One of the questions I field frequently in both practice and here at Cartagena surgery is – What is an acute care nurse practitioner (ACNP)?  This is usually bracketed by statements such as, “I didn’t know NPs could work in surgery.  I thought you only worked in [primary care] clinics.”  Sometimes it’s patients asking the questions – sometimes it’s the surgeons themselves.

This is usually followed by questions or statement about whether ACNPs belong in this role, and if we function at a ‘satisfactory level’ in acute care settings such as intensive care units, emergency departments and specialty surgery practices.

The answer lies in the research, and the overwhelming majority of the literature states that we do, in fact, function very well, in our role to augment  (not replace) physician services.  We do so well, in fact, that the most recent literature is primarily focused on surgeons in other countries and their efforts to import the NP models to their countries (Japan, the UK specifically) over the last few years.

But I don’t expect readers to take my word for it.  Hopefully by now, you’ve all become informed consumers – so I’ve posted some references with links below.  In many cases the entire article was not available [without subscription] so in those cases, particularly long articles – I’ve posted a link to the abstract.  In some cases, there is no abstract available on-line so I’ve included the citation.

Unfortunately many of the larger studies on patient satisfaction are based in the primary care setting, so I have omitted them.

Since I’ve gotten quite a bit of interest on this topic from medical providers, other nurses and readers – I’ve added a section for literature relating to nurse practitioners, which I will try to update periodically, since it is too large of a project for a single post.

Nurse Practitioners in Surgical Specialties/ Acute Care Settings: Review of the available literature

1. The role, productivity, and patient satisfaction of surgical nurse practitioners compared to medical surgeons at VA outpatient clinics.  Palmquist, D. (2010).  Graduate dissertation at Tui University.  This is actually a head to head comparison of NPs to MDs which showed greater productivity by MDs (saw more patients) but greater patient satisfaction with care by NPs. [abstract only].  This isn’t surprising in that surgeons have an enormous amount of responsibilities and demands placed on their time.

2. Patient satisfaction with a nurse practitioner in a university emergency service. Rhyee, K & Dermyer, A. (1995). Annals of Emergency Medicine, Volume 26, Issue 2 , Pages 130-132, August 1995.    Study showed no difference between patient satisfaction with care by either MD or NP. Notably, the primary author was a physician [abstract only].

3. Acute care pediatric nurse practitioner: a vital role in pediatric cardiothoracic surgery.  Okuhara CA, Faire PM, Pike NA.  J Pediatr Nurs. 2011 Apr;26(2):137-42  [abstract only].  These NPs are actually dually certified in most cases – in pediatrics and acute care.

4.  The effect of a multidisciplinary hospitalist/physician and advanced practice nurse collaboration on hospital costs.  Cowan MJ, Shapiro M, Hays RD, Afifi A, Vazirani S, Ward CR, Ettner SL.  J Nurs Adm. 2006 Feb;36(2):79-85.  Reduced length of stay, reduced patient costs, and hospital costs on teams with nurse practitioners.

5. The evolving role of the acute care nurse practitioner in critical care.  Howie-Esquivel J, Fontaine DK.  Curr Opin Crit Care. 2006 Dec;12(6):609-13. A nice article that talks about how the NP role is expanding internationally to copy American health care models.

6. The advanced practice nurse in an acute care setting. The nurse practitioner in adult cardiac surgery care.  Callahan M.  Nurs Clin North Am. 1996 Sep;31(3):487-93.  [abstract only].  This article was actually written by researchers at my alma mater, Vanderbilt.

7.  Outcomes of tube thoracostomies performed by advanced practice providers vs trauma surgeons.  Bevis LC, Berg-Copas GM, Thomas BW, Vasquez DG, Wetta-Hall R, Brake D, Lucas E, Toumeh K, Harrison P.  Am J Crit Care. 2008 Jul;17(4):357-63. [full text article].  This is a nice study that actually compares NP/ MDs performing invasive procedures – in this case, chest tube placement.

