The Perinatal Nurse Practitioner: An Innovative Model of Advanced Practice

The Perinatal Nurse Practitioner: An Innovative Model of Advanced Practice Deborah Cooper McGee, RNC, MSN, PNNP

When a major urban hospital received notice it would no longer have resident physicians to serve its perinatal population, nurses and physicians joined forces with ;3 private university to develop a curriculum for advanced level caregivers. This willingness to rise to a challenge helped to create the Perinatal Nurse Practitioner Program and has paved the way for other needed inpatient nurse practitioner roles. Accepted: March 1994

he crisis in health care today involves economic demands on the health care system, its responsiveness to society, and the performance and credibility of its practitioners. Meanwhile, there is a shift from the traditional scientific model of diagnosis and treatment of disease to a more holistic one. This new model has challenged the present order with change and innovation.

Background: Tbe Perinatal Nurse Practitioner The critical need for health care providers to serve pregnant women at high risk spurred an innovation in advanced nursing practice in Denver. A new role, the perinatal nurse practitioner, evolved as a small group responded to problems in their community. Because the focus of medicine was on an academic model rather than a service model, resident physicians had become less available to the area’s tertiary-care facility. To continue the delivery of high-quality care to pregnant women at low risk and high risk in the Rocky Mountain region, a group of nurses and perinatologists worked with a local university to develop a graduate level curriculum for caregivers with advanced skills. The four-semester program of rigorous study stresses scientific knowledge, nursing theory and research, critical thinking, communication, and advanced technical

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skills. Modeled after the neonatal nurse practitioner (NNP), the perinatal nurse practitioner (PNNP) role blends critical thinking and advanced technical skills within the nursing process. The PNNP scope of practice includes advanced physical assessment, history taking, and psychosocial assessment. Also part of the practice are specific perinatal technical skills-basic ultrasound, biophysical profile, insertion of internal monitoring devices, hemodynamic monitoring, and first assisting for obstetric surgical cases. In addition, PNNPs possess in-depth knowledge about high-risk pregnancy, including cultural, spiritual, and ethical issues. The PNNP works collaboratively with peers, physicians, and allied health care providers. The PNNP can foster collaboration and communication within a multidisciplinary team of health care professionals. The PNNP is an expert case manager, mentor, model of holistic care, and patient advocate. Both the PNNP and NNP generally are employed by a hospital to provide ongoing assessment of patients’ health. Notable differences between nurse practitioners and staff nurses are in the formal education and training nurse practitioners receive, their increased autonomy, and their responsibility for the care of patients at high risk. The American Nurses Association (ANA) describes the specialist in nursing practice as a nurse who, through study and supervised practice at the graduate level, has become an expert in a defined area of knowledge and practice in a selected clinical area of nursing. The ANA further describes this specialization as “a mark of ad-

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The four-semester PNNP program is one of rigorous study in which scientific knowledge, nursing theory and research, critical thinking, communication, and advanced technical skills form the cornerstone.

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As an expert care provider and a patient advocate, the PNNP is in a pivotal role to foster positive relationships within a multidisciplinary team of health care professionals.

vancement of the nursing profession” (Zukowsky & Coburn, 1991, p. 129). Nurse practitioners who work at nontraditional clinical practice sites may prepare themselves to move into critical care settings, where they can address the need for innovative practice models and begin a process of change.

Implications for Nursing Rapid changes in health care call for flexibility and creativity. Today’s patients often are sicker, the technology is more complicated, and the treatments are remarkably more complex. New ideas, methods, and devices have been introduced at an astounding rate during the last decade. Nurses incorporate all these elements into their patient care using methods that have changed little over the years. Care delivery needs redesign and change (Schade, 1991). Much has been written about staff nurses’ attitudes toward their profession. Frequent complaints of too much responsibility, too little autonomy, underuse of skills, and limited professional recognition are heard. This dissatisfaction contributes to rapid employment turnover of nurses and to nurses leaving the profession. The opportunity for advanced practice may quell the discontent of some staff nurses. Nurse practitioners’ special qualifications and talents involve them in patient care, counseling, and decision making at a more advanced level. The role of the hospital nurse practitioner would be ideal for the staff nurse who wants to continue as a fulltime provider of direct care without making an administrative career move to advance in rank and salary. It is a professional role that can reduce nurses’ dissatisfaction and bring magnetism back to nursing. The nursing knowledge, abilities, and skills the nurse practitioner blends with medical activities makes him or her a unique health care provider. Knowledge gained through advanced education enables the practitioner to communicate more effectively with physician colleagues about patient care. This greater understanding of medicine translates into more comprehensive caregiving. The differences in the education of the nurse practitioner and the physician result in content and style differences in practice. Nursing uses a broader, more holistic approach to patient care, emphasizing physical and psychosocial aspects of care. Patients in medical centers need and deserve primary providers who can apply nursing and medical principles to their problems. A nurse

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practitioner is able to give the patient consistent guidance, care, help, understanding, education, and comfort.

