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Advanced practice registered nurses (APRNs) significantly contribute to health promotion, disease prevention, and disease management. Yet, barriers to APRN practice exist, including regulatory, state, and institutional barriers, that hinder their ability to practice to the full extent of their education, licensure, and certification. Nurse leaders can play an important role in helping reduce unnecessary institutional barriers to APRN practice.

In response to the COVID-19 pandemic, Tennessee's Governor issued executive orders temporarily suspending certain practice restrictions on advanced practice registered nurses (APRN), which expired after 2 months as the pandemic worsened.This purpose of this qualitative study was to analyze APRN interview data to evaluate how prepandemic APRN practice barriers, executive orders, and the pandemic affected APRN practice in Tennessee.Fifteen Tennessee APRNs who completed the National APRN Practice and Pandemic study also completed follow-up interviews via a HIPAA-compliant Zoom platform. Given the unprecedented circumstances associated with the COVID-19 pandemic, we conducted a qualitative descriptive study seeking descriptions and unique perspectives of Tennessee APRNs. Consistent with qualitative study design, we conducted an atheoretical study that featured interviews, purposeful sampling with maximum variation sampling, and content analysis.The major themes were practice changes, impact of executive orders, and ongoing care barriers. The data revealed that patients, APRNs, and other health care providers were strained in new and profound ways during the pandemic. An underlying theme was Tennessee APRNs' frustration with continued regulatory and other practice barriers despite their state's health and health care disparities and under resourced health care system.These findings indicate the need to improve care access and health outcomes, advocate for full practice authority for APRNs, support telehealth expansion, address transportation deficiencies, and respond to the pandemic-precipitated mental health crisis.

Successful academic-clinical partnerships are mutually beneficial for academic nursing and clinical organizations, supporting the long-term success of nursing programs while simultaneously improving patient outcomes. Advocated by the American Association of Colleges of Nursing in their 2016 report, Advancing Healthcare Transformation: New Era for Academic Nursing, this position paper provides six actions for transforming academic nursing. However, developing sustainable academic-practice models has proven challenging despite this roadmap, as research has not substantiated their benefits. This article describes an innovative academic-practice model that transitioned advanced practice registered nurses practicing at Le Bonheur Children's Hospital to full-time faculty, with a continued primary clinical practice role, in the College of Nursing at the University of Tennessee Health Science Center. We present the origin, development, and implementation of this academic-practice partnership model, offering recommendations for its replication by other universities and clinical agencies on this journey. Creating a sustainable model requires a shared vision, buy-in at all levels, frequent and transparent communication, planning that considers the individual policies of the partnering agencies, and persistence despite leadership changes. Two years into the partnership and remaining intact despite critical leadership changes within the clinical agency, the next phase of the relationship will permit us to document the model's impact on academic and clinical outcomes.

Background The impact of the COVID-19 pandemic on Advanced Practice Registered Nurse (APRN) practice is not well known. Purpose This study aimed to describe state practice barriers and explore the effects of the COVID-19 pandemic on APRN practice. Methods A descriptive study design used a 20-item web-based survey open from June 1 through September 23, 2020. Findings A total of 7,467 APRNs responded from all 50 states, including nurse practitioners (n = 6,478, 86.8%), certified registered nurse anesthetists (n = 592, 7.9%), certified nurse-midwives (n = 278, 3.7%), and clinical nurse specialists (n = 242, 3.2%). A number of barriers to practice prior to the pandemic were identified. Most respondents (n = 6334, 84.8%) identified that practice barriers limited the ability of APRNs to provide care during the pandemic. Discussion Barriers to APRN practice continue to restrict aspects of patient care and patient access to care, even in states with Full Practice Authority (FPA), during the COVID-19 pandemic and with state executive orders waiving practice restrictions. The study findings can be used to advocate for policy changes to support APRN practice authority.

