(Received November 27, 1968; revision accepted for publication February 11, 1969.) ADDRESS: (D.W.S.) Littleton Clinic, 1950 West Littleton Boulevard, Littieton, Colorado 80120.
62
THE
PEDIATRIC
NURSE
PRACTITIONER
IN
THE
OFFICE
OF
PEDIATRICIANS
IN
PRIVATE
PRACTICE
Donald W. Schiff, M.D., Charles H. Fraser, M.D., and Heather L. Walters, R.N., B.S.
From the Department of Pediatrics, University of Colorado School of Medicine, Denver
ABSTRACT. The experience of a two-man pedi-atric practice with a pediatric nurse practitioner indicates that this is an economically sound means
of partially relieving the immediate manpower short-age and of improving medical care to children. The pediatric nurse practitioner provides skill and com-petent services to patients and their parents which is well accepted by them. Having the pediatric
nurse practitioner in the office is an economic asset. She is a valuable associate in managing a variety of
day-to-day problems. Her presence has resulted in
an increase in the number of patients seen and an overall improvement of services provided.
Pediat-rics, 44:62, 1969, PEDIATRIC PRACTICE, HEALTH PROFESSIONALS, PEDIATRIC NURSE PRACTITIONER, HEALTH MANPOwER, OFFICE PRACTICE ECONOMICS.
T
HE medical profession, as well as thegeneral public, is becoming increas-ingly aware of the need for additional llealth workers to provide care to children. The growing population and the relative decrease in the number of physicians to serve this population have been well documented)’ It has been demonstrated
that a need for increased health services for children now exists and that the measures
(more Inedical schools, larger medical schools, and so forth) already instituted to correct an inadequate physician-to-child ratio probably will not be adequate in the future to meet the need for well trained personnel to provide more and better
pedi-atric service. A number of pioneer programs have been initiated to help fill this need for additional health care. The pediatric nurse practitioner program instituted by H. K. Silver and co-workers at the University of Colorado, and other programs reported by Stead,’ Lewis and Resnick,6 and Ford, Seacat, and Silver7 are in the forefront of this movement.
Pediatricians have followed with interest the progress of these programs and the as-sessment of the advantages and problems
associated with their implementation. This report presents the experience gained by two pediatricians and a pediatric nurse practitioner in providing a new and
aug-mented type of pediatric service in the
pri-vate practice of pediatrics.
METHOD
Preparation
of
the PediatricNurse Practitioner
The pediatric nurse practitioner is a graduate nurse with a baccalaureate degree who had received 4 months of intensive
theory and practice in pediatrics in Silver’s
pediatric nurse practitioner program at the
University of Colorado Medical Center.4’5
During this period she had improved her
interviewing techniques and had learned to
perform a complete physical examination,
including the basic skills of inspection,
pal-pation, percussion, and auscultation, as well as the use of such instruments as the stetho-scope and otoscope. Emphasis had been placed on increasing her understanding of various aspects of parent-child relation-ships, variations of growth patterns, physi-cal and psychosocial development, nutri-tional and cultural factors affecting health, and the acquisition of proficiency in coun-seling parents and children. She learned to assist in the management of healthy
chil-dren and those with a variety of acute and
chronic disorders and to evaluate hearing
defects, speech difficulties, visual
impair-ments, and various congenital and acquired
deformities.1b0
ARTICLES 63
The Pediatric Office
The pediatric office that the pediatric
nurse practitioner joined in June 1967 is a
private practice which is part of a multi-specialty group located in a middle-class suburb of Denver. There were two
pediatri-cians in the group; for the past 10 years
they had had a joint practice in which they
each had their own clientele but saw pa-tients interchangeably when necessary.
Introduction of Pediatric Nurse Practitioner to the Practice
Before the nurse joined the group, the
pediatricians held special meetings with the
pediatric nursing staff, the receptionist, and their medical colleagues to describe the
background and training of the nurse prac-titioner and her anticipated role in the
practice. Questions were encouraged.
Al-though some reservations were evidenced regarding the contemplated change, accep-tance was generally excellent.
