Maureen A. Madden RN MSN PCCNP FCCM Pediatric Critical Care Nurse Practitioner Bristol- Myers Squibb Children s s Hospital Assistant Professor of

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1 Maureen A. Madden RN MSN PCCNP FCCM Pediatric Critical Care Nurse Practitioner Bristol- Myers Squibb Children s s Hospital Assistant Professor of Pediatrics UMDNJ- Robert Wood Johnson Medical School New Brunswick, New Jersey, USA

2 Nurse Practitioner and Advanced Practice Roles are em erging and being identified worldwide. A NP/ APN is a registered nurse who has acquired the expert knowledge base, com plex decision- m aking skills and clinical com petencies for expanded practice, the characteristics of which are shaped by the context and or country in which s/ he is credentialed to practice. A Masters degree is recom m ended for entry level I CN 2002

3 Graduate degree in Nursing. Conduct com prehensive healt h assessm ent s Dem onstrate a high level of autonom y Possess expert skills in the diagnosis and treatm ent of com plex responses of individuals, fam ilies and com m unities I ntegrate education, research, m anagem ent, leadership and consult at ion Collegial relationships with nursing, physicians and ot her healt h care professionals ANA Congress of Nursing Practice

4 Educat ional Preparat ion Nature of Practice Regulat ory Mechanism s

5 Educational Preparation at the advanced level advanced clinical competencies Preparation for full extent of role Facilitate lifelong learning & maintenance of competencies Form al recognition of educational program s preparing nurse practitioners/ APN practice roles accredit ed or approved Form al system of licensure, registration, certification and credentialing Preferably at Mast er s s level

6 Not focused on 1 disease or body system extensive knowledge pathophysiology, pharm acology Clinical m anagem ent not currently undertaken by nurses already have a background in professional nursing practice. Focus is in the medical model including differential diagnosis, clinical decision making, medical t herapeut ics and pharm acology. new skills, knowledge Collaborat ive, not independent, pract ice trust Need for supervised clinical pract ice

7 I ntegrates research, education, practice and m anagem ent High degree of professional autonom y and independent/ collaborat ive pract ice Caseload- focused on specific group of patients s Advanced healt h assessm ent skills, decision- m aking skills and diagnost ic reasoning skills Recognized advanced clinical com petencies Perform and prescribe t herapeut ic m easures Provision of consult at ion services Plans, im plem ents and evaluates

8 Right to diagnose Authority to prescribe m edication Authority to prescribe treatm ent Authority to refer clients to other professionals Authority to adm it patients to hospital Legislation to confer and protect the title Nurse Pract it ioner/ Advanced Pract ice Nurse Legislation or som e other form of regulatory m echanism specific t o advanced pract ice nurses Officially recognized titles for nurses working in advanced pract ice roles

9 International Council of Nurses estimates nearly 40 countries have established or em erging advanced practice roles. Alm ost 140,000 APNs in the USA NPs in the U.S.A: 115,000 in the year certified NNPs in 2003 Approxim ately 150 NPs practicing in Pediatric Critical Care New Zealand: 25 NP in 2006 (including NNP) Aust ralia: int roduced NP role in 2001 UK: NP not a protected title- no uniform regulations for educational preparation or professional standards ICN I nternational Nurse Practitioner/ Advanced Practice Network- 68% of advanced practice nursing has research functions as part of their role

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11 Hist orically Nurse Pract it ioner Recent ly prim ary care, m edical m odel NPs into acute, specialist areas NNP, ACNP, PCCNP

12 Clinical pract ice Educat ion Leadership / Managem ent Research

13 Five broad areas of care m anagem ent Coordinat ion of care Recording the history and perform ing the physical exam Ordering diagnostic tests Perform ing t herapeut ic procedures Prescribing m edicat ions Shah H, et al. An evaluation of the role and practices of the acute care nurse practitioner. AACN Clinical Issues 1997;8:

