Advance Practice Register Nurse Role and Goals

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The Journal for Nurse Practitioners www.npjournal.org

An Official Journal of the American Association of Nurse Practitioners JNP, The Journal for Nurse Practitioners, is also affiliated with the Australian College of Nurse Practitioners

Volume 21, Issue 5,

Editors

May 2025

Editor in Chief Karen S. Moore, PhD, DNP, APRN, ANP-BC, FNP-C, CGNC, FAANP, FAAN Saint Louis University School of Nursing St. Louis, MO [email protected]

Senior Publisher Dawn Nahlen, MA Elsevier, Inc. North Little Rock, AR [email protected]

The Journal for Nurse Practitioners

Associate Editor Leslie Davis, PhD, FAANP, FPCNA, FAHA, FAAN University of North Carolina at Chapel Hill Chapel Hill, NC

Associate Editor Social Media Director Jayne Jennings Dunlap, DNP, APRN, FNP-C Texas Woman’s University, Houston, TX

Editorial Board

Contributors By Faculty for Faculty

Kenneth P. Miller, PhD, MJ, CFNP, FAAN, FAANP Associate Dean for Ambulatory Services and Professor UT Health San Antonio School of Nursing San Antonio, TX [email protected]

Elsie Duff, PhD, NP University of Manitoba Saskatchewan Polytechnic, Saskatchewan, Canada

AnnMarie Hart, PhD, FNP-BC, FAANP School of Nursing, University of Wyoming, Laramie, WY

Mohamed Toufic El Hussein RN, PhD, NP Mount Royal University School of Nursing and Midwifery and University of Calgary, Calgary, Canada

Carol M. Patton, DrPH, FNP-BC College of Nursing and Health Professions, Drexel University Philadelphia, PA

Mary Lauren Pfieffer, DNP, FNP-BC, CNE, CPN Vanderbilt University School of Nursing, Nashville, TN Family primary care, women’s health, adolescent health, nursing education, simulation

Courtney J. Pitts, DNP, MPH, FNP-BC, FAANP Emory University Atlanta, GA

Robin Arends, DNP, FNP-BC, PMHNP-BC, CNE, GS-C, FAAN, FAANP South Dakota State University, Brookings, Sioux Falls, South Dakota

Christopher Blackwell, PhD, AGACNP-BC, CNE, FAANP University of Central Florida Orlando, FL

Lois Wessel, DNP, FNP-BC Georgetown University School of Nursing and Health Studies Takoma Park, MD

Letha Joseph, DNP, AGPCNP-BC, FFNMRCSI, FAANP Director, Geriatric and Extended Care Nurse Practitioner Residency Durham VA Healthcare System Consulting Associate Duke University School of Nursing Durham, North Carolina

Valerie J. Fuller, PhD, DNP, AGACNP-BC, FNP-BC, FNAP Maine Medical Center, Portland, ME

Associates

Parmeet Atwal, FNP-C, JD, MPH Georgetown University Washington, DC

Maura Dowling, PhD, RNT, RGN, RM Cert Oncology National University of Ireland Galway, Ireland

Margaret Fry, NP, PhD Nursing and Midwifery Directorate NSLHD University of Technology Sydney Sydney, Australia

Laurel Hallock-Koppelman, DNP, FNP-C, APRN, FAANP Orgeon Health & Science University Portland, Oregon

Tsui-Sui Annie Kao, PhD, FNP-BC, FAANP Michigan State University East Lansing, MI

April Kapu, DNP, APRN, ACNP-BC, FAANP, FCCM, FAAN Vanderbilt University Nashville, TN

Debra A. Kosko DNP, MN, FNP-BC, FAANP Georgetown University Washington, DC Assanatu (Sana) Savage, PhD, DNP, FNP-BC, Commander, Navy Uniformed Services University Bremerton, WA Wesley Davis, DNP, ENP-C, FNP-C, AGACNP-BC, CEN, FAANP University of South Alabama College of Nursing Mobile, AL

Department Editors

Prescription Pad Timothy Nguyen, PharmD, BCPS Long Island University Brooklyn, NY

Global Passports Daniela Lehwaldt, PhD, MScEd, BNS, RGN, RNT, SFHEA, CGFNS Dublin City University Dublin, Ireland

Current Topics in Gender Health Denise G. Link, PhD, WHNP, FAAN Phoenix, AZ

Parmeet M.S. Atwal, DNP, JD, NP-BC, MPH Georgetown University Washington, DC

Under the Dome Gale Adcock, MSN, FNP-BC, FAANP, FAAN SAS Institute, Cary, NC North Carolina State Senate

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Transverse-Myelitis-in-a-Rural-Australian-Emergenc.pdf

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The Journal for Nurse Practitioners 21 (2025) 105365

Contents lists avai

The Journal for Nurse Practitioners

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Case Report

Transverse Myelitis in a Rural Australian Emergency Department: Case Report

Mitchell Copeman, Nadia Hulsbos, Jessica Levick

Keywords: myelitis nurse practitioner rural nursing transverse myelitis

a b s t r a c t

Acute transverse myelitis (ATM) is a rare neurologic condition with rapid onset of weakness, sensory changes, and occasional bowel or bladder symptoms. This case report will explore a male patient presenting with symptoms consistent with ATM to a rural Australian emergency department. This case report explores the diagnosis of ATM with further discussions on the difficulties and importance of the nurse practitioner ephysician relationship surrounding patient care. This case report also outlines the difficulties of providing care to patients in the rural hospital setting, along with a focus on clinical considerations that nurse practitioners encounter in day-to-day practice.

Brief Introduction description was vague and not isolated to a particular derma-

Acute transverse myelitis (ATM) is a rare immune-mediated neurologic condition. It involves an inflammatory response to the spinal cord resulting in neurologic injury to the affected area.1-3

ATM is a rare disease process with incidence rates reported be- tween 1 and 8 new cases per 1,000,000 people.2 However, a recent retrospective study revealed a point prevalence of 7.86 cases per 100,000 people.4 There have been reports that ATM has a bimodal peak between ages 10 and 19 years and between ages 30 and 39 years.5

Case Presentation

Chief Complaint

A 59-year-old man with the pseudonym John reported an acute onset of painless left leg weakness while walking. The patient re- ported 20 hours of left leg weakness with associated paresthesia and an inability to weight bear. There were no other complaints or symptoms of headache, seizurelike activity, dizziness, blurred vision, facial droop, or upper limb weakness. John’s symptomology led him to present to his local rural emergency department for review.

History of Present Illness

John reported first noticing his symptoms the day prior as he was leaving work. On standing to walk, his leg felt weak, dragging gait with no other neurologic symptoms. On waking the following morning, John became increasingly concerned due to the increased severity of left leg weakness to the point of being unable to weight bear. John also reported new-onset paresthesia; however, the

tome(s) of the left leg. John declined that the weakness and paresthesia occurred in an ascending pattern. These symptoms were constant, with no aggravation or relieving factors. John also stated that he was incontinent of urine while attempting to walk to the toilet, which was new to him.

Medical History

John’s medical history was inclusive of hypertension, type 2 diabetes mellitus, and gout. The patient did not report any previous cardiovascular events or episodes of incontinence.

Medications

The patient had no known allergies and took regular medica- tions inclusive of allopurinol 300 mg once daily, olmesartan 40 mg once daily, amlodipine 10 mg once daily, hydrochlorothiazide 12.5 mg once daily, and metformin 1 g twice daily, all taken orally.

Family History

The patient denies any family cardiovascular history or inherited neurologic disorders.

Personal/Social/Developmental History

The patient is independent with mobility and activities of daily living, lives at home with his wife, and works as a maintenance worker at the local hospital. He reports consuming approximately 4 standard alcoholic beverages per week. He denies smoking or recreational drug use.

Delta:1_given-name

Delta:1_surname

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M. Copeman et al. / The Journal for Nurse Practitioners 21 (2025) 1053652

Review of Symptoms

There were no other complaints of headache, confusion, seizurelike activity, dizziness, blurred vision, facial droop, fecal in- continence, or upper-limbweakness. The patient did not report any recent infective symptoms, pain, or fever. Therewere no complaints of chest pain, palpitations, dyspnea, and diaphoresis.

Pertinent Physical Examination Findings

John’s vital signs included a respiratory rate of 18 breaths/min, heart rate of 90 beats/min, temperature of 36.1 �C, blood pressure of 149/66 mmHg, oxygen saturation of 98% on room air, and blood glucose level of 218.02 mg/dL (12.1 mmol/L). Cardiac examination revealed S1 and S2 regular heart sounds without clicks or mur- murs, and the electrocardiogram demonstrated a normal sinus rhythm. Respiratory examination was clear lung auscultation, equal chest rise and fall, with no increased effort or accessory muscle use. His abdomen was soft and nontender, with no palpable masses or hepatomegaly noted. Neurologically, the pa- tient was alert and orientated, with a Glasgow Coma Scale score of 15 and normal cranial nerve examination findings. Upper limbs: equal strength, normal sensation and coordination throughout; lower limbs: right normal strength, sensation, and coordination. The left leg had 4/5 strength throughout with ataxia, hyporeflexia, and gross paresthesia to light touch and pinprick that was not isolated to a particular dermatome(s). Written consent was obtained and the patient had unilateral saddle anesthesia, and anal tone was intact. The lower limbs bilaterally were warm, with strong peripheral pulses throughout and appropriate capillary refill. The paresthesia resolved while in the emergency department; however, left leg neurologic symp- toms remained.

Diagnostic Studies

John was triaged as category 2 and seen immediately in the emergency resuscitation bay and was discussed with the telestroke service and underwent computed tomography (CT) of the brain and angiography, which returned normal results. The initial pathology, including full blood cell count, urea and electrolytes, liver function testing, coagulation studies, C-reactive protein, and venous blood gas, were grossly normal. It was decided that a CT perfusion scan should not be performed because transfer for endovascular clot retrieval would take approximately 6 hours, therefore falling outside the clot retrieval timewindow due to late presentation. The patient was then discussed with an accepting physician on call at the accepting hospital and was transferred urgently through to their emergency department via aeromedical transport. On arrival at the referral hospital emergency department, the patient under- went CT of the thoracolumbar spine. This investigation showed an L2 to L5 disc bulge with L5 to S1 moderate to severe foraminal narrowing with L5 nerve root impingement. The patient was then referred to neurology and admitted for further investigations. The patient received magnetic resonance imaging (MRI) of the brain, which returned results with no acute ischemic change, space- occupying lesion, or intracranial haemorrhage to indicate neuro- logic symptoms. The patient then received an MRI of their whole spine, which returned results demonstrating a central cord focus between C7 to T1 indicating cord signal abnormality indica- tive of an ATM diagnosis. Additionally, the MRI of the spine reported lumbar spondylitic changes with an unremarkable cauda equina and no further cord abnormalities. A lumbar puncture was performed under CT guidance, which had normal opening pressure, normal cerebrospinal fluid, with a mildly elevated protein

level of 0.08 g/dL (0.83 g/L) (normal, 0.02-0.06 g/dL [0.19-0.65 g/L]). Further pathology revealed an erythrocyte sedimentation rate of 18 mm/hr (normal, 0-15 mm/hr), a ferritin level of 589 ng/mL (589 mg/L) (normal, 30-400 ng/mL [30-400 mg/L]), an iron level of 39.1 mg/dL (7 mmol/L) (normal, 44.7-167.6 mg/dL [8-30 mmol/L]), and transferrin saturation of 12% (normal, 15%-45%). Results of the lipid profile, vitamin B12, folate, virology, thyroid function, immunology, and heavy metals testing were grossly normal. The patient returned a positive antinuclear antibody with titer 1:160 and a speckled pattern; however, following this result, subsequent testing returned a negative extractable nuclear antigen test result.

Discussion

This case study explored the complex presentation of an otherwise well male who presented with acute onset of left lower limb weakness. The differential diagnosis considered in this case included stroke, compressive myelopathy such as cauda equina, or lumbar foraminal stenosis. The patient had a normal cranial nerve examination and isolated lower limb weakness. These pre- sentations of symptoms made stroke diagnosis doubtful but also the most acute pathology to exclude which lead to prompt dis- cussion with telestroke team.6 Urinary incontinence and saddle anesthesia are common symptoms of cauda equina; however, it is uncommon for this to present without low back pain and intact anal tone.7 Additionally, spinal cord infarction and Guillain-Barr�e syndrome were considered. Guillain-Barr�e syndrome usually pre- sents with bilateral sensorimotor deficits and bladder dysfunction; although rare, there are reported cases of asymmetrical onset of sensorimotor deficits.8 Other differential diagnoses were inclusive of dural arteriovenous fistula, epidural hematoma, metabolic, toxic, and neoplastic.

ATM is classified as an acute inflammatory necrosis or demye- lination involving the spinal cord.9 Its focal pathological changes involve inflammation or swelling of myelin, proliferation of lym- phocytes, axonal degeneration, rapid increase of perivascular in- flammatory cells, and demyelination.9 Typically, patients who present with ATM will present with a sudden onset of back pain, muscle weakness, sensory alteration, and possible urinary or bowel symptoms with or without dysfunction.5 Commonly, ATM is clas- sified into subtypes inclusive of acute partial, acute complete, and longitudinally extensive transverse myelitis.2 Acute partial trans- verse myelitis is dysfunction of the spinal cord that is asymmetrical and mild, usually showing lesions on 1 to 2 vertebral segments on MRI.2 Complete ATM is more severe, causing symmetrical dysfunction of the spinal cord, which can cause complete or near- complete neurologic dysfunction.2 Longitudinally extensive trans- verse myelitis can be complete or incomplete spinal dysfunction, which will have a corresponding lesion on MRI involving 3 or more vertebral segments.2

ATM is commonly caused by other specific inflammatory and noninflammatory conditions.2 There is no single specific etiology identifiable with this disease process; however, there are condi- tions attributable (Tables 1 and 2). If there is no cause identified, it is classified as idiopathic.2

John did not have any of the previously discussed comorbidities that have been directly linked as a causative factor of ATM; how- ever, the inflammatory process and consequences of type 2 dia- betes as a comorbidity must be considered. Patients with diabetes have an increased risk of infection because it impairs immune response to invading pathogens.11 Diabetes acts on the polyol pathway, causing a downregulation of glutathione, leading to endothelial cell damage and depletion of nitric oxide, negatively impacting nerve vasculature.11 It forms advanced glycation end

Table 1 Inflammatory Causes for Acute Transverse Myelitis

CNS demyelinating disorders Multiple sclerosis, neuromyelitis optica spectrum disorder, myelin oligodendrocyte glycoprotein antibody-associated disease, and acute disseminated encephalomyelitis2-4

Autoimmune disorders Rheumatoid arthritis, antiphospholipid syndrome, SLE, Sjogren disease, sarcoidosis, ankylosing spondylitis, Behcet disease, and systemic sclerosis2-4

Infections Enterovirus, HIV, human T-lymphotropic virus 1, measles, rubella, HSV, EBV, VZV, West Nile virus, arbovirus, tickborne infections, syphilis, and SARS-CoV-22-4,10

Other Idiopathic, paraneoplastic syndromes, vaccinations, and astrocytopathy2-4

CNS ¼ central nervous system; EBV ¼ Epstein-Barr virus; HSV ¼ herpes simplex virus; SARS-CoV-2 ¼ severe acute respiratory syndrome coronavirus 2; SLE ¼ systemic lupus erythematosus; VZV ¼ varicella-zoster virus.

