go beyond current models by describing 24 scholarly activities organized into 4 areas: quality, governance, leadership, and knowledge development. Three years of data describing the scholarly activities of a college of nursing faculty engaged in practice are presented to demonstrate the effectiveness of the indicators in achieving these goals. These data can provide valuable information for trend analysis and, through heightened awareness of opportunities, increase faculty clinical scholarship activities.

Integral Nursing: an emerging framework for engaging the evolution of the profession.

These are turbulent times for health care as well as nursing. Nursing needs to consciously evolve to survive and thrive in the 21st century. The authors suggest that nursing has many of the theoretical and conceptual models needed to facilitate this evolution. However, the profession would benefit from the addition of a comprehensive framework that can integrate various aspects of nursing and serve as a device to effectively interface nursing with the rest of the health care system. We believe that the Integral Nursing approach described here is such a framework. In this article, we describe the model and explore benefits of its application for nursing within health care.