RESEARCH - EDUCATIONImproving prescribing practices A pha.docx

RESEARCH - EDUCATION
Improving prescribing practices: A pharmacist-led educational
intervention for nurse practitioner students
Jennifer A. Sabatino, PharmD, BCACP (Clinical Pharmacist)1,
Maria C. Pruchnicki, PharmD, BCPS, BCACP, CLS
(Associate Professor)2, Alexa M. Sevin, PharmD, BCACP
(Assistant Professor)2, Elizabeth Barker, PhD, CNP,
FAANP, FACHE, FNAP, FAAN, FNP-BC (Professor Emeritus
of Clinical Nursing)3, Christopher G. Green, PharmD
(Specialty Practice Pharmacist)4, & Kyle Porter, MAS (Senior
Consulting Research Statistician)5
1Department of Pharmacy, Memorial Hospital Medication
Therapies Center, Marysville, Ohio
2Division of Pharmacy Practice and Science, The Ohio State
University College of Pharmacy, Columbus, Ohio
3College of Nursing, The Ohio State University, Columbus,
Ohio
4Department of Pharmacy, The Ohio State University Wexner
Medical Center, Columbus, Ohio
5Center for Biostatistics, The Ohio State University, Columbus,
Ohio
Keywords
Pharmacotherapy; education; prescriptions;
students; pharmacists; nurse practitioner;
advanced practice nurse.
Correspondence

Maria C. Pruchnicki, PharmD, BCPS, BCACP,
CLS, Division of Pharmacy Practice and Science,
The Ohio State University College of Pharmacy,
500 West 12th Avenue, Columbus, OH 43210.
Tel: 614-292-1363; Fax: 614-292-1335; E-mail:
[email protected]
Received: 22 May 2016;
accepted: 6 January 2017
doi: 10.1002/2327-6924.12446
Previous presentations: Poster presentation at
the American Pharmacists Association Annual
Meeting, March 2014, Orlando, Florida.
Encore poster presentation at the Ohio
Pharmacists Association 136th Annual Meeting,
April 2014, Columbus, Ohio.
Podium presentation at the Ohio Pharmacy
Resident Conference, May 2014, Ada, Ohio.
Encore podium presentation at the Celebration
of Educational Scholarship “Advances in Health

Sciences Education” at The Ohio State
University College of Medicine, November
2014, Columbus, Ohio.
Encore poster presentation at the American
Pharmacists Association Annual Meeting,
March 2015, San Diego, California.
Abstract
Background and purpose: To assess impact of a pharmacist-led
educational
intervention on family nurse practitioner (FNP) students’
prescribing skills, per-
ception of preparedness to prescribe, and perception of
pharmacist as collabora-
tor.
Method: Prospective pre–post assessment of a 14-week
educational interven-
tion in an FNP program in the spring semester of 2014. Students
participated in
an online module of weekly patient cases and prescriptions
emphasizing legal
requirements, prescription accuracy, and appropriate therapy. A
pharmacist fa-
cilitator provided formative feedback on students’ submissions.
Participants com-
pleted a matched assessment on prescription writing before and
after the module,
and a retrospective postsurvey then presurvey to collect
perceptions.

Conclusion: There was significant improvement in performance
on error iden-
tification and demonstration of prescription elements from
preassessment to
postassessment (+17%, p < .001). The mean performance on
both assessments
was less than the 70% passing score. Students reported
significant positive
changes in perceptions, including all statements regarding their
preparedness to
prescribe and those addressing willingness to collaborate with
pharmacists.
Implications for practice: Formative education on prescribing
enhanced stu-
dents’ understanding of safe and effective medication use with
improved recog-
nition and avoidance of prescribing errors, although it did not
result in compe-
tency. Exposure to pharmacist expertise in this area may
encourage collaboration
in practice.
Introduction
Like physicians, nurse practitioners have prescriptive
authority within the scope of their practice (Newhouse
et al., 2011). In the 2009–2010 American Association
of Nurse Practitioners Sample Survey of 13,562 nurse
practitioners, 97.6% reported prescribing medications to
patients, averaging 22 prescriptions per day in full-time
practice (Goolsby, 2011). However, studies have shown
that new prescribers often do not feel adequately prepared
(Hilmer, Seale, Le Couteur, Crampton, & Liddle, 2009;
Rauniar, Roy, Das, Bhandari, & Bhattacharya, 2008).
Evaluation of errors in various settings has determined

248 Journal of the American Association of Nurse Practitioners
29 (2017) 248–254
C©2017 American Association of Nurse Practitioners
J. A. Sabatino et al. Improving prescribing practices
that most preventable adverse drug events occur as the
result of errors made in the prescribing stage (Thomsen,
Winterstein, Søndergaard, Haugbølle, & Melander, 2007).
A study by Kuo, Phillips, Graham, and Hickner (2008)
reported that 70% of errors made in primary care physi-
cians’ offices were prescribing errors. Medication selection
and dose were the most common types of prescribing er-
ror, with the most error-prone factors being incorrect drug
selection, contraindications such as medication allergies,
incorrect dosing, and including insufficient information
on the prescription. In the study, pharmacists were re-
sponsible for preventing the errors from reaching patients
the majority of the time, consistent with their training
and expertise. However, pharmacists may not be routinely
utilized to their potential by nurse practitioners. In the
Nurse Practitioner Sample Survey, the reported frequency
of pharmacist consultation by nurse practitioners was
weekly (30.3%), monthly (29.9%), one to two times per
year (29.7%), daily (6.9%), and never (3.2%, Goolsby,
2011). Yet incorporation of pharmacists into the patient
care team has been identified as a healthcare strategy with
positive outcomes for patients, including improvement in
clinical markers such as hemoglobin A1c, LDL cholesterol,
and blood pressure and reduction in adverse drug events
(Chisholm-Burns et al., 2010).
This is the first study to assess the impact of a pharmacist

educating nurse practitioner students on the elements of
appropriate, safe, and complete prescription writing with
weekly online patient cases. We hypothesized that the
incorporation of a pharmacist in nurse practitioner stu-
dent learning could improve preparedness to prescribe as
well as encourage collaboration with pharmacists as part
of an interprofessional healthcare team. The purpose of
this study was to evaluate an existing educational inter-
vention in the family nurse practitioner (FNP) curriculum
to assess the impact on: (a) students’ clinical and proce-
dural accuracy of prescribing, (b) students’ perception of
preparedness to prescribe, and (c) students’ perception of
a pharmacist as a collaborator.
Methods
This study was a prospective pre–post assessment of a
14-week educational intervention designed to improve
technical and clinical aspects of prescribing of FNP stu-
dents. This research was determined to be exempt by The
Ohio State University Institutional Review Board.
Educational intervention
In an effort to expand interprofessional learning beyond
experiential educational settings, our faculty–practitioner
team developed and implemented a pharmacist-directed
prescribing intervention, delivered as a 14-week online
education module for FNP students. The intention of the
program was for a clinical pharmacist to educate students
at The Ohio State University (Ohio State) and provide
them longitudinal practice for appropriate prescribing
habits, including the identification and correction of the
factors commonly associated with prescribing errors. The
technical aspect of appropriate prescribing requires the

provider to include all necessary elements for a legally
complete and accurate prescription. Clinical prescribing
errors have a greater potential to cause patient harm and
involve medication choice and dosing with respect to indi-
cation as well as patient specific factors including concur-
rent medications or comorbidities (Velo & Minuz, 2009).
FNP students enrolled in a clinical practicum during
spring semester 2014 participated in an online mod-
ule delivered using the course management platform at
Ohio State (Carmen; [email protected]). Each week,
the pharmacist facilitator posted a patient case to the
discussion board and students were asked to review a
corresponding prescription for accuracy and appropriate-
ness or to generate a prescription for the patient. The
weekly exercises emphasized legal requirements and ac-
curacy (technical elements) as well as patient safety
considerations (clinical elements). A summary of the
various clinical prescribing issues addressed in the weekly
exercises is provided in Table 1. Students were asked to
identify any errors in the prescription, provide three pa-
tient counseling points for the medication prescribed, and
then demonstrate a correct prescription for the patient.
Each week, the pharmacist posted a response that pro-
vided formative feedback on errors commonly identified
and/or missed by the students, addressed any miscon-
ceptions from the class, and answered additional ques-
tions that had been raised by the class. The exercises were
graded as satisfactory/unsatisfactory based on student
participation.
Assessments
Prescribing skills before and after the didactic interven-
tion were assessed using an original assessment tool, de-
veloped with input from Ohio State’s University Center for

Advancement of Teaching (a campus-wide teaching cen-
ter). The assessment was reviewed for face validity and
content validity by the investigator team and the collabo-
rating educational consultants, respectively. Students were
given limited time (20 min) to complete each assessment
in order to simulate the limited decision-making and pre-
scribing time that is available in practice. Research as-
sessments were administered at predetermined times dur-
ing the study protocol, specifically before and after the
14-week online educational intervention. All students
249
Improving prescribing practices J. A. Sabatino et al.
Table 1 Description of clinical prescribing issues addressed in
intervention
Case number Clinical issues addressed
1 Prescribing a medication without a clinical indication
Medication allergy to prescribed agent
Medication dosed incorrectly
Quantity prescribed does not cover duration of
treatment
Drug–drug interaction
2 Topical formulation prescribed when oral formulation

indicated
Ambiguous directions contributing to inaccurate dosing
Refills inappropriate as patient should be reevaluated
3 Drug–disease state interaction
Maximum safe daily dose exceeded
4 Drug–age interaction
Drug–disease state interaction
Alternative drug choice more appropriate based on
patient-specific factors
5 Inappropriate dosage form for pediatric patient
Dose inaccurate based on patient weight
6 Additional medication not indicated based on
therapeutic goals
Maximize current therapy before adding additional
agent

