ever gain some power in nursing schools, the
pic-ture will change.
ECONOMICS
Then there’s the buck. Bolstered by a new prac-lice law, nurses in the state of Washington are seeking Medicare and Medicaid reimbursement as independent practitioners. If nurses can indeed perform some of the same tasks as well as physi-cians, it is doubtful that they will continue to tol-erate earning one third to one half as much in-come. A struggle for patients and dollars, couched, of course, in more “respectable” terms, appears inevitable. Whether the ardor of nurses for greater independence is dampened when they experience 24-hour on-call responsibility and malpractice liability remains to be seen.
WHAT’S
LEFT FOR THE
PEDIATRICIAN?
So what’s left for the pediatrician?
Hospital-based
subspecialists
are here
to stay,
but
in finite
quantities. The number of neonatal intensive-care units or cardiac catheterization labs required to serve a region is not difficult to calculate. (Would that training program’ directors used their slide rules
before
advertising
for fellows.)
How
about
the
plain
old baby
doctor
with
no
gimmicks? Skilled pediatricians with active prac-tices shouldn’t worry. My wife and I prize the care given our children by their pediatrician; I’m certain most American families concur.
Storm clouds, however, loom on the horizon. The pediatric internship at the University of Washington is one of the most competitive in the
country, yet only six of our current twelve now
plan
to
remain
in
pediatrics.
Admittedly,
this
year’s attrition might be a quirk, but more talk is heard from younger practitioners about “jumping ship.”
DISSONANCE
BETWEEN
TRAINING
AND NEEDS
The
tragic
irony
is that
while
pediatricians
are
groping, there are important unmet child health needs to which their unique talents could be ap-plied. Why can’t the talent and needs connect? Look no further than our residency programs.
Maghadam states: “While it is recognized that
child health care requires special knowledge and skill, it is equally well known that special skills of pediatricians as acquired in present training, are largely superfluous for the day to day
needs
of the
great majority of “
He
further says thatpediatric trainees are rarely, if at all, exposed to “health care of handicapped children outside of
hospitals, health problems of school aged chil-dren, particularly learning disorders,
the effect
of
physical,
social
andeducational
environment
on a
child’s
health
and,
conversely,
the
effect
of
a
child’s
health
problems
on his education.”2
Pless,
in a recent
paper
that
is must
reading
for all
con-cerned
with
the
future of primary pediatrics,ex-plores
alternatives
in greater
detail.3
We have
over
650 children
withcerebral
palsy
under
care
at
our hospital; none of our pediatric house staff are involved with any of them. I know veryfew
pediatric
faculties
are
doing
anything about the disparity between training andchild-health
needs.
I have
the
awfulfeeling
that
most
of
them
have
their
heads
in the sand
and aren’t
even
talking
about
the
issue.
A final
point.
Even
in the
event
that
programs
were
to turn
out
appropriately
trained
primary
pediatricians, they would not be viable given the
present
“procedure-oriented”
fee
structure
in
medicine. Quality pediatric care involves
spend-ing more
time
withfewer
children
in need
of
spe-cial
skills.
Rather
than
tests
and
shots,
fees
must
reflect
the
pediatrician’s
most
valuable
asset,
time.
There
is plenty
of room
on pediatric
turf
for a
variety
of breeds
devoted
to the
health
of
chil-dren.
Unless
some
vigorous
modifications
of
train-ing programs
take
place,
pediatricians
will not
re-main
among
them.
ABRAHAM
B.
BERGMAN,M.D.
Director,
Outpatient
Services
Children’s
Orthopedic
Hospital
and
Medical
Center
Associate
Professor
of Pediatrics
and
Health
Ser-vices, University
of Washington
P.O. Box 5371
Seattle, Washington
98105
REFERENCES
1. McAtee, P. A., and Silver H. K.: Nurse practitioners for
children-past and future. Pediatrics, 54:578, 1974.
2. Moghadam, H.: The rare and plentiful-a dilemma in pediatric manpower. Can. Med. Assoc.
J.,
110:497-498, 1974.3. Pless, I. B.: The changing face of primary pediatrics. Pe-diatr. Clin. North Am., 21:223-244, 1974.
