Mid-Level Providers: What Do We Do? Victoria F. Owens, RN, FNP, Tina L. Palmieri, MD, FACS, David G. Greenhalgh, MD, FACS
Changes in resident physician work hours have made it increasingly more difficult for physicians to meet the needs of their patients. In many facilities, mid-level providers (MLPs; advanced practice nurses and physician assistants) have become integral members of the medical team in both inpatient and outpatient settings. The purpose of this study was to identify the roles of MLPs in the American Burn Association (ABA) and within burn care teams. There was a 49% return survey response rate. Respondents included 28 (58%) nurse practitioners and 16 (33%) physician assistants. Forty-six percentage of the MLPs had at least 11 years of burn care experience. Forty respondents (87%) worked both inpatient and outpatient settings. Thirty-four (74%) of the providers ran independent clinics. Job responsibilities were in areas of direct patient care, education, and administrative duties. The majority of respondents were members of the ABA, attended annual conferences, and were advanced burn life support instructors. Forty-two (91%) of the MLPs were satisfied with their jobs. In conclusion, MLPs are highly experienced, ABA members and assume direct care of the burn patient. (J Burn Care Res 2016;37:122–126)
Resident physicians are an integral part of the medical staff team in teaching hospitals. In order to provide comprehensive care for hospitalized patients 24 hours, 7 days per week, residents rotate and cover patient’s needs during off hours; including evenings, nights, weekends, and holidays. In July 2003, the Accreditation Council for Graduate Education introduced reform that limits the residents’ workweek to 80 hours.1 Additional restrictions on maximal shift length and guidelines regarding direct supervision based on the resident physician’s level of experience and competency were made effective in July 2011.2 These changes in resident physician work hours have made it increasingly difficult for physicians to meet the needs of their patients. In many facilities, mid-level providers (MLPs; nurse practitioner [NP], physician assistant [PA], and clinical nurse specialist [CNS]) have filled the gap created by resident hour
From the Shriners Hospital for Children, Northern California, Sacramento. Address correspondence to Victoria F. Owens, Shriners Hospital for Children, Northern California, 2425 Stockton Blvd, Sacramento, California 95817. Email: [email protected] Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site. Copyright © 2014 by the American Burn Association 1559-047X/2014 DOI: 10.1097/BCR.0000000000000229
122
decreases, assuming expanded roles in both the inpatient and outpatient settings. The purpose of this study was to identify the various roles that MLPs play within burn care teams and their level of involvement in the American Burn Association (ABA) activities.
METHODS A 30-item questionnaire was developed and, in July and August 2006, sent to providers who supplied their email or postal mailing address to the ABA MLP special interest group (SIG; see Appendix, Supplemental Digital Content 1, at http://links.lww.com/ BCR/A23). Surveys were also available at the 2007 ABA conference MLP SIG meeting. The questionnaire assessed professional licensure, ABA membership and involvement, and work practice responsibilities. Approval for the study and survey was obtained from the Internal Review Board, Office of Research, University of California, Davis. The surveys were coded and sent with a cover letter with instructions for return by email, fax, or standard mail. A second request follow-up letter with an attached survey was sent to those who did not respond to the initial mailing. Once the completed surveys were returned, the information was entered, maintained, and tabulated in a Microsoft ACCESS program. Calculations for individual questions were based on the number of respondents who answered the question.
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Owens, Palmieri, and Greenhalgh 123
Figure 1. Practice settings for MLPs by state. MLP, mid-level provider.
RESULTS One-hundred and eight surveys were sent, 67 via email, 34 via U.S. postal service, and seven were completed at the 2007 ABA. Eleven surveys were returned unopened because of address changes; therefore, 97 surveys were successfully delivered. Forty-eight (49%) surveys were completed and returned, 28 (58%) email, 13 (27%) standard mail, and seven (15%) at the ABA. Thirty-eight (79%) of the respondents were women. There were 28 (58%) NPs, 16 (33%) PAs, 2 (4%) CNSs, and 2 (4%) respondents did not designate their title. Nearly half (46%) of the MLPs started their healthcare careers as NPs or PAs. Thirty-five (74%) of the MLPs had advanced degrees. Of those providers, 34 had a master’s degree and one had a doctorate. All 16 (100%) of the PAs and 24 (86%) of the NPs held practice certifications. Practice locations included 27 states, Mexico, and Canada. States with the most practicing MLPs were New York, Massachusetts, California, and Florida (Figure 1). Fifteen (33%) of the respondents had a minimum of 15 years of burn care experience and six (13%) had from 11 to 15 years of burn care experience. Eight (17%) had been in their current MLP position for
more than 15 years and five (11%) from 11 to 15 years (Figures 2 and 3). More than half (57%) of the respondents worked only for the burn service. MLPs also worked for plastic and reconstructive surgery, ortho-hand, craniofacial, general surgery, vascular surgery, and the wound service. Forty-one (85%) of the respondents were members of the ABA, 24 (51%) had presented abstracts at an annual conference, and 28 (61%) were advanced burn life support
Figure 2. Years of burn care experience by provider type.
