Objective and Concept Studied: The effectiveness and productivity of Primary Care NPs have been documented in many studies over the past three decades. However, the more recently introduced Acute Care NP role is still emerging and hence the track record of research based literature remains scant. The utilization of ACNPs has become a strong trend, particularly in cities such as New York that have historically relied on medical residents to perform the day to day operations in hospitals. The recent developments in New York that have increased the demand for ACNPs include the advent of health care finance reform in the late 1990s which brought graduate medical education under sharp scrutiny and resulting in a shrinking pool of housestaff. In addition, the dramatic change in the acuity of the in-patient population and the urgency to control length of stay suggested a need for profound changes in the delivery of care in acute care settings. This, coupled with the regulatory limits on the number of hours that residents can work and greater attention paid to the educational components of residency training, created conditions in which ACNPs could advance. Despite the demand for ACNPs, little empirical, data-based research is available to assess the daily activities of ACNPs as they pertain to workforce requirements of acute care facilities
Design and Method: With the input of NPs at two NYC health science centers and after a thorough review of the literature, a unique data collection tool was developed for NPs to log and describe their daily activities. Creating an instrument that could capture the complexity and diversity of activities performed by the ACNPs as well as a measure of the time spent on each activity was a critical objective for the research team. Twenty-six discrete activities were clustered around the five roles for NPs: direct care, indirect care, education, research and administration. Personal time, demographic, employment and educational data were also collected. Several open-ended questions were included to obtain qualitative data. After securing IRBA approval the survey was administered to all NPs at each institution yielding a total of 76 respondents in one institution and 51 in the other. This represented a response rate of 65 percent and 56 percent, respectively. This analysis, however, examines only the Acute Care NPs in each institution, with totals of 31 ACNPs from one and 25 from the other. The instrument proved to be quite reliable, with alpha reliability over .55. The alpha reliability for the direct care subscale was particularly strong at .86.
Findings: The findings reveal that ACNPs are found in a wide range of medical and surgical sub-specialties. With respect to the amount of time spent per week in specific activities, four categories comprise over half of the ACNPs efforts: (1) conducted H &P, examined, assessed, admitted patients, (2) developed a treatment plan, (3) monitored/followed up patients treatment plan, and (4) consulted/collaborated with physician. Three of these are components of direct care. Aside from participation in grand rounds and precepted a student, very little time was spent in activities related to education and research. Some differences exist between the two institutions, however, there was strong agreement in the ranking and amount of time spent in the main activities. These data strongly support the fact that ACNPs are performing many of the tasks previously associated with housestaff. More importantly, in addition to “medical tasks”, the ACNPs provide nursing care including discharge planning, case management, consulted with RNs or other health care professional, as well as educating/counseling patients and family members.
Conclusion and Implications: Acknowledging the contributions of ACNPs in New York’s hospitals is a critical step in establishing public recognition of the ACNPs in the health care delivery system nationwide. The experiences of New York’s hospitals are relevant to other cities struggling to provide effective and quality care in a managed care environment. From an institutional perspective, these data afford a mechanism for staffing, long-term planning and collaborative work with residents and physicians. Educational programs for ACNPs can benefit from a clear grasp of the current work expectation for these practitioners. The availability of an instrument that reliably measures the practice patterns of ACNPs provides institutions, as well as researchers and policy makers, the opportunity to examine workforce trends over time and among different institutions, thus establishing a data-driven repository for policy development on ACNPs.
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