Nurse Practitioners – PediaCast 317

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DESCRIPTION
Welcome to Nurses Week 2015! Join Dr Mike in the PediaCast Studio as we explore the important role nurse practitioners play in the delivery of pediatric healthcare. We also cover nurse practitioner training and their involvement with education and research. Guests include three nurse practitioners from Nationwide Children’s: Maryanne Tranter, Debbie Terry and Erin Keels.

TOPIC
Nurse Practitioners

GUESTS
Maryanne Tranter
Ambulatory Nurse Practitioner
Nationwide Children’s

Debbie Terry
Neurology Nurse Practitioner
Nationwide Children’s

Erin Keels
Neonatal Nurse Practitioner
Nationwide Children’s

LINKS
Nurse Practitioners – An Historical Timeline
American Association of Nurse Practitioners
National Association of Pediatric Nurse Practitioners
National Association of Neonatal Nurse Practitioners

Transcription

Announcer 1: This is PediaCast.

[Music]

Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.
 
Dr. Mike Patrick: Hello everyone, and welcome once again to PediaCast. It's a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio. It is May 6th, 2015, Episode Number 317. And we're calling this one, "Nurse Practitioners".

I want to welcome everyone to the program.

Nurses Week 2015 kicks off today and, of course, we appreciate all of our nurses at Nationwide Children's Hospital. And I'll take that step further and say that… I believe I speak for my physician colleagues as a whole when I say that we appreciate nurses everywhere and in every capacity they serve, not just here at Nationwide Children's. And no, I'm not just saying that because my wife is a nurse, although she is, and maybe saying will earn me some bonus brownie points. Although knowing her, I sort of doubt that it will. In fact, I might negative points for mentioning her on the show.

Anyway, while we do appreciate all of our nurses, we are going to focus on one particular type of nurse on our program today and those are nurse practitioners. Now, I'm sure you've come across a nurse practitioner at some point in your health care journey whether that's a visit to your primary care office, or an urgent care center, or grocery store quick clinic, or during to a visit to a subspecialty program, or even a trip to the operating room. They're everywhere these days, which is quite a feat since there were hardly any nurse practitioners at all in this country as recently as John F. Kennedy's presidency.

0:02:01

Today, there are nearly 200,000 nurse practitioners taking care of patients, providing education, and even conducting research. Now, if that doesn't seem a very large number, consider this — there are only 750,000 practicing physicians in the United States. So it's a good thing we have another 200,000 providers in the form of nurse practitioners, otherwise a whole lot of people would have a considerable problem with access to quality evidence-based care.

So how do this profession come to pass? We're going to take a look at the history, and in our usual nuts and bolts fashion, we'll cover a lot more, including the similarities and differences when nurse practitioners are compared to other provider types including physicians and physician assistants.

What kind of training and certification and licensure does it take to become a nurse practitioner? Where will you find them practicing? How do they fit into the healthcare landscape not only in providing care, but also in medical education and research?

What's a day like in a life of a nurse practitioner? What are the unique rewards and the challenges? Finally we'll have some advice for students embarking on a nursing education, as well as those just beginning their careers. And we'll have some tips for seasoned nurses as well. Maybe you're thinking about becoming a nurse practitioner. What do you need to know before you make that leap? We'll fill you in.

Also on our usual nuts and bolts fashion, I have some great studio guests lined up to help me with the topic. We have three nurse practitioners from Nationwide Children's joining us — Maryanne Tranter, Debbie Terry and Erin Keels.

I'm really excited about this line up because we have many years of experience in the room, and they'll be able to enlighten us on nurse practitioners in many settings including administration, primary care, sub-specialty care, intensive care, education and research. 

So stick around, we have a great show. Lots coming your way in our form of an official kick-off to Nurses Week 2015. 

Before we get started, I do want to remind you that PediaCast is your show. So if you have a topic that you'd like us to talk about or you have a question for me, it's easy to get in touch. Just head to PediaCast.org and click on the Contact link. We also have a voice line. You can call and leave a message that way. It is 347-404-KIDS. 347-404-5437.

0:04:20

Also, I want to remind you, the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child's health, be sure you call your doctor and arrange a face to face interview and hands on physical examination. 

Also your use to this audio program is subject to the PediaCast Terms of Use Agreement which you can find at PediaCast.org.

All right, let's take a quick break, and we'll get our guests settled into the studio and be back to talk about nurse practitioners right after this. 

[Music]

Dr. Mike Patrick: All right, we are back. And as I mentioned, I'm joined by three nurse practitioners from Nationwide Children's Hospital. 

Maryanne Tranter is a nurse practitioner at the Northland Close to Home Center at Nationwide Children's where she practices primary care pediatrics. Let's welcome her to the studio. Thanks for stopping by.

Maryanne Tranter: Thank you very much.

Dr. Mike Patrick: Really appreciate it.

And Debbie Terry is a nurse practitioner with the hospital's neurology program. Warm welcome to you as well.

Debbie Terry: Thank you. Glad to be here.

Dr. Mike Patrick: And Erin Keels is director of Neonatal nurse practitioners. We also appreciate you making time to join us.

Erin Keels: Good to see you.

Dr. Mike Patrick: And Erin, I just want to point out, I'd mentioned when you stopped by today that we worked together actually a long time ago. This was back in the mid-90s or so in the NICU here. And my wife worked with you in the SICU back in the day.

