The pediatric nurse practitioner role in the tertiary setting is one of several emerging roles gaining recognition in the various groups of advanced practice nursing programs today. The advanced practice nurse (APN) who is a pediatric nurse practitioner (PNP) in an acute care setting helps to provide cost-effective, quality patient care for critically and chronically ill children who are in these settings. The foundation of advanced practice nursing in this role incorporates the general role expectations of advanced nursing preparation, including case management, clinical pathway development, consultation and education, research, and collaboration, with the specific knowledge and skills of the pediatric nurse practitioner to function effectively with sick children in the acute care areas.
The acute care nurse practitioner (ACNP) specializing in pediatrics is one of several new and emerging advanced clinicians being developed in nursing
education for employment in the complex acute care health settings around the country. By combining the expertise of the pediatric nurse practitioner (PNP), the preparation to function in the tertiary pediatric intensive care units of some hospitals, and the role expectations of the nurse in advanced practice, the ACNP can provide a range of benefits to the health system and the children they serve. This specialty practitioner is one of several advanced practice nursing (APN) career choices in nursing programs today. Based on the roles of clinical nurse specialists (CNSs) and primary care nurse practitioners (NPs), two of several APNs, the ACNP can have a wide range of nursing experiences that offers effective solutions to manage complex and uncertain situations (Parr, 1996).
Foundations of Advance Practice Nursing -- Specialists and Practitioners
APNs include the various specialized advanced nursing professionals who may be NPs, CNSs, certified registered nurse anesthetists (CRNAs), and certified nurse midwives (CNMs). Their roles have been repeatedly demonstrated through research to be associated with high quality care, cost effectiveness, and patient satisfaction (Ingersoll, 1995).
The roles of the CNS and the NP were developed for two reasons primarily related to economic conditions: (a) to improve nursing practice and (b) to improve patient care. The role of the CNS was developed by nurse educators in the post World War II era in an effort to improve the quality of nursing care in a period of massive knowledge and technical growth (Hamric, Spross, & Hanson, 1996). CNSs are educated and trained as consultants and professional experts. They act as case managers, educators, and directors of patient care, although typically not as direct caregivers. They are unique in their ability to provide holistic care without direct patient involvement. The role of NP was developed in the 1960s in response to a physician shortage in primary care. In 1964 the first pediatric NP program was started at the University of Colorado, soon followed by Massachusetts General Hospital, and by 1980 there were nearly 300 NP programs (Millonig, 1994). NPs are trained in direct patient care and are able to perform assessment, diagnosis, and management of conditions, including prescribing treatments.
Just as the NP role was created in the primary care setting in response to economic conditions, a new role is emerging for the advanced practice nurse in acute care. As health consumers demand safe, quality, and cost-effective health care in today's tertiary care settings, nursing has responded (Keanne, Richmond, & Kaiser, 1994). By blending some of the similar characteristics of CNS and NP roles in graduate preparation, nursing education has developed an advanced practice clinician role, producing a nurse who may be able to take on a variety of responsibilities. APNs as practitioners are not only seen in the primary care setting, but are also emerging as practitioners in the acute care setting. Because of decreasing department budgets as well as decreasing numbers of residents in hospitals, the ACNP has emerged to assist with managing patients who are acutely ill or who have exacerbations of chronic health problems. This new type of APN combines the direct care provision of the NP with the traditional CNS care services in acute care to produce the advanced practice clinical role (Dracup et al., 1994).
The new ACNP offers many unique contributions to the tertiary care setting. The ACNP role differs from the CNS role. While the CNS works with staff nurses giving direction and education, they traditionally do not do direct patient care. The ACNP brings medical and nursing paradigms to the acute care setting (Keanne et al., 1994). The ACNP is responsible for direct patient management through admission, performing histories and physicals, evaluating clinical data, prescribing treatments, performing invasive procedures, educating and supporting the families, and facilitating patient discharges. The ACNP collaborates with other members of the health care system, writes orders, and has prescription privileges (although these privileges vary from state to state). This acute care advanced nurse can be found in specialty areas such as pediatric and neonatal intensive care units, oncology, cardiology, gastrointestinal, and pulmonary acute care settings.
