Novice Providers & Mortality

  1. "Patients cared for by physicians in their first year as hospitalists have worse 30-day and hospital mortality when compared with more experienced hospitalists. Hospitalists very early in their careers may benefit from additional support and reduced caseloads."

    Recently reported in JAMA was that the 30-day mortality rate for patients cared for by a physician hospitalist in their first year of practice was 10.51% compared to 9.97% for the second year of practice, and OR of 0.90. These rates stabilized after the second year of practice.

    It is a humbling statistic for all providers to consider mortality rates for care, and while this study addresses only our physician colleagues, the concern can easily be extrapolated to NP practice. It does raise the question of what the profession can do to help stabilize novice providers during their transition/role socialization especially given that while physicians have completed essentially 2-3+ years of supervised practice (residency) there are now states where this is not required of novice NPs.

    In light of these data, are there ways that active NPs can help address support novices in the first year of practice?

    One proposed solution is active mentorship that extends beyond formal training into clinical practice. Mentorship has been shown in the literature to be a significant factor in both in terms of role socialization and novice clinical practice. Should the impetus fall on the novice provider to establish one or more clinical mentors? Should it fall on NP programs to foster mentorship? Should it fall on the BON to require it int he first year of practice?

    Residency/fellowship programs are often suggested as well, however, if the physician residency program still result in a higher mortality in the first year of practice would these program do anything to combat that ultimate transition?

    Other thoughts?

    Hope there is a constructive discussion on the issue.

    Goodwin, J. S., Salameh, H., Zhou, J., Singh, S., Kuo, Y. F., & Nattinger, A. B. (2017). Association of Hospitalist Years of Experience With Mortality in the Hospitalized Medicare Population. JAMA internal medicine.
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    13 Comments

  3. by   traumaRUs
    In IL, our state's APRN organization has a structured mentorship program for new clinicians. Will be interesting to see data from this program
  4. by   Oldmahubbard
    Even where states require novice NP supervision or collaboration, in practice the oversight and mentor-ship is typically very superficial.

    It cannot be compared to medical residency and fellowship programs. Not even close.

    In NY, the collaboration consists of a review of a handful of charts. It can be done by email.

    No requirement that the collaborator ever see or examine any of the patients, or meet face to face with the novice NP.

    That being said, I had a death early on my career. Directly connected to medication I prescribed.

    It was totally unforeseeable. And very sobering.

    But it had not a thing to do with my inexperience.
  5. by   BCgradnurse
    I was fortunate to have had an assigned mentor during my first year of practice. All new practitioners, be they MD, NP, or PA were paired with an experienced provider. I think it made a positive difference in my confidence and competency. We met regularly, in addition to the several times a day "on the fly" conversations when I had questions. Our patient population was both medically and psycho-socially complex, and it was beneficial to have a mentor to bounce things off of and learn from.
  6. by   Oldmahubbard
    Quote from BCgradnurse
    I was fortunate to have had an assigned mentor during my first year of practice. All new practitioners, be they MD, NP, or PA were paired with an experienced provider. I think it made a positive difference in my confidence and competency. We met regularly, in addition to the several times a day "on the fly" conversations when I had questions. Our patient population was both medically and psycho-socially complex, and it was beneficial to have a mentor to bounce things off of and learn from.
    This is great, but it costs money. Time is money, without question. If the supervisor or mentor resents the role for any reason, it won't be of much help.

    I was also fortunate to have a couple of good mentors, and some horrible ones, who taught me just as much.
  7. by   BCgradnurse
    Quote from Oldmahubbard
    This is great, but it costs money. Time is money, without question. If the supervisor or mentor resents the role for any reason, it won't be of much help.

    I was also fortunate to have a couple of good mentors, and some horrible ones, who taught me just as much.
    I was at a FQHC that had lots of grants and we were all NHS scholars/loan repayers, so money was not an issue for the site. I can definitely see that it would be an issue for a practice that didn't have this kind of funding.
  8. by   juan de la cruz
    It's an interesting study. I've worked in various types of hospitals as a nurse and ACNP and there's certainly a degree of variation in the care hospitalist's bring in terms of knoweldge base and skills. I never saw the length of years as a hospitalist as a factor. In my unscientific/anecdotal assessment, I find those who did residencies in less selective programs and some IMG's being less competent. This is a distinction that wasn't illuminated in the study and is probably hard to to research in the first place.

