Minimally invasive aesthetic medicine (MIAM) is a relatively new field, which lacks a clearly defined scope of practice. The purpose of this project was to clarify the scope of practice for nurse practitioners in MIAM in California. Without a clearly defined scope of practice, nurse practitioners are unable to practice to the full extent of their license which causes them to be underutilized and face liability issues. This project sought to answer the question: What is the scope of practice of the nurse practitioner in MIAM in the state of California? The model of professional nursing practice regulation was the model used to guide this project. Sources of evidence included case law that has emerged since 1983; reviewing documents from 3 state boards of nursing; and a survey of nurse practitioners who practice in the field of MIAM. The evidence was analyzed noting themes while determining what the legal backbone is for nurse practitioner's scope of practice in California. This project found that nurse practitioners in this field keep up to date in their knowledge, educate their patients, utilize methods to maintain competency, feel support in their environment, assess and refer to others when appropriate, and teach both staff and patients evidence-based practices. It also found that standardized procedures are the legal backbone to understanding the scope of practice in California. A scope of practice was developed based on the findings of this project which was then reviewed by an expert. It is recommended that nurse practitioners utilize their resources to obtain and maintain knowledge as well as learn what the standardized procedures are in their facility. The implications for clarifying the scope of practice will serve this population to fully utilize their capabilities and practice safely, as well as help to develop this relatively new field.

Canadian doctors have historically been an extremely powerful interest group. While there are many variables that account for their political influence, it is widely accepted that much of their power is due to their control over specialized knowledge. To determine whether or not physicians’ control over knowledge is changing, I examine doctors’ position relative to the state, the public and other health professionals. This research finds that, in all three relationships, physicians’ control over knowledge is weakening. Moreover, organized medicine’s response to these developments has largely been a strategy of co-optation, demonstrating that doctors are aware that these changes often cannot be openly fought. This strategy signals that the medical profession recognizes that some changes in its control over knowledge are bound to occur. This study concludes that these changes could contribute to a ‘critical juncture’ signalling the potential for significant change in the physician-state relationship.

Purpose: to describe the knowledge, beliefs, and attitudes of physicians and hospital administrators regarding the role and scope of practice of acute care nurse practitioners in rural Montana. Background: Nurse practitioners have been increasingly called upon to provide high quality and cost-effective healthcare in variety of settings and have consistently shown to provide a high-level of patient care in both the primary and acute care settings. The acute care nurse practitioner specialty is relatively new, and with very few licensed acute care nurse practitioners in the state of Montana, the role and scope of practice is not well understood by physicians and hospital administrators who are often tasked with hiring and recruiting providers in the hospital setting. The Consensus Model, which served as the conceptual framework for this project, advocates that nurses provide care for the population that is specific to their licensure, accreditation, certification, and education. Method: Some 28 physicians and hospital administrators completed a survey that included 21 Likert scale statements that were divided into the subscales of Knowledge, Belief, and Attitude. Results included: 1) An existing gap in knowledge regarding the role and scope of practice of acute care nurse practitioners, 2) acute care nurse practitioners should always have some form of physician oversite, and 3) there is disparity in patient outcomes when patient care is provided by nurse practitioners. Conclusion: Attitudes of survey respondents were overwhelmingly positive for the future of acute care nurse practitioners filling various provider roles in the hospital setting. These results can provide a foundation for future inquiry and can assist in the development of education and collaborative efforts to further advance the utilization of acute care nurse practitioners in Montana.

Cardiopulmonary resuscitation (CPR) and defibrillation are the interventions performed by health care professionals in order to preserve the life of a patient suffering cardiac arrest. These tasks are important to the role of nurses because they are the most common first responders to in-hospital cardiac arrest scenarios. The early initiation of CPR and defibrillation is essential in increasing the likelihood of a patient surviving cardiac arrest. Despite possessing the knowledge, skills, training, and professional obligation to deploy CPR and defibrillation independently, nurses may hesitate to perform the appropriate actions in a timely manner. This topic has been studied previously; however, there have been no studies directly examining this issue in the Ontario context. This thesis explored the factors that influence the behaviour of nurses in the first responder role by employing a mixed-methods research design. The quantitative portion of the study consisted of a series of scales on an online survey that examined teamwork factors and nurses’ experience with CPR events. The qualitative part of the study consisted of open-ended questions on the survey as well as individual interviews with nurses to understand the barriers and enablers to the role of nurses in the enactment of basic life support (BLS). The qualitative data were analyzed with a modified grounded theory approach. The qualitative data analysis followed the guidelines developed by Charmaz (2006) and employed the conceptual framework on optimizing scopes of practice developed by the Canadian Academy of Health Sciences (2014) to extrapolate findings on the influence of nurses’ scope of practice on their behaviour. This study revealed a number of contextual factors in Ontario influencing nurses’ deployment of CPR and defibrillation including variations in hospital unit types, geography, workload, the availability and quality of technology, legislation and regulation, accountability, as well as economic constraints.

