Winne, Maria RN, MS, NE-BC; Cashavelly, Barbara MSN, RN, AOCN; Annese, Christine MSN, RN; Nagle, Beth RN, MSN; Shiga, Takashi MD; Chisari, Roger Gino RN, DNP; Lee, Susan PhD, RN
New models of care delivery are providing expanding opportunities for acute care nurse practitioners (ACNPs) in academic medical centers. This is largely due to the need to shift some of the work of medical residents who are restricted to an average of 80 hours a week by the Accreditation Council for Graduate Medical Education (ACGME).1 The surge in utilization of ACNPs also parallels the 1990s physician hospitalist movement. The first ACNP certification examination was administered in 1995. By 2008, more than 5,000 ACNPs were certified in the United States.2,3 An increasing number of nurse practitioners (NPs) are working in acute care settings because, in large part, of the increased acuity levels of hospitalized patients and the need for advanced practitioners to help manage the care of patients with complex acute health conditions. The focus on cost containment and the challenges to shorten length of stay (LOS) are also influencing the rapid growth of the ACNP role. The urgent national agendum to provide high-quality, continuous, accessible, cost-effective care has contributed to ACNP utilization.4
The ACNP is educated and trained to provide advanced nursing care to acutely ill patients. ACNPs practice in a variety of settings, including outpatient, acute inpatient, and critical care units. Components of the ACNP role include patient care management for acute, critical, and complex chronic illness, as well the provision of diagnostic reasoning to formulate a plan of care in conjunction with evidence-based and research-based clinical practice.2
This article describes the development and implementation of 2 ACNP models at Massachusetts General Hospital (MGH) in which nurses took leading roles in the design and creation of these collaborative care models. The development and implementation of these ACNP models are aligned with 2 key recommendations put forth by the Institute of Medicine’s The Future of Nursing: Leading Change, Advancing Health.5 The first recommendation is that advanced practice registered nurses (APRNs) should be able to practice to the full extent of their education and training.5 A second recommendation is to expand opportunities for nurses to lead and manage collaborative efforts with physicians and others to redesign and improve practice environments and health systems.5 Each of the 2 ACNP models was collaboratively designed by nurse managers in conjunction with physicians to meet the needs of patients and families on their units. The first model, the Academic Hospitalist Service (AHS), was designed to care for 13 patients on a general medical unit. The second model, the Oncology Inpatient Nurse Practitioner Service (OINPS), was designed to care for 14 medical oncology patients.
NP Models in the Literature
Since 2002, a variety of ACNP models have been described in the literature. One example of a successful ACNP model at the University of California San Francisco Medical Center expanded the capacity of the medical service and improved efficiency and quality of patient care.6 The efficiency of care was improved by the ACNPs because their primary goal was to admit and manage an acute medical population of patients that, in the past, was cared for by the house staff. This change allowed the academic medical service to abide by the limitations set forth by credentialing agencies on the maximum number of patients admitted by medical residents. The quality of patient care was positively impacted by the continuity of the ACNPs. The ACNPs were available throughout the day to interact with patients, families, and the nursing staff, without the distraction of academic learning requirements. Another successful model described by Brown et al7 was the development of a pediatric critical care NP program. Implemented at Akron Children’s Hospital, the model improved patient flow and continuity of care to the patients and families in the pediatric intensive care unit (ICU). D’Agostino and Halpern8 described the development and function of critical care ACNPs in an adult ICU at Memorial Sloan-Kettering Cancer Center. Yeager et al9 reported on the development and implementation of the neuroscience ACNP role at 2 institutions, the University of Virginia Health System and Riverside Methodist hospitals in Columbus, Ohio. These authors underscored less tangible outcomes and benefits seen with the implementation of ACNPs. These benefits included easy accessibility of the ACNP to the staff nurse because the NPs are a constant presence on the unit. Their presence led to improved patient care by expediting the input of clinical orders and fostered prompt open dialogue between the staff nurse and NP related to patient care concerns.
The literature supports the unique value-added contributions that ACNPs have in intensive care inpatient settings. Kleinpell et al10 reviewed more than 145 articles related to the role of the NP and physician assistant (PA) in ICU settings. The authors found that integrating NPs and PAs in an ICU setting positively impacted patient care. The NPs and PAs were found to more frequently discuss patient care issues with the ICU nurses and interacted more with patients’ families than did their physician colleagues. It was evident that having ACNPs in the inpatient setting led to the enhancement of patient workflow and enriched the education of patients, families, and nursing staff. Kleinpell11 conducted a 5-year longitudinal study of the role of the ACNP. Through survey research, the author noted expanding practice settings, activities, and procedures performed by ACNPs (eg, performing cardioversions, initiating and adjusting mechanical ventilation, and performing wound care, and debridement) and increased satisfaction of ACNPs with their role.
