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Nurses’ roles changing to maximize benefits
Most of the clamor about health care reform has focused on patients’ rights and curbing managed care abuses. Federal health officials are also taking stock of how health care providers, including critical care nurses, are redefining themselves in the changing reimbursement environment.
According to one expert, job descriptions in acute-care nursing are changing to meet new economic demands. Bedside nurses in critical care are likely to benefit from the trend, says Paul Logan, CRNP, MSN, an acute-care nurse practitioner at Montgomery Hospital. The 180-bed medical-surgical facility in Norristown, PA, operates two 10-bed CCUs.
How? They are likely to get strong day-to-day clinical support from highly trained members of their own profession — RNs.
Buried in the federal Balanced Budget Act of 1997, for example, is a significant provision that concerns one of the fastest-growing segments of advanced practice nursing: the acute-care nurse practitioner (NP).
The budget law mandated nurse certification programs for acute-care NPs require a minimum of a master’s degree in nursing or its equivalent. In doing so, the government established specific educational criteria for acute-care NPs, in effect affirming their importance in the ICU, according to Logan. This means the educational requirement for NPs in your ICU will have to meet the federal standard.
How will this development affect unit managers? Here are a few pointers:
• NPs will become more common in the ICU/CCU.
Already, hundreds of hospitals and clinics employ primary care NPs (they have for years). In the past decade, dozens of hospitals have also hired acute-care NPs and used them in different clinical capacities. However, staff nurses may not be familiar with the exact role of the acute-care NP. Their increased presence may better define their role and importance in the unit, Logan says.
• More NPs will narrow their job focus and speed up their integration in critical care.
Acute-care NPs are being used by hospitals in a variety of ways that may not take into account their stated purpose. NPs and nurse managers insist staff nurses usually welcome the expertise and the extra help with patients in the unit.
Rarely is there a disagreement over turf or clinical issues. More often, it’s a question of what exactly the acute-care NP is supposed to do in the ICU/CCU. These issues may subside as NP become a stronger presence in the unit, says Therese Richmond, CRNP, PhD, director of the acute-care NP program at the University of Pennsylvania School of Nursing in Philadelphia. The school offers one of a handful of accredited graduate programs for acute-care nurse practitioners in the nation.
"The field is quite new and still evolving. Hospitals are searching for ways to use NPs effectively, and they will," Richmond says.
• NPs will expand and underscore the importance of care management teams.
As part of a multi-disciplinary care team, "the NP serves as a bridge between the attending physician and our bedside nurses," says nurse manager Penny Shames, RN, Montgomery Hospital’s clinical coordinator. "They’ve got the formal education and clinical expertise to be valued tools while still being nurses like us."
Part of the problem, even for veteran managers who work closely with NPs, is their prescribed role in the unit. Acute-care NPs usually coordinate the physician’s care plan for each patient. They work with nurses to monitor the progress of several patients at a time.
NPs are authorized to perform history and physicals, prescribe medications, order tests, and change treatment plans. They also play a big role in the patient’s ultimate destination within the hospital. Some NPs act as case manager and do discharge planning, says Logan. (For list of criteria, see chart, p. 20.)
• Employment status will determine their duties.
NPs are circumscribed by their employ- ment agreements. Unit-based NPs typically are employed by the hospital and responsible for all of the unit’s patients. In contrast, practice-based NPs are employed by medical groups and chiefly responsible only for the patients under the medical group’s care.
Whether these differences persist will depend on how hospitals decide to use acute-care NPs. Most experts, including Richmond, aren’t certain these differences will change much in the future.
How should you best use your acute-care NP?
• Depend on them to expedite and coordinate patient care.
Use them to get answers to specific clinical questions and provide guidance when the attending physician or house staff isn’t available, Shames says. The NP should be viewed as an expert consultant on individual patient issues and team player in the daily clinical management effort. This can be done in a global (entire unit) sense or at the micro-level (with individual patients or nurses), Shames adds.
• Give them considerable latitude.
Unit managers should not place the NP under their direct supervision. Nor should NPs be given management authority over staff nurses. Although they are still nurses, NPs should have sufficient independence to function outside of the bedside nursing team. In cases in which they are employed by a physician practice, this becomes obvious.
The same level of independence should apply to unit-based NPs, according to Yvonne Ruddy-Stein, RN, MSN, an acute-care NP at Egleston Children’s Hospital in Atlanta. Independence reinforces the NPs status as a clinical specialist.
• Use them as teaching resources.
Inservice training is a great way to use your NP, says Richmond. This way, they will underscore the NP’s position as a clinical resource while improving the bedside nurses’ patient management skills. The inservice sessions also can become problem-solving sessions and a chance for staff nurses to highlight particular issues that need addressing by a physician.
At many hospitals, the roles of the NP and clinical nurse specialist (CNS) sometimes overlap. However, according to Logan and others, the CNS’s focus is on system issues such as how to get patients through the system faster. The acute-care NP’s emphasis is more on patient-care issues such as managing medication dosages.
• Support their bond with your nursing staff.
"Having been nurses, we can communicate closely with patients and their families," says Ruddy-Stein. More than anyone else in the unit, NPs also can work closely with nurses "because we are nurses."
That understanding, when coupled with the advanced clinical role played by NPs and constant interaction with the attending physician, make for an improved working relationship among members of the care management team. Managers can encourage such close associations by publicly supporting their NPs, Ruddy-Stein says.
"The most important part of working with your NP is in highlighting not the differences but similarities with others in the unit. We are still nurses in every sense," Ruddy-Stein concludes.