The Physician Assistant and Nurse Practitioner professions initially began in response to healthcare shortages after the Vietnam War in the 1960s. Highly trained combat medical personnel developed into highly skilled PAs, while during this same time nurses began advanced practices that ultimately evolved into the position of NPs. Since this time, the roles and responsibilities delegated to each of these fields have drastically evolved, and are expected to continue to do so in the face of current health care reform under President Obama's Patient Protection and Affordable Care Act initiated in 2010. Originally perceived as "understudies" to physicians, PAs and NPs have become much more trained in their expertise, respected in their roles, and autonomous in their practice. Due to this, it has been predicted that PAs and NPs will become the major primary care providers in the face of increasing demands in this area of medicine. Large numbers of aging populations and up to 32 million newly insured patients seeking healthcare, coupled with physician shortages, have increased demands on PAs and NPs to fill these employment gaps. As there has been an increased demand on the PA and NP profession, there has been a paralleled increase in the number of educational programs producing graduates, larger class sizes, and larger numbers of PAs and NPs entering the workforce. The problem is posed when PAs and NPs, who desire to pay off student loans quickly and, understandably, seek high wages and professional advancement, pursue specialty and subspecialty employment versus filling in primary care gaps as anticipated. As the roles of PAs and NPs change, and more is expected of them in terms of practice and reliability, there are barriers to their growth. Professional tensions between these providers and physicians, poor understanding of what roles PAs and NPs hold by the public, unequal reimbursement for comparable services, and strict state legislation that limits the scope of practice of both PAs and NPs all inhibit these healthcare professionals from practicing to their fullest potential. This, in turn, may hinder persons becoming PAs and NPs from funneling into the ever increasingly demanding primary care field of medicine, and may pose future problems as patient populations increase under the Affordable Care Act. This paper assesses the current roles and responsibilities of PAs and NPs, how each profession is expected to grow, and the evolution of these healthcare providers as the potential "solution" to primary care needs. Statistics regarding current distributions of PAs and NPs in practice, educational expansion, obstacles that these professions must overcome, and the capabilities of PAs and NPs alike are analyzed, and conclusions drawn on what the contributions of these healthcare professionals may be in the future. Overall, it is expected that PA and NP presence in the medical field will undoubtedly increase. Whether these professionals will serve as an adequate source of primary care providers in the face of increasing demands imposed by the Affordable Care Act is yet to be seen, however. Barriers including professional tensions, reimbursement policies, wages, and strict state restrictions on the scope of practice of these individuals will need to be addressed. While it is projected that PAs and NPs will "solve" the current and future primary care physician shortage, this fact truly remains to be seen.

abstract: Health care providers (HCPs) are an important source of physical activity (PA) information. Two studies were conducted to qualitatively and quantitatively examine nurse practitioners'(NPs) and physician assistants' current PA counseling practices, knowledge and confidence to provide PA counseling and providers' perceptions about their current PA counseling practices. The specific aims for these two studies included quantitatively and qualitatively identifying the prevalence of PA counseling, perceived counseling knowledge and confidence, and educational training related to counseling. In study 1, survey respondents were currently practicing NPs and physician assistants. Participants completed a modified version of the Promotion of Physical Activity by Nurse Practitioners Questionnaire either online or in person during a population specific conference. The majority of both NP and physician assistant respondents reported routinely counseling patients about PA. There were no differences in perceived knowledge or confidence to provide PA counseling between the two populations. Approximately half of all respondents reported receiving training to provide PA counseling as part of their educational preparation for becoming a health practitioner. Nearly three-quarters of respondents reported interest in receiving additional PA counseling training. In study 2, five focus groups (FGs), stratified by practice type, were conducted with NPs and physician assistants. Both NPs and physician assistants reported discussing PA with their patients, particularly those with chronic illness. Participants reported that discussing lifestyle modifications with patients was the most common type of PA counseling provided. Increased confidence to counsel was associated with having PA knowledge and providing simple counseling, such as lifestyle modifications. Barriers to counseling included having more important things to discuss, lack of time during appointments, the current healthcare system, lack of reimbursement and perceived patient financial barriers. PA recommendation knowledge was highly variable, with few participants reporting specific guidelines. FG participants, while not familiar with the American College of Sports Medicines' "Exercise is Medicine" initiative indicated interest in its use and learning more about it. The findings of these two studies indicate that while NPs and physician assistants are knowledgeable, confident and currently providing some amount of PA counseling to patients, additional training in PA counseling is needed and desired. / Dissertation/Thesis / Ph.D. Exercise and Wellness 2011

Information from anecdotal interviews at a practicum site indicated a lack of training for advanced practice providers (APPs) in core competencies critical for effective practice in a heart failure (HF) unit. The goal of this project was to assess the APPs' verbal reports and develop HF unit-specific training for APPs. The practice-focused question examined whether unit-specific training for HF APPs improved knowledge and skills in HF management. The Johns Hopkins nursing evidence-based practice model and Knowles's adult learning theory were used to create a survey, a focus group, and a pre/posttest assessment of knowledge and skills gap. Descriptive and inferential statistics could be used to analyze pre/post survey data, and thematic analysis could be used to analyze focus group data. Assessment data could be used to develop a targeted HF program based on identified skill deficiencies. The implications of this project related to social change are the potential to increase APPs' knowledge, job engagement, and retention. The program could affect length of stay and 30-day readmission of patients in the HF unit.