Academic Hospitalist Service
Development, Design, and Structure
In the spring of 2010, the department of medicine, in collaboration with the medical nursing service, at MGH developed a new model of care called the AHS, with the goal of expediting admissions of acutely ill general medical patients from the emergency department. The AHS consists of a dedicated group of hospitalist physicians, medical students, and ACNPs who collaboratively provide continuity of care to general medical patients. The AHS supports the academic mission of the hospital by providing learning opportunities for fourth year medical students. This model was intended to improve patient satisfaction, positively impact the patients’ LOS, and attain the overall goal of providing safe, quality care.
The AHS (Figure 1) is responsible for 13 regionalized beds located on 2 inpatient units; 8 beds are located on a mixed medical/progressive care unit, and the remaining 5 beds are located on a general medical unit.
The nurse director (manager of direct care on 1 or 2 patient care units) of the medical/progressive care unit assumed a leadership role in paving the way for the introduction of this innovative service. The nurse director worked in collaboration with physicians and administrators to plan and implement a unique service beginning in July 2010. The AHS consists of 1 hospitalist physician, 1 ACNP, and 2 subinterns (fourth year medical students) who cover the service from 7 AM to 7 PM. The physician and ACNP each care for a patient caseload of 5 to 7 patients, on average. From 7 PM to 7 AM, all 13 patients are cared for by a hospitalist. The ACNPs report operationally to the nursing director of the medical/progressive care unit. A medical director serves as their supervisory physician.
Recruitment and Selection
During the first phase of this process, the team began by describing the desired experience and qualities required by the role of ACNP. The ACNPs would be caring for acutely ill general medical patients who would be admitted directly from the emergency department. They would be responsible for managing patients in collaboration with a multidisciplinary care team to facilitate a comprehensive plan of care and to coordinate resources. It was decided that the best candidates would have experience caring for acutely ill patients on a general medical unit or in an ICU. In addition, it was very important that the candidates have a pioneering mindset, which included the ability to be flexible, adapt well to change, embrace challenges, and be proactive in the ongoing development of this newly formed service. Interviews were conducted by human resources, nurse directors, clinical nurse specialists, and the medical director of the program. By May 2010, 2.5 full-time equivalent employees (FTEs) were hired. Two of the newly hired ACNPs were novice to the advanced practice role, although they were previously expert staff nurses with ICU experience at our institution. We created tailored orientations for the novice NPs by providing additional time for role transition. The third ACNP had several years of NP experience at another institution in a similar model and worked for several years as a staff nurse on medical/surgical units at our institution.
Integration to the APRN role is dependent upon a successful orientation that maximizes the available educational and clinical resources at our institution. This orientation consisted of 3 phases, including an introduction to the advanced practice role, patient- and family-centered care, and the medical management of acutely ill medical patients.
Socialization, networking, and mentorship were essential elements toward the integration of the ACNPs into their new role. The nurse director realized how important it would be for the ACNPs to have a network of colleagues and develop relationships with individuals on whom they could rely for guidance as they journeyed through this process. The 2 novice ACNPs participated in a 4-week orientation and the seasoned ACNP completed her individualized orientation in 3 weeks owing to her past experience as an ACNP on a similar service at a different institution. The educational orientation phase for all of the NPs included shadow days with experienced ACNPs and physicians medical, oncology, and cardiac services to get acquainted with key individuals. They also learned the admission and discharge processes, order entry, consults, and daily documentation. The AHS ACNPs are not responsible for billing; therefore, this was not a part of their orientation. This type of orientation provided the ACNPs with a wide variety of experiences that facilitated their understanding of the organizational culture, informatics, the consultation process, clinical observations, and role development.
The orientation also included a meet and greet day where the ACNPs met with the nursing director, the clinical nurse specialists, social workers, case managers, nutritionists, and unit secretaries to get to know their team. Each ACNP then worked with the AHS hospitalists for 4 to 7 days before having full responsibility for patient care, an experience that was described as an invaluable part of the orientation process. During this time, ACNPs did not take full responsibility for the care of their patients, rather they co-coordinated plans of care with AHS hospitalists.
Daily collaboration with many healthcare providers is necessary to provide seamless care for patients. The AHS physician and the ACNP participate in patient rounds along with staff nurses, case mangers, and social workers. The AHS physician is available to provide the NP with input and mentorship on the general management of patients, as well as assisting with emergencies. Because the ACNPs, AHS physicians, and other team members are often together on the unit, there are more opportunities for timely discussion and resolution of patient care issues as well as staff education.
