APNs Appointed as House Officers

Nurse practitioners fill role traditionally held by physicians

House officers are floor nurses with medical authority, particularly during night shift. Typically, medical authority has been carried out by residents, fellows or junior staff, or sometimes contracted physicians with practices elsewhere.

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At Cleveland Clinic’s regional hospitals, the traditionally after-hours “side job” house officer role has become more difficult to fill in recent years. This difficulty in scheduling quality medical providers who could deliver the best patient care became the impetus for Cleveland Clinic to look to advanced practice nurses (APNs) and the skill set they bring.

Thus, Cleveland Clinic’s Advanced Practice Provider House Officer Program was born. Hiring and training APNs began in mid-2015, and the program is a win-win-win. Regional hospitals now have reliable full-time Cleveland Clinic staff house officers. APNs are thriving in a new role with advanced responsibilities and autonomy, and nursing staff are pleased with the support they receive from their specialty-trained counterparts.

APNs began serving as house officers at Cleveland Clinic South Pointe Hospital in March 2016. The team of five provides 24/7 coverage, in 12-hour shifts. Another team began serving Cleveland Clinic Euclid Hospital in August, and another started at Cleveland Clinic Avon Hospital in November 2016.

Eventually, most of Cleveland Clinic’s regional hospitals in Cleveland will use the Advanced Practice Provider House Officer Program.

How APNs prepare for this advanced role

“All program participants are acute care nurse practitioners with critical care experience,” says Christine Lynch, MS, ACNP, who manages the program for Cleveland Clinic hospitals on the East Side. “We train APNs in additional skill sets through Cleveland Clinic’s Anesthesiology Institute, and offer regular refresher training to maintain competencies.”

House officers trained through Cleveland Clinic’s program have a critical care focus, rather than a hospitalist focus. They provide hands-on care in critical care units as well as on general nursing floors.

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Training takes three months and includes:

  • Receiving one week of didactic lectures by medical directors and leading nurse practitioners
  • Participating in rotations with the adult medical emergency team at Cleveland Clinic’s main campus
  • Shadowing teams in cardiac, neurological and other critical care unit populations
  • Participating on a stroke alert team and observing first-line care from neurologists
  • Learning acute pain management
  • Working in various surgical suites and cadaver labs to gain experience in intubation and placing arterial and central lines

What APNs do as house officers

“House officers support nursing staff and are on call to respond to emergencies,” explains Doris Patrick, CNP, a house officer at Euclid Hospital. “We help with Code Blues, rapid response calls, stroke alerts, admissions to intensive care, intubations, line placement, EKG interpretation and providing consent for blood draws — anything for which floor nurses need backup support.”

Night shift is usually busier than day shift, since fewer physicians are available. Nighttime house officers are more involved with managing critically ill patients. Daytime house officers have time to round, observe units in action and proactively offer assistance.

“There’s value in having full-time employees in house officer roles,” says Lynch. “They’re trained by our organization to uphold our standards. And, unlike former house officers who were contracted by the day, they’re a consistent presence, ensuring Cleveland Clinic’s exceptional level of care.”

Reactions and feedback

So far, physicians have been receptive to APN house officers. And floor nurses have been vocal about how well the new program is going. “Nurses say we’re accessible and quick to respond,” says Patrick. “Even attending physicians thank us for helping take care of their patients.”

But the transition has required some sensitivity. “We’re taking over a role traditionally performed by physicians,” says Lynch. “We expected there would be some concern. But this will subside as our APNs provide evidence of their capabilities. Their critical care and problem-solving skills make them well-suited for their positions.”

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Lynch is continuing to hire and train dozens of new APN house officers for Cleveland Clinic hospitals. “Nursing leaders and hospital administrators around the U.S. should recognize that critical care APNs can thrive in this hugely satisfying job,” she says. “If trained properly and allowed to work to the fullest extent of their license, they can provide a consistent, quality service to hospitals.”

Insights from House Officer Doris Patrick, CNP

On house officer training: “Previously, when I worked in the medical intensive care unit at Cleveland Clinic, I didn’t have as much opportunity to place lines or respond to emergency calls. When I became a house officer, I had to learn new procedures for assessing, diagnosing and treating patients in critical situations.”

About a typical day: “Some days, I’m on my feet nonstop. When things have slowed down and the call room is quiet, I’ll make rounds, letting floor nurses know they can feel comfortable asking me for help — even for something like a difficult blood draw.”

On why APNs make good house officers: “APNs are RNs. We know what it’s like to be at the bedside when a patient becomes unstable and the clinical nurse has other patients to manage, and is not able to write the orders needed to assess, diagnose or treat the instability. That’s where APN house officers can make a difference for floor nurses.”