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Nurse practitioners as primary care providers: Creating favorable practice environments in New York State and Massachusetts Lusine Poghosyan Jingjing Shang Jianfang Liu Hermine Poghosyan Nan Liu Bobbie Berkowitz Background: Policy makers, health care organizations, and health professionals are calling for the expansion of the nurse practitioner (NP) workforce in primary care to ensure access to high-quality, cost-effective care. However, to date, little is known about NP practice environments in primary care settings and how they may affect the expansion of this workforce and their practice. Purposes: The aims of this study were to investigate NP practice environments in two states, Massachusetts (MA) and New York State (NY), and determine the impact of state and organization on NP practice environment. Methodology: A cross-sectional survey design was used. Practice environments were measured using the Nurse Practitioner Primary Care Organizational Climate Questionnaire in terms of NPYphysician relations, NPYadministration relations, support, NP role comprehension, and NP independent practice. In MA, 291 NPs were recruited from the Massachusetts Provider Database through mail surveys. In NY, 278 NPs were recruited from the NY Nurse Practitioner Association membership list through online surveys. Data were collected from May through September 2012.
Key words: nurse practitioner, practice environment, primary care Lusine Poghosyan, PhD, MPH, RN, is Assistant Professor, Columbia University School of Nursing, New York. E-mail: [email protected]. Jingjing Shang, PhD, RN, OCN, is Assistant Professor, Columbia University School of Nursing, New York. Jianfang Liu, PhD, MAS, is Data Analyst, Columbia University School of Nursing, New York. Hermine Poghosyan, PhD, MPH, is Assistant Professor, College of Nursing and Health Sciences, University of Massachusetts Boston. Nan Liu, PhD, is Assistant Professor, Department of Health Policy and Management Mailman School of Public Health, Columbia University, New York. Bobbie Berkowitz, PhD, RN, CNAA, FAAN, is Dean and Mary O’Neil Mundinger Professor, Columbia University School of Nursing, New York. This study was funded by the Agency for Healthcare Research and Quality, and internal funding was received from the Columbia University School of Nursing. This article was presented and supported in part by the 2012 Michigan Symposium on Effectiveness and Implementation Science, sponsored by the University of Michigan School of Nursing, on September 26, 2012. The study was approved by the Institutional Review Board of Columbia University Medical Center. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. DOI: 10.1097/HMR.0000000000000010 Health Care Manage Rev, 2015, 40(1), 46Y55 Copyright B 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins
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Descriptive statistics were computed. Multivariate analysis of variance was conducted to investigate the effect of state and organization type on NP practice environments. Findings: Nurse practitioners reported favorable relationships with physicians, deficiencies in their relationships with administrators, and lack of support. Nurse practitioners from MA reported better practice environments. Nurse practitioners from hospital-affiliated practices perceived poorer practice environments than did NPs practicing in physician offices and community health centers. Practice Implications: Optimal working relations with physicians and administration, access to resources, and clarity in NP role are necessary to create practice environments where NPs can function effectively as primary care providers.
P
olicy makers, health care organizations, and professionals are calling for the redesign of our primary care system to increase efficiency, promote access, and improve patient outcomes. There are noteworthy concerns that the existing primary care system is overburdened and lacks the effectiveness necessary to meet patients’ needs (Margolius & Bodenheimer, 2010). This insufficiency is fueled by a critical shortage of primary care providers (PCPs) and the surging demand in services related to an aging population and the epidemic of chronic diseases (Colwill, Cultice, & Kruse, 2008; Institute of Medicine, 2012; Sargen, Hooker, & Cooper, 2011). In addition, with the passage of the Affordable Care Act (ACA), 32 million people will gain health insurance (Patient Protection and Affordable Care Act, 2010). This change in the health care system brings more attention to increasing the capacity of primary care in the country to ensure that patients will have access to timely care. Similar health reform initiatives have been enacted in Massachusetts (MA) in 2006, which led to an influx of about a half-million MA residents into the health care system (Commonwealth of Massachusetts, 2006), which was already experiencing a shortage of primary care physicians (Massachusetts Medical Society, 2009). The full implementation of the ACA will likely have similar consequences on a national scale for overall primary care. To accommodate the demand, MA passed new legislation in 2008 to recognize nurse practitioners (NPs) as PCPs (Commonwealth of Massachusetts, 2008). One need only extrapolate this example from the state to a national level to understand not only the projected impact of the ACA on care demand but also the implications it has for the future of the NP workforce. To meet the demand, improve patient outcomes, and ensure timely access and cost control, many have called for expanding the NP workforce in primary care and promoting their optimal practice (Institute of Medicine, 2010; RAND Health, 2009). Nurse practitioners are educated to deliver primary care to both adult and pediatric populations in a variety of care settings, including private practices, nurse-managed centers, and community health centers among others (Esperat, Hanson-Turton, Richardson, Debisette, & Rupinta, 2012;
Hing, Hooker, & Ashman, 2011). They provide a broad spectrum of care from initial contact to follow-up care and produce clinical outcomes comparable with those of physicians (Laurant et al., 2009; Newhouse et al., 2011). The number of NPs in general has increased significantly over the past several years and will continue to do so in the future (Pearson, 2012). Nationally, it is projected that the NP workforce will increase by 130% from 2008 to 2025 (Auerbach, 2012). However, many barriers such as state-level and practice-level restrictions placed on NP practice affect their optimal utilization (Pearson, 2012; Poghosyan, Nannini, Stone, & Smaldone, 2013). Limited efforts have been devoted to systematically investigate these barriers. This study provides an overview of NP practice environments in primary care settings; compares NPs’ perceptions of their practice environments between two states with and without health reform, MA and New York State (NY), respectively; and determines the influence of state and organization type on NP practice environments. Nurse practitioner scope of practice varies between the two states involved in this study. For example, whereas in MA, NPs can independently diagnose and treat patients and collaborative agreement with a physician is required only for prescriptive authority, in NY, a collaborative agreement with a physician is required for all three aspects of NP practice: treatment, diagnosis, and prescribing authority (Pearson, 2012). In NY, it is also required to have the practice agreement on file with the state; there is no such requirement in MA. In addition to state-level variations affecting NPs, organizational policies may also create challenges, and to date, limited evidence exists about NP practice environments. For primary care organizations shifting toward a larger NP workforce, creating and maintaining favorable practice environments for NPs are necessary and critical for promoting their successful practice and ability to deliver high-quality patient care.
Conceptual Framework Organizational structures in the work settings impact employee performance more than inherent personal characteristics do (Kanter, 1976). Kanter’s (1976) theory of
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structural power is fundamental in studying organizations and suggests that organizational structures can either impede or promote employee performance regardless of employees’ personal tendencies. Kanter (1993) argues that workplace structures are important in shaping organizational behaviors and relationships. They also can empower employees, providing access to information, support, and resources. Organizations that fail to enhance the performance of employees will see reduced productivity and adverse outcomes. Thus, it is necessary to study organizations employing NPs and the NP practice environments in those organizations. The quality of practice environments in health care settings and their impact on provider, patient, and organizational outcomes have been well studied in recent decades (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Benzer et al., 2011). Evidence is accumulating that health care organizations with poor practice environments with lack of support and resources for providers and staff, a lack of collegiality, and poor relationships between clinicians and leadership tend to have poor quality of care, resulting in higher rates of adverse patient outcomes (Clarke, 2006; Linzer et al., 2009). These inadequacies in practice environments also lead to poor provider outcomes such as diminished effectiveness, job dissatisfaction, and turnover (Brazil, Wakefield, Cloutier, Tennen, & Hall, 2010; De Milt, Fitzpatrick, & McNulty, 2011). Although the impact of practice environments on providers and the care they deliver is generally understood, the evidence about how to create quality practice environments for primary care NPs is limited. This evidence is necessary because of the projected significant increase in the numbers of NP in their organizations and their continuously evolving and expanding scope of practice. Some primary care organizations may not be familiar with the NP role, and their practice environments might not be designed to support effective NP practice. Lack of understanding about the NP role as a PCP may limit managers’ abilities to create productive NP practice environments. Suboptimal NP practice environments have been reported in several studies where NPs expressed dissatisfaction with intrapractice partnerships (De Milt et al., 2011; Schiestel, 2007) and a lack of physician support (Lindeke, Jukkala, & Tanner, 2005; Weiland, 2008). Nurse practitioners also did not receive the same level of support as physicians did to deliver the same services (Bryant-Lukosius, DiCenso, Browne, & Pinelli, 2004). Even when NPs and physicians have similar PCP roles, in some organizations, physicians may have medical assistant support whereas NPs might not receive the same assistance (Poghosyan, Nannini, Stone, et al., 2013). These are examples of suboptimal NP practice environments that may prevent NPs from effectively utilizing their skills and knowledge to provide high-quality care, leading to inefficiencies in their organizations (Liu, Finkelstein, & Poghosyan, 2013).
