Nurse practitioners are widely recognized for their holistic, patient-centered approach, which addresses the needs of patients, their families, and the communities they serve. Nurse practitioner care is noted internationally for reducing health disparities by improving care access and quality for underserved populations. However, there is limited empirical evidence on how well nurse practitioners are integrated into care models, which impacts the nurse practitioner workforce’s ability to reduce health disparities. This study aimed to explore how the extent of the integration of nurse practitioners within care models influences health disparities. This was part of a larger Delphi study guided by the Nurse Practitioner Integration Model. Open-ended surveys were sent to scholars and practice experts with experience in nurse practitioner integration. Data were collected from 29 participants. Inductive content analysis and member checking ensured the rigor and credibility of the results. Two core themes emerged: First, poor integration and limited role autonomy in the collaborating organization restrict nurse practitioner capacity to promote equity and decrease disparities, largely due to organizational policies that fail to prioritize nurse practitioner integration. Second, the distinct nurse practitioner approach is an untapped opportunity to increase equity and reduce disparities in low-integration settings, whereby well-integrated nurse practitioners could significantly impact outcomes in underserved populations. Effective nurse practitioner integration is crucial for advancing the United Nations Sustainable Development Goals, which emphasize improving health and wellbeing for all through diminished disparities. Policies and investment should prioritize full integration of nurse practitioners into care teams and organizations, maximizing their holistic, patient-centered approach to care and leveraging their unique contributions to expand access and promote health equity for underserved populations.
Switzerland faces challenges in long-term care due to its high life expectancy and the resulting increased prevalence of non-communicable diseases and functional dependence among older adults. Nursing homes are addressing increasingly complex acute care needs amid healthcare professional shortages. The nurse practitioner role has emerged globally as a key strategy to enhance the accessibility, quality, and coordination of care in these settings. While the role was recently legislated in the canton of Vaud, there's a scarcity of solid scientific data on nurse practitioner implementation and impact in Switzerland. The aim of this study is to assess the implementation of the nurse practitioner role in nursing homes in order to develop a toolkit that supports the sustainability of this new role's deployment in Switzerland. This two-phase study will evaluate the implementation of the nurse practitioner role in two distinct nursing homes in the canton of Vaud, using the PEPPA Plus model (based on Donabedian's framework) as a guide. Phase 1 employs an embedded mixed-method case study design across three work packages (WPs). WP1 uses Rapid Ethnography (observations, interviews, document analysis) to assess structural elements influencing implementation before and one year after nurse practitioner deployment. WP2 uses a prospective descriptive quantitative design where NPs log their activities per act daily or five consecutive days each month over the course of one year. WP3 uses a longitudinal multi-method approach, combining a pre-post quasi-experimental quantitative component to measure resident, staff, and institutional outcomes (e.g., hospitalizations, pressure sores) at 3, 6, and 12 months, with qualitative interviews. Phase 2 (WP4) will use Thoele's three-step methodology-data preparation, focus group evaluation, and toolkit design-to develop a best practices toolkit to support the nurse practitioner role's sustainability based on Phase 1 results. For Phase 1 analysis, data from each nursing home will be analyzed separately (intra-case analysis) and then compared (inter-case analysis). Qualitative data (interviews) will be analyzed using thematic content analysis and triangulated with quantitative data for a comprehensive understanding. Quantitative outcomes will be analyzed using descriptive statistics and generalized linear models (e.g., Poisson regression) for pre-post comparisons over two six-month periods. All procedures will comply with the ethical principles outlined in the Declaration of Helsinki. Given the nature of the study, ethical approval from the Ethics Commission of the Canton of Vaud was not required, according to the latter. Data and material will be available on request from the authors. 10.17605/OSF.IO/7FX8M.
