Self-care in Heart Failure Hospital Discharge Instructions—Differences Between Nurse Practitioner and Physician Providers

Patients with heart failure (HF) are at risk for frequent readmission potentially due to self-care deficits. Medical doctors (MDs) and nurse practitioners (NPs) both provide discharge instructions. However, each type of provider may emphasize different elements of care. The aim of this study was to analyze and compare the content of the documentation of 50 discharge instructions of heart failure patients written by NPs and MDs. Compared with MDs, NPs placed greater emphasis on symptom identification, and were more likely to advise and schedule follow-up appointments with primary care and cardiology providers rather than advising an appointment was needed without scheduling one.     

Educational strategies to enhance placement and retention of nurse practitioners in rural Arkansas

PURPOSE: To examine the factors and incentives enhancing nurse practitioners' (NPs') long-term employment in rural areas. DATA SOURCE: The participants were 121 master's prepared or higher educated NPs located in rural Arkansas. A survey about role preparation and employment factors was mailed to the participants. CONCLUSIONS: We found that 10% of all respondents were not currently employed in the role of an NP. The majority of rural-employed NPs had didactic content focusing on rural-practice opportunities and engaged in rural practicums while in graduate school. Rural NPs were much more likely to have graduated from research-intensive universities. Nearly 90% of NPs reported they were somewhat to very well prepared for practice in rural Arkansas. IMPLICATIONS FOR EDUCATION: The shortage of health care providers remains one of the most irresolvable problems in the U.S. health care delivery system. Compounding the shortage is the unequal distribution of health care practitioners in rural areas. Evidence indicates that NP students engaged in rural clinical practicums were more likely to practice in rural areas. In light of this information, nurse educators should expand the NP educational process beyond rurally located practicums to deliver the entire educational process to the NP students' rural homes.     

Florida nurse practitioners' attitudes and practices regarding oral cancer prevention and early detection

PURPOSE: To examine Florida nurse practitioners' (NPs') attitudes and practices regarding oral cancer prevention and early detection. DATA SOURCE: A statewide mail survey was conducted among Florida NPs who provided primary care. The questionnaire was adapted from an existing survey instrument used to measure NPs' knowledge, attitudes, and practices about oral cancer prevention and early detection. A total of 448 Florida NPs (33% response rate) completed the survey. CONCLUSIONS: Florida NPs reportedly were not well prepared for oral cancer prevention and early detection. Although most NPs realized the importance of annual oral cancer screening for high-risk populations and held positive attitudes toward the benefit of early detection, only 39.3% of respondents thought his or her knowledge about oral cancer was current and more than half had never provided oral cancer examinations. IMPLICATIONS FOR PRACTICE: Florida has among the nation's highest oral cancer rates, but persons at highest risk are among those least likely to see a dentist. Therefore, a multidisciplinary approach involving all relevant healthcare providers, including NPs, may be more effective than relying only on dentists' efforts in improving survival rates for oral cancer. Strategies are needed to increase the involvement of Florida's NPs in oral cancer detection.     

Nurse practitioner and physician roles: delineation and complementarity of practice

Because of differences in education and role preparation, nurse practitioners (NPs) and physicians (MDs) may assume either complementary or substitutive roles in patient care. To describe role complementarity and similarity, the role perceptions of 15 NPs and 15MDs in joint practice were assessed. Ten NP and MD respondent pairs were selected from a variety of ambulatory primary care settings (urban, rural, public, private, and health maintenance organizations), and five NP-MD pairs were chosen at random. A questionnaire of nine patient vignettes was created; respondents rated the appropriateness of their role in managing the clients described in each vignette using an 8-point scale. Significant differences existed between NP and MD perceived roles for six vignettes, p less than .05. NPs identified as highly role appropriate those vignettes necessitating psychosocial support and health education; MDs identified as highly role appropriate vignettes representing high risk physical conditions. The differences in NP and MD role perception were complementary.     