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Methods This study used a cross-sectional survey design to collect data from primary care NPs. The Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ), a self-report survey instrument specifically designed for NPs (Poghosyan, Nannini, Finkelstein, Mason, & Shaffer, 2013), was used to measure NP practice environments. Using a 4-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree), the questionnaire asks NPs to evaluate several aspects of their practice environments: (1) NPYphysician relations, in terms of assessing NP perceptions about the collaboration and team work between NPs and physicians. The tool also captured other aspects of their collaboration, such as physicians seeking NP input and suggestions in care delivery; (2) independent practice of NPs, in terms of NPs’ perceptions about whether they were able to freely apply their knowledge and skills to provide care and if their clinics create an environment where they can practice independently; (3) NPYadministration relations, in terms of administrators being open to NPs’ ideas to improve care and taking NP concerns seriously. Moreover, NPs were asked to compare the relationships they had with the administrators to that of the physicians; (4) comprehension and visibility of NP role, in terms of whether their role was well understood and valued in their organizations; and (5) organizational support and resources, in terms of the support that NPs had, such as staff help. These aspects of practice environments are critical for successful NP practice (Poghosyan, Nannini, Stone, et al., 2013). In MA, NPs were recruited from the Massachusetts Health Quality Partners (MHQP) Massachusetts Provider Database (MPD). Each year, MHQP contacts clinics in MA and requests information about primary care physicians and specialists practicing in those sites who are listed as providers by at least one of the five major health plans. These plans together cover over 50% of MA’s commercially insured residents (MHQP, 2012). In 2011, MHQP also requested information about NPs. No other database or existing list in MA allows for the identification of NPs practicing in primary care settings and their role as an NP specialist or PCP. By using practice addresses extracted from the MPD, surveys were mailed to the 807 primary care NPs. Included with the survey was a cover letter and consent form describing the study purpose, its voluntary nature, and the confidentiality of their responses. Nurse practitioners were asked to complete the questionnaire and return it to the research team in a prepaid envelope. Following the Dillman (2007) guide for mailed surveys to encourage response rate, a postcard reminder and second survey were sent to nonrespondents. Two hundred ninety-one NPs completed and returned the surveys, yielding a response rate of 39%, which is a comparable response rate with that of other nurse surveys (Aiken et al., 2010; Smith, 2008). Nurse practitioners practiced in 148 different clinics,
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and the number of NPs from each clinic ranged from one to seven. In NY, NPs were recruited from the membership of The Nurse Practitioner Association (NPA). The NPA sent an e-mail invitation to 1,950 members who had adult, pediatric, family, gerontology, or women’s health specialties because these NPs are likely to practice in primary care settings. The e-mail described the study and eligibility criteria for participation. It asked for NP participation and provided the link to the online survey. As the NP practice location and the type of the organization could not be determined, an additional item was included to determine NP eligibility. Only NPs who self-identified as primary care NPs were prompted to take the survey. The survey was created in the professional version of SurveyMonkey. Second and third e-mail reminders were sent after the initial e-mail invitation to encourage a high response rate (Dillman, 2007). Overall, 342 NPs accessed the survey, 278 completed the survey, and 64 NPs self-identified as not practicing in primary care. The accurate response rate for the NY sample was not calculated because the number of targeted NPs practicing in primary care could not be determined. Our e-mail invitation might have reached NPs practicing in acute or other care settings, thus making them ineligible for the study. Both the mail and the online surveys took about 15 minutes to complete. Data collection took place from May through September 2012. There might be differences in response rate and data quality when the mixed-mode data collection approach is used; however, the differences are minor, and both modes yield comparable results (Beebe, Locke, Barnes, Davern, & Anderson, 2006; Deutskens, de Ruyter, & Wetzels, 2006). The study was approved by the Institutional Review Board of the Columbia University Medical Center.
Data Analysis Data from the mail survey in MA were entered into a database created in SPSS Version 18 software (SPSS Inc., 2009). New York State data were extracted from SurveyMonkey. The data in both databases were investigated for missing values and outliers before merging. Descriptive statistics were computed including means and frequencies for the demographic and work characteristics of the respondents. For group comparison between the NY and MA states, t test for continuous variables and chi-squares for categorical variables were used. The overall alpha level was set at .05 to control Type I error throughout the study. We coded the single items measuring various aspects of practice environments by combining strongly agree and agree responses into one category and strongly disagree and disagree responses into the other category to allow for differentiation of NPs’ favorable and less favorable responses on each item and calculated the proportions. We also com-
puted the mean scores on each of the five NP-PCOCQ dimensions to measure NP practice environments. The effects of potential confounding variables such as NPs’ age, gender, race (two levels: White vs. non-White), location of practice site (three levels: rural, suburban, and urban), and educational degree (three levels: master’s, doctor of nursing practice, and other) were considered and analyzed to investigate the effect of state and organization type in which NPs practiced on their practice environments. Bivariate correlation analyses were run first and indicated no statistically significant relationship between age, location of practice site, and the outcome measures, which were the mean scores on each of the five NP-PCOCQ dimensions measuring NP practice environments. Higher mean scores indicate better NP practice environment. Nurse practitioners’ educational degree was included as the only confounding variable because of the correlations between NPs’ educational degree, gender, and race. The vast majority of NPs were women (93.4%) and White (93%). Thus, we used a 3 2 3 customized multivariate analysis of variance (MANOVA) to investigate the effect of state and organization type after controlling for the main effect of NPs’ educational degree. The fixed factors were state (two levels: MA vs. NY), organization types (three levels: physician offices, community health centers, and hospital-affiliated practices), and degree. The responses of NPs practicing in urgent care clinics, nurse-managed clinics, school-based clinics, and in other nondefined settings were combined into the ‘‘other clinic’’ category given the small number of practicing NPs in each individual category. Nurse practitioners in the ‘‘other clinic’’ category comprised less than 10% of the total sample and were excluded from the 3 2 3 MANOVA and the corresponding univariate analysis and post hoc analysis. Assumptions were checked before the analysis, and post hoc multiple comparison with Bonferroni’s correction was applied when an overall statistical significance was detected.
