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Disenfranchised grief is a form of grief that remains unacknowledged and unsupported. Building on Doka's foundational concept of disenfranchised grief, the guiding framework for this pilot project was the Knowledge to Action framework. This study is a quantitative cross-sectional web-based survey, which included a validated questionnaire: the Witnessing Disenfranchised Grief Scale. The Witnessing Disenfranchised Grief Scale measures how participants feel their grief is recognized and validated by friends and family versus administrators or supervisors. A χ2 analysis (P < .05) was completed with findings suggesting that palliative care advanced practice registered nurses broadly experienced higher levels of support from witness C types (colleagues, coworkers, family, or friends) when compared with witness A types (supervisors, bosses, or persons with administrative responsibility). A 2-sample t test also demonstrated significance when comparing both witness groups. Overall mean scores were significantly higher (P < .001) in the witness C group (mean, 68.7) versus the witness A group (mean, 51.2). Higher mean scores indicate a higher level of support reported by the participant. The findings affirm that advanced practice registered nurses working in palliative care continue to grieve both death and non-death-related losses and report a higher degree of witnessed grief by their friends, family members, and colleagues. Participants' supervisors, bosses, or administrators provide less grief acknowledgment., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 by The Hospice and Palliative Nurses Association. All rights reserved.)

Background: With the expansion of professional autonomy and prescriptive authority of advanced practice registered nurses (APRNs), interactions with industry are under greater scrutiny. As of July 1, 2021, pharmaceutical and medical device companies must publicly report all payments to APRNs through the Centers for Medicare and Medicaid Services' Open Payments website., Purpose: To gauge APRNs' familiarity with, and perceptions of the Open Payments database and discuss whether and how APRNs should respond., Methodology: Virtual workshops consisting of a didactic presentation and interactive exercises with APRNs recruited through professional networks, associations, and conferences. Transcripts were analyzed using a qualitative interpretive approach, grounded in an everyday ethics theoretical framework., Results: Thirty-six APRN clinicians, students, and faculty participated in nine workshops. Seeing sponsored meals reported in Open Payments as "payments" prompted participants to see familiar interactions in a new way. Participants valued the enhanced transparency as a way to identify risks of bias but were concerned that reporting might undermine public trust in APRNs. Emphasizing awareness as a precursor to action, participants desired greater preparation for ensuring independence in practice., Conclusions: The importance of tackling the ethical issues associated with industry interactions is heightened within the context of an existing climate of distrust within health care. However, many participants were concerned about the effects of transparency on public trust rather than how APRNs individually or collectively can be more trustworthy., Implications: Open Payments can serve as a useful tool to catalyze broader conversations about ethics, integrity in decision making, and health policy advocacy., Competing Interests: Competing interests: The authors report no conflicts of interest., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Association of Nurse Practitioners.)

Many minoritized patients experience discrimination in health care. The same is true for minoritized health care clinicians, including the advanced practice registered nurse (APRN). Specifically, Black Americans have historically and disproportionally been privy to both structural racism and interpersonal racial discrimination (J Subst Abuse Treat 2022;133:108551). For patients, such exposure is associated with physical and mental health consequences, including hypertension, obesity, depression, anxiety, psychological distress, and mortality (Health Serv Res 2019;54 suppl 2(suppl 2):1399-1408). For minoritized clinicians, the subsequent result of discrimination additionally includes poor job satisfaction, decreased productivity, and high turnover (JAMA Health Forum 2023;4(12):e235249). Allyship, the act of supporting minoritized individuals while not being a member of that group, is potentially useful in improving the practice experience of minoritized APRNs, as well as positively impacting minoritized patients' outcomes. This article aims to provide actionable and practical skills for the APRN to create safe spaces for minoritized patients and partners in palliative practice. Explicitly, the role of the palliative care APRN as an ally will be reviewed as well as guidance on how to implement changes that will affect the health care experience for both patients and clinicians., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 by The Hospice and Palliative Nurses Association. All rights reserved.)

Abstract: Research indicates that knowledge gaps and unfavorable attitudes among primary care advanced practice registered nurses (APRNs) are linked to stigma surrounding psychiatric care, affecting the management of patients experiencing mental illness. Despite standards of practice and educational guidelines set forth by professional nursing organizations to increase quality of care, challenges exist when delivering care to patients with mental health disorders. Lack of integration of mental health education throughout graduate nursing courses contributes to an underestimation of its significance and applicability within advanced practice nursing in primary care. Advancing mental health education across primary care APRN curricula promotes access to psychiatric care, reduces disparities, and enhances health outcomes in the United States. Such practices increase competence and skills for primary care APRNs in the care of patients with mental health illness. This cultivates an advanced practice nursing workforce prepared to meet the evolving needs of diverse patients across the lifespan. Primary care APRNs offer a combination of clinical knowledge, holistic approach to care, and a strong focus on patient advocacy; therefore, we feel that enhancing primary care APRNs' knowledge in mental health may lead to decreased health care costs, increased access to psychiatric care, and decreased need for emergency mental health services., Competing Interests: Competing interests: The authors report no conflicts of interest., (Copyright © 2024 American Association of Nurse Practitioners.)

This study, which focuses on the follow-up of respiratory failure in neuromuscular patients, highlights the need to improve the supply of care and to compensate for gaps in care. Advanced practice nurses (APNs) as part of a multidisciplinary approach, could be the missing link. Improving the management of neuromuscular disorders is a key concern for the Filnemus neuromuscular rare disease network, the reference centers and the AFM-Téléthon. This is also where the need for an APN specialized in neuromuscular disorders is being discussed, and which could meet needs that are not covered, or are insufficiently covered, in the healthcare pathway., (© 2024 médecine/sciences – Inserm.)

