Advance Practice Nurses In Many Roles
Kathleen Holbrook, MS, ANP, and Thomas Edrick, MD, review a patient’s file in the Weiner Center for Preoperative Evaluation.
Attendees at a pre-operative care conference held last year heard about a “new approach” to assessing patients that involves a nurse practitioner who provides a complete pre-operative evaluation including a history and physical and risk and medication assessments. This approach saves the patient from having to make several appointments with different care providers.
“They were talking about a single provider model, and talking about it exactly as we do it at Brigham and Women’s Hospital,” said Patricia Kidik, RNCS, one of about 20 nurse practitioners in the Weiner Center for Preoperative Evaluation.
So Kidik and Kathleen Holbrook, RNCS, authored a paper that has been accepted for publication in the Journal of PeriAnesthesia Nursing. “Our model at BWH really is a benchmark for pre-operative care around the country,” Holbrook said.
Kidik, Holbrook and the team of NPs in the Weiner Center are among more than 200 nurses practicing in an expanded role at BWH. The Ostomy and Wound Care clinical nurse specialists provide care for inpatients and outpatients. Psychiatric advance practice nurses are building a program of psychological nursing care. Midwives have played a vital role in caring for patients in Obstetrics for decades, helping BWH achieve and maintain its status as Boston’s busiest birthing center. There are eight certified nurse anesthetists working in the OR, and just this year, BWH became a clinical site for nurse anesthetist students. And there are NPs in BWH health centers and several service lines, including cancer care, heart failure, and diabetes management.
The Peter Bent Brigham Hospital began to employ advanced practice nurses (APNs) in the early 1970s and was home to the Harvard-Brigham Nurse Practitioner program, according to Grace Tucker, who graduated from that first class. “It was the first certification program for nurse practitioners in Massachusetts,” said Tucker, who is now retired and living in Marblehead. The 10-month program, which was separate from the PBB School of Nursing, trained registered nurses to care for patients with long-term illnesses. In the late 1970s, the program was transitioned from the Brigham to Simmons College.
The first nurse practitioners in the United States were educated at the University of Colorado in a program begun in 1965 to provide cost-efficient, easily accessible primary care to persons in rural or underserved areas. State boards of nursing regulate all advance practice nurses (NPs, midwives, nurse anesthetists and clinical nurse specialists) through the individual state’s nurse practice act. All APNs now are required to have a master’s degree and advanced clinical training.
The expanded role for advance practice nurses includes advanced physical assessment, diagnosis and treatment. Some advance practice nurses have authority to prescribe medication, as well, and work closely with physician colleagues who provide medical supervision for this aspect of the expanded role.
NPs at BWH
The number of advance practice nurses at BWH is growing. Among the hospital’s 200 advance practice nurses, 150 are nurse practitioners located in more than 25 departments caring for patients in inpatient and outpatient clinics as well as in research programs.
At Brookside Community Health Center in Jamaica Plain, NPs deliver primary care to families, adults and children. And given the need for more primary care services created by the state’s new health care reform law, demand for NPs is likely to increase. “We have all these new patients who need a primary care provider,” said Beth Scanlan, NP, Brookside’s nurse manager. “I have patients who have seen a only a nurse practitioner during the last 30 years for their care.”
Ann Crowley, RNC, and patient Michael Hollick review his medications during his preoperative evaluation in the Weiner Center.
Nurse practitioners provide patient care that is comprehensive, high quality, efficient and effective. At Brookside, for example, Linda Foxworthy, NP, has developed expertise in diagnosing and treating skin problems. Rebecca Reed, NP, has a talent in connecting with and motivating adolescent patients. “She has a real skill, and all our NPs have unique skills that enable us to understand what matters to our patients and to provide a broad scope of care for them right here where they live,” Scanlan said.
The Diabetes Management Service utilizes a team of three NPs and three physicians to care for patients with diabetes in the hospital and in ambulatory clinics. “We are a responsive patient care team. We write orders for prescriptions, tests and labs and change meds when appropriate, so our patients receive prompt and effective treatment,” said Amy Jarry, NP. Nurse practitioners provide excellent care for patients with chronic conditions, she added. “As nurses, we focus on the needs and strengths of the particular patient; we try to understand what having diabetes means for him or her and how to support that patient to live well with a chronic disease,” she said. “And as nurse practitioners, we know about disease management, as well”
Mary Carr Reynolds became a nurse practitioner in 1992 after being precepted by an NP in the ED early in her career. As an NP, she worked in a preoperative clinic for a number of years, and in 2000, she was the first NP hired in Radiation Oncology. There are now three NPs in the department. “We see patients at initial consultation, perform the history and physical, present the patient to an attending physician and follow the patient during treatment,” she said. Rad-Onc NPs treat common side effects of radiation therapy by writing prescriptions for medications to treat nausea, and managing skin breakdown, pain and fatigue.
Jennifer Kales, NP, sees patients throughout the hospital as a member of the Palliative Care consult service as well as on the Intensive Palliative Care Unit. Kales’ role began with her arrival in January 2007, and in addition to following her own caseload of patients, she frequently makes recommendations to clinical nurses and physicians working together to alleviate pain and discomfort for hospitalized patients. “I enjoy the challenge and rewards of caring for patients while working collaboratively with every member of the care team, PCAs, OT, PT, physicians and staff nurses,” Kales said.