Findings The demographic characteristics of NPs are presented in Table 1. The mean age of NPs was about 51 years; 6.2% self-identified as male; 7% self-identified as non-White; and 45.4% of NPs practiced in physician offices, 22.9% practiced in community health centers, 22.3% practiced in primary care clinics affiliated with hospitals, and 9.3% practiced in other settings such as urgent care clinics and nursemanaged clinics. Compared with NPs in MA, NPs in NY were older (52.3 vs. 49.3 years; p G .001) and more likely to be male (9.8% vs. 2.9%; p G .001). More NPs in NY worked in practices affiliated with hospitals (32.3% vs. 15.2%), whereas more NPs in MA worked in community health centers (30.1% vs. 12.8%). The demographic characteristics of NPs in our sample were comparable with those of
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Table 1
Demographic and work characteristics of the study participants Characteristic Demographics Age (years) Mean (SD) Range Sex, n (%) Female Male Race, n (%) White Non-White Highest nursing degree, n (%) Master’s degree Doctor of nursing practice Other Work characteristics, n (%) Years in the current position Less than 1 year 1Y6 years More than 7 years Average number of hours worked in the past month 1Y20 21Y40 940 Number of other nurse practitioners in their practice 0 1Y5 6Y10 910 Main practice site Physician’s office Community health center Hospital-based clinic Other Location of practice Urban Suburban Rural
Total (N = 564)
New York State (n = 278)
Massachusetts (n = 291)
50.58 (10.4) 24Y75
52.3 (9.2) 24Y75
49.34 (11.1) 26Y71
p
G.001 G.001 488 (93.8) 32 (6.2)
220 (90.2) 24 (9.8)
268 (97.1) 8 (2.9)
477 (93.0) 36 (7.0)
219 (92.8) 17 (7.2)
258 (93.1) 19 (6.9)
463 (88.4) 24 (4.6) 37 (7.1)
205 (84.0) 18 (7.4) 21 (8.6)
258 (92.1) 6 (2.1) 16 (5.7)
55 (10.5) 205 (39.2) 263 (50.3)
37 (15.2) 99 (40.7) 107 (44.0)
18 (6.4) 106 (37.9) 156 (55.7)
.507
.006
.001
G.001 64 (12.2) 295 (56.4) 164 (31.3)
43 (17.6) 104 (42.6) 97 (39.8)
21 (7.5) 191 (68.5) 67 (24.0) G.001
63 307 82 69
(12.1) (58.9) (15.7) (13.2)
48 156 23 17
(19.7) (63.9) (9.4) (7.0)
15 (5.4) 151 (54.5) 59 (21.3) 52 (18.8)
214 108 105 44
(45.4) (22.9) (22.3) (9.3)
98 25 63 9
(50.3) (12.8) (32.3) (4.6)
116 83 42 35
G.001 (42.0) (30.1) (15.2) (12.7) G.001 248 (47.7) 214 (41.2) 58 (11.2)
NPs in the 2008 National Sample Survey of Registered Nurses (NSSRN) in terms of age, education, and other characteristics (Health Resources and Services Administration, 2008). Almost 50% of NPs in the NSSRN were 50 years or older. We investigated the NP responses on the individual survey items. Compared with physicians in MA, physicians in NY were more likely not to collaborate with NPs (19.4% vs. 5.2%; p = .014), not to ask them for suggestions (32.4% vs. 18.6%; p = .005), or not seek NP input when delivering patient care (38.1% vs. 22.3%; p = .013). More NPs in NY
84 (34.6) 111 (45.7) 48 (19.8)
164 (59.2) 103 (37.2) 10 (3.6)
than in MA disagreed that in their organizations they were able to provide all patient care within their scope (18.7% vs. 4.5%; p G .001) or that their organizations created an environment where NPs can practice independently (20.1% vs. 9.6%; p = .018). In MA, administrators were more likely to share information equally with NPs and physicians, and NPs were more likely to be included in committees within their organization. More than half of the NPs (53.2%) in NY reported that administration does not share information equally with NPs and physicians. About 38% of NPs in MA report this finding. Twenty-three percent of NPs in
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MA and 36.3% in NY disagree with the statement that the administration is open to NPs’ ideas to improve patient care. There was no statistically significant difference between states in terms of communication patterns between NPs and administration. In NY, 40% of NPs reported that their role is not understood and 31.7% did not feel valued by their organizations. About 21% of NPs in NY and 6.5% of NPs in MA reported lack of resources. There was no statistically significant difference between the states in terms of support for care management between NPs and physicians. Three-way customized MANOVA compared the mean scores on each NP practice environment dimension between MA and NY, controlling for the main effect of NPs’ educational level. The multivariate results indicated difference in NP practice environment between MA and NY (Wilks 1 = .918, F = 7.37, p G .05), with medium to large effect size ()’2 = .082). Nurse practitioner practice environment was also different among the three types of health care organizations (Wilks’ 1 = .942, F = 2.52, p G .05), with small to medium
effect size ()’2 = .030). There was no significant multivariate interaction effect between state and organization type. The main effect of the confounding variable, NPs’ educational level, was significant (Wilks 1 = .951, F = 2.10, p G .05), with small to medium effect size ()’2 = .025). The univariate results in Table 2 present the effects of state and organization type, physician offices, community health centers, and hospital-affiliated practices on each of the five practice environment dimensions separately after taking into account the main effect of NPs’ educational degree. The multivariate results discussed above were confirmed. The mean scores on each of the NP practice environment dimensions were different between the MA and NY states: NPYphysician relations (F = 21.56, p G .05), NPYadministration relations (F = 8.90, p G .05), support and resources for NP practice (F = 21.03, p G .05), comprehension and visibility of NPs as care providers (F = 26.08, p G .05), and independent practice of NPs (F = 14.51, p G .05). Also, four of the subscales, NPYphysician
Table 2
Univariate effects of state and organization type on dimensions of NP practice environment in physician offices, community health centers, and hospital-affiliated practices, after controlling for the main effect of NP educational degree Effect NPYphysician relations Degree State Organization type State Organization type NPYadministration relations Degree State Organization type State Organization type Support and resources for NP practice Degree State Organization type State Organization type Visibility of NPs as care providers Degree State Organization type State Organization type Independent practice of NPs Degree State Organization type State Organization type
Mean square
F
p
Partial )2
Observed power
0.457 6.351 0.922 0.730
1.55 21.56 3.13 2.48
.213 .000* .045* .085
.007 .049 .015 .012
.329 .996 .600 .497
1.062 3.911 1.230 0.944
2.42 8.90 2.80 2.15
.091 .003* .062 .118
.011 .021 .013 .010
.486 .845 .549 .439
0.337 5.771 2.198 0.196
1.23 21.03 8.01 0.72
.294 .000* .000* .490
.006 .048 .037 .003
.267 .996 .956 .171
1.223 9.988 1.558 0.264
3.19 26.08 4.07 0.69
.042* .000* .018* .503
.015 .059 .019 .003
.609 .999 .722 .166
1.011 3.217 1.203 0.024
4.56 14.51 5.43 0.11
.011* .000* .005* .898
.021 .034 .025 .001
.774 .967 .845 .066
Note. NP = nurse practitioner. *Statistically significant at the .05 level.
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relations (F = 3.13, p G .05), support and resources for NP practice (F = 8.01, p G .05), comprehension and visibility of NPs as care providers (F = 4.07, p G .05), and independent practice of NPs (F = 5.43, p G .05), had different scores in the three types of health care organizations. None of the univariate interaction effects on the five subscales were statistically significant, which was consistent with the multivariate results. The results of the post hoc multiple comparisons in Figure 1 indicate that NPs practicing in physician offices, community health centers, and hospital-affiliated practices in MA reported better practice environments on all of the five dimensions than did NPs in NY, as evidenced by the higher mean scores. The mean score on the comprehension and visibility of NP role dimension of the practice environment was 2.89 in NY compared with 3.24 in MA. Figure 2 compares the mean scores on each NP practice environment dimension among the three types of health care organizations. The results are from the post hoc multiple comparison of the main effect of the organization type. The mean score on the NPYphysician relations dimension was the highest in the physician offices. This score was comparable between community health centers and hospital-affiliated practices. Hospital-affiliated practices scored lower than did both physician offices and community health centers on the NP practice environment dimensions.
Discussion This study provides a comprehensive overview of the NP practice environments in two states and three types of organizations and determines the impact of state and organization type of practice environments. Nurse practitioner practice environments were assessed in terms of NPs’ perceptions about their relationships with physicians and administration, the support they receive to deliver patient care, their ability to practice independently, and comprehension of their role. The study findings demonstrate that, in general, NPs have positive perceptions of their relationship with physicians and are able to independently deliver care as evidenced by higher mean scores measuring these aspects of NP practice environments. However, significant deficiencies exist in NPs’ perceptions of their relationships with administration and how their role is understood and valued in their organizations. Although NPs’ responses on single survey items were informative, the major emphasis is on the multiple item measures of NP practice environment. Nurse practitioners practicing in MA reported better practice environments than did NPs practicing in NY. The mean scores on all five dimensions of NP practice environments were higher in MA. Given the NP scope of practice variations between these two states, this finding should be interpreted in the context of the specific state regulations.