0:06:11

Erin Keels: Right, right. We don't really have to talk about years.

[Laughter]

Dr. Mike Patrick: Yeah, exactly. I agree with you, and just exactly how long ago that was. Let's start with the definition. Maryanne, what exactly is a nurse practitioner? How would you define that role?

Maryanne Tranter: Well, A nurse practitioner, it's an advanced practiced registered nurse who has completed advanced course work and either has a master's degree or higher doctorate degree. They're nationally board-certified, and they manage acute and chronic medical conditions, diagnose medical problems, order treatments, perform advanced procedures and may also prescribe medications.

Dr. Mike Patrick: So I think, a couple really important points with this is you basically start as an RN. So you're a registered nurse, and then you had advanced training and then become certified as a nurse practitioner. Is that correct?

Maryanne Tranter: Correct. That's correct. 

Dr. Mike Patrick: And in addition to certification there's also a state licensure requirement, meaning that the state then is recognizing you as an independent provider. 

Maryanne Tranter: Correct.

Dr. Mike Patrick: And you do practice independently, but you have a collaborative agreement with a physician.

Maryanne Tranter: Correct. We have a collaborative agreement with physicians that we practice directly with.

Dr. Mike Patrick: Sure. And I think that's something that really… In the medical field, I mean all of us collaborate really in the form of if you're in a group practice, and you say, "Hey, I got this patient that…" You know, whatever, "What do you think?" Because when you put two or more brains together, you are also putting together different experiences, and so with the nurse practitioners, there's just a formal definition of what collaboration is, but really that's something that all of us do. 

Maryanne Tranter: That's correct and it differs from state to state, the amount of involvement and what defines that collaboration. 

Dr. Mike Patrick: Yeah. That's a good point. So in some states, they may not be any definition for collaboration, and then in another, it's really formally set out. Is that correct?

0:08:07

Maryanne Tranter: Correct.

Dr. Mike Patrick: So how do nurse practitioners then differ from other forms of nurses? So we said you start as a nurse, what different sorts of nurses are out there? 
 
Maryanne Tranter: So there are number of different kinds of nurses. There are licensed practical nurses (LPNs), registered nurses – with and without their bachelor's degrees – and then there are registered nurses that still practices RNs that have gotten advanced degrees and for instance, a master's degree.

Dr. Mike Patrick: So you go to nursing school and then you become an RN, and then you have a BSN program or Bachelor of Science in Nursing, and then a master's program or doctorate program. Then, you would take a test to get certified, get your licensure and that's kind of the pathway, would you agree? 

Maryanne Tranter: I guess that's not exactly the whole pathway. You can choose to practice as licensed practical nurse, an LPN. And that has a different role with than a registered nurse.
 
Dr. Mike Patrick: Sure.

Maryanne Tranter: You can practice as a registered nurse without a bachelor's degree, but there's not the foundation with the bachelor's degree as a registered nurse. So that is confusing about the differences in nursing at that level.

Dr. Mike Patrick: So do you have to have the bachelor's degree before you go on to get the master's and the doctorate, and that's all required in order then to become a nurse practitioner?

Debbie Terry: Generally speaking, yes, but there are a small number of professionals who elect to come from one profession, say like in biology, and enter what's called a grad-entry program too. And those folks want to be an advanced practice registered nurse and now enter a program that lasts a bit longer and they will get their registered nurse license. They'll work at the bedside but they'll continue to go to school, and they actually won't get a bachelor's degree. They'll actually come out to school with a master's or a doctorate.

0:10:08

Dr. Mike Patrick: Got you. So it is kind of confusing because there are so many different pathways to get to the end point, but the fact remains that you still have to pass the same tests and you still have to have the same criteria in order to be licensed in order to call yourself a nurse practitioner.

Debbie Terry: That's right.

Dr. Mike Patrick: And then how does that pathway differ, I think most folks recognize that in order to be a physician, you go to undergrad school for four years, you go to medical school for another four years. And then, you complete a residency or a fellowship after that in order to be specialized. 

What about physician assistants? That's another role that in some ways seems similar to nurse practitioners? Are any of you familiar with that profession? And I won't hold you to it because you're not physician assistants.

Maryanne Tranter: No, you know, in Ohio there's not a lot of physician assistants yet, but to help fill the gap that we need for health care providers, there is this physician assistant role. They are trained at a master's or higher degree level. They are trained in more of a general fashion, but then they can sub-specialize into certain areas, like pediatrics does have a physician assistant certification now or orthopedics. 

So their training is a little bit different, but if you run into a physician assistant at the bedside, they may do many of the same functions as I think practice nurse would do.

Dr. Mike Patrick: Yeah. When we say advanced practice nurse, this is a synonym, right, for nurse practitioner? Correct?

Maryanne Tranter: Yes. Yes.

Dr. Mike Patrick: OK. I just want to make it clear for everybody.

Maryanne Tranter: So there are four types. Yes. On advanced practice registered nurse is a large category of advanced practice nurses who are educated at the master's degree level and then there are four types. So one is a nurse practitioner, one is a nurse midwife, one is a clinical nurse specialist, and one is a CRNA or certified registered nurse anesthetists. Those are the four types. 

0:12:07

Dr. Mike Patrick: If a nurse practitioner is involved with your child's care or your care, there's nothing wrong with asking them, you know, like what pathway or "Explain what your training was so I have a better understanding of who you are and what you do." I mean is that a reasonable thing if parents have questions?

