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Allied Health Personnel in Child Health Care
.
Allied Health Personnel In Child Health Care JOHN P. CONNELLY, M.D.':' ALFRED YANKAUER, M.D.':":'
HISTORICAL DEVELOPMENT In recent years several national commissions have pointed out the need for more physicians and the interrelated need for more welltrained teammates and associates. In 1952, the President's Commission on the Health Needs of the Nation 9 pointed out that the technician shortage was a serious block to the provision of medical services. It called particular attention to the need for development of schools of "auxiliary medical services." In 1956 the Report on Paramedical Personnel of the Surgeon-General's Consultant Group on Medical Education 6 compiled extensive data on supply and resources of paramedical personnel, finding there were not enough paramedical personnel to meet present or expected needs, particularly for persons suffering from chronic illness. The Bane Committee (the Surgeon-General's Consultant Group on Medical Education)R in 1959 found it necessary to associate the problems of medicine with those of related health professions, pointing out that physicians could not carry out their responsibilities without collaborating ancillary health workers. Intensive recruitment in all professional and technical health fields was urged. In 1965 the President's Commission on Heart Disease, Cancer and Stroke lO made the observation that lagging physician supply was a critical element lacking in a full-scale attack on these diseases but stressed that shortages existed in all health professions. Two major solutions were proposed: (1) more effective utilization of present man-
':'Chairman, Committee on Manpower, Council on Pediatric Practice, American Academy of Pediatrics; Pediatrician to the Children's Service, Massachusetts General Hospital; Associate Professor of Pediatrics, Harvard Medical School, Boston, Massachusetts ':'*Consultant, Committee on Manpower, Council on Pediatric Practice, American Academy of Pediatrics; Co-Medical Director, Pediatric Nurse Practitioner Program of the Massachusetts General Hospital; Senior Research Associate, Harvard School of Public Health, Boston, Massachusetts Pediatric Clinics of North America- Vol. 16, No.4, November, 1969
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power resources and (2) massive programs for the training of additional physicians, dentists, nurses, and other health personnel. The Coggeshall Report of 1965 ("Planning for Medical Progress through Education")2 found general agreement among medical educators that the nation's need for physicians would continue to exceed the ability of existing medical schools to produce physicians and that physician-led teams would have to be formed to compensate for this deficiency. This report gave medical schools the task of seeing that persons needed for allied health professions and occupations are appropriately trained. Each member of the Task Force on Health Manpower of the National Commission on Community Health Services in 19667 agreed on the urgency of developing and effectively using allied and auxiliary health personnel of many kinds, feeling that if the report was to make any long-term contributions it would be in its emphasis on this approach. Finally, the major point of the 1967 medical manpower report,l1 besides reinforcing the fact that there was a "crisis" in American health care due to manpower shortages, was that vast increases in manpower and money would be of little use unless the system itself were changed. The report charged that the present system channels health manpower in significant numbers into inefficient and inappropriate activities.
PEDIATRICIANS' RESPONSE Recognition of these pressures prompted the American Academy of Pediatrics to establish the Committee on Pediatric Manpower in 1966 as one of the major divisions of its Council on Pediatric Practice. The committee was aware that solutions to the pediatric manpower shortage that existed and were developing would have to be multiple; for example, there must be an absolute increase in pediatricians, more lay health education, changes in the organizational relationships between doctors and hospitals, particularly in regard to the emergency ward and outpatient departments, assumption by hospitals or newly established health centers of continuous care of large segments of the population not now presently served, and changes in the medical educational system that would provide more learning experiences in continuous, unfragmented, family-centered, and preventive care. Medical students presently are not given the opportunity to work with other associated disciplines or aide-assistants in a team fashion mainly because the educational systems of medicine, nursing, and allied health sciences are planned and executed independently of one another. Another major change the council anticipates is a move away from solo to multispecialty or group practice. This is expected to improve efficiency and extend services to more people and provide the setting in which doctors can share responsibility for care with other professionals. As an initial thrust, the committee chose to pursue in depth the concept of interprofessional care of the ambulatory patient; this concept involves more widespread use of allied health workers. The committee discovered that there were virtually no data available concerning the
ALLIED HEALTH PERSONNEL IN CHILD HEALTH CARE
923
