ISSUES IN NURSING ORGANIZATIONS: INTEGRATING THE ROLE IN THE ACUTE

CARE ENVIORNMENT

MAY 1, 2018
 Traditionally in the United States, an increased mismatch between the number of

available providers and the public demand for care has been addressed with reforms in healthcare

delivery systems. Development of the roles and responsibility of nurses has often been the

response to a supposed emergency in healthcare delivery (Asubonteng, McCleary & Munchaus,

1995; Coombs, Chaboyer & Sole, 2007). NPs have repeatedly been called upon to fulfill

healthcare needs among those underserved patient populations most vulnerable to the shortage of

healthcare providers (Asubonteng, McClear, & Munchus, 1995). The need for critical care-

proficient NPs increased throughout the country following work hour constraints for resident

physicians set forth by the Accreditation Council for Graduate Medical Education (ACGME,

2012), although lifting these limitations is currently under consideration.

The expansion of nursing practice among NPs has been met with some opposition in the

medical community. Evidence shows that NP care is much better that provided care is supposed

to be undesirable by patients and likely care of inferior quality when compared to physician

care. (Pioro et al., 2001; Roblin, Becker, Adams, Howard, & Roberts, 2004). Researchers found

no statistically significant difference in outcomes for patients cared for by NPs or physicians. In

addition, increased patient satisfaction was identified in the NP interactions when compared to

attending physicians.

The American College of Critical Care Medicine Task Force on Models of Critical Care

Delivery pursued to establish critical care medicine guidelines that defined the intensivist and

critical care practice (Brilli et al., 2001). The report suggested critical care delivery via

intensivist physician-led multidisciplinary teams. The benefit of this collaborative approach was

validated in a reviewing study by Meyer and Miers (2005) who examined the impact of

collaborative care between cardiovascular surgeons and nurse practitioners in postoperative

cardiovascular surgery patients. A reduction in hospital length-of-stay (LOS) was identified,

which resulted in an estimated cost savings of over 5,000 dollars per patient.

The cost of providing critical care in the United States (U.S.) increased 44 percent (from

$56.6 to $81.7 billion) between the 2000 and 2005 (Halpern & Pastores, 2010). Enhanced

clinical outcomes in critically ill patients, as well as reduced length-of-stay (LOS), were directly

related to improved utilization of staff trained specifically in critical care ( Pronovost et al.,

2002). Although management of critically ill patients by intensivists has demonstrated reduced

morbidity and mortality and healthcare costs, physician intensivists manage only 37% of all

intensive care unit (ICU) patients in this country (Logani, Green, & Gasperino, 2011). The goal

of increased critical care trained physician staffing is likely unachievable, given the current and

projected increased need for critical care services (Kelley et al., 2004)

The role domains of APN derived from the data are advanced clinical practice, practice

development, education, research, consultation, and administration. All the APN domains and

processes facilitate the goals of staff development, practice development, and organizational

development. Advanced practice nurses are well placed to provide leadership at both strategic

and clinical levels (Manley et al., 2008), which is a key mechanism for achieving and drive in

transformation in practice.

A range of factors can challenge APN role performing, the organizational challenges,

resource challenges, interaction challenges, and role challenges are not mutually exclusive, but

they influence each other. The organizational challenges , rising from the innovation of the APN

role, lack of role clarity, healthcare system challenges, and lack of management support and

recognition, were often recognized to be aggravating APN role implementation.

 The APN role per se is recognized to be challenging many ways. The APN role is diverse

and complex in nature causing stress and turmoil in performance of the role, the excessive

workload is deepened by APN role overload, working in isolation and concern with becoming

“physician assistants”, rather than nurse practitioners as well as a mismatch between their

influence and authority. The goal of APN is optimized quality of care, improved quality of care,

and practice and staff development, as well as sustaining of experienced nurses. Outcomes of the

APN positions can be viewed through the scopes of the patient, staff, practice, and organization.

When supported well, developed carefully, and evaluated regularly, the APN role should benefit

clients.

Integration of the NP into the critical care team has been identified as an effective method

of healthcare delivery in critical care. NPs can help to alleviate the growing disparity between

numbers of providers and numbers of patients. Collaboration between critical care trained NPs

and critical care physicians can expand the range and availability of services for critically ill

patients. The expanding difficulty in caring for critically ill patients validates the need for inter

professional, critical care residency programs. NPs who wish to practice in critical care require

substantial didactic and experiential education to attain confidence and competence as a

provider.

Kleinpell (2005) completed a five-year longitudinal study of ACNP practice related to

role perception and role preparation. Distributed after the initial year of ACNP certification, a

44-item questionnaire evaluated the respondents' perceptions of educational preparation for the

ACNP role. Only 19% reported that they were very well prepared for practice.

Recommendations for ACNP educators were solicited from respondents. The foremost
recommendation offered by 66% of respondents was additional clinical or residency hours; 56%

of respondents suggested additional time with practicing ACNPs.

Hart and Macnee (2006) evaluated self-perception of preparedness following completion

of fundamental NP education by NP conference attendees, utilizing a cross-sectional descriptive

study method. Analysis of the questionnaire data revealed that 10% of respondents felt very well

prepared for NP practice and 51% reported feeling somewhat or minimally prepared. There was

no significant difference in responses among varying age groups of respondents. The study

supported the assertion that many NPs do not feel adequately prepared for practice upon

graduation from educational programs. Of note, 87% of respondents reported interest in a NP

residency program, if such a program had been available.

Successful completion of a critical care residency/fellowship that incorporates inter

professional practice and competency benchmarks could enable the NP to function at the full

scope-of-practice necessary to care for the most complex patient populations. Proficiency and

confidence attained may empower NPs to facilitate and lead inter professional, collaborative

practice teams. Implementation of NP residency/fellowship programs could also improve patient

access to competent, highly skilled critical care providers. Advanced practice nurse residencies

can benefit not only novice NPs but also NPs entering a different and unfamiliar specialty

practice. In sum, increased availability of NP residencies/fellowships can provide additional

opportunities for lifelong learning in advanced nursing practice.

Nurses in advanced practice to increase patients’ access to emergency and critical care is

appealing and the implementation of advanced practice nursing roles in the emergency and

critical care settings improves patient outcomes. The transformation of healthcare delivery

through effective utilization of the workforce may alleviate the impending rise in demand for
health services. However, it is necessary to first prepare an approachable framework to effect

sustainable change. In conclusion, critical care NP residency programs could offer a viable

solution to the existing and anticipated workforce shortage by providing novice NPs with

specialized, intensive experience with expert mentorship in the critical care setting.

References

Accreditation Council for Graduate Medical Education (2011). The ACGME 2011 duty
hour standard: Enhancing Quality of Care, Supervision and Resident Professional
Development.http://www.acgme.org/Portals/0/PDFs/jgme-monograph%5b1%5d.pdf

Alexandrov, A. W., Brethour, M., Cudlip, F., Swatzell, V., Biby, S., Reiner, D., . . .
Yang, J. (2009). Postgraduate fellowship education and training for nurses: The NET SMART
experience. Critical Care Nursing Clinics of North America, 21(4), 435-449.
doi:10.1016/j.ccell.2009.09.001

American Association of Colleges of Nursing. (2011). The essentials of master's

education in nursing. Retrieved from http://www.aacn.nche.edu/education-
resources/MastersEssentials11.pdf