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research-article2014
JPOXXX10.1177/1043454214531455Journal of Pediatric Oncology NursingGolden
Article
A Nurse Practitioner Patient Care Team: Implications for Pediatric Oncology
Journal of Pediatric Oncology Nursing 2014, Vol. 31(6) 350–356 © 2014 by Association of Pediatric Hematology/Oncology Nurses Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043454214531455 jpo.sagepub.com
Julia Rose Golden, RN, MSN, CPHON1
Abstract The role of the pediatric advanced practice registered nurse continues to evolve within the ever-changing field of health care. In response to increased demand for health care services and because of a variety of changes in the health care delivery system, nurse practitioner patient care teams are an emerging trend in acute care settings. Care provided by nurse practitioner teams has been shown to be effective, efficient, and comprehensive. In addition to shorter hospital stays and reduced costs, nurse practitioner teams offer increased quality and continuity of care, and improved patient satisfaction. Nurse practitioner patient care teams are well suited to the field of pediatric oncology, as patients would benefit from care provided by specialized clinicians with a holistic focus. This article provides health care professionals with information about the use of nurse practitioner patient care teams and implications for use in pediatric oncology. Keywords nurse practitioners, patient care team, pediatric oncology
Overview/Background The role of the advanced practice registered nurse (APRN)1 continues to evolve alongside the ever-changing field of health care. In 2010, the Vision of Pediatrics 2020 task force observed an increasing diversity in the variety of medical providers caring for children and speculated that the structure of the pediatric workforce will continue to evolve and adapt to changes in the health care delivery system (Stanton, 2010). The use of nurse practitioner patient care teams is part of that evolution and has begun to revolutionize the practice of medicine, with nurse practitioners taking on responsibilities traditionally held by medical residents (Hoekelman, 1998). Children’s hospitals have reported a trend of transferring work assignments from pediatric residents and fellows to APRNs such that by 2011, 48% of children’s hospitals increased the number of full-time pediatric APRNs (Freed, Dunham, Moran, Spera, & Research Advisory Committee of the American Board of Pediatrics, 2012). The role of the nurse practitioner is expanding within acute care settings and studies have confirmed that APRNs provide safe, effective, and quality care to specific patient populations (Newhouse et al., 2011). Originating in the neonatal intensive care unit (NICU), pediatric APRN patient care teams have successfully expanded to other pediatric medical units. While literature currently does not exist on the use of pediatric APRN patient care teams in pediatric oncology, this model offers
continuity of care, increased quality of care, and improved patient satisfaction, which render it worthy of consideration for use in this specialty.
Nurse Practitioners in Acute Care: Patient Care Outcomes Adult Outcomes In the acute care setting, nurse practitioners provide consistency within a unit and play an important role in facilitating communication between staff, patients, and families. A comparison between nurse practitioners and medical fellows working in an adult intensive care setting found that APRNs spend more time communicating with patients, families, and other team members, which provides better coordination of care (Hoffman, Tasota, Scharfenberg, Zullo, & Donahoe, 2003). Increased communication and care coordination may be attributed to the APRN’s more extended investment in a unit (Pioro et al., 2001; Riportella-Muller, Libby, & Kindig, 1995).
1
The University of Pennsylvania, Philadelphia, PA, USA
Corresponding Author: Julia Rose Golden, RN, MSN, CPHON, 1 Perkins Square,, Akron, OH 44302, USA. Email: [email protected]
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Golden Studies show that APRNs in the hospital setting provide equivalent or superior care in comparison with medical residents, as measured by outcomes such as rate of readmission, duration of ventilator dependence (Hoffman, Tasota, Zullo, Scharfenberg, & Donahoe, 2005; Russell, VorderBruegge, & Burns, 2002), and mortality (Gracias et al., 2008; Hoffman et al., 2005; Pioro et al., 2001). Consistent, efficient, and effective care provided by nurse practitioners contributes to a decreased length of hospitalization and reduced cost of care (Morris et al., 2012; Russell et al., 2002). APRNs also promote safe, evidencebased clinical practice, as they are more likely to adhere to clinical practice guidelines (Gracias et al., 2008; Voogdt-Pruis, Van Ree, Gorgels, & Beusmans, 2011), and the use of screening tools (Morris et al., 2012). A systematic review of 59 studies on outcomes of nurse practitioner care in the emergency department found patient satisfaction was consistently high. This could be attributed to increased quality of care, improved communication, and shorter length of stay compared with care by medical residents (Carter & Chochinov, 2007). The numerous advantages of APRN-managed care, including increased patient satisfaction, decreased length of hospital stay, adherence to clinical guidelines, continuity of care and holistic approach, help explain why many hospitals have transitioned to the APRN model.
