The role of a nurse practitioner in an ambulatory surgery unit

AORN Journal,  March, 2004  by Barbara A. Guido

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Nurses in advanced practice are increasing in number, as well as in the variety of roles they perform. In the year 2000, the US Department of Health and Human Services conducted a survey of RNs in the United States and found that an estimated 196,279 RNs were prepared to practice in advanced practice nursing. (1) This is a 21.4% increase from the estimated 161,712 RNs who were prepared to practice in advanced practice nursing in 1996. (2)

Perioperative nurses are most familiar with certified RN anesthetists (CRNAs), one of the earliest advanced practice nursing roles that developed. As advanced practice nursing expands to other practice settings, however, perioperative nurses are apt to encounter advanced practice nurses (APNs) in other roles in the perioperative environment. This article provides a brief overview of advanced practice nursing and describes the role of nurse practitioners (NPs) in an ambulatory surgery unit at a large, suburban, not-for-profit, academic hospital.

ADVANCED PRACTICE NURSES

The American Nurses Association (ANA) defines an APN as a nurse who

   has a master's or doctoral education
   concentrating in a specific area of
   advanced nursing practice, had
   supervised practice during graduate
   education, and has ongoing clinical
   experiences. (3 (p2))

Advanced nursing practice differs from basic nursing in that an APN has a "greater depth and breadth of knowledge, a greater degree of synthesis of data, and complexity of skills and interventions." (3(p2) The scope of practice of an APN is to

   provide comprehensive health assessments
   and demonstrate a high level
   of autonomy and expert skill in the
   diagnosis and treatment of the complex
   human responses of individuals,
   families, or communities to actual or
   potential health problems. (3 (p1))

The specific scope of practice for an individual APN is based on what legally is allowed in the state in which he or she practices and is defined in the state's nurse practice act or advanced nursing practice act. A summary of the legal authority for APN scope of practice by state is presented in Table 1.

Advanced practice nurses can be categorized into four major roles: certified nurse midwife, clinical nurse specialist (CNS), CRNA, and NP. (3,4) Table 2 summarizes the numbers of APNs in each of these four major roles in the United States, according to a March 2000 national survey.

In addition to these four major roles, an evolving fifth APN role recently has been identified--that of the APN case manager. (4) AORN also has identified another APN role--the perioperative APN. AORN defines the perioperative APN as

   a registered professional nurse who
   uses specialized knowledge and skills
   in the care of patients and families
   undergoing operative and other invasive
   procedures, and has a graduate
   degree in nursing. (5 (p149))

THE NP ROLE

Nurse practitioners are the largest group of APNs. In 2000, 44.9% (88,186) of APNs were prepared to practice as NPs. (1) In addition, because of some role overlap, another 7.5% (14,643) of APNs were prepared to practice as both NPs and CNSs. (1) Of these 102,829 RNs prepared as NPs, it was estimated that 64% held a position with the title of nurse practitioner. (1) The ANA defines an NP as a

   skilled health care provider
   who utilizes critical
   judgment in the performance
   of comprehensive
   health assessments, differential
   diagnosis, and
   the prescribing of pharmacologic
   and non-pharmacologic
   treatments in
   the direct management of
   acute and chronic illness
   and disease. (3 (p4))

The NP role was developed in the 1960s to provide primary health care, especially in underserved areas, in response to a physician shortage. (6) The first NPs practiced in pediatrics, and later, the role evolved to include adult, family, and women's health. Nurse practitioners traditionally have practiced in primary care settings, such as clinics, health maintenance organizations, public health departments, and private medical practices. More recently, NPs have expanded their roles into acute care settings to meet the needs of patients who are hospitalized or acutely ill. (7-14) A shortage of medical resident physicians often is cited as the impetus for the movement of NPs into acute care. (11) In addition, cost-cutting measures and a limit to the number of hours that a resident physician can work have contributed to the expansion of NPs into hospitals and other acute care settings. (7)

All NPs are prepared to take comprehensive health histories, perform physical examinations, and diagnose and treat many acute and chronic health problems. Prescriptive authority is another important role component for NPs. Nurse practitioners in all 50 states and the District of Columbia now have some degree of prescriptive authority. (15) The degree of autonomy varies from state to state and ranges from requiring some type of physician involvement to prescribing privileges without any requirements for physician involvement. (15)