Patricia Allen
A joint practice
in the hospital
As we sat in the nursing office talking swallow, he’ll get a false reading that
about her joint practice in otolaryngol- it’s not leaking.”
ogy nursing, Elaine Henson-Archdea- Later, in a visit to the patient, Hen-
con, RN, picked up the phone to take a son-Archdeacon and t h e resident,
page. Gerald Zahtz, MD, took turns examin-
“I can’t come up right now,” she said ing the patient. The fistula wasn’t com-
to the caller. “Are you going to give him pletely closed, and Henson-Archdeacon
methylene blue now? Well, give it to explained the problem and shared his
him. Just be sure he swallows. Some- frustration about the delayed dis-
times they just hold it in their mouth charge. Then, after the resident left t o
and spit it out. He’s been getting just continue his rounds, she and the nurs-
tube feedings, so he hasn’t had a lot of ing care coordinator, Maryanne Gilles-
practice swallowing. Let me know what pie, RN, assisted the patient in learning
happens.” how to change his laryngectomy tube.
The caller was a medical resident in For three years, Henson-Archdeacon
otolaryngology. Their conversation il- has been in joint practice as a nurse
lustrated what she had been saying practitioner with Allan L Abramson,
about her evolving practice at Long Is- MD, director of otolaryngology at the
land Jewish-Hillside Medical Center. hospital. The position was established
The 693-bed hospital is located in the jointly by Director of Nursing Rachel
New York City suburb of New Hyde Rotkovich and Dr Abramson.
Park. In developing the nurse practitioner
“He wants me to check a man we did a role, the two realized that patients re-
laryngectomy on a month ago who has quire more than medical diagnosis and
developed a pharyngeal cutaneous fis- treatment for good health. They be-
tula,” she said. The patient’s discharge lieved that a properly prepared nurse
had been postponed until the fistula could learn basic otolaryngologic health
closed so he could swallow food. The screening and assessment ,adding these
staff had been using the blue dye to de- skills t o nursing’s counseling, teaching,
tect whether the fistula was mended. and psychosocial assessment skills.
“The resident hasn’t done this be- This nurse could be a coordinator of care
fore,” Henson-Archdeacon said, ((sohe’s within the hospital and in the commun-
checking with me. If the patient doesn’t ity-a link between patient and institu-
ti0n.l
From these general objectives, qual-
Patricia Allen is assistant editor of the AORN ifications €or the nurse practitioner at
Journal. their hospital were developed. Prepara-
d-
150 AORN Journal, July 1979, V o l 3 0 , No 1
Henson-Archdeacon, nurse
practitioner in otolaryngology,
talks with a medical resident who
is seeking advice on how to
check a patient with pharyngeal
cutaneous fistula. Later, (far right)
she collaborates with the
resident, Gerald Zahtz, MD, in
administering the dye to check
the patient’s fistula.
tion for the position includes a bacca- tional Joint Practice Commission. Es-
laureate degree in nursing and post- tablished in 1972 at the recommenda-
graduate study in a specialized clinical tion of the American Nurses’ Associa-
area of nursing. This specialty training tion and the American Medical Associa-
includes knowledge and skills once tion, the Commission has developed def-
solely in the domain of medicine. The initions and statements on new roles
nurse practitioner’s practice is charac- and relationship^.^
terized by close collaboration with Although joint practice is most com-
physicians, jointly providing care to a mon in physicians’ offices, clinics, and
clinically defined patient population.2 other outpatient setting^,^ it is also
Joint practice between nurses and being applied in hospitals. In these
physicians is a developing area of more complex organizations, issues of
health care in which the nurse, rather collaboration may also be more compli-
than assisting the physician, directly cated. There is great need for continuity
assists the patient by independently as- of care for hospital patients, but there
sessing and acting on his health needs. are also obstacles. Decisions must be
Usually, the nurse practitioner man- made about who the nurse practitioner
ages patients with routine minor and reports to, who will pay her, and how
chronic illnesses, and the physician she will be supervised. The role must be
manages patients with acute major or defined for the particular institution,
unstable chronic i l l n e ~ s e sThe
. ~ guiding and there must be agreement on basic
principle of joint practice is that both functions among department adminis-
physician and nurse plan their care trators. For the nurse practitioner in
around the patient rather than the the hospital, joint practice is compli-
physician delegating to the nurse. cated by the numbers of departments
A national focus for physician-nurse and individuals she must forge new re-
collaboration is provided by the Na- lationships with.