Pediatric Outcomes Pediatric APRNs have cared for hospitalized children since the 1970s with the introduction of the first neonatal nurse practitioner (Okuhara, Faire, & Pike, 2011). APRNs are now commonly employed in the inpatient pediatric setting and have positively influenced patient care outcomes in cardiac surgery, trauma, asthma, and cystic fibrosis services as well as in pediatric and neonatal intensive care units (Bissinger, Allred, Arford, & Bellig, 1997; Borgmeyer, Gyr, Jamerson, & Henry, 2008; Brown, Besunder, & Bachmann, 2008; Fanta et al., 2006; Karlowicz & McMurray, 2000; Mitchell-DiCenso et al., 1996; Okuhara et al., 2011; Rideout, 2007; Schultz, Liptak, & Fioravanti, 1994). Studies suggest that nurse practitioner care in the pediatric setting decreases length of hospital stay, increases parent/patient satisfaction, and improves coordination and consistency of care (Bissinger et al., 1997; Brown et al., 2008; Fanta et al., 2006; Rideout, 2007; Silvestri et al., 2005). In addition, care provided by NICU nurse practitioners consistently produces equivalent clinical outcomes as care provided by pediatric residents, as measured by rates of rehospitalization and mortality (Bissinger et al., 1997; Karlowicz & McMurray, 2000; Mitchell-DiCenso et al., 1996; Schultz et al., 1994).
Differences in care between pediatric APRNs and residents are often attributed to nurse practitioners’ familiarity with individual patients, communication skills, continuous presence on the unit, and early identification of patient needs (Bissinger et al., 1997; Carzoli et al., 1994; Karlowicz & McMurray, 2000). This level of care contributes to outcomes that encourage use of pediatric APRNs as patient care providers.
Nurse Practitioner Patient Care Teams Models in Adult Medical Centers In an era when medical institutions must meet demands of increasing census and decreased availability of medical residents, several institutions have pioneered the use of a nurse practitioner patient care team. Studies comparing medical management provided by teams of APRNs and attending physicians, versus fellows and attending physicians, consistently showed that equal care was provided by both teams (Hoffman et al., 2005; Pioro et al., 2001). In fact, one study found patients managed by an APRN and attending physician team were less likely to require reintubation than patients managed by the fellow/ attending team. The authors suggest this positive outcome may be related to the greater amount of time APRNs spent on the unit closely watching and managing their patients (Hoffman et al., 2005). Additionally, teams evaluated by Hoffman et al. (2005) and Morris et al. (2012) had an average of 15 years’ experience caring for patients of their current APRN specialty, which likely contributes to the success of the APRN teams. In a study by Pioro et al. (2001), APRNs leading a general medicine unit were present for 12 hours on weekdays and for morning rounds on weekends. However, overnight medical resident and fellow coverage was critical for successful implementation of a nurse practitioner patient care team in both general medicine and trauma settings (Morris et al., 2012; Pioro et al., 2001). To minimize house staff involvement and to promote autonomy of the nurse practitioner team, protocols were developed for treatment of fever, chest pain, and shortness of breath (Pioro et al., 2001).
Models in Adult Oncology There are 2 reports describing the implementation of an adult oncology nurse practitioner patient care team developed to serve patients who have specialized acute and chronic needs. A large Massachusetts hospital concluded that an oncology nurse practitioner care team was the best fit for the inpatient service in comparison with several physician models, from the perspective of quality, safety,
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Table 1. Daily Intensive Care Unit Nurse Practitioner. Situation
Responsibility
Prerounds
Review the chart, laboratory results, and X-rays Assess the patient Formulate tentative plan of care Carry out urgent interventions Rounds Present data and plan of care Finalize plan of care Postrounds Provide medical management according to plan of care Accompany patients to diagnostic exams Perform invasive procedures Communicate with consulting services Update families Document daily progress notes New Stabilize the patient admissions Obtain and document history and physical Develop differential diagnoses Write orders Communicate with consulting service Source. Adapted from Molitor-Kirsch, Thompson, and Milonovich (2005).
patient satisfaction, cost, and ability to decrease length of stay (Winne et al., 2012). At a large cancer center in New York, which also implemented this model, candidates with acute care nurse practitioner (ACNP) degrees were evaluated and selected based on their educational background, national certification, and clinical experience (D’Agostino & Halpern, 2010). Both centers hired APRNs with oncology experience, considering their familiarity with the nuances of cancer care. Recruited candidates were motivated, self-directed, resourceful, flexible, ambitious, and possessed leadership abilities. (D’Agostino & Halpern, 2010; Winne et al., 2012). New-hire APRNs spent 2 months in orientation, which involved observing resident teams and attending physicians. Topics covered during orientation included infectious diseases, renal and oncologic emergencies, chemotherapy, and pulmonary and cardiac diagnoses (Winne et al., 2012). Communication training involved simulation of difficult conversations with patients and families, delivering bad news, introducing palliative care, and withdrawal of life support. Roles of the critical care oncology nurse practitioner were developed, some of which are outlined in Table 1 (D’Agostino & Halpern, 2010). At these institutions, the oncology APRNs work closely with the attending oncologist during the admission process and on a daily basis to develop and confirm the patient care plan. They also participate in daily multidisciplinary rounds. As a constant presence on the unit,
the APRNs become uniquely familiar with patients, families, and staff, which contributes to improved patient care outcomes (D’Agostino & Halpern, 2010; Winne et al., 2012). The oncology nurse practitioner patient care team allows for better access for patients, families, and nurses to an ordering provider, promoting continuity of care and increased patient satisfaction (Winne et al., 2012).
