Creating Favorable Organizational Climate for Primary Care Nurse Practitioner Workforce

1. Creating Favorable Organizational Climate for Primary Care Nurse Practitioner Workforce Lusine Poghosyan, PhD, MPH, RN Assistant Professor, Columbia University School of Nursing New York, NY 10032Office: 212-305-7081 lp2475@columbia.edu Angela Nannini, PhD Associate Professor, University of Massachusetts Lowell Arlene Smaldone, DNSc, CPNP, CDEAssociate Professor,Columbia University School of Nursing Pat W. Stone, PhD, FAANDirector of the Center for Health Policy, Centennial Professor in Health Policy Columbia University School of Nursing • The 2012 State of the Science Congress on Nursing Research Discovery through Innovation, September 13-15, 2012

2. NP Workforce in Primary Care 2010: more than 55,625 NPs delivered primary care 2011: about 20% of the total primary care workforce 2008-2025: substantial growth of NP workforce 130% (244,000 NPs in 2025) NP workforce represents a substantial supply of primary care providers to meet the increased demand—ONLY if we can assure work environments that promote their optimal utilization and productivity.

3. Institute of Medicine(IOM) ReportThe Future of Nursing: Leading Change, Advancing Health • To meet the demand for high quality care and address workforce shortages, IOM calls for the expansion of the Nurse Practitioner (NP) workforce in primary care. • Challenges and barriers impact the effectiveness of the NP workforce. • To remedy these barriers, the IOM report calls for policy changes to assure that nurses at all practice levels functionto the fullest extent of their training and licensure.

4. Work Environments in Massachusetts • Design.Qualitative descriptive design was implemented to collect data through one group interview and 16 individual in-depth interviews. • This study is part of a larger investigation conducted in Massachusetts regarding primary care NP professional practice and work environments. Funded: American Nurses Foundation (ANF)

5. Participants and Recruitment • Through purposive sampling, primary care NPs were recruited from the members of the Massachusetts Coalition of Nurse Practitioners. • NPs were eligible to participate if: 1) they practiced in a primary care setting in MA; 2) had been employed in that setting for at least 6 months; 3) provided care mainly to an adult patient population; 4) English was their primary language. Approved by IRB. The transportation expenses for the group interview participants were reimbursed. Each individual interview participant received a $15 gift card.

6. Interview Guide • Interview guide was developed and pretested with two other eligible NPs.

7. Data Collection • Group interview: One group interview with 7 NPs, lasted 98 minutes • Assess the interview guide • Add additional content • Gather collective testimonies from NPs • Individual interviews: With 16 NPs , lasted from 30-70 minutes • All interviews were conducted by one researcher March-May 2011

8. Data Analysis • Each interview was audio-taped and transcribed by a professional transcriptionist. • Data were imported into Atlas.ti 6.1 qualitative software, and analyzed by three researchers. They immersed themselves in the data by reading and rereading the data. • Content analysis was used.

9. Findings • NP-Physician Relations • Autonomy & Independent Practice • Organizational Support & Resources • NP-Administration Relations • Professional Visibility

10. NP-Physician Relations 6 subthemes: • Communication • Support • Trust/rapport • Respect • Collaboration and teamwork • Collegiality as important for NP-physician relations • Physicians supportive of NP role. • “The physicians that I’ve had experience with have been respectful and value what I do.” - NP who worked in a primary care site affiliated with a large academic medical center • Longer NPs worked with the physicians, the more they trusted NPs. • for the first year or so on my job he might have been kind of watching me quietly from the sidelines and once he had a level of trust and realized that I was competent and that patients were pleased with the services that they were getting, I think he backed off a bit. Now I really don’t get a lot of unnecessary oversight from him or criticism… - NP who worked in her practice site for about eight years • Some physicians were not supportive of NP practice. • the office I was in before did not respect Nurse Practitioners; they really wanted another physician there and they really resented the fact that I was there, but they also knew because there was no primary care physician to take the spot that they needed me… - NP who changed her job to work with supportive physicians

11. Autonomy & Independent Practice 4 Subthemes: • Independent decision making • Responsible for patient care • Policies • Practice within the scope of practice • NPs practice independently despite this state requirement. • “it’s not that anybody expects us to run patients by them; I will ask a doc or another Nurse Practitioner questions, and people will ask me questions whether they’re a doc or not… we all have our different experiences.” - NP from a hospital-affiliated outpatient practice • Each practice site had differing policies defining/limiting NP independence. • “it’s frustrating to not be able to do things that I’ve always been able to do. I also have to tell patients who request to have their physicals by me that the hospital doesn’t allow me.”– NP from a hospital-based primary care clinic that did not allow NPs to conduct physical assessments • NP autonomy and independence is supported and encouraged by physicians. • “The supervising physician doesn’t limit; she completely encourages autonomy because honestly that’s then less work she has to do.” - NP who had worked in her practice for about 10 years

12. Organizational Support & Resources • NPs have adequate support and resources to provide patient care. • “I have staff that is very attuned to what I am doing, what patient I’m with…They’re really keeping track of my flow… helping me get patients through as fast as we can.- NP for more than 20 years • Support for processing patients as unequal or preferential to physicians. • “when I went to this new office...they gave me one exam room and basically I was expected to see patients like….I had two exam rooms.” - NP, who was a critical care nurse before becoming an NP two years ago • Physicians have dedicated medical assistant help while NPs do not. • “the doctor has first preference so the doctor always has the same Medical Assistant so if it’s my Medical Assistant also, the doctor – and I’m here – the doctor trumps so the doctor gets the Medical Assistant.” - NP who has been in her practice for 11 years