Advanced Practice Roles
According to the American Nurses Association (ANA), advanced practice nurses perform comprehensive health assessments and demonstrate skilled autonomy in the diagnosis and treatment of individuals, families, and communities to manage acute and chronic illness and promote wellness. The ANA states that nurses from all the various areas of advanced clinical nursing practice must be masters prepared. The ACNP receives advanced training focusing on the assessment and pharmacological management of patients in acute care settings. Nurses in advanced practice bring cohesiveness between nurses, physicians, and other members of the health care team (Berger et al., 1996). The general areas of advanced roles in this specialty practice can include: case management, clinical pathway development, educator/consultant, research, and collaboration.
Case management. Case management assists providers and consumers in the pediatric tertiary setting in order to ensure continuity of care, cost containment, and quality outcomes. National standards of practice that have been established by the Case Management Society of America (CMSA) guide care management responsibilities. CMSA specifies standards of practice that include assessment, case identification and selection, problem identification, planning, monitoring, and evaluating outcomes (CMSA, 1995). Case management models are designed to provide high quality care in a cost-effective manner. Two nursing case management models were developed in the mid 1980s after the introduction of Diagnostic-Related Grouping (DRG) reimbursement system.
The New England Medical Center (NEMC) model focuses on the control of resources used during the patient's hospitalization. Through the use of protocols, decreased cost, decreased length of hospitalization, and decreased variability of patient care have all been achieved. The NEMC model enhances quality of care, increases provider and patient satisfaction, and reduces the cost of care delivery (Cook, 1998).
The Professional Nursing Care Management (PNCM) model integrates nursing services across the care continuum. Developed at St. Mary's Hospital in Tucson, Arizona, the PNCM model focuses on the supportive environment, both in the institution and in the community. The goals of the PNCM model are 'high satisfaction and quality, lowered costs, and reduced length of stay' (Cook, 1998, p. 38).
The pediatric ACNP can be in a unique position to fill the case manager role. Although CNSs and professional nurses are capable of performing these functions, facilitation of planning, communication, and coordination of care can be provided by the ACNP in a leadership role (Sohl-Kreiger, Lagaard, & Scherrer, 1996). ACNPs who are PNPs can apply critical thinking and advanced knowledge to promote holistic care in managing clinical situations (Berger et al., 1996). These case managers would be uniquely qualified to facilitate uniform, consistent care for children in a tertiary setting.
Clinical pathway development. Clinical pathways are multidisciplinary plans used to follow events for patients with the same diagnosis. A natural extension in the role of the advanced nurse as case manager is a role in development of clinical pathways. While traditionally a CNS function, the ACNP can add clinical management knowledge to the interdisciplinary task. Pathways were first developed and brought into the health care system in 1980 in response to health care employers and consumers demanding efficiency and cost effectiveness. Tertiary care is often complex and expensive. Pathways promote positive patient outcomes and satisfaction as well as decrease cost and utilization of health care resources (Capuano, 1995). Pathways are used to create effective and efficient organization of care (Uzark et al., 1998) in the tertiary setting.
In hospital settings, continued utilization of pathways occurs following review of the benefits of pathways. Some physicians are resistant to the use of pathways, feeling that they infringe on clinical judgment and individual decision making. The ACNP can present positive outcomes of the use of pathways to the medical team and can help ensure the success of pathways. Key responsibilities for the advanced nurse in development and review of clinical pathways include: (a) developing pathways in areas of expertise, (b) reviewing pathways with families, (c) following pathways to ensure their use, (d) reviewing outcome analysis, (e) developing a plan for resolution of problems involved with patient care, (f) acting as a resource for the health care team, (g) acting as communication liaison between members of the health care team, (h) attending clinical pathway meetings, and (i) revising pathways as indicated (Capuano, 1995).