Figure 1
Post hoc multiple comparison of practice environments between New York State and Massachusetts. NP = nurse practitioner
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Primary Care Nurse Practitioner Practice Environment
Figure 2
Post hoc multiple comparison of practice environments among physician offices, community health centers, and hospital-affiliated practices. NP = nurse practitioner
State regulations of NP practice scope in MA seem more favorable than those in NY. The policy restrictions placed on NPs in NY that require NPs to have a collaborative agreement with other providers to care for their patients may affect NPs’ perceptions of their practice environment and explain the less favorable responses of NPs in NY. In addition to state-level differences, there were also differences in practice environments across three types of organizations employing NPs. Consistently, all five dimensions of practice environments were ranked lower in clinics affiliated with hospitals compared with those in physician offices and community health centers. Even though NPs ranked their ability to practice independently higher among all dimensions of practice environment, this dimension was significantly lower in hospital-affiliated practices compared with physician offices and community health centers. This finding indicates that various organizational policies within the practice settings may affect NP practice environments. Hospitals are characterized by large administrative structures and governed by multiple committees, which may not have NP representation to gather NP input in decision making and promote the NP role. More research is needed to better understand NP practice environments in these settings to identify ways to promote NP practice. The findings of this study indicate that to ensure successful NP practice and promote their ability to provide high-quality care, both state and organizational policies should be taken into consideration. More evidence is needed to better understand the impact of practice environments on NP outcomes, NP supply, and their retention in primary care
and, subsequently, on patient care and outcomes. Such evidence is needed to remove policy and organizational barriers so that promoters of optimal practice can be nurtured to favor high-quality care. The study findings should be interpreted in the context of its limitations. A convenience sample of NPs was recruited for this study. Practice environment measures relied on NP self-reports, and nonresponse bias might have been an issue given the response rate. However, studies show that nurses are reliable informants, with no significant differences in nurse-reported measures between responders and nonresponders (Aiken et al., 2010; Smith, 2008). This study utilized mixed-mode data collection, which may have impacted the study findings. In NY, NPs were members of the NP state organization, and they might have different practice experiences than those who were not. Also, NPs in MA have been practicing in a health reform environment since 2006, and there might be other health care system factors contributing to the state differences in NP practice environments that were not captured in our survey.
Practice Implications Regardless of the variations in NP scope of practice regulations, NPs in both states raised similar issues when it came to their practice environments within their organizations. Practice managers and administrators can address these issues to ensure that these providers deliver high-quality care to patients. They should make efforts and proactively identify practice environment issues in their organizations that
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affect NPs and create infrastructures that support NP practice and allow them to practice to the fullest extent of their scope. Optimal utilization of all PCPs within organizations will ensure better patient care, improve patient outcomes, and maintain safety. Nurse practitioners face challenges in significant aspects of their practice environments, such as clarity of the NP role in their organization and the relationship with administration. Kanter (1993) states that organizations can empower employees by placing them in positions that highlight the value of their role and its relevance to the organization. Managers should make efforts to establish a clear NP role within their organization and promote the visibility of the NP role. Even though NPs’ perceptions about their relationship with physicians seem satisfactory, the teamwork and collaboration aspects rather than physicians seeking NP input and the lack of clarity in NP role in the organizations may challenge effective teamwork between these different types of PCPs. Managers should focus on improving the relationship between NPs and administrators and opening the channels of communication. This will help to create mechanisms for information dissemination and will ensure that providers have necessary information to make care decisions, especially when NPs report that administration is not open to NP ideas to improve patient care. Having access to information and resources empowers employees (Kanter, 1993). In addition, NP underrepresentation in their organization’s decision-making committees may further their perception of being less visible. One way to successfully integrate NPs is to provide avenues for NPs to become involved in organizational governance, such as being members of committees. Managers should create infrastructures to provide support for NPs. Having adequate support will promote the effective use of NPs’ advanced skills and knowledge. Lack of adequate use of their skills in their organizations increases cost and decreases the efficiency of care (Liu et al., 2013). Furthermore, supportive practice environments are necessary for the implementation of new primary care models, such as Patient Centered Medical, which foster multidisciplinary team-based care homes Patient-Centered Medical Home (PCMH) (National Committee for Quality Assurance, 2011). Nurse practitioner responses indicated less favorable practice environments in hospital-affiliated practices compared with physician offices and community health centers, which may lead to future difficulties in recruiting and retaining NPs in this type of practices. With the expanding of NP roles and the increasing care demand, hospital administrators should consider modification of the administrative structures to involve NPs in decision-making processes. In addition, a regular assessment of NPs’ needs will help to identify concerns and deficiencies in hospital-affiliated clinics. By doing this, administrators would be actively involved in a dynamic understanding of NP practice in their organizations and be poised to address problems on a timely
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manner. This would enable them to provide a healthy practice environment for a more effective expansion of the NP workforce in their organizations and ultimately improve patient care. Acknowledgments
We thank NPA and the New York and Massachusetts Health Quality Partners for assisting with the data collection. We also thank Kristine M. Kulage, MA, for editing the manuscript. References Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association, 288(16), 1987Y1993. doi: 10.1001/jama .288.16.1987 Aiken, L. H. S., Douglas, M., Cimiotti, J. P., Clarke, S. P., Flynn, L., Seago, J. A., I Smith, H. L. (2010). Implications of the California nurse staffing mandate for other states. Health Services Research, 45(4), 904Y921. doi: 10.1111/j.1475-6773.2010 .01114.x Auerbach, D. I. (2012). Will the NP workforce grow in the future? New forecasts and implications for healthcare delivery. Medical Care, 50(7), 606Y610. doi: 10.1097/MLR.0b013e 318249d6e7 Beebe, T. J., Locke, G. R., Barnes, S. A., Davern, M. E., & Anderson, K. J. (2006). Mixing web and mail methods in a survey of physicians. Health Services Research, 42(3 Pt. 1), 1219Y1234. Benzer, J. K., Young, G., Stolzmann, K., Osatuke, K., Meterko, M., Caso, A., I Mohr, D. C. (2011). The relationship between organizational climate and quality of chronic disease management. Health Services Research, 46(3), 691Y711. Brazil, K., Wakefield, D., Cloutier, M., Tennen, H., & Hall, C. (2010). Organizational culture predicts job satisfaction and perceived clinical effectiveness in pediatric primary care practices. Health Care Management Review, 35(4), 365Y371. doi: 10 .1097/HMR.0b013e3181edd957 Bryant-Lukosius, D., DiCenso, A., Browne, G., & Pinelli, J. (2004). Advanced practice nursing roles: Development, implementation and evaluation. Journal of Advanced Nursing, 48(5), 519Y529. doi: 10.1111/j.1365-2648.2004.03234.x Clarke, S. P. (2006). The relationship between safety climate and safety performance: A meta-analytic review. Journal of Occupational Health Psychology, 11, 315Y327. Colwill, J. M., Cultice, J. M., & Kruse, R. L. (2008). Will generalist physician supply meet demands of an increasing and aging population? Health Affairs, 27(3), w232Yw241. Commonwealth of Massachusetts. (2006). Chapter 58 of the Acts of 2006: An act providing access to affordable, quality, accountable health care. Retrieved March 25, 2013, from http:// www.mass.gov/legis/laws/seslaw06/sl060058.htm 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. Retrieved August 10, 2012, from http://www.mass.gov/legis/ laws/seslaw08/sl080305.htm
