- Email: [email protected]
APRN Practice: Challenges, Empowerment, and Outcomes
APRN Practice: Challenges, Empowerment, and Outcomes Marilyn Dubree, RN, MSN, NE-BC, Pam Jones, DNP, RN, NEA-BC, April Kapu, DNP, APRN, ACNP-BC, and Clifford Lee Parmley, JD, MD, MMHC
I
n her 2008 article entitled “Advanced Practice
there are more than 267,000 APRNs across the
Registered Nurses: The Impact of Patient
United States, practicing in communities, hospitals,
Safety and Quality,” Eileen O’Grady reported that
and many other healthcare settings. APRNs are cat-
the advanced practice registered nurse (APRN)
egorized as certified nurse practitioners (NPs), certi-
workforce “has been growing exponentially with
fied
APRNs employed in every health care sector.”1 The
specialists (CNS), and certified registered nurse
Bureau of Labor Statistics agreed, underscoring the
anesthetists (CRNAs).3 All groups continue to
demand for APRNs with the ever-increasing need for
increase in number and effectiveness as integral
2
access to cost-effective, quality health care. Today,
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nurse
midwives
(CNM),
certified
nurse
members of the healthcare team.
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BACKGROUND With the evolution of practices, APRNs have sought to standardize requirements for education, clinical training, and competency in the provision of effective, safe, and quality care. An overarching framework has developed that includes accreditation of educational programs, curriculum requirements for education, and guidelines for regulation of practice, licensure, and board certification. All elements build the foundation for the individual APRN’s scope of practice. Beyond the 4 categories of APRNs outlined above, the Joint Consensus Model for APRN regulation developed in 2008 and endorsed by more than 45 national nursing and government organizations, described the specialties within each of the categories.3 For example, an NP must have a specialty and age-specific certification, such as an adult gerontology acute care nurse practitioner (AGACNP), which is a NP educated and clinically trained to diagnose and manage treatment of adults patients who are acutely ill. A family nurse practitioner (FNP), by contrast, is a primary care practitioner educated, licensed, and certified to treat patients of all ages. With national standards for practice, APRNs are educated and clinically trained to practice to the scope of their respective licensure and certification.4 The general category of APRN is broad and encompasses a variety of nursing providers. Each specialty has specific nuances to their scope of practice and the climate surrounding their practice. Although this article touches on highlevel APRN practice considerations, there is specific attention to NP practice highlighted. The evolution of APRN practice has occurred within the context of a national mandate for significant improvements in our healthcare system. The growing body of evidence of the outcomes associated with APRN practice has influenced recommendations for future direction contained in consumer reports and healthcare policy initiatives. APRN practice outcomes have been studied for evidence of improved access to care, quality care delivery, and financial impact in terms of cost savings for the consumer and the healthcare system. These themes are reflected in the recommendations summarized below. In 1999, the Institute of Medicine (IOM) issued the report To Err Is Human: Building a Safer Health System5 with the premise that there are high numbers of preventable medical errors contributing to poor outcomes and costly care, errors that could be prevented from improved systems, processes, and coordinated care delivery. Follow-up reports, Crossing the Quality Chasm and Health Professions Education: A Bridge to Quality, underscored the need to better utilize resources and that all healthcare professions should work together to provide interdisciplinary, evidence-based practice and promote safe, effective, patient-centered, timely, efficient, and equitable care.6,7 The IOM 2010 report The Future of Nursing: Leading Change, Advancing Health specifically described recommendations for nursing’s role in the healthcare delivery system.8 The report emphasized the critical role that nurses needed to play in the effort to improve costeffective and quality healthcare delivery. The report under-
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scored that in order to remove barriers to accessible, quality, and cost-effective care, nurses, including advanced practice nurses, should be able to practice to the full extent of their education and training.8
CHALLENGES Despite significant improvements, APRNs continue to face challenges in practicing to the full extent of their education, clinical training, licensure, and certification. The recommendations contained in the IOM report targeting barriers to practice included: optimization of benefits coverage and reimbursement for services provided by APRNs; removal of state regulations that restrict APRNs from providing care to the extent that they are qualified; and the elimination of regulations that promote competition versus collaboration among healthcare providers. Organizations were also encouraged to expand opportunities for interprofessional collaboration and to include nurses in research and redesign efforts to improve health care systems and delivery. Recommendations regarding the development of transition to practice programs to integrate nurses into the practice environment and allow practice to the full extent of license and certification were particularly pertinent to APRNs. This article briefly reviews literature related to APRN outcomes, with specific attention to NPs, which constitute over 70% of the APRN workforce. The intent of this article is to invoke the reader to explore strategies that empower the APRN to work at top of license and deliver cost-effective, quality care. Furthermore, the article considers the optimal environment in which APRNs experience job satisfaction and excel in clinical practice, scientific inquiry, and education.
APRN OUTCOMES REVIEW A summary of studies specific to NPs is provided in Table 1.9–22 The majority of studies listed found improvement in patient care outcomes after adding NPs to the respective practice.9–18,20–22 One study compared outcomes between NPs and/or APRNs to other healthcare providers with either improvement or no difference in patient care outcomes.19 Additionally, NPs showed significant cost savings and cost avoidance in the provision of care. Newhouse et al. (2011) conducted a meta-analysis of APRN outcomes.19 A database search of multiple electronic sources revealed 27,993 studies, from which 37 studies were selected for comparison. Exclusion criteria included key factors such as requirement to be conducted within the United States, given that education, certification, and licensure, as well as the US healthcare system, are unique. The studies included were randomized control trials and observational studies that included at least 2 groups of providers and situations that were able to isolate the impact of APRNs. Outcomes were aggregated to include a minimum of 3 studies with the same outcome. Results revealed the positive impact of APRNs on patient satisfaction, self-reported perceived health, functional status, glucose control, lipid control, blood pressure, emergency department visits, hospitalization, duration of mechanical ventilation, length of stay (LOS), and mortality.19
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COST EFFECTIVENESS The literature has other examples that explore the value of APRNs. Many studies have directly associated cost savings and cost avoidance related to APRN practice outcomes. Kapu et al.16 in “Quality and Financial Impact of Adding Nurse Practitioners to Inpatient Care Teams” found a significant reduction in both actual and risk-adjusted LOS in 4 adult intensive care units before and after adding NPs. Bauer,23 in his 2010 article regarding NPs, outlined the evidence correlating the quality of care delivery with significant cost savings to the consumer and to the practice, stating that NPs were an underutilized resource for addressing the quality and cost imperatives of health care reform. The Perryman Group24 projected the economic impact associated with the greater use of APRNs could be an immediate savings of over $16 billion that would increase over time. Chenoweth et al.25 correlated healthcare costs with the utilization of an on-site NP practice for 4000 employees and dependents; they found a savings of $0.8 to 1.5 million and a benefit-to-cost ratio of 15 to 1. Lastly, United Health26 in 2009 recommended that by utilizing NPs to manage nursing home patients, there could be over $166 billion in healthcare savings. These examples provide overwhelming evidence that APRNs provide quality care and contribute to substantial cost savings as a result. With the knowledge that APRNs contribute to quality and cost effectiveness, many organizations have implemented APRNs in practice or are currently exploring implementation. It is increasingly important that leaders understand the processes and structures that contribute to the success of APRN practice models.Vanderbilt University Medical Center (VUMC), an academic medical center located in Nashville, Tennessee, has a large APRN practice presence with over 700 APRNs practicing across the organization. The growth of APRN practice at the Medical Center has been accomplished through a robust partnership between nursing and physician leaders. It is the authors’ hope that VUMC’s journey toward a strong APRN practice environment can provide insight for other leaders.
