Primary Child Health Care by Family Nurse Practitioners

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Child Health

Care by Family



Robert A. Greenberg, M.D., Frank A. Loda, M.D., C. Glenn Pickard, M.D.,

Phoebe Collins, R.N., MPH., Betty S. Compton, R.N., Glenda 0. Hargraves, R.N.,

and Margaret J. Wilkman, R.N., M.P.H.

From the Departments of Pediatrics and Internal Medicine, School of Medicine and School of Nursing, University of North Carolina, Chapel Hill

ABSTRACT. This study analyzes the child health care role of four family nurse practitioners (FNPs) serving 990

fami-lies with 1,300 children in a rural clinic 30 miles from a

hospital base. In a 12-month program they were trained to give primary care, using standing orders, to all family

mem-bers. Respiratory infections, well child care, psychogenic

problems, allergic conditions and injuries comprised 75.5% of

pediatric cases. The FNPs managed 70.3% of all cases

with-out physician consultation. Respiratory infections, well child

care and gastrointestinal problems which comprised 57% of

all cases were managed with a combined consultation rate of 14.3%. The physician maintained primary responsibility for the management of 3% of all cases. Review of medical

records revealed that 93% of the cases were managed

properly by the FNPs. The positive experience reported in

this study indicates that the FNP role should be developed

as one method of providing primary health care. Pediatrics,




Desire to improve the quality, availability and

cost-effectiveness of health care has led to an

in-terest in utilizing nonphysicians to deliver primary health rvi2 The appropriateness of expanding the role of nurses in particular has been investigated

because the skills and goals of professional nursing

combined with the ability to diagnose and manage common health problems appear to give the nurse

unique advantages as a provider of comprehensive

primary ar4 Patient and physician attitudes

to-wards this new role have been generally positive.58

Poor distribution of primary care physicians has been recognized as an important element of the health care delivery problem in the United States.9 Rural areas in particular have had difficulty

re-cruiting and retaining physicians.10 The distribution of nurses who do not practice their profession, at least in North Carolina, makes it quite likely that

they would be more available than new physicians for rural areas.1’ The challenge of an expanded role

serving their own commuilty might stimulate

non-practicing nurses who comprise nearly half of the nurses in the United ta213 to return to health care delivery.

The concept of a single practitioner caring for all

family members, though becoming popular again

throughout the country, is a particularly strong

tra-dition in rural areas. In addition, it is difficult for small, isolated communities to support the number of specialized practitioners required to provide

pri-mary care. Therefore the role of a nurse practitioner who is prepared to provide health care to families and individuals of all ages would seem to be a logi-cal one to develop in a rural setting.

The collaboration between pediatricians and the

pediatric nurse practitioner in extending health

services to meet increasing demands has been widely publicized.8’ 1446 Although several training programs for family nurse practitioners have been

describedl7lB and some aspects of practices

an-alze32#{176} there have been no studies documenting the nature or extent of child care services that such a generalist can provide. The purpose of this paper is to describe the child health care role of four family nurse practitioners in a rural clinic.

(Received October 15; revision accepted for publication

December 26, 1973.)

The family nurse practitioner training program was supported

in part by contract 1-0-160-4401-ML092 with the National

Center for Health Services Research and Development. The

Prospect Hill Clinic was supported by grant 40405 from the

Office of Economic Opportunity to Orange-Chatham

Compre-hensive Health Services, Inc.

ADDRESS FOR REPRINTS: (R.A.G. ) Department of








1-OCTOBER 1, 1972


The FNP practice is located in Prospect Hill-a

crossroads in rural, piedmont North Carolina, 30

miles from the University of North Carolina School

of Medicine and the affiliated North Carolina

Me-morial Hospital. There had been no source of

medi-cal care within a ten-mile radius despite repeated

attempts by the community to recruit a physician

from 1959, when the last general practitioner in the

community died, until July 1971 when the clinic

opened. The clinic was established as a joint

en-deavor between a community-based corporation


Orange-Chatham Comprehensive Health Services,

Inc.) and the University of North Carolina with

fund-ing from the Office of Economic Opportunity (OEO).