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De Milt, D. G., Fitzpatrick, J. J., & McNulty, R. (2011). Nurse practitioners’ job satisfaction and intent to leave current positions, the nursing profession, and the nurse practitioner role as a direct care provider. The Journal of American Academy of Nurse Practitioners, 23(1), 42Y50. doi: 10.1111/j.1745-7599 .2010.00570.x Deutskens, E., de Ruyter, K., & Wetzels, M. (2006). An assessment of equivalence between online and mail surveys in service research. Journal of Service Research, 8(4), 346Y355. Dillman, D. A. (2007). Mail and Internet surveys: The tailored design method (2nd ed.). New York, NY: John Wiley & Sons Inc. Esperat, M. C. R., Hanson-Turton, T., Richardson, M., Debisette, A. T., & Rupinta, C. (2012). Nurse-managed health centers: Safety-net care through advanced nursing practice. Nursemanaged health centers as safety nets. Journal of the American Academy of Nurse Practitioners, 24(1), 24Y31. doi: 10.1111/ j.1745-7599.2011.00677.x Health Resources and Services Administration. (2008). National sample survey of registered nurses. Retrieved March 1, 2012, from http://datawarehouse.hrsa.gov/nursingsurvey.aspx Hing, E., Hooker, R. S., & Ashman, J. J. (2011). Primary health care in community health centers and comparison with officebased practice. Journal of Community Health, 36(3), 406Y413. doi: 10.1007/s10900-010-9322-x Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Retrieved from http://www.iom.edu/ Reports/2010/The-Future-of-Nursing-Leading-Change-AdvancingHealth.aspx Institute of Medicine. (2012). Living well with chronic illness: A call for public health action. Retrieved February 1, 2013, from http://iom.edu/Reports/2012/Living-Well-with-Chronic-Illness.aspx Kanter, R. M. (1976). The impact of hierarchical structures on the work behavior of women and men. Social Problems, 23(4), 415Y430. Kanter, R. M. (1993). Men and women of the corporation (Second ed.). New York, NY: Basic Books. Laurant, M., Reeves, D., Hermens, R., Braspenning, J., Grol, R., & Sibbald, B. (2009). Substitution of doctors by nurses in primary care: Cochrane Review. Cochrane Database of Systematic Reviews, 1, 1Y39. Lindeke, L., Jukkala, A., & Tanner, M. (2005). Perceived barriers to nurse practitioner practice in rural settings. Journal of Rural Health, 21(2), 178Y181. doi: 10.1111/j.1748-0361.2005.tb00079.x Linzer, M., Manwell, L., Williams, E. S., Bobula, J. A., Brown, R. L., Varkey, A. B., I Schwartz, M. D. (2009). Working conditions in primary care: Physician reactions and care quality. Annals of Internal Medicine, 151(1), 28Y36. Liu, N., Finkelstein, S. R., & Poghosyan, L. (2013). A new model for nurse practitioner utilization in primary care: Increased efficiency and implications. Health Care Management and Review, 39(1), 10Y20. Margolius, D., & Bodenheimer, T. (2010). Transforming primary
care: From past practice to the practice of the future. Health Affairs, 29(5), 779Y784. doi: 10.1377/hlthaff.2010.0045 Massachusetts Health Quality Partners. (2012). Quality insights: Clinical quality in primary care, 2011. Retrieved December 10, 2012, from http://www.mhqp.org/quality/clinical/ cqMeasInfo.asp?nav=032400&MeasureID=33 Massachusetts Medical Society. (2009). Physician workforce study. Retrieved January 10, 2012, from http://www.massmed .org/AM/Template.cfm?Section=Home6&TEMPLATE=/CM/ ContentDisplay.cfm&CONTENTID=31511 National Committee for Quality Assurance. (2011). Patientcentered medical home. Retrieved May 16, 2012, from http:// www.ncqa.org/tabid/631/default.aspx Newhouse, R. P., Stanik-Hutt, J., White, K. M., Johantgen, M., Bass, E. B., Zangaro, G., I Weiner, J. P. (2011). Advanced practice nurse outcomes 1990Y2008: A systematic review. Nursing Economics, 29(5), 1Y22. doi: 10.1234/12345678 Patient Protection and Affordable Care Act. (2010, March 23). Act of 2010. Public Law 111-148, 124 Stat. 119 thru 124 Stat. 1025. Pearson, L. P. (2012). The 2012 Pearson Report: A National Overview of Nurse Practitioner Legislation and Health Care Issues. Retrieved March 12, 2013, from www.webnponline.com Poghosyan, L., Nannini, A., Finkelstein, S. R., Mason, E., & Shaffer, J. (2013). Development and psychometric testing of the Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ). Nursing Research, 62(5), 325Y334. Poghosyan, L., Nannini, A., Stone, P., & Smaldone, A. (2013). Nurse practitioner organizational climate in primary care settings: Implications for professional practice. Journal of Professional Nursing, 29(6), 338Y349. RAND Health. (2009). Controlling health care costs in Massachusetts: An analysis of options. Retrieved February 5, 2011, from http://www.rand.org/pubs/technical_reports/2009/ RAND_TR733.pdf Sargen, M., Hooker, R. S., & Cooper, R. A. (2011). Gaps in the supply of physicians, advance practice nurses, and physician assistants. Journal of the American College of Surgeons, 212(6), 991Y999. doi: 10.1016/j.jamcollsurg.2011.03.005 Schiestel, C. (2007). Job satisfaction among Arizona adult nurse practitioners. Journal of the American Academy of Nurse Practitioners, 19(1), 30Y34. doi: 10.1111/j.1745-7599.2006.00187.x Smith, H. L. (2008). Double sample to minimize bias due to nonresponse in a mail survey. In A. Ruiz-Gazen, P. Guilbert, D. Haziza, & Y. Tille´ (Eds.), Survey methods: Applications to longitudinal studies, to health, to electoral studies and to studies in developing countries (pp. 334Y339). Paris, France: Dunod. SPSS Inc. (2009). PASW statistics for windows, version 18.0. Chicago, IL: SPSS Inc. Weiland, S. A. (2008). Reflections on independence in nurse practitioner practice. Journal of the American Academy of Nurse Practitioners, 20(7), 345Y352. doi: 10.1111/j.1745-7599 .2008.00330.x
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Nurse practitioners as primary care providers: Creating favorable practice environments in New York State and Massachusetts Lusine Poghosyan Jingjing Shang Jianfang Liu Hermine Poghosyan Nan Liu Bobbie Berkowitz Background: Policy makers, health care organizations, and health professionals are calling for the expansion of the nurse practitioner (NP) workforce in primary care to ensure access to high-quality, cost-effective care. However, to date, little is known about NP practice environments in primary care settings and how they may affect the expansion of this workforce and their practice. Purposes: The aims of this study were to investigate NP practice environments in two states, Massachusetts (MA) and New York State (NY), and determine the impact of state and organization on NP practice environment. Methodology: A cross-sectional survey design was used. Practice environments were measured using the Nurse Practitioner Primary Care Organizational Climate Questionnaire in terms of NPYphysician relations, NPYadministration relations, support, NP role comprehension, and NP independent practice. In MA, 291 NPs were recruited from the Massachusetts Provider Database through mail surveys. In NY, 278 NPs were recruited from the NY Nurse Practitioner Association membership list through online surveys. Data were collected from May through September 2012.
Key words: nurse practitioner, practice environment, primary care Lusine Poghosyan, PhD, MPH, RN, is Assistant Professor, Columbia University School of Nursing, New York. E-mail: [email protected]. Jingjing Shang, PhD, RN, OCN, is Assistant Professor, Columbia University School of Nursing, New York. Jianfang Liu, PhD, MAS, is Data Analyst, Columbia University School of Nursing, New York. Hermine Poghosyan, PhD, MPH, is Assistant Professor, College of Nursing and Health Sciences, University of Massachusetts Boston. Nan Liu, PhD, is Assistant Professor, Department of Health Policy and Management Mailman School of Public Health, Columbia University, New York. Bobbie Berkowitz, PhD, RN, CNAA, FAAN, is Dean and Mary O’Neil Mundinger Professor, Columbia University School of Nursing, New York. This study was funded by the Agency for Healthcare Research and Quality, and internal funding was received from the Columbia University School of Nursing. This article was presented and supported in part by the 2012 Michigan Symposium on Effectiveness and Implementation Science, sponsored by the University of Michigan School of Nursing, on September 26, 2012. The study was approved by the Institutional Review Board of Columbia University Medical Center. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. DOI: 10.1097/HMR.0000000000000010 Health Care Manage Rev, 2015, 40(1), 46Y55 Copyright B 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins
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Primary Care Nurse Practitioner Practice Environment
Descriptive statistics were computed. Multivariate analysis of variance was conducted to investigate the effect of state and organization type on NP practice environments. Findings: Nurse practitioners reported favorable relationships with physicians, deficiencies in their relationships with administrators, and lack of support. Nurse practitioners from MA reported better practice environments. Nurse practitioners from hospital-affiliated practices perceived poorer practice environments than did NPs practicing in physician offices and community health centers. Practice Implications: Optimal working relations with physicians and administration, access to resources, and clarity in NP role are necessary to create practice environments where NPs can function effectively as primary care providers.