Dose too high
7 Drug contraindicated in pregnant patient
Stepwise dose increase more appropriate
agent
9 Ambiguous directions contributing to inaccurate dosing
10 Dosing of medication inappropriate due to narrow
therapeutic index
11 Patient requires additional work up before prescribing
12 Medication allergy to prescribed agent
13 Prescribing medication without accompanying
prescription for supplies
guidelines

Drug choice and cost considerations
Ambiguous directions making accurate dosing
challenging
were required to complete the assessments as part of the
course requirements, but only those consenting to the re-
search had their responses included in the study. All stu-
dents enrolled in the course were eligible to participate in
the study.
The preassessment consisted of questions regarding four
prescription cases and a demographic survey. Cases 1–3
asked the students to identify any clinical or technical
errors in the corresponding prescriptions. Case 4 prompted
the students to write a prescription on the prescription
blank provided. Demographic questions targeted baseline
characteristics of participants: age, gender, primary lan-
guage, prior exposure to pharmacists or pharmacy stu-
dents, and the number of prescriptions written prior to the
activity.
The postassessment included the identical prescription
cases and a retrospective postsurvey then presurvey,
which was used to collect information on the students’
perceived preparedness to prescribe, willingness to collab-
orate with pharmacists, and perception of the pharmacist
as the educator. The retrospective postsurvey then presur-
vey differs from the more common presurvey then post-
survey design in that respondents complete both surveys at
the conclusion of the intervention. This is done to address
the fact that respondents who have little experience with
a subject prior to an educational intervention are unable
to accurately assess their perceptions of the subject on a

presurvey (Rockwell & Kohn, 1989). This tool was chosen
to allow the students to self-report their perceived change
over time using the same scale for pre- and postresponses
and without the potential bias introduced by a traditional
pretest. The 11 perception questions or statements were
rated on a 4-point Likert scale ranging from “strongly dis-
agree” to “strongly agree” and from “highly unlikely” to
“highly likely,” as appropriate. In answering the postsur-
vey then presurvey, students were asked to provide a re-
sponse to each question or statement first with what their
perceptions were at the point of conclusion of the educa-
tional intervention and then think back to the point prior
to starting the educational intervention.
Data analysis
Errors to be identified in the assessment were grouped
by type (i.e., technical or clinical), level of impact (i.e., pa-
tient harm, inconvenience, or minimal impact), and cat-
egory of error (i.e., directions, dosing, patient elements,
medication elements, etc.). Four practitioner investigators
individually assigned the groupings of each error and then
met to achieve consensus on the final groupings prior to
administration of the preassessment. The prescription as-
sessment was scored for each student as the percentage of
errors correctly identified/avoided, both overall and within
each specific category of errors. Competency was assessed
by comparing the overall score to 70%, a standard passing
score for a graduate nursing program. Improvement from
preassessment to postassessment was measured as the in-
crease in percentage correct for each category. Preassess-
ment, postassessment, and change scores are reported as
median with interquartile range (first quartile to third
quartile) across the 26 students. Nonparametric Wilcoxon
250

sign rank tests were applied to the change scores to as-
sess within-student improvement overall and within er-
ror type, severity of impact, and category using SAS 9.3
(Cary, NC). For the retrospective postsurvey then presur-
vey, responses were reported as frequency and percent-
age. The primary questions measuring student perceptions
by signed rank test were assessed with the null hypothesis
being zero change. No adjustments were made for multiple
comparisons.
Results
All of the 30 FNP students enrolled in the course
consented for the study. Of those, two students were
ineligible due to nonattendance at the administration of
the preassessment and two more students withdrew from
the course before the postassessment was administered,
resulting in a final participant pool of 26. The majority of
participants were female, aged 25–30, spoke English as a
primary language, and were registered nurses. Work ex-
perience was the most common exposure to pharmacists
or pharmacy students (Table 2).
Prescribing ability
The overall performance on the prescription cases
from the preassessment to postassessment showed
improvement with a median increase of 17% (p <
.001); the overall median score for the postassess-
ment was 57% (Table 3). Identification of errors
and demonstration of clinical and technical pre-

scription elements from preassessment to postassess-
ment also improved (p < .001). Individually, two of
26 students (8%) had an overall score greater than 70%
on the postassessment, compared to zero students on the
preassessment.
The performance on technical elements was consis-
tently greater than the performance on clinical elements,
with legal requirements of controlled substance pre-
scribing showing the least improvement from preassess-
ment to postassessment. When errors to be identified
were grouped by potential patient impact, the improve-
ment was significant from preassessment to postassess-
ment across all three levels of potential impact: harm
(p < .001), inconvenience (p < .001), and minimal
impact (p = .01). Improvement from preassessment
to postassessment on categories of errors was signif-
icant for those pertaining to directions, dosing, pa-
tient elements, prescriber elements, medication elements,
and other required elements (see Table 3). Only the
change in performance from preassessment to postassess-
ment on error-prone abbreviations was not significant
(p = .17).
Table 2 Demographic characteristics of 26 family nurse
practitioner
studentsa
N (%)
Age
<24 years 3 (12)
25–30 years 13 (50)

31–35 years 6 (23)
>35 years 4 (15)
Gender
Female 22 (85)
Primary language
English 25 (96)
Other 1 (4)
Credentials earned
RN 20 (77)
BSN 13 (50)
Other 1 (4)
Exposure to pharmacists or pharmacy students
Work experience 13 (50)
Part of a required course 10 (38)
Experiential rotations 7 (27)
Part of an elective course 4 (15)
Volunteer experience 3 (12)
No previous exposure 2 (8)

Student organization 2
Family member or close friend who is a pharmacist
Yes 9 (35)
Number of prescriptions written
<10 prescriptions 1 (4)
11–50 prescriptions 8 (31)
>100 prescriptions 5 (19)
aThe Ohio State University, 2014.
Perceptions
On the retrospective postsurvey then presurvey, the
students reported statistically significant increases in the
perception ratings on all statements that addressed their
preparedness to prescribe. Following the educational
intervention, there was an increase in agreement that
classroom education and clinical rotations prepared the
students for prescribing (p = .03 and p = .04, respectively)
and that nurse practitioners should have formal training
on writing prescriptions (p = .03). The largest positive
change was seen in response to the statement, “I feel
completely prepared to prescribe medications” (p < .001).
Students who reported having written fewer prescrip-
tions prior to the online prescribing module showed a
significantly larger positive change from preassessment
to postassessment in response to the statement, “I feel
completely prepared to prescribe medications” (p = .01).

A similar trend was seen on all statements that ad-
dressed the pharmacist as the educator, as students agreed
that a pharmacist-led prescribing activity is helpful in
251
Table 3 Family nurse practitioner student performancea on
assessmentsb
Median (IQR) Preassessment Postassessment Changec p-Value
Overall 38% (30–47%) 57% (49–66%) 17% (11–23%) <.001
Type of error
Clinical 27% (18–36%) 45% (36–55%) 16% (5–23%) <.001
Technical 44% (36–60%) 68% (60–76%) 20% (12–28%) <.001
Patient impact
Harm 30% (22–39%) 48% (35–57%) 15% (4–26%) <.001
Inconvenience 50% (39–67%) 72% (67–78%) 25% (11–33%)
<.001
Minimal impact 33% (17–50%) 50% (33–83%) 17% (0–33%)
.01
Category of error

Directions 19% (13–38%) 44% (25–50%) 19% (0–38%) .003
Dosing 25% (0–50%) 50% (25–50%) 25% (0–50%) .02
Error-prone abbreviations 25% (0–25%) 25% (0–50%) 0% (0–
25%) .17
Patient elements 80% (60–100%) 100% (80–100%) 10% (0–
40%) .004
Prescriber elements 40% (40–60%) 80% (80–100%) 40% (20–
60%) <.001
Medication elements 50% (38–63%) 63% (63–75%) 13% (13–
25%) <.001
Other required elements 33% (17–50%) 67% (50–83%) 17% (0–
50%) <.001
aPerformance measured as percentage of possible errors
identified for each category and reported as median and
interquartile range (IQR: first and third
quartiles) across all 26 students.
bThe Ohio State University, 2014.
cChange reported as median of individual differences calculated
from preassessment to postassessment for each of 26 students.
preparing nurse practitioners to prescribe (p = .01) and
that pharmacists are qualified to educate nurse practition-
ers on prescribing (p = .03). Significant positive changes
in perception were also demonstrated on three out of five
statements that addressed their willingness to collaborate
with a pharmacist in practice (Figure 1).
Discussion

In our study, a pharmacist-led educational intervention
resulted in significant improvement in prescribing abilities
for FNP students, almost entirely across the spectrum of
abilities assessed. The prescription cases in the assessment
highlighted examples of factors most commonly associated
with prescribing errors, including dosing and other med-
ication elements. Students demonstrated significant im-
provement in their ability to identify/avoid these errors,
suggesting that instruction in both the technical and clin-
ical components of prescribing supported appropriate and
safe prescription writing. In particular, there was signifi-
cant improvement in identification and avoidance of er-
rors that were categorized as having potential for patient
Figure 1 Family nurse practitioner student perceptions regarding
collaboration with pharmacist in practices.
252
harm. In general, improvements on items related to tech-
nical proficiency were greater than those related to clinical
performance, with the exception being the legal require-
ments of controlled substance prescribing which remained
very low on both assessments.
Unfortunately, the overall postassessment average
remained below the standard passing score for a graduate
nursing program, and a >30% error rate would be far
from acceptable in patient care. This suggests that longitu-
dinal, online learning activities are effective in improving

prescribing abilities; however this single module was not
sufficient in itself. Our results are consistent with findings
of a published systematic review that examined the impact
of various therapeutic tutorials and workshops on new
practitioner knowledge and prescribing skill (Kamarudin,
Penm, Chaar, & Moles, 2013). In the included studies, a
range of interventions were studied with many showing
improvements in prescribing performance, including those
incorporated into structured academic curricula. However,
subjects were most commonly medical interns and the
intervention was typically a single session without the
opportunity for prescribing practice or formative feedback.
The study in the review most similar to our research
utilized an 8-week intervention for medical students com-
prised of four 1-h physician and pharmacist-led tutorials
and eight 1-h practical sessions on prescribing (Sandilands
et al., 2011). Students were given a pretest and posttest
to assess incidence of prescribing errors and self-reported
confidence. Those investigators demonstrated improved
performance and confidence, but also with continued
prescribing errors made on the posttest and overall mean
posttest performance �70%.
To build upon previously studied interventions, we
designed our online prescribing module to provide both
longer-term (longitudinal) practice and formative feed-
back on prescribing. Students specifically had regular
practice with repeated exposure to technical elements
of prescription writing (which showed the greatest im-
provements), while each clinical element was addressed
only a maximum of three times over 14 weeks (Table 1).
The importance of practice as a research-based learning
strategy is well-known. In the book How Learning Works:
7 Research Based Principles for Smart Teaching, authors note
that both sufficient quantity of practice and practice
over time (accumulating practice) are needed (Ambrose,