STRUCTURAL EMPOWERMENT Forming a central advanced practice nursing center was a foundational step towards a strong APRN practice environment at VUMC. The Center was established to provide centralized, consistent resources and support to APRNs and leaders across the organization. High-priority activities included APRN-specific credentialing and privileging; compliance with national, state, and other regulatory guidelines; development of staffing models and business cases based on both actual billing and downstream return on investment; evaluation of placement opportunities for APRNs; and facilitating peer engagement and support. The Center’s leadership engaged actively with physician leaders across the organization to cultivate robust, collaborative relationships. Physician champions worked to organize the evolving healthcare team with an effective combination of providers, each working at the top of his or her license, to provide high-quality patient www.nurseleader.com
care. In addition, the adjacent school of nursing has an established nursing program, graduating 400⫹ APRNs per year, many of whom are hired to the Medical Center after graduation. Most of the CNM and NPs employed by the Medical Center hold faculty appointments in either the school of nursing or school of medicine, expanding the role beyond clinical practice into the Medical Center mission of excellence in research, education, and patient care. This fundamental infrastructure has contributed to the growth of APRN practices at VUMC. Leaders of the organization have continued to gain knowledge and incorporate strategies for success. Kapu et al.,27 when describing the formation of an intensive care unit NP program, suggested the importance of executive-level support for advanced practice, physician engagement and buy-in, administration and nursing advocacy, detailed business planning, consistent staffing models, and the development of APRN quality metrics and a professional practice evaluation system. The work was further explored by Jones.28 A conceptual model for structural empowerment of NPs in the inpatient environment was developed through an extensive literature review and interviews of a sample (n ⫽ 10) of inpatient NPs practicing in the adult hospital. The concept of structural empowerment is based on the work of Kanter29 related to the organizational characteristics and circumstances that contribute to employees being empowered. Structural empowerment is defined as those environmental and situational characteristics that promote empowerment.30 Participants in the interviews indicated the following as important contributors to feelings of empowerment: practice-site physician relationships and trust; having a specific leader who was an APRN; being part of a highly functional interprofessional team; and autonomy of practice and effective communication.28 In addition, Jones’ conceptual framework suggests that engagement of both nursing and physician leadership, financial sustainability, physician attitudes and behaviors, organizational structure and support, as well as career development opportunities, are all important considerations.28 A particular concern within VUMC has been the accurate representation of the scope of APRN education, certification, and practice. Understanding an APRN’s parameters for practice has been essential to optimal utilization: maximizing efficiency, productivity, and quality care delivery. Administrators, healthcare professionals, and even patients have often asked the difference between an APRN and a physician. Many physicians might view the APRN workforce as a threat both economically and to the integrity of the practice of medicine. Understanding fundamental nursing education, grounded in nursing theory, with the addition of advanced clinical training focused on a particular specialty and age is critical to understanding the APRN’s scope of practice. Active involvement of physicians, nursing leaders, and administrators to align incentives and appropriately delegate roles and responsibilities is key to cultivating an organizational culture of mutual respect and support for the role and its unique contribution to the team and impact on patient care.
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Table 1. Literature Review of APRN Outcomes
Author(s)
Methodology
Outcomes
Comparison of ventilator days, LOS and perpatient cost after adding an OM-NP as compared to before OM-NP was added. postNP n ⫽ 125, 5 adult ICUs over 1 quarter, as compared with, pre-NP n ⫽ 575
Mean ventilator days post-NP ⫽ 11, pre-NP ⫽ 17. Mean LOS post-NP ⫽ 23, pre-NP ⫽ 32. Per patient cost postNP ⫽ $69,118, pre-NP ⫽ $85,411.
Burns et al., 200310
Retrospective comparison of baseline pre–OM-NP, 18 months, to prospective 12 months where OM-NPs were added to 5 adult ICUs. Clinical and financial data compared.
Post addition of OM-NP showed decreased ventilator days by 1 day, ICU LOS by 3 days, hospital LOS by 2 days, and mortality rate from 38% to 31%. Over $3,000,000 in cost savings in the OM-NP group.
Butler et al., 201111
Prospective analysis of NP documentation and charge capture. NPs used standardized templates for documentation in 3 ICUs over 3 years.
Increase in charge capture by 48%.
Chen et al., 200912
Retrospective data analysis of drug utilization and costs of NP-led care compared to usual care. Experimental group n ⫽ 581 patients and control group n ⫽ 626 patients.
Total drug costs per patient for NP⫽$636, control ⫽$844; average daily drug costs for NP⫽$89, control ⫽ $96; Average drug days for NP ⫽ 66, control ⫽ 80.
Collins et al., 201413
One year prospective study of adding trauma NPs to a stepdown service, compared with 2 years prior.
Total service (stepdown and floor) ALOS down by 0.8 day, no difference in injury severity from year to year; estimated cost avoidance of $27,800,000 in hospital charges.
Cowan et al., 200614
Quasi-experimental design comparing NP-led group to control group of usual care. LOS and hospital profit determined from cost savings.
Average LOS of NP group ⫽ 5 days, usual care ⫽ 6. Hospital profit NP group ⫽ $1591 per patient, usual care ⫽ $639 per patient.
Ettner et al., 200615
1207 patients randomized to either an NP/MD group or an MD-only group. Comparison regression-adjusted costs between groups.
NP/MD group had net cost savings of $978 per patient over MD-only group.
Kapu et al., 201416
Comparison of LOS, actual and risk-adjusted, of 4 ICUs pre and post adding NPs to the practice.
Both actual and risk-adjusted LOS were decreased after adding NPs to the ICU practice.
Lenz et al., 200417
1316 patients randomly assigned to either an NP- or physician-run primary care practice.
No difference in health status, physiological measures, satisfaction; physician patients had more primary care visits than NP patients.
Meyer et al., 200518
Retrospective comparison of 1 year of patient and economic outcomes of postoperative cardiovascular care before NPs added and another year after NPs added.
After NPs added, LOS decreased by 1.91 days and total cost decreased by $5039 per patient.
Newhouse et al., 201119
Systematic review of 37 published studies comparing NP outcomes to those of physicians.
No difference in patient satisfaction, patientperceived health status, functional status, hospitalizations, ED visits, and biomarkers such as blood glucose, serum lipids, and blood pressure.
Paez and Allen, 200620
228 adults with hypercholesterolemia and CHD after coronary revascularization; patients randomized to receive 1-year lipid management by an NP; cost-effective ratio using costs and percent change in LDL-C.
Cost-effective ratio for NP-managed group showed $26.03 per mg/dl and $39.05 per percent reduction in LDL-C.
Burns and Earven, 20029
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Table 1. Literature Review of APRN Outcomes (cont.)
Author(s)
Methodology
Outcomes
Russell et al., 200221
Prospective analysis of LOS, rates of UTIs and skin breakdown pre and post addition of NPs to the practice. The baseline included randomized sample of 122 patients admitted to neuro ICU over 12 months as compared to 402 patients admitted in first 6 months of the following year after NPs added.