M. Copeman et al. / The Journal for Nurse Practitioners 21 (2025) 105365 3

products, which can cause irreversible death of Schwann cells and increase inflammatory cytokine release, resulting in a proin- flammatory state.11 Diabetes causes oxidative stress, causing reac- tive free radical release and leading to microvasculature damage of the nervous system.11 It must be contemplated that the increased risk of infection along with the microvasculature and inflammatory consequences of diabetes on the nervous system could increase the likelihood of developing ATM in addition to prolonging recovery duration.

There is no effective cure for ATM, and treatment focuses on symptom reduction caused by spinal cord inflammation.2

Frequently, patients have some neurologic recovery without med- ical intervention.4 One of the most important aspects of manage- ment in ATM is determining the disease-specific etiology, and this requires comprehensive history taking and vast investigations, which leads to successful management.7 Importantly, an infectious cause of ATM or a spinal dural arteriovenous fistula must be excluded because immunotherapy treatment can exacerbate these conditions.7 ATM is a complicated disease process mainly due to its expanding list of complex etiologies, which most recently has linked cases to the severe acute respiratory syndrome coronavirus 2 virus and its vaccine.2-4

Management of ATM

In patients with ATM, first-line pharmacotherapy includes a short course of high-dose intravenous glucocorticoid, usually methylprednisolone or dexamethasone.2,4 Additionally, patients who are unresponsive to corticosteroids can be administered plasma exchange or intravenous immunoglobulin as second-line rescue therapies. There is evidence that suggests plasma ex- change and high-dose intravenous methylprednisolone compared with methylprednisolone alone reduced the likelihood of a relapse in patients with ATM.2 There has been recent research into extended-release dalfampridine, which increases postsynaptic ac- tion potentials in the spinal cord, and this evidence suggests that dalfampridine improves walking speed in patients with ATM.2

Additionally, certain relapsing immune-mediated myelopathies require ongoing immunotherapy to prevent relapse.2

Additional pharmacologic and nonpharmacologic management of the neurologic sequelae must also be considered when caring for a patient with ATM. Primarily, the focus of treatment is to reduce spinal cord inflammation to improve the neurologic outcomes.10

Patients with ATM have poorer mobility, therefore, venous thromboembolism prophylaxis must be addressed.10 Often,

Table 2 Noninflammatory Causes for Acute Transverse Myelitis

Metabolic Vitamin B12 deficiency, copper deficiency, and mitochondrial disorders2,3,1

Structural Cervical spondylosis, disc herniation, spinal cord syrinx, Chiari malformati Other Arteriovenous fistula, dural arteriovenous fistula, and spinal cord infarctio

This research did not receive any specific grant from funding agencies in the public, com

constipation and urinary symptoms are common sequelae of neurologic deficits that further complicate treatment, leading to urinary tract infections.10 Involvement of a comprehensive multi- disciplinary team is crucial to promoting physical therapy to improve return of function, optimize recovery, and reduce neuro- logic symptoms.10 Additionally, neuropathic pain is common, and often tricyclic antidepressants, gabapentinoids, and selective se- rotonin reuptake inhibitors, in addition to serotonin and noradrenaline reuptake inhibitors, are being used to treat neuro- pathic pain.10

John was treated as having an idiopathic transverse myelitis. Treatment with steroids was considered, but neurologic symptoms improved without intervention. Physiotherapy aided in rehabilita- tion, mobility, and restrengthening exercises. After approximately 2 weeks at the accepting hospital, the patient returned to the rural facility with regular inpatient physiotherapy involvement and was discharged aweek later. The patient made a partial recovery as John still experiences intermittent episodes of mild weakness in his left leg. Approximately 25% of all patients with idiopathic transverse myelitis experience a relapse, with young age at onset, female sex, low vitamin D levels, and longitudinally extensive transverse myelitis increasing the risk of relapse.12 Additionally, it must be considered that if this patient does develop diabetic neuropathy due to poorly controlled type 2 diabetes, it may increase the risk of misdiagnosis of a relapse of ATM and/or delay a diabetic neuropa- thy diagnosis.

Medical Comanagement

The rural center had the ability to perform CT of the spine to provisionally assess for possible compressive myelopathies. This patient was comanaged by a medical officer and a nurse practi- tioner (NP), who had joint responsibility for this patient’s ongoing care. Comanagement allows physicians and NPs to share re- sponsibilities, leading to optimization of complex care, increased completion of tasks, and, ultimately, better patient outcomes.13

Common attributes that ensure successful comanagement of pa- tients are a shared philosophy of care, effective communication, andmutual respect and trust.8 The treating NP deemed it necessary for a CT of the whole spine for further diagnostic clarification. The NP escalated concerns and explained thought processes and possible differential diagnoses; however, the medical officer in charge disagreed, leading to investigations not being completed. The recommendation for CT of the whole spine from the NP was clearly documented on a referral letter. There were no cost or

on with cord compression, dorsal arachnoid web, and spinal cord herniation2,3,10

n2,3,10

mercial, or not-for-profit sectors.

M. Copeman et al. / The Journal for Nurse Practitioners 21 (2025) 1053654

insurance barriers to obstruct this type of imaging for this patient, and this incident was reported to the health service manager of the hospital. The patient did undergo CTof thewhole spine on arrival at the referral facility, and this delay in imaging did not cause direct harm to the patient; however, if there were any findings needing neurosurgical intervention, the hospital did not have this specialty. Often, rural health care facilities encounter patients where the services that are needed cannot be facilitated by the treating hospital.

Complexities of Rural Health Care

Frequently, rural health care facilities provide a high level of medical care to a multitude of patients with input from specialist services from referral hospitals. Recurrently, rural clinicians are faced with the question, “Does this patient require services that their facility cannot provide?” Additionally, clinicians must keep in mind that patients in the rural health care setting have increased rates of coronary heart disease, lung cancer, diabetes, chronic kid- ney disease, and suicide, and a lower life expectancy compared with people in urban cities.14 These rates are due to access to health care from geographical spread, low population density, limited availability of services, and additional time and costs to access the care needed.14 Additionally, treating clinicians, particularly NPs, in rural health facilities need to have in-depth knowledge of their accepting larger hospitals. This knowledge includes the specialties they provide, bed capacity, clinical assessment equipment such as imaging machinery, and limitations of care. NPs also need to manage multiple considerations for patient care, including patient transfer procedures, resources, and costs of the service while providing gold-standard, evidence-based care. One of the primary reasons for transfer to the accepting hospital was that the initial hospital the patient presented to did not have MRI capability.

Conclusion

In patients presenting with acute-onset weakness, sensory changes, and urinary or bowel symptoms, the clinical condition of ATM should be considered as a possible differential diagnosis. ATM is a rare neurologic condition that can be inflammatory and noninflammatory in nature. Its onset is rapid and can cause debil- itating neurologic changes to a patient’s normal physiologic func- tion. ATM is complicated further by its extensive list of complex etiologies that frequently accompany its onset. Clinicians must be made aware that patients in the rural and remote setting have a lower life expectancy and increased risk of disease processes compared with patients in the urban setting. Clinicians in the rural setting have the responsibility to advocate for their patients to be transferred and receive specialist care at local referral hospitals. Additionally, NPs can sometimes encounter patients who can be complex in nature, where diagnostically they cannot request or perform investigations that they may require. The NP in this case advocated for the patient to receive appropriate investigations; however, the medical officer ultimately declined. It is important that we effectively communicate with our physician counterparts to ensure the best possible outcomes for our patients.

CRediT authorship contribution statement

Mitchell Copeman: Conceptualization, Methodology, Investi- gation, Data curation, Writing - original draft, Writing - review &

editing, Project administration. Nadia Hulsbos: Data curation, Writing - original draft, writing - review & editing. Jessica Levick: Conceptualization, Methodology, Writing - original draft, Writing - review & editing, Supervision, Project administration.

Declaration of Competing Interest

The author Mitchell Copeman declares a conflict of interest as one of the treating clinicians in this case study.

Funding

The project was not supported by any grants or funding.

References

1. Annunziata P, Masi G, Cioni C, et al. Clinical, laboratory features, and prog- nostic factors in adult acute transverse myelitis: an Italian multicenter study. Neurol Sci. 2019;40(7):1383-1391. https://doi.org/10.1007/s10072-019- 03830-6

2. Fiani B, Covarrubias C, Jarrah R. Neuroimmunology and novel methods of treatment for acute transverse myelitis. Cureus. 2021;9(13):17043. https:// doi.org/10.7759/cureus.17043

3. Murphy OC, Barreras P, Villabona-Rueda AF, Mealy MA, Pardo CA. Identifica- tion of specific causes of myelopathy in a large cohort of patients initially diagnosed with transverse myelitis. J Neurol Sci. 2022;442:120425. https:// doi.org/10.1016/j.jns.2022.120425

4. Abbatemarco JR, Galli JR, Sweeney ML, et al. Modern look at transverse myelitis and inflammatory myelopathy. Neurol Neuroimmunol Neuroinflamm. 2021;8(6):1071. https://doi.org/10.1212/nxi.0000000000001071

5. Ali A, Bareeqa SB, Riaz A, Ahmed SI, Shaikh MH, Ghauri MI. Assessment of clinical outcomes in patients presenting with transverse myelitis: a tertiary care experience from a developing country. Cureus. 2019;11(3):e4342. https:// doi.org/10.7759/cureus.4342

6. Price HL, Campbell SG. Isolated lower limb weakness following hemorrhagic stroke: a case report. Cureus. 2023;15(5):38798. https://doi.org/10.7759/ cureus.38798

7. Zeb J, Zaib J, Khan A, Farid M, Ambreen S, Shah SH. Characteristics and clinical features of cauda equina syndrome: insights from a study on 256 patients. SICOT J. 2023;9:22. https://doi.org/10.1051/sicotj/2023019

8. Leonhard SE, Mandarakas MR, Gondim FAA. Diagnosis and management of GuillaineBarr�e syndrome in ten steps. Nat Rev Neurol. 2019;15:671-683. https://doi.org/10.1038/s41582-019-0250-9

9. Wen X, Xu D, Yuan S, Zhang J. Transverse myelitis in systemic lupus erythe- matosus: a case report and systematic literature review. Autoimmun Rev. 2022;21(6):103103. https://doi.org/10.1016/j.autrev.2022.103103

10. Tisavipat N, Flanagan EP. Current perspectives on the diagnosis and manage- ment of acute transverse myelitis. Expert Rev Neurother. 2023;23(4):389-411. https://doi.org/10.1080/14737175.2023.2195095

11. Luna R, Talanki Manjunatha R, Bollu B, et al. A comprehensive review of neuronal changes in diabetics. Cureus. 2021;13(10):19142. https://doi.org/ 10.7759/cureus.19142

12. Lee EK, Kim S, Sohn E. Clinical characteristics and predictive factors of recur- rent idiopathic transverse myelitis. Front Neurol. 2024;15:1416251. https:// doi.org/10.3389/fneur.2024.1416251

13. Norful AA, Ye S, Van der-Biezen M, Poghosyan L. Nurse practitionerephysician comanagement of patients in primary care. Policy Polit Nurs Pract. 2018;19(3- 4):82-90. https://doi.org/10.1177/1527154418815024

14. Australian Institute of Health and Welfare. Rural and remote health. Published 2024. Accessed February 28, 2024. https://www.aihw.gov.au/reports/rural- remote-australians/rural-and-remote-health

Mitchell Copeman, BN/BPara, GradCertEd(Nursing), Transitional Nurse Practitioner, and Nadia Hulsbos, BN/BPara, GradCertEd(Nursing), GradDipMidwifery, Stroke Clinical Nurse Consultant, are both at Moree Hospital Emergency Department, Hunter New England Health Service, in Moree, New South Wales, Australia. Mr. Copeman can be reached at [email protected]. Jessica Levick, PhD, BSc(Hon), BOccThpy, Lecturer of Occupational Therapy is at the School of Health and Medical Sciences and the Centre for Health Research, University of Southern Queensland, in Ipswich, Queensland, Australia; ORCID: https://orcid.org/0000-0003-1243-671X.

https://doi.org/10.1007/s10072-019-03830-6

https://doi.org/10.7759/cureus.17043

https://doi.org/10.1016/j.jns.2022.120425

https://doi.org/10.1212/nxi.0000000000001071

https://doi.org/10.7759/cureus.4342

https://doi.org/10.7759/cureus.38798

https://doi.org/10.1051/sicotj/2023019

https://doi.org/10.1038/s41582-019-0250-9

https://doi.org/10.1016/j.autrev.2022.103103

https://doi.org/10.1080/14737175.2023.2195095

https://doi.org/10.7759/cureus.19142

https://doi.org/10.3389/fneur.2024.1416251

https://doi.org/10.1177/1527154418815024

https://www.aihw.gov.au/reports/rural-remote-australians/rural-and-remote-health

mailto:[email protected]

https://orcid.org/0000-0003-1243-671X

Transverse Myelitis in a Rural Australian Emergency Department: Case Report

Brief Introduction
Case Presentation

Chief Complaint
History of Present Illness
Medical History
Medications
Family History
Personal/Social/Developmental History
Review of Symptoms
Pertinent Physical Examination Findings
Diagnostic Studies

Discussion

Management of ATM
Medical Comanagement
Complexities of Rural Health Care

Conclusion
CRediT authorship contribution statement
Declaration of Competing Interest
Funding
References

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Region 4 e KY, NC, SC, TN Irene Bean, DNP, FNP-BC, PMHNP-B

Region 5 e IL, IN, MI, MN, OH, W Debbi Lindgren-Clendenen, RN, MN, FAANP

Region 6 e AR, LA, OK, TX Robert Metzger, DNP, MBA, APRN,

Region 7 e IA, KS, MO, NE Miranda Kliment, DNP, APRN, FNP

Region 8 e CO, MT, ND, SD, UT, Jason Gleason, DNP, FNP-BC, FAAN

Region 9 e AZ, CA, HI, NM, NV, P Theresa Brown, DNP, ACNP-BC, AAC

Region 10 e AK, ID, OR, WA Laurel Hallock Koppelman, DNP, FN

Region 11 e AL, FL, GA, MS, U.S. Doreen Cassarino, DNP, APRN, FNP-

Volume 21, Issue 5, May 2025 The Journal for Nurse Pract

Second, holistic patient-centered relationships are core to NP care. NPs dedicate significant time to each patient, allowing for comprehensive assessments of social determinants like housing and food insecurity. Such relationships empower patients and directly mirror value- based metrics like patient satisfaction and long-term outcomes, transcending traditional fee-for-service incentives.