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124 Owens, Palmieri, and Greenhalgh
instructors. Of those MLPs who were members of the ABA, 17 (41%) paid their own membership dues. Forty respondents (87%) worked both inpatient and outpatient settings. Five (11%) NPs worked only in the clinic and one NP worked only inpatient. All (100%) of the PAs worked both inpatient and outpatient. Thirty-one of the MLPs (67%) treated both pediatric and adult patients. Thirtyfour (74%) of the providers ran independent clinics, 36 (78%) completed admission history and physicals, 39 (85%) discharged patients, 27 (59%) assisted in the operating room (OR), 12 (26%) performed central venous line (CVL) placement, and 11 (24%) took call-time. More than 65% of the MLPs were a resource for resident physicians and medical students as well as being involved in staff and community education. Twenty-five (54%) of the MLPs were involved in clinical research. Forty-one (89%) of the MLPs spent at least 20 hours each week in direct patient care. Of those, 15 (37%) reported working more than 40 hours in direct patient care. All of the responses to the question about job responsibilities were grouped under the categories of patient care, education, or administrative duties and provided in graph format (Figures 4–6). Some MLPs wrote in additional duties they would like to have; assist in the OR, placement of chest tubes, CVL placement, and more time for research and community outreach. The majority of the respondents reported being satisfied with their jobs; 32 (70%)
Figure 4. Job responsibilities in patient care.
Figure 3. Years in current MLP position by provider type. MLP, mid-level provider.
were extremely satisfied; and 10 (22%) were somewhat satisfied. Four (9%) reported being somewhat or extremely dissatisfied with their jobs.
DISCUSSION Various terms are used to identify those healthcare professionals who have attained education above the baccalaureate level of nursing education but less than a clinical doctoral degree. Examples are nonphysician providers,3 physician extenders,4 nonphysician clinical staff,5 and MLPs all of which
Journal of Burn Care & Research Volume 37, Number 2
Figure 5. Job responsibilities in education.
can include PAs and advanced practice nurses. Advanced practice nurse encompasses NPs, CNSs, nurse midwives, and certified registered nurse anesthetists.6 Training programs for the NPs and PAs (MLPs) began in the 1960s.4 The goal was to improve access to care created by a shortage of physicians.4,6,7 Initially, MLPs provided primary care for the underserved population. During the past four decades, MLPs have worked in variety of settings; in underserved areas, medical offices, clinics, and hospitals. The advanced training received by NPs and PAs have allowed them the flexibility to work in both primary care and specialty care settings. Master’s programs to prepare nurses as clinical specialists began in 1954.8 For the purposes of this study, MLP includes NPs, PAs, and CNS. Rules and regulations regarding scope of practice, prescribing, and reimbursement for these provider groups can vary from state to state. The NP journal provides an annual update on numbers of NPs per state and is a resource for information on variations in state legislation, reimbursement, and prescriptive authority for advanced practice nurses.9 The website for the American Academy of Physician Assistants is a good resource for specific laws and regulations that affect practice for PAs in the United States.10 Respondents for this study were a good representation across the United States. States with the most respondents for the study were among the top five states for all practicing MLPs, with one exception. Massachusetts does not fall within the top 10 states for practicing PAs.9,10 With this in mind, the duties and responsibilities detailed from this survey should match the potential skill set for MPLs in general. Results from this study did not identify any job responsibility that was isolated to NPs or PAs
Owens, Palmieri, and Greenhalgh 125
Figure 6. Administrative job responsibilities.
