The Journal of the New York State Nurses Association, Volume 49, Number 2

THE JOURNAL

of the New York State Nurses Association

Volume 49, Number 2

n Editorial: Nurses Stimulate Innovation in Health Care by Wielding Leadership, Vision, and Compassion Using the Art and Science of Nursing

by Anne Bové, MSN, RN-BC, CCRN, ANP; Audrey Graham-O’Gilvie, DNP, RN, ACNS-BC, CCRN-k; Meredith King-Jensen, PhD, MSN, RN; Alsacia L. Sepulveda-Pacsi, PhD, DNS, RN, FNP, CCRN, CEN; and Coreen Simmons, PhD-c, DNP, MSN, MPH, RN

n “Blameless”: Using Popular Entertainment Media to Build Social Context in Nursing Students

by Nancy Scanlan, PMHNP-BC, and Shannon Hanshaw, PhD, RN, CNE

n Nurse Practitioners and Barriers to Practice in Primary Care

by Reeja Mathew, BSN, RN-BC, CV-BC, and Margaret Marie Cox, DNP, ANP-C, RN

n The Role of the Nurse Practitioner and Emergency Preparedness

by Christine Pfeifer, BSN, RN, OCN, and Margaret Marie Cox, DNP, ANP-C, RN

n What’s New in Healthcare Literature

n CE Activities: “Blameless”: Using Popular Entertainment Media to Build Social Context in Nursing Students; Nurse Practitioners and Barriers to Practice in Primary Care; The Role of the Nurse Practitioner and Emergency Preparedness

THE JOURNAL

Anne Bové, MSN, RN-BC, CCRN, ANP; Audrey Graham-O'Gilvie, DNP, RN, ACNS-BC, CCRN-k; Meredith King-Jensen, PhD, MSN, RN; Alsacia L. Sepulveda-Pacsi, PhD, DNS, RN, FNP, CCRN, CEN; and Coreen Simmons, PhD-c, DNP, MSN, MPH, RN

THE JOURNAL

of the New York State Nurses Association

n

The Journal of the New York State Nurses Association editorial board

Anne Bové, MSN, RN-BC, CCRN, ANP Alsacia L. Sepulveda-Pacsi, PhD, DNS, RN, FNP, CCRN, CEN Clinical Instructor Registered Nurse III New York, NY New York-Presbyterian Adult Emergency Department New York, NY

Audrey Graham-O’Gilvie, DNP, RN, ACNS-BC, CCRN-k Coreen Simmons, PhD-c, DNP, MSN, MPH, RN Assistant Professor Professional Nursing Practice Coordinator

Touro College School of Nursing Teaneck, NJ

Hawthorne, NY

Meredith King-Jensen, PhD, MSN, RN Nurse Consultant Veterans Administration

Bronx, NY

Adjunct Instructor Mercy College

Dobbs Ferry, NY

n Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD, Co-Managing Editor Lucille Contreras Sollazzo, MSN, RN-BC, NPD, Co-Managing Editor Christina Singh DeGaray, MPH, RN-BC, Editorial Assistant

The information, views, and opinions expressed in The Journal articles are those of the authors, and do not necessarily reflect the official policy or position of the New York State Nurses Association, its Board of Directors, or any of its employees. Neither the New York State Nurses Association, the authors, the editors, nor the publisher assumes any responsibility for any errors or omissions herein contained.

The Journal of the New York State Nurses Association is peer reviewed and published biannually by the New York State Nurses Association. ISSN# 0028-7644. Editorial and general offices are located at 131 West 33rd Street, 4th Floor, New York, NY, 10001; Telephone 212-785-0157; Fax 212-785-0429; email info@nysna.org. Annual subscription: no cost for NYSNA members; $17 for nonmembers.

The Journal of the New York State Nurses Association is indexed in the Cumulative Index to Nursing, Allied Health Literature, and the International Nursing Index. It is searchable in CD-ROM and online versions of these databases available from a variety of vendors including SilverPlatter, BRS Information Services, DIALOG Services, and The National Library of Medicine’s MEDLINE system. It is available in microform from National Archive Publishing Company, Ann Arbor, Michigan.

©2023 All Rights Reserved  The New York State Nurses Association

Nurses Stimulate Innovation in Health Care by Wielding leadership, Vision, and Compassion using the Art and Science of Nursing

Rather than imitate the past or consort with “what’s most popular,” nurses inspire innovation in health care by wielding leadership, vision, and compassion.

In “’Blameless’: Using Popular Entertainment Media to Build Social Context in Nursing Students,” the authors discuss a unique class that used popular media to help prepare students for entering nursing work with diverse populations. When nursing students meet a patient, their first impression may be one of “someone lying on a stretcher or hospital bed.” The authors hold that clinical encounters mold a student’s concepts of “patient,” “nurse,” and “nursing practice.” With time and experience, that student becomes a working nurse and develops an ability to glance at a patient and more widely view a person’s greater world—and how that context can influence a patient’s current and potential future state of health. During the pandemic, the opportunities to develop this skill through meeting people in person and visiting clinical sites was limited for educators and students. In response, the course in this study utilized popular media as a way for students to supplement their clinical skills. While watching “real” people with “real” problems, students were guided to enrich their understanding of the social context and complexities they were seeing, and look for contexts where physical and mental illness had the potential to thrive. Looking at a problem and effectively putting innovative and resourceful ideas into action is part of the science and art of nursing.

In “Nurse Practitioners and Barriers to Practice in Primary Care,” authors outline the professional, social, and legal blockades that can prevent medical institutions from meeting the primary care needs of the public. This paper discusses how nurse practitioners are in a unique position to encourage states to expand access to primary care through professional advocacy and public awareness. Having a vision for better meeting communities’ healthcare needs and bringing nurses and nurse practitioners more fully into the fold to advocate for critical changes is part of the science and art of nursing.

In “The Role of the Nurse Practitioner and Emergency Preparedness,” the authors share insights on how to promote the competencies necessary for nurse practitioners to serve in the many roles emergency management calls for. In a time when uncertainty is the norm, communities experiencing disasters rely on healthcare providers more than ever. Nurse practitioners are skilled in crisis communication, maintaining situational awareness, hazard risk assessment, and adaptive management. Such skills provide a sound foundation for nurse practitioners’ roles in leadership, analysis, and clinical first responder and supplemental surge capacity. As such, nurse practitioners are in a unique position as leaders in emergency preparedness and emergency situations—another example of the science and art of nursing. Artists train for years honing their skills in order to depict their unique perspectives of the world through various mediums. Their work may astound and change observers and society at large. It is no wonder nursing students cultivating their profession’s craft were successfully educated through use of others’ craft. Using methods and facts accumulated through time, the scientist asks questions, interprets findings, and proposes actions which shape the future. As artists and scientists, nurses work to collectively improve health, mitigate suffering, and advance our profession. Nurse unions succeed in channeling the power of the profession to ensure nurses have what they need to equitably deliver the care society demands.

Anne Bové, MSN, RN-BC, CCRN, ANP

Audrey Graham-O’Gilvie, DNP, RN, ACNS-BC, CCRN-k

Meredith King-Jensen, PhD, MSN, RN

Alsacia L. Sepulveda-Pacsi, PhD, DNS, RN, FNP, CCRN, CEN

Coreen Simmons, PhD-c, DNP, MSN, MPH, RN

“blameless”: using Popular entertainment media to build Social Context in Nursing Students

Nancy Scanlan, PMHNP-BC Shannon Hanshaw, PhD, RN, CNE

n Abstract

Significant challenges face educators as they prepare nursing students to work with diverse populations. Educators capitalized on high levels of media viewing to build social context among students.

A pilot nursing course used the television series Shameless to explore issues of social justice and equity. Students engaged in analysis involving the interrelationship of medical and psychiatric illnesses, and environmental conditions. A mixed methods approach to data analysis was used. Students were surveyed regarding their ability to apply what they learned to real-world situations, and content analysis of qualitative comments was conducted.

One hundred percent of students who completed the survey (n = 27) reported that the course impacted their ability to understand the connection between mental and physical health and their ability to apply medical and psychiatric knowledge to real-world situations. Three themes were identified: bringing issues to life and illuminating the material, application of learning to clinical nursing practice, and breadth and depth of material

Educators must prepare students to care for individuals of varying backgrounds and social circumstances. The use of entertainment media is a nontraditional strategy for teaching concepts that can bridge the gap between the classroom and the practice setting.

Keywords: media, social justice, social determinants of health, nursing education

Introduction

Nursing students are often unfamiliar with the social determinants of health, tending to see a patient’s mental or medical illness as an isolated occurrence without social context. The Centers for Disease Control and Prevention (CDC) define these determinants as the conditions in

the places where people live, learn, work, and play that affect their health. (Centers for Disease Control [CDC], 2021). Undergraduate nursing programs may not have clinical opportunities for students to learn about those from different backgrounds and about the social and cultural factors that influence health. Preparing nurses to

Nancy Scanlan, PMHNP-BC, and Shannon Hanshaw, PhD, RN, CNE State University of New York Plattsburgh, Plattsburgh, New York

address the social determinants of health is a key principle for promoting more equitable health outcomes for patients, families, and communities. Educators must find engaging ways to help students understand social and cultural issues, and television has the potential to assist with this. The purpose of this study is to examine the use of television media to facilitate understanding of social and cultural issues in undergraduate nursing students.

background

Entertainment education can provide “unconventional perspectives on social issues” (Klein, 2011) and can be used to illustrate social determinants of health. Entertainment media as provided by Showtime, Netflix, etc., can be used by educators to take advantage of a medium that is already used by many college students daily. Looking at the years 2013–17, a study found 74.1% of 20- to 24-year-olds watched television for approximately 2.17 hours on any given day (Krantz-Kent, 2018). According to a 2021 report by the U.S. Bureau of Labor Statistics, that number has grown. Television viewing was the top leisure activity of Americans, occupying 2.9 hours per day and accounting for over half of people’s total leisure time (U.S. Department of Labor, Bureau of Labor Statistics, 2022).

Few can argue the influence of media on our daily lives and cultural values. Even when it is not intentionally designed to teach, media carries messages about social interactions and about the nature and value of groups in the society that can influence attitudes, values, and actions among its viewers. It serves as a source of information about the world, whether viewers seek entertainment or enlightenment (Huston et al., 1992). Entertainment television content can offer unconventional perspectives on social issues that are important in a nursing context. Understanding different cultures helps provide meaningful and patient-centered care, and a responsibility of nurse educators is to educate students regarding “culturally congruent care” (Leininger, 2012). There is limited research on the effect of television media on nursing students’ knowledge and values; however, nursing has used film viewing as a method of teaching psychomotor skills for decades. A systematic review by Hoffman and colleagues (2018) suggests that the integration of entertainment television into medical education is feasible and acceptable and that further study is needed to determine if this type of entertainment education increases nursing students’ understanding of social context and health.

In the 2018–19 academic year, 45 out of 48 students in the authors’ nursing classes had watched at least one full season of the popular television show Shameless (Abbot, 2011–2021), which ran for 11 seasons. The series allows viewers to experience vicariously the social, medical, and psychiatric issues of characters from the South Side of Chicago. It portrays the saga of

the poverty-stricken Gallagher family, whose children fend for themselves due to absentee, alcoholic parents. Issues of sexuality, substance abuse, racism, and poverty are addressed in an irreverent, insightful way. Executive producer John Wells described the Shameless writing staff as “really damaged people” who had experiences similar to those portrayed on the show (Rochlin, 2011). The popularity of the show offers the potential for a huge educational impact on a large fan base.

Psychiatric and medical-surgical nursing educators collaborated on the development of the course “Blameless,” which used this television series to explore the issues of homelessness, racism, sexuality, substance abuse, organ failure and transplantation, access to medical care, trauma, and mental illness. The course description and content list are displayed in Appendix A. Students were assigned specific episodes of Shameless to view and provided a series of questions for reflection prior to viewing. Students then participated in class discussion regarding the issues and assigned topics.

