BACKGROUND: Lack of access to health care is a worldwide public health crisis. In primary care it has led to increases in the implementation of nurse practitioners and heightened interest in their patient panel capacity. The aim of this study was to examine factors influencing nurse practitioner patient panel size in team-based primary care in Ontario, Canada.
METHODS: We used a multiple case study design. Eight team-based primary care practices including rural and urban settings were purposively selected as cases. Each case had two or more nurse practitioners with a minimum of two years experience in the primary care setting. Interviews were conducted in-person, audio recorded, transcribed and analysed using content analysis.
RESULTS: Forty participants, including 19 nurse practitioners, 16 administrators (inclusive of executives, managers, and receptionists), and 5 physicians were interviewed. Patient, provider, organizational, and system factors influenced nurse practitioner patient panel size. There were eight sub-factors: complexity of patients\' health and social needs; holistic nursing model of care; nurse practitioner experience and confidence; composition and functioning of the multidisciplinary team; clerical and administrative supports, and nurse practitioner activities and expectations. All participants found it difficult to identify the panel size of nurse practitioners, calling it- \"a grey area.\" Establishing and maintaining a longitudinal relationship that responded holistically to patients\' needs was fundamental to how nurse practitioners provided care. Social factors such as gender, poverty, mental health concerns, historical trauma, marginalisation and literacy contributed to the complexity of patients\' needs. Participants indicated NPs tried to address all of a patient\'s concerns at each visit.
CONCLUSIONS: Nurse practitioners have a holistic approach that incorporates attention to the social determinants of health as well as acute and chronic comorbidities. This approach compels them to try to address all of the needs a patient is experiencing at each visit and reduces their panel size. Multidisciplinary teams have an opportunity to be deliberate when structuring their services across providers to meet more of the health and social needs of empanelled patients. This could enable increases in nurse practitioner panel size.

Integrated behavioral health can improve primary care and mental health outcomes. Access to behavioral health and primary care services in Texas is in crisis because of high uninsurance rates, regulatory restrictions, and lack of workforce. To address gaps in access to care, a partnership formed among a large local mental health authority in central Texas, a federally designated rural health clinic, and the Texas A&M University School of Nursing to create an interprofessional team-based health care delivery model led by nurse practitioners in rural and medically underserved areas of central Texas. Academic-practice partners identified 5 clinics for an integrated behavioral health care delivery model. From July 1, 2020, through December 31, 2021, a total of 3183 patient visits were completed. Patients were predominantly female (n = 1719, 54%) and Hispanic (n = 1750, 55%); 1050 (33%) were living at or below the federal poverty level; and 1400 (44%) were uninsured. The purpose of this case study was to describe the first year of implementation of the integrated health care delivery model, barriers to implementation, challenges to sustainability, and successes. We analyzed data from multiple sources, including meeting minutes and agendas, grant reports, direct observations of clinic flow, and interviews with clinic staff, and identified common qualitative themes (eg, challenges to integration, sustainability of integration, outcome successes). Results revealed implementation challenges with the electronic health record, service integration, low staffing levels during a global pandemic, and effective communication. We also examined 2 patient cases to illustrate the success of integrated behavioral health and highlighted lessons learned from the implementation process, including the need for a robust electronic health record and organizational flexibility.

The 2021 American Association of Colleges of Nursing (AACN) Essentials: Core Competencies for Professional Nursing Practice articulate the standards for baccalaureate and graduate level nursing education in the 21st century. Integral to these expectations is the call for nurse educators to implement a competency-based education format. For nurse practitioner education programs, the curriculum must not only align with core competencies described by the National Organization of Nurse Practitioner Faculties (NONPF) and with the standards of the National Task Force (NTF), but will now also be framed in the Essentials. This article demonstrates a template for how nurse practitioner faculty can develop learning opportunities for students to demonstrate competency as they integrate and apply knowledge in the context of authentic practice situations. The impact of this innovation and standardization of nursing education sets the stage for a dynamic learning environment where all students can expect the same education and every employer can expect the same competence from their new hires.