Organizational climate affects patient, clinician, and healthcare organization outcomes. The 29-item Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ) has been a valuable research tool for measuring four domains of NP organizational climate in primary care settings: Professional Visibility, Independent Practice and Support, NP-Administration Relations, and NP-Physician Relations. It can benefit from shortening to reduce survey burden and improve response rates. To design a shortened NP-PCOCQ-2 and assess the psychometric reliability and validity. To shorten the NP-PCOCQ, in Phase 1, we used data from 1,212 NPs collected in a cross-sectional survey of primary care NPs in 2018-2019. We used quantitative data and expert content review to select the items to retain in the NP-PCOCQ-2, based on data from half the sample. With the other half of the sample data, we evaluated the NP-PCOCQ-2's reliability, factor analytic structure, and correlation with the original scores and two key NP job outcomes, job satisfaction and intention to leave. In Phase 2, we used data from a new sample of 915 NPs to further evaluate the reliability, factor analytic structure, and correlation to job satisfaction and intention to leave, and compared the categorical classification of the organizational climate of NP practices of the NP-PCOCQ-2 to the original NP-PCOCQ. In Phase 1, the NP-PCOCQ-2 subscales were all reliable, demonstrated a four-factor Confirmatory Factor Analysis (CFA) fit, and were highly correlated with scores on the 29-item NP-PCOCQ. All subscales were significantly positively correlated with job satisfaction and negatively correlated with intention to leave. In Phase 2, we found the same patterns: the NP-PCOCQ-2 subscales were all reliable, demonstrated a four-factor CFA fit, and were highly correlated with scores on the 29-item NP-PCOCQ. All subscales were significantly positively correlated with job satisfaction and negatively correlated with intention to leave. Additionally, each NP-PCOCQ-2 subscale classified greater than 75% of NP's practices the same as the NP-PCOCQ. The 17-item NP-PCOCQ-2 demonstrated reliability, maintenance of the constructs measured by the original scale, and convergent validity. Researchers can use the NP-PCOCQ-2 to measure the four domains of NP's organizational climate in primary care.
Lung cancer remains the leading cause of cancer-related mortality in the United States, yet profound advances in screening, diagnosis, treatment, and survivorship have redefined what is possible for patients. Despite this progress, nihilism, fatalism, and stigma continue to shape public and professional perceptions, discouraging screening and delaying help-seeking. Nurse practitioners occupy a central and trusted position across the lung cancer continuum and are uniquely equipped to counter these barriers through compassionate, stigma-informed communication. This perspective article synthesizes current evidence to illuminate how nurse practitioners can translate empathy, equity, and behavioral science into tangible practice actions that reduce stigma and nihilism and instill compassion and hope. Key strengths-language, empathy, tobacco treatment integration, social context awareness, community engagement, and hope-form the "Permission to Hope" framework. By leveraging these strengths, nurse practitioners can transform everyday interactions into opportunities to rebuild trust, improve screening participation, and redefine what survivorship means in lung cancer care.
PhD-prepared nurse practitioners (NPs) bring a unique combination of attributes to work within university settings. However, models for integrating clinical practice within academia are lacking for nursing faculty. As four PhD-prepared NPs, we completed a pilot collaborative self-study to explore how PhD-NPs working in academia experience the integration of clinical practice with academic work, and how clinical practice fits within workload and academic promotion models. Following initial data collection by email, we conducted a virtual focus group and analyzed the data using Braun and Clarke's Reflexive Thematic Analysis. Identified themes included the value of clinical work; lack of understanding of the PhD-NP role; synergy between teaching, research, and clinical practice; challenges including time constraints and competing responsibilities; and the lack of formal models for PhD-NP role organization and compensation. PhD-prepared NPs felt clinical work added value to their teaching and research, although academic-clinical role organizational models were lacking. This pilot data must be contextualized within current North American policies and practice settings. Findings can be used to inform further study on the development of models for clinical practice in academia.
As nurse practitioner (NP) education adopts competency-based education, programs lack workplace-based, behaviorally anchored tools to track longitudinal competency progression and assess practice readiness. The purpose was to develop and validate the Nurse Practitioner Clinical Competency Progression Rubric (NP-Clin-CPR), a rubric aligning Dreyfus novice-to-expert stages with entrustable professional activity entrustment levels to monitor competency progression across core NP clinical activities. The NP-Clin-CPR defines 5 Dreyfus-aligned levels across autonomy, knowledge, standard of work, and contextual understanding; encounter complexity is recorded separately. Behavioral descriptors were drafted using structured large language model prompts informed by the American Association of Colleges of Nursing and National Organization of Nurse Practitioner Faculty indicators and refined to consensus. Eight NP experts rated relevance and clarity on a 4-point scale; item-level content validity indices (I-CVI) ≥ 0.78 and scale-level CVI/Ave ≥ 0.90 were targeted. After 2 rounds, all 40 descriptors met I-CVI and scale-level CVI/Ave thresholds for relevance and clarity. The NP-Clin-CPR is a valid, behaviorally anchored, complexity-stratified rubric integrating Dreyfus and entrustable professional activity frameworks.