Bridges, DiPietro, Lovett, & Norman, 2010, pp. 133–136).
Typically, instructors and students alike underestimate
how much practice is needed. Therefore, additional cases
focused on clinical components related to patient factors,
errors with potential for patient harm, error-prone abbre-
viations, and legal requirements of controlled substance
prescribing would likely have benefited the study partici-
pants, and may have resulted in greater change. A strategy
for continuing the online exercises throughout the FNP
didactic curriculum could be explored and studied further.
The retrospective postsurvey then presurvey examined
the impact of the intervention as perceived by the stu-
dents, with the greatest significant increase in percep-
tion rating from preassessment to postassessment on the
statement, “I feel completely prepared to prescribe.” Af-
ter completion of the educational intervention, 81% of
students agreed that they were completely prepared to
prescribe medications, compared to only 27% of students
who agreed with the statement prior to completion of the
educational intervention. Those students who had writ-
ten fewer prescriptions prior to the intervention showed
a significantly larger positive change on the survey state-
ment regarding feeling completely prepared to prescribe.
Though the general perception of preparedness is not con-
sistent with our objective results, an expected benefit of
targeted feedback is to help students more accurately dis-
cern change in learning behaviors and assess their own
progress. The “nonpassing” postassessment scores may
suggest that students did not review all of the posted feed-
back from the weekly exercises. Online posting of the
feedback with student-directed review cuts down on the
time investment required from the pharmacist facilitator
and allows for broader application with limited resources.
Kamarudin et al. suggest that prescriber feedback in the

form of “provider letters” is a cost-effective teaching strat-
egy (Kamarudin et al., 2013), but the heavy reliance on
student independence and student inexperience may have
limited the learning gains in our format.
Despite the poor prescribing performance on the pre-
assessment, students ranked highly their previous instruc-
tion for prescribing (i.e., prescribing activities in previ-
ous classes and during clinical rotations, provided before
this educational intervention). This was unexpected, as
we believed students would recognize that they were not
highly prepared at the time of the preassessment. How-
ever, students were never given the results of, or solu-
tions to, the preassessments in an effort to prevent re-
call bias. Therefore, the students did not seem to clearly
differentiate between the respective impact of the studied
educational module versus prior classroom education and
clinical rotations. Module enhancements such as provid-
ing the students with the objective scores on the preassess-
ments and postassessments, conducting formal review ses-
sions, and/or having the weekly feedback being facilitated
as asynchronous online discussions should be considered
to encourage students to rework cases, consider alterna-
tives, and self-assess.
Ninety-six percent of students agreed with the state-
ment, “Involving a pharmacist in the prescribing pro-
cess would result in better patient outcomes” with no
change from the preassessment to postassessment ratings.
253

Although the students also strongly agreed that pharma-
cists should be involved in prescribing, there was actually
the least change in perception on the statement, “How
likely are you to consult a pharmacist for help writing
a prescription?” (69% on the preassessment vs. 77% on
the postassessment). Though positive, this trend was not
found to be significant. A possible explanation for this
is that the students may not have anticipated requiring
help writing a prescription after the educational interven-
tion (i.e., expecting they were now proficient). Percep-
tions regarding collaboration with a pharmacist in prac-
tice prior to the educational intervention may have been
confounded by consistent promotion of interprofessional
collaboration by nurse practitioner educators within the
curriculum.
Though the tools utilized were not validated, a major
strength of the study is that the assessments were designed
and implemented collaboratively between pharmacist and
nurse practitioner researchers and educational/assessment
experts. The use of the retrospective postsurvey then
presurvey was intended to reduce response shift bias as
a threat to internal validity (Rockwell & Kohn, 1989).
Self-reporting is generally vulnerable to bias as learners
may respond in the way that they believe their educator
wants them to. Another limitation specific to the retro-
spective design of the survey was the potential inaccuracy
of student recall when responding to the statements based
on what their perceptions were prior to the activity.
Finally, the study was limited by the small population
included, especially in that the results may not be directly
applicable to teaching and learning strategies for other
professional students. Repeating the study with the use
of a control group may more accurately demonstrate the
impact of the intervention.

Future directions include evaluation of the duration and
timing of the educational intervention in FNP student cur-
ricula, to optimize outcomes and also to identify the point
at which incorporation of pharmacist-provided prescribing
practice would be most meaningful, for example, in didac-
tic versus experiential coursework. Broadening the appli-
cation to prescriber training in other disciplines should also
be explored.
Conclusions
Formative education on appropriate prescribing, includ-
ing the opportunity for longitudinal practice, enhances
preparedness of future nurse practitioner prescribers.
Well-prepared prescribers would be expected to make
fewer prescribing errors, leading to fewer preventable ad-
verse drug events and reduction in delays initiating or op-
timizing drug therapy. Exposure of the nurse practitioner
students to pharmacist expertise in this area during train-
ing may also encourage future collaboration in practice,
which could further reduce errors and impact outcomes
for patients.
Acknowledgments
The authors wish to thank Stephanie Rohdieck and
Teresa Johnson of The Ohio State University Center for
the Advancement of Teaching. Jennifer Sabatino, Maria
Pruchnicki, Alexa Sevin, Elizabeth Barker, and
Christopher Green developed the instrument and
performed data analysis; Jennifer Sabatino administered
the instrument, collected data, and wrote the initial draft
of the article; Kyle Porter provided statistical analysis; all
authors developed the research project and revised the
article for final submission. There is no funding to disclose.

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Prescription writing skills of pre-clinical medical and dental
undergraduate
students. Journal of Nepal Medical Association, 47(172), 197–
200.
Rockwell, S. K., & Kohn, H. (1989). Post-then-pre evaluation.
Journal of
Extension, 27(2). Retrieved from
http://www.joe.org/joe/1989summer/a5.html.
Sandilands, E. A., Reid, K., Shaw, L., Bateman, D. N., Webb,
D. J., Dhaun, N., &
Kluth, D. C. (2011). Impact of a focussed teaching programme
on practical
prescribing skills among final year medical students. British
Journal of Clinical
Pharmacology, 71(1), 29–33.
Thomsen, L. A., Winterstein, A. G., Søndergaard, B.,
Haugbølle, L. S., &
Melander, A. (2007). Systematic review of the incidence and
characteristics
of preventable adverse drug events in ambulatory care. Annals
of
Pharmacotherapy, 41(9), 1411–1426.
Velo, G. P., & Minuz, P. (2009). Medication errors: Prescribing

faults and
prescription errors. British Journal of Clinical Pharmocology,
67(6), 624–
628.
254
Position Paper Grading Rubric - 125 pts (2)
Position Paper Grading Rubric - 125 pts (2)
Criteria
Ratings
Pts
This criterion is linked to a Learning OutcomeLength
5.0 pts
Meets length requirement
0.0 pts
Does not meet length requirement
5.0 pts
This criterion is linked to a Learning OutcomePoint Analysis
30.0 pts
The central idea is developed and expanded with depth of
critical thought.
25.5 pts
The central idea is discernible and developed.
22.5 pts
The central idea needs more development with points tying back
to the thesis.
18.0 pts
The central idea is not developed, and the analysis lacks critical
thought.
0.0 pts
No effort

30.0 pts
This criterion is linked to a Learning OutcomeSupport
30.0 pts
The writing supports claims with several detailed and
persuasive examples.
25.5 pts
The writing supports claims with examples, but additional
analysis or examples could strengthen the argument.
22.5 pts
The writing supports claims with examples, but the examples
are not well-developed or examined. Additional examples and
analysis are needed to make the argument more persuasive.
18.0 pts
The central idea is not well-supported by claims and/or
examples.
0.0 pts
No effort
30.0 pts
This criterion is linked to a Learning OutcomeOrganization
25.0 pts
Paper is clear and cohesive. Introduction and conclusion support
the overall flow of the paper.
21.25 pts
Paper is basically clear and well-organized with a minimum of
non-related material present.
18.75 pts
Paper has some issues with clarity, flow, and cohesion. Paper
lacks organization.
15.0 pts
Paper lacks organization and has difficulty staying on track.
Central themes are difficult to identify.
0.0 pts
No effort

25.0 pts
This criterion is linked to a Learning OutcomeWriting:
Mechanics & Usage
10.0 pts
The writing is free of major errors in grammar, spelling, and
punctuation that would detract from a clear reading of the
paper.
8.5 pts
The writing contains a few major errors in grammar, spelling,
and punctuation, but the errors do not detract from a clear
reading of the text.
7.5 pts
The writing contains some major errors in grammar, spelling,
and punctuation that need to be addressed for a clearer reading
of the paper.
6.0 pts
The writing contains several major errors in grammar, spelling,
and punctuation that impede a clear reading of the paper.
0.0 pts
No effort
10.0 pts
This criterion is linked to a Learning OutcomeClarity & Flow
10.0 pts
The writing contains strong word choice that clarifies ideas and
masterful sentence variety aids with the flow of ideas.
8.5 pts
The writing contains varied word choice and sentence structures
that clarify ideas and aid with the flow of ideas.
7.5 pts
The writing contains word choice and sentence structures that
can be revised for better clarification of ideas and flow of ideas.
6.0 pts
The writing contains wording and sentence structures that are
awkward and/or unclear, impeding the clarity and flow of ideas.
0.0 pts

No effort
10.0 pts
This criterion is linked to a Learning OutcomeVoice
5.0 pts
The writing maintains third-person point of view/objective
voice throughout the entire text.
4.25 pts
The writing maintains third-person point of view/objective
voice throughout much of the text.
3.75 pts
The writing has some deviation from third-person point of
view/objective voice that needs to be revised so as not to sound
biased or patronizing.
3.0 pts
The writing deviates significantly from third-person point of
view/objective voice that needs to be revised so as not to sound
biased or patronizing.
0.0 pts
No effort
5.0 pts
This criterion is linked to a Learning OutcomeAPA Format
10.0 pts
All sources are properly integrated and cited in the text and
references page demonstrating a mastery of integrating
resources and APA format.
8.5 pts
Most sources are integrated and cited in the text and references
page. Some minor errors may exist in integration and/or
citation, but it does not interfere with understanding the source
of the information.
7.5 pts
Most sources are integrated and cited in the text and references
page. Some errors may exist in integration and/or citation that
need to be addressed to clarify the source of information.

