Impact of Nurse–Physician Collaboration, Moral Distress, and Professional Autonomy on Job Satisfaction among Nurses Acting as Physician Assistants

Although there is considerable literature on job satisfaction among nurses in various settings, there is little research about contributing factors, including moral distress to job satisfaction among a certain group of nurses, such as nurses acting as physician assistants. The purpose of this study was to verify the impact of nurse–physician collaboration, moral distress, and professional autonomy on job satisfaction among nurses acting as physician assistants. Descriptive and correlational research was conducted on a convenience sample of 130 nurses from five general hospitals in South Korea. In the final regression model, the adjusted R square was significant, explaining 38.2% of the variance of job satisfaction (F = 8.303, p < 0.001), where ‘cooperativeness’ (β = 0.469, p = 0.001) from nurse–physician collaboration, ‘institutional and contextual factor’ from moral distress (β = −0.292, p = 0.014), and professional autonomy (β = 0.247, p = 0.015) were included. In hospital environments, a more cooperative inter-professional relationship between nurses and physicians led to less moral distress caused by organisational constraints. A higher level of professional autonomy among nurses acting as physician assistants is required to increase their job satisfaction.

Family Medicine and Emergency Redeployment: Unrealized Potential

Background and Objectives: Discussions of scope of practice among family physicians has become a crucial topic amidst the COVID-19 pandemic, coupled with new attention to residency training requirements. Family medicine has seen a gradual narrowing of practice due to a host of issues, including physician choice, expanding scope of practice from physician assistants and nurses, an increased emphasis on patient volume, clinical revenue, and residency training competency requirements. We sought to demonstrate the flexibility of the family medicine workforce as shown through their scopes of practice, and argue that this is indication of their potential for redeployment during emergencies. Methods: This study computes scopes of practice for 78,416 family physicians who treat Medicare beneficiaries. We used Evaluation and Management (E/M) codes in Medicare’s 2017 Part-B public use file to calculate volumes of services done across six sites of service per physician. We aggregated counts and proportions of physicians and the E/M services they provided across sites of practice to characterize scope, and performed a separate analysis on rural physicians. Results: The study found most family physicians practicing at a single site, namely, the ambulatory clinic. However, family physicians in rural areas, where need is greater, exhibit broader scope. This suggests that a significant number of family physicians have capacity for COVID-19 deployment into other settings, such as emergency rooms or hospitals. Conclusions: Family physicians are a potential resource for emergency redeployment, however the current breadth of scope for most family physicians is not aligned with current residency training requirements and raises questions about the future of family medicine scope of practice.

Positionspapier der Deutschen Gesellschaft für Thorax-, Herz- und Gefäßchirurgie zum Einsatz von Physician Assistants in der Herzchirurgie

ZusammenfassungEine qualitativ hochwertige medizinische Behandlung von herzchirurgischen Patienten erfordert den Einsatz und die Rekrutierung von qualifiziertem Personal mit besonderem Blick auf die Fluktuation. Dieser Aspekt gestaltet sich unter den aktuellen Gegebenheiten des Fachkräftemangels wie auch den Rahmenbedingungen im deutschen Gesundheitswesen zunehmend schwieriger. Durch die Einbindung von Physician Assistants (PA) in herzchirurgischen Fachabteilungen kann das bestehende Personalkonzept innovativ, bedarfsgerecht und insbesondere nachhaltig ergänzt werden. Die jahrzehntelange Erfahrung aus anglo-amerikanischen Ländern belegt, dass mit einem PA-System eine hochwertige medizinische Behandlungsqualität nicht nur stabilisiert, sondern potenziell sogar verbessert werden kann. Gleichzeitig können Ärzte in der herzchirurgischen Facharzt-Weiterbildung von alltäglich anfallenden Tätigkeiten ohne ärztlichen Vorbehalt entlastet werden und somit freiwerdende Ressourcen für eine fundierte und vielfältige Facharztweiterbildung nutzen. Auch positive Effekte auf ökonomische Faktoren der Institution sind denkbar. Die erforderliche Delegation von ärztlichen Tätigkeiten auf nicht-ärztliche Mitarbeiter ist in Deutschland bereits jetzt gesetzlich verankert, ohne dass es spezifische, auf den Physician Assistant ausgerichtete rechtliche Rahmenbedingungen gibt. Die verbindliche Festlegung der Tätigkeiten für einen PA durch medizinische Fachgesellschaften sind in diesem Zusammenhang eine wichtige Aufgabe. In diesem Positionspapier werden unter Erörterung der medizinischen, rechtlichen und ökonomischen Aspekte Tätigkeiten für Physician Assistants in der Herzchirurgie strukturiert dargelegt.

