Advanced Independent Nursing (AIN): An Improved Model For Independent Nursing

Background

Discuss an improved model for Independent Nursing hereby referred to  as Advanced Independent Nursing AIN.

Advanced Nursing Practice includes various roles such as nursing practitioner, nurse anesthetist, clinical nursing specialist, and nursing midwives. Nursing practitioner is a form of registered nursing practice, which includes professionals with a nursing graduation degree and a certification on a specialty subject which shows a specific expertise of the nurse. Independent Nursing Practitioner is a type of Nursing Practitioner, who are capable of conducting theory practice independent of the doctor’s and GP’s supervision (Rigolosi & Salmond, 2014; Antohe et al., 2016). This is a rapidly growing profession, which allows the providence of care for the patients across various care settings and can provide different types of care for the patients (such as long term care, palliative care, acute care, chronic care, specialty care, primary care and also provide referrals for other healthcare services (Hamric et al., 2013; MacPhee & Borram, 2012). The functions of the INP are ever diversifying, and require the nurses to have special skills and competencies in order to deal with them. This profession can help to develop access to care for many individuals, and also through the objectives of the profession focus on the overall health and well being of the patient. Models on INP can inform how the care can be delivered by Independent nurses, and how they can be implemented in real life to ensure the wellbeing of the clients and patients.

The purpose of this report is to discuss an improved model for Independent Nursing hereby referred to  as Advanced Independent Nursing AIN, identifying the various strategies and types of care that is provided by the independent nurses and also to identify the specific enablers and barriers faced by the profession in order to understand how they might be overcome. Similarly, strategies for implementation of Advanced Independent Nursing Practice and evaluation of the care provided are also outlined in the report.

Independent Nursing Practice (INP) can be understood as a form of nursing, or a speciality of registered nurses, where, the nurses are able to provide professional nursing services as a business proprietor involving direct providence of care to the patients, and also involve in research, education, consultation and administration (ipnig.ca, 2018; Rigolosi & Salmond, 2014; Antohe et al., 2016). The practice allows the nurses to work independently of general practitioners (GP), and also enable working in collaboration with them to provide care for the patient. INP can independently (that is without the need of GP supervision) prescribe medications (Rigolosi & Salmond, 2014). The INP can function as a small and private business, and require the nurses to travel a lot, in order to provide care at different client places and locations and in different types of care settings (Hamric et al., 2013). These can include: like non aged care centre, home health care centre, primary care centres, long term care centre, rehabilitation centre and counselling centre (ukhealthcare.uky.edu, 2018). Due to this, Independent Nursing Professionals need to be highly mobile, and exhibit significant amount of flexibility in order to provide care to patients across various locations and different care settings, providing a range of care to different clients (Buppert, 2014). In home setup, the INP can provide a range of non acute care such as monitoring of blood pressure, blood glucose, blood clotting, physical and mental health status, regular health checkups, wound care, continence care, helping with medications as well as providing referrals to other services (nursingmidwiferyboard.gov.au, 2018; Nursing.upenn.edu, 2018). AINP would have the same characteristics of the INP and incorporate improvements across various aspects. First   some of the aspects about the INP must be discussed, which shall be incorporated in the AINP model.

Overview of the NP Model/ Service Improvement Plan

The INP can be done independently of GP, they can provide medical care without the physician’s oversight, and can perform health assessment, diagnosis and interpretation of the diagnosis and prescribe medicines independently, which can be effective in various types of settings such as ambulatory care, acute care and long term care (Moran et al., 2016; Halcomb et al. 2014). The specialities of the INP also helps them to function as providers of both primary as well as speciality care, and enable them to teat both acute and chronic conditions (Anderson, 2017; Kilpatrick et al. 2013). INP can also act as health educators, counsellors and leaders in healthcare (Billings & Halstead, 2015). Clinical and Administrative leadership allows the Independent Nursing Practitioners to develop plans and programs for care, as well as influence other healthcare nurse in developing their skills and competencies (Grossman & Valiga, 2016). As educators, the INP can also help to develop the understanding of the disease, by educating the patients and their care givers, which can help to improve the care (Billings & Halstead, 2015). As social support and advocates, the INP can also ensure the overall wellbeing, and assist in the providence of uninterrupted care (especially for long term and palliative care) and improve access to healthcare services (by providing care at client’s home settings or providing referrals as and when needed) (Council, 2013). The aspects of the INP will be incorporated in the proposed model of AINP.

