WEBVTT
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- [Woman] Dr. Lusine Poghosyan is
an internationally recognized
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health services researcher.
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Dr. Poghosyan is the principal investigator on
multiple-research projects including those funded
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by the National Institute on Minority Health and
Health Disparities, the Agency for Healthcare
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Research and Quality, and
the National Institute on Aging.
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Dr. Poghosyan is the chair of the Primary Care
Expert Panel at the American Academy of Nursing
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and the past chair of the Interdisciplinary Research
Group on Nursing Issues at AcademyHealth.
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She is a fellow of the American Academy of
Nursing and New York Academy of Medicine.
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She is also The Stone Foundation and Elise D.
Fish professor of nursing at Columbia University.
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- [Dr. Poghosyan] Hello, everyone.
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I am Lusine Poghosyan.
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I'm a professor at Columbia
University School of Nursing.
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And it's my great pleasure to be part of this
symposium today and share with you all some of
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the work we have done at Columbia University
School of Nursing with support from NCSBN.
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The study I will present is entitled "State Policy
Change and Organizational Response:
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Expansion of Nurse Practitioner Scope of Practice
Regulation in New York State," the study I have
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conducted with my wonderful colleagues Affan
Ghaffari, Jianfang Liu, He Jin, and Grant Martsolf.
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It is not a secret that the primary care demand is
growing in United States because
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of aging population, growing chronic disease
burden, and insurance expansion.
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Many patients need access to timely, high-quality,
cost-effective primary care services,
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yet our health care system is often
unable to meet the needs of these patients.
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Many solutions have been proposed
by policymakers, researchers, administrators,
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and clinician to really increase the capacity of
primary care system and the overall health care
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workforce to meet the demand
for growing primary care services.
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One of the most critical solutions and strategies
that has been getting lot of attention during the
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past decade is the growing
workforce of nurse practitioners.
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Institute of Medicine report made it clear that
advanced practice registered nurse workforce,
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particularly nurse practitioners,
can play a critical and a significant role,
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helping the country to meet the
demand for primary care services.
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Nurse practitioners are primary care providers who
are trained, and educated, and capable of
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delivering safe, high-quality primary care services.
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This workforce had grown significantly in the past,
and projections show the workforce is going to
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almost double between 2013 and 2025.
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We have seen that from 2007 and 2019,
the workforce grew significantly, and by 2025,
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NPs will comprise about 27%
of all primary care providers.
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Other primary care providers are
physicians and physician assistants.
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While we are optimistic that this growing workforce
can help the country to meet the demand for
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primary care services, there are many state, and
policy, and organizational barriers that affect the
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optimum utilization of nurse practitioners.
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One particular example is the state-level scope of
practice regulations across the country.
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We know that many states impose unnecessary
restrictions on NP practice by requiring NPs to have
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a supervisory or collaborative relationship
with physicians to provide care.
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So these are state-level policies that
every state has its own regulation.
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In addition to state-level barriers,
organizations employing NPs also create barriers
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for the optimal practice of nurse practitioners.
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Very often, NPs do not have
access to necessary organizational resources,
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there is lack of clarity in their role, and they
have challenging relationships with practice
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administrator or management.
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Right now, nurse practitioner scope of practice
policies are categorized into three main categories.
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There are many factors that are part
of this definition, yet in general,
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in full scope of practice states,
nurse practitioners can deliver care independently
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without involvement of any other clinicians, and
patients can have access to care delivered by nurse
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practitioners without further restrictions.
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Other states have a reduced scope of practice
policy, which requires NPs to have some kind of
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collaborative relationship with a physician to
be able to deliver care to their patients.
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And the most restricted states have
restricted scope of practice regulations
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which require physician supervision.
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So physicians have to supervise nurse
practitioners so NPs can deliver care to patients.
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And this is one of the most recent maps that
demonstrate the scope of practice regulations
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in the United States.
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The most recent state that changed its scope of
practice regulation is Massachusetts.
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But in this study, I will speak about New York State.