actual allocation of tasks to allied health workers in practitioners' offices, where the vast majority of American children receive their health care; therefore, a questionnaire was prepared and mailed to regular fellows of the American Academy of Pediatrics in 1968. It was designed to obtain (1) information about existing allied health worker utilization and (2) opinions on this subject from all pediatricians who were members of the academy. This survey will be reported in depth in the near future. 14 Important conclusions that can be drawn from the data are as follows: 1. Registered nurses in pediatric offices are utilized to an appreciable extent for the performance of clerical, laboratory, and technical tasks, but not in preference to other workers when such workers are available. Patient care tasks (as distinct from technical or clerical tasks) are much less frequently delegated to any health worker, but when delegated the registered nurse is preferred over others. 2. The number of health workers employed in the practice affects the delegation of technical, clerical, and laboratory tasks more strongly than that of patient care tasks. Patient care task delegation depends strongly upon the presence of one or more registered nurses. 3. The patient care tasks pediatricians most frequently delegate are those that reflect the most urgent and least controllable pressures of practice (telephone calls) and those that can be most easily routinized, such as instruction to the patient and formal history taking. The tasks least frequently delegated are those that involve clinical judgment or a more intimate patient care relationship, such as a physical examination and interval history taking. 4. A striking contrast is evident between the proportion of respondents presently delegating patient care tasks and the proportion indicating they would do so if capable, trained personnel were available. The vast majority indicated they would hire such personnel and that their utilization would increase the volume or improve the quality of pediatric care or both. 5. At least two thirds of the respondents indicated they would be willing to hire an allied health worker on a full-time basis to carry out patient care tasks that are now predominantly performed by the pediatrician. The specific tasks to which highest priority was allocated were those of information giving (e.g., child care and feeding), information seeking (history taking), and counseling (e.g., advice concerning minor medical complaints in office or by telephone and advice concerning feeding and development).
The most important general conclusion the survey identified was the fact the great majority (80 per cent of academy members) appeared to favor the development of a method of meeting patient care needs that would involve greater patient care responsibilities for the registered nurse and the use of aides, assistants, or secretaries for many of the present activities of the nurse. Armed with these facts, as well as with confirmatory data gathered by the Joint Council of National Pediatric Societies,t3 the academy explored the legal and economic considerations these changes implied and found that these considerations, while raising concerns which must be addressed, did not preclude the forward motion of encouraging task allocation to allied health workers. In fact, the major obstacle to execution of the necessary changes has been identified as lack of trained workers, standardization of classifications, certification of individuals, and certification of training programs and institutions. To help establish legal precedent, the academy's executive board, on the recommendations of the Committee on Manpower, stated as an official position of the academy that "a physician may delegate to a
924
JOHN
P.
CONNELLY, ALFRED YANKAUER
properly trained individual working under his jurisdiction the responsibility of providing appropriate portions of the health examinations and health care for infants and children." In the academy manual entitled "Standards of Child Health Care," specific areas, particularly in the preventive pediatric sphere, will be identified as being areas that can be handled by an assistant or associate if the responsible physician wishes. These actions it was felt will allow task delegation to be interpreted legally as part of "usual and customary" practice. The executive board further stated that guidelines for programs to train pediatric personnel who are not physicians should be developed, that such personnel should be appropriately trained, and that they must work under the supervision of a physician.
LEGAL OPINION This action is in keeping with the legal opinion rendered by the law division of the American Medical Association, which states: 1 In considering the risks of liability in the use of new kinds of paramedical personnel to assist physicians in new ways, it seems inevitable that such medical innovations must increase risks. The risk, of course, is lessened if the assistant is thoroughly trained and carefully supervised. It is reduced still further if a formal training program is established and effectively operated by a medical school or a teaching hospital. It is minimized further if appropriate medical and specialty societies establish standards for training and a program for private certification of students who satisfactorily complete the approved training. Official state certification would add only a little protection. Compulsory state licensing would not further reduce the risk for the employing physician.
This opinion goes on to state: In some states, added protection may also be obtained by amending the Medical Practice Act. In a few instances these laws grant general authority to physicians to use competent assistants substantially at the physician's discretion. One of the best provisions along this line is that in the Oklahoma Act, as follows: - Nothing in this article shall be so construed as to prohibit service rendered by a physician's trained assistant, a registered nurse or a licensed practical nurse if such service be rendered under the direct supervision and control of a licensed physician. Where strict compulsory licensing laws are unreasonably impeding the effective use of new paramedical personnel, a statutory amendment along this line might be advisable. This might be especially helpful in problem areas like California. A final suggestion might be appropriate. The history of professional nursing has been one of steadily expanding paramedical function. Without any substantial opposition, nurses are today carrying out procedures which would have been shocking to the medical profession and the public ten years ago. Without any change in the Nursing Practice Act, in most instances, it is probable that delegation to nurses under physician supervision can be made of virtually any medical procedure that does not, on a scientifically determined basis, require the personal knowledge, skill and judgment of a physician. This has already been accomplished with respect to nurse anesthetists without the benefit of any special statute. It seems likely that it can be done gradually in relation to many other important medical functions, provided that the competence of the nurses for the assigned duty is assured by comprehensive training.