The proposed model for AINP addresses the various types of care that can be provided by an Advanced Independent Nursing Practitioner (AINP) as well as the different strategies that can be used to improve care for the clients using the AINP care model:

Primary Care: As primary care professional, AINP can function as a GP. This means, that AINP can order and/or perform health assessment, diagnosis and interpretation of diagnostic test or laboratory investigation reports, prescribe medications, provide treatment for acute and chronic conditions, supervise other healthcare workers and provide referrals to hospital or other medical services, which is the case with INP (Yee et al., 2013; Poghosyan et al. 2013).

Speciality Care: As a speciality care provider, AINP is able to provide specialist medical services, often with collaboration with other healthcare professionals and services. The different types of services AINP can provide as a part of speciality care includes: perfusion, Intraoperative care, neuromonitoring services, and deep brain stimulation. Sterile processing of medical equipments, medical and clinical consultation, surgical assist service, and support /assist clinical decision making, as is outlined in the functions of the INP (Raftery, 2013; Dougherty & Lister, 2015)

Types of Care

Home Health Care: In a residential care setup, the AINP can provide home nursing service, sub acute care, home therapy, long term care, rehabilitation service, counselling service. This can also help to improve access to care for many patients, who are unable to visit healthcare centres (Yee et al., 2013; Nettina & Nettina, 2013).

Health Literacy: AINP can also support health literacy, by acting as Educators, improving the understanding of the disease, and strategies of care for both the patients and their care givers. This can also ensure the patients and their carers are able to make informed and appropriate healthcare decisions and healthy lifestyle choices (Cafiero, 2013; Johnson, 2014).

Counselling: The AINP can also provide counselling service for different types of mental health conditions (Dougherty & Lister, 2015).

The different strategies for providing and improving care in the AINP model include:

1. Ensuring that the nursing professional focuses on understanding the experiences of the patient, as a central part of the care and foster the development of a therapeutic relation between the nurse and the patient/client
2. Assisting the planning and development of complex care for the patients or clients, which can include multispecialty care
3. Support the development and maintenance of a partnership network, comprising of various healthcare and support professionals from different specializations or from different domains.
4. Foster a value based care approach
5. Utilising the existing support framework for healthcare and strategic enablers to provide and improve care
6. Develop health literacy among the patients and their care givers
7. Increasing access to healthcare services, by providing care directly to the patients at various client setups
8. Implementing various programs for health advocacy, health promotion and health improvement among target populations or client groups.

(centralhealth.net, 2018)

The key enablers of AINP are factors such as information technology, service line operating model, strategy implementation, business planning as well as marketing and branding. Information Technology can play a vital role in the improvement of the information flow/information transfer and communication between the healthcare professionals (such as nurses, clinical staff, care and support workers along with the patients and their caregivers) (Bodendorf, 2013). Implementation of Information technology can also help to integrate patient health records in a better, safer and more effective manner, and in format that can be easily shared with other healthcare professionals when needed (Kellermann & Jones, 2015). This can also help to reduce paper works, prevent redundant or incorrect entries (by automating the documentation or recording processes) and improve both the safety and quality of care. Information technology can also help to support health education and reduce medical errors, and thus ensure the wellbeing of the clients (Middleton et al., 2013). The service line operating model can be that of a small business, where the AINP can function as a proprietor in healthcare, working independent but in collaboration with GP. The operating model can also include functions of INP as the innovator (providing high quality care and better patient experiences), diversifier (increasing the strengths and capabilities of the practitioner and thus the individual nurses to address new business opportunities and address gaps in the existing care system), aggregator (developing the process of analysing sustainable cost advantage using actual and virtual scales for different services) and health manager (fostering the usage of clinical and technological expertise to improve health, manage costs and improve care affectivity and efficiency (deloitte.com, 2018; nursinglibrary.org, 2018). Strategy Implementation can include the strategies of care identified above, which can help to improve care for the clients and patients, and can thus support the INP profession (cno.org, 2018). The Business Planning similarly will be that of a small business, with nurse as an entrepreneur or proprietor. This also involves the professions to be mobile and flexible in order to accommodate the treatment in various setups, as per the convenience of the clients (nurse.org.nz, 2018; nursing.utk.edu, 2018). Effective business planning can also help the professionals to effectively structure the practice, and plan future development and growth in the industry (cno.org, 2018). Development in the practice and business can also occur through effective marketing and branding of the service or provider by increasing the presence of the AINP in healthcare setups, promoting independent nursing practitioners and increasing the awareness of the patients and caregivers of the practice of AINP. These key enablers can be strategic to allow the development and growth of the practice (cno.org, 2018).