only. Limitations in MLP job responsibilities may be because of specific state regulations, hospital policies, or departmental needs. Burn care requires a team approach. MLPs are able to work with the team on many levels. Their goal is not to take over the role of resident physicians but to work in conjunction with them and in a collaborative role with the attending physicians. As a new rotation of residents comes through, MLPs serve as a resource by orienting them to hospital protocols and imparting information specific to the treatment of burn injuries. Burn wound care can vary by facility, provider, and stage of healing. In order to ensure good patient outcomes, it is important to provide consistent, ongoing care to each individual burn patient. MLPs are a consistent member of the burn team and can bridge the gap between changes in resident rotations and work hours, help to ensure continuity of care while allowing the resident physicians the opportunity to learn. MLPs are often the first clinician notified of patient care needs during the day and will evaluate the patient and make adjustments in treatment as needed. Other daytime duties may include bedside sedation procedures and placement of CVLs. As MLPs are readily available to treat the more routine patient care needs the attending physician is better able to focus on the acute unstable patients or in the OR. Levels of independence can vary depending on the needs of the institution. Many MLPs are highly experienced and run independent clinics. Burn injuries that do not require inpatient admission can easily be managed and cared for in the outpatient setting. Other patients suitable for MLP clinics are postoperative follow-up visits and routine visits for established patients. Established patients are evaluated for reconstructive surgeries. These patients are
Journal of Burn Care & Research March/April 2016
126 Owens, Palmieri, and Greenhalgh
then referred back to the burn or plastic surgeon for surgical intervention. Most of the MLPs work in both the inpatient and outpatient settings. Burn patients have complex needs that can extend for months to years after the initial encounter. Being able to follow a patient from inpatient care through discharge and clinic followup can improve outcomes through continuity of care. They demonstrate a commitment to burn care with more years of burn care experience than years in the current MLP role. Many have worked in the burn care arena before continuing their training and education to become an NP or PA. Commitment to burn care is also demonstrated by MLP presence at annual ABA conferences as well as teaching advanced burn life support courses to improve the quality of burn care provided. One potential limitation to this study is the return rate of surveys. We started with 108 surveys and had a 49% return rate. Also, the provider list was obtained through the MLP SIG group. Therefore, only providers who had some connection with the ABA were surveyed. Additionally, this survey was sent before the most recent changes in resident work hours that took effect in July 2011. A more current survey would likely also demonstrate MLPs as significant members of the burn team but with more responsibility and in greater numbers.
CONCLUSION MLPs bring many years of burn experience to the ABA and burn care team. By filling a variety of roles
often performed by the resident physician, MLPs are able to help bridge the gap created by resident duty hour decreases. MLPs are a stable resource for nursing staff, residents, and the burn surgeon, allowing more opportunity to meet the complex needs of the burn patient. More extensive use of MLPs can help to improve the efficiency, quality, and continuity of patient care provided by the burn team. REFERENCES 1. Philibert I, Friedmann P, Williams WT; ACGME Work Group on Resident Duty Hours. Accreditation Council for Graduate Medical Education. New requirements for resident duty hours. JAMA 2002;288:1112–4. 2. Iglehart J. The ACGME’s final duty-hour standards-special PGY-1 limits and strategic napping. N Engl J Med 2010;363(17):1589–91. 3. Physician assistants and nurse practitioners. American College of Physicians. Ann Intern Med1994;121(9):714–6. 4. DeNicola L, Kleid D, Brink L, et al. Use of pediatric physician extenders in pediatric and neonatal intensive care units. Crit Care Med 1994;22:1856–64. 5. Miller JA, Nelson J, Whitcomb W. Use of non-physician clinical staff in hospitalist programs. In: Hospitalists: a guide to building and sustaining a successful program. Chicago: Health Administration Press; 2007. p. 101–10. 6. Delametter GL. Advanced practice nursing and the role of the pediatric critical care nurse practitioner. Crit Care Nurs Q 1999;21:16–21. 7. American Academy of Pediatrics. Committee on Hospital Care. The role of the nurse practitioner and physician assistant in the care of hospitalized children. Pediatrics 1999;103(5 Pt 1):1050–2. 8. Smoyak SA. Specialization in nursing: from then to now. Nurs Outlook 1976;24:676–81. 9. Phillips SJ. 25th annual legislative update: evidence-based practice reforms improve access to APRN care. Nurse Pract 2013;38:18–42. 10. The American Academy of Physician Assistants. http:// www.aapa.org/. Accessed 22 Oct. 2013.