ALLIED HEALTH PERSONNEL IN CHILD HEALTH CARE
925
CLASSIFICATIONS The American Academy of Pediatrics has tentatively adopted the following classifications of allied health personnel: 1. Pediatric Nurse Associate. A registered nurse who has completed a diploma nursing program or an associate degree nursing program or is a graduate of a baccalaureate nursing program. This associate will also have completed a recognized pediatric nurse associate (practitioner) program of about 4 months' duration. A pediatric nurse associate's responsibilities may include activities that are directly related to patient care, e.g., obtaining medical and health histories, performing portions of the physical examination, giving information and counsel, and managing health problems. These tasks will be performed under the supervision of a physician. 2. Pediatric Office Assistant. A pediatric office assistant will, when possible, have completed at least 2 years of college or its equivalent, which will include a minimum of 9 months training in general medical background oriented toward child care, or be a graduate licensed vocational or licensed practical nurse with postgraduate pediatric training. She will work under the supervision of a physician or a nurse associate. Her responsibilities may include activities that aid the physician or nurse associate in patient care, e.g., obtaining medical histories, performing screening procedures, and such other administrative, clerical, and minor technical functions or other duties as the physician or nurse associate may direct. 3. Pediatric Aide. A pediatric aide, when possible, will have completed at least high school or its equivalent. A pediatric aide will usually be trained on the job by a pediatrician certified by the American Board of Pediatrics. She will work under the supervision of a physician, pediatric assistant, or pediatric nurse associate.
A simultaneous but crucial step in this process was the establishment within the academy of the Division of Allied Child Health Manpower to oversee and coordinate these efforts. This division will seek to further develop program guidelines, recommend curricula for various training programs, develop relationships with other professional groups, consider the possible establishment of an organization for the various classifications of allied health personnel under academy sponsorship, and develop a pediatric preceptor program to teach pediatric skills to members of these new classifications of allied pediatric manpower.
EXISTING PROGRAMS Demonstration projects that have been or are being developed in the country in this area of allied pediatric practice have been progressing since 1963. 3 • 4 Some of the existing pediatric nurse practitioner training programs are as follows: 1. Pediatric Nurse Associate Program, Good Samaritan Hospital, Cincinnati, Ohio; University of Cincinnati, College of Medicine. 2. Pediatric In-Service Education Program for Public Health Nurses, Department of Pediatrics, Montefiore Hospital (Morrisania Health Center), New York, New York. 3. Pediatric Nurse Assistant Program, the University of Rochester, School of Medicine and Strong Memorial Hospital, Rochester, New York. 4. Pediatric Nurse Practitioner Program, Massachusetts General Hospital,
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CONNELLY, ALFRED YANKAUER
Bunker Hill Health Center of the Massachusetts General Hospital, Charlestown, Massachusetts. 5. Pediatric Nurse Practitioner Program, University of Colorado School of Medicine and School of Nursing, Denver, Colorado. 6. Health Nurse Clinician Program, Wayne State University, College of Nursing, Detroit, Michigan (M.S. program). 7. Family Nurse Practitioner Program, University of California, Los Angeles, School of Public Health and the California State Department of Public Health (M.S. program) (started September, 1969). 8. Los Angeles County Health Department, In-Service Program for Extending Role of Public Health Nurse in Pediatric Care. 9. Pediatric Nurse Assistant Program, Division of Health Services, Department of Preventive Medicine, University of Washington School of Medicine, Seattle, Washington (special project for recruiting inactive nurses), in cooperation with the University of Washington School of Nursing. 10. Expanded Role of Nurse in Care of Child with Long-Term Illness, University of Florida School of Nursing, Gainesville, Florida (M.S. program for pediatric nurses). 11. Pediatric Nurse Practitioner Program, Maine Medical Center, Portland, Maine. Silver and Duncan 12 describing the experience of a nurse practitioner in a pediatric office found that only two of 182 children examined by the nurse practitioner were assessed differently by the pediatrician; 95 per cent of parents of patients in that practice were satisfied with this arrangement between the pediatrician and the nurse practitioner; more than half felt joint care was better than previous care by the pediatrician alone; the pediatrician could manage more patients; and finally, the increased cost of adding a nurse practitioner to office practice was more than offset by the added income she generated. Pediatric assistants at various levels of training are in process at the following centers: 1. Wake Forest College, Bowman Gray School of Medicine. An associate degree graduate is given additional training of 1 year in the hospital, learning anatomy, growth and development, and physical diagnosis, and a second year as an "intern" in a pediatrician's office. Under the sponsorship of a pediatrician, this person screens and assesses the health status of children. They are taught history taking. Therapeutics is not included beyond an orientation to immunization. 2. University of Colorado, Denver, Colorado (Child Health Associate). This research project gives selected high school graduates 2 years of undergraduate college training followed by a 2-year course of instruction at the University of Colorado Medical Center, in Denver, and a I-year internship. This program is to start in September, 1969.