8. Effect of an outcomes-managed approach to care of neuroscience patients by acute care nurse practitioners.  Russell D, VorderBruegge M, Burns SM.  Am J Crit Care. 2002 Jul;11(4):353-62. [full text article].  This article is one of a series of articles published by researchers at UVA which led the changes in the University of Virginia policy – (the results were so compelling that UVA)  to advocate for exclusive use of nurse practitioners in all acute care areas.  It showed shorter length of stays, less infections for patients care for by NPs versus residents.

Several Japanese researchers are looking at the role of nurse practitioners, as mentioned above.

1.  Nurse practitioners in surgical services in the United States.  Okano A.  Nippon Geka Gakkai Zasshi. 2011 May;112(3):207-10. Japanese.  No abstract available.

2.  Considering the feasibility of introducing nurse practitioners into Japanese thoracic services.  Komatsu T, Coutler L, Henteleff H, Johnston M, Bethune D. Ann Thorac Cardiovasc Surg. 2010 Aug;16(4):303-4  [full text article].  An interesting article, written by Canadians, who have just started to recognize NPs in the acute care/ surgical settings.The comments from the surgeons at the Canadian facility are quite interesting as well.   I wouldn’t mind helping the thoracic surgeons in Japan get used to ACNPs..  🙂

3.   [Surgeons’ hope: expanding the professional role of co-medical staff and introducing the nurse practitioner/physician assistant and team approach to the healthcare system].  [Article in Japanese]  Maehara T, Nishida H, Watanabe T, Tominaga R, Tabayashi K. Nippon Geka Gakkai Zasshi. 2010  Jul;111(4):209-15.

Summary: The healthcare system surrounding surgeons is collapsing due to Japan’s policy of limiting health expenditure,market fundamentalism, shortage of healthcare providers, unfavorable working environment for surgeons, increasing risk of malpractice suits, and decreasing number of those who desire to pursue the surgery specialty. In the USA,
nonphysician and mid-level clinicians such as nurse practitioners (NPs) and physician assistants (PAs) have been working since the 1960s, and the team approach to medicine which benefits patients is functioning well. One strategy to avoid the collapse of the Japanese surgical healthcare system is introducing the NP/PA system. The division of labor in medicine can provide high-quality, safe healthcare and increase the confidence of the public by contributing to: reduced postoperative complications; increased patient satisfaction; decreased
length of postoperative hospital stay: and economic benefits. We have requested that the Ministry of Health, Labor and Welfare establish a Japanese NP/PA system to care for patients more efficiently perioperatively. The ministry has decided to launch a trial profession called “tokutei (specifically qualified) nurse” in February 2010. These nurses will be trained and
educated at the Master’s degree level and allowed to practice several predetermined skill sets under physician supervision. We hope that all healthcare providers will assist in transforming the tokutei nurse system into a Japanese NP/PA system.

Note: This is also ground-breaking, as other countries have been slow to implement nurse practitioners in any areas of their medical care system.  The fact that this is a surgical setting is  even more encouraging. These researchers have also published research on the introduction of NPs in other surgical specialties.

NPs and Residents: a delicate balancing act

In fact, nurse practitioners are the reason that recent changes (July 2011) in surgical/ medicine residency hours are even possible. Without the services that NPs provide, it would be impossible for large teaching institutions to implement the new mandated resident hour restrictions.

Even before the newest restrictions – nurse practitioners have been called to take up the slack (when resident hours were previously reduced both here and in Canada.)  However, it was these restrictions that gave us our greatest opportunities for larger acceptance in the acute care specialties.  (Nurse practitioners have worked in acute care since our inception but were not widely known in this acute care role.)  Fortunately, the data shows that not only have NPs made up for the lack of residents, we’ve actually improved the level of care and patient satisfaction [in comparison to care given by residents].

More information of resident hour restrictions

Next time – I’ll include several more articles, including some more looking at my own specialty – cardiothoracic surgery.