NUR 480 Melissa James Presentation

1. NUR 480 - Senior Practicum Date: May 2017 Student: Melissa A. James Presented to: Dr. Sherry Leviner PhD, RN, FNP-C, CEN & Members of the Class

2. Project Design & Implementation • Overview: • Project design (9) “other alternative or service learning project as proposed and approved by instructor” was chosen. • The project was implemented by shadowing a Nurse Practitioner (NP) for a total of 50 hours and 20 minutes. • Details: • The NP I shadowed is employed by Takoma Regional Medical Center in Greenville, TN. • She works at a clinic associated with the hospital and practices internal medicine. • The clinic employs 1 MD, 1 NP, and 1 Physician Assistant (PA).

3. Overall Goal & objectives • Overall Goal: To determine whether or not I would like to become a NP. • Objectives: • Explore the Characteristics of NPs. • Examine the influencing factors that motivate general practitioners (GPs) to hire NPs. • Determine what clinical skills and procedures a NP must possess to be successful. • Determine whether NPs are making a difference in Health Professional Shortage Areas (HPSA). • Examine the working conditions of NPs, especially work hours and overtime. • Reflect on assumptions of the NP role prior to, insights gained during, and conclusions following my shadowing experience.

4. Review of the literature • Literature Requirements Based on Project Type (9): “Literature review must include a minimum of 5 journal articles published within the last 5 years about your alternative or service learning project”. • Articles Reviewed: • Hooker, R. S., Brock, D. M., & Cook, M. L. (2016). Characteristics of nurse practitioners and physician assistants in the United States. Journal of The American Association of Nurse Practitioners, 28(1), 39-46. doi:10.1002/2327-6924.12293 • Van der Biezen, M., Derckx, E., Wensing, M., & Laurant, M. (2017). Factors influencing decision of general practitioners and managers to train and employ a nurse practitioner or physician assistant in primary care: a qualitative study. BMC Family Practice, 181-10.doi:10.1186/s12875-017-0587-3 • Kippenbrock, T., Lo, W., Odell, E., & Buron, B. (2015). The Southern states: NPs made an impact in rural and healthcare shortage areas. Journal of The American Association of Nurse Practitioners, 27(12), 707-713. doi:10.1002/2327-6924.12245 • Laustsen, G. (2013). What do nurse practitioners do? Analysis of a skills survey of nurse practitioners. Journal of The American Association of Nurse Practitioners, 25(1), 32-41. doi:10.1111/j.1745-7599.2012.00750.x • Bae, S., & Champion, J. D. (2016). Nurse practitioners' work hours and overtime: How much, and under what working conditions? Journal of The American Association of Nurse Practitioners, (3), 138. doi:10.1002/2327-6924.12285

5. Article 1 – Characteristics of NPs • Purpose: To differentiate the roles of NPs & PA to ensure optimal employment utilization • Methods: Synthesized and analyzed data from public information sources • Results: • NPs & PAs majority female (92.3%) (75.0%) • NPs & PAs majority white (86.5%) (81.6%) • NPs & PAs majority practicing in physician’s offices or acute care hospitals (83.2%) (88.7%) • Wages & growth prediction almost equal • Outpatient care centers had highest median wage ($45/hr NPs, $46.88/hr PAs) • Colleges, universities, and professional schools had lowest wages ($41.94/hr NPs, $43.55/hr PAs) • NPs notably older with median age of 49 vs. 38 for PAs • PAs on average had less experience (8 years) vs. NPs (10.4 years) • NPs reported higher levels of education 97.6% with master’s or doctoral degree vs. 68.1% of PAs • Distribution showed NP concentration in Mississippi-Ohio Valley, Northeast, and South • PA concentration in Northeast, Northern Plains, West coast, Texas, Oklahoma, Florida, and Wisconsin

6. Article 1 – Characteristics of NPs • Purpose Achieved: No, although the article offered some good statistical comparisons, they were unrelated to professional roles. • Suggestion: It would have been more helpful to compare job descriptions, patient loads, procedures performed, and other job functions. • Take-away: • NPs and PAs share similar characteristics of gender, race, and practice areas • NPs, on average, have more education and experience and are paid less than PAs

7. Article 2 – Why GPs hire mid-levels • Purpose: To provide insight into factors influencing the decision of GPs and managers to train and employ a NP/PA within their organization • Methods: Individual semi-structured interviews and data analysis • Results: • Analysis of interview data resulted in 3 themes and 11 categories • Theme 1: Reasons to employ a NP/PA • Categories: Substitution of care, quality improvement, and new/additional services • Summary: • Increased demand on practice (ageing population and shift to primary/preventive) • Replace a GP (tend to leave after experience) • Expand practice (# of patients/services like hospital visits) • Relieve patient load so GP can focus on more complex patients, study, or other activities • Believed would help continuity of care and monitoring of target populations