Debbie Terry: Yeah. I think you always want to know who's taking care of your child and what kind of experience they have and certifications and that sort of thing. And there are different pathways to become a nurse practitioner and there are different, you know, some have years and years of experience, others are newer, and that's okay to understand that. 

Regardless of what their level of experience is, they still have the same responsibility of doing what's within their scope of care and practice what they know. If they don't know something, there are always lots of other people for them to go ask questions to.

Dr. Mike Patrick: To collaborate.
 
Debbie Terry: Right. And there are some things that they can answer when you don't have years and years of experience, and sometimes you need that greater experience for some other things.

Dr. Mike Patrick: Yeah, absolutely. One other thing about physician assistants, in my experience, I practiced in Florida for a few years and they were a lot more physician assistants because there are more physician assistants schools and programs down there than there are here in Ohio. And I think there are more nurse practitioner programs. There was one nurse practitioner program that was just getting started at Central Florida University when I was down there, but there were a lot of physician assistants. 

And my experience with them is very similar with my experience with nurse practitioners in terms of their competence and training, and that they're very good to work with. 

Erin Keels: That's right. Wherever you find the schools of nursing or physician assistants, you'll find more of those kinds of providers. In Ohio, they've increased the number of physician assistant schools, so we'll probably see more of that role here in Ohio.
 
Dr. Mike Patrick: Yeah. In terms of a little bit of history, I'm a bit of a history buff so I had not looked this up before. Maryanne, can you tell us a little bit about the history of the nurse practitioners as a profession?

0:14:12

Maryanne Tranter: Sure. In the 1940s, that's when the beginning of nurse anesthetist and the need for more anesthetists and also midwives began.

Then in the 1950s, psychiatric nurse practitioners came on to the scene. Primary care started in 1965 and it was due to a physician shortage at that time. Loretta Ford and Henry Silver were the physicians that decided to help spearhead this movement.

Dr. Mike Patrick: Sure. Yeah. And that was the University of Colorado. 

And then in 1967, Boston College initiated one of the earliest master's degree programs for nurse practitioners. It really just kind of ballooned from there.

Incredible growth during the 1970s. By 1973 there were 65 nurse practitioner programs in the United States and by 1979, 15,000 nurse practitioners. 

And then really, in the 80s is when it became, I guess, more of an organized professional organizations started to appear. So in 1985 the American Academy of Nurse Practitioners was established. And then in 1989, the peer-reviewed journal, Journal of the AANP. What kind of research is published in that journal? Is anybody?

Erin Keels: Well, because there are so many different types of nurse practitioners, there's going to be lots of different types of research. So when you look at the journal, you'll see anything from population, health management, say diabetes or obesity to mental health issues and management of that to pregnancy health and wellness, so it runs the gamut.

Dr. Mike Patrick: And then, the 1990s kind of saw more of an international growth really where nurse practitioners expanded outside of the United States. In 1992, the American Academy of Nurse Practitioners worked with the Royal College of Nursing in the United Kingdom to start a program there.

0:16:15 

And then, in the 2000s, we've gone from 1979 having 15,000 nurse practitioners in the United States to having almost 200,000 in the United States today. So really, that's why I say you folks are going to come across nurse practitioners. If you haven't already, you're going to more and more. You see, that's just a fair assessment.

Maryanne Tranter: Yes.

Debbie Terry: I think yes, absolutely.

Dr. Mike Patrick: Yup. So Maryanne, if you can enlighten us, we talked a little bit about the main types of nurse practitioners. So we talked about nurse anesthetist, midwives, in psychiatry, and in primary care. There was another one too that I'm missing.

Maryanne Tranter: So there are — the nurse practitioners is one of the advanced practice nurses, so that was what we discussed a little bit later with midwives — the nurse anesthetist, the nurse practitioners, and then the clinical nurse specialists. So those were the different kinds of advanced practice.

Now, within the nurse practitioners, there are several different tracks and training that NPs can do as well. There is adult NPs, family nurse practitioners, pediatric nurse practitioners, neonatal, psychiatric and mental health, acute and primary care. 

So there are all these different types of specialties that nurse practitioners can now go into also and be trained specifically for.

Dr. Mike Patrick: I'm kind of embarrassed that I don't know all these ins and outs. And I think there are a lot of physicians out there who hear the word APN, an advanced practice nurse and nurse practitioner and really just kind of, maybe it's just me, but I bet not, it kind of gets confusing, but as we break it down and talk about it it's easier to see how a structure is there. 

0:18:05

So there are lots of different pathways advanced practice nurse. So we're going to talk specifically right now about nurse practitioners as a type of advanced practice nurse. And then, within nurse practitioners you mention you can specialize in family, pediatric, geriatric, all those and neonatal, those kind of roles.

What kind of career path is then, So once you become trained in one of those specialties, let's say that you're a pediatric nurse practitioner, what kind of career paths and health care roles are possible for you?

Debbie Terry: Well, there is a wide range of things that you can do as a nurse practitioner and you can really focus on whatever that specialty is — psychiatric, primary care — usually start in one of those even general areas, and then some people would go into more of a subspecialty area. 

Most of what nurse practitioners are doing is taking care of patients, but as a nurse practitioner, some will venture more into research or into education or into management of how to administratively just to support nurse practitioners in what they're doing.