Competing Interests: Competing interests: M. Ainslie: is senior fellow for the National Organization of Nurse Practitioner Faculties; has received support from the Faculties Fellowship stipend and institutional funds; and is consultant of competency-based education. M. Verdi reports no conflicts of interest.

Background: An increased demand for pediatric-focused advanced practice providers (APPs) exists to address the health care needs of children with medical complexity. Postlicensure advanced practice fellowship programs have been developed to help improve novice provider transition to practice, reducing attrition., Objectives: The objectives of this integrative review are to (1) identify outcome measurements of pediatric-focused advanced practice fellowship programs and (2) evaluate the outcome measures to guide future implications for practice., Data Sources: A systematic integrative literature review was conducted in accordance with the Preferred Reporting Items for Systemic Reviews and Meta-Analyses. PubMed, CINAHL, Embase, and Google Scholar were searched in August and September 2022. Articles met inclusion criteria if they included new graduate APPs, reported the intervention of a pediatric fellowship program, and shared outcome measurements. Studies were excluded if they did not directly report on fellowship program outcome measures. Thirteen studies met inclusion criteria and were summarized and appraised for quality using the Johns Hopkins Evidence-Based Practice Model., Conclusions: Four themes from the literature included the favorable impact of advanced practice fellowship programs on (a) job satisfaction, (b) retention, (c) clinical and professional performance, and (d) financial outcomes. Variable strategies were used to measure outcomes across programs., Implications for Practice: Postlicensure pediatric-focused advanced practice fellowship programs seem to improve retention and job satisfaction, increase provider confidence, and bring a favorable return on investment for the organization. Future work should include investment in developing validated, standardized assessment tools to support future development of these programs in the pediatric population., Competing Interests: Competing interest: The authors report no conflicts of interest., (Copyright © 2024 American Association of Nurse Practitioners.)

Abstract: A virtual book club (VBC) was created for advanced practice registered nurses (APRNs) to foster engagement, connect with peers, and apply readings to their personal and professional development. Microsoft Teams virtual platform was used. Books chosen focused on professional development and health care-related topics. As a quality-improvement project, 60 participants completed an anonymous Likert-scale survey about their perception of the VBC. Respondents survey completion rate was 71%. Sixty survey evaluations stated that they agreed or strongly agreed (mean 4.78-4.82/5) that the VBC encourages peer engagement, professional applicability, intention to read professional books, and willingness to invite peers to future VBCs. Participants were neutral (mean 3.25/5) about reading professional or health care-related books outside of the VBC. Virtual book clubs offer opportunities for APRNs to socially connect with peers and apply readings to both their personal and professional development. The results from this project may be applied to help encourage connection with other APRNs during these times of provider burnout., Competing Interests: Competing interests: The authors report no conflicts of interest., (Copyright © 2024 American Association of Nurse Practitioners.)

Community-based palliative care (CBPC) models address the growing needs of patients and caregivers with chronic and serious illnesses. From pediatrics to geriatrics, individuals prefer to receive care within their local community and at home. Delivering care at the community level and within the home improves health outcomes, reduces disparities, and supports local economic activity. Various models of CBPC have developed through partnerships with existing services, such as home health agencies, but ongoing challenges and barriers exist for further expansion of specialty palliative care. Advanced practice registered nurses increasingly manage chronic and serious illnesses and are essential for all health care teams, particularly for CBPC. As trusted providers within the community, advanced practice registered nurses create lasting relationships that allow for meaningful exchanges with patients and caregivers. This article reviewed the concept and features of CBPC offered within the United States and describes an advanced practice registered nurse-led embedded palliative care program for advanced lung disease., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 by The Hospice and Palliative Nurses Association. All rights reserved.)

Background: Despite available training programs for neonatal advanced practice providers (Neo APP), including neonatal nurse practitioners and physician assistants, it is difficult to meet the demand for these providers. There are no publications regarding training models with greater than 1 Neo APP learner per mentor., Purpose: To create and measure outcomes of a 12-month program to educate Neo APP "Super-Mentors" able to train 2 Neo APP learners simultaneously., Methods: Super-Mentors were selected and attended monthly classes to learn mentorship concepts and receive support. Learners received didactic content and support through a Fellowship program. Quantitative data regarding recruitment and retention, as well as Misener Nurse Practitioner Job Satisfaction Scale (MNPJSS) results were compared pre- and postprogram. Qualitative satisfaction measures via survey from 21 stakeholders were analyzed through a phenomenological approach., Results: Six Super-Mentors trained 14 Neo APPs, as compared to 7 in the previous year. One Neo APP left after training. Summative preprogram MNPJSS scores were better (5.1 ± 0.37) than postprogram (4.7 ± 0.47) ( P < .001). The most important preprogram subscale item was "vacation" versus "quality of assistive personnel" postprogram. Both pre- and postprogram scores reflected positive job satisfaction so differences may not be clinically significant. Qualitative program benefits included faster and increased onboarding, stronger relationships, and dedicated time. Challenges included role clarity among other stakeholders, learning culture, and spacial/technological logistics., Implications for Practice: Super-Mentors can train twice the number of Neo APP learners, with optimal preparation and support of all stakeholders, adequate space, and appropriate technology., (Copyright © 2024 by The National Association of Neonatal Nurses.)

