The role of nurse practitioners (NPs) and physician assistants (PAs) in the neuroscience intensive care unit (ICU) is an evolving one (Fry, 2011; Sidani & Doran, 2010; Hoffman, Happ, Scharfenberg, DiVirgilio-Thomas, & Tasota, 2004). Over the past several years, an increasing number of NPs and PAs now work in the ICU setting, but little has been studied about the impact of their involvement on patient care and satisfaction (Gracias et al., 2008; Kleinpell, Ely, & Grabenkort, 2008; Russell, VorderBruegge, & Burns, 2002). The NPs and PAs in the ICU setting are known to provide stability and cohesion in an ever-changing environment with resident staff who often rotate frequently. The added value of excellent clinicians who are the backbone of a unit is immeasurable. Tasks performed by NPs and PAs commonly include invasive procedures, rounding, education of staff and family members, research, and administrative duties (Gracias et al., 2008; Kleinpell et al., 2008; Russell et al., 2002). In this study, we investigated the demographics of the neuroscience ICUs as well as the perceptions of Neurocritical Care Society (NCS) members on the impact of NPs and PAs in the neuroscience ICU on staff, patient, and family satisfaction, safety, communication, and prevention of neurological deterioration. The data collected provide areas for improvement and further study.
Local institutional review board and NCS approval were obtained before beginning the study. All current members of the NCS were asked to respond via a Google survey on the following: country of practice, state of practice (if in the United States), type of provider, role in ICU, size of ICU, type of ICU, and types of patients seen. The NCS is a multidisciplinary group composed of physicians, nurses, pharmacists, and PAs. Most of both the society and the respondents were physicians. The survey was stratified after the basic demographic questions. For those who work with NPs or PAs, the survey continued; for those, who do not work with NPs or PAs, the survey ended. Additional questions asked of the NP/PA subset included how many NPs or PAs are in the NICU, how long have you had the NP or PA role, types of procedures performed, type of documentation, and primary roles in the ICU. The ability of the NP or PA was also evaluated on a 1–5 Likert scale from poor to outstanding. Members were asked to rate NPs and PAs on their ability for six areas: response to a team member’s concerns, response to a patient’s or family’s concerns in a timely manner, safety, effective communication, promotion of a team environment, and anticipation or prevention of a neurological deterioration. Space was provided for any qualitative input as well. The study was open for 8 weeks, and per the NCS, surveys are only distributed once. No compensation was provided for responses.
Variables for each of the six ratings were compared individually using ordinal logistic regression. Variables with p < .2 were included in a multivariate logistic model. A Mantel–Haenszel chi square and ordinal logistic regression model were used to determine statistical significance of p < .05.
There were 196 responses, or 15% of members who responded at least partially. Only members who completed the entire survey were used for this study. One hundred thirty-eight members completed the full survey, or a 10% response rate. Of the 5% of eliminated responses, most were from international members who do not have an NP or PA role. Table 1 shows the breakdown of responses based on job title. This breakdown is similar to the number of physicians, NPs, registered nurses, pharmacists, and PAs who belong to the society.
For all six categories, below average and poor responses were combined together as the number of responses was minimal. Above average and outstanding responses were also combined. At least 80% of members agreed that care provided is either above average or outstanding for safety, communication, and ability to respond to team member or patient/family concerns. For promotion of a team environment and ability to prevent or anticipate a neurological deterioration, responses of above average/outstanding were 75% and 69%, respectively.
Table 2 highlights the significant responses for each of the six categories: response to a team member’s concerns, response to a patient or family’s concerns in a timely manner, safety, effective communication, promotion of a team environment, and anticipation or prevention of a neurological deterioration. For response to a team member’s concern, both the number of roles and the number of years of having an NP or PA in the ICU were significant. For response to a patient or family, the results were the same but with the addition of the number of NPs or PAs in the unit meeting significance. Safety not surprisingly involved the number of procedures, the amount of documentation, years of NPs or PAs, and the number of roles. More procedures were performed, and more experience of the NP or PA was translated to higher safety ratings. For communication, increased documentation improved results. The number of procedures and amount of documentation increased team environment. The ability to anticipate sudden neurological deterioration was rated higher for type of ICU, number of NP or PAs, number of procedures, amount of documentation, years of NP or PAs, and number of roles. The resounding theme throughout the results was the increased number of roles translated into higher scores for all six categories. For each of the six categories, a higher number of roles (rounding, procedures, documentation, education, orientation, research, and administrative duties) translated into higher scores. Table 3 illustrates the multivariate analysis of the additional number of roles for NPs and PAs in the ICU. For those NPs and PAs with greater than four roles, the results for all six categories was very high and statistically significant. Other influential responses included the number of years NPs or PAs have worked in the unit, the number of NPs and PAs in the ICU, amount of documentation, number of procedures, and type of ICU (dedicated neuroscience vs. trauma, surgical, mixed, or medical). Background information not meeting statistical significance included size of ICU, type of provider in charge, number of patients per provider, and hours worked.