Dr. Mike Patrick: Yeah. Maryanne, tell us. So you've been in primary care pediatrics for…

Maryanne Tranter: Twenty years.

Dr. Mike Patrick: For 20 years, so a long time. Tell us about some of the changes that you've seen over that time period in terms of the role of nurse practitioners.

Maryanne Tranter: So as you've said, the numbers have definitely increased. I appreciate when I started as one of the three that were working in the primary care system at that time. It was almost like how do we figure out this role in our primary care system and start? And since then, it's become a lot more smooth, a smoother transition or when we have newer people come in. And now, there's a cohort of NPs that work in the ambulatory setting that I have. So for me personally, throughout working with Children's, I've seen that flow as difference.

0:20:17

We've also had differences in policy and laws. So we are now — while other states have done it years ago — in Ohio in recent years, gained prescriptive authority, as well as now, we prescribe Schedule II medications. 

So there have been those kind of changes throughout my career that, with extra training that I have also had participated in, allowed this service to be given to patients without having to figure out a way to get it done.

Dr. Mike Patrick: And with that increasing responsibility also come increasing accountability and liability and those sorts of things. There has sometimes some criticism, "Well, can nurse practitioners prescribe medications?" And that's why it was a legislative battle so to speak to get that. But now that you have it, you're not just going to do it willy-nilly. You want to be trained because you're held accountable. Correct?
 
Erin Keels: That's right. Yeah. The state has mandated quality monitors that we participate in to ensure the safety of our prescribing, both to the state as well as to the organization that we work in. And we all want to be as safe as we possibly can and so, there are a lot of quality monitors and metrics and initiatives throughout the hospital to make sure not only nurse practitioners, but also physicians and other providers are prescribing safely.

Dr. Mike Patrick: Absolutely. Yeah. Yup. Absolutely. And I think, really, as safety has become more of a focused in terms of the health care system in general. We hear about quality and quality initiatives, and I mean, that's really good for everybody.

Erin Keels: That's right.

Dr. Mike Patrick: Yup. Tell us a little bit about what your day to day life is like as a primary care nurse practitioner. What's it like taking care of patients in the primary care clinic.

Maryanne Tranter: Well, in the primary care clinic, I start my days much like the physicians do. My days look very similar where we look at lab results or charts from previous visits, look at the schedule for the day. The nurses and MAs, medical assistants I work with will get the patients ready in the rooms, so I'll go into the rooms, see the patients and then do just the follow-up and charting after that. Spent days look very much like the physicians and pediatricians I work with.

0:22:34

One of the differences is my template is a little bit different than the physician's template, where I am given a little bit extra time with each patient which allows for a little bit more education for the patients, and it's for their well-being as well my practice. So that's one of the differences, is my template looks a little bit different. 

But patients are just put on our templates. They can request a provider, but usually it's just whenever anybody's open, so I don't see or exclude certain patients.

Dr. Mike Patrick: Sure. Are you involved with education as well in the primary care clinics?

Maryanne Tranter: Within our patient care, I am of course. Some nurse practitioners in primary care do additional clinics or training or education sessions for obesity or asthma management or breastfeeding. So some primary care NPs will offer extra sessions for patients to meet and discuss that. If the patients want that, and especially in offices with a population that's pretty stable to offer those.

Dr. Mike Patrick: Sure. And then training a new nurse practitioners, do you have nurse practitioner students in the clinics as well?

Maryanne Tranter: Yes. We have nurse practitioner students that will work with us during our clinic rotations and their clinic rotations. So, yes.

0:24:03

Dr. Mike Patrick: What about research? Is there opportunity in primary care to get involved with any research projects?

Maryanne Tranter: Certainly. Especially, you know, nurse practitioners are just like the physicians in primary care when they are taking on a project. They can be part of those teams of researchers. They can take on their own projects that they would like.

There's also a move to provide evidence-based practice and to look into the research as well as supply that research in our settings. And many nurse practitioners are going on for further education in getting their doctorate, allowing them this additional skill to provide, look into that research, do research in the clinics.

Dr. Mike Patrick: We're seeing kind of an explosion of convenience store clinics around the country that are primarily staffed with nurse practitioners. Is that something… As you, being a nurse practitioner in a primary care clinic affiliated with the Children's Hospital, you really are more of a medical home for people, correct?

Maryanne Tranter: Correct.

Dr. Mike Patrick: And then you have the urgent care centers, which as we know a lot of primary care actually does end happening, whether there are urgent care centers or other urgent care centers. And then you have these sort of the grocery store clinics, I'm not asking you to cast a judgment upon those, but what are some of the advantages and some of the disadvantages? 

Anybody can try chime in here because I think this is just something that affects the medical community as a whole. What do you think of those?

Debbie Terry: Well, I think obviously, as a parent, you're just so busy and having that availability is nice. It is. You might think your baby has an ear infection or maybe your teenager has strep throat. So it's convenient which is why it's called a convenience clinic, right? 

But I do think the challenges to make sure that what's happened at that clinic then interfaces with the primary care provider, so that there's that good communication and hand-off of care. So that your doctor or your nurse practitioner in your pediatrician's office knows that you took your baby to have an ear check and got a prescription for amoxicillin. That needs to be very very seamless. And I think that's one of the things that we're concerned about some types. 