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So we know that full scope of practice states create
optimal environment for nurse practitioners to
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deliver care to their patients.
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Our research is clear that full scope of practice is
related to better patient outcomes,
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better access for patients to high-quality, safe care,
while reduced and restricted states limit patients'
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access to timely, high-quality care.
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And many researchers have conducted studies to
produce evidence about the importance of allowing
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nurse practitioners to practice fully
and limiting restrictions on NP practice.
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Yet, we also know that these scope of practice
regulations that are determined at the state level
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may also affect employers,
may also affect organizations that
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hire NPs, employ NPs.
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Yet, we know very little how the state-level policies
impact the organizations and, particularly,
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the work environment of NPs.
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We know that work environments are critical for
clinicians to be able to deliver high-quality,
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safe patient care, thus,
it is important for us to understand the impact
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of state-level policies on the work environment of
nurse practitioners within their employment settings.
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In this study, I will talk about New York State which
implemented nurse practitioner modernization
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act in 2015.
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Before 2015, all nurse practitioners in New York
were required to have a written practice
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agreement with physicians.
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Yet, New York State, whilst facing
unequal distributions of primary care
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provider across the state, many residents
of New York in rural and underserved
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areas were lacking access to high-quality care.
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So in 2015, New York State passed the policy
called nurse practition modernization act,
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which removed the required written practice
agreement between physicians and experienced
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nurse practitioners, those who have 3,600 hours
of clinical practice, which is about
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2 years of experience.
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So starting from 2015, in New York State,
nurse practitioners with more than 2 years
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of experience are able to deliver care without
requirement of written practice
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agreement with physician.
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So this opportunity, this policy change, created
an opportunity for our research team to assess
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and understand whether this policy change had
an impact on nurse practitioner work environment,
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what changes we observed after this
policy change within the work environment.
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So we have designed a study and proposed to
examine nurse practition work environment three
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years before the policy change in New York State
and three years after the policy change.
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So we were fortunate enough that we had survey
data already collected from nurse practitioners in
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2012 about their work environment.
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Building on that survey, we designed a
cross-sectional survey to collect data
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from the same sample of nurse practitioners in 2018,
which would allow us to see if the work environment
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in New York State changed after
a 2015 policy expansion.
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So in 2012, we had data from 278 primary care
nurse practitioners in New York State who were
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recruited from the membership list of New York
nurse practitioner association membership list.
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New York nurse practitioner association
was wonderful partner with us.
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They helped us to recruit nurse practitioners.
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They send online surveys to their members,
asking them if they were primary care
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nurse practitioners, and only
primary care nurse practitioners were able
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to complete our survey in 2012.
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After receiving support from NCSBN, we designed
a study to repeat the same study in 2018.
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So we partnered, again,
with New York nurse practitioner association,
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which send a survey link to its membership,
and only primary care nurse practitioners were able
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to access the survey.
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Nurse practitioners in both years,
both in 2012 and 2018,
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completed validated measures of work
environment, and also, we collected information
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about nurse practitioner demographics.
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The most widely used measure to assess nurse
practitioner work environment is the Nurse
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Practitioner Primary Care
Organizational Climate Questionnaire.
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It has been used by many researchers to
assess the work environment of NPs.
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The instrument has 29 items, and it measures
work environments with 4 subscales:
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nurse practitioner-physician relations,
nurse practitioner-administration relations,
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independent NP practice and support,
and professional visibility.
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Research shows that these four subscales
are important domains of NP work environment.
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For example, some of the questions in
NP-physician relation was asking NPs to evaluate
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the communication, the teamwork that nurse
practitioners had with physicians.
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NP-administration relation items are asking similar
questions, whether NPs receive necessary support
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from administration, necessary
information from administration.
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And the professional visibility,
which was an interesting subscale,
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it asks nurse practitioners how well their role is
defined or visible within their organization.
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As we know, with the growth of NP workforce,
many organizations were new
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to nurse practitioner practice.
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So we collected the survey data from nurse
practitioners, and we merged 2012 and 2018 survey
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data to achieve the aims of this study.
