A
PROGRAM
TO
INCREASE
HEALTH
CARE
FOR
CHILDREN:
THE
PEDIATRIC
NURSE
PRACTITIONER
PROGRAM
Henry K. Silver, M.D., Loretta C. Ford, Ed.D., and Susan G. Steady, M.S.
From the Department of Pediatrics of the School of Medicine and the School of Nurs-ing, University of Colorado Medical Center, Denver
(Received October 18, accepted for publication December 21, 1966.)
Supported by a grant from the Commonwealth Fund, New York, with additional assistance from the
Research Committee of the University of Colorado Medical Center, the Denver Health Department
and the Huerfano-Las Animas Health Department.
Presented at the Thirty-fifth Annual \Ieeting of the American Academy of Pediatrics at Chicago, Illinois, October 24, 1966.
L.C.F. is Professor of Nursing, and S.G.S. is Clinical Assistant in Pediatrics, University of Colorado
School of Nursing.
ADDRESS: (H.K.S.) University of Colorado Medical Center 4200 East Ninth Avenue, Denver, Colorado 80220.
PEDIATHICS, Vol. 39, No. 5. MLIV 1967 756
T
HE INCREASE in population of theUnited States is occurring at a much
more rapid rate than the increase in
medi-cal and nursing personnel available to
maintain health services at an optimum
level. Unless the pattern of furnishing
health care, particularly to lower
socioeco-nomic groups in both urban and rural area,
is drastically improved, these groups will
suffer from increasingly inadequate health
supervision. This paper describes an educa-tional and training program in pediatrics for professional nurses (the “pediatric nurse
practitioner” program) which prepares
them to assume an expanded role in
pro-viding increased health care for children in areas where there are limited facilities for
such care.
METHODS
The pediatric nurse practitioner program
was developed under the combined
aus-pices of the Department of Pediatrics of the
School of Medicine and the School of
Nurs-ing of the University of Colorado. The
proj-ect is conducted in two phases. The first is
carried out at the University of Colorado
Medical Center in Denver where each
nurse receives approximately 4 months of
intensive theory and practice in pediatrics
under the direction of senior faculty
mem-bers of the schools of medicine and nursing.
The second phase of the nurses’ educational
program involves the application of the
nurses’ newly acquired knowledge and
skills in field offices in areas with many
resi-dents of low socioeconomic status who have
an obvious need for improved and
aug-mented health care.
During the initial phase at the \Iedical
Center, the program for pediatric nurse
practitioner trainees includes a variety of
educational experiences:
They are assigned to the regular
well-child clinic, the special clinic for low birth weight infants, and the newborn nurseries where they see patients in conjunction with
one of the project directors (H.K.S.) and
other members of the pediatric staff. Here, and in other clinics and teaching seminars, the project nurses focus on increasing their
knowledge and skills and learn improved
interviewing techniques appropriate for
their expanded roles and responsibilities, methods for obtaining significant
informa-tion necessary for optimum counseling of
parents in child-rearing practices, the
es-sentials of a complete basic physical
exam-ination, and techniques of assessing and
managing many minor problems of the
healthy child. In other seminars conducted
by the medical and nursing project
direc-tors and others, various aspects of
parent-child relationships, variations of growth
patterns, physical and psychosocial
(including breast feeding, the prescription
and modification of formulas, introduction
of solid foods, vitamin and other nutritional
requirements, etc.), and immunization
pro-cedures and schedules (including
modifica-tion of schedules in individualized
circum-stances) are reviewed.
The nurse practitioner trainees partici-pate actively in clinics and the emergency
room in the workup of both well and ill
children with a variety of acute and
chron-ic problems. They interview families,
per-form appropriate examinations, and
partici-pate in discussions regarding patient care.