Tbe Nurse Practitioner: An Evolving Concept Although the role of the nurse practitioner has existed for almost 30 years, its evolution is ongoing. The first nurse practitioner program in the United States began in Denver in 1965 (Perspectives 20 Years Later, 1985). Initially, the nurse practitioner worked in primary health care because of the perceived lack of physician providers. Early nurse practitioner education was received through continuing education programs that awarded certificates on completion (Abdellah, 1982; Hayes, 1985). Few practitioner programs were associated with a college or a university. Initially, many nurse educators questioned the validity of the nurse practitioner role. Educators conceptualized that nurses were workers who gave sustaining care, and physicians were workers who gave curative care; mixing the roles of caring and curing left the nurse practitioner suspect. Martha Rogers, a vocal critic of the nurse practitioner role, thought that it was a step backward for nursing and that those who became nurse practitioners had, in effect, left the nursing profession, falling for a ploy by physicians to lead nurses into “paying obeisance to an obsolete hierarchy” (Elder & Bullough, 1990, p. 79). In spite of such resistance, the innovators were supported by a climate for change, provided with resources, and encouraged by prominent national visionaries in nursing and medicine. A small number of universities began to set up programs, first in pediatric care and then in other specialty areas. Slowly the opposition softened, and programs changed from the certificate level to those requiring master’s preparation. Currently, master’s degree programs are the norm for most nurse practitioner specialties (Elder & Bullough, 1990). In addition, in its 1993 position paper about the regulation of advanced practice nursing, the National Council of State Boards of Nursing, Inc. included “graduate degree with a major in nursing or a graduate degree with a concentration in an advanced nursing practice category” as a basis of advanced practice nursing. Since their inception, nurse practitioners have been used in areas underserved by physicians (Koch, Pazaki, & Campbell, 1992; Stanford, 1987). As the role of the nurse practitioner has developed, its practice areas have expanded beyond the original primary care setting. The demand for nurse practitioners in areas of practice other than primary care has increased (Edmunds & Ruth, 1991). In the acute care setting, the question of nurses substituting for house staff has arisen. This idea was explored by Silver and McAtee (1988), who labeled such practitioners as “nurse associate residents.” A person in this role would assume all house staff activities, including night call, but would continue to retain his or her identity as a nurse. The exact need and demand for this role has not been determined, but a sample of directors of house

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The role of the hospital nurse practitioner would be ideal for the staff nurse who wants to continue as a full-time provider of direct care without making an administrative career move to advance in rank and salary.

staff training programs and officers of various medical specialties indicated a need and a willingness to use associate residents (Silver & McAtee, 1988). A person in this role would come to know more about established protocols and the work-up and management of problems related to a particular specialty than an intern or a resident who rotates through a specialty area for a short period of time. Physician resistance to an advanced practice role in which a nurse can substitute for a house physician can be expected. Physicians must be made aware that the perceived competition is a misconception. Inpatient nurse practitioners would not substitute for physicians in the community. In fact, the decreased use of residents traditionally needed in teaching hospitals would lead to a reduced number of specialists and subspecialists who enter practice after completion of residency training. This would actually reduce competition between physicians (Ginzberg, 1981; Silver 8r McAtee, 1984, 1988). Conversely, the nurse practitioner in independent practice can be seen as a direct threat to fee-for-service solo practitioners (Hayes, 1985). Clinics and ambulatory care facilities will become increasingly appealing to physicians as it becomes more difficult to establish private practices, and nurse practitioners currently employed in these settings will face increasing physician competition for primary care positions.