For many students in the course, the show was their only source of context for the kinds of social factors that influence health explored on the series. Klein (2011) described the phenomena in which viewers observe social issues in entertainment television and then take that background with them to other experiences where they encounter that issue. Viewing the television show Shameless provided a context from which students could draw to engage in larger discussions of social issues.

method & research Design

A mixed methods approach was used to collect and analyze data on the pilot course and the second offering of “Blameless.” The college Institutional Review Board determined that completion of the survey implied consent and the study was exempt.

Sample & Setting

The pilot for the elective nursing course during fall of 2019 enrolled nine students. In fall 2021 the course was offered again, and enrolled 23 students, for a total sample size of N = 32. Of the 32 total students, 30 were female and two were male. Sixteen were unlicensed students in a bachelor of nursing program, and 16 were registered nurses with their associate degrees who were enrolled in a bachelor’s completion program. Table 1 displays the sample demographics.

The course was offered at an upstate New York SUNY college. It was initially offered on campus, delivered in a face-to-face format, but the modality was changed to a virtual course delivery during the pandemic.

educators must find engaging ways to help students understand social and cultural issues, and television has the potential to assist with this.

The course began with the analysis of adverse childhood experiences (ACE) among the characters, using the CDC-Kaiser Permanente Adverse Childhood Experiences Study (Felitti et al., 2019). This study was based on confidential surveys of over 17,000 Health Maintenance Organization members from Southern California and uncovered how ACEs are strongly related to the development of risk factors for disease and well-being throughout life. Survey questions related to physical and sexual abuse, neglect, divorce, mental illness, substance abuse, and incarceration (American Academy of Pediatrics, 2014). The influence of ACE was followed throughout the course as students analyzed characters with addiction, depression, and sociopathy. Individuals’ emotional and physical responses to trauma and household dysfunction were explored, along with the socioeconomic and cultural factors that contributed to their illnesses.

Table 1

Sample Demographics (N = 32)

The interrelationship between medical and psychiatric illness was emphasized throughout the course. Physiological, psychological, and social factors can each have an impact on health and wellness. Changes to physiological or psychological processes, or social factors can increase the likelihood that someone living with a mental illness or medical illness will develop a comorbidity (Evans et al., 2005; Leucht et al., 2007). Students engaged in critical analysis involving the interrelationship of medical illness and psychiatric illness. They were able to draw from the experiences of the characters in the show to gain insight and deeper understanding of how the conditions in which individuals live can impact health, both medically and mentally.

An anonymous survey was completed by all nine enrolled students at the end of the “Blameless” course. The students completed an 11-item Likert scale which contained items regarding course content and the ability to apply concepts such as social justice, the connection between mental and physical health, and the impact of social determinants on health. A copy of the Likert scale survey is included in Appendix B. The subsequent offering of the course composed of 23 students used a standardized university Course Opinion Survey which addressed general satisfaction with teaching methods. Additionally, qualitative data was gathered through the survey.

Data Analysis

The in-person pilot course used an 11-question survey to collect quantitative data regarding the understanding of concepts such as socioeconomic status, environment, and experiences on health.

Qualitative data were reviewed using content analysis to identify themes. Student comments were coded and analyzed for repeated themes. Researchers reviewed coding and emerging patterns and came to consensus on the themes identified.

Findings & Discussion

One hundred percent of students who completed the surveys (n = 9) in the pilot offering agreed with statements regarding the positive impact the course had on their ability to understand the connection between mental and physical health and their ability to apply medical and psychiatric knowledge to real-world situations. The 18 students who completed surveys following the second offering of the course revealed similar satisfaction with class content. Comments were collected and analyzed using a qualitative approach. A sample of these comments follow:

It was interesting and I often found myself watching the YouTube videos that played after the assigned ones out of interest.

We covered a surprisingly wide range of topics. The content was engaging and never felt lacking.

The design of the course shows a deep thoughtfulness into how to grab our attention and illuminate the material.

I was pleasantly surprised by the depths this course went to and the thought-provoking discussions. It brought issues to life in such a way that I sometimes recall the discussions and videos while at work when interacting with certain patients.

The instructor stimulated my interest in the subject more so than I expected.

More classes should be set up this way.

The subject matter is very interesting and I felt very involved in all discussion.

I love how this was incorporated with our nursing practice! It made me reflect on topics such as mental illness, addiction, pain management, and barriers to health care.

The researchers identified three themes: bringing issues to life and illuminating the material, application of learning to clinical nursing practice, and breadth and depth of material.

Bringing issues to life and illuminating the material —students indicated that the course was engaging and grabbed their attention. The topics were interesting and presented in a way that fostered deeper understanding of the concepts of culture, socioeconomic status, and social determinants of health.

Application of learning to clinical nursing practice —students indicated that they recalled course content while interacting with specific patients during their clinical practice.

Breadth and depth of material—students identified that there was a wide range of topics and were surprised by the depth of thought-provoking discussions and course materials.

Researchers initially developed the pilot course to address the gap between knowledge and clinical practice related to the impact of culture and socioeconomic status on health. Both qualitative and quantitative data results indicate a positive influence on closing this gap. Based on these results, the course was integrated into the nursing curriculum.

Integrating popular entertainment television with guided analysis may be an innovative way to ... build social context for students.

limitations & Strengths

A strength of this study was that the content could be delivered virtually or in person, which was especially useful during the pandemic. Limitations of the study were that two different evaluation tools were used, and the course was face-to-face during the first pilot and online for the

second offering. Other limitations were a small sample size, a primarily female sample, and the fact that students self-selected into this elective course. It would be worthwhile to explore the long-term impact of such a course on students’ values using a mixed methods research strategy.

Implications for Nursing Practice

Nursing students care for a microcosm of society and often begin their education with limited knowledge of the cultural and socioeconomic factors that drive mental and medical illnesses. Creative approaches to teaching students about the social context in which illness develops is needed. Integrating popular entertainment television with guided analysis may be an innovative way to address this need and build social context for students.

“Blameless”: Using Popular Entertainment Media to Build Social Context in Nursing Students

Abbot, P. (creator). (2011–2021). Shameless [TV series]. Showtime, John Wells Productions Warner Bros.

American Academy of Pediatrics. (2014). Adverse childhood experiences and the lifelong consequences of trauma. https://cdn.ymaws.com/ www.ncpeds.org/resource/collection/69DEAA33-A258-493B-A63FE0BFAB6BD2CB/ttb_aces_consequences.pdf

Centers for Disease Control and Prevention. (2021). Social determinants of health: Know what affects health . https://www.cdc.gov/ socialdeterminants/

Evans, D. L., Charney, D. S., Lewis, L., Golden, R. N., Gorman, J. M., Krishnan, K. R. R., Nemeroff, C. B., Bremner, J. D., Careny, R. M., Coyne, J. C., Delong, M. R., Frasure-Smith, N., Glassman, A. H., Gold, P. W., Grant, I., Gwyther, L., Ironson, G., Johnson, R. L., Kanner, A. M., Katon, Valvo, W. J. (2005). Mood disorders in the medically ill: Scientific review and recommendations. Biological Psychiatry (1969), 58(3), 175–189. http://doi:10.1016/j.biopsych.2005.05.001

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., Marks, J. S. (2019). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 56(6), 774–786. (Reprinted from American Journal of Preventive Medicine 1998; 14(4): 245–258. https://doi.org/10.1016/S0749-3797(98)00017-8)

Hoffman, B. L., Hoffman, R., Wessel, C. B., Shensa, A., Woods, M. S., Primack, B. A. (2018). Use of fictional medical television in health sciences education: a systematic review. Adv in Health Sci Educ, 23, 201–216. https://doi.org/10.1007/s10459-017-9754-5

Huston, A. C., Donnerstein, E., Fairchild, H. H., Feshbach, N. D., Katz, P. A., Murray, J. P., Rubinstein, E. A., Wilcox, B. L., & Zuckerman, D. (1992). Big world, small screen: The role of television in American society. University of Nebraska Press.

Klein, B. (2011). Entertaining ideas: Social issues in entertainment television. Media, Culture & Society, 33(6), 905–921. https://doi. org/10.1177/0163443711411008

Krantz-Kent, R. (2018). Television, capturing America’s attention at prime time and beyond. Beyond the numbers (United States. Bureau of Labor Statistics), 7(14), 1–11. https://www.bls.gov/opub/btn/volume-7/ television-capturing-americas-attention.htm

Leininger, M. (2012, January 25). Madeleine Leininger Interview Part 1 [Video]. YouTube. https://www.youtube.com/watch?v=a4GTo_uthZQ

Leucht, S., Burkard, T., Henderson, J., Maj, M., & Sartorius, N. (2007). Physical illness and schizophrenia: a review of the literature. Acta Psychiatrica Scandinavica, 116(5), 317–333. https://doi.org/10.1111/ j.1600-0447.2007.01095.x

Rochlin, M. (2011, January 2). The family that frays together. The New York Times.

U.S. Department of Labor, Bureau of Labor Statistics (2022, June 23). American time use survey, 2021 results [Press release].

Appendix A elective Course Description

Course name and number: N ur 317; blameless

Course credit hours: 3 credits

Course description: This course focuses on medical and psychiatric conditions of characters in media. Individuals’ emotional and physical responses to trauma are explored, in the context of the social and economic determinants of health. Concepts considered are population health, equitable care, culture, social justice, and diversity with focus on health restoration. Will cover mature content which some may consider offensive. This course includes simulated learning experiences.

Required course materials:

Access to “Shameless” on Showtime or Netflix, selected episodes from Seasons 2, 3, 4, 8, 9.

Suggested course materials:

Boyd, M. A., Luebbert, R. (2021). Psychiatric nursing: Contemporary practice (7th ed.). Wolters Kluwer.

Hinkle, J., & Cheever, K. (2021). Brunner & Suddarth’s Textbook of MedicalSurgical Nursing (15th ed.). Wolters Kluwer.