Healthcare Providers Face Numerous Challenges in Treating Patients with Psoriasis: Results from a Mixed-Methods Study

Background The paradigm shift toward biologic medications in psoriasis care requires healthcare providers (HCPs) to become acquainted with mechanisms of action and safety profiles of these new treatments to confidently use them in practice. A better understanding of this paradigm shift is necessary to provide adequate education for HCPs in psoriasis care. Objectives This study assessed clinical practice gaps and challenges experienced by HCPs caring for patients with psoriasis. Methods A mixed-methods approach was used to identify practice gaps and clinical challenges of dermatologists, rheumatologists, primary care physicians, physician assistants, and nurse practitioners with various levels of clinical experience in academic and community-based settings. Qualitative and quantitative data were collected sequentially. Interviews were transcribed and thematically analyzed. Results A total of 380 psoriasis care providers in Canada and the US participated in this study. Analysis revealed challenges in establishing an accurate diagnosis of psoriasis (including screening for sub-type and distinguishing psoriasis from other skin conditions), selecting treatment (particularly regarding recently approved treatments), monitoring side effects, and collaborating with other HCPs involved in psoriasis care. Conclusion These findings highlight educational needs of HCPs involved in psoriasis care that could have repercussions on accurate and timely diagnosis of the condition, treatment initiation, side effect monitoring, and continuity of care. Findings provide a starting point for clinicians to reflect on their practice and for the improvement of continuing professional development interventions that would bridge these gaps.

Geriatric Knowledge Gaps of Community-Based Providers: A National Study of Asked Questions

Primary care providers (PCP) - internists, family practitioners, nurse practitioners, physician assistants - play an integral role in the care of older adults, although many receive limited geriatrics education. We sought to examine what questions community-based PCPs had about geriatrics and clinical care of older adults. As part of large clinical continuing medical education (CME) conferences across 12 states (FL,GA,CA,IL,NY,MA,DC, PA,AZ,TX,TN,WA), PCPs attended a live in-person 60-minute geriatrics-focused lecture and entered questions into a mobile application. Questions were then qualitatively analyzed using constant-comparison and tie-break methodology. At all sites, 103 questions were asked with 158 upticks (PCPs could check off that they had similar question) with a range of 3-18 questions per lecture. PCPs asked questions on the following common themes: 1.) Medication-related (e.g. discontinuing medicines in asymptomatic patients, optimizing pain relief), 2.) Dementia (e.g. prevention, nutraceuticals, agitation) 3.) Medicare Coding 4.) Falls 5.) Weight loss, and 6.) Insomnia. There were a number of questions referencing incorrect practices (e.g. prescribing inappropriate medications such as benzodiazepines for sleep, placement of gastric tubes in late-stage dementia, antibiotics to treat asymptomatic bacteria). In conclusion, community-based PCPs nationally experience gaps in geriatric knowledge and several utilize practices that could jeopardize older adult health. While attending CME-based lectures is one means of overcoming these gaps, some PCPs may not find time or realize geriatrics as an educational need. PCPs need to be better supported with opportunities to ask geriatric care-related questions in order to improve the care of older adults.

Comparison of Older Adult and Healthcare Provider Beliefs About Fall Prevention Strategies

Older adults reported about 36 million falls in 2018. Although effective strategies are available to minimize fall risk, little is known about older adults’ and healthcare providers’ awareness of these strategies. This study describes and compares older adults’ and healthcare providers’ beliefs about fall prevention strategies. Demographic and fall-related data for older adults were obtained from the 2019 fall cohort of Porter Novelli ConsumerStyles. Similar data from primary care practitioners, nurse practitioners, and physician assistants, were gathered from the 2019 cohort of DocStyles. Percentages and 95% confidence intervals were calculated to compare older adults and providers. Most providers (91.3%) and older adults (85.1%) believed falls can be prevented. High percentages of providers and older adults identified strength and balance exercises (90.7% and 82.8% respectively) and making homes safer (90.5% and 79.9% respectively) as strategies that help prevent falls. More providers reported that Tai Chi (45.7%) and managing medications (84.2%) can prevent falls compared to older adults (21.7% and 24.0% respectively; p&lt;0.0001). Sizable percentages of providers and older adults endorsed less evidence-based strategies including aerobic exercise (70.7% and 58.4% respectively) and being more careful (69.3% and 81.6% respectively). Among older adults, lower endorsement of evidence-based strategies (e.g., Tai Chi, medication management) coupled with higher endorsement of limited evidence-based strategies (e.g., being careful, aerobic exercise) suggest some older adults lack awareness of effective fall prevention interventions. Increased patient and provider communication can increase awareness about the benefits of evidence-based strategies for fall prevention.