SUMMARY The vast majority of pediatricians agree that the nature of ambulatory pediatric care and the increased consumer demand for such care, coupled with a decrease in the medical manpower available to deliver it, make it essential that allied health personnel be utilized more heavily in child health health care. The nurse, a pediatric assistant, and an aide are logical links between the patient and the doctor, provided he retains supervision and responsibility.
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The acceptance and inclusion of such persons cannot be done at the sacrifice of personal care. Fox5 has suggested that the personal doctor's independent existence may be jeopardized if he leaves all dressings to the nurse, sympathy to the receptionist, messages to the secretary, and solutions of problems in the home to the social worker. We add only that (1) the personal physician's existence is equally jeopardized when he is so overwhelmed with patients that he can give only cursory attention to each and (2) many of the patient care services now carried out by a pediatrician can be performed just as effectively by a pediatric nurse associate and office assistant responsible to him.
REFERENCES 1. Bergen, R P.: Irregular assistants and medical risks. J.A.M.A., 207:1027,1231,1969. 2. Coggeshall, L. T.: Planning for Medical Progress through Education. A report submitted to the Executive Council of the Association of American Medical Colleges, Evanston, Illinois. The Association of American Medical Colleges, April, 1965. 3. Connelly, J. P.: Vse of ancillary personnel in children's out-patient departments. Clin. Pediat., 4:233, 1965. 4. Connelly, J. P., Stoeckle, J. D., Lepper, E. S., and Farrisey, R M.: The physician and the nurse - Their interprofessional work in office and hospital ambulatory settings. New Eng. J. Med., 275:765-769,1966. 5. Fox, T. F.: The personal doctor and his relations to the hospital: Observations and reflections on some American experiments in general practice by groups. Lancet, 1 :473, 1960. 6. Mobilization and Health Manpower. II. A Report of the Subcommittee on Paramedical Personnel in Rehabilitation and Care of the Chronically Ill. Washington, D.C., V.S. Government Printing Office, 1956. 7. National Commission on Community Health Services. Report of the Task Force on Health Manpower. Bethesda, Maryland, 1966. 8. Physicians for a Growing America. Report of the Surgeon-General's Consultant Group on Medical Education. Public Health Service Publication No. 709, Washington, D.C., V.S. Government Printing Office, 1959. 9. President's Commission on the Health Needs of the Nation. Vol. I. Washington, D.C., V.S. Government Printing Office, 1952. 10. President's Commission on Heart Disease, Cancer and Stroke. Report to the President: A National Program to Conquer Heart Disease, Cancer and Stroke. Vols. I and II. Washington, D.C., V.S. Government Printing Office, 1964-1965. 11. Report of the National Advisory Commission on Health Manpower. Washington, D.C., V.S. Government Printing Office, 1967. 12. Silver, H. K., and Duncan, B. R: Evaluation of the Pediatric Nurse Practitioner. Report to the 79th Annual Meeting of the American Pediatric Society, Atlantic City, New Jersey, May, 1969. 13. Weil, W.: The Challenge of Meeting the Health Needs of American Children-Manpower Considerations. Presentation on behalf of the Joint Council of National Pediatric Societies before the Labor-Health, Education and Welfare Subcommittee of the Committee on Appropriations, House of Representatives, May 20, 1969. 14. Yankauer, A., Connelly, J. P., and Feldman, J. J.: Pediatric practice in the Vnited States with special attention to utilization of allied health services. Pediatrics. (In press.) 73 High Street Charlestown, Massachusetts 02129
Allied Health Personnel In Child Health Care JOHN P. CONNELLY, M.D.':' ALFRED YANKAUER, M.D.':":'
HISTORICAL DEVELOPMENT In recent years several national commissions have pointed out the need for more physicians and the interrelated need for more welltrained teammates and associates. In 1952, the President's Commission on the Health Needs of the Nation 9 pointed out that the technician shortage was a serious block to the provision of medical services. It called particular attention to the need for development of schools of "auxiliary medical services." In 1956 the Report on Paramedical Personnel of the Surgeon-General's Consultant Group on Medical Education 6 compiled extensive data on supply and resources of paramedical personnel, finding there were not enough paramedical personnel to meet present or expected needs, particularly for persons suffering from chronic illness. The Bane Committee (the Surgeon-General's Consultant Group on Medical Education)R in 1959 found it necessary to associate the problems of medicine with those of related health professions, pointing out that physicians could not carry out their responsibilities without collaborating ancillary health workers. Intensive recruitment in all professional and technical health fields was urged. In 1965 the President's Commission on Heart Disease, Cancer and Stroke lO made the observation that lagging physician supply was a critical element lacking in a full-scale attack on these diseases but stressed that shortages existed in all health professions. Two major solutions were proposed: (1) more effective utilization of present man-