They work with members of the pediatric
faculty and house staff in the evaluation
and management of children with a variety
of disorders including upper respiratory
in-fections, otitis media, croup, various skin eruptions, diarrhea, constipation, allergic
disorders, and the common contagious
dis-eases. The trainees learn how to obtain
var-ious specimens including diagnostic
cul-tures and to perform hemoglobin
deter-minations, white blood counts, and
urinal-yses. They also assist in the management
of a number of emergency situations,
in-eluding poisonings, accidents, hemorrhage,
apnea, etc. Competence is developed in
as-sessing the overall status of an ill child in
order to determine the acuteness and
sever-ity of disease so that a decision can be
made regarding the illnesses which can be
managed by the nurse and those which will
need immediate referral to a medical
facili-ty. Specific guidelines have been
estab-lished to assist them in judging when refer-ral to a physician is indicated.
The nurse trainees are assigned to the
Developmental Clinic where they are
trained to perform and evaluate a
develop-mental screening test for children and to
gain competence in assessing a child’s
at-tainments.
They participate in seminars and other
teaching exercises in the Adolescent Clinic
and in Child Psychiatry where various
as-pects of emotional and personality
develop-ment and their deviations from normal are
reviewed. Particular emphasis is placed on
understanding the effect of various social,
economic, and ethnic factors as they apply
to the families with whom they will be
working.
In the Mental Retardation Clinic and the
Pediatric Neurology Clinic they develop
skills in understanding and evaluating
var-ious types of mental retardation and
con-vulsive disorders and in counseling parents
of children with various neurologic and
emotional problems.
During their assignments at the Medical Center, the nurse trainees are taught to use
the otoscope and the stethoscope so that
definite decisions based on objective data
can be made. They evaluate hearing
de-fects, speech difficulties, visual impair-ments, and various congenital and acquired
orthopedic deformities. They also learn the
essentials of good dental care and methods
of evaluating dental problems. From a
nu-tritionist they receive additional
informa-tion regarding dietary needs, food
substitu-tions, and low-cost balanced diets.
The 4-month training period at the
Medi-cal Center is followed by a 20-month
pen-od of continued training in a community
setting where a large number of children
from low-income families reside. Here, the
pediatric nurse practitioners establish field
stations (called “Child Health Stations” or
“Pediatric Nursing Stations”). At the health stations the nurses have office hours daily,
make home visits, and participate in the
follow-up care of those of their patients
who had been referred to other health facil-ities. Well child conferences and immuniza-tion clinics are held at specified periods
when patients are seen by appointment.
Sick children are seen at any time that the
health stations are open.
The project nurses offer their services to selected families with well and ill children
who are referred by physicians, by the
ex-isting public personnel, by other agencies,
and by self-referral. Although the nurses’ major efforts are in the area of child care, total family-centered services are also
pro-vided in selected cases. Communication
758
so as to afford the patients optimum service
without overlapping or duplication. The
nurse practitioners function within the
scope of the Professional Nurse Practice
Act of the State of Colorado. Their roles are
sharply defined, and a careful review of
their activities by members of the State
Board of Nursing Examiners, various
medi-cal societies, as well as by the insurance carrier who underwrites their malpractice
insurance, has demonstrated that their
functions are entirely ethical and legal and
in the highest tradition of the nursing
profession. The nurses coordinate their
ser-vices with existing community resources,
including physicians who visit the health
stations, the local health department,
spe-cial programs of the state health
depart-ment, the school health program, Project
Head Start centers, and the after-care
pro-grams of various referral centers. The
pm-cipal focus of the pediatric nurse practition-ems is on direct patient care; they function
within established guidelines agreed upon
with local and state health department
staffs.
Sick children who have minor illnesses
(mild upper respiratory infections, mild
gastrointestinal disturbances, minor skin
eruptions, etc.) are cared for by the nurses
using a previously established plan of
man-agement. More severely ill patients are
me-ferred to a physician for immediate medical
care. Children with chronic illnesses or
those needing special diagnostic and
thera-peutic studies are referred to an
appmopmi-ate medical facility to be seen at a later
time. Nurses may refer patients to
coop-erating local physicians, to the regional
health officers or health department clinics,
to established special clinics (e.g., orthope-die, epilepsy, hearing, tuberculosis, etc.), to
specialists in various fields who visit the
health stations or health department clinics
as consultants to the project, and to various
consultation clinics of the Medical Center.