6.0 pts
Sources are not properly integrated/cited in the text/references
page. Formatting contains several errors that suggest a lack of
understanding of the integration of resources and APA format.
0.0 pts
No effort
10.0 pts
Total Points: 125.0
PreviousNext
Top
Running Head: HOMELESSNESS AND POOR STATE OF
HEALTH 1
Homelessness and the poor state of health
Professor Sparza
Fausto D Masaira
05/24/2020
HOMELESSNESS AND POOR STATE OF HEALTH 2
Con-proposal
Subject: Homelessness and poor health.
Research question: What are the causes that to homelessness
and their contribution to the poor

state of health in the United States.
Claim:
Homelessness and the poor state of health are intertwined;
consequently,
the number of homeless civilians in the United States has been
accelerating gradually in the recent past while homelessness is
directly
related to the poor state of health which is caused by poverty,
domestic
violence and unemployment (Robertson & Greenblatt, 2013).
Research proposal: This research concentrates on gaining an
understanding of the contributing
factors to homelessness and how the aspect of homelessness is
contributing to a poor state of health in the United States. The
research
seeks to evaluate if the eligibility requirements already in
existence for
healthcare services present constraints to homeless civilians
from
receiving quality health services. Also, the study aims to do an
evaluation
on the efficiency of healthcare services on homeless civilians

plus to come
up with recommendations on the steps to be taken by federal,
state and
local levels of governments and also the role of private
institutions in the
improving the delivery and availability of healthcare services to
homeless
civilians. Studies established in 2017 that approximately
554,000 people
are homeless and can’t access quality health care facilities in
the United
Fausto D Masaira
98440000000104709
Fausto D Masaira
98440000000104709
Your thesis should not be cited? You just want your argument
and three key points.
States, which is about 0.17% of all the population in the United
States.
This portrays that homelessness is a crucial issue in the state of
health in

the United States, which requires urgent mitigation. Sadly, a
considerable
number of civilians have their residence in the streets with poor
medical
conditions and inability to access quality healthcare services. At
the same
time, no one seems to care both about their living conditions
and their
state of health (Schutt & Garrett, 2013).
A lot of misconceptions exist on the causes of homelessness in
the
United States, with this research I'm out to establish the
contributing
factors to homelessness and how they lead to the poor state of
health in the
United States. Participants in my study include homeless people
together
with their relatives, nurses and health practitioners, security
workers, and
community workers. The obtaining of information in my
research might
be complicated based on the state of health of those involved
and the
reasons they ended up in the streets since some might have

terrible
experiences that they might be buried in the past. Asking them
about the
same might bring out the recollection of events of these awful
experiences.
Relatives might have already disowned their kins with adverse
medical
conditions and might not be comfortable talking about it.
Getting
homeless people to research might be difficult since most are
out to look
for food during the day, which requires my research to be
conducted at
night when most can be available while most may be
experiencing pain
and adverse medical conditions. My research establishes that
there's a
Amy Szpara
98440000000104709
semicolon to correct this run-on
Amy Szpara
98440000000104709
I think for this to be an argument, you probably need to state
what needs to happen to help this.

stereotype regarding homeless civilians to be termed as
mentally ill
unanimously, which is a result of severe disorders, for instance,
schizophrenia, which are generally overrepresented in homeless
people
living in the streets. Currently, there’s well utilized and
commendable
healthcare and healthcare-related programs being implemented
in
improving the quality of healthcare services for homeless
people. The
solution to the poor state of health brought up by homelessness
include the
provision of stable residences to homeless civilians, for
prevention and
reduction of levels of homelessness civilians, need incomes that
would
ensure housing affordability, supportive systems to homeless
people, and
providing quality healthcare services offered to homeless
civilians
(Fischer & Collins, 2002).

Source collection via a synthesis matrix
Source: use an APA
in-text citation
1st con-point
Poverty
2nd con-point
Domestic violence
3rd con-point
Unemployment
(Schutt & Garrett,
2013)
Ascertains that the
element of poverty is
directly a
contributing factor to
homelessness, which
leads to the poor state

Amy Szpara
98440000000104709
Will you be conducting interviews or using research? Or both?
of health among
homeless people.
(Fischer & Collins,
2002)
Establishes that
approximately not
less than 80% of
women who are
homeless are due to
the element of
domestic violence
that contributes to the
poor state of health,
for instance, injury.
(Robertson &

Greenblatt, 2013)
States that lack of
employment and
employment
insecurity are
contributing factors
to homelessness.
Elements such as lack
of jobs make access
to quality healthcare
services a challenge.
Amy Szpara
98440000000104709
These sources are all a bit dated, being that they are all older
than five years old.
References
Fischer, K., & Collins, D. J. (2002). Homelessness, health care,
and welfare provision.

Routledge.
Robertson, M. J., & Greenblatt, M. (2013). Homelessness: A
national perspective. Springer
Science & Business Media.
Schutt, R. K., & Garrett, G. R. (2013). Responding to the
Homeless: Policy and practice.
Springer Science & Business Media.
Amy Szpara
98440000000104709
Citations look good, but the sources are older than they should
be.
TYPE SHORT TITLE IN ALL CAPS 2
Title in Upper and Lower Case
Your Name
Chamberlain College of Nursing
Course Number: Course Name
Term Month and Year
Running head: TYPE SHORT TITLE IN ALL CAPS 1
TYPE SHORT TITLE IN ALL CAPS 3

Title of your Paper in Upper and Lower Case (Centered, not
Bold)
Type your introduction here and remove the instructions.. The
introduction should begin with an attention grabber and end
with your working thesis statement. Remember to employ an
objective tone by applying only 3rd person point of view (no
1st: I, me, my, we, our, us, mine) or 2nd: you, your person point
of view).
Context
Begin to type the body of your paper here. Use as many
paragraphs as needed to cover the content appropriately. As
noted in the Lecture’s outline, the context section should
include potential qualifiers, and definitions. It is essentially
background information that provides your audience with the
context needed to understand your claim.
1st Con-Point
Begin with a topic sentence written in your own words that
presents your grounds. Next, apply the evidence/warrant.
Signal phrases are highly recommended to introduce new
sources (ex: According to Dr. John Smith, head physician at the
Mayo Clinic…). Cite your sources in APA format via
parenthetical citations. Follow through with a few sentences
examining the evidence and connecting it back to your main
point. Strive for a minimum of 5 developed sentences in a
college level paragraph. Remember to refer back to the outline
in our Week 2 Lesson if you need to review the structure of the
paper.
Repeat this process for your 2nd and 3rd Con-Points, dedicating
a paragraph to each.
Conclusion
Papers should end with a conclusion. Unpack your thesis (do
not copy/paste it) and apply a concluding technique. It should
be concise and contain no new detail. No matter how much
space remains on the page, the references always start on a
separate page.

References (centered, not bold)
Type your references in alphabetical order here using hanging
indents. See your APA Manual and the resources in your APA
folder in Course Resources for reference formatting.
RESEARCH - EDUCATION
Improving prescribing practices: A pharmacist-led educational
intervention for nurse practitioner students
Jennifer A. Sabatino, PharmD, BCACP (Clinical Pharmacist)1,
Maria C. Pruchnicki, PharmD, BCPS, BCACP, CLS
(Associate Professor)2, Alexa M. Sevin, PharmD, BCACP
(Assistant Professor)2, Elizabeth Barker, PhD, CNP,
FAANP, FACHE, FNAP, FAAN, FNP-BC (Professor Emeritus
of Clinical Nursing)3, Christopher G. Green, PharmD
(Specialty Practice Pharmacist)4, & Kyle Porter, MAS (Senior
Consulting Research Statistician)5
1Department of Pharmacy, Memorial Hospital Medication
Therapies Center, Marysville, Ohio
2Division of Pharmacy Practice and Science, The Ohio State
University College of Pharmacy, Columbus, Ohio
3College of Nursing, The Ohio State University, Columbus,
Ohio
4Department of Pharmacy, The Ohio State University Wexner
Medical Center, Columbus, Ohio
5Center for Biostatistics, The Ohio State University, Columbus,
Ohio

Keywords
Pharmacotherapy; education; prescriptions;
students; pharmacists; nurse practitioner;
advanced practice nurse.
Correspondence
Maria C. Pruchnicki, PharmD, BCPS, BCACP,
CLS, Division of Pharmacy Practice and Science,
The Ohio State University College of Pharmacy,
500 West 12th Avenue, Columbus, OH 43210.
Tel: 614-292-1363; Fax: 614-292-1335; E-mail:
[email protected]
Received: 22 May 2016;
accepted: 6 January 2017
doi: 10.1002/2327-6924.12446
Previous presentations: Poster presentation at
the American Pharmacists Association Annual
Meeting, March 2014, Orlando, Florida.
Encore poster presentation at the Ohio
Pharmacists Association 136th Annual Meeting,
April 2014, Columbus, Ohio.

