Family physician/nurse practitioner: stories of collaboration

AIMS: This paper presents the experiences of nurse practitioners and family physicians working in collaborative practice at four Canadian rural primary care agencies. It focuses on the qualitative segment of a larger study examining the impact of an educational intervention on interprofessional practice. BACKGROUND: Growing awareness of the importance of health promotion and disease prevention, the increased complexity of community-based care, and the need to use scarce human healthcare resources, especially family physicians, far more efficiently and effectively, have resulted in increased emphasis on primary healthcare renewal in Canada. Key to primary healthcare renewal is care delivery through interdisciplinary teams that include nurse practitioners. METHODS: Narrative analysis, a form of interpretive analysis that respects the integrity of the stories told by participants, was chosen as the strategy to examine the narrative data gathered in two sets of interviews with the nurse practitioners and family physicians. The study was undertaken during 2000. RESULTS: Thirteen family physicians and five nurse practitioners with diverse educational backgrounds and varied experience with collaboration participated in the qualitative component of the study. A number of issues related to working in a shared practice were identified in nurse practitioner and family physician interviews across the research sites. The themes identified in participants' stories included issues related to the scope of practice, emphasizing the importance of role clarity and trust, the ideological difference regarding disease prevention and health promotion, differences in perceptions about the operation of collaborative practice, and the understanding that collaborative relationships evolve. CONCLUSIONS: The placement of nurse practitioners and family physicians in a common clinical practice without some form of orientation process does not produce collaborative practice. Educational strategies related to role expectations are necessary to facilitate the development of care delivery partnerships characterized by interdependent practice.     

Mentoring: nurturing the critical care nurse

Mentoring is an active process that is currently receiving widespread attention in education, in the corporate world, and increasingly in health care. Job satisfaction of the critical care nurse may be related to the fulfillment of personal needs and goals. The attainment of these needs and goals ultimately will lead to increased job productivity, which in turn will promote cost-effectiveness, an outcome cherished by management. Therefore, recognizing the worth of job satisfaction to the institution and the possibility that mentoring may have an effect on it among the professional staff may be a key to the future of improved health care and cost reduction in an increasingly specialized and technologic health care environment. Certainly, the nursing shortage is no longer news to the lay public or those of us engaged in the practice of nursing. In critical care that shortage is acutely apparent. Attrition of qualified critical care nurses is increasing and various solutions to the shortage have been proposed, some being met with more enthusiasm than others. A more basic solution might be to answer the question, "How can we maintain a high quality of patient care while promoting job satisfaction and instilling a sense of self-worth within the critical care nurse?" Critical care nurses need to play a pivotal role in nurturing and developing other critical care nurses as a means to retain those individuals. How can they do that effectively? Mentoring is one answer.     

The impact of positive practices on nurse work environments: emerging applications of positive organizational scholarship

The overall purpose of improving work environments in health care is to enhance patient care delivery and improve the retention of nurses by engaging nurses in a model of cultural change that enhances communication and collaboration and actively involves nurses in organizational and clinical decision making. This article reports the findings from a 5-year study that describes an educational intervention for nurse leaders and a unit-based educational intervention for nursing staff, based on the application of Positive Organizational Scholarship (POS) and its impact on nursing work environments.     

Nurse practitioner research: issues in practice and theory

Since the inception of the nurse practitioner role, numerous studies have focused on the characteristics of NPs, including their educational preparation, their practice settings, demographic characteristics of clients, cost analysis, and the quality of services within a medical context. The two major conclusions of the majority of these studies have been that the delivery of health care by nurse practitioners has been fully accepted by patients, and that nurse practitioners are competent in the delivery of quality care. A brief historical overview of nurse practitioners is presented; the major methodological and conceptual issues of nurse practitioner research are reviewed. Views on practice issues and nursing theory development are shared, and directions for future nurse practitioner research are explored.     

