Nurse Practitioners at Barrow Neurological Institute
Denita Ryan, RN, NP
Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical
Center, Phoenix, Arizona
In general, the role of nurse practitioner developed in response to widespread economic constraints mandated by third-party payers. The goals of introducing this role at our institution were to increase patient satisfaction, to improve patient outcomes, to decrease lengths of stay, and to reduce the workload of residents. This article examines models of advanced practice nursing and how they have been implemented in the context of the neurosciences.
Key Words: advanced practice nursing, neuroscience, nurse practitioner
Many changes in the healthcare delivery system are the result of managed care, concerns about controlling costs, and the nursing shortage. At this institution, the expansion of patient care areas coupled with economic restrictions mandated by third-party payers increased the workload of the neurosurgical residents, the nursing staff, and case managers. Collaborative efforts among the medical director of the neurosurgical institution, nursing administration, nursing, and various ancillary departments resulted in a proposal to recruit for advanced practice nursing positions to facilitate patient care. The primary goals for the new role were to increase patient satisfaction and to improve patient outcomes. An additional benefit was the reduction of tasks and responsibilities previously held by the resident staff. This article reviews the development and implementation of the role of nurse practitioners (NPs) at Barrow Neurological Institute.
Advanced Practice Nursing
As described elsewhere, in 1995 Davies and Hughes described advanced practice nursing as a position that extends beyond roles. Conceptually, they defined advanced practice nursing as follows: “Advanced nursing practice is the application of an expanded range of practical, theoretical, and research-based therapeutics to phenomena experienced by patients within a specialized clinical area of the larger discipline of nursing.” This position paper stipulated that advanced practice nursing include basic nursing education plus a graduate degree with a major in nursing or a graduate degree with a concentration in an advanced nursing category. The latter includes both didactic and clinical components, advanced nursing theory, physical and psychosocial assessment, appropriate interventions, and management of health care. Hamric listed the criteria that define an advanced practice nurse: graduate education, certification, and a patient-focused practice. These primary criteria must co-exist with various competencies such as clinical practice expertise, expert guidance and coaching, consultation, research skills, clinical and professional leadership, collaboration, change-agent skills, and ethical decision-making skills.
Advanced practice nursing is a broad category composed of all nurses practicing in an advanced role. Included may be NPs, clinical nurse specialists, nurse anesthetists, and nurse midwives. NPs can be classified further as specializing in neonatal, pediatric, family, adult, geriatric, psychiatric, or acute care. Furthermore, NPs are recognized in the Medicare Federal Registry and are eligible to bill directly for services provided.
Development of the Role of NPs
Since its introduction in the 1960s, the role of NPs has been controversial. In the early 1960s,the Millis Report indicated that many children were receiving inadequate medical care because of the shortage of physicians. A survey by the American Academy of Pediatrics found that most physicians were willing to delegate some patient care tasks. In response to these concerns, a plan was developed to increase the scope of nurses. In 1965 the title “nurse practitioner” was first used at the University of Colorado in a special demonstration funded by the Commonwealth Foundation. The purpose of the demonstration was to prepare professional nurses for an expanded role in the care of ambulatory patients. The advantages and benefits associated with NPs soon expanded their role into all areas of healthcare, including acute care settings.
Acute care NPs are advanced practice nurses who primarily work with acutely ill patients within hospital settings. They receive advanced clinical education and frequently have experience in the arena of acute and critical care nursing. Among other case-specific and hospital-specific requirements, the role of the acute care NP includes assessment, evaluation, and diagnosis of patients; performance of therapeutic interventions specific to the area of expertise; appropriate consultations; patient and family teaching; and interaction with consultants and ancillary departments (e.g., speech, occupational, and physical therapy).
The job descriptions of the acute care NP can be difficult to define because roles vary from hospital to hospital. Specific responsibilities may be defined by specialty, patient population, state legislation, and individual hospital policy. Regardless of the practice setting, standards for advanced practice nursing are defined by national legislation, although specific changes are made at the level of the state by each State Board of Nursing.
The role of acute care NPs has been controversial, especially within teaching institutions. An acute care NP was first documented in the late 1970s in response to an undersupply of neonatal specialists. In the early 1990s,in response to a cutback in residency programs, hospital cost-containment, increasing numbers of patients, and decreased lengths of stay mandated by third-party payers, the role of NPs further expanded. Nurses received advanced training in a specialty area to relieve residents of various functions, such as focused assessments, ordering and interpreting diagnostic tests, ordering medications and therapies, and transferring patients to lower levels of care or discharging home.