The clinic staff is composed of family nurse

prac-titioners, physicians, community health workers and

supporting personnel. Each of the four family nurse

practitioners had been a registered nurse prior to

her nurse practitioner training. Three of the four

had had public health nursing experience and/or

training. Three had been residents of this area of

North Carolina for many years. One FNP had

served this community as a public health nurse

before leaving active practice.

The FNP training program consisted of six

months of instruction and clinical practice on a

full-time basis at the University of North Carolina

fol-lowed by a six-month preceptorship during which

almost all patients were seen by both an FNP and a physician. The curriculum is outlined in Table I.

During the next six months a physician was

avail-able in the clinic at all times for supervision. For

the ten months prior to and during the study period

described in this paper the same pediatrician



and internist




had each been

present 13 days a week to see patients referred by

the FNPs and to review and countersign all medical

records. One-half day a week an obstetrician

per-formed similar functions for the FNPs’ obstetrics

and gynecology practice.

The supporting personnel and the six community

health workers are residents of the community.

The community health workers work primarily

out-side the clinic and make home visits to provide

health education and nursing services, to make

socioeconomic and environmental assessments and

to facilitate access to social services.

Each family who registers in the clinic is assigned

to one FNP who assumes principal responsibility

for primary health care for all its members. The

FNP makes diagnoses on the basis of history and

physical examination, counsels patients and

pre-scribes treatment or makes referrals using

stand-ing orders.

Subject Duration

Phase I 1 Month

Improvement of Basic Nursing Skills

Appreciation of the FNP Role

Medical History Taking

Phase II 4 Months

Increasing Physical Examination Skills

Management of Common Health Problems

Management of Minor Trauma

Emergency Care

Basic Concepts in Infectious Diseases Growth and Development of Children

Family Dynamics as Related to the Health of

the Individual

Structure of Communities as Related to the Health of the Individual

Phase III 1 Month

Further Experience in Management of Patients

Appropriate for the FNP Role

Development of Knowledge and Skills in Areas

Selected by the FNP

Phase IV 6 Months

Clinical Preceptorship

The pediatric standing orders were developed by four faculty pediatricians and the first class of

family nurse practitioners. The orders for each

con-dition contain sections on definition, etiology, signs,

symptoms, complications, treatment, follow-up, and

referral. Information is as specific as possible con-cerning indications for medications, dosage, dura-tion of treatment and indications for physician

con-sultation. They are in loose-leaf form since revisions

are made frequently, based in part on their utility

for actual FNP practice.



Registere d Patients Average No. of

Visits per


No. %

<1 21 0.7 4.7

1-4 278 9.3 1.7

5-14 938 31.4 0.8

15-24 590 19.7 1.3

25-44 499 16.7 2.3

45-64 426 14.3 2.8

>65 235 7.9 3.6




Problem No. of Cases % of Total Cases No. of Cases Requiring


of Each Problem Category Requiring

(N= 270) Consultation Consultation

36.6 18.2

15.6 2 4.8

8.9 12 50.0

7.4 7 35.0

7.0 11 58.0

(10) (3) ( I) 5.2 5 (2) (2) (I) 35.7

13 4.8 2 15.4

9 (3) (2) (4) 3.3 8 (2) (2) (4) 88.8 5 ( 5) 1.9 1 (1) 20.0

25 9.3 14 56.0

270 100.0 80 29.6


Respiratory Infections

Upper Respiratory Infections Purulent Otitis Media


Serous Otitis Media Croup Cervical Adenitis Pneumonitis Well-Child Care Psychogenic Abdominal Pain Behavior/Emotional Encopresis Allergic Bronchial Asthma Atopic Dermatitis Urticaria Allergic Rhinitis Drug Eruption Desensitization Reaction

