Liego, Megan DNP(c), ACNP-C; Loomis, Jo DNP, FNP-C; Leuven, Karen Van PhD, FNP; Dragoo, Susan DNP, WHNP
Author Affiliations: Doctor of Nursing Practice Student (Ms Liego), Assistant Professor (Dr Loomis), and Associate Professor (Dr Van Leuven), School of Nursing and Health Professionals, University of San Francisco, California; and Acute Care Nurse Practitioner (Ms Liego), Heart and Vascular Center, and Advance Practice Nurse (Dr Dragoo), Women’s Services, St. Joseph Hospital, Orange, California.
The authors declare no conflicts of interest.
Correspondence: Ms Liego, University of San Francisco, 2130 Fulton St, San Francisco, CA 94117-1080 (firstname.lastname@example.org; email@example.com).
The Value-Based Purchasing Program is forcing hospitals to improve outcomes and decrease costs. This has led to recognition of new care models to improve outcomes and reimbursement. One model is the application of an acute care nurse practitioner (ACNP) into the hospital setting. Model success is dependent on proper implementation to create a synergistic relationship with the organization, ACNP, and patient to improve the quality of care and decrease costs for the hospital.
Lowering costs and improving quality of care have become primary concerns of hospitals and the healthcare industry.1 With the launch of the Value-Based Purchasing Program (VBP) in 2011, hospitals have been forced to improve outcomes to maximize reimbursement for Medicare patients.2,3 Private insurance companies are also starting to base reimbursement and contracts around similar ideals.1 This is forcing many hospitals to look at new care models to improve outcomes and reimbursement. One model being examined is the introduction of an acute care nurse practitioner (ACNP) into the hospital setting.4-6
An ACNP is a master’s-prepared advance practice nurse (APN) who provides care to patients with complex healthcare conditions in acute care and hospital-based settings. The ACNP role was developed in the early 1990s when it was recognized that the needs of patients in the hospital setting were not being met by current providers.7 Advanced education allows the ACNP to diagnose, treat, and manage acute and chronic diseases. The primary responsibility of the ACNP is to direct the management and coordination of patient care through history taking, performing advance physical examinations, ordering laboratory and diagnostic testing, and performing procedures.7,8
On the basis of education and training, an ACNP can provide care similar to that of a physician; however, the ACNP’s patient-centered education improves patient care coordination and health through sensitivity to the impact of social and cultural factors, such as environment and family situation.7,8 Patient-centered education allows for the implementation of quality initiatives, standardization of care, and acute transition management. This in turn results in decreasing length of stay, which can lead to compliance with VBP initiatives and reduction in complications and readmissions.7-9 Several studies have shown that the utilization of ACNPs can help decrease costs and improve revenue for the hospital. Kapu and Jones10 showed that after the addition of ACNPs to hospitalist and intensive care unit teams for 3 months, the facility reported savings of $4,656 per case through a reduction in length of stay (LOS). Another study, by Meyer and Miers,11 found that ACNP-surgeon teams for a cardiac surgery program had a statistically significant (P = .039) lower mean LOS compared with a group of surgeons working alone. After accounting for the salaries of the 4 ACNPs, the estimated savings to the healthcare system was $3,388,015.20 per year.11 These studies illustrate how the ACNP is well positioned to decrease costs and improve revenue for the hospital as well as benefit the patient.
Despite these outcomes, several barriers remain to the advancement and adoption of the role. One barrier is the improper implementation of the role by hospital administrators.12 One of the most common reasons that the role does not succeed is the lack of understanding of the ACNP and the nurse practitioner (NP) roles in the hospital.12 As the ACNP role in hospitals expands, administrators must understand the ACNP role functions, competencies, capabilities, and scope of practice to avoid role confusion.12-14 According to the American Association of Critical Care Nurses (AACN) Scope and Standards for Acute Care Nurse Practitioner Practice,15 the ACNP role is designed to stabilize and promote the health and wellness of patients in the acute care setting. Expanding job descriptions to include the AACN Scope and Standards criteria can help minimize confusion about the role expectations and allow ACNPs to practice to the extent of their scope.15,16
To help guide the actual implementation of the role, administrators should use a systematic and evidenced-based approach for role development that incorporates the ACNP standards and scope of practice.12,15,16 To help with the successful implementation of an NP, such as an ACNP, Bryant-Lukosius and DiCenso developed the PEPPA (participatory, evidence-based, patient-focused process for guiding the development, implementation, and evaluation of advance practice nursing) framework, a 9-step process for the implementation and maintenance of the APN role (Table 1).16-19
The PEPPA framework provides an organized process to properly implement and to evaluate the implementation of the ACNP role.17,18 Starting with the initial step through step 5, administrators are led to analyze their current model of care and desired quality outcomes.16 For example, to achieve the best results with VBP, an examination of hospital composite quality and process scores from the Center for Medicare and Medicaid Services and patient demographics will illustrate which patient population the ACNP can have the largest impact for improving outcomes.12,16 With this information, administrators can develop the ACNP role to meet the needs of the organization, hospital, and patients.