Course Topic Outline:

I. Patient Responses to Psychiatric Stressors

A. Adverse Childhood Events (ACEs)

1. Emotional and physical abuse

2. Neglect

3. Sexual abuse

II. Patient Responses to Medical Trauma

A. Sensory-perceptual alterations

B. Emergency/disaster situations

III. Patient Responses to Environmental Influences

A. Nutrition

B. Housing

C. Transportation

D. Access to medical care

E. Adaptation to complex situations

IV. Substance Abuse

V. Trauma-informed care

VI. Patient Responses to Alterations in Health

A. Hepatic failure

B. Traumatic injury

VII. Perspectives on Social Justice

A. Vulnerability and resiliency in health

B. Ethics of organ transplantation

C. Social assistance programs

D. Social determinants of health

Course Student Learning Outcomes:

At the end of this course, the student will be able to:

1. Assume the role of the professional nurse by incorporating standards of professional practice;

2. Apply the nursing process in assessing, planning, and providing patient-centered care to individuals and families experiencing complex alterations in health function;

3. Employ a systematic process to make decisions using the best available research evidence, theory, expertise, and patient preferences;

4. Actively prevent or limit unsafe or unethical care practices through promotion of a culture of safety;

5. Engage in teaching and learning activities that promote best healthcare practices among patients and colleagues;

6. Demonstrate effective professional communication through verbal, non-verbal, written and electronic methods;

Appendix b Survey “blameless” Course Survey

1. I am a: Nursing Junior Nursing Senior

2. The course stimulated my interest in the subject of social justice.

Strongly agree agree neutral disagree strongly disagree n/a

3. The use of television clips reinforced concepts of mental health and mental illness.

Strongly agree agree neutral disagree strongly disagree n/a

4. The class reinforced the connection between socioeconomic status and physical health.

Strongly agree agree neutral disagree strongly disagree n/a

5. The class reinforced the connection between socioeconomic status and mental health

Strongly agree agree neutral disagree strongly disagree n/a

6. My understanding of the challenges the poor face in society has increased with this course.

Strongly agree agree neutral disagree strongly disagree n/a

7. The knowledge from this class helps me understand concepts presented in other nursing classes.

Strongly agree agree neutral disagree strongly disagree n/a

8. The course increased my understanding of the connection between mental health and physical health.

Strongly agree agree neutral disagree strongly disagree n/a

9. The course helped me understand the impact of trauma on overall health.

Strongly agree agree neutral disagree strongly disagree n/a

10. I am able to apply psychiatric content portrayed in this TV series to real-world clinical situations.

Strongly agree agree neutral disagree strongly disagree n/a

11. I am able to put medical knowledge into context using this TV series, and apply it to real-world situations.

Strongly agree agree neutral disagree strongly disagree n/a

12. Would you consider taking another course using popular media to learn nursing concepts?

Yes No Maybe

Introduction

Nurse Practitioners and barriers to Practice in Primary Care

Reeja Mathew, BSN, RN-BC, CV-BC

Margaret Marie Cox, DNP, ANP-C, RN

Abstract

The nurse practitioner (NP) workforce has increased steadily over the past two decades. This growth occurred in every region of the United States and was driven by the rapid expansion of education programs that attracted nurses of the millennial generation. Approximately 270,000 NPs are licensed to practice in the United States in various settings (Gigli et al., 2019). The number of primary care NPs is projected to increase by 93% between 2013 and 2025 (Poghosyan, 2018). With the increasing primary care physician shortage and the 150 million adults with one or more chronic conditions, the U.S. healthcare system must rely on advanced nurse practitioners as alternative primary care providers. (Luo et al., 2021). The expanding workforce of NPs in the United States could play a vital role in meeting the increasing demand for primary care. Removing state-level scope of practice (SOP) restrictions, regulations that govern the degree of prescriptive and/or practice authority granted to NPs, has been debated as a strategy to increase access to care since the time of healthcare reform (Patel et al., 2018). This paper aims to identify the barriers to NP practice in primary care and examine transformational leadership (TFL) principles as an effective framework for promoting NP practice.

Keywords: nurse practitioner (NP), advanced practice registered nurse (APRN), scope of practice, primary care

Nurse practitioners (NPs) in primary care face many challenges and barriers that impede their practice. This paper focuses on barriers to practice, such as practice authority, prescriptive authority, and reimbursement issues to work independently as primary care providers and their implications for practice. The theory framework of transformational leadership (TFL) is recognized as a practical leadership style to overcome these barriers. According to Fitzpatrick

and McCarthy (2014), transformational leadership is the process of developing a mutual relationship with followers that elevate and nurture them to become leaders. Nurse practitioners can apply the four elements of transformational leadership—idealized influence, inspirational motivation, intellectual stimulation, and individual consideration—to guide their practice (Collins et al., 2019). In TFL, people require a sense of mission and purpose to work effectively, as in primary care when NPs have to work with physicians.

Reeja Mathew, BSN, RN-BC, CV-BC

Mt. Sinai South Nassau, Oceanside, New York & Adelphi University, Garden City, New York

Margaret Marie Cox, DNP, ANP-C, RN Adelphi University, Garden City, New York

even with the exponential growth of nurse practitioners at the national level, scope of practice restrictions limit the full-service potential of NPs’ education and qualifications.

Practice Authority

Nurse practitioners are advanced practice registered nurses (APRNs) who receive graduate education at the master’s, post-master’s, or doctoral level and obtain national board certification. Established educational standards for NP education ensure the attainment of the APRN core, role core, and population core competencies (American Association of Nurse Practitioners [AANP], 2019). The APRN’s clinical role is defined by the scope of practice (SOP) set by the state statutes. It varies from state to state. The Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education (LACE) is the landmark policy that establishes principles outlining the SOP for all APRNs (Gonzalez & Gigli, 2021).

Even with the exponential growth of NPs at the national level, SOP restrictions limit the full-service potential of NPs’ education and qualifications. Policy and organizational barriers still affect the NP workforce and its ability to deliver high-quality, cost-effective, patient-centered care. (Poghosyan et al., 2021). In the United States, the NP SOP policy is categorized as “full,” “reduced,” or “restricted” at the state level (Patel et al., 2018). The American Association of Nurse Practitioners (AANP) defines full practice authority (FPA) as “evaluate patients; diagnose, order and interpret diagnostic tests; and initiate and manage treatments, including prescribing medications and controlled substances, under the exclusive licensure authority of the state board of nursing” (Ayami & Furlong, 2019). Currently, 22 states (44%) and the District of Columbia grant FPA, which allows NPs to manage all aspects of patient care, including practicing and prescribing, without physician supervision. The remaining states granted “reduced practice” (17 states, or 34%) and “restricted practice” (12 states, or 24%), respectively (Peterson, 2017). Restricted practice requires physician supervision to provide select practice or prescriptive activities. In reduced practice, NPs need physician supervision in all aspects of rendering care. (Patel et al., 2018).

Prescriptive Authority

Prescriptive authority refers to a nurse practitioner’s authority to prescribe pharmacologic medications and nonpharmacological therapies (AANP, 2019). In contrast to RNs who carry out practitioners’ orders, APRNs have the capacity to prescribe medications. NPs acquired the prescriptive ability through didactic training in pharmacology and pharmacotherapeutics in their educational curriculum endorsed by the Commission on Collegiate Nursing Education (CCNE) (Diegel Vacek & Vuckovic, 2019). NPs’ prescriptive authority differs considerably depending on the state laws (Germack, 2020). The District of Columbia and 22 states with FPA allow NPs to prescribe medications independently without physician supervision.

States with reduced authority require a relationship with a physician that outlines the NP’s prescribing abilities. NPs have reduced authority in 16 states and work alongside physicians in joint practice agreements (Zhang & Patel, 2021; Park et al., 2018). NPs in states with restricted practice are required to have physician supervision or delegation when prescribing medications and controlled substances. Some states specify whether a nurse practitioner must complete a transition to practice period before being able to prescribe independently.

reimbursement

The current healthcare industry is focusing on “value-based purchasing” and shifting away from a system that rewards volume to one that focuses on efficiency and value. The U.S. Department of Health and Human Services declared plans to transition 50% of Medicaid and 100% of Medicare fee-for-service reimbursements to alternative payment models (i.e., bundled payment, accountable care organizations (ACOs), or patient-centered medical homes) by 2025 (Razavi et al., 2021). These transformations challenge clinicians to deliver services more efficiently by holding them accountable for the cost and quality of care, whereas nurse practitioners are well fitted for these goals.

The Balanced Budget Act of 1997 granted NPs the authority to bill Medicare for services that they perform directly. However, NPs are reimbursed at 85% of the physician rate in the Medicare reimbursement policy (Bischof & Greenberg, 2021). The COVID-19 pandemic unlocked the necessity for NPs to extend their care in more settings, leading to the temporary removal of practice restrictions and access to care in many states. This pandemic proved the NP’s ability to provide health care in various settings, including rural, underserved, and vulnerable populations such as older adults and those with low socioeconomic status (Bischof & Greenberg, 2021). Hence there is a crucial need to make primary care reimbursement for all primary care providers equitable. Uniformity of reimbursement would increase the number of practicing primary care NPs to meet the growing healthcare needs of primary care.

The NP’s role as Primary Care Provider

According to AANP, more than 75% of actively practicing NPs in primary care are essential to the U.S. primary care workforce. Some states recognize an NP as a primary care provider, whereas others do not. NPs are prepared through advanced graduate education and clinical training to deliver comprehensive health services to people of all ages. They have an active role in diagnosing, prescribing, treating, counseling, and teaching. NPs diagnose, order, perform and interpret lab results, and manage acute and chronic conditions with an emphasis on health promotion and disease prevention. As our nation encounters the future challenges of an aging population, rising healthcare costs, and the increasing burden of chronic disease, there is an imperative need for NPs as primary care providers to practice to the maximum capacity of their scope of practice (Patel et al., 2018). They can provide high-quality, patient-centered, and costeffective care. There are challenges and tensions between advanced nurse practitioners and physicians to create a collaborative relationship and recognize the individual characteristics required for their specific roles. Some physicians are embarrassed by the change in roles in primary care. They lack confidence in the adequacy of the training and education provided for the advanced nursing role and, therefore, in the nurse’s

Figure 1

Nurse Practitioner Reimbursement From Medicare and Medicaid Services Over Time

1965 1977 1990 1997 2020

 Medical Inception

 NPs may only bill under a physician's “incident to.”

 Rural Health Clinic Service Act

 NPs can receive direct reimbursement in rural health clinics at 85%.

 Omnibus Reconciliation Act

 Reimbursement is extended to rural areas and nursing homes at 85%.

 Balanced Budget Act

 Location restrictions removed 85% reimbursement remains.

 COVID-19

 Many states temporarily removed practice restrictions. Reimbursement still at 85%.

Note : The chart shows nurse practitioner reimbursement from Medicare and Medicaid services over time. From “Post COVID-19 Reimbursement Parity for Nurse Practitioners,” by A. Bischof and S. Greenberg, 2021, OJIN: The Online Journal of Issues in Nursing, 26(2) (https://doi.org/10.3912/ojin.vol26no02man03).

skills and abilities to take on the responsibilities of a primary provider role (Perloff et al., 2017).

Implications for Practice

The present and future of the primary care healthcare system in the United States rest on the adequacy and reliability of a pool of primary care professionals. With the increasing shortage of primary care physicians, the healthcare system should consider advanced practitioners as alternative providers. However, the supply of NPs is limited due to their restricted scopes of practice, which prevents them from practicing to the fullest capacity of their education. Restrictive practices also increase healthcare costs related to physician supervision, limited healthcare services, and access to care, especially in underserved and uninsured populations (Peterson, 2017). The full SOP of NPs most benefit people in rural areas and those with demanding medical care needs. The FPA of NPs promotes professional independence that facilitates more efficient allocation of the health labor force in all settings.

NPs across the United States are attaining FPA, including approval to prescribe legend and controlled drugs. Unconfined prescriptive authority is necessary for NPs to practice to the full extent of their education and training. NPs have the prescriptive authority to prescribe controlled substances in all 50 states. However, NPs cannot prescribe Schedule II substances in some states and must apply separately for these privileges after state-specified requirements such as time in practice or additional training requirements are satisfied (National Council of State Boards of Nursing, 2021). The opioid use disorder and the current COVID-19 pandemic have proven the need for full prescriptive authority for NPs, especially those working in rural, remote, and underserved areas where physicians are not readily available (Germack, 2020). The Affordable Care Act (ACA) has resulted in increased workload and patient demands for primary care, necessitating the FPA for maximum utilization of advanced practice providers (Zhang & Patel, 2021). Expanding the prescriptive authority of APRNs is one mechanism to alleviate the increased healthcare needs of the public.

The independent practice ability of NPs within organizations promotes their role as primary care providers. The key to success is negotiating the position between team members and reaching a consensus on how the different health professionals work together. There

is uncertainty about the NP’s practice across all geographical regions of the United States without appropriate financial reimbursement, similar to primary care physicians (Poghosyan, 2018). The application of the transformational leadership style to nursing practice help to alleviate the practice resistance in primary care.

Conclusion

There is an inevitable necessity for full practice and prescriptive authority for NPs serving different population foci in primary health care settings in order to achieve maximum patient benefits in health care delivery. NPs working in primary care also deserve equal reimbursement and funding to that of physicians for delivering health services. Studies have shown that NPs can provide quality, cost-effective, and holistic care with better patient outcomes than physicians (Aymami & Furlong, 2019). The APRN workforce is essential to meet the future healthcare needs of the nation with its aging population and patients with chronic diseases. Furthermore, NPs have a high potential to meet the healthcare needs of rural, underserved, uninsured, and vulnerable populations.

