key: cord-0836847-cp4hqdp3 authors: Myers, Carole R.; Muñoz, Lauren Renee; Stansberry, Tracey; Schorn, Mavis; Kleinpell, Ruth; Likes, Wendy title: COVID‐19 effects on practice: Perspectives of Tennessee APRNs date: 2022-02-21 journal: Nurs Forum DOI: 10.1111/nuf.12711 sha: b8dbdd0f7f7a00deeb7b59fac5c182d46f5a9473 doc_id: 836847 cord_uid: cp4hqdp3 BACKGROUND: In response to the COVID‐19 pandemic, Tennessee's Governor issued executive orders temporarily suspending certain practice restrictions on advanced practice registered nurses (APRN), which expired after 2 months as the pandemic worsened. PURPOSE: This purpose of this qualitative study was to analyze APRN interview data to evaluate how prepandemic APRN practice barriers, executive orders, and the pandemic affected APRN practice in Tennessee. METHODS: Fifteen Tennessee APRNs who completed the National APRN Practice and Pandemic study also completed follow‐up interviews via a HIPAA‐compliant Zoom platform. Given the unprecedented circumstances associated with the COVID‐19 pandemic, we conducted a qualitative descriptive study seeking descriptions and unique perspectives of Tennessee APRNs. Consistent with qualitative study design, we conducted an atheoretical study that featured interviews, purposeful sampling with maximum variation sampling, and content analysis. RESULTS: The major themes were practice changes, impact of executive orders, and ongoing care barriers. The data revealed that patients, APRNs, and other health care providers were strained in new and profound ways during the pandemic. An underlying theme was Tennessee APRNs' frustration with continued regulatory and other practice barriers despite their state's health and health care disparities and under resourced health care system. CONCLUSION: These findings indicate the need to improve care access and health outcomes, advocate for full practice authority for APRNs, support telehealth expansion, address transportation deficiencies, and respond to the pandemic‐precipitated mental health crisis. APRNs-including NPs, certified nurse-midwives (CNMs), certified registered nurse anesthetists, and clinical nurse specialists-are credentialed by national organizations and licensed by individual states. State practice authority laws can be classified into three categories: full practice authority (FPA), reduced practice authority, and restricted practice authority. These categories regulate APRNs' ability to function independently in the four APRN practice domains: evaluation, diagnosis, diagnostic test ordering and interpretation, and treatment initiation and management. 5 In FPA, APRN practice is not subject to physician supervision or collaboration. Reduced and restricted practice authority denotes varying degrees of physician collaboration or supervision in at least one practice domain. 5 In early 2020, 22 states had FPA, 16 had reduced practice authority, and 12 (including Tennessee) had restricted practice authority. 6, 7 Physician organizations' strong opposition to FPA continued during the pandemic. [8] [9] [10] The American Medical Association urged the Centers for Medicare and Medicaid Services (CMS) to resume practice restrictions rather than extending temporary waivers. 11 Meanwhile, state medical associations encouraged governors to resume practice restrictions once executive orders expired. 12 No exception to this trend, the Tennessee Medical Association (TMA) expressed disapproval of practice restriction suspension and pressured the Governor not to renew it. 13 TMA's lobbying efforts ensured that Tennessee APRNs experienced the executive orders' benefits for less than 2 months. When Tennessee's governor issued the executive orders removing APRN practice revisions, the TNA approached nurse researchers at three universities and asked them to conduct this study. Consequently, this study had the following aims: Evaluate the impact of APRN practice barriers before the pandemic and document how the pandemic and Governor Lee's executive orders affected APRN practice. 14 National APRN leaders and various state and national organizations also expressed interest in the study, prompting the researchers to administer the survey nationally. Ultimately, the study data were collected from two sources: a nationally distributed survey and subsequent interviews with Tennessee APRNs. This article describes the findings from the Tennessee APRN interviews. Fifteen Tennessee APRNs who completed the National APRN Practice and Pandemic study also completed follow-up interviews via a HIPAA-compliant Zoom platform. Given the unprecedented circumstances associated with the COVID-19 pandemic, we conducted a qualitative descriptive study 15 seeking descriptions and unique perspectives of Tennessee APRNs. Consistent with qualitative study design, we conducted an atheoretical study that featured interviews, purposeful sampling with maximum variation sampling, and content analysis. 16 14 The Tennessee APRNs who took the survey could volunteer to be interviewed by clicking on a link to send a secure email. Potential participants then were emailed a secure link to schedule a 60-min Zoom interview. Three study team members completed the Collaborative Institutional Training Initiative program and signed a confidentiality pledge before conducting interviews using a HIPAA-compliant Zoom platform. One of three study members conducted each of the interviews. Before the interview, each of the 15 participants recorded a verbal consent to participate in the study and be recorded. Semi-structured interview questions were based on preliminary survey results. Interviews were closed for several reasons, including: we met our goal of conducting at least 12 interviews, consistent with an oft-cited recommendation 17 ; the study was about specific topics in a relatively homogeneous population where semi-structured interview questions and subsequently codes aligned with study aims 18 ; we conducted interviews for almost 4 months; the primary survey which as a prerequisite for the interviews closed; and we ceased to be contacted by