Finally, evidence consistently highlights NP-led care as cost-efficient without sacrificing quality. Simply put, NPs excel at optimizing patient outcomes while eliminating waste d the very definition of value-based contracting.

Value-based contracting is finally rewarding NP longstanding practices. The health care system’s movement toward value doesn’t merely validate NP practice d it acknowledges the innovation, efficacy and patient-centered focus NPs have championed all along.

irectors

VT , FAANP

AACC, EBP-C, FAANP

WV , FAANP

C, FAAN, FAANP, FNAP

I GNP-BC, AGPCNP-BC,

FNP-BC

WY P

acific U.S. Territories C, FAANP

P-C, APRN, FAANP

Virgin Islands BC, BC-ADM, FAANP, FNAP

Executive Staff Jon Fanning, MS, CAE, CNED Chief Executive Officer Sharon Allen, SPHR, SHRM-SCP VP, Human Resources Bryan Black, BA VP, Communications and Marketing Katharine Bradley, PhD, MBA VP, Research Theresa M. Campo, DNP, APRN, FAANP, FAAN VP, Accreditation, Conferences and Education Amanda Friedman, MPAff, MPA, CPA VP, Finance Taynin Kopanos, DNP, APRN, FNP-BC, FAANP VP, State Government Affairs Liz Messner, CAE, IOM VP, Membership Monique Morman, BS, CMP VP, Association Governance Erin Berry Philp, MA, JD VP, Legal Affairs Sreeni Reddy, BS, MS VP, Information Technology MaryAnne Sapio, MPA VP, Federal Government Affairs Johnnie Sue Wijewardane, PhD, APRN, FNP-BC, FAANP VP, Professional Practice Jan Towers, PhD, NP-C, CRNP, FAANP, FAAN Senior Policy Consultant

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The Original Value Providers: How NPs Set the Standard

Engaging-Emerging-Scholars_2025_tjnp.pdf

Karen S. Moore PhD, DNP, APRN, ANP- BC, FNP-C, CGNC, FAANP, FAAN

npjournal.org

Volume 21, Issue 5, May 2025

EDITORIAL

Engaging Emerging Scholars

s you authors are reading today, think

Aback to how we all began our writing and publishing endeavors. We excitedly composed our manuscripts, stumbled through the submission process, and waited anxiously for feedback. When the feedback came, it was met with trepidation and sometimes had a bit of a sting as colleagues and people we respected provided a critique of our manuscript. If we were tenacious enough, we thanked the re- viewers for their comments, adjusted and edited our manuscript, and resubmitted for further evaluation. On the other hand, if the critique landed harshly, our enthusiasm for writing was diminished or, worse in some cases, extinguished. Honest and forthright peer review that is delivered with compassion and care is always an admirable goal.

As editors and peer reviewers, we want to be a source of encouragement and growth and help develop the next generation of NP scholars. To foster these relationships and support novice authors, I am excited to announce our first-of-its-kind project, the Emerging Scholars Program. Through honest feedback and presubmission manuscript development, we will provide new or developing authors with additional editorial support and resources. Our former Editor-in-Chief, Dr. Julee Waldrop, will serve as the Emerging Scholars Program Editor and share her decades of experience with new authors.

The Emerging Scholars Program is designed to assist new or developing authors in the writing and editing processes necessary to achieve a publishable

The Journal for Nurse Practitioners

manuscript. Specifically, the application process for the Emerging Scholars Program is as follows:

1. The author should submit a letter of intent along with a manuscript to both the Editor-in-Chief and the Emerging Scholars Program Editor via email at karen. [email protected] and [email protected]

2. Manuscripts will be considered based on the following criteria:

a. Topic suitability to JNP readers b. Currency and relevance to NP

practice/research c. Recency of references d. Evidence-based content e. Evidence of expertise in the area

of focus 3. A limited number of manuscripts

will be accepted for the program. Manuscripts will be given an initial scoring as follows: a. Ready for submission b. Requires minimal editing prior

to submission c. Requires moderate editing prior

to submission d. Requires substantial editing

prior to submission e. Out of scope for the current

program 5. The author will be notified of the

score and provided with options for moving the manuscript forward.

6. If the Emerging Scholars Program Editor accepts the manuscript

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into the program, she will work with the author to prepare the manuscript for submission and peer review. All types of articles (e.g., brief reports, original research, case studies) may be considered.

Acceptance into the Emerging Scholars Program does not guarantee manuscript acceptance for publication. All manuscripts that receive developmental

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assistance from the Emerging Scholars Program Editor must subsequently be submitted in the editorial system, go through the formal peer review process, and meet the same criteria for publication and scholarly work as every manuscript published in JNP.

We sincerely hope that new authors will find motivation to continue their writing journey and the readers of JNP will hear new perspectives from fresh voices in clinical practice.

Karen S. Moore PhD, DNP, APRN, ANP-BC, FNP-C, CGNC, FAANP, FAAN

Editor in Chief

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Engaging Emerging Scholars

Table-of-Contents_tjnp.pdf

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An Official Journal of the American Association of Nurse Practitioners JNP, The Journal for Nurse Practitioners, is also affiliated with the Australian College of Nurse Practitioners

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Patient Education d Cornerstone of Diabetes Care

By Adam Schragin, AANP Communications Writer and Editor

urse practitioners (NPs) working or interested in

Nendocrinology have a great deal of literature and new advancements to help them treat patients. One NP expert, Eligio David P. Soliman Jr., DNP, APRN, FNP-BC, CDCES, CMSRN, shared his perspective on the disease and treatment with the American Association of Nurse Practitioners®

(AANP) on NP Pulse: The Voice of the Nurse Practitioner®. Soliman is a clinical associate professor for the DNP

program at the Hahn School of Nursing and Health Science at the University of San Diego. He completed his doctoral degree from the University of Pennsylvania and is a nationally recognized speaker on the topics of diabetes care and endocrinology. One of the topics he spoke about on NP Pulse was the increase of diabetes diagnosis during the COVID-19 pandemic.

In part, Soliman states that the increase in diagnosis was due to patients having undiagnosed diabetes that was recognized when they saw a health care provider during the pandemic. “When COVID hit, everybody who got sick was seeking treatment. This included the people who were staying away from their primary care providers, who hadn’t seen a doctor for many years. And all of a sudden, they need to see a provider to treat their COVID, and it unmasks an existing metabolic problem.” Another factor, he notes, was the change in lifestyle that accompanied being locked indoors. “Everybody stayed home d we significantly altered our way of life. You know, the way we eat or, people who are going to the gym every day d all of a sudden, the gyms are closed, right?”

With the increase in diabetes diagnosis after the pandemic came an opportunity for Soliman to utilize his favorite tool to combat diabetes d patient education. He says that

Volume 21, Issue 5, May 2025 The Journal for Nurse Pract

“education for med diabetes self-management educationd is the cornerstone of diabetes care.” Soliman emphasizes that patients must feel connected to the continuum of care recommended by their NPs or other health care providers. “My friend and first mentor in the diabetes education realm, her name is Beverly Tomasi, and she runs this business in training diabetes educators. That’s where I got my first training, and I always resonate with her phrase: ‘Our words matter.’ One of the key points in terms of helping [patients] navigate and hit our goals and targets is by reconstructing the way we communicate with our patients. I avoid saying to ‘control’ your blood sugar…because control connotes a negative aspect in human behavior. It’s so hard to control anything. I focus on blood sugar goals or targets. ‘We're not yet on target’ versus ‘we're not controlling your blood sugar.’ It's like a whole different aspect of seeing things, and they can solidify their efforts and hit that target versus controlling something.”

To Soliman, that often means couching the language of diabetes into terminology his patients can comprehend. “In terms of blood sugars, I would tell [patients], ‘Your body can survive on almost any nutrient. But now, your body can't process carbohydrates. It's like buying a new car that requires a new kind of fuel. If you drive something that was diesel before, and now you drive an unleaded car and try putting in diesel, what will happen? It won’t start. And that's the same reason why when your blood sugar is so elevated, you feel sluggish because your body can't burn that fuel.’ It lights a light bulb… now, it's not about restricting. It's not about punishing myself. It’s about making my system work better because now I understand how it works.”

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What to Expect at the 2025 AANP National Conference

By Alex Fernandez, AANP Content Marketing Manager

This summer, thousands of nurse practitioners (NPs) will join the American Association of Nurse Practitioners® (AANP) in San Diego, California, at the biggest NP event of the year. The 2025 AANP National Conference, June 17-22, is a weeklong celebration filled with continuing education (CE), exclusive keynote speakers, legislative and policy updates, hands-on workshops, lively exhibitors and unparalleled collegial networking opportunities.

Regardless of whether you’re a practicing NP, an NP student or advocate for the NP role, AANP’s national conference offers a variety of educational and networking opportunities you can’t miss. Read on to gain more information on this highly anticipated event and hear from past attendees about the benefits of the national conference experience.

For those looking to learn and earn valuable CE credit, you’ll find more than 330 sessions and workshops at the in- person 2025 AANP National Conference. With the sheer breadth of sessions available, NPs at every experience level and specialty can find something of interest, as Vicki Brooks, DNP, APRN, FNP-C, CNEcl, FAANP, explains: “The variety of sessions that we have, the different levels, whether you're a novice or an expert, it just brings a big opportunity to cross over at whatever you need.”

In addition to the hundreds of sessions waiting for you in San Diego, dozens of sessions from the in-person conference will be made available on demand just days after the conference concludes! If you register for the in-person conference package, you can access the full on-demand package at no extra charge from June 27 to Aug. 4. Enjoy access to those select sessionsd and approximately 75 contact hours of CE credit d all from the comfort of your home.

Volume 21, Issue 5, May 2025 The Journal for Nurse Pract

While attending the 2025 AANP National Conference at the San Diego Convention Center, you and your fellow NPs can explore and enjoy the multitude of attractions and entertainment that San Diego has to offer. Make sure to add on a day or two outside of the conference to enjoy everything from sparkling beaches to laid-back neighborhoods, explore the cultural wonders of Balboa Park, take an epic coastal hike or discover your new favorite restaurant. Whatever makes you smile, there's more of it waiting for you when you stay a few extra days in San Diego!

This year, attendees can expect an inspiring speech from opening general session keynote speaker Matthew Luhn. You may not recognize Luhn’s name, but you definitely know his work: The Simpsons, Toy Story, Toy Story 2, Toy Story 3, Monsters Inc., Monsters University, Finding Nemo, Cars, Up and Ratatouille. After a stellar 30-year career at Disney/Pixar, he turned his focus to helping the corporate world leverage the art and science of storytelling for business success, authoring The Best Story Wins and consulting companies such as Charles Schwab and Adidas.

A top speaker on storytelling, creativity and innovation, he has delighted a range of Fortune 1000 audiences including Apple, Capital One, Clorox, Facebook, Gartner, Google, Microsoft, PayPal, Procter&Gamble, Sony, Target and Vrbo. His keynotes and workshops have been featured at BNY Mellon, BMW, Walt Disney Imagineering, Walt Disney Family Museum, Lego, Prudential Insurance, Salesforce, Volkswagen, Wells Fargo and many more. Luhn will share his process for creating new ideas, great stories, memorable characters and how to make stronger connections with attendees at the 2025 AANP National Conference!

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Recognizing Nursing Trailblazers With the National Leadership Awards

By Adam Schragin, AANP Communications Writer and Editor

Honoring the contributions of Jan Towers, PhD, NP-C, CRNP, FAAN, FAANP, FAAN, FAANP, the Towers Pinnacle Award is presented annually to an individual who, through policy, practice or education, has made outstanding contributions that resulted in increased recognition of nurse practitioners (NPs) nationally or internationally and expanded opportunities for NPs to care for patients. The Sharp Cutting Edge Award honors Nancy J. Sharp, MSN, RN, FAAN, an exemplar of excellence in organizational leadership within nursing. This award recognizes individuals who have performed extraordinary service activities on behalf of NPs on a national or international scale. Learn more about past recipients of both awards and why it is important to recognize these NP trailblazers.

Nancy J. Sharp was not an NP herself but acted as an advocate for NPs in nursing leadership. Her past role as nurse representative for the U.S. Joint Working Group on Telehealth is just one of the leadership positions she undertook over the years in support of the nursing profession, which extended to specific support for NPs. “I think NPs are the answer to the health care system’s problems. I’m not an NP, but I believe in the NP role,” she said. “Truly, some people do not know what NPs do or what they are capable of. The vast majority of the time, NPs listen to you, spend more time with you, hear your story and direct their care to meet your specific needs.”

