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Maureen Madden RN MSN PCCNP FCCM Pediatric Critical Care


									 Maureen A. Madden RN MSN PCCNP FCCM
  Pediatric Critical Care Nurse Practitioner
  Bristol- Myers Squibb Children’ s Hospital
      Assistant Professor of Pediatrics
UMDNJ- Robert Wood Johnson Medical School
     New Brunswick, New Jersey, USA
Nurse Pract it ioner and Advanced Pract ice
 Roles are em erging and being ident ified
 worldwide. A NP/ APN is a regist ered
 nurse who has acquired t he expert
 knowledge base, com plex decision - m aking
 skills and clinical com pet encies for
 expanded pract ice, t he charact erist ics of
 which are shaped by t he cont ext and or
 count ry in which s/ he is credent ialed t o
 pract ice. A Mast ers degree is
 recom m ended for ent ry level – I CN 2002
  Graduat e degree in Nursing.
  Conduct com prehensive healt h assessm ent s
  Dem onst rat e a high level of aut onom y
  Possess expert skills in t he diagnosis and
  t reat m ent of com plex responses of individuals,
  fam ilies and com m unit ies
  I nt egrat e educat ion, research, m anagem ent ,
  leadership and consult at ion
  Collegial relat ionships wit h nursing, physicians
  and ot her healt h care professionals

ANA Congress of Nursing Pract ice - 1992
Educat ional Preparat ion
Nat ure of Pract ice
Regulat ory Mechanism s
Educat ional Preparat ion at t he advanced level
• advanced clinical competencies
• Preparation for full extent of role
• Facilitate lifelong learning & maintenance of
Form al recognit ion of educat ional program s
preparing nurse pract it ioners/ APN pract ice roles
accredit ed or approved
Form al syst em of licensure, regist rat ion,
cert ificat ion and credent ialing
Preferably at Mast er ’ s level
Not focused on 1 disease or body syst em
 • ext ensive knowledge pat hophysiology,
   pharm acology
Clinical m anagem ent not current ly undert aken
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
 • t rust
Need for supervised clinical pract ice
I nt egrat es research, educat ion, pract ice and
m anagem ent
High degree of professional aut onom y and
independent / collaborat ive pract ice
Caseload - focused on specific group of pat ient s
Advanced healt h assessm ent skills, decision -
m aking skills and diagnost ic reasoning skills
Recognized advanced clinical com pet encies
Perform and prescribe t herapeut ic m easures
Provision of consult at ion services
Plans, im plem ent s and evaluat es
Right t o diagnose
Aut horit y t o prescribe m edicat ion
Aut horit y t o prescribe t reat m ent
Aut horit y t o refer client s t o ot her professionals
Aut horit y t o adm it pat ient s t o hospit al
Legislat ion t o confer and prot ect t he t it le “ Nurse
Pract it ioner/ Advanced Pract ice Nurse ”
Legislat ion or som e ot her form of regulat ory
m echanism specific t o advanced pract ice nurses
Officially recognized t it les for nurses working in
advanced pract ice roles
International Council of Nurses – estimates nearly 40
count ries have est ablished or em erging advanced pract ice
Alm ost 140,000 APNs in t he USA
NPs in the U.S.A:
• 115,000 in the year 2006
• 3295 certified NNPs in 2003
• Approxim at ely 150 NPs pract icing in Pediat ric Crit ical 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 nt ernat ional Nurse Pract it ioner/ Advanced Pract ice
Network- 68% of advanced pract ice nursing has research
functions as part of their role
Hist orically
•   Nurse Pract it ioner
      prim ary care, “ m edical m odel ”