Steps 6 and 7 are focused on planning and initiation of a plan for the implementation of the role. It is here that administrators must look at eliminating barriers to achieving the desired outcomes of the role. Acceptance of the role by the medical staff, administration, and the multidisciplinary teams in the acute care setting is crucial. Without this preparation, there will be a lack of synergy between the ACNP, patient, and organization, which can negatively impact the quality of patient care.16,19 Depending on the state, the ACNP may also require physician supervision and/or collaboration to practice. Therefore, having a physician to both support and promote the role is vital to the success of the ACNP.
The last 2 steps are evaluation and long-term monitoring of the role. These steps are often forgotten but are important in our current hospital environments. APNs and ACNPs are often the 1st to be considered when reductions are made during hard financial times. Through the tracking of outcomes such as LOS, compliance with clinical practice guidelines, readmission rates, mortality, and morbidity, ACNPs can demonstrate their positive impact on patient care and costs and thereby validate the importance of their positions. Furthermore long-term outcome monitoring allows for the role to evolve to meet the changing governmental regulations and needs of the population served.12,16,19
The ACNP role has the potential to be a resource to help hospitals improve quality and decrease costs on both an organizational and a patient care level. Proper implementation of the role is crucial to achieve improved outcomes for the hospital. To effectively implement this role, nursing leaders and nonclinical administrators need to understand the scope and standards of the ACNP role. A systematic and evidenced-based approach, such as the PEPPA Framework, should be used to help with the implementation of the role. With appropriate implementation of the ACNP role, a synergistic relationship can be created with the organization, the ACNP, other providers, and the patients. This synergistic relationship can be vital in improving outcomes to support VBP and decrease the overall healthcare costs in the hospital and across the country.
1. O’Grady ET, Brassard A. Health-care reform: opportunities for APRNs and urgency for modernizing nurse practice acts. J Nurs Regul. 2011; 2 (1): 4–9.
2. HHS Press Office. Administration implements affordable care act provisions to improve care, lower costs: value-based purchasing will reward hospitals based on quality of care for patients. 2011. http://www.hhs.gov/news/press/2011pres/04/20110429a.html
. Accessed February 19, 2013.
4. Fry M. Literature review of the impact of nurse practitioners in critical care services. Nurs Crit Care. 2011; 16 (2): 58–66.
5. Kleinpell RM. Outcome Assessment in Advanced Practice Nursing. 2nd ed. New York, NY: Springer Publishing Company, LLC; 2009.
6. Newhouse RP, Stanik-Hutt J, White KM, et al. Advanced practice nurse outcomes 1990-2008: a systematic review. Nurs Econ. 2011; 29 (5): 230–250.
7. Hamric AB, Spross JA, Hanson CM. Advance Practice Nursing: An Integrative Approach. 4th ed. St Louis, MO: Saunders Elsevier; 2009.
8. National Panel for Acute Care Nurse Practitioner Competencies. Acute care nurse practitioner competencies. Washington, DC: National Organization of Nurse Practitioner Faculties; 2004.
9. Kleinpell RM. Acute care nurse practitioner practice: results of a 5-year longitudinal study. Am J Crit Care. 2005; 14 (3): 211–221.
10. Kapu A, Jones P. 133: financial impact of adding acute care nurse practitioners (ACNPs) to inpatient models of care [abstract]. Crit Care Med. 2012; 40 (12): 1–328.
11. Meyer SC, Miers LJ. Cardiovascular surgeon and acute care nurse practitioner: collaboration on postoperative outcomes. AACN Clin Issues. 2005; 16 (2): 149–158.
12. Sangster-Gormley E, Martin-Misener R, Downe-Wamboldt B, DiCenso A. Factors affecting nurse practitioner role implementation in Canadian practice settings: an integrative review. J Adv Nurs. 2011; 67 (6): 1178–1190.
13. Barton D, Mashlan W. An advanced nurse practitioner-led service—consequences of service redesign for managers and organizational infrastructure. J Nurs Manage. 2011; 19 (7): 943–949.
14. Curley MQ. Patient-nurse synergy: optimizing patients’ outcomes. Am J Crit Care. 1998; 7 (1): 64–72.
15. American Association of Critical Care Nurses. AACN Scope and Standards for Acute Care Nurse Practitioner Practice. Aliso Viejo, CA: AACN Critical Care Publication; 2012.
16. Bryant-Lukosius D, DiCenso A. A framework for the introduction and evaluation of advanced practice nursing roles. J Adv Nurs. 2004; 48: 530–540.
17. Spitzer WO. Evidence that justifies the introduction of new healthcare professionals. In: Slayton P, Trebilcock MJ, eds. The Professions and Public Policy. Toronto, Ontario, Canada: University of Toronto Press; 1978; 211–236.
18. Dunn K, Nicklin W. The status of advanced nursing roles in Canadian teaching hospitals. Can J Nurs Adm. 1995; 8 (1): 111–135.
19. McNamara S, Giguere V, St-Louis L, Boileau J. Development and implementation of the specialized nurse practitioner role: use of the PEPPA framework to achieve success. Nurs Health Sci. 2009; 11: 318–325.