Objectives: to validate the Brazilian version of the Modified Scale for Delineating Advanced Practice Nursing Roles., Methods: this was a methodological study for the clinical validation of an instrument, conducted with 207 nurses working in primary care. Exploratory and confirmatory factor analysis, Cronbach's alpha test, and z-test for proportion comparison were used., Results: the internal reliability of the scale was 0.944, with alpha greater than 0.80 in most domains, except for Education (0.786). In the exploratory factor analysis, considering the criterion of eigenvalue greater than one, eight factors were identified, explaining 79.38% of the variance. In the comparison of proportions, the adequate responses (≥ 2) in the domain of Comprehensive Direct Care, in both analyzed groups, were statistically equal. This domain had the highest score of adequate responses, followed by Education and Systems Support. Insufficient scoring was observed in the domains of Publication and Professional Leadership., Conclusions: the instrument demonstrated stability and reliability to be used in the evaluation of advanced nursing practice.

Background: Guided by Clinical Pharmacogenomic Implementation Consortium (CPIC) guidelines for >140 medications, pharmacogenomic tests inform medication selection and dosing to optimize efficacy while minimizing toxicities., Purpose: This study assessed pharmacogenomic self-reported curricular content, knowledge, skills, attitudes, and usage in advanced practice registered nurses (APRNs) with prescriptive privileges., Methodology: An online survey was administered assessing pharmacogenomic curricular content, knowledge, skills, attitudes, and usage., Results: Data from 266 APRNs were analyzed. Most graduated with their highest nursing degree ∼10 years ago and reported pharmacogenomic curricular content ( n = 124, 48%). Pharmacogenomic curricular content was associated with pharmacogenomic familiarity ( p = .045) but not with knowledge confidence ( p = .615). Pharmacogenomic usage, defined as ordering a pharmacogenomic test within the past year, was low ( n = 76, 29%) and most ( n = 210, 84%) reported never using CPIC Guidelines. Advanced practice registered nurses ( n = 162) who did not anticipate ordering a pharmacogenomic test in the next year ( n = 77, 48%) indicated that they did not know what test to order., Conclusions: Deficits were identified in APRN pharmacogenomic knowledge and skills despite academic training. Most reported not ordering pharmacogenomic tests, did not know what test to order, and did not use CPIC guidelines., Implications: Pharmacogenomics is a quality and safety issue. Academic training did not result in practice integration and most reported capacity deficits. Recommendation for overcoming academic deficits include: (1) assessment of pharmacogenomics curricular content and faculty teaching capacity; (2) training addressing identified deficiencies; and (3) Commission of Collegiate Nursing Education policies that include pharmacogenomics in advanced pharmacology. Practicing APRN plans include on-the-job training and/or mandatory training at the time of relicensure., Competing Interests: Competing interests: The authors report no conflicts of interest., (Copyright © 2024 American Association of Nurse Practitioners.)

Objectives: The field of oncology has been revolutionized by precision medicine, driven by advancements in molecular and genomic profiling. High-throughput genomic sequencing and non-invasive diagnostic methods have deepened our understanding of cancer biology, leading to personalized treatment approaches. Precision health expands on precision medicine, emphasizing holistic healthcare, integrating molecular profiling and genomics, physiology, behavioral, and social and environmental factors. Precision health encompasses traditional and emerging data, including electronic health records, patient-generated health data, and artificial intelligence-based health technologies. This article aims to explore the opportunities and challenges faced by advanced practice nurses (APNs) within the precision health paradigm., Methods: We searched for peer-reviewed and professional relevant studies and articles on advanced practice nursing, oncology, precision medicine and precision health, and symptom science., Results: APNs' roles and competencies align with the core principles of precision health, allowing for personalized interventions based on comprehensive patient characteristics. We identified educational needs and policy gaps as limitations faced by APNs in fully embracing precision health., Conclusion: APNs, including nurse practitioners and clinical nurse specialists, are ideally positioned to advance precision health. Nevertheless, it is imperative to overcome a series of barriers to fully leverage APNs' potential in this context., Implications for Nursing Practice: APNs can significantly contribute to precision health through their competencies in predictive, preventive, and health promotion strategies, personalized and collaborative care plans, ethical considerations, and interdisciplinary collaboration. However, there is a need to foster education in genetics and genomics, encourage continuous professional development, and enhance understanding of artificial intelligence-related technologies and digital health. Furthermore, APNs' scope of practice needs to be reflected in policy making and legislation to enable effective contribution of APNs to precision health., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Abstract: Meaningful job recognition is a pillar for sustaining healthy work environments and proven beneficial for job satisfaction and retention. However, few dedicated award recognition programs exist for advanced practice registered nurses (APRNs), and no available literature evaluates the impact on professional practice, sense of belonging, and job retention or satisfaction. The purpose of this study was to introduce a novel award recognition program for APRNs and physician associates (PAs) in a large academic medical system and evaluate it's impact on job satisfaction, retention, and sense of belonging. Five awards were created to recognize areas of achievement for clinically practicing APRNs or PAs within an academic health system. Nomination letters were collected, deidentified, and reviewed by an award committee. Winners were announced and received a plaque. A survey was sent to employed APRNs evaluating their response to the program. The survey was sent to both APRNs (83%) and PAs (17%). Survey end points included job satisfaction, willingness to stay in role for 1 and 5 years, sense of community, something to work toward, and increasing recognition of APRNs. Results showed statistical significance in three areas. Advanced practice registered nurses or PAs who were aware of award opportunities and/or nominated for an award showed higher job satisfaction, more likely to stay in job for 1 year, and felt a greater level of recognition. Dedicated APRN award programs may have a positive impact on job satisfaction and retention. This model may be extrapolated to provide greater opportunities for meaningful recognition among clinical APRNs., Competing Interests: Competing interests: The authors report no conflicts of interest., (Copyright © 2023 American Association of Nurse Practitioners.)