Podium presentation at the Ohio Pharmacy
Resident Conference, May 2014, Ada, Ohio.
Encore podium presentation at the Celebration
of Educational Scholarship “Advances in Health
Sciences Education” at The Ohio State
University College of Medicine, November
2014, Columbus, Ohio.
Encore poster presentation at the American
Pharmacists Association Annual Meeting,
March 2015, San Diego, California.
Abstract
Background and purpose: To assess impact of a pharmacist-led
educational
intervention on family nurse practitioner (FNP) students’
prescribing skills, per-
ception of preparedness to prescribe, and perception of
pharmacist as collabora-
tor.
Method: Prospective pre–post assessment of a 14-week
educational interven-
tion in an FNP program in the spring semester of 2014. Students
participated in
an online module of weekly patient cases and prescriptions
emphasizing legal

requirements, prescription accuracy, and appropriate therapy. A
pharmacist fa-
cilitator provided formative feedback on students’ submissions.
Participants com-
pleted a matched assessment on prescription writing before and
after the module,
and a retrospective postsurvey then presurvey to collect
perceptions.
Conclusion: There was significant improvement in performance
on error iden-
tification and demonstration of prescription elements from
preassessment to
postassessment (+17%, p < .001). The mean performance on
both assessments
was less than the 70% passing score. Students reported
significant positive
changes in perceptions, including all statements regarding their
preparedness to
prescribe and those addressing willingness to collaborate with
pharmacists.
Implications for practice: Formative education on prescribing
enhanced stu-
dents’ understanding of safe and effective medication use with
improved recog-
nition and avoidance of prescribing errors, although it did not
result in compe-
tency. Exposure to pharmacist expertise in this area may
encourage collaboration
in practice.
Introduction
Like physicians, nurse practitioners have prescriptive
authority within the scope of their practice (Newhouse
et al., 2011). In the 2009–2010 American Association
of Nurse Practitioners Sample Survey of 13,562 nurse

practitioners, 97.6% reported prescribing medications to
patients, averaging 22 prescriptions per day in full-time
practice (Goolsby, 2011). However, studies have shown
that new prescribers often do not feel adequately prepared
(Hilmer, Seale, Le Couteur, Crampton, & Liddle, 2009;
Rauniar, Roy, Das, Bhandari, & Bhattacharya, 2008).
Evaluation of errors in various settings has determined
248 Journal of the American Association of Nurse Practitioners
29 (2017) 248–254
C©2017 American Association of Nurse Practitioners
that most preventable adverse drug events occur as the
result of errors made in the prescribing stage (Thomsen,
Winterstein, Søndergaard, Haugbølle, & Melander, 2007).
A study by Kuo, Phillips, Graham, and Hickner (2008)
reported that 70% of errors made in primary care physi-
cians’ offices were prescribing errors. Medication selection
and dose were the most common types of prescribing er-
ror, with the most error-prone factors being incorrect drug
selection, contraindications such as medication allergies,
incorrect dosing, and including insufficient information
on the prescription. In the study, pharmacists were re-
sponsible for preventing the errors from reaching patients
the majority of the time, consistent with their training
and expertise. However, pharmacists may not be routinely
utilized to their potential by nurse practitioners. In the
Nurse Practitioner Sample Survey, the reported frequency
of pharmacist consultation by nurse practitioners was
weekly (30.3%), monthly (29.9%), one to two times per
year (29.7%), daily (6.9%), and never (3.2%, Goolsby,

2011). Yet incorporation of pharmacists into the patient
care team has been identified as a healthcare strategy with
positive outcomes for patients, including improvement in
clinical markers such as hemoglobin A1c, LDL cholesterol,
and blood pressure and reduction in adverse drug events
(Chisholm-Burns et al., 2010).
This is the first study to assess the impact of a pharmacist
educating nurse practitioner students on the elements of
appropriate, safe, and complete prescription writing with
weekly online patient cases. We hypothesized that the
incorporation of a pharmacist in nurse practitioner stu-
dent learning could improve preparedness to prescribe as
well as encourage collaboration with pharmacists as part
of an interprofessional healthcare team. The purpose of
this study was to evaluate an existing educational inter-
vention in the family nurse practitioner (FNP) curriculum
to assess the impact on: (a) students’ clinical and proce-
dural accuracy of prescribing, (b) students’ perception of
preparedness to prescribe, and (c) students’ perception of
a pharmacist as a collaborator.
Methods
This study was a prospective pre–post assessment of a
14-week educational intervention designed to improve
technical and clinical aspects of prescribing of FNP stu-
dents. This research was determined to be exempt by The
Ohio State University Institutional Review Board.
Educational intervention
In an effort to expand interprofessional learning beyond
experiential educational settings, our faculty–practitioner
team developed and implemented a pharmacist-directed

prescribing intervention, delivered as a 14-week online
education module for FNP students. The intention of the
program was for a clinical pharmacist to educate students
at The Ohio State University (Ohio State) and provide
them longitudinal practice for appropriate prescribing
habits, including the identification and correction of the
factors commonly associated with prescribing errors. The
technical aspect of appropriate prescribing requires the
provider to include all necessary elements for a legally
complete and accurate prescription. Clinical prescribing
errors have a greater potential to cause patient harm and
involve medication choice and dosing with respect to indi-
cation as well as patient specific factors including concur-
rent medications or comorbidities (Velo & Minuz, 2009).
FNP students enrolled in a clinical practicum during
spring semester 2014 participated in an online mod-
ule delivered using the course management platform at
Ohio State (Carmen; [email protected]). Each week,
the pharmacist facilitator posted a patient case to the
discussion board and students were asked to review a
corresponding prescription for accuracy and appropriate-
ness or to generate a prescription for the patient. The
weekly exercises emphasized legal requirements and ac-
curacy (technical elements) as well as patient safety
considerations (clinical elements). A summary of the
various clinical prescribing issues addressed in the weekly
exercises is provided in Table 1. Students were asked to
identify any errors in the prescription, provide three pa-
tient counseling points for the medication prescribed, and
then demonstrate a correct prescription for the patient.
Each week, the pharmacist posted a response that pro-
vided formative feedback on errors commonly identified
and/or missed by the students, addressed any miscon-
ceptions from the class, and answered additional ques-
tions that had been raised by the class. The exercises were

graded as satisfactory/unsatisfactory based on student
participation.
Assessments
Prescribing skills before and after the didactic interven-
tion were assessed using an original assessment tool, de-
veloped with input from Ohio State’s University Center for
Advancement of Teaching (a campus-wide teaching cen-
ter). The assessment was reviewed for face validity and
content validity by the investigator team and the collabo-
rating educational consultants, respectively. Students were
given limited time (20 min) to complete each assessment
in order to simulate the limited decision-making and pre-
scribing time that is available in practice. Research as-
sessments were administered at predetermined times dur-
ing the study protocol, specifically before and after the
14-week online educational intervention. All students
249
Table 1 Description of clinical prescribing issues addressed in
intervention
Case number Clinical issues addressed
1 Prescribing a medication without a clinical indication
Medication allergy to prescribed agent
Medication dosed incorrectly

Quantity prescribed does not cover duration of
treatment
Drug–drug interaction
2 Topical formulation prescribed when oral formulation
indicated
Ambiguous directions contributing to inaccurate dosing
Maximum safe daily dose exceeded
4 Drug–age interaction
Drug–disease state interaction
5 Inappropriate dosage form for pediatric patient
6 Additional medication not indicated based on
therapeutic goals

agent
Dose too high
7 Drug contraindicated in pregnant patient
agent
9 Ambiguous directions contributing to inaccurate dosing
10 Dosing of medication inappropriate due to narrow
therapeutic index
11 Patient requires additional work up before prescribing
12 Medication allergy to prescribed agent

13 Prescribing medication without accompanying
prescription for supplies
guidelines
Drug choice and cost considerations
Ambiguous directions making accurate dosing
challenging
were required to complete the assessments as part of the
course requirements, but only those consenting to the re-
search had their responses included in the study. All stu-
dents enrolled in the course were eligible to participate in
the study.
The preassessment consisted of questions regarding four
prescription cases and a demographic survey. Cases 1–3
asked the students to identify any clinical or technical
errors in the corresponding prescriptions. Case 4 prompted
the students to write a prescription on the prescription
blank provided. Demographic questions targeted baseline
characteristics of participants: age, gender, primary lan-
guage, prior exposure to pharmacists or pharmacy stu-
dents, and the number of prescriptions written prior to the
activity.
The postassessment included the identical prescription
cases and a retrospective postsurvey then presurvey,
which was used to collect information on the students’
perceived preparedness to prescribe, willingness to collab-

orate with pharmacists, and perception of the pharmacist
as the educator. The retrospective postsurvey then presur-
vey differs from the more common presurvey then post-
survey design in that respondents complete both surveys at
the conclusion of the intervention. This is done to address
the fact that respondents who have little experience with
a subject prior to an educational intervention are unable
to accurately assess their perceptions of the subject on a
presurvey (Rockwell & Kohn, 1989). This tool was chosen
to allow the students to self-report their perceived change
over time using the same scale for pre- and postresponses
and without the potential bias introduced by a traditional
pretest. The 11 perception questions or statements were
rated on a 4-point Likert scale ranging from “strongly dis-
agree” to “strongly agree” and from “highly unlikely” to
“highly likely,” as appropriate. In answering the postsur-
vey then presurvey, students were asked to provide a re-
sponse to each question or statement first with what their
perceptions were at the point of conclusion of the educa-
tional intervention and then think back to the point prior
to starting the educational intervention.
Data analysis
Errors to be identified in the assessment were grouped
by type (i.e., technical or clinical), level of impact (i.e., pa-
tient harm, inconvenience, or minimal impact), and cat-
egory of error (i.e., directions, dosing, patient elements,
medication elements, etc.). Four practitioner investigators
individually assigned the groupings of each error and then
met to achieve consensus on the final groupings prior to
administration of the preassessment. The prescription as-
sessment was scored for each student as the percentage of
errors correctly identified/avoided, both overall and within
each specific category of errors. Competency was assessed
by comparing the overall score to 70%, a standard passing

score for a graduate nursing program. Improvement from
preassessment to postassessment was measured as the in-
crease in percentage correct for each category. Preassess-
ment, postassessment, and change scores are reported as
median with interquartile range (first quartile to third
quartile) across the 26 students. Nonparametric Wilcoxon
250
sign rank tests were applied to the change scores to as-
sess within-student improvement overall and within er-
ror type, severity of impact, and category using SAS 9.3
(Cary, NC). For the retrospective postsurvey then presur-
vey, responses were reported as frequency and percent-
age. The primary questions measuring student perceptions
by signed rank test were assessed with the null hypothesis
being zero change. No adjustments were made for multiple
comparisons.
Results
All of the 30 FNP students enrolled in the course
consented for the study. Of those, two students were
ineligible due to nonattendance at the administration of
the preassessment and two more students withdrew from
the course before the postassessment was administered,
resulting in a final participant pool of 26. The majority of
participants were female, aged 25–30, spoke English as a
primary language, and were registered nurses. Work ex-
perience was the most common exposure to pharmacists
or pharmacy students (Table 2).

