The Nurse Practitioner in Tertiary Care
Therese S. Richmond, MSN, RN, CCRN Anne Keane, EdD, RN Today's healthcare environment is typified by patients with specialized healthcare needs who are hospitalized for acute illness, but discharged quickly with continued needs. Dramatic changes in healthcare coupled with increasingly complex patients have challenged leaders in tertiary care settings. The nurse practitioner (NP) role, although initially conceptualized as a response to primary care needs, can and should be expanded to the care of patients with specialized healthcare needs in tertiary care. There is precedent for the NP role in tertiary care. For example, the neonatal NP whose primary base of practice is the neonatal intensive care unit. The decision to extend the NP role into tertiary care and the responsibility to implement the role rests with the nurse executive. We spoke with seven nurse executives in tertiary care hospitals to explore their ideas concerning why the role is needed and to discuss issues critical to successful implementation of the NP role. JUSTIFICATION OF THE ROLE
The need for NPs in tertiary care settings must be established within the context of today's cost-conscious, quality-driven healthcare environment. The nurse executives identified five key factors leading to the need for the NP in tertiary care. Therese S. Richmond, MSN, RN, CCRN, research assistant and doctoral student, Anne Keane, EdD, RN, Associate Professor, School of Nursing, University of Pennsylvania, Philadelphia.
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• Changes in medical residency programs: Changes in residency programs in tertiary care facilities are consistently identified as a major stressor. The changes that directly affect patient care include a decrease in the size of programs coupled with increasing acuity and complexity of patients, difficulty in filling existing residency slots, and reconfiguration of residency programs with increased emphasis on primary care.1'2 In at least one state, the hours per week that residents may work is limited. Taken together, these changes leave gaps in the in-hospital continuous management of acutely ill patients. These changes in the residency programs are causing physicians, nurse executives, and hospital administrators to evaluate the best way to provide coverage for complex patients. One solution is to use physician's assistants or NPs. The choice is critical. NPs provide a different level of care than the physician assistant and bring a unique nursing perspective to the care of patients. • Consumer access: Access to appropriate levels of healthcare is puzzling and poses a challenge for the public. NPs in the near future may assume the role of gatekeeper to healthcare services. NPs could facilitate access to physicians, efficient referral patterns, and develop a holistic plan of care (of which one piece would be medical management). Although physicians primarily build their foundations in highly specialized areas, the NP in tertiary care could be the central figure who inte-
grates the diverse aspects of the healthcare arena with the unique needs of the patient. Physician access: Limited access by patients to the attending physician in teaching hospitals due to their practice and academic duties is an issue. NPs could provide a contact point. For the public, clamoring for input into healthcare decisions, increased opportunities to talk with their healthcare providers are critical. NPs represent the physician and thus increase accessibility. NPs bring a unique blend of knowledge and communication skills of a nurse that support dialogue and joint decision making. Bridging the gap: The need for improved marketability and flexibility in the healthcare system is critical for the continued evolution of advanced practice nurses. The NP in tertiary care has clinical assessment and decision-making skills tailored to the needs of complex patients; direct responsibility for a case load of patients that allows quantification of productivity; ability to carry a case load and write medical and nursing orders; and the ability to function as a decision maker and as a first-line diagnostician. The ability to bridge the gap between the nursing and the medical world, including the understanding of quality care and factors leading to satisfied patients, is critical for the future. Fragmented care: Continuity of care, although valued, is increasContinued
IN MY OPINION ingly difficult to deliver in today's specialized healthcare environment. Patients, particularly those with complex healthcare problems, go from one episodic exacerbation to another and are at risk for fragmented care. Recidivism is high for these patients resulting in increased consumption of healthcare resources. There is no member of the healthcare team at present who is interested or equipped to provide the linkage between episodes of illnesses. The NP in tertiary care, spanning inpatient and outpatient settings, is one who would be prepared with the skills necessary to manage multiple transitions in care. NPs, focused on the total care of the patient, can evaluate the many factors contributing to the need for healthcare, explore specific factors that stimulated this occurrence, and assess resources needed upon discharge and thus minimize recidivism. ORGANIZATIONAL CONSIDERATIONS
How might the NP best fit in the tertiary care setting? The nurse executives identified two major models: the joint professional practice model and the nursing-based model. • Joint professional practice model: In this model, NPs join a specialty physician practice plan and establish a collaborative practice. NPs directly report to the partners of the practice plan with dotted-line or matrixed reporting to a nurse director or nurse executive. Advantages of the joint professional practice model include a cohesive medical/nursing approach to the care of patients with specialized needs, ability to care for patients in all phases of their illness/injury (pre-, intra-, and posthospital care), securing a salary outside of the nursing budgetary process, and being viewed as
a member of medical and nursing worlds by healthcare team members and patients. Additionally, NPs increase accessibility for the patient to individuals who directly represent physicians, but who have integrated nursing's professional values and unique approach to patient care. Disadvantages of the joint professional practice model include potential for limited use of advanced nursing knowledge and skills, tension resulting from differential definitions of the meaning of team and team leader within the practice group, and loss of identification with nursing and nursing issues over time. • Nursing-based model: NPs report directly to nursing directors or executives with matrixed reporting to physician specialists. When the nurse executive is responsible for patient care services beyond the nursing department, the nursing-based model is preferred. NPs now practice in emergency departments, critical care units, and orthopedic specialty areas and are gradually becoming more specialty oriented with expectations that they are prepared to care for acutely ill patients with specialized needs. Advantages of the nursingbased model include a strong and clear identity with nursing and nursing issues, increased opportunity to maintain focus on advanced nursing practice vs. medical practice, the ability to move toward direct reimbursement by third party payers directly into nursing departments, and the enhancement of nursing's ability to clearly demonstrate involvement in product line activities and patient care outcomes. Disadvantages surface in the nursing-based model. Although these practitioners are critical to the effective management of specialized populations, they are a
major line item in a budget that is increasingly scrutinized. Budgetary justification of NPs may be difficult but not impossible. The second disadvantage is the potential for limited collaborative relationships with peer specialty physicians. Matrixed reporting is critical in order for physicians to view NPs as a benefit rather than a threat. Regardless of the model chosen, credentialling of NPs for the tertiary care setting is a dual process. The nursing department must have a credentialling system for advanced practice nurses and clearly delineate the scope of practice. Concurrently, NPs must be credentialled by the medical department to delineate the scope of practice from a medical perspective. FOOD FOR THOUGHT
Are nurse practitioners moving into tertiary care? We strongly believe, and the nurse executives to whom we spoke agree, that nurse practitioners are needed in tertiary care now. The decision to bring NPs into tertiary care is a critical one that will affect patient care and help shape the profession of nursing well into the future. ACKNOWLEDGMENT
The authors thank Anne Cote, MPA, RN, Karen Javie, MSN, RN, Joyce Johnson, DNSc, RN, Mary Kinneman, MSN, RN, Mary Ann McGinley, MSN, RN, Margaret Sovie, PhD, FAAN, and William Warfel, PhD, RN, for their participation in discussions concerning the nurse practitioner in tertiary care. REFERENCES
1. Petersdorf RG, BentleyJ. Residents' hours and supervision. Acad Mod. 1989;64:175-181. 2. Foster HW, Seltzer V. Accommodating to restrictions on resident's working hours. Acad Mod. 1991;66:94-31.
JONA • Vol. 22, No. 11 • November 1992