Education/consultation. The advanced nursing roles of educator and consultant, while not unique to the tertiary setting, have a beneficial influence on patients, families, and multidisciplinary team members. The education/consultant role of the APN in the acute care setting has grown dramatically because of the increase in chronically ill children requiring complex management.
The ACNP performs in the role of educator in relationships with patients and families as well as in daily interactions with staff. The ACNP in the role of patient or family educator brings relevant information while integrating theories as a means to influence patient outcomes (Parrinello, 1995). Relevant nursing theories provide a strong foundation for the ACNP to educate patients regarding their plan of care, self-care, prevention issues, discharge planning, and follow-up. The ACNP, who is more often a direct hands-on provider of care, may also work with the CNS in the role of staff educator, coordinating educational nursing in-services and teaching didactic content, skills, and competencies in critical care orientation (Parr, 1996). Over time, the ACNP and the nursing staff may form a collaborative relationship in which the staff seek clinical consultation from the ACNP's expert knowledge.
The ACNP may also participate in schools of nursing activities as a nursing educator, as well as serve as a clinical preceptor for students, staff, and others (Parrinello, 1995). Through classroom activities and in practice, ACNPs can act as role models for new ACNPs, offering an exemplary foundation on which to base their practice.
The ACNP consultant role aims at improving patient care and nursing practice based on expertise in various areas of specialization (Parrinello, 1995). The ACNP is able to analyze clinical data and discuss outcome benefits for the patient and family. ACPN's clinical expertise allows them to act as consultants when planning critical pathways for specific populations. The consultant role places the ACNP in the position to develop patient and family teaching materials that will enhance overall patient outcomes.
Research. Research is essential for the expansion and enhancement of all the APN roles (Porter- O'Grady, 1996). Current trends in health care delivery have dramatically affected both the mode of APN's practice and the demands placed upon them. As a result, nurses can no longer rely solely on experience in making policy and patient care decisions, but must provide evidence that their delivery of health care will positively affect patient outcomes while containing cost (McGuire & Harwood, 1996). Nursing research provides that evidence by validating and quantifying the outcomes of advanced nursing practice as unique, cost-effective, and efficient. Additionally; research provides a scientific basis for advanced nursing practice and provides evidence of accountability (Talbot, 1995). Research also provides an avenue to introduce innovations that can change and improve practice. According to Hawkins and Thibodeau (1996), research is essential to define, implement, validate, and evaluate advanced nursing practice.
Changes in today's health care system challenge all APNs to develop a research-based practice that ensures personal and professional competence (Talbot, 1995). Research questions evolve from problems noted in clinical practice, education, political or ethical issues, and from needs identified in specific patient populations and/or communities. Specialists and practitioners commonly explore research findings from the analyses of existing research and databases. Issues surrounding role definition and credibility must be explored to expand the role of the ACNP. Answers to these questions provide a scientific basis for nursing practice (Hawkins & Thibodeau, 1996). ACNPs must use the research utilization process to interpret and integrate research findings into practice, to evaluate studies to examine nursing practice, and to gather material that will generate knowledge and define optimal nursing interventions and outcomes.
Collaboration. Collaboration implies that all members of the health team agree to work cohesively to strive for a common goal. Effective collaboration requires the understanding and acceptance of each other's practice, roles, and responsibilities. Cooperation and effective communication can only be achieved through mutual trust and respect between health care professionals. The nurse with advanced education brings to the table a unique set of skills in health promotion, prevention, adaptation, education, counseling, and access to community resources. Understanding each provider's scope of practice and responsibilities enhances the advanced practice clinician's role as a team member.
The ACNP, in addition, must demonstrate clinical competence and credibility in order to collaborate effectively with the medical team. Credibility can be achieved through education and experience, as well as commitment to direct patient care. APNs can promote collaboration by establishing productive, respectful, and contributory relationships with the medical team as well as with their patients and families.