Overall, the results were overwhelmingly positive in all six categories. There was a direct effect on the number of roles and a higher score in all categories as additional roles of NPs and PAs translated into higher scores for all six categories. However, it is difficult to distinguish between an experienced clinician inheriting additional responsibility or more roles resulting in additional time in the ICU or at the bedside. Is satisfaction improved for these providers because NPs and PAs are most often providing continuity of care in a busy ICU where physicians typically rotate on and off service?
NPs and PAs were deliberately grouped together for this study. Although training and education can vary, the roles of both ICU NPs and PAs in many institutions are similar. The authors represent both disciplines and were interested in the overall benefit both disciplines provide to the ICU setting.
In the safety category, the number of procedures performed, amount of documentation, and length of time of NPs and PAs in the ICU resulted in higher scores. The NPs and PAs are often the providers who routinely place invasive lines and train new resident staff. Additional documentation such as daily progress notes, history and physicals, event notes, procedure notes, and discharge summaries may mean that these clinicians are routinely at the bedside and readily available to evaluate patients. For team environment, if one is at the bedside performing multiple procedures and contributing to various types of documentation, one has the opportunity to interact with staff and improve the team dynamics.
Perhaps, the most important category is the ability to anticipate or prevent a sudden neurological deterioration. Statistically significant responses included the type of ICU, number of roles, amount of documentation, and number of procedures. Clinicians specializing in a dedicated neurocritical care ICU rather than mixed or a surgical unit likely more routinely see patients with life-threatening neurological conditions. The experience of daily work in such a specialized unit may explain how the addition of an NP or PA to a neurocritical care team could improve the ability to anticipate or ideally prevent a neurological decline.
It is important to note that some of the responses were below average or poor. For several of these responders, the roles of their NPs or PAs were grossly limited, and in some instances, the only responsibility was dictating discharge summaries. Only five or 4% of members reported below average or poor for the six categories. The number or roles for these NPs or PAs was limited and varied from discharge summaries only to discharge summaries, admission notes, and daily progress notes. Unsurprisingly, if a clinician is not utilized to their full potential and removed from the bedside, one would not expect a high mark on any of the six categories surveyed.
A limitation of the study is a small sample size. The survey was sent to an international audience, but few responders outside of the United States work with or have worked with NPs or PAs. Another limitation was the inability to redistribute the survey to members. Without a reminder email to members, the success of a survey is drastically reduced. No financial compensation was awarded to enhance the response rate. The survey used was the first of its kind and, as such, is not validated. Finally, there was little to no commentary provided by responders to justify or qualify responses. The small sample size could be attributed to more than the above reasons. Although the survey results were quite positive, it is possible that some members have negative perceptions of NPs and PAs and deliberately did not complete the survey. It is also important to note that this survey was mainly of physicians and was not primarily composed of NPs and PAs. Consequently, the interpretation of the findings is based on the perception of the role of the NP and PA rather than a survey of fellow NPs and PAs.
Additional limitations include the possibility of surveys completed by clinicians from the same ICU or hospital. The survey was designed to not limit the number of responses from the same hospital. The authors were concerned that limiting the response to a single person in an ICU within the same hospital may pinpoint one particular clinician as many of the ICUs have a small number of NPs or PAs. Some of the positive responses may be because of the extraordinary ability of one NP or PA as well as the same reasoning for the negative responses.
Care provided by NPs and PAs in the neuroscience ICU setting is valued by the members of NCS. Patient safety was positively impacted by the addition of NPs and PAs on the neuroscience ICU team. Proper orientation, continued training, and a unified goal of maximal use of the NP and PA role is needed to obtain and improve on these results (Verger, Marcoux, Madden, Bojko, & Barnsteiner, 2005). Additional responsibility yields the highest marks; as a result, effort should be taken to maximize care provided by NPs and PAs to their full scope of practice (Gershengorn et al., 2011). These results could be extrapolated to other ICUs and across the country. Further study needs to be done to look at the roles of NPs and PAs in their respective ICUs to determine if the amount of autonomy and additional responsibilities translate into improved safety and satisfaction.
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