LOS post-NP ⫽ 8 days vs. baseline ⫽ 11. UTI NP ⫽ 2% vs. baseline 6%; skin breakdown NP ⫽ 0% vs. baseline ⫽ 2%. Patient days showed 2306 fewer days than baseline group, with total cost savings of $2,467,328.
Sise et al., 201122
Prospective analysis of adding NPs to Level 1 trauma center. Analysis of demographics, injury severity scores, LOS, complications, total direct costs of care and outcomes.
After addition of NPs, decrease in complications by 28.4%, LOS by 36.2%, costs of care by 30.4%
ALOS, average length of stay; CHD, coronary heart disease; ED, emergency department; ICU, intensive care unit; LDL-C, low-density lipoprotein cholesterol; OM-NP, outcomes management nurse practitioner; UTI, urinary tract infection.
It is also important to note the guidance provided by expert bodies in nursing standards. Both the American Nurses Credentialing Center’s Magnet® standards and The Joint Commission emphasize that nursing leadership is a key component to maximizing the utilization of APRNs, identifying the chief nursing officer as responsible for all nursing care delivery.31 This suggests that leadership support at all levels within the organization is essential to the sustainability of APRN practice and APRN practice outcomes. The Magnet standards emphasize the importance of structural empowerment, stating that “solid structures and processes developed by influential leadership provide an innovative environment where strong professional practice flourishes and where the mission, vision and values come to life to achieve the outcomes believed to be important for the organization.”32 Other authors have addressed the concepts related to NP empowerment. Shea’s analysis33 of NP satisfaction indicates that lack of opportunity for advancement, perceived lack of professional value for their work, lack of collegial relationships with physicians, and lack of support from nursing administration were all identified as major factors contributing to job dissatisfaction. Shea states that administrators should be cognizant that factors impacting NP satisfaction also impact NP practice. Pasarón34 states that successful patient outcomes are influenced by NP job satisfaction. He states that NP satisfaction can be divided into 3 categories: primary (based on extrinsic or intrinsic factors), secondary, and outcome-related. Primary factors include physician acceptance and collaboration, autonomy, participatory leadership, incentives recognizing NP contributions, and advancement opportunities. Secondary factors include sufficient orientation and role transition, clear role expectations and clinical competency requirements, promotional programs, and years of experience. Outcome-related NP satisfaction factors include achievement of quality and financial indicators assowww.nurseleader.com
ciated with their practice, which may include length of stay, healthcare costs, readmission rates, adherence to evidencebased practice, complications, resource use, continuity of care, patient access to care, patient education, and staff education.34 (p2595) Brown et al.35 supported this work in a national survey of pediatric NPs to identify opportunities to standardize practice and optimize service delivery. This survey correlated professional dissatisfaction with clinical stressors such as acuity and volume of patients, communication issues, clinical selfdoubt, time management, and practice variation.35
IMPLEMENTATION In 2013, to further understand the status of APRN practices at VUMC, the executive chief nursing officer launched an enterprise workflow analysis to review productivity, quality outcomes, and barriers to optimal efficiency and effectiveness. Multispecialty interdisciplinary teams, including physician and nursing leaders, facilitated APRN focus groups to map clinical effort towards overarching APRN practice missions. APRNs identified key indicators of quality relevant to their practice including: LOS, readmission, wait times, resource utilization, hospital-acquired complications, and coordinated care across the continuum. A survey of barriers to efficient and effective practice, as well as job satisfaction, revealed that workload, volume of patients, complex communication systems, care coordination support, informatics inefficiencies, documentation requirements, and staffing were significant stressors working against optimal care delivery. Factors that contributed to job satisfaction included role-specific education and training, role expectations, physician support, and opportunities for professional growth and advancement.36 With this information from the Vanderbilt study, the Center for Advanced Practice Nursing reemphasized the importance of professional practice support to APRNs, frontline clinical teams, and service line–focused healthcare teams,
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known as patient care centers. The key components of centralized professional practice guidance and support to key areas include: • Advanced practice leadership structure • Professional practice evaluation and advancement • Continuing education and professional development support • Structured resources for staffing models and business case development • Strategic partnership for recruitment, compensation, and benefits • Licensure, certification, and regulatory guidance • Support and development of quality metrics for APRN practice • Shared governance model for APRN decision making • Networking opportunities through APRN councils and committees • Support for interprofessional initiatives Furthermore, executives, leaders, and sponsors included the APRN findings regarding barriers to optimal efficiency and effectiveness into overarching enterprise redesign initiatives and included APRNs as subject matter experts in focused workgroups on areas such as technology, documentation, and care continuum improvement. Beyond the survey results, we continued to build expertise in utilization of APRNs throughout the organization.The frontline knowledge and expertise of the APRNs supported the integration into many practice areas. In addition, some areas found the “Participatory, Evidence-Based, Patient-Focused Process for Advanced Practice Nursing (PEPPA)” framework to be a helpful resource for planning, implementation, and evaluation of APRN practices.37 Using evidence through our own research and seeking evidence-based tools for APRN practice development has been a successful strategy, particularly when targeting APRNimpacted outcomes and long-term successful integration.
DISCUSSION The evidence reviewed in this article indicates that effective use of APRNs in the healthcare system presents an opportunity to decrease cost and sustain or improve quality. The successful addition of these professionals to an existing healthcare system is, however, a journey. An organization must be attentive to the climate and culture that allows these individuals to practice to the top of their license and training, consistent with the IOM recommendations. Attention must be given to both the organization’s workforce characteristics and the economic climate. For example, in an academic medical center with a large NP training program, these professionals are readily available. There may be restraining factors in other communities, such as limited numbers of NPs to teach and mentor, which might impede full implementation. The receptivity to physician partners in the community and organization is also extremely important. Implementation will be hindered if economic conditions or physician perceptions position the APRNs as competition. This dynamic cannot be underestimated. Careful and methodical attention must be given to the cultivation of effective relationships among
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physicians, APRNs, and appropriate administrative personnel. These relationships must be solid enough to allow for honest and productive conversations to break down barriers, align incentives, and create a win–win for all parties involved. In addition to the importance of physician relationships, it is also the belief of these authors that a significant linkage to nursing leadership is crucial. Without a balanced and partnering approach between physician leaders and nursing leaders, APRNs run a significant risk of feeling isolated and vulnerable. The concepts of structural empowerment discussed in this article provide guidance on the structures and processes required to promote full functioning of the APRN as an integral member of the interprofessional team.