154 AORN Journal, July 1979, Vol30, No 1
In thinking about how their practice ganization chart, the nurse practitioner
might be linked more closely with falls under the nursing service, and her
physicians, OR nurses will want to be salary is paid out of that budget. For
aware of the application ofjoint practice supervision and evaluation, she reports
t o hospitals. OR nurses may encounter jointly to the nursing service and the
some of the same issues as Henson- otolaryngologist until he certifies her
Archdeacon. Administrative coopera- competencies in the newly acquired oto-
tion and support and professional ter- laryngology skills.
ritories would be two such issues. At present, there is no means avail-
For Henson-Archdeacon, establish- able for her to receive direct third-party
ing joint practice meant collaborating reimbursement from insurance com-
not only with Dr Abramson but also panies, although she has discussed the
with attending physicians and resi- possibility with the hospital's accoun-
dents in the Department of Otolaryn- tant. According to existing reimburse-
gology, the emergency room, and other ment policies, she must have a physi-
services treating otolaryngology pa- cian countersign bills even if she is the
tients. It also meant developing rapport only one who sees the patient. Simi-
with unit nurses, public health and vis- larly, she cannot prescribe drugs inde-
iting nurses, and with many kinds of pendently but must have a physician's
patients-private patients, Medicaid countersignature.
and Medicare patients, outpatients, and In addition to a baccalaureate degree
discharged patients in their homes who in nursing from Wagner College, New
need followup. York City, Henson-Archdeacon brought
The definition of the nurse prac- to the job 11 years of nursing experi-
titioner role was approved by the medi- ence, much of it at Long Island Jew-
cal executive committee of the hospital ish-Hillside Medical Center. She had
before she was employed. On the or- been a staff nurse, camp nurse, public
d-
AORN Journal, July 1979, Vol30, No 1 155
With Maryanne Gillespie, RN, nursing care coordinator,
Henson-Archdeacon instructs the patient in how to change his
laryngectomy tube.
health nurse, and had also practiced in those practicing in these fluid, evolving
inservice education, private duty, and areas. As her practice has grown, Hen-
nuclear medicine nursing. After accept- son-Archdeacon has realized the impor-
ing the position, she spent six months tance of strong interpersonal skills and
learning to do basic ear, nose, and an awareness of her limitations.
throat (ENT) assessments and exami- A short while later, she answered
nations. She attended medical specialty another page. A physician on another
courses in human head and neck anat- service was calling to ask about a pa-
omy, where she dissected a cadav- tient with tracheomalacia. He wanted
er. “I nearly passed out when they the nurse t o evaluate her for a speaking
handed me a head to dissect,” she said. tracheostomy tube and change the tube.
.
Then, at an affiliated hospital, she ex- “I have to be really careful of my re-
amined “scores of patients, looking at sponsibility here,” she said. “It’s not my
hundreds of noses, larynxes, and ears.” patient, and I’m not exactly sure of the
“Out of that I have achieved an exper- strength of the woman’s trachea. Not
tise in otolaryngology that physicians only that, she’s a 94-year-old alien who
not in this specialty often do not have,” speaks only French. The physician
she said, adding that nonspecialist might like me to go ahead and change
physicians often consult her about their the tube when he’s not there. I won’t do
patients. that, but I’ll change it with him. I won’t
No matter how well developed in- compromise.What if I took the tube out,
stitutional policies are, there is a need the trachea collapsed, and I couldn’t get
for a well-developed sense of profes- the tube back in? There are definite de-
sional and personal accountability for cisions you have t o make as you go
158 AORN Journal, July 1979, V o l 3 0 , No 1
The patient practices changing the
laryngectomy tube so he will be able to
perform this aspect of care when he
goes home.
along. was called to the emergency room (ER)
“I think you’re always responsible for to see a woman patient in respiratory
your own professional actions, so I carry distress. The director of otolaryngology
my own malpractice insurance,” she and the residents were in the OR and
said. “I evaluate each act to be sure it’s unavailable.
within my limitations. When the oto- After examining the patient’s larynx
laryngologist is teaching me a new skill, three times to be sure, she told the
he supervises me until he decides I’m physician at hand that it was perfectly
qualified and adept,” she added. normal. The physician treated the
As her practice has developed, Hen- woman for asthma, and she responded
son-Archdeacon has recognized the immediately. On the way out of the ER,
need to set different geographical limits Henson-Archdeacon encountered an
for her nursing and her medical func- ENT resident and asked him to verify
tions. her diagnosis. He did.
“In the beginning, I used to change “The next day, I got a call from the
tracheostomy tubes in patients’ homes, director of otolaryngology. He had re-
but I’ve decided against that because ceived a memo from the attending
I’m not sure of my coverage and physician in charge of the ER saying I
backup,” she said. “I consider myself to had been misrepresenting myself as a
have access to the physician and t o be physician,” Henson-Archdeacon said.
covered if I’m practicing in the institu- “Evidently, he had been observing
tion. It might not be direct supervision, while I conducted the examination. He
but he’s available.” spent several months writing memos,
She remembers a time when her turf but after awhile, the situation cooled
within the hospital was not as well es- down.”
tablished. One day, after she had been In contrast, Henson-Archdeacon does
in the position about four months, she not feel there are geographical limits to
AORN Journal, July 1979, V o l 3 0 , N o 1 161
Interpersonal skills
are key to success of
collaborative practice.