Nurse practitioner curriculum for the 21st century: a model for evaluation and revision

The popularity and acceptance of the nurse practitioner (NP) role, developed in response to a need for additional health care providers, have led to large numbers of educational programs that prepare nurses for NP practice. These programs, following guidelines developed by the National Organization of Nurse Practitioner Faculties Curriculum Guidelines Task Force prepare NPs who are able to provide care to individuals and families throughout the life span. However, in the present health care environment, the NP curriculum constantly must be monitored and evaluated to reflect change. The authors developed a model for curricula revision that incorporates the elements of health policy, community needs and demands, and curriculum goals. This model promotes ongoing reflection on the educational product and assesses graduates' abilities to serve clients and communities within the constraints and opportunities afforded by the current health care system. This model is proactive and embraces the nurse practitioner curriculum guidelines as its core.     

Strengthening frontline nurse investment in organizational goals

Frontline nurses are foundational to any organizational goal concerning patient care. In addition, healthcare delivery reform has supported the formalization of specific goals that hospitals must advance to stay financially viable and to deliver high-quality care. As a result, goals for frontline staff are continuously evolving. Frontline nurses must demonstrate a commitment not only to delivering excellent patient care but also to advancing larger institutional performance. The authors discuss a framework for nurse executives to help organizations achieve enhanced nurse investment in organizational goals.     

A trial of nurse practitioner scope of practice

AIMS: The aim of this paper is to report a trial to investigate the feasibility of the nurse practitioner role in local health service delivery and to provide information about the educational and legislative requirements for nurse practitioner practice. BACKGROUND: Nurse practitioners have been shown to offer a beneficial service and fill a gap in health care provision. However, the lack of publications describing, critiquing, or defending the way that existing nurse practitioner roles have been developed may lead to a lack of clarity in comparing the nurse practitioner scope of practice internationally. In Australia, credible exploratory research is needed to realize the potential of nurse practitioners to bridge the divide of inequitable distribution of health services. A trial of nurse practitioner services in the Australian Capital Territory provided an excellent opportunity to investigate these scope and continuity issues. METHODS: This was an observational analytic study using multiple data sources. Four models of nurse practitioner service were chosen from a competitive field of applications that were evaluated according to efficacy, feasibility, and sustainability across specified selection criteria. Each model in the trial included a clinical support team, with the nurse practitioner candidate 'working-into-the-role' and collecting demographic, clinical practice, patient outcome, and health service and consumer survey data over a 10 month period. FINDINGS: The trial identified the broad potential of the nurse practitioner role, its breadth and limitations, and its impact on selected health services in the Australian Capital Territory. Data from individual models were compared highlighting generic elements, and formed the basis for the development of the scope of practice for the Australian Capital Territory nurse practitioner models. CONCLUSIONS: This study has validated a research-based, iterative process for initial development of nurse practitioner scope of practice for any Australian specialization. Importantly, the study concluded with the scope of practice as a finding, rather than commencing with it a priori. Although general areas of health care need and under-servicing were identified at the outset, the process tested both the expansion and parameters of the roles.     

Application of Curriculum Mapping Concepts to Integrate Multidisciplinary Competencies in the Care of Older Adults in Graduate Nurse Practitioner Curricula

The number of Americans ages 65 and older is projected to more than double over the next four decades and to equal nearly one-fourth of the entire population by 2060. Recognizing that the health care workforce in the United States is not sufficiently prepared to meet the care needs of this growing population, the National Academy of Medicine has recommended curricular enhancements for health professional educational programs. To meet this challenge, the University of South Florida College of Nursing applied curriculum mapping principles and concepts to examine and align Family Nurse Practitioner and Adult-Gerontology Primary Care Nurse Practitioner program curricula for congruence with Partnership for Health in Aging multidisciplinary geriatric competencies. Through this process, we developed a geriatric-specific curriculum map and threaded geriatric-specific content, learning experiences, and learning assessment strategies to promote attainment of all 23 competencies. Given the growing role that nurse practitioners are projected to play in the delivery of primary care for older adults in the future, it is imperative that colleges and schools of nursing provide students with learning experiences to support attainment of the knowledge and skills graduates will need to care for older adults in practice. The techniques and strategies described here represent our approach.     