CONCLUSION The current healthcare imperative for improved quality and cost-effective care have created the optimal environment for APRNs to showcase their contributions to practice. With considerable evidence to support APRN outcomes, optimizing support and empowerment of APRNs to practice to the top of their licenses and experience high levels of job satisfaction leads to quality care delivery and successful practice outcomes. There are also opportunities for nursing, advanced practice nursing, and physician leaders, scholars, and researchers to enhance the body of knowledge about structures and process that promote APRN practice consistent with the recommendations outlined in the IOM 2010 report.8 NL References 1. O’Grady ET. Advanced practice registered nurses: the impact on patient safety and quality. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. AHRQ Publication No. 08-0043. Rockville, MD: Agency for Healthcare Research and Quality; March 2008. 2. Bureau of Labor Statistics, US Department of Labor. Registered nurses. Occupational Outlook Handbook. 2006–07 ed. http://www.bls.gov/ooh/ healthcare/registered-nurses.htm. Accessed August 1, 2014. 3. APRNs in the U.S. The Consensus Model for APRN Regulation, Licensure, Accreditation, Certification and Education. https://www.ncsbn.org/4213.htm. Accessed August 1, 2014. 4. American Association of Colleges of Nursing. Advancing Higher Education In Nursing: Position Statement. October 2004. http://www.aacn.nche.edu/ dnp/dnp-position-statement. Accessed August 1, 2014. 5. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington DC: National Academies Press; 1999. 6. Institute of Medicine. Crossing the Quality Chasm. Washington DC: National Academies Press; 2001. 7. Institute of Medicine. Health Professions Education: A Bridge to Quality. Washington DC: National Academies Press; 2003. 8. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Report Recommendations. Washington DC: National Academies Press; 2010. http://www.iom.edu/Reports/2010/The-Future-of-NursingLeading-Change-Advancing-Health/Recommendations.aspx. Accessed August 1, 2014. 9. Burns SM, Earven S. Improving outcomes for mechanically ventilated medical intensive care unit patients using advanced practice nurses: a 6year experience. Crit Care Nurs Clin North Am. 2002;14:231-243. 10. Burns SM, Earven S, Fisher C, et al. Implementation of an institutional program to improve clinical and financial outcomes of mechanically ventilated patients: one-year outcomes and lessons learned. Crit Care Med. 2003;31:2752-2763. 11. Butler KL, Calabrese R, Tandon M, Kirton OC. Optimizing advanced practitioner charge capture in high-acuity surgical intensive care units. Arch Surg. 2011;146:552-555. 12. Chen C, McNeese-Smith D, Cowan M, Upenieks V, Afifi A. Evaluation of a nurse practitioner-led care management model in reducing inpatient drug utilization and cost. Nurs Econ. 2009;27:160-168.
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13. Collins N, Miller R, Kapu A, et al. Outcomes of adding acute care nurse practitioners to a Level I trauma service with the goal of decreased length of stay and improved physician and nursing satisfaction. J Trauma Acute Care Surg. 2014;76:353-357. 14. Cowan MJ, Shapiro M, Hays RD, et al. The effect of a multidisciplinary hospitalist/physician and advanced practice nurse collaboration on hospital costs. J Nurs Adm. 2006;36:79-85. 15. Ettner SL, Kotlerman J, Afifi A, et al. An alternative approach to reducing the costs of patient care? A controlled trial of the multi-disciplinary doctornurse practitioner (MDNP) model. Med Decis Making. 2006;26:9-17. 16. Kapu AN, Kleinpell R, Pilon B. Quality and financial impact of adding nurse practitioners to inpatient care teams. J Nurs Adm. 2014;44:87-96. 17. Lenz ER, Mundinger MO, Kane RL, Hopkins SC, Lin SX. Primary care outcomes in patients treated by nurse practitioners or physicians: two-year follow-up. Med Care Res Rev. 2004;61:332-351. 18. Meyer SC, Miers LJ. Cardiovascular surgeon and acute care nurse practitioner: collaboration on postoperative outcomes. AACN Clin Issues. 2005;16:149-158. 19. Newhouse RP, Stanik-Hutt J, White KM, et al. Advanced practice nurse outcomes 1990-2008: a systematic review. Nurs Econ. 2011;29:230-250; quiz 251. 20. Paez KA, Allen JK. Cost-effectiveness of nurse practitioner management of hypercholesterolemia following coronary revascularization. J Am Acad Nurse Pract. 2006;18:436-444. 21. Russell D, Vorderbruegge M, Burns SM. Effect of an outcomes-managed approach to care of neuroscience patients by acute care nurse practitioners. Am J Crit Care. 2002;11:353-362. 22. Sise CB, Sise MJ, Kelley DM, et al. Resource commitment to improve outcomes and increase value at a level I trauma center. J Trauma. 2011;70:560-568. 23. Bauer JC. Nurse practitioners as an underutilized resource for health reform: evidence-based demonstrations of cost-effectiveness. J Am Acad Nurse Pract. 2010;22:228-231. 24. Perryman Group. The Economic Benefits of More Fully Utilizing Advanced Practice Registered Nurses in the Provision of Care in Texas: An Analysis of Local and Statewide Effects on Business Activity. Waco, TX: Perryman Group; 2012. http://c.ymcdn.com/sites/flanp.site-ym.com/resource/resmgr/ articles_and_research/Perryman-APRN-Ultilization-E.pdf. Accessed August 1, 2014. 25. Chenoweth D, Martin N, Pankowski J, Raymond LW. A benefit-cost analysis of a worksite nurse practitioner program: first impressions. J Occup Environ Med. 2005;47:1110-1116. 26. United Health Group. Federal Health Care Cost Containment: How in Practice Can It Be Done? Options With a Real World Track Record of Success. Working Paper 1. 2009. http://www.unitedhealthgroup.com/~/media/uhg/pdf/2009/ unh-working-paper-1.ashx? Accessed August 1, 2014. 27. Kapu AN, Thomson-Smith C, Jones P. NPs in the ICU: the Vanderbilt initiative. Nurse Pract. 2012;37(8):46-52. 28. Jones P. Structural Empowerment and Role Definition of Unit-Based Advanced Practice Registered Nurses (APRN) [ Doctoral]. Nashville, TN: Vanderbilt University School of Nursing; July 2013. 29. Kanter RM. Men and Women of the Corporation. New York, NY: Basic Books; 1977. 30. Manojlovic M. Power and empowerment in nursing: looking backward to inform the future. OJIN Online J Issues Nurs. 2007;12(1):Manuscript 1. http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPerio dicals/OJIN/TableofContents/Volume122007/No1Jan07/LookingBackwardtoIn formtheFuture.html. Accessed August 1, 2014. 31. Moote M, Krsek C, Kleinpell R, Todd B. Physician assistant and nurse practitioner utilization in academic medical centers. Am J Med Qual. 2011;26:452-460. 32. American Nurses Credentialing Center. Announcing a New Model for ANCC’s Magnet Recognition Program [brochure]. 2008. http://www.nursecredentialing. org/Documents/Magnet/NewModelBrochure.pdf. Accessed August 1, 2014. 33. Shea ML. Determined persistence: achieving and sustaining job satisfaction among nurse practitioners. J Am Assoc Nurse Pract. 2015;27:31-38. 34. Pasarón R. Nurse practitioner job satisfaction: looking for successful outcomes. J Clin Nurs. 2013;22:2593-2604. 35. Brown AM, Christie LM, Higgerson RA, Mikhailov TA, Stojadinovic BJ, Forbes ML. A national survey of PICU nurse practitioners—opportunities to standardize practices and optimize service delivery. Pediatr Nurs. 2012;38:249250, 277. 36. Dubree M, Kapu A. Optimized efficiency and effectiveness: impact of an academic medical center APRN workflow analysis. Vanderbilt University Medical Center; March, 2014; Nashville, TN. 37. Bryant-Lukosius D, Dicenso A. A framework for the introduction and evaluation of advanced practice nursing roles. J Adv Nurs. 2004;48:530-540.