Oncology Inpatient Nurse Practitioner Service
Development, Design, and Structure
In 2009, the cancer center nurse and physician leaders were charged with developing an inpatient service in response to the changes in the ACGME requirements that would begin at the beginning of the academic year 2011. In 2003, ACGME introduced the 80-hour work week limit for residency programs. Then in 2011, the ACGME implemented more changes to the work-hour guidelines that have governed residency programs. Under these new guidelines, postgraduate year 1 interns are not permitted to work for more than 16 consecutive hours. Postgraduate year 2 residents can work up to 24 consecutive hours. Because of the ACGME requirements, interns and residents work fewer hours at the bedside.1
In response to the decreased resident work hours, the newly designed service was necessary to provide medical coverage for 14 medical oncology patients. A multidisciplinary task force convened to evaluate 3 models of practice—a hospitalist model, a moonlighter model, and an NP model (NPM). Hospitalists are physicians whose primary practice is hospital medicine. They are dedicated to the delivery of comprehensive medical care to hospitalized patients.12 A moonlighter is a physician who has another primary job and works extra shifts as a secondary job. The NPM is a dedicated inpatient NP providing inpatient care. The advantages and disadvantages of each model were discussed in detail. The task force unanimously considered the NPM as the best fit from all perspectives, including quality and safety, patient satisfaction, cost, ability to decrease LOS, and enhancement of the multidisciplinary practice in the cancer center. Maintaining continuity and involvement with their patient’s plan of care was important to the oncology attendings. The task force believed that the NPM would support a collaborative working relationship with the attendings. They would be able to work closely with the inpatient NP with decisions related to their patient’s plan of care. The oncologists have dedicated oncology NPs (ONPs) in their outpatient disease center practice. The ONPs work in collaboration with oncology physicians. Patients are seen by the ONP for a follow-up visit or an urgent care visit. They manage symptoms of disease or treatment. They are a liaison for the patient and family for the rest of the healthcare team to make sure patients receive the best care possible. The role of the ONP has been fully integrated in the outpatient multidisciplinary disease practices in the cancer center. The development of this new inpatient NPM was viewed as an expansion of the successful outpatient oncology NPM to the inpatient setting.
Once the NPM was agreed upon, the task force worked together to design, develop, and implement the OINPS. The group determined the budget, staffing needs, anticipated coverage, and schedules and identified the patient population to be admitted to this service. In June 2010, this newly formed OINPS was implemented.
The OINPS provides consistent care to 14 medical oncology patients. The patients are located on 2 inpatient units—a medical oncology unit and a medical/surgical unit. Patients are admitted from the outpatient multidisciplinary disease practices, oncology infusion unit, emergency department, or home. The admitting attending oncologist determines if the patient is appropriate for the OINPS. The oncology inpatient NP (OINP) works with the oncologist initially to admit the patient and then daily to determine the plan and goals of care for the patient. The OINP focuses on the care of patients admitted for acute symptoms or medical management related to disease progression, treatment-related adverse effects, or end-of-life care. Patients diagnosed with a solid tumor can be admitted to the OINPS. All patients admitted to the OINPS are required to have a stable cardiopulmonary status. Patients who become unstable are transferred to the general medical service after discussion with the attending oncologist and medical senior resident.
The OINPs report operationally to the nurse director of the medical oncology unit (Figure 2). The clinical director of the service serves as their supervising physician. The OINPS has both full-time and part-time NPs. The OINPs work 12-hour shifts only. There are 2 OINPs on the 7 AM to 7 PM shift, 1 OINP on the 3 PM to 3 AM shift, and 1 OINP on the 7 PM to 7 AM shift. A 3 PM to 3 AM shift was implemented a few months into the program to accommodate the increased workload of admissions that occur later in the afternoon.
Recruitment and Selection
In the spring of 2010, recruitment commenced with the goal of establishing an OINPS by June 2010. Prior experience as an RN or an NP in an acute care inpatient setting was considered a prerequisite for employment. Similar for all ACNPs roles, a master’s degree in nursing, NP certification, and preparation in either the adult or acute care educational track were essential. Candidates were also required to have oncology experience.
Similar to the AHS, we also decided that it was important that candidates were interested in being part of a new endeavor, willing to take a chance on an uncharted role and program. Candidates who were motivated, self-directed, flexible, and ambitious and possessed leadership abilities were chosen. We realized that this program was new and we would learn as the program grew and developed. We acknowledged that there would be some challenges and possible changes with the development of the program. The NP team needed to be resilient to be able to grow and have the ability to adapt to change and develop their role with the program. Interviews were conducted by human resources, the nurse director, and the clinical director of the program. By May 2010, 9.5 FTEs, both full-time and part-time NPs, were hired. Each individual had acute care experience and some oncology experience.
