WEBVTT
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- [Moderator] Louise Kaplan is a family nurse
practitioner and associate professor
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at Washington State University.
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She has conducted research on varied topics,
including APRN workforce issues, NP education,
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rural NP practice, prescriptive authority,
and medical marijuana.
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Her professional activities focus on
legislative and regulatory issues.
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She's a fellow of both,
the American Association of Nurse Practitioners
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and the American Academy of Nursing.
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Dr. Tracy Klein is an associate professor at Washington
State University College of Nursing.
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She is a fellow in the American Association of Nurse
Practitioners, American Academy of Nursing,
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and the Institute of Regulatory Excellence, and a
faculty member at the Oregon State University
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College of Pharmacy, where she mentors
and teaches PharmD residents.
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Her research focuses on prescribing,
scope, and policy aspects of advanced practice.
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- [Dr. Klein] Hello, I'm Dr. Tracy Klein,
family nurse practitioner,
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and I will be doing the first part of this presentation
on hiring, credentialing, and privileging
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of nurse practitioners as hospitalists.
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We would like to acknowledge our collaborators
and our funders for this presentation.
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We received a Center of Regulatory Excellence grant
to conduct our study, and we'd like to thank CRE
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for the funding, as well as the
Society of Hospital Medicine,
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National Association of Medical Staff Services,
and the American Association of Nurse Practitioners
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for their collaboration and support.
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In developing the plan for this study,
we did a review of what is published about hospitalists
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in the United States primarily.
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And our focus was looking at hospital medicine
groups caring for adults,
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that increasingly employed nurse practitioners.
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The majority of the studies we found
combine nurse practitioners and physician assistants
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to compare care to that of physicians,
assess patient care outcomes,
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examine staffing models, quality improvement,
and patient safety, and to analyze financial effects.
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Our interest was, on the other hand,
in identifying specifically some things about the nurse
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practitioner hospitalist and their experience
in the hospitalist role.
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In searching for literature
regarding nurse practitioner hospitalists,
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we identified three key gaps.
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The first is a lack of published studies describing
the factors influencing hospital hiring,
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credentialing, and privileging of acute care nurse
practitioners as hospitalists
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compared to those with other NP certifications,
such as family nurse practitioners.
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We also saw gaps in nurse practitioner described
perception, working as a hospitalist,
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of the work environment, including relationships with
physicians, utilization of education and of scope
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of practice, and self-reported job satisfaction.
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Finally, we wanted to spend more time identifying what
it's actually like to work as a nurse practitioner
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hospitalist caring for adults.
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We did not see studies in our review of the literature
that specifically focused on the day to-day
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work experience from a qualitative perspective.
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We conducted our study in three phases.
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We examined the following aspects of nurse practitioner
hospitalists working with adult patients.
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The factors that influence their hiring,
credentialing, and privileging,
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the workforce characteristics of hospitalist practice,
and the day-to-day work experience
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for the nurse practitioner.
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In Phase 1 of our study,
we conducted a cross-sectional mixed mode survey,
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with a sample of members of the National Association of
Medical Staff Services, Society of Hospital Medicine,
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as well as a selected sample of chief nurse officers
and nurse executives of magnet hospitals.
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These are subjects for our study that are responsible
for hiring, privileging, or credentialing
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of nurse practitioners.
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We had a 26-item questionnaire
that was developed and validated.
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The survey was administered online,
with a paper questionnaire mailed once,
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and with up to seven contacts after.
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A $50 gift card was offered as an incentive.
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The analysis of our Phase 1 results
included descriptive statistics,
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we evaluated the mean importance of each item in two
questions rating the importance of factors used
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to hire and credential nurse practitioner hospitalists,
such as certification and experience.
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We conducted ANOVA to compare post hoc means among the
different groups, and we evaluated differences
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in preferences and requirements between states with
full, limited, and restricted scope of practice.
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In the second phase of our study,
we had five questions, which were deployed in the
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American Association of Nurse Practitioners
2019 National Nurse Practitioner Sample Study.
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Three of these questions were adapted from the 2012
National Sample Survey of Nurse Practitioners.
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Our Phase 2 analysis included descriptive statistics,
correlations between relationships with a physician
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and the state's scope of practice,
and we correlated the extent to which nurse
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practitioners reported using their
education and scope of practice
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with their self-reported job satisfaction.
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Phase 3 was a series of focus groups
that we evaluated using
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qualitative exploratory methods.
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Nurse practitioner hospitalists were recruited from the
Society of Hospital Medicine NP/PA special
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interest groups, and five sessions were conducted using
a guide with eight-semi structured questions on Zoom.