Recent ly
•   NPs int o acut e, specialist areas
Clinical pract ice
Educat ion
Leadership / Managem ent
Five broad areas of care
m anagem ent
• Coordinat ion of care
• Recording t he hist ory and perform ing t he
  physical exam
• Ordering diagnost ic t est s
• 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: 147- 155.
I nvolved in physical and t echnical
aspect s of care
Engaged in crit ical t hinking and
decision m aking
Provide cont inuit y of care
Also involved in educat ion, research
and support of syst em s
 Kleinpell, 1997; Richmond & Keane, 1996; DeNicola, 1993;
 Spisso, 1990; Bissinger, 1997; Schultz, 1993; Verger, 1997
     Pract ice influences….Environm ent
I ncreasing need for skills of an advanced pract ice
nurse in specialties and in hospitals
  • Changing reim bursem ent policies
  • Short ening lengt h of hospit al st ay
  • Num ber of pat ient s rapidly m oving t hrough t he
    health care system
  • Changes in m edical t raining program regulat ions
  • Focus on well child care
Pediat ricians fam iliar wit h working wit h NPs
Team approach in hospit als
Acut e care role of NNP developed in m id
1970 ’ s
Educat ion incorporat ed - t echnical and
diagnost ic skills
Manage populat ion of infant s in NI CU-
prem at ure t hru neonat al age group
I m pet us: Gap bet ween expanding service
needs, decreasing house st aff availabilit y
         Original concept based on hospit al ’ s needs at
         bedside - highly professional and skilled
         professionals necessary
         Over past 30 years- shift from cert ificat e t o
         graduat e degree required
         St andardizat ions of educat ional program s
           • USA: Nat ional Associat ion of Neonat al Nurses ( NANN)
                     NCC ( certifying body for NNPs)- graduate degree required
         NNP shift ed from st rict ly clinical role t o:
           •   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): 225- 8.
       Direct provider of care for infant s
       and neonat es
       Advocat e
       Consult ant
       Manager of syst em s
NANN, 2002 Elaboration of curriculum content for the professional role of the NNP.
NNPs perform at least com parably
and in som e cases bet t er t han
physicians in t raining
•                   Bissinger,             Carzoli,
    Trotter, 1994; Bissinger, et al, 1997; Carzoli, 1994; Schultz, 1994; Mitchell, et al, 1995;
    Mitchell- DiCenso,
    Mitchell- DiCenso, et al.,1996

Role viewed favorably by nurses,
physicians and parent s
•                              Ruth-
    Trotter, 1994; Beal, 1997; Ruth- Sanchez, 1996
     Responsibilities, roles & staffing patterns of nurse
      practitioners in the neonatal intensive care unit
        Design: prospect ive descript ive st udy in conj unct ion wit h
        regional multi- site outcomes study
        Met hods: 22 NPs surveyed, 5 regional level I I / I I I NICUs NE
          • NP roles included all levels of NICU care as well as antepartal
            consultation, delivery room management, transport, outpatient
            follow- up
          • NPs equally involved w it h all degrees of com plexit y and
          • Some NPs cared for smaller and sicker babies
        I m plicat ions: NP provide invaluable cont ribut ion wit h parent
        support and teaching, post- NICU follow- up care,
        professional research and education
        NP role in NI CU should not be viewed as a subst it ut ion for
        resident physicians

Beal JA, et al. MCN Am J Matern Child Nurs. 1999; 24(4): 168- 75
    The Nurse Practitioner Role in the NICU as
              perceived by Parents
       Purpose: underst and and describe t he
       nat ure of NP care delivery in t he NI CU as
       perceived by parent s of crit ically ill
       neonat es
       Met hods: 8 parent s; phenom enological
       m et hod
       Result s: NPs consist ent ly perceived as:
         •   effect ively m anage t he m edical care
         •    “ being posit ive and reassuring ”
         •    “ being present ”
         •    “ caring ”
         •    “ t ranslat ing inform at ion ”
         •    “ m aking parent s feel at ease ”
Beal JA, Quinn M. MCN Am J Matern Child Nurs. 2002; 27(3): 183- 8.
Consist ent care providers- part icularly
wit h ext rem ely prem at ure neonat es
Enhanced com m unicat ion
I m proved discharge planning
Role in follow - up care
Reduct ion in overall cost of care
          Pract ice influences…..APN roles
PNP in prim ary care
 • Well child care in out pat ient set t ing
Mast ers prepared nurses in specialt y pract ice
( CNS)
 • I npat ient wit h direct and indirect care
   responsibilit ies for pat ient s and fam ilies
Neonat al nurse pract it ioners
 • Acut e and crit ically ill neonat es
PNPs in - pat ient and out - pat ient
 • Responsibilit y for pat ient s in pediat ric
   specialt y areas
       Educat ion
                                                                                Role Responsiblities PNP Critical Care
         • Acut e care ( 36% ) ;
           CNS t o post m ast ers                                                              4%
           acut e/ crit ical care                                                24%                                  Leadership
           NP ( 27% ) ; Prim ary                                                                                      Coordination of Care
           care ( 37% )
         • PNP in crit ical care
           3 yrs. ( 1 - 7 yrs) ;
           Nursing 14.4 years
           ( 5 - 26 yrs)
Verger, Barnsteiner “Use of Nurse Practitioners in the Pediatric Intensive Care Unit", Research Presentation,
Pediatric Critical Care Colloquium, Hot Springs, AK, September, 1997.
         N u r se Pr a ct it ion e r s
in Pe dia t r ic Cr it ica l Ca r e - M e t h ods