P
olicy makers, health care organizations, and professionals are calling for the redesign of our primary care system to increase efficiency, promote access, and improve patient outcomes. There are noteworthy concerns that the existing primary care system is overburdened and lacks the effectiveness necessary to meet patients’ needs (Margolius & Bodenheimer, 2010). This insufficiency is fueled by a critical shortage of primary care providers (PCPs) and the surging demand in services related to an aging population and the epidemic of chronic diseases (Colwill, Cultice, & Kruse, 2008; Institute of Medicine, 2012; Sargen, Hooker, & Cooper, 2011). In addition, with the passage of the Affordable Care Act (ACA), 32 million people will gain health insurance (Patient Protection and Affordable Care Act, 2010). This change in the health care system brings more attention to increasing the capacity of primary care in the country to ensure that patients will have access to timely care. Similar health reform initiatives have been enacted in Massachusetts (MA) in 2006, which led to an influx of about a half-million MA residents into the health care system (Commonwealth of Massachusetts, 2006), which was already experiencing a shortage of primary care physicians (Massachusetts Medical Society, 2009). The full implementation of the ACA will likely have similar consequences on a national scale for overall primary care. To accommodate the demand, MA passed new legislation in 2008 to recognize nurse practitioners (NPs) as PCPs (Commonwealth of Massachusetts, 2008). One need only extrapolate this example from the state to a national level to understand not only the projected impact of the ACA on care demand but also the implications it has for the future of the NP workforce. To meet the demand, improve patient outcomes, and ensure timely access and cost control, many have called for expanding the NP workforce in primary care and promoting their optimal practice (Institute of Medicine, 2010; RAND Health, 2009). Nurse practitioners are educated to deliver primary care to both adult and pediatric populations in a variety of care settings, including private practices, nurse-managed centers, and community health centers among others (Esperat, Hanson-Turton, Richardson, Debisette, & Rupinta, 2012;
Hing, Hooker, & Ashman, 2011). They provide a broad spectrum of care from initial contact to follow-up care and produce clinical outcomes comparable with those of physicians (Laurant et al., 2009; Newhouse et al., 2011). The number of NPs in general has increased significantly over the past several years and will continue to do so in the future (Pearson, 2012). Nationally, it is projected that the NP workforce will increase by 130% from 2008 to 2025 (Auerbach, 2012). However, many barriers such as state-level and practice-level restrictions placed on NP practice affect their optimal utilization (Pearson, 2012; Poghosyan, Nannini, Stone, & Smaldone, 2013). Limited efforts have been devoted to systematically investigate these barriers. This study provides an overview of NP practice environments in primary care settings; compares NPs’ perceptions of their practice environments between two states with and without health reform, MA and New York State (NY), respectively; and determines the influence of state and organization type on NP practice environments. Nurse practitioner scope of practice varies between the two states involved in this study. For example, whereas in MA, NPs can independently diagnose and treat patients and collaborative agreement with a physician is required only for prescriptive authority, in NY, a collaborative agreement with a physician is required for all three aspects of NP practice: treatment, diagnosis, and prescribing authority (Pearson, 2012). In NY, it is also required to have the practice agreement on file with the state; there is no such requirement in MA. In addition to state-level variations affecting NPs, organizational policies may also create challenges, and to date, limited evidence exists about NP practice environments. For primary care organizations shifting toward a larger NP workforce, creating and maintaining favorable practice environments for NPs are necessary and critical for promoting their successful practice and ability to deliver high-quality patient care.
Conceptual Framework Organizational structures in the work settings impact employee performance more than inherent personal characteristics do (Kanter, 1976). Kanter’s (1976) theory of
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structural power is fundamental in studying organizations and suggests that organizational structures can either impede or promote employee performance regardless of employees’ personal tendencies. Kanter (1993) argues that workplace structures are important in shaping organizational behaviors and relationships. They also can empower employees, providing access to information, support, and resources. Organizations that fail to enhance the performance of employees will see reduced productivity and adverse outcomes. Thus, it is necessary to study organizations employing NPs and the NP practice environments in those organizations. The quality of practice environments in health care settings and their impact on provider, patient, and organizational outcomes have been well studied in recent decades (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Benzer et al., 2011). Evidence is accumulating that health care organizations with poor practice environments with lack of support and resources for providers and staff, a lack of collegiality, and poor relationships between clinicians and leadership tend to have poor quality of care, resulting in higher rates of adverse patient outcomes (Clarke, 2006; Linzer et al., 2009). These inadequacies in practice environments also lead to poor provider outcomes such as diminished effectiveness, job dissatisfaction, and turnover (Brazil, Wakefield, Cloutier, Tennen, & Hall, 2010; De Milt, Fitzpatrick, & McNulty, 2011). Although the impact of practice environments on providers and the care they deliver is generally understood, the evidence about how to create quality practice environments for primary care NPs is limited. This evidence is necessary because of the projected significant increase in the numbers of NP in their organizations and their continuously evolving and expanding scope of practice. Some primary care organizations may not be familiar with the NP role, and their practice environments might not be designed to support effective NP practice. Lack of understanding about the NP role as a PCP may limit managers’ abilities to create productive NP practice environments. Suboptimal NP practice environments have been reported in several studies where NPs expressed dissatisfaction with intrapractice partnerships (De Milt et al., 2011; Schiestel, 2007) and a lack of physician support (Lindeke, Jukkala, & Tanner, 2005; Weiland, 2008). Nurse practitioners also did not receive the same level of support as physicians did to deliver the same services (Bryant-Lukosius, DiCenso, Browne, & Pinelli, 2004). Even when NPs and physicians have similar PCP roles, in some organizations, physicians may have medical assistant support whereas NPs might not receive the same assistance (Poghosyan, Nannini, Stone, et al., 2013). These are examples of suboptimal NP practice environments that may prevent NPs from effectively utilizing their skills and knowledge to provide high-quality care, leading to inefficiencies in their organizations (Liu, Finkelstein, & Poghosyan, 2013).
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Methods This study used a cross-sectional survey design to collect data from primary care NPs. The Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ), a self-report survey instrument specifically designed for NPs (Poghosyan, Nannini, Finkelstein, Mason, & Shaffer, 2013), was used to measure NP practice environments. Using a 4-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree), the questionnaire asks NPs to evaluate several aspects of their practice environments: (1) NPYphysician relations, in terms of assessing NP perceptions about the collaboration and team work between NPs and physicians. The tool also captured other aspects of their collaboration, such as physicians seeking NP input and suggestions in care delivery; (2) independent practice of NPs, in terms of NPs’ perceptions about whether they were able to freely apply their knowledge and skills to provide care and if their clinics create an environment where they can practice independently; (3) NPYadministration relations, in terms of administrators being open to NPs’ ideas to improve care and taking NP concerns seriously. Moreover, NPs were asked to compare the relationships they had with the administrators to that of the physicians; (4) comprehension and visibility of NP role, in terms of whether their role was well understood and valued in their organizations; and (5) organizational support and resources, in terms of the support that NPs had, such as staff help. These aspects of practice environments are critical for successful NP practice (Poghosyan, Nannini, Stone, et al., 2013). In MA, NPs were recruited from the Massachusetts Health Quality Partners (MHQP) Massachusetts Provider Database (MPD). Each year, MHQP contacts clinics in MA and requests information about primary care physicians and specialists practicing in those sites who are listed as providers by at least one of the five major health plans. These plans together cover over 50% of MA’s commercially insured residents (MHQP, 2012). In 2011, MHQP also requested information about NPs. No other database or existing list in MA allows for the identification of NPs practicing in primary care settings and their role as an NP specialist or PCP. By using practice addresses extracted from the MPD, surveys were mailed to the 807 primary care NPs. Included with the survey was a cover letter and consent form describing the study purpose, its voluntary nature, and the confidentiality of their responses. Nurse practitioners were asked to complete the questionnaire and return it to the research team in a prepaid envelope. Following the Dillman (2007) guide for mailed surveys to encourage response rate, a postcard reminder and second survey were sent to nonrespondents. Two hundred ninety-one NPs completed and returned the surveys, yielding a response rate of 39%, which is a comparable response rate with that of other nurse surveys (Aiken et al., 2010; Smith, 2008). Nurse practitioners practiced in 148 different clinics,
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and the number of NPs from each clinic ranged from one to seven. In NY, NPs were recruited from the membership of The Nurse Practitioner Association (NPA). The NPA sent an e-mail invitation to 1,950 members who had adult, pediatric, family, gerontology, or women’s health specialties because these NPs are likely to practice in primary care settings. The e-mail described the study and eligibility criteria for participation. It asked for NP participation and provided the link to the online survey. As the NP practice location and the type of the organization could not be determined, an additional item was included to determine NP eligibility. Only NPs who self-identified as primary care NPs were prompted to take the survey. The survey was created in the professional version of SurveyMonkey. Second and third e-mail reminders were sent after the initial e-mail invitation to encourage a high response rate (Dillman, 2007). Overall, 342 NPs accessed the survey, 278 completed the survey, and 64 NPs self-identified as not practicing in primary care. The accurate response rate for the NY sample was not calculated because the number of targeted NPs practicing in primary care could not be determined. Our e-mail invitation might have reached NPs practicing in acute or other care settings, thus making them ineligible for the study. Both the mail and the online surveys took about 15 minutes to complete. Data collection took place from May through September 2012. There might be differences in response rate and data quality when the mixed-mode data collection approach is used; however, the differences are minor, and both modes yield comparable results (Beebe, Locke, Barnes, Davern, & Anderson, 2006; Deutskens, de Ruyter, & Wetzels, 2006). The study was approved by the Institutional Review Board of the Columbia University Medical Center.