Healthcare organizations and policy- and decision-makers need to redefine the boundaries of advanced practitioners and support practice transformation to integrate and maximize NPs to the full extent of their capacities. Transformational leadership can be applied to promote nurse practitioner practice in primary care. Transformation to APRNs’ fullest scopes of practice in primary care settings is a promising strategy for enhancing the quality and efficiency of primary care and managing the immense unmet healthcare needs of individuals, families, and communities.

Healthcare organizations and policy- and decision-makers need to redefine the boundaries of advanced practitioners and support practice transformation to integrate and maximize nurse practitioners to the full extent of their capacities.

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Introduction

The role of the Nurse Practitioner and emergency Preparedness

Christine

Pfeifer, BSN, RN, OCN Margaret Marie Cox, DNP, ANP-C, RN

Extreme events such as pandemics, natural disasters, and mass violence have put the health of communities at risk. Nurse practitioners (NPs) are critical to response and recovery efforts. Providing evidence-based emergency preparedness education in NP curriculum, having onsite simulations, and offering adaptive management skills training will give NPs the foundation to lead during a crisis. In addition, removing barriers to allow NPs full practice authority in all 50 states would accelerate response and enhance decision-making. NPs are leaders shaping the future of our healthcare system and are paramount during times of uncertainty. This paper is a position statement on the need to implement NP emergency preparedness in graduate education through the lens of Florence Nightingale’s Environmental Theory.

Keywords: nurse practitioner role, emergency preparedness, emergency response, disaster preparedness, disaster competencies, crisis communication, crisis leadership, environmental theory

The nurse practitioner (NP) role is essential to emergency preparedness. Extreme events such as pandemics, natural disasters, and mass violence have put the health of communities at risk. NPs are on the front lines providing emergent illness treatment and playing a vital role in injury mitigation, response, and recovery. They blend their expertise in diagnosing and treating health conditions to bring a comprehensive perspective and personal touch to health care (Zak et al., 2020). NPs’ contributions to disaster efforts are critical to patient survival. Educators can utilize several

educational strategies to incorporate emergency preparedness into NP graduate curriculum. For practicing NPs, having onsite simulation scenario training and adaptive management skills instruction can help prepare them to lead in a crisis.

During the surge of the COVID-19 pandemic, the Coronavirus Aid, Relief, and Economic Security (CARES) Act of 2020 temporarily lifted state restrictions, waiving physician supervision and allowing NPs full practice authority (FPA) (O’Reilly-Jacob et al., 2022). Removing barriers and allowing NPs to practice independently would accelerate response and enhance

Christine Pfeifer, BSN, RN, OCN Memorial Sloan Kettering Cancer Center, New York, New York, & Adelphi University, Garden City, New York

Margaret Marie Cox, DNP, ANP-C, RN Adelphi University, Garden City, New York

decision-making in major emergencies with disaster training. Being at the forefront of patient care, NPs should incorporate crisis communication to disseminate data and situational awareness to hospital staff and the community. NPs are crucial in providing efficient patient care, especially during times of uncertainty. This paper discusses the importance of emergency preparedness education in the NP curriculum and other factors that affect NPs practicing in the clinical setting.

environmental Theory

In 1859, Florence Nightingale developed the Environmental Theory after the Crimean War. This theory defines the environment as the center of influence on human organisms and development, which favors or disfavors the progress of disease (Breigeiron et al., 2021). The Environmental Theory influences nursing to not spread diseases by organizing work through management protocols, incorporating scientific-based evidence, promoting quality education and training, stressing the importance of patient safety, and advocating for patient-centered care (Breigeiron et al., 2021). Florence Nightingale championed the significance of well-trained nursing through quality education and professional training. This theory therefore relates to the concepts of education, practice, and emergency preparedness of NPs. By providing emergency preparedness education in the graduate curriculum and

Figure 1

onsite training, professionals can be highly qualified to act in an emergency. It is a priority to invest in the curriculum so NPs can have a skilled and solid foundation to lead in public health, primary care settings, and within the community when a catastrophe emerges.

emergency Preparedness education education in NP Curriculum

Disaster education and response measures designed for NPs have increased since the COVID-19 pandemic. Most states require annual comprehensive disaster training. A sense of competency and confidence in disaster management can be linked to response efficacy (Charney et al., 2019). In NP education, incorporating crisis competencies into the curriculum provides students with improved psychological preparedness and knowledge when responding to emergencies (The International Council of Nurses [ICN], 2019). As shown in Figure 1, the The International Council of Nurses (ICN) identifies four areas and ten domains for core nursing competencies in disaster preparedness.

Curricula should also include making a hazard risk assessment, identifying phases of disaster management and incident management roles, ensuring multiagency emergency response communication, legal and regulatory requirements, collecting and reporting data, understanding

Care Nursing Competencies in Disaster Preparedness

 Policy development and planning for risk reduction

 Disease prevention and health promotion Mitigation/Prevention

 Education and simulations

 Communication and information sharing

 Accountability Preparedness

 Ethical and legal practice

 Psychological care of the individuals, families, vulnerable populations, and communities Response

 Short and long-term recovery of individuals, families, and communities Recovery/Rehabilitation

Note: Adapted from Core Competencies of Disaster Nursing version 2.0, by the International Council of Nurses, 2019 (https://www.icn.ch/sites/default/files/inline-files/ICN_Disaster-Comp-Report_WEB.pdf).

the location of shelters, connecting survivors to available resources, and implications of the loss of community resources (Chegini et al., 2022). As NPs, becoming familiar with various emergency preparedness resources is integral to health care. The Centers for Disease Control and Prevention (CDC) offers clinicians training opportunities on how to prepare for and respond to public health threats and emergencies (Centers for Disease Control and Prevention [CDC], 2022). This can be achieved by communicating relevant information about disease outbreaks, disasters, and terrorism to the community. The Federal Emergency Management Agency (FEMA) also provides education and exercises for first responders, offering courses from the Center for Domestic Preparedness (CDP), the Emergency Management Institute (EMI), and the National Training and Education Division (NTED) in national preparedness to meet the needs at the federal, state, and local levels (Federal Emergency Management Agency [FEMA], 2022). These numerous training resources can be utilized in the NP curriculum to instill confidence in the NP to react calmly and contribute to disaster efforts.

education for Practicing Nurse Practitioners Onsite Simulation

Several educational strategies can be utilized to educate practicing NPs in emergency preparedness, such as onsite simulation and adaptive management skills. Onsite simulation prepares NPs in the clinical practice setting to be emergency ready. Evidence suggests that training for large-scale events can improve mental preparedness during disasters (Chegini et al., 2022). Crisis scenarios envision what could happen in a catastrophe and help to understand what is at stake through didactics and mock drills. This enhances response and demonstrates how to mitigate unpredictable circumstances.

For instance, in the case of an active shooter, hands-on training can be done in a healthcare environment to allow staff to practice how to spring into action in a dangerous situation. First responders are the most important players, controlling the scene and minimizing potential threats (Jannussis et al., 2021). Clear communication and having situational awareness will aid the NP in comprehending the incident, hazards, risks, and operational activities (National Fire Chiefs Council, 2022). Effective situational awareness is fundamental to the ability to make sound decisions. The three components of situational awareness are:

1. Information gathering: acquiring voice, video, and data about the events

2. Understanding information: interpreting and making sense of the information gathered

3. Anticipation: projecting how the incident might develop, and the impact of actions taken (National Fire Chiefs Council, 2022)

Furthermore, health professionals can incorporate an evidence-based framework, such as the National Response Framework, developed by FEMA to reduce risk and improve responses (Wood et al., 2020). NPs interested in enhancing their knowledge in public health response can also volunteer with the Disaster Medical Assistance Teams (DMATs). These regional teams are comprised of volunteers who are part of a more extensive National Disaster Medical System that integrates NPs’ levels of expertise into preparedness planning (Wood et al., 2020). Compliance exercises of new skills identify gaps and provide professionals with an opportunity to experiment before a crisis (Boin et al., 2017). Enhanced training and collaboration across

enhanced training and collaboration across organizations give the nurse practitioners specialized skills, knowledge, and strategic planning tools to implement during all stages of a disaster.

organizations give the NP specialized skills, knowledge, and strategic planning tools to implement during all stages of a disaster.

The principles of situational awareness learned from hands-on training will allow NPs to react quickly, identify changes, and use their diagnostic skills to triage patient care. NPs will rise to leadership roles with their education in practice, policy, planning, and preparation for an emergency.

Adaptive Management Skills

Adaptive management skills (AMS) are what the NP learns in simulation training and education competency courses, which they apply directly to their practice. Crisis communication is a form of AMS used in the clinical setting as an evidence-based tool for emergency preparedness when developing AMS. NPs and other healthcare providers expand their narrative to explain what happened, what is at stake, and what is being done to mitigate the situation. The story should be factually correct, offer actionable advice, show empathy, and instill confidence in the crisis response (Boin et al., 2017). During stressful times, the information can become convoluted. The NP focuses on remaining safe while ensuring all disaster responders are assigned to provide the fastest triage and best care possible (Wood et al., 2020).

Crisis and emergency risk communications (CERC) tactics use an evidence-based framework based on psychology and communication sciences that combines six principles: be first, be right, be credible, express empathy, promote action, and show respect (CDC, 2018). NPs are the leaders responsible for gathering information to keep the public and disaster teams informed about what is going on and provide guidance on patient care. They streamline data to meet the unique demands of disaster management. Utilizing AMS increases the NP’s knowledge and resilience to execute safety plans in extreme situations.

Full Practice Authority

Executing FPA throughout the 50 states would allow NPs to be leaders in their domain, equivalent to chiefs in fire and police departments. During a disaster, NPs can gather data and generate situational awareness reports

utilizing adaptive management skills increases the nurse practitioner's knowledge and resilience to execute safety plans in extreme situations.

for the healthcare system and the local community. With the COVID19 pandemic, states lifted collaborative practice agreements for physician supervision of NPs (Wood et al., 2020). State governing bodies temporarily removed NP practice barriers to increase access to health care. NPs were able to certify home healthcare services for Medicare beneficiaries and lifted telehealth restrictions, expanding the pool of telehealth providers (O’Reilly-Jacob et al., 2022).

When Hurricane Michael, a Category-5 hurricane in Florida, caused massive destruction that collapsed the health infrastructure, the need for NPs amplified to provide health care in devastated communities. Amid this intense hurricane, barriers to FPA were lifted, enabling NPs to prioritize patients and provide immediate care to patients with life-threatening chronic conditions (Wilson, 2020). This practice change gave NPs more independence to manage patient care and respond successfully to meet patient needs during a crisis. Expanding the SOP of the NP and providing disaster response training will help the NP to be prepared to serve the community.

Implications for Practice

Education in emergency preparedness in the NP graduate curriculum and NP practice, as well as FPA, will improve NP responses in disaster situations. Although FPA is discussed in this paper and its relevance to emergency preparedness for NPs, it is a topic that needs further exploration and more data to support legislation to change practice.

Emergency preparedness significantly impacts the NP’s role. As seen with the COVID-19 pandemic, establishing data collection, and utilizing a succinct structure will guide state and local authorities. The use of jurisdictional systems that automate data collection via electronic health records, bed management, or inventory systems should be encouraged. Such systems reduce the data collection burden and increase data quality (Raske, 2021). Healthcare providers, hospitals, clinics, and public health departments must submit reports on unusual patterns of illness to answer the pleas for relief of human suffering (DeNisco, 2021).

NPs who can factually state what is happening and use CERC techniques in planning and responding to emergencies will be successful. The NP will gather information, provide two-way communication with active listening to assess the situation, evaluate the risk and resources available, and then can take action (CDC, 2018).