The novel coronavirus disease SARS‐CoV‐2 (COVID‐19) outbreak rapidly generated an unprecedented global, national, and state public health crisis with the need to rapidly develop alternate care sites (ACS) to care for COVID‐19 patients within an overburdened health care system. A hospital care model ACS to increase the health care capacity, provide care for mild to moderately symptomatic patients, and offer local self‐sustainment for a surge of patients was developed in Memphis, Tennessee located in Shelby County. We completed a temporary conversion of a large unused newspaper publication building to a health care facility for COVID‐19 patients. Developing an ACS from ground zero was met with many challenges, and throughout the process important lessons were learned. With the goal to complete the building conversion within a 28‐day timeframe, collaboration among the numerous governmental, health care, and private agencies was critical and nursing leadership was key to this process. The purpose of this paper is to describe the development of a COVID‐19 ACS in Memphis, TN, which has a large at‐risk population with limited access to health care. Specifically, we will discuss the strong leadership role of nursing faculty, key challenges, and lessons learned, as well as provide checklists and models for others in similar circumstances.

Female genital cosmetic surgeries (FGCSs) and procedures are increasingly being advertised as common, simple, and complication-free, capable of not only improving aesthetic appearance but also increasing self-esteem and sexual pleasure.Guidelines for physicians and clear, scientifically correct information for patients must be made available, to minimize the number of ineffective or deleterious procedures.The International Society for the Study of Vulvovaginal Disease positions/recommendations regarding FGCS are as follows:1. There is a wide variation regarding genital normalcy; providers must be able to explain this to women.2. There are no data supporting FGCS including, G-spot augmentation, hymenoplasty, vulvar and perianal bleaching/whitening, vaginal tightening procedures, and other procedures aimed at increasing sexual function.3. Women should not be offered FGCS before the age of 18 years.4. Women undergoing FGCS should be evaluated by a provider with expertise in vulvovaginal diseases, including attention to their psychological, social, and sexual context. Evaluation by an experienced mental health provider should be considered when the motivation for seeking surgery and/or expectations are not clear or realistic.5. Female genital cosmetic surgery is not exempt from complications.6. Informed consent must always be obtained.7. Surgeons performing FGCS should refrain from solicitous advertising or promoting procedures without scientific basis, including on Web sites.8. Surgeons should not perform surgery that they do not agree with and explain their rationale/position when pressured by patients.9. The genital surgeon must be adequately trained in performing FGCS including knowledge of the anatomy, physiology and pathophysiology of the vulva, vagina and adjacent organs.

Nurse practitioner preparation and education, while evolving, still remains at a crossroads. In a recent article by Mundinger and Carter, a timeline and analysis of the number of Doctor of Nursing Practice (DNP) programs in the United States clearly demonstrated that since inception of the DNP degree, 85% of DNP programs are nonclinical. Many of the nonclinical programs in leadership and administration do not require additional clinical preparation beyond the bachelor's or master's degree in nursing. Thus, registered nurses and advanced practice registered nurses (APRNs) may obtain a DNP degree without additional clinical skill preparation beyond a baccalaureate or master's degree, respectively. Several aspects of the nonclinical DNP are concerning. Among the most challenging issues that nonclinical DNPs present is confusion on the part of other health care providers and the public. The relatively low number of clinically focused DNP programs is also problematic. If we do not prepare APRNs at the clinical doctoral level, then other providers such as physician assistants will meet the health care needs of the community. The future of APRNs could be threatened, especially in primary care.

Background: Many changes have occurred in DNP programs since they first began. University of Tennessee Health Science Center began the practice doctoral program in 1999 and today enrolls over 100 new baccalaureate nursing (BSN)-to-Doctor of Nursing Practice (DNP) students each year. More than 500 DNPs have graduated to date. Method: A review of the history and challenges of this program are presented as a potential exemplar for other programs to consider. Results: Several changes have taken place, including a shift from Master of Science in Nursing (MSN)-to-DNP programs to almost all BSN-to-DNP programs, a new appreciation for writing skills, and movement away from a separate DNP project. Conclusion: Understanding these changes may help other schools of nursing as they begin DNP programs or transition from their MSN-to-DNP programs to BSN-to-DNP programs. [ J Nurs Educ . 2016;55(10):563–567.]

