Position Statements

USE OF ALL TERRAIN VEHICLES

Description

The following statement was developed by the Trauma Special Interest Group (SIG) of the American Pediatric Surgical Nurses Association, Inc. (APSNA) and originally approved by the APSNA membership at the 2009 Annual Meeting.

APSNA Position

It is the position of APSNA that:

1. There is NO safe age to ride an ATV.
2. Health care providers will be educated in teaching children, adolescents and families about the dangers of All Terrain Vehicles (ATV).
3. A proactive teaching approach is imperative to provide anticipatory guidance prior to ATV use.
4. Each provider is encouraged to utilize appropriate teaching strategies with this group to highlight the inherent dangers of ATVs.
5. Childhood ‘injuries’ are not accidents, yet preventable sequelae of unsafe behaviors that could be prevented with proper education, adult supervision and legislative support. ATV requirements differ by State.
6. All health care providers, teachers, legislators, public safety advocates and government officials are encouraged to join a proactive effort against ATV use in children and adolescents.

Background

An ATV, also known as a Quad, Quad bike, 3-wheeler, or 4-wheeler, is defined by the American National Standards Institute as a vehicle that travels on low pressure tires, with a seat that is straddled by the operator, along with handlebars for steering. Single rider vehicles are intended for use by a single operator without a passenger. ATVs come in various sizes, they are not “one size fits all.”

Statistics

• Between the years of 1982 –2016 there were 3232 (this is 22% of the total 14,653) ATV related fatalities of children under the age of 16 years; 44% were under the age of 12 years (2016 Consumer Product Safety Commission, 2014).
• In 2012, 225,244 ATVs were sold in the United States.
• In 2016 there were 101,200 ATV related Emergency Department visits; 26% were under 16 years of age. The most common cause of death related to ATV crashes is head injury. Injuries to solid organs, spinal cord and bones are also common.

Facts

• ATVs come in numerous sizes ranging from 215 – 840 pounds, with the average weighing 550 pounds. Over 95% of children are riding an adult sized vehicle when injured.
• ATVs can reach up to 85mph.
• ATVs have a high center of gravity and can be unstable, making “roll over” crashes common.
• ATVs have no seat belts, safety cages or roll bars making it easy to be thrown off the vehicle.
• Children under 16 have generally not developed the perceptual abilities or the judgment
  required for the safe use of a vehicle.
• Children lack the size, strength, and coordination necessary to drive an ATV.
• Children can be seriously injured on an ATV even when riding as a passenger.
• There is NO safe age to ride an ATV.

Recommendation to mitigate the dangers of ATVs:

• If a child must ride an ATV:
  • Always wear protective gear, including a helmet and eye protection
  • Attend a “hands on” driving course
  • Don’t drive an ATV with a passenger on board and don’t ever be a passenger.
  • Don’t ever drive on paved roads or public roadways.
  • Do not permit children to drive or ride on an adult sized ATV.
  • Do not drive an ATV while using drugs or alcohol.
  • Do not drive an ATV at night
  • Be aware of State laws

References:

ATV Safety Institute. (2017) State all-terrain vehicle requirements. Retrieved from www.atvsafety.org/wp-content/uploads/2018/03/ASI-Parents-Youngsters-ATV-2018.pdf

Consumer Product Safety Commission. (December 2017). 2016 annual report of ATV-related deaths and injuries. Retrieved from https://www.cpsc.gov/s3fspublic/atv_annual_Report_2016.pdf?vIcLfTM9VNDc23qe6FQyhJq7A7454xCr

Kids Health.org. (April, 2014). ATV safety. Retrieved from https://kidshealth.org/en/teens/atvsafety.html?WT.ac=ctg#catsafebasics

National Conference of Safety Legislatures. (December, 2013). Transportation review all-terrain vehicle safety. Retrieved from http://www.ncsl.org/documents/transportation/atv_trjan2014.pdf

Effective Date: 2019
Originated by: Trauma Special Interest Group
Adopted by: APSNA Board of Directors
Original approval (May, 2009)
Reaffirmed on: March, 2019

CARE OF THE CHILD WITH A CHEST WALL ANOMALY

Description:

The scope of care for patients with chest wall anomalies varies among institutions and may be limited to only a surgical perspective. To treat these patients comprehensively, the extent of their care needs to be broadened to include all applicable non-surgical options in order to provide optimum care of the chest wall anomaly and to consider comprehensive recommendations for treatment of the patient. The care and treatment of these patients must include a multidisciplinary team approach with surgeons, nurses, nurse practitioners, physician assistants, physical therapy, orthotics and other healthcare providers. The variants of chest wall anomalies need to be addressed individually and comorbidities should be assessed and triaged appropriately.