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Our thematic analysis and synthesis
will be discussed further in our results,
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we transcribed sessions using inductive coding,
and identified and refined themes inherent in the nurse
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practitioner hospitalist role.
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Our key conceptual framework for this analysis utilized
empowerment theory, based on the results we found
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in our prior Phase 2 study.
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I'm going to, next, introduce my colleague,
Dr. Louise Kaplan, who will be discussing the Phase 1
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results and the subsequent results of our study.
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- [Dr. Kaplan] Thank you, Dr. Klein.
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I'd like to present the results of Phase 1
of our study.
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We had a 31% response rate,
with 405 respondents who met eligibility criteria.
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We asked about preferred certification,
and we had 42.4% respond adult NP
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and 31.5% respond acute care NP
as the two preferred requirements for hiring.
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Acute care was most preferred, 53.4%,
and adult-gero primary care
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was the least preferred certification.
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We asked our participants to
rate factors influencing hiring.
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Almost half rated adult nurse practitioner
certification as very or extremely important,
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with 27.5% rating acute care NP very
or extremely important.
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The chief nursing officers were more likely to value
the number of years that the nurse practitioner had
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as an RN and national certification
as an acute care NP and adult nurse practitioner.
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We also identified rating factors that
influence credentialing.
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Almost half rated that no prior, current,
or pending discipline by the board of nursing
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was not at all important.
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No history of denial, suspension,
or revocation of national board certification
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was not at all important to 44.3% of respondents.
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About two-thirds rated as not at all important
no history of denial, suspension,
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or revocation of participation in a health plan,
no prior, current, or pending health care lawsuits,
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and no prior or current substance use disorder.
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In asking about scope of practice,
among those who hire,
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there was no statistically significant difference for
any question by state scope of practice,
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And among those who credential, national certification
as a family nurse practitioner and no prior, current,
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or pending discipline by a board of nursing
were significantly more important
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in a restricted-practice state,
than in a full-practice state.
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We also asked about the APRN Consensus Model,
and only a quarter of the participants were familiar
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with the model, although three-quarters
of the chief nursing officers were.
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And few, only 11%, use the model to hire or credential.
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In Phase 2, the results of our survey with the NP
hospitalists included 366 who practiced
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with adult patients.
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Just over half were certified
as family nurse practitioners.
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Twenty of these family nurse practitioners had
an additional certification.
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Almost three-quarters were certified in primary care,
and these were family, adult,
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adult gerontology and pediatric primary care,
gerontology, and women's health certifications.
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We asked the participants what qualifications they had
for their NP hospitalist role.
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The most often selected, and they could choose all that
applied, was on-the-job training,
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followed by initial NP Education,
board certification,
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boot camp, which refers to an offering of the
Society of Hospital Medicine, and other.
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And the least common qualification was
the participation in a postgraduate residency
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or fellowship program.
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Additional results related to the relationship of the
nurse practitioner hospitalists with physicians.
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The most commonly selected,
because they could, again, choose all that applied,
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was that NPs collaborated with a physician on site.
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The NP was considered
an equal colleague to the physician by 38%.
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And then you can see in our slides that
there were a variety of other relationships,
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and the least common one selected was that
the NP was supervised by a physician
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and had to accept the clinical decisions
about patient care.
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Interestingly, NPs in restricted states,
were significantly less likely to be considered equal
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to the physician.
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We also asked the NP hospitalists to report,
what types of services they provided.
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Histories and physical exams, ordering,
performing, and interpreting lab tests
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and diagnostic studies, and prescribing drugs,
were the most common services provided
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for almost all patients.
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Thirty two percent did not perform any procedures,
and about a quarter perform procedures on most
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or almost all patients.
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We were also interested in job satisfaction, and we
found that almost a third were very satisfied,
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and a little over a half were satisfied,
so you can see that over three quarters were satisfied
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or very satisfied, while only 4% were
dissatisfied or very dissatisfied.
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And there was a significant correlation with full
utilization of one's education and practicing
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to the full extent of the state's scope of practice.
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For our Phase 3 study, we had 26 participants
from all four US census regions.
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And just as a reminder, our Phase 3 was our
qualitative study with focus groups.
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The participants were employed at hospitals ranging in
capacity from 25 to 2000 beds.
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And we had representation from NPs with family, adult,
adult-gero, acute care certification.
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Central themes that we identified related to our
initial finding in our prior studies
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of psychological empowerment,
so we affirmed that central finding,
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and identified through our analysis
five subthemes of empowerment,
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which included collegiality, autonomy,
role preparation, the road traveled, and pathfinder.
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Within each theme, there were
empowering processes and empowered outcomes.