8. Article 2 – Why GPs hire mid-levels • Theme 2: Influencing factors • Categories: organizational factors, factors regarding professional relations, factors regarding GP workload and job satisfaction, and experience with NP/PA profession • Summary: • Preparation of adding NP/PA to practice is burdensome (financial consults/support from other departments and staff) • GPs varied in expectations on how their caseload would be influenced • Some feared a more complex caseload while others saw this as a positive • Some doubted it would decrease their caseload • GPs with previous exposure to NP/PAs had a more favorable outlook • In general, GPs considered PAs to be more medically educated and NPs to be better connected with care in general • GPs citied NP’s prior clinical experience as beneficial • GPs expressed concern over future changes to NP/PA reimbursement and scope of practice

9. Article 2 – Why GPs hire mid-levels • Theme 3: NP/PA responsibilities • Categories: Direct & indirect patient care • Summary: • Most GPs did not develop clear roles and responsibilities for NPs/PAs but when they did they varied greatly • Some GPs had them focus only on target populations while others had a broad caseload • GPs had differing opinions as to whether NPs/PAs should treat patients with chronic illness • All GPs agreed they could treat minor ailments • Most GPs agreed that it was inappropriate for NPs/PAs to treat potentially life-threatening conditions • GPs agreed that NPs/PAs could perform non-patient related tasks such as developing protocols or training support staff but most wanted them to focus on direct patient care.

10. Article 2 – Why GPs hire mid-levels • Purpose Achieved: Yes, the interview process was an effective approach and categorizing the information into recurring themes was useful for drawing conclusions. • Take-away: • NPs are hired for various reasons and they should determine what goals they are helping their GP/organization to achieve • NPs should also ascertain what role and scope of practice their GP/organization wants them to adopt because each place of employment will vary • NPs should also understand the differences between themselves and PAs and stress their years of clinical experience and general care knowledge as assets and qualifications that set them apart from PAs in the interview process

11. Article 3 – Analysis of NP Skills • Purpose: To report findings from a survey indicating the frequency and criticality of the clinic skills and procedures used by NPs and data regarding demographic, geographic, and educational preparation • Methods: Employment of a descriptive survey. The first section contained demographic, geographic, and practice-related questions. The second section contained a checklist of 90 skills. • NPs were asked to identify what skills they used, how frequently, and how critical those skills were. They were also asked to indicate where they learned the skills. • Demographic/Geographic Results: • Specialty – 70% family practice, 18% adult, 11% pediatric, 4% geriatric • Location – 45.7% urban, 23.3% suburban, 30.3% rural, 0.7% frontier • Education – 81.4% master’s degree, 9.8% certificate, 8.3% post mater’s certificate, 0.4% doctorate • Number of annual patient visits: 40% > 10k, 25% 5k-10k, 20% 2.5K-5k, and 15% <2.5k

12. Article 3 – Analysis of NP Skills • Demographic/Geographic Results: • Ease of access to physician for collaboration – 74% physician on site, 16% <5 miles, 7% 5-50 miles, 3% >50 miles • Ease of access to specialist for collaboration – 11% said cardiologist >50 miles • Skills Results: • Most commonly learned in school: cerumen impaction, pap smears, microscopy • Least used: Vasectomy, tick removal, ENT foreign body removal, burn debridement • Most used: Pap smears, microscopy, x-ray interpretation • Most important: Pap smears • Least important: Tick removal

13. Article 3 – Analysis of NP Skills • Purpose Achieved: Partly, the survey format yielded good information regarding frequency of use but the category on criticality may have been misunderstood. Did the authors mean critical as in life-saving or critical as in important to their role. Also, the survey was limited to the state of Oregon and only a few practice areas. • Suggestion: It would have been useful to include a question as to whether NPs felt prepared for practice after graduating and if not why? • Take-away: • NP programs most likely will not teach all of the skills needed to be a successful practitioner • Knowing this will protect a student from disillusionment and shock when entering practice • Students should inquire what skills will be taught at their schools, determine what skills are needed in the type of practice they wish to enter, and seek out those experiences in clinical rotations