The Physician Assistant/associate Medical Workforce: 2020-2035

Background: Physician assistant/associates (PAs) are health care professionals whose roles expand universal access to a broad range of people across many nations. In the US, there is a growing shortage of physicians. PAs and advanced practice registered nurses (APRNs) were developed to help span medical providers' supply and demand gap. A forecasting project was undertaken to predict the likely census of PAs in the medical workforce spanning 2020 to 2035. Methods: Microsimulation modeling of the American PA workforce was performed using standard stock and flow format. The number of clinically active PAs employed in 2020 formed the baseline. Graduation rates and PA program expansion were factored as critical parameters to predict annual growth; attrition estimates balanced the equation. Two models, one based on data from the Bureau of Labor Statistics (BLS) and another based on data from the National Commission on Certification of Physician Assistants (NCCPA), were analyzed to estimate future annual PA numbers. Results: As of 2020, the BLS estimated 125,280 PAs were employed in the medical workforce; the NCCPA estimate was 148,560 PA in active practice. The mean age was 40, and 76% were female. The Accreditation Review Commission accredited 277 PA education programs for the Physician Assistant (ARC-PA), and 99% had a graduating class. The mean annual graduation cohort was 45. The BLS model predicted approximately 204,243 clinically active PAs by 2035; the NCCPA-based model predicted 211,537 PAs in clinical practice. Conclusions: A physician assistant/associate predictive model based on two data sources projects the supply of PAs by 2035 between 204,000 and 212,000: a growth rate of ± 35% (3.5% model differences). If the most likely scenario is realized, the 15-year growth of the PA will help improve the gap in the supply and demand of American medical service.

Oncology Advanced Practice Providers Chemotherapeutic Prescribing Practices

Background: Physician Assistants (PA) and Nurse Practitioners (NP), referred to as Advanced Practice Providers (APPs), are an integral part of cancer care today in community oncology (ONC) and academic institutions across the country. It has been shown, a team approach using APPs can extend the ONC workforce (PMID: 25009939). The need for ONC services will increase with the rise in cancer incidence and prevalence. As the rise continues, studies have shown ONC services will dramatically increase due to the predicted shortages of oncologists. Increasing the use of APPs is a viable solution to this shortage (PMID: 21037868). PAs and NPs have validated their value by safely prescribing chemotherapy (CT) as they provide cancer care. This value has been key for both patient and physician colleagues. The Association of Physician Assistants in Oncology (APAO) pursued research to better understand CT prescribing practices of ONC PAs. The focus was on whether or not PAs were allowed to prescribe CT drugs in their day to day practice. Methods: A survey was used to collect data. The survey focused on APPs scope of practice to include prescribing CT independently (IND) or were there restrictions by the state or organizations they are employed by. For those allowed to prescribe CT, further questions regarding training programs and time periods to demonstrate competency were asked. The survey also viewed physician and employer attitudes towards APPs prescribing CT. The survey was sent in January 2021 to 1307 APAO members via email with a 30-day collection period. Eleven percent were returned (N=149). Results: Respondents (R) were PAs, 95%, NPs, 3% and other 1%. The majority of R worked in Hematology/Medical ONC, 87%, with fewer in Surgical ONC 6%, Radiation ONC 1%, other 6%. R came from 34 states with the largest number representing Texas, 13%, New York 12%, Pennsylvania, 8%, North Carolina,7%, Massachusetts 6% and Florida 5%. Most of the R had been in ONC for 1-8 years (y) (59%), followed by 9-16 y (21%), 17-24 y (16%), and 25+ y (3%). The survey was divided into two arms, those who could IND sign CT orders and those who could not IND sign CT orders. The survey demonstrated 44% of the R were able to IND sign CT orders and 56 % of the R could not. With regard to work setting, 60% of R in this arm worked in academic ONC centers and 35% worked in community ONC centers. Also in this arm, 23% were only allowed to sign existing CT plans that did not require modification and 77% were not. The majority of R could sign existing CT orders (89%) and fewer could initiate and sign new CT orders (35%). Most R were able to prescribe intravenous and oral medication (98%), while fewer could prescribe intrathecal 34%) and clinical trial medications (49%). Of the R in the second arm, 74% worked at academic ONC centers and 19% worked at community ONC practices. When asked if their state medical board prohibited prescribing CT, the majority (77%) reported this was not the case, then if their institution/facilities prohibited prescribing CT, the majority (69%) reported this was true. To explore physician/employer attitudes, a question was posed to ask the APP if their physicians believe that limiting CT to physicians is a safety measure. Responses were mixed, 36% reporting this is true, 33% reporting this was false and 31% as unsure. Next, the APPs were asked if their physicians believed experienced APPs should be allowed to prescribe CT. Again, responses were mixed, 44% agreeing, while 11% disagreeing. Finally, 44% were unsure. When asked if their employer believed limiting CT to physicians is an important safety measure, 47% of the R reported this is true, 19% R reported this is false and 34% were unsure. When asked if their employer believed experienced APPs should be allowed to prescribe CT, 30% of the R reported this is true, 20% R report this is false and 49% were unsure. Conclusion: CT prescribing privileges, are not universal for APPs and the reason for inconsistencies in prescribing CT is not clear. This survey provided insight to the wide range of prescribing practices throughout the US based on ONC settings, geographic regions, and experience of the APP. As APPs are valued team members in extending the ONC workforce, and prescribing CT is a common practice in cancer care which APPs participate in. This would seem worthy of further research to understand the reasons why such discrepancies exist. Disclosures Diaz Duque: Morphosys: Speakers Bureau; Hutchinson Pharmaceuticals: Research Funding; Incyte: Consultancy; Astra Zeneca: Research Funding; Epizyme: Consultancy; ADCT: Consultancy.