Nurse Practitioners at Barrow Neurological Institute
Denita Ryan, RN, NP
Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical
Center, Phoenix, Arizona
In general, the role of nurse practitioner developed in response to widespread economic constraints mandated by third-party payers. The goals of introducing this role at our institution were to increase patient satisfaction, to improve patient outcomes, to decrease lengths of stay, and to reduce the workload of residents. This article examines models of advanced practice nursing and how they have been implemented in the context of the neurosciences.
Key Words: advanced practice nursing, neuroscience, nurse practitioner
Many changes in the healthcare delivery system are the result of managed care, concerns about controlling costs, and the nursing shortage. At this institution, the expansion of patient care areas coupled with economic restrictions mandated by third-party payers increased the workload of the neurosurgical residents, the nursing staff, and case managers. Collaborative efforts among the medical director of the neurosurgical institution, nursing administration, nursing, and various ancillary departments resulted in a proposal to recruit for advanced practice nursing positions to facilitate patient care. The primary goals for the new role were to increase patient satisfaction and to improve patient outcomes. An additional benefit was the reduction of tasks and responsibilities previously held by the resident staff. This article reviews the development and implementation of the role of nurse practitioners (NPs) at Barrow Neurological Institute.
Advanced Practice Nursing
As described elsewhere, in 1995 Davies and Hughes described advanced practice nursing as a position that extends beyond roles. Conceptually, they defined advanced practice nursing as follows: "Advanced nursing practice is the application of an expanded range of practical, theoretical, and research-based therapeutics to phenomena experienced by patients within a specialized clinical area of the larger discipline of nursing." This position paper stipulated that advanced practice nursing include basic nursing education plus a graduate degree with a major in nursing or a graduate degree with a concentration in an advanced nursing category. The latter includes both didactic and clinical components, advanced nursing theory, physical and psychosocial assessment, appropriate interventions, and management of health care. Hamric listed the criteria that define an advanced practice nurse: graduate education, certification, and a patient-focused practice. These primary criteria must co-exist with various competencies such as clinical practice expertise, expert guidance and coaching, consultation, research skills, clinical and professional leadership, collaboration, change-agent skills, and ethical decision-making skills.
Advanced practice nursing is a broad category composed of all nurses practicing in an advanced role. Included may be NPs, clinical nurse specialists, nurse anesthetists, and nurse midwives. NPs can be classified further as specializing in neonatal, pediatric, family, adult, geriatric, psychiatric, or acute care. Furthermore, NPs are recognized in the Medicare Federal Registry and are eligible to bill directly for services provided.
Development of the Role of NPs
Since its introduction in the 1960s, the role of NPs has been controversial. In the early 1960s,the Millis Report indicated that many children were receiving inadequate medical care because of the shortage of physicians. A survey by the American Academy of Pediatrics found that most physicians were willing to delegate some patient care tasks. In response to these concerns, a plan was developed to increase the scope of nurses. In 1965 the title "nurse practitioner" was first used at the University of Colorado in a special demonstration funded by the Commonwealth Foundation. The purpose of the demonstration was to prepare professional nurses for an expanded role in the care of ambulatory patients. The advantages and benefits associated with NPs soon expanded their role into all areas of healthcare, including acute care settings.
Acute care NPs are advanced practice nurses who primarily work with acutely ill patients within hospital settings. They receive advanced clinical education and frequently have experience in the arena of acute and critical care nursing. Among other case-specific and hospital-specific requirements, the role of the acute care NP includes assessment, evaluation, and diagnosis of patients; performance of therapeutic interventions specific to the area of expertise; appropriate consultations; patient and family teaching; and interaction with consultants and ancillary departments (e.g., speech, occupational, and physical therapy).
The job descriptions of the acute care NP can be difficult to define because roles vary from hospital to hospital. Specific responsibilities may be defined by specialty, patient population, state legislation, and individual hospital policy. Regardless of the practice setting, standards for advanced practice nursing are defined by national legislation, although specific changes are made at the level of the state by each State Board of Nursing.
The role of acute care NPs has been controversial, especially within teaching institutions. An acute care NP was first documented in the late 1970s in response to an undersupply of neonatal specialists. In the early 1990s,in response to a cutback in residency programs, hospital cost-containment, increasing numbers of patients, and decreased lengths of stay mandated by third-party payers, the role of NPs further expanded. Nurses received advanced training in a specialty area to relieve residents of various functions, such as focused assessments, ordering and interpreting diagnostic tests, ordering medications and therapies, and transferring patients to lower levels of care or discharging home.
Development of the NP Role at Barrow
During the early 1990s, the transitions in healthcare were felt at Barrow, as they were nationally. Although residency programs were cut elsewhere, at our institution patient populations, including many with complex conditions, were increasing. The large patient loads increased responsibilities for the resident staff. The medical director and administration of the institution decided that the addition of NPs might relieve the residents of some of their responsibilities while helping to decrease overall length of stay and to increase patient satisfaction.