Although nursing and other unions have included advanced practice nurses (APNs) in collective bargaining units, there is a universal and often un-discussed perception that nurse practitioners, clinical nurse specialists and nurse midwives are not especially well served by collective bargaining units. In response to these contentions, as well as to address presumptions related to APN need, we have developed a series of communications to review nursing practitioner issues and needs best addressed through the collective bargaining process.

Note: While the focus is on the role of the nurse practitioner as part or the lead of the hospitalist team, many hospitals also use critical care registered nurses as part of the hospitalist team and their rights should be protected through the collective bargaining process.

The traditional role of the nurse practitioner has been primary care, with emphasis on health promotion, illness prevention, and management of common ambulatory health problems. By the 1990s, the evolution of the role of the acute care nurse practitioner (ACNP) highlighted the diagnostic and management skills of nurse practitioners and the specialized knowledge necessary to care for patients with acute illnesses. More than 70 graduate programs are training ACNPs today (1).

Many hospitals have been hiring or adapting this specialty role of the nurse practitioner to serve as hospitalists. In this model, the nurse practitioner usually admits the patient, performs some emergency procedures and either monitors or helps the hospitalist monitor the patient (2). Other hospitals, after seeing the benefits of utilizing ACNPs in the role hire nurse practitioners without specialized education to fulfill this role and have come to adapt the role to hospital policies. (3).

Studies have been conducted of nurse who serve as hospitalists are on teams with hospitalists. Conducted in various settings and on various units, all have found benefits in the use of nurse practitioners as hospitalists (4). "Systems such as the VA have historically made more use of nurse practitioners," says Lucy N. Marion, PhD, RN, professor and associate dean of academic nursing at the University of Illinois at Chicago School of Nursing.

At the University of Virginia Health System, for example, "a nurse practitioner model introduced in the neurosciences area in 1999 cut about 2,000 inpatient days on a similar volume and case mix of patients, resulting in a $2.4 million savings the first year," says Dale Shaw, RN. "This on an investment of about $150,000 in salaries and benefits--a return on investment of about 1,600 percent."

At the University Hospitals Health System, Cleveland, "nurse practitioners not only serve as dedicated care managers in high-intensity service areas, including heart failure, they also admit and supervise general medical patients," says Robin J. Rowell-Leinweber, RN, manager of the nurse practitioner service.

The University of California, San Francisco, Medical Center, an academic facility used changes in healthcare delivery to incorporate creative models of care in the medical service. One such model included the use of hospitalists and ACNPs primarily to expand the medical service's capacity, but also to improve the efficiency and quality of patients' care.

A growing number of hospitals are suing MD hospitalists, physicians who are specialized in hospital care, to manage patients while they are at the hospital. However, attending physicians in academic medical centers usually cannot spend enough time on inpatient activities to meet the definition of a hospitalist. In many places, it is not feasible to have full-time MD hospitalists at the bedside; and non-hospitalist attending physicians in academic medical centers do not spend as much time as hospitalists in inpatient care setting. Thus, studies of hospitalists tend to reflect use of multidisciplinary teams. A 2002 study supported by the Agency for Healthcare Research and Quality (HS10734) indicated that teams comprised of multidisciplinary physicians and nurse practitioners (NPs), working together on daily rounds and post-discharge patient follow up, can reduce the costs of inpatient care (5). This study, combined with the body of studies of nurse practitioners used in this role, specifically supports the quality of care and economies of scale offered with the inclusion of nurse practitioners and clinical nurse specialists on hospitalists teams (6).

NPs followed protocols to minimize overuse of unneeded services, such as limiting the use of cardiac monitoring and narrowing use of broad-spectrum antibiotics when indicated. Intervention costs were $1,187 per patient and were associated with a significant $3,331 reduction in usual care costs. About $1,947 of the savings were realized during the initial hospital stay, with the remainder attributable to reductions in post-discharge service use. A reasonable estimate of the cost offset was $2,165, minus an estimated $1,187 per-patient cost for the intervention, for a net cost savings of $978 per patient. Patient perceptions of care and health-related quality of life were at least as good for intervention as usual care patients (7-9).