nursing care. She is active in coordinat- her role as coordinator, consultant, and
ing nursing care for otolaryngology pa- educator. “If there are procedures that
tients outside the hospital, a role she are new or different, I’ll speak with the
feels comfortable with because of her unit nursing staff to clarify with slides
public health background. With her or diagrams if necessary. Often, I’ll ob-
teaching and consultation, 11 families serve the procedure in the OR so I can
of children with tracheostomies are car- explain it and the care required after-
ing for them at home. She makes predis- ward.
charge home visits to assess the ability “As a specialist, I can provide unit
of the family to provide care and then nurses with details about patient care
spends 20 to 30 hours teaching them and feedback about patients after dis-
total tracheostomy care. charge. They seem to feel that nursing
When referrals to public health or vis- consultants are helpful and make their
iting nurses are called for, Henson- jobs easier. It also helps that I came
Archdeacon invites them to the hospital from the nursing grassroots in this hos-
rather than sending a referral through pital and have worked with them
the mail. “This introduction and orien- through the years.”
tation gives the public health nurse Patients have also been receptive to
built-in credibility, gives the family the nurse practitioner. “I think if the
continuity, and assures us that these nurse practitioner is supported and
nurses know our criteria for care,” she given credibility by the physician from
said. the outset, and they meet the patients
Interpersonal skills are a key to the and families together, there’s abso-
success of collaborative practice, Hen- lutely no objection to the nurse prac-
son-Archdeacon believes. In fact, these titioner managing care,” Henson-
skills may be the deciding factor in the Archdeacon said. “In fact, patients feel
effectiveness of the practitioner. comfortable calling and asking ques-
“There’s mutual trust that develops be- tions they might not ask a physician.”
tween the nurse practitioner and the She gives her home phone number to
physicians,’’ she said. Yt’s not just patients with critical conditions who
granted with the titles. It’s developed are at home in case they need to consult
over time, after many experiences to- on an emergency. Then she can advise
gether.” them and make arrangements for them
With nurses and patients, too, her re- to be met at the hospital if necessary.
lationships have grown and become Having worked both with wealthy
stronger. “I have found acceptance from suburbanites and patients on Medicaid,
nurses to be phenomenal,” she said of Henson-Archdeacon has noticed no dif-
162 AORN Journal, July 1979, V o l 3 0 , No 1
ference in their willingness to accept time to provide for these.”
care from the nurse practitioner. Henson-Archdeacon advised OR
For her, joint practice extends beyond nurses t o take advantage of oppor-
nursing and medicine. That afternoon, tunities t o grow in their practices,
she planned to join a hospital social acknowledging that often physicians
worker in meeting with a cancer patient hold the power to help nurses grow.
and his wife. Because the patient had “I’m sure there are a lot of physicians
had a maximum dose of radiation to in this country who are becoming more
treat a tumor in his neck, surgeons had open and receptive to joint practice.
recommended removal of part of the jaw Once a physician works with you and
bone as his only chance for cure. sees the caliber of service you provide,
“I want to meet with them and go into things change,” she said. “He sees the
exactly how disfiguring the surgery will satisfaction and increased compliance
be and help the patient decide whether of his clients with the regimen of care,
this is a procedure he can live with,” she because they have been included in that
said. “The patient is scared to death, plan of care. This is something he hasn’t
and his wife is even more scared. But his been able to do, and he will call on you
chances are best with surgery. I need again and again. And he will recom-
the social worker t o give me her mend you t o his colleagues. These are
perspective.” very subtle gains, but they are excit-
Henson-Archdeacon discussed how ing.” 0
she had resolved her questions about Notes
her identity in the expanded role. “First 1. Elaine Henson-Archdeacon, Allan Abramson,
I thought I was a physician’s assistant, “Role of the nurse practitioner in otolaryngology,”
then I thought I was a medical role paper presented at the American Academy of Oto-
model,” she said. “Finally I realized that laryngology meeting, Las Vegas, Sept 10-14, 1978,
2.
the acquired medical skills serve as a 2. /bid, 3.
tool that you incorporate back into nurs- 3. Kathleen Cavanah Brown, “Nature and
ing. It’s much easier now that I know scope of services: Joint practice,”JournalofNursing
what I really do is nursing.” Administration 7 (December 1977) 13-15.
“I think a nurse has a different focus 4. “Three statements from the National Joint
Practice Commission,” Supervisor Nurse 8
t h a n a physician,” she continued. (November 1977) 20-21.
“When she incorporates medical skills 5. Berton RouechB, ed., Together: A Casebook
into nursing, she can provide more com- of Joint Practice in Primary Care (Chicago: National
prehensive care. Certainly, you can Joint Practice Commission, 1977) vii.
make a diagnosis by looking in the ear,
but then you have the sensitivity to
share what you have found with the
family and patient-to educate them.
“I have to approach the family, ex-
plain the procedure in terms a physician
might not use, and take the time to work
with them that a physician might not
have. I think the physician has realized
that medical care is just a part of the
patient’s needs. There are education,
counseling, and psychosocial needs.
Perhaps someone other than the physi-
cian is better prepared and has more
164 AORN Journal, July 1979, V o l 3 0 , No 1