Cost Effectiveness Analyses of the cost effectiveness of nurse practitioners suggest that the use of practitioners results in cost savings to society (Mahoney, 1988). A nurse practitioner keeps the quality of care high and reduces hospital expenses (Abdellah, 1982; Ginzberg, 1981; Shanks-Meile, Shipley, Collins, bz Tacker 1989; Stanford, 1987). The arrangement for using nurse practitioners in primary care is based on their potential to improve access and to lower costs without compromising care. This premise is derived from several assumptions: 1. Nurse practitioners can perform basic and routine medical tasks traditionally performed by physicians. 2. Physicians working with nurse practitioners will be freed to focus on more serious and complex medical care problems. 3. Educational costs are lower for the preparation of a nurse practitioner than of a physician. 4. Lower costs associated with nurse practitioner services will result in lower prices for the services provided. 5 . Improved access to care resulting from the addition of nurse practitioners will increase the possibility of early detection of disease and reduce medical care expenses. (Aiken, 1982). In new clinical settings for the nurse practitioner, the usefulness and cost effectiveness of the'role may differ considerably from the traditional outpatient clinic or office-based practice model. As the role evolves, studies examining these expanded practice areas will reveal important information that may have an impact on future use of nurse practitioners.

Discussion

Quality of Care The quality of care provided by nurse practitioners has been demonstrated to be equivalent to that of physicians as judged by standards developed within practice settings. Superiority of care has even been shown in selected areas (Abdellah, 1982; Mitchell et al., 1991; Spitzer, 1984; Stanford, 1987). The Burlington Randomized Trial of the Nurse Practitioner (Sackett et al., 1974) examined physical, emotional, and social outcomes of two groups of patients: patients receiving conventional care from two family physicians and patients receiving care from two nurse practitioners. After 1 year, the results indicated that the nurse practitioners were effective and safe providers of care. In addition, research has shown that on completion of a graduate degree program, neonatal nurse practitioners demonstrate the knowledge and the problem-solving and clinical skills of a pediatric resident (Mitchell et al., 1991).

Normal and expected reactions to change are resistance, anger, and concern. It is not surprising that response to this or any new advanced practice nursing role is slow. Physicians and hospitals are unsure of how they can use this role, other nurses are concerned about how a PNNP might overlap with or affect their jobs, and patients are ignorant of different levels of nursing education. Adding another person to their health care delivery may compound the patient's confusion. Although no formal interviews were conducted with the staff nurses in the medical center that employs PNNPs, discussions with the staff nurses revealed initial concern and protectiveness of their turf. After several months of working together, the staff expressed overwhelming satisfaction with the new role. The practitioners address patient care concerns staff may have, and the availability of a practitioner at all times is seen as a great benefit. Because they are nurses, the practitioners may be viewed as more approachable than physicians and more knowledgeable about nursing issues than interns. Professional relationships between interns and PNNPs seem amicable; in spite of this, there has been some dissatisfaction on the part of interns, who feel prac-

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titioners are interfering with the amount of experience they are able to obtain in this setting. Practitioners are not involved with patient care provided by interns except by invitation. Interns, however, are no longer exposed daily to the care of patients at high risk, nor are they asked to serve as first assistant in perinatal surgery. A few of the private physicians quickly accepted PNNPs, asking them to assess patients, perform ultrasonography, and serve as first assistant. Several physicians have requested PNNP assistance in research activities. In addition, PNNPs are participating in a multicenter research project. Not surprisingly, a few physicians are resistant to the use of practitioners and have expressed concern that the practitioner will consult with the perinatologist regarding questions related to the private patient instead of calling the private physician. Other physicians use practitioners sporadically, but the frequency increased during the 1st year of PNNP practice. One of the most important aspects of this role is its acceptance by patients. Informal discussions with patients and families indicate that there is an extremely high level of satisfaction in having a practitioner involved with patient care. Patients and families have indicated that education by the PNNP regarding patient and fetal status has been extremely helpful. They also have indicated that they are consulted about choices involving their daily routine and care, which returns to them some of the control they have lost by being hospitalized. Patient rounds by the PNNP with long-term antepartum patients allow much greater opportunity for lengthy patient contact than busy physician schedules permit. Frequent rounds are opportunities to develop rapport with patients and their family members and to build trusting relationships. Patient and family are free to ask questions because the practitioner is not rushing out of the room; important issues may be discovered that might otherwise go undetected. The length of time spent with patients and families and devoted to patient education and psychosocial issues presents an area to be investigated. Future studies should focus on nursing intervention as well as medical intervention performed by PNNPs. Because nurse practitioners tend to spend more time with patients, they may appear inefficient if only the tasks they perform are considered. In a capitated system, patient noncompliance can be costly and can create a negative outcome for the patient and her fetus. Time spent by the caregiver in developing a trusting relationship with the patient, providing adequate education, and allowing the patient to ask questions might prove to be beneficial and cost saving in the long run. These are critical factors in differentiating the nursing role from the medical role and may substantiate how this new role is different from a physician’s assistant or a “junior doctor.” Studies may reveal more similarities than differences between physicians and nurse practitioners because most studies have been based on medical tasks and outcomes rather than on the components of nursing practice. Such studies have not been useful in bringing to light the full