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So in this study, we had two independent variables,
which were study time, one was 2012 and 2018,
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and nurse practitioner experience
level within employment setting.
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Remember that NP modernization act is supposed
to impact NPs who have a little bit more than two
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years of experience.
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So we categorize NPs,
those equal or less than three years,
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because that's what our variable was asking, NPs
between one to three years of experience.
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And we also had a study variable that was capturing
the study time, three years before the policy
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implementation and three years
after the policy implementation.
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Our dependent variable in the
study was NP work environment.
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NP work environment was measured by the four
subscales at the nurse practitioner organizational
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climate questionnaire, and we looked
at the NP-physician relations,
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we looked at NP-administration relations,
we looked at the independent practice and support,
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and professional visibility subscale.
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So we wanted to see if this work environment
have changed between 2012 and 2018.
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So we conducted a descriptive analysis.
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We compared the characteristics of the sample in
2012 and 2018 to see if the NP workforce still
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looked like similarly.
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And then we built multiple linear-regression models
to assess the relationship between year of the
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survey administration, which is proxy
for the before and after policy
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implementation and nurse
practitioner work environment.
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In this table, we present some of the
demographic characteristics of our sample.
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As you see, in 2012,
278 nurse practitioners completed the survey.
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In 2018, 348 nurse practitioner
completed the survey.
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Most of the average age of NPs in our study
was about 52 to 53 years.
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Majority were female,
almost 90% of our participants were female,
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and the workforce were significantly white.
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And the difference was that, in 2018,
there were more nurse practitioners with a DNP or
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other doctoral degree.
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So that was one of the biggest changes we
observed in the demographic characteristics
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of our sample.
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In this table, we also provide some information
about NP work and practice characteristics.
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Here, we see that NPs practice in rural, urban,
suburban, and there were some differences
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in between two years.
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And we also see that, in 2012,
the largest proportion of NPs were practicing
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in physician offices, while in 2018,
more NPs were employed in practices affiliated
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with hospitals or some kind of medical centers.
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In this chart, we compare nurse practition
work environment over time.
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So we computed in scores on each
subscale of NPPCOCQ.
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The dark orange color is the 2012,
the red represent 2018.
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What we see here is, it appears from this bar
chart, that nurse practition work environment was
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significantly better in 2018 than in 2012.
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Particularly, there was a significant difference
between NP-physician relations,
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independent practice and support,
and professional visibility.
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And also, these subscales were much highly
rated by NPs than NP-administration relations.
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As you see, the lowest mean scores reported by
NPs were on NP-administration relation,
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and this is an interesting and consistent finding
across all of the studies we have done,
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that NP-administration relation typically gets much
lower rating from NPs than other aspect
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of their work environment.
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In this bar chart, we assessed whether there was a
difference in work environment in those years
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between experienced and not experienced NPs,
those NPs with less than three years of experience
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and those who have more
than three years of...
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The lighter color is NPs with less than three years of
experience, and the darker bar chart is NPs with
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more than three years of experience.
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What we are seeing here, that it
seems NPs with little bit more experience
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report better work environment.
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Yet, some of the differences are not significant.
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There is no significant
difference in NP-administration relations.
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It seems like, in 2012, both experienced
and non-experienced NPs were reporting
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similar type of relationship.
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There was some improvement
in NP-physician relationship.
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It appears that experienced NPs are telling
us that their relationship with physicians is
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better with experience.
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The only significant difference we
observed was in professional visibility.
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We noticed that, in 2012, experienced NPs
were telling us that their role is more
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understood within their employment setting,
their role is more visible.
00:17:43.180 --> 00:17:47.500 position:50% align:middle
You know, while we saw some
minor differences in the scores,
00:17:47.500 --> 00:17:50.525 position:50% align:middle
we did not observe major differences
between experienced and
00:17:50.525 --> 00:17:53.095 position:50% align:middle
non-experienced nurse practitioners.