':'Chairman, Committee on Manpower, Council on Pediatric Practice, American Academy of Pediatrics; Pediatrician to the Children's Service, Massachusetts General Hospital; Associate Professor of Pediatrics, Harvard Medical School, Boston, Massachusetts ':'*Consultant, Committee on Manpower, Council on Pediatric Practice, American Academy of Pediatrics; Co-Medical Director, Pediatric Nurse Practitioner Program of the Massachusetts General Hospital; Senior Research Associate, Harvard School of Public Health, Boston, Massachusetts Pediatric Clinics of North America- Vol. 16, No.4, November, 1969
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P.
CONNELLY, ALFRED YANKAUER
power resources and (2) massive programs for the training of additional physicians, dentists, nurses, and other health personnel. The Coggeshall Report of 1965 ("Planning for Medical Progress through Education")2 found general agreement among medical educators that the nation's need for physicians would continue to exceed the ability of existing medical schools to produce physicians and that physician-led teams would have to be formed to compensate for this deficiency. This report gave medical schools the task of seeing that persons needed for allied health professions and occupations are appropriately trained. Each member of the Task Force on Health Manpower of the National Commission on Community Health Services in 19667 agreed on the urgency of developing and effectively using allied and auxiliary health personnel of many kinds, feeling that if the report was to make any long-term contributions it would be in its emphasis on this approach. Finally, the major point of the 1967 medical manpower report,l1 besides reinforcing the fact that there was a "crisis" in American health care due to manpower shortages, was that vast increases in manpower and money would be of little use unless the system itself were changed. The report charged that the present system channels health manpower in significant numbers into inefficient and inappropriate activities.
PEDIATRICIANS' RESPONSE Recognition of these pressures prompted the American Academy of Pediatrics to establish the Committee on Pediatric Manpower in 1966 as one of the major divisions of its Council on Pediatric Practice. The committee was aware that solutions to the pediatric manpower shortage that existed and were developing would have to be multiple; for example, there must be an absolute increase in pediatricians, more lay health education, changes in the organizational relationships between doctors and hospitals, particularly in regard to the emergency ward and outpatient departments, assumption by hospitals or newly established health centers of continuous care of large segments of the population not now presently served, and changes in the medical educational system that would provide more learning experiences in continuous, unfragmented, family-centered, and preventive care. Medical students presently are not given the opportunity to work with other associated disciplines or aide-assistants in a team fashion mainly because the educational systems of medicine, nursing, and allied health sciences are planned and executed independently of one another. Another major change the council anticipates is a move away from solo to multispecialty or group practice. This is expected to improve efficiency and extend services to more people and provide the setting in which doctors can share responsibility for care with other professionals. As an initial thrust, the committee chose to pursue in depth the concept of interprofessional care of the ambulatory patient; this concept involves more widespread use of allied health workers. The committee discovered that there were virtually no data available concerning the
ALLIED HEALTH PERSONNEL IN CHILD HEALTH CARE
923
actual allocation of tasks to allied health workers in practitioners' offices, where the vast majority of American children receive their health care; therefore, a questionnaire was prepared and mailed to regular fellows of the American Academy of Pediatrics in 1968. It was designed to obtain (1) information about existing allied health worker utilization and (2) opinions on this subject from all pediatricians who were members of the academy. This survey will be reported in depth in the near future. 14 Important conclusions that can be drawn from the data are as follows: 1. Registered nurses in pediatric offices are utilized to an appreciable extent for the performance of clerical, laboratory, and technical tasks, but not in preference to other workers when such workers are available. Patient care tasks (as distinct from technical or clerical tasks) are much less frequently delegated to any health worker, but when delegated the registered nurse is preferred over others. 2. The number of health workers employed in the practice affects the delegation of technical, clerical, and laboratory tasks more strongly than that of patient care tasks. Patient care task delegation depends strongly upon the presence of one or more registered nurses. 3. The patient care tasks pediatricians most frequently delegate are those that reflect the most urgent and least controllable pressures of practice (telephone calls) and those that can be most easily routinized, such as instruction to the patient and formal history taking. The tasks least frequently delegated are those that involve clinical judgment or a more intimate patient care relationship, such as a physical examination and interval history taking. 4. A striking contrast is evident between the proportion of respondents presently delegating patient care tasks and the proportion indicating they would do so if capable, trained personnel were available. The vast majority indicated they would hire such personnel and that their utilization would increase the volume or improve the quality of pediatric care or both. 5. At least two thirds of the respondents indicated they would be willing to hire an allied health worker on a full-time basis to carry out patient care tasks that are now predominantly performed by the pediatrician. The specific tasks to which highest priority was allocated were those of information giving (e.g., child care and feeding), information seeking (history taking), and counseling (e.g., advice concerning minor medical complaints in office or by telephone and advice concerning feeding and development).
