The safety net for health care in the United States is becoming increasingly strained by an aging population, more uninsured low-income Americans, impending health care reform, and a shrinking physician workforce. States are challenged to devise alternative solutions to meet the health care needs of their citizens, particularly those who are uninsured, publicly funded, and dependent on community clinics and health centers for their primary and specialty services. In California, the problem is especially acute when accessing orthopedic care. According to the statewide community clinics’ 2007 Specialty Care Access Survey of California, the typical waiting period for the most acutely ill orthopedic patients ranged from 1 to 3 months (Canin & Wunsch, 2009). Nurse practitioners (NPs) can improve access to care, but few are prepared in orthopedics. The development of the Doctor of Nursing Practice (DNP) degree by the American Association of Colleges of Nursing (AACN, 2006) was designed to prepare nurses at the highest level of nursing practice. The Institute of Medicine’s (IOM, 2010) call for the implementation of residency programs to facilitate the transition of advanced practice nurses into a new area of clinical practice, such as an orthopedic residency specialty for NPs within the DNP, is one option to make orthopedic care more available to low-income patients.
For the master’s-prepared NP desiring specialty preparation, an orthopedic specialty within the DNP fits well with the intent of the AACN (2006) to create a practice-focused nursing doctorate and is consistent with the licensure, accreditation, certification, education model proposed by the National Council of State Boards of Nursing (2008) that places specialty preparation beyond the population focus. The DNP awards the graduate with a terminal degree and eliminates the need for post-Master of Science in Nursing (MSN) certificates that leave the graduate holding only the master’s degree. Because DNP programs require a practice immersion experience, variously referred to as the DNP residency, the option of an orthopedic specialty within the DNP allows the NP to make the transition to orthopedic practice with the appropriate didactic foundation and clinical supervision by qualified faculty, as the IOM report (2010) advocates. Within this context, we explore the need for orthopedic care and, using the logic model for program planning and evaluation (W.K. Kellogg Foundation, 2004), describe a process for establishing an orthopedic DNP residency program for NPs that will lead graduates to achieve national board certification in specialty practice as orthopedic NPs.
Access to Orthopedic Care
The supply of orthopedic surgeons is projected to be outpaced by the future demand for orthopedic service. According to an American Academy of Orthopedic Surgeons (2011) report, the supply of general orthopedic surgeons is dwindling because the rate of newly trained physicians in this specialty is not keeping pace with the expected number of retiring orthopedic surgeons. In addition, more surgeons are becoming highly specialized in orthopedic subspecialties such as sports medicine or total joint replacement. At the same time, the demand for orthopedic services is expected to rise for several reasons: (a) the aging population is increasing, (b) rising fracture rates are occurring as a result of the high rates of osteoporosis, and (c) the obesity epidemic is leading to greater damage to load-bearing limbs and joints.
Existing Models of NP Orthopedic Care
Evidence exists regarding the effectiveness of current models of orthopedic care provided by NPs across the United States. Canin and Wunsch (2009) described the existing specialty care practice in California of using NPs in high-demand specialties, including orthopedics. According to their study, NPs were used in a broad range of inpatient and outpatient orthopedic settings, as well as in community clinics. At one large health maintenance organization, NPs and physician assistants manage 80% to 90% of patient cases, with the remaining more complex surgical cases being referred to surgeons.
In another study, NPs were found to provide more cost-effective specialty care, as they often generated more revenue than the cost of their compensation (Dower & Christian, 2009). In addition to the financial benefits discovered in that study, the integration of NPs into specialty practice also improved access to care and the quality of care, as measured by the decreased waiting times for patients to get an appointment, the increased number of patients seen, and the improved coordination of care, which led to improved patient satisfaction scores. Additional outcome data on NPs in specialty care included more time for physicians to attend to complex cases, shortened hospital length of stay, and reduced readmission rates for hospitalized patients (Dower & Christian, 2009).