Anal health and anal cancer are rarely addressed in HIV primary care. We sought to understand factors that impeded or promoted addressing anal health in HIV primary care from providers' perspectives. In this exploratory study, HIV primary care providers from the Mid-South region of the United States participated in brief individual interviews. We analyzed transcribed data to identify barriers and facilitators to addressing anal health. Our study sample included five physicians and four nurse practitioners. The data revealed a number of barriers such as perception of patient embarrassment, provider embarrassment, external issues such as time constraints, demand of other priorities, lack of anal complaints, lack of resources, and gender discordance. Facilitators included awareness, advantageous circumstances, and the patient-provider relationship. Anal health education should be prioritized for HIV primary care providers. Preventive health visits should be considered to mitigate time constraints, demands for other priorities, and unequal gender opportunities.

To identify factors affecting the quality of life (QOL) of African American women (AAW) family caregivers of individuals with kidney failure.Ferrans' Conceptual Model of QOL provided the framework for this literature review. Included studies were (a) peer- reviewed, (b) published within the last ten years, (c) written in English, and (d) examined QOL of AAW family caregivers. Using CINAHL© and PubMed©, we found 14 studies that described factors associated with these caregivers' QOL.Few studies document the QOL of AAW who are family caregivers, especially in the context of kidney failure. Psychiatric Mental Health Advanced Practice Registered Nurses need to learn about the factors influencing the QOL of these caregivers.No studies were found within the last ten years that explored the QOL of AAW family caregivers of individuals with kidney failure. Findings reflected the QOL of AAW family caregivers in the context of other chronic conditions. Various factors such as stress, insomnia, and employment were linked to an impaired QOL. Implications for practice, research and education for PMH-APRNs are suggested.PMH-APRNs are uniquely trained to address many factors that affect the QOL of these caregivers and may provide holistic care aimed at promoting satisfactory QOL for these caregivers.

Nurse practitioner preparation and education, while evolving, still remains at a crossroads. In a recent article by Mundinger and Carter, a timeline and analysis of the number of Doctor of Nursing Practice (DNP) programs in the United States clearly demonstrated that since inception of the DNP degree, 85% of DNP programs are nonclinical. Many of the nonclinical programs in leadership and administration do not require additional clinical preparation beyond the bachelor’s or master’s degree in nursing. Thus, registered nurses and advanced practice registered nurses (APRNs) may obtain a DNP degree without additional clinical skill preparation beyond a baccalaureate or master’s degree, respectively. Several aspects of the nonclinical DNP are concerning. Among the most challenging issues that nonclinical DNPs present is confusion on the part of other health care providers and the public. The relatively low number of clinically focused DNP programs is also problematic. If we do not prepare APRNs at the clinical doctoral level, then other providers such as physician assistants will meet the health care needs of the community. The future of APRNs could be threatened, especially in primary care.

In this article, sexual assault of older persons is analyzed in a literature review and case series, and exemplar pseudocases of suspected older person sexual assault are discussed.

Objective. To describe the advanced practice clinician (APC) membership of the American Society for Colposcopy and Cervical Pathology (ASCCP). Materials and Methods. Members of the APC Task Force designed a 34-question survey and sent it by electronic mail to 270 APC ASCCP members in the fall of 2006. The survey assessed demographics, preparation for colposcopy practice, current practice environment, and educational needs. Descriptive statistics evaluate findings. Results. Response to the electronic membership survey was 28%. Most responders are master's degree prepared nurse practitioners specializing in women's health with 6 to 10 years of experience practicing colposcopy. Several members identified a desire to precept new learners, but some practice environments are perceived as limiting. Respondents express support for the ASCCP Mentorship Program and need ongoing continuing education in the management of lower genital tract disease. Conclusions. The APC membership of ASCCP represents a growing constituency within the organization. Advanced practice clinician members are dedicated learners who value ASCCP's educational offerings and aspire to participate more actively in the organization. Through their educational preparation and demonstration of competency, APCs are determined to learn new and complex skills that will contribute to best practices and evidence-based care. Advanced practice clinicians actively engage in the education of others learning colposcopy and related skills. Building on the groundwork of early pioneer nurse colposcopists, APCs have affirmed their role in the care of individuals with lower genital tract disease.