00:17:53.095 --> 00:18:00.350 position:50% align:middle
After the descriptive work, we developed
our multiple linear-regression model
00:18:00.350 --> 00:18:09.994 position:50% align:middle
to demonstrate the relationship between scope of
practice, which is year 2012 and year 2018,
00:18:09.994 --> 00:18:12.220 position:50% align:middle
and nurse practitioner work environment.
00:18:12.220 --> 00:18:19.310 position:50% align:middle
As you'll see in our model,
we control the model for NP's gender, age,
00:18:19.310 --> 00:18:25.010 position:50% align:middle
length of time in the current primary position,
location, whether NPs worked in rural, urban,
00:18:25.010 --> 00:18:29.060 position:50% align:middle
or suburban, practice setting,
whether it was community health center,
00:18:29.060 --> 00:18:32.790 position:50% align:middle
hospital-based clinic, and also
average hours of work.
00:18:32.790 --> 00:18:40.580 position:50% align:middle
So controlled for all those variables,
what we observed was that the work environment
00:18:40.580 --> 00:18:47.362 position:50% align:middle
for nurse practitioners was significantly
better in 2018 than in 2012.
00:18:47.362 --> 00:18:55.360 position:50% align:middle
We notice that, particularly,
improvements were noticed in IPS,
00:18:55.360 --> 00:18:58.840 position:50% align:middle
independent practice and
support, professional visibility,
00:18:58.840 --> 00:19:02.590 position:50% align:middle
and nurse practitioner and
physician relation subscales.
00:19:02.590 --> 00:19:07.510 position:50% align:middle
After the policy change in New York State,
these three domains of nurse practition work
00:19:07.510 --> 00:19:11.730 position:50% align:middle
environment in New York improve.
00:19:11.730 --> 00:19:17.180 position:50% align:middle
There was no significant difference
in nurse practition-administration relation
00:19:17.180 --> 00:19:19.604 position:50% align:middle
between 2012 and 2018.
00:19:19.604 --> 00:19:26.020 position:50% align:middle
And our model also demonstrated that,
controlling for potential covariates,
00:19:26.020 --> 00:19:32.442 position:50% align:middle
we did not see any difference in any of the mean
subscale scores for the work environment
00:19:32.442 --> 00:19:37.500 position:50% align:middle
measures between experienced
and less experienced NPs.
00:19:37.500 --> 00:19:45.022 position:50% align:middle
Our model show, work environment improved from
2012 to 2018, yet there was no difference in the
00:19:45.022 --> 00:19:48.970 position:50% align:middle
improvement for experienced
and less experienced NPs.
00:19:48.970 --> 00:19:51.050 position:50% align:middle
So what are our results telling us?
00:19:51.050 --> 00:19:58.750 position:50% align:middle
Our results are telling us that nurse practitioner
report significantly better work environment in 2018
00:19:58.750 --> 00:20:04.153 position:50% align:middle
when we control for individual and organizational
characteristics, and positive changes were
00:20:04.153 --> 00:20:07.052 position:50% align:middle
observed both for experienced
and less experienced NPs.
00:20:07.052 --> 00:20:14.490 position:50% align:middle
One thing we need to understand that, you know,
our study took advantage of this natural experiment
00:20:14.490 --> 00:20:19.090 position:50% align:middle
that happened in New York State to show how the
work environment improved for nurse practitioners.
00:20:19.090 --> 00:20:27.665 position:50% align:middle
So it creates a discussion about how other states
can remove their unnecessary restriction on NPs to
00:20:27.665 --> 00:20:34.570 position:50% align:middle
really improve NP work environment and allow
nurse practitioner to be able to deliver care
00:20:34.570 --> 00:20:35.380 position:50% align:middle
to their patients.
00:20:35.380 --> 00:20:42.040 position:50% align:middle
So our findings really show important insights about
a potential impact of the scope of practice laws
00:20:42.040 --> 00:20:44.700 position:50% align:middle
on the work environment and nurse practitioners.
00:20:44.700 --> 00:20:49.661 position:50% align:middle
And we know that work environments are important
for patient safety, they're important for quality of
00:20:49.661 --> 00:20:52.870 position:50% align:middle
care, and they're important for patient outcomes.