This report traces the trajectory of education and role development of nurse practitioners (NPs) in Japan from its beginnings to the present. An overview of the qualifications of advanced practice nursing roles, including NPs, is provided. The necessity of the NP role in the setting of the country's demographics and current health care system is discussed. Considerations for the future of the role are explored.
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HIV self-testing is an important strategy in the US Ending the HIV Epidemic initiative. To facilitate uptake of self-testing, we developed the mLab app, which complements existing self-test options to support the potential for higher uptake of the HIV self-test. Syphilis, a sexually transmitted infection with currently rising prevalence and overlap in risk profiles with HIV, could similarly benefit from the advantages of companion diagnostic mobile apps such as mLab. Due to the success of the mLab app in promoting HIV self-testing during a randomized controlled trial and the scientific evidence of need for at-home syphilis testing, our team developed the mLab+ app, which supports both HIV and syphilis testing through an image processing algorithm that incorporates a duplex HIV and syphilis point-of-care test. We conducted a pilot study to assess the feasibility and usability of the mLab+ app for HIV and syphilis testing. We recruited participants who were assigned male sex at birth and reported sex with another man. Participants came to the Nurse Practitioner Group clinic for baseline and follow-up visits. Participants rated the usability of the app using the Health Information Technology Usability Evaluation Scale and the Post-Study System Usability Questionnaire at their 3-month follow-up visit. The primary outcome was the number of participants who were able to self-administer the DPP HIV-Syphilis test with the assistance of the mLab+ app. Feasibility was measured through recruitment pace, retention over 3 months, app usability, and paradata. Of the 20 participants, 19 identified as male and 1 identified as nonbinary. Most participants (n=16) were able to complete the DPP HIV-Syphilis test with facilitation support from the mLab+ app. The average duration of an app session, from after authentication until log-out or abandonment, was 30 minutes and 33 seconds (SD 21 minutes and 40 seconds). Apart from the 27% (13/48) of sessions that were 5 minutes or less, the distribution of session durations was approximately normal. Users spent the longest time viewing testing screens (ie, timer screens, initial testing screen, test guided walkthroughs, test results, and picture and result upload). The overall mean scores on the Post-Study System Usability Questionnaire (2.65, SD 1.06) and Health Information Technology Usability Evaluation Scale (3.62, SD 1.07) indicated medium to high usability. The retention rate for the 3-month trial was 80% (16/20). The findings support the use of the mLab+ app as a tool for assisting consumers in self-testing for HIV and syphilis. The limitations of the study design warrant further examination outside of clinic settings to better understand the utility of these tools for improving consumer health outcomes.
Leadership development programs in health care often fail due to their lack of adaptability to the schedules of busy clinicians. This study addressed the need for scalable, flexible programs tailored to nurse leaders. This study evaluated the acceptability, appropriateness, and feasibility of the Relational Playbook, an evidence-based leadership development program developed in the Veterans Health Administration delivered through the Whistle Systems employee recognition web application and mobile app. A 1-year, single-team pilot was deployed using descriptive survey data and qualitative interview analysis. The Relational Playbook's educational content and interventions were hosted on the Whistle platform, which integrates behavioral science and gamification strategies. Content was delivered weekly via app-based nudge notifications and email. Engagement metrics included activity completion rates. User experience data were collected through weekly reflection surveys (with Likert-scale responses and open-text options); monthly check-ins; and a postimplementation acceptability, appropriateness, and feasibility survey and interview. Descriptive statistics summarized engagement levels and trends, and qualitative data were analyzed using content analysis to identify recurring concepts. Quantitative and qualitative data were analyzed sequentially for comprehensive insights. The section chief and 4 practicing cardiology nurse practitioners from a large academic medical center participated. The nurse practitioner section chief deemed the Whistle platform an acceptable, appropriate, and feasible technology for delivering the Relational Playbook content. They valued the weekly nudges, microlearning content, and flexibility of the web application and mobile app. The Relational Playbook content supported their personal growth and fostered positive shifts in attitudes toward work. Delivering leadership development content through the Whistle platform is an acceptable approach to support the growth and well-being of busy nurse leaders. The small sample and absence of a comparison group limit generalizability.