A Pediatric APRN Patient Care Team Implementation Pediatric APRN patient care teams have found success in neonatal intensive care units for decades and more recently have been adopted in pediatric intensive and emergency care settings. Understanding the successes and challenges of APRN care team models that have been successfully implemented in other pediatric specialties will facilitate the development of APRN patient care teams in pediatric oncology. Pediatric critical care nurse practitioner patient care teams were recently developed in a midsized Ohio children’s hospital and a large Texas children’s hospital (Brown et al., 2008; Molitor-Kirsch et al., 2005). Most of the nurse practitioners hired for the critical care team at the Ohio hospital had pediatric intensive care unit (PICU) registered nurse (RN) experience and were motivated team leaders, spending 80% of their time in clinical practice and dedicating 20% to continuing education, teaching, research, and consultation. They served the unit for 10-hour shifts Monday to Friday with 1 APRN covering weekends and holidays and reported to an APRN coordinator with 50% clinical and 50% administrative duties. Both institutions required an orientation of at least 2 months and up to 1 year, which included PICU-specific education, observation, and feedback from attending physicians (Brown et al., 2008, Molitor-Kirsch et al., 2005). APRNs at the Ohio hospital were also required to have Pediatric Advanced Life Support certification (Brown et al., 2008). Each APRN at the Texas hospital held a master’s degree in acute care nursing with a minimum of 3 years PICU RN experience (Molitor-Kirsch et al., 2005). With more than 30 pediatric critical care APRNs, they provided 24/7 coverage in the trauma ICU and covered 7 a.m. to 7 p.m.,7 days a week in the cardiothoracic ICU (Molitor-Kirsch et al., 2005). Expectations of pediatric critical care APRNs included chairing PICU multidisciplinary rounds, coordinating care for chronically ill and complex patients, and providing education for nursing staff (Brown et al., 2008; Molitor-Kirsch et al., 2005). Additional daily responsibilities of the pediatric critical care APRN are included in Table 1.
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Golden Table 2. Role and Duties of Acute Care Pediatric and Neonatal Nurse Practitioner. Role Consultation
Teaching
Leadership
Duty Admit patients to service Record in-depth medical histories Perform detailed physical exam Write orders Medication reconciliation Prescribe/order medications and therapies Write admission/discharge/daily note Interpret diagnostic studies Write necessary consults Develop and evaluate therapeutic management plans Discharge planning Independent and interdependent decision making Direct accountability for clinical judgment Patient and family education Nursing education Interdisciplinary education Initiate multidisciplinary rounds Involvement in unit and hospital committees Engage in research, continuing education, teaching Consultation and advocacy
Source. Adapted from NAPNAP (National Association of Pediatric Nurse Practitioners) Position Statement on the Acute Care Pediatric Nurse Practitioner (2011); Brown et al. (2008); Moote, Krsek, Kleinpell, and Todd (2011); Steven (2004); Wilson, (2005).
In a Level 3 NICU in Arkansas, a university teaching hospital, and a NICU in Florida, neonatal nurse practitioner (NNP) patient care teams staffed the unit around the clock. During the daytime, the NNP teams worked with an attending neonatologist performing responsibilities included in Table 2 and NNPs staffed the unit overnight (Carzoli et al., 1994; Lee & Jones, 2004; Karlowicz & McMurray, 2000). Between the 3 institutions using the NNP team model of care, nurse practitioners had 2 to 12 years of experience (Carzoli et al., 1994; Lee & Jones, 2004; Karlowicz & McMurray, 2000) and just 5 years after implementation of the NNP team in Arkansas, the nurse practitioners felt they transitioned from novices to experts in their field (Lee & Jones, 2004). Silvestri et al. (2005) illustrate the use of a pediatric APRN patient care team in an emergency department’s extended care unit in a large Pennsylvania children’s hospital. Here, the pediatric APRNs must have a minimum of 3 years primary care experience, a pediatric or family nurse practitioner degree, and excellent assessment and communication skills. Pediatric APRNs then acquire additional knowledge of diagnoses and treatment by working closely with attending physicians. Patient and
parent satisfaction is driven by the consistency of care provided by the pediatric APRN team that serves as a link between primary care physicians, specialists, and social services, and is responsible for patient management from 7 a.m. to 1 a.m. The pediatric APRN patient care team promotes comprehensive, cost-effective, and time-efficient care, which additionally contributes to patient satisfaction.