Tertiary Nurse Practitioners

Tertiary nurse practitioners are proposed to meet the specialized health care needs of complex patients. Societal changes, increasing numbers of medically vulnerable people and increased costs of health care demand innovative responses to health care delivery. Nurse practitioners' effectiveness in primary care settings supports their introduction into acute care settings. Nurse practitioners are involved in tertiary care in response to a need for the delivery of care to patients with specialized needs. The evolution of the tertiary nurse practitioner role pre-dated the response of educational institutions to provide appropriate preparation for practitioners in tertiary care. Curricular imperatives and policy issues that will influence professional practice of the tertiary nurse practitioner are discussed .     

Suggestions for the reorganization of nurse training and improvement of patient care in a hospital for the mentally handicapped

Traditionally, the service requirements of hospitals and the health service have dominated the educational needs of training nurses. With the impending implementation of the Briggs Report on Nursing, the relationship between service and educational needs, especially the regulation for clinical experience, requires fresh thought. The author argues, taking one mental hospital as an example, that the present regulations for clinical experience, in the existing hospital structure, have negative effects both on the quality of nurse education and on the quality of patient care. He argues that both patient care and nurse education can be improved by a rethinking of the regulation for clinical experience and a change in the structure of mental handicap hospitals.     

An application of health literacy research.

Finding methods to improve the delivery of educational materials by the practicing nurse is imperative in the current health care arena. Time, energy, and effectiveness are all aspects that are critical as the health care provider attempts to meet the growing needs of the compromised client. Low functional health literacy is one public health problem that impacts the nurse's ability to effectively provide health instruction in a timely, organized manner. This article presents a pilot research project used to investigate the mastery of educational information by clients in a West Texas area. The research project is used as the foundation for discussion of several interesting facets resulting from the initial research. Ideas are presented as a direction for implementation for practice within the health care community. Low health literacy is a grave challenge, which currently is not understood nor considered by the nurse at the bedside. Practicing health care providers need the opportunity to carefully and specifically investigate the role of health care literacy in producing positive client outcomes.     

Future preparation of occupational health nurse managers

This article presents the results of a national survey of job activities of corporate level occupational health nurse managers. The survey was designed to identify the relative amount of time spent and importance attributed to specific areas of their current job. In general this sample tended to have more management experience and educational preparation than previously cited studies: over 50% had completed a graduate degree. The scores for importance and time spent were highly correlated. That is, occupational health corporate nurse managers seemed to allocate their time to job responsibilities they considered most important. Management activities related to policy, practice standards, quality assurance, staff development, and systems for client care delivery appear to represent the core responsibilities of occupational health nursing management. Curriculum recommendations for management positions in occupational health include: health policy, program planning, and evaluation; business strategy; applications of management information systems; quality assurance; and marketing.     

Factors influencing knowledge,attitudes, and compliance of hypertensive patients

Using a factorial design, four aspects of an educational program for 160 hypertensive patients were manipulated: number of meetings, patient responsibility and participation, directiveness of the intervention, and emphasis on negative consequences of uncontrolled hypertension. Validity checks on the manipulations included content analysis of the nurse-patient interaction and interview-based measures of the patient's responsibility, participation, and awareness of dangers. Outcome variables included repeated measures of patient knowledge, assessment by the nurse of patient attainment of identified goals, and reduction of the patient's mean arterial blood pressure. High indirect interventions tended to lead to higher goal attainment, particularly in the psychosocial area. Emphasis on negative consequences tended to promote learning for patients with long standing diagnoses, but to retard learning for recently diagnosed patients. Additional meetings and emphasis on patient responsibility were not helpful alone, but in combination they tended to lead to greater learning. Although as a whole, patients in the program tended to reduce their blood pressures, there were no statistically significant main effects or interaction effects of the educational approach variables on blood pressure reduction.     