Prescribing ability
The overall performance on the prescription cases
from the preassessment to postassessment showed
improvement with a median increase of 17% (p <
.001); the overall median score for the postassess-
ment was 57% (Table 3). Identification of errors
and demonstration of clinical and technical pre-
scription elements from preassessment to postassess-
ment also improved (p < .001). Individually, two of
26 students (8%) had an overall score greater than 70%
on the postassessment, compared to zero students on the
preassessment.
The performance on technical elements was consis-
tently greater than the performance on clinical elements,
with legal requirements of controlled substance pre-
scribing showing the least improvement from preassess-
ment to postassessment. When errors to be identified
were grouped by potential patient impact, the improve-
ment was significant from preassessment to postassess-
ment across all three levels of potential impact: harm
(p < .001), inconvenience (p < .001), and minimal
impact (p = .01). Improvement from preassessment
to postassessment on categories of errors was signif-
icant for those pertaining to directions, dosing, pa-
tient elements, prescriber elements, medication elements,
and other required elements (see Table 3). Only the
change in performance from preassessment to postassess-
ment on error-prone abbreviations was not significant
(p = .17).
Table 2 Demographic characteristics of 26 family nurse
practitioner
studentsa

N (%)
Age
<24 years 3 (12)
25–30 years 13 (50)
31–35 years 6 (23)
>35 years 4 (15)
Gender
Female 22 (85)
Primary language
English 25 (96)
Other 1 (4)
Credentials earned
RN 20 (77)
BSN 13 (50)
Other 1 (4)
Exposure to pharmacists or pharmacy students
Work experience 13 (50)
Part of a required course 10 (38)

Experiential rotations 7 (27)
Part of an elective course 4 (15)
Volunteer experience 3 (12)
No previous exposure 2 (8)
Student organization 2
Family member or close friend who is a pharmacist
Yes 9 (35)
Number of prescriptions written
<10 prescriptions 1 (4)
>100 prescriptions 5 (19)
aThe Ohio State University, 2014.
Perceptions
On the retrospective postsurvey then presurvey, the
students reported statistically significant increases in the
perception ratings on all statements that addressed their
preparedness to prescribe. Following the educational
intervention, there was an increase in agreement that
classroom education and clinical rotations prepared the
students for prescribing (p = .03 and p = .04, respectively)
and that nurse practitioners should have formal training

on writing prescriptions (p = .03). The largest positive
change was seen in response to the statement, “I feel
completely prepared to prescribe medications” (p < .001).
Students who reported having written fewer prescrip-
tions prior to the online prescribing module showed a
significantly larger positive change from preassessment
to postassessment in response to the statement, “I feel
completely prepared to prescribe medications” (p = .01).
A similar trend was seen on all statements that ad-
dressed the pharmacist as the educator, as students agreed
that a pharmacist-led prescribing activity is helpful in
251
Table 3 Family nurse practitioner student performancea on
assessmentsb
Median (IQR) Preassessment Postassessment Changec p-Value
Overall 38% (30–47%) 57% (49–66%) 17% (11–23%) <.001
Type of error
Clinical 27% (18–36%) 45% (36–55%) 16% (5–23%) <.001
Technical 44% (36–60%) 68% (60–76%) 20% (12–28%) <.001
Patient impact
Harm 30% (22–39%) 48% (35–57%) 15% (4–26%) <.001

Inconvenience 50% (39–67%) 72% (67–78%) 25% (11–33%)
<.001
Minimal impact 33% (17–50%) 50% (33–83%) 17% (0–33%)
.01
Category of error
Directions 19% (13–38%) 44% (25–50%) 19% (0–38%) .003
Dosing 25% (0–50%) 50% (25–50%) 25% (0–50%) .02
Error-prone abbreviations 25% (0–25%) 25% (0–50%) 0% (0–
25%) .17
Patient elements 80% (60–100%) 100% (80–100%) 10% (0–
40%) .004
Prescriber elements 40% (40–60%) 80% (80–100%) 40% (20–
60%) <.001
Medication elements 50% (38–63%) 63% (63–75%) 13% (13–
25%) <.001
Other required elements 33% (17–50%) 67% (50–83%) 17% (0–
50%) <.001
aPerformance measured as percentage of possible errors
identified for each category and reported as median and
interquartile range (IQR: first and third
quartiles) across all 26 students.
bThe Ohio State University, 2014.
cChange reported as median of individual differences calculated
from preassessment to postassessment for each of 26 students.

preparing nurse practitioners to prescribe (p = .01) and
that pharmacists are qualified to educate nurse practition-
ers on prescribing (p = .03). Significant positive changes
in perception were also demonstrated on three out of five
statements that addressed their willingness to collaborate
with a pharmacist in practice (Figure 1).
Discussion
In our study, a pharmacist-led educational intervention
resulted in significant improvement in prescribing abilities
for FNP students, almost entirely across the spectrum of
abilities assessed. The prescription cases in the assessment
highlighted examples of factors most commonly associated
with prescribing errors, including dosing and other med-
ication elements. Students demonstrated significant im-
provement in their ability to identify/avoid these errors,
suggesting that instruction in both the technical and clin-
ical components of prescribing supported appropriate and
safe prescription writing. In particular, there was signifi-
cant improvement in identification and avoidance of er-
rors that were categorized as having potential for patient
Figure 1 Family nurse practitioner student perceptions regarding
collaboration with pharmacist in practices.
252
harm. In general, improvements on items related to tech-
nical proficiency were greater than those related to clinical
performance, with the exception being the legal require-

ments of controlled substance prescribing which remained
very low on both assessments.
Unfortunately, the overall postassessment average
remained below the standard passing score for a graduate
nursing program, and a >30% error rate would be far
from acceptable in patient care. This suggests that longitu-
dinal, online learning activities are effective in improving
prescribing abilities; however this single module was not
sufficient in itself. Our results are consistent with findings
of a published systematic review that examined the impact
of various therapeutic tutorials and workshops on new
practitioner knowledge and prescribing skill (Kamarudin,
Penm, Chaar, & Moles, 2013). In the included studies, a
range of interventions were studied with many showing
improvements in prescribing performance, including those
incorporated into structured academic curricula. However,
subjects were most commonly medical interns and the
intervention was typically a single session without the
opportunity for prescribing practice or formative feedback.
The study in the review most similar to our research
utilized an 8-week intervention for medical students com-
prised of four 1-h physician and pharmacist-led tutorials
and eight 1-h practical sessions on prescribing (Sandilands
et al., 2011). Students were given a pretest and posttest
to assess incidence of prescribing errors and self-reported
confidence. Those investigators demonstrated improved
performance and confidence, but also with continued
prescribing errors made on the posttest and overall mean
posttest performance �70%.
To build upon previously studied interventions, we
designed our online prescribing module to provide both
longer-term (longitudinal) practice and formative feed-
back on prescribing. Students specifically had regular
practice with repeated exposure to technical elements

of prescription writing (which showed the greatest im-
provements), while each clinical element was addressed
only a maximum of three times over 14 weeks (Table 1).
The importance of practice as a research-based learning
strategy is well-known. In the book How Learning Works:
7 Research Based Principles for Smart Teaching, authors note
that both sufficient quantity of practice and practice
over time (accumulating practice) are needed (Ambrose,
Bridges, DiPietro, Lovett, & Norman, 2010, pp. 133–136).
Typically, instructors and students alike underestimate
how much practice is needed. Therefore, additional cases
focused on clinical components related to patient factors,
errors with potential for patient harm, error-prone abbre-
viations, and legal requirements of controlled substance
prescribing would likely have benefited the study partici-
pants, and may have resulted in greater change. A strategy
for continuing the online exercises throughout the FNP
didactic curriculum could be explored and studied further.
The retrospective postsurvey then presurvey examined
the impact of the intervention as perceived by the stu-
dents, with the greatest significant increase in percep-
tion rating from preassessment to postassessment on the
statement, “I feel completely prepared to prescribe.” Af-
ter completion of the educational intervention, 81% of
students agreed that they were completely prepared to
prescribe medications, compared to only 27% of students
who agreed with the statement prior to completion of the
educational intervention. Those students who had writ-
ten fewer prescriptions prior to the intervention showed
a significantly larger positive change on the survey state-
ment regarding feeling completely prepared to prescribe.
Though the general perception of preparedness is not con-
sistent with our objective results, an expected benefit of
targeted feedback is to help students more accurately dis-