Data Analysis Data from the mail survey in MA were entered into a database created in SPSS Version 18 software (SPSS Inc., 2009). New York State data were extracted from SurveyMonkey. The data in both databases were investigated for missing values and outliers before merging. Descriptive statistics were computed including means and frequencies for the demographic and work characteristics of the respondents. For group comparison between the NY and MA states, t test for continuous variables and chi-squares for categorical variables were used. The overall alpha level was set at .05 to control Type I error throughout the study. We coded the single items measuring various aspects of practice environments by combining strongly agree and agree responses into one category and strongly disagree and disagree responses into the other category to allow for differentiation of NPs’ favorable and less favorable responses on each item and calculated the proportions. We also com-
puted the mean scores on each of the five NP-PCOCQ dimensions to measure NP practice environments. The effects of potential confounding variables such as NPs’ age, gender, race (two levels: White vs. non-White), location of practice site (three levels: rural, suburban, and urban), and educational degree (three levels: master’s, doctor of nursing practice, and other) were considered and analyzed to investigate the effect of state and organization type in which NPs practiced on their practice environments. Bivariate correlation analyses were run first and indicated no statistically significant relationship between age, location of practice site, and the outcome measures, which were the mean scores on each of the five NP-PCOCQ dimensions measuring NP practice environments. Higher mean scores indicate better NP practice environment. Nurse practitioners’ educational degree was included as the only confounding variable because of the correlations between NPs’ educational degree, gender, and race. The vast majority of NPs were women (93.4%) and White (93%). Thus, we used a 3 2 3 customized multivariate analysis of variance (MANOVA) to investigate the effect of state and organization type after controlling for the main effect of NPs’ educational degree. The fixed factors were state (two levels: MA vs. NY), organization types (three levels: physician offices, community health centers, and hospital-affiliated practices), and degree. The responses of NPs practicing in urgent care clinics, nurse-managed clinics, school-based clinics, and in other nondefined settings were combined into the ‘‘other clinic’’ category given the small number of practicing NPs in each individual category. Nurse practitioners in the ‘‘other clinic’’ category comprised less than 10% of the total sample and were excluded from the 3 2 3 MANOVA and the corresponding univariate analysis and post hoc analysis. Assumptions were checked before the analysis, and post hoc multiple comparison with Bonferroni’s correction was applied when an overall statistical significance was detected.
Findings The demographic characteristics of NPs are presented in Table 1. The mean age of NPs was about 51 years; 6.2% self-identified as male; 7% self-identified as non-White; and 45.4% of NPs practiced in physician offices, 22.9% practiced in community health centers, 22.3% practiced in primary care clinics affiliated with hospitals, and 9.3% practiced in other settings such as urgent care clinics and nursemanaged clinics. Compared with NPs in MA, NPs in NY were older (52.3 vs. 49.3 years; p G .001) and more likely to be male (9.8% vs. 2.9%; p G .001). More NPs in NY worked in practices affiliated with hospitals (32.3% vs. 15.2%), whereas more NPs in MA worked in community health centers (30.1% vs. 12.8%). The demographic characteristics of NPs in our sample were comparable with those of
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Table 1
Demographic and work characteristics of the study participants Characteristic Demographics Age (years) Mean (SD) Range Sex, n (%) Female Male Race, n (%) White Non-White Highest nursing degree, n (%) Master’s degree Doctor of nursing practice Other Work characteristics, n (%) Years in the current position Less than 1 year 1Y6 years More than 7 years Average number of hours worked in the past month 1Y20 21Y40 940 Number of other nurse practitioners in their practice 0 1Y5 6Y10 910 Main practice site Physician’s office Community health center Hospital-based clinic Other Location of practice Urban Suburban Rural
Total (N = 564)
New York State (n = 278)
Massachusetts (n = 291)
50.58 (10.4) 24Y75
52.3 (9.2) 24Y75
49.34 (11.1) 26Y71
p
G.001 G.001 488 (93.8) 32 (6.2)
220 (90.2) 24 (9.8)
268 (97.1) 8 (2.9)
477 (93.0) 36 (7.0)
219 (92.8) 17 (7.2)
258 (93.1) 19 (6.9)
463 (88.4) 24 (4.6) 37 (7.1)
205 (84.0) 18 (7.4) 21 (8.6)
258 (92.1) 6 (2.1) 16 (5.7)
55 (10.5) 205 (39.2) 263 (50.3)
37 (15.2) 99 (40.7) 107 (44.0)
18 (6.4) 106 (37.9) 156 (55.7)
.507
.006
.001
G.001 64 (12.2) 295 (56.4) 164 (31.3)
43 (17.6) 104 (42.6) 97 (39.8)
21 (7.5) 191 (68.5) 67 (24.0) G.001
63 307 82 69
(12.1) (58.9) (15.7) (13.2)
48 156 23 17
(19.7) (63.9) (9.4) (7.0)
15 (5.4) 151 (54.5) 59 (21.3) 52 (18.8)
214 108 105 44
(45.4) (22.9) (22.3) (9.3)
98 25 63 9
(50.3) (12.8) (32.3) (4.6)
116 83 42 35
G.001 (42.0) (30.1) (15.2) (12.7) G.001 248 (47.7) 214 (41.2) 58 (11.2)
NPs in the 2008 National Sample Survey of Registered Nurses (NSSRN) in terms of age, education, and other characteristics (Health Resources and Services Administration, 2008). Almost 50% of NPs in the NSSRN were 50 years or older. We investigated the NP responses on the individual survey items. Compared with physicians in MA, physicians in NY were more likely not to collaborate with NPs (19.4% vs. 5.2%; p = .014), not to ask them for suggestions (32.4% vs. 18.6%; p = .005), or not seek NP input when delivering patient care (38.1% vs. 22.3%; p = .013). More NPs in NY
84 (34.6) 111 (45.7) 48 (19.8)
164 (59.2) 103 (37.2) 10 (3.6)
than in MA disagreed that in their organizations they were able to provide all patient care within their scope (18.7% vs. 4.5%; p G .001) or that their organizations created an environment where NPs can practice independently (20.1% vs. 9.6%; p = .018). In MA, administrators were more likely to share information equally with NPs and physicians, and NPs were more likely to be included in committees within their organization. More than half of the NPs (53.2%) in NY reported that administration does not share information equally with NPs and physicians. About 38% of NPs in MA report this finding. Twenty-three percent of NPs in
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MA and 36.3% in NY disagree with the statement that the administration is open to NPs’ ideas to improve patient care. There was no statistically significant difference between states in terms of communication patterns between NPs and administration. In NY, 40% of NPs reported that their role is not understood and 31.7% did not feel valued by their organizations. About 21% of NPs in NY and 6.5% of NPs in MA reported lack of resources. There was no statistically significant difference between the states in terms of support for care management between NPs and physicians. Three-way customized MANOVA compared the mean scores on each NP practice environment dimension between MA and NY, controlling for the main effect of NPs’ educational level. The multivariate results indicated difference in NP practice environment between MA and NY (Wilks 1 = .918, F = 7.37, p G .05), with medium to large effect size ()’2 = .082). Nurse practitioner practice environment was also different among the three types of health care organizations (Wilks’ 1 = .942, F = 2.52, p G .05), with small to medium
effect size ()’2 = .030). There was no significant multivariate interaction effect between state and organization type. The main effect of the confounding variable, NPs’ educational level, was significant (Wilks 1 = .951, F = 2.10, p G .05), with small to medium effect size ()’2 = .025). The univariate results in Table 2 present the effects of state and organization type, physician offices, community health centers, and hospital-affiliated practices on each of the five practice environment dimensions separately after taking into account the main effect of NPs’ educational degree. The multivariate results discussed above were confirmed. The mean scores on each of the NP practice environment dimensions were different between the MA and NY states: NPYphysician relations (F = 21.56, p G .05), NPYadministration relations (F = 8.90, p G .05), support and resources for NP practice (F = 21.03, p G .05), comprehension and visibility of NPs as care providers (F = 26.08, p G .05), and independent practice of NPs (F = 14.51, p G .05). Also, four of the subscales, NPYphysician
Table 2
Univariate effects of state and organization type on dimensions of NP practice environment in physician offices, community health centers, and hospital-affiliated practices, after controlling for the main effect of NP educational degree Effect NPYphysician relations Degree State Organization type State Organization type NPYadministration relations Degree State Organization type State Organization type Support and resources for NP practice Degree State Organization type State Organization type Visibility of NPs as care providers Degree State Organization type State Organization type Independent practice of NPs Degree State Organization type State Organization type
Mean square
F
p
Partial )2
Observed power
0.457 6.351 0.922 0.730
1.55 21.56 3.13 2.48
.213 .000* .045* .085
.007 .049 .015 .012
.329 .996 .600 .497
1.062 3.911 1.230 0.944
2.42 8.90 2.80 2.15
.091 .003* .062 .118
.011 .021 .013 .010
.486 .845 .549 .439
0.337 5.771 2.198 0.196
1.23 21.03 8.01 0.72
.294 .000* .000* .490
.006 .048 .037 .003
.267 .996 .956 .171
1.223 9.988 1.558 0.264
3.19 26.08 4.07 0.69
.042* .000* .018* .503
.015 .059 .019 .003
.609 .999 .722 .166
1.011 3.217 1.203 0.024
4.56 14.51 5.43 0.11
.011* .000* .005* .898
.021 .034 .025 .001
.774 .967 .845 .066
Note. NP = nurse practitioner. *Statistically significant at the .05 level.
