Physician assistants and nurse practitioners: a missing component in state workforce assessments

Due to current or predicted health workforce shortages, policy makers worldwide are addressing issues of task allocation, skill mix, and role substitution. This article presents an example of this process in the United States (US). Health workforce analysts recommend that US physician workforce planning account for the impact of physician assistants (PAs) and nurse practitioners (NPs). We examined 40 state workforce assessments in order to identify best practices for including PAs/NPs. Most assessments (about 60%) did not include PAs/NPs in provider counts, workforce projections or recommendations. Only 35% enumerated PAs/NPs. Best practices included use of an accurate data source, such as state licensing data, and combined workforce planning for PAs, NPs, and physicians. Our findings suggest that interprofessional medical workforce planning is not the norm among the states in the US. The best practices that we identify may be instructive to states as they develop methods for assessing workforce adequacy. Our discussion of potential barriers to interprofessional workforce planning may be useful to policy makers worldwide as they confront issues related to professional boundaries and interprofessional workforce planning.     

The Future of Emergency Medicine

Background

The specialty of emergency medicine (EM) continues to experience a significant workforce shortage in the face of increasing demand for emergency care.

Summary

In July 2009, representatives of the leading EM organizations met in Dallas for the Future of Emergency Medicine Summit. Attendees at the Future of Emergency Medicine Summit agreed on the following: 1) Emergency medical care is an essential community service that should be available to all; 2) An insufficient emergency physician workforce also represents a potential threat to patient safety; 3) Accreditation Council for Graduate Medical Education/American Osteopathic Association (AOA)-accredited EM residency training and American Board of Medical Specialties/AOA EM board certification is the recognized standard for physician providers currently entering a career in emergency care; 4) Physician supply shortages in all fields contribute to—and will continue to contribute to—a situation in which providers with other levels of training may be a necessary part of the workforce for the foreseeable future; 5) A maldistribution of EM residency-trained physicians persists, with few pursuing practice in small hospital or rural settings; 6) Assuring that the public receives high quality emergency care while continuing to produce highly skilled EM specialists through EM training programs is the challenge for EM's future; 7) It is important that all providers of emergency care receive continuing postgraduate education.     

Physician Perceptions of Advanced Practice Providers on Hospitalist Teams

Little is known about physician perceptions of nurse practitioners (NPs) and physician assistants (PAs) on hospitalist teams and the factors that impact their perceptions. Academic physician hospitalists were surveyed to better understand those factors, focusing on NP/PA experience, training, and physician experience with NPs/PAs. Perceptions by hospitalist physicians of NPs/PAs were strongly positive. Notable findings include the perceived positive impacts of NPs/PAs on clinical care provided, practice efficiency, and physician satisfaction. Most respondents prefer working with NPs and PAs with multiple years of clinical experience, particularly those who have participated in training beyond NP/PA graduate programs of study.     

EMS systems in Lithuania

In Lithuania pre-hospital medical services were started at the end of the 19th century. Emergency care for patients is provided free of charge and funded from a Compulsory Health Insurance Fund and by Government. Ambulance response target times are 15 min in urban areas and up to 30 min in rural areas. Personnel on ambulances consist of nurses and physicians. In the near future it is expected that paramedics will replace ambulance drivers. The emergency medical system is in a transition period: Admission departments are developing into emergency departments, residency programmes for emergency medicine are being prepared, and emergency medicine is going to be recognised as a separate specialty.     

Physician assistants and nurse practitioners: a missing component in state workforce assessments

Due to current or predicted health workforce shortages, policy makers worldwide are addressing issues of task allocation, skill mix, and role substitution. This article presents an example of this process in the United States (US). Health workforce analysts recommend that US physician workforce planning account for the impact of physician assistants (PAs) and nurse practitioners (NPs). We examined 40 state workforce assessments in order to identify best practices for including PAs/NPs. Most assessments (about 60%) did not include PAs/NPs in provider counts, workforce projections or recommendations. Only 35% enumerated PAs/NPs. Best practices included use of an accurate data source, such as state licensing data, and combined workforce planning for PAs, NPs, and physicians. Our findings suggest that interprofessional medical workforce planning is not the norm among the states in the US. The best practices that we identify may be instructive to states as they develop methods for assessing workforce adequacy. Our discussion of potential barriers to interprofessional workforce planning may be useful to policy makers worldwide as they confront issues related to professional boundaries and interprofessional workforce planning.     