Objective/hypothesis: Advanced practice provider (APP) employment is becoming common in pediatric otolaryngology practices, though few studies have evaluated the consequences that APP-led clinics have on access to care. The objectives of this study were: 1) to investigate whether access to bilateral myringotomy with tympanostomy tube placement (BMT) for recurrent acute otitis media (RAOM) differed between patients seen in otolaryngologist and APP-led clinics 2) to compare clinical characteristics of patients seen by provider type., Methods: Retrospective cohort study at an academic, tertiary care pediatric otolaryngology practice. All children were <18 years old and underwent evaluation for RAOM followed by BMT. We compared time in days from scheduling pre-operative appointment to appointment date and time from appointment to BMT between patients seen by APPs and otolaryngologists using Mann-Whitney U tests and multivariate linear regression models. We compared clinical characteristics by provider type using Mann-Whitney U tests and Fisher exact tests., Results: A total of 957 children were included. Children seen by APPs had significantly shorter wait times for appointments (median 19 vs. 39 days, P < .001) and shorter times from preoperative appointment to BMT (median 25 vs. 37 days, P < .001). Patients seen by otolaryngologists had increased prevalence of craniofacial abnormalities, Down Syndrome, hearing loss, history of otologic surgery, and higher ASA physical status classification., Conclusions: Children seen by APPs received care more quickly than those seen by otolaryngologists. Patients seen by otolaryngologists tended to be more medically complex. Implementation of independent APP clinics may expedite and improve access to BMT for children with RAOM., Level of Evidence: 3 Laryngoscope, 131:2133-2140, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc..)

This study aimed to develop a locally suitable advance care planning (ACP) program for older community-dwelling adults and a training program for nurse facilitators in Korea, and to evaluate their feasibility from the facilitators' experiences. This was a mixed methods pilot study that assessed the feasibility of an ACP program by analyzing survey, checklist, and focus group interview data. The ACP program was named CLOSE (Communicating and Listening to Our Seniors' voices about End-of-life care). Home health care nurses (N = 9) participated in this study. The participants reported that CLOSE was applicable to older community-dwelling adults and the training program was useful for increasing facilitator competency. We suggest some lessons from this pilot study that can be used to improve the ACP program and encourage community health nurses to participate in ACP as facilitators.

Background: The role of the advanced practice provider (APP) is rapidly expanding in healthcare, whereas infrastructure to support it is not keeping pace. A large academic healthcare organization implemented the role of a director of APPs; supported by the C-suite, one who understands scope of practice, revenue models, and compliance and addresses engagement and retention to meet this challenge. This article chronicles the implementation of innovative success strategies, supporting APPs across a large academic health system, employing more than 1000 APPs, which has led to improvements in APP-generated revenue, patient access, engagement, and alignment., Methods: Emory Healthcare rapidly expanded the number of APPs (nurse practitioners and physician assistants) over the past 10 years. APPs reported to administration or nursing leadership leading to APP dissatisfaction, questions on return on investment (ROI) and productivity, and poor utilization due to lack of role clarity. An APP leadership structure was created so that every APP reported to an APP leader. In alignment with the goals and plan for Emory Healthcare, standardized service line productivity and accountability expectations were developed and implemented, as well as a vision and strategic plan to support APPs., Results: Improvement in productivity was seen across service lines, supported by the increase in full-time equivalent numbers, while improving the ROI for the organization. A roadmap to aligning an APP and organizational strategic plan has been created and implemented. Improvement in APP engagement was realized., Conclusions: An APP director and leadership structure are vital to the creation of infrastructure to support APPs in this healthcare. Optimization and standardization of APP practice resulted in role clarity and allowed for support of practice development., Competing Interests: The author declares no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Responding to National Academy of Medicine and National Council of State Boards of Nursing recommendations, the Department of Veterans Health Affairs (VHA) implemented full practice authority (FPA) for Advanced Practice Registered Nurses in VHA medical centers (VAMCs) in 2017., Purpose: To evaluate FPA policy implementation's impact on quality indicators including access to care as measured by new patient appointments in primary, specialty and mental health services., Methods: Linear growth models compared early (n = 85) vs. late (n = 55) FPA implementing VAMCs on the trajectories of each of the three quality indicators., Findings: Early FPA implementing VAMCs showed greater rates of improvement over time in new patient appointments completed within 30 days of preferred date for primary care (p = .003), specialty care (p = 0.05), and mental health (p = 0.001)., Discussion: VAMCs that started implementation of FPA policy early showed greater improvement in access to care for Veterans over time than VAMCs that did not., (Published by Elsevier Inc.)

Introduction : One solution proposed by the authorities to address public health issues is to deploy a new category of professionals with a greater range of skills : advanced practice nurses (APNs). The literature identifies the complexity of the deployment projects of these professionals. The PEPPA model approved by the International Council of Nurses is the reference model for the introduction of APNs. The objectives of this study were to explore various stakeholders' perceptions on the introduction of APNs into health institutions, in order to propose recommendations to support the institutions.Method : A multicenter qualitative study was conducted in France's Provence-Alpes-Côte d'Azur region with physicians, managers, nurses, patients, and advanced practice students.Results : APNs are beneficial for patients and the health system, but their introduction into health institutions brings with it risks, primarily linked to their integration. APN introduction projects need to be well planned and should prioritize their integration.Discussion : Results consistent with the PEPPA model identified seven recommendations to facilitate the successful introduction of APNs into hospitals.Conclusion : This work needs to be continued with studies related to the out-of-hospital setting and the evaluation of the successfulness of APNs' introduction.

