Journal of the American Association of Nurse Practitioners最新文献

Background: Continuous glucose monitoring (CGM) has been associated with improved glycemic control in individuals with non-insulin-treated type 2 diabetes (T2D), but adoption in endocrinology clinics remains limited.

Local problem: This quality improvement (QI) project aimed to explore the use of CGM for non-insulin-treated patients with T2D within an endocrinology clinic in Los Angeles County and to evaluate feasibility of its adoption in this practice setting.

Methods: It was a retrospective chart review.

Interventions: Eligible patients were adults (≥18 years) with T2D and hemoglobin A1c (HbA1c) >7% who had not been treated with insulin. Ten patients met inclusion criteria. Descriptive statistics summarized HbA1c and time-in-range (TIR) over 6 months. An interrupted time series was also conducted on two patients with sufficient longitudinal data to assess HbA1c changes before and after CGM use.

Results: After 6 months of initial CGM use, 8 of 9 patients achieved HbA1c reductions of ≥0.3%. One patient demonstrated a ≥8% increase in TIR with adequate device use. Interrupted time series analyses illustrated individual HbA1c trajectories, showing immediate reductions after CGM initiation and nonsignificant downward trends over time.

Conclusion: This QI project showed that patients with T2D treated with noninsulin medications successfully initiated and used CGM. Early improvements in HbA1c were observed; however, sustained glycemic outcomes varied depending on consistent CGM wear and adherence to follow-up, underscoring the need for individualized support. Nurse practitioners can play a key role in promoting sustained CGM use through structured diabetes education, integration of CGM data into lifestyle counseling, and regular follow-up.

Background: Nurse practitioners (NPs) are a rapidly growing segment of the US health care workforce and are increasingly integral to patient care in hospital settings. Despite their expanding roles, little is known about the work environment factors that affect their well-being in hospital settings.

Purpose: To examine the factors that influence hospital-based NPs' work environments and identify strategies to enhance their well-being and support retention.

Methodology: This qualitative descriptive study used directed content analysis to examine responses from 493 NPs across 264 hospitals in 10 US states with varying scope-of-practice laws to three open-text survey questions regarding their workplace experiences and work environment, drawn from the 2024 Penn Nurses4All Study. To identify factors influencing healthy work environments, themes were developed using both inductive and deductive analytic approaches, guided by the American Association of Critical-Care Nurses' Healthy Work Environment (HWE) framework.

Results: Six emergent themes related to factors that influence NPs' work environments included the following: (1) structural barriers to effective communication; (2) workplace incivility and lack of inclusion; (3) limited clinical autonomy and organizational influence; (4) misalignment between NP roles and staffing demands; (5) invisibility and devaluation of NP contributions; and (6) leadership gaps in supporting NP practice and well-being.

Conclusions: Hospital-based NPs face unique barriers to a HWE that affect their well-being and hinder optimal practice.

Implications: Implementing NP-informed strategies can foster supportive work environments that enhance NP well-being, retention, and the quality of patient care.

Background: When patients with an implantable cardioverter-defibrillator (ICD) near the end-of-life (EOL), shock therapy from the device can cause unnecessary suffering. Professional guidelines recommend timely discussions on the shock deactivation option with ICD recipients.

Local problem: At the project site, many older patients with serious illnesses have shock therapy active in their ICDs. This project aimed to improve ICD recipients' knowledge, attitudes, and decision making regarding EOL device management options by providing guideline-recommended patient education.

Methods: Single-site, quality improvement project employing pre/post survey design among ICD recipients in the outpatient setting. The Experiences, Attitudes, and Knowledge of End-of-Life Issues in ICD Questionnaire was used for the survey.

Interventions: The key intervention was a structured patient education session (SPES) in the device clinic led by a cardiac electrophysiology nurse practitioner.

Results: Of the 90 participants, 94.4% were ≥60 years old and 95.6% were males. After the SPES, the responses to all ICD knowledge items showed significant positive differences based on the McNemar test significance (p ≤ .001). Responses to five attitude items on EOL ICD discussions/actions also showed significant positive changes after the education with McNemar Test significance <.05.

