D.Cur. / The goal of this research was to generate and describe a support approach for the advanced practitioner in psychiatric nursing to utilize for the neonatal intensive care nurse, working in a neonatal intensive care unit, in order to promote, to maintain and to restore mental health as integral part of health. Many changes occurred in the health care industry during the twentieth century. In South Africa, health care and social services that have developed, are grossly inefficient and inadequate. The Reconstruction and Development Program (R.D.P.), (1994:42-47), of the government of National Unity, designed therefore a number of programs to restructure the health care services , in order to contribute to the increasing prosperity and quality of life for all South Africans. Free health care has thus to be provided in the public sector for children under six, pregnant and nursing mothers. Free health care makes it more accessible for thousands of people who have avoided seeking help in the past, because of lack of funds. This large influx of patients to health facilities has placed a strain on staff, due to the increased workload. The neonatal intensive care nurses' workload and responsibilities have thus increased.

Burnout among primary care providers, which include physicians, nurse practitioners, and physician assistants, can negatively impact patients, providers, and organizations. Researchers have reported that up to 37% of primary care physicians experience burnout, yet the prevalence, predictors, and outcomes associated with primary care nurse practitioner burnout remains unknown. Since 69% of nurse practitioners provide primary care to patients, this dissertation investigates the predictors and outcomes associated with primary care nurse practitioner burnout. A history of burnout as well as the importance of investigating burnout among primary care nurse practitioners are discussed in the first chapter. A systematic review of the predictors and outcomes of primary care provider burnout is discussed in the second chapter. The third chapter describes a cross-sectional study conducted among 396 primary care nurse practitioners from New Jersey and Pennsylvania, which investigated whether the practice environment is associated with nurse practitioner burnout. The fourth chapter describes a cross-sectional study investigating whether the use of multifunctional electronic health records is associated with primary care nurse practitioner burnout. The fifth chapter includes another cross-sectional study examining the relationship between primary care nurse practitioner burnout and quality of care, and if the practice environment moderates the relationship between burnout and quality of care. Finally, the sixth concluding chapter summarizes the findings from chapters two to five and provides recommendations for future research, practice, and policy.

Currently, 6 million Americans have Alzheimer’s disease and Alzheimer’s disease-related dementias (AD/ADRD). As the segment of Americans aged 65 and older continues to increase, the number of older adults with AD/ADRD (referred to as Persons Living with Dementia [PLWD]) also grows. Additionally, the use of health care services, such as hospitalizations, is increasing among PLWD. Indeed, hospitalizations are more prevalent among PLWD compared to older adults without dementia. Some of these hospitalizations are ambulatory care sensitive condition hospitalizations that can be prevented if individuals have better access to high-quality primary care. However, delivering high-quality primary care is becoming increasingly challenging given the projected PLWD population increase and the shortage of primary care providers. On the other hand, the number of primary care nurse practitioners who can deliver high-quality and cost-effective care to older adults has grown in recent years and will continue to increase with demand. Nonetheless, little is known about how to strengthen essential practice features (i.e., structural capabilities) needed to deliver high-quality care in practices where nurse practitioners provide care to PLWD. Enhancing primary care delivery by strengthening structural capabilities in primary care, such as electronic health records, care coordination, community integration, and reminder systems, can be an effective way to reduce hospitalizations among PLWD. The overall objective of this dissertation is to assess the effects of primary care structural capabilities in practices employing nurse practitioners on both ambulatory care sensitive conditions and all-cause hospitalizations among PLWD. This dissertation entails five chapters. Chapter 1 describes the significance of structural capabilities and related outcomes among PLWD. Chapter 2 includes a systematic review of existing dementia care models in various ambulatory care settings and summarizes the impact of dementia care models on hospitalizations among community-residing PLWD in the United States. Chapter 3 describes the availability of the selected structural capabilities in primary care practices where nurse practitioners provide care to PLWD. The structural capabilities of practices that provide care to a high volume of PLWD are also compared to those caring for a low volume of PLWD in this chapter. Chapter 4 assesses the impact of structural capabilities in primary care practices employing nurse practitioners on hospitalizations among PLWD. Finally, Chapter 5 summarizes the findings from Chapters 2 to 4 and includes information on the strengths, limitations, and implications of the research and findings of the dissertation.