Changes in resident physician work hours have made it increasingly more difficult for physicians to meet the needs of their patients. In many facilities, mid-level providers (MLPs; advanced practice nurses and physician assistants) have become integral members of the medical team in both inpatient and outpatient settings. The purpose of this study was to identify the roles of MLPs in the American Burn Association (ABA) and within burn care teams. There was a 49% return survey response rate. Respondents included 28 (58%) nurse practitioners and 16 (33%) physician assistants. Forty-six percentage of the MLPs had at least 11 years of burn care experience. Forty respondents (87%) worked both inpatient and outpatient settings. Thirty-four (74%) of the providers ran independent clinics. Job responsibilities were in areas of direct patient care, education, and administrative duties. The majority of respondents were members of the ABA, attended annual conferences, and were advanced burn life support instructors. Forty-two (91%) of the MLPs were satisfied with their jobs. In conclusion, MLPs are highly experienced, ABA members and assume direct care of the burn patient. (J Burn Care Res 2016;37:122–126)
Resident physicians are an integral part of the medical staff team in teaching hospitals. In order to provide comprehensive care for hospitalized patients 24 hours, 7 days per week, residents rotate and cover patient’s needs during off hours; including evenings, nights, weekends, and holidays. In July 2003, the Accreditation Council for Graduate Education introduced reform that limits the residents’ workweek to 80 hours.1 Additional restrictions on maximal shift length and guidelines regarding direct supervision based on the resident physician’s level of experience and competency were made effective in July 2011.2 These changes in resident physician work hours have made it increasingly difficult for physicians to meet the needs of their patients. In many facilities, mid-level providers (MLPs; nurse practitioner [NP], physician assistant [PA], and clinical nurse specialist [CNS]) have filled the gap created by resident hour
From the Shriners Hospital for Children, Northern California, Sacramento. Address correspondence to Victoria F. Owens, Shriners Hospital for Children, Northern California, 2425 Stockton Blvd, Sacramento, California 95817. Email: [email protected] Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site. Copyright © 2014 by the American Burn Association 1559-047X/2014 DOI: 10.1097/BCR.0000000000000229
122
decreases, assuming expanded roles in both the inpatient and outpatient settings. The purpose of this study was to identify the various roles that MLPs play within burn care teams and their level of involvement in the American Burn Association (ABA) activities.
METHODS A 30-item questionnaire was developed and, in July and August 2006, sent to providers who supplied their email or postal mailing address to the ABA MLP special interest group (SIG; see Appendix, Supplemental Digital Content 1, at http://links.lww.com/ BCR/A23). Surveys were also available at the 2007 ABA conference MLP SIG meeting. The questionnaire assessed professional licensure, ABA membership and involvement, and work practice responsibilities. Approval for the study and survey was obtained from the Internal Review Board, Office of Research, University of California, Davis. The surveys were coded and sent with a cover letter with instructions for return by email, fax, or standard mail. A second request follow-up letter with an attached survey was sent to those who did not respond to the initial mailing. Once the completed surveys were returned, the information was entered, maintained, and tabulated in a Microsoft ACCESS program. Calculations for individual questions were based on the number of respondents who answered the question.
Journal of Burn Care & Research Volume 37, Number 2
Owens, Palmieri, and Greenhalgh 123
Figure 1. Practice settings for MLPs by state. MLP, mid-level provider.
RESULTS One-hundred and eight surveys were sent, 67 via email, 34 via U.S. postal service, and seven were completed at the 2007 ABA. Eleven surveys were returned unopened because of address changes; therefore, 97 surveys were successfully delivered. Forty-eight (49%) surveys were completed and returned, 28 (58%) email, 13 (27%) standard mail, and seven (15%) at the ABA. Thirty-eight (79%) of the respondents were women. There were 28 (58%) NPs, 16 (33%) PAs, 2 (4%) CNSs, and 2 (4%) respondents did not designate their title. Nearly half (46%) of the MLPs started their healthcare careers as NPs or PAs. Thirty-five (74%) of the MLPs had advanced degrees. Of those providers, 34 had a master’s degree and one had a doctorate. All 16 (100%) of the PAs and 24 (86%) of the NPs held practice certifications. Practice locations included 27 states, Mexico, and Canada. States with the most practicing MLPs were New York, Massachusetts, California, and Florida (Figure 1). Fifteen (33%) of the respondents had a minimum of 15 years of burn care experience and six (13%) had from 11 to 15 years of burn care experience. Eight (17%) had been in their current MLP position for
more than 15 years and five (11%) from 11 to 15 years (Figures 2 and 3). More than half (57%) of the respondents worked only for the burn service. MLPs also worked for plastic and reconstructive surgery, ortho-hand, craniofacial, general surgery, vascular surgery, and the wound service. Forty-one (85%) of the respondents were members of the ABA, 24 (51%) had presented abstracts at an annual conference, and 28 (61%) were advanced burn life support
Figure 2. Years of burn care experience by provider type.
