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Is There a Nurse Practitioner in the House?

Monday June 4, 2001
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There is nothing like starting a shift with a bang. Unless the bang is a patient who has tried unsuccessfully to walk to the bathroom without assistance. Or a patient who greets you with a smile and a wave of her urinary catheter with the balloon still inflated. And keeping with Murphy's Law, all of the patients who are having difficulties have different attending physicians who have finished rounds and have left the building. Now what do you do?
Step One: Take a deep breath.
Step Two: Page the house officer.
While the second step is possible at a large teaching hospital with a residency program, at a smaller community hospital there may be no such person to call. That is not the case, however, at Greater Southeast Community Hospital in Washington, DC.
When someone places a call to the house officer at Greater Southeast, he or she may get a response from a nurse practitioner (NP). The hospital has a unique and innovative system composed of multidisciplinary teams - and headed by NPs - who provide coverage for the hospital 24 hours a day. Cathy Chapman, RN, MSN, CS, FNP, CEN, who serves as the managing director for the team, likens it to "in-house triage." Team members in addition to the NPs include physicians, residents, and physician's assistants.
The diversity of the group of practitioners enhances the program. "The camaraderie and collegiality is like nothing I've ever seen," says Chapman. Care and coverage is seamless. Chapman says, "It's really something to see [the team] give a report and not be able to tell one from the next."
It's All in the Approach
At Greater Southeast, the NP carries out the same functions as a traditional house officer. If Michelle Melenwick, RN, FNP-C, is on call when you page the house officer, there is a chance she was already on her way to the unit to do a history, physical, or admitting orders for a new patient. She could also be doing a transfer summary for a patient whose attending is tied up in surgery and whose ambulance is scheduled to arrive within the hour. With full prescribing privileges, she can adjust a pain medication or order a diagnostic work up on the patient in respiratory distress.
The biggest difference between an NP and a traditional house officer is in the approach. For example, when Melenwick is writing a discharge summary for a patient diagnosed with HIV, she looks at more than the
patient's length of stay. Melenwick may not want the patient to have to wait for the attending to finish office hours, preferring to get the patient back into an environment where he or she is best able to function. Melenwick says her thoughts are on questions other than, "When is your ride coming to pick you up?" She also thinks:
"What's realistic for this patient?"
"Has the patient been on medications?"
"Is the patient taking the medications? If not, why not?"
"Is this patient's diagnosis a result of IV drug use? If so, is the patient getting treatment for it?"
"Is the patient a woman? If so, is she getting well woman care?"
"What are the needs of this patient? Are the needs being met?"
Lyn Hopkinson, RN, BSN, MSN, CFNP, describes this approach as an "extension of primary care." The Greater Southeast team handles the acute management of patients, but is also cognizant of what happens after discharge. "The whole team works to make sure the ball doesn't get dropped," Hopkinson says.
Chapman says the team works hard to get patients the most benefits from the unique system. "It's not whether I can write prescriptions, it's what happens afterward," she says, "That's where I make the difference."
One of Chapman's patients had untreated sickle cell anemia for 18 years. His underdeveloped body made him look like an 11-year old, and the challenges of inner city living made seeing a hematology specialist a low priority. When Chapman called to follow up with the patient's aunt - who had been raising him in addition to her six children - the aunt said, "You're the only person who has ever called or cared."
Staff and NP Collegiality
The Greater Southeast NPs offer an added advantage for staff nurses, as seconds seem like hours when you are waiting for something. Chapman says, "There is a certain degree of security that you have a resource. If a patient falls, the staff nurse knows that somebody is going to be there. The patient gets a full evaluation."
Melenwick adds, "It's anxiety producing for nurses to see something happening and not be able to do anything until they get orders."
The advantage of having been in the staff nurse role - and being able to make a difference - further enhances the NP's job satisfaction. "You have better insight into patient's feelings, emotional aspects, and the anxiety of being in the hospital. With the nursing culture, you are more aware of that and feel more comfortable attending to patient needs," says Melenwick. Hopkinson agreed, adding that the autonomy and access to more resources in-house to comprehensively manage patients make this advanced practice role rewarding.
The biggest challenge in this ever-evolving team has been to educate outsiders about the role of the NP as house officer. Chapman says all members of the team are "committed to enhancing education in a colleagial way." Some days, it may involve teaching a critical care course. Others may focus on familiarizing medical staff with the NPs' role and the benefits they have to offer as a "second pair of eyes" for the physicians.
Or, the NPs may do what nurses have been recommending for years - precepting medical students.