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Marilyn Dubree, RN, MSN, NE-BC, is executive chief nursing officer at Vanderbilt University Medical Center in Nashville, Tennessee. Pam Jones, DNP, RN, NEA-BC, is chief nursing officer at Vanderbilt University Hospital in Nashville. April Kapu, DNP, APRN, ACNP-BC, is associate nursing officer and director of advanced practice at the Center for Nursing Excellence, Vanderbilt University Medical Center; she can be reached at [email protected]. Clifford Lee Parmley, JD, MD, MMHC, is chief of staff at Vanderbilt University Hospital. 1541-4612/2014/ $ See front matter Copyright 2015 by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2015.01.007
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I
n her 2008 article entitled “Advanced Practice
there are more than 267,000 APRNs across the
Registered Nurses: The Impact of Patient
United States, practicing in communities, hospitals,
Safety and Quality,” Eileen O’Grady reported that
and many other healthcare settings. APRNs are cat-
the advanced practice registered nurse (APRN)
egorized as certified nurse practitioners (NPs), certi-
workforce “has been growing exponentially with
fied
APRNs employed in every health care sector.”1 The
specialists (CNS), and certified registered nurse
Bureau of Labor Statistics agreed, underscoring the
anesthetists (CRNAs).3 All groups continue to
demand for APRNs with the ever-increasing need for
increase in number and effectiveness as integral
2
access to cost-effective, quality health care. Today,
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nurse
midwives
(CNM),
certified
nurse
members of the healthcare team.
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BACKGROUND With the evolution of practices, APRNs have sought to standardize requirements for education, clinical training, and competency in the provision of effective, safe, and quality care. An overarching framework has developed that includes accreditation of educational programs, curriculum requirements for education, and guidelines for regulation of practice, licensure, and board certification. All elements build the foundation for the individual APRN’s scope of practice. Beyond the 4 categories of APRNs outlined above, the Joint Consensus Model for APRN regulation developed in 2008 and endorsed by more than 45 national nursing and government organizations, described the specialties within each of the categories.3 For example, an NP must have a specialty and age-specific certification, such as an adult gerontology acute care nurse practitioner (AGACNP), which is a NP educated and clinically trained to diagnose and manage treatment of adults patients who are acutely ill. A family nurse practitioner (FNP), by contrast, is a primary care practitioner educated, licensed, and certified to treat patients of all ages. With national standards for practice, APRNs are educated and clinically trained to practice to the scope of their respective licensure and certification.4 The general category of APRN is broad and encompasses a variety of nursing providers. Each specialty has specific nuances to their scope of practice and the climate surrounding their practice. Although this article touches on highlevel APRN practice considerations, there is specific attention to NP practice highlighted. The evolution of APRN practice has occurred within the context of a national mandate for significant improvements in our healthcare system. The growing body of evidence of the outcomes associated with APRN practice has influenced recommendations for future direction contained in consumer reports and healthcare policy initiatives. APRN practice outcomes have been studied for evidence of improved access to care, quality care delivery, and financial impact in terms of cost savings for the consumer and the healthcare system. These themes are reflected in the recommendations summarized below. In 1999, the Institute of Medicine (IOM) issued the report To Err Is Human: Building a Safer Health System5 with the premise that there are high numbers of preventable medical errors contributing to poor outcomes and costly care, errors that could be prevented from improved systems, processes, and coordinated care delivery. Follow-up reports, Crossing the Quality Chasm and Health Professions Education: A Bridge to Quality, underscored the need to better utilize resources and that all healthcare professions should work together to provide interdisciplinary, evidence-based practice and promote safe, effective, patient-centered, timely, efficient, and equitable care.6,7 The IOM 2010 report The Future of Nursing: Leading Change, Advancing Health specifically described recommendations for nursing’s role in the healthcare delivery system.8 The report emphasized the critical role that nurses needed to play in the effort to improve costeffective and quality healthcare delivery. The report under-
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scored that in order to remove barriers to accessible, quality, and cost-effective care, nurses, including advanced practice nurses, should be able to practice to the full extent of their education and training.8
CHALLENGES Despite significant improvements, APRNs continue to face challenges in practicing to the full extent of their education, clinical training, licensure, and certification. The recommendations contained in the IOM report targeting barriers to practice included: optimization of benefits coverage and reimbursement for services provided by APRNs; removal of state regulations that restrict APRNs from providing care to the extent that they are qualified; and the elimination of regulations that promote competition versus collaboration among healthcare providers. Organizations were also encouraged to expand opportunities for interprofessional collaboration and to include nurses in research and redesign efforts to improve health care systems and delivery. Recommendations regarding the development of transition to practice programs to integrate nurses into the practice environment and allow practice to the full extent of license and certification were particularly pertinent to APRNs. This article briefly reviews literature related to APRN outcomes, with specific attention to NPs, which constitute over 70% of the APRN workforce. The intent of this article is to invoke the reader to explore strategies that empower the APRN to work at top of license and deliver cost-effective, quality care. Furthermore, the article considers the optimal environment in which APRNs experience job satisfaction and excel in clinical practice, scientific inquiry, and education.
APRN OUTCOMES REVIEW A summary of studies specific to NPs is provided in Table 1.9–22 The majority of studies listed found improvement in patient care outcomes after adding NPs to the respective practice.9–18,20–22 One study compared outcomes between NPs and/or APRNs to other healthcare providers with either improvement or no difference in patient care outcomes.19 Additionally, NPs showed significant cost savings and cost avoidance in the provision of care. Newhouse et al. (2011) conducted a meta-analysis of APRN outcomes.19 A database search of multiple electronic sources revealed 27,993 studies, from which 37 studies were selected for comparison. Exclusion criteria included key factors such as requirement to be conducted within the United States, given that education, certification, and licensure, as well as the US healthcare system, are unique. The studies included were randomized control trials and observational studies that included at least 2 groups of providers and situations that were able to isolate the impact of APRNs. Outcomes were aggregated to include a minimum of 3 studies with the same outcome. Results revealed the positive impact of APRNs on patient satisfaction, self-reported perceived health, functional status, glucose control, lipid control, blood pressure, emergency department visits, hospitalization, duration of mechanical ventilation, length of stay (LOS), and mortality.19
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COST EFFECTIVENESS The literature has other examples that explore the value of APRNs. Many studies have directly associated cost savings and cost avoidance related to APRN practice outcomes. Kapu et al.16 in “Quality and Financial Impact of Adding Nurse Practitioners to Inpatient Care Teams” found a significant reduction in both actual and risk-adjusted LOS in 4 adult intensive care units before and after adding NPs. Bauer,23 in his 2010 article regarding NPs, outlined the evidence correlating the quality of care delivery with significant cost savings to the consumer and to the practice, stating that NPs were an underutilized resource for addressing the quality and cost imperatives of health care reform. The Perryman Group24 projected the economic impact associated with the greater use of APRNs could be an immediate savings of over $16 billion that would increase over time. Chenoweth et al.25 correlated healthcare costs with the utilization of an on-site NP practice for 4000 employees and dependents; they found a savings of $0.8 to 1.5 million and a benefit-to-cost ratio of 15 to 1. Lastly, United Health26 in 2009 recommended that by utilizing NPs to manage nursing home patients, there could be over $166 billion in healthcare savings. These examples provide overwhelming evidence that APRNs provide quality care and contribute to substantial cost savings as a result. With the knowledge that APRNs contribute to quality and cost effectiveness, many organizations have implemented APRNs in practice or are currently exploring implementation. It is increasingly important that leaders understand the processes and structures that contribute to the success of APRN practice models.Vanderbilt University Medical Center (VUMC), an academic medical center located in Nashville, Tennessee, has a large APRN practice presence with over 700 APRNs practicing across the organization. The growth of APRN practice at the Medical Center has been accomplished through a robust partnership between nursing and physician leaders. It is the authors’ hope that VUMC’s journey toward a strong APRN practice environment can provide insight for other leaders.