cern change in learning behaviors and assess their own
progress. The “nonpassing” postassessment scores may
suggest that students did not review all of the posted feed-
back from the weekly exercises. Online posting of the
feedback with student-directed review cuts down on the
time investment required from the pharmacist facilitator
and allows for broader application with limited resources.
Kamarudin et al. suggest that prescriber feedback in the
form of “provider letters” is a cost-effective teaching strat-
egy (Kamarudin et al., 2013), but the heavy reliance on
student independence and student inexperience may have
limited the learning gains in our format.
Despite the poor prescribing performance on the pre-
assessment, students ranked highly their previous instruc-
tion for prescribing (i.e., prescribing activities in previ-
ous classes and during clinical rotations, provided before
this educational intervention). This was unexpected, as
we believed students would recognize that they were not
highly prepared at the time of the preassessment. How-
ever, students were never given the results of, or solu-
tions to, the preassessments in an effort to prevent re-
call bias. Therefore, the students did not seem to clearly
differentiate between the respective impact of the studied
educational module versus prior classroom education and
clinical rotations. Module enhancements such as provid-
ing the students with the objective scores on the preassess-
ments and postassessments, conducting formal review ses-
sions, and/or having the weekly feedback being facilitated
as asynchronous online discussions should be considered
to encourage students to rework cases, consider alterna-
tives, and self-assess.
Ninety-six percent of students agreed with the state-
ment, “Involving a pharmacist in the prescribing pro-
cess would result in better patient outcomes” with no

change from the preassessment to postassessment ratings.
253
Although the students also strongly agreed that pharma-
cists should be involved in prescribing, there was actually
the least change in perception on the statement, “How
likely are you to consult a pharmacist for help writing
a prescription?” (69% on the preassessment vs. 77% on
the postassessment). Though positive, this trend was not
found to be significant. A possible explanation for this
is that the students may not have anticipated requiring
help writing a prescription after the educational interven-
tion (i.e., expecting they were now proficient). Percep-
tions regarding collaboration with a pharmacist in prac-
tice prior to the educational intervention may have been
confounded by consistent promotion of interprofessional
collaboration by nurse practitioner educators within the
curriculum.
Though the tools utilized were not validated, a major
strength of the study is that the assessments were designed
and implemented collaboratively between pharmacist and
nurse practitioner researchers and educational/assessment
experts. The use of the retrospective postsurvey then
presurvey was intended to reduce response shift bias as
a threat to internal validity (Rockwell & Kohn, 1989).
Self-reporting is generally vulnerable to bias as learners
may respond in the way that they believe their educator
wants them to. Another limitation specific to the retro-
spective design of the survey was the potential inaccuracy
of student recall when responding to the statements based

on what their perceptions were prior to the activity.
Finally, the study was limited by the small population
included, especially in that the results may not be directly
applicable to teaching and learning strategies for other
professional students. Repeating the study with the use
of a control group may more accurately demonstrate the
impact of the intervention.
Future directions include evaluation of the duration and
timing of the educational intervention in FNP student cur-
ricula, to optimize outcomes and also to identify the point
at which incorporation of pharmacist-provided prescribing
practice would be most meaningful, for example, in didac-
tic versus experiential coursework. Broadening the appli-
cation to prescriber training in other disciplines should also
be explored.
Conclusions
Formative education on appropriate prescribing, includ-
ing the opportunity for longitudinal practice, enhances
preparedness of future nurse practitioner prescribers.
Well-prepared prescribers would be expected to make
fewer prescribing errors, leading to fewer preventable ad-
verse drug events and reduction in delays initiating or op-
timizing drug therapy. Exposure of the nurse practitioner
students to pharmacist expertise in this area during train-
ing may also encourage future collaboration in practice,
which could further reduce errors and impact outcomes
for patients.
Acknowledgments
The authors wish to thank Stephanie Rohdieck and
Teresa Johnson of The Ohio State University Center for

the Advancement of Teaching. Jennifer Sabatino, Maria
Pruchnicki, Alexa Sevin, Elizabeth Barker, and
Christopher Green developed the instrument and
performed data analysis; Jennifer Sabatino administered
the instrument, collected data, and wrote the initial draft
of the article; Kyle Porter provided statistical analysis; all
authors developed the research project and revised the
article for final submission. There is no funding to disclose.
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254
Shedding Light on Nurse Practitioner
Prescribing
Elissa Ladd, PhD, FNP-BC, and Alex Hoyt, PhD, RN
The Jo166
ABSTRACT
Transparency initiatives in society are growing. In the realm of
prescribing, recent
federal, state, and private initiatives are shedding light on
health care provider practice
and payments. These transparency initiatives commonly include
information on nurse
practitioners. Recently implemented federal and state Sunshine
laws are discussed.
Also, the newly released Medicare Part D data, which include
nurse practitioner
identified information, are described in the context of the

federal data release as well as
the news outlets that are utilizing this watershed of information
to inform the public
on health care provider practice.
Keywords: Medicare Part D, nurse practitioner, pharmaceutical
industry, prescribing,
Sunshine laws, transparency
� 2016 Elsevier, Inc. All rights reserved.
e live in a transparent world, whether we
like it or not. In recent years, society,
Wboth explicitly and implicitly, has moved
toward increasing transparency in multiple realms,
such as science, business, government, and politics.
This growing cultural shift toward transparency over
the past 50 years has been seen in such noteworthy
initiatives such as WikiLeaks or the Obama Admin-
istration’s Open Government Program. This trend is
also noted in health care, from the movement toward
acknowledging fault in medical errors, to multiple
public data sources on health care provider practices.
This paper addresses some of the recent trends in
federal, state, and private initiatives that seek to shed
light on health care provider practice in general, and
includes information on nurse practitioners (NPs)
more specifically. Policy and practice implications of
current transparency initiatives are highlighted.
THE PATIENT PROTECTION AND AFFORDABLE CARE
ACT: SUNSHINE PROVISIONS
In 2010, Congress passed the landmark Patient
Protection and Affordable Care Act. One less well-
known provision of the law, the Sunshine Act
(Section 6002) was included in order to increase

the transparency of financial relationships between
health care providers and the pharmaceutical and
urnal for Nurse Practitioners - JNP
medical devise industries.1 The Sunshine Act grew
out of an increasing concern regarding the financial
relationships that physicians have with industry.
Although some of these relationships are thought
to be beneficial and contribute to the development
of new drugs and devices, other relationships can
generate conflicts of interest in both research and
practice. Numerous studies over the past 20 years
have reported high levels of financial interaction
between physicians and the pharmaceutical
industry.2-5 Broadly, these studies demonstrate
that payments in the form of speakers fees, meals,
consulting, and sponsored continuing education
programs impact clinical decision-making and that
such interactions between clinicians and industry
can lead to biased prescribing practices and conflicts
of interest.6,7
The Sunshine Act requires that all pharmaceutical
and medical device manufacturers providing products
via Medicare, Medicaid, and the Children’s Health
Insurance Program disclose payments made to
hospitals and all licensed physicians (doctors of med-
icine, osteopathy, dentists, podiatrists, optometrists,
and chiropractors). These payments are reported
to the Center for Medicare and Medicaid Services
(CMS) and are available on the public website Open
Payments (www.cms.gov/OpenPayments/). The
Volume 12, Issue 3, March 2016
http://www.cms.gov/OpenPayments/
http://crossmark.crossref.org/dialog/?doi=10.1016/j.nurpra.2015
.09.017&domain=pdf

On Oct. 7, 2015 Senators Grassley (R-Iowa) and
Blumenthal (D- Connecticut) introduced Senate Bill S.
2153, an amendment that would require industry to
include information regarding payments made to
physician assistants, nurse practitioners, and other
advance practice nurses in transparency reports sub-
mitted to the Center for Medicare and Medicaid, Open
Payments website.
types of payments that are reportable include general
payments, such as speakers’ fees, honoraria, travel and
entertainment expenses, food, and education. Pay-
ments of < $10, unless over the course of a year
exceeding $100, are exempt. Investment interests
and research payments are also included.
It is important to note that other health care
professionals who have prescriptive authority, such as
NPs, physician assistants (PAs), psychologists, and
pharmacists (in designated states), are not included in
the statute. The exclusion of these professionals has
generated broad concern for several reasons. NPs
and other prescribers have been described as being
vulnerable or “soft targets” to industry’s promotional
activities, and flying “under the radar” of educational
initiatives that seek to mitigate conflicts of interests
between industry and prescribers.8,9 Also, the omission
of data on other prescribing clinicians may incentivize

manufacturers to shift financial relationships to these
other prescribers.10 Moreover, as transparency expands
around the financial transactions between physicians
and industry, other prescribers who are not included in
the law may become more vulnerable to the conflicts
of interest that have heretofore plagued physician/
industry relationships.11
Federal Data Surprises
Despite the fact that NPs, PAs, and other prescribers
were not included in the federal Sunshine statute,
many manufacturers, nonetheless, are reporting pay-
ments made to these prescribers. This information is
publically available on the CMS Open Payments
website. NPs and PAs are listed together in 1 category:
Physician Assistants & Advance Practice Nursing
Providers/Nurse Practitioners. Additional designations
are listed by specialty, namely Adult, Family, Acute,
Pediatric, Psych/Mental Health, Women’s Health, and
Neonatal. The initial data (August to December 2013)
were released in 2014, and the full data for 2014 were
released on June 30, 2015.
Importantly, the data disclose specific identifying
information, such as name, workplace address, and
specialty. The data also include the total dollar
amount that the individual has received; what the
payment covered, such as food and beverage, travel,
speaking fees, consulting, etc; and the drug or
www.npjournal.org
medical devices being promoted, along with the
name of the manufacturer. It is important to note
that, although this broad category does not differ-
entiate NPs from PAs, the information is readily
available on the internet with a simple Google search
of the clinician’s name.

