National Nurses Week is a time to celebrate the diverse ways in which nurses touch people's lives and to thank them for all the hard work they do. Nurses provide the bulk of patient care, and yet the pivotal role they play is rarely credited.

Today, with residents mandated to work fewer hours and with the influx of registered nurses still dwindling, a nurse's job is more challenging than ever. Increasingly, one type of advanced practice nurse is stepping into the critical crossroads between doctors and nurses: the nurse practitioner.

Nurse practitioners, from left, Diane Law, Marylin Schactman and Linda Hutchins on Halsted 5 (not pictured: Cheryl Bridges, Shelly Conaway) Deborah Starr on Bayview's CIMS Yolanda Ogbolu on Bayview's NICU MaryLou Rosenblatt in the Adolescent Clinic.

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 arrangement?"

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."

-Lindsay Roylance

Yolanda Ogbolu

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 a hit.

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.

-Suzy Harrington

MaryLou Rosenblatt

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."

-LR

Deborah Starr

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 staff.

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."

-SH