OBJECTIVE: The aim of this research was to evaluate a nurse practitioner\'s clinical practicum module designed with a capability education framework. The objectives were to determine if the module prepared students adequately for their role and to determine if the Mini-CEX assessment tool was suitable for use with nurse practitioners.
BACKGROUND: Capability is a necessary part of expertise, where a capable person takes responsibility to develop their own education, knowledge and skills. The capability learning framework offers nurse practitioners flexible learning pathways between the student, the university and clinical practice. This capability learning framework focuses on the wider complexities of nurse practitioner practice as opposed to a point-in-time assessment.
METHODS: A case study design was used.
METHODS: Mixed methods including, document review, focus group and field notes were used in the case study evaluation adhering to the standards for the reporting of organisational case studies.
RESULTS: A layered incremental approach to learning and assessments were applied. Students and assessors were satisfied with using the Mini-CEX assessment tool in the module. The Mini-CEX tool was familiar to clinical mentors, who compared students demonstrating competency in a similar manner to medicine. The feedback component of the tool provided deep and meaningful engagement for students. The module provided mentors with insight and understanding of the nurse practitioner role. Students identified the transitioning process from competent to capable practitioners. The module learning and assessments were mapped to regulatory nurse practitioner standards and requirements.
CONCLUSIONS: The module provided comprehensive preparation for students to develop their nurse practitioner role. The Mini-CEX assessment tool is a fitting assessment for nurse practitioner students, particularly when supplemented with a corresponding reflective exercise. The assessments and feedback provided the students with opportunities to focus on agreed learning outcomes in their specialist area of practice.
CONCLUSIONS: Nurse practitioners are required to practice autonomously and independently at a level of capability in clinical practice. The education preparation of nurse practitioner students must be directed appropriately.

The purpose of this study was to create and implement a nurse practitioner model of care in the initiation of a pre-exposure prophylaxis (PrEP) protocol with African American men who have sex with men (MSM).
A case series design was used to implement the protocol for a nurse practitioner PrEP-based model of care.
The participatory, evidence-based, patient-focus process (PEPPA) framework and the American Association of Colleges of Nursing (AACN) Doctoral Essentials for Advanced Practice were aligned to guide the development, implementation, and evaluation of this advanced practice role in an urban medical clinic.
Seven African American HIV-negative MSM who received treatment under the nurse practitioner PrEP-based model of care had increased PrEP knowledge and medication adherence and did not contract a sexually transmitted infection.
New models of care can be created to meet the Getting to Zero HIV initiative of reducing rates of HIV infections with MSM.

The implementation of telemonitoring (TM) has been successful in terms of the overall feasibility and adoption in single disease care models. However, a lack of available research focused on nurse-led implementations of TM that targets patients with multiple and complex chronic conditions (CCC) hinders the scale and spread to these patient populations. In particular, little is known about the clinical perspective on the implementation of TM for patients with CCC in outpatient care.
This study aims to better understand the perspective of the clinical team (both frontline clinicians and those in administrative positions) on the implementation and normalization of TM for complex patients in a nurse-led clinic model.
A pragmatic, 6-month implementation study was conducted to embed multicondition TM, including heart failure, hypertension, and diabetes, into an integrated nurse-led model of care. Throughout the study, clinical team members were observed, and a chart review was conducted of the care provided during this time. At the end of the study, clinical team members participated in qualitative interviews and completed the adapted Normalization Measure Development questionnaires. The Normalization Process Theory guided the deductive data analysis.
Overall, 9 team members participated in the study as part of a larger feasibility study of the TM program, of which 26 patients were enrolled. Team members had a shared understanding of the purpose and value of TM as an intervention embedded within their practice to meet the diverse needs of their patients with CCC. TM aligned well with existing chronic care practices in several ways, yet it changed the process of care delivery (ie, interactional workability subconstruct). Effective TM normalization in nurse-led care requires rethinking of clinical workflows to incorporate TM, relationship development between the clinicians and their patients, communication with the interdisciplinary team, and frequent clinical care oversight. This was captured well through the subconstructs of skill set workability, relational integration, and contextual integration of the Normalization Process Theory.
Clinicians successfully adopted TM into their everyday practice such that some providers felt their role would be significantly and negatively affected without TM. This study demonstrated that smartphone-based TM systems complemented the routine and challenging clinical work caring for patients with CCC in an integrated nurse-led care model.