Challenges and Limitations Institutions faced several challenges in implementing APRN patient care teams. The New York hospital was challenged with the adjustment of unit culture, as most of the nurses were not used to working with APRNs (D’Agostino & Halpern, 2010). However, the Texas Children’s Hospital found that nurses preferred to address their concerns with an APRN, as opposed to a physician, after successful establishment of a nurse practitioner patient care team. This preference was related to the constant presence of APRNs on the unit and their dual medical and nursing perspectives (Molitor-Kirsch et al., 2005). Another challenge related to the transition from the role of a bedside nurse to the role of nurse practitioner (D’Agostino & Halpern, 2010). APRNs have a different type of authority and autonomy than the bedside RN, so sufficient training and orientation are necessary for successful role transition. Several studies addressed attending physician concern about the level of knowledge and skill possessed by the APRNs and their ability to address end of life care with patients and families (D’Agostino & Halpern, 2010; Garland & Gershengorn, 2013). Over time, however, their worry resolved due to extensive training and a level of trust that was built between the nurse practitioners and attending physicians (D’Agostino & Halpern, 2010). Despite successful implementation of a nurse practitioner patient care team for the ICU at the Texas Children’s Hospital, expansion of the program proved challenging. Molitor-Kirsch et al. (2005) attributes this difficulty to a limited number of qualified APRN graduates, which results from the relatively few programs offering training for pediatric acute care nurse practitioners. Unfortunately, despite the increasing reliance on nurse practitioner–led care teams, there has been no increase in new graduates of pediatric APRN programs over the past 15 years and the lack of qualified applicants remains (Freed et al., 2012).
Implications of a Proposed Pediatric Oncology APRN Patient Care Team Studies in both adult and pediatric populations demonstrate that nurse practitioner patient care teams, in collaboration with attending physicians, provide equitable
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clinical outcomes to care provided by medical residents and fellows in varying patient populations (Bissinger et al., 1997; Borgmeyer et al., 2008; Brown et al., 2008; Carter & Chochinov, 2007; Carzoli et al., 1994; Fanta et al., 2006; Gracias et al., 2008; Hoffman et al., 2005; Karlowicz & McMurray, 2000; Mitchell-DiCenso et al., 1996; Morris et al., 2012; Pioro et al., 2001; Rideout, 2007; Russell et al., 2002; Schultz et al., 1994). Hospitalized patients benefit from the consistency provided by a single practitioner. With appropriate training, support, and supervision, a nurse practitioner can effectively manage a caseload of acutely, chronically, and/or critically ill patients, and hospitalized patients benefit from the consistency provided by a single practitioner (Hoffman et al., 2005). Literature supports the APRN-run unit as a viable option for the care of acute and critically ill children; such a model would be a valuable option in the pediatric oncology setting. A nurse practitioner pediatric oncology patient care team would ensure continuity of care to patients and families of a child with cancer. Recurring hospital admissions are incredibly stressful and it is reassuring for oncology patients and families to see a familiar inpatient provider who is well versed in a child’s history. Based on experiences with previous admissions, APRNs are more keenly aware than rotating residents of physical and emotional signs in patients that reflect their current picture of health, therefore providing personalized and improved care (Steven, 2004). In order to ease the transition to this model of care, units implementing a nurse practitioner pediatric oncology patient care team should consider including a rotation for their hired nurse practitioners at a hospital currently using this patient care model (Brown et al., 2008). Additionally, developing protocols (Pioro et al., 2001) for common pediatric oncology medical problems may assist in APRN clinical decision making. Standard protocols may increase the productivity and efficiency of a pediatric oncology nurse practitioner patient care team (Pioro et al., 2001).
Anticipated Challenges Development of pediatric oncology nurse practitioner teams may be challenging as there are a limited number of qualified practitioners; only 10% of nurse practitioner students choose to enter pediatrics (Freed et al., 2012); the University of Pennsylvania (2013) is currently the only school offering specialized ACNP training in pediatric oncology. Recruitment into pediatric subspecialties can be challenging due to the need for specialized skills and knowledge. It is therefore vital to support pediatric ACNP graduate education programs that precept and train future
graduates who will enter the workforce as pediatric oncology nurse practitioners (Okuhara et al., 2011).
Future Research With the development of the pediatric ACNP degree and increased demand for nurse practitioners in the acute care setting, future research should be dedicated to examining the role of the acute care APRN team and the impact on patient outcomes. Patient outcomes will help identify aspects of this care model requiring additional research and/or revision. From an operational perspective, future studies should include investigating optimal work hours to yield maximum productivity of a nurse practitioner patient care team as well as clinician job satisfaction. Further research should also be conducted to evaluate the financial impact of nurse practitioner patient care teams.
Conclusion Nurse practitioners provide safe, effective, and efficient care in inpatient adult and pediatric settings. APRN patient care teams are a current trend in medical centers, and several studies illustrate successful implementations of this model. The steps for establishment of a pediatric APRN nurse practitioner team include identifying a patient population that would benefit from this model of care, defining the role and responsibilities of the nurse practitioner, hiring qualified personnel with an appropriate educational background, providing a comprehensive orientation, establishing an administrative APRN role, and anticipating challenges to implementation. A pediatric oncology nurse practitioner patient care team would provide holistic, high-quality, oncologyfocused care, and positively affect this specialized patient population. Declaration of Conflicting Interests The author is currently an employee of Akron Children’s Hospital which is one of the institutions that has successfully implemented the pediatric nurse practitier patient care team as discussed in this article..
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
Note 1. In this article, the terms APRN and nurse practitioner are used interchangeably.
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Author Biography Julia Rose Golden, RN, MSN, CPHON, currently practices as an Acute Care Pediatric Hematology/Oncology/Bone Marrow Transplant Nurse Practitioner at Akron Children’s Hospital in Akron, Ohio. She earned her MSN from the University of Pennsylvania in 2013 and her BSN from Case Western Reserve University in 2009.
