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Correction
for
Committee on Child Abuse and Neglect,
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PEDIATRICS Vol. 103 No. 5 May 1999, pp. 1050-1052
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ABSTRACT |
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Abstract
Conclusion
Recommendation
References
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The positions of nurse practitioner and physician assistant were created approximately 30 years ago. Since then, the role and responsibilities of these individuals have developed and grown and now may include involvement in the care of hospitalized patients. The intent of this statement is to suggest a manner in which nurse practitioners and physician's assistants may participate in and contribute to the care of the hospitalized child on the general inpatient unit, among other areas.
During the 1960s, nurse practitioner (NP) and physician
assistant (PA) training programs were initiated1 in
response to a perceived shortage of physicians, especially in medically underserved communities that were often also economically deprived. NPs
and PAs were originally considered to be alternative health care
personnel who would function under the supervision of physicians, extending the ability of the physician to provide service to a greater
number of patients.
During the last 10 years, however, the scope of practice of NPs
and PAs in pediatrics has been expanded to include the care of
hospitalized patients.2 This expansion has been driven by
continuing regional shortages of physicians, efforts to reduce the cost
of health care, and decreasing funding for graduate medical education
which means fewer residents (residency positions). A major concern has
been that the expansion of the scope of practice of NPs and PAs may
impact on the management of pediatric inpatients3 and
create a two-tier system of health care. Another issue is that resident
experience may be diluted when NPs and PAs assume some of the
responsibilities for patient care.
The first PA program was created at Duke University (Durham, NC)
in 1965, at approximately the same time as the first pediatric NP
program was being developed under the combined auspices of the
Department of Pediatrics of the School of Medicine and the School of
Nursing of the University of Colorado, Denver. During the 30 years
since their inception, the education, training, and practice of NPs and
PAs have changed substantially.
NP
A NP is a registered nurse with advanced education and
clinical training beyond the usual 2 to 4 years of basic nursing
education required for state licensure. The additional education may be through a certificate program or a master's degree program. Thus, the
education of a NP may be completed in as little as 2 years of junior
college and 9 months in an advanced NP certification program or in as
much as 4 years of college and 2 years in a combined master's and
certification program. Most NPs acquire a master's degree in nursing
as their route to certification.
In some states, the NP is required by law to work in collaboration with
a physician. The NP can provide only those services specifically
articulated by state statute and in accordance with a written practice
agreement with a licensed physician. In other states, NPs have been
granted independent practice and prescribing authority.4
PA
A PA is registered by the state after 2 or more years of
undergraduate education followed by 9 to 12 months of preclinical didactic studies and 9 to 15 months of physician-supervised clinical education. Some educational programs for PAs graduate child health associates, who receive specialized training in pediatrics. By law, PAs
may perform medical services, but only when supervised by a physician
and only when such acts and duties are within the scope of practice of
the supervising physician.
As initially conceived, the roles of NPs and PAs in pediatrics
were to assist the physician in the provision of primary care for well
children and those with acute minor illnesses. During the past 30 years, subspecialty areas for NPs, such as the neonatal NP, have
developed. PAs have been used more extensively in hospital departments
of surgery, in which they may obtain initial histories and perform
physical examinations and minor surgical procedures, under physician
supervision.
Despite the original intent for the roles of NPs and PAs, current
economic pressures have promoted their increased use and expanded
scopes of practice. This is true despite data from ambulatory settings
clearly demonstrating that although NPs and PAs individually earn lower
incomes than physicians, their involvement in care costs the same or
more per patient encounter because they tend to spend more time with
each patient and usually work a 40-hour week, while physicians treat
patients more expeditiously and work longer hours.5,6
However, a role may exist for NPs and PAs on the pediatric inpatient
unit. The NPs and PAs who are used in such positions require additional
precepted education, beyond that required for certification. The
additional precepted education should be the responsibility of the
pediatric unit director and should include orientation to hospital and
departmental policies and protocols and direct teaching of clinical
skills needed for the specific unit. The NPs and PAs should work under
the close direct supervision of an attending physician, and the
patient's primary physician must always remain readily available to
answer questions and provide backup to the NP or PA. Decisions
regarding the need for admission, management plans, and appropriateness
for discharge must be made with the involvement of the attending
physician.
Management of hospitalized patients in an inpatient setting should
always be directed by a physician; therefore, the responsibility and
legal accountability belongs to the physician. The establishment of and
adherence to written protocols for NP involvement in the care of
hospitalized infants and children should be required.
It is incumbent on the hospital to develop a detailed
credentialing process for NPs and PAs if they are used in the inpatient setting. This process must include a clear delineation of privileges, just as is done for members of the medical staff. Because PAs work
directly under the supervision of a physician, they should be
credentialed through a medical staff process. Because NPs are nurses,
they should initially be credentialed through nursing channels;
however, delineation of privileges for inpatient care should be done in
collaboration with the medical staff and clearly state that the
physician of record retains ultimate responsibility for the management
of patients.
Recredentialing of NPs and PAs should be part of any hospital-wide
quality improvement program. The NPs and PAs should be considered when
developing standards of patient care, quality care, and outcome
standards. Evaluations of NPs working on an inpatient unit should be
performed jointly by nursing supervisory personnel and the unit medical
director; evaluations of PAs should be performed by the unit medical
director.
After the patient is discharged from the hospital, follow-up
may be performed by the NP or PA, provided well-delineated parameters exist for the care to be given. The determination of the specific follow-up needs of each patient must be made by the team providing care
before discharge from the hospital.
NPs or PAs working with a physician have a meaningful role
in the management of hospitalized children. Having already demonstrated their abilities to perform in supervised intensive care settings, NPs
and PAs should be effective on the general pediatric inpatient unit. As
the scope of ambulatory care continues to expand, the children admitted
to the general inpatient unit of the hospital have increasingly more
complex illnesses. The responsibility for the management of the
hospitalized child should be under the supervision of a qualified
physician, because the physician has the most education and training
for this role. Nevertheless, the NP and PA can play a valuable role in
the care of the hospitalized child by contributing specialized skills
that improve the quality of patient care. The NPs and PAs who
participate in the care of the hospitalized child must have the
additional education and training that such involvement requires.
EDUCATION AND LICENSURE
ROLES AND RESPONSIBILITIES
RELATIONSHIP WITH THE PHYSICIAN
CREDENTIALING
POSTHOSPITALIZATION FOLLOW-UP
CONCLUSION
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Abstract
Conclusion
Recommendation
References
RECOMMENDATIONS
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Abstract
Conclusion
Recommendation
References
COMMITTEE ON HOSPITAL CARE, 1997-1998
Henry A. Schaeffer, MD, Chairperson
David R. Hardy, MD
Paul H. Jewett, MD
John M. Neff, MD
John M. Packard, Jr, MD
Marleta Reynolds, MD
Curt M. Steinhart, MD
LIAISON REPRESENTATIVES
Elizabeth J. Ostric
American Hospital Association
Mary T. Perkins, RN, DNSc
Society of Pediatric Nurses
Elias Rosenblatt, MD
Joint Commission on Accreditation of Healthcare Organizations
Eugene Wiener, MD
National Association of Children's Hospital and Related Institutions
Jerriann M. Wilson, CCLS, MEd
Association for the Care of Children's Health
SECTION LIAISON
Theodore Striker, MD
Section on Anesthesiology
CONSULTANTS
Jess Diamond, MD
Mary E. O'Connor, MD
James E. Shira, MD
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FOOTNOTES |
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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ABBREVIATIONS |
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NP, nurse practitioner; PA, physician assistant.
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REFERENCES |
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Conclusion
Recommendation
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