Reflections on independence in nurse practitioner practice

Purpose: To examine factors that influence the ability of nurse practitioners (NPs) to practice as independent primary care providers.
Data sources: Extensive literature search on CINAHL, OVID, MEDLINE, Internet journal sources, and professional association Web sites.
Conclusions: The legal authority for NPs to practice independently is recognized; however, the ability to put that authority into practice is undermined by the historical failure of political, professional, and social entities to recognize NPs as providers capable of providing primary care autonomously. Nonrecognition is responsible for complex reimbursement policies (both federal and state) that economically and professionally restrain the NP role; hence, NPs remain in a financially dependent relationship despite 40 years of proven safe practice. NPs must articulate their independence as practitioners more vociferously in order to meet society's healthcare requirements, as well as to attain professional fulfillment and forge collegial relationships.
Implications for practice: NPs will never be seen as members of a profession by either themselves or others without the practicality of independence and autonomy. Although legal independence is a fact, real practice independence in the pragmatic sense is contingent upon reimbursement. Without fiscal sustainability, practice independence is an impossibility. And, without professional autonomy, NPs will have only an employee's voice in the dynamic healthcare system in which they are really key players in providing healthcare services to the poor and undeserved populations.     

The nurse practitioner role in evidence-based medication strategies.

Nurse Practitioners at Brigham and Women's Hospital Weiner Center for Preoperative Evaluation use evidence-based medication strategies in their assessment of high risk elective surgical patients. Our objective is to identify those patients who meet the criteria for perioperative beta blockade and for deep vein thrombosis prophylaxis. Nurse practitioners were provided with education and training in using established guidelines in identifying those patients at risk. The nurse practitioner communicates with the appropriate member of the health care team (anesthesiologist, primary care physicians, surgeons, and anticoagulation service) and provides patient education. This process improves the utilization of these guidelines with improved patient outcomes.     

Integrating evidence-based practice in nurse practitioner education

This column normally focuses on a specific clinical practice guideline (CPG). This month's column deviates from that practice to demonstrate how evidence-based practice (EBP) was integrated into the nurse practitioner (NP) curriculum at the University of Texas at Austin School of Nursing. Processes of EBP were linked to student clinical assignments across core NP clinical courses, culminating in a student-published CPG. When students research and analyze available scientific evidence for a CPG, they learn to critically evaluate and logically organize knowledge for use in clinical practice, and those critical-thinking skills can lead to improved clinical reasoning and decision making.     

Ensuring safe and optimal medication use in older community residents: Collaboration between a nurse and a pharmacist

The purpose of this retrospective review is to describe 1) a nurse-pharmacist collaboration within a home based nurse-occupational therapist-handyman program called CAPABLE and 2) potential medication problems and 3) information communicated to participants and prescribers about those problems. A chart review was performed for each participant that one CAPABLE nurse referred to the pharmacists. We identified recommendations provided by pharmacists, synthesized common questions posed to the pharmacists' and developed exemplar cases of participant encounters. Fifty-nine participants were reviewed. The median number of total medications was 11 (IQR 9–14.5). Participants were most commonly taking antihypertensives (93%), statins (66%), and supplements/vitamins (61%). Pharmacists provided 83 unique recommendations for the 59 participants. The recommendations from the pharmacist were communicated for 49 of the 59 participants (83%), by the nurse. The nurse-pharmacist collaboration identified medication-related problems and solutions aimed at improving the quality of life for home-dwelling seniors with functional limitations.     

Perceived impact of faculty practice on nurse practitioner education

BackgroundFaculty practice is believed to positively affect health education, however limited research exists on the impact of faculty practice on nurse practitioner education.PurposeThe purpose was to explore the perceived impact of faculty practice on nurse practitioner education.MethodsA 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.ResultsStudy 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.ConclusionThis 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.     

Potentially inappropriate medication use in elderly Japanese patients

Background: Modified Beers criteria for elderly Japanese patients were developed in 2008 by consensus among 9 experts to reflect regional clinical practice and available medications in Japan. Since then, many physicians and pharmacists have expressed interest in obtaining more information about the criteria and alternative drug choices.Objective: This study examined the incidence, health care utilization, and costs associated with potentially inappropriate medications (PIMs) in elderly patients based on the modified Beers criteria.Methods: A retrospective, observational cohort study was conducted using health insurance claims data in Japan. The study population included elderly patients aged ≥65 years who had at least 2 pharmacy claims in separate months over a 1-year period (April 2006 through March 2007). Use of the PIMs was identified using the modified criteria, and 1-year incidence rates were calculated for the total study population and for subgroups stratified by age and sex. A logistic regression model was used to examine demographic and clinical characteristics associated with PIMs. Health care utilization rates and costs were also analyzed and compared between patients with and without PIMs using generalized linear models. All models included dummy variables indicating age category, female sex, hospitalization, polypharmacy, index month, and number of Elixhauser comorbidities to adjust for potential confounders.Results: Among 6628 elderly patients, 71.2% (4721/6628) were female and 62.9% (4167/6628) were aged 65 to 74 years; 43.6% (2889/6628) were prescribed at least one PIM. The most commonly used PIMs were histamine-2 blockers (20.5% [1356/6628]), benzodiazepines (11.4% [756/6628]), and anticholinergics and antihistamines (7.9% [526/6628]). No significant differences in incidence rates were observed based on age or sex. Inpatient service use, polypharmacy, and comorbidities of peptic ulcer, depression, and cardiac arrhythmias were significant predictors of PIM use while controlling for other factors. PIM users had significantly higher hospitalization risk (1.68-fold), more outpatient visit days (1.18-fold), and higher medical costs (33% increase) than did nonusers.Conclusions: In a group of elderly Japanese patients, 43.6% used at least one PIM over a 1-year period in this study. PIM use was associated with greater health care utilization rates and costs.     

药师参与糖尿病患者家庭用药指导效果的研究

目的探讨药师参与糖尿病患者家庭用药指导的效果。方法随机选取曾在我院住院后出院的糖尿病患者60例,其中随访组30例,对照组30例。随访组定期以电话、走访、授课等方式给予药学服务。结果随访组药学服务前后用药依从性从66．7％提高到90．0％,对照组不予任何干预,半年后用药依从性从70．0％提高到76．7％。随访组糖化血红蛋白随访前后从（7．10±2．73）％下降到（6．18±0．89）％（P〈0．05）;与之相反,对照组糖化血红蛋白从随访前到半年后由（6．18±2．59）％改变为（6．64±1．19）％（P〈0．05）。结论药师开展药学服务,指导糖尿病患者家庭用药,能提高患者用药依从性,血糖控制指标明显优于对照组。     

Patient acceptance of the family nurse practitioner.

Because of the limitations of published studies concerning patient acceptance of new health professionals and in the absence of published studies of patient acceptance of the family nurse practitioner, the present study compared levels of satisfaction among patients seeing a family nurse practitioner (Primex) with satisfaction levels among patients seeing traditional providers (doctors, nurses) withing the same setting. Based upon 1,912 patient-provider encounters using multiple evaluation criteria in ten ambulatory care settings, it was found that patient satisfaction with the Primex was equal to or more favorable than levels of satisfaction with traditional providers on four out of five measures.