So this is just a thought... like many potential great ideas...
But just imagine a new advanced practice speciality, a bedside clinician acting as a registered nurse AND a nurse practitioner, the "Bedside Nurse Practitioner." They would be practicing in the ICU/stepdown units, taking care of very high risk complication patients. They would stay with the patients for 12hrs (regular shift) and will be able to assess, diagnose, treat and prescribe medications/treatments while at the bedside.
I know it's a far fetch idea (now)... but very interesting nonetheless. Thoughts?
Just what we need - another type of provider title at the bedside. We have UAPs, CNAs, LPNs/LVNs, RNs (with and without the BSN). And then we have all those clinical ladder titles...
It would just splinter us more and cause more confusion for the pts and general public.
And I see money as an issue also as others have posted.
Again, these are BOLD ideas for nursing (just like the APRN ideas 50 years ago). This idea came to mind when I'm I was working at the bedside one night and I needed a simple order for decreasing fluids and a breathing treatment. After 3 calls, I was not getting a reply and it was a bit annoying. The patient wasn't in distress or anything but I thought at that time wouldn't it be something if I were able to prescribe at the bedside.
This role I'm putting out there (however bold it is) are combining two already established nursing scopes of practice. Registered nursing and to an extent , advanced nursing as well, is at times seen as dependent on medicine. I know, know, we are an autonomous profession (blah blah blah) but I feel like why not push the role expansion even farther?
As far as oversight, there would still be a Nurse Practitioner available for collaboration PRESENT on the floor (as opposed to an MD or DO).
And of course I don't expect this to happen overnight. This kind of expansion may take decades (even generations) to become reality.
If the nurse practitioner will be available for collaboration, then why have one at the bedside? Couldn't a RN call the NP and ask?
Again, these are BOLD ideas for nursing (just like the APRN ideas 50 years ago). This idea came to mind when I'm I was working at the bedside one night and I needed a simple order for decreasing fluids and a breathing treatment. After 3 calls, I was not getting a reply and it was a bit annoying. The patient wasn't in distress or anything but I thought at that time wouldn't it be something if I were able to prescribe at the bedside.
This role I'm putting out there (however bold it is) are combining two already established nursing scopes of practice. Registered nursing and to an extent , advanced nursing as well, is at times seen as dependent on medicine. I know, know, we are an autonomous profession (blah blah blah) but I feel like why not push the role expansion even farther?
As far as oversight, there would still be a Nurse Practitioner available for collaboration PRESENT on the floor (as opposed to an MD or DO).
And of course I don't expect this to happen overnight. This kind of expansion may take decades (even generations) to become reality.
I'll speak strictly about the ICU since that was the original problem (if you have a patient in step down that needs one on one NP care then you have a different problem).
First look at your problem mentioned above. You need an order for fluid titration and neb. Not sure why you would need to urgently need to decrease fluids unless the patient is volume overloaded (then that should be addressed). My question in an ICU is why are you making calls? In your system above there is an NP present for "collaboration". Why can't that person place the order? What it sound like you need is a provider present in the unit to place orders. Thats what we do.
As far as one on one NP care, it neglects the reality of ICU care. For a 20 bed unit we run as many as between 6 and 11 providers (MD, resident, PA and NP) during the day and 2-3 at night. If you can't find someone to give an order then you really aren't trying hard.
As far as one on one NP care, I fail to see what an NP can do that a good ICU nurse with reasonable PRN and communication orders is already doing. For that matter if you have a good relationship with the nurses, you will get proactive help when they know you will cover them. The end of my shift is usually 2-3 nurse coming with orders such as can you put in the 50 mcg of Fentanyl I gave.
The other corollary is giving parameters that allow nurses to do their job. For example our order sets have titration parameters for vasoactives. In sepsis I will frequently put in a communication order "for MAP
From a legal standpoint nursing salaries are submitted on the hospitals Medicare part A reimbursement report. NP charges are billed on Medicare part B. Hospitals are not allowed to bill for NP services on part A its called fraud.
From an operations standpoint the reality is a very ill patient usually requires close attention for an hour or two and then is relatively stable (what we refer to jokingly as stably critically ill). Once the patient is stabilized I would think that an NP would be underutilized (at least in our unit). In examining our billing data we occasionally have one patient that will get over 6 hours of critical care billing in one 13 hour shift but its a rare event (the record is 17 hours of billing in a 24 hour period).
Finally as a number of other people have commented on, blurring roles is never good. I frequently have to caution new grad NPs about stepping away from the bedside role. Its the nurse at the bedsides job and responsibility to titrate the gtts since its also their responsibility to chart (I also occasionally have to tell residents to stay away from the pumps). I'm happy to pull up a patient, hold them while we get them cleaned, get them a blanket etc. But the care of the patient rests with the nurse.
Fundamentally if you as a nurse are frustrated about not being able to get an order its either because there is not enough provider support or you aren't being given sufficient latitude to make nursing decisions. Thats what I would work on, not changing the person at the bedside.
I hear you on not being able to reach someone for a non-emergent order, but isn't that a different problem? Wouldn't it be easier to resolve that issue rather than create an entirely different position?
You have a systems problem. I'm all for creative problem solving, but changing roles in this instance is not the answer.
...and, IMHO, not bold-think about it....like Esme and others have stated blurred lines...I shudder the thought of RNs being kicked out of the bedside and NP salaries going down, as well as the work done for 50 years GONE.
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
As a Critical Care NP, the fastest way you can make me run like a bat out if hell from a position is if you ask me to not only be an ICU provider but also require me to ensure my hourly vital signs and I and O's are correctly documented, order meds and run to the Pyxis to grab them, scan my patient to administer them, suction my patient, write vent orders and call the RT, and make sure my patient is turned. That's just the run of the mill ICU patient. My head will explode if I have to do those things on a patient on CRRT and/or ECMO.
gettingbsn2msn, MSN, RN
610 Posts
And I called the hospitalist the other day to get an order for tylenol for a patient headache. I was told NO, GIVE a percocet, I already ordered that!