Dr Reid-Ponte: Who influenced your decision to pursue your current program of research?
Dr Poghosyan: I was a nurse instructor in Armenia, where I grew up and where there were no graduate nursing programs, so I pursued a master's in public health (MPH) degree at the American University of Armenia (AUA). I've always been interested in improving the health of populations and receiving MPH was the best way to accomplish that in Armenia. In that timeframe, I was introduced to Linda Aiken, PhD, RN, FAAN, from the University of Pennsylvania, who, along with my professors at AUA-Susan McMarlin and Michael Thompson-encouraged me to pursue my doctoral work at the University of Pennsylvania, which I completed in 2008. I am currently a tenured associate professor at Columbia University, where I teach graduate and PhD students and conduct research with a team of researchers both from my own institution as well as from other institutions across the nation who are interested in assuring that nurse practitioners (NPs) are fully utilized as independent providers of primary care.
Dr Reid-Ponte: Could you describe a major challenge facing healthcare organizations and the general public today related to your program of research?
Dr Poghosyan: There are not enough primary care providers in the US. I am committed to assuring that people have access to primary care, and NP workforce is a key solution to that. The NP workforce will soon almost double. Between 2013 and 2025, the number of NPs will increase by 93%, and the majority of NPs will be involved in delivering primary care. However, we need to learn how to optimally utilize NPs in primary care. Findings from my studies suggest a number of challenges, making it more difficult for NPs to practice to their full extent. First, of course, the state scope of practice regulations governing NP practice vary across the country with some states posing unnecessary restrictions on NP practice. There is strong advocacy in those states to change the laws governing NP practice. However, even in states where full practice laws do exist some NPs are not managing panels of patients but rather being used in urgent care practice models where long-term patient/provider relationships are not part of the structure. Research is clear about the importance of care continuity for positive patient outcomes and NPs should be able provide continuous primary care to their own panel of patients over time to assure best outcomes.
The 2nd challenge is that even when the states expand the scope of practice laws, some organizations and or practice groups do not change their bylaws to allow full practice. Thus, the organizations are not taking advantage of the full capabilities of the NP.
The 3rd challenge that we have discovered is that in practices and organizations don't include NPs in their governance structures. Whereas MDs and registered nurses (RNs) are represented by medical and nursing directors in organizational governance, NPs are often are not represented.
More and more organizations are developing "Chief NP" or "NP Director" roles. The individuals in these roles are accountable for assuring standards, policies and practice structures are consistent with other providers, and they represent the interests of the NP workforce. We have also found that NPs often are not able to participate in healthcare organization governance structures because they have none or very limited nonclinic working hours. They are seeing patients every hour of the week. Additionally, many NPs are not provided with the same clinic support as MDs receive to assure they are practicing at the top of their license at all times, such as medical assistants, RNs and others to support their practice. NPs are therefore hindered by activities that don't require an NP to perform (taking blood pressures, weights, straightforward information gathering) and therefore their productivity is lower. Another structural issue we have found is that NPs often have 1 exam room, whereas other clinicians have 2, which prohibits effective, efficient, and optimal patient flow. These challenges need to be ameliorated to assure that healthcare organizations optimize NP role.
We have developed a tool, the NP-PCOQ-Nurse Practitioner Primary Care Organizational Climate Questionnaire,1 which measures organizational climate in primary care settings. The tool asks NPs to report certain work attributes that are present within their employment settings, such as the relationship they have with physicians or administrators, or support they receive for care delivery. The tool can be used to gather important information about NPs' organizations which can then help to create an environment conducive for productive practice.
Dr Reid-Ponte: How do you address the similarities and differences in the role of physician assistants (PAs) and NPs in your research?
Dr Poghosyan The competence, education, training and roles of NPs and PAs are distinctly different. So, in our research, we don't address the role of PAs and I don't believe we should combine these 2 different workforces together. They deliver care using a completely different model and focus and regulations that guide their practice are different, and both NP and PA workforce should be studied separately to produce evidence about how to best utilize both workforce within the healthcare system.
Dr Reid-Ponte: What are your thoughts about doctorate of nursing practice (DNP)-prepared NPs?
Dr Poghosyan: DNP programs are growing across the country, and we need to learn more about these programs and their impact on patient care and NP career trajectories. Terminal education is important for NPs as it has been important for other healthcare providers such as physicians, physical therapists, pharmacists, and soon, occupational therapists and certified registered nurse anesthetists. We need to continue promoting doctoral nursing education to achieve one of recommendations in the Future of Nursing report,2 regarding doubling the number of doctorally prepared nurses by 2020.
Dr Reid-Ponte: What would you like JONA readers to know that they may not already know?
Dr Poghosyan: NPs are essential to the high-quality, efficient care for patients and their families with chronic disease. NPs and nurse leaders need to work together to assure that consumers have access the NPs who are fully supported within their organizations with practices that are thriving and highly productive. Some of the work that needs to be done is policy related within organizations and states. Both NPs and nurse leaders must be courageous and informed about the evidence and how to use it to bring about needed change at all levels. This matters for every patient in the country and will also have influence over time with global health challenges.
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