Some of the latter meet periodically near
the health stations themselves.
Throughout the entire program particular
emphasis has been placed on defining the
dimensions and limitations of the expanded role that the pediatric nurse practitioners
fill and in evaluating the feasibility and
practicality of the program of training and
its effectiveness in affecting the quality of
health came in the community. Frequent
communication is maintained with the
Medical Center which continues to provide
supervision, consultation, and support of
the activities of the nurses, as well as
con-tinuing the evaluation of the skills they have acquired.
Initially, nurses selected for the project
were required to have a master’s degree in
public health nursing, but, subsequently,
nurses have been accepted with only a
bac-calaureate degree. Previous experience in
public health nursing has been found to be of particular value.
Presently, trainees are being prepared to
enter pediatrician’s offices where they will
act as nurse practitioners and associates of
the physician.
COMMENT
The pediatric nurse practitioner program
herein described prepares the nurse to
fur-nish comprehensive well child care to chil-dren of all ages, to identify and appraise
acute and chronic conditions and refer
them to other facilities as indicated, and to
evaluate and temporarily manage
emergen-cy situations until medical assistance is
available. Project nurses increase their
knowledge and skills in assessing the
physi-cal and psychosocial development of well
children; study variations of growth
pat-tems; learn to perform developmental tests
and evaluative procedures, such as history
taking, basic physical examinations and a
limited number of laboratory procedures; cou.nsel parents in child-rearing practices;
and carry out immunizations.
The program encourages earlier
iden-tification of children with physical or
emo-tional problems so that the children can be
referred for appropriate treatment. The
nurses serve in medically-deprived
commu-nities where they are in a position to
su-ARTICLES 759
pervision of the health care available to
children from low income families. As a
result of their training and their proximity
to their patients, the nurse practitioners can
initiate and carry out augmented
preven-live health services, improve the rate of
im-munization, and increase child health
su-pervision.
Throughout the United States the need
for increased health care for children is
great. It has been pointed out that there
a!-ready exists a shortage of scientific
man-power including physicians,1 nurses,2 social
workers, and nutritionists,3 and it has been predicted that there will be an even greater
shortage in the future.’ In order to
maintain the 1960 ratio of physicians
to population in 1970, it would be
neces-sary to have a net growth of more than
50,000 doctors, about 20% of the 1960
sup-ply of 257,000. Since such an increase is
not likely to occur, every effort needs to be
made for the best possible use of those men
and women akeady trained and qualified in
scientific careers.#{176}
The demand for medical and nursing
su-pervision and care is so great that doctors
and nurses need to determine what their
functions and roles should be so as to
intro-duce effective programs to meet these
needs.’’ It is becoming increasingly clear that competent professional nurses working
cooperatively with physicians can make
greater contributions to overall patient
care. Nurses are already performing many
duties which not long ago were considered
strictly the responsibility of doctors, and
there is reason to believe that professional
nurses could and should make still more
de-cisions regarding health care as the rapidly
increasing complexity of patient care
evolves and ways are sought to improve the
utilization of the skills of all available
health personnel.8 Increasingly, nurses are
expected to perform specialized tasks and
use independent judgment in meeting their
responsibilities.9 In order to do this, nurses must receive adequate training to perform the duties required by their broadened role.
Lesser1#{176}has emphasized that the gaps in
child health supervision in the pre-school
years, the inadequacies in the quality and
quantity of medical care received by
chil-dren in many low income families, the need
for more effective methods of case finding,
and the special problems of the
handi-capped child all point to the need for new
approaches in providing adequate health
care. Assistance to medically-deprived
chil-dren must take on a more extensive and
imaginative approach than society general-ly has offered. This will require
experimen-tation in the most effective use of
physi-cians, public health nurses, and others;
pro-grams need to be developed and supported
to test the effectiveness of different meth-ods of identifying children with significant
health problems. Some efforts have been
made in this direction, but more research is
indicated. It is recognized that the pediatric
nurse practitioner program herein
de-scnibed tends to aggravate an already
cx-isting nursing shortage, but it is expected that further realignment of the functions and role relationships of other groups in the
health professions will permit a more
effec-tive utilization of personnel at all levels.