Existing Orthopedic NP Programs
Historically, on-the-job training and physician mentoring have been the primary means to prepare orthopedic NPs. Although a few orthopedic NP programs do exist, none are currently situated at the doctoral level. Regardless of the type of preparation, NPs with a minimum of 2,500 hours of orthopedic experience are eligible to take the national Orthopedic Nurse Practitioner Certification Examination. This examination was first offered in 2007 by the Orthopedic Nurse Certification Board (ONCB). The ONCB’s (2012) published statistics indicate that the examination pass rate in 2011 was 72.2%.
Use of the Logic Model to Plan and Evaluate a DNP Orthopedic Residency
Given the identified community need for more orthopedic providers, including NPs, the logic model (W.K. Kellogg Foundation, 2004) can serve as a roadmap for stakeholders to guide this process. This model has been used by educators in nursing and other disciplines to develop and evaluate new programs (Armstrong & Barsion, 2006; Dykeman, MacIntosh, Seaman, & Davidson, 2003; Ellermann, Kataoka-Yahiro, & Wong, 2006; Hulton, 2007; Lane & Martin, 2005; MacFee, 2009; Medeiros et al., 2005). The logic model indicates the resources (input) needed to achieve this goal, the actions (activities) that are required, and the curriculum (output), results (outcomes), and improved access to orthopedic care (impact) that we expect to achieve.
Any new residency option should adhere to existing national guidelines and the academic requirements within the individual school. The standards for the orthopedic specialty are provided by the ONCB, which stipulates the required content and role knowledge domains and the clinical eligibility criteria for their examination (ONCB, 2012). Existing post-MSN DNP programs for NPs with a residency requirement of additional direct care clinical hours in a defined area of practice could include the option for a specialty focus.
In addition to having an established educational framework for this specialty, it is essential to have a board-certified NP in orthopedics who has teaching experience and the availability to serve as faculty and liaison to the local orthopedic community. Thus, we recruited a board-certified orthopedic NP (D.M.P.) with teaching experience to the inaugural class of our post-MSN DNP program. She provides the expertise for curriculum development, teaching, and clinical supervision, particularly because education at this level requires students to integrate orthopedic practice with the scholarship and leadership expectations of the DNP degree.
As with any new academic initiative that addresses a community need, building stakeholder support for the orthopedic residency and future employment requires a pool of potential students; administrative approvals; faculty and employer buy-in; and financial, educational, and community resources to be successful.
To determine whether there is a market for this specialty, it is important to survey the local, regional, and national NP organizations to gauge the interest of their members to ensure the minimum enrollment needed to sustain such a program. Gaining approval for this proposal within an academic setting begins with introducing the proposal to the administration, which is led by the faculty member spearheading this initiative. After approval, the concept should be vetted by faculty for comments and suggestions. This input is essential to identify the effect of the program on other curricular offerings of the institution, to identify additional resources that will be needed, and to identify the potential barriers that may interfere with the success of the program. For example, it is important to anticipate how additional students in the orthopedic residency will affect the workload of faculty already overseeing other aspects of the DNP curriculum.
As we reviewed ONCB eligibility requirements for future graduates of our DNP program, student ability to apply the residency clinical hours toward ONCB certification requirements was unclear. NPs applying for certification were expected to acquire the 2,500 required clinical hours in orthopedics through professional practice after graduating from their original NP program. After consultation with the ONCB governing board, it was determined that DNP residency hours acquired prior to graduation would count toward the requirement, as these hours are supervised by board-certified NPs or physicians (B. Lasley, President, ONCB, personal communication, January 5, 2012.
Because these clinical hours must take place at qualified orthopedic clinical sites, the number of sites may need to be expanded, as some schools may have only a few affiliation agreements with orthopedic practices in the community. Potential strategies to address this situation include:
- Sending formal letters to the local chapter of the Orthopaedic Association to announce the interest of the school in developing the residency program.
- Surveying local orthopedic providers regarding their interest in serving as preceptors and potential employers.
- Educating potential preceptors about the benefits of working with students, such as the opportunity to improve patient outcomes through the implementation of an evidence-based DNP project and an opportunity to mentor a potential future employee who is already a licensed and credentialed NP with Drug Enforcement Administration and Medicare billing numbers.