Incorporating evidence-based disaster training into the curriculum and at-work training sessions will give NPs the foundation to lead during a crisis. NPs can now be equipped with preparedness, situational awareness, crisis communication, and incident management competencies. The combination of advanced clinical knowledge and emergency preparedness skills will lay the groundwork for NPs to play an intricate role in a disaster.

Future Preparedness

The pandemic has forced NPs and nurse leaders to become expert strategic planners. Most providers receive little training in the leadership and management skills that can be the difference between life and death for patients (Blanding, 2022). The pandemic has shown that NPs could benefit from leadership skills and disaster training. Emergency preparedness and response can include pandemic flu planning, preparedness campaigns, mass dispensing of vaccinations, shelter operations and support, first-responder rehab, and mass casualty incident response (DeNisco, 2021).

In addition, hospitals need to have enough resources for personal protective equipment, a plan for surge hospital capacity, emergency department volume and acuity, supply of blood products, and adequate safe staffing (Raske, 2021). A more informed learning process is required, upgrading crisis management performance in a more fundamental forwardlooking fashion (Boin et al., 2017). This will create stability when a disaster arises. Emergency preparedness training can empower NPs to utilize the knowledge and skills they learn in graduate education and onsite clinical practice education to advance patient care.

Conclusion

Florence Nightingale’s Environmental Theory is a vital component of emergency preparedness in graduate education and onsite training. The theory emphasizes the importance of a solid foundation for a skilled workforce and its leaders. As seen during the COVID-19 pandemic, nursing teams have sought innovation in care and made crucial decisions during a rapidly changing environment. The significance of the NP’s clinical knowledge associated with their work and role as a leader has been evident (Breigeiron et al., 2021).

Disaster education can catapult providers from chaos to confident crisis leaders. Incorporating emergency core competencies into curricula and providing onsite workplace exercises with AMS training provides NPs with skills to take charge when disaster strikes. This expertise is essential in assisting communities during and after a catastrophe. NPs can distribute data efficiently and have the resources to empower clear critical decisionmaking during an incident. Early detection means faster deployment of resources, which can save lives and accelerate patient care. NPs can now break out of reactive mode and respond more proactively to crises (Boin et al., 2017). This lays the foundation for constructing our healthcare system’s infrastructure during an emergency.

NPs can make a difference in the lives of the community by being empowered to deal with the challenges of momentous disasters. NPs have become crisis leaders of multidisciplinary teams. They are the linchpin to improving patient outcomes during extreme events.

Blanding, M. (2022). Lessons from COVID-19: The business skills doctors need. Harvard Business School Working Knowledge. https://hbswk. hbs.edu/item/lessons-from-covid-19-the-business-skills-doctors-need

Boin, A., Paul, T. H., Stern, E., & Sundelius, B. (2017). The politics of crisis management: Public leadership under pressure (2nd ed.). Cambridge University Press.

Breigeiron, M., Vaccari, A., & Ribeiro, S. (2021). Florence nightingale: Legacy, present and perspectives in COVID-19 pandemic times. Revista Brasileira de Enfermagem, 74 (suppl 1). https://doi.org/ 10.1590/0034-7167-2020-1306

Centers for Disease Control and Prevention [CDC]. (2018). Crisis emergency risk communication. https://emergency.cdc.gov/cerc/ppt/ CERC_Introduction.pdf

Centers for Disease Control and Prevention [CDC]. (2022). Resources for Emergency Health Professionals. https://emergency.cdc.gov/healthprofessionals.asp

Charney, R. L., Lavin, R. P., Bender, A., Langan, J. C., Zimmerman, R. S., & Veenema, T. (2019). Ready to respond: A survey of interdisciplinary health-care students and administrators on disaster management competencies. Disaster Medicine and Public Health Preparedness, 14(6), 705–712. https://doi.org/10.1017/dmp.2019.96

Chegini, Z., Arab-Zozani, M., Kakemam, E., Lotfi, M., Nobakht, A., & Aziz Karkan, H. (2022). Disaster preparedness and core competencies among emergency nurses: A cross-sectional study. Nursing Open, 9(2), 1294–1302. https://doi.org/10.1002/nop2.1172

DeNisco, S. M. (2021). Role development for the nurse practitioner (3rd ed.). Jones & Bartlett Learning.

Federal Emergency Management Agency. (2022). National training and education division. https://www.firstrespondertraining.gov/frts/npcc

International Council of Nurses. (2019). Core competencies of disaster nursing version 2.0. https://www.icn.ch/sites/default/files/inline-files/ ICN_Disaster-Comp-Report_WEB.pdf

Jannussis, D., Mpompetsi, G., Vassileios, K. (2021). The role of the first responder. In: Pikoulis, E., & Doucet, J. (Eds.)., Emergency medicine, trauma and disaster management (11–18). Springer Cham. https://222. doi:10.1007/978-3-030-34116-9_2

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O’Reilly-Jacob, M., Perloff, J., Sherafat-Kazemzadeh, R., & Flanagan, J. (2022). Nurse practitioners’ perception of temporary full practice authority during a COVID-19 surge: A qualitative study. International Journal of Nursing Studies, 126, 104141. https://doi.org/10.1016/j. ijnurstu.2021.104141

Raske, K. E. (2021). Future preparedness: Data collection & monitoring recommendations to support public health and health care response during emergencies. Greater New York Hospital Association. https:// www.hhs.gov/sites/default/files/fy-2022-phssef-cj.pdf

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IN HEALTHCARE LITERATURE

n Alcohol-related liver Disease Clinical Practice Guidelines

n French Association for the Study of the Liver. (2022, June 1). https://reference.medscape.com/viewarticle/974654

The French Association for the Study of the Liver recommends that general and specialty practitioners use the AUDIT-C questionnaire to assist in detecting excessive alcohol consumption. All patients with cirrhosis and/or hepatocellular carcinoma should be counseled to completely and permanently stop all alcohol consumption to limit the risk of excess mortality. Symptomatic alcohol withdrawal should be treated with benzodiazepines until symptoms disappear. Additionally, consider pharmacological treatment for promoting the maintenance of alcohol consumption targets (abstinence or reduced consumption) in dependent patients.

All patients with alcohol-related liver disease should undergo noninvasive assessment of liver fibrosis. To confirm the clinical suspicion of alcoholic hepatitis in patients who are potential candidates for specific treatment, a liver biopsy is recommended.

In the absence of liver biopsy, use the National Institute on Alcohol Abuse and Alcoholism classification to offer treatment only to patients with probable alcoholic hepatitis.

The following criteria is used to identify people with advanced alcoholrelated liver disease in the general population: aged ≥ 40–45 years with an AUDIT score predictive of hazardous consumption and/or consumption of ≥ 14 standard drinks/week.

n Nonalcoholic Fatty liver Disease Clinical Practice Guidelines

n American Association of Clinical Endocrinology (2022, June 1). https://reference.medscape.com/viewarticle/974587

The guidelines are designed to help clinicians screen and identify patients at risk for nonalcoholic fatty liver disease (NAFLD) in the primary care setting so they may receive appropriate treatment promptly.

 Screen all patients at high risk for NAFLD, including those with prediabetes, type 2 diabetes, obesity, and/or at least two cardiometabolic risk factors, or those with hepatic steatosis identified on imaging, and/or elevated plasma aminotransferase levels that persist for longer than 6 months.

 Evaluate those undergoing bariatric surgery for the presence and severity of nonalcoholic steatohepatitis (NASH); liver biopsy should be recommended for patients whose pre-surgical stratification suggests indeterminate or high risk for liver fibrosis.

 Use the fibrosis-4 (FIB-4) index, which is calculated using the patient’s age, AST level, platelet (PLT) count, and ALT level: FIB-4 score = age (years) x AST (U/L)/PLT (109/L) x ALT ½ (U/L). The FIB-4 index classifies patients as being at low, intermediate, or high risk for liver fibrosis. The FIB-4 is not recommended for pediatric patients because the age part of the equation is not accurate for

them; liver enzyme tests are appropriate for pediatric patients at high risk resulting from clinical factors.

 Patients with low risk can be managed in primary care or endocrinology settings with an emphasis on management of obesity and prevention of cardiovascular disease. Studies about whether NAFLD is an independent risk factor for CVD and whether this risk increases as NAFLD progresses to more severe disease have shown mixed results, but lifestyle modifications (e.g., diet and exercise) and medications can help improve cardiometabolic health and reduce the increased cardiovascular risk linked with NAFLD.

 For those at intermediate risk, a second noninvasive test, such as a liver stiffness measurement by elastography or an enhanced liver fibrosis (ELF) test, is recommended. Referral to a liver specialist for additional testing, including possible biopsy, is advised for those with high risk or whose risk is still unclear after two non-invasive tests.

 Individuals with high risk on the FIB-4 require a hepatology referral. Those in intermediate- and high-risk groups require multidisciplinary management that includes a hepatologist, endocrinologist, and others for prevention of cardiovascular disease and development of cirrhosis.

n Peripheral Arterial Disease Clinical Practice Guidelines

n Canadian Cardiovascular Society (2022, May 31). https://reference.medscape.com/viewarticle/974518

Diagnosis and Screening

 Use an ankle-brachial index (ABI) and/or toe-brachial index (TBI) to confirm PAD in symptomatic patients.

 A broad, population-based PAD screening strategy is not recommended for individuals without claudication signs/symptoms.

Management

 Smoking cessation is recommended to prevent PAD, as well as to prevent major adverse cardiovascular (CV) events (MACE) and major adverse limb events (MALE) in those with PAD. Recommended smoking cessation interventions include but are not limited to intensive counselling; pharmacotherapy (e.g., nicotine replacement therapy [NRT], bupropion, varenicline); and, occasionally, nicotinecontaining e-cigarettes.

 Offer a sodium-glucose cotransporter 2 inhibitor (SGLT-2I) to diabetic patients with PAD rather than usual diabetic control for MACE reduction without a rise in amputation risk.

 Administer lipid-modifying therapy to patients with PAD to lower death and CV death, nonfatal myocardial infarction (MI) and nonfatal stroke (MACE), and MALE. Use the maximally tolerated statin therapy. Use statin add-on therapies (ezetimibe and/or proprotein convertase subtilisin/kexin-9 inhibitors [PCSK-9Is]) if, while on maximally tolerated statin therapy, the level of lowdensity lipoprotein cholesterol (LDL-C) is ≥ 1.8 mmol/L, of nonhigh-density lipoprotein cholesterol (non-HDL-C) is ≥2.4 mmol/L, or of apolipoprotein B100 is ≥ 0.7 mg/dL.

 For those with PAD on maximally tolerated statin therapy but have a triglyceride level of 1.5–5.6 mmol/L, consider using icosapent ethyl to reduce CV death, nonfatal MI, and nonfatal stroke.

 Unless there are contraindications, first-line treatment of hypertension in PAD is angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs).

 Routine antithrombotic therapy (antiplatelet or anticoagulant) is not recommended for those with isolated asymptomatic lower extremity (LE) PAD.

For patients with symptomatic LE PAD and who are:

 At high risk for ischemic events (high-risk comorbidities [e.g., polyvascular disease, diabetes, heart failure history, renal insufficiency]) and/or high-risk limb presentation (following peripheral revascularization, limb amputation, rest pain, ischemic ulcers), and at low bleeding risk: Use rivaroxaban 2.5 mg twice daily (BID) with aspirin (80–100 mg daily)

 At low bleeding risk and without high-risk limb comorbidities or high-risk limb presentation: Use rivaroxaban 2.5 mg BID with aspirin or single antiplatelet therapy (SAPT)

 At high bleeding risk and still eligible for antithrombotic therapy: Consider SAPT with aspirin (75–325 mg) or clopidogrel (75 mg)

 For those with stable LE PAD, additional full-dose anticoagulation with antiplatelet therapy is not recommended to reduce MACE and MALE events.

