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Why Hospital Staffing Models Need to Change to Utilize NPs and PAs

Posted on October 2, 2017   |   by   |   Advanced Practice Structure, Employers, Job Seekers, Leadership Skills APPs

Is your healthcare organization maximizing the potential offered by Nurse Practitioners (NPs) and Physician Assistants (PAs)? Carmel A. McComiskey, CRNP, Director of Nurse Practitioners for the University of Maryland Medical Center, shares her insights.

In today’s healthcare environment, hospital leadership is challenged to improve patient outcomes, boost productivity and increase staff retention. A big key to reaching these goals is having effective staffing models that utilize Nurse Practitioners (NPs) and Physician Assistants (PAs) to the fullest extent of their scope of practice and training.

If you look at most hospital staffing models, there are usually people in different roles doing the same job. It is highly inefficient to have a resident, a nurse practitioner, and an attending physician managing the same patient, but that’s often what happens. As leaders, we need to find ways to use staff at all levels more appropriately.

Hospital Staffing: Common Mistakes Lead to Inefficiency and Staff Turnover

There are two common scenarios I frequently see in which Advanced Practice Providers (APPs) are utilized below their scope of practice.

First is the model in which a physician group hires an NP to assist with teamwork. Because they haven’t really given adequate thought to everything the nurse practitioner could do, NPs are assigned the role of the care coordinator—and quickly become frustrated.

Early in my own role as a nurse practitioner, I did a lot of work that could be done by a nurse. Part of that was my choice because I was working for a small practice without a nurse. But it eventually became a bone of contention for me because I couldn’t expand my role to do more complex patient management. In my current role as Director of Nurse Practitioners, I am very sympathetic to NPs who feel they are working below their capabilities.

The other scenario involves hospitals where unit-based leadership has decided that integrating NPs or PAs will assist with regulatory requirements, medication reconciliation, and restraint ordering. Unfortunately, these duties don’t reflect the full capabilities of the APP.

If NPs or PAs do not feel empowered to make crucial decisions, advance the care of patients, and work independently, they’ll quickly become disheartened.

Defining the Organizational Role of the Advanced Practice Provider

When thinking about the need for an NP or PA, consider the following questions: Is this a job that could be done by a registered nurse or a scribe? Or, is this a job that requires the specialized training and knowledge that is within the advanced practice provider scope?

The generalized scope of practice for NPs and PAs includes patient assessment, history, physical examination, laboratory assessment, differential diagnosis, treatment, prescription, follow-up care, care coordination, and consultation organization. So, if the role requires that level of knowledge, skill, and ability, then you can argue that it should be performed by an NP or PA.

Generally speaking, Advanced Practice Providers are not satisfied serving as scribes, putting orders in, and handling medication reconciliation and paperwork. If they don’t have the opportunity to be physically involved in examining patients, and developing and executing treatment plans, they will look for an environment where their skills are recognized.

That’s why it’s crucial to have physician colleagues who understand the needs of APPs and how to effectively develop an NP/PA model. I know a critical care ICU Unit Director who is very open about how his initial NP/PA model failed at another organization, resulting in costly turnover. Now, he has become a “physician champion” at the table, helping to move the organization in a way that utilizes NP and PAs effectively.

Hospital Staffing: Top Two Strategies for Adding NPs or PAs to the Healthcare Team

There are some key steps to successfully adding nurse practitioners and physician assistants to a hospital team.

First, understand the novice-to-expert trajectory of the nurse practitioner and physician assistant. New NP and PA graduates don’t have the level of experience necessary to independently take care of highly complex, critically ill patients in their first year of practice. To avoid overwhelming new NPs and PAs, and disappointing physicians, we need solid orientation and onboarding programs for novice providers. We also need to provide close support and mentoring until they get to a place, usually around 18 months, where they are confident in their abilities. That’s when you’ll really see a difference.

Second, we must ensure that an NP or PA’s skills, ability, and education are aligned correctly with their position and patient population. For example, hospital leadership should prevent the type of situation where a family nurse practitioner is hired to work in a critical care setting that is completely unrelated to his or her training.

Frequent variability between hospital bylaws and NP/PA scope of practice laws also require our attention. When full practice authority was granted in Maryland, I had a frank conversation with our system CMOs. As an organization, we had to recognize that the state board of nursing would no longer be restricting what our NPs were authorized to do, so our hospital bylaws needed to reflect that.

These are important discussions that need to happen with our physician colleagues, credentialing offices, and medical staff offices.

Flexibility: The Key to Satisfaction for Physicians, Advanced Practice Providers, and Patients

It’s easy to see the difference in healthcare settings where NPs and PAs are utilized effectively. But, success doesn’t happen overnight.

The incredible evolution in the NP role has occurred over the last 50 years, beginning with primary care settings in rural areas. In today’s hospitals and academic environments, we are still in the early stages of effectively modeling complex inter-professional teams.

In the organization where I am privileged to work, there is still some trial and error. We frequently find ourselves saying, “this didn’t work well,” and “this person might not have been the right fit,” or “this job wasn’t right.” So, my final point is that as leaders, and as organizations, we have to be adaptable. If anyone had told me I would become more flexible as I got older, I wouldn’t have believed it. But over my career, I’ve learned to do it, so I know others can too.

To maximize the effectiveness of the Advanced Practice Provider role, we must be people who are willing to identify what works, remember what works, and continually learn how to work better together.


About Carmel A. McComiskey, DNP, CRNP, FAANP, FAAN

Carmel is the Director of Nurse Practitioners at University of Maryland Medical Center and holds faculty appointments as Assistant Professor at the University of Maryland School of Nursing and Instructor at the University of Maryland School of Medicine. She is the co-chair of the Graduate Education and Practice Committee of the UM Nursing partnership.

Carmel is a Pediatric Nurse Practitioner at University of Maryland Medical Center, Division of Pediatric Surgery and Urology, where she began in 1981 as a nurse coordinator before becoming an NP in 1996, centering her specialty care around managing children with intestinal failure and long-term bowel and bladder problems. In 2007, she initiated an NP-managed Center for Bowel and Bladder Management, which sees patients with both daytime and nocturnal enuresis and/or encopresis. 

In addition to serving on numerous committees, teams and councils at UMMC, Carmel is also a member of many professional committees and organizations including Sigma Theta Tau International, American Academy of Nurse Practitioners, Nurse Practitioner Association of Maryland, National Association of Pediatric Nurse Associates and Practitioners, and the American Pediatric Surgical Nurses’ Association, an organization where she is a charter member, served on its Board of Directors for many years and served as president from 1999-2000 and was the recipient of the APSNA Founder’s award in 2007. Most recently she worked with the ANA to revise the scope and standards of Pediatric nurses and APNs.

Carmel’s clinical interests include voiding dysfunction and pediatric obesity and pediatric bariatric treatment. She served as the co-investigator on a Phase 3 clinical trial of tolterodine and is currently evaluating the efficacy of the treatment of voiding dysfunction.  She has given many professional presentations and published articles in many journals. She is an editor of Nursing Care of the Pediatric Surgical Patient and served as the Associate Editor of Bariatric Nursing and Surgical Patient Care from 2010-2013.

Carmel is involved with community service through her work on the St. Mark Pastoral Council and the Parent Advisory Council at the John Carroll School. She was the recent keynote speaker at the American Association of University Women- Harford Association’s Educational Foundation Awards Luncheon “Judith Resnick Mathematics/Science Awards”.

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