Point of View Managed Outcomes: A Strategy to Improve the Nation's Health

Current health care delivery systems in the United States have led to high cost, uneven quality, less than universal coverage, undue emphasis on a medical/clinical model, and scant attention to primary care and prevention. In the context of health care reform, a new strategy is introduced that reverses present trends and incentives, called managed outcomes. This strategy is not specific to any particular health care delivery system. Managed outcomes encourages experimentation and flexibility in the design of health care systems and fosters primary care, health promotion, and disease prevention models. It links purchasing decisions to established specific and measurable goals that can provide quality and cost-effective services to improve health.     

Teaching the home care client

Patient education in home health care continues to hold many challenges for the professional nurse. With the changing climate of the health care delivery system, an increasing number of clients are returning to their home "quicker but sicker." The demand on the nurse to provide more in-depth patient education in the client's home will increase. The nurse must be prepared to make a thorough assessment of the client's learning needs, develop and implement an effective teaching plan, evaluate learning, and revise the plan as necessary, as well as document the teaching. All of this must be achieved to ensure continuity of quality patient care and reimbursement by third-party payers.     

The Global Summit on Nurse Faculty Migration

As global demand for health care workers burgeons, information is scant regarding the migration of faculty who will train new nurses. With dual roles as clinicians and educators, and corresponding dual sets of professional and legal obligations, nurse faculty may confront unique circumstances in migration that can impact nations' ability to secure an adequate, stable nursing workforce. In a seminal effort to address these concerns, the Honor Society of Nursing, Sigma Theta Tau International, and the International Council of Nurses invited a diverse group of international experts to a summit designed to elucidate forces that drive nurse faculty migration. The primary areas of consideration were the impact on nurse faculty migration of rapid health care workforce scale-up, international trade agreements, and workforce aging. Long-term summit goals included initiating action affecting national, regional, and global supplies of nurse educators and helping to avert catastrophic failure of health care delivery systems caused by an inadequate ability to educate next-generation nurses.     

Forensic Nurse Hospitalist: The Comprehensive Role of the Forensic Nurse in a Hospital Setting

Forensic nursing is an evolving specialty designed to address the unique, intersecting health and legal needs of patients who are victims, suspects, and perpetrators of trauma. The “Forensic Nurse Hospitalist” is proposed as a new term to describe the role of the nurse who is qualified by licensure and education as a specialist in forensic nursing and practices specifically in the hospital setting. The forensic nurse hospitalist can provide comprehensive, medicolegal care to patients receiving treatment for trauma-related injury and questionable death in the acute care setting. The purpose of this paper is to highlight the need and importance of the forensic nurse hospitalist and describe the multifaceted responsibilities of the role as a transformational leader in health care today. It is vital that health care systems employ forensic nurse hospitalists to deliver expert patient care, offer specialized consultation and collaboration, and implement systemwide policy and educational initiatives to best meet the needs of patients who have experienced intentional or unintentional trauma.     

Veteran Affairs Centers of Excellence in Primary Care Education: Transforming nurse practitioner education

To integrate health care professional learners into patient-centered primary care delivery models, the Department of Veterans Affairs has funded five Centers of Excellence in Primary Care Education (CoEPCEs). The main goal of the CoEPCEs is to develop and test innovative structural and curricular models that foster transformation of health care training from profession-specific “silos” to interprofessional, team-based educational and care delivery models in patient-centered primary care settings. CoEPCE implementation emphasizes four core curricular domains: shared decision making, sustained relationships, interprofessional collaboration, and performance improvement. The structural models allow interprofessional learners to have longitudinal learning experiences and sustained and continuous relationships with patients, faculty mentors, and peer learners. This article presents an overview of the innovative curricular models developed at each site, focusing on nurse practitioner (NP) education. Insights on transforming NP education in the practice setting and its impact on traditional NP educational models are offered. Preliminary outcomes and sustainment examples are also provided.