One
nurse’s
view
of pediatric
nurse
practitioners
COMMENTARIES 535 framework for this commentary on the article,
“Nurse Practitioners for Children-Past and
Fu-ture” by McAtee and Silver.1 My earlier
associa-tion with Silver as a co-director of the first pediat-nc nurse practitioner project at the University of Colorado makes these comments, hopefully, like
conversations and challenges between colleagues. My remarks address those issues concerned with establishing priorities in the preparation of teach-er-practitioners, the development of
interdiscipli-nary collaboration, the need for studies of effec-tiveness of nurse practitioners, and an opinion on the recommendation to prepare “assistant nurse practitioners.”
PRIORITIES
IN PREPARING
TEACHER-PRACTITIONERSAfter a hectic decade of increasing health
man-power production, an oversupply of physicians, nurses, and dentists is predicted.2 Albeit manpow-er predictions are hazardous because the assump-tions, data base, and future changes are multicom-plex, it is known that in certain kinds of services, e.g., primary care, shortages and maldistribution of manpower persist; quality and deployment, not quantity of personnel alone, now demand our at-tention. In nursing, commonly reported deficits are in well-prepared nurse clinicians, teachers, and researchers. This raises the question of at-tempting (as suggested by McAtee and Silver) to incorporate the nurse practitioner philosophy and competencies at the baccalaureate level without first preparing the current and future teachers of nursing. The mass preparation of teachers of nurs-ing to function as practitioners and the antici-pated curriculum adaptations will require more extensive considerations than suggested by Mc-Atee and Silver. The service settings used for din-ical teaching-including those on academic health centers-will require complete reorganiza-tion from bureaucratic to professional modes of operation. High ratios of students to faculty in nursing education programs, the exorbitant num-ber of student contact hours per week, the lack of
nurse faculty involvement in practice, the dearth
of qualified nurse colleagues in service settings, the schisms between nursing and medical educa-tion, and the minimal financial support enjoyed by nursing schools complicate the suggestion-plausible as it seems-to introduce nurse practi-tioner competencies at the baccalaureate level. (I agree in principle but not in priority, except in unusual circumstances where there are commit-ments for the unification of nursing service and education, for the preparation of nurse practition-ers, for the advancement of nursing through
re-search, for faculty/clinician practice patterns, and for nurse/physician collegiality in delivering health care-including primary care.)
CONCERN
FOR INTERDISCIPLINARY
EDUCATION
AND PRACTICE
McAtee and Silver make little mention of the importance of interdisciplinary and interpro-fessional education and practice. It would be disastrous to the future of health care if nurse faculty members were prepared to teach as prac-titioners without developing continuous collegial relationships with
medical
school
faculty
to the
benefit of both faculties, their student groups, and the students’ eventual functioning as health-team members. Interdependent collaboration should be an educational goal for students in all the health professions. Students need to have experiences with interdisciplinary faculty and team practice models and to learn to cope effectively and effi-ciently in dynamic role relationships.
To accomplish
such
a goal,
changes
in the
cur-ricula of both nursing and medical schools will be required. During the past decades, many nursing school curricula have changed radically using in-tegrated, health-oriented, holistic, person-, fami-ly-, and community-centered care approaches. The basic framework of many baccalaureate cur-ricula is conducive to the nurse contributing to the health maintenance of defined population groups throughout the life span. It is particularly timely that these changes will allow future nurses in baccalaureate programs to function effectively in primary care. Additional competencies, such as those in the practitioner model, are very possible. Indeed, some schools have begun the process of integration. However, physicians, too, should be educated in the delivery of primary care. Why prepare nurses for new roles in isolation from medical colleagues? The nurse practitioner model
is complementary to and not competitive with the medical models. Promoting the integrity and uniqueness of each discipline should strengthen each professional group and promote interdepen-dent relationships, not isolationism.
THE ISSUE OF CERTIFICATION
McAtee and Silver mention, only in passing, the crucial issue of certffication. A profession’s
right to control its own destiny in practice is
para-mount to its continuing growth and development.