14 I nvolved in physical and technical aspects of care Engaged in critical thinking and decision m aking Provide continuity of care Also involved in education, research and support of system s Kleinpell, 1997; Richmond & Keane, 1996; DeNicola, 1993; Spisso, 1990; Bissinger, 1997; Schultz, 1993; Verger, 1997

15 Pract ice influences.environm ent I ncreasing need for skills of an advanced practice nurse in specialties and in hospitals Changing reim bursem ent policies Shortening length of hospital stay Num ber of patients rapidly m oving through the health care system Changes in m edical t raining program regulat ions Focus on well child care Pediatricians fam iliar with working with NPs Team approach in hospit als

16 Acute care role of NNP developed in m id 1970 s Education incorporated- technical and diagnost ic skills Manage population of infants in NI CU- prem ature thru neonatal age group I m petus: Gap between expanding service needs, decreasing house st aff availabilit y

17 Original concept based on hospital s s needs at bedside- highly professional and skilled professionals necessary Over past 30 years- shift from certificate to graduat e degree required St andardizat ions of educat ional program s USA: National Association ion of Neonatal al Nurses (NANN)( NCC ( certifying body for NNPs)- graduate degree required 2000 NNP shifted from strictly clinical role to: Clinical Research Nursing and medical education Administration Nagle CW, Perlmutter DF. The evolution of the nurse practitioner role in the neonatal intensive care unit. Am J Perinatol. 2000; 17(5):

18 Direct provider of care for infants and neonat es Teacher Researcher Advocat e Consult ant Manager of system s Leader NANN, 2002 Elaboration of curriculum content for the professional role of the NNP.

19 NNPs perform at least com parably and in som e cases better than physicians in t raining Trotter, 1994; Bissinger,, et al, 1997; Carzoli,, 1994; Schultz, 1994; Mitchell, et al, 1995; Mitchell- DiCenso,, et al.,1996 Role viewed favorably by nurses, physicians and parent s Trotter, 1994; Beal, 1997; Ruth- Sanchez, 1996

20 Responsibilities, roles & staffing patterns of nurse practitioners in the neonatal intensive care unit Design: prospective descriptive study in conjunction with regional multi- site outcomes study Methods: 22 NPs surveyed, 5 regional level I I / I I I NICUs NE US Results: NP roles included all levels of NICU care as well as antepartal consultation, delivery room management, transport, outpatient follow- up NPs equally involved with all degrees of com plexity and birthweights Some NPs cared for smaller and sicker babies I m plications: NP provide invaluable contribution with parent support and teaching, post- NICU follow- up care, professional research and education NP role in NI CU should not be viewed as a substitution for resident physicians Beal JA, et al. MCN Am J Matern Child Nurs. 1999; 24(4):

21 The Nurse Practitioner Role in the NICU as perceived by Parents Purpose: understand and describe the nature of NP care delivery in the NI CU as perceived by parents of critically ill neonat es Methods: 8 parents; phenom enological m ethod Result s: NPs consist ent ly perceived as: effectively m anage the m edical care being posit ive and reassuring being present caring translating inform ation m aking parents feel at ease Beal JA, Quinn M. MCN Am J Matern Child Nurs. 2002; 27(3):

22 Consistent care providers- particularly with extrem ely prem ature neonates Enhanced com m unicat ion I m proved discharge planning Role in follow- up care Reduction in overall cost of care

23 Pract ice influences..apn roles PNP in prim ary care Well child care in outpatient setting Masters prepared nurses in specialty practice (CNS) I npatient with direct and indirect care responsibilities for patients and fam ilies Neonat al nurse pract it ioners Acute and critically ill neonates PNPs in- patient and out- patient Responsibility for patients in pediatric specialt y areas