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research-article2014
JPOXXX10.1177/1043454214531455Journal of Pediatric Oncology NursingGolden
Article
A Nurse Practitioner Patient Care Team: Implications for Pediatric Oncology
Journal of Pediatric Oncology Nursing 2014, Vol. 31(6) 350–356 © 2014 by Association of Pediatric Hematology/Oncology Nurses Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043454214531455 jpo.sagepub.com
Julia Rose Golden, RN, MSN, CPHON1
Abstract The role of the pediatric advanced practice registered nurse continues to evolve within the ever-changing field of health care. In response to increased demand for health care services and because of a variety of changes in the health care delivery system, nurse practitioner patient care teams are an emerging trend in acute care settings. Care provided by nurse practitioner teams has been shown to be effective, efficient, and comprehensive. In addition to shorter hospital stays and reduced costs, nurse practitioner teams offer increased quality and continuity of care, and improved patient satisfaction. Nurse practitioner patient care teams are well suited to the field of pediatric oncology, as patients would benefit from care provided by specialized clinicians with a holistic focus. This article provides health care professionals with information about the use of nurse practitioner patient care teams and implications for use in pediatric oncology. Keywords nurse practitioners, patient care team, pediatric oncology
Overview/Background The role of the advanced practice registered nurse (APRN)1 continues to evolve alongside the ever-changing field of health care. In 2010, the Vision of Pediatrics 2020 task force observed an increasing diversity in the variety of medical providers caring for children and speculated that the structure of the pediatric workforce will continue to evolve and adapt to changes in the health care delivery system (Stanton, 2010). The use of nurse practitioner patient care teams is part of that evolution and has begun to revolutionize the practice of medicine, with nurse practitioners taking on responsibilities traditionally held by medical residents (Hoekelman, 1998). Children’s hospitals have reported a trend of transferring work assignments from pediatric residents and fellows to APRNs such that by 2011, 48% of children’s hospitals increased the number of full-time pediatric APRNs (Freed, Dunham, Moran, Spera, & Research Advisory Committee of the American Board of Pediatrics, 2012). The role of the nurse practitioner is expanding within acute care settings and studies have confirmed that APRNs provide safe, effective, and quality care to specific patient populations (Newhouse et al., 2011). Originating in the neonatal intensive care unit (NICU), pediatric APRN patient care teams have successfully expanded to other pediatric medical units. While literature currently does not exist on the use of pediatric APRN patient care teams in pediatric oncology, this model offers
continuity of care, increased quality of care, and improved patient satisfaction, which render it worthy of consideration for use in this specialty.
Nurse Practitioners in Acute Care: Patient Care Outcomes Adult Outcomes In the acute care setting, nurse practitioners provide consistency within a unit and play an important role in facilitating communication between staff, patients, and families. A comparison between nurse practitioners and medical fellows working in an adult intensive care setting found that APRNs spend more time communicating with patients, families, and other team members, which provides better coordination of care (Hoffman, Tasota, Scharfenberg, Zullo, & Donahoe, 2003). Increased communication and care coordination may be attributed to the APRN’s more extended investment in a unit (Pioro et al., 2001; Riportella-Muller, Libby, & Kindig, 1995).
1
The University of Pennsylvania, Philadelphia, PA, USA
Corresponding Author: Julia Rose Golden, RN, MSN, CPHON, 1 Perkins Square,, Akron, OH 44302, USA. Email: [email protected]
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Golden Studies show that APRNs in the hospital setting provide equivalent or superior care in comparison with medical residents, as measured by outcomes such as rate of readmission, duration of ventilator dependence (Hoffman, Tasota, Zullo, Scharfenberg, & Donahoe, 2005; Russell, VorderBruegge, & Burns, 2002), and mortality (Gracias et al., 2008; Hoffman et al., 2005; Pioro et al., 2001). Consistent, efficient, and effective care provided by nurse practitioners contributes to a decreased length of hospitalization and reduced cost of care (Morris et al., 2012; Russell et al., 2002). APRNs also promote safe, evidencebased clinical practice, as they are more likely to adhere to clinical practice guidelines (Gracias et al., 2008; Voogdt-Pruis, Van Ree, Gorgels, & Beusmans, 2011), and the use of screening tools (Morris et al., 2012). A systematic review of 59 studies on outcomes of nurse practitioner care in the emergency department found patient satisfaction was consistently high. This could be attributed to increased quality of care, improved communication, and shorter length of stay compared with care by medical residents (Carter & Chochinov, 2007). The numerous advantages of APRN-managed care, including increased patient satisfaction, decreased length of hospital stay, adherence to clinical guidelines, continuity of care and holistic approach, help explain why many hospitals have transitioned to the APRN model.