Injuries and Bites

Dermatologic (Nonallergic) Impetigo Furunculosis Tinea Versicolor Gastroenteritis Genitourinary Enuresis

Urinary Tract Infection Other


Iron Deficiency Anemia

Miscellaneous 99 (30) (29) (18) (16) ( 2) ( 2) ( 2) 42 24 (12) (11) ( 1) 20 ( 8) ( 6) ( 2) ( 2) ( I) ( 1) 19 14 18 (1) (9) (I) (2) (1) (2) (2) (6) (5) (1) (5) (0) (0) (0) (1) (I)

The FNP can consult the physician in person if

he is in the clinic or by telephone at any time. A

patient can be scheduled to see the physician at a

later time in the clinic or sent to North Carolina

Memorial Hospital where emergency and specialty

services are always available. Transportation to the

hospital and to the clinic is provided if necessary.

The clinic is open eight hours a day, five days a

week. An FNP is available by telephone evenings

and weekends.

Approximately 3,000 patients representing over

900 families and 1,300 children comprised the FNP

practice during the study period. The age

distribu-tion of the clinic population very closely

approxi-mated the entire community. Sixty-eight percent of

clinic patients were black compared to 50% of the

community. Fifty-six percent of the clinic families

had incomes below the Federal poverty level

com-pared to 60% of the entire community. Payment is

by fee for service with charges based on income.

The care of families who are below the poverty

level is subsibized completely by Federal funds.

Clinic utilization rates are shown in Table II.

Rates for the very young and the elderly were high

compared to other age groups. This was due in part




Consultation Pattern


No. %



No Consultation 190 70.3



Pediatrician Confirmation -i FNP 28 10.4

FNP Pediatrician Additional Management -p FNP 19 7.0

FNP ----p Emergency Room -‘ FNP 8 3.0

FNP Pediatrician Long-Term Management 8 3.0



Pediatrician -p Clinic or Hospital


17 6.3

Total 270 100.0

care providers to young infants and seriously ill

older adults in this medically deprived community. The rates in Table II do not include the active home

visiting program of the FNPs.

During the 12-week period between September

18 and December 11, 1972, the pediatrician’s usual

medical record review was expanded to include an

analysis of clinical problems seen and patterns of consultation. All pediatric visits were analyzed. For

the purposes of this analysis a case represents an

episode of care for a particular problem regardless

of the number of visits made. If more than one

problem was managed at a visit, the case was

classi-fled under the problem which primarily prompted

that visit. A consult was defined as any

communica-lion between a FNP and a physician concerning

the evaluation or management of a patient. The

FNP is expected to record in the medical record

all sources of information used in making decisions,

such as standing orders, telephone consultations or

physician consultations in the clinic. In addition,

the consulting pediatrician (R.A.G.


noted all FNP

consultations at the time they occurred.


The frequency with which various clinical

prob-lems of children were seen by the FNPs is shown in

Table III. This table also lists the frequency


consultations for #{149}the various patient problems. The

overall rate of consultation was 29.6%. The FNPs

were able to manage the common conditions

(res-piratory infections, well child care, and

gastrointes-final infections


with low rates of consultation.

These conditions, which comprised 57% of all cases,

had a combined consultation rate of only 14.3%. The

standing orders called for consultation in most cases

of genitourinary disease because of the relative

complexity of these problems. The relatively high

rate of consultation in the miscellaneous category

can be accounted for in part by problems not

coy-ered by standing orders or single cases of problems

rarely seen by the FNPs.

Table IV schematically depicts the consultation pattern and role of the consultant. The FNPs

man-aged 70.3% of the cases without consultation. In

10.4% of the cases the FNP requested a consultation which resulted in a confirmation of the evaluation

and management plan already outlined by the FNP.

These cases were returned to her for management.

In 7% of the cases the pediatrician provided addi-tional management. Following this, these patients were returned to the FNP for follow-up. The FNP found it necessary to refer 3% of the cases to the emergency room of the supporting hospital because the physician was not present in the clinic.