Hospitals are under increased pressure to address both financial and capacity constraints to improve their clinical operations. Effective capacity management programs have become a key driver of clinical operations for managing the flow of patients into and out of the hospital. Many high-functioning medical centers have developed capacity management programs to strategically address patient throughput. Discharging patients from the hospital is one fundamental, but complex, patient flow initiative for efficient patient throughput. Despite advances in optimizing patient flow, there is a lack of understanding associated with the structure and processes to efficiently discharge patients. This article outlines a discharge timeliness project where advanced practice providers are principal leaders of designing a safe and efficient patient discharge prototype. Design thinking was used to develop a patient discharge prototype that included 6 key areas that led to improved discharge times on a cardiac surgery step-down unit. High tech solutions were incorporated into the electronic medical record system to enhance communication across phases of care and inform the interdisciplinary team of patient progress.

Background: Advanced practice registered nurses (APRNs) play a pivotal role in meeting the increasing needs of elder care given the aging population. A good understanding of the characteristics of gerontological APRNs is important for future workforce planning., Purpose: To understand the demographic, employment, and practice characteristics of APRNs who provide elder care., Methods: A 34-item survey was distributed to 2,500 current members of the Gerontological Advanced Practice Nurses Association. Three hundred and sixty-four members provided demographic information and employment and practice patterns. To examine the sample representativeness, the survey sample was compared with a sample drawn from the National Sample Survey of Nurse Practitioners 2012. Descriptive statistics were used for analysis., Results: Most respondents were older than 55 years, held a master's degree, were certified as a Gerontology APRN, worked in a long-term/elder care setting as an APRN, earned a salary ranging from $105,001 to $125,000, and practiced in urban or suburban areas. Most respondents worked full time, provided care for people who were 55 to 75 years old, and prescribed under a collaborative agreement., Implications for Practice: The study results suggested that gerontological APRNs have the experience and competence to meet the increasing needs of elder care, practice in a variety of settings, including in rural areas, and spend much time with patients. Future efforts are needed to support APRN practice, such as improving their autonomy and independence.

Background: Midwifery practice is essential in achieving high-quality maternal and newborn care in all settings and countries. However, midwifery practice has become more complex over the past decades. Considerable demands are being placed on midwives to meet increasing epidemiological, socio-economic, and technological challenges. These require a well-trained midwifery workforce ready to shape the care in the near and long-term future., Objective: To discuss advanced midwife practitioner role implementation in Belgium as a possible answer to healthcare-related challenges that impact midwifery practice. Furthermore, to stimulate a debate within the profession at all levels in Belgium and in countries considering advanced midwife practitioner roles., Method: The framework by De Geest et al. (2008) served as a basis for discussing the drivers for advanced midwife practitioner role implementation: the legal, policy and economic context, workforce issues, education, practice patterns, and healthcare needs of the population., Findings: A legal basis for advanced midwife practitioner role implementation is lacking in Belgium. Remuneration opportunities for the non-clinical part of these roles (e.g. leadership and innovation activities) are missing. It might be challenging for healthcare organisations to support the implementation of such roles, as immediate revenues of non-clinical activities are absent. However, sufficient potential resources are available to fill in future advanced midwife practitioner positions. Additionally, advanced midwife practitioner specific master programmes are being planned in the near future., Conclusions: Although several barriers for the implementation of advanced midwife practitioner roles were identified, a discussion should be held on the opportunities of implementing these roles to facilitate the development of new models of care that meet current and future challenges in midwifery practice and healthcare. After initial discussions amongst midwives in academic, managerial, and policy positions, stakeholders such as obstetricians, general practitioners, associations representing healthcare organisations, and policy makers should be involved as a next step., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2020. Published by Elsevier Ltd.)

Unresolved work stress contributes to burnout, compassion fatigue, disengagement, and other work-contextualized factors. The impact of occupational stressors extends to the organization in a negative fashion as well. In 2017, advanced practice providers (APPs) from four health systems, including nurse practitioners, clinical nurse specialists, nurse midwives, nurse anesthetists, and physician assistants, participated in a quantitative online cross-sectional survey; 754 participants responded to a free-text question related to work stress and work-family balance. Suggested organizational strategies were ordered into 29 codes, 10 subthemes, and four main themes: "reduce job stressors," "improve leadership and operations," "promote APP well-being," and "maintain the status quo." Findings are consistent with other research related to occupational stress with many of the reported strategies considered as evidence-based. Targeted interventions for reducing job stress will need to include improved autonomy for APPs, role delineation, support for work-family balance, and better communication as part of management practices.

Aims and Objectives: To evaluate the knowledge and attitudes towards sexual and gender minority (SGM) oncology patients' needs among advanced practice providers (APPs)., Background: SGM individuals experience health disparities, in part due to lack of access to knowledgeable providers. Despite the important role of APPs in cancer care, less is known about their attitudes and knowledge towards SGM cancer patients., Design: Cross-sectional study., Methods: A survey of APPs at a National Cancer Institute-Designated Comprehensive Cancer Center assessed self-reported demographics, attitudes, knowledge and postsurvey confidence in knowledge of SGM oncology patient needs. Reporting of this study adheres to STROBE guidelines., Results: Knowledge of health needs was low with an average of 2.56 (SD = 1.27) items answered correctly out of 6. The majority of APPs self-reported being comfortable treating SGM patients (93.6% and 87.2%, respectively), but less confident in knowledge of their health needs (68.0% and 53.8%, respectively). Although less than half of APPs believed education should be mandatory (44.9%), 79.5% were interested in education about SGMs' unique health needs. Political affiliation, medical specialty, licensure, and having SGM friends or family were associated with various attitude items, but not knowledge. Moderation analyses indicated that APPs who had greater overall knowledge scores were more likely to agree, on average, that knowing sexual orientation, gender identity and sex assigned at birth are important to providing quality oncology care., Conclusion: APPs report being comfortable providing care for SGMs with cancer, but knowledge gaps remain that may inhibit the quality of care provided. Given the interest in education, results would support the development of SGM-related healthcare training for oncology APPs., Relevance to Clinical Practice: Targeted education for providers during training and continuing education is likely to improve the provision of quality care for SGMs with cancer., (© 2020 John Wiley & Sons Ltd.)