The aim of this study was to explore the acceptability of an educational video among primary care clinicians as a tool to promote the use of stigma-free language in interactions with individuals with type 2 diabetes (T2D). The language used by primary care clinicians in interactions with adults living with T2D can contribute to perceptions and experiences of diabetes-related stigma and be a barrier to achieving and sustaining glycaemic targets. In 2017, the American Diabetes Association (ADA) and the Association for Diabetes Care & Education Specialists (ADCES) issued a guidance paper with recommendations to promote stigma-free communication about diabetes. The educational video, developed by the research team, presents two versions of a vignette in which a nurse practitioner interacts with an adult with T2D in a primary care setting. The first version of the vignette features the nurse practitioner using stigmatizing language as outlined in the ADA and ADCES guidance paper; the second demonstrates the use of stigma-free language by the nurse practitioner. A narrator highlights the linguistic differences. The study participants, comprising physicians (n = 8), nurse practitioners (n = 9), and physician assistants (n = 1), were recruited through professional networks and via online forums and listservs for healthcare professionals. Participants viewed the educational video and were interviewed via Zoom by a research team member using a semi-structured interview guide. The transcripts of the interviews were analysed using a qualitative descriptive approach. Three main themes emerged from the data: aligning video content with existing attitudes and beliefs, reducing the use of stigmatizing language, and increasing the use of stigma-free language. Findings suggest that an educational video promoting the use of stigma-free language in interactions with adults with T2D is acceptable among primary care clinicians.
In this paper we respectfully present a counter argument to Jesse Michael Kay's thesis, as we understand it, in his article titled, "The Nurse Practitioner Ethicist: Distinct from a Nurse Ethicist?" Foundational to our analysis is that we take the distinction between nursing as a discipline and a practice profession, and clinical ethics as an emerging discipline seriously. The distinctions between them are well described in the literature. The two have different reasons for existence. While we agree that one's professional background can inform a secondary endeavor such as clinical ethics the goals are incommensurable. Moreover, we present an expanded definition of nursing ethics to explain the historical development of nursing goals and perspectives and its codes of ethics or conduct. Importantly, we provide support for the assertion that nurse practitioners are nurses in expanded roles but still accountable to nursing codes of ethics. Additionally, nurses who are working in the role of clinical ethicist are accountable to the goals of clinical ethics.
The evolving population demographics, healthcare system, and epidemiological transition have highlighted the need for interdisciplinary teamwork to deliver cost-effective and quality care. Despite its importance, research shows it is not consistently practiced in healthcare settings. This study aims to determine nurses' perceptions of interdisciplinary teamwork in clinical settings. A descriptive cross-sectional study was conducted in selected tertiary hospitals, Kathmandu. Sample size was calculated using Cochrane formula and convenient sampling was used to enroll 216 nurses. Data were collected using a self-administered modified version of the Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ). Frequnecy, percentage and mean were calculated as well as chi-square test was done for analysis. Among 216 nurses, 56.9% had negative perception of teamwork. The overall item mean score and standard deviation for NP-PCOCQ was 2.66 and 0.383, respectively. Perception regarding nurse-physician relations have the highest mean score and nurse-administrative relations have lowest. The majority of nurses in emergency and medical care had positive perception while those in surgical and critical care had negative perceptions of teamwork. The overall moderate perceptions of teamwork were reflected in the NP-PCOCQ score, highlighting the influence of clinical work environment on nurses' collaborative experiences. Majority of nurses have negative perception of teamwork with nurse-administrative relations scoring the lowest among subscales. Organizations should create a supportive work environment through strategic planning, effective communication, and regular collaboration to ensure teamwork.