13. NP-Administration Relations • Administrations lacked understanding of NP role, not supportive • “it’s somewhat new to have the number of NPs that they have and so they didn’t quite know where to put us …we’re basically looked at like Nursing staff, medical assistants and that kind of staff.”“we don’t feel that we matter at all to the upper management that makes all the financial decisions…that needs the biggest improvement.” - NP from a family practice setting • Administrators who had past experience of working with NPs had better knowledge of NP role. • “We got a new Office Manager who knows what Nurse Practitioners can do and she’s been able to advocate so that I can see more and more stuff.” • Physicians more valued and involved in decision-making by the administration than NPs. • “the pecking order of leadership or authority in that office - the physician, of course, is at the top.” - NP from internal medicine practice • Administration should recognize NP contributions. • “I’ve been there 8 years and I think they need to acknowledge us that we are the practice…that practice would not be run without us.” - NP who was the only NP when she started working in her practice

14. Professional Visibility • Administrators, physicians, and even staff members do not have good understanding about NP role. • “I’m not sure whether it’s just because my organization is just not that familiar with NP role.” - NP who took her first NP position two years ago • “They [administration] have no idea what to do with us.” - NP who joined her practice a year ago but has been an NP for about 20 years • Productivity and quality of care data did not support retrieval of data by individual NPs because physicians were listed as provider of the record. • “I’ve been practicing for 25 years and I still cannot go in and look at my data to say what impact I’ve made in Health Care…. I would have to find my patients through multiple physicians.” • Lack of recognition of NPs as provider of record impaired flow of clinical information to NPs and made it difficult for them to conduct follow-ups. • the Pap smear [results]- because of where I am in the organization, they get buried in the Electronic Record; they don’t come to me so patients are calling me a month later, what’s my Pap smear results? I don’t know. • NPs who were enrolled in the DNP program reported concerns about the NP role not being clear and visible to the larger community and to their patients.

15. Discussion • While the relation between NPs and physicians seem satisfactory, issues in relations with administrations, unnecessary organizational restrictions, lack of support and involvement in governance may threaten NP professional practice • Determining and resolving these challenges, which are responsive to managerial interventions, is necessary for promoting NP practice within their scope, delivering high quality care, and maintaining patient safety • More research is needed to understand the impact of work environments on patient and NP outcomes

16. Policy and Practice Recommendations • The relationship between NPs and physicians should be clearly defined at the organizational level and the practice sites should promote collegial NP-physician relations • Promote NP independent practice and autonomy • Improve communication between NPs and Administrations • Provide access to organizational resources • Track, evaluate, and recognize NPs’ contributions to patient care

17. Future Work • We are developing a new survey tool to measure organizational climate for primary care NPs: Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ) • Measuring organizational climate for NPs in New York State & Massachusetts

18. NP Practice in Massachusetts and New York State (preliminary results) Survey of NPs practicing in primary care settings 1. Mail - MA, N=185 2. Online- NY, N=286 (data collection in process) Funded: Agency for Healthcare Research and Quality (AHRQ)

19. Selected References • Agency for Healthcare Research and Quality. (January, 2012). Primary Care Workforce Facts and Stats No. 3: Distribution of the U.S. Primary Care Workforce Retrieved February 13, 2012, from http://www.ahrq.gov/research/pcwork3.htm • Auerbach, D. I. (2012). Will the NP workforce grow in the future? New forecasts and implications for healthcare delivery. Medical Care, 1. doi: 10.1097/MLR.0b013e318249d6e7 • Chapman, S. A., Wides, C. D., & Spetz, J. (2010). Payment regulations for advanced practice nurses: implications for primary care. Policy, Politics, & Nursing Practice, 11(2), 89-98. • Commonwealth of Massachusetts. (2008). Chapter 305 of the Acts of 2008: An act to promote cost containment, transparency and efficiency in the delivery of quality health care, from http://www.mass.gov/legis/laws/seslaw08/sl080305.htm • Fairman, J. A., Rowe, J. W., Hassmiller, S., & Shalala, D. E. (2011). Broadening the scope of nursing practice. New England Journal of Medicine, 394(3), 193-196. • Horrocks, S., Anderson, E., & Salisbury, C. (2002). Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal, 24(7341), 819-823. doi: 10.1136/bmj.324.7341.819 • Kalist, D. E. (2004). The effect of state laws on the supply of advanced practice nurses. International Journal of Health Care Finance and Economics, 4(4), 271-281. doi: 10.1023/b:ihfe.0000043758.12051.98 • Lugo, N., O’Grady, E., Hodnicki, D., & Hanson, C. (2007). Ranking state NP regulation: Practice environment and consumer health choice. American Journal of Nurse Practitioners, 11(4), 8-24. • Newhouse, R. P., Stanik-Hutt, J., White, K. M., Johantgen, M., Bass, E. B., Zangaro, G., . . . Weiner, J. P. (2011). Advanced practice nurse outcomes 1990-2008: A systematic review. Nursing Economics, 29(5), 1-22. doi: 10.1234/12345678 • Robert Wood Johnson Foundation. (July 2011). Primary care health workforce in the United States. The Synthesis Project, Issue 22 Retrieved December 10, 2011, from http://www.rwjf.org/pr/product.jsp?id=72579

20. Acknowledgments • Jane Tuttle, PhD, FNP-BC, CPNP, FAANP NPA • Sean Clarke, PhD, CRNP, FAAN • Lindsay Rauch, RN • Massachusetts Coalition of Nurse Practitioners (MCNP) • Nurse Practitioner Association of New York (NPA) • Massachusetts Health Quality Partners (MHQP) • American Nurses Foundation (ANF) • Agency for Healthcare Research and Quality (AHRQ)