To help patients become acquainted with
the nurse, a letter was mailed to the parents
of all current patients explaining the nurse’s
expanded role in the office and suggesting
that the nurse’s special training would be of benefit to them, particularly in the areas of newborn care, developmental evaluation,
and counseling. The pediatricians
intro-duced her to many patients in the office as
they came in for appointments and to
mothers in the hospital in the immediate postpartum period. For the latter group, spe-cial emphasis was placed on contacts with primiparous women. Appointments of well
children and those with a variety of prob-lems were encouraged, but the parents could
decide themselves whether they wanted to receive this service from the nurse. At first, tile receptionist was responsible for making
many of the initial well-child appointments
for the nurse; as calls came in for
appoint-ments for checkups, the receptionist briefly
described the nurse’s training and role, and
recommended an appointment with the nurse. The receptionist explained that the pediatrician would also see the child at the
end of the visit. The nurse became ac-quainted with other families by doing part of the preliminary work-up on patients scheduled to see the physicians and by
seeing patients who came into the office
without appointments.
Role Development
An appreciable proportion of the nurse practitioner’s time during the early weeks
in the office was spent in becoming
ac-quainted with the physicians’ criteria for evaluating specific conditions and in learn-ing how to manage a number of problems.
Although there were no major differences
between the material she had learned in
the training period at the medical center and the evaluative criteria and techniques of the pediatricians in the office, there were minor variations in the way the pediatri-cians managed such conditions as diarrhea, constipation, skin care and minor skin
rashes, introduction of various foods,
feed-ing problems, and certain other items that
harass and perplex mothers. Gradually, the
nurse practitioner became more proficient in taking a complete history, performing a
thorough physical examination, carrying out the developmental evaluation, and managing a patient in a manner consistent
with the methods used by the physicians. At first, every patient was checked thor-oughly by one of the physicians after the nurse had completed her examination. Soon
the physicians’ knowledge of her skill and
ability and their confidence in her
discern-ment and performance permitted them to
be quite selective in carrying out their
ex-amination and in counseling parents.
The principal activities of the pediatric
nurse practitioner in the office include: (1)
total work-up of the well child-boys
gener-ally are checked by her up to the age of 9
years, while some girls are seen through adolescence- (2) assisting in the evaluation of sick patients particularly during those
periods of the year when illnesses are more prevalent; (3) counseling of mothers,
hospi-64
tal;
(
4)
liaison with social workers and other paramedical personnel to facilitatepatient care; (5
)
taking selected telephonecalls from the parents and giving advice or
referring the call to the physician as
mdi-cated;
(
6)
performing and evaluatingde-velopmental screening tests and screening for abnormalities of hearing, vision, and
speech.
Types of Visits Managed
by thePediatric Nurse Practitioner
ROUTINE CHECKUP: In a routine, well-child checkup, the nurse introduces herself
as the pediatric nurse practitioner who will
perform the initial part of the examination of the child and explains that the physician will
carry out his portion of the work-up at the
end of the visit. At each visit, a number of
topics are reviewed, depending on the age of
the child and the questions that the mother
may have. For example, during a typical
checkup of a young infant, the nurse will
discuss feeding
(
the ingredients of thefor-mula; number, volume, and interval
be-tween feedings; acceptance; regurgitation),
solid foods (when and how to introduce,
va-riety), developmental milestones, bowel
and urinary patterns, play habits, sleep
pat-terns, mother’s feelings about the infant, re-lationship with siblings, father’s role in
care, recent illnesses, accident prevention,
immunizations (type, need, reactions,
man-agement), minor problems such as thumb
sucking, and any other items that may be
pertinent. Height, weight, and head
cir-cumference arc measured for all children when indicated. Vision is tested with the Snellen “E” chart or the Sloan letter chart for children over the age of 5 years and the Titmus Stereotests or the Cuibor Nearpoint
“E” chart for those below the age of 5
years. As part of a thorough assessment, the
nurse performs a developmental evaluation
using the Denver Developmental Screening
Test for children under 6 years. A complete physical examination is then carried out (including funduscopic and otoscopic
ex-amination and use of the stethoscope for appropriate regions of the body). Blood
pressure determination and urinalysis are included as routine procedures. Gross test-ing of hearing and localization of sounds is accomplished in infants by use of high and
low frequency noise makers. If further
au-dionietric testing is necessary, the child
may be referred elsewhere. Either the nurse
practitioner or one of the other nurses in
the office administers immunizing agents at the end of the visit.