Patient navigation (PN) is a new initiative in health care aimed at reducing disparities by assisting patients in overcoming barriers within the health care system. As PN programs grow around the country, it is important to consult the key stakeholders in the development of these programs. The purpose of this qualitative study was to discuss the needs of medically underserved cancer patients and allow them the opportunity to provide input on models of care to meet their needs. Four focus groups were conducted in three major cities across Tennessee. Research participants (n = 36) were recruited by the staff in area cancer support programs and treatment programs across the state and through recruitment flyers at various treatment centers and community organizations. Findings revealed four key themes in the development of PN programs: (1) the PN needs to address access to quality care issues; (2) the PN needs to address the emotional and practical concerns of the cancer survivor, (3) the PN needs to address family concerns; (4) the PN needs to be involved across the continuum of care from time of diagnosis into long-term survivorship. Oncology social workers have a unique opportunity to meet the needs of medically underserved cancer patients through the PN movement. Our profession is a key stakeholder in this movement. We need to advocate for trained oncology social workers to actively pursue the role of patient navigators to ensure that the needs of medically underserved cancer survivors and their families are met.

ObjectiveThe incidence of anal cancer is higher in women than men in the general population and has been increasing for several decades. Similar to cervical cancer, most anal cancers are associated with human papillomavirus (HPV), and it is believed that anal cancers are preceded by anal high-grade squamous intraepithelial lesions (HSIL). Our goals were to summarize the literature on anal cancer, HSIL, and HPV infection in women and to provide screening recommendations in women.MethodsA group of experts convened by the American Society for Colposcopy and Cervical Pathology and the International Anal Neoplasia Society reviewed the literature on anal HPV infection, anal SIL, and anal cancer in women.ResultsAnal HPV infection is common in women but is relatively transient in most. The risk of anal HSIL and cancer varies considerably by risk group, with human immunodeficiency virus-infected women and those with a history of lower genital tract neoplasia at highest risk compared with the general population.ConclusionsWhile there are no data yet to demonstrate that identification and treatment of anal HSIL leads to reduced risk of anal cancer, women in groups at the highest risk should be queried for anal cancer symptoms and required to have digital anorectal examinations to detect anal cancers. Human immunodeficiency virus-infected women and women with lower genital tract neoplasia may be considered for screening with anal cytology with triage to treatment if HSIL is diagnosed. Healthy women with no known risk factors or anal cancer symptoms do not need to be routinely screened for anal cancer or anal HSIL.

To evaluate the acetowhite changes of the vulva as a predictor for high grade vulvar intraepithelial neoplasia.We performed retrospective analysis from 344 patients referred to our gynecology oncology clinic for genital dysplasia. All patients underwent vulvar colposcopy. Vulvar biopsies were performed for acetowhite changes and visible vulvar lesions such as ulceration, hyperpigmentation, and thickening of the vulvar tissue. High grade vulvar dysplasia was defined as vulvar intraepithelial neoplasia 2 or worse. Results of the vulvar pathology were collected and sensitivity, specificity, negative and positive predictive values.Of the 344 women who underwent vulvoscopy 241 patients had acetowhite lesions, of whom 89 had true high grade dysplasia. Using colposcopic acetowhite changes as a marker for high grade vulvar dysplasia, the test's sensitivity was 97 %, specificity was 40 %, negative predictive value was 98 %, and the positive predictive value was 37 %.Acetowhitening of the vulva has high sensitivity but low specificity as a predictor of high grade vulvar intraepithelial neoplasia. The absence of acetowhite lesion can reassure that high grade vulvar lesion is absent.

Vulvovaginal pain problems are major health concerns in women of childbearing age. Controlled studies have shown that vulvovaginal pain can adversely affect women and their partners' general psychological well-being, relationship adjustment, and overall quality of life. These women have significantly lower levels of sexual desire, arousal, and satisfaction, as well as a lower intercourse frequency than normal controls. They also report more anxiety and depression, in addition to more distress about their body image and genital self-image. Empirical studies indicate that specific psychological and relationship factors may increase vulvovaginal pain intensity and its psychosexual sequelae. Randomized clinical trials have shown that psychosexual interventions, namely cognitive–behavioral therapy (CBT), are efficacious in reducing vulvovaginal pain and improving associated psychosexual outcomes. Women reporting significant psychological, sexual, and/or relationship distress should be referred for psychosexual treatment. A multimodal approach to care integrating psychosexual and medical management is thought to be optimal.

