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Simulation as a pedagogy is used extensively to educate healthcare professionals in both academic and clinical arenas with the intent to improve the delivery of care and patient outcomes. Advanced practice nursing (APN) programs use simulation as a pedagogy even though APN accreditation and certification organizations prohibit substituting simulation hours for the minimum 500 clinical hours. The purpose of this qualitative study was to explore faculty perceptions of educating APN students using simulation. Focus groups were conducted with a convenience sample of APN simulation faculty. Disruptive innovation theory was used by the researchers to guide the data analysis. Themes emerging during analysis included: 1) extrinsic tension and pressure in the midst of chaos, 2) internal vulnerability, and 3) passion and tenacity to remain resilient. The study results provide clarity to understand integration of APN simulation in the current environment, and introduce the impact of simulation as a disruptive innovation.

Abstract Background: Access to adequate palliative care has been identified as a challenge globally, in Canada, and in the province of Ontario. While pockets of excellence exist, there is a national call for allocation of resources and implementation of best practices to improve the care for individuals with life limiting illnesses. Furthermore, the location of care along with a desire for dying at home has shifted responsibility onto family members often without the equivalent shift in community resources to meet patient and family needs. To respond to issues of access and quality, nurse practitioners (NPs) have been increasingly added to diverse practice settings across the globe and research showing how they are contributing to diverse care settings. As a strategy to improve community palliative care locally, NPs have been added to community settings in Ontario. However, because NPs are new to palliative care settings little is known about how NPs enact their role within this unique context. NP role enactment is defined as the actual activities that NPs engage in that constitute their daily work. Aim: The purpose of this study is to better understand how NPs enact their role as consultants in a specific community palliative care setting in Ontario. Methodology and Methods: A focused ethnography was conducted in one specific geographic health administration region of Ontario between July of 2018 and October of 2020. A convenience sample was used recruiting NPs from one community palliative care consultation team. Data collection methods included observation (487.5 hrs over 89 discrete observation sessions, distributed across 7 study participants), fieldnotes and semi-structured interviews with participants (n = 7 NPs). Results: The NPs enacted their role with patients by formulating relationships, that for them, facilitated a deeper understanding of the patient and family situation, strengths, challenges and desires. Using conversations and conversational skills to have difficult and important conversations, NPs facilitated future planning for patients. Conversations also included addressing questions about MAiD, which were nuanced and often about more than MAiD, also addressing fears of suffering and uncertainty. The NPs used advanced clinical judgment and skill to diagnose and treat complex and difficult to manage symptoms and supported families to understand complicated medication regimes. Valuing their role as educators, the NPs supported their peers by offering teaching and providing clinical support in complex care scenarios. Pull together disparate and loosely connected care providers, NPs created a shared understanding of patient needs. Deficiencies in community care resourcing and organization made it difficult at times for NPs to facilitate continuity in care or to build capacity. The NPs often navigated an environment where nursing staffing was transient, inconsistent and overextended and where physicians were inconsistently available to support rapidly evolving situations. Conclusion: Findings suggest that NPs have an important role to play in supporting patients and families as well as supporting their nursing and physician colleagues. Furthermore, the broader system would benefit from embedding palliative care NPs more systematically. However, broader structural enhancements like shared communication and documentation mechanisms and adequate staffing across care settings need to be addressed to maximize the potential contributions NPs are able to offer.

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The Doctor of Nursing Practice (DNP) Family Nurse Practitioner (FNP) curriculum was developed to incorporate learning outcomes and experiential opportunities for students to attain the core FNP knowledge for doctoral education. Historically, challenges related to developing clinical skills in blended/online programs has been problematic. The appeal of online FNP education has challenged educators to develop new ways to provide students opportunities to experience hands-on clinical skills within the subspecialties of the DNP, FNP role. With limited clinical sites, and now with more clinical access constraints imposed by the COVID-19 pandemic, it is imperative that new models of instruction provide students opportunities for skills training. The purpose of this project is to describe use of scaffolding methodology to design student skills learning activities using synchronous online and on-ground sessions during DNP intensives. Student and faculty input identified the types of practice skills and procedures needing improvement, such as suturing, electrocardiogram, etc. An intensive task force was organized to evaluate curricular elements; content was then mapped to analyze gaps. The first step included aligning advanced practice nursing skills sessions in each intensive with the related clinical courses offered within that semester. Then, students were organized into a skills rotation plan based on their date of admission and place within their program of study. Modifications required by COVID-19 on-ground restrictions necessitated re-thinking intensive skills sessions. Student satisfaction scores significantly improved after the intensive sessions were restructured. Faculty continue to seek feedback from the students to provide beneficial practice opportunities during the DNP intensives.