Strategies for Care

Different barriers exist in the AINP which challenges the provision of care to the clients, such as opposition from GP, challenges to get proper funding, shortage of experienced and capable workforce and use of technology and equipments.

According to Hain and Fleck (2014), the AINP faces opposition from many GP, as they do not support the practice of nursing independent of GP. The opposition is mainly because of certain factors such as: perceptions by several doctors that the independent nursing can affect their profession by taking away easy cases, or that increase in the diversity of care provided by AINP can lead to the doctors losing their skills in those aspects, giving INP an edge over them. Also, significant concerns exist in the medical community regarding the skills and competencies possessed by the independent nurses, which can allow them to work independent of GP. The concern lies in the perception that only the doctors have the training, skills and intellect to perform assessment, diagnosis, and treatment for different diseases, due to their extensive training needed to quality them as doctors. In comparison, the training given to nurses does not prepare them for the role of a General Practitioner. Many doctors believe that the nurses are either too inexperienced or might have too much confidence, which can affect the treatment of the patients (Kleinpell et al., 2014).

Funding is another significant barrier to AINP, since the practitioners have to sustain several different expenses on their own (being an independent professional) such as loss of pay during extensive travelling, time constraint, covering the costs of equipments and information technology, limited support system for AINP, lack of a sustainable source of income (since the nurses might just be dealing with one case after the other). Costs are also associated with the marketing and branding of the profession, to increase the awareness of the profession in the target crowd. With the lack of proper funding system available for AINP, covering all these expenses independently can be a challenge for an independent Nursing Practitioner (Hain and Fleck, 2014).

Also, a lack of skilled workforce in the profession results in the existing independent nurses being faced with an increased demand for case. This is also a significant challenge, since it makes the provision of care for everyone a much difficult task. The practice requires skills and clinical competencies over a wide range of domains, which allows the nurses to provide care in different forms, in different setups and circumstances. This implies the necessity of a skilled workforce. Some authors have claimed that the existing nursing training is not completely capable to address such needs (Hain and Fleck, 2014).

Implementing AINP in the selected context requires addressing and overcoming the different challenges associated with the practice, as well as developing the key strengths and enablers of the process. The challenges related to the concern over AINP regarding their independent practice can, and getting support from GP or other healthcare professionals can be reduced through the demonstration of efficiency and competency, autonomy and career development in the profession, as well as through the implementation of good clinical skills, interpersonal skills and managerial skills, which can help the practitioner to successfully integrate competencies in clinical and professional skills with critical thinking and managerial skills (Chinn & Kramer, 2013; Parahoo, 2014). Also, developing positive relations with other healthcare professionals, building trust, and proper communication between the professionals, having a strategic leadership and mentorship can also help the development of working relations with doctors, help to instil their trust in AINP, and thus help to overcome the resistance to the practice by other healthcare professionals (Butterworth & Faugier, 2013). Challenges related to the lack of support and infrastructure of independent nurses can also be addressed by the inclusion of strong system of governance, ensuring the practice has sufficient clarity related to the scope of support, developing organizational resources, which can support independent nursing profession (Hain & Fleck, 2014). Organizational resources can also help to address the challenges related to the expenses that are insured by the INP during the providence of care. Provision of adequate resources to cover the expenses of travelling, implementing information technology, employing skilled workers and maintaining the practice independently can also help to develop sustainability in the profession (Yeager et al., 2014).

Implementation strategies can also focus on the strengthening of the usage of Information Technology to facilitate communication between the healthcare professionals. This can also help for centralized and easy management of patient information, and prevent manual errors in documentation process. The service line operating model which is based on a small business model also provides information on the implementation strategy, which can ensure that the nurse can function as an innovator, diversifier, aggregator and health manager. Improving these aspects can help to strengthen the profession by improving the skills and competencies of the independent nurses, enable them to act as leaders, educators and researchers and perform administrative duties in healthcare too. Improving communication strategies can also be a significant step towards successful collaboration with both the clients and patients (and thus foster the development of a therapeutic relation) and with other healthcare professionals (thereby supporting the development of a multidisciplinary healthcare team in the form of a partnership network). The centrality of patient’s experiences can also be pivotal to develop a patient centric care, and thus foster value based care (centralhealth.net, 2018).