Conclusion: A SPES in the device clinic improved patients' ICD knowledge and attitude toward shock deactivation at EOL. Further work is required to assess the long-term impacts.

Abstract: Objective structured clinical examinations (OSCEs) are widely used in competency-based education (CBE) to assess clinical competencies in Doctor of Nursing Practice (DNP) students. However, OSCE-related anxiety can hinder performance and affect competency evaluation. This quality improvement (QI) project implemented a structured OSCE preparation workshop in an advanced health assessment (AHA) course to improve preparation, reduce anxiety, and enhance performance. The workshop incorporated three evidence-based activities: video case evaluation, a structured clinical reasoning exercise, and mock OSCEs. A pre-/postsurvey design assessed changes in preparedness and anxiety, and students rated the usefulness of each activity. Objective structured clinical examination performance and remediation rates before and after implementation were compared. Across three semesters, 181 DNP students participated. After the workshop, preparedness significantly increased ( p < .001), anxiety significantly decreased ( p < .001), and mean OSCE scores significantly improved ( p = .002). Remediation rates declined from 7.6% to 3.3%. Student feedback was overwhelmingly positive, with mock OSCEs rated as the most beneficial component. This structured OSCE preparation workshop improved student preparation, reduced anxiety, and enhanced performance, supporting its potential as a sustainable, evidence-informed QI initiative in AHA and other clinical courses. Limitations include self-reported measures, unmatched pre- and postsurvey responses, and a single-institution setting. Building on the success of the workshop, this model is highly scalable for other DNP programs. The low-cost, evidence-based activities can be adapted to diverse curricula, resources, and learner needs, making it a sustainable strategy for supporting CBE.

Background: Hawaii faces a critical shortage of health care providers, underscoring the vital role of nurse practitioners (NPs) in ensuring access to quality care. However, limited research exists on burnout and effective mitigation strategies in Hawaii NPs.

Purpose: This study examined the psychometric properties of the Maslach Burnout Inventory (MBI) among Hawaii NPs, with a focus on dimensionality, internal consistency reliability, and criterion validity.

Methodology: Survey data from 143 NPs in a large Hawaii health system were analyzed. Exploratory factor analysis (EFA) assessed dimensionality. An adapted 17-item MBI model was developed, and reliability was evaluated using Cronbach alpha. Analysis of variance tested demographic associations, and correlations with the Areas of Worklife Scale (AWS) assessed criterion validity.

Results: Pairwise correlations were acceptable, and the EFA resulted in an adapted model containing 17 items (7 for Emotional Exhaustion, 5 for Personal Accomplishment, and 5 for Depersonalization). The adapted MBI and its three factors showed good reliability; gender showed significant associations, and factors were significantly correlated with AWS domains as anticipated.

Conclusions: The adapted MBI demonstrated strong reliability and meaningful correlations with AWS domains. Gender differences were significantly associated with burnout. These findings contribute to the growing body of research on the MBI's performance in diverse and understudied populations.

Implications: Psychometric analysis of the adapted MBI among NPs in Hawaii demonstrated acceptable psychometric properties, supporting its suitability for assessing burnout in this population. Future research is recommended to further examine the MBI's psychometric performance, and validations studies are needed to test the adapted model.

Abstract: Cardiac amyloidosis is a rare and challenging condition characterized by abnormal protein deposition in the heart. This clinical case report discusses the intricate diagnostic and management challenges in cardiac amyloidosis, emphasizing the need for a multidisciplinary approach. With vague symptoms complicating diagnosis, collaboration between specialties is critical. Advanced imaging and biopsy techniques aid in subtype identification. Individualized care underscores the importance of tailored treatments. Advanced practice registered nurses, clinicians, and researchers in the field can benefit from the insights provided by this case report in their clinical practice and future research endeavors.

Background: Patients with diabetes are using advanced diabetes self-management technology, such as integrated insulin pumps with continuous glucose monitors (CGM) during hospitalization. Concerns surround their use in the inpatient setting ranging from safety risks to provider and nursing comfort in overseeing these devices.