Purpose As more young female patients with cancer survive their primary disease, concerns about reproductive health related to primary therapy gain relevance. Cancer therapy can often affect reproductive organs, leading to impaired pubertal development, hormonal regulation, fertility, and sexual function, affecting quality of life. Methods The Children's Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancer (COG-LTFU Guidelines) are evidence-based recommendations for screening and management of late effects of therapeutic exposures. The guidelines are updated every 2 years by a multidisciplinary panel based on current literature review and expert consensus. Results This review summarizes the current task force recommendations for the assessment and management of female reproductive complications after treatment for childhood, adolescent, and young adult cancers. Experimental pretreatment as well as post-treatment fertility preservation strategies, including barriers and ethical considerations, which are not included in the COG-LTFU Guidelines, are also discussed. Conclusion Ongoing research will continue to inform COG-LTFU Guideline recommendations for follow-up care of female survivors of childhood cancer to improve their health and quality of life.

Persistent human papillomavirus (HPV) infections can cause intraepithelial neoplasia of the lower genital tract. Immune-compromised women have higher rates for all lower genital tract intraepithelial neoplasia. We wish to study the distribution of genital intraepithelial neoplasia in women with and without an immune system.The study consisted of 343 women with an abnormal genital lesion or cervical cytology who were referred to a gynecologic oncologist. All patients underwent vulva, vaginal, cervical and anal colposcopy. Any lesion detected was biopsied. Demographic and medical data were collected. The Chi-square test was used to determine the relationship between immunosuppression status and various variables, including sites of intraepithelial neoplasia.Immune-compromised women (N = 33) are more likely than immune-competent women (N = 310) to have intraepithelial neoplasia of the vulva (p0.05) and vagina (p0.05), but not more likely to have intraepithelial neoplasia of the anus or cervix. Immune-compromised women are more likely than immune-competent women to have multifocal intraepithelial neoplasia (p0.001). In addition, immune-compromised women are more likely to have higher grade disease of the vulva and vagina (p0.05), and no more likely to have higher grade disease on the cervix or anus than immune-competent women.Women with conditions suppressing the immune system are at higher risk for HPV-related disease outside of the cervix and for worse HPV-related diseases than immune-competent women. This study highlights the need for vigilant evaluation of the complete lower genital tract in women with immune-compromised systems.

Objective Cigarette smoking is a risk factor for cervical, vaginal, vulvar, and anal dysplasia. We will study the prevalence of cigarette smoking in patients with genital dysplasia and effect of counseling on smoking cessation. Methods All patients with genital dysplasia were screened for smoking history. One clinician provided smoking cessation counseling using the US Department of Health 5 A's technique: ask patients about their smoking status, advise smokers to quit, assess their readiness to quit, assist with their smoking cessation effort, and arrange for follow-up visits. Patients were informed on how smoking may cause worsening of genital dysplasia and increased risk of progression to cancer. Each patient received 2 counseling sessions, but no pharmacological or psychological interventions. Smoking cessation was evaluated by patient self-report via phone or during clinic visits. Results From January 2007 to December 2010, 344 patients were referred to our gynecologic oncology clinic for evaluation of genital dysplasia. Patients who were smokers (n=125, 36%) were counseled to cease smoking in 2 counseling sessions, with 100% compliance for attendance. At study analysis (July 2011), 83 patients still smoke and 40 patients quit smoking (smoking cessation rate of 32%). Caucasian patients (P=.0013) and patients with vulvar dyplasia (P=.411) seemed to smoke more than other races and patients with cervical/vaginal dysplasia respectively. Conclusion Smoking cessation counseling for the genital dysplasia patients who smoked was associated with smoking cessation in 32% of the patients.