14. Article 4 – NPs making a difference in HPSAs • Purpose: To investigate the distribution of NPs in the US southern region with a focus on rural and underserved areas and to describe NP characteristics and their workplace distribution relative to rural and Health care Professional Shortage Areas (HPSAs) • Methods:A survey was developed to examine whether NPs are working within or outside of HPSAs, in rural or urban areas, and to obtain demographic information including gender, race, income, practice specialty, and employer type • Results: • Majority female 90.7% • Mean age 45.5 years • Majority white 89% • Two-thirds said they worked 40 or more hours per week • % in primary care and family practice highest in rural areas 59.7% primary/45.1% family • Salaries: 57% <50k, 48% 50k-100k, 41% >100k • Length of employment: 39.9% in 1st 5 years, 20.9% 6-10 years, 22% 11-15 years, 17.2% 16 or more years

15. Article 4 – NPs making a difference in HPSAs • Purpose Achieved: Yes, the method was an effective approach but it was limited to the South and the survey response rate was low • Suggestion: The data may have been more easily and accurately obtained by gathering information from employers rather than being dependent on survey response. • Take-away: • NPs are making a difference in rural and underserved health care areas • More diversity is needed within NP practice to better reflect and reach the communities they serve

16. Article 5 – NP work conditions • Purpose:To explore the nature and prevalence of NP overtime, work hours, and their relationship to practice within NP work conditions • Methods:A cross-sectional secondary analysis of data that was collected from the 2012 National Sample Survey of NPs. • Results: • 60% 45 years or greater • 93% female • 87% non-Hispanic white • 93% married • 95% master’s degree or doctoral degree • 85% practiced in urban areas • 53.3% worked in ambulatory care • 32.3% worked in hospital setting • On average worked 37.6 hours per week in principal position • 10.6 additional hours in second position • 34% worked 40 or more hours per week

17. Article 5 – NP work conditions • Results: • The following work setting factors were positively correlated with NPs working >40 hours per week: • Hospital or long-term care facilities • Use of electronic records • With hierarchical relationships with physicians or when physicians signed off on patients they examined • Intuitively, the more patients they saw the longer number of hours they worked • NPs in primary care tended to work less than those in internal medicine or surgical specialties • NPs who worked 35 hours per week or less reported that 82% of their time was spent caring for patients and documenting • NPs who worked over 40 hours per week reported more time teaching, supervising, and managing • No difference was found in work hours and geographic location

18. Article 5 – NP work conditions • Purpose Achieved: Yes, their overtime, work hour, and demographic categories were sufficient • Suggestions: • They could have included weekend, holiday, and after normal hours of operation categories. They also could have included information regarding PTO and sick time averages. • I would have liked them to include faculty, research, and administration participants • Take-away: • NPs, on average, work near or over 40 hours per week • Working hours vary by practice area and patient load • NPs who would like to work less hours and have more control over their schedule should consider working more autonomously and in primary care not associated with hospitals, long-term care facilities, internal medicine, or surgical specialties

19. Planning • To evaluate my project, I focused on the objectives stated on my project plan (as approved by my instructor) • In My Clinical Journals: • I found and critiqued research articles related to each objective • Compared that research with my personal experiences as a RN • And compared it with my shadowing experiences • Also, each research article was discussed with the NP I shadowed for additional insight • Meeting each objective via research, critique, reflection, shadowing experience, and discussion gave me the information needed to reach my overall goal of determining whether or not to become a NP

20. Implementation • I shadowed a NP practicing internal medicine for 50 hours and 20 minutes • This NP handled the ‘overflow’ patients for the clinic’s primary Dr. • She saw mostly acute care visits and pre or post operation visits • On average she saw 10 patients per day • She worked 8 hours per day 5 days per week • She fit the demographics described in the research articles; white, married, master’s prepared, about 20 years of previous clinical experience • My role was strictly observation (Due to hospital requirements) • Types of Patients Treated: • Management of chronic diseases (diabetes/hypertension/hyperlipidemia) • Injuries such as fractures and falls • Medication re-fills • Acute pain/anxiety/depression

21. implementation • Observations and Lessons: • Collaborating with the interdisciplinary team • Reviewing patient history prior to each visit • Critical importance of understanding pharmacology • Importance of follow-up (5 RNs for 3 providers) • Critical thinking skills to assess true intention of visits • Letter for home care for asthma patient • Need for on-the-job training and experience after graduation • Orthopedics • Joint injections • Critical thinking skills to assess the whole person • Psychosocial needs causing/contributing to physical complaints • Anxiety (IBS) • Attention craving • When motivations are psychosocial in nature, addressing medical necessity or stated complaints alone will not solve their underlying problem and they may return repeatedly and unnecessarily • Sensitive and appropriate referrals without damaging provider-patient trust/relationship

22. implementation • Observations and Lessons: • Gentle but assertive approach to re-center patients and providing more in-depth education • Weight loss surgery (Belize) • Knee surgery with cardiac issues • The importance of humanizing patients as unique, dynamic, and complex individuals • Must consider their context outside of the healthcare environment • Failure to consider the unique attributes and social context of patients would be detrimental because it would foster unhelpful or inappropriate diagnoses and interventions • Alcoholic gallbladder pt. • Brain Mass with fractured hand