OBJECTIVE: To describe the mentoring process between the ICN Advanced Practice Nurse Network practice subgroup and the University of Pécs to support the emerging advanced practice role in Hungary, and explore the creation of a mentoring algorithm for faculty and other key stakeholders worldwide who wish to develop advanced practice nursing programs.
BACKGROUND: Advanced practice nurses provide comprehensive clinical care and expand access to care in more than 70 countries. In March of 2017, a representative of the Faculty of Health Sciences of the University of Pécs requested assistance in curricula development for the inaugural advanced practice nursing program in Hungary.
METHODS: A mixed-methods single case study was undertaken. The sources of evidence include interviews, e-mails, review of the literature, and related documents. Qualitative data were analyzed for content, and frequencies were calculated for quantitative indicators.
CONCLUSIONS: The findings highlight the importance of clear communication, development of shared goals, and determination to see the project through. Enriching information was provided by colleagues from diverse global settings. Credibility was gained in Hungary from the support of national and international experts.
CONCLUSIONS: The mentoring foundation and process facilitated the role development in Hungary and contributed to an increased understanding of advanced practice nurses\' scope of practice. The intentional approach and the careful ongoing reflection may lead to future successful endeavors. Multinational engagement and collaborations will promote advanced practice nursing contributions globally.
CONCLUSIONS: Mentoring can effectively empower nurses and advanced practice nurses to work to their full capacity. The shared experiences of international mentoring colleagues can contribute to and support the development and acceptance of national policies for the advanced practice nursing roles.

Joint pain is a common presentation in the Emergency department. There are countless potential causes for pain and swelling in a joint. Septic arthritis is a true joint emergency as it can lead to rapid, irreversible destruction of the joint. If not diagnosed early this infection can lead to considerable functional deficit. Our case is unique in that our patient presented to the Emergency department requesting referral to the fracture clinic for continued management of a suspected scaphoid bone fracture but was found to have Neisseria gonorrhoea causing septic arthritis of the joint. This case highlights the importance of accurate history taking, clinical examination and assessment of the patients presenting with joint pain.

OBJECTIVE: Prior to 2015 residents in our Accreditation Council for Graduation Medical Education (ACGME) colon and rectal surgery training program were in charge of managing, with faculty oversight, the outpatient anorectal clinic at our institution. Starting in 2015 advanced practice providers (APPs) working in the division assumed management of the clinic. The effect of APPs on ACGME resident index diagnostic case volumes has not been explored. Herein we examine ACGME case log graduate statistics to determine if the inclusion of APPs into our anorectal clinic practice has negatively affected resident index diagnostic anorectal case volumes.
METHODS: ACGME year-end program reports were obtained for the years 2011 to 2019. Program anorectal diagnostic index volumes were recorded and compared to division volumes. Analysis of variance (ANOVA) and analysis of covariance (ANCOVA) tests were conducted to assess whether the number of cases per year (for each respective case type) prior to the introduction of APPs into the anorectal clinic (2011-2014) differed from the number of cases per year with the APP clinic in place (2015-2018). A p-value <0.05 was considered statistically significant.
METHODS: Mayo Clinic, Rochester, Minnesota (quaternary referral center).
METHODS: Colon and rectal surgery resident year-end ACGME reports (2011-2019).
RESULTS: ANOVAs revealed a marginally significant (p = 0.007) downtrend for hemorrhoid diagnostic codes, and a significant uptrend (p = 0.000) for fistula cases. Controlling for overall division volume, ANCOVA only reveled significance for fistula cases (p = 0.004) with the involvement of APPs.
CONCLUSIONS: At our institution we found the inclusion of APPs into our anorectal clinic practice did not negatively affect colon and rectal surgery resident ACGME index diagnostic anorectal case volumes. Inclusion of APPs into a multidisciplinary practice can promote resident education by allowing trainees to pursue other educational opportunities without hindering ACGME index case volumes.

A nurse practitioner\'s experience in managing children with intraluminal pulmonary vein stenosis. A case study of a 3-year-old patient with multi-vessel intraluminal pulmonary vein stenosis.