The recent schisms developing between two pro-fessional organizations (the ANA and the AAP) over the certification of pediatric nurse practi-tioners have alerted thoughtful nurses throughout the land to the dangers inherent in any
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ments which control the practice of one profes-sion that is not mutually and equally shared for the control of team practice. The quality of prac-tice must be scrutinized continuously-and if team practice is a way of life, then nurses ought to be involved in the certification of the medical
group!
NEED FOR EVALUATIVE
RESEARCH
The descriptive findings of studies in the 1960s, some of which are reported by McAtee and Silver, should now advance to include sophisticated evaluative designs to study impacts on patient out-comes, such as those recently reported by Spitzer
et al.,3 Storms,4 and Lewis.5 The difficult questions
about the impact of nurse practitioners on the quality of care and the measurement of that care in the health status of patients remain unan-swered. (These questions, by the way, have not been answered adequately by any professional group; however, the questions must be raised.) Costs, too, should be examined. Cost analysis and cost-benefit study techniques should be applied to the preparation and practice for new health man-power roles. It is doubtful that the matter of com-petency of the nurse practitioner will be an issue; the next question is whether or not society is will-ing and able to pay for high-quality comprehen-sive
health
care. Data are pertinent to the deci-sion-making of educators, legislators, and granting agencies if any full-scale movement to prepare nurse practitioners is contemplated. I have no doubt that the cost of preparation of nurse practi-tioners would prove to be a wise investment if so-ciety is committed to comprehensive health care. However, adequate funding noted by McAtee and Silver must be provided for high-quality educa-tional programs and reimbursement mechanisms for services rendered by nurse practitioners must be provided through health insurance plans. In-formal estimates of the cost of preparing nurse practitioners in continuing education programs indicate that this type of preparation is expensive ($4,000 to $5,000 per student). Further, health in-surance benefits must allow for reimbursement mechanisms for the services of the nurse practi-tioners.ASSISTANT
NURSE PRACTITIONERS
HISTORY
REVISITED
The suggestion by McAtee and Silver to use the least well-prepared people in the occupation of nursing to function relatively independently as “assistant nurse practitioners” to meet the needs of many medically deprived rural and urban areas raises serious questions about the rights of all our
population to comprehensive health care, the
po-tential hazards to maintaining quality of service rendered, and concerns for the continuous career development of those individuals providing the care. Perpetuating a chronic problem in the occu-pation of nursing in preparing people in many diverse (and often divisive) educational patterns without adequate planning controls of quantity or
quality does not serve the consumer, the
individu-al provider, or the professional group. The least
qualified persons in any field should be working in
highly structured and supervised arenas of prac-tice. (Public Health nurses found in the early 1900s that advanced education was necessary to function in relatively independent practice set-tings.) Professionals who know the scope and
na-ture of the field must be involved and ultimately responsible for the delivery of high-quality
health
care. The argument that “no medical care can be delivered because doctors won’t go out to the boondocks” prompts me to ask, “Why send assist-ant nurse practitioners or others who are less
qual-ified to provide medical care?” or, “What makes the authors think that nurses (including LPNs and others) will be any more willing than the physi-cian to be isolated and unsupported?” Consider, however, the potential that a well-prepared nurse
who is a
health
practitioner and a medical practi-tioner, articulated within a system of health care, have to offer as a team. Perhaps, the answer to maldistribution lies in a combination of efforts in-cluding making the consumer himself more corn-petent, able, and willing to assume responsibility for his health, using Applications Technology Sat-ellites (ATS-6) (New York Times, May 24, 1974) to provide voice and picture communication to medical resources for care of individuals and group health teaching, and offering specialized benefits identified by providers to be of value to them in accepting hardship posts.In umrnary, this commentary challenges Mc-Atee and Silver to consider more expansively priorities for the preparation of teacher-practi-tioners, the importance of interdisciplinary colla-boration, the issue of certification, the need for evaluative research, and serious unresolved prob-lems of delivering comprehensive health care. Hopefully, health professionals addressing these issues together can influence the direction of the nation’s health manpower policy.
LORETrA C. Foiw, R.N., Ed.D.