When nurse practitioners or clinical nurse specialists are tasked with this role or the role of interventionist (10), the collective bargaining unit should immediately review the collective bargaining agreement to ascertain whether it addresses the following concerns:

Note: Many have questioned whether this hospitalists role is being used in the collective bargaining setting. As I wrote this e-blast, I conducted a survey of the internet listings for nurse practitioner hospitalists and found advertising for such services at the following collective bargaining and non-collective bargaining institutions: Exeter Health Resources, Exeter, Massachusetts, OhioHealth, Columbus, Ohio; Baptist Health, Jacksonville, Florida, Team Health, Tifton, Georgia, The Hospitalists Company, Quincy, Massachusetts, Fairview Health Services, Minnesota; Hospitalists Management Group, New York, New York; Aspirus Clinic, Wasau, Wisconsin; Spartanburg Regional Healthcare System, Spartanburg, S.C. Additionally, I also found advertisements for RN hospitalists and RNs to work in Critical Care Centers with hospitalists.

In the 1990s, hospitals, like all other organizations that bill Medicare, experienced declining reimbursement for residency training programs (13). Combined with the guidelines that limit medical residents to 80 hours per week implemented by the Accreditation Council for Graduate Medical Education five years ago, a need emerged which highlighted the unique skills and expertise of nurse practitioners. More importantly, when nurse practitioners or clinical nurse specialists are utilized in this role, hospital and nursing staffs have documented hospital savings and improved patient outcomes. During the collective bargaining process unions should request financial information to ascertain benefits and hospital savings accrued from the utilization of APN nurses as hospitalists and negotiate bonuses which are calculated based on the savings benefit accrued from expansion of the role. Places to look for nurse hospitalists through the information request process include the following:

• NPs who have been given the authority to do preoperative workups are usually working as hospitalists thereby decreasing laboratory costs and surgical delays. Request position descriptions of NPs to ascertain if the hospital clearly delineates between the role of the hospitalists and the NP as the primary care providers. Also discuss this issue with bargaining unit NPs who can tell you other areas where their work has been documented;
• NPs and CNSs are tasked with the authority to develop guidelines and education for individualized patient care. Additional cost savings result from the development of guidelines to individualize patient care. Again, ask for the position descriptions of the NP and CNS who function in these roles to ascertain whether this function has been incorporated into their role; also request quality information on the benefits of the guidelines and individualized patient care plans;
• NPs and CNS who discusss or who can s how they work with physicians to decrease lengths of stay for seriously injured patients, decrease lengths of stay for seriously injured patients, improve documentation in medical records, decrease waiting time in the outpatient clinics and reduce complaints from patients obviously have been given quality indicators or other research methodology for documenting the benefits of the service. Ask the APN to review the information request to ensure you are able to properly request all documentation of quality care;
• Critical care coordinators who tend to be registered nurses working on the multidisciplinary hospitalist team or with MD hospitalists should obtain additional compensation for this role. Ask the RNs if there is a hospitalist team with RNs working with the team. Often the hospital will avoid the coordinator title, but find out if RNs are filling this role; and
• Units with staffing of nurse practitioners to address acute care needs such as stroke, MI in emergency rooms, typically are utilizing NPs as hospitalists.

As the role has been defined and implemented, the nurse hospitalist tends to work with both staffs (11). Combining the unique education and nursing skills, the hospitalist not only diagnoses, but often provides direct care for his/her patients. Thus, there should be language within the collective bargaining agreement that clarifies who directs and supervises nurse practitioner practice as well as who evaluates their practices.

Many collective bargaining agreements have career ladders which tend to place nurse practitioners in the upper mid-level for entry to the top levels as experienced NPs. These levels should be adjusted to promotion and wage increase potential comparable to RN managers. The NP who chooses to work bedside should not be penalized for clinical practice, especially when that practice benefits the hospital (12).