Indiana University-Purdue University Indianapolis (IUPUI) / Introduction: The U.S. is faced with a primary care (PC) workforce shortage; an estimated 43 percent of the population has unmet health care needs and 18.2 percent of the adult population lacks a usual source of care (USC) provider. The workforce shortage limits even those with a USC from receiving the full scope of recommended clinical services. One promising solution is reforming scope-of-practice (SOP) policies for PC nurse practitioners (NPs). Objectives: The primary objective of this dissertation was to assess the impact of NP SOP policy implementation on NP practice patterns and patient access to PC by evaluating NP time spent delivering patient care, NP role as USC providers, patient travel times, and appointment availability. Methods: The studies discussed in this dissertation leveraged cross-sectional data from the National Sample Survey of Nurse Practitioners (NSSNP), time-series data from the Medical Expenditure Panel Survey (MEPS), and the Nurse Practitioner Professional Practice Index (NPPPI) to quantify variations in state policy environments. We used generalized mixed effects models to examine relationships in the cross-sectional data analyses and two-way fixed effect models to evaluate longitudinal data. Results: Our analyses revealed several key findings: NP SOP policies do impact the percentage of time NPs spend providing direct patient care; the NP workforce role as USC providers has increased as SOP policies have changed; states with supportive reimbursement policies have more NPs working as USC providers; and states with fewer NP supervision requirements have shorter patient travel times to USC providers. Conclusion: The U.S. health care system must continue to evolve to address the growing demand for PC services. While strategies to increase the supply of PC providers may be an effective long-term solution, our findings suggest that NP SOP reform may be a viable and complementary strategy to increasing the capacity of the PC workforce, providing more immediate relief. / 2 years

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Primary care physician (PCP) shortages have been a barrier to accessing care for millions of Americans, particularly those living in areas facing the worst shortages - primary care health professional shortage areas (HPSAs). Increased use of nurse practitioners (NPs) has been proposed as a solution to the shortages as NPs can effectively substitute for PCPs. However, this proposal has been hampered by regulatory restrictions on NP scope-of-practice (SOP) that exist in many states. While some states permit NPs to practice and prescribe medications independent of physicians (NP independence), others require extensive physician supervision that limit NPs ability to provide care and substitute for PCPs. Despite the limitations that restrictive regulations pose to improving access to primary care, research evidence of their effect on access in primary care HPSAs is limited. This dissertation fills this gap in the literature. Using individual-level data from the Medical Expenditure Panel Surveys (1996-2015) and a difference-in-differences approach, I exploit variation in NP independence across states and over time to evaluate the impact of NP independence on access to primary care in HPSAs Further, I examined for heterogeneity in the effect of NP independence between HPSAs and non-HPSAs as well as effect heterogeneity in HPSAs based on individual (age, insurance status, and insurance type) and health system characteristics (availability of primary care facilities and NP Medicaid reimbursement rate) I find that NP independence led to a 5% increase in the number of individuals with a primary care provider and a 2% increase in the use of non-physicians (relative to physicians) as the primary care provider in HPSAs. However, non-HPSAs experienced no significant changes in access to care. Further, I find evidence of heterogeneity in the effect of NP independence in HPSAs for all three individual characteristics but find no significant effect heterogeneity for any of the health system characteristics. Non-elderly individuals experienced greater improvements in access following NP independence compared to their elderly counterparts, and while both insured and uninsured individuals experienced improvements in access to care, uninsured individuals benefitted more from NP independence. Further, I find evidence of greater improvements in access to care among Medicaid beneficiaries relative to their privately insured and Medicare counterparts. These findings imply that removing regulatory restrictions on NP SOP could be an effective policy strategy for mitigating the effects of PCP shortages and improving access to care in HPSAs. Further, they demonstrate that NP independence could be a viable tool for addressing access to care issues in two traditionally underserved populations – the uninsured and Medicaid beneficiaries. Beyond addressing access issues, NP independence could also mitigate rising health care costs. The finding of increased use of lower-cost non-physicians rather than their more costly physician counterparts after NP independence indicates that this policy change could also bring about cost savings for society.

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