Heart failure (HF) is one of the main reasons for hospitalizations and readmissions. A local hospital collaborated with a skilled nursing facility (SNF) in 2012 with the goal of reducing systolic HF readmissions. This collaboration consisted of having an Advanced Practice Nurse (APN) who specializes in cardiac care follow up with all patients discharged from the hospital to the SNF with a diagnosis of systolic HF. The practice-focused question for this project addressed whether early follow-up and continuity of care by a cardiac APN would decrease hospital readmission within 30 days in patients with systolic HF who are discharged to a SNF. This project evaluated the effectiveness of this intervention using the Donabedian quality framework. The Donabedian quality framework consists of 3 concepts: structure, process, and outcome. Sources of evidence were obtained through the electronic medical record systems at both facilities. Total of 1,009 patients were seen by the cardiac APN from 2012 to 2016. Results showed a steady decline in readmissions from 47% to 6%. This supported the conclusion that collaboration between hospitals and SNFs post hospital discharge is essential to improve the management and readmissions of HF. Specialized APNs, such as the cardiac APN in this study, may be more effective in the management and coordination of care for a specific patient population. Implications of this successful collaboration include better working relationships between nonaffiliated health care facilities, improved patient care outcomes, decreased readmissions for HF patients, and an improved community health care system.

Advanced practice providers (APPs), consisting of nurse practitioners and physician assistants, face many challenges in the provision of evidence-based practice in their management of hospitalized adult patients with diabetes. Some of the barriers faced by APPs at a Northeast acute care facility are poor communication between disciplines, lack of confidence in initiating insulin, limited understanding of the management of insulin and the insulin pump, and insufficient treatment of the hospitalized patient with diabetes that aligns with current clinical guidelines for the management of inpatient hyperglycemia. This quality improvement project focused on the development of an evidence-based theory supported educational intervention to improve APPs' knowledge regarding glycemic management. An interdisciplinary team created the educational intervention using the analyze, design, develop, implement, and evaluate (ADDIE) instructional model. A 10-member expert panel validated the program utilizing both a formative and summative evaluation. The results from the formative evaluation was discussed with the interdisciplinary team, corrections were made, and was returned to the expert panel. Once the changes were made to the satisfaction of the expert panel, the program was then validated and submitted to the institution as a completed project to be used by the institution for APPs. This project addresses social change by increasing awareness in the management of inpatients with diabetes therefore decreasing fragmented care delivered by the APPs which will improve quality of care and patient safety.

Professional organizations offer nurses services and resources for professional growth throughout their careers; yet, membership has declined over the past 10 years. Accordingly, this study was to understand the barriers in membership and identify positive changes that will increase membership and retain members. A quantitative descriptive design was employed within a convenience sample of 150 advanced practice registered nurses (APRNs) who were past or nonmembers of a professional organization. Exchange theory was applied and the Professional Association Membership Questionnaire (PAMQ) was administered to assess the barriers to APRNs participating in a specific professional organization. Statistical analysis included mean scores for each of the PAMQ's 34 questions with groupings by benefits and barriers using a 7-point Likert-type scale. Study results indicated 71% (n = 106) of 150 participants ranked continuing education as the most important benefit when considering joining a professional organization. Although prior literature frequently reported cost as a barrier to membership in professional organizations, fewer than 50% (n = 56) of participants in this study ranked cost as a barrier to membership. Professional organizations can bring about positive social change by providing accessible continuing education to membership. To do so will improve the quality of nursing services through evidence-based practice, education, and leadership. Membership in a professional organization allows the nurse to maintain current awareness of health care changes and policies. Significant membership is necessary in order for the organization to have a major impact in the profession.

The purpose of this qualitative dissertation study was to examine the lived experience and meaning making of challenges, benefits, satisfaction, and professional sustainability for the advanced practice provider in the burn surgery specialty service. The problem addressed was the knowledge gap resulting from a lack of literature describing aspects of the advanced practice provider role in the burn specialty. An interpretive phenomenological analysis, informed by the philosophy of Dr. Martin Heidegger, was undertaken. Participants were solicited from the American Burn Association Advanced Practice Provider (APP) special interest group site. The results provided a thick description of the lived experience of the Burn APP offering, illuminating commonalities and distinctions to promote role gratification and fulfillment leading to professional success and prolonged engagement. Keywords: advanced practice provider, nurse practitioner, physician assistant, interpretive phenomenology, hermeneutics.

Background: Graduate nursing academic faculty rely heavily on clinical preceptors for mentorship and clinical practicum experiences for BSN-DNP degree-seeking family nurse practitioner (FNP) students. Thus, it is important that preceptors have documented clinical competencies to assure the delivery of quality, evidence-based practice that meets regulatory requirements prior to precepting students.Objectives: The objectives of this quality improvement project were to develop and implement APRN competency validation tools (CVTs) in nurse-led clinic settings.Methods: Rapid Cycle Quality Improvement (RCQI) strategies were used to develop and implement APRN CVTs.Results: Three APRN CVTs were successfully developed, tested, refined, and implemented in four nurse-led clinics in rural east Tennessee. With one exception, the APRN preceptors had documentation of clinical competency prior to approval as a SPADES preceptor. Graduate academic faculty, preceptors, and students reported satisfaction with the SPADES project.Conclusion: CVTs are feasible tools for documentation of validated clinical APRN preceptors’ competency in nurse-led clinics. The CVTs and the medical record review checklist are available upon request from the primary author.Implications for Nursing: Use of APRN CVTs provides documentation that the preceptor uses evidence-based practice in the clinic setting prior to precepting students.