0:26:15

Dr. Mike Patrick: And I would encourage parents and, of course, our audience is not just here in Central Ohio . Here in Central Ohio, Nationwide Children's has some great urgent care centers all around town. We've talked about those many times on this program. But really, for anybody out there, I would encourage you, before you visit any place other than your medical homes, to give your doctor a phone call and just say, Hey. Because there's always someone that's on call for the practice and just say, "Here's what's wrong with my kid. Here's what my concerns are. Where's the appropriate place to go?" And your primary care provider is going to know who has pediatric expertise in your area, who's not so great at pediatrics, maybe fantastic for adults but may not translate as well to pediatrics and would be able to provide you some wisdom in terms of where the best place to take your child is.

OK, Debbie, so you are in the neurology clinic here in Nationwide Children's. How does a nurse practitioner become an expert in pediatric subspecialty?

Debbie Terry: You know, all nurse practitioners like I started in primary care. That was my training anyway, was a primary care pediatric nurse practitioner. So you get a good bases of pediatrics. And then when you go into a subspecialty, you have access to a lot of other physicians you work with, other nurse practitioners who have really developed a specialty in that area.

And then you do that every day, so it's really just the experience of every day seeing the same type of problem rather than I don't need to know as much about asthma, diabetes, those kinds of things. I really need to focus particularly for myself, I see patients with epilepsy. So that's all I do all day long and that's the journals I read. Those are the questions that I answer every day. There's a meeting I go to every year, a national meeting about epilepsy. 

And so, I gradually, in the first year or two, I'm not… expertise at it, and I do need to rely on others quite a bit to answer questions and figure things out. But then, after you had a couple of years that that's all your doing, you get very good at it.

0:28:29

Dr. Mike Patrick: Yeah. Especially when you have kind of a slice of pediatric care that you're really concentrating on. 

Debbie Terry: Right.

Dr. Mike Patrick: And you're the type of person who is going to pursue reading journals, looking at this as professional development. 

Debbie Terry: Right. 

Dr. Mike Patrick: What other kind of educational opportunities are available to continue deepening your knowledge about epilepsy?

Debbie Terry: Well, in any specialty, there's all sorts of different types of educational programs. I went to Lake Forest for a four-day program specifically about pediatric epilepsy that was for nurse practitioners and physicians. Within our department, we have speakers that come. We have new conferences. We're always learning. Everybody within the department, not just the nurse practitioners, the physicians are doing that as well.

Dr. Mike Patrick: That's really where evidence-based medicine becomes important. We're going to look at the research. We're going to evaluate this is good research or was it not so great research and then sometimes things change. What we say is right, maybe different from one year to the next depending on what the evidence is showing.

[Laughter]

Debbie Terry: Yeah. In the 17 years I've been doing this, there's things that when I first started was like, "Well, of course, we should do this." Now we're learning that really isn't the best way to care for patients. So we're always learning.

Dr. Mike Patrick: Absolutely. Tell us a little bit about the pediatric subspecialty team. That's kind of a phrase that's thrown around here a lot — the team approach. What is a pediatric subspecialty team?

0:30:04

Debbie Terry: Well, I think as you said earlier, no one is practicing in isolation. You're always, 

Dr. Mike Patrick: Well, there are people who do, but that's not ideal. Correct?

[Laughter]

Debbie Terry: Well, there's some people who are practicing in isolation, but they still have… They can pick up the phone if nothing else and call somebody and ask them things. So I think there's a lot of teamwork going on everywhere, but particularly within a subspecialty area, these are children for example with epilepsy that have very specialized needs, and for example, the neurologist can't know everything about what that child needs. 

So we need social workers who can help with how to get access to care, how to get access to medications, access to home care. We need psychologists who can help the child deal with the fact that they have seizures or have other just emotional and learning problems that go along with epilepsy. We need a clinical pharmacist who really helps us with understanding the medications and the best way to do that. 

And so, nurse practitioners are part of that team, and we also kind of bring our own interest and our special knowledge of that patient population to the table. So, for example, with epilepsy, I have really developed an interest and really more of an expertise and understanding how are seizures managed in school. So that I'll have neurologists come and ask me for advice about how can we manage seizures in school.

So everyone's bringing something different to the table, so that everyone can focus on a certain area, bring it all together for the patient to do what's best for them.

Dr. Mike Patrick: Great. What advantage, Well, I guess you've really kind of described what advantage the team approach has in terms of every aspect of the child's care, someone is addressing it who has experienced with that aspect. But there must be some challenges that go along with the team approach as well. What kind of challenges do you see?

0:32:04

Debbie Terry: Well, communication is always going to be one of the biggest challenges just in general, in health care, but you do have to have very good communication among the team members. And that's why we have on Thursdays, for example, we have specifically a multi-disciplinary epilepsy clinic that where all these different types of providers are in the same place, so that we can talk directly to each other. Sometimes it's about a patient we're seeing that day and maybe about another patient that we've seen maybe when the whole team wasn't there. So really, just building those relationships and having ways to communicate as directly as we can. 

Dr. Mike Patrick: I could see that as a big advantage having everyone in one place because even if you have all those different things set up, parent has a question, and you may feel like, "Well, I don't want to step into the territory of someone else," so you may be hesitant to answer the parent's question. At the same time, you may answer it in a way that was different than the psychologist would've answered that question. 

So I can see where having everyone in the same physical space will definitely be an advantage, which isn't necessarily the case how it is everywhere.

Debbie Terry: Right. Right.