Caring behaviors as perceived by nurse practitioners

PURPOSE: To investigate nurse pratctitioners' (NPs') perceptions of their own caring behaviors and to examine NPs' demographics as a function of their caring behaviors. DATA SOURCES: Responses to the Caring Behaviors Inventory(CBI) and a demographic inquiry from 348 NPs in Louisiana. CONCLUSIONS: CBI mean scores and subscale scores were high for all 348 NPs. No statistically significant difference was found between male NPs' and female NPs' total mean CBI scores or between urban or rural total mean CBI scores. The interaction between nurse gender and area o practice was not statistically significant. IMPLICATIONS FOR PRACTICE: NPs often work in clinic situations where productivity is the most valued characteristic and where little time is afforded for identifying caring behaviors of the NP and/or establishing a caring relationship with the patient. NPs must be extremely conscious of the need not to "throw out the baby with the bathwater" and sacrifice characteristics that are inherent in nursing for those emphasized in primary care practice. As their responsibilities in the health care setting continue to expand, NPs must continually evaluate and validate their roles to ensure quality care that satisfies patients.     

Patient satisfaction with primary care: does type of practitioner matter?

OBJECTIVE: The objective of this study was to evaluate the association of patient satisfaction with type of practitioner attending visits in the primary care practice of a managed care organization (MCO). STUDY DESIGN: We conducted a retrospective observational study of 41,209 patient satisfaction surveys randomly sampled from visits provided by the pediatrics and adult medicine departments from 1997 to 2000. Logistic regression, with practitioner and practice fixed effects, of patient satisfaction versus dissatisfaction was estimated for each of 3 scales: practitioner interaction, care access, and overall experience. Models were estimated separately by department. Independent variables were type of practitioner attending the visit and other patient and visit characteristics. RESULTS: Adjusted for patient and visit characteristics, patients were significantly more likely to be satisfied with practitioner interaction on visits attended by physician assistant/nurse practitioners (PA/NPs) than visits attended by MDs in both the adult medicine and pediatrics practices. Patient satisfaction with care access or overall experience did not significantly differ by practitioner type. In adult medicine, patients were more satisfied on diabetes visits provided by MDs than by PA/NPs. Otherwise, patient satisfaction for the combined effects of practitioner type and specific presenting condition did not differ. CONCLUSIONS: Averaged over many primary care visits provided by many physicians and midlevel practitioners, patients in this MCO were as satisfied with care provided by PA/NPs as with care provided by MDs.     

Toward a predictive model of patient satisfaction with nurse practitioner care

PURPOSE: (a) To determine if caring behaviors of nurse practitioners (NPs), gender of NPs, setting (urban or rural), and age, gender, ethnicity, education, and income of patients were predictors of patient satisfaction; (b) to determine which of these characteristics was the best predictor(s) of patient satisfaction; and (c) begin to develop a conceptual model for explaining patient satisfaction with NP care. DATA SOURCES: Responses to the Caring Behaviors Inventory (CBI) and a demographic inquiry by 348 NPs in Louisiana and completion of the Di'Tomasso-Willard Patient Satisfaction Questionnaire (DWPSQ) and a demographic inquiry from 817 patients in Louisiana served as data sources. A predictive modeling design explored which variable(s) is the best predictor of patient satisfaction, and multiple regression was used to determine the equation for the best-fitting line and the optimal model for the best predictor(s) of patient satisfaction. CONCLUSIONS: CBI mean scores were high for all NPs. No statistically significant difference was found between male NPs' and female NPs' total mean CBI scores and between urban or rural total mean CBI scores. DWPSQ mean scores and subscale scores indicated high satisfaction with NP care. No statistically significant relationships were found between the NPs' CBI mean scores and the patients' DWPSQ mean scores. There were significant relationships between the DWPSQ subscales, including Wait Time and Patient Management. Stepwise linear regression revealed that patients' age group was a predictor of DWPSQ total mean scores. IMPLICATIONS FOR PRACTICE: NPs need to be aware of developmental differences in all age groups and the differences in perceptions of care. There are many variables to consider when determining patient satisfaction with care, including the patients' sociodemographic and health variables, the healthcare system, and characteristics of the healthcare providers. Awareness of these variables may affect how NPs deliver care and ensure quality care with which the patients are satisfied.     