Pediatric Outcomes Pediatric APRNs have cared for hospitalized children since the 1970s with the introduction of the first neonatal nurse practitioner (Okuhara, Faire, & Pike, 2011). APRNs are now commonly employed in the inpatient pediatric setting and have positively influenced patient care outcomes in cardiac surgery, trauma, asthma, and cystic fibrosis services as well as in pediatric and neonatal intensive care units (Bissinger, Allred, Arford, & Bellig, 1997; Borgmeyer, Gyr, Jamerson, & Henry, 2008; Brown, Besunder, & Bachmann, 2008; Fanta et al., 2006; Karlowicz & McMurray, 2000; Mitchell-DiCenso et al., 1996; Okuhara et al., 2011; Rideout, 2007; Schultz, Liptak, & Fioravanti, 1994). Studies suggest that nurse practitioner care in the pediatric setting decreases length of hospital stay, increases parent/patient satisfaction, and improves coordination and consistency of care (Bissinger et al., 1997; Brown et al., 2008; Fanta et al., 2006; Rideout, 2007; Silvestri et al., 2005). In addition, care provided by NICU nurse practitioners consistently produces equivalent clinical outcomes as care provided by pediatric residents, as measured by rates of rehospitalization and mortality (Bissinger et al., 1997; Karlowicz & McMurray, 2000; Mitchell-DiCenso et al., 1996; Schultz et al., 1994).
Differences in care between pediatric APRNs and residents are often attributed to nurse practitioners’ familiarity with individual patients, communication skills, continuous presence on the unit, and early identification of patient needs (Bissinger et al., 1997; Carzoli et al., 1994; Karlowicz & McMurray, 2000). This level of care contributes to outcomes that encourage use of pediatric APRNs as patient care providers.
Nurse Practitioner Patient Care Teams Models in Adult Medical Centers In an era when medical institutions must meet demands of increasing census and decreased availability of medical residents, several institutions have pioneered the use of a nurse practitioner patient care team. Studies comparing medical management provided by teams of APRNs and attending physicians, versus fellows and attending physicians, consistently showed that equal care was provided by both teams (Hoffman et al., 2005; Pioro et al., 2001). In fact, one study found patients managed by an APRN and attending physician team were less likely to require reintubation than patients managed by the fellow/ attending team. The authors suggest this positive outcome may be related to the greater amount of time APRNs spent on the unit closely watching and managing their patients (Hoffman et al., 2005). Additionally, teams evaluated by Hoffman et al. (2005) and Morris et al. (2012) had an average of 15 years’ experience caring for patients of their current APRN specialty, which likely contributes to the success of the APRN teams. In a study by Pioro et al. (2001), APRNs leading a general medicine unit were present for 12 hours on weekdays and for morning rounds on weekends. However, overnight medical resident and fellow coverage was critical for successful implementation of a nurse practitioner patient care team in both general medicine and trauma settings (Morris et al., 2012; Pioro et al., 2001). To minimize house staff involvement and to promote autonomy of the nurse practitioner team, protocols were developed for treatment of fever, chest pain, and shortness of breath (Pioro et al., 2001).
Models in Adult Oncology There are 2 reports describing the implementation of an adult oncology nurse practitioner patient care team developed to serve patients who have specialized acute and chronic needs. A large Massachusetts hospital concluded that an oncology nurse practitioner care team was the best fit for the inpatient service in comparison with several physician models, from the perspective of quality, safety,
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Table 1. Daily Intensive Care Unit Nurse Practitioner. Situation
Responsibility
Prerounds
Review the chart, laboratory results, and X-rays Assess the patient Formulate tentative plan of care Carry out urgent interventions Rounds Present data and plan of care Finalize plan of care Postrounds Provide medical management according to plan of care Accompany patients to diagnostic exams Perform invasive procedures Communicate with consulting services Update families Document daily progress notes New Stabilize the patient admissions Obtain and document history and physical Develop differential diagnoses Write orders Communicate with consulting service Source. Adapted from Molitor-Kirsch, Thompson, and Milonovich (2005).
patient satisfaction, cost, and ability to decrease length of stay (Winne et al., 2012). At a large cancer center in New York, which also implemented this model, candidates with acute care nurse practitioner (ACNP) degrees were evaluated and selected based on their educational background, national certification, and clinical experience (D’Agostino & Halpern, 2010). Both centers hired APRNs with oncology experience, considering their familiarity with the nuances of cancer care. Recruited candidates were motivated, self-directed, resourceful, flexible, ambitious, and possessed leadership abilities. (D’Agostino & Halpern, 2010; Winne et al., 2012). New-hire APRNs spent 2 months in orientation, which involved observing resident teams and attending physicians. Topics covered during orientation included infectious diseases, renal and oncologic emergencies, chemotherapy, and pulmonary and cardiac diagnoses (Winne et al., 2012). Communication training involved simulation of difficult conversations with patients and families, delivering bad news, introducing palliative care, and withdrawal of life support. Roles of the critical care oncology nurse practitioner were developed, some of which are outlined in Table 1 (D’Agostino & Halpern, 2010). At these institutions, the oncology APRNs work closely with the attending oncologist during the admission process and on a daily basis to develop and confirm the patient care plan. They also participate in daily multidisciplinary rounds. As a constant presence on the unit,
the APRNs become uniquely familiar with patients, families, and staff, which contributes to improved patient care outcomes (D’Agostino & Halpern, 2010; Winne et al., 2012). The oncology nurse practitioner patient care team allows for better access for patients, families, and nurses to an ordering provider, promoting continuity of care and increased patient satisfaction (Winne et al., 2012).