Development of the NP Role at Barrow
During the early 1990s, the transitions in healthcare were felt at Barrow, as they were nationally. Although residency programs were cut elsewhere, at our institution patient populations, including many with complex conditions, were increasing. The large patient loads increased responsibilities for the resident staff. The medical director and administration of the institution decided that the addition of NPs might relieve the residents of some of their responsibilities while helping to decrease overall length of stay and to increase patient satisfaction.
Although the NP role was implemented and directed by the medical service, other stakeholders were identified as beneficiaries of the position. Timely discharges and movement of patients through the continuum were increasingly difficult for the case management and nursing departments to achieve because the neurosurgical residents were not readily available. The amount of time the residents needed to spend in areas such as the operating rooms and emergency rooms rendered them less available to the nursing floors for patient rounds. Consequently, discharges could be delayed. The residency program, administration, case management, and nursing were all seeking a solution to these frustrations.
In January 1994, a trial of expanded scope of practice was proposed and implemented. Advanced practice nurses with a concentrated focus and experience in the neurosciences were uncommon. Therefore, it was decided to hire two experienced registered nurses (RNs) who had expressed a desire and a commitment to pursue a graduate degree in nursing and to obtain NP certification. Both nurses obtained master’s degrees in the fall of 1996 and were certified as adult NPs in the spring of 1998. They were then hired as NPs.
The NP positions were trail-blazing unknown territory, and every department had a different idea of their responsibilities. Each resident also had a different idea of what the duties of the NPs should be, how long they should round and with whom, and whom their “first-line” responsibilities included — the junior residents with whom the NPs rounded daily or the chief resident.
Case management also had a specific idea about the purpose of the NPs: to assist with and be a part of their department in terms of discharge planning. Although always supportive, nursing sometimes found the changed roles of the NPs to be challenging. Just before changing their role, the NPs had worked with other bedside nurses to provide patient care. Floor nurses did not know whether to call the NPs to assist with patient problems, to administer medications, or to start intravenous lines. Technically, these tasks were no longer part of the responsibilities of the NPs. Education was needed throughout the patient care continuum to define the responsibilities, to clarify the roles, and to reinforce the advanced scope of the NP’s practice.
Another obstacle was the lack of structure to encourage collaboration among other NPs in the neurosciences. Although literature was available on the roles of cardiac NPs working within the hospital setting, no information existed about NPs in the neuroscience setting. With the support of the medical director, chief and junior residents, and nursing managers, the NPs attempted to clarify their role.
Models of Advanced Practice Nursing
Literature on the various aspects of role development for advanced practice nursing was reviewed during the early development of the NP roles at Barrow. Three models of advanced practice nursing are frequently cited. The first model, referred to as the physician practice model, represents a collaborative practice between NPs and a specific physician or group of physicians. The NPs report directly to the medical director. This model, however, tends to be physician-driven and is not always patient-driven. NPs are often expected to follow physician methods of care, ignoring or not giving the “appropriate respect” for the nursing component of the NP position. For example, rounds may be expected to be completed within a certain amount of time. This requirement fails to consider extra time needed for patient and family counseling and teaching. Reporting to the medical director, who may be removed from daily hospital issues, is another potential problem. It may be more appropriate for NPs to report directly to the chief resident.
The second model is the nursing model. In this model NPs report directly to a nursing director, which fosters a collegial relationship with the nursing staff. Although this relationship closely aligns NPs with nursing, it can also be a disadvantage because it can alienate physicians. The efficacy of this model depends on the collaborative role of the nursing director and the physicians working directly with the NPs.
The third model is the joint practice model. In this collaborative practice model, the NP and physician form a team that shares authority for providing care. Each professional contributes his or her own areas of expertise. This particular model reflects NPs and physician(s) in private practice together with a well defined relationship.
Regardless of the advanced practice model adopted, it must be based on collaborative practice between the NPs and physician(s).