The Nurse Practitioner (NP) workforce expanded rapidly from 2010-2023, especially in rural counties, where patients today are nearly as likely to receive care from an NP as from a physician. At the same time, rural health outcomes and access to health care continue to worsen relative to urban areas. Empirical research on how NPs interact with or substitute for physicians remains limited. This paper exploits county-level openings of graduate nursing programs to test how they impact the local supply of NPs and primary care physicians. Using data from the Integrated Postsecondary Education Data System and Area Health Resource Files, we estimate staggered difference-in-differences frameworks. We show that new graduate programs lead to large increases in the local NP supply and find positive spillover effects for nearby rural counties and counties with low provider to population ratios. We find that over the decade after a program first graduates students, up to 30% of students become licensed NPs in the same county, and for rural programs, the majority of graduates add to the regional supply of NPs. We find no adverse impact of local NP increases on the number of primary care physicians, suggesting that broader access to NP education boosts the local supply of providers overall. This paper illustrates the importance of rural medical education in increasing local access to primary care providers and in addressing existing inequities in access to care.
Traditionally, the nurse practitioner curriculum has not focused on acute care obstetrics, particularly in adult gerontology acute care. The rise in maternal mortality rates, primarily from preventable causes, highlights the need for competent providers, including nurse practitioners, as members of the health care team. Utilizing a multimodal instructional approach, a comprehensive, targeted curriculum focusing on acute care obstetrics was integrated into an adult gerontology acute care nurse practitioner curriculum.
The Centers for Disease Control and Prevention Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022 emphasizes the need to establish referral options for patients with opioid use disorder. The purpose of this quality improvement (QI) project was to determine the effectiveness of the integration of Webster and Webster's Opioid Risk Tool (ORT) into current opioid prescribing practices to improve identification of patients at risk for opioid use disorder for appropriate referrals and pain treatment. A QI design was used to compare referral rates to pain management, behavioral health, and substance use disorder treatment facilities before and after the implementation of the ORT among patients with chronic noncancer pain in an integrated primary care clinic in a rural region of Arizona. This article is a report of the project and compares pre- and postimplementation data to assess outcomes of a practice change. There were 375 participants in the project, including 212 in the preimplementation group and 163 in the postimplementation group. There were 46 referrals (22%) in the preimplementation group compared with 55 referrals (34%) in the postimplementation group. In this project, referral rates to pain management, behavioral health, and substance use disorder treatment facilities increased after integration of the ORT. Providers can use the ORT to identify at-risk patients and provide a network of treatment options.
High-quality evidence on the benefits of primary care in long-term care (LTC) is lacking. This study investigated the effect of primary health care services, continuity of care and care patterns on the risk of mortality and hospitalisation-related outcomes in LTC facility residents. A retrospective cohort study of 358 354 residents of 2948 LTC facilities across Australia was conducted (1 January 2013-31 December 2019). Primary care services, general practitioner (GP) continuity of care, and care patterns were examined. One-year risk of all-cause/premature mortality and nine hospitalisation measures were investigated. Propensity-score-adjusted survival models were employed. Residents with a care pattern inclusive of high preventive health services utilisation and low urgent after-hours attendances had lower risks of mortality [vs. high overall use, hazard ratio (HR) = 0.91, 95% confidence interval (CI) = 0.88-0.94; vs. high reactive use, HR = 0.91, 95% CI = 0.88-0.94] and most outcomes examined [e.g. fractures, subdistribution hazard ratio (sHRs) range = 0.90-0.91, 95% CI range = 0.84-0.97] compared to those with other care patterns. Residents who continued to see their usual GP had a lower risk of emergency department presentations (sHR = 0.92, 95% CI= 0.90-0.94), unplanned hospitalisations (sHR = 0.94, 95% CI= 0.92-0.96), falls (sHR = 0.89, 95% CI= 0.86-0.92), malnutrition (sHR = 0.88, 95% CI= 0.82-0.96), and dementia/delirium hospitalisations (sHR = 0.79, 95% CI= 0.72-0.87) than those who did not. Nurse practitioner attendances, optometrical services, comprehensive medication reviews, health assessments, management plans and podiatry attendances on their own were associated with lower premature mortality and some hospitalisation-related outcomes. Care patterns focusing on prevention and disease management, GP continuity of care and certain primary care services can positively impact residents' health and outcomes in LTC facilities.
