At the Heart of Health Care
Not quite physician, not quite nurse, the nurse practitioner inhabits
a fuzzy domain. Like nurses, NPs are interested in promoting health-in
fact, teaching patients about nutrition, stress reduction and disease
prevention is their top priority. But like physicians, NPs can also
prescribe medication, make referrals to specialists, order and interpret
laboratory studies, diagnose and treat common illnesses and injuries,
and provide follow-up care. "The beauty of it all is that they're
a blend of both roles," says Deborah Dang, director of nursing
professional programs. "For the patient, nurse practitioners represent
a perfect bridge between nursing and doctors."
The first NP program, established to help improve children's access
to health care, opened at the University of Colorado in 1965. Today,
more than 200 universities and colleges, including Hopkins, are educating
nurses to provide lower-cost, direct patient care. NPs are educated
at the master's level and are licensed and certified in various areas,
including adult, family, women, newborns, the elderly, children, mental
health and acute care.
Scores of NPs are employed by the University, and within the Department
of Nursing, 63 NPs are practicing in acute care and outpatient clinics
throughout Hopkins hospital, in departments like surgery, medicine,
emergency medicine, oncology and pediatrics. Particularly in surgery,
the ranks of NPs are swelling. "They can be especially helpful
on the unit while the physicians are in the OR," explains Dang.
Here are a few examples-in both primary and acute care settings-of the
complex roles these health advocates play.
The NPs on Halsted 5
Seven years ago, a new service staffed entirely by nurse practitioners
revolutionized the pattern of inpatient cardiac care on Halsted 5. The
nurse practitioner service has since grown into a team of five NPs.
Everyday, two to three of them, on average, manage as many as 16 patients
a day. The team works with physicians to treat patients undergoing various
diagnostic and interventional cardiac procedures, handling both routine
care and any crises that may arise from admission to discharge.
Originally, this had been the terrain of medical residents and interns.
But as medical education evolved to include more outpatient coverage,
and as interns, particularly in the mid-1990s, were pulled away to shore
up the shortage of physicians in primary care, nurse practitioners were
called on to fill the gap in acute care.
NPs were a logical fit. "Initially, no one knew what a nurse practitioner
could do in this setting, and I think the physicians were surprised
at the depth of our knowledge and what we could provide," says
Diane Law, the first NP on the service. "We have training in both
disciplines: Our basic education is in nursing, but our advanced education
is in medical diagnosis and management. Because of that, we're also
natural liaisons between the medical staff and nurses. Nurses come to
us when they need some help, whether they're on Halsted 5 or the other
floors in Medicine."
"We make them feel at ease because we've been where they are,"
explains NP Marylin Schactman, who has been with the service for six
years. "We love them!" Barb Dauses, charge nurse on Halsted
5, says of the NPs. "They know the ropes and they're approachable."
The NP service has wide-ranging responsibilities, including patient
education and precepting students in nurse practitioner programs at
both Hopkins and the University of Maryland. Because an NP's time on
the unit isn't constrained by making rounds, the service is highly efficient-better
for both the patient and the budget. "Something like 70 percent
of our patients leave in 24 hours, with an average length of stay of
about two days," says Schactman. "The physicians trust the
care we deliver. We're thorough, because as nurses we view a patient
holistically. It's not just about their coronary disease. It's about
who they're going home with. Do they need a nutritional consult? A rehab
Something must be working, because six months ago, Hopkins' cardiac
surgery team took the Halsted 5 model and launched an NP service of
its own. "We're making a difference," says Halsted 5 NP Shelly
Conaway. "When our patients are discharged, they're lots better
off than they were when they came in. That's the bottom line."
A 15-year, veteran neonatal nurse practitioner, Yolanda Ogbolu practices
on the neonatal intensive care unit at Johns Hopkins Bayview Medical
Center. Her talents, though, are hardly limited to her native Baltimore.
This past winter, Ogbolu shared her specialized skills on an international
level when she traveled to Nigeria to teach neonatal resuscitation.
Certified as an instructor in 1998 in the American Heart Association
and American Academy of Pediatrics' Neonatal Resuscitation Program (NRP),
Ogbolu was invited to teach the course at Fati Lami Women's and Children's
Hospital in Kebbi State, Nigeria. In a country in which the number of
infant deaths is 72.3 per 1,000 live births, compared to 6.6 deaths
per 1,000 in America, the need is especially pressing. For Ogbolu, who
long had dreamed of going to Africa to teach, it was a mission made
to order. "I felt that if I could teach even one person who could
then save 100 lives, I could make an impact."
Overcoming initial self-doubts about cultural and religious differences,
language barriers and gender issues, and using her own resources and
vacation time, Ogbolu took her family to Nigeria for the winter holidays.
