Is There a Nurse Practitioner in the House?
By Scott Fields, Photos by Marissa Roth
Published Apr 1, 2013 8:00 AM
More and more, a visit to the doctor means a meeting with a nurse practitioner. These hybrid health-care providers are becoming increasingly common—and increasingly critical—as the medical industry braces for the consequences of the Affordable Health Care Act.
Afflicted with pulmonary arterial hypertension and having great trouble breathing, Carol Volckmann was unable to get much help from the physicians near her home in the Cascade Mountains in Washington State. Desperate, she began consulting physicians elsewhere and ultimately chose UCLA pulmonologist Dr. Rajan Saggar.
Volckmann says the result was "excellent care," as well as a new and vital member of her health-care team: Kathy McCloy M.S.N. '96, one of 160 nurse practitioners (NPs) spread across the UCLA Health System.
"Dr. Saggar prescribed very aggressive medication for my treatment. Then Kathy came in and spent a lot of time with me and my husband, making us feel comfortable," explains Volckmann, who speaks with Mc-Cloy regularly from Washington. "This could all be very scary, but we don't feel scared because we know she's right there for us."
Hundreds of miles south and a world away at the UCLA School of Nursing Health Center at the Union Rescue Mission in downtown Los Angeles, nurse practitioner Hannah Bampton M.S.N. '11 spends Wednesday nights on the women's and family floor, where the homeless families stay.
"I'm available all night for families that need to be seen for anything," she says. "By doing that, we've decreased the number of unnecessary urgent-care visits. Someone might call 911 if there was no one there, but with a night nurse there, the kid doesn't need to go to an ER, because I'm going to help him here. I'm physically there with them."
McCloy and Bampton are a new breed of healthcare provider that figures to play a pivotal role in health-care reform in this country. Increasingly, it is a nurse practitioner that patients see when they go to their doctor's office. They visit them at the Minute Clinic at CVS stores and in the hospital. In fact, more than 600 million visits are made to the nation's 155,000 nurse practitioners every year.
Those visits are going to skyrocket as 35 million new patients enter the system in the next few years via the Affordable Health Care Act. At the UCLA School of Nursing, this vital new front in health care is taking shape.
The "Physician Extenders"
McCloy, a nurse practitioner at UCLA for 16 years who calls herself a "physician extender," says that her schedule enables closer patient follow-up leading to improved outcomes. "The patient receives more advanced care in between visits with the doctor," she says.
Like most nurse practitioners, McCloy is a registered nurse who returned to graduate school for advanced practice training in comprehensive health assessments, ordering and interpreting diagnostic tests, using differential diagnosis to reach a medical diagnosis, ordering a plan of care and evaluating outcomes related to the plan of care.
After receiving a Nurse Practitioner Certificate, new NPs begin performing standardized procedures as defined by the California Nursing Practice Act that include taking health histories, reviewing systems, conducting physical examinations, formulating medical diagnoses, creating plans for care, furnishing medications and devices, and ordering therapeutic modalities. They are also certified to do invasive procedures, such as the placement of a central venous catheter.
"The program really builds on your experience as a nurse," says Carla Caraccio M.S.N. '11, who has been working as a nurse practitioner in the Cardiothoracicm Surgery ICU at the Ronald Reagan UCLA Medical Center since graduating from the UCLA School of Nursing NP program in 2011. "It painted a bigger picture of the medical field and opened my eyes to research. And even though I'd worked in the operating room off and on for 13 years, I didn't realize all the amazing things that are done in surgery."
"When I first tried to get approval to have NPs act in this expanded role, we met with a great deal of skepticism" from the panel of physicians, says Dr. Cynthia Barrett, chair of UCLA's Allied Health Professionals Committee, who first brought NPs into the system in 1980. "But now there is none." As for the nurses: "There was some questioning from the RNs, but within six months, they were fully enthusiastic," Barrett explains.