Dr. Mike Patrick: Yeah. I would imagine in subspecialty care, you're also involved in educating nurse practitioners who come through and in research opportunities as well just like in primary care.

Debbie Terry: Yeah. We'll do that and we're actually involved quite a bit in research, have our own research studies that we do. Again, I did some research in relation to children and how they cared for in schools. So we do our own research and then are part of teams that are doing research within a subspecialty.

Dr. Mike Patrick: Great. Anything else that you want to let us know about the epilepsy program here at Nationwide Children's before we move on because it's a great program. We just had Dr. Patel on the talk about medical marijuana for one of our CME podcasts that came out last week, so it's kind of a hot topic right now.

Debbie Terry: Oh, yeah. Yeah.

Dr. Mike Patrick: Tell us a little bit about the program. Put it in a plug for the epilepsy program here at Children's.

0:34:02

Debbie Terry: Well, again, we have a great team of people, and everyone is playing a part in how to help kids with epilepsy. And it does take a team approach. One person can never know everything and so you really need everybody there working together.

Dr. Mike Patrick: It's one of those things where again knowing the provider that's with… If you're a parent and you have a question… Because you can have a nurse practitioner who's had years of experience compared to the neurologist who's fresh out of their fellowship who in some of that critical thinking because you've not had as many experiences, then the nurse practitioner may really be the go to person or maybe the other way around too. There could be a neurologist who's been there for years and years and the nurse practitioner is just out of their training. And so that's where, Just knowing that everybody is supporting one another. And if parents have questions, just ask.

Debbie Terry: Right. As I said, I don't think anybody's practicing in isolation, and everybody has the same goal. Every provider's trying to do the best for the child. And if they can't answer the question, we go get somebody who can and that may be a psychologist, maybe a nurse practitioner, maybe a physician. 

Dr. Mike Patrick: And you know, sometimes parents get upset because things aren't going, Their child's care is not progressing in the way that in a perfect world they'd really like it to go. They may not be getting better. 

This goes with any subspecialty and anything in pediatrics in general. It is sort of natural for the parent to sort of lash out at the provider who they feel's not getting it done, where any other provider in that same situation would be doing the same thing. But sometimes it's helpful for the parent to pull another provider in, to get that opinion just to give them some reassurance. We can't really take that personally because if that was our kid, we'd probably doing the very similar thing.

Debbie Terry: Right. And very often, parents will be frustrated. Although I'm pretty confident there is not anything different we need to be doing, but that's when I get the neurologist and have them come in at that visit or schedule an appointment for them to see him. 

0:36:07

Most often, it's just to reassure them that yeah, we're on the right path and that can help ease the parents, which is a perfect perfectly appropriate. If you have concerns, you're not happy with how things are going, you should always ask for another opinion, another set of eyes. 

Dr. Mike Patrick: Absolutely. So we've talked about nurse practitioners in primary care settings and in pediatric subspecialty settings. Let's talk about the intensive care environment. So Erin, tell us a little bit about the role of a neonatal nurse practitioner. What is that?

Erin Keels: So a neonatal nurse practitioner is actually a subspecialty. I'd like to say a super subspecialty. We only take care of babies from the time they're born up to the time that they're two years of age. And so you'll find most neonatal nurse practitioners working in NICUs, neonatal intensive care units. 

NNPs, which is acronym for neonatal nurse practitioner, will go to high risk-deliveries. So if the baby is showing any kinds of distress during labor and delivery or has prematurity issues or perhaps a prenatal diagnosis of a birth defect, you'll find an NP there in the delivery room, with or without a physician there, to help transition that baby after birth and take care of the baby, and provide whatever support is necessary.

Then, you'll see many NNPs in the NICUs taking care of teams of babies, so just anywhere from a couple of babies up to maybe 10 or 15 babies along with a team approach. So in the NICU just as Deb described in subspecialty care in the pediatric environment, 
in the NICUs we have team-based care as well. So we'll take care of a team of babies alongside the attending neonatologist. An neonatologist is a specialized pediatrician, a pediatrician who's specialized into the care of babies or neonates.

0:38:07

So you have neonatologist and sometimes you'll have fellows or advanced residents who are training to become a neonatologist, pediatric residents, respiratory therapist, pharmacist, nurses, social workers, lactation specialists, you name it. So we have big teams in the NICUs because when you look at this little tiny preterm sick baby, they need a lot of resources. 

Dr. Mike Patrick: And then, this is a situation where in most places then that team is going to be together all in one physical location and be able to interact with each other and get advice from one another. 

Erin Keels: Yeah. In most cases, in our big tertiary care facility like here at Main Campus, in our NICUs you'll find these big teams. If you go into more rural areas, you may find just a physician and a neonatal nurse practitioner and a nurse. So depending on the severity of illness will sort of depend on that size of the team, but there are lots of supports readily available for them.

Dr. Mike Patrick: Sure. Now in terms of training neonatal nurse practitioners, so you're an RN first.

Erin Keels: Yup.

Dr. Mike Patrick: And then you do a nurse practitioner program, is it NNP-specific right out of the gate? Or are you a nurse practitioner first and then further specialized?

Erin Keels: So right, our trajectory is a little bit different from a primary care or even specialized care PNP in that when I went to become a neonatal nurse practitioner, I go to school specifically for that. So my graduate and soon to be doctoral programs only specialize in learning to take care of neonates.