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extent of the knowledge and skills of the nurse in clinical practice (Stanford, 1987). Typically, nurse practitioners provide outpatient care to the medically underserved and to people who often have a blend of cognitive, socioeconomic, physical, and family problems. The traditional health care system perpetuates medical technologies that fail to address multifactor causality, ignores the impact of environment, and exercises undue social controls on health care delivery. Nurse practitioner philosophy emphasizes a holistic orientation to persons in a state of illness or health and focuses on physiologic, psychologic, and spiritual responses. The nurse practitioner combines the abilities to deliver care, teach about health, deal with emotional problems, and coordinate the multiple health resources involved in a family’s care (Ford, 1980; Mahoney, 1988).

Conclusions Clinical expertise is an essential attribute of nursing and a significant component in the delivery of excellent perinatal care. New roles are emerging, and old roles are being redefined. Societal forces have had an effect on health care delivery. For example, the women’s movement, changes in the financing of health care, the consumer movement, changes in demography, increasing litigation, and an increasingly high-tech society have influenced the health care system. Some of these forces have resulted in a shortage of physician providers of obstetric care, a deterioration in the health status of women and infants, increased cultural diversity in providers and consumers of health care, and rapidly expanding technologies in an era of decreasing resources. These changes mandate negotiation of new role relationships, increased sensitivity to cultural diversity, pro-active management of new technologies, revision in the concept of advocacy, and development of an ethical framework for collaborative practice (Strohbach, 1991). The climate is right for recognition of advanced practice roles. As nurse practitioners, nurses make a more complete contribution to health care. The role presents a key opportunity to influence prescriptive care and shape orders that reflect nursing diagnosis and management from admission through discharge. Nurse practitioners are providing comprehensive case management and patient care (Hanson & Martin, 1990). The time has come to broaden our perspective of the nurse practitioner and expand advanced practice.

References Abdellah, F. G. (1982). The nurse practitioner 17 years later: Present and emerging issues. Inquiry, 29,105-1 16. Aiken, L. H. (1982). Nursing in the 1980%:Crisis, opportunities, challenges. Philadelphia: J . B. Lippincott Company. Edmunds, M. W., & Ruth, M. W. (1991). NPs who replace physicians: Role expansion or exploitation? Nurse Practitioner, 16(9), 46,49. Elder, R. G., & Bullough, B. (1990). Nurse practitioners and

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clinical nurse specialists: Are the roles merging? Clinical Nurse Specialist, 4(2), 78-84. Ford, L. C. (1980). Nursing at the cutting edge of health services reform. AmericanJournal ofNursing, 80(8),1476-1479. Ginzberg, E. (1981). The economics of health care and the future of nursing. Nurse Educator, 6(3), 29-33. Hanson, C., & Martiri, L. L. (1990). The nurse practitioner and clinical nurse specialist: Should the roles be merged?Journal of the American Academy ofNurse Practitioners 2( l ) , 2-9. Hayes, E. (1985). The nurse practitioner: History, current conflicts, and future survival. College Health, 34, 144-147. Koch, L. W., Pazaki, S. H., & Campbell, J. D. (1992). The first 20 years of nurse practitioner literature: An evolution of joint practice issues. Nurse Practitioner, 17(2), 62-71. Mahoney, D. F. (1988). An economic analysis of the role of the nurse practitioner. Nurse Practitioner, 13(3), 44-52. Mitchell, A., Watts, J., Whyte, R., Blatz, S., Norman, G. R., Guyatt, G. H., Southwell, D., Hunsberger, M., & Paes, B. (1991). Evaluation of graduating neonatal nurse practitioners. Pediatrics, 88(4), 789-794. Perspectives 20 years later: From the pioneers of the NP movement (1985). Nurse Practitioner, 10(1), 15-18,20-22. Sackett, D. L., Spitzer, W. O., Gent, M., Roberts, R. S., Hay, W. I., Lefroy, G. M., Sweeny, G. P., Vandervlist, I., Sibley, J. C., Chambers, L. W., Goldsmith, C. H., Macpherson, A. S., & McAuley, R. G. (1974). The Burlington randomized trial of the nurse practitioner: Health outcomes of patients. Annals of Internal Medicine, 80(2), 137- 142. Schade, J. (1991). Innovative nursing models: Are you ready: Aspen Adtiisor, 6(7), 6, 7. Shanks-Meile, S. L., Shipley, A. C., Collins, P. A , , & Tacker, A.