In nursing practice, the process of evaluating service delivery plays a crucial role, which helps in the analysis of the nursing practice and service delivery model, and helps to identify the strengths, limitations and potential scopes for improvement. It is therefore important that strategies for evaluation of AINP must exist in order to ascertain its efficacy and affectivity and to understand where her further improvements might be needed in the service delivery model or practice. Evaluation also helps to determine improvement in the well being of the client, determine if the expected outcomes are achieved and thus if the care was successful (Keating, 2014; Posavac, 2015). The evaluation phase can be comprised of the following activities such as: identification of the standards and criterion for evaluation, collection of the evaluated data, interpreting and summarising the findings from the data, documenting the findings and revise care plan if needed, based on the findings (Ozcan, 2014).

To identify the criteria and standards for evaluation, the nurses must first know what to look for (like specific symptoms or outcomes). Developing an understanding towards the goals of the client and their expected outcomes can provide the criterion of the evaluation process. For the collection of the data, the response of the client to the care provided can be collected through the techniques of health assessments (like discussing how the client feels, observing the client’s skills, and assessments of the health condition of the client). This evaluation can be performed at the time of care during the analysis of the status and progress of the client. Hence both subjective and objective data needs to be collected and recorded accurately. For the interpretation and preparing the summary of findings, the nurses can utilize research based evidences to make decisions related to the condition of the client, and develop clinical decisions, match the results from the patient evaluation with the expected outcomes identified from the evidence base and best practice guidelines in order to understand if there is any improvement in client condition (Moule et al., 2016). Documentation of the findings includes nursing notes, assessment sheets and clinical data, which can inform about the present condition of the patient, the clinical and medical history and progress towards the expected outcomes (Halvorsen et al., 2016). The Care Plan Revision is done after the evaluation of the expected outcomes which can show if the objectives have been met or not. Based on which any changes in the care plan can be made (Adib-Hajbaghery & Safa, 2013; da Costa, 2017).

Evaluation can be performed using the following steps: step 1: information related to the desired outcomes is collected. Step 2: Patient data is compared with the desired outcomes. Step 3: determining the activities needed to achieve the outcomes. Step 4: Understanding the problem status and step 5: implementing the findings from step 4 to understand whether to continue, modify or terminate the care (Doengesn et al., 2016).

Conclusion:

The advanced independent Nursing Profession can allow the nurse to work independent of the doctors and GP, and provide care for clients in different care settings, and give care in various conditions. The profession requires the nurses to be very mobile (travelling extensively), show flexibility in practice (giving care in different client settings and for various conditions), exceptional clinical, medical and diagnostic skills (to deal with a range of different conditions), acting as health educators for clients and their caregivers and also acting as healthcare leaders and managers (developing care plans and strategies supporting other care workers, and influencing other to develop professional and clinical skills). The Advanced Independent nurse can provide primary care, specialty care, home care as well as health literacy and counseling services for clients. Moreover, AINP can also ensure development of patient centered care, helping the development of complex and specialty care, fostering the development of a multidisciplinary team and partnership network for the overall care of the client, develop communication with clients and with other care professionals, increase health literacy as well as improving access to care and advocating for the clients or client groups, representing their healthcare needs, and healthcare goals. However, the profession is met with several challenges such as opposition from doctors, time constraint, financial constraints and lack of proper infrastructure. Implementing the practice of AINP requires these challenges to be addressed and overcome (through financial support systems and infrastructure), and evaluation strategies be devised for analyzing the efficacy and affectivity of the care provided by the independent nurses, which can help to further improve the care provided.

References:

Adib-Hajbaghery, M., & Safa, A. (2013). Nurses' Evaluation of Their Use and Mastery in Health Assessment Skills: Selected Iran's Hospitals. Nursing and midwifery studies, 2(3), 39.

Anderson, H. (2017). Professional identity and the advanced nurse practitioner in primary care: A qualitative study (Doctoral dissertation, University of York).

Antohe, I., Riklikiene, O., Tichelaar, E., &Saarikoski, M. (2016). Clinical education and training of student nurses in four moderately new European Union countries: Assessment of students' satisfaction with the learning environment. Nurse education in practice, 17, 139-144.