STRUCTURAL EMPOWERMENT Forming a central advanced practice nursing center was a foundational step towards a strong APRN practice environment at VUMC. The Center was established to provide centralized, consistent resources and support to APRNs and leaders across the organization. High-priority activities included APRN-specific credentialing and privileging; compliance with national, state, and other regulatory guidelines; development of staffing models and business cases based on both actual billing and downstream return on investment; evaluation of placement opportunities for APRNs; and facilitating peer engagement and support. The Center’s leadership engaged actively with physician leaders across the organization to cultivate robust, collaborative relationships. Physician champions worked to organize the evolving healthcare team with an effective combination of providers, each working at the top of his or her license, to provide high-quality patient www.nurseleader.com
care. In addition, the adjacent school of nursing has an established nursing program, graduating 400⫹ APRNs per year, many of whom are hired to the Medical Center after graduation. Most of the CNM and NPs employed by the Medical Center hold faculty appointments in either the school of nursing or school of medicine, expanding the role beyond clinical practice into the Medical Center mission of excellence in research, education, and patient care. This fundamental infrastructure has contributed to the growth of APRN practices at VUMC. Leaders of the organization have continued to gain knowledge and incorporate strategies for success. Kapu et al.,27 when describing the formation of an intensive care unit NP program, suggested the importance of executive-level support for advanced practice, physician engagement and buy-in, administration and nursing advocacy, detailed business planning, consistent staffing models, and the development of APRN quality metrics and a professional practice evaluation system. The work was further explored by Jones.28 A conceptual model for structural empowerment of NPs in the inpatient environment was developed through an extensive literature review and interviews of a sample (n ⫽ 10) of inpatient NPs practicing in the adult hospital. The concept of structural empowerment is based on the work of Kanter29 related to the organizational characteristics and circumstances that contribute to employees being empowered. Structural empowerment is defined as those environmental and situational characteristics that promote empowerment.30 Participants in the interviews indicated the following as important contributors to feelings of empowerment: practice-site physician relationships and trust; having a specific leader who was an APRN; being part of a highly functional interprofessional team; and autonomy of practice and effective communication.28 In addition, Jones’ conceptual framework suggests that engagement of both nursing and physician leadership, financial sustainability, physician attitudes and behaviors, organizational structure and support, as well as career development opportunities, are all important considerations.28 A particular concern within VUMC has been the accurate representation of the scope of APRN education, certification, and practice. Understanding an APRN’s parameters for practice has been essential to optimal utilization: maximizing efficiency, productivity, and quality care delivery. Administrators, healthcare professionals, and even patients have often asked the difference between an APRN and a physician. Many physicians might view the APRN workforce as a threat both economically and to the integrity of the practice of medicine. Understanding fundamental nursing education, grounded in nursing theory, with the addition of advanced clinical training focused on a particular specialty and age is critical to understanding the APRN’s scope of practice. Active involvement of physicians, nursing leaders, and administrators to align incentives and appropriately delegate roles and responsibilities is key to cultivating an organizational culture of mutual respect and support for the role and its unique contribution to the team and impact on patient care.
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Table 1. Literature Review of APRN Outcomes
Author(s)
Methodology
Outcomes
Comparison of ventilator days, LOS and perpatient cost after adding an OM-NP as compared to before OM-NP was added. postNP n ⫽ 125, 5 adult ICUs over 1 quarter, as compared with, pre-NP n ⫽ 575
Mean ventilator days post-NP ⫽ 11, pre-NP ⫽ 17. Mean LOS post-NP ⫽ 23, pre-NP ⫽ 32. Per patient cost postNP ⫽ $69,118, pre-NP ⫽ $85,411.
Burns et al., 200310
Retrospective comparison of baseline pre–OM-NP, 18 months, to prospective 12 months where OM-NPs were added to 5 adult ICUs. Clinical and financial data compared.
Post addition of OM-NP showed decreased ventilator days by 1 day, ICU LOS by 3 days, hospital LOS by 2 days, and mortality rate from 38% to 31%. Over $3,000,000 in cost savings in the OM-NP group.
Butler et al., 201111
Prospective analysis of NP documentation and charge capture. NPs used standardized templates for documentation in 3 ICUs over 3 years.
Increase in charge capture by 48%.
Chen et al., 200912
Retrospective data analysis of drug utilization and costs of NP-led care compared to usual care. Experimental group n ⫽ 581 patients and control group n ⫽ 626 patients.
Total drug costs per patient for NP⫽$636, control ⫽$844; average daily drug costs for NP⫽$89, control ⫽ $96; Average drug days for NP ⫽ 66, control ⫽ 80.
Collins et al., 201413
One year prospective study of adding trauma NPs to a stepdown service, compared with 2 years prior.
Total service (stepdown and floor) ALOS down by 0.8 day, no difference in injury severity from year to year; estimated cost avoidance of $27,800,000 in hospital charges.
Cowan et al., 200614
Quasi-experimental design comparing NP-led group to control group of usual care. LOS and hospital profit determined from cost savings.
Average LOS of NP group ⫽ 5 days, usual care ⫽ 6. Hospital profit NP group ⫽ $1591 per patient, usual care ⫽ $639 per patient.
Ettner et al., 200615
1207 patients randomized to either an NP/MD group or an MD-only group. Comparison regression-adjusted costs between groups.
NP/MD group had net cost savings of $978 per patient over MD-only group.
Kapu et al., 201416
Comparison of LOS, actual and risk-adjusted, of 4 ICUs pre and post adding NPs to the practice.
Both actual and risk-adjusted LOS were decreased after adding NPs to the ICU practice.
Lenz et al., 200417
1316 patients randomly assigned to either an NP- or physician-run primary care practice.
No difference in health status, physiological measures, satisfaction; physician patients had more primary care visits than NP patients.
Meyer et al., 200518
Retrospective comparison of 1 year of patient and economic outcomes of postoperative cardiovascular care before NPs added and another year after NPs added.
After NPs added, LOS decreased by 1.91 days and total cost decreased by $5039 per patient.
Newhouse et al., 201119
Systematic review of 37 published studies comparing NP outcomes to those of physicians.
No difference in patient satisfaction, patientperceived health status, functional status, hospitalizations, ED visits, and biomarkers such as blood glucose, serum lipids, and blood pressure.
Paez and Allen, 200620
228 adults with hypercholesterolemia and CHD after coronary revascularization; patients randomized to receive 1-year lipid management by an NP; cost-effective ratio using costs and percent change in LDL-C.
Cost-effective ratio for NP-managed group showed $26.03 per mg/dl and $39.05 per percent reduction in LDL-C.
Burns and Earven, 20029
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Table 1. Literature Review of APRN Outcomes (cont.)
Author(s)
Methodology
Outcomes
Russell et al., 200221
Prospective analysis of LOS, rates of UTIs and skin breakdown pre and post addition of NPs to the practice. The baseline included randomized sample of 122 patients admitted to neuro ICU over 12 months as compared to 402 patients admitted in first 6 months of the following year after NPs added.
LOS post-NP ⫽ 8 days vs. baseline ⫽ 11. UTI NP ⫽ 2% vs. baseline 6%; skin breakdown NP ⫽ 0% vs. baseline ⫽ 2%. Patient days showed 2306 fewer days than baseline group, with total cost savings of $2,467,328.