00:20:52.870 --> 00:20:59.722 position:50% align:middle
So policymakers in other states should take actions
to remove unnecessary restrictions on NPs to
00:20:59.722 --> 00:21:05.699 position:50% align:middle
improve NP work environment, and we believe
that it will also lead to better quality of care
00:21:05.699 --> 00:21:07.068 position:50% align:middle
and patient outcomes.
00:21:07.068 --> 00:21:14.280 position:50% align:middle
This study is one of the first studies to show a direct
impact of state-level scope of practice regulations
00:21:14.280 --> 00:21:17.280 position:50% align:middle
on the organizations employing nurse practitioner.
00:21:17.280 --> 00:21:22.090 position:50% align:middle
Of course, our study is not free of limitation.
00:21:22.090 --> 00:21:23.880 position:50% align:middle
The study has several limitation.
00:21:23.880 --> 00:21:27.890 position:50% align:middle
One is we rely on the self-reported
measures from nurse practitioners.
00:21:27.890 --> 00:21:32.260 position:50% align:middle
So NPs are the ones who are
telling us about their work environment.
00:21:32.260 --> 00:21:38.570 position:50% align:middle
We are unable to link exact person responses from
2012 to 2018, so we don't know if it's the same
00:21:38.570 --> 00:21:42.800 position:50% align:middle
NP responding, but it's the
same membership list we used.
00:21:42.800 --> 00:21:44.260 position:50% align:middle
We don't have any control group.
00:21:44.260 --> 00:21:48.460 position:50% align:middle
We don't know if similar changes
have been observed in other states.
00:21:48.460 --> 00:21:54.390 position:50% align:middle
And also, the study was conducted only
in one state, with a limited generalizability.
00:21:54.390 --> 00:22:01.326 position:50% align:middle
Despite this, we believe that our study indeed
produced robust and interesting findings to inform
00:22:01.326 --> 00:22:08.840 position:50% align:middle
policy discussions about removing unnecessary
scope of practice restrictions on nurse practitioners.
00:22:08.840 --> 00:22:10.450 position:50% align:middle
I have not done this work by myself.
00:22:10.450 --> 00:22:15.073 position:50% align:middle
I have a fantastic team of researchers
and collaborators to thank.
00:22:15.073 --> 00:22:18.670 position:50% align:middle
And I also thank our funder,
National Council of State Boards of Nursing.
00:22:18.670 --> 00:22:21.450 position:50% align:middle
Without their support,
this work would have not been possible.
00:22:21.450 --> 00:22:22.430 position:50% align:middle
Thank you.
00:22:42.060 --> 00:22:48.600 position:50% align:middle
Thank you, everyone, for participating
and for the opportunity to share the
00:22:48.600 --> 00:22:51.160 position:50% align:middle
findings of our research.
00:22:51.160 --> 00:22:59.216 position:50% align:middle
We enjoyed working together in our team to do the
research that we found timely and important to
00:22:59.216 --> 00:23:05.660 position:50% align:middle
change the scope of practice policies,
to provide more evidence that it's important for the
00:23:05.660 --> 00:23:12.753 position:50% align:middle
states to create a positive policy environment, so
health care organizations can create better
00:23:12.753 --> 00:23:18.730 position:50% align:middle
environment within their clinics and practice
settings that employ nurse practitioners.
00:23:18.730 --> 00:23:24.250 position:50% align:middle
So I think our study is one of the first
studies that actually shows that, you know,
00:23:24.250 --> 00:23:29.470 position:50% align:middle
favorable policy environment may lead
to favorable work environment.
00:23:29.470 --> 00:23:36.020 position:50% align:middle
And we know how critically
important favorable work environment is.
00:23:36.020 --> 00:23:43.440 position:50% align:middle
Research is clear that a good work environment
is beneficial both for patient, providers,
00:23:43.440 --> 00:23:46.140 position:50% align:middle
and overall health care organizations.