After the nurse has completed the
exami-nation of the child and has discussed
perti-nent items with the parent, she reviews the
findings with the physician, who carries out
whatever part of the work-up he feels is in-dicated and evaluates and confirms the
nurse’s findings. He counsels the parent as indicated.
SICK-CHILD VISITS: Although most of the
patients seen by the nurse are well, she also sees an appreciable number of children with relatively mild illnesses. During these visits she concentrates on tile current illness, but she follows the previously described
work-UP whenever possible. Before the physician
sees the child, she may order certain
labora-tory tests such as blood count, urinalysis,
throat, stool or lesion cultures, transparent tape tests for pinworms, or smears for
monilia. More definitive laboratory studies, including roentgenograms, are ordered by the physician. After the physician has seen the child, confirmed the nurse’s assessment, and made a diagnosis, the pediatric nurse practitioner further explains the nature of
the illness and the therapy that has been
prescribed, and answers any questions that
the mother may still have.
POSTPARTUM VISITS TO THE HOSPITAL:
The pediatric nurse practitioner makes post-partum visits to the hospital to allow the
mother to ask questions and obtain advice about subjects that she may forget or ne-glect to bring to the attention of the pedia-trician. At this time the nurse also has the
ARTICLES 65
OTHER VISITS: Special visits limited to de-velopmental testing alone, or for counseling
of minor developmental problems are
occa-sionally made to the nurse. She may also meet with the families of children with dis-eases such as newly discovered diabetes to teach them various aspects of the disease and its care, or assist in teaching
environ-mental control to families whose children
have some type of allergic disorder.
RESULTS
Acceptance
by PatientsParents’ acceptance of the pediatric nurse practitioner has increased as the par-ents recognized that the nurse’s
examina-tions and the advice she gave quite consis-tently received the approbation of the physician.#{176} The parent’s confidence in the
nurse has been demonstrated by the fre-quency with which the mother has
sponta-neously dressed the child and been ready to
leave even before the pediatrician’s confir-matory checking of the nurse’s examination
has been performed, and by the increas-ingly larger number of appointments that are being made directly with the nurse. Less than 1% of patients have indicated that they preferred seeing one of the pedia-tricians alone rather than receiving joint
care from the pediatrician and the nurse practitioner.
Acceptance by the Staff
It was readily apparent that good work-ing relationships with other staff members
was essential to the success of the pediatric nurse practitioner in the office. Thus, the
o Two extensive surveys of the effectiveness and acceptance of combined care by pediatricians and pediatric nurse practitioners are now being completed and will be the subject of forthcoming reports.’’2 In one, an independent objective stir-vey of parent’s opinions showed that the care and services provided by nurse practitioners are found to be highly satisfactory to parents; in the other,
a high degree of competence of the nurse’s
per-formance was demonstrated by a review of joint
assessment of a large group of children who were
seen initially by a pediatric nurse practitioner and,
shortly thereafter, by a pediatrician.
manner in which the receptionist presented the nurse to parents who had not met her
previously influenced their acceptance of the nurse. The receptionist in this office has
played a major role in the nurse
practition-er’s success. Acceptance by the two full-time and one part-time trained and skillful graduate nurses, whose services are also
utilized in the office, was also important. Although the role of the nurse practitioner
is significantly different than that of the
other nurses, she was soon considered to be an integral member of “the team.” There has been a community of interest between all members of the staff; all have referred
patients to the nurse practitioner, and she in turn assists the others in performing their activities.
Office
Visits and FinancesHaving a pediatric nurse practitioner in
the office has had a significant effect on the number of patients seen in the office and on its finances. The nurse sees an average of
eight children per day; during periods of the year when the office load of patients is particularly heavy, she sees even more. The proportion of patients seen by her who are ill depends upon the season of the year and on the overall number of sick children seen in the office. This has varied from a high of 52% in February to a low of 9.5% in July.
Initially, the nurse performed prelimi-nary work-ups for the physicians, but saw relatively few patients who had specifically made appointments for her. Within a few months, the number of scheduled appoint-ments for the pediatric nurse practitioner
had increased appreciably; after being asso-ciated with the office for 1 year, appoint-ments with over 90% of her patients were
being made directly with her.