Strategies to Enhance the ACNP Role
In the changing health care world ACNPs must establish strategies to increase their credibility and success in the acute care setting. Acute care training programs for practitioners at the graduate level is vital to ensure the ACNP credibility. Training should include management of acute illnesses and chronic conditions in children. In addition to graduate education, certification by a professional nursing organization and licensure by the state in an advanced practice category are credentials needed to legitimize the practice of the ACNP.
Practitioners must market themselves by advertising their important contributions in the acute care setting. APNs in acute care must be assertive in controlling their practice and defining what constitutes advanced practice. Practitioners must emphasize that they are not replacing medical residents. ACNP skills go beyond history taking and physicals; they do more than provide direct patient care. The ACNP's unique approach to health care results in a high level of patient care and satisfaction.
PNPs who can function in advanced roles in acute care bring his or her background in pediatric nursing to the tertiary care setting that provides a base of expertise and allows them to understand and communicate with other pediatric nurses. PNPs also have the advanced degree that gives them a strong medical understanding thereby facilitating communication with the physicians. Therefore, care provided by a PNP to an acutely ill pediatric patient can have several advantages over care provided by a physician, CNS, or professional baccalaureate prepared nurse in certain situations.
ACNPs can solidify their role through active collaboration with physicians, problem solving with nurses, conducting and facilitating research, and continuing role development and protocols for the profession (Hravnak, Rosenweig, & Baldisseri, 1996). The lack of a clear definition of the advanced practice role in education, title, and credentialing has contributed to confusion within the nursing profession and within members of the health care system. Future advanced roles will need to have delineated requirements for advanced practice skills. Practitioners in advanced practice roles must be accountable to all patients and families under their care.
Evaluating Outcomes for the ACNP
ACNPs must demonstrate the value of their role through evaluation of outcomes. Evaluation can be done via structure factors, process evaluations, outcome measurements, and through evidence of cost effectiveness. Evaluation will allow the ACNP to explore practice-setting characteristics, examine direct patient care, and follow-up for short or long-term outcomes of patients seen by the APN (Ingersoll, 1997). Other types of evaluations that can be useful include performance evaluations and ratings from nursing colleges. Performance evaluations must include: clinical practice, education, consultation, research, and professional development. Activity logs are important to ACNPs since they can be used as evidence of the impact of care provided by practitioners over time. According to Ingersoll (1997), items to include in activity logs are listings of consumers, peers, medical records, consultation notes, process logs, quarterly reports, letters, meetings, hospital quality improvements, publications, presentations, and grant proposals.
There is mounting evidence that the advanced practice role in acute care is cost effective and credible extrapolated from research on other advanced roles. Unfortunately, barriers to, advanced practice still exist. Through marketing strategies, evaluation outcomes, continued education, and dedication to direct patient care, APNs as acute care practitioners can overcome existing barriers. The role of the ACNP should be defined to allow accountability for practice to be shared between nursing and medicine where indicated. Shared accountability will benefit children and their families.
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Stacey Teicher, MS, RN-CS, CNS, CPNP, is a pediatric oncology nurse, Lucile Salter Packard Children's Hospital at Stanford, Palo Alto, CA.
Karl Crawford, MS, RN-CS, CNS, CPNP, is a pediatric CT surgery/Cardiology nurse, Brenner Children's Hospital, Winston-Salem, NC.
Barbara Williams, MS, RN-CS,CNS, CPNP, is a pediatric CT surgery nurse, Alfred I. duPont Hospital for Children, Wilmington, DE.
Brandy Nelson, MS, RN-CS,CNS, CPNP, is a pediatric CT surgery/Cardiology nurse, National Children's Medical Center, Washington, DC.
Cheryl Andrews, MS, RN-CS, CNS, CPNP, is NICU Case Manager, University of Maryland Medical Center, Baltimore, MD.