Journal of Burn Care & Research March/April 2016
124 Owens, Palmieri, and Greenhalgh
instructors. Of those MLPs who were members of the ABA, 17 (41%) paid their own membership dues. Forty respondents (87%) worked both inpatient and outpatient settings. Five (11%) NPs worked only in the clinic and one NP worked only inpatient. All (100%) of the PAs worked both inpatient and outpatient. Thirty-one of the MLPs (67%) treated both pediatric and adult patients. Thirtyfour (74%) of the providers ran independent clinics, 36 (78%) completed admission history and physicals, 39 (85%) discharged patients, 27 (59%) assisted in the operating room (OR), 12 (26%) performed central venous line (CVL) placement, and 11 (24%) took call-time. More than 65% of the MLPs were a resource for resident physicians and medical students as well as being involved in staff and community education. Twenty-five (54%) of the MLPs were involved in clinical research. Forty-one (89%) of the MLPs spent at least 20 hours each week in direct patient care. Of those, 15 (37%) reported working more than 40 hours in direct patient care. All of the responses to the question about job responsibilities were grouped under the categories of patient care, education, or administrative duties and provided in graph format (Figures 4–6). Some MLPs wrote in additional duties they would like to have; assist in the OR, placement of chest tubes, CVL placement, and more time for research and community outreach. The majority of the respondents reported being satisfied with their jobs; 32 (70%)
Figure 4. Job responsibilities in patient care.
Figure 3. Years in current MLP position by provider type. MLP, mid-level provider.
were extremely satisfied; and 10 (22%) were somewhat satisfied. Four (9%) reported being somewhat or extremely dissatisfied with their jobs.
DISCUSSION Various terms are used to identify those healthcare professionals who have attained education above the baccalaureate level of nursing education but less than a clinical doctoral degree. Examples are nonphysician providers,3 physician extenders,4 nonphysician clinical staff,5 and MLPs all of which
Journal of Burn Care & Research Volume 37, Number 2
Figure 5. Job responsibilities in education.
can include PAs and advanced practice nurses. Advanced practice nurse encompasses NPs, CNSs, nurse midwives, and certified registered nurse anesthetists.6 Training programs for the NPs and PAs (MLPs) began in the 1960s.4 The goal was to improve access to care created by a shortage of physicians.4,6,7 Initially, MLPs provided primary care for the underserved population. During the past four decades, MLPs have worked in variety of settings; in underserved areas, medical offices, clinics, and hospitals. The advanced training received by NPs and PAs have allowed them the flexibility to work in both primary care and specialty care settings. Master’s programs to prepare nurses as clinical specialists began in 1954.8 For the purposes of this study, MLP includes NPs, PAs, and CNS. Rules and regulations regarding scope of practice, prescribing, and reimbursement for these provider groups can vary from state to state. The NP journal provides an annual update on numbers of NPs per state and is a resource for information on variations in state legislation, reimbursement, and prescriptive authority for advanced practice nurses.9 The website for the American Academy of Physician Assistants is a good resource for specific laws and regulations that affect practice for PAs in the United States.10 Respondents for this study were a good representation across the United States. States with the most respondents for the study were among the top five states for all practicing MLPs, with one exception. Massachusetts does not fall within the top 10 states for practicing PAs.9,10 With this in mind, the duties and responsibilities detailed from this survey should match the potential skill set for MPLs in general. Results from this study did not identify any job responsibility that was isolated to NPs or PAs
Owens, Palmieri, and Greenhalgh 125
Figure 6. Administrative job responsibilities.
