evolving role of the acute care nurse practitioner, The

Nurse Practitioner, Apr 2000 by Geier, Wendy

The acute care setting is not unchartered ground for advanced practice nurses. The clinical nurse specialist (CNS) role, created in the late 1960s, provided a clinical expert and a resource for staff nurses in the clinical setting (see Table 1).1 In contrast, the first documented role of the acute care nurse practitioner (ACNP) was the neonatal nurse practitioner (NNP).

The NNP role developed in the late 1970s, when pediatric resident physicians were spending a limited amount of time in neonatal intensive care units. NNPs began filling positions when there was an undersupply of neonatal health care specialists.2

In the early 1990s, changes in the health care delivery environment were the thrust for the ACNP role development. Specifically, the downsizing of hospital staff and the projected shortages of resident physicians in metropolitan centers resulted in the need for more patient care providers in large tertiary hospitals. The expansion of hospital speciality services despite the decreased staffing created a further need for acute care providers.3

Advanced Practice Evolution

A new role for NPs is emerging in the acute care hospital setting. Although this role has not been fully defined, ACNPs are collaborating with physicians to manage patients in diverse practice specialties and hospital sites. Important to the successful development of this evolving role is the description of practice.

Acute care nurse practitioners' perceptions reveal the role's value in the hospital setting, how practice boundaries and responsibilities are defined, the clinical expertise needed, and socialization experiences. Seven female NPs practicing in different specialties, including cardiothoracic surgery, cardiology, oncology, pulmonary critical care medicine, and emergency medicine, participated in a qualitative research study (see Table 2). Although barriers to practice persist, ACNPs are in the process of generating, defining, and establishing practice boundaries and incorporating their values and experience into practice, while placing emphasis on an interactive practice approach.4

ACNPs' Organizational Placement

Historically, nurses have encountered political issues in practice that are resolved by the most powerful people in the organizational structure.5 ACNPs are no longer considered to be on the lower rung of the hospital hierarchical infrastructure. Traditionally, staff nurses, including CNSs, have held the least powerful positions because their professional judgment has been regarded as subordinate to physicians'.6 This Observation has far-reaching implications for ACNPs, specifically in forming their practice boundaries.

Although organizational imperatives in large institutions shape work environment, new constituents within the group dynamic can represent a new power. Consequently, the advanced practice nursing role represents a new role and a change in nursing's status in the hospital setting. The ACNPs' role descriptions revealed a collaborative rather than subordinate relationship with physicians.

The participants described a role with increased visibility, value, power, and prestige. ACNPs address their need to be heard and the importance of their nursing background. Practice is based on their own experience and personal values. The power to define and establish practice boundaries is within their reach.

A Paradigm Shift

The participants acknowledged that they are nurses practicing within a medical practice model. These ACNPs did not view themselves as physician substitutes nor did they want to be viewed as such.

Acute care nurse practitioners are creating a new nursing role by blending two dimensions of practice: nursing and medical. Practice is based on a holistic patient management approach using a medical treatment protocol. This includes performing certain medical procedures that had previously only been performed by physicians. For example, ACNPs perform lumbar punctures, insert chest tubes, and write medical orders for nurses.

Hospitals fail to reimburse ACNPs directly for their services, however. This lack of role recognition is exemplary of a structural "discounting" experience that is a predominant theme throughout the findings.7 For example, a cardiothoracic NP who was interested in performing more medical procedures found her request was ignored by her department.

Descriptions of the ACNP role socialization process underscored the significance of having NP role models and ongoing support from NP colleagues, and the importance of comprehending normative steps in role making. The study findings demonstrated that several elements are vital to the participant's role development: an interactive practice approach; the presence of fluid ACNP practice boundaries; and ongoing open communication among nursing, medical, and hospital administration staffs.

In the past, both the nursing and medical professions articulated that a merger should not occur. This new model of practice is developing at a time when many consumers are dissatisfied with the traditional health care delivery system. Many health care consumers are looking for alternatives to traditional medicine. Acute care nurse practitioners' effective integration of the two practice models is a viable alternative in the acute care setting.