Last year’s Sharp Cutting Edge Award went to Angela Golden, DNP, FNP-C, FAANP, FOMA, past president of AANP and founding co-chair of AANP’s Obesity Community. In announcing her award, AANP announced that Golden’s “… partnerships with elected officials,

4 www.npjournal.org The Journal for Nurse Practitione

national agencies and professional organizations have enhanced the understanding of how NPs positively impact health care access and social justice across all its complex facets.”

Towers graduated from one of the first baccalaureate programs for NPs at Duke University and became an NP in 1976. The American Academy of Nurse Practitioners was famously founded under an apple tree in her backyard, and as AANP wrote about Towers, “There isn’t an aspect of the NP role that has not been influenced by Dr. Towers. If you’re an NP, much of how you practice has been shaped by the work she has done over the last four decades.”

Last year’s recipient of the Towers Pinnacle Award was Kahlil Demonbreun, DNP, RNC-OB, WHNP-BC, ANP- BC, FAANP, FAAN. Demonbreun is a women’s health NP and as the women’s health medical director at the Columbia VA Health Care System, and just a few of his many achievements include a “ten-year sustained participation on the AANP Health Policy Committee,” which “resulted in summaries of more than 75 articles of federal and state legislation to advance NP practice.”

The recipients of the Towers Pinnacle and Sharp Cutting Edge awards are honored at AANP’s national conference. The 2025 AANP National Conference will take place in San Diego, California, from June 17-22. In addition to the Opening General Session, at which both award recipients will be recognized, the conference features more than 330 sessions and workshops where attendees may earn up to 34 contact hours of continuing education credit d and many opportunities to network and attend industry-supported and sponsored events.

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https://www.aanp.org/news-feed/2024-national-leadership-award-recipients-announced

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Outline placeholder

Patient Education — Cornerstone of Diabetes Care
What to Expect at the 2025 AANP National Conference
Recognizing Nursing Trailblazers With the National Leadership Awards

Increasing-Provider-Utilization-of-Apps-for-Anxiet.pdf

lable at ScienceDirect

The Journal for Nurse Practitioners 21 (2025) 105348

Contents lists avai

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Increasing Provider Utilization of Apps for Anxiety and Depression Management

Jurate Brigham, Susan Catchings, Rebecca Kitzmiller

Keywords: anxiety app depression mental health mobile application primary care

a b s t r a c t

Use of mobile phone applications (apps) may reduce the delay between symptom onset and treatment de- livery for the 1 in 5 US adults affected by mental illness. Following an app selection process, provider edu- cation, and clinic workflow redesign, providers recommended the Sanvello app to patients who scored �5 on Patient Health Questionnaire-9 or 7-item Generalized Anxiety Disorder scale screenings across 12 weeks. Of 434 eligible patients, 75 received Sanvello recommendation, representing a 17.3% increase over baseline of 0%. This initiative offers insights about provider interest, workflow design, and barriers and facilitators to app use for improving mental health care in primary care settings. © 2025 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar

technologies.

Introduction primary care setting was feasible and acceptable, with perceived

Mental illness affects 1 of 5 adults in the United States,1 with anxiety (19.1%) and major depression (8.4%) occurring most frequently.2 On average, those with mental illness experience an 11-year delay between symptom onset and receipt of treatment.2

Of the nearly 53 million US adults with mental illness, only 46% received mental health treatment in 20202 due to stigma, cost, and limited mental health resources.3,4 Mental illness contributes significantly to economic and personal burden, with major depressive disorder considered a leading cause of disability worldwide.5 As the debate about universal screening for anxiety and depression continues,6,7 research indicates that many patients exhibit mental illness symptoms in primary care,8 suggesting that primary care settings may offer significant opportunity for early identification and treatment. However, primary care providers struggle with time constraints, inadequate insurance coverage, and lack of community mental health resources to refer patients for treatment.4 These ongoing issues suggest a need for innovative strategies to support primary care providers.

Available Knowledge

Increased use of mobile phone applications (apps) may help overcome both patient and primary care provider barriers to mental health treatment. Apps are low cost and can be used at any time in the privacy of one’s home, lessening the perception of stigma.9 There are approximately 10,000 mental healthefocused apps available, and existing literature suggests that they are effec- tive for management of depression, anxiety, and stress.3,10-15

Hoffman et al16 found that integrating mental health apps into a

d, including those for text and data

benefit from patients and providers. Smartphoneebased mental health apps may reduce cost and improve access to care for those experiencing symptoms of anxiety and depression.

Despite the substantial number of apps available, providers seem reluctant to recommend them to patients due to difficulties ascertaining which apps to use and how to effectively share them.14,17 Although few studies examine systematic methods to improve provider utilization of apps, several qualitative studies found that provider education, time to explore the app, supportive resources and protocols, an app vetting process, and evidence of effectiveness increased the number of provider app recommenda- tions for managing symptoms of anxiety and depression.4,16-20

These strategies resulted in increased app recommendations among providers.4,17

Framework

This initiative used the Institute for Healthcare Improvement Model for Improvement (MFI) framework, developed by the As- sociates in Process Improvement21 to guide the implementation of a mental health app, Sanvello (Sanvello Health), in a single primary care practice. Facilitated by Plan-Do-Study-Act (PDSA) evaluation cycles, MFI promotes rapid innovation by identifying changes that contributed to improvements. Thus, MFI allows an organization to determine success beforewider implementation. This framework is widely used across health care settings and is regarded as effective for promoting provider behavior change.22 This initiative was designed and reported in accordance with the Standards for QUality Improvement Reporting Excellence (SQUIRE 2.0) guidelines.23

mining, AI training, and similar technologies.

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All wellness and mental health visits with pa ents ≥ 18

J. Brigham et al. / The Journal for Nurse Practitioners 21 (2025) 1053482

Aim

This quality improvement (QI) initiative aimed to increase provider recommendation of Sanvello to patients �18 years old who scored �5 on Patient Health Questionnaire-9 (PHQ-9) or 7- item Generalized Anxiety Disorder scale (GAD-7) screenings.

Was PHQ9 or GAD7 completed?

Score ≥ 5?

Methods

Setting and Participants

The initiative took place in a single clinic, part of a network of more than 35 independently owned practices, in North Carolina. The clinic provided care to children and adults, averaging just fewer than 400 patient visits per week. Services included primary, urgent, and preventive care; care management; nutrition services; and behavioral health. The site employed 5 advanced practice pro- viders, 2 family nurse practitioners, 2 physician assistants, and 1 family physician. This initiative focused on adult (�18 years old) patients experiencing symptoms of anxiety or depression, defined as a PHQ-9 or GAD-7 score �5. This score was chosen as the cutoff because it indicates the presence of mild symptom severity.24,25

Visit included in data collec on

Was Sanvello recommended?

Yes No

Figure 1. Flow diagram of the chart review process. GAD-7 ¼ 7-item Generalized Anxiety Disorder scale; PHQ-9 ¼ Patient Health Questionnaire-9.

Interventions

App Selection Available apps were vetted using standardized and clinic-

specific criteria. Using the mHealth Index and Navigation Data- base, a validated public database of more than 600 mental health apps, and One Mind PsyberGuide, a collection of professional re- views of mental health digital tools, Sanvello was selected for this initiative.

Sanvello provided app-based self-management of stress, anxi- ety, and depression. Moberg et al26 found that Sanvello users (n ¼ 500) experienced significantly less depression, anxiety, and stress and greater self-efficacy after 30 days of use and at 2 months’ follow-up. Sanvello’s customizable evidence-based interventions included mood tracking, symptom assessment, psychoeducation, cognitive behavioral therapy (CBT) techniques, mindfulness medi- tation, thought journals, goal setting, peer support, coaching, and psychotherapy.

Workflow Integration In addition to treatment as usual, for patients presenting with

elevated symptoms of anxiety or depression (ie, PHQ-9 or GAD-7 score �5), providers recommended Sanvello use. Supportive re- sources included a poster placed in examination rooms that facil- itated provider conversations with patients, and a “browse phrase” that provided a templated block of text copied into the electronic medical record (EMR) for providers to document the Sanvello referral.27

Provider Education An educational session, offered to providers both in person and

via zoom, included the following:

� Evidence for mental health apps3,10-15

� Evidence for Sanvello and interventions delivered25

� Process for: o Identifying patients for app recommendation o Recommending Sanvello o Documenting the referral

� Time and support to download and use Sanvello

Implementation Following review by the institutional review board and site

preparation, implementation took place July through October 2023 using 3 successive PDSA cycles. Each PDSA cycle included data collection and analysis, feedback to providers, and revised imple- mentation strategies to improve provider adherence to care guidelines and protocols.28

Study of the Interventions

Evaluative data were collected from providers and the EMR to 1) describe the effectiveness of the initiative to improve provider recommendation of Sanvello (outcome), 2) understand the impact of app recommendation on workflow and time (balance) as well as providers’ perceptions of implementation strategies, and 3) identify barriers and facilitators (process) to recom- mending apps. Data were recorded in MS Word or Excel (Microsoft Corp).

Demographics To determine the average number of at-risk patients the clinic

saw monthly, 30 days of baseline data were collected using EMRs. To describe the patient population for whom apps were

Table Demographic Data for Baseline and Intervention Patients

Characteristic Baseline Group Meeting Inclusion Criteria (n ¼ 153) Intervention Group (n ¼ 434)

Age, y, range (mean) 18-80 (39) 18-92 (40) Sex, % Female 68.6 71.2 Male 30.7 27.2 Transgender male 0.7 0.9 Transgender female 0 0.7

Race, % White e 77.6 Declined to answer 12.7 Black 4.8 Asian 1.6 Hispanic 1.8 Other 1.4

Visit type, % Mental health related 53 52.5 Wellness 47 47.5

Previous mental health diagnosis, % e 89.6 Prescribed psychotropic medications, % e 77.2 PHQ-9 score, range (mean, standard deviation) 0-27 (9.78, 5.65) 0-25 (8.44, 4.85) GAD-7 score, range (mean, standard deviation) 0-21 (8.69, 5.29) 0-21 (8.13, 5.22)

GAD-7 ¼ 7-item Generalized Anxiety Disorder scale; PHQ-9 ¼ Patient Health Questionnaire-9.

J. Brigham et al. / The Journal for Nurse Practitioners 21 (2025) 105348 3

recommended, age, sex, race, primary reason for visit, previous mental health diagnosis, medications, and PHQ-9 or GAD-7 score were collected (Figure 1).

To describe initiative participants, an online survey collected provider type, age, sex, years of practice experience, years working at the initiative site, and previous experience using apps, profes- sionally or personally.

Provider Perceptions Before and after the intervention, providers completed an

online survey asking about their experience and comfort rec- ommending mental health apps to patients. In each PDSA cycle, an emailed survey asked about the impact of app recommen- dation on time and requested recommendations to further improve the process. Results were used to refine implementa- tion strategies. Finally, a brief focus group conducted via Zoom captured provider perceptions of the value of initiative strategies.29

1 2 3 4 5 6

Pe rc en

ta ge

of Vi sit s

Week of Impl

Percentage of Pa ent Visits w Clinic

Survey

Figure 2. Run chart of applicati

Analysis

Using IBM SPSS Statistics for Windows version 29.0.1.0 (171) (IBM Corp), descriptive statistics were used to describe partici- pants, patients, screening rates, and the weekly Sanvello recom- mendation rate. A c2 test was used to detect change in app recommendation rate from baseline. Qualitative data were analyzed using content analysis to identify predominant provider perceptions.

Results

At-Risk Patient Population

Baseline data captured 30 days’ encounters (n ¼ 1,254). Both the PHQ-9 and GAD-7 screenings were administered in 80.7% (n ¼ 344) ofwellness andmental healtherelated encounters (n¼ 426). Among all patients, 12.2% (n ¼ 153) scored �5 on the PHQ-9 or GAD-7.

7 8 9 10 11 12

ementa on

ith App Recommenda on Average

Handout

Survey

on recommendation rates.

1 3 6

P5 P1 P2 P4 P3

Pe rc en

ta ge

Provider

Percentage of Visits with App Recommenda on per Provider Clinic Average

Figure 3. Application recommendation rates by provider (P).

J. Brigham et al. / The Journal for Nurse Practitioners 21 (2025) 1053484

Demographics

Of the 2,984 patient visits that occurred during the QI initiative, 434 met the criteria for Sanvello recommendation. Patients were predominantly white and female, had a preexisting mental health diagnosis, and were undergoing psychotropic medication treat- ment (Table 1).

Participants included 5 providers: 2 nurse practitioners, 2 physician assistants, and 1 family physician. Four of the providers were female and 1 was male. Providers varied in age (<35 to 55-65 years) and years in practice (<5 to 20þ years).

App Recommendation

Overall, 17.3% of patients experiencing symptoms of anxiety or depression received a recommendation for Sanvello, representing a statistically significant improvement (c2

1 ¼ 30.313, P < .001) over baseline app recommendations of 0%.

App recommendation rates varied throughout the imple- mentation period (Figure 2). At the beginning of week 9, a handout was introduced in response to provider requests for materials to distribute to patients.

App recommendation rates varied widely between providers; the lowest performer recommended the app in 1% of visits, and the highest recommended the app in 55% of visits (Figure 3).

PDSA Cycle Results

PDSA Cycle 1 PDSA cycle 1 data collection revealed that providers inconsis-

tently screened for anxiety and depression during follow-up visits. Although providers were referring Sanvello to patients with di- agnoses or concerns of anxiety and depression, lack of a PHQ-9 or GAD-7 score excluded patients from data collection. Clinic staff and providers agreed to screen all patients �18 years old.

During PDSA cycle 2, providers indicated that it took too much time to have patients scan the QR code and download the app during the visit and requested an informational handout to give to patients during visits. In response, a handout for patients was designed and placed in each examination room and at the desks where medical assistants (MAs) worked.

In PDSA cycle 3, providers shared that they struggled to remember to recommend Sanvello during patient visits. Providers reported that the new handout was helpful to reduce time and provide patients with information they could take home.

