New Role for Nurse Practitioners - The Hospitalist

By Linda Sullivan DSN, FNP-BC, PNP-BC
Director of Advanced Practice, Mississippi Board of Nursing

We've come a long way baby,” or so the saying goes. Dr. Loretta Ford and Dr. Henry Silver probably had no idea when they created the role of pediatric nurse practitioner nearly 40 years ago just how far we would come. The nurse practitioner role was developed in 1965 at Colorado University Schools of Nursing and Medicine when a shortage of primary care physicians provided an opportunity to demonstrate advanced practice in nursing. Drawing from Dr. Ford’s background as a public health nurse and Dr. Silver’s pediatric expertise, an advanced educational program that focused on the expansion and empowerment of the registered nurse’s role in health care delivery was developed. Today, as the health care provider shortages continue and fewer doctors enter into the family or general practice specialties, those shortages are felt even more by those that can least afford to go without care. Nurse practitioners have long helped to fill the void for those patients who are poor and without medical services.  Today, many nurse practitioners practice in areas that would otherwise be without available health care.  Nurse practitioners currently practice in primary, tertiary, and long term care settings all over the state.  As the practice of nursing evolves so do opportunities for practice broaden and become more inclusive of many areas that we heretofore did not anticipate becoming involved. 

The role of the Hospitalist is a relatively new role for health care providers.  It is only in the last 10 years that medical schools have introduced this role with some programs now offering residencies in this area of practice.  Broadly defined, the Hospitalist is a health care provider who is a hospital-based practitioner.  Hospitalists assume the care of hospitalized patients in place of the patients' primary care physician while that patient is in the hospital and, once discharged, the patient is referred back to the primary health care provider.

The term "Hospitalist" was first introduced in 1996 by R.M. Wachter and L. Goldman to describe physicians who devote much of their professional time and focus to the care of hospitalized patients.  The Hospitalist model is growing rapidly as a result of the role of managed care organizations, the increasing complexity of inpatient care, and the pressures of busy outpatient practices.  Today, many institutions have “Hospitalist Teams” which are composed of physicians, nurse practitioners and physician assistants.  The team’s job is to care for the patient who is in the hospital and allow the primary care provider more time to concentrate on out-patient care.  While there has been some criticism of this role from both health care providers and consumers, it was born out of necessity and seems to support quality of care for those patients who are referred to the team.  Studies have determined that care of the patient by the team provides quality care for the patient and patient outcomes have improved since instituting this role in the hospital setting.

When exploring roles for the nurse practitioner, the Hospitalist emerged as a likely role for the acute care practitioner.  When investigating who was best prepared for the role and examining of how advanced practice nurses were currently being utilized in the hospital, it was clear that when functioning within the scope of practice delineated for each specialty, other specialties could also fill this role.

The Mississippi Board of Nursing recently began to explore how best to define the role of Hospitalist for the advanced practice nurse and, working with a variety of nurses and reviewing the current literature related to the nurse practitioner and the role, the Board developed a definition for this role. The following definition reflects what evolved from extensive discussion and research and will, for the time being, serve as a guide for role description of the Hospitalist nurse practitioner in the state of Mississippi. Other states may have, or may be working toward, similar definitions.

The Hospitalist is a nationally certified nurse practitioner whose primary practice site is the hospital and one who has no outside primary or tertiary practice site.  He/she will be part of a Hospitalist team that can consist of other nurse practitioners, physician assistants and at least one physician whose specialty/practice is compatible with the training of the nurse practitioner.  The most likely specialties to practice in this role would be the Acute Care Practitioner and the Family Nurse Practitioner with each paying great regard to their scope of practice as outlined by their national certification and licensure organizations.  It is possible that other specialties (i.e. GNP, PNP) may be considered a part of the Hospitalist team, but this would be only when that person meets all the criteria set forth in this role description and meets the criteria set forth by the institution.

 The extent of involvement for the nurse practitioner will depend on the degree of complexity and acuity of the patient and the training experiences of the nurse practitioner. Generally, duties of the nurse practitioner will include, but not be limited to: 

• Admit and discharge patients;
• Manage the care of patients who are hospitalized with simple to complex acute health problems with the collaboration of the   physician Hospitalist;
• Make rounds on patients and write orders as needed;
• Perform skills/procedures that are within the scope of practice;
• Order and interpret laboratory and diagnostic tests;
• Diagnose common health problems;
• Prescribe medications and interventions for the treatment of health problems; and
• Plan and coordinate the discharge, rehabilitation, home health care and follow-up of patients with acute health problems.

The Hospitalist nurse practitioner will be a valuable member of the Hospitalist team and will provide yet another avenue for improving health for the citizens of Mississippi and other states that share a similar resolve.