Tertiary nurse practitioners

Nurse practitioners and the growth of palliative medicine

As Americans live longer they are likely to suffer from chronic, life-limiting illness. Because there are not enough hospice and palliative medicine (HPM) trained physicians to care for these people, there have been recent calls to increase the number of HPM trained physicians. We, however, believe that greater involvement of nurse practitioners (NPs) is a step in remedying this deficit. The philosophy and culture in which nurse practitioners are trained make them ideal clinicians to provide excellent palliative care. In addition, NPs are not only numerous, they can provide care that is on par with that provided by physicians. Removal of barriers to NP practice and increasing the quality of their palliative care education/training needs to occur in order to make this suggestion a reality.

Levels of autonomy of nurse practitioners in an acute care setting

PURPOSE

The purpose of this descriptive study was to determine the level of autonomy of nurse practitioners (NPs) providing care to an adult patient population in an acute care setting.

DATA SOURCES

Data were collected from 54 NPs in different specialty areas currently working in a large metropolitan hospital. The Dempster Practice Behaviors Scale was used to measure the autonomy of the NPs.

CONCLUSIONS

The overall mean autonomy score of 117.37 (SD = 14.55) indicates a high level of autonomy of the NPs in this study. Forty-one percent of the participants had very high levels of autonomy, 31.5% had extremely high levels of autonomy, and 19% had moderate levels of autonomy. Demographic variables of age; years worked as an NP, as an RN, and at current job; highest educational level; basic nursing preparation; NP certification; and specialty had no statistically significant relationship with autonomy scores.

IMPLICATIONS FOR PRACTICE

The results of this study provided preliminary evidence of the level of autonomy of NPs providing inpatient care to adult patients in an acute care setting. The findings could lead to future research on the impact of NP services on patient outcomes and clinical productivity in acute care settings.

The Role of the Nurse Practitioner in Disaster Planning and Response

Advanced practice nurses (APNs) and nurse practitioners (NPs) have provided health care services during disasters; however, little appears in the literature about their role. APNs and NPs represent a significant portion of the nursing workforce. This article focuses on critical factors to consider when preparing and planning for the role of NPs.

Using multiple data sources for curriculum revision

Traditionally, curriculum revisions have been made based primarily on guidelines and standards set forth by professional organizations that identify a core of knowledge that pediatric nurse practitioners (PNPs) must know regardless of their practice setting. However, the number and complexity of pediatric health conditions managed by PNPs have expanded beyond this core knowledge. To meet the PNP's changing role and employment needs, curriculum revisions based on the information gathered from surveys of alumni, employers, and a national survey of PNP graduates, as well as on traditional standards and guidelines, were made.

Challenges of advanced practice nursing in pediatric acute and critical care: education to practice

The APN role of the future is dependent on our ability to document through research that NPs, CNSs, and the consolidated role of the NP/CNS plays a critical role in the delivery of high quality cost-effective care. Further information is needed regarding how the APN contributes to and enhances the care delivered by the healthcare team. Cost effectiveness and quality outcome studies are needed including those that describe morbidity and mortality rates, patient satisfaction, and cost effectiveness of models of care that includes APNs. Brooten and Naylor suggest the inclusion of sensitive nursing outcomes, including functional status, mental status, stress level, satisfaction with care, caregiver burden, cost of care. Defining and clarifying the APN functions and qualities of scope of practice is imperative. Perhaps there are populations best served by APNs. Contributions such as continuity, consistency of care, attention to issues such as immobility, skin integrity, and health promotion may have a value added effect. Time motion studies and process logs may add to the information about APNs in pediatric acute and critical care. Professional certification validating competence is essential for the practice of APNs caring for sick children and their families. A disparity exists between the primary care examination now available and the practice of NPs in pediatric acute and critical care. A certification examination is needed with content consistent with the practice of pediatric acute care NP. APNs must possess sufficient knowledge and skill to meet the needs of patients and families in the changing healthcare environment. According to Strodtbeck and colleagues, flexibility, ability to be a self directed learner, critical thinking, relationship skills, and leadership skills including interpersonal insight, interpersonal competence, and ability to stimulate group discussion will serve APNs well as they move into the century. Transitioning brings exciting opportunities along with challenges. Using a blend of abilities, the pediatric acute care APN can provide optimal care to sick children and families.

Expanding the perioperative role. The surgeon's assistant

The role of Surgeon's Assistant continues to be a contentious issue within the perioperative environment. Questions arise as to whether theatre nurses both want to and ought to extend their role into the medical margins. Suzanne Boss surveys the literature and draws preliminary conclusions on this development in nursing practice. This article was submitted in entry for the Alison Bell Writer's Competition 2001.