00:23:46.140 --> 00:23:50.890 position:50% align:middle
And we know that our clinicians are facing
challenging work environment, and I think
00:23:50.890 --> 00:23:54.710 position:50% align:middle
COVID-19 pandemic really made it more visible.
00:23:54.710 --> 00:23:58.820 position:50% align:middle
So if you have any questions about the study,
I'll be more than happy to answer.
00:23:58.820 --> 00:24:02.630 position:50% align:middle
And, I think, the paper is
published in Nursing Outlook.
00:24:02.630 --> 00:24:04.130 position:50% align:middle
Where it was very recently.
00:24:04.130 --> 00:24:11.213 position:50% align:middle
So if you want more details, it can be found
in the manuscript, in Nursing Outlook.
00:24:21.030 --> 00:24:26.370 position:50% align:middle
I see there are no...oh, there's a question.
00:24:26.370 --> 00:24:29.860 position:50% align:middle
So there is a question that
says, "Nice presentation."
00:24:29.860 --> 00:24:30.670 position:50% align:middle
Thank you.
00:24:30.670 --> 00:24:34.770 position:50% align:middle
It says, "What was the percent of your sample in
relation to total number of primary care
00:24:34.770 --> 00:24:35.750 position:50% align:middle
NP in New York?
00:24:35.750 --> 00:24:40.310 position:50% align:middle
Did you include all population-based
NPs, percentage reflected?"
00:24:40.310 --> 00:24:42.060 position:50% align:middle
This is a very good question.
00:24:42.060 --> 00:24:47.030 position:50% align:middle
To be honest, I mean, one of the interesting things,
it's very difficult to track the actual number
00:24:47.030 --> 00:24:50.561 position:50% align:middle
of NPs in New York because that
information is really not collected.
00:24:50.561 --> 00:24:56.639 position:50% align:middle
But, you know, so we only had about 300 nurse
practitioners, and I think there are more than
00:24:56.639 --> 00:24:58.765 position:50% align:middle
10,000, I believe, nurse practitioners in New York.
00:24:58.765 --> 00:25:04.230 position:50% align:middle
But the way the data is collected about nurse
practition in New York is challenging for me to give
00:25:04.230 --> 00:25:08.070 position:50% align:middle
you accurate number,
but we collected data from all NPs.
00:25:08.070 --> 00:25:14.880 position:50% align:middle
We asked them...we first selected primary care
specialties, family nurse practitioner,
00:25:14.880 --> 00:25:20.300 position:50% align:middle
adult nurse practitioner, and then PNPs,
and then we asked the NPs to self-identify also.
00:25:20.300 --> 00:25:27.770 position:50% align:middle
So in addition for us to create, you know,
to sample NPs who have a primary care specialty,
00:25:27.770 --> 00:25:29.720 position:50% align:middle
we also asked NPs to self-identify.
00:25:29.720 --> 00:25:35.410 position:50% align:middle
So those are the two criterias that
we use to narrow our sample.
00:25:35.410 --> 00:25:37.760 position:50% align:middle
Thank you.
00:25:37.760 --> 00:25:45.704 position:50% align:middle
And most of our research is on primary care NPs
because we do believe that primary care NPs do
00:25:45.704 --> 00:25:51.523 position:50% align:middle
play a critical role in helping to meet a demand for
health care services and are a key workforce to
00:25:51.523 --> 00:25:57.049 position:50% align:middle
study and to understand how to effectively utilize
these NPs to really meet the demand for care.
00:26:03.480 --> 00:26:05.670 position:50% align:middle
Well, thank you, everyone, for participating.
00:26:05.670 --> 00:26:06.970 position:50% align:middle
I don't see any questions.
00:26:06.970 --> 00:26:11.480 position:50% align:middle
But if you have any more question,
please, feel free to reach out of me via email,
00:26:11.480 --> 00:26:14.170 position:50% align:middle
and I'll be more than happy to answer.
00:26:14.170 --> 00:26:15.300 position:50% align:middle
Thank you, everyone.