Primary
Child Health
Care by Family
Nurse
Practitioners
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,
53:900, 1974, NURSE PRACTITIONER, RURAL HEALTH CARE,
AMBULATORY PEDIATRICS, PHYSICIAN EXPANDERS, MEDICAL
MANPOwER.
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
TABLE I
FAMILY NURSE PRACTITIONER CURRICULUM,
UNIVERSITY OF NORTH CAROLINA
TABLE II
REGISTERED PATIENTS AND CueIc UTILIZATION RAits
BY AGE, PROSPECT HILL CLINIC, OCTOBER 1, 197
1-OCTOBER 1, 1972
DESCRIPTION OF CLINIC, PATIENT POPULATION, AND STUDY METHODS
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
(R.A.G.
)
and internist(
C.G.P.)
had each beenpresent 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.
Age
(yr)
Registere d Patients Average No. of
Visits per
Ps-reur
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
FREQUENCY OF ALL CASES AND OF CASES REQUIRING CONSULTATION BY PROBLEM, FAMILY Nuasx PRACTITIONER
CHILD CARE PRACTICE, PROSPECT HILL CLINIC, SEPTEMBER 18, 1972-DECEMBER 1 1, 1972
Problem No. of Cases % of Total Cases No. of Cases Requiring
a/;
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
TABLE III
Respiratory Infections
Upper Respiratory Infections Purulent Otitis Media
Pharyngitis
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
Hematologic
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
TABLE IV
FREQUENCY OF Ci.sas BY CONSULTATION PATrERN, FAMILY Nuas PRACTITIONER CHILD CAER PRACTICE, PROSPECT HILL CLINIC, SEPTEMBER 18, l972-DEcMBER 1 1, 1972
Consultation Pattern
Cases
No. %
FNP
-‘
No Consultation 190 70.3FNP
-‘
Pediatrician Confirmation -i FNP 28 10.4FNP Pediatrician Additional Management -p FNP 19 7.0
FNP ----p Emergency Room -‘ FNP 8 3.0
FNP Pediatrician Long-Term Management 8 3.0
FNP
‘
Specialty
Pediatrician -p Clinic or Hospital
Admission
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 FNPconsultations at the time they occurred.
RESULTS
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
of
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
TABLE V
ERRORS IN MANAGEMENT, FAMILY Nuas PRACTITIONER CHILD CARE PRACTIcE, PROSPECT HILL CLINIC,
SEPTEMBER 18, l972-DEuBER 1 1, 1972
Error
)fo. of
Cases
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
pediatrician.
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
(
RAG.)
analyzedthe 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%.DISCUSSION
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 casesin 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.
SUMMARY
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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ACKNOWLEDGMENT
We would like to express our appreciation to Ms. Betsy
Steel for technical assistance in analyzing the data and to
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