Professional practice of pediatric nurse practitioners: implications for education and training of PNPs

INTRODUCTION

The purpose of this study was to describe the characteristics of employment, the characteristics of children served, and the role functions of recent graduates of pediatric nurse practitioner (PNP) programs and to compare these characteristics across programs.

METHOD

A 60-item multiple-choice survey tool was sent to graduates from 1996-1998 of 6 universities across the United States.

RESULTS

A total of 137 surveys were received for a return rate of 52%. Less than half of the respondents (44%) indicated that they were employed in a primary care practice. Seventy percent indicated they "often" or "sometimes" provided care to children with acute/critical conditions, and 77% reported caring for children with chronic conditions. Role functions of case management, staff development, consultation, administration, and implementation of research were performed "often" or "sometimes" by more than 50% of respondents. Findings were fairly consistent in 5 out of 6 programs surveyed.

DISCUSSION

Graduates of PNP programs are increasingly called on to provide care to children with complex health care needs in non-primary care settings. Role functions beyond the traditional areas required for pediatric primary care are now common practice. Educational programs should address these dynamic changes by assessing the adequacy of their curricula and clinical residencies in preparing graduates.

Comprehensive trauma patient care by nonphysician providers

Nonphysician providers are being increasingly used to care for trauma patients. As these complex patients recover, they require meticulous medical management and time-consuming psychosocial care. A retrospective evaluation of a unique patient care service staffed by nonphysician providers is presented. The Intermediate Care Service is designed to facilitate the management and long-term placement of trauma patients who no longer require intensive care while recovering from their injuries. The new diagnoses, physician order changes, and disposition of 93 patients cared for during a 6-month period are described. Most patients were admitted with neurologic injury. The most common new diagnosis was constipation; the most frequent new orders related to medications, including bowel management, and rehabilitation consultations. All patients were discharged from the hospital. The Intermediate Care Service represents a unique and valuable model for the collaborative management of complex trauma patients.

Ethics of case management: implications for advanced practice nursing

The healthcare system is under pressure to provide quality care with less money for a growing and aging populace, and the resulting changes in the system could pose ethical problems for advanced practice nurses. Expanding healthcare needs, the increased use of technology, and dwindling resources all place burdens on advanced practice nurses, who have taken on the role of case manager in an attempt to reduce costs, meet patient outcomes, and provide improved, personalized, high-quality care. This paper explores the ethical concerns that can arise from managed care delivery systems and discusses the role of advanced practice nurses as case managers and the possible implications for nursing practice and research.

Defining the role of the pediatric critical care nurse practitioner in a tertiary care center

OBJECTIVE

To describe the development and implementation of a pediatric critical care nurse practitioner role in a tertiary academic pediatric intensive care unit.

DATA SOURCES

Selected relevant articles from the literature.

DATA EXTRACTION/SYNTHESIS

Over the past two decades, the role of critical care nurse practitioners in neonatal and adult settings has developed. More recently, the role has emerged in the setting of pediatric critical care. Literature to date focuses on implementation of the nurse practitioner role in neonatal and adult critical care units, with limited publications on the role in the pediatric critical care arena. In addition, information on the practice of critical care nurse practitioners in tertiary care centers is lacking. We therefore, sought to describe the design, implementation, scope of practice, and outcomes to date of a pediatric nurse practitioner program in our pediatric critical care unit.

CONCLUSIONS

A pediatric critical care nurse practitioner role can be implemented successfully in a tertiary center's pediatric intensive care unit. However, before integration of the pediatric critical care nurse practitioner into the health care team, definition of entry level requirements and the overall role with respect to scope of practice, daily operations, and professional practice is essential. Future endeavors should include evaluation of the impact of the pediatric critical care nurse practitioner on patient outcomes in the tertiary care center.

A conceptual framework for evaluating the nurse practitioner role in acute care settings

The conceptualization and enactment of the ACNP role varies across settings, potentially leading to variability in outcome achievement. A conceptual framework for evaluating the ACNP role is proposed. The framework is an adaptation of the Nursing Role Effectiveness Model which was developed to facilitate the identification and investigation of nursing-sensitive outcomes. The framework represents the complex system of interrelated factors that are present in the ACNP practice situation and that affect role effectiveness. It includes three components: (i) structure--encompassing patient, ACNP and organizational variables; (ii) process--consisting of the ACNP role components (clinician, educator, researcher and administrator) and the ways in which the role is enacted; and (iii) outcomes--including patient- and cost-related outcomes. The framework proposes specific relationships among the structure, process and outcomes components. Empirical support for the framework propositions is provided, based on a review of pertinent literature. Implications for future ACNP impact studies are discussed.