Barrow Model of Advanced Practice Nursing
The model used at Barrow blends the above three models. The responsibilities of the NPs are strongly related to the physician model in that the NPs assumed many of the day-to-day responsibilities on the ward that formerly were assumed by the resident staff. Each NP sees the patients of a specific group of physicians. The NPs round with these physicians daily and relay problems and concerns directly to them. The NPs are available to the nursing and ancillary staff for questions and are the “first-line” to be called when there are concerns about a patient or orders are needed. As in the physician model, many of the responsibilities of the NPs are physician-driven. Unlike the physician model, the direct line of reporting is to an NP manager, who was originally involved in the proposed advanced practice nursing role at Barrow. In turn, the NP manager reports to the Director of Neuroscience Nursing, thereby consolidating the overall ties to nursing.
Elements of the joint practice model are also a strong part of the Barrow model. Each NP and each resident and attending surgeon make individual contributions to the care of each patient. Each role provides its own expertise to patient care. Frequent communication among the NPs, residents, and attending surgeons is necessary to assure optimal patient care. Besides communicating with the neurological staff, the NPs also communicate directly with physicians from various specialties to further facilitate patient care.
The Barrow model evolved to meet specific institutional needs, goals, and expectations. The NP role was developed to function directly within the hospital setting, working directly with the residents and attending physicians. The NPs have almost no contact with patients before treatment or during outpatient follow up.
Developing the advanced practice role at Barrow has been exciting and challenging. In the book Advanced Practice Nursing: An Integrative Approach, Brykczynski discussed the professional challenges confronting advanced practice nurses. First, role ambiguity occurs when role expectations are unclear. This problem manifests when responsibilities overlap with those of other roles and uncertainty exists about expectations. Although the NP job descriptions were clear about roles and responsibilities, it took time and considerable communication with other departments to decrease the ambiguity associated with their positions.
Role incongruity is another potential obstacle to success. This issue arises when the skills needed are incompatible with the obligations of the role. The NP positions began as NP interns (students) who worked directly under the supervision of residents. Their challenge was to learn and develop the skills needed to function in the more autonomous role of NP.
Intraprofessional role conflict is the third obstacle. Brykcynski asserted that the most common conflicts occur between NPs and physicians, typically over role infringement. Such issues probably reflect ambiguity about roles. The recommended solution is open communication between all concerned parties. Fortunately, role conflicts between the NPs and physicians at this institution have rarely surfaced. Indeed, the Barrow physicians have been strong supporters, teachers, and mentors of the NPs.
Counsell and Gilbert stated that the role of the advanced practice nurse in a tertiary teaching hospital positively affects several dimensions of healthcare: quality of care, cost-effectiveness, length of stay, and patient satisfaction. In fact, the nursing staff has frequently communicated satisfaction with the support that they receive from the NPs who are available to answer questions by phone or to assess patients with actual or potential problems. Rather than consulting a resident, the floor nurses appear to be comfortable discussing patient care issues with the NPs and asking for their help with difficult family situations or other patient-related problems that seem closely aligned with nursing practice. In turn, the NPs strive to be mentors and to support the floor nurses in their pursuit of professional growth. As nurses, NPs are aware of the difficulty of furthering education, formally or informally, because daily patient-related tasks make it difficult to attend meetings or inservices. The NPs have assumed the responsibility of being available—either bedside or at informal inservices—for teaching nurses and reviewing their assessment skills.
At Barrow, another important function of the NP role is to help identify and implement the appropriate level of care for each patient on the neurosurgical service. Occasionally, patients must be transferred to a higher level of care if their medical or neurological status declines. Usually, however, patients are transferred from the ICU or intermediate care unit to a general floor. Beds then become available for patients transferring from the ICU, emergency room, or operating room. A major concern of administration and case management is facilitation of timely discharge. One responsibility of the NPs therefore is to round on the floors and to identify patients ready for discharge. The NPs spend time with patients and their families discussing and planning for discharge and follow-up. The NPs work with the case management and therapy departments to determine patients’ needs for follow-up therapies, equipment, or transportation. Because of their responsibilities in the operating room, residents are seldom able to round the floors in the mornings and may be unavailable until late afternoon or evening. Therefore, the NPs have the responsibility of facilitating timely transfers and discharges.
Undoubtedly, the role of NP in this teaching institution will continue to evolve to meet the needs of all stakeholders. Organizational socialization requires adapting to the needs of the organization, in this case the hospital, residency program, nurses, NPs, and, most importantly, patients. Within legislative and hospital guidelines, the role of the NP will no doubt continue to change in response to healthcare trends and the specific needs of the hospital.
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