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COMMENTARY |
Columbia University School of Nursing
New York, NY, 10032
The Committee on Pediatric Workforce published a policy statement in the February 2003 issue of Pediatrics that calls for high standards and clear accountability in the care of children.1 In a time when adequate care is threatened because of deteriorating economic resources and fragmented access, and when high-quality and optimal outcomes are increasingly sought by all patients, payors, and providers, a call for excellence is timely and appropriate. The proposed methods to achieve these worthy goals are, however, deeply flawed, particularly as concerns nurse practitioners.
Team approaches to pediatric care are fundamental to providing the seamless, comprehensive care required by children and their families. There may be no other group of individuals so in need of the broad scope of care that only a team of diverse specialists can provide. A child’s health needs change as he grows and experiences challenges to optimal well-being; illness and disease are only a small part of those challenges. Therefore, the disease specialist—the pediatrician—merits leadership of the team only when disease is the major concern. At other times, it may be the nurse practitioner or the psychologist or learning specialist who directs the team. And perhaps most important, it may sometimes be the parent.
The premise that all non-physician providers can be lumped together leads to several misinterpretations. Nurse practitioners are independently licensed and are distinctive in education and in scope of practice from other disciplines, including medicine. Whereas nursing and medicine have a great deal of overlap (diagnosis and treatment of initially undetected disease or ongoing care of chronic illness), nurse practitioners have additional intensive education in individual risk reduction and prevention strategies, health promotion, and health education, and they have significant supervised clinical training in community sites, schools, long-term care settings, and home care, as well as conventional hospital and office-based practices. In contrast, pediatric residency training focuses primarily on hospital care of acute and serious illnesses.
The American Academy of Pediatrics has long recommended that pediatricians include prevention, early detection, and management of behavioral, developmental, and social problems in the context of primary care.2–4 Although epidemiologic studies indicate that 13% to 20% of all children have an emotional or behavioral problem, many of these conditions remain undetected and undertreated, because they are underidentified, underdiagnosed, and underreferred in pediatric primary care.5–7 The risks and long-term consequences of the psychosocial morbidities are significant. Interventions for these complex and multifactorial problems require expertise that goes beyond the medical model of pediatric care. The coordination of care for children requires input and intervention from multiple sources and in multiple settings. This cannot easily be accomplished in the brief well care encounters of conventional primary care delivered by pediatricians. Children require a primary care provider who is experienced in and understands family dysfunction, developmental, behavioral and emotional problems, school stress, and inadequate nutrition. Nurse practitioners have developed an early warning system because of education and training in all of these aspects of care. Unless a child is experiencing life-threatening, unstable, or complex illness, the nurse practitioner may be the provider of choice for the pediatric team.
The authors of the policy statement are right to raise concerns about pediatricians’ increased liability when they assume supervisory oversight. Whereas pediatricians see more complex, life-threatening conditions, which raise their potential for bad outcomes, nurse practitioners generally practice at the gateway to care, often making decisions about subtle cues regarding the need for specialist interventions. Each group—physicians and nurse practitioners—faces its own unique challenges. Nurse practitioners are independently licensed and authorized to provide care within state regulations, and they are independently liable for their practice. Even in the 6 states where physician supervision is required, nurse practitioners cannot relinquish the responsibility inherent in their licensure. It would be folly to impose physician supervision where none is called for.
Nurse practitioners carry their own liability insurance. Their premiums, as for physicians, are based on malpractice experience of the specialty. Nurse practitioner premiums are only a fraction of the amount physicians in the same specialty must pay, and the difference is attributable to the much lower incidence of malpractice claims against nurse practitioners. With over 35 years of nurse practitioner practice—and those in pediatric primary care were the very first—there is no evidence of claims against nurse practitioners even approaching those of physicians. Malpractice insurance premiums are a valid national indicator of the potential harm that can accrue to patients from health care practitioners, and in every nurse practitioner/physician specialty the claims against nurse practitioners are tiny compared with those for physicians.