Impact of a gerontological nurse practitioner on the nursing home elderly in the acute care setting

A retrospective analysis of the length of stay of nursing home elderly patients admitted to the hospital demonstrates a significant decrease when patients are comanaged by a nurse practitioner and attending physicians. A comparison of the 20 most heavily populated diagnostic groups between 1993 and 1994 reveals a shorter average length of stay in 17 of the 20 diagnostic groups, and an overall mean decrease of 2.78 days for all groups. This article discusses the impact of the gerontological nurse practitioner on hospital length of stay of the nursing home elderly with acute illness. Research is needed to document advanced practices that decrease length of stay, as well as to control for extraneous variables.

Planning for the future: advanced nursing practice in critical care

The subject of advanced nursing practice has become a topic of great interest and considerable debate in recent years. It has as a concept, however, been increasingly obscured by the plethora of terms used to denote its particular role and function. The purpose of this paper is to suggest how a consensus may be achieved in terms of role clarification, educational preparation, intellectual skill, level of performance and remuneration. Fundamental elements of the current debate are seen to be the need for advanced nursing practice, how it will be recognized in practice, the parameters of the expanding role and the centrality of the patient rather than professional boundaries in delineating advanced nursing practice for critical care. The debate will no doubt continue. It is not the aim of this paper to reach a definitive understanding, but to provide a platform so that essential elements can be confronted and the development of the role carefully considered.

Neonatal nurse practitioners: identity as advanced practice nurses

OBJECTIVE

To define how neonatal nurse practitioners (NNPs) perceive their identity as advanced practice nurses.

DESIGN

Non-experimental descriptive and correlational survey.

SETTING

Nationwide random sample drawn from NNPs certified by the National Certification Corporation.

PARTICIPANTS

Two hundred fifty-eight neonatal nurse practitioners practicing in neonatal intensive-care units across the United States.

MAIN OUTCOME MEASURES

Neonatal Nurse Practitioners indicated on a visual analogue scale at which point their philosophy of practice fell on a continuum from nursing to medicine and specified on a 5-point bipolar Likert scale how various role socialization factors influenced their identity.

RESULTS

The NNPs predominantly were certificate-prepared and aligned themselves with a medical philosophy. Those NNPs who were master's-prepared (p < .01), precepted by another NNP (p < .05), espoused a philosophy of nursing (p < .001), belonged to a professional nursing organization (p < .05), and had an NNP role model (p < .001) were more likely to have a strong nursing identity (95% confidence interval).

CONCLUSIONS

The issues of role differentiation, socialization, and identity of advanced practice nurses in tertiary care need further exploration. These data support the American Nurses' Association mandate of graduate nursing education for advanced nurse practitioners.

Current questions with regard to acute care nurse practitioner preparation and role implementation

The role of the acute care nurse practitioner is being implemented in acute and tertiary care settings. As the role evolves, questions arise. Some of these questions relate to: 1) whether a need for the role has been clearly established; 2) whether the scope of acute care nurse practitioner practice has been identified distinctly; 3) the adequacy of educational preparation; 4) certification versus licensure; and 5) the nature of the relation between this role and other forms of advanced practice nursing. In this article, the authors identify and discuss some of these questions, provide information regarding current status, and postulate further potential resolutions.

Outcomes management: an interdisciplinary search for best practice

Rising U.S. health-care costs have resulted in mandates to reform the health system. Payors are closely scrutinizing care delivery and have empowered themselves as gatekeepers for consumer health-care access. In the late 1980s, outcomes management emerged as an interdisciplinary process advocating the measurement of health outcomes among populations undergoing medical care. Outcomes management provides a mechanism to foster development of patient-driven health services aimed to impact clinical quality through intermediate and long-term outcome analysis. Outcomes measurement facilitates ongoing enhancement of interdisciplinary health-care delivery, enabling determination of "best" practice and identification of opportunities for practice improvement. The advanced practice nurse's unique educational preparation provides a framework for development of the prerequisite leadership qualities necessary to cultivate an outcomes management program.

Perioperative nurse practitioners

Perioperative nursing roles are evolving in response to health care reform, technological developments, and changing opportunities for advanced practice nursing. One response to these changes is the development of the perioperative nurse practitioner role. The perioperative base for this new advanced practice role is described in this article. The advanced practice role is effective in other specialty settings and can be developed readily in a variety of surgical settings. This role requires a master's degree in nursing to provide the academic and practice preparation for clinical decision making and patient management in the perioperative setting. Future opportunities for perioperative advanced practice nursing are discussed.

Rethinking the merger of the clinical nurse specialist and the nurse practitioner roles

The clinical nurse specialist (CNS) and nurse practitioner (NP) have been distinct and separate advanced nursing practice roles since the 1960s. The forces of economics and health care reform have fostered an interest in merging these two advanced practice roles. Economic and regulatory advantages have been noted in the literature for both roles. What is not so evident are the possible disadvantages. Several aspects of the merger issue are explored as is the recent background of the creation of the CNS and NP roles. Problems and questions are asked to stimulate future discussions in nursing's professional associations and in education and service settings.