It's still a new kind of health-care provider, though, and challenges still remain for NPs, particularly in training. Dr. Mary Marfisee M.P.H. '08, medical director at the Union Rescue Mission, doesn't believe that training is always adequate.
"They throw the NPs out in the workforce as soon as they've graduated, and they have to make all these decisions," she says. "I'd like to see more nurse practitioner residencies."
Marfisee also believes that the performance level of new NPs often depends on how much time they've previously spent in nursing. Concurs Caraccio, "We have a lot of nurses who have gone back for NP programs after just a couple years of nursing, and I'm not sure how they are doing it. I don't think it's enough."
Abigail Striblea, an NP at the Union Rescue Mission, adds, "I felt like I had all the necessary tools when I graduated, but just like anyone who graduates, there's always the sense of ‘I don't know it all.' When I started working, I really put all that knowledge into practice and used those tools to intensify my experience. The other thing that I enjoy that I didn't consider initially was the academic experience of mentoring—precepting other nurse practitioner students. This is very important to all NPs because there is a great need for clinical preceptors. We have NP students who come from UCLA as part of their clinical training, and we do some interdisciplinary activities and teachings [and] the NP students and medical students are able to work together."
Sharing a Huge Burden
Still, by all accounts nurse practitioners are taking a huge load off physicians in an overburdened national health system. They are also filling gaps created by a reduction in the number of primary-care physicians, as well as by the national cap placed on hours per week worked by hospital residents.
"Nurse practitioners in the NICU provide a stable workforce of competent professionals," explains Heidi Crooks, UCLA chief nursing officer and senior associate director of operations and patient-care services. "It's a significant improvement over residents rotating in and out every few weeks."
NP Lora Johnstone, a 13-year veteran of the NICU, says, "We function like pediatric residents, but the difference is there's continuity with us. We're able to build strong relationships with the parents, where we can all work as a team together."
This view is echoed across the UCLA system. "NPs are stepped in nursing, and nurses are nurturers," says Courtney Lyder, dean of the UCLA School of Nursing and an accomplished nurse practitioner himself. "Physicians want to manage the interesting and challenging stuff. NPs thrive on treating chronic conditions."
But the relationship is, in practice, a working partnership. In the neurotrauma intensive care unit at the Ronald Reagan UCLA Medical Center, nurse practitioner Carl Wherry spends just about every morning rounding with Dr. Paul Vespa, the unit's attending neurointensivist physician. "I bring input from a nursing perspective to raise concerns from the nursing end, and to ensure that the order and plans developed can be easily translated by nursing staff," says Wherry.
Wherry cites a trend where NPs are getting doctorates in nursing, a result of an effort by nurses to convince state legislatures to allow advanced-practice nurses to function more autonomously by raising the entry requirements. "I'm planning to go back to school in the next few years," Wherry says. "I‘d like to bring new research methodologies and quality assurance to my role."
Tomorrow's Health Begins Today
"Nurse practitioners are truly the answer to healthcare reform," says Lyder, who, in addition to referencing the lower cost of employing NPs over doctors, also cites studies showing that NPs are just as effective, or more effective, than physicians in 80 percent of all primary-care procedures.
"We can't have 35 million more patients on the backs of the physicians," he says. "If we are to look at how to employ people to keep the population healthier, it will be to hire nurse practitioners and other health specialists—dietitians, nutritionists, psychologists. The key is not to provide less care, but to provide the right care at the right time. Then the cold doesn't turn into pneumonia, then you decrease costs to the system."
To meet the needs of the Affordable Health Care Act, the UCLA School of Nursing is increasing class size in many specialties. Other nursing schools across the country are doing the same, and in some states where the nurse practitioner role is more limited than in California, the Institute of Medicine of the National Academies is recommending that legislation be passed to enable NPs to practice within the realm of their knowledge base.
Because we're going to need all the NPs we can get. "The model hasn't been written yet," Lyder says about the outcome of the looming changes in American health care. "This is all new territory. We can either put our head in the sand, or chart our own destiny."