The addition of the nurse practitioner to the office staff has been associated with an 18.8% increase in the number of patient visits to the office as compared to the num-ber of patients previously seen by the two
pediatricians together.
The pediatric nurse practitioner receives
46% greater than the salary of other regis-tered nurses in the office. The nurse
practi-tioner’s added skills and increased responsi-bilities make this differential acceptable to the other employees.
An analysis of the added income brought into the office indicates that the gross
charges for all services rendered by the nurse practitioner during the past year have
been quite consistently around $1,400 per month
(
$16,800 per year). This hasoc-curred with essentially no increase in
over-head or space requirements. Patients are charged the same for visits to see both the nurse and the physician as they are charged for visits to see only the physician. Net
in-come from charges made for the nurse’s ser-vices exceeded the pediatric nurse practi-tioner’s salary by the fifth month of her association with the office. The physicians have not had to spend more time in the
office, despite the increase in the number of patients seen.
Time Spent on Visits
Initially, the nurse spent from 35 to 45 minutes on a well-child checkup, but this has now been shortened to an average of 30 minutes for this type of visit. However, she may spend even longer if the situation re-quires. There is a wide range in the time
spent by the physicians with the patients already seen by the nurse, but in most
in-stances this is 2 to 10 minutes, with an av-erage of just over 4 minutes. This compares with the previous average of approximately 14 minutes per child seen only by the phy-sician. The length of the physician’s portion
of the visit will depend on the findings re-ported to him by the nurse during a brief discussion outside the examining room, on the mother’s possible apprehension and need for reassurance, and on the physician’s
assessment of the problems that may be
present. Despite the significant decrease in
f Current representative fees in this office are: office visit-$6.0O; urinalysis-$3.00; DPT or triva-lent Sabin vaccine-$3.00 each; smallpox
vaccina-tion or Tine test-$2.00 each; measles
vaccine-$7.00; throat culture-$2.50.
the time that the physician spends with the patient, he is able to be more selective and concentrate on the more significant portions
of the examination, and thus he is able to provide more effective care. The parents, in turn, gain greater reassurance when
exami-nations by two health professionals are in
agreement.
COMMENT
When a patient is seen by both the phy-sician and a pediatric nurse practitioner, the mother has a greater opportunity to ask
questions and to discuss a variety of prob-lems that may have been bothering her.
Mothers frequently will discuss things with the nurse which they may have considered
to be too trivial to bring to the attention of the physician. When the nurse spends a rel-atively long and uninterrupted period of
time with the mother, the latter will fre-quently become quite communicative and participate in a much more meaningful dis-cussion. This, in turn, has resulted in earlier recognition and more effective nlanagement of behavior problems that are already
pres-ent or, in other instances, in the initiation of measures to prevent their development.
As associates of pediatricians in private practice, pediatric nurse practitioners can give almost complete well-child care, as well as participate in the care of the sick
child. Combined care by a physician and a nurse expands the traditional role of the nurse and results in a realignment of func-tions traditionally performed by physicians.
This allows both the physician and the
nurse to assume responsibility for those
as-pects of the patient’s needs that they can
perform most effectively. The nurse can
play a major role in the assessment and
management of many of the problems of
child health which occupy a large propor-tion of the professional time of most physi-cians in private practice, thus enabling him to administer more effective health care to a greater number of children and to apply his specialized knowledge to the more com-plex medical and developmental problems
pa-ARTICLES 67
tient first and makes an initial assessment of any problems that may exist, the physician can then serve as a consultant to his own
patients. The nurse’s thorough physical ex-amination lays emphasis on the
differentia-tion of normal from abnormal findings. This
allows the physician to focus on those items
in the work-up which are most pertinent and relevant to the problem at hand and
leads to more efficient and effective use of the time and skills of both the physician
and nurse.
Acceptance of the pediatric nurse practi-tioner has been remarkably good. Response
from physicians, parents, and paramedical
personnel has been favorable. Many
fami-lies are pleased, not only with the skill and
thoroughness of the nurse but also with the
fact that the pediatrician has more time to
discuss meaningful problems with them.
In order for the nurse to be successful in
expanding her role so as to include
func-tions which were formerly within the realm
of the physician, it is necessary for the
phy-sician to demonstrate his active support of
this method of providing health care. The physician must also be willing to serve as a
teacher and counselor to the nurse and to recognize her increased knowledge and
skill in dealing with the child, the family, and the community; then he can be com-fortable in transferring some of his
func-tions and responsibilities to her.