Provider Perceptions

The preimplementation survey indicated that most providers were comfortable treating symptoms of anxiety and depression and recommending apps to patients. About half reported recom- mending mental health apps in the past.

Despite multiple email reminders, only 2 postimplementation surveys were returned. All implementation strategies were acknowl- edged as valuable, particularly the handout and EMR browse phrase, both deemed very useful.

Focus Group Four of 5 providers participated in the focus group. Providers

stated that they thought Sanvello was beneficial to patients and indicated that they intended to continue offering the app to patients.

Barriers. Providers reported that amid the complexity of care and documentation demand, they may forget to recommend Sanvello.

P1: “I will say when we're going into a room, we're not usually just addressing the depression, the anxiety. We're addressing their diabetes, their blood pressure, we’re doing their physical as well. So, it's just that sense of not homing in on it specifically …

It's hard to change routine.”

J. Brigham et al. / The Journal for Nurse Practitioners 21 (2025) 105348 5

P4: “Because, bottom line, it takes time …. And then there's so much documentation that we do, that I think I probably rec- ommended it more than I documented it.”

Facilitators. Posters, patient handouts, and automated app feed- back served as reminders to providers.

Informational Materials.

P2: “I think having those [posters] on the back of the door did help, though, because as I was leaving sometimes, I see it and ‘Oh, yeah,’ then I'd be able to remind it to them and bring it up.”

P3: “And then theywould have the actual cards [handout] that you made, sitting there in their hands. I'd be like ‘Oh, let me explain to you why you have that in your hand.’ So that really helped a lot.”

P4: “I think those cards [handout] were the best thing …

because I did much better …. You don't have time to have them scan it [QR code]. Well, I'll give you a piece of paper [handout] about it [and you can download the app] later.”

App Interaction.

P3: “I downloaded the app myself to my phone so that I could tell patients ... I kind of forgot about it myself. But everymorning it pops up and says: ‘So, how are you feeling today?’”

Missed Opportunities. Providers identified the need to integrate the MA into the referral process and to improve EMR integration.

P1: “Having the MA [give handout to patients] … because the MAs are the ones that give out the PHQ-9 and the GAD-7. So, if they could have lumped that inwith it, I think that probably would have worked.”

P4: “One thing that would be nice is to have something like…the pediatric screening built-in tool… Or even the GAD-7…a place to say… ‘tool given.’ Because that's the one thing I failed to do …

document that I gave it… Because otherwise I don't remember who I gave it to … I don't want to repeat this.”

Approach to Selecting Patients for Referral. Providers who frequently recommended the app were asked to share their thought process about how they determined which patients should receive a referral for Sanvello. Themes included symptom severity, experi- ence with psychotherapy, and age.

P4: “I even gave it to people that didn’t have as severe of a GAD- 7 or PHQ-9 because this is helpful.”

P1: “People that have been in therapy for years … I might have said, ‘here, you could try this, but if you've been in therapy for years, there might not be anything new.’ … it didn't stop me from deliv- ering it. It just mademewarn them that this may ormay not benefit you if you've had years of CBT already.”

P3: “With my elderly patients, I would give it to them with a “Okay, this may be something you're not used to … if you don't want to do it, that's totally fine. Maybe your grandson could use it, or somebody else in your family.” So, I still gave it to them, even if I didn't think they really would do it.”

Discussion

The high prevalence of anxiety and depression in the United States underscores the critical need for effective mental health in- terventions in primary care settings. Combined with delay in treatment for more than half of people diagnosed as having mental health disorders, untreated mental health contributes to substan- tial personal and economic burden.5,30 This initiative highlights the

potential role of apps in supporting care delivery in the primary care setting. Not only did providers welcome the opportunity to recommend an app, but with support for process change, app recommendation to patients experiencing depression or anxiety increased from 0% to 17.3%. The success of this initiative suggests that with adequate support, apps can be an effective tool for enhancing mental health care in primary care practices.

Despite employing various strategies (eg, email reminders, audit, and feedback in the form of run charts, posters, and hand- outs) some providers faced challenges in recommending the app. Recommendation rates exhibited considerable variation across providers (1% vs 55%). Our initiative identified several factors that may contribute to variability, raising questions about how experi- ence affects incorporating new screening and recommendation processes into complex patient care. Less experienced providers indicated cognitive overload as a factor influencing the prioritiza- tion and delivery of care. Although health care worker burnout is extensively documented in the literature, limited information ex- ists about change fatigue and the impact of continuous improve- ment initiatives on health care professionals.31 These factors pose challenges when integrating new practices, potentially affecting patient care, provider well-being, and organizational outcomes.

Initiative findings emphasize the need to involve all clinic staff in change processes. Recognizing the collaborative nature of care delivery, 1 participant engaged their MA in the recommendation process, thus contributing to their emergence as the highest performer. Other providers acknowledged the efficacy of such an approach and expressed regret for not adopting a similar strategy. Although a cultural assessment was conducted, formal stakeholder analysis or process mapping before implementation may have facilitated earlier recognition of the crucial role of MA involve- ment.21,32 Integration of the MA in the recommendation process could have enhanced rates, especially for providers struggling with cognitive overload, as the inclusion of another individual in the process could have served as a reminder. The integration of the MA by the most successful provider emphasizes the importance of identifying all stakeholders involved in a care process, and then involving those stakeholders in the early stages of implementation.21,22,33

Initiative providers welcomed a systematic approach to evidence-based app selection facilitated by the mHealth Index and Navigation Database and One Mind PsyberGuide.34 Furthermore, provider engagement with the app improved recommendation, findings similar to other studies.4,16 The app's daily notification feature emerged as a potential facilitator, serving as an additional reminder for providers to recommend the app to their patients. A systematic method for evaluating app functionality combined with opportunities to engage with an app may be important to their adoption and recommendation among primary care providers.

Although others note the following desires by providers, initiative participants did not request the ability to track behaviors and moods or to view trends of this information.19,20,34 Rather providers identified opportunities for EMR functionality to improve recommendation and documentation, promoting consistent per- formance while reducing cognitive burden. Increasingly, providers expect to monitor patient app use and track progress through EMR integration.4,17,19,20,34 Once an app proves to be useful in clinical practice, integration into EMR processes would provide support for long-term change.

Strengths and Limitations

Strengths of this initiative include a small group of providers, previous use of apps for a different patient group, and a dedicated commitment to early recognition and treatment of anxiety and

J. Brigham et al. / The Journal for Nurse Practitioners 21 (2025) 1053486

depression. App selection using a well-constructed database with respected evaluation criteria increased confidence in app effec- tiveness. Using evidence-based change strategies with demon- strated efficacy, including frequent performance feedback, provided a solid foundation for this initiative.

This initiative experienced several limitations that affect the overall scope of the initiative. Due to time constraints, EMR func- tionality could not be fully maximized, challenging providers’ ability to track app recommendation, app uptake by patients, and patient response to app use. Integrationwithin the EMR, a provider desire noted by others,4,17,19,20,34 may have facilitated data collec- tion about the number of patients who downloaded and used the app, allowing for further assessment of the initiative's clinical sig- nificance. Although the addition of the browse phrase, the only feasible EMR modification that could be made within the con- straints of the initiative, received high praise from providers, further EMR integration is likely needed to support consistent app recommendation. Next, the threshold score of �5 on the PHQ-9 or GAD-7 guided data collection. However, during the focus group, providers indicated that they recommended Sanvello to patients who were below the threshold symptom score. Because these pa- tients were not included in data collection and analysis, the clinic likely performed at a higher recommendation rate than reflected in the results. Future initiatives should consider including all patients, irrespective of symptom scores, as mental health apps may prove beneficial even for those with minimal symptoms. Additionally, incorporating patients diagnosed as having anxiety or depression, regardless of their score, could enhance the comprehensiveness of data collection. Finally, leading a QI initiative as a change agent (eg, personnel external to a clinic), rather than as a change champion, posed challenges to integration within the clinic. As a nonem- ployee, the initiative lead lacked a preexisting relationship with the clinic, communicated via email rather than through embedded EMR methods, and visited the clinic once a week. Thus, missed opportunities to provide timely updates, coach, and engage in real- time problem-solvingmay have impacted the initiative's continuity and resulted in lower recommendation rates. These lessons collectively provide insight for refining future QI initiatives, emphasizing the need for comprehensive team involvement, effective communication strategies, and shared responsibility.

Conclusion

The initiative significantly improved app recommendation rates from 0% to 17.3%. Thoughtful and consistent engagement with providers revealed valuable insights about QI strategies that in- fluence provider behaviors within primary care. The variation in recommendation rates among providers emphasizes the need for tailored approaches, considering differences in experience, cogni- tive load, and individual adoption patterns. Lessons learned high- light the importance of early stakeholder involvement and process mapping, effective communication, and shared responsibility for successful implementation and sustainability. Further research is warranted to explore the impact of improvement initiatives on health care professionals, addressing gaps in understanding change fatigue and burnout. Overall, this initiative provides foundational insights for refining mental health app recommendation efforts in primary care settings.

Declaration of AI

During the preparation of this work, the authors used ChatGPT to improve the readability and language of the work. After using this tool/service, the authors reviewed and edited the content and take full responsibility for the content of the publication.

CRediT authorship contribution statement

Jurate Brigham:Writing e review & editing, Writing e original draft, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Rebecca Kitzmiller: Writing e review & editing, Writing e original draft, Validation, Supervision, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Susan Catch- ings: Writing e review & editing, Validation, Supervision, Project administration, Methodology, Conceptualization.

Declaration of competing interest

In compliance with standard ethical guidelines, the authors report no relationships with business or industry that may pose a conflict of interest.

Funding

No external or internal funding was provided.

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All authors are with the University of North Carolina School of Nursing at Chapel Hill. Jurate Brigham, DNP, PMHNP-BC, was a doctoral candidate at the time of work and can be reached at [email protected], Susan Catchings, DNP, FNP-C, is a clinical assistant professor, and Rebecca Kitzmiller, PhD, MHR, RN, BC, is a clinical associate professor and interim program director, health care leadership and administration.

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mailto:[email protected]

Increasing Provider Utilization of Apps for Anxiety and Depression Management

Introduction

Available Knowledge
Framework
Aim

Methods

Setting and Participants
Interventions

App Selection
Workflow Integration
Provider Education
Implementation

Study of the Interventions

Demographics
Provider Perceptions

Analysis

Results

At-Risk Patient Population
Demographics
App Recommendation
PDSA Cycle Results

PDSA Cycle 1

Provider Perceptions

Focus Group

Barriers
Facilitators

Informational Materials
App Interaction

Missed Opportunities
Approach to Selecting Patients for Referral

Discussion
Strengths and Limitations
Conclusion
Declaration of AI
CRediT authorship contribution statement
Declaration of competing interest
Funding
References

Pursuing-an-Australian-Nurse-Practitioner-Career--.pdf

lable at ScienceDirect

The Journal for Nurse Practitioners 21 (2025) 105378

Contents lists avai

The Journal for Nurse Practitioners

journal homepage: www.npjournal .org

Original Research

Pursuing an Australian Nurse Practitioner Career: Barriers and Enablers

Michaila MacAskill, Randall Oliver, Priya Martin, William MacAskill

Keywords: advanced practice education preceptors regional rural training

a b s t r a c t

Nurse practitioners (NPs) are valuable health care sector contributors. However, barriers and enablers to becoming an NP in Australia are poorly understood. To better understand these barriers and enablers, semistructured focus groups were conducted at a professional symposium for nurses, NPs, and NP candi- dates/students. Responses were thematically analyzed. Transcripts included 20 participants from regional and rural areas and generated the themes “Pathway Clarity” and “Financial Viability.” Providing clear path- ways through training, endorsement, and credentialing, structured on-site training programs, and funded positions for students and preceptors are support training outcomes for NPs, therefore maintaining and growing a high-quality NP workforce. © 2025 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http://

creativecommons.org/licenses/by/4.0/).

Introduction Reduced awareness and transparency of NPs’ scope of practice is

Nurse practitioners (NPs) are a relatively new addition to the Australian health workforce, with NPs first endorsed to practice in December 2000.1 Australia provides free health care to everyone in Australia via Medicare, which is funded by a levy of up to 2.0% of each individual’s taxable income. There are >2,500 Australian NPs working across multiple clinical areas, including aging and pallia- tive care, chronic and complex care, child and family health care, emergency and acute care, mental health care, and primary health care.2,3 After graduation from an approved NP graduate program in Australia, which requires the completion of 300 hours of super- vised clinical practice placement, NPs are then endorsed by the Australian Health Practitioner Regulation Agency and apply for recognition by Services Australia to obtain a provider number (to allow for billing for services) and prescriber number for Pharma- ceutical Benefits Scheme (to enable prescription of government subsidized medications under the Pharmaceutical Benefits Scheme). Using the full nursing scope of practice can help reduce the burden of the increasing demands on the health care system.4

Barriers toNPsworking to their full scopeofpractice includea lack of peer networks and support, resistance from medical officers, deficiency in funded training positions, inadequate designated pre- ceptors time, and insufficient support from their organizations and other health care workers.5,6 Further barriers in the Australian context include limited access to theMedicare Benefits Schedule and reduced authority to prescribe through the Pharmaceutical Benefits Scheme.7NPs relative scarcity,flexible rolesandscopeofpractice, and unclear training pathways result in thembeing poorly understood by health care workers and the wider community.5 These barriers pre- vent NPs from fully contributing to the health care system.5,7,8

r Inc. This is an open access article

partly due to nonuniform approaches to NP education.4 Conse- quently, NPs have inconsistent clinical knowledge, skills, and capabilitiesdeven among NPs within the same practice area.4

Structured expectations for ongoing education and development after graduation from a master of NP course are also lacking in Australia. This is unfortunate, because structured in-house NP ed- ucation programs with preceptorship arrangements and contin- uous targeted skills and knowledge assessments improve new NPs’ confidence, competence, and transition into practice.9 Further- more, the capacity of these NPs to provide higher level care de- velops more rapidly, therefore improving patient safety and enhancing organizational rate of return on investment.9

Pathways into the Australian NP profession are demanding, complex, and sometimes lack clarity. Australia NP endorsement requires unconditional general registration as a registered nurse, 5,000 hours of recent and relevant advanced practice experience, completion of a program of study approved by the Nursing and Midwifery Board of Australia, and compliance with the NP regis- tration standards for practice.10 Australian university master of NP enrollment applications require endorsement by a hospital and written commitment from a clinical support team comprised of appropriately experienced clinicians who commit to providing educational support for the duration of the student’s course. NP students in Australia are then provided with a generalized course applicable for all NPs, regardless of specialty area, with clinical skills taught by each NP students’ clinical support team.