Sise et al., 201122
Prospective analysis of adding NPs to Level 1 trauma center. Analysis of demographics, injury severity scores, LOS, complications, total direct costs of care and outcomes.
After addition of NPs, decrease in complications by 28.4%, LOS by 36.2%, costs of care by 30.4%
ALOS, average length of stay; CHD, coronary heart disease; ED, emergency department; ICU, intensive care unit; LDL-C, low-density lipoprotein cholesterol; OM-NP, outcomes management nurse practitioner; UTI, urinary tract infection.
It is also important to note the guidance provided by expert bodies in nursing standards. Both the American Nurses Credentialing Center’s Magnet® standards and The Joint Commission emphasize that nursing leadership is a key component to maximizing the utilization of APRNs, identifying the chief nursing officer as responsible for all nursing care delivery.31 This suggests that leadership support at all levels within the organization is essential to the sustainability of APRN practice and APRN practice outcomes. The Magnet standards emphasize the importance of structural empowerment, stating that “solid structures and processes developed by influential leadership provide an innovative environment where strong professional practice flourishes and where the mission, vision and values come to life to achieve the outcomes believed to be important for the organization.”32 Other authors have addressed the concepts related to NP empowerment. Shea’s analysis33 of NP satisfaction indicates that lack of opportunity for advancement, perceived lack of professional value for their work, lack of collegial relationships with physicians, and lack of support from nursing administration were all identified as major factors contributing to job dissatisfaction. Shea states that administrators should be cognizant that factors impacting NP satisfaction also impact NP practice. Pasarón34 states that successful patient outcomes are influenced by NP job satisfaction. He states that NP satisfaction can be divided into 3 categories: primary (based on extrinsic or intrinsic factors), secondary, and outcome-related. Primary factors include physician acceptance and collaboration, autonomy, participatory leadership, incentives recognizing NP contributions, and advancement opportunities. Secondary factors include sufficient orientation and role transition, clear role expectations and clinical competency requirements, promotional programs, and years of experience. Outcome-related NP satisfaction factors include achievement of quality and financial indicators assowww.nurseleader.com
ciated with their practice, which may include length of stay, healthcare costs, readmission rates, adherence to evidencebased practice, complications, resource use, continuity of care, patient access to care, patient education, and staff education.34 (p2595) Brown et al.35 supported this work in a national survey of pediatric NPs to identify opportunities to standardize practice and optimize service delivery. This survey correlated professional dissatisfaction with clinical stressors such as acuity and volume of patients, communication issues, clinical selfdoubt, time management, and practice variation.35
IMPLEMENTATION In 2013, to further understand the status of APRN practices at VUMC, the executive chief nursing officer launched an enterprise workflow analysis to review productivity, quality outcomes, and barriers to optimal efficiency and effectiveness. Multispecialty interdisciplinary teams, including physician and nursing leaders, facilitated APRN focus groups to map clinical effort towards overarching APRN practice missions. APRNs identified key indicators of quality relevant to their practice including: LOS, readmission, wait times, resource utilization, hospital-acquired complications, and coordinated care across the continuum. A survey of barriers to efficient and effective practice, as well as job satisfaction, revealed that workload, volume of patients, complex communication systems, care coordination support, informatics inefficiencies, documentation requirements, and staffing were significant stressors working against optimal care delivery. Factors that contributed to job satisfaction included role-specific education and training, role expectations, physician support, and opportunities for professional growth and advancement.36 With this information from the Vanderbilt study, the Center for Advanced Practice Nursing reemphasized the importance of professional practice support to APRNs, frontline clinical teams, and service line–focused healthcare teams,
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known as patient care centers. The key components of centralized professional practice guidance and support to key areas include: • Advanced practice leadership structure • Professional practice evaluation and advancement • Continuing education and professional development support • Structured resources for staffing models and business case development • Strategic partnership for recruitment, compensation, and benefits • Licensure, certification, and regulatory guidance • Support and development of quality metrics for APRN practice • Shared governance model for APRN decision making • Networking opportunities through APRN councils and committees • Support for interprofessional initiatives Furthermore, executives, leaders, and sponsors included the APRN findings regarding barriers to optimal efficiency and effectiveness into overarching enterprise redesign initiatives and included APRNs as subject matter experts in focused workgroups on areas such as technology, documentation, and care continuum improvement. Beyond the survey results, we continued to build expertise in utilization of APRNs throughout the organization.The frontline knowledge and expertise of the APRNs supported the integration into many practice areas. In addition, some areas found the “Participatory, Evidence-Based, Patient-Focused Process for Advanced Practice Nursing (PEPPA)” framework to be a helpful resource for planning, implementation, and evaluation of APRN practices.37 Using evidence through our own research and seeking evidence-based tools for APRN practice development has been a successful strategy, particularly when targeting APRNimpacted outcomes and long-term successful integration.
DISCUSSION The evidence reviewed in this article indicates that effective use of APRNs in the healthcare system presents an opportunity to decrease cost and sustain or improve quality. The successful addition of these professionals to an existing healthcare system is, however, a journey. An organization must be attentive to the climate and culture that allows these individuals to practice to the top of their license and training, consistent with the IOM recommendations. Attention must be given to both the organization’s workforce characteristics and the economic climate. For example, in an academic medical center with a large NP training program, these professionals are readily available. There may be restraining factors in other communities, such as limited numbers of NPs to teach and mentor, which might impede full implementation. The receptivity to physician partners in the community and organization is also extremely important. Implementation will be hindered if economic conditions or physician perceptions position the APRNs as competition. This dynamic cannot be underestimated. Careful and methodical attention must be given to the cultivation of effective relationships among
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physicians, APRNs, and appropriate administrative personnel. These relationships must be solid enough to allow for honest and productive conversations to break down barriers, align incentives, and create a win–win for all parties involved. In addition to the importance of physician relationships, it is also the belief of these authors that a significant linkage to nursing leadership is crucial. Without a balanced and partnering approach between physician leaders and nursing leaders, APRNs run a significant risk of feeling isolated and vulnerable. The concepts of structural empowerment discussed in this article provide guidance on the structures and processes required to promote full functioning of the APRN as an integral member of the interprofessional team.