Although the information provided in the Open
Payment website is very specific and detailed, it is not
comprehensive and does not include information
from all manufacturers. Notably, a number of larger
companies, such as Pfizer, Eli Lilly, and Boehringer
Ingelheim, are not included on the list of manufac-
turers that provided payments to NPs and PAs. It is
likely that they chose not to report NP and PA data
as it was not their legal responsibility to do so. For the
companies that did choose to submit payment in-
formation for NPs and PAs, the reasons for doing so
can only be postulated. It may be due in part to a
companies’ interest in total transparency of payments
made to prescribers, or may simply be a result of the
difficulties in teasing out provider designations. It is
important to note, however, that CMS designated
this provider type in their data because provider
designations were based on the federal government
taxonomy codes for health care professionals (CMS,
personal communication, July 9, 2015).
Embedded in these data were 1,711 reports of
payments made to NPs and PAs in 2013 and 1,618
reports of payments made in 2014. The total
amounts reported in the data were $82,843 for 2013
(5 months) and $75,567.59 for 2014. However, the
average amount paid to these providers was $47.14,
with the vast majority of payments categorized
under Food and Beverage. Also, there were errors
noted in the data because some of the covered re-
cipients, while being identified as NPs or PAs, were
actually physicians.
The Journal for Nurse Practitioners - JNP 167
http://www.npjournal.org

STATE-LEVEL TRANSPARENCY INITIATIVES
Currently, there are 9 states that have enacted
legislation that mandates the transparency of in-
teractions between health care providers (institution
or individual) and the pharmaceutical and medical
device industries. The laws, which vary by state,
typically include behavioral prohibitions (bans or
limits on gifts, meals, or entertainment) or disclosure
requirements (the nature, value, and purpose of
industry-sponsored payments or activities).12
Minnesota was the first state to enact “Sunshine”
legislation in 1993 with other states following suit
over the ensuing 2 decades.
Massachusetts enacted the Pharmaceutical and
Medical Device Manufacturer Code of Conduct
Law in 2010,13 which is widely considered to be one
of the most comprehensive laws of its kind in the US.14
This law requires that health care practitioners not only
disclose payments from industry but also banned certain
gifts and meals that are provided in non‒health care
settings.15 Although the Law was amended in 2012
to allow for meals in some non‒health care settings
(ie, restaurants), it still maintains comprehensive
disclosure requirements for practitioners who fall
outside the federally mandated Sunshine Act.16
Six of these states or jurisdictions (Vermont,
Minnesota, Massachusetts, West Virginia, Con-
necticut, and the District of Columbia) include
NPs in their definition of “covered recipients.” This
includes full bans for food (Vermont), a prohibition

on practitioner gifts (Minnesota) to other reportable
activities, such as the receipt of samples (Vermont),
attendance at industry-funded educational events,
and other payments for speaking and consultation.17
Moreover, 2 states recently expanded their disclosure
laws to include other advanced practice clinicians,
in part because these prescribers were not included
in the federal Sunshine Act reporting obligations.
Minnesota expanded their law in 2014 to include
NPs, PAs, and dental therapists (HF 2402).18
Connecticut recently passed legislation in 2014 aimed
to create reporting mechanisms of industry payments
that are made specifically to advanced practice
registered nurses. Also, this is the first such law in the
US that was directly tied to a state’s independent
scope of practice law for advanced practice registered
nurses (see Table).19
The Journal for Nurse Practitioners - JNP168
MEDICARE REIMBURSEMENT AND PRESCRIBING
DATA
Since the inception of Medicare 50 years ago,
CMS has concealed the claims records of providers
participating in Medicare. This secrecy was upheld as
a result of a permanent injunction in 1979 that was
won by the American Medical Association against
Medicare to prevent the release of physician payment
data. In 2013, this injunction was lifted by the US
District Court in Florida. As a result, in 2014, CMS
released the first public use files that identified pro-
vider payment claims.20
Moreover, as a part of the Obama Administra-
tion’s goals of “better care, smarter spending, and
healthier people,” CMS released Medicare Part D

data, identifying the providers and the drugs pre-
scribed. The purpose of the release of these data was
to provide transparency to consumers, researchers,
health systems, and other stakeholders to identify
how many prescription drugs are prescribed by
individual prescribers and how much these drugs
cost the health system.21 Although public, the data
are not easily manipulated and there are no data
tools, such as in Open Payments, available at
this time.
OTHER PUBLICALLY SEARCHABLE DATABASES
News outlets are taking notice and are starting to
utilize data that have previously been difficult to
access or was unavailable. Propublica, an indepen-
dent, not-for-profit organization that produces
in-depth investigative journalism in the public interest,
provides several data sources that contain NP data and
are searchable by the public. Based on their data tools,
they have published numerous articles that pertain to
health care, which have earned a number of promi-
nent journalism awards, including 2 Pulitzer Prizes
(2010 and 2011) and a Peabody Award (2013).
Two of their recent investigations, Dollars for Docs:
How Industry Money Reaches Physicians and Prescriber
Checkup: Inside the Government’s Drug Data, are
particularly applicable to prescribing practices of
health care providers. These investigations include
numerous stories in series format and are accompa-
nied by user-friendly data tools that allow the public
to search for health care providers by name if
included in the federal data.
Volume 12, Issue 3, March 2016

Table. State-based Transparency Laws
Covered Recipient
Disclosure/
Reporting
Law Reportable Activities Gift/Food Ban
Federal (PPACA:
Sunshine Act)
� MDs, DOs, DPMs
� DDSs, DMDs
� Teaching hospitals
Yes � Consulting
fees
� Honoraria
� Speaking fees
� Food
� Travel
� Entertainment
� Role in CME
� Research
� Royalties
� Investment
No
VT � All from the

federal
Sunshine Act
� NPs, PAs,
� Pharmacists
� Employees of
prescribers
� Nonteaching
hospitals/clinics
� Health plans
� Pharmacies
� Universities
� Nonprofit
foundations
� Patient advocacy
associations
� Professional
associations
Yes � All from the
federal
Sunshine Act
� Samples
� OTC drugs and
devices

� Demo units
� Coupons
� Vouchers
� Co-pay cards
� Patient
starter kits
� Accredited
CME
� Patient
education
and disease
management
materials
Total ban on
food and
other gifts
MA � All from the
federal
Sunshine Act
� NPs, PAs
� Residents
� Pharmacists

� Employees of
prescribers
� Nonteaching
hospitals/clinics
� Nursing homes
Yes � All from the federal
Sunshine Act
� Accredited CME
� Anatomic models, charts
Yes (allows
modest out
of office
meals)
MN � All from the
federal
Sunshine Act
� NPs, PAs
� Dental therapists
� Residents
� Not pharmacists
Yes ($50

limit on
meals)
� All from the federal
Sunshine Act
Yes
WV � All from the
federal
Sunshine Act
� NPs, PAs
� Residents
� Not pharmacists
Yes � All from the federal
Sunshine Act
� All national and print drug
advertising
No
DC All licensed health
care providers
(eg, RNs, CDEs,
nutritionists,
radiology techs,

etc.)
� Teaching and
nonteaching
hospitals/clinics
� Universities
� Patient advocacy
organizations
Yes ($25
limit on
meals)
� All from the federal Sunshine Act
� Print and media drug advertising
within DC
Yes
CT APRNs only (APRNs who work
independently according to newly
expanded scope of practice statute)
Yes (no
minimum

reporting
amount)
� All from the federal Sunshine Act No
APRN ¼ advanced practice registered nurse; CDE ¼ certified
diabetes educator; CME ¼ continuing medical education; DDS
¼ doctor of dental surgery; DO ¼ doctor of
ophthalmology; DPM ¼ doctor of podiatric medicine; MD ¼
medical doctor; NP ¼ nurse practitioner; OTC ¼ over the
counter; PA ¼ physician’s assistant; PPACA ¼ Patient
Protection and Affordable Care Act; RN ¼ registered nurse.
Adapted from: (1) Gorlach I, Pham-Kanter G. Physician
Payment Sunshine Act: review of individual state reporting
requirements. 2013. http://www.policymed.com/2014/04/
physician-payments-sunshine-act-review-of-individual-state-
reporting-requirements.html/; and (2) Finan A. Shining a light
on Connecticut’s version of the Sunshine Act.
2015. Available at:
http://www.law360.com/articles/659984/shining-a-light-on-
conn-s-version-of-the-sunshine-act/.
The Dollars for Docs series is based on 2 sources of
data. Beginning in 2010, Propublica compiled data
based on payment reports that resulted from legal
www.npjournal.org
settlements with the federal government. These set-
tlements often were based on whistleblower lawsuits
that alleged improper marketing or kickbacks. As a
The Journal for Nurse Practitioners - JNP 169
http://www.policymed.com/2014/04/physician-payments-
sunshine-act-review-of-individual-state-reporting-
requirements.html/
http://www.policymed.com/2014/04/physician-payments-
sunshine-act-review-of-individual-state-reporting-

requirements.html/
http://www.law360.com/articles/659984/shining-a-light-on-
conn-s-version-of-the-sunshine-act
http://www.npjournal.org
part of these settlements, pharmaceutical companies
entered into corporate integrity agreements with the
Department of Health and Human Services, Office
of the Inspector General. A number of companies
had corporate integrity agreements that mandated the
reporting of payments made to health care providers.
It was these payment data that populated Propublica’s
first data tool and provided the basis for the first series
of articles in the Dollars for Docs series.22 This first data
tool, which covers payments made between 2009
and 2013, contains numerous references to NPs that
are searchable by profession, name, and state, and is
quite robust in terms of identifying clinicians who
received payments from industry (http://projects.
propublica.org/d4d-archive/).
The second source of data used in the Dollars for
Docs series is based on information compiled from the
CMS Open Payments program. Like the data from
the Open Payments program, the Dollars for Docs
searchable tool contains information on payments
made to physicians and hospitals, and includes in-
formation on NPs and PAs. However, unlike the
Figure 1. Propublica’s Prescriber Checkup: Example NP Pee
De-identified.) From: Prescriber Checkup. Available at: http
1144295544/.
Used with permission from Propublica.
The Journal for Nurse Practitioners - JNP170

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