 Administer rivaroxaban 2.5 mg BID daily with aspirin (80–100 mg daily) for patients with LE PAD after elective open revascularization, and with or without short-term clopidogrel for elective endovascular revascularization.

 For those with PAD and intermittent claudication, supervised exercise programs are first-line therapy to improve maximal and pain-free walking distance and time, as well as quality of life (QoL); walking is the preferred form of exercise in exercise programs. When there are no available supervised exercise programs or when not desired by the patient, offer a structured home-based or community exercise program to improve leg symptoms and QoL.

n burn Care Clinical Practice Guidelines

n Japanese Society for Burn Injuries (2022, May 27). https://reference.medscape.com/viewarticle/973946

The severity of an inhalation injury can be diagnosed via bronchofiberscopy and chest computed tomography (CT) scanning, but no single definitive severity indicator currently exists.

Patients with burns who need initial fluid resuscitation include the following:

 Adult patients whose burn area is greater than 15% of their total body surface area (TBSA) and children with a burn area greater than 10% of their TBSA

 Patients with burn areas that are clearly greater than 20% of their TBSA

 Resuscitation should be carried out using a salt-containing fluid infusion as based on weight and percentage burn in adult patients with a burn area greater than 20% of their TBSA and pediatric patients with a burn area greater than 10% of their TBSA

The use of silver-containing Hydrofiber wound dressings is strongly recommended as local therapy for partial-thickness burns within 1 week post injury. It is recommended that cryopreserved allogeneic skin grafting be employed during surgery for extensive burns.

To prevent infection, isolation in a private room should be provided to patients with burns covering more than 20% of their TBSA. In patients with severe burns, commencement of enteral nutrition as early as possible within 24 hours post injury is strongly recommended. In patients with severe burns, immunonutrition with glutamine is strongly recommended. It is strongly recommended in electrical burn patients that if compartment pressure increases or neuropathy or blood flow disorders are present, surgical decompression including fasciotomy be carried out. In patients with chemical injury, irrigation with water as soon as possible post injury is strongly recommended to remove or dilute the attached chemical agent. In burn patients, it is recommended that deep vein thrombosis be prevented with mechanical prophylaxis. However, “the indication should be carefully decided” in patients who have lower limb burns.

n Heart Failure Clinical Practice Guidelines

n American College of Cardiology, American Heart Association, and Heart Failure Society of America (2022, May 19). https://reference.medscape.com/viewarticle/972957

These guidelines replace the 2013 and 2017 recommendations with significant and paradigm-shifting additional treatment options that include new/repurposed drug therapies that benefit almost without regard to ejection fraction (EF); additional disease-staging terminology that characterizes HF as a continuum; updated recommendations for advanced HF, acute HF, and comorbidities; as well as other guidance.

Top 10 Key Points

1. Four core foundational medication classes (sodium-glucose cotransporter-2 inhibitors [SGLT2Is], beta blockers, mineralocorticoid receptor antagonists [MRAs], and renin-angiotensin system [RAS] inhibitors) are now included in guideline-directed medical therapy (GDMT) for HF with reduced EF (HFrEF).

2. SGLT2Is are a class 2a (moderate) recommendation in HF with mildly reduced EF (HFmrEF), whereas angiotensin receptorneprilysin inhibitors (ARNIs), angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), MRAs, and beta blockers are class 2b (weak) recommendations for this patient population.

3. There are new recommendations for HF with preserved EF (HFpEF) for SGLT2Is (class 2a), MRAs (class 2b), and ARNIs (class 2b). Renewed recommendations include those for treatment of hypertension (class 1 [strong]) and of atrial fibrillation (AF) (class 2a); use of ARBs (class 2b); as well as avoidance of the routine use of nitrates or phosphodiesterase-5 (PDE5) inhibitors (class 3 [no benefit]).

4. Patients with previous HFrEF who now have a left ventricular (LV) EF above 40% should be referred to as having improved LVEF; they should continue their HFrEF treatment.

5. The ACC/AHA/HFSA created value statements for select recommendations in which there are high-quality, cost-effectiveness studies of the intervention published.

6. New amyloid heart disease treatment recommendations include screening for serum and urine monoclonal light chains, bone scintigraphy, genetic sequencing, tetramer stabilizer therapy, and anticoagulation.

7. It is important for evidence to support increased filling pressures for the diagnosis of HF if the LVEF is over 40%. Such evidence can be obtained from noninvasive (e.g., natriuretic peptide, diastolic function on imaging) or invasive testing (e.g., hemodynamic measurement).

8. Refer those with advanced HF who desire prolonged survival to a team that specializes in HF. These teams review HF management, assess candidacy for advanced HF therapies, and use palliative care such as palliative inotropes when it is consistent with the patient’s goals of care.

9. Primary prevention is crucial for those at risk for HF (stage A) or pre-HF (stage B). The revised stages of HF emphasize the new terminologies of “at risk” for HF for stage A and pre-HF for stage B.

10. Updated and new recommendations cover select patients with HF and iron deficiency, anemia, coronary artery disease, AF, valvular heart disease, cardiomyopathy, hypertension, type 2 diabetes, sleep disorders, and malignancy.

n Tuberculosis Clinical Practice Guidelines

n World Health Organization (2022, April 29). https://reference.medscape.com/viewarticle/972831

Clinical practice guidelines for 2022 for the management of tuberculosis (TB) in children and adolescents were published online on March 21 by the World Health Organization (WHO) as part of the WHO Consolidated Guidelines on Tuberculosis. New recommendations include those for diagnostic approaches to TB, a shorter treatment duration for children with non-severe drug-susceptible TB, another treatment option for TB meningitis, the use of bedaquiline and delamanid in young children with multidrug- and rifampicin-resistant TB, and decentralized and familycentered, integrated models of care for case detection and prevention of TB in children and adolescents.

Diagnostic Approaches

 Rapid molecular tests called Xpert Ultra should be used as the initial test for TB in children and adolescents. Diagnostic testing can now include noninvasive specimens, such as stool samples. (Updated: Strong recommendation)

 In children with presumptive pulmonary TB being cared for at healthcare facilities, treatment decision algorithms may be used to diagnose pulmonary TB. (New: Interim, conditional recommendation)

Treatment Regimens

 Children with mild TB can be treated with a shorter regimen of 4 months, rather than 6 months. (New: Strong recommendation)

 Two oral medications for drug-resistant TB (bedaquiline and delamanid) are now recommended for use in children of all ages. (New: Conditional recommendation)

 Children and adolescents with bacteriologically confirmed or clinically diagnosed TB meningitis may be treated with a 6-month intensive regimen as an alternative to the 12-month regimen. (New: Conditional recommendation)

Models of TB Care

 In settings with high TB burden, decentralized TB services may be used for children and adolescents with evidence of TB and/or exposure to TB. (New: Conditional recommendation)

 Family-centered, integrated services may be added to standard TB services in children and adolescents with signs and symptoms of TB and/or exposure. (New: Conditional recommendation)

n rheumatoid Arthritis Clinical Practice Guidelines

n Japan College of Rheumatology (2022, April 5). https://reference.medscape.com/viewarticle/971501

Methotrexate (MTX) is recommended in patients with active rheumatoid arthritis (RA).

Folic acid is recommended in RA patients using MTX. Concomitant use of a TNF inhibitor is recommended in RA patients with moderate or severe disease activity who have had an inadequate response to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs). Concomitant use of a non-TNF inhibitor is recommended in RA patients with moderate or severe disease activity who have had an inadequate response to csDMARDs. A non-TNF inhibitor (T-cell selective co-stimulation modulator) and a TNF inhibitor are equally recommended when a biological disease-modifying antirheumatic drug (bDMARD) is used in combination with MTX in RA patients with moderate or severe disease activity who have had an inadequate response to MTX. A non-TNF inhibitor (IL-6 inhibitor) is

recommended when a bDMARD is used without MTX in RA patients with moderate or severe disease activity who are intolerant to MTX or who have had an inadequate response to MTX. Reference bDMARDs and biosimilars are equally recommended in RA patients with high or moderate disease activity who have had an inadequate response to csDMARDs.

Use of appropriate doses of disease-modifying antirheumatic drugs (DMARDs) is recommended with careful consideration for safety in RA patients with moderate or severe renal dysfunction. Rheumatologists should treat RA patients positive for hepatitis B surface (HBs) antigen in collaboration with a hepatologist. Rheumatologists should treat hepatitis B virus (HBV)-infected RA patients negative for HBs antigen according to the usual treatment strategy with regular monitoring for HBV infection. Rheumatologists should treat hepatitis C virus (HCV)-infected patients with RA according to the usual treatment strategy in collaboration with a hepatologist.

n management of Spine Injury Clinical Practice Guidelines

n American College of Surgeons (2022, April 1). https://reference.medscape.com/viewarticle/971300

Initial Measures

Spinal motion restriction (SMR) can be achieved with a backboard, scoop stretcher, vacuum splint, ambulance cot, or other similar devices. When indicated, it should be applied to the entire spine.

The cervical collar can be discontinued without additional radiographic imaging in an awake, asymptomatic adult trauma patient with (1) a normal neurologic exam, (2) no high-risk injury mechanism, (3) free range of cervical motion, and (4) no neck tenderness. Collar removal is recommended for an adult blunt trauma patient with no neurologic symptoms and a negative helical cervical computed tomography (CT) scan. A negative helical cervical CT scan suffice for collar removal in an adult blunt trauma patient who is obtunded or unevaluable.

Plain radiographs of the cervical and thoracolumbar spine are not recommended in the initial screening of spinal trauma; non-contrast multidetector CT (MDCT) is the initial imaging modality of choice. Magnetic resonance imaging (MRI) is the only modality for evaluating the internal structure of the spinal cord.

Management of Injury

Occipital condyle fractures without neural compression or craniocervical misalignment can be managed with a rigid or semi-rigid cervical orthosis. Treatment of cervical fractures is individualized according to fracture type and patient factors (e.g., age). Stable thoracolumbar fractures without neurologic deficits can be treated with adequate pain control and early ambulation without a brace.

The vast majority of penetrating spinal cord injuries (SCIs) result in complete (American Spinal Injury Association [ASIA] A) injuries. Few gunshot SCIs require surgical stabilization. Steroids are not recommended.

Care of Patients with Spinal Cord Injury

Hypotension must be avoided. The use of mean arterial pressure (MAP) goals of 85-90 mm Hg for 7 days must be weighed against data limitations and associated risks. An agent with both alpha- and beta-adrenergic activity is recommended. The use of methylprednisolone within 8 hours following SCI cannot be definitively recommended. No other potential therapeutic agents have demonstrated efficacy. Chemoprophylaxis for venous thromboembolism (VTE) should be initiated as early as medically possible (typically ≤ 72 hrs.), with duration determined on an individualized basis. Surveillance duplex ultrasonography (US) is not recommended in asymptomatic patients but may be considered in high-risk patients who cannot have chemoprophylaxis during the acute period. Treatment of persistent bradycardia or intermittent severe bradycardia may include a beta2-adrenergic agonist, chronotropic agents, or phosphodiesterase inhibitors. Early tracheostomy is recommended to aid in mechanical ventilation in high SCI. Stimulation of the diaphragm should be considered. Open or percutaneous tracheostomy can be performed early after anterior cervical spinal stabilization without increasing the risk of infection or other wound complications. Pain management is a priority in acute SCI and should be delivered via a multimodal approach.

