It is evident sweeping healthcare policy changes, more medically complex patient hospitalizations and an aging population will continue to grow demand for advanced practice nurses in inpatient settings.
The care provided by advanced practice nurses has been shown to optimize patient outcomes by improving delivery and cost-effectiveness.1 In addition, the advanced practice role consists of leadership, education and research.2
From the Beginning
Since the inception of the APN in the 1960s, the need and demand for them has risen dramatically. Various articles and literature reviews demonstrate the clinical and financial impacts NP’s have on patient care.
For example, patient care outcomes are similar with the use of nurse practitioners as physicians, and with a high level of patient satisfaction. These findings were initially studied by the U.S. Office of Technology (OTA) and published in 1981, and each subsequent study reviewed for this article showed a steady increase in patient satisfaction.
Outcomes proven to be associated with advanced practice nursing include developing healthy patient behaviors, higher functional status, disease control, satisfactions with care and easy accessibility to care. Team based approaches to patient care in the hospital setting with nurse practitioners and physicians providing care have shown NP’s are fully qualified and even necessary in providing care for cost-effective outcomes.3
The literature indicates successfully introducing the advanced practice role in a hospital-based setting can be challenging and barriers have been identified to a successful implementation.
At our regional hospital in northern Texas, three advanced practice nurses (APN) positions were established in the cardiovascular, pain management and palliative care service lines.
There is no clear-cut method to introduce the concept of APNs to an inpatient setting, and there is limited data available regarding the successful introduction of an advanced practice nurse in the hospital setting.
The current literature lacks a working framework to develop such a model, though there have been other articles describing individual implementations. As well, the literature lacks information regarding how to implement APN practice into an inpatient setting.
Our model was thus developed with the following thoughts:
- the healthcare needs of the population served;
- practice patterns;
- educational programs;
- workforce issues, legal and policy context; and
- evidence from research outcomes.1
Also introduced into our model was a merged framework that involved a participatory, evidenced-based, patient-centered process for the APN role as described by Lukosius et al, 2004. The closest we could get to workable models included articles by Linda Herrmann and Susan Yeager. Herrmann, an APN practicing with a neurosurgical group, used the Tandem Practice Model, which provides a model for collaboration between the physician and nurse practitioner.4 Yeager’s article outlined an orientation plan for trauma service nurse practitioner.5
These two articles helped develop the foundation of our APN roles.
Once the hospital administration determined the need for APN services based on service line needs, the multi-level interview process began with the various disciplines.
Upon our hiring, the advertising process began with meetings throughout the various departments to let staff and providers know of our services.
Based on these initial showings, the use of our services grew through consults from physicians, many of which were obtained from staff nurses’ requests. At present, inpatient consults for pain are significantly improving on a monthly basis.
More education has been done for the staff regarding our role and respective specialty. The staff continues to refer questions and patient care issues to our attention, and a sense of trust has blossomed after we began to attend the weekly ground rounds on some of the units.
Professional boundaries have been employed utilizing a slow, balanced approach. Other disciplines collaborate with us regarding patients. And we have become vital to ensuring quality measures and compliance issues are met.
Pain Management NP
In the role of pain management nurse practitioner, I function as an employee of the hospital, where I work 20 hours per week; the other 20 hours I work at the physician’s private practice.
Trying to find a balance and not to exceed hours at either practice was difficult at first.
The hospital staff was familiar with pain management services, however, prior to the development of my position coverage had been an issue. It became established that the bedside leaders had a consistent presence of the nurse practitioner in the hospital for the pain management service.
I spent time with the staff initially establishing introductions and what my role would be in the hospital. At this point the staff feels comfortable asking for my opinion regarding care of a pain patient and will seek out my services themselves or by asking the physicians at the hospital to write an order for a pain management consult.
I was introduced to the medical staff at the various service line monthly meetings. At these meetings I introduced myself briefly describing my background, and how our practice would benefit the hospital. It was a positive step in my being able to attend and speak at these meetings.
My supervising physician was well known to the medical staff so they were aware of our practice and what services we would provide for them. Pain management had been an anticipated and welcome addition to the hospital practice – and one that had been needed for some time.
Cardiovascular Nurse Practitioner
My service line is cardiovascular this includes cardiology, cardiothoracic and vascular surgical patients. Therefore, my practice is diversified on many levels. I follow patients for five cardiothoracic surgeons, two vascular surgeons and 10 cardiologists.
My duties include rounding on inpatients, authoring service notes, transferring and discharging patients as well as educating patients, families and staff regarding the care of the patients while I collaborate with the wide-ranging healthcare team.
My insight helps to determine the needs of the patients as an inpatient and what resources will be required upon discharge. I ensure a seamless transition from inpatient to outpatient through management of their follow-up. My other patient duties entail troubleshooting and managing changes to the patient’s clinical condition. I also remove drains, lines and other invasive monitoring equipment. Currently, I see 8-12 patients on a daily basis.
In addition to my clinical duties, I also sit on various hospital and system wide committees. This allows me to interact and engage with other members and departments. I feel my perspective as an APN on these committees brings a unique point of view. Due to my experience as a staff RN and now as a provider, I am able to help clarify and present a point of view many may not have considered.
Where We Want To Go
Our orientation to the facility was informal and hybrid. It included general nursing orientation and the rest self -directed trial and error. This was encountered at other facilities within our hospital system with other APNs. Therefore, a system wide process is being developed to “on boarding” process to orient future APNs.
In addition to the “on boarding” of new APNs, as a system we are striving to improve educational needs and funding and a streamlined hospital credentialing process.
Also on our horizon is performing research in conjunction with staff nurses to incorporate them in the research process. By doing so we will increase their knowledge and allow the experience of developing evidence-based practice.
1. DeGeest, S., et al. (2008). Introducing advanced practice nurses/nurse practitioners in health care systems: A framework for reflection and analysis, Swiss Med Weekly, 138(43-44), 621-628.
2. Lukosius, D.B, & DiCenso, A.. (2004). A framework for the introduction and evaluation of advanced practice nursing roles. Journal of Advanced Nursing, 48(5), 530-540.
3. Bauer, J.C. (2010). Nurse practitioners as a underutilized resource for health reform: Evidence-based demonstrations of cost-effectiveness, Journal of the American Academy of Nurse Practitioners, 22(4), 228-231.
4. Herrmann, L.L, & Zabramski, J.M. (2005). Tandem Practice Model: A model for physician-nurse practitioner collaboration in a specialty practice, neurosurgery. Journal of the American Academy of Nurse Practitioners, 17(6), 213-218.
5. Yeager, S. (2010) Detraumatizing nurse practitioner orientation, Journal of Trauma Nursing, 17(2), 85-101.
Leah Wood is a pain management nurse practitioner and Margie Amity is a cardiovascular nurse practitioner, both at Baylor Regional Medical Center at Grapevine in Texas.