CRNAs
Ann Schwartz, manager of certified nurse anesthetists at BWH, started her nursing career as an RN in the OR at Massachusetts General Hospital where she was introduced to nurse anesthetist practice. Nurse anesthetists were the first nursing specialty group in the country; Sister Mary Bernard, a Catholic nun who practiced at St. Vincent’s Hospital in Erie, Penn., became the first nurse anesthetist in 1877.
Nurse anesthetists, or CRNAs, are nurse practitioners licensed to administer all types of anesthesia—general local and regional anesthesia—to patients in collaboration with surgery teams. Massachusetts law requires CRNAs to work under the overall direction of a qualified physician expert of the anesthesia care team, and Partners HealthCare requires that physician to be an anesthesiologist.
Just two years ago, when Schwartz joined BWH, there were two CRNAs at the hospital. Now there are eight CRNAs providing anesthesia to patients, and the hospital is actively recruiting more. And this year, BWH became a clinical practice site for student nurse anesthetists at Northeastern University.
Midwives
Midwives were introduced to the United States in 1925 in rural Kentucky when Mary Breckinridge launched the Frontier Nursing Service built on the nurse-midwifery model in place at the time in England and Scotland. After seeing dramatic reductions in maternal and infant mortality rates which resulted from care provided by midwives, Breckenridge opened the Frontier Graduate School of Midwifery in 1939. Massachusetts formally recognized midwives in 1977.
BWH midwives Alva Nash, CNM, and Nancy Curran, CNM, second and third from left, respectively, were present 30 years ago when Massachusetts lawmakers signed midwifery into law. In October, they celebrated the 30th anniversary with Cathy Moore, CNM, at left, and Ann Russell, CNM, far right, and many more from the Massachusetts Chapter of the American College of Nurse Midwives.
“We’ve been here at BWH and its predecessor hospitals since midwifery was legal,” said Miriam Mahler, CNM, who has been at BWH for 19 years.
Nurse midwives hold a master’s degree in nursing and complete a rigorous clinical training program. Midwives are practitioners with prescriptive authority who are specialists in normal pregnancy, childbirth and postpartum care for both the mother and baby. Midwives also serve as family practice care providers and can provide a full scope of care for women.
At BWH, there are nearly 40 midwives, including HVMA/Atrius midwives. They play a crucial role in caring for women of childbearing age, and they are involved in more than 2,000 childbirths each year.
“Sometimes patients are surprised there are so many midwives in an academic medical center,” said Mahler. Traditionally, midwives were commonly associated with home births or birthing centers. “Midwives at BWH play a critical role on the care team.”
Clinical Nurse Specialists
Clinical nurse specialists (CNS) are expert in the care of specific patient populations with complex needs. The dimensions of the CNS role may include expert clinician, consultant, leader, educator and researcher. Working closely with clinical nurses to improve practice and outcomes, for particular patients, the CNS focus is on improving care for populations of patients in their clinical specialty. Clinical nurse specialists hold a master’s degree in nursing which includes a concentration of study in the particular specialty practice. Expert in patient assessment, identification, implementation and evaluation of nursing care, they provide expert teaching and consultation to nursing staff, and may provide education to patients and families.
Charged with providing leadership for developing a program of care to meet the ongoing psychological nursing care needs of patients and families and the consultation and coaching needs of nurses, program managers Monique Mitchell and Barbara Lakatos are psychiatric advance practice nurses working collaboratively with nurse leaders and the multidisciplinary teams on 7AB, 14ABCD and 15 ABCD. Through partnerships with leaders and staff on these pilot units, the program managers assess current care practices, resource requirements and learning needs of staff through bedside coaching and evaluation of patients with complex psychological needs. Nurses on the pilot units directly access the psychiatric nursing resource service when they are challenged around the psychological care and management of patients. The goal of this service is to improve psychological nursing care provided to patients and their families and the comfort level of caregivers. Program outcomes focus on improving safety and care through mental status assessment and the early recognition and intervention for patients at risk for delirium. Their research interests include delirium, alcohol withdrawal, depression and the psychological care and management of patients in the acute care setting.
Three clinical nurse specialists staff provide ostomy and wound care either directly to patients or through consultation to clinical nurses. “We collaborate with the entire team of care providers at BWH: surgeons, general medicine physicians, therapists, nutritionists, staff nurses,” said Ilene Fleischer MS, RN, CWOCN.
“We work very closely with clinical nurses to achieve the best possible outcomes for our patients with ostomies,” said Diane Bryant, MS, RN, CWOCN.
“As clinical nurse specialists, we care for ostomy patients throughout the entire process, from preoperative evaluation and site marking and during the inpatient stay and post-hospital care, with the goal of helping patients return to full and active lives,” said Mary Willis, MS, RN, CWOCN.
The ostomy and wound clinical nurse specialists care for about 200 patients each month in specialty practices of Gynecologic Oncology, Neonatology, Radiation Therapy, Emergency and General Medicine, General Surgery, Gastroenterology, Urology, and Colorectal surgery in both inpatient settings and in the outpatient Stoma Clinic. They also lead hospital-wide efforts to reduce pressure ulcers.