any additional interview volunteers. All volunteers who conducted us and followed-through with an interview appointment were interviewed. When interviews were complete, the interviewers dictated their field notes on the Zoom recording. The Zoom m4a (audio) files then were uploaded into a HIPPA-compliant secure folder and transcribed. The research team used conventional (inductive) content analysis 19 that began with multiple transcript read-throughs to allow them to get a holistic sense of each interview. Three researchers created preliminary codes (nodes) in NVivo and sorted quotes into these codes. The researchers met to discuss first-pass coding and establish a new threelayer coding structure, as the initial coding was deemed too interpretive, inconsistent with the descriptive methodology employed. Next, the researchers re-coded the transcripts based on the new coding structure. When the second coding round was complete, the researchers merged their NVivo files and met to identify overarching themes. Each researcher reviewed and refined one theme, with theme definitions and exemplary quotes discussed at a later meeting. Since analysis was descriptive rather than interpretive and the new codes aligned with the study aims and interview questions, the researchers readily reached agreement on the final themes and the data they encompassed. Member checking was not employed, consistent with, 20 who has noted that since the researchers of a study are trained in data analysis, they, not the participants, are responsible for the findings. Table 1 contains participant demographic information. The semistructured interview protocol included questions from three topics: pandemic impact on practice, practice barriers, and executive order impact on practice. The participants indicated that the pandemic precipitated major changes in APRN practice in care delivery, patient volume and mix, patient circumstances and needs, and resource availability. The pandemic required APRNs to continue their existing tasks while responding to the new pandemic related demands: administering COVID-19 tests while adopting new protocols for personal protective equipment (PPE), increased patient flow, and higher patient volumes. One significant practice change was the telehealth expansion facilitated by CMS regulatory changes 21 Similarly, another PMHNP stated, "We do need to be able to see our patients every so often… for me to feel… I'm giving them the service they need and so I can do a good assessment and figure out… our next step." Many participants reported a decline in patient volume during the first 6 months of the pandemic. An adult gerontology NP (AGNP) relayed, "They shut down our clinic completely to any appointments whatsoever." An FNP said, "Our volume… dropped by about 50%." In contrast, some practices saw increased patient volume for pandemic related services, including testing. An AGNP from a rural county health department mentioned that when the National Guard members deployed to help administer 200-300 COVID-19 tests per day were redeployed, the existing staff had to cover the testing in addition to usual clinical services. Patient needs increased during the pandemic, due in part to other pandemic effects (job loss) and longstanding issues (transportation). and see them and they can see you… but you can't talk through the glass and the mask… I just… sense that they feel isolated and alone, more so than normally. One unexpected finding was that 14 of 15 participants reported mental health issues among their patients, despite the lack of direct questions about this topic. The lack of PPE was a major concern among some participants Although only four participants were PMHNPs and we did not ask direct questions about the pandemic's mental health effects, widespread concern for patient and provider mental health was evident in the data. Fourteen of 15 APRNs described mental health challenges experienced by their patients, and 13 referenced provider mental health. APRNs were particularly concerned about the effects of social isolation, new and worsening psychiatric complaints, and feeling burned out at work. With no hospital visitors allowed and health care professionals minimizing patient contact, an acute care NP expressed concern over the isolation that COVID inpatients experienced. He said, "… while iPads with FaceTime to family members and to nurses through the door is a way to build connection, I don't think it's as authentic and genuine as actual human interaction with someone two feet away from you." One FNP reported seeing more patients with suicidal ideation-both adults and children-during the first few months of the pandemic than in her entire 10 years of practice. Health care professionals' mental health also suffered during the pandemic. A PMHNP with 24 years of experience reported seeing an influx of physicians and nurses seeking mental health services because of the amount of death they were seeing as they cared for COVID patients. Another PMHNP said she and others in her practice were "overwhelmed" from longer hours and larger caseloads. Her days seemed to be full of patients in crisis situations, making her feel like she was providing "back-to-back trauma care." Interviews with 15 Tennessee APRNs conducted July through September 2020 painted a portrait of patients, APRNs, other health care professionals, and a health care system strained in new and profound ways. While executive orders to mobilize health care professionals were appropriate for the severity of the crisis, they were not in effect long enough to prompt widespread or consistent adoption, and expired before the surge in pandemic case numbers, hospitalizations, and deaths experienced in late 2020 and early 2021. Unfortunately, the executive orders may not have been renewed for political reasons, as the TMA formally opposed lifting any APRN practice restrictions. Furthermore, the TMA has dismissed overwhelming evidence of the patient benefits seen in states that have removed APRN practice restrictions. One underlying theme was participants' frustration with regulatory and other practice barriers. An APRN practice barrier is defined as anything that impedes, blocks, or prevents APRNs from delivering care to the fullest extent of their education and training. 