    The article was right to point out that the transition phase from resident to new hospitalist needs to be investigated further to see what factors contributed to the results. It's hard to analyze the study as it relates to NP's who work as hospitalists as we practice in a range of models from close collaboration to supervision to full independence. Mentorship is always a good thing no matter what, but the quality of the mentorship experience will make a big difference.
  9. by   Oldmahubbard
    My opinion only, the IMG and other less selective programs, are lower quality candidates on multiple levels.

    I worked as an NP a few years ago with an American IMG.

    A superficially nice lady, but grossly non-impressive. To put it rather mildly.

    This woman was an MD, and on a regular basis, she openly and regularly stole employees' food out of the refrigerator.

    Apparently she thought people wouldn't know. Or she was just that entitled.

    After about 6 months, and multiple complaints, I finally approached this clueless female to inform her that her body order stunk to high heaven.

    She came to work every day smelling like a hyena cage.

    Sad to say, this person is probably somewhere in the greater NYC area, working as a "psychiatrist".

    My God, she is dumber than a box of rocks, but maybe she is still wearing the product I recommended.

    Secret deodorant.

    She also claimed to be a serious Christian.

    People are often not what they seem on paper.
  10. by   Medic/Nurse
    I'm confused. Genuinely.

    When I entered clinical practice as a paramedic 25 years ago, I was told that my patients would now be "writing my tuition check going forward", and the cost of that tuition was now going to be paid with their life if I really messed up - yep, that motivated me to WORK harder post licensure than in college then and later as a new RN and with every new role since. That tuition they may pay is a privilege, I take seriously and I give it everything I have.

    Yeah, I think that speech might apply here. Pass it on.

    When did clinical mentorship or high standards of clinical practice for any provider become a bad thing? Why would it be surprising that inexperienced providers with high case loads have worse outcomes?

    Any wheel you come up with will still need to be round to roll, eh?

    Since it is a life and death business (high stakes environment), why is that entry into clinical practice such a vicious environment that punishes unsuspecting patients and can literally kill them - pointlessly, needlessly.

    Do these patients gave a right to know how "new" their providers are? Would you want to know?

    Medical error is the 3rd leading cause of death.

    Overworked, under-supported is not a badge of honor.

    Some tuition really can be just too high.

  11. by   Knotanoonurse
    For NP's, CNMs, CRNAs, there needs to be further study re. Their background. I know those who have not practiced as a nurse perform"just as well" on a number of parameters as those previously working as RNs. However, I think more research is needed. It would be interesting to see some qualitative studies. What is the "experience" of these providers? How does it differ? I would suspect that NPs and CRNAs who had 5 years of acute experience may emotionally handle death and support families differently than those without that background. I know this is kind of off topic from the originally posting which is more about physicians and their diagnostic and treatment capabilities.
  12. by   Jules A
    Quote from Medic/Nurse
    When did clinical mentorship or high standards of clinical practice for any provider become a bad thing? Why would it be surprising that inexperienced providers with high case loads have worse outcomes?
    Now I'm confused. Genuinely.

    I took the initial post to mean that if new physicians are struggling despite their extensive education and clinical hours where does that leave NPs with our brief, superficial education and current lack of admission standards at many schools? In a sad state imo.
  13. by   knurse10
    Maybe Nurse Practitioners are more prepared for the stress of practicing as newbies?

    I think back to being a new nurse, having little frame of reference for clinical judgement, pathophysiology, medications, and technique for nursing procedures (IV's working the pump, placing ng tubes and catheters, etc). Not saying I wasn't educated, but working through that lack of experience is not unfamiliar ground for new grad NP's. So in a sense, we may be more prepared than new MD's and DO's. We may have more skills with troubleshooting, researching, and asking for help.

    The role is certainly different than registered nursing, and it would be helpful if there was more of a structured entry into practice across the board. At least some sort of mentorship program with another health professional would be valuable,and would hopefully make it a safer situation for patients.
  14. by   Riburn3
    Interesting article. The takeaway is that real experience is king. I'm not sure what a residency program for NP's would do since this article is discussing full fledged physicians already done with their residency. NP's in many states already sort of operate in a functional capacity similar to residency since they have physician supervision of varying degrees. I would imagine even with a hospitalist NP residency, NP's would improve along the lines of physicians after a year of "real" experience. How many times have we read on this very website when new NP's are asking for advice about being overwhelmed "your first year is always the hardest, but it gets easier after the first year"?

    I would love a little more data breakdown comparing residency programs and specialty (since hospitalists can be both internal medicine or family practice).

    From an NP prespective, the real question needs to be "do NP's working in collabrative or supervisory states produce better outcomes than NP's working in independent practice states". Our data is harder to compile since the degree in which we can practice is different in 50 different states.

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