Background: Rapid changes in the health care marketplace are driving health care systems to modify operations by which the advanced practice registered nurse (APRN) and physician assistant (PA) clinicians serve patients. By identifying more effective and efficient utilization workflows, organizations can meet these demands resulting in high-functioning clinical teams., Local Problem: With the growing number of APRNs and PAs within a large academic medical center, there was a recognized need to establish effective and efficient utilization practices for these health care providers., Methods: Directors of the Advanced Practice Provider Best Practice Center developed an internal nurse practitioner (NP)/certified nurse midwife (CNM)/clinical nurse specialist (CNS)/PA assessment service in which evaluations were conducted to optimize APRN and PA practice at the clinical/department level. This assessment excluded certified registered nurse anesthetists., Interventions: Thirty-two clinical areas were evaluated between September 2016 and May 2019. This included an NP/CNM/CNS/PA survey and over 200 individual NP/CNM/CNS and PA provider interviews. Assessments addressed utilization, billing practices, professional development, and communication among team members., Results: Qualitative and quantitative reports were compiled. Many common themes were identified. These were broken down into three major categories: productivity, clinical operations, and professional development/support., Conclusions: Several recommendations were presented to department leaders regarding NP/CNM/CNS/PA practice. Those departments who implemented several of the recommendations showed positive outcomes. This was evidenced by increased financial gain (increased relative value units, increase in revenue generated), increased patient access (increased clinic densities), and overall NP/CNM/CNS/PA satisfaction.

Aims and Objectives: To explore the effectiveness of nurse-led interventions to prevent urinary tract infections in older adults living in residential aged care facilities., Background: While most empirical studies focus on the treatment of urinary tract infections, few studies have examined the effectiveness of nurse-led interventions in preventing urinary tract infections., Design: Systematic review., Methods: Eight electronic databases were searched for relevant studies published between 2008-2018. The inclusion criteria were as follows: (a) a focus on older adults, (b) evaluation of nurse-led interventions, focusing on prevention of urinary tract infection, (c) implemented in residential aged care facilities, and (d) outcomes reported as incidence or prevalence of urinary tract infection. The selected papers were critically appraised using the Mixed Methods Appraisal Tool. The data were analysed with narrative synthesis, and findings were reported following the PRISMA guidelines., Results: A review of 1,614 titles and abstracts identified four studies that met the inclusion criteria. Three types of nurse-led interventions were identified: (a) the appointment of advanced practice nurses, (b) those focused on a single specific nursing intervention, and (c) implementation of a multicomponent nursing intervention. All included studies reported at least some positive outcomes. However, the included studies were highly heterogeneous and it was impossible to determine the most effective intervention approach., Conclusions: Nurses are leaders in health care and are well placed to lead prevention of urinary tract infections in residential aged care; however, evidence of the effectiveness of a nurse-led approach is limited. High-quality randomised controlled trials are warranted to address the knowledge gap and advance practice in this area., Relevance to Clinical Practice: When developing an effective nurse-led intervention programme, the programme should be grounded in nurse-led principles and consider the complex staffing factors to ensure that nurse-led programmes are tailored to an effective level., (© 2020 John Wiley & Sons Ltd.)

Aim: To examine work environment differences between hospital certified nurse practitioners (CNPs) and certified registered nurse anaesthetists (CRNAs)., Background: Nurse work environments impact patient and nurse outcomes. How differing advanced practice nurse (APRN) roles influence work environments is unknown., Methods: Multi-level cross-sectional survey design. APRNs (n = 490) completed the APRN Organizational Climate Questionnaire and Psychological Ownership Questionnaire. Nurse executives (N = 24) reported on Scope of Practice and Institutional Voice. Descriptive, t test, chi-square and linear and mixed-effects regression statistical analyses were employed., Results: CNPs reported better organisational climate and job ownership than CRNAs. The largest effects involved relationships with physicians, control over practice and independent practice. Among CNPs, a significant positive relationship was observed between relations with physicians and work engagement. In CRNAs, a similar positive relationship between physician relations and work engagement was only observed for those working in higher scope of practice settings, not for those working in more restrictive settings., Conclusions: Significant differences exist in the perceived work environments between CNPs and CRNAs that may be related to differences in job design and historical relations with physician colleagues., Implications for Nursing Management: Efforts to improve APRN work environments in hospital settings should consider differing CRNA and CNP perspectives., (© 2020 John Wiley & Sons Ltd.)

Aims: To create a cohort of advanced practice nurses from across the UK and to report the initial questionnaire including demographics, work experiences and well-being., Background: In the UK, advanced nursing practice is not regulated. This has led to the concern that advanced nurses are working in very different ways with different levels of autonomy and support., Methods: Participants were recruited via university and Royal College of Nursing mailing lists, and social media adverts. They completed the initial questionnaire about their background and workplace, work experiences, credentialing and well-being., Results: A total of 143 nurses were recruited to the cohort and 86 completed the survey. Over 40 job titles were reported, across five pay bands. Job title was not correlated with pay band (p = .988). Participant well-being was not significantly different from the UK general population, but they reported high rates of work-related stress (44.2%) compared with the National Health Service national average (37.9%)., Conclusion: There is a wide disparity in pay, which is not reflected in title or setting. The high levels of work-related stress require further exploration., Implications for Nursing Management: The range of experiences reported here should encourage managers to evaluate whether title, pay and support mechanisms for Advanced Practice Nurses in their organisations align with suggested national standards set by Royal Colleges and government departments., (© 2020 The Authors. Journal of Nursing Management published by John Wiley & Sons Ltd.)