It is necessary for medical and nursing leadership to come together to integrate
their work in order to solve the problems of
current and future needs for adequate
health services and to elucidate the new
roles they each have to fill. Physicians and
nurses can and should work together to
de-termine which of them can best assume
me-sponsibility for a particular aspect of a
pa-tient’s therapeutic regime at any point in
time. There is nothing in the code of ethics
of either the medical or nursing profession
which would preclude realignment of
func-tions carried out by physicians and nurses.11
Ways must be found to deliver improved
health services to children and their fami-lies. Special education of the physician and nurse is the powerful force upon which mcli-ance must be placed,12 and the
responsibil-ity for education lies within the province of
medical and nursing schools, which should
collaborate in developing programs of
as-760
pects of these programs will, of necessity,
be experimental and novel, but the need is
so great that traditional, hierarchical
orga-nizational structures need to be set aside so as to provide personnel capable of
achiev-ing the highest quality of health care.
SUMMARY
The pediatric nurse practitioner program
herein described is a new educational and
training program in pediatrics for
profes-sional nurses which has been developed to
provide increased health care for children
in both rural and urban areas. The program
prepares nurses to furnish comprehensive
well child care to well children, to identify
and appraise acute and chronic conditions,
and to evaluate and temporarily manage
emergency situations until medical
assis-tance is available.
The details of the educational and
train-ing program and its implications in
improv-ing the utilization of scientific manpower are described.
REFERENCES
1. Rockefeller Brothers Fund Prospect for
Amer-ica: The Rockefeller Panel Reports. New
York: Doubleday, 1961.
2. Annual Meeting of the American Public
Health Association, October 1964, New York, New York.
3. United States Labor Department: Manpower Report of the President and Report on Manpower Requirements, Resources,
Utili-zation and Training by Department of
La-bor transmitted by Congress, 1963
(Publi-cation #0-676922). Washington, D.C.:
U.S. Government Printing Office, 1963.
4. Physicians for a Growing America. Report of the Surgeon General’s Consultant Group on
Medical Education, U.S. Public Health Ser-vice Publication Number 709. Washington,
D.C. : U.S. Government Printing Office, 1959.
5. Toward Quality in Nursing. Report of the
Surgeon General’s Consultant Group on Nursing. U.S. Public Health Service Publi-cation Number 992. Washington, D.C.: U.S. Government Printing Office, 1964.
6. President of the United States: National Ac-tion to Combat Mental Retardation (state-ment by the President regarding the need). President’s Panel on Mental Retardation. Washington, D.C. : U.S. Government Print-ing Office, 1962.
7. Perspectives for Nursing, A Report Prepared by the Committee on Perspectives of the National League for Nursing. New York, New York, 1965.
8. Pratt, H. : The doctor’s view of the changing nurse-physician relationship. J. Med. Educ., 40:767, 1965.
9. Toward Quality in Nursing Needs and Goals. Report of the Surgeon General’s Consulta-tion Group on Nursing, U.S. Department of Health, Education and Welfare. Wash-ington, D.C. : U.S. Government Printing Office, 1963.
10. Health of Children of School Age, U.S.
De-partment of Health, Education and Welfare,
Children’s Bureau Publication Number 427. Washington, D.C. : U.S. Government Print-ing Office, 1964.
11. Pellegrino, E. D. : The ethical implications of
changing patterns of medical care. North
Carolina Med. J., 26:73, 1965.
12. Schlotfeldt, R. M. : The nurse’s view of the changing nurse-physician relationship. J.