    Convenience Sam ple
     • Dist ribut ed via int ernet , post al m ailing and
       personal cont act t o 81 individuals
     • Part of larger st udy looking at APNs in Pediat rics
    Mult i - it em survey ( 61 quest ions)
     • Exam ining educat ion & experience, pract ice
       environm ent , adm inist rat ive 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): 396- 408.
               Nurse Pract it ioners
        in Pediat ric Crit ical Care - Result s
               74 respondent s
               Mast er ’ s prepared
               18 st at es represent ed
               29 Hospit als
                • 35 Unit s

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): 396- 408.
                        Nurse Pract it ioners
  in Pediat ric Crit ical Care - Act ivit ies


                                                                               Direct Pt. Care
                                                                               Coordination of Care
                                                                   0%          Support of Systems


                 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): 396- 408.
              Nurse Pract it ioner
in Pediat ric Crit ical Care - Responsibilit ies
Clinical Practice               Technical Skills
 • History/Physical Exam-       •   Peripheral IV- 98%
   100%                         •   Feeding Tube Placement-93%
 • Order Medications-100%       •   Endotracheal Intub.-84%
 • Order/interpret Lab Test-    •   Arterial Lines-83%
   100%                         •   Chest Tube Removal-81%
 • Interpret ECG-100%           •   Central Lines- 80%
 • Order Blood Therapy-97%
                                Caring Practices
 • Adjust Mechanical
                                • Administer Sedation-93%
 • Titrate Vasoactive Drugs -                 AACN Synergy Model
              Nurse Pract it ioner
in Pediat ric Crit ical Care - Responsibilit ies

 Clinical Inquiry           Facilitator of Knowledge
  • Participate Research-    • Pat ient / Fam ily Educ. - 100%
    60%                      • Nursing Education- 90%
                             • Medical Education- 82%

                                        AACN Synergy Model
    Direct Com prehensive Care
    Support of Syst em s
    Educat ion
    Publicat ion & Professional Leadership

Ackerman M., Norsen L., Martin B. (1996) American Journal of Critical Care;5: 68- 73.
Mick D., Ackerman M., (2000) Heart and Lung; 29(3): 210- 221.
        Where are we now?

              Pract ice m odels…..
Direct clinical m anagem ent of a few
pat ient s or overall account abilit y and
influence for a group of pat ient s
Prot ect ed t im e for cont inuing educat ion,
clinical research, int egrat e int o t he
leadership of t he unit
I npat ient and out pat ient responsibilit ies
Coverage M- F days t o 24/ 7
Work in a t eam , highly collaborat ive roles
Aut horit y rest s wit h com pet ence
APNs dist inct group by t raining and
experience …int erchangeable wit h ot her
healt h care providers is not an effect ive
m odel
     Set of skills dist inguish from MDs, PAs
Dependent on individual ’ s educat ion,
cert ificat ion, years of experience and
charact erist ics of t he pract ice set t ing
1 - 2 years t o funct ion independent ly
          Nurse Pract it ioners
 in I nt ensive Care - Conclusions

Growing segm ent of APNs
 • Represent s increasing areas around t he world
 • Pract ice set t ings varied
Role com ponent s include Clinical Pract ice and
ot her APN responsibilit ies
 • I ncluding Educat ion, Support of Syst em s,
 • Variabilit y of % of t im e spent

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