Variable processes across employers add further complexity. Procedures after conferral of an NP qualification include endorse- ment by the Australian Health Practitioner Regulation Agency in addition to local credentialingda process that verifies the

under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

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M. MacAskill et al. / The Journal for Nurse Practitioners 21 (2025) 1053782

clinician’s qualifications, experiences, and ability to provide safe, high-quality health care.11

Purpose

Barriers and enablers to education and recruitment pathways (eg, enrollment pathways, variable scope of practice, funding and time constraints, and education programs structure, etc.) are not well reported in the literature. This study explored the experiences and perceptions of Australian rural and regional nurses, NP candi- dates, NP students, and NPs of the barriers and enablers faced by nurses pursuing an NP career.

Methods

Methodology and Research Design Overview

This study was conducted using qualitative phenomenological methods. This research paradigm acknowledges that there are multiple realities and truths that can be understood by examining a participant’s subjective (first-person) experiences.

Data were collected through 3 focus groups with participants from regional and rural areas. Focus groups were timed to coincide with a professional symposium for NPs and prospective NPs in 2024 to enable in-person data collection. Participants joined 1 of the 3 groups based on their experience. Experienced NPs (ENP) included thosewhohad beenworking asNPs>1 year, novices (NNP) included thosewhohad completed�1year of theirNP trainingorhad<1year experience as an NP, and students (SNP) included those who were less than 1 year into their NP training or were considering enrolling. Before commencing the focus group, participants completed apaper survey to collect demographic information.

The Darling Down Health Human Research Ethics Committee granted approval for this study (LNR/2023/QTDD/101655).

Participants

Participants were nurses, NP candidates, NP students, and NPs working in public or private health care services in Australia and attending the professional symposium. Inclusion criteria were holding a nursing qualification, being aged �18 years, and current or previous experienceworking in a regional or rural health service. NP candidates and NP students are nurses enrolled in a master of NP qualification program and undertaking working placement with a health care service; however, only NP candidates are paid for their clinical placement hours. NP candidates and NP students are henceforth referred to as student NPs (SNPs).

Recruitment Invitations to participate in this study were emailed upon

registration for the professional symposium. All participants were provided with a copy of the participant information and consent form upon registration. Participants provided informed written consent before participation.

Reflexivity

Because some researchers were known to participants, an external researcher facilitated the focus groups and survey collec- tion to minimize perceived power imbalances. Authors considered how their professional backgrounds, experiences, and prior as- sumptions affected data extraction and analysis. M.M. is a clinical nurse from a rural hospital and was (at time of data collection) a NP candidate. R.O. is an experienced NP in a regional hospital and a symposium organizer. W.M. is a rural health researcher with a

background in education and physiology. P.M. is an occupational therapist and rural health researcher with expertise in using qualitative methods. M.M. approached data collection and analysis with the lens of a rural NP candidate, R.O. from the perspective of regional NP preceptor, and W.M. and P.M. approached these pro- cesses from an educator’s perspective free of expectations of what NP education should resemble.

Data Collection and Analysis

Three separate focus groups were facilitated, one each for ENPs, NNPs, and SNPs. Focus group guides were used to facilitate the discussions (see Supplemental Materials 1, available online at http://www.npjournal.org). Focus groups were audio recorded and transcribed using Sonix (https://shopsonix.com/). Transcripts were manually checked for accuracy and deidentified. Line-by-line cod- ing and thematic analysis and synthesis was performed using an established 6-step analytical process12 and the NVivo 1.7.2 software package (QRS International). Initial codes were developed by one author to ensure congruity and comprehensiveness, further refined by a second author, and verified by all authors.

Trustworthiness

We ensure the trustworthiness of this research by demon- strating credibility, dependability, transferability, and confirm- ability.13 To ensure credibility, we have provided sufficient detail regarding data collection and data analysis and included all data in our analysis. Two researchers engaged in the analysis process and participated in peer checking and ensured data conformability. Coding decisions were tracked, and regular discussions occurred during data analysis processes to ensure dependability. Trans- ferability of findings to other settings was supported by our use of a professional symposium for recruitment purposes, yielding a participant pool covering a radius of >230 km from the district’s only regional public hospital. We ensured objectivity through our declaration and discussion of biases, by remaining objective through the study process, and by taking a neutral stance when reflecting the participant’s voice in the findings. Those of us known to participants recused ourselves from data collection. We acknowledged our different areas of expertise, subjective biases, methodological preferences, and world views as we worked throughout the study, thereby demonstrating reflexivity.14

Results

Overview

Twenty participants were recruited (Table). Focus group dura- tions ranged from 42 to 54 minutes. Participants were mostly women, aged in their 40s, with >10 years of nursing experience.

Thematic Analysis

Thematic analysis generated 2 themes and 2 subthemes: pathway clarity (enrollment and unstructured education) and financial viability.

Pathway Clarity Participants discussed their concerns and confusion regarding

the pathway from nurse to NP. Subthemes explored participants’ views on navigating enrollment, organizational expectations, un- structured on-site education, and their views on the endorsement and credentialing processes that follow the completion of their formal master’s program.

http://www.npjournal.org

https://shopsonix.com/

Table Participant Demographic information

Variable Experienced Nurse Practitioners Novice Nurse Practitioners Student Nurse Practitioners

(n ¼ 10) (n ¼ 5) (n ¼ 5)

Sex Female 5 5 4 Male 5 0 1

Employment Regional 9 4 4 Rural 1 1 1

Age, years 45 ± 7 (36-63) 41 ± 9 (30-54) 40 ± 7 (32-51) Nursing experience, years 25 ± 9 (11-46) 14 ± 5 (11-20) 19 ± 7 (10-30) Nurse practitioner experience, years 7 ± 4 (0.5-12) <1 0

Data are presented as number of participants or as mean ± SD (range).

M. MacAskill et al. / The Journal for Nurse Practitioners 21 (2025) 105378 3

1. Enrollment Participants reflected on the onerous enrolment processes. For

instance, university application processes requiring health services executive approvals and prearranged hospital-based support teams. University expectations often clashed with those of execu- tive officers and support team members, at times creating a “feedback loop” (SNP1) impeding nurses attempting to enroll in an NP course.

Executive wouldn't sign off… they're like “well,who is your support team?”…the support team [said] “So you had executive approval?” …I need somebody to sign something so the next person will sign something. (SNP3

Students and experienced NPs suggested existing NP teams could identify high-quality nursing staff who could “transition” into NP education pathways (SNP3). This selection process would pro- vide quality assurances for executives approving applications and provide applicants with NP guidance, thereby simplifying enroll- ment processes. Participants felt experienced NPs should provide targeted education for applicants and be involved in interview and credentialing processes to ensure applicants meet service needs.

[Current NPs] don't have a say in who is a candidate. We can see that [we can] mould this person because they've got huge poten- tial… let's start [role-]modelling [to] them early, get them that exposure. (SNP3)

2. Unstructured education Participants described being frustratedwith the lack of structure

provided for on-site education. Supervised clinical placement was described as “ad hoc” by 1 participant (ENP3), whereas 2 others said there was “no [educational] program [provided for them to deliver]” (ENP6, ENP3). ENPs explained how the lack of “clear curriculum or clear framework” in their own education left them with a “lack of confidence” and unanswered questions about their readiness for clinical practice (ENP3). Another stated, “I’m not exactly sure what I need to know to be a safe practitioner… in a rural setting” (SNP1). Preceptors experienced high supervision workload, which was exacerbated by limited paid preceptorship time, education program structure, and high clinical workload as barriers to providing SNP with education and supervision.

You'll end up staying back a couple of hours to try and catch up… because you've been teaching and mentoring the whole day… it's very enjoyable… but it is exhausting taking that on for two years. (ENP1)

ENPs also identified larger systemic issues affecting the educa- tion of prospective NPs. These issues included limited input from the

Australian College of Nurse Practitioners into SNP education, knowledge, and skill requirements; the need for hospital and health services (HHS) to incorporate a mandatory NP “post grad year” (ENP1), “really good internship” (ENP4) or fellowship program, and limited NP resource sharing between HHS. The burden is on each HHS, workplace, and often upon individual NPs, to develop their own local framework to support student learning in the workplace.

We haven't been well organised as a profession… We have the College [Australian College of Nurse Practitioners (ACNP)]. It kind of struggles… to make an impact… we haven't got an emergency College… [Every hospital] develops their own frameworks for different things… Districts need to be talking. (ENP3)

Some comments from SNPs and NNPs paralleled education concerns raised by ENPs. For instance, there was consensus that a competencies list they could “tick off” was desirable to support their education and “give confidence” to potential employers (NNP1). Other comments related to niche or rural settings, such as challenges related to developing models of care and business cases to create new NP positions. Several participants reflected on countless personal hours spent writing models of care, business proposals, and collecting statistics and demographics to create an NP position with “no guarantee that I will get the role” (NNP4) that they worked to create.

It took… three years of me continually writing business cases, models of care… I'd written everything… [the job advertisement] went worldwide because [government employer] knew I was the only [NP in my clinical field] in Australia. (ENP1)

Students raised concerns about their lack of understanding around the endorsement process. Some felt they had “no idea how this process works” (SNP1), whereas others expressed their limited understanding of local credentialing processes.

After you get a job… in 12 months, you get your credentials? (SNP4)

I thought you had to be credentialed before you practice? (SNP3)

I think there’s confusion about credentialing. (SNP1)

[After you] get your degree and your… endorsement and start working… you have to find a role… your own model of care… credential,… [there are] hidden bits and pieces which we haven't looked into before we start university. Sowe [are]… not aware of all this background work that needed to be done. (SNP2)

An emotive topic among students was the limited knowledge of NP educational requirements among preceptors and the students themselves. This posed a barrier to finding clinicians willing to join

M. MacAskill et al. / The Journal for Nurse Practitioners 21 (2025) 1053784

their clinical support team and to receiving education from their preceptors. One student described an encounter while trying to form a clinical support team who was asked “What does your course require me to do as a clinical supervisor?” and they realized “oh… I don't know either” (SNP1). Other students found that medical officers “don’t knowwhat [to] expect” fromNP supervision (SNP2), were unaware of the workload commitment or too time poor to volunteer as preceptors. (SNP4)

They [supervisors] don't know what… the expectation… from a student is… so I think they need to be educated… That's another barrier… nobody wants to be your supervisor. (SNP4)

Another barrier to accessing education, particularly in rural hospitals, was a reluctance from some medical officers to support SNP education.

Some doctors… often say, “I don't have time to help you today” … And you're like, seriously? And then they come to you like, “I need you to do this, this and this.” And you're like, “I'm an [NP candidate] today. I've got my own patients”… “I'm the doctor, you're the nurse, your title still has nurse written on it” … [some] doctors don't see the need for us. (NNP1).

Financial Viability All groups identified limited funded positions for SNP education

as a barrier to NP course completion. Sometimes, unfunded SNPs made substantial life changes to pursue their education.

We sold our house,we've downsized. I've dropped my hours so that I can do the study because the candidate positions just don't seem to be there. (SNP3)

Unfunded positions extended the time needed for master’s study and negatively affected quality of life, mental health, and overall well-being.

It's very different for a candidate because they're… a funded role. I was an NP student. You are funding yourself and everything. You were using all your holidays to do your prac… You were taking leave without pay. (ENP1)

It was suggested that funded SNP positions could be centrally managed to further streamline the education process.

There's no candidate position attached to [university places]… [there] should be. It would be nice if there were a central place where you applied… I think there's just that disjoint between [university and employer] funding. (ENP4)

Discussion

This research explored the perspectives of nurses undertaking NP education and of NP preceptors. The main barriers to pursuing an NP career are that pathways to becoming an NP are unclear, onsite education that is unstructured or absent, and there is limited access to funded clinical placement positions. Clear organizational processes for NP selection, clinical support team formation, and approval of university enrollment was desired. Key enablers to pursuing an NP career include incorporation of an internship, postgraduate year, or fellowship program for new NPs, additional funded preceptor time, preceptor understanding of educational

needs, and a greater leadership from the NP national college on matters relating to formalizing SNP education, mandating of clin- ical skills, competencies, and knowledge requirements similar to medical collages.