24 Educat ion Acute care (36% ); CNS to postm asters acute/ critical care NP (27% ); Prim ary care (37% ) Experience PNP in critical care 3 yrs. (1-7 yrs); Nursing 14.4 years (5-26 yrs) Role Responsiblities PNP Critical Care 24% Verger, Barnsteiner Use of Nurse Practitioners in the Pediatric Intensive Care Unit", Research Presentation, Pediatric Critical Care Colloquium, Hot Springs, AK, September, % 72% CDM/Management Leadership Coordination of Care

25 Nurse Practitioners in Pediatric Critical Care - Methods Convenience Sam ple Distributed via internet, postal m ailing and personal cont act t o 81 individuals Part of larger study looking at APNs in Pediatrics Multi- item survey (61 questions) Exam ining education & experience, practice environm ent, adm inistrative issues, role responsibilit ies, clinical skills Verger, J.T., Marcoux, K.K., Madden, M.A., Bojko, T., and Barnsteiner, J. (2005). Nurse Practitioners in Pediatric Critical Care: Results of National Survey. AACN Clinical Issues: Advanced Practice in Acute and Critical Care 2005; 16(3):

26 Nurse Practitioners in Pediatric Critical Care - Resultss 74 respondent s Mast er s s prepared 18 states represented 29 Hospit als 35 Units Verger, J.T., Marcoux, K.K., Madden, M.A., Bojko, T., and Barnsteiner, J. (2005). Nurse Practitioners in Pediatric Critical Care: Results of National Survey. AACN Clinical Issues: Advanced Practice in Acute and Critical Care 2005; 16(3):

27 Nurse Practitioners in Pediatric Critical Care - Activities 11% 8% 2% 4% 3% 0% Direct Pt. Care Education Coordination of Care Research Support of Systems Consultation 72% Bedside Care Verger, J.T., Marcoux, K.K., Madden, M.A., Bojko, T., and Barnsteiner, J. (2005). Nurse Practitioners in Pediatric Critical Care: Results of National Survey. AACN Clinical Issues: Advanced Practice in Acute and Critical Care 2005; 16(3):

28 Nurse Practitioner in Pediatric Critical Care - Responsibilitiesies Clinical Practice History/Physical Exam- 100% Order Medications-100% Order/interpret Lab Test- 100% Interpret ECG-100% Order Blood Therapy-97% Adjust Mechanical Ventilation-97% Titrate Vasoactive Drugs - 91% Technical Skills Peripheral IV- 98% Feeding Tube Placement-93% Endotracheal Intub.-84% Arterial Lines-83% Chest Tube Removal-81% Central Lines- 80% Caring Practices Administer Sedation-93% AACN Synergy Model

29 Nurse Practitioner in Pediatric Critical Care - Responsibilitiesies Clinical Inquiry Participate Research- 60% Facilitator of Knowledge Patient/ Fam ily Educ. -100% Nursing Education- 90% Medical Education- 82% AACN Synergy Model

30 Direct Com prehensive Care Support of System s Research Educat ion Publicat ion & Professional Leadership Ackerman M., Norsen L., Martin B. (1996) American Journal of Critical Care;5: Mick D., Ackerman M., (2000) Heart and Lung; 29(3):

31 Where are we now? Practice m odels.. Direct clinical m anagem ent of a few patients or overall accountability and influence for a group of patients Protected tim e for continuing education, clinical research, integrate into the leadership of the unit I npatient and outpatient responsibilities Coverage M-M F days to 24/ 7 Supervision

32 Work in a team, highly collaborative roles Authority rests with com petence APNs distinct group by training and experience interchangeable interchangeable with other health care providers is not an effective m odel Set of skills distinguish from MDs, PAs Dependent on individual s s education, certification, years of experience and characteristics of the practice setting 1-2 years to function independently

33 Nurse Pract it ioners in I ntensive Care - Conclusions Growing segm ent of APNs Represents increasing areas around the world Practice settings varied Role com ponents include Clinical Practice and other APN responsibilities I ncluding Education, Support of System s, Research Variability of % of tim e spent

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