only. Limitations in MLP job responsibilities may be because of specific state regulations, hospital policies, or departmental needs. Burn care requires a team approach. MLPs are able to work with the team on many levels. Their goal is not to take over the role of resident physicians but to work in conjunction with them and in a collaborative role with the attending physicians. As a new rotation of residents comes through, MLPs serve as a resource by orienting them to hospital protocols and imparting information specific to the treatment of burn injuries. Burn wound care can vary by facility, provider, and stage of healing. In order to ensure good patient outcomes, it is important to provide consistent, ongoing care to each individual burn patient. MLPs are a consistent member of the burn team and can bridge the gap between changes in resident rotations and work hours, help to ensure continuity of care while allowing the resident physicians the opportunity to learn. MLPs are often the first clinician notified of patient care needs during the day and will evaluate the patient and make adjustments in treatment as needed. Other daytime duties may include bedside sedation procedures and placement of CVLs. As MLPs are readily available to treat the more routine patient care needs the attending physician is better able to focus on the acute unstable patients or in the OR. Levels of independence can vary depending on the needs of the institution. Many MLPs are highly experienced and run independent clinics. Burn injuries that do not require inpatient admission can easily be managed and cared for in the outpatient setting. Other patients suitable for MLP clinics are postoperative follow-up visits and routine visits for established patients. Established patients are evaluated for reconstructive surgeries. These patients are
Journal of Burn Care & Research March/April 2016
126 Owens, Palmieri, and Greenhalgh
then referred back to the burn or plastic surgeon for surgical intervention. Most of the MLPs work in both the inpatient and outpatient settings. Burn patients have complex needs that can extend for months to years after the initial encounter. Being able to follow a patient from inpatient care through discharge and clinic followup can improve outcomes through continuity of care. They demonstrate a commitment to burn care with more years of burn care experience than years in the current MLP role. Many have worked in the burn care arena before continuing their training and education to become an NP or PA. Commitment to burn care is also demonstrated by MLP presence at annual ABA conferences as well as teaching advanced burn life support courses to improve the quality of burn care provided. One potential limitation to this study is the return rate of surveys. We started with 108 surveys and had a 49% return rate. Also, the provider list was obtained through the MLP SIG group. Therefore, only providers who had some connection with the ABA were surveyed. Additionally, this survey was sent before the most recent changes in resident work hours that took effect in July 2011. A more current survey would likely also demonstrate MLPs as significant members of the burn team but with more responsibility and in greater numbers.
CONCLUSION MLPs bring many years of burn experience to the ABA and burn care team. By filling a variety of roles
often performed by the resident physician, MLPs are able to help bridge the gap created by resident duty hour decreases. MLPs are a stable resource for nursing staff, residents, and the burn surgeon, allowing more opportunity to meet the complex needs of the burn patient. More extensive use of MLPs can help to improve the efficiency, quality, and continuity of patient care provided by the burn team. REFERENCES 1. Philibert I, Friedmann P, Williams WT; ACGME Work Group on Resident Duty Hours. Accreditation Council for Graduate Medical Education. New requirements for resident duty hours. JAMA 2002;288:1112–4. 2. Iglehart J. The ACGME’s final duty-hour standards-special PGY-1 limits and strategic napping. N Engl J Med 2010;363(17):1589–91. 3. Physician assistants and nurse practitioners. American College of Physicians. Ann Intern Med1994;121(9):714–6. 4. DeNicola L, Kleid D, Brink L, et al. Use of pediatric physician extenders in pediatric and neonatal intensive care units. Crit Care Med 1994;22:1856–64. 5. Miller JA, Nelson J, Whitcomb W. Use of non-physician clinical staff in hospitalist programs. In: Hospitalists: a guide to building and sustaining a successful program. Chicago: Health Administration Press; 2007. p. 101–10. 6. Delametter GL. Advanced practice nursing and the role of the pediatric critical care nurse practitioner. Crit Care Nurs Q 1999;21:16–21. 7. American Academy of Pediatrics. Committee on Hospital Care. The role of the nurse practitioner and physician assistant in the care of hospitalized children. Pediatrics 1999;103(5 Pt 1):1050–2. 8. Smoyak SA. Specialization in nursing: from then to now. Nurs Outlook 1976;24:676–81. 9. Phillips SJ. 25th annual legislative update: evidence-based practice reforms improve access to APRN care. Nurse Pract 2013;38:18–42. 10. The American Academy of Physician Assistants. http:// www.aapa.org/. Accessed 22 Oct. 2013.