Dr. Mike Patrick: In terms of education, there are a lot of educational opportunities in primary care and subspecialty care, and there are some specific educational things that go along with teaching moms to take care of premature babies I'm sure. 

Erin Keels: Right, we teach and we learn a lot every day. So we teach families how to take care of their babies. We teach our staff. We continually inform and update and educate the nursing staff and other support staff. We educate the residents and the fellows who are going to be tomorrow's pediatricians and neonatologists. We educate each other, and we educate the public. But we also learn a lot too. 

0:40:23

So you alluded to the sort of beginnings of nurse practitioners back when JFK was president. Well, that's really when the interest in neonatology or the care of the sick newborn began is when JFK's son, Patrick, died of what we know now as the RDS or Respiratory Distress Syndrome.

Dr. Mike Patrick: Very interesting. Not only in the actual neonatal intensive care unit, but once a parent goes home with a premature baby, I'm sure that there's a lot of anxiety and there's a lot of on-going education. Do you also see folks in follow-up after their discharge from the NICU?

Erin Keels: Yeah, we will. So because NNPs are certified to take care of babies up to the age of two, you will find some NNPs in follow-up clinics. For instance, here in Nationwide Children's Hospital, in our neonatal follow-up clinic, we will have some NNPs there seeing the patients back for their follow-up. Then, there's this transition of about two years of age into a PNP, to pediatric nurse practitioner.

Dr. Mike Patrick: Sure. And I would imagine that there's also a lot of research opportunities, especially in a large tertiary care center in a big NICU. So there's a lot of research projects going on that nurse practitioners get involve with as well in the NICU.

Erin Keels: Exactly. We just started studying the care of newborns back in the 1960s, so you can only imagine that we are still learning. And so, you'll see NNPs involved in research at the hospital level but also at the national and international levels. 

Dr. Mike Patrick: Great. Everybody can kind of chime in here. What are some of the most rewarding moments that you have as nurse practitioners?

0:42:06

Debbie Terry: Well, certainly surrounding the patients. And when you see patients come back and they're doing well, or they understand something that they didn't understand very well before, and they finally kind of have an "Aha!" moment. It was like, "OK, now I understand why they're telling me to do this." Those can be the most rewarding things.

Maryanne Tranter: Yes. Definitely it's probably the same as all physicians. They're same rewards. I've had a patient coming back monthly working on their weight because of their obesity and due to that. So they have been coming every month and the whole family is involved, and they show me how lose their clothes are when they come in the clinic to see me. To see those changes and the family embrace it, and them to be excited about the health of their family is wonderful.

Erin Keels: Yeah. And so in the NICUs , obviously when you take a critically ill preterm baby and you see them go home with their families and you see them come back and they're growing and they look awesome, that's obviously a great reward. But sometimes it's really just working with the families, helping them understand and cope with the disease that is affecting their child and their family and just helping them with that.

Dr. Mike Patrick: What are some of the challenges of being a nurse practitioner?

Maryanne Tranter: Well I think that for me, for primary care, it's like also the same challenges as physicians. It's the amount of primary care need especially in rural areas. 

So that is not unique to NPs, but that is one of our big challenges. The same thing is the time with patients. That's a challenge that we have as well as physicians. I guess, thirdly, a challenge which is making sure, like we said, it's a little complicated to find out what are NPs, and it's educating the public and having people understand our role. 

0:44:00

Dr. Mike Patrick: I'm sure you guys have this challenge. Just the amount of information that's out there on health care and helping parents sort through what's good information and what's not so good information, what's evidence-based and what's rumors and myths. I think, much more difficult with that today than it was probably when you started 20 or 30 years ago.

Debbie Terry: Yeah, right. Google changed everything.

Dr. Mike Patrick: Yes. 

[Laughter]

Dr. Mike Patrick: And not all for the better.

Maryanne Tranter: Right, exactly. 

Dr. Mike Patrick: One thing I was thinking about as I was putting the show together is if you're an RN, and then you're embarking down the nurse practitioner path with a master's and/or a doctorate degree, is it encouraged to be a practicing nurse first and then pursue this? Or are there folks who start nursing school day one, they're going to be a nurse practitioner and kind of go through that whole thing? What are your thoughts on that? Because I'm completely clueless. Is that something that people do?

Erin Keels: Well, there are people who do that, just as we sort of talked about the grand entry programs where I'm a Biology major, and now I'm going to be a nurse. But what you'll find is as that person gains the RN licensure, that person will work at the bedside as a nurse, while the person is working on their advanced degree to become a nurse practitioner. 

So by the time this person becomes a nurse practitioner, he or she will have a couple of years of being a nurse under their belt. But that's said, I mean I think we all agree that the more years of experience that you have as a nurse is going to help you in the long run transition to the advanced practice role, it's just going to help you feel a little more confident when making decisions and helping others.

Dr. Mike Patrick: Sure.

Maryanne Tranter: But I do want to say that that's the same thing that goes for people that practice as a medical assistant before they go to nursing school. When you are working in a hospital taking vital signs as a medical assistant, knowing this system, feeling comfortable speaking with patients, knowing all of those components, those MAs will be better nurses.

0:46:04

So can it be done? Yes. I mean physicians during their training, when they start med school, they haven't been in a hospital necessarily with their undergraduate degree. For anybody, I believe, the more experience with the hospital setting, I mean that's just going to make you a better provider no matter what your role is.