- Offering an evidence-based preceptor training course with continuing education units to potential preceptors.
- Soliciting support from members of the local Community Health Improvement Partnership by educating them about the potential to meet the specialty care needs of the underserved community by hiring our graduates. Although graduates of our nursing programs are not guaranteed employment, they can be mentored by faculty in the art of professional networking and portfolio development to enhance their job prospects and secure employment.
According to the IOM report (2010), the development and implementation of nurse residency programs should be funded by health care organizations, the Center for Medicare and Medicaid Services, and philanthropic organizations. Stipend support can be generated through private and government grants. Industry support for residency tuition is possible through orthopedic medical device and surgical instrument supply companies, as many have educational grant funds. In addition, the U.S. Public Health Service contributes to the educational costs incurred during medical and nursing school enrollment by forgiving student loans when students work in an underserved community after graduation.
A dedicated semester-long, 3-academic unit (45 contact hours), didactic orthopedic course informed by the Core Curriculum for Orthopaedic Nursing (National Association of Orthopedic Nurses, 2007), including advanced study in anatomy and pathophysiology, should be a requirement prior to the DNP residency. This course should cover the key elements of orthopedic NP practice and should prepare graduates to take the ONCB’s examination after completion of 2,500 hours of orthopedic practice, many of which can be completed during the residency. Classroom learning should be supplemented with laboratory experiences in diagnostic reasoning, history taking, and physical examination by using artificial bone and joint models, simulations, and standardized patients. This course should be embedded within the DNP core curriculum and should also challenge students to identify the philosophical and theoretical basis for their advanced nursing practice to differentiate it from NP practice that is based solely on the medical model.
With this foundation, students will be prepared for their clinical residency, during which they will have the opportunity to demonstrate mastery of the knowledge and skills needed for reflective practice as an orthopedic NP. Following the National Task Force on Quality Nurse Practitioner Education’s Criteria for Evaluation of Nurse Practitioner Programs (2008), qualified faculty should provide indirect supervision of students’ clinical experience with board-certified orthopedists and orthopedic NPs serving as preceptors who oversee no more than two students at a time. Using the AACN’s DNP Essentials (2006) document as the framework for the DNP program of study, scholarly and leadership outcomes in orthopedics at the systems level can be achieved in the realm of translational science, epidemiology, program planning and evaluation, health policy, health care economics, strategic planning, and information technology, and culminates in a final DNP project.
Periodic formative and summative evaluations of important quality indicators measure the success of the DNP orthopedic specialty. These indicators include student, faculty, and preceptor satisfaction; scholarly dissemination of the students’ work; graduation rates; successful transition to orthopedic NP practice, as measured by the rates of employment and increasing competence over time; certification pass rates; and employer satisfaction. This feedback is essential to track what is working and what elements of the program need improvement.
The ability of low-income patients to access orthopedic care in our community by graduates of the DNP orthopedic specialty will be the ultimate measure of the program’s success. These data will be tracked annually to assess the extent to which these graduates are making a difference. Orthopedic NPs who serve the underinsured and uninsured have the potential to increase access to care, decrease wait times for specialty care appointments, and improve or maintain quality of care in a financially sustainable practice (Dower & Christian, 2009). NPs in private orthopedic practices will be able to see patients for nonsurgical orthopedic care and postoperative follow-up, thus freeing the surgeon to spend more time in the operating department and more time to see complex cases. Increased numbers of orthopedically trained NPs will be able to address several Healthy People 2020 (U.S. Department of Health and Human Services, n.d.) goals, including the prevention of arthritis, osteoporosis, back pain, disability, injury, and obesity.
An orthopedic NP residency will actualize two of the eight recommendations called for by the IOM’s 2010 report on the future of nursing and health care. These include fostering the transition to specialty practice residencies for advance practice RNs and increasing the number of doctorally prepared nurses to improve the health of our nation. As the IOM report advocates, nurses should be in full partnership with physicians and other health care providers. An orthopedic focus in a DNP residency will provide NPs with the educational and experiential foundation to achieve this level of participation and improve access to orthopedic care.
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