7 Some barriers are functional: the fragmented health care system, workforce recruitment challenges, and high turnover rates. 7 The case for FPA should emphasize how its economic benefits also confer health benefits and promote health equity. To maximize health care access, the telehealth expansion begun during the pandemic should continue. Adequate reimbursement, mental health services reimbursement parity, and an ongoing favorable regulatory environment are essential for robust telehealth use. A Tennessee law passed in a special session in 2020 extended state telehealth permissions and reimbursement parity. 36 These permissions should be maintained and extended to currently excluded APRNs. Even before the pandemic, the American Association of Nurse Practitioners officially stated that telehealth services "are not a separate specialty or the practice of any one profession," and "health care provided via technology should be recognized, regulated, and reimbursed on parity with the same services delivered in person." 37 Still, APRNs must receive suitable training, such as immersive simulation, to effectively provide telehealth services. 38 Broadband access is another key issue in telehealth promotion. Because approximately 492,000 Tennesseans, primarily in rural areas, lack access to affordable broadband services, 38 efforts to develop broadband infrastructure in underserved areas should be prioritized. An assessment of patient-centered options to improve scheduling flexibility and transportation availability in rural areas is needed, including services offered by Tennessee human resources agencies. Same-day and other scheduling options and accommodations for multiple stops should be offered. Providing comprehensive same-day services for various specialists and needed labs and diagnostic tests could increase efficiency and decrease transportation burdens. Opportunities to support public, private, and public-private partnerships to provide needed transportation for rural residents also are needed. The results of this qualitative analysis of interview data from Tennessee APRNs indicated that the pandemic decreased care access at a time of increased need. While an executive order removed some APRN practice restrictions, its 2-month duration was insufficient to implement or evaluate any meaningful changes. It is incongruent that APRNs in Tennessee were considered important assets in the initial pandemic response, but within a short period and before the pandemic began to wane, the less restrictive practice regulations were abandoned. Surprisingly, the resistance to easing APRN practice barriers increased in Tennessee during the pandemic. Despite this resistance, now is the time for nurses to claim their role in expanding Tennesseans' access to high quality, holistic, and patient-centered health care. The data that support the findings of this study are available from the corresponding author upon reasonable request. An order suspending provisions of certain statutes and rules and taking other necessary measures in order to facilitate the treatment and containment of COVID-19 An order amending executive order no. 15 and taking other necessary measures to facilitate the treatment and containment of COVID-19 Farmer BTN nurse practitioners return to pre-pandemic paperwork as emergency rules expire COVID-19 State emergency response: Temporarily suspended and waived practice agreement requirements American Association of Nurse Practitioners (AANP) American Association of Nurse Practitioners (AANP) The future of nursing: Leading change, advancing health. The National Academies Press APRNs: overcoming scope of practice barriers Lardieri A Amid provider shortage, California doctors oppose expanding nurse practitioner abilities Updates on the quest for full practice authority t permanently relax rules on physician oversight Raderstorf T Americans need nurses and demand more access, not less: Physician groups say no TMA raises concerns over collaboration rules changes in Executive Order #28 Impact of COVID-19 pandemic on APRN practice: results from a national survey What's in a name? Qualitative description revisited Characteristics of qualitative descriptive studies: a systemic review How many interviews are enough? An experiment with data saturation & variability Three approaches to qualitative content analysis Critical analysis of strategies for determining rigor in qualitative inquiry Medicare telemedicine health care provider fact sheet An order suspending provisions of certain statutes and rules and taking other necessary measures in order to facilitate the treatment and containment of COVID-19 The macroeconomic benefits of Tennessee APRNs having full practice authority Certified nurse practitioners--Drug prescriptions--Temporary certificate--Rules and regulations General Provisions United Health Foundation (UHF) Physician supply and distribution in Tennessee Urban percentage of the population for states The gap between demand and physician supply reports/policy-perspectives-competition-regulation-advancedpractice-nurses Massachusetts 23rd state to grant nurse practitioners full practice authority Massachusetts journey to full practice authority for nurse practitioners /home/my-practice/nurse-practitioner-careerresources/massachusetts-full-practice-authority-nurse-practitioners/ Published Telehealth improves access to treatment for substance use disorders Broadband access as a public health issue: the role of law in expanding broadband access & connecting underserved communities to better health outcomes Wicklund E Tennessee lawmakers pass new telehealth coverage law -with limits American Association of Nurse Practitioners (AANP) Telehealth: preparing advanced practice nurses to address healthcare needs in rural and underserved populations COVID-19 Effects on Practice: perspectives of Tennessee APRNs