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We also identified attributes
of the nurse practitioners,
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assets that contributed to successful
empowerment processes and outcomes.
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Collegiality was inclusive of teamwork,
trust, and bidirectional care.
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And we have some quotes in our results
that we feel best represent what these things were.
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Autonomy was reflected as the ability to be
decision makers and to practice
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without written policies to direct
the nurse practitioners.
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And one of the themes that we found was related to
hospital bylaws, and even with the requirement that
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in some hospital bylaws,
the nurse practitioner had to be supervised
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by the physician, there was still a sense of autonomy,
and that there was trust and rapport
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with the supervising physicians,
that allowed them to practice to their highest level
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of what they were educated for.
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Another one of our themes was shaping the role,
this identified RN experience,
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self-identified learning experiences,
and is exemplified by the quote,
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"As my clinical time in school didn't have
anything in the way of acute care,
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I did receive a prolonged orientation of six months
upon hire and really had to seek
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out my own opportunities.
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We did not have an onboarding situation.
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We did not have access to any of the boot camps.
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So really, I was just shadowing
and went right into the sharks."
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Another one of our subthemes was pathfinder,
this related to being the first NP in the role,
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creating a path, building the role,
as exemplified by the quote,
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"We were all floundering on what does our day
look like, and what can you do?
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I think it helps you grow stronger as a clinician
when you're not spoonfed.
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I think it's really important that you have the ability
to go and find out the answers that you need."
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The road traveled reflected the experience of
mentorship, navigating barriers, and leveraging state
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scope of practice.
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And then we identified the attributes that focused on
self initiative, flexibility, competence,
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capability and reputation.
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And these were what the nurse practitioner hospitalists
felt made them extremely successful.
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From our analysis, we have implications and
recommendations to share with you.
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We recommend that there be a comprehensive National
Nurse Practitioner Hospitalists Workforce study
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to analyze the educational, experiential,
and regulatory factors that contribute
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to an NP being able to function
in the hospitalist role.
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We recommend, inclusive of that,
that there be an investigation as to whether
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FNP hospitalists work in the same units
as acute care NP hospitalists,
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and whether they fulfill the same or different roles.
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We also recommend an evaluation
of what constitutes on-the-job training.
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Educational programs must align with practice.
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We would recommend that there be a reconciliation
between the mismatch of primary care NP
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and educational preparation, and the knowledge,
skills and competencies required
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for the NP hospitalist since we identified that
nearly half...or slightly over half of our sample
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were certified as FNPs.
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In addition, the acute care NPs in our focus groups
also identified that many of them did not have
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appropriate education for hospitalist work,
and felt that their program should also be revised.
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Repeatedly in our work, we found that hospital bylaws
were a barrier to NP hospitalist practice,
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and it is time for those bylaws to be updated.
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We recommend that the Joint Commission
and legislative action could accomplish this.
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The APRN Consensus Model is ready for revision.
00:19:14.827 --> 00:19:21.954 position:50% align:middle
Extensive changes have occurred in health care,
and particularly in the use of NP hospitalists,
00:19:21.954 --> 00:19:31.587 position:50% align:middle
since the model was adopted in 2008, and we recommend
the model reflect current NP roles and practices.
00:19:32.740 --> 00:19:40.830 position:50% align:middle
In conclusion, we'd like to comment on the mutuality in
the empowerment process that was evident in our work.
00:19:41.300 --> 00:19:48.490 position:50% align:middle
Physicians do not need to change their role and become
less empowered for nurse practitioner hospitalists
00:19:48.490 --> 00:19:50.856 position:50% align:middle
to feel empowered in their role.
00:19:51.242 --> 00:19:57.546 position:50% align:middle
And we also think that the nurse practitioner
hospitalist role should serve as a model for true
00:19:57.546 --> 00:20:03.455 position:50% align:middle
interprofessional team-based care,
in which no one person loses or gains power.
00:20:03.670 --> 00:20:09.280 position:50% align:middle
Instead, the strength of the team provides and guides
the path to optimal patient care.
00:20:10.820 --> 00:20:16.340 position:50% align:middle
We thank you for this opportunity,
we have two published articles that are available
00:20:16.340 --> 00:20:24.800 position:50% align:middle
for your review, and we welcome your feedback and
comments and look forward to questions and answers.
00:20:24.800 --> 00:20:25.987 position:50% align:middle
Thank you very much.
00:20:42.785 --> 00:20:46.934 position:50% align:middle
Thank you very much to all of the participants who
are with us today.
00:20:47.360 --> 00:20:54.449 position:50% align:middle
We would like to thank NCSBN for the invitation to
participate in the symposium.