Contrary to the AAP policy statement, it is questionable that non-pediatric physicians are more qualified to care for children than pediatric nurse practitioners. Education for non-pediatric physicians is often limited to 1-month clerkships in pediatric medicine during the third year of medical school. The only non-pediatric physicians who usually have additional pediatric experience are those in family practice. However, their residency training encompasses <1 semester of pediatric care, and most of that occurs in the acute care setting. Pediatric nurse practitioners, by distinction, have 5 semesters of pediatric training, mostly in ambulatory settings.
Even within pediatric primary care, the pediatric nurse practitioner has value-added skills and a perspective different from a pediatrician’s. Conventional education for a pediatric nurse practitioner is 6 years—4 to earn the bachelor of science (with pediatric hospital and home care experiences and family and community and developmental psychology training), as well as 2 years of pediatric primary care. Increasingly, patients seek and need the skills that differentiate nurse practitioners from physicians. The increased prevalence of chronic illness in children requires family and community-based approaches, and prevention and education are crucial to good control. The number and vulnerability of the underserved are growing in crisis proportions, and nurse practitioners have served this population with distinction and excellence since the inception of the nurse practitioner role in 1965.8–10
The authors of the policy statement cite the serious inadequacy of pediatrician delivered care to these populations, showing that <40% can be served with today’s pediatrician resource. Nurse practitioners practicing independently can fill the gap—both geographically and numerically—when pediatric service access is inadequate. If nurse practitioners were limited to working under physician direction or within physician-led teams, pediatric patients would be denied full and open access to the quality care they need and want. And nurse practitioners do more than substitute for conventional care; they bring a style of engagement and patient empowerment that is particularly valuable in the advancement of self care and wellness. So important has been the nurse practitioner resource for the underserved that the federal government mandated that all state Medicaid programs must authorize pediatric nurse practitioners and family nurse practitioners for direct payment for primary care services.
Medicaid is not the only area where broad acceptance of nurse practitioners is evident. In the Balanced Budget Act of 1997, Medicare authorized direct payment to nurse practitioners for all Part B services in any site.
Commercial insurers also have recognized the value and quality of nurse practitioners as providers of primary care. Faculty nurse practitioners at Columbia University School of Nursing are included as full primary care providers in the same contracts Columbia physicians hold, and the fees are identical. The 36 nurse practitioners credentialed by the school of nursing and medical departments have admitting privileges to the medical center hospital and are valued colleagues of the Columbia physicians. There are no supervisory relationships, but teamwork is brilliantly apparent, including the relationships developed in pediatrics. Contrary to the citations in the American Academy of Pediatrics policy statements, these Columbia nurse practitioners were found to be equivalent to physicians in terms of outcomes and patient satisfaction in a randomized trial where the nurse practitioners were in independent, not supervised practice.11
The nursing community is in agreement with the American Academy of Pediatrics in their call for high standards, adequate education, and clear accountability. Columbia University School of Nursing is currently engaged in a national initiative to advance the formal training of nurse practitioners as they assume more independent and full scope practices. A clinical doctorate is long overdue for the nursing profession.
Columbia University School of Nursing was the first to require formal courses in genetics and evidence-based practice for all its nurse practitioner students. Pediatric medicine is changing its residency training to incorporate more developmental and behavioral aspects of pediatric care, but this concentration, along with the community and family focus, have been the core of pediatric nurse practitioner training for over 35 years; this educational training has provided a large and reliable professional resource for children and families. To negate that resource and suggest that the great majority of pediatricians carry out this broad scope of practice in a better way than nurse practitioners is contrary to fact.
Telemedicine is a tool we can all benefit from, but imposing it as a supervisory method when none is needed, or requiring a new level of physician oversight when nurse practitioners have a long history of unblemished excellence is wasteful and inappropriate. The literature speaks unequivocally about nurse practitioner competence; the children need us all.
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FOOTNOTES |
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Address correspondence to Mary O. Mundinger, DrPH, Columbia University School of Nursing, 630 W 168 St, Rm 139, New York, NY 10032. E-mail: mm44{at}columbia.edu
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This article has been cited by other articles:
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  S. A. Shipman, J. D. Lurie, and D. C. Goodman The General Pediatrician: Projecting Future Workforce Supply and Requirements Pediatrics, March 1, 2004; 113(3): 435 - 442. [Abstract] [Full Text] [PDF]
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