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relations (F = 3.13, p G .05), support and resources for NP practice (F = 8.01, p G .05), comprehension and visibility of NPs as care providers (F = 4.07, p G .05), and independent practice of NPs (F = 5.43, p G .05), had different scores in the three types of health care organizations. None of the univariate interaction effects on the five subscales were statistically significant, which was consistent with the multivariate results. The results of the post hoc multiple comparisons in Figure 1 indicate that NPs practicing in physician offices, community health centers, and hospital-affiliated practices in MA reported better practice environments on all of the five dimensions than did NPs in NY, as evidenced by the higher mean scores. The mean score on the comprehension and visibility of NP role dimension of the practice environment was 2.89 in NY compared with 3.24 in MA. Figure 2 compares the mean scores on each NP practice environment dimension among the three types of health care organizations. The results are from the post hoc multiple comparison of the main effect of the organization type. The mean score on the NPYphysician relations dimension was the highest in the physician offices. This score was comparable between community health centers and hospital-affiliated practices. Hospital-affiliated practices scored lower than did both physician offices and community health centers on the NP practice environment dimensions.
Discussion This study provides a comprehensive overview of the NP practice environments in two states and three types of organizations and determines the impact of state and organization type of practice environments. Nurse practitioner practice environments were assessed in terms of NPs’ perceptions about their relationships with physicians and administration, the support they receive to deliver patient care, their ability to practice independently, and comprehension of their role. The study findings demonstrate that, in general, NPs have positive perceptions of their relationship with physicians and are able to independently deliver care as evidenced by higher mean scores measuring these aspects of NP practice environments. However, significant deficiencies exist in NPs’ perceptions of their relationships with administration and how their role is understood and valued in their organizations. Although NPs’ responses on single survey items were informative, the major emphasis is on the multiple item measures of NP practice environment. Nurse practitioners practicing in MA reported better practice environments than did NPs practicing in NY. The mean scores on all five dimensions of NP practice environments were higher in MA. Given the NP scope of practice variations between these two states, this finding should be interpreted in the context of the specific state regulations.
Figure 1
Post hoc multiple comparison of practice environments between New York State and Massachusetts. NP = nurse practitioner
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Primary Care Nurse Practitioner Practice Environment
Figure 2
Post hoc multiple comparison of practice environments among physician offices, community health centers, and hospital-affiliated practices. NP = nurse practitioner
State regulations of NP practice scope in MA seem more favorable than those in NY. The policy restrictions placed on NPs in NY that require NPs to have a collaborative agreement with other providers to care for their patients may affect NPs’ perceptions of their practice environment and explain the less favorable responses of NPs in NY. In addition to state-level differences, there were also differences in practice environments across three types of organizations employing NPs. Consistently, all five dimensions of practice environments were ranked lower in clinics affiliated with hospitals compared with those in physician offices and community health centers. Even though NPs ranked their ability to practice independently higher among all dimensions of practice environment, this dimension was significantly lower in hospital-affiliated practices compared with physician offices and community health centers. This finding indicates that various organizational policies within the practice settings may affect NP practice environments. Hospitals are characterized by large administrative structures and governed by multiple committees, which may not have NP representation to gather NP input in decision making and promote the NP role. More research is needed to better understand NP practice environments in these settings to identify ways to promote NP practice. The findings of this study indicate that to ensure successful NP practice and promote their ability to provide high-quality care, both state and organizational policies should be taken into consideration. More evidence is needed to better understand the impact of practice environments on NP outcomes, NP supply, and their retention in primary care
and, subsequently, on patient care and outcomes. Such evidence is needed to remove policy and organizational barriers so that promoters of optimal practice can be nurtured to favor high-quality care. The study findings should be interpreted in the context of its limitations. A convenience sample of NPs was recruited for this study. Practice environment measures relied on NP self-reports, and nonresponse bias might have been an issue given the response rate. However, studies show that nurses are reliable informants, with no significant differences in nurse-reported measures between responders and nonresponders (Aiken et al., 2010; Smith, 2008). This study utilized mixed-mode data collection, which may have impacted the study findings. In NY, NPs were members of the NP state organization, and they might have different practice experiences than those who were not. Also, NPs in MA have been practicing in a health reform environment since 2006, and there might be other health care system factors contributing to the state differences in NP practice environments that were not captured in our survey.
Practice Implications Regardless of the variations in NP scope of practice regulations, NPs in both states raised similar issues when it came to their practice environments within their organizations. Practice managers and administrators can address these issues to ensure that these providers deliver high-quality care to patients. They should make efforts and proactively identify practice environment issues in their organizations that
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affect NPs and create infrastructures that support NP practice and allow them to practice to the fullest extent of their scope. Optimal utilization of all PCPs within organizations will ensure better patient care, improve patient outcomes, and maintain safety. Nurse practitioners face challenges in significant aspects of their practice environments, such as clarity of the NP role in their organization and the relationship with administration. Kanter (1993) states that organizations can empower employees by placing them in positions that highlight the value of their role and its relevance to the organization. Managers should make efforts to establish a clear NP role within their organization and promote the visibility of the NP role. Even though NPs’ perceptions about their relationship with physicians seem satisfactory, the teamwork and collaboration aspects rather than physicians seeking NP input and the lack of clarity in NP role in the organizations may challenge effective teamwork between these different types of PCPs. Managers should focus on improving the relationship between NPs and administrators and opening the channels of communication. This will help to create mechanisms for information dissemination and will ensure that providers have necessary information to make care decisions, especially when NPs report that administration is not open to NP ideas to improve patient care. Having access to information and resources empowers employees (Kanter, 1993). In addition, NP underrepresentation in their organization’s decision-making committees may further their perception of being less visible. One way to successfully integrate NPs is to provide avenues for NPs to become involved in organizational governance, such as being members of committees. Managers should create infrastructures to provide support for NPs. Having adequate support will promote the effective use of NPs’ advanced skills and knowledge. Lack of adequate use of their skills in their organizations increases cost and decreases the efficiency of care (Liu et al., 2013). Furthermore, supportive practice environments are necessary for the implementation of new primary care models, such as Patient Centered Medical, which foster multidisciplinary team-based care homes Patient-Centered Medical Home (PCMH) (National Committee for Quality Assurance, 2011). Nurse practitioner responses indicated less favorable practice environments in hospital-affiliated practices compared with physician offices and community health centers, which may lead to future difficulties in recruiting and retaining NPs in this type of practices. With the expanding of NP roles and the increasing care demand, hospital administrators should consider modification of the administrative structures to involve NPs in decision-making processes. In addition, a regular assessment of NPs’ needs will help to identify concerns and deficiencies in hospital-affiliated clinics. By doing this, administrators would be actively involved in a dynamic understanding of NP practice in their organizations and be poised to address problems on a timely
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manner. This would enable them to provide a healthy practice environment for a more effective expansion of the NP workforce in their organizations and ultimately improve patient care. Acknowledgments
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