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Nurses' Week, May 6-12
Role of Nurse Practitioners Expands at NIH

By Marianna L. Crane and Cathryn Lee

Nurses' Week, celebrated this year from May 6 to 12, is a time not only to recognize the contributions of nurses at NIH, but also to appreciate a subtle shift that has taken place within nursing ranks. Over the last few years there has been a steady growth of skilled nurses with advanced degrees. In 1996, there were approximately seven nurse practitioners at NIH. In just 4 years, that number has grown to 43. Twelve are working in the Clinical Center and 31 are employed within seven of the institutes.

What is a Nurse Practitioner?

In general, nurse practitioners are nurses who hold a master's degree in nursing. Most are credentialed by the American Nurses Credentialing Center in specialty areas such as adult, pediatrics, family and acute care. Different states have different statutory definitions of a nurse practitioner. Nurse practitioners can perform history and physical exams, diagnose disease, order, perform and interpret laboratory, radiographic and other diagnostic tests and prescribe and dispense medications. In some states, nurse practitioners can practice independently. Historically, nurse practitioners have filled the gap in health care delivery to the underserved such as those living in rural areas, on reservations and in the inner cities. More recently, nurse practitioners may be found in acute care settings, health maintenance organizations, private physician practices and NIH.

History of Nurse Practitioners at NIH

The Pediatric Branch of the National Cancer Institute was the first to hire nurse practitioners in the early 1980's. Their primary role was and continues to be management of pediatric oncology patients. They also help provide continuity of care in a setting that consists of rotating clinical fellows.

Several years later, the AIDS epidemic led to an expansion of the pediatric program. With this came the hiring of more nurse practitioners. These NPs work in collaboration with a senior attending and a full-time pediatrician to provide medical care for all the children enrolled in HIV treatment protocols in both the clinic and inpatient setting.

In 1992, NCI's Medicine Branch integrated nurse practitioners into its clinical fellowship program. With downsizing of the fellowship program, more nurse practitioners were hired. As with pediatric NPs, each one medically manages a population of patients, provides continuity of patient care, and assists in the education of clinical fellows. They also perform all necessary procedures such as lumbar punctures and bone marrow biopsies.

Over the next few years, NPs were established in a variety of settings including: gynecology, rheumatology, endocrinology, pulmonology, cardiology, psychiatry, nuclear medicine and infectious disease. Each new NP brings to the role a unique variation in his or her practice.

Recently Emerging Roles

In the summer of 1998, the National Heart, Lung, and Blood Institute decided to phase out the Clinical Associate Program. The clinical associates were third-year residents responsible for the day-to-day clinical care of patients. The associates were here for a limited amount of time, causing a lack in continuity of patient care. By July 1999, each of the four NHLBI branches had hired nurse practitioners to replace the third-year residents. The Hematology Branch has three NPs that care for bone marrow transplant patients: Jeanine Superata, Martha Marquesen and Donna Chauvet. The NPs are skilled in doing bone marrow biopsies, thoracentesis, and will eventually learn to do lumbar punctures. Dr. Neil Young, chief of the Hematology Branch, says NPs "become quite expert at the problems that we deal with; provide continuity (and are) very responsible colleagues."

NPs Donna Chauvet (l) and Jeanine Superata care for bone marrow transplant patients in the Hematology Branch.

While in some institutes the NPs are a replacement, in other areas they play a consulting role. The Internal Medicine Consult Service, an innovative program that started in November 1998, pairs a physician, Dr. Fred Gill, with nurse practitioners Laura Shay and Tracy MacGregor. The program functions within the Clinical Center and the team is consulted by other institutes for problems that arise in protocol patients such as hypertension, hyperthyroidism and hyperglycemia. In addition, the service often helps manage patients with extremely complex medical problems. They coordinate all necessary testing and referrals for comprehensive work-up and management of the problem. Gill says, "This allows the attending research team to focus on protocol issues." The NPs add an extra dimension of coordinating followup care. "This extra dimension would not be as effective if the team were composed of all physicians. In this context, the nurse practitioner often fulfills the role of both nurse and physician." Gill adds, "The team is working very well and I hope we are contributing to the high quality of patient care at the Clinical Center."

The Internal Medicine Consult Service includes nurse practitioners Laura Shay (l) and Tracy MacGregor, and Dr. Fred Gill.

In other settings, the NP may fill in for a temporary need and/or provide services that the principal investigator may routinely do in assessing patients. Karen Baker is employed by the Clinical Center and has been a nurse at NIH for 15 years. She wears many hats. She works as a clinical nurse specialist in performance improvement for the nursing department and is an NP who works with the Internal Medical Consult Service when they need an extra hand. She also provides surgical clearance for patients undergoing dental procedures in the National Institute of Dental and Craniofacial Research and within the same institute does histories and physicals on patients with Sjogren's disease. Baker is a member of a team comprised of the principal investigator, research nurse and herself. Their goal is to identify patients eligible for several protocols for the treatment and evaluation of Sjogren's. Baker says the "principal investigator is free to do more of the bench research while the nurse practitioner obtains the clinical data base."

The Nurse Practitioner and Research

NPs would like to initiate more nursing research but they cite time and a hectic work schedule as obstacles. Dr. Anne Thomas, a nurse practitioner and Ph.D., joined the National Institute of Nursing Research in October 1999 as its clinical director for the Division of Intramural Research. One of her goals is to "promote nurses' involvement in their own clinical studies." Because Thomas is an NP, she will be able to provide clinical oversight for nursing research protocols. She will open a Health Promotion Clinic at the Clinical Center 2 days a week. In this clinic, she and Rose May, also an NP, will be conducting research on health promotion in the geriatric population. One of the major reasons Thomas decided to join NIH was recent growth in the number of NPs here. She notes, "There is a wealth of nursing talent and expertise here that cannot be found elsewhere."

The Future

Nurses' Week provides an opportunity to recognize the contributions of all nurses at NIH, and offers a chance to view the future of nurse practitioners. This advanced practice group has gained inroads into research programs and specialty services here in areas never dreamed possible years ago. This clinically rich environment has many possibilities to offer as new roles are developed. Clearly, NPs are making a difference within NIH today. Their contributions will continue to grow and support excellent research and patient care at NIH.

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