Billings, D. M., & Halstead, J. A. (2015). Teaching in Nursing-E-Book: A Guide for Faculty. Elsevier Health Sciences.

Bodendorf, F. (2013). Information Technology in Healthcare.

Buppert, C. (2014). Nurse practitioner's business practice and legal guide. Jones & Bartlett Publishers.

Butterworth, T., & Faugier, J. (2013). Clinical supervision and mentorship in nursing. Springer.

Butterworth, T., & Faugier, J. (2013). Clinical supervision and mentorship in nursing. Springer.

Cafiero, M. (2013). Nurse practitioners' knowledge, experience, and intention to use health literacy strategies in clinical practice. Journal of health communication, 18(sup1), 70-81.

centralhealth.net. (2018). Central Health Strategic Plan. Centralhealth.net. Retrieved 3 March 2018, from https://www.centralhealth.net/wp-content/uploads/2014/08/FY14-16_StratPlan_FINAL.pdf

centralhealth.net. (2018). Central Health Strategic Plan. Centralhealth.net. Retrieved 3 March 2018, from https://www.centralhealth.net/wp-content/uploads/2014/08/FY14-16_StratPlan_FINAL.pdf

centralhealth.net. (2018). Strategic Plan - Central Health. Central Health. Retrieved 6 March 2018, from https://www.centralhealth.net/initiatives/strategic-plan/

Chinn, P. L., & Kramer, M. K. (2013). Integrated Theory & Knowledge Development in Nursing-E-Book. Elsevier Health Sciences.

Chinn, P. L., & Kramer, M. K. (2013). Integrated Theory & Knowledge Development in Nursing-E-Book. Elsevier Health Sciences.

cno.org, &. (2018). AJN, American Journal of Nursing. Retrieved from https://www.cno.org/globalassets/docs/prac/41011_fsindepprac.pdf

Council, S. A. N. (2013). Code of ethics for nursing practitioners in South Africa. Pretoria: South African Nursing Council, 3-5.

da Costa, T. D., Santos, V. E. P., Junior, M. A. F., Vitor, A. F., de Oliveira Salvador, P. T. C., & Alves, K. Y. A. (2017). Evaluation procedures in health: Perspective of nursing care in patient safety. Applied Nursing Research, 35, 71-76.

deloitte.com. (2018). Rethinking the Health System Operating Model. Retrieved from https://www2.deloitte.com/content/dam/Deloitte/us/Documents/life-sciences-health-care/us-lshc-systemness-part1-operating-model-122214.pdf

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nursing diagnosis manual: Planning, individualizing, and documenting client care. FA Davis.

Dougherty, L., & Lister, S. (Eds.). (2015). The Royal Marsden manual of clinical nursing procedures. John Wiley & Sons.

Dougherty, L., & Lister, S. (Eds.). (2015). The Royal Marsden manual of clinical nursing procedures. John Wiley & Sons.

Grossman, S., & Valiga, T. M. (2016). The new leadership challenge: Creating the future of nursing. FA Davis.

Hain, D., & Fleck, L. (2014). Barriers to NP Practice that Impact Healthcare Redesign. Nursingworld.org. Retrieved 3 March 2018, from https://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-19-2014/No2-May-2014/Barriers-to-NP-Practice.htm

Hain, D., & Fleck, L. (2014). Barriers to NP Practice that Impact Healthcare Redesign. Nursingworld.org. Retrieved 3 March 2018, from https://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-19-2014/No2-May-2014/Barriers-to-NP-Practice.htm

Halcomb, E. J., Salamonson, Y., Davidson, P. M., Kaur, R., & Young, S. A. (2014). The evolution of nursing in Australian general practice: a comparative analysis of workforce surveys ten years on. BMC family practice, 15(1), 52.

Halvorsen, K., Eide, H. K., Sortland, K., & Almendingen, K. (2016). Documentation and communication of nutritional care for elderly hospitalized patients: perspectives of nurses and undergraduate nurses in hospitals and nursing homes. BMC nursing, 15(1), 70.

Ipnig.ca. (2018). Independent Practice Nurses | Professional Practice. Retrieved from https://ipnig.ca/professionalpractice/profpractice.html

Ipnig.ca. (2018). Independent Practice Nurses | Professional Practice. Retrieved from https://ipnig.ca/professionalpractice/profpractice.html

Johnson, A. (2014). Health literacy, does it make a difference?. Australian Journal of Advanced Nursing, The, 31(3), 39.