Many patients with end-stage renal disease come to rely on catheters as their only means of hemodialysis when other options are no longer viable. These patients have a very poor quality of life due to their chronic illness as well as many long-term complications related to the use of tunneled catheters. Many prior attempts have been made to understand these catheter-related problems. Yet, they continue to be a major cause of morbidity and mortality in chronic catheter-reliant patients. We hope to examine the rate as well as long term time course of these complications such that in future, we may decrease their occurrence. We predict that over time, chronic catheter use decreases the mean indwell time for each catheterization and increases the incidence of complications. To study this, we conducted a retrospective study looking at all patients who had three or more tunneled catheter exchanges between July 2003 and July 2008. We collected information from Yale IDX database on the patients age and gender, the type of catheter used, the indwell time of the catheter, the vessel used as access, the indication for catheter removal, whether the procedure was performed by a medical doctor (M.D.) or physicians assistant (P.A.) and whether it was a de novo insertion or over-the-wire exchange. We collected a total of 764 data points on 191 patients (89 males and 102 females). They ranged from 8 to 87 years old with a median age of 56 years. Infection was the number one indication for catheter removal at 37%. The rate of infection was 3.34 per 1,000 catheter days. There was no difference in the rate of complications by the side of vessel accessed nor by type of catheter. However, right-sided catheters had a longer indwell time of 117 + 159 days compared to left-sided catheters, 87 + 124 days (p =0.008). There was no significant difference in the indwell duration of first catheter in comparison to all subsequent placements. There was also no difference in complications whether the catheter was exchanged over the wire or placed de novo. Nor were complication rates different among M.D. versus P.A. conducted procedures. We conclude that our rates of infection are similar to other institutions and the vessels located on the right-side of the neck are preferable to left-sided vessels to increase catheter longevity. Future research is needed to better assess how rates and incidences of complications change with long standing catheter-reliance.

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.

Health disparities in minorities and those of low socioeconomic status persist despite efforts to eliminate potential causes. Differences in the delivery of services can result in different healthcare outcomes and therefore, a health disparity. Some of this difference in care may attribute to discrimination resulting from clinical biases and stereotyping which may provide a possible source for the persistence of health disparities. Health disparities may occur because the delivery of services at some level is inadequate. Disparities resulting from the quality and quantity of care delivered by a practitioner result in differentiated delivery of healthcare, thus unequal health outcomes. The purpose of this study is to evaluate and identify potential disparities in routine screening practices of physician assistants.A randomized sample of practicing physician assistants in Kentucky were analyzed (N= 112) to determine if the race or socioeconomic status of a patient influenced their likelihood of offering different routine screening recommendations and screening test recommendations. Clinical vignettes were created with only the race and socioeconomic status of the patient modified, resulting in four separate vignettes. Through the use of a survey instrument, participants were randomly assigned to one of four written clinical vignettes. Statistical analysis using a MANOVA revealed that the race of a patient had a statistically significant multivariate effect on differences in screening recommendations and race and socioeconomic status had significant multivariate effects on screening test recommendations.Study results suggest that race and socioeconomic status continues to be a significant factor in the prevalence of healthcare disparities. More importantly, this study reveals that Physician Assistants may provide differentiated care based on a patient’s race. Limitations and future directions for this study may be used to examine PA educational curriculums for the inclusion of health disparities and possible continuing medical education opportunities for practicing PAs.

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Qualitative case study research on Physician Assistants / Background: The Ministry of Health and Long Term Care (MOHLTC) introduced Physician Assistants (PAs) into the Ontario health care system in 2006 to help increase patient access to care, decrease wait times, and improve continuity of care. As a new addition to Ontario, little research exists to describe the roles and contributions of PAs. The aim of this dissertation is to explore PA role integration through an in-depth analysis of setting and role descriptions, barriers and facilitators of role integration, and healthcare provider perceptions. Methods: An exploratory, multiple-case study was used to examine PA role integration in four clinical settings: family medicine, emergency medicine, general surgery, and inpatient medicine. Inductive thematic analysis was used within each of the four cases and for the cross-case thematic analysis. Results: Forty-six health care providers and administrators were interviewed across 19 different healthcare sites. Support for PA contributions across various health care settings, the importance of role awareness, supervisory relationship attributes, and role vulnerability (in relation to sustainability and funding) are interconnected and dynamic in general surgery, inpatient medicine, emergency department and family medicine settings. These findings demonstrate how the flexible and adaptable nature of the PA role and the PAs ability to build relationships allows for the establishment of interprofessional, collaborative, and person-centered care. Conclusions: This dissertation provides a rich understanding of the role of PAs in the Ontario healthcare system through an exploration of role definition, impact on patient care, and professional perceptions. The findings from this dissertation are important from a broad systems perspective as the results help fill existing knowledge and practice gaps regarding the role of PAs, and will help inform the design of human health resource research in order to optimize health care system efficiencies. / Thesis / Doctor of Philosophy (PhD) / Physician Assistants (PAs) are a new health care profession in Ontario, and were introduced by the Ministry of Health and Long Term Care (MOHLTC) in 2006 to help increase access to care and decrease wait times for patients. PAs are trained to work with physicians to extend healthcare services. This research study was undertaken to explore how the PA role has been integrated into number of health care settings, including family practices, emergency departments, general surgery and inpatient medicine settings. The research design is a qualitative case study, which allows for an in-depth exploration of the PA role. Findings revealed that PAs are flexible, collaborative, and adaptable members of healthcare teams in Ontario, who have an interest in enhancing patient care. Despite these benefits, role optimization is often limited by factors such as lack of funding and resistance from other healthcare providers. The findings from this study help fill research gaps around the PA profession in Ontario, and will help inform stakeholders interested in optimizing the impact of PAs in the Ontario healthcare system.

No description available.

No description available.