The positions of nurse practitioner and physician assistant were created approximately 30 years ago. Since then, the role and responsibilities of these individuals have developed and grown and now may include involvement in the care of hospitalized patients. The intent of this statement is to suggest a manner in which nurse practitioners and physician’s assistants may participate in and contribute to the care of the hospitalized child on the general inpatient unit, among other areas.
During the 1960s, nurse practitioner (NP) and physician assistant (PA) training programs were initiated1 in response to a perceived shortage of physicians, especially in medically underserved communities that were often also economically deprived. NPs and PAs were originally considered to be alternative health care personnel who would function under the supervision of physicians, extending the ability of the physician to provide service to a greater number of patients.
During the last 10 years, however, the scope of practice of NPs and PAs in pediatrics has been expanded to include the care of hospitalized patients.2 This expansion has been driven by continuing regional shortages of physicians, efforts to reduce the cost of health care, and decreasing funding for graduate medical education which means fewer residents (residency positions). A major concern has been that the expansion of the scope of practice of NPs and PAs may impact on the management of pediatric inpatients3 and create a two-tier system of health care. Another issue is that resident experience may be diluted when NPs and PAs assume some of the responsibilities for patient care.
As initially conceived, the roles of NPs and PAs in pediatrics were to assist the physician in the provision of primary care for well children and those with acute minor illnesses. During the past 30 years, subspecialty areas for NPs, such as the neonatal NP, have developed. PAs have been used more extensively in hospital departments of surgery, in which they may obtain initial histories and perform physical examinations and minor surgical procedures, under physician supervision.
Despite the original intent for the roles of NPs and PAs, current economic pressures have promoted their increased use and expanded scopes of practice. This is true despite data from ambulatory settings clearly demonstrating that although NPs and PAs individually earn lower incomes than physicians, their involvement in care costs the same or more per patient encounter because they tend to spend more time with each patient and usually work a 40-hour week, while physicians treat patients more expeditiously and work longer hours.5,6
However, a role may exist for NPs and PAs on the pediatric inpatient unit. The NPs and PAs who are used in such positions require additional precepted education, beyond that required for certification. The additional precepted education should be the responsibility of the pediatric unit director and should include orientation to hospital and departmental policies and protocols and direct teaching of clinical skills needed for the specific unit. The NPs and PAs should work under the close direct supervision of an attending physician, and the patient’s primary physician must always remain readily available to answer questions and provide backup to the NP or PA. Decisions regarding the need for admission, management plans, and appropriateness for discharge must be made with the involvement of the attending physician.
NPs or PAs working with a physician have a meaningful role in the management of hospitalized children. Having already demonstrated their abilities to perform in supervised intensive care settings, NPs and PAs should be effective on the general pediatric inpatient unit. As the scope of ambulatory care continues to expand, the children admitted to the general inpatient unit of the hospital have increasingly more complex illnesses. The responsibility for the management of the hospitalized child should be under the supervision of a qualified physician, because the physician has the most education and training for this role. Nevertheless, the NP and PA can play a valuable role in the care of the hospitalized child by contributing specialized skills that improve the quality of patient care. The NPs and PAs who participate in the care of the hospitalized child must have the additional education and training that such involvement requires.