Nursing literature has recognized deficits in lesbian, gay, bisexual, transgender, queer-specific care. Of particular concern is lack of knowledge about gender minorities. Lack of knowledge remains despite this populations' increased health disparities. This pilot study investigates pre- and post-knowledge of medical guidelines, disparities, policies, and attitudes specific to gender minorities among advanced practice nursing students attending a gender minority health module. All participants in this pilot study completed a questionnaire on content and a transphobia scale to evaluate its effect on attitudes. Students were also surveyed on previous experience with gender minority patients. Students indicated sex and gender identity as female, with a mean age of 33.5 years. Twenty-seven percent of the students reported experience with gender minority patients. Wilcoxon signed rank test indicated statistically significant improvement in knowledge and improved scores on transphobia. This study demonstrated a module on the health of gender minorities is an effective method for increasing student knowledge of gender minority health care.

Over the course of four billion years, humans have developed an intimate relationship with the more than 37 trillion microbes that inhabit our bodies. This relationship runs the gamut from symbiosis to pathogenesis. The number of microbial cells is roughly equivalent to that of mammalian cells in the body. However, due to substantial microbial diversity in host-associated communities, the genetic content of the microbiome is roughly 150 times greater than that of the human genome. Microbial genes encode for proteins capable of producing a wide variety of molecules essential for our health and survival. Many factors such as mode of birth, diet, chlorination of water, and medications significantly affect the richness and diversity of the microbiome. Advanced practice nurses have important roles to play as clinicians, scientists, educators, and patient advocates as our understanding of the microbiome's effects on health becomes better articulated. An understanding of how the microbiome can affect an individual's health or the efficacy of treatment will soon be essential in the clinical setting, and nurses should be encouraged to educate themselves on the relationship between our microbial partners, the environment, and human health.

The US health care system has seen unprecedented growth in health care cost with only a mediocre return on investment. Achieving sustained quality improvement will require innovation that is effectively integrated into complex systems of care. Complexity leadership has the ability to place value on traditional quality improvement processes, with less focus on rigid structure and more attention on the potential for flexibility and creativity at the point of care. Clinical team leaders, such as nurse practitioners, must nurture adaptability to the constantly changing clinical environment while balancing structured thinking of team members. Nurse practitioners operating in interdisciplinary teams are well positioned to foster adaptive change through rapid cycle improvements at the point of care. As a learning approach to quality improvement, the PDSA (plan-do-study-act) method should be seen as a useful tool for organizations to create an emergent quality improvement process. This article discusses the significance of nurse practitioner leadership using the PDSA method informed by complexity leadership theory and the impact for clinical practice.

Problem: Despite knowing the importance of the early detection of adverse experiences, mental health disorders beginning or occurring during early childhood can be difficult to recognize. To address this gap, this manuscript describes the care of a parent-child dyad utilizing the nursing process in an illustrative case., Methods: This illustrative case provides a scenario that includes the early detection of infant mental health (IMH) in primary care with referral to a psychiatric mental health advanced practice nurse (PMHNP) and highlights how integrative care with PMHNP can facilitate the use of the nursing process to promote optimal early childhood growth and development and prevent long-term mental health problems., Findings: The collaboration between the primary care provider and PMHNP in addressing a common diagnosis observed in IMH (i.e., feeding disorder) where a 6-month-old infant presented with poor weight gain due to detached parenting, secondary to maternal depression, resulted in early infant-parent intervention that reduced maternal depression and normalized infant growth., Conclusions: The screening of IMH in pediatric primary care promotes early referral and collaboration with the PMHNP to address IMH problems to promote optimal growth and social-emotional development in early childhood., (© 2019 Wiley Periodicals, Inc.)

Purpose: Nurse practitioners, physician assistants, and pharmacists are advanced practice providers who are highly trained and qualified healthcare professionals that can help support traditional demands on oncologists' increased time in direct patient care. The purpose of this study was to detail and assess the creation of a privileging process for this group of medical professionals within an academic medical center. Obtaining the designation of limited oncology practice provider (LOPP) gives the right to modify chemotherapy orders and to order supportive care medications., Methods: An interdisciplinary team developed a comprehensive training process inclusive of required educational domains, knowledge goals, and educational activities to become an LOPP. In 2018, five years after the implementation of the privileging process, a survey was distributed to assess perceptions of the training process and integration of LOPPs within oncology practice., Results: Most oncologists noted that working with LOPPs is beneficial to oncology practice (94%) and that they make modifying chemotherapy orders more efficient (87%). Greater than 82% of LOPPs also reported that their privileges streamline the chemotherapy process and make them feel valuable., Conclusion: The creation of the LOPP designation is an effective way to integrate nurse practitioners, physician assistants, and pharmacists within oncology practice. The inclusion of a focused privileging process ensures the safety of cancer care provided and has created a streamlined process for chemotherapy modifications and supportive care.