The pediatrician maintained primary responsi-bility for the management of 3% of all the cases. Two of these patients represented complicated medical problems and six were older boys with behavioral or emotional problems that the female



SEPTEMBER 18, l972-DEuBER 1 1, 1972


)fo. of


Overdosage of Pseudoephedrine 3

Overdosage of Oral Ampicillin 1

Overdosage of Oral Penicillin 1

Underdosage of Pseudoephedrine 2

Appropriate Medication but No Standing Order 2

Inadequate Description of Physical Findings 6

Indicated Immunization not Given 1

Elevated B.P. Recorded but Not Noted by FNP 1


FNPs felt would be managed better by the male


In 6.3% of the cases there was further referral by

the pediatrician to specialty clinics or for inpatient hospital care.

In 25% of the consultations the physician and

FNP felt that it was not necessary for the

physi-cian to see the patient after discussing the situation

in person or by telephone.

The consulting pediatrician





the FNPs’ clinical decision-making ability, the

com-pleteness of the medical record and the

appropri-ateness of therapy by the method of record review.

The standing orders and the pediatrician’s own

cr1-teria of good practice were used as standards.

Seventeen errors in management were discovered in

the 270 cases analyzed (Table V). In the other 93%

of the cases, management was considered proper.

Follow-up of appropriate cases revealed that no

patient morbidity was associated with the errors.

There was no significant difference between the

four FNPs in the number of cases seen or errors in

management. However, one FNP consulted

signifi-cantly less (p < 0.001


than the other three-16.1% of cases as opposed to the overall rate of 29.6%.


The decision to develop a family nurse practitioner

program at the University of North Carolina was

mo-tivated by more than just solving medical manpower

problems similar to those of Prospect Hill. Analyses

of primary care practices indicate that a more

appropriate assignment of patient care tasks

be-tween physicians and nurses might increase job

satisfaction for both professions and simultaneously

increase the number of patients for whom care can

be provided.8’ 2123 Also the quality of care rendered

might be improved by the specific nursing orienta-tion to patients. The practice of professional

nurs-ing is defined as “diagnosing and treatment of

human responses to actual or potential health

prob-lems through such services as case finding, health

teaching, health counseling, and provision of care

supportive to or restorative of life and well-being.”24

This orientation of nursing might make it possible

for the nurse practitioner to manage psychosocial problems, health education, nutritional counseling,

family and behavioral counseling and problems of

child development with greater emphasis and skill

than either a physician or another type of physician

expander. These areas are of high priority in

pri-mary child care and there is evidence that they do

not receive appropriate attention in a busy

physi-cian practice.25’ 26 However, as the nurse’s role

ex-pands and traditional physician responsibilities are

assumed, there is a risk that the nursing approach

may not be applied.27

It should be emphasized that the FNP both in

concept and in actual practice is not a second-rate

physician, but a health professional who can bring

unique qualities to patients. With this in mind, the

training program must be carefully tailored to meet

the expected demands of the FNPs’ practice. It was

a policy of the program for the FNPs to maintain

the nursing approach while adjusting to their new

role. A time-motion study of FNP activity done in

the spring of 1972 at Prospect Hill Clinic revealed

that although they were devoting 40% of their time

to activities for which physicians usually assume

responsibility such as history taking from a sick

patient and performing physical examinations, the

FNPs did continue to practice very important

corn-ponents of their traditional role such as counseling

and teaching.28 The opportunity to include home

visiting in their practice and to utilize the skills of

local community health workers further

strength-ened the role of the FNPs.

It is particularly helpful in rural areas to recruit

FNPs from the local community. Not only will they

tend to be more familiar with local mores and

health practices but also their long-term

commit-ment to the community may be stronger.

The decision to train and utilize family nurse

practitioners rather than pediatric nurse

practition-ers to provide child care was based on several

considerations. First, tradition in rural areas favors a single health care provider for all family members.