The new OINPs underwent an in-depth, 8-week educational orientation program. The educational orientation program included “shadowing” various colleagues—inpatient medical resident teams, ONPs in the outpatient oncology clinics, and those in the step-down cardiac unit. A curriculum was developed that included topics such as infectious diseases, renal and oncologic emergencies, chemotherapy, and pulmonary and cardiac diagnoses. The educational sessions were taped, and the PowerPoint presentations, along with the recordings, were posted on an online site. They also learned the admission and discharge processes, order entry, consults, daily documentation, and billing procedures.
Collaboration with all disciplines is essential for providing exceptional care for oncology patients. The OINPs are collaborative with other members of the team but function autonomously. They speak with the attending oncologist each morning to discuss the status of the patient and plan of care. The OINPs round on each unit with all of the disciplines: staff nurses, charge nurses, case managers, physical therapists, social workers, dieticians, and the nurse director. Rounds include discussion of the patients’ clinical issues and needs, goals of care, discharge needs, and any other pertinent issues that need to be addressed in the team rounds.
Future Directions and Next Steps
The OINPS is so successful in the first year that an additional 14 beds will be added to the OINPS, totaling 28 beds and requiring the addition of 3 NPs. Additionally, a physician hospitalist will be added to cover the night shift. The patient population admitted to the OINPS will expand to include patients with bone marrow transplant/leukemia and solid tumors.
Commonalities of the AHS and the OINPS
Orientation and Continuing Education
After assisting the NPs to obtain credentialing and acute cardiac life support certification, a comprehensive, tailored orientation program was provided to all NPs in both the AHS and the OINPS. An ACNP education program previously developed by staff in the Norman Knight Nursing Center for Clinical and Professional Development was customized for the NPs in the new services. The new NPs were directed to use a Web-based platform that included videos and slide presentations to facilitate their orientation and training.
Simulated learning was another component of orientation. Clinical simulation is an active learning strategy that is now widely used to provide an opportunity for deliberate practice to foster experiential learning and the application of clinical knowledge. The simulation sessions were also intended to facilitate the NPs’ transition from RN role to the provider role.
A 4-hour program was developed by nursing simulation staff, nurse directors, and physicians to provide exposure to specific clinical experiences. The simulation was run using a full-scale, high-fidelity, computer-integrated, and physiologically responsive patient simulator. The program included 4 scenarios that were created to replicate medical emergencies that the NPs would likely encounter in practice—pulmonary embolism, urosepsis, gastrointestinal bleed, and hypercalcemia. Each NP had the opportunity to independently manage 1 of these patients, whereas the other NPs observed the scenario from an adjoining room. All NPs participated in the postscenario debriefing, during which the simulation staff reviewed video-recorded segments of the scenario and encouraged participants to reflect on the scenario and their performance. This reflection and discussion with staff and peers led to a deeper understanding of their actions, assumptions, and communication with family and other healthcare members. At the end of the debriefing, the physician provided a brief presentation on the recognition and management of the specific medical emergency as well as indications for calling in medical expertise. This program provided the NPs with an opportunity to acquire knowledge and skills in a risk-free, experiential learning environment to improve the quality of care and promote safety for the patient. The simulation sessions were also intended to facilitate the NPs.
The opportunity to develop and implement 2 ACNP models helped create and shape the direction of innovative models of patient care. The role of the ACNP continues to evolve and grow in this ever-changing healthcare environment. Although the 2 models described here are designed and structured differently, the primary role of the NP in each model is to manage patients’ care.
This article describes the ways in which nurses acted as full partners in leading the redesign of the care delivery models in their departments. Both models provide improved accessibility to ACNPs by patients, families, nurses, and the healthcare team. Furthermore, the models contribute to continuity of care because the ACNPs, through their continual and consistent presence on the units, are expert at knowing the patients, families, and staff. The ACNP models make significant contributions in the coordination of care for a wide range of patients, using the full extent of education and training. Although there are relatively little data on these models, we have received anecdotal positive feedback from highly satisfied patients, families, physicians, nursing staff, and case managers. Length of stay is the primary metric that is reviewed monthly. The data have shown that the ONP service has decreased their LOS by 1.5 days. The AHS has decreased their LOS by 0.9 days, although the results are not totally attributable to the ACNPs because a hospitalist and an ACNP share the patient caseload on a daily basis. Robust models that place advanced practice nurses on units with strong physician support are well positioned to meet the 6 quality aims—safe, effective, patient-centered, timely, efficient, and equitable care.4
The authors acknowledge Jeanette Ives Erickson, RN, DNP, FAAN, senior vice president for patient care and chief nurse; Theresa M. Gallivan, RN, MS, associate chief nurse; and Jacqueline Somerville, RN, PhD, former associate chief, MGH, for their insightful leadership on the project.
© 2012 Lippincott Williams & Wilkins, Inc.