Background: Numerous nursing and physician studies have reported the effects of workload, environment, and life circumstances contributing to burnout. Effects may include job dissatisfaction, poor quality of life, and associated negative patient outcomes. Although assessing clinician burnout to determine effective interventions has become a topic of great importance, there are minimal studies specific to advanced practice registered nurses (APRNs)., Purpose: This single-center study was conducted to assess the prevalence and impact of APRN burnout and to recommend targeted interventions toward improvement of overall health and well-being., Methods: A cross-sectional, mixed methods design was used. The voluntary, anonymous survey examined perceptions of wellness, inclusion, social support, personal coping mechanisms, and status of burnout., Results: The 78-question survey was sent to 1,014 APRNs (94%) and PAs (6%), with a 43.6% response rate (n = 433); 76.4% were nurse practitioners. Participants were identified as currently experiencing burnout, formerly burned out, or never having experienced burnout. Profiles were developed, and similarities and differences between each group were compared. Of 433 respondents, 40.4% (n = 175) reported having never experienced burnout, 33.3% (n = 144) reported they had formerly experienced burnout, and 26.3% (n = 114) reported they were currently experiencing burnout., Implications for Practice: The results of the study identified that some APRNs report experiencing burnout at different times in their careers. Recommendations by participants to mitigate burnout included self-care, organizational promotion of health and well-being, career development, and leadership support. This study is one of the first to report on burnout among APRNs and potential interventions to build resilience; however, additional research is warranted., Competing Interests: Competing interests: The authors report no conflicts of interest., (Copyright © 2019 American Association of Nurse Practitioners.)

The nursing professional who treats critically ill children with cerebral injury is a key element within the pediatric intensive care team, since, through exhaustive assessment, plans nursing care in an integral manner aimed at the child and the family, and plays an essential role in the care of patients mainly at the hospital level (as well as at home). Therefore, the role played by nursing in the care of children with severe brain trauma is crucial. This guide offers nursing recommendations on neurocritical care, focusing on a systemic view based on nursing diagnoses according to the North American Nursing Diagnosis Association., Competing Interests: The authors report no conflicts of interest in this work., (Sociedad Argentina de Pediatría.)

Background: Utilizing skills identified in previous research on successful role transition, this study evaluated the relationship between a strategically designed practicum course and the readiness for role transition to family nurse practitioner (FNP) in graduate nursing students., Methods: A mixed methods approach evaluated pre- and post-participation survey data for the FNP role preparedness in graduate nursing students in a strategically designed practicum course. The survey addressed 22 skills associated with readiness for role transition and had three open-ended questions to collect narrative student perceptions., Results: Mann-Whitney U tests revealed readiness for the FNP role increased from pre to post-participation in the course for 19 out of 22 skills with significant increases (P < 0.05) for one skill and marginally significant increases (P < 0.10) for three skills. Qualitative findings yielded an overall sense of readiness in students for novice FNP roles., Conclusion: A well-designed practicum course that reviews prior knowledge gained through the program and reinforces critical thinking, assessment, and decision-making skills facilitates role transition from registered nurse to novice FNP., (© 2019 Wiley Periodicals, Inc.)

Aims: To provide an overview of the practice patterns of advanced practice nurses and to explore their perceptions of their role in Singapore., Background: Role expansion of advanced practice nurses is increasingly popular in healthcare systems. However, their practice patterns remain variable, thereby introducing role ambiguity. Uncertainty revolves around how advanced practice nurses perceive their practice, competency and readiness for role expansion., Methods: A nationwide survey of advanced practice nurses was conducted in Singapore. Statistical analyses of closed-ended responses and content analysis of open-ended responses were undertaken., Results: A total of 87 participants were surveyed (42.8% response rate). Significant discrepancies existed between current practices and their expectations. Readiness for and acceptance of role expansion were discerned but multiple barriers to practice have remained., Conclusion: This pioneering study in Asia provides important evidence to support the call for greater clarity in the role of APNs and for review of existing institutional practice restrictions. It provides insights into healthcare systems in similar developmental stages of advanced practice nursing., Implications for Nursing Management: When outlining the goals and role priorities of advanced practice nurses APNs, nurse administrators can consider their best contributions in practice. This allows for long-term sustainability of their role., (© 2019 John Wiley & Sons Ltd.)

Since Sackett et al.'s epic throw down of the gauntlet in 1996, the hallmark of quality health care practice has been evidence-based clinical decision making. But what does it mean to base one's practice on evidence, and what are the barriers to evidence-based prescribing? The current article addresses these questions and offers suggestions to improve one's evidence-based practice. [Journal of Psychosocial Nursing and Mental Health Services, 57(6), 9-13.]., (Copyright 2019, SLACK Incorporated.)

The longstanding partnership between the Birmingham Veterans Affairs Medical Center (BVAMC) and the University of Alabama at Birmingham School of Nursing inspired the establishment of one of the country's first psychiatric-mental health nurse practitioner (PMHNP) residencies and subsequent formation of a Resident Continuity Clinic (RCC). Within the RCC, PMHNP residents deliver evidence-based care that is informed by measurement-based care (MBC) to improve patient outcomes and reduce time to recovery. Determined by the BVAMC Institutional Review Board to be a quality improvement project, PMHNP residents administered the Patient Stress Questionnaire (PSQ), a MBC tool that uses four independently validated screening tools to measure the behavioral health symptoms of depression, anxiety, trauma, and alcohol use. Additional clinical variables of interest included patient use of illicit substances, participation in psychotherapy, and use of psychotropic medications. PSQ scores were reviewed retrospectively via descriptive statistics and nonparametric tests. Analysis demonstrated statistically significant improvements in depression and anxiety. Data also revealed that patients engaged in psychotherapy demonstrated greater improvements on all PSQ screening tools compared to patients not involved in psychotherapy. The results reinforce the value of MBC in psychiatric care and highlight the importance of engaging Veterans in psychotherapy to improve outcomes. [Journal of Psychosocial Nursing and Mental Health Services, 57(6), 30-38.]., (Copyright 2018, SLACK Incorporated.)