Unless the hospital specifically hires critical care nurse practitioners, the nurse practitioner who has been moved to this role should immediately have the opportunity to participate in grand rounds and participate in multidisciplinary teaching and education sessions. And, the educational component of this practice should be incorporated into the nurse's position description. Likewise, should a nurse practitioner or clinical nurse specialist who has been moved into this role choose to go back to school to obtain acute care nurse practitioner specialty certification, the hospital or health institution should be required to pay for the courses necessary for specialty certification.

To maximize savings many hospitals attempt to under-staff nurse practitioners requiring doubling of shifts. When negotiating nurse practitioner hospitalists provisions, use financial and quality data to reinforce the overall net profits obtained from using nurse practitioners in this role. Over and over again, the data reflect decreased hospital stays and improved care which pays for the use of nurse practitioners within this role.

Some hospitals maintain their own quality data and research, which is used to improve quality within care settings, while others keep data in response to mandated reporting requirements developed through legislation.

Check with your legislative unit and/or with the state hospital association to ascertain whether the state requires the retention of hospital quality data and if so, whether that data may benefit you.

If the hospital is required to report the data to the state, we recommend requesting the data periodically prior to the initiation of the collective bargaining process directly from the state agency. Also, some hospitals and health institutions are voluntarily reporting on quality and evidenced based practice through participation in government studies or data collection programs (NDNQI). Request this information prior to the collective bargaining period. You can cross-reference that data requested against information provided by the hospital in response to information requests.

References

1. Kleinpell, RM, Perez, DF, McLaughlin, R. Educational options for acute care nurse practitioner practice, J Am Acad Nurse Pract. 2005 Nov; 17 (11): 460-71.
2. Chris Schrieber, Boon or Bust? Nurse Practitioners as part of the on-site hospitalist team, NurseWeek, March 25, 2000 as found at Nurseweek.
3. Deborah Gesensway, Why hospitalists may be destined to become the first responders for inpatient stroke, Today's Hospitalist 2007 as found at Today's Hospitalist
4. See Howie, Jill, Erickson, Mitchel, Acute Care Nurse Practitioners: Creating a Model of Care for an Inpatient General Medical Service, AJCC 11(5):448 (2002). This article also includes citations and summaries of studies conducted related to the use of nurse practitioners in impatient settings from 1998 to 2002 as found at AJCC
5. Physician/NP teams can reduce the costs while maintaining care quality.(MEDSURG MINUTE) (nurse practitioners) (brief article), as found at MedSurg Nursing, August 1, 2007 Acute Care/Hospitalization, Collaboration of hospitalists/attending physicians and nurse practitioners can reduce hospital stays and increase profit found at: AHRQ Acute Care/Hospitalization, Multidisciplinary physician/nurse practitioner teams can reduce the costs of hospital care while maintaining care quality as found at : AHRQ
6. See also "An alternative approach to reducing the costs of patient care? A controlled trial of the multi-disciplinary doctor-nurse practitioner (MDNP) model," by Susan L. Ettner, Ph.D., Jenny Kotlerman, M.S., Abdelmonem Afifi, Ph.D., and others in the January 2006 as found at Medical Decision Making 26, pp. 9-17
7. "The effect of a multidisciplinary hospitalist/physician and advanced practice nurse ollaboration on hospital costs," by Dr. Cowan, Martin Shapiro, Ph.D., M.D., Ron D. Hays, Ph.D., and others, in the February 2006 as discussed at: Journal of Nursing Administration 36(2), pp. 79-85, with abstract
8. Berthold, Jessica, Eliminating disparities in stroke outcomes, ACP Hospitalist, 2008 as found at ACP Online
9. Logan, Paul, The acute care nurse practitioner as hospitalist, as found at Nurse Practitioner, 1999
10. Howie and Erickson, ibid.
11. Larking, Howard, The Case For Nurse Practitioners as reported at Hospitals and Health Networks