Adults with neurofibromatosis type 1 and plexiform neurofibroma (NF1-PN) experience multiple clinical symptoms and diverse manifestations, which place a burden on patients and impact quality of life. This qualitative study aimed to improve understanding of disease burden, healthcare experience, and unmet needs of adults with NF1-PN in the United States, from patient and caregiver perspectives. Telephone interviews were conducted with adults who had a diagnosis of NF1-PN, or with caregivers, focusing on patient background, diagnosis, interactions with healthcare professionals, disease and symptom management, transition of care, and unmet needs. The study included 11 adult patients with NF1-PN and 2 caregivers; 85% of patients were diagnosed in childhood. Patients lived with multiple conditions associated with NF1, including pain disorders, psychiatric disorders, and chronic migraines. NF1-PN impacted daily living, work, school, relationships, and mental and emotional health. Most patients (82%) transitioned from pediatric to adult care, although there was variability in the transition experience. Some dropped out of care (23%) due to various factors, including time constraints, physician location, financial insecurity, lack of insurance, and perception of no available treatments/cure. Medical management primarily comprised medications to relieve symptoms associated with NF1 manifestations. Respondents identified a need to be more informed about their care. Improved treatment options for NF1-PN are desired, particularly medications that stop or slow PN growth. The study demonstrated that NF1-PN has a profound impact on adult patients' lives. Several unmet needs exist for the adult population, including medications to treat the PN and its associated symptoms.
Residential Medication Management Review (RMMR) is a government-funded pharmacist-led service to address medication-related problems, such as polypharmacy, which are prevalent in aged care. Despite known benefits, concerns remain about the service's effective implementation to benefit residents. We aimed to explore stakeholders' perspectives of the service and identify challenges and improvement opportunities. A qualitative study was conducted using individual interviews and focus groups with 21 stakeholders, including general practitioners (GPs), a nurse practitioner, registered nurses, pharmacists and consumers. Audio transcripts of the discussions were thematically analysed using inductive coding. Seven interconnected themes were identified, highlighting complexities in RMMR implementation and its role in medication optimisation in aged care. Consumer participation was limited, with low awareness and engagement despite a strong desire for involvement. General practitioners played a central role, acting as both enablers and gatekeepers. Despite the recognised value of interdisciplinary collaboration, professional silos and communication gaps created tensions. Review quality varied, with resident-centred and contextualised recommendations seen as more impactful. Improved integration of digital systems was viewed as a key enabler, though existing systems were often fragmented. Workforce and funding constraints limited provider motivation and service delivery. Finally, RMMRs were often reactive, highlighting opportunities to shift towards more proactive and transparent processes. Overall, RMMRs are a complex system-dependent process. Initiatives addressing identified challenges and strengthening consumer participation, improving interdisciplinary collaboration, integrating digital solutions and targeted policy reforms may enhance RMMR uptake and impact in Australian aged care.
In 2024, approximately 25% of adults in the United States, or 60 million persons, had a mental health condition. It is well established that those with psychiatric diagnoses experience a reduction in life expectancy compared to those without and are more likely to experience a greater burden of medical comorbidity. Despite the increased risk of multiple medical comorbidities among those with psychiatric diagnoses, as many as 20% of individuals experiencing mental health challenges do not receive primary care services. In some cases, psychiatric providers might be the only source of medical care for those receiving mental health treatment. While psychiatric providers often focus on the psychiatric interview and mental status examination, it is also imperative that providers adequately identify medical comorbidities to facilitate referral to primary care as needed. This article provides a brief overview of three clinical cases, underscoring the importance of addressing medical comorbidities and engaging in collaborative care within the outpatient telepsychiatric setting. Case examples include hypertensive crisis requiring emergency evaluation; Wolff-Parkinson-White syndrome in a patient with anxiety; and lithium-exacerbated hypothyroidism, each underscoring the need for psychiatric providers to be cognizant of medical comorbidities that warrant referral or emergency evaluation.