A Pediatric APRN Patient Care Team Implementation Pediatric APRN patient care teams have found success in neonatal intensive care units for decades and more recently have been adopted in pediatric intensive and emergency care settings. Understanding the successes and challenges of APRN care team models that have been successfully implemented in other pediatric specialties will facilitate the development of APRN patient care teams in pediatric oncology. Pediatric critical care nurse practitioner patient care teams were recently developed in a midsized Ohio children’s hospital and a large Texas children’s hospital (Brown et al., 2008; Molitor-Kirsch et al., 2005). Most of the nurse practitioners hired for the critical care team at the Ohio hospital had pediatric intensive care unit (PICU) registered nurse (RN) experience and were motivated team leaders, spending 80% of their time in clinical practice and dedicating 20% to continuing education, teaching, research, and consultation. They served the unit for 10-hour shifts Monday to Friday with 1 APRN covering weekends and holidays and reported to an APRN coordinator with 50% clinical and 50% administrative duties. Both institutions required an orientation of at least 2 months and up to 1 year, which included PICU-specific education, observation, and feedback from attending physicians (Brown et al., 2008, Molitor-Kirsch et al., 2005). APRNs at the Ohio hospital were also required to have Pediatric Advanced Life Support certification (Brown et al., 2008). Each APRN at the Texas hospital held a master’s degree in acute care nursing with a minimum of 3 years PICU RN experience (Molitor-Kirsch et al., 2005). With more than 30 pediatric critical care APRNs, they provided 24/7 coverage in the trauma ICU and covered 7 a.m. to 7 p.m.,7 days a week in the cardiothoracic ICU (Molitor-Kirsch et al., 2005). Expectations of pediatric critical care APRNs included chairing PICU multidisciplinary rounds, coordinating care for chronically ill and complex patients, and providing education for nursing staff (Brown et al., 2008; Molitor-Kirsch et al., 2005). Additional daily responsibilities of the pediatric critical care APRN are included in Table 1.
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Golden Table 2. Role and Duties of Acute Care Pediatric and Neonatal Nurse Practitioner. Role Consultation
Teaching
Leadership
Duty Admit patients to service Record in-depth medical histories Perform detailed physical exam Write orders Medication reconciliation Prescribe/order medications and therapies Write admission/discharge/daily note Interpret diagnostic studies Write necessary consults Develop and evaluate therapeutic management plans Discharge planning Independent and interdependent decision making Direct accountability for clinical judgment Patient and family education Nursing education Interdisciplinary education Initiate multidisciplinary rounds Involvement in unit and hospital committees Engage in research, continuing education, teaching Consultation and advocacy
Source. Adapted from NAPNAP (National Association of Pediatric Nurse Practitioners) Position Statement on the Acute Care Pediatric Nurse Practitioner (2011); Brown et al. (2008); Moote, Krsek, Kleinpell, and Todd (2011); Steven (2004); Wilson, (2005).
In a Level 3 NICU in Arkansas, a university teaching hospital, and a NICU in Florida, neonatal nurse practitioner (NNP) patient care teams staffed the unit around the clock. During the daytime, the NNP teams worked with an attending neonatologist performing responsibilities included in Table 2 and NNPs staffed the unit overnight (Carzoli et al., 1994; Lee & Jones, 2004; Karlowicz & McMurray, 2000). Between the 3 institutions using the NNP team model of care, nurse practitioners had 2 to 12 years of experience (Carzoli et al., 1994; Lee & Jones, 2004; Karlowicz & McMurray, 2000) and just 5 years after implementation of the NNP team in Arkansas, the nurse practitioners felt they transitioned from novices to experts in their field (Lee & Jones, 2004). Silvestri et al. (2005) illustrate the use of a pediatric APRN patient care team in an emergency department’s extended care unit in a large Pennsylvania children’s hospital. Here, the pediatric APRNs must have a minimum of 3 years primary care experience, a pediatric or family nurse practitioner degree, and excellent assessment and communication skills. Pediatric APRNs then acquire additional knowledge of diagnoses and treatment by working closely with attending physicians. Patient and
parent satisfaction is driven by the consistency of care provided by the pediatric APRN team that serves as a link between primary care physicians, specialists, and social services, and is responsible for patient management from 7 a.m. to 1 a.m. The pediatric APRN patient care team promotes comprehensive, cost-effective, and time-efficient care, which additionally contributes to patient satisfaction.