(1989). Changes in the advertised demand for nurse practitioners in the United States, 1975-1986. Nurse Practitioner, 14(9), 41-49. Silver, H. K.,& McAtee, P. A. (1984). On the use of non-physician ‘associate residents’ in overcrowded specialty training programs. New England Journal of Medicine, 31 2(5), 326-328. Silver, H. K., & McAtee, P. A. (1988). Speaking out: Should nurses substitute for house staff?AmericanJournal ofNursing, 88(12), 1671-1673. Spitzer, W. 0. (1984). The nurse practitioner revisited: Slow death of a good idea. New England Journal of Medicine, 310(16), 1049-105 1. Stanford, D. (1987). Nurse practitioner research: Issue in practice and theory. Nurse Practitioner, 12(1), 64-75. Strohbach, M. E. (1991). Beyond clinical expertise: Agenda for excellence in perinatal nursing. The Journal of Perinatal andNeonatalNursing, 5,(3), 1-6. Zukowsky, K., & Coburn, C. E. (1991). Neonatal nurse practitioners: Who are they? Journal of Obstetric, Gynecologic, andNeonatalNursing, 20,128-132.

Addressf o r correspondence: Deborah Cooper McGee, Master in Nursing Program, Regis University, 3333 Regis Boulevard, Denver, CO 80221-1099. Deborah Cooper McGee is coordinator,perinatal nurse practttioners, Presbyterian-St. Luke’s Medical Center, Denver, and clintcal liaison, Perinatal Nurse Practittoner Program, Master in Nursing Program, Regis University, Denver, CO.

JOGhWReview Panel: 1995 Cydney I. Afriat, CNM, MSN, RDMS Erin Anderson, RN, MSN Lauren Arnold, RN, PhD Mary Lee Barron, RN-CS, MSN, FNP Marie Biancuzzo, RN, MS Linda Boisvert, MScN Mary C. Brucker, CNM, DNSc Rebekah Carey, RNC, MSN Judith A. Carveth, RN, CNM, PhD Beth A. Collins, RNC, PhD Elizabeth G. Damato, RNC, MSN Kathryn V. Deitch, RNC, PhD Pamela Dill, RNC, MSN Peggy Gordin, RNC, MS Jeanne T. Grace, RNC, PhD Maureen Griese, RNC, BSN Maureen Heaman, RN, MN Mary Henrikson, RNC, MN, ARNP

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Pamela Hill, RN, PhD Diane Holditch-Davis, RN, PhD M. Katherine Hutchinson, RNC, PhD Pamela L. Jordan, RN, PhD Margaret H. Kearney, RNC, PhD Carole Kenner, RNC, DNS Virginia Kinnick, RN, CNM, EdD Cheryl Kish, RN, MSN, EdD Nancy Lowe, CNM, PhD Nancy MacMullen, RNC, PhD Laura Mahlmeister, RN, PhD Louise Martell, RN, PhD Linnea J. Mead, RN, MSN, PNP Barbara Medoff-Cooper, PhD, FAAN Mary Ann Miller, RN, PhD Anne A. Moore, RNC, MSN Karen Moore, RNC, MSN, IBCLC Michelle Murray, RNC, PhD

Rita H. Pickler, RN, PhD Margaret Primeau, RN, MBA, MS, CANP Linda Pugh, RNC, PhD Deborah A. Raines, RNC, PhD Diana Reiser, RN, MAEd, MN Jacque R. Repke, RNC, MS Jeanne Sala, RNC, MSN, CNM Maureen Shogan, RNC, MN Sharleen H. Simpson, MSN, PhD, ARNP Jan Weingrad Smith, CNM, MS, MPH Rosemary Theroux, RNC, MS Susan E. Trippet, RN, DSN Nan H. Troiano, RN, MSN Cheryl Wallerstedt, RNC, MS, FACCE Lenore R. Williams, RN, MSN Jeanne M. Wilton, RN, MS, IBCLC

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