23. implementation • Ethical Standards (ANA Code of Ethics): • Provision 7 – advance the profession through research and scholarly inquiry • Research on the job and article critiques • Provision 1 – practice with compassion and respect for the inherent dignity, worth, and unique attributes of every person • Vulnerable populations (homosexual and reduced cognitive function) • Considering the whole person within their unique social and life-span context • Provision 4 – have the authority, accountability, and responsibility for nursing practice by making decisions and taking actions consistent with the obligation to promote health and to provide optimal care • Desire to address underlying psychosocial needs • Professional Nursing Roles: • Clinical outcomes manager as an educator • Diet/Exercise regimens • Recognizing the influence of macro and microsystems that influence health • Team manager • Delegating and using team resources effectively • Systems analyst/risk anticipator • Pre-surgical risk assessments • Professional Nursing Values: • Human dignity by allowing patients to have autonomy • Permission to be present • Pt.’s desire not to treat his cancer • Designing care in a way that considers the whole person • Social justice by assuring equal treatment and equal access to healthcare • Vulnerable populations • Altruism by desiring to address underlying mental health causes of patient complaints • Uncomfortable to address but in the best interest of patient

24. Evaluation • My project was implemented through shadowing experience • Each of my objectives were met through research and article critiques and by comparing that research with my nursing experience and shadowing experience • My overall goal was also met. Synthesizing the information and experiences gained in this course, I was able to reach a conclusion as to whether I would like to be come a NP. • My Conclusions: • If I desire to practice in primary care with an advanced degree, I think PA school is the better option. • Medical model – disease and treatment • If I desire to practice in an area that focuses on holistic care with an emphasis on prevention, health promotion, and/or education, I think NP school is the better option. • Nursing model – integrative care with a focus on the whole person • My interests are in preventative care and health promotion mostly • Need to explore job options for NPs that focus on these areas • I also love pediatrics and think I would enjoy primary care in that specialty • Need to look for a shadowing opportunity at a pediatric clinic before committing to PA school

25. Evaluation • Participant Reaction: • Very helpful for achieving overall goal • Gained great insight into the role of a provider vs. nurse • Site Reaction: • It was very difficult to find a place to shadow • NP was very gracious and expressed desire to help others learn • Project Benefits: • Provided an opportunity for me to peek into the world of a provider and determine whether I want to become one • Provided opportunity for me to exercise nursing ethics, roles, and values and reflect on them • Provided opportunity for me to critically think about patient-provider dynamics • And a chance to take a step back from the task-driven nature of the ER to remember the unique humanity of each pt. • Project Limitations: • I would have preferred a shadowing experience in a pediatric clinic but one did not become available • I would have also liked to shadow a PA to gain even more insight into the differences between the two approaches

26. References • American Association of Colleges of Nursing (July 2007). White paper on the education and role of the clinical nurse leader. Retrieved from http://www.aacn.nche.edu/publications/white-papers/ClinicalNurseLeader.pdf • American Nurses Association (January 2015). Code of ethics for nurses with interpretive statements. Retrieved from http://nursingworld.org/DocumentVault/Ethics-1/Code of Ethics-for-Nurses.html • Bae, S., & Champion, J. D. (2016). Nurse practitioners' work hours and overtime: How much, and under what working conditions? Journal of The American Association of Nurse Practitioners, (3), 138. doi:10.1002/2327-6924.12285 • Hooker, R. S., Brock, D. M., & Cook, M. L. (2016). Characteristics of nurse practitioners and physician assistants in the United States. Journal of The American Association of Nurse Practitioners, 28(1), 39-46. doi:10.1002/2327-6924.12293 • Kippenbrock, T., Lo, W., Odell, E., & Buron, B. (2015). The Southern states: NPs made an impact in rural and healthcare shortage areas. Journal of The American Association of Nurse Practitioners, 27(12), 707-713. doi:10.1002/2327-6924.12245 • Laustsen, G. (2013). What do nurse practitioners do? Analysis of a skills survey of nurse practitioners. Journal of The American Association of Nurse Practitioners, 25(1), 32-41. doi:10.1111/j.1745-7599.2012.00750.x • Van der Biezen, M., Derckx, E., Wensing, M., & Laurant, M. (2017). Factors influencing decision of general practitioners and managers to train and employ a nurse practitioner or physician assistant in primary care: a qualitative study. BMC Family Practice, 181-10.doi:10.1186/s12875-017-0587-3

27. The End