Dean
School of Nursing University of Rochester
260 Critteriden Boulevard
COMMENTARIES 537
REFERENCES
1. McAtee, P. A., and Silver, H. K.: Nurse practitioners for children-past and future. Pediatrics, 54:578, 1974. 2. Edwards, C. C.: A candid look at health manpower
problems. J. Med. Educ., 49: 19, 1974.
3. Spitzer, W. 0., et al.: The Burlington randomized trial of the nurse practitioner. New Eng. J. Med., 209:251, 1974.
4. Storms, D. M.: Training of the Nurse Practitioner: A
Clinical and Statistical Analysis. North Haven, Con-necticut: Connecticut Health Services Research
Se-ties No. 4, 1973.
5. Lewis, M. A.: Child initiated care. Am. J. Nurs., 74:652, 1974.
Why
Another
Growth
Chart?
The paper by Duncan and colleagues in a
pre-vious issue’ presents growth charts based on an
earlier report by McCammon2 which summarized measurements collected by the Denver Child Re-search Council since 1933. Any “new” growth charts should have compelling advantages over those already in common use.3’4 Such advantages might reflect the nature and size of the sample, the up-to-date character of the sample, and artis-tic or novel features of the charts themselves.
It is only in the latter category that the Denver charts seem to have succeeded. That is, weight, height, and head circumference measurements are depicted graphically for two age intervals on one sheet of paper. In order to achieve some sep-aration between percentiles, a logarithmic scale was used for the first 24 months of life. Yet the charts are still so compressed vertically that Un-less considerable caution and small dots are used in recording measurements, an accurate measure in length may be depicted 1 or 2 cm in error.
In the case of the Denver charts, no more than
95
children (boys and girls) were represented at any point in time during :he first eight years, andthereafter the numbers ( . ‘eased progressively to
between 40 and 50 sub . s at age 18 years. At
best, it is a questionable .ctice to derive the 3rd and 97th percentiles wh&’ . i.he number of subjects
is so small. McCammon was content with 10th and 90th percentiles.2 The use of such a small sample may attenuate the variance, especially when the same children representing a relatively narrow socioeconomic range are measured at suc-cessive ages. The loss of either end of the distribu-tion, or of both ends, will result in underestima-tions of height and weight variability for clinical
work since it is the extremes which are of greatest interest to the clinician. If a large number of inch-viduals were represented in the sample, the 3rd and 97th percentiles (more so for height than for weight), would closely approximate 2 below and above the mean respectively. However, one can-not “legitimately” calculate percentiles from the means and .
The trend lines (50th percentile or median) of the Colorado charts do compare favorably with those from other longitudinal studies conducted during the same era,3’4 although, at least for boys, they are slightly below those in the Fels longitudi-nal data from Southwestern Ohio.5 They are also below the more recently and cross-sectionally de-rived Kaiser-Permanente data6’7 and Health Ex-amination Survey data.8 These observations suggest that more recent information on Denver children may be more useful for locally applica-ble charts.
Duncan et al. noted that their charts may not be ideal for use in assessing Mexican-Americans
(
or native Americans or blacks) in their communi-ty. While genetic differences in maximal growth potential may not be large,9bo it may be inferred from recent studies involving large numbers of children that if socioeconomic variables were more similar for the general population, differ-ence, e.g., between blacks and whites, might be greater and be evident at earlier ages than are now detected.68’11’12The ideal situation, probably unachievable, would be if incremental growthl314 and body size of children of different skin colors, races, or ethnic groups in the United States could be evaluated in relation to reference data based on measurements of appropriate numbers of socioeconomically favored children of the same background.’5 In-ter-marriage and genetic pooling obviously corn-promise the potential usefulness of skin-color- or racial- or ethnic-specffic reference data.
We reiterate that growth charts based on large numbers of children who are randomly selected from well-designed cross-sectional samples in re-cent years are accurately measured and repre-sented only once in the data will be more useful than those derived from longitudinal studies.8,16 With a data base numbered in the thousands and with socioeconomic distributions defined, the
op-portunity is available to design far more useful
“new” growth charts.
GEORGE M. OWEN, M.D.
Department of Pediatrics
University of New Mexico School
of Medicine
Albuquerque, New Mexico 87131
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1974;54;534
Pediatrics
Loretta C. Ford
One nurse's view of pediatric nurse practitioners
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