To improve patient safety a major change in health care reduced medical resident work hours to limit provider fatigue, in 2002 (Philibert, Friedmann, Williams, & Hours, 2002). This resulted in mid-level practitioners filling this provider void in health care teams, including critical care units (Buchanan, 1996; Christmas et al., 2005; Hoffman, Tasota, Scharfenberg, Zullo, & Donahoe, 2003; Hoffman, Tasota, Zullo, Scharfenberg, & Donahoe, 2005; Hooker & McCaig, 1996, 2001; Kaups, Parks, & Morris, 1998; Miller, Riehl, Napier, Barber, & Dabideen, 1998; Yeager, Shaw, Casavant, & Burns, 2006). In order to make appropriate clinical decisions for patients in critical care settings, mid-level practitioners are required to interpret data from multiple sources and to assimilate this information in a timely manner (Bernard, Corwin, & MacIntyre, 2000). Although these practitioners are actively involved in decision making individually and among interdisciplinary teams in critical care units, their decision making has not been described in the literature to date (Shortell et al., 1994). Therefore, the purpose of this qualitative study was to describe how critical care mid-level practitioners (N= 17) make decisions within an interdisciplinary team, undergirded by the cognitive continuum theory. A qualitative research design using focus groups guided by naturalistic inquiry enabled data collection. An interview guide, developed from the literature review and undergirded by the cognitive continuum theory, was used to structure discussion in the focus groups. Additionally, a demographic questionnaire and vignette were used to aid in description of findings. Data was managed by note based analysis and summarized on a Microsoft Excel document. Qualitative description was used to illustrate the findings. Prior to this study, there was a paucity of empirical literature describing the clinical decision making of critical care mid-level practitioners. The findings revealed a web of complexity in mid-level practitioner decision making on an interdisciplinary team. This included an overarching theme of quality of care, with central overlapping themes of judgment, resources, and negotiation interwoven with sub-themes of trust, communication, experience, and team structure. This study’s findings have direct implications for mid-level practitioner training courses, mid-level training, critical care orientation programs, theory development, and health policy.

In many states, outdated rules and regulations restrict nurse practitioners (NPs) from practicing to their full potential, often limiting patients’ access to primary care. Modernizing NP state scope of practice laws and allowing patients greater access to NPs services is a priority. Unlike other professions, nurse practitioners have been unable to consistently influence legislative changes to health policy. This study examined the political efficacy and participation of nurse practitioners in the United States today (N=632). A descriptive cross sectional design, in conjunction with a political efficacy framework, evaluated nurse practitioners’ participation in political activities and their internal and external political efficacy. Increased internal political efficacy was significantly (p < 0.001) associated with NPs who were older, had specific health policy education, and have been mentored in health policy. Our findings show that NPs vote at consistently higher rates (94%) than the general population and almost 50% report contacting legislators via mail/email/phone. As a group however, NPs report limited participation in other political activities, especially grassroots efforts. These findings hold significant implications for the profession as we strive to make policy changes across the country. It is important that educators assess our current methods of educating NPs about politics and health policy. Professional organizations and policy makers must reexamine outreach and strategies to inspire greater grassroots engagement of NPs.

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That nurse practitioners (NPs) delivery high-quality care, equivalent to that provided by physicians, is well documented. However, many states have laws that restrict NPs from full practice authority, limiting their ability to comprehensively meet patient needs. North Carolina is a state that has very restrictive laws, with NPs working under physician supervision. In this article we address the effect restricted practice has had in North Carolina and the introduction of Senate Bill 695 (the Modernize Nursing Practice Act) that, if passed, would legislate full practice authority for NPs in our state.