Some SNPs experienced financial barriers during their studies. Financial challenges, when combined with high tertiary study costs and the insecure employment opportunities, may represent a substantial barrier to nurses pursuing a career as an NP. This finding is consistent with the experiences of New Zealand NPs who report personal costs, arduous application processes, and a lack of guar- anteed employment as barriers to becoming an NP.6 Similarly, recommendations have made been in New Zealand to provide supportdincluding consistent and appropriately funded supernu- merary practicedto SNPs throughout their NP pathway.15

The Australian Nursing and Midwifery Accreditation Council defines the expectation of NP clinical capabilities through the Nurse Practitioner Accreditation Standards.16 Standard 8 stipulates that SNP receive “…a range of health care experiences that supports knowledge and skills development in patient centered care that is consistent with the principles of primary health care and comple- ments the student’s specialty skills and knowledge.”16

It has been noted within Australian policy research that the standard lacks any specific detail of the expected clinical skills, knowledge, and attributes to be attained, leaving substantial po- tential variation in the capabilities of future NPs.4 This lack of specificity is reflected by participant frustration with unstructured SNP education and desire for deliverables such as a competency checklist. This overall call for consistency in education and better transparency around skills and competence is supported by earlier research recommending the removal of the specific number of advanced practice clinical placement hours required in favor of competency-based assessments and specific performance indicators.4

Changes at the local and district level should prioritize the development of consistent educational processes, clear goals and expectations, availability of educational opportunities, and provi- sion of trained preceptors for all SNP. Such changes could reduce uncertainty for SNPs and their preceptors, while concurrently building SNP’s knowledge, networks, and clinical skills. Ongoing education and professional support after graduation is also crucial for SNPs. For instance, internships benefit medical practitioners by providing supported roles, a safe opportunity to continue to learn, and a transition into practicedwithout the expectation to perform similar to senior clinicians.17 Internships, fellowships, and mentor- ship programs provide similar benefit to early career NPs.18-22

The programs can also support the development of credentialing and educational frameworks.23We note that some Australian states have clearer guidelines on NP developmentdwith some providing NP coordinators to support NP and SNP educational needs, gover- nance, and role developmentdpotentially addressing some of the barriers identified by participants.24

Participants in this study emphasized that NP teams should stream capable nurses into NP pathways. This would support them to develop advanced clinical skills and build professional relation- ships with NPs and consultants, thereby supporting them to establish clinical support teams for master’s course entry re- quirements. This streaming process and preexisting professional preceptorship relationships would provide assurances to execu- tives signing off on enrolment applications. This recommendation parallels literature reporting that NP leaders support the transition of registered nurses to NPs, aid SNP progression and development, and facilitate communication between SNPs and executive staff.14,25 Identifying individuals for NP streaming could occur during annual performance development assessments, through clinician recommendations, and use of the Australian Advanced

M. MacAskill et al. / The Journal for Nurse Practitioners 21 (2025) 105378 5

Practice Nursing Self-Appraisal (ADVANCE) tool.26 Streamlining the enrollment processdfor instance, by creating local or statewide policies outlining governance requirements similar to those in New South Wales24dmay support those pursuing NP study. Local or statewide policies could alsominimize “political agendas, turf wars, and professional hierarchies” that challenge Australian nurses seeking endorsement as NPs.27

Additional paid SNP positions, jointly managed by health care organizations and universities, would ease the financial and time burdens of NP study and limit bureaucratic delays. This change would reduce the need for SNPs to use leave or work additional hours to complete their studies, addressing a substantial barrier to course completion. Education, supervision quality, and supervision workload could improve by including preceptorship time within working hours and offering appropriate remuneration for work outside their standard roster.

Limitations

This study is potentially limited by sampling bias because par- ticipants were drawn only from participants at a professional symposium. However, this sampling method also ensured that participants were drawn from facilities across a wide geographic area encompassing rural and regional areas and public and private providers, increasing the generalizability of the findings.

Conclusion

This study explored the views of ENPs, NNPs, and SNPs on the barriers and enablers faced by nurses pursuing an NP career. The main perceived barriers to becoming an NP were lack of pathway clarity (particularly complex course enrollment processes), diffi- culty finding preceptors, a lack of structured education programs and on-site education, limited funded clinical education time for preceptors, and an insufficient supply of funded SNP positions. Perceived enablers included the clinical support team supporting SNPs, district health executives, NPs, and universities collaborating to streamline enrollment processes, structuring NP clinical place- ments, and identifying potential NPs early and tailoring their ed- ucation towards an NP skill set. The development of formalized district or statewide education programs and clear knowledge and skill expectations should be established to ensure consistently high-quality NP graduates. The burden of NP education and grad- uate quality can be further improved with sufficient paid time for SNPs and preceptors and graduate transition into practice pro- grams such as fellowships, internships, and postgraduate positions. Enhancing NP education for regional and rural nurses will strengthen the quality, capability, and confidence of new NPs and support higher-quality patient care, improved patient satisfaction, and a faster return on investment for health care organizations.

CRediT authorship contribution statement

Michaila MacAskill: Writing e review & editing, Writing e

original draft, Methodology, Formal analysis, Conceptualization. Randall Oliver: Writing e review & editing, Validation, Resources, Conceptualization. Priya Martin: Writing e review & editing, Validation, Methodology, Conceptualization. William MacAskill: Writing e original draft, Validation, Supervision, Methodology, Investigation, Formal analysis, Conceptualization.

Declaration of competing interest

In compliance with standard ethical guidelines, the authors report no relationships with business or industry that may pose a conflict of interest.

Funding

This work was supported in part by a Rural Health Multidisci- plinary Training (RHMT) program grant issued to Griffith University by the Australian Federal Government’s Department of Health and Aged Care.

Data and Resource Availability

The data that support the findings of this study are available upon reasonable requests from the corresponding author.

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6. Adams S, Carryer J. Establishing the nurse practitioner workforce in rural New Zealand: barriers and facilitators. J Prim Health Care. 2019;112:152-158. https://doi.org/10.1071/HC18089

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12. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;32:77-101.

13. Olmos-Vega FM, Stalmeijer RE, Varpio L, Kahlke R. A practical guide to reflexivity in qualitative research: AMEE Guide No. 149. Med Teach. 2023;453: 241-251. https://doi.org/10.1080/0142159X.2022.2057287

14. Bengtsson M. How to plan and perform a qualitative study using content analysis. NursingPlus Open. 2016;2:8-14. https://doi.org/10.1016/ j.npls.2016.01.001

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17. Carlsson Y, Bergman S, Nilsdotter A, Liljedahl M. The medical internship as a meaningful transition: a phenomenographic study. Med Educ. 2023;5712: 1230-1238. https://doi.org/10.1111/medu.15146

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Michaila MacAskill, NP, is a clinical nurse at Darling Downs Health, Dalby, Queensland, Australia. Randall Oliver, NP, is a nurse practitioner at Darling Downs Health, Too- woomba, Queensland, Australia. Priya Martin, PhD, is an adjunct associate professor at the Rural Clinical School, The University of Queensland, Toowoomba, and an associate professor in the School of Health and Medical Sciences, University of Southern Queensland, Toowoomba, Queensland, Australia. William MacAskill, PhD, is a research fellow at the Rural Clinical School, Griffith University, Toowoomba, and postdoctoral research fellow at the Rural Medical Education Australia, Toowoomba, Queensland, Australia, and can be reached at [email protected].

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mailto:[email protected]

Pursuing an Australian Nurse Practitioner Career: Barriers and Enablers

Introduction
Purpose
Methods

Methodology and Research Design Overview
Participants

Recruitment

Reflexivity
Data Collection and Analysis
Trustworthiness

Results

Overview
Thematic Analysis

Pathway Clarity
Financial Viability

Discussion
Limitations
Conclusion
CRediT authorship contribution statement
Data and Resource Availability
Declaration of competing interest
Funding
Funding
References

Longitudinal-Simulation-and-Procedural-Skills-Curr.pdf

lable at ScienceDirect

The Journal for Nurse Practitioners 21 (2025) 105366

Contents lists avai

The Journal for Nurse Practitioners

journal homepage: www.npjournal .org

By Faculty for Faculty

Longitudinal Simulation and Procedural Skills Curriculum for Pediatric Critical Care Nurse Practitioners

Katie K. Wolfe, Anna McCormick, Sarah Weyhrich, Lindsey Kerley

Keywords: critical care education procedure simulation

a b s t r a c t

Background: Pediatric nurse practitioners (NPs) in the intensive care unit (ICU) have inconsistent opportu- nities for iterative practice and formative feedback in acute patient management and procedural skills. Method: A curriculum was developed and implemented using simulation-based mastery learning theory and Kern’s curriculum development methodology. NPs from the pediatric and cardiac ICUs participated in monthly 1-hour sessions focused on procedural skills and simulated cases. Narrative feedback and satisfac- tion data were collected at the end of each session and 1 year after implementation. Results: A longitudinal simulation-based NP-focused curriculum in pediatric critical care was successfully implemented with strong engagement. All participating NPs reported increased confidence and perceived knowledge in care of critically ill children. In addition, all participants reported clinically relevant content and satisfaction with the use of simulation as a teaching method. Discussion: Participation in a longitudinal simulation-based curriculum for pediatric critical care NPs was associated with increased perception of knowledge and confidence in clinical and procedural skills. Simu- lation is an engaging and effective modality for ongoing NP education. Future work will assess the impact on NP-delivered patient care in the ICU. © 2025 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY-NC license

(http://creativecommons.org/licenses/by-nc/4.0/).

Introduction preparatory training curriculum for early physician learners.16-18

Pediatric critical care nurse practitioners (NPs) are integral to a functioning intensive care unit (ICU) team.1-3 The increasing vol- ume and complexity of the pediatric population requires a strong multidisciplinary approach.4 NPs have been shown to have a pos- itive impact on the academic environment, enhancing the educa- tional experience and decreasing workload of physician trainees, improving adherence to institutional guidelines, and leading pa- tient safety and quality improvement efforts.3,5,6

Despite efforts to standardize the role of NPs in the pediatric ICU (PICU), there is institutional variability in perceived clinical practice roles and responsibilities.2,3,7 Several organizations have worked to develop standardized competencies in pediatric acute care for NPs. Successful adherence to these recommendations requires thoughtful postgraduate orientationwith continuing education.8-12

Building on foundational common knowledge and skills with continual education for NPs is critical to maintenance of clinical excellence in the PICU.

Simulation-based medical education has been increasingly used to enhance the physician training environment and undergraduate and graduate nursing education.13 This instructional methodology facilitates learning through practice of skills essential in critical care medicine.13-15 “Bootcamps” (intensive educational events held over a short time) have demonstrated success as an intensive

ier Inc. This is an open access artic

Most of the simulation literature in the PICU has been dedicated to team performance in high-risk clinical situations.19-23 Descriptions of the use of simulation in teaching postgraduate pediatric NPs are limited.24-27 The simulation “bootcamp” model has been used to train NPs in common high-risk procedures and clinical scenarios with success.28-30 However, there remains a gap in longitudinal opportunities for iterative practice and formative feedback in acute patient management and procedural skills. To address this lack of ongoing education for pediatric critical care NPs, a longitudinal simulation and procedure skills curriculum was developed and implemented with the goal of increasing confidence and perceived knowledge in the care of critically ill and injured children.

Methods

Study Design

A descriptive educational intervention study was conducted, reviewed by the school of medicine institutional review board and considered exempt. The goals of this curriculum were to increase NP confidence in critical situations, increase perceived knowledge and application of knowledge to clinical practice, increase aware- ness of resource availability in the ICU environment, increase confidence in performance of procedures, and increase NP

le under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).

Delta:1_given-name

Delta:1_surname

Delta:1_given-name

Delta:1_surname

http://creativecommons.org/licenses/by-nc/4.0/

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www.sciencedirect.com/science/journal/15554155

http://www.npjournal.org

https://doi.org/10.1016/j.nurpra.2025.105366

http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1016/j.nurpra.2025.105366

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participation in simulation education. Each NP was expected to attend at least 2 procedural skill sessions and 6 simulated patient encounters (3 sessions) in 1 year. The curriculumwas structured in 1-hourmonthly sessions, alternating between procedural skills and simulated patient encounters. An additional half-day session with procedural skills and simulated clinical encounters was held near the end of the year to allow for maximal participation. Participating NPs had 2 options for attendance each month to increase flexibility and allow for smaller groups in each session. As designed, the participants would be exposed to the variety of represented path- ophysiology over 2 years of participation.

Participants and Faculty

Thirty-one NPs working in the PICU and cardiac ICU (CICU) at a single quaternary academic children’s hospital participated in this curriculum. Faculty volunteers and facilitators included pediatric intensivists, pediatric cardiac intensivists, pediatric critical care medicine (PCCM) fellows, and simulation center staff.

Setting and Equipment

This curriculum was implemented in the hospital’s simulation center. The simulation center provided task trainers for procedural teaching (central venous line, airway, arterial line, lumbar puncture task trainers). High-fidelity mannikins were used for the patient scenarios (Laerdal Corporation SimBaby, SimJunior, SimNewB). Zoll defibrillator, crash cart, and other equipment available in the ICU were available in the simulation center.

Table 1 Educational Methods

Month Educational Methods Simulation Scenarios

January Discussion Demonstration Task Training

Airway managementdba

February High-Fidelity Simulation Reflection

Septic shock Hemorrhagic shock

March Discussion Demonstration Task Training

Central venous catheter p Arterial puncture

April High-Fidelity Simulation Reflection

Tamponade Pulmonary hypertensive

May Discussion Demonstration Task Training

Airway managementdba

June High-Fidelity Simulation Reflection

VT (Benadryl ingestion) SVT with hemodynamic c

August High-Fidelity Simulation Reflection

DKA with cerebral edema Herniation/increased ICP

September Discussion Demonstration Task Training

Central venous catheter p Arterial puncture

October High-Fidelity Simulation Reflection Task Training

Hemorrhagic shock ETT/tracheostomy obstru Airway management Central venous catheter p Arterial puncture Lumbar puncture

November Discussion Demonstration Task Training

Lumbar puncture Chest tube

December High-Fidelity Simulation Reflection

Intubation of patient in c

DKA ¼ diabetic ketoacidosis; DOPE ¼ dislodgement ¼ obstruction, pneumothorax, equip electrical activity; SVT ¼ supraventricular tachycardia; VT ¼ ventricular tachycardia. One year of simulation and procedural curriculum for critical care NPs. Didactics consiste setup, and execution. Clinical cases were included in these discussions at the discretion objectives and content reviewed during the sessions. We held a half-day simulation and p nurse practitioners who were unable to attend all sessions during the year.