The most important general conclusion the survey identified was the fact the great majority (80 per cent of academy members) appeared to favor the development of a method of meeting patient care needs that would involve greater patient care responsibilities for the registered nurse and the use of aides, assistants, or secretaries for many of the present activities of the nurse. Armed with these facts, as well as with confirmatory data gathered by the Joint Council of National Pediatric Societies,t3 the academy explored the legal and economic considerations these changes implied and found that these considerations, while raising concerns which must be addressed, did not preclude the forward motion of encouraging task allocation to allied health workers. In fact, the major obstacle to execution of the necessary changes has been identified as lack of trained workers, standardization of classifications, certification of individuals, and certification of training programs and institutions. To help establish legal precedent, the academy's executive board, on the recommendations of the Committee on Manpower, stated as an official position of the academy that "a physician may delegate to a
924
JOHN
P.
CONNELLY, ALFRED YANKAUER
properly trained individual working under his jurisdiction the responsibility of providing appropriate portions of the health examinations and health care for infants and children." In the academy manual entitled "Standards of Child Health Care," specific areas, particularly in the preventive pediatric sphere, will be identified as being areas that can be handled by an assistant or associate if the responsible physician wishes. These actions it was felt will allow task delegation to be interpreted legally as part of "usual and customary" practice. The executive board further stated that guidelines for programs to train pediatric personnel who are not physicians should be developed, that such personnel should be appropriately trained, and that they must work under the supervision of a physician.
LEGAL OPINION This action is in keeping with the legal opinion rendered by the law division of the American Medical Association, which states: 1 In considering the risks of liability in the use of new kinds of paramedical personnel to assist physicians in new ways, it seems inevitable that such medical innovations must increase risks. The risk, of course, is lessened if the assistant is thoroughly trained and carefully supervised. It is reduced still further if a formal training program is established and effectively operated by a medical school or a teaching hospital. It is minimized further if appropriate medical and specialty societies establish standards for training and a program for private certification of students who satisfactorily complete the approved training. Official state certification would add only a little protection. Compulsory state licensing would not further reduce the risk for the employing physician.
This opinion goes on to state: In some states, added protection may also be obtained by amending the Medical Practice Act. In a few instances these laws grant general authority to physicians to use competent assistants substantially at the physician's discretion. One of the best provisions along this line is that in the Oklahoma Act, as follows: - Nothing in this article shall be so construed as to prohibit service rendered by a physician's trained assistant, a registered nurse or a licensed practical nurse if such service be rendered under the direct supervision and control of a licensed physician. Where strict compulsory licensing laws are unreasonably impeding the effective use of new paramedical personnel, a statutory amendment along this line might be advisable. This might be especially helpful in problem areas like California. A final suggestion might be appropriate. The history of professional nursing has been one of steadily expanding paramedical function. Without any substantial opposition, nurses are today carrying out procedures which would have been shocking to the medical profession and the public ten years ago. Without any change in the Nursing Practice Act, in most instances, it is probable that delegation to nurses under physician supervision can be made of virtually any medical procedure that does not, on a scientifically determined basis, require the personal knowledge, skill and judgment of a physician. This has already been accomplished with respect to nurse anesthetists without the benefit of any special statute. It seems likely that it can be done gradually in relation to many other important medical functions, provided that the competence of the nurses for the assigned duty is assured by comprehensive training.