She taught NR to a diverse group of 48 students consisting of village
community health nurses, midwives, obstetricians, general practitioners
and medical students. Enrollment was more than double the expected group
of 20 students. The one-day course extended to two days. The 10 texts
and used equipment donated by Bayview's maternal and child staff were
Now Ogbolu is back at Bayview where, as part of a team of seven NPs
who work independently on the 25-bed, level III NICU, she provides acute
care and intensive management for pre- and full-term infants. The NPs
attend high-risk deliveries, round daily with the neonatologists and
perform procedures such as inserting breathing tubes, chest tubes, intravenous
and intra-arterial lines, and resuscitating critically ill babies. As
NICU team members, they are always available to provide medical leadership
and education to the registered nurses on the floor.
In her "spare time," between her NP work and her family (she
has three children, ages 13 months to 20 years), Ogbolu is already preparing
to return to Nigeria. She is writing letters to the Nigerian and United
States governments requesting help to set up a regional instruction
training program. Because simple resuscitation equipment, such as ambu
bags, bulb syringes and feeding tubes, are in short supply in Nigerian
villages, she is locating the funding to purchase it. And, she is taking
the regional trainers certification course so she can "train the
trainers" and help the communities build self-sufficient programs.
She is fulfilling her dream and then some.
Becoming a primary care nurse practitioner in the adolescent clinic
was "a natural evolution" for MaryLou Rosenblatt. Having earned
her nursing degree in 1976 and then working for three years in the pediatric
intensive care unit at Hopkins Hospital, she was ready for regular hours,
kids who weren't acutely ill, and an advanced degree.
So Rosenblatt went back to school and earned a master's degree, completing
her thesis in how adolescents make decisions. She took a nurse practitioner
position split between two Hopkins pediatric clinics. Then in 1987,
Rosenblatt was promoted to senior nurse practitioner in the adolescent
clinic, where she now sees 10- to 21-year-olds in her office and adjoining
exam room in the Jefferson Street Building.
"Most of my job is patient care," she says. "Teens come
in for physicals or for illnesses. They might call me, or they might
just pop in. They could have reproductive health issues, or asthma,
or depression-pretty much everything you can think of. Most of the kids
I see are actually healthy, they just have something to talk about in
a certain area. We talk about issues at home, at school; about drugs,
alcohol, cigarettes. And I try to involve the parents."
In the primary care setting, the lines between nurse practitioner and
physician can blur. "Patients often call me 'Dr. Rosenblatt,'"
she says, then clarifies: "I'm looking for common problems, like
ear infections, belly aches, sore throats. If a patient were to come
in with an STD, I would do the exam, get specimens and send cultures.
If they needed medication, I'd prescribe it. Physicians have a much
deeper training. They're fine-tuned to their specialty, and they're
there for me as a resource if something seems a bit off. In my mind,
the difference is the general health and wellness perspective [nurse
practitioner] versus the specific illness and cure perspective [physician]."
Rosenblatt stresses the importance of the health education and prevention
portion of her job, and of treating what she calls "the whole person"-looking
not just at physical aspects of health, but also the mental or environmental
factors that can compound health issues. "Reading between the lines,
figuring out what the patient is really there for is something I've
gotten good at over the years. One of the best parts about being here
as long as I have is that my older patients are now bringing their own
kids in. People tend to stick with you once you've developed that trust."
After practicing as an RN in a hospital emergency department, Deborah
Starr decided she was ready for more. Seeking a means to blend her nursing
and health promotion expertise with her medical skills, she enrolled
in a nurse practitioner's program and went on to use her NP talents
in a variety of settings, including a retirement community, primary
care and a college health center. Then, five years ago, Starr found
her niche in acute care at Johns Hopkins Bayview Medical Center on the
Zieve Medical Unit.
In the past, NPs certified in acute care (Starr is triple certified
in adult health, women's health and acute care, and certified in therapeutic
touch) had practiced principally in the emergency room or ICU. The Bayview
unit was the setting for one of the first acute care programs for NPs
in internal medicine in the nation.
Today, Starr practices there as part of the collaborative inpatient
medical service, or CIMS. She is part of a medical team that consists
of five NPs, five physician assistants and five hospitalists (see article,
page one). There are no house staff on the service. All providers on
the team are partners and have an equal and collaborative voice. On
any given day, 40 percent of the approximately 72 medicine patients
are assigned to the CIMS team. Patients with highly complex diagnoses
or those with "high teaching value" are admitted to the house
On CIMS, typical patient medical diagnoses include chest pain, congestive
heart failure, cellulitis, pancreatitis and uncontrolled diabetes. The
NPs manage the medical care on the floor, performing physical exams
and assessing labs, ECGs and test results. They provide patient education,
discharge planning and preventive health counseling.
"Patients benefit from comprehensive discharge planning and education,"
says Starr. "The hospital benefits because the team, with the two
master's-prepared nurses and a hospitalist on the medicine unit daily,
is an accessible resource to nurses and house staff."
The team also provides stability and continuity to the medicine unit,
she adds, without overburdening residents and house staff. As the team's
senior nurse practitioner, Starr plans to maximize opportunities for
mentoring, research and academic pursuits for the NP/physician assistant
group. "CIMS is continually evolving," says Starr, "and
as it grows, my goal is to pull everyone together into a cohesive team."