Assessment of knowledge,attitude and practice regarding oxygen therapy at emergency departments in Riyadh in 2017: A cross-sectional study

BACKGROUND: Administering oxygen therapy (OT) has an essential role in preventing/managing hypoxemia in both acute and chronic conditions. It should be adjusted to achieve the normal oxygen saturation of 94%-98% in most cases. This study aims to evaluate knowledge, attitude and practice (KAP) of nurses, paramedics, emergency medical technicians (EMTs) and Emergency Medical Services (EMS) physicians working at emergency departments (ED) in Riyadh, Saudi Arabia. METHODS: In this cross-sectional study, a structured questionnaire was used to assess KAP related to OT of nurses, paramedics, EMTs and EMS physicians currently working at an ED of a tertiary care hospital. Knowledge and attitude were assessed using a Likert scale from 1-5, whereas practice was assessed as a yes/no categorical variable. RESULTS: A total of 444 emergency health-care workers (EHCWs) participated, of which 225 (50.7%) were male, with the majority (77%) in the age group of 20-35 years. Over half of the sample were nurses (266; 59.9%). The mean score for knowledge about OT was 5.51±1.45, attitude was 26.31±3.17 and for practices 4.55±1.76. The main factors which were associated with poor KAP were workload and lack of local guidelines. The distribution of overall practice score was significantly better among paramedics - nurses group and EMT - nurses group. CONCLUSION: This study demonstrates that there is a gap in EHCWs’ KAP, particularly regarding when to provide OT to a patient. This gap can affect patients’ safety. Extensive educational and training programs about OT are needed to raise awareness among health-care providers.     

Rethinking Traditional Emergency Department Care Models in a Post-Coronavirus Disease-2019 World

As the nursing shortage in United States emergency departments has drastically worsened since the coronavirus disease-2019 (COVID-19) pandemic, emergency departments have experienced increased rates of inpatient onboarding, higher rates of patients leaving without being seen, and declining patient satisfaction scores. This paper reviews the impacts of the coronavirus disease-2019 pandemic on the current nursing shortage and considers how various medical personnel (emergency nurse-extenders) can ameliorate operational challenges by redesigning emergency department systems. During the height of the coronavirus disease-2019 pandemic, the psychological effects of increased demand for emergency nurses coupled with the fear of coronavirus infection exacerbated nursing turnover rates. Health care workers who can be trained to augment the existing emergency department workforce include paramedics, Emergency Medical Technicians, emergency department technicians, ancillary staff, scribes, and motivated health sciences students. Utilizing non-nurse providers to fulfill tasks traditionally assigned to emergency nurses can improve emergency department flow and care delivery in a post-coronavirus disease-2019 world.     

Caring for older people in prehospital emergency care: can nurses make a difference?

Aims and objectives. The aim of this paper is to explore older people's experiences in prehospital emergency care, and identify benefits and difficulties associated with developing a nurse‐led ambulance service. Data were collected at sites in Sweden and Norway. Focus group interviews were conducted to enable the collection of data from paramedics, ambulance nurses and nursing students, while individual interviews were utilized to gather data from older people. Background. There is little research on the quality of care older people over 65 years old receive in prehospital emergency care. Older people often present with multiple pathology and diverse needs that nurses are well equipped to deal with, but presently there is no clearly defined role for nurses in prehospital emergency care in the United Kingdom, although other countries such as Sweden and Norway are developing an ambulance nurse role. Conclusions. If the multiple needs of older people were addressed in the prehospital field, a reduction in readmissions and increased functional ability might be achieved. Comprehensive training is required for ambulance staff to enable them to meet such needs. While nurses have a great foundation for this care, additional specialist ambulance training is required alongside a need for education on older people's needs and attitudes to older people. Relevance to clinical practice. The introduction of ambulance nurses will result in role differentiation between paramedics and ambulance nurses, which has the potential for creating role conflict. To ensure a smooth transition appropriate training and education for nurses and paramedics should be provided. The end result is a potentially greatly enhanced ambulance care provision, enabling high quality care to all patients.     