Second, specialized practice is less practical in

sparsely populated smaller communities. Third,

al-though not proven, it is possible that the

compre-hensiveness of the care offered individual patients

could be increased by someone familiar with the

problems of the entire family. Conversely there will

be pressure for the FNPs’ time from all age groups.

It is therefore important for the physicians working

with FNPs to be certain that adequate attention is

given to preventive medicine and well-child care

in training and actual practice.

Comparison of the problems seen by the FNPs

with published data from private pediatrician

prac-tices reveals that the leading diagnostic problems

are similar: respiratory infections, well child care,

psychogenic (including emotional and behavioral)

problems, allergic problems and injuries or

acci-dents.293’ The major difference is the relatively

small percentage


15.6%) of well-child-care cases

in the FNP practice in Prospect Hifi. Most pediatric

practices devote 35% to 50% of their activity to well

child care.2931 The reasons for the low frequency

of FNP well-child-care cases are based on the

necessity of setting priorities due to limitations of


em-phasis given the large number of untreated or

in-completely treated relatively sick patients in this

medically underserved area and teen-aged females

for sex education and birth control services. In

addition, there were only a small number of young

infants in the practice, a group given priority for

well child visits.

The FNP child care consultation rate (29.6%) is

comparable to that reported by one of the original

pediatric nurse practitioner programs in which 71%

of visits to an urban neighborhood child health

station were managed by the nurse alone.14 Such

comparisons, however, can be misleading without

considering the frequency of various patient

prob-lems. Well child care which was 15.6% of the

Prospect Hill FNP pediatric practice usually

corn-prises well over 50% of pediatric nurse practitioner

practices and rates of consultations for such visits

are very low in all tti15 In-service education

programs and more extensive standing orders

might lower the FNP consultation rate even further.

This would apply particularly to the management

of injuries, allergic disorders and psychogenic

dis-orders, problems which occur frequently and

pro-duced relatively high rates of consultation.

An experienced FNP can allow a physician to supervise the care of an increased number of

pa-tients or devote more time to an expanded role in

community child health. However, during the period

immediately following the formal FNP training, the

physician must be prepared to devote considerable

time to precepting. It is during this period that the

FNPs’ skills should increase considerably and the

physician develop and convey a respect for the FNP

as well as acquire a thorough appreciation of the

FNP’s level of competence and limitations. These

processes are enhanced by limiting the precepting and eventual supervision of the nurses to the

small-est number of physicians possible.

There have been several studies documenting

patient acceptance of an expanded role for nurses

as health care providers in pediatric and adult

78 14, 32, 33 We have not evaluated this

aspect of our program but there are several

indica-tions of the acceptance of the FNP in Prospect Hill.

1. Prior to the opening of the clinic, a community survey indicated the concept of a nurse practitioner

was acceptable.34

2. The proportion of middle-income patients

registered in the clinic matched their distribution

in the community. This group presumably could

purchase alternative health care services.

3. A physician consultation was requested by

pa-tients in only three out of the 270 pediatric cases.


This study analyzes child health care in the

fam-ily practice of four FNPs in an isolated rural clinic. With the aid of standing orders they were able to

independently manage over 70% of all pediatric cases.

Consultation rates were particularly low for the

common conditions-respiratory infections, well

child care and gastrointestinal infections.

By combining traditional nursing functions with

some of the activities for which physicians usually

assume responsibility, they acted as unique health

professionals caring for families and individuals of

all ages. The importance of the supportive role of

the physician supervisor is stressed.

While more extensive evaluation of the

effective-ness of the FNP is needed, the experience reported

in this study suggests that the basic concept of the

FNP is sound and deserves further development.


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We would like to express our appreciation to Ms. Betsy

Steel for technical assistance in analyzing the data and to




Glenda O. Hargraves and Margaret J. Wilkman

Robert A. Greenberg, Frank A. Loda, C. Glenn Pickard, Phoebe Collins, Betty S. Compton,

Primary Child Health Care by Family Nurse Practitioners


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