Symptoms associated with SCI, such as acute autonomic dysreflexia, spasticity, and skin breakdown, should be adequately addressed. A bowel management program should be initiated for all acute SCI patients. Bladder management should be individualized. Physical and occupational therapy should be initiated within one week after injury for acute SCI patients who are determined to be medically ready.

n Type 2 Diabetes mellitus Clinical Practice Guidelines

n Società Italiana di Diabetologia and the Associazione Medici Diabetologi (2022, March 31). https://reference.medscape.com/viewarticle/971166

In patients with type 2 diabetes who are undergoing treatment with drugs that can induce hypoglycemia, it is recommended that the target hemoglobin A1c (HbA1c) level be between 49 mmol/mol (6.6%) and 58 mmol/mol (7.5%). In patients with type 2 diabetes who are undergoing treatment with drugs that cannot induce hypoglycemia, it is recommended that the target HbA1c level be below 53 mmol/mol (7%). It is suggested that structured medical nutrition therapy (made up of nutritional assessment, diagnosis, intervention, and monitoring) be employed in type 2 diabetes treatment. Regular physical exercise is suggested for type 2 diabetes treatment. Combined (aerobic and resistance) training, rather than aerobic training alone, is suggested for type 2 diabetes treatment.

In patients with type 2 diabetes who have not had previous cardiovascular events, metformin is recommended as a first-line, longterm treatment. As second-line agents, sodium-glucose cotransporter-2 (SGLT-2) inhibitors or glucagon-like peptide-1 (GLP-1) receptor agonists

are recommended, while as third-line treatments, consideration should be given to pioglitazone, dipeptidyl peptidase 4 (DPP-4) inhibitors, acarbose, and insulin.

In patients with type 2 diabetes with previous cardiovascular events but without heart failure, the use of metformin, SGLT-2 inhibitors, or GLP-1 receptor agonists is recommended as first-line, long-term treatment. As second-line treatments, consideration should be given to DPP-4 inhibitors, pioglitazone, acarbose, and insulin. In patients with type 2 diabetes who have suffered previous heart failure, SGLT-2 inhibitors are recommended for first-line, long-term treatment. Consideration should be given to GLP-1 receptor agonists and metformin as second-line treatments, and to DPP-4 inhibitors, acarbose, and insulin as third-line treatments.

It is recommended that all patients with type 2 diabetes who require treatment with basal insulin receive basal insulin analogues rather than neutral protamine Hagedorn (NPH) insulin.

It is not suggested that in patients with type 2 diabetes who are on basal-bolus insulin therapy, continuous glucose monitoring (continuous or on demand) instead of self-monitoring of blood glucose be practiced.

n Clinical Guidelines for the Prevention and Control of mrSA in Healthcare Facilities

n Healthcare Infection Society and Infection Prevention Society (2022, February 1). https://reference.medscape.com/viewarticle/967593

Patient Screening

Use a targeted approach at a minimum, but universal screening may be appropriate, depending on local facilities. If a patient undergoes decolonization therapy, consider determining the success of

decolonization with repeat MRSA screening 2–3 days after therapy. Do not postpone surgery if repeat screening remains positive. Staff screening and management is needed. For employees with positive test results, consider also screening the throat, hairline, and groin/perineum because if positive, the risk increases for shedding into the environment and MRSA transmission. Develop local policies regarding exclusion from work and return of staff colonized with MRSA, Considering the worker’s risk for transmission to patients.

n Ce Activity: “blameless”: using Popular entertainment media to build Social Context in Nursing Students

Thank you for your participation in “’Blameless’: Using Popular Entertainment Media to Build Social Context in Nursing Students,” a new continuing education (CE) activity offered by NYSNA. NYSNA members and nonmembers are invited to take part in this activity, and you do not need to be a resident of New York State.

INSTRUCTIONS

In order to receive contact hours (CHs) for this educational activity, participants are to read the article presented in this issue of The Journal, complete and return the post-test and evaluation form, and earn 80% or better on the post-test.

This activity is free to NYSNA members and $10 for nonmembers. Participants can pay by check (made payable to NYSNA) or credit card. The completed answer sheet and evaluation form may be mailed or faxed back to NYSNA; see the evaluation form for more information.

The New York State Nurses Association is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

This program has been awarded 1.0 contact hour through the New York State Nurses Association Accredited Provider Unit.

The New York State Nurses Association is accredited by the International Accreditors for Continuing Education and Training (IACET) and is authorized to issue the IACET continuing education credits (CEUs). The New York State Nurses Association is authorized by IACET to offer 0.1 CEU for this program.

In order to receive CHs and CEUs, participants must read the entire article, fill out the evaluation, and get 80% or higher on the post-test.

Presenters disclose no conflict of interest.

NYSNA wishes to disclose that no commercial support or sponsorship was received.

NYSNA Program Planners, Presenters, and Content Experts declare that they have no financial relationship with an ineligible company.

Declaration of Vested Interest: None.

INTRODUCTION

There has long been a scarcity of clinical sites for nursing students. The COVID-19 pandemic further limited access to clinical sites, motivating nurse educators to find creative ways to educate students. The majority of nursing students tend to see patients’ mental or medical illnesses as isolated occurrences without social context. Nursing students must gain experience working with patients whose socioeconomic and cultural factors may contribute to physical and psychological illness. According to the American Academy of Pediatrics, adverse childhood events (ACEs), such as physical and sexual abuse, neglect, divorce, mental illness, substance abuse, and incarcerations are associated with an elevated risk of addiction, depression, and sociopathy. To augment clinical opportunity, a pilot course was developed using popular media (the television series Shameless) to introduce students to various social contexts. This paper discusses the results of

a pilot nursing course designed to meet the need to adequately prepare nursing students for socially conscious practice. Through participation in this CE Activity, participants will learn how entertainment education may be used to teach nursing students the social context surrounding many socially driven health outcomes. This methodology bridges the gap between the classroom and practice settings. Implementing coursework that prepares nurses to address the social determinants of health is key to promoting more equitable health outcomes for patients, families, and communities.

LEARNING OUTCOME

Participants will identify an educational strategy to supplement clinical learning by introducing nursing students to people with various backgrounds, values, and social circumstances via popular media.

OBJECTIVES

By completion of the article, the reader will be able to:

1. Restate how popular media constitutes a new educational opportunity for nursing students to learn about social factors that influence health.

2. Identify social factors that impact the interrelationships between medical and psychiatric illness.

Please answer either True or False to the questions below. Remember to complete the answer sheet by putting the letter of your corresponding answer next to the question number. Each question has only one correct answer.

The 1.0 CH and 0.1 CEU for this program will be offered until January 30, 2026.

1) Television has recently been introduced as a method of teaching skills to nursing students.

a. True

b. False

2) Authors suggest that nursing students may have limited perspectives regarding social factors that can influence health, including mental and/ or medical illnesses.

a. True

b. False

3) The show Shameless, a series depicting a poverty-stricken family, doesn’t really give students any insights into social factors that may influence the health of patients.

a. True

b. False

4) Adverse childhood experiences, including the experience of having a member of one’s household being incarcerated, can have long-term impacts on a child.

a. True

b. False

5) Students employed critical analysis to make correlations between the experiences that the characters in the show Shameless to learn about interrelationships between psychiatric and medical illnesses.

a. True

b. False

6) Participating students reported that analyzing the characters and experiences of the characters in the show throughout the course failed to enhance their ability to apply knowledge to actual situations.

a. True

b. False

7) Knowledge and the critical analysis of the many cultural and socioeconomic factors that can drive medical and mental illness can enable nurses to facilitate the development of nursing care plans that are patient specific, culturally competent, and facilitate more equitable outcomes.

a. True

b. False

8) Incorporating the use of media in learning can make sense, particularly with a population of learners who are between the ages of 20–24, because data show that more than half of the people in this age group already watch more than two hours of television per day.

a. True

b. False

9) Most of the students in the course had extensive experience with social factors that adversely influence health and there was no need to incorporate additional ways to explore and absorb societal impacts on health.

a. True

b. False

10) The authors infer that vicariously experiencing the social and psychiatric issues of characters on a television show can prepare students to care for patients with similar social experiences, particularly when nursing instructors are faced with diminishing access to clinical experiences for nursing students.

a. True

b. False

Answer Sheet

“blameless”: using Popular entertainment media to build Social Context in Nursing Students

Note: The 1.0 CH and 0.1 CEU for this program will be offered until January 30, 2026.

Please print legibly and verify that all information is correct.

First Name: MI: Last Name:

Street Address: City: State: ZIP Code:

Daytime Phone Number (Include area code):

Email:

Profession: Currently Licensed in NY State? Y / N (Circle one)

NYSNA Member # (if applicable): License #: License State:

ACTIVITY FEE: Free for NYSNA members/$10 nonmembers

PAYMENT METHOD

Check—payable to New York State Nurses Association (please include “Journal CE” on your check).

Credit Card: Mastercard Visa Discover American Express

Card Number: Expiration Date: / CVV#

Name: Signature: Date: / /

Please print your answers in the spaces provided below. There is only one answer for each question.

Please complete the answer sheet above and course evaluation form on reverse. Submit both the answer sheet and course evaluation form along with the activity fee for processing.

Mail to:

NYSNA, attn. Nursing Education and Practice Dept. 131 West 33rd Street, 4th Floor, New York, NY 10001 Or fax to: 212-785-0429

Journal of the New York State Nurses Association, Vol. 49 No. 2

learning Activity evaluation

“blameless”: using Popular entertainment media to build Social Context in Nursing Students

Please use the following scale to rate statements 1–7 below:

1. The content fulfills the overall purpose of the CE Activity.

2. The content fulfills each of the CE Activity objectives.

3. The CE Activity subject matter is current and accurate.

4. The material presented is clear and understandable.

5. The teaching/learning method is effective.

6. The test is clear and the answers are appropriately covered in the CE Activity.

7. How would you rate this CE Activity overall?

8. Time to complete the entire CE Activity and the test? ____ Hours (enter 0–99) _____ Minutes (enter 0–59)

9. Was this course fair, balanced, and free of commercial bias? Yes / No (Circle one)

10. Comments:

11. Do you have any suggestions about how we can improve this CE Activity?

n Ce Activity: Nurse Practitioners and barriers to Practice in Primary Care

Thank you for your participation in “Nurse Practitioners and Barriers to Practice in Primary Care,” a new continuing education (CE) activity offered by NYSNA. NYSNA members and nonmembers are invited to take part in this activity, and you do not need to be a resident of New York State.

INSTRUCTIONS

In order to receive contact hours (CHs) for this educational activity, participants are to read the article presented in this issue of The Journal, complete and return the post-test, evaluation form, and earn 80% or better on the post-test.

This activity is free to NYSNA members and $10 for nonmembers. Participants can pay by check (made payable to NYSNA) or credit card. The completed answer sheet and evaluation form may be mailed or faxed back to NYSNA; see the evaluation form for more information.

The New York State Nurses Association is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

This program has been awarded 1.0 Contact Hour through the New York State Nurses Association Accredited Provider Unit.

The New York State Nurses Association is accredited by the International Accreditors for Continuing Education and Training (IACET) and is authorized to issue the continuing education credits (CEUs). The New York State Nurses Association is authorized by IACET to offer 0.1 CEU for this program.

In order to receive CHs and CEUs, participants must read the entire article, fill out the evaluation and get 80% or higher on the post-test.

Presenters disclose no conflict of interest.

NYSNA wishes to disclose that no commercial support or sponsorship was received.

NYSNA Program Planners, Presenters, and Content Experts declare that they have no financial relationship with an ineligible company.

Declaration of Vested Interest: None.

INTRODUCTION

As the primary care physician shortage grows and an aging population continues to develop chronic conditions, there is an increasing demand for primary care services in the United States. Although the nurse practitioner (NP) workforce has grown, categorical barriers limit the role of the NP as a primary care provider. Many NPs, healthcare providers, policy-makers, as well as the public, are unaware of these limitations or what could be done to remove these barriers.