Improving Rural Access to Emergency Physicians

The recent Institute of Medicine report entitled The Future of Emergency Care in the United States Health System acknowledges workforce issues in rural America but does not adequately address the current shortage of emergency medicine residency–trained and board-certified emergency physicians in rural America. Areas worthy of further attention to ameliorate this threat include 1) government and hospital support of emergency medicine resident educational debt load, 2) modification of residency review committee for emergency medicine guidelines to permit modified training programs that are rural focused, and 3) support of pilot projects designed to modify the delivery of rural emergency care under remote supervision by academic medical center–based practitioners. The authors discuss these potential solutions to help guide policy makers seeking to enhance rural emergency care delivery through a stronger emergency medicine workforce.     

Patient perceptions of the specialty of emergency medicine

The study objective was to determine emergency department (ED) patients' perceptions of the specialty of emergency medicine. We surveyed a convenience sample of adult ED patients regarding their knowledge of the specialty of emergency medicine. Responses included: 22% believing that ED physicians have their own practice outside the ED; 26% of patients with primary care physicians expected to be seen by their primary care physician in the ED; 19% thought ED physicians care for patients after admission; 26% thought that ED physicians perform surgery, 62% perceived emergency medicine to be a specialty; 15% have heard of the American College of Emergency Physicians; 71% thought that ED physicians are board certified and 15% thought paramedics were ED physicians. Patients estimated ED physicians' mean annual mean salary to be $100,000 and 61% believe that ED physicians are hospital employees. In conclusion, the specialty of emergency medicine is not well understood by our patients.     

The education of UK specialised neonatal nurses: Reviewing the rationale for creating a standard competency framework

This paper examines the influences surrounding formal education provision for specialised neonatal nurses in the UK and presents a standardised clinical competency framework in response.National drivers for quality neonatal care define links to the numbers and ratios of specialised neonatal nurses in practice. Historical changes to professional nursing governance have led to diversity in supporting education programmes, making achievement of a standard level of clinical competence for this element of the nursing workforce difficult. In addition responsibility for funding specialised education and training has moved from central to local hospital level.Evaluating these key influences on education provision rationalised the development, by a UK professional consensus group, of a criteria based framework to be utilised by both formal education and service providers. The process identified clinical competency (in terms of unique knowledge and skills), evidence of achievement, and quality education principles.Access to specialised education relies on the availability of programmes of study and clear funding strategies. Creating a core syllabus for education provides a tool to standardise course content, commission education and audit clinical competency. In addition partnerships between healthcare and education providers become successful in achieving standard specialised education for neonatal nurses.     

Regionalization of Emergency Care Future Directions and Research: Workforce Issues

The provision of emergency care in the United States, regionalized or not, depends on an adequate workforce. Adequate must be defined both qualitatively and quantitatively. There is currently a shortage of emergency care providers, one that will exist for the foreseeable future. This article discusses what is known about the current emergency medicine (EM) and non‐EM workforce, future trends, and research opportunities. ACADEMIC EMERGENCY MEDICINE 2010; 17:1286–1296 © 2010 by the Society for Academic Emergency Medicine     

Paramedics and triage: Effect of one training session on triage in the emergency department

This 3-stage intervention study enrolled all adult patients referred to a universitybased emergency department (ED) during randomly assigned 1-week preeducation or posteducation periods. Triage decisions recorded by ED paramedics (n=8) both before and after an educational training session were compared to decisions made by emergency physicians (EPs). Triage decisions of paramedics and EPs in the preeducation phase showed poor consistency (κ =0.317, κ=0.388). Triage decisions in the posteducation phase increased slightly but were still found to be low. On the other hand, consistency between the triage assessments recorded by paramedics and EPs of the general appearance of patients increased from low in the preeducation phase to moderate in the posteducation phase (κ =0.327, κ=0.500, respectively). The training session was associated with a slight increase in the consistency of triage decisions recorded by paramedics and EPs.     

Performanc of aeromedical crewmembers: Training or experience?

In a clinical trial testing delivery of cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC) in a medical helicopter, 40–45% of physicians, nurses, and paramedics certified in advanced cardiac life support (ACLS) performed below standard as compared with full-time flight nurses and paramedics. Personnel regularly engaged in aeromedical activities perform far better than those similarly qualified but less familiar with the aviation environment. Because regular ACLS techniques apply during air transport, training, comfort, experience, and confidence are critical factors in crew performance and may affect outcome. The ideal crew should include regular partners who train and work together. The temptation to assign personnel to aeromedical duties without adequate preparation, testing, and commitment must be resisted. Those responsible for the medical direction of hospital-based helicopter services should insist on full-time crew members and provide them with liberal training opportunities and opportunities for skill maintenance.