Keating, S. B. (2014). Curriculum development and evaluation in nursing. Springer Publishing Company.

Kellermann, A. L., & Jones, S. S. (2013). What it will take to achieve the as-yet-unfulfilled promises of health information technology. Health affairs, 32(1), 63-68.

Kilpatrick, K., Lavoie?Tremblay, M., Lamothe, L., Ritchie, J. A., & Doran, D. (2013). Conceptual framework of acute care nurse practitioner role enactment, boundary work, and perceptions of team effectiveness. Journal of advanced nursing, 69(1), 205-217.

Kleinpell, R., Scanlon, A., Hibbert, D., Ganz, F., East, L., Fraser, D., ... & Beauchesne, M. (2014). Addressing issues impacting advanced nursing practice worldwide. Online journal of issues in nursing, 19(1).

Kleinpell, R., Scanlon, A., Hibbert, D., Ganz, F., East, L., Fraser, D., ... & Beauchesne, M. (2014). Addressing issues impacting advanced nursing practice worldwide. Online journal of issues in nursing, 19(1).

Middleton, B., Bloomrosen, M., Dente, M. A., Hashmat, B., Koppel, R., Overhage, J. M., ... & Zhang, J. (2013). Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA. Journal of the American Medical Informatics Association, 20(e1), e2-e8.

Moule, P., Aveyard, H., & Goodman, M. (2016). Nursing research: An introduction. Sage.

Nettina, S. M., Msn, A. B., & Nettina, S. M. (2013). Lippincott manual of nursing practice. Lippincott Williams & Wilkins.

nurse.org.nz. (2018). Business plan. Retrieved from https://www.nurse.org.nz/user/file/373/NPNZ%20Business%20case%203.pdf

nursing.utk.edu. (2018). Business Plan for Nurse Managed Primary Care Clinic University of Xxxxxxxx School of Nursing, RS-Xxxx and Xxxx Introduction. Retrieved from https://nursing.utk.edu/wp-content/uploads/sites/36/2017/02/business-plan-sample-2.pdf

nursinglibrary.org, R. (2018). The Service Line Model - A Novel Model for Delivering Medical-Surgical Nursing Services. Retrieved from https://www.nursinglibrary.org/vhl/bitstream/10755/621263/1/McClelland_81663.pdf

Ozcan, Y. A. (2014). Evaluation of Performance in Health Care. In Health Care Benchmarking and Performance Evaluation (pp. 3-14). Springer, Boston, MA.

Parahoo, K. (2014). Nursing research: principles, process and issues. Palgrave Macmillan.

Parahoo, K. (2014). Nursing research: principles, process and issues. Palgrave Macmillan.

Poghosyan, L., Nannini, A., Stone, P. W., & Smaldone, A. (2013). Nurse practitioner organizational climate in primary care settings: Implications for professional practice. Journal of Professional Nursing, 29(6), 338-349.

Posavac, E. J. (2015). Program evaluation: Methods and case studies. Routledge.

Raftery, C. (2013). Nurse practitioner succession planning: forward thinking or just an after-thought?. Australian Health Review, 37(5), 585-587.

Rigolosi, R., & Salmond, S. (2014). The journey to independent nurse practitioner practice. Journal Of The American Association Of Nurse Practitioners, 26(12), 649-657. https://dx.doi.org/10.1002/2327-6924.12130

Yeager, V. A., Menachemi, N., Savage, G. T., Ginter, P. M., Sen, B. P., & Beitsch, L. M. (2014). Using resource dependency theory to measure the environment in health care organizational studies: A systematic review of the literature. Health care management review, 39(1), 50-65.

Yeager, V. A., Menachemi, N., Savage, G. T., Ginter, P. M., Sen, B. P., & Beitsch, L. M. (2014). Using resource dependency theory to measure the environment in health care organizational studies: A systematic review of the literature. Health care management review, 39(1), 50-65.

Yee, T., Boukus, E., Cross, D., & Samuel, D. (2013). Primary care workforce shortages: Nurse practitioner scope-of-practice laws and payment policies. National Institute for Health Care Reform Research Brief, 13, 1-7.

Yee, T., Boukus, E., Cross, D., & Samuel, D. (2013). Primary care workforce shortages: Nurse practitioner scope-of-practice laws and payment policies. National Institute for Health Care Reform Research Brief, 13, 1-7