CONCLUSION The current healthcare imperative for improved quality and cost-effective care have created the optimal environment for APRNs to showcase their contributions to practice. With considerable evidence to support APRN outcomes, optimizing support and empowerment of APRNs to practice to the top of their licenses and experience high levels of job satisfaction leads to quality care delivery and successful practice outcomes. There are also opportunities for nursing, advanced practice nursing, and physician leaders, scholars, and researchers to enhance the body of knowledge about structures and process that promote APRN practice consistent with the recommendations outlined in the IOM 2010 report.8 NL References 1. O’Grady ET. Advanced practice registered nurses: the impact on patient safety and quality. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. AHRQ Publication No. 08-0043. Rockville, MD: Agency for Healthcare Research and Quality; March 2008. 2. Bureau of Labor Statistics, US Department of Labor. Registered nurses. Occupational Outlook Handbook. 2006–07 ed. http://www.bls.gov/ooh/ healthcare/registered-nurses.htm. Accessed August 1, 2014. 3. APRNs in the U.S. The Consensus Model for APRN Regulation, Licensure, Accreditation, Certification and Education. https://www.ncsbn.org/4213.htm. Accessed August 1, 2014. 4. American Association of Colleges of Nursing. Advancing Higher Education In Nursing: Position Statement. October 2004. http://www.aacn.nche.edu/ dnp/dnp-position-statement. Accessed August 1, 2014. 5. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington DC: National Academies Press; 1999. 6. Institute of Medicine. Crossing the Quality Chasm. Washington DC: National Academies Press; 2001. 7. Institute of Medicine. Health Professions Education: A Bridge to Quality. Washington DC: National Academies Press; 2003. 8. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Report Recommendations. Washington DC: National Academies Press; 2010. http://www.iom.edu/Reports/2010/The-Future-of-NursingLeading-Change-Advancing-Health/Recommendations.aspx. Accessed August 1, 2014. 9. Burns SM, Earven S. Improving outcomes for mechanically ventilated medical intensive care unit patients using advanced practice nurses: a 6year experience. Crit Care Nurs Clin North Am. 2002;14:231-243. 10. Burns SM, Earven S, Fisher C, et al. Implementation of an institutional program to improve clinical and financial outcomes of mechanically ventilated patients: one-year outcomes and lessons learned. Crit Care Med. 2003;31:2752-2763. 11. Butler KL, Calabrese R, Tandon M, Kirton OC. Optimizing advanced practitioner charge capture in high-acuity surgical intensive care units. Arch Surg. 2011;146:552-555. 12. Chen C, McNeese-Smith D, Cowan M, Upenieks V, Afifi A. Evaluation of a nurse practitioner-led care management model in reducing inpatient drug utilization and cost. Nurs Econ. 2009;27:160-168.
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13. Collins N, Miller R, Kapu A, et al. Outcomes of adding acute care nurse practitioners to a Level I trauma service with the goal of decreased length of stay and improved physician and nursing satisfaction. J Trauma Acute Care Surg. 2014;76:353-357. 14. Cowan MJ, Shapiro M, Hays RD, et al. The effect of a multidisciplinary hospitalist/physician and advanced practice nurse collaboration on hospital costs. J Nurs Adm. 2006;36:79-85. 15. Ettner SL, Kotlerman J, Afifi A, et al. An alternative approach to reducing the costs of patient care? A controlled trial of the multi-disciplinary doctornurse practitioner (MDNP) model. Med Decis Making. 2006;26:9-17. 16. Kapu AN, Kleinpell R, Pilon B. Quality and financial impact of adding nurse practitioners to inpatient care teams. J Nurs Adm. 2014;44:87-96. 17. Lenz ER, Mundinger MO, Kane RL, Hopkins SC, Lin SX. Primary care outcomes in patients treated by nurse practitioners or physicians: two-year follow-up. Med Care Res Rev. 2004;61:332-351. 18. Meyer SC, Miers LJ. Cardiovascular surgeon and acute care nurse practitioner: collaboration on postoperative outcomes. AACN Clin Issues. 2005;16:149-158. 19. Newhouse RP, Stanik-Hutt J, White KM, et al. Advanced practice nurse outcomes 1990-2008: a systematic review. Nurs Econ. 2011;29:230-250; quiz 251. 20. Paez KA, Allen JK. Cost-effectiveness of nurse practitioner management of hypercholesterolemia following coronary revascularization. J Am Acad Nurse Pract. 2006;18:436-444. 21. Russell D, Vorderbruegge M, Burns SM. Effect of an outcomes-managed approach to care of neuroscience patients by acute care nurse practitioners. Am J Crit Care. 2002;11:353-362. 22. Sise CB, Sise MJ, Kelley DM, et al. Resource commitment to improve outcomes and increase value at a level I trauma center. J Trauma. 2011;70:560-568. 23. Bauer JC. Nurse practitioners as an underutilized resource for health reform: evidence-based demonstrations of cost-effectiveness. J Am Acad Nurse Pract. 2010;22:228-231. 24. Perryman Group. The Economic Benefits of More Fully Utilizing Advanced Practice Registered Nurses in the Provision of Care in Texas: An Analysis of Local and Statewide Effects on Business Activity. Waco, TX: Perryman Group; 2012. http://c.ymcdn.com/sites/flanp.site-ym.com/resource/resmgr/ articles_and_research/Perryman-APRN-Ultilization-E.pdf. Accessed August 1, 2014. 25. Chenoweth D, Martin N, Pankowski J, Raymond LW. A benefit-cost analysis of a worksite nurse practitioner program: first impressions. J Occup Environ Med. 2005;47:1110-1116. 26. United Health Group. Federal Health Care Cost Containment: How in Practice Can It Be Done? Options With a Real World Track Record of Success. Working Paper 1. 2009. http://www.unitedhealthgroup.com/~/media/uhg/pdf/2009/ unh-working-paper-1.ashx? Accessed August 1, 2014. 27. Kapu AN, Thomson-Smith C, Jones P. NPs in the ICU: the Vanderbilt initiative. Nurse Pract. 2012;37(8):46-52. 28. Jones P. Structural Empowerment and Role Definition of Unit-Based Advanced Practice Registered Nurses (APRN) [ Doctoral]. Nashville, TN: Vanderbilt University School of Nursing; July 2013. 29. Kanter RM. Men and Women of the Corporation. New York, NY: Basic Books; 1977. 30. Manojlovic M. Power and empowerment in nursing: looking backward to inform the future. OJIN Online J Issues Nurs. 2007;12(1):Manuscript 1. http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPerio dicals/OJIN/TableofContents/Volume122007/No1Jan07/LookingBackwardtoIn formtheFuture.html. Accessed August 1, 2014. 31. Moote M, Krsek C, Kleinpell R, Todd B. Physician assistant and nurse practitioner utilization in academic medical centers. Am J Med Qual. 2011;26:452-460. 32. American Nurses Credentialing Center. Announcing a New Model for ANCC’s Magnet Recognition Program [brochure]. 2008. http://www.nursecredentialing. org/Documents/Magnet/NewModelBrochure.pdf. Accessed August 1, 2014. 33. Shea ML. Determined persistence: achieving and sustaining job satisfaction among nurse practitioners. J Am Assoc Nurse Pract. 2015;27:31-38. 34. Pasarón R. Nurse practitioner job satisfaction: looking for successful outcomes. J Clin Nurs. 2013;22:2593-2604. 35. Brown AM, Christie LM, Higgerson RA, Mikhailov TA, Stojadinovic BJ, Forbes ML. A national survey of PICU nurse practitioners—opportunities to standardize practices and optimize service delivery. Pediatr Nurs. 2012;38:249250, 277. 36. Dubree M, Kapu A. Optimized efficiency and effectiveness: impact of an academic medical center APRN workflow analysis. Vanderbilt University Medical Center; March, 2014; Nashville, TN. 37. Bryant-Lukosius D, Dicenso A. A framework for the introduction and evaluation of advanced practice nursing roles. J Adv Nurs. 2004;48:530-540.
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Marilyn Dubree, RN, MSN, NE-BC, is executive chief nursing officer at Vanderbilt University Medical Center in Nashville, Tennessee. Pam Jones, DNP, RN, NEA-BC, is chief nursing officer at Vanderbilt University Hospital in Nashville. April Kapu, DNP, APRN, ACNP-BC, is associate nursing officer and director of advanced practice at the Center for Nursing Excellence, Vanderbilt University Medical Center; she can be reached at [email protected]. Clifford Lee Parmley, JD, MD, MMHC, is chief of staff at Vanderbilt University Hospital. 1541-4612/2014/ $ See front matter Copyright 2015 by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2015.01.007
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