ALLIED HEALTH PERSONNEL IN CHILD HEALTH CARE
925
CLASSIFICATIONS The American Academy of Pediatrics has tentatively adopted the following classifications of allied health personnel: 1. Pediatric Nurse Associate. A registered nurse who has completed a diploma nursing program or an associate degree nursing program or is a graduate of a baccalaureate nursing program. This associate will also have completed a recognized pediatric nurse associate (practitioner) program of about 4 months' duration. A pediatric nurse associate's responsibilities may include activities that are directly related to patient care, e.g., obtaining medical and health histories, performing portions of the physical examination, giving information and counsel, and managing health problems. These tasks will be performed under the supervision of a physician. 2. Pediatric Office Assistant. A pediatric office assistant will, when possible, have completed at least 2 years of college or its equivalent, which will include a minimum of 9 months training in general medical background oriented toward child care, or be a graduate licensed vocational or licensed practical nurse with postgraduate pediatric training. She will work under the supervision of a physician or a nurse associate. Her responsibilities may include activities that aid the physician or nurse associate in patient care, e.g., obtaining medical histories, performing screening procedures, and such other administrative, clerical, and minor technical functions or other duties as the physician or nurse associate may direct. 3. Pediatric Aide. A pediatric aide, when possible, will have completed at least high school or its equivalent. A pediatric aide will usually be trained on the job by a pediatrician certified by the American Board of Pediatrics. She will work under the supervision of a physician, pediatric assistant, or pediatric nurse associate.
A simultaneous but crucial step in this process was the establishment within the academy of the Division of Allied Child Health Manpower to oversee and coordinate these efforts. This division will seek to further develop program guidelines, recommend curricula for various training programs, develop relationships with other professional groups, consider the possible establishment of an organization for the various classifications of allied health personnel under academy sponsorship, and develop a pediatric preceptor program to teach pediatric skills to members of these new classifications of allied pediatric manpower.
EXISTING PROGRAMS Demonstration projects that have been or are being developed in the country in this area of allied pediatric practice have been progressing since 1963. 3 • 4 Some of the existing pediatric nurse practitioner training programs are as follows: 1. Pediatric Nurse Associate Program, Good Samaritan Hospital, Cincinnati, Ohio; University of Cincinnati, College of Medicine. 2. Pediatric In-Service Education Program for Public Health Nurses, Department of Pediatrics, Montefiore Hospital (Morrisania Health Center), New York, New York. 3. Pediatric Nurse Assistant Program, the University of Rochester, School of Medicine and Strong Memorial Hospital, Rochester, New York. 4. Pediatric Nurse Practitioner Program, Massachusetts General Hospital,
926
JOHN
P.
CONNELLY, ALFRED YANKAUER
Bunker Hill Health Center of the Massachusetts General Hospital, Charlestown, Massachusetts. 5. Pediatric Nurse Practitioner Program, University of Colorado School of Medicine and School of Nursing, Denver, Colorado. 6. Health Nurse Clinician Program, Wayne State University, College of Nursing, Detroit, Michigan (M.S. program). 7. Family Nurse Practitioner Program, University of California, Los Angeles, School of Public Health and the California State Department of Public Health (M.S. program) (started September, 1969). 8. Los Angeles County Health Department, In-Service Program for Extending Role of Public Health Nurse in Pediatric Care. 9. Pediatric Nurse Assistant Program, Division of Health Services, Department of Preventive Medicine, University of Washington School of Medicine, Seattle, Washington (special project for recruiting inactive nurses), in cooperation with the University of Washington School of Nursing. 10. Expanded Role of Nurse in Care of Child with Long-Term Illness, University of Florida School of Nursing, Gainesville, Florida (M.S. program for pediatric nurses). 11. Pediatric Nurse Practitioner Program, Maine Medical Center, Portland, Maine. Silver and Duncan 12 describing the experience of a nurse practitioner in a pediatric office found that only two of 182 children examined by the nurse practitioner were assessed differently by the pediatrician; 95 per cent of parents of patients in that practice were satisfied with this arrangement between the pediatrician and the nurse practitioner; more than half felt joint care was better than previous care by the pediatrician alone; the pediatrician could manage more patients; and finally, the increased cost of adding a nurse practitioner to office practice was more than offset by the added income she generated. Pediatric assistants at various levels of training are in process at the following centers: 1. Wake Forest College, Bowman Gray School of Medicine. An associate degree graduate is given additional training of 1 year in the hospital, learning anatomy, growth and development, and physical diagnosis, and a second year as an "intern" in a pediatrician's office. Under the sponsorship of a pediatrician, this person screens and assesses the health status of children. They are taught history taking. Therapeutics is not included beyond an orientation to immunization. 2. University of Colorado, Denver, Colorado (Child Health Associate). This research project gives selected high school graduates 2 years of undergraduate college training followed by a 2-year course of instruction at the University of Colorado Medical Center, in Denver, and a I-year internship. This program is to start in September, 1969.