SPECULATION
Our nation needs to adopt new methods of utilizing available health manpower to meet the health care requirements of the child population. One way to do this would be for more pediatricians to develop an as-sociation with a pediatric nurse practitioner which would allow the physicians to
pro-vide effective, high-quality, comprehensive care to a greater number of patients.
Hope-fully, many of these new patients will be children from low-income families who have been receiving health care from
county hospitals, neighborhood health
clin-ics, well-baby clinics, and other public health facilities rather than from physicians
in their private offices where the best
health care for ambulatory children is now
being provided. To facilitate the provision of even better health services to this seg-ment of the child population, the nurse
practitioner will need extra training and ex-perience in those specific areas which in-crease her understanding in dealing with their special needs and problems. The
pedi-atric nurse practitioners in private offices could act as catalysts in bringing together the private and public sectors of health care, and in establishing more effective
liai-son between physicians and public health agencies.
The pediatric nurse practitioner can play
an important role in providing an
appreci-able part of the health care to children. Sil-ver’3 has shown that pediatric nurse
practi-tioners by themselves can provide effective,
comprehensive care to more than three fourths of all patients who are brought to an urban neighborhood health station where a
physician was present only one-half day each
week. Silver suggested that the training and utilization of 20 nurses a year for a period of
5
years at each of 100 pediatric centers, agoal that is readily attainable, would result in a 20% increase in the total quantity of health care available for children. We
recom-mend that more pediatricians consider taking a pediatric nurse practitioner or other allied health professional into their practices. We
expect that many pediatricians would be
willing to do so if such health professionals
were available, since a recent survey by the American Academy of Pediatrics of the uti-lization of allied health workers showed
that four out of five pediatricians felt that
greater use of allied health workers would improve the quality and/or quantity of health care.14
SUMMARY
nurse practitioner to be a highly satisfac-tory professional solution to their problem. The pediatric nurse practitioner provides
skilled and competent services to patients and their parents. Having her in the office
is an economic asset. She is a valuable as-sociate in managing day-to-day problems, she is well accepted by parents and office
staff, and her presence has increased the
number of patients seen and has resulted in an overall improvement of services provided.
REFERENCES
1. Physicians for a Growing America. Report of
the Surgeon General’s Consultant Group on
Medical Education. U.S. Public Health Ser-vice Publication No. 709. Washington, D.C.: U.S. Government Printing Office, 1959.
2. United States Labor Department: Manpower
Report of the President and Report on Man-power Requirements, Resources, Utilization
and Training by Department of Labor
Transmitted by Congress, 1963 (Publication
No. 0676922). Washington, D.C.: U.S.
Gov-ernment Printing Office, 1963.
3. Christopherson, E. H.: Pediatric projections. Presented at the Annual Meeting, American
Medical Association, June27, 1966.
4. Silver, H. K., Ford, L. C., and Day, L. R.:
The pediatric nurse practitioner program. J.A.M.A., 204:298, 1968.
5. Stead, E. A.: The Duke plan for, physician’s assistants. Med. Times, 95:40, 1967. 6. Lewis, C. E., and Resnik, B. A: Nurse clinics
and progressive ambulatory patient care.
New Eng. J. Med., 277:1236, 1967.
7. Ford, P. A., Seacat, M. S., and Silver, G. A.:
The relative roles of the public health nurse
and the physician in prenatal and infant su-pervision. Amer. J. Pub. Health, 56:1097, 1966.
8. Silver, H. K., Ford, L. C., and Stearly, S.: A program to increase health care to children: The pediatric nurse practitioner program.
PEDIATRICS, 39:756, 1967.
9. Stearly, S., Noordenbos, A., and Crouch, V.:
Pediatric nurse practitioner. Amer. J. Nurs., 67:2083, 1967.
10. Ford, L. C., and Silver, H. K.: The expanded role of the nurse in child care. Nurs. Out-look, 15:43, 1967.
11. Day, L. R., Egli, R., and Silver, H. K.: Per-sonal communication.
12. Duncan, B. R., and Smith, A.: Personal com-munication.