Ethical conflict in nurse practitioners and physician assistants in managed care

BACKGROUND: More patients are receiving healthcare services from nurse practitioners (NPs) and physician assistants (PAs). These providers are likely to be confronted with a variety of ethical issues as they balance quality care with their patients' rising cost concerns. However, very little is known about the ethical conflicts and causes of these conflicts experienced by these clinicians in their daily practice. OBJECTIVE: To identify ethical concerns and conflicts NPs and PAs encounter related to managed care in the delivery of primary care to patients and the factors that influence ethical conflict. METHODS: A cross-sectional self-administered mailed questionnaire was sent to 3,900 NPs and PAs randomly selected from primary care and primary care subspecialties in the United States (adjusted response rate, 50.6%). Respondents were surveyed on ethical issues and concerns, ethics preparedness, and ethical conflict. Bivariate and multiple linear regression analyses were used to evaluate predictors of ethical conflict. RESULTS: Insurance constraints were reported to have interfered with the ability to provide quality patient care by 72% of respondents, with 55.3% reporting daily to weekly interferences. Nearly half of respondents (47%) have been asked by a patient to mislead insurers to assist them in receiving care. A perceived obligation to advocate for patients, even if it means exaggerating the severity of a patient's condition, was the single most significant predictor of ethical conflict, explaining 25% of the variance. DISCUSSION: NPs and PAs are experiencing ethical conflict often associated with their perceived professional obligations to advocate for patients. Being well-prepared in ethics and having sufficient professional independence help clinicians balance the ethical complexities and demands of meeting patients' needs within a constrained healthcare system.     

Professional Autonomy: Essential for Nurse Practitioner Survival in the 21st Century

This article examines nurse practitioners' (NPs) professional autonomy as a critical component of future practice success and survival. Professional autonomy provides the basis for defining and negotiating NPs' work and worth in primary care. Outcome data and analyses that delineate the unique and overlapping practice roles and responsibilities of physicians and NPs will help determine the relative value of their work. Nurse practitioners practicing as physician "substitutes" risk professional survival. Nurse practitioners need to identify nursing as their practice paradigm and nurses as their professional identity.     

The Quality and Effectiveness of Care Provided by Nurse Practitioners

Evidence regarding the impact of nurse practitioners (NPs) compared to physicians (MDs) on health care quality, safety, and effectiveness was systematically reviewed. Data from 37 of 27,993 articles published from 1990-2009 were summarized into 11 aggregated outcomes. Outcomes for NPs compared to MDs (or teams without NPs) are comparable or better for all 11 outcomes reviewed. A high level of evidence indicated better serum lipid levels in patients cared for by NPs in primary care settings. A high level of evidence also indicated that patient outcomes on satisfaction with care, health status, functional status, number of emergency department visits and hospitalizations, blood glucose, blood pressure, and mortality are similar for NPs and MDs.     

Diabetes medical nutrition therapy: practical tips to improve outcomes

PURPOSE: To describe the evolving and expanding role of nurse practitioners (NPs) in providing diabetes medical nutrition therapy (MNT) as the United States faces epidemics of diabetes and obesity. DATA SOURCES: Scientific literature and reports from the public health, diabetes, and nutrition fields. CONCLUSIONS: Although clinically effective for both prevention and treatment of diabetes, MNT is often underutilized. The majority of people with diabetes are cared for by primary care providers; the role of NPs as primary care providers is evolving and expanding. NPs are recognized as leaders who creatively adapt to the rapidly changing health care delivery system. IMPLICATIONS FOR PRACTICE: NPs can serve as role models by presenting accurate, basic nutrition messages, referring patients to registered dietitians for MNT, reinforcing nutrition and the importance of lifestyle change as primary treatments for their disease, and following up on their patients' progress with nutrition interventions.     

Nurse practitioner, nurse midwife and physician assistant attitudes and care practices related to persons with HIV/AIDS

Although multiple studies of nurses' attitudes toward people living with HIV/AIDS (PLWAs) can be found in the literature, little is known about the attitudes, beliefs and practices of nurse practitioners (NPs), certified nurse midwives (CNMs), and physician assistants (PAs). A survey including a 21-item AIDS Attitude Scale measuring the constructs of Avoidance and Empathy was sent to 1,291 NPs, CNMs and PAs in Louisiana, Arkansas and Mississippi to describe their attitudes and care practices related to PLWAs. Respondents who were more comfortable treating PLWAs had significantly lower avoidance scores and significantly higher empathy scores than respondents with lower comfort levels in providing care. Greater than 80% of respondents indicated that they would provide health care to HIV-infected individuals. Respondents who referred HIV/AIDS patients for all care did so primarily due to lack of experience with HIV and the availability of more experienced providers. Avoidance and empathy scores were not found to be significantly associated with referral for care. This study suggests that this group of providers has relatively low avoidance and high empathy toward PLWAs and is willing to care for HIV-infected individuals.