Mental health conditions, particularly substance use disorders, are a growing public health threat that affect millions of Americans. Drug use disorders (DUDs), a subset of substance use disorders, are chronic conditions characterized by clusters of behavioral, cognitive, and physiological symptoms related to the use of opioids, hallucinogens, stimulants, cannabis, anxiolytics/hypnotics/sedatives, inhalants, multiple drugs, other drugs, or unknown drugs. The prevalence of DUDs among older adults ages 65 and older is growing. In 2021, almost 2 million older adults in the United States (U.S.) had a DUD. DUDs have a detrimental effect on health, especially among older adults with DUDs, who are more likely to have comorbid chronic conditions such as chronic obstructive pulmonary disorder, diabetes, and chronic heart failure than older adults without DUDs or other age groups with DUDs. The medications and symptoms of these comorbid conditions can interact with DUD-associated drugs and cause high risk for falls, delirium, medication interactions, chronic disease exacerbations, and acute emergency department (ED) utilization. Thus, in addition to the alarming growth in the prevalence of DUDs in older adults, this population faces additional risks for poor health and acute ED utilization.Despite similar prevalence of DUDs among rural and urban older adults, older adults in rural areas have decreased access to DUD care. In rural areas, there is lower availability of DUD specialists and treatment centers. In 2019, 1,149 rural counties did not have a provider who could prescribe buprenorphine (a medication for opioid use disorder), compared to only 57 urban counties. Rural residents must drive an average of 49.1 minutes to receive DUD treatment, compared to just 7.8 minutes for urban residents. Enhanced availability of DUD treatment in primary care settings may fill the gap in access to mental health and substance use care in rural communities as older adults seek primary care providers for other routine care. Prior studies have shown that patients who seek and receive pharmacologic or psychological interventions in primary care settings may have improved DUD outcomes such as lower rates of relapse, increased retention in treatment, and abstinence. The Affordable Care Act increased funding for rural primary care practices to deliver integrated mental and physical health care, which may improve outcomes for older adults with DUDs. Yet, many rural older adults with DUDs do not receive DUD screening and treatment in primary care. Presently, only 45% of patients are screened for DUDs in the community. Primary care providers often report that they do not have the confidence to address DUDs. While some research shows that organizational support such as DUD-specific training and clinical resources are key to improving primary care provider confidence in addressing opioid use disorder, there is very little research focused on the unique needs of rural primary care providers in delivering DUD services. Research on organizational factors that influence the availability and quality of DUD services in rural primary care practices is needed to bolster primary care capacity to serve older adults with DUDs in rural areas. Rural primary care practices increasingly rely on the growing nurse practitioner (NP) workforce to deliver care. Over one-quarter of the rural primary care workforce is NPs. Most research on the rural primary care NP workforce and DUD services focuses on NP prescribing of buprenorphine, a medication for opioid use disorder. Half of the new buprenorphine providers in rural areas are NPs, and NPs treat more patients with buprenorphine than physicians in rural areas. Despite NPs’ contribution to DUD care for rural patients, studies show that many NPs practice in challenging work environments that negatively impact their ability to deliver patient care. The NP work environment is often characterized by a lack of resources, autonomy, and support, which affects the delivery of patient-centered care, high-quality care, and health services utilization among patients with chronic conditions. Studies have suggested that work environment factors such as teamwork and autonomy may influence NP prescribing of buprenorphine. Yet, no studies have focused on NP work environments in primary care practices and how they affect care for older adults with DUDs in rural areas. The overall purpose of this dissertation is to produce evidence on enhancing the primary care NP workforce’s ability to deliver mental health and DUD services. The first study in this dissertation (Chapter 2) was a systematic review of the literature focused on the effectiveness of NP care for patients with mental health conditions (i.e., anxiety, depression, and substance use disorders) in primary care settings. These conditions were included to identify the state of the literature base focused on NP mental health care delivery in primary care settings, particularly focused on gaps in evidence related to NP care for rural older adults with DUDs. The second study in this dissertation (Chapter 3) conceptualized primary care provider confidence in addressing opioid use disorder to understand how to support providers (i.e., physician, NPs, and physician assistants) in delivering DUD care through policy, practice, and research innovations. The third study of this dissertation (Chapter 4) assessed the relationship between the NP work environment and rural NP practices’ capacity to serve older adults with DUDs. Finally, the fourth study (Chapter 5) examined the impact of the NP work environment in rural primary care practices on ED utilization among older adults with DUDs. Findings from the studies included in this dissertation can be used to improve primary care delivery in rural areas and inform policy and research innovations to address the growing public health threat of DUDs among rural older adults. Materials and Methods This dissertation utilized novel materials and methods to inform the development of policy, practice, and research innovations that enhance the primary care NP workforce’s ability to deliver mental health and DUD services. The following presents the study design of each individual chapter to achieve the study’s aims. Study 1 | Chapter 2: This systematic review of the evidence addressed the effectiveness of NP care for patients with mental health conditions in primary care settings. We followed Joanna Briggs Institute (JBI) Manual for Evidence Synthesis for systematic reviews of effectiveness and reports results according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The review protocol is published with PROSPERO (ID = CRD42021269816). Study 2 | Chapter 3: This concept analysis followed the Walker and Avant framework to conceptualize primary care provider confidence in addressing opioid use disorder. Study 3 | Chapter 4: The goal of this study was to assess the impact of the NP work environment on the capacity of rural primary care practices to serve older adults with DUDs in rural areas. To achieve this aim, we conducted a secondary data analysis of cross-sectional NP survey data from 2018-2019 merged with Medicare claims from 2018. We conducted our statistical analysis using fractional logistic regression. Study 4 | Chapter 5: The goal of this study was to examine the association between the NP work environment and ED utilization among older adults with DUDs in rural areas. To achieve this aim, we conducted a secondary data analysis of cross-sectional NP survey data from 2018-2019 merged with Medicare claims from 2018. We conducted our statistical analysis using multilevel logistic regression. Conclusions This dissertation produced evidence that enhances the primary care NP workforce’s ability to deliver mental health and DUD services. In Chapter 2, the systematic review of the literature identified a lack of high-quality research focused on NP primary care for patients with mental health conditions, particularly among patients with substance use disorders in rural areas. Chapter 3 conceptualized primary care provider confidence in addressing opioid use disorder and found that teamwork, organizational culture, resources, and support may uniquely influence provider confidence, which is associated with positive patient outcomes, increased delivery of and access to opioid use disorder services, and provider attitude changes. In Chapters 4 and 5, our studies found that the NP work environment in rural primary care practices is associated with increased practice capacity to serve older adults with DUDs and reduced ED utilization in this population. These dissertation findings provide important insights that will allow policymakers, practice administrators, and researchers to invest in productive efforts to enhance the primary care NP workforce’s ability to deliver mental health and DUD services.

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