Dr. Mike Patrick: But someone's going to get that experience to start somewhere. I mean at some point is day one, right?

Erin Keels: Right.
 
Maryanne Tranter: That's right. 

Debbie Terry: I think the experiences as an RN is the decision making. And I think that having that some experience with, "I've got a patient, I have to make a decision about something for this patient." I think that is what can help you then when you become a nurse practitioner.

But there are more and more people, nurse practitioners, originally really were more often RNs for several years, then went back to school. Now we're seeing the move that that's not the case, and I think we're going to have to learn how to help them, this type of training how to help them get assimilated into the role to get better.

Dr. Mike Patrick: And that's something I think that healthcare system in general needs to look at each individual provider as they're coming out of training and to know their background and what kind of support that they going to need. Because there is going to be a huge difference between someone who's been an RN and at the bedside for 20 years, and then they're a nurse practitioner and someone who's fresh out in terms of critical thinking skills and experience.

Erin Keels: And I would say that really in any organization, there is a process for that. So when we hire a new nurse practitioner, number one they go through credentialing just like a physician. And they have a quality program and education plan, and they're proctored and they're evaluated to make sure that they can make these decisions and have critical thinking and are safe and have quality care.

Dr. Mike Patrick: What advice do you have for students who may be taking their very first steps in nursing education today?

0:48:04

Erin Keels: I say yay. 

[Laughter]

Erin Keels: You know, with the Affordable Care Act, there's a lot more people that have access to healthcare. We need providers. We need nurse practitioners. We need physicians. We need physician assistants. And so, for those who are thinking about going into the field, good for you. Reach out and see what resources people can offer and recommendations. I think it's always really great to shadow.

We go through our Department of Professional Development and arrange foreshadowing experience with a nurse practitioner to help you figure out where you might want to concentrate your education. 

Maryanne Tranter: Other advice, definitely throughout their process in education, throughout their nursing education if they go decide become a nurse practitioner, the being a self-learner, because you're going to have to your whole career. And so not doing your assignments in school for… You want to be the best provider for this family, and so being that self-learner, not doing it for the grade, doing it for the experience that you're going to be using. So thinking of that and keeping that to focus, I think, is a good first step.

Dr. Mike Patrick: Great. 

Debbie Terry: I just think, nursing in general is a great career, and it's something that you can do every day and it can be rewarding. I tell my kids all the time, I want them to find something they really love to do so that it's not a job. And I think for most nurses, you don't go into nursing for money. There's got to be something behind that.

Dr. Mike Patrick: Don't go to pediatrics for money.

Debbie Terry: No, yes.

[Laughter]

Debbie Terry: So nursing in general is just a great career, and there's so many different avenues that you can take. 

Dr. Mike Patrick: And what advice do you have for season nurse who maybe thinking about doing this? Would you encourage them to do it or would you "No, having gone this path, maybe I would think twice"?

0:50:04

Debbie Terry: I'd absolutely recommend it. I think it's just really the greatest decision I've made. I've never had any regrets about it and it just pushes you to a higher level of decision-making and care, and it's a great job.

Erin Keels: Yeah. I'd echo that too. Being an expert bedside nurse and making that leap to becoming a novice all over again is challenging for those folks, but we have great supports in place to help folks transition and learn and excel at this. 

Dr. Mike Patrick: So maybe scary, but you're going to find yourself well-supported.

Maryanne Tranter: Absolutely.

Debbie Terry: Right. Right.

Dr. Mike Patrick: All right. Is there anything else about nurse practitioners that we did not cover or clarify? Did we hit it all?

Erin Keels: I don't know. I think so.

Dr. Mike Patrick: Good. All right. Well, I appreciate all of you taking time out of your day. Maryanne Tranter, Debbie Terry, Erin Keels, really appreciate you stopping by.

Maryanne Tranter: Thank you very much.

Debbie Terry: Thank you.

Erin Keels: Thank you.

Dr. Mike Patrick: Let's take a quick break and I'll be back to wrap up the show, right after this.

[Music]

Dr. Mike Patrick: All right, we are back and I want to remind you, we do have some links for you in the Show Notes. If you head over to PediaCast.org, Episode 317, we have a link to the nurse practitioner historical timeline. So we talked a little bit about the history of the profession, if you're more interested in the history, you can follow that link again in the Show Notes, PediaCast.org Episode 317.

0:52:06

I also have a link to the American Association of Nurse Practitioners, the National Association of Pediatric Nurse Practitioners, and the National Association of Neonatal Nurse Practitioners. All of those links will be in the Show Notes again at PediaCast.org.

I want to thank each and every one of you for taking time out of your day to make PediaCast a part of it. Really do appreciate that.

And thanks to our nurse practitioners from Nationwide Children's Hospital — Maryanne Tranter, Debbie Terry and Erin Keels. I appreciate you guys taking time out of your busy day and enlightening the audience on nurse practitioners. 

That's all the time we have today. PediaCast is a production of Nationwide Children's Hospital. Don't forget, you can find PediaCast in all sorts of places. We're in iTunes and most podcasting apps for iPhone and Android, including the Apple Podcast App, Downcast, iCatcher, Podbay, Stitcher and TuneIn. 
 
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0:54:15

That's all the time we have and until next time, this is Dr. Mike, saying stay safe, stay healthy, and stay involved with your kids. So long, everybody. 

[Music] 

Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.onwide Children's. Thanks for listening. We'll see you next time on PediaCast.