Application of Theory

This curriculum was rooted in simulation-based mastery learning theory,31 which combines constructivist, behavioral, and social cognitive learning theory.32-34 Self-directed problem-solving and building on prior knowledge are key to participant knowledge and skill acquisition. Distributed practice was used in the curricu- lum design to increase retention.35,36 Finally, facilitator-guided, semistructured debriefing framework aligned with reflective practice.37,38

Curriculum Development

This curriculum was developed using Kern’s curriculum devel- opment methodology.39 First, in early 2022, 18 PICU NPs partici- pated anonymously in a general and targeted needs assessment of NP education in the PICU. This demonstrated low satisfaction with NP education in the ICU and poor attendance at dedicated simu- lation time. NPs reported a lack of interest in participating in simulation and a lack of structure during NP dedicated simulation time. NPs also reported feeling judged during previous experiences with simulation-based assessments. This needs assessment asked about preferred instructional methods and settings. All responding NPs reported that NP-specific education, ideally integrated into the clinical workday was preferred and that attendance at education focused primarily on residents or fellows was less useful. NPs re- ported infrequent opportunities to perform procedures and mini- mal procedural training, limiting their confidence. Based on these data, curricular components (Table 1) and objectives were

g mask ventilation, airway adjuncts, patient positioning, endotracheal intubation

lacement

crisis g mask ventilation, airway adjuncts, patient positioning, endotracheal intubation

ompromise

lacement

ction (DOPE)

lacement

ardiogenic shock

ment failure; ETT ¼ endotracheal tube; ICP ¼ intracranial pressure; PEA ¼ pulseless

d of an interactive discussion of procedures including indications, contraindications, of faculty. Procedural sessions and simulations included short summary of learning rocedure makeup session to allow for repeated exposure or additional attendance by

Table 2 Participant Demographics

N (%)

Duration of experience as NP (years) 0e4 11 (36) 5e10 10 (32) >10 10 (32)

Primary ICU PICU 19 (61) CICU 12 (39)

No. of sessions attended 1e4 6a (19) 5e9 25 (81) 10e12 0 (0)

CICU ¼ cardiac intensive care unit; NP ¼ nurse practitioner; PICU ¼ pediatric intensive care unit. Description of the characteristics of NPs participating in this curriculum, including experience, primary ICU, and attendance at sessions.

a One PICU NP left the organization midyear, and 2 other PICU NPs were not credentialed to do procedures due to their employment agreements.

K.K. Wolfe et al. / The Journal for Nurse Practitioners 21 (2025) 105366 3

developed. Kirkpatrick’s model of assessment was used in the development of objectives, beginning at the levels of reaction and learning.40 Implementation of the curriculum began in January 2023 and continued through December 2023. The overarching goals were to increase structure and improve utilization of simu- lation time for NPs and to improve the confidence of NPs in critical situations in the ICU as well as improve procedural confidence. Multimodal educational strategies were used including discussion, demonstration, simulation, and reflection/debriefing.

Simulation Scenarios and Debriefing

Simulation sessions included prebriefing, 2 clinical cases, typi- cally 10 minutes in duration, each followed by semistructured, facilitated debriefing. Cases included clinical scenarios in which NPs would typically be called to a patient’s bedside (e.g., tachy- cardia, seizure, hypoxemia) as well as low-frequency, high-risk events (e.g., pulmonary hypertensive crisis, cardiac tamponade). In addition to the overall curricular goals, specific learning objectives were developed for each scenario. These cases were designed to align with the typical role of the NP in the ICU, specifically the clinical situations in which NPs would typically be the first person to respond to a clinical change and need to escalate care. A sample scenario outline is represented in Appendix 1. Two to 3 NPs were self-selected to be primarily involved in the scenario itself, with the remainder of participants observing. Two to 3 different NPs were primary responders in the second scenario. All participating NPs acted in their usual clinical role. Non-NP provider roles (e.g., bedside nurse, charge nurse, respiratory therapy, consulting phy- sicians) were played by faculty and simulation center staff. After scenario completion, a facilitator-guided debriefingwas completed, based on PEARLS framework.41 Debriefing included faculty facili- tators and all NPs present, including those who were observers during the scenario. This encouraged reflection of how each NP would typically practice and allowed for all participating NPs to engage in the discussion of physiology applied in the scenario.

Procedural Training

The procedural aspect of the curriculum focused on airway management (including bag mask ventilation and endotracheal intubation), central venous catheter placement, arterial line placement, and lumbar puncture; expected procedural compe- tencies for critical care NPs. Procedure-oriented sessions began with an interactive discussion focused on the specific procedure, including indications, contraindications, complications, and other important considerations. Additional resources, including images and videos, were provided and facilitators demonstrated the pro- cedure. In the second half of the hour, participants practiced these skills on task trainers, with faculty and peer supervision and facil- itation. NPs assisted each other in troubleshooting, including positioning and use of equipment.

Measurement

Demographic data was collected from all participating NPs. At the end of each session, data regarding confidence, relevance, knowledge acquisition and satisfaction were collected electroni- cally using a QR code and Microsoft Forms. Responses were rated primarily on a 3-point Likert scale (disagree, neutral, agree). Narrative feedback was collected after each session. One year after program implementation (December 2023), data regarding satis- faction with the curriculum as well as confidence in critical events and procedural skills were collected electronically using Qualtrics.

Results

Thirty-one NPs have participated in this curriculum in the year since implementation. Nineteen (61%) of participating NPs work primarily in the PICU, and 12 (39%) are primarily members of the CICU team. The majority of participants (64%) have 5 or more years of experience as critical care NPs (Table 2). The majority of partic- ipants (81%) attended more than 5 of the 12 sessions, although attendance at 4 sessions was the minimum required.

All participating NPs completed post-session evaluations. Ninety-seven percent of participants reported that the sessions increased their confidence in patient care and their knowledge in management of a deteriorating patient. All NPs reported that the sessions were relevant to their daily practice, and 98% indicated that simulation was an effective educational method (Table 3). Following 1 year of implementation, responding NPs (n ¼ 13, 42% response rate) reported increased confidence in management of critical situations and an increased awareness of resources. The majority of participants (77%) also reported increased confidence in performing procedures. Narrative feedback regarding content was universally positive. NPs cited improved utilization of simulation time, appreciation of physician investment in NP education, and the opportunity to practice commonly encountered clinical scenarios as curriculum strengths. Simulation allowed NPs to make connec- tions at the bedside after participation.

Discussion

This longitudinal simulation-based training curriculum for pe- diatric critical care NPs created an engaging and effective learning environment, regardless of level of experience. NPs reported that participation was worthwhile and enhanced their clinical confi- dence in patient care, procedure performance, and resource utili- zation. The current literature on the use of simulation for ongoing education of nonphysician providers in general, and in NPs in pe- diatric critical care specifically, is sparse. This curriculum adds to the literature and its longitudinal design is innovative in this pop- ulation of professionals. The curriculum’s longitudinal design allowed for application of distributed practice which has been shown to increase overall retention.35,36 NPs commonly remarked on making connections at the bedside following experiences in the simulation lab. Additionally, the simulated patient scenarios and procedure sessions, even when developed from existing resources, were adapted specifically for the role and learning needs of NPs. This involved modification of the learning objectives and patient

Table 3 Outcomes: Summary of Evaluation Data From the Post-Session and 1-year Assessments

Post-session Evaluations (n ¼ 62) n (%)

This session increased my confidence in patient care Agree 60 (97) Neither agree nor disagree 2 (3) Disagree 0 (0)

This session increased my knowledge in the care of a deteriorating patient Agree 60 (97) Neither agree nor disagree 2 (3) Disagree 0 (0)

The content of this session was relevant to my daily practice Agree 62 (100) Neither agree nor disagree 0 (0) Disagree 0 (0)

Simulation and/or skills-based training is an effective educational method Agree 61 (98) Neither agree nor disagree 1 (2) Disagree 0 (0)

The session had sufficient time for my learning Agree 61 (98) Neither agree nor disagree 1 (2) Disagree 0 (0)

End of Year Assessment (n ¼ 13)

This curriculum was a worthwhile use of my time Agree 12 (92) Neither agree nor disagree 0 (0) Disagree 1 (8)

I have acquired new medical knowledge Agree 12 (92) Neither agree nor disagree 0 (0) Disagree 1 (8)

I have increased confidence in critical situations Agree 13 (100) Neither agree nor disagree 0 (0) Disagree 0 (0)

I have increased awareness of my resources and how to use them Agree 12 (92) Neither agree nor disagree 0 (0) Disagree 1 (8)

I have increased confidence in performing procedures Agree 10 (77) Neither agree nor disagree 1 (8) Disagree 2 (15)

K.K. Wolfe et al. / The Journal for Nurse Practitioners 21 (2025) 1053664

scenarios to align with their clinical role in the ICU. For example, NPs were not expected to function independently as team leader during a code event or place a pericardial drain in the case of car- diac tamponade but were expected to identify physiologic de- rangements, develop a differential diagnosis, initiate appropriate management, and call for help. The focus on the NP learners’ needs promoted participation and collaboration throughout the process.

The positive impact on the confidence of a group of experienced NPs is another unique aspect of this curriculum. Most published simulation literature discusses the benefits of simulation for novice learners and practitioners.24-27 However, these data demonstrated that even experienced NPs (64%with 5 ormore years of experience) perceived benefit from participation in the curriculum. This dem- onstrates the importance and impact of continued education for NPs, recognizing that clinical experiences were enhanced by reg- ular reiteration of pathophysiology and deliberate practice.

An aspect of this curriculum that was difficult to measure but important was the resultant engagement. The investment of time from PCCM faculty and fellows, along with NP leadership and the simulation center staff, was noticed and appreciated by the participating NPs. Attitudes surrounding the utility of simulation in their education increased among NPs with improving attendance

and participation during the year. PCCM faculty and fellows acted as facilitators in the simulation lab but also took on clinical re- sponsibility for NPs working in the unit during simulation to allow their attendance and participation. Future iterations of this work will explore the relationships between physician and nonphysician team members.

Future Directions

This simulation curriculum remains in place with regular eval- uation and modification. The post-session evaluation form has been modified to collect more information about the content of each session to refine future scenarios and teaching. Based on end- of-year feedback, the structure will include 10 case-based simula- tion sessions per year and 2 half-day procedure skills sessions. This will allow for additional flexibility in NP attendance, with the goal of NPs attending during clinical service time to respect their time away from the hospital and assurance that procedure skills are able to be efficiently reviewed for maintenance of credentialing pur- poses. As this program continues, the scenarios will increase in complexity, and NPs will be engaged in scenario design, facilitation, and debriefing. Within the Kirkpatrick Model of Assessment, the curriculum is currently at the reaction and learning levels.40 As the NPs become more comfortable with simulation, more formal assessment and individualized formative feedback will be incor- porated, moving up to Kirkpatrick’s behavior and ultimately results levels. This may allow for determination of an optimal cadence of required participation. Further, assessment of NP performance in the clinical environment will be completed and used to assess ef- ficacy in a more patient-focused way. Incorporation of other multidisciplinary team members, including bedside nurses, fel- lows, and faculty, into NP simulations can enhance collaboration in the learning environment and increase the fidelity of the simulations.

Limitations

There are limitations to the applicability, generalizability, and impact of this work. This curriculum was implemented at a single institution. Given the variability in role and experience of NPs in the PICU and CICU settings, this could limit its application to other institutions. However, independent of the specific NP role in an ICU, an understanding of pediatric pathophysiology, and the ability to ask for help is nearly universal. Therefore, this curriculum could be adapted to a different institution or setting with minimal modifi- cations. Competence was not assessed for the participating NPs during or after participation in the curriculum. Although this was intentional in the design of this study to create an environment conducive to risk taking and formative feedback, it is a limitation of these data. Perceptions of increased knowledge do not necessarily result in improved provision of patient care, which is the ultimate goal of any educational intervention. As NPs have gained comfort with simulation as an educational tool, assessment of competence and the impact on patient care is an important next step. Assess- ment will include the use of checklists during simulation and procedure skills training as well as tracking of NP clinical perfor- mance and procedural competence. While tracking of the number of procedures performed by NPs before and after implementation of this curriculumwas intended, the data gathered were inaccurate and therefore unable to be used to draw any conclusions. There was also a missed opportunity in post-session evaluations to assess the impact of experience on the increases in confidence. Because of the longitudinal nature of this curriculum and concurrent efforts to improve the learning environment for NPs in the PICU and CICU, the increase in confidence among NPs may not be completely

K.K. Wolfe et al. / The Journal for Nurse Practitioners 21 (2025) 105366 5

attributable to this specific curriculum. While the immediate post- session evaluations were consistently completed by all participants, there was limited response to the end-of-year assessment. This may result in inaccurate assessment of the overall experience of the participating NPs. Additionally, the time and effort invested on the part of PCCM faculty and fellows may limit this program’s appli- cability in a different setting because it would not have been feasible without this investment and support.

Conclusion

Pediatric critical care NPs are a growing and vital portion of the pediatric critical care workforce. A longitudinal, simulation and procedural skills curriculum designed for pediatric critical care NPs increased confidence in clinical reasoning and procedural skills. This curriculum provided NPs with engaging and clinically relevant ongoing education and future work will explore the impact of ed- ucation on NP-delivered clinical care.

CRediT authorship contribution statement

Katie K. Wolfe: Writing e review & editing, Writing e original draft, Methodology, Formal analysis, Data curation, Conceptuali- zation. Anna McCormick: Writing e original draft, Project administration, Data curation. Sarah Weyhrich: Project adminis- tration. Lindsey Kerley: Writing e review & editing, Project administration, Methodology, Conceptualization.

Declaration of Competing Interest

In compliance with standard ethical guidelines, the authors report no relationships with business or industry that may pose a conflict of interest.

Funding

No external or internal funding was provided.

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Katie K. Wolfe, MD, Med, is an assistant professor in the Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, and can be reached at [email protected]. Anna McCormick, DO, is an assistant professor in the Department of Pediatrics, University of Chicago Chicago, IL. Sarah Weyhrich, MSN, RN, NPD-BC, is a clinical education specialist, St. Louis Children’s Hospital, St. Louis, MO. Lindsey Kerley, MSN, CPNP-AC, is a nurse partitioner supervisor, Pediatric Intensive Care Unit, St. Louis Children’s Hospital, St. Louis, MO.

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http://refhub.elsevier.com/S1555-4155(25)00049-2/sref39

http://refhub.elsevier.com/S1555-4155(25)00049-2/sref40

https://doi.org/10.1097/SIH.0000000000000072

mailto:[email protected]

Longitudinal Simulation and Procedural Skills Curriculum for Pediatric Critical Care Nurse Practitioners

Introduction
Methods

Study Design
Participants and Faculty
Setting and Equipment
Application of Theory
Curriculum Development
Simulation Scenarios and Debriefing
Procedural Training
Measurement

Results
Discussion

Future Directions
Limitations

Conclusion
CRediT authorship contribution statement
Declaration of Competing Interest
Funding
References