Challenges and Limitations Institutions faced several challenges in implementing APRN patient care teams. The New York hospital was challenged with the adjustment of unit culture, as most of the nurses were not used to working with APRNs (D’Agostino & Halpern, 2010). However, the Texas Children’s Hospital found that nurses preferred to address their concerns with an APRN, as opposed to a physician, after successful establishment of a nurse practitioner patient care team. This preference was related to the constant presence of APRNs on the unit and their dual medical and nursing perspectives (Molitor-Kirsch et al., 2005). Another challenge related to the transition from the role of a bedside nurse to the role of nurse practitioner (D’Agostino & Halpern, 2010). APRNs have a different type of authority and autonomy than the bedside RN, so sufficient training and orientation are necessary for successful role transition. Several studies addressed attending physician concern about the level of knowledge and skill possessed by the APRNs and their ability to address end of life care with patients and families (D’Agostino & Halpern, 2010; Garland & Gershengorn, 2013). Over time, however, their worry resolved due to extensive training and a level of trust that was built between the nurse practitioners and attending physicians (D’Agostino & Halpern, 2010). Despite successful implementation of a nurse practitioner patient care team for the ICU at the Texas Children’s Hospital, expansion of the program proved challenging. Molitor-Kirsch et al. (2005) attributes this difficulty to a limited number of qualified APRN graduates, which results from the relatively few programs offering training for pediatric acute care nurse practitioners. Unfortunately, despite the increasing reliance on nurse practitioner–led care teams, there has been no increase in new graduates of pediatric APRN programs over the past 15 years and the lack of qualified applicants remains (Freed et al., 2012).
Implications of a Proposed Pediatric Oncology APRN Patient Care Team Studies in both adult and pediatric populations demonstrate that nurse practitioner patient care teams, in collaboration with attending physicians, provide equitable
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clinical outcomes to care provided by medical residents and fellows in varying patient populations (Bissinger et al., 1997; Borgmeyer et al., 2008; Brown et al., 2008; Carter & Chochinov, 2007; Carzoli et al., 1994; Fanta et al., 2006; Gracias et al., 2008; Hoffman et al., 2005; Karlowicz & McMurray, 2000; Mitchell-DiCenso et al., 1996; Morris et al., 2012; Pioro et al., 2001; Rideout, 2007; Russell et al., 2002; Schultz et al., 1994). Hospitalized patients benefit from the consistency provided by a single practitioner. With appropriate training, support, and supervision, a nurse practitioner can effectively manage a caseload of acutely, chronically, and/or critically ill patients, and hospitalized patients benefit from the consistency provided by a single practitioner (Hoffman et al., 2005). Literature supports the APRN-run unit as a viable option for the care of acute and critically ill children; such a model would be a valuable option in the pediatric oncology setting. A nurse practitioner pediatric oncology patient care team would ensure continuity of care to patients and families of a child with cancer. Recurring hospital admissions are incredibly stressful and it is reassuring for oncology patients and families to see a familiar inpatient provider who is well versed in a child’s history. Based on experiences with previous admissions, APRNs are more keenly aware than rotating residents of physical and emotional signs in patients that reflect their current picture of health, therefore providing personalized and improved care (Steven, 2004). In order to ease the transition to this model of care, units implementing a nurse practitioner pediatric oncology patient care team should consider including a rotation for their hired nurse practitioners at a hospital currently using this patient care model (Brown et al., 2008). Additionally, developing protocols (Pioro et al., 2001) for common pediatric oncology medical problems may assist in APRN clinical decision making. Standard protocols may increase the productivity and efficiency of a pediatric oncology nurse practitioner patient care team (Pioro et al., 2001).
Anticipated Challenges Development of pediatric oncology nurse practitioner teams may be challenging as there are a limited number of qualified practitioners; only 10% of nurse practitioner students choose to enter pediatrics (Freed et al., 2012); the University of Pennsylvania (2013) is currently the only school offering specialized ACNP training in pediatric oncology. Recruitment into pediatric subspecialties can be challenging due to the need for specialized skills and knowledge. It is therefore vital to support pediatric ACNP graduate education programs that precept and train future
graduates who will enter the workforce as pediatric oncology nurse practitioners (Okuhara et al., 2011).
Future Research With the development of the pediatric ACNP degree and increased demand for nurse practitioners in the acute care setting, future research should be dedicated to examining the role of the acute care APRN team and the impact on patient outcomes. Patient outcomes will help identify aspects of this care model requiring additional research and/or revision. From an operational perspective, future studies should include investigating optimal work hours to yield maximum productivity of a nurse practitioner patient care team as well as clinician job satisfaction. Further research should also be conducted to evaluate the financial impact of nurse practitioner patient care teams.
Conclusion Nurse practitioners provide safe, effective, and efficient care in inpatient adult and pediatric settings. APRN patient care teams are a current trend in medical centers, and several studies illustrate successful implementations of this model. The steps for establishment of a pediatric APRN nurse practitioner team include identifying a patient population that would benefit from this model of care, defining the role and responsibilities of the nurse practitioner, hiring qualified personnel with an appropriate educational background, providing a comprehensive orientation, establishing an administrative APRN role, and anticipating challenges to implementation. A pediatric oncology nurse practitioner patient care team would provide holistic, high-quality, oncologyfocused care, and positively affect this specialized patient population. Declaration of Conflicting Interests The author is currently an employee of Akron Children’s Hospital which is one of the institutions that has successfully implemented the pediatric nurse practitier patient care team as discussed in this article..
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
Note 1. In this article, the terms APRN and nurse practitioner are used interchangeably.
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Author Biography Julia Rose Golden, RN, MSN, CPHON, currently practices as an Acute Care Pediatric Hematology/Oncology/Bone Marrow Transplant Nurse Practitioner at Akron Children’s Hospital in Akron, Ohio. She earned her MSN from the University of Pennsylvania in 2013 and her BSN from Case Western Reserve University in 2009.
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