Restrictions on practice authority, prescriptive authority, and reimbursement vary between state and federal laws. Due to the relatively low percentage of states granting full practice authority—where a NP manages all aspects of patient care —access to primary health care in the United States remains unnecessarily restricted.

Participants in this continuing education module will be informed of the ways access to primary care could be expanded throughout the United States with NPs, and how to identify various ways to overcome the barriers related to NPs’ scope of practice and their full reimbursement for the primary care services they provide.

LEARNING OUTCOME

Participants will be able to identify existing barriers to nurse practitioners from delivering primary care.

OBJECTIVES

By completion of the article, the reader will be able to:

1. Identify three existing impediments to primary care NP practice.

2. Identify factors that shape practice authority for NPs.

3. Identify prescriptive authority differences throughout the United States for NPs.

4. Identify ways in which the differences between doctors and NPs for the reimbursement of expenses impacts primary care practice.

Please answer either True or False to the questions below. Remember to complete the answer sheet by putting the letter of your corresponding answer next to the question number. Each question has only one correct answer.

The 1.0 CH and 0.1 CEU for this program will be offered until January 30, 2026.

1) The NP workforce has declined over the past 20 years.

a. True

b. False

2) The licensure, accreditation, certification, and education (LACE) policy outlines the scope of practice for advanced practice registered nurses exclusively in New York State.

a. True

b. False

3) In the United States, NP scope of practice policy is categorized as “full,” “reduced,” or “restricted.”

a. True

b. False

4) In the District of Columbia and 55% of U.S. states, NPs are granted full practice authority, thus giving NPs a broad reach and the ability to render necessary care to patients.

a. True

b. False

5) There is wide variation state-by-state in the prescriptive authority given NPs, which can limit what NPs are able to do for the patients they serve.

a. True

b. False

6) The COVID-19 pandemic led to the temporary removal of practice restrictions, which improved access to care in several states. This demonstrates that NPs play an important role in the healthcare system and increasing access to care.

a. True

b. False

7) Uniformity of reimbursement, where NPs are reimbursed by Medicare at the same rate as physicians, would incentivize more NPs to work in primary care settings and help meet the growing need for providers in primary care in the United States.

a. True

b. False

8) All states recognize NPs as a primary care providers.

a. True

b. False

9) To practice to the full extent of their training and education, NPs should be given unrestricted prescriptive authority. This would result in patients having to rely less on doctors, who are diminishing in numbers.

a. True

b. False

10) The Balanced Budget Act of 1997 extended direct reimbursement for nursing home care to NPs, resulting in increases in primary care access for patients in that setting.

a. True

b. False

Journal of the New York State Nurses Association, Vol. 49,

Answer Sheet

Nurse Practitioners and barriers to Practice in Primary Care

Note: The 1.0 CH and 0.1 CEU for this program will be offered until January 30, 2026.

Please print legibly and verify that all information is correct.

First Name: MI: Last Name:

Street Address:

City: State: ZIP Code:

Daytime Phone Number (Include area code):

Email:

Profession: Currently Licensed in NY State? Y / N (Circle one)

NYSNA Member # (if applicable): License #: License State:

ACTIVITY FEE: Free for NYSNA members/$10 nonmembers

PAYMENT METHOD

Check—payable to New York State Nurses Association (please include “Journal CE” on your check).

Credit Card: Mastercard Visa Discover American Express

Card Number: Expiration Date: / CVV#

Name: Signature: Date: / /

Please print your answers in the spaces provided below. There is only one answer for each question.

Please complete the answer sheet above and course evaluation form on reverse. Submit both the answer sheet and course evaluation form along with the activity fee for processing. Mail to:

NYSNA, attn. Nursing Education and Practice Dept. 131 West 33rd Street, 4th Floor, New York, NY 10001 Or fax to: 212-785-0429

The Journal of the New York State Nurses Association, Vol. 49 No. 2

learning Activity evaluation

Nurse Practitioners and barriers to Practice in Primary Care

Please use the following scale to rate statements 1–7 below:

1. The content fulfills the overall purpose of the CE Activity.

2. The content fulfills each of the CE Activity objectives.

3. The CE Activity subject matter is current and accurate.

4. The material presented is clear and understandable.

5. The teaching/learning method is effective.

6. The test is clear and the answers are appropriately covered in the CE Activity.

7. How would you rate this CE Activity overall?

8. Time to complete the entire CE Activity and the test? ____ Hours (enter 0–99) _____ Minutes (enter 0–59)

9. Was this course fair, balanced, and free of commercial bias? Yes / No (Circle one)

10. Comments:

11. Do you have any suggestions about how we can improve this CE Activity?

n Ce Activity: The role of the Nurse Practitioner and emergency Preparedness

Thank you for your participation in “The Role of the Nurse Practitioner and Emergency Preparedness,” a new continuing education (CE) activity offered by NYSNA. NYSNA members and nonmembers are invited to take part in this activity, and you do not need to be a resident of New York State.

INSTRUCTIONS

In order to receive contact hours (CHs) for this educational activity, participants are to read the article presented in this issue of The Journal, complete and return the post-test and evaluation form, and earn 80% or better on the post-test.

This activity is free to NYSNA members and $10 for nonmembers. Participants can pay by check (made payable to NYSNA) or credit card. The completed answer sheet and evaluation form may be mailed or faxed back to NYSNA; see the evaluation form for more information.

The New York State Nurses Association is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

This program has been awarded 1.0 Contact Hour through the New York State Nurses Association Accredited Provider Unit.

The New York State Nurses Association is accredited by the International Accreditors for Continuing Education and Training (IACET) and is authorized to issue the IACET continuing education credits (CEUs). The New York State Nurses Association is authorized by IACET to offer 0.1 CEU for this program.

In order to receive CHs and CEUs, participants must read the entire article, fill out the evaluation and get 80% or higher on the post-test.

Presenters disclose no conflict of interest.

NYSNA wishes to disclose that no commercial support or sponsorship was received.

NYSNA Program Planners, Presenters, and Content Experts declare that they have no financial relationship with an ineligible company.

Declaration of Vested Interest: None.

INTRODUCTION

The regular occurrence of hazards and disasters have direct implications for healthcare providers and calls for a workforce educated and skilled in disaster management. Nurse practitioners (NPs) are in a unique position to fill roles in all phases of the emergency management cycle. As skilled direct care providers, they are essential to response and recovery efforts for individuals, as well as communities at large. States have role in enabling NPs to care for more patient needs through expanding practice agreements. Several resources are available to NPS for the development of competencies in disaster preparedness, but many NPs are not fully aware of their potential to gain competency in emergency management. Additional specialized education and training in emergency preparedness could further enhance the roles of NPs.

LEARNING OUTCOME

Participants will be able to identify the ways in which nurse practitioners can enhance their roles in emergency preparedness and response.

OBJECTIVES

By completion of the article, the reader will be able to:

1. Identify opportunities for education in NP emergency preparedness curriculum.

2. Identify emergency preparedness resources.

3. Identify methods for learning and skills related to emergency preparedness for NPs.

Please answer either True or False to the questions below. Remember to complete the answer sheet by putting the letter of your corresponding answer next to the question number. Each question has only one correct answer.

The 1.0 CH and 0.1 CEU for this program will be offered until January 30, 2026.

1) NPs can play an essential role in emergency preparedness and response as they continue their practice on the front lines. With training, NPs can be well-versed leaders in a position to blend their expertise in diagnosing and treating health conditions with their skills in the application of crisis management principles.

a. True

b. False

2) According to the International Council of Nurses, mitigation and prevention involves the physical and psychological care of individuals.

a. True

b. False

3) The use of simulations for emergency preparedness are an evidence-based method for improving mental preparedness during disasters. Simulation crisis scenarios envision what could happen in a catastrophe and help learners to understand what is at stake through didactics and mock drills.

a. True

b. False

4) Components of situational awareness involve gathering data; interpreting the information gathered; and projecting how the incident might develop, and the impact of actions taken. These skills are necessary for instilling confidence in NPs’ abilities to react calmly and contribute effectively to disaster relief efforts.

a. True

b. False

5) Crisis communication is a structured way to communicate information during an emergency and is a skill that can and should be included in NP curriculum.

a. True

b. False

6) A principle of crisis and emergency risk communications is to express empathy for patients in crisis.

a. True

b. False

7) States responded during the COVID-19 pandemic by lifting mandatory collaborative practice agreements between physicians and NPs. This temporary ruling demonstrated the increased need for NPs’ skills during crisis, and provided evidence-based data to support arguments in favor of the permanent dissolution of such practice agreements.

a. True

b. False

8) NPs with leadership and managerial skills can help save lives during a disaster response. Initial training and retraining help to develop and maintain these skills.

a. True

b. False

9) Hospital surge capacity is a proactive measure hospitals can design to mitigate crisis and improve performance.

a. True

b. False

10) A curriculum designed to prepare NPs for disaster management would include making a hazard risk assessment.

a. True

b. False

Answer Sheet

The role of the Nurse Practitioner and emergency Preparedness

Note: 1.0 CH and 0.1 CEU for this program will be offered until January 30, 2026.

Please print legibly and verify that all information is correct.

First Name: MI: Last Name:

Street Address: City: State: ZIP Code:

Daytime Phone Number (Include area code):

Email:

Profession: Currently Licensed in NY State? Y / N (Circle one)

NYSNA Member # (if applicable): License #: License State:

ACTIVITY FEE: Free for NYSNA members/$10 nonmembers

PAYMENT METHOD

Check—payable to New York State Nurses Association (please include “Journal CE”on your check).

Credit Card: Mastercard Visa Discover American Express

Card Number: Expiration Date: / CVV#

Name: Signature: Date: / /

Please print your answers in the spaces provided below. There is only one answer for each question.

Please complete the answer sheet above and course evaluation form on reverse. Submit both the answer sheet and course evaluation form along with the activity fee for processing. Mail to: NYSNA, attn. Nursing Education and Practice Dept. 131 West 33rd Street, 4th Floor, New York, NY 10001 Or fax to: 212-785-0429

learning Activity evaluation

The role of the Nurse Practitioner and emergency Preparedness

Please use the following scale to rate statements 1–7 below: Poor Fair Good Very Good Excellent

1. The content fulfills the overall purpose of the CE Activity.

2. The content fulfills each of the CE Activity objectives.

3. The CE Activity subject matter is current and accurate.

4. The material presented is clear and understandable.

5. The teaching/learning method is effective.

6. The test is clear and the answers are appropriately covered in the CE Activity.

7. How would you rate this CE Activity overall?

8. Time to complete the entire CE Activity and the test? ____ Hours (enter 0–99) _____ Minutes (enter 0–59)

9. Was this course fair, balanced, and free of commercial bias? Yes / No (Circle one)

10. Comments:

11. Do you have any suggestions about how we can improve this CE Activity?

THE JOURNAL

of the New York State Nurses Association

Call for Papers

The Journal of the New York State Nurses Association is currently seeking papers.

Authors are invited to submit scholarly papers, research studies, brief reports on clinical or educational innovations, and articles of opinion on subjects important to registered nurses. Of particular interest are papers addressing direct care issues. New authors and student authors are encouraged to submit manuscripts for publication.

Information for Authors

For author’s guidelines and submission deadlines, go to the publications area of www.nysna.org or write to journal@nysna.org

Call for editorial board members

Help Promote Nursing research

The Journal of the New York State Nurses Association is currently seeking candidates interested in becoming members of the publication’s Editorial Board.

Members of the Editorial Board are appointed by the NYSNA Board of Directors and serve one 6-year term. They are responsible for guiding the overall editorial direction of The Journal and assuring that the published manuscripts meet appropriate standards through blinded peer review. Prospective Editorial Board members should be previously published and hold an advanced nursing degree; candidates must also be current members of NYSNA. For more information or to request a nomination form, write to journal@nysna.org