Local problem: At a 332-bed hospital in the Southeastern United States, the inpatient insulin pump policy did not support current evidence-based clinical recommendations.

Methods: An updated policy was designed, allowing patients to continue using automated insulin pumps during hospitalization. Pre- and postpolicy nursing knowledge surveys, patient glucose metrics (including mean Glucose and Time in Range of 70-180 mg/dl), and patient narratives were evaluated to determine if the inpatient policy maintained optimal glucose control, improved patient satisfaction, and increased nursing comfort levels.

Interventions: The updated policy was applied to all patients admitted using automated insulin pumps over 19 weeks. Nursing education was provided on the new policy release.

Results: Mean glucose was 153.6 mg/dl for time segments on automated insulin pump, versus 201.4 mg/dl for stand-alone insulin pump without CGM and 262.3 mg/dl with subcutaneous insulin injections. Time in range was achieved at 72.1% (goal >70%) for time segment patients continued automated insulin pump, versus 44.3% insulin pump without CGM and 31.7% on subcutaneous insulin injections. Five of nine realms on the postnursing survey showed significant improvement ( p < .05).

Conclusions: Applying an evidence-based policy that allows patients to remain on their automated insulin pump during hospitalization maintains glycemic control and patient satisfaction, as well as improves nursing comfort levels.

Background: Continuous glucose monitors (CGM) are supported by national clinical practice guidelines for glucose monitoring in many people with diabetes. However, CGM data are often underutilized in primary care settings, where most adults with diabetes are treated.

Local problem: Despite a growing patient population using CGM in a complex primary care clinic, the clinic lacks a structured workflow process for manually uploading CGM reports to the electronic health record. As a result, CGM data are inconsistently used by primary care providers for clinical decision-making during routine visits.

Methods: Using the Plan-Do-Study-Act methodology, workflow processes for registered nurses (RNs), licensed practical nurses (LPNs), doctors of medicine (MDs), family nurse practitioners (FNPs), and clinical pharmacists (PharmDs) were examined and improved to support the project goals.

Interventions: Patients actively using CGM were identified daily. Assigned clinic nurses (n = 3; 1 RN and 2 LPNs) uploaded CGM logs as precharting to the visit, which were then used by providers (n = 3; 1 MD and 2 FNPs) during clinical encounters. When nurses were not available, the MD, FNPs, or PharmD (n = 1) completed the workflow.

Results: Ambulatory glucose profiles were uploaded to precharting in 43 of 45 patients (96%) with active CGM during the project evaluation period. Providers discussed CGM in 38 (88%) of these cases, using it correctly 100% of the time. The current procedural terminology code 95251 was billed in 35 (92%) of the applicable visits.

Conclusions: Interprofessional teamwork to implement clinic workflow process improvements supports the delivery of guideline-driven diabetes care for adults using CGM.

Abstract: Inherited thrombophilias are genetic conditions that increase the lifetime risk of venous thromboembolism (VTE), specifically deep vein thromboembolism and pulmonary embolism. However, most people with thrombophilia never develop a VTE. The five classic inherited thrombophilias, such as Factor V Leiden, prothrombin G20210A mutation, protein C deficiency, protein S deficiency, and antithrombin deficiency, differ in prevalence and VTE risk, influenced by factors such as zygosity and coinheritance. Current clinical guidelines discourage universal thrombophilia testing, recommending it only when a positive result would alter patient-management decisions or where family members might benefit. These recommendations are based on low-certainty evidence due to the lack of high-quality outcome data. Conflicting guidance is common, and questions remain about some clinical scenarios clinicians encounter in practice. Two national guidelines from the American Hematology Association and the American College of Obstetricians and Gynecologists illustrate thrombophilia testing considerations. Advanced practice nurses play a central role in providing individualized risk assessment, working collaboratively with others to guide testing decisions and interpretation of results, and coordinating care. When used selectively, thrombophilia testing can enhance VTE prevention while avoiding unnecessary and expensive screening.