The evolving role of advanced practice nurses in surgery

AORN Journal,  May, 1998  by Denise M. Hodson

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* Seventy percent of ORs use personnel other than physicians to first assist because the majority of physicians are not reimbursed by third-party payers.

* Sixteen percent of hospitals use RNFAs; 7% use PAs; 5% use surgical technologists; and 3% use foreign medical graduates.

* Fifty-one percent of RNFAs are compensated the same as staff nurses; 38% receive some form of compensation; and 62% do not receive compensation.

* Of RNFAs receiving compensation, 10% receive across-the-board salary increases; 8% receive across-the-board dollar increases; and 5% receive compensation within the clinical ladder system.

* Thirty percent of facilities bill for RNFA services, and 60% of facilities do not receive reimbursement. Thirty-four percent of institutions have RNFAs on call.

* Of those RNFAs on call, 38% receive call pay and 26% do not. When RNFAs are not available to assist, scrub personnel are provided 49% of the time.

* Finally, 57% of facilities reported that nonqualified OR staff members are expected or assigned to assist in surgeries.(51)

Reimbursement. Only Florida and Minnesota have specific state legislation to support RNFA reimbursement through private insurers. A comparison of PA reimbursement at 20% versus RNFA reimbursement at 16% on 23 common surgical procedures revealed a total savings of $104,796 by using RNFAs.(52) Effective Jan 1, 1998, the balanced budget plan by Congress extended Medicare payment to all NPs and CNSs, regardless of geographic area. Certified nurse midwives and CRNAs already are reimbursed under Medicare part B, and until now, NPs and CNSs were only reimbursed in designated rural areas. Registered nurse first assistants are not affected and are not eligible for direct Medicare payment because they are considered specialized only within perioperative nursing and not advanced practice. Reimbursement on a greater level also may depend on advanced practice preparation.

LITERATURE REVIEW

A comprehensive literature review generated a picture of what is known about role development and evaluation of APNs in the surgical environment. Surgical arena literature included articles on the use of APNs in orthopedics,(53) cardiovascular surgery,(54) head and neck surgery, general surgery, pediatrics, neurosurgery, otolaryngology, and nephrology.(55)

The extensive review of 2,391 articles revealed that the most formal evaluations of APNs have focused on primary care or community-based practices.(56) The most significant is the comprehensive literature review of APNs in ambulatory and primary care by the 1986 Office of Technology Assessment (OTA).(57) The OTA summarized

* 10 studies that concluded the quality of care provided by APNs and the quality of care provided by physicians were equivalent,

* 14 studies that demonstrated a difference in the quality of care, and

* 12 studies that showed APN quality of care was better than that given by physicians.

The review discovered that APNs spent more time with their patients and had better communication, counseling, and interviewing skills. Physicians were better at many problems that required technical solutions;(58) however, it was estimated that 50% to 90% of primary care provided by physicians could be provided by APNs.(59) In addition, the services could be provided by APNs at approximately one third of physicians' salaries.(60) Employing APNs instead of physicians has been reported to save 24%.(61) The federal cost of education for APNs also is much less than physician education. This information is useful in extrapolating hypotheses for role development and evaluation of surgical APNs.