SUMMARY The vast majority of pediatricians agree that the nature of ambulatory pediatric care and the increased consumer demand for such care, coupled with a decrease in the medical manpower available to deliver it, make it essential that allied health personnel be utilized more heavily in child health health care. The nurse, a pediatric assistant, and an aide are logical links between the patient and the doctor, provided he retains supervision and responsibility.
ALLIED HEALTH PERSONNEL IN CHILD HEALTH CARE
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The acceptance and inclusion of such persons cannot be done at the sacrifice of personal care. Fox5 has suggested that the personal doctor's independent existence may be jeopardized if he leaves all dressings to the nurse, sympathy to the receptionist, messages to the secretary, and solutions of problems in the home to the social worker. We add only that (1) the personal physician's existence is equally jeopardized when he is so overwhelmed with patients that he can give only cursory attention to each and (2) many of the patient care services now carried out by a pediatrician can be performed just as effectively by a pediatric nurse associate and office assistant responsible to him.
REFERENCES 1. Bergen, R P.: Irregular assistants and medical risks. J.A.M.A., 207:1027,1231,1969. 2. Coggeshall, L. T.: Planning for Medical Progress through Education. A report submitted to the Executive Council of the Association of American Medical Colleges, Evanston, Illinois. The Association of American Medical Colleges, April, 1965. 3. Connelly, J. P.: Vse of ancillary personnel in children's out-patient departments. Clin. Pediat., 4:233, 1965. 4. Connelly, J. P., Stoeckle, J. D., Lepper, E. S., and Farrisey, R M.: The physician and the nurse - Their interprofessional work in office and hospital ambulatory settings. New Eng. J. Med., 275:765-769,1966. 5. Fox, T. F.: The personal doctor and his relations to the hospital: Observations and reflections on some American experiments in general practice by groups. Lancet, 1 :473, 1960. 6. Mobilization and Health Manpower. II. A Report of the Subcommittee on Paramedical Personnel in Rehabilitation and Care of the Chronically Ill. Washington, D.C., V.S. Government Printing Office, 1956. 7. National Commission on Community Health Services. Report of the Task Force on Health Manpower. Bethesda, Maryland, 1966. 8. Physicians for a Growing America. Report of the Surgeon-General's Consultant Group on Medical Education. Public Health Service Publication No. 709, Washington, D.C., V.S. Government Printing Office, 1959. 9. President's Commission on the Health Needs of the Nation. Vol. I. Washington, D.C., V.S. Government Printing Office, 1952. 10. President's Commission on Heart Disease, Cancer and Stroke. Report to the President: A National Program to Conquer Heart Disease, Cancer and Stroke. Vols. I and II. Washington, D.C., V.S. Government Printing Office, 1964-1965. 11. Report of the National Advisory Commission on Health Manpower. Washington, D.C., V.S. Government Printing Office, 1967. 12. Silver, H. K., and Duncan, B. R: Evaluation of the Pediatric Nurse Practitioner. Report to the 79th Annual Meeting of the American Pediatric Society, Atlantic City, New Jersey, May, 1969. 13. Weil, W.: The Challenge of Meeting the Health Needs of American Children-Manpower Considerations. Presentation on behalf of the Joint Council of National Pediatric Societies before the Labor-Health, Education and Welfare Subcommittee of the Committee on Appropriations, House of Representatives, May 20, 1969. 14. Yankauer, A., Connelly, J. P., and Feldman, J. J.: Pediatric practice in the Vnited States with special attention to utilization of allied health services. Pediatrics. (In press.) 73 High Street Charlestown, Massachusetts 02129