This pilot study investigated the prevalence and distribution of human papillomavirus (HPV) type in vulvar lesions in women with a history of vulvar intraepithelial neoplasia. Fifty-two specimens were collected. Uncommon HPV subtypes were found among the specimens, which may have implications for HPV vaccination coverage.

In addition to the physical suffering experienced by cancer survivors, there are considerable financial hardships and access barriers to quality health care. The current study explored the financial burden of breast cancer on African American medically underserved women. Four focus groups were conducted in three major cities across Tennessee. Research participants (N=36) were recruited by the staff of cancer support and treatment programs in the area. Findings revealed that participants' lack of insurance or inadequate insurance resulted in missed, delayed, or fewer treatment opportunities. The financial burden of cancer was not limited to the acute treatment phase. The women in the current study reported extreme economic hardship resulting from this disease into long-term survivorship. This exploratory study confirms the importance of providing care across the continuum to address the complex needs of low-income cancer survivors.

Objective To explore women's experiences with vulvar intraepithelial neoplasia during diagnosis and treatment. Design Two focus groups, each with 3 participants, were conducted as a pilot study. Participants were asked open-ended questions about their experiences, quality of life, sexual functioning, body image, and well-being. Responses were audio taped, transcribed, and independently analyzed by 2 researchers to identify themes and develop categories of the participants' experiences. Setting Participants were recruited from an urban oncology clinic. Patients/Participants The study population consisted of 6 White women ranging in age from 22 to 72 years. Methods Participants with a diagnosis of vulvar intraepithelial neoplasia were recruited using flyers posted in their oncologist's office. An interview guide was used focusing on participants' experiences. Results Participants described a cyclic journey with vulvar intraepithelial neoplasia related to the recurrent nature of the disease. Two internal influences on the journey were described: spirituality and time in life. Five external influences were discussed: significant others, health care providers, family, friends, and others with vulvar intraepithelial neoplasia. Conclusion Health care providers cannot alter the recurrent nature of vulvar intraepithelial neoplasia; however, they can better understand a woman's experience and the variables that impact her experience in a negative or positive way.

As aesthetic labial reduction is becoming a more common practice, it is necessary to look at the state of the science, what we know, and, more importantly, what we do not know about this practice. This article reviews the literature to date on labial reduction and describes the concerns related to the lack of understanding of the outcomes associated with this procedure.

Objectives The objectives were to evaluate associations between size of excision, grade of VIN, demographic variables, location of excision and laterality and sexual function and quality of life (QOL) in women with vulvar intraepithelial neoplasia (VIN) following vulvar excision. Methods Forty-three women with VIN who had undergone a vulvar excision completed the Female Sexual Function Index (FSFI) and the European Organization for Research and Treatment of Cancer QLQ-C30 (QLQ C-30) scale to provide an assessment of sexual function and QOL. Medical records of the participants were reviewed for pathology results, operative reports, and medication history. Correlation and multiple regression analyses were performed to determine associations between collected variables and sexual function and QOL scores. Results Most participants (n = 43) were Caucasian (76.6%) and smoked (69.8%). Age significantly correlated with FSFI total score (Pearson r = − .470, p = .001), along with size of excision (r = − .412, p = .009). Neither VIN grade, location of excision, nor time since excision correlated with sexual function or QOL. Conclusions Older age and a more extensive vulvar excision were associated with poorer sexual function and QOL in women following surgical treatment for VIN. Further study with a larger sample and additional variables is needed to better understand the effect of vulvar excision on women's sexual function and QOL.

The present investigation extends the validation of the Female Sexual Function Index (FSFI; Rosen et al., 2000) to include women with vulvar excisions for vulvar intraepithelial neoplasia (VIN). No instrument previously has been validated in this population. We administered the instrument to 43 women (n = 43) with VIN treated with vulvar excision and age-matched healthy controls (n = 43). We found the FSFI to have high reliability and validity in the VIN excision population. Discriminant validity and internal consistency were within acceptable ranges. Using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ C-30; Agronson et al., 1993) and the FSFI in this population, we found a correlation between a related construct of quality of life and sexual function.