00:20:54.880 --> 00:21:04.251 position:50% align:middle
We, again, would like to thank CRE funding,
which gave us the opportunity to conduct this study.
00:21:04.691 --> 00:21:12.700 position:50% align:middle
And we would like to also share with you that we
learned today that we have a new publication that will
00:21:12.700 --> 00:21:20.000 position:50% align:middle
be forthcoming in Nursing Outlook
that focuses on our focus group research with members
00:21:20.000 --> 00:21:22.377 position:50% align:middle
of the Society of Hospital Medicine.
00:21:22.627 --> 00:21:31.810 position:50% align:middle
So we're very grateful for this opportunity,
we think the work is really important as the adoption
00:21:31.810 --> 00:21:40.960 position:50% align:middle
of the nurse practitioner hospitalist role increases in
hospitals across the country, both big and small.
00:21:40.960 --> 00:21:47.600 position:50% align:middle
And we're very happy to take any questions
and respond to them,
00:21:47.600 --> 00:21:55.228 position:50% align:middle
and if you are interested in contacting us,
our email addresses are available,
00:21:55.228 --> 00:22:00.440 position:50% align:middle
both on our last slide,
and you can find us at Washington State University.
00:22:04.229 --> 00:22:10.747 position:50% align:middle
Dr. Klein, any comments from you?
I'm not seeing any questions yet in the chat box.
00:22:13.290 --> 00:22:20.740 position:50% align:middle
- No comments yet other than this has been a very
interesting process, and we anticipate doing more
00:22:20.740 --> 00:22:26.150 position:50% align:middle
exploration on this, we've already been
contacted by various stakeholders
00:22:26.150 --> 00:22:29.710 position:50% align:middle
who are interested in these results and the
implications that they might have.
00:22:30.454 --> 00:22:36.110 position:50% align:middle
We do want to point out that in this study,
we were really focusing in Phase 1 on those who hire,
00:22:36.110 --> 00:22:38.900 position:50% align:middle
credential, and privilege nurse practitioners.
00:22:38.900 --> 00:22:43.850 position:50% align:middle
We know that there have been studies that have been
done before, although not very many focusing
00:22:43.850 --> 00:22:47.900 position:50% align:middle
on hospitalist practice,
but of nurse practitioners themselves,
00:22:47.900 --> 00:22:54.490 position:50% align:middle
or some of the regulatory issues,
so it was really helpful to talk to the credentialers,
00:22:54.490 --> 00:22:58.128 position:50% align:middle
and we were surprised by
some of the results we found.
00:23:03.100 --> 00:23:07.430 position:50% align:middle
- So at this time, I'm not seeing
any comment, any questions.
00:23:07.430 --> 00:23:13.170 position:50% align:middle
Thank you to those who we know who are
participating today for identifying yourselves.
00:23:17.841 --> 00:23:19.513 position:50% align:middle
- Looks like we just had one come up.
00:23:19.890 --> 00:23:22.577 position:50% align:middle
- I'm not seeing the question, could you...?
00:23:22.796 --> 00:23:28.081 position:50% align:middle
- Yes. The question is, "What changes are you
hoping to see in the APRN Consensus Model,
00:23:28.081 --> 00:23:31.355 position:50% align:middle
recognition of a hospitalist NP population focused?"
00:23:31.355 --> 00:23:35.027 position:50% align:middle
- Kevin, I'm having trouble hearing you.
You seem to be breaking up a little bit.
00:23:43.188 --> 00:23:49.257 position:50% align:middle
- So the question was, "What changes are you
hoping to see in the APRN Consensus Model
00:23:49.257 --> 00:23:53.131 position:50% align:middle
recognition of a hospitalist in population focused?
00:24:05.720 --> 00:24:08.749 position:50% align:middle
- Tracy, did you want to start,
or do you want me to start?
00:24:09.349 --> 00:24:10.588 position:50% align:middle
- Go ahead.
00:24:10.877 --> 00:24:13.714 position:50% align:middle
- Okay.
- [inaudible]
00:24:16.020 --> 00:24:25.495 position:50% align:middle
- We were very interested in how the consensus model
has roles, populations,
00:24:25.495 --> 00:24:37.473 position:50% align:middle
and how the professional guidelines for hospitalists
that come from different nurse practitioner
00:24:37.473 --> 00:24:45.963 position:50% align:middle
organizations all recommend the acute care,
gerontology, adult-gero acute care, or
00:24:47.385 --> 00:24:52.018 position:50% align:middle
pediatric acute care NP certification,
and for those with prior certifications,
00:24:52.018 --> 00:24:54.380 position:50% align:middle
just the acute care NP certification.
00:24:54.600 --> 00:25:01.700 position:50% align:middle
But yet we found that hospitals are hiring nurse
practitioners with multiple other certifications,
00:25:01.700 --> 00:25:12.766 position:50% align:middle
and we think that needs to be reflected that the
employers are not seeking employees simply based
00:25:12.766 --> 00:25:14.728 position:50% align:middle
on certification.
00:25:14.728 --> 00:25:21.520 position:50% align:middle
And in fact, just to reiterate one of our findings,
many employers didn't even know about
00:25:21.520 --> 00:25:28.460 position:50% align:middle
the APRN Consensus Model,
so in addition to some revisions,
00:25:28.460 --> 00:25:33.937 position:50% align:middle
it would likely be really important to do better
dissemination of the consensus model.
00:25:35.210 --> 00:25:37.014 position:50% align:middle
Tracy, would you like to add anything?
00:25:39.772 --> 00:25:46.700 position:50% align:middle
- Sure. To that point,
in the first published results that we had in the
00:25:46.700 --> 00:25:52.390 position:50% align:middle
Journal of Nursing Regulation,
we found that the people who hire, credential, and
00:25:52.390 --> 00:25:58.680 position:50% align:middle
privilege nurse practitioners,
they were given a link in the survey to the APRN
00:25:58.680 --> 00:26:02.230 position:50% align:middle
Consensus Model, and we asked them
about their familiarity with it,
00:26:02.230 --> 00:26:08.910 position:50% align:middle
and only about 24% were familiar, and then we asked
them how many of them incorporated that into their
00:26:08.910 --> 00:26:15.471 position:50% align:middle
decision to hire, credential, or privilege, and the
response rate was very low, I t was about 11%.
00:26:16.333 --> 00:26:20.740 position:50% align:middle
The chief nurse officers,
which were a much smaller group in the study,
00:26:20.740 --> 00:26:26.847 position:50% align:middle
were familiar with the consensus model,
probably because of their experience in nursing.
00:26:27.110 --> 00:26:31.580 position:50% align:middle
Many of the people who hire, and credential,
and privilege are not nurses,
00:26:31.580 --> 00:26:35.876 position:50% align:middle
and are not as familiar
with nursing norms and expectations.
00:26:40.688 --> 00:26:47.560 position:50% align:middle
- And I see we do have another comment,
that there's a big disconnect between clinical
00:26:47.560 --> 00:26:53.254 position:50% align:middle
experiences and what's expected on the job,
and a dual program that combines primary and
00:26:53.254 --> 00:26:57.309 position:50% align:middle
hospital-based training would be a great idea
across the board.
00:26:57.309 --> 00:27:06.585 position:50% align:middle
And it's a very important comment because
one of the other findings that I think is important
00:27:06.585 --> 00:27:16.282 position:50% align:middle
is that the experience of the NP as a
registered nurse was very relevant to
00:27:16.282 --> 00:27:18.246 position:50% align:middle
whether or not they were hired.
00:27:18.430 --> 00:27:26.060 position:50% align:middle
And so, we don't typically endorse that,
you're a registered nurse experience be used for your
00:27:26.060 --> 00:27:32.910 position:50% align:middle
hiring in an NP role,
but yet that seemed to be a very important factor,
00:27:32.910 --> 00:27:40.520 position:50% align:middle
and off and some of the participants in our focus
groups were people who had worked in the facility,
00:27:40.520 --> 00:27:47.180 position:50% align:middle
that they were as a registered nurse and then were
working in the facility as a
00:27:47.180 --> 00:27:48.240 position:50% align:middle
nurse practitioner hospitalist.
00:27:48.240 --> 00:27:59.930 position:50% align:middle
So the organization's familiarity with the applicant
was very important, and as we also said,
00:27:59.930 --> 00:28:07.660 position:50% align:middle
the acute care NP also indicated that they didn't get
enough clinical experience in their educational
00:28:07.660 --> 00:28:16.110 position:50% align:middle
programs in the hospital itself,
and so that's another curricular revision that we think
00:28:16.110 --> 00:28:20.600 position:50% align:middle
should be considered by educational programs as well.
00:28:21.418 --> 00:28:23.476 position:50% align:middle
- Tracy, anything you'd like to add to that?
00:28:32.601 --> 00:28:34.142 position:50% align:middle
Any other questions?
00:28:38.371 --> 00:28:45.250 position:50% align:middle
Well, seeing none, I'd like to thank you all very much
for participating today, and feel welcome to contact us
00:28:45.250 --> 00:28:51.875 position:50% align:middle
and we'd be very interested in your feedback and any of
your ideas for future studies.