APSNA Position:

1. Patients with a pectus carinatum or pectus excavatum should be cared for in a holistic manner, especially including assessment of self-image, pain management throughout treatment, and assessment of other associated conditions requiring referrals to other subspecialties.
2. First-line treatment of pectus carinatum is bracing and should rarely be considered for surgical intervention.
3. Postoperative management of pectus excavatum that was corrected with placement of a metal bar must include adequate pain management and education about activity restrictions.

Background:

Children with a chest wall anomaly (pectus excavatum or pectus carinatum) may have poor selfimage because of the abnormal shape of their chest (Krille et al., 2012). They may withdraw from social activities such as swimming to avoid embarrassment or questions from their peers. Body image has been shown in both pectus excavatum and pectus carinatum patients to be highly impaired with reported body image dissatisfaction affecting quality of life and self-esteem (Steinmann et al., 2011). Up to 59% of those with pectus carinatum cited “appearance” as a motivational factor to pursue and complete treatment for correction (Dekonenko et al., 2019b). Over 70% of patients with either a pectus excavatum or pectus carinatum report that having the anomaly impeded their daily activities, either socially or physically (Steinmann et al., 2011). Pectus anomalies can have associated conditions such as scoliosis and connective tissue disorders. Up to 25% of those with a pectus anomaly have been noted to have mild scoliosis (Kelly & Martinez-Ferro, 2020). Although the statistics are unclear for an association with a connective tissue disorder, having a pectus anomaly is often a feature, or part of diagnostic criteria, for certain connective tissue disorders such as Marfan’s syndrome (Tocchioni, Ghionzoli, Messineo & Romagnoli, 2013). The pediatric general surgery subspecialty team does not specialize in either scoliosis or connective tissue disorders, thus subspecialties such as orthopedics, genetics, or cardiovascular genetics can augment the care of the pectus patient. The most common symptoms of pectus excavatum reported are shortness of breath, exercise intolerance, lack of endurance and chest pain (Kelly & Martinez-Ferro, 2020). Those who undergo operative correction of pectus excavatum will experience postoperative pain. Occasionally, pain or discomfort associated with the presence of the metal bar and/or surgical stabilizers may persist throughout the one to three years during which the hardware is in place. A child’s general well-being can be affected by both perceived self-image and pain and must be managed appropriately. Inflammation of the costal cartilage (costochondritis) can be seen with a chest wall anomaly, causing discomfort to the area of the affected chest. Pectus carinatum has transitioned to an almost completely non-operative diagnosis. Only very rare severe cases or mixed excavatum/carinatum anomalies should be considered for operative repair. Bracing is an effective, non-operative way to correct pectus carinatum and should be considered first-line treatment (Martinez-Ferro, Fraire & Bernard, 2008). Non-surgical treatment eliminates the risks of surgery, leaves no visible scar, avoids hospital admission, avoids activity restrictions, and dramatically reduces the cost of treatments (Kelly & Martinez-Ferro, 2020). A survey study of pectus carinatum patients who were corrected with a brace indicated that all patients regarded the bracing treatment as worthwhile, with 94% rating their carinatum correction outcome of 8 or greater on a 1-10 scale (Dekonenko et al., 2019). Perioperative pain management techniques for pectus excavatum should take a multimodal approach to optimize pain control (Millspaugh, 2019). The use of intraoperative cryoanalgesia has significantly decreased hospital stay, length of opioid treatment and allows a faster transition to oral pain medication (Dekonenko et al., 2019; Parrado et al., 2019). Cryoanalgesia allows pain management regimens to include very minimal use of opioids along with NSAIDs, and other non-opioid pain medications such as acetaminophen and gabapentin to successfully treat postoperative pain management (Graves, Idowu, Lee, Padilla, & Kim, 2017; Sujka et al., 2019). Postoperative activity recommendations after pectus excavatum repair may vary between institutions. It is difficult to ethically conduct evidence-based research regarding the safety of physical activities after excavatum repair. In the interest of optimizing safety and reducing risks for pain and potential reoperation if a pectus bar becomes displaced, conservative recommendations for activities following excavatum repair should be given. Activities that could cause a blunt force injury to the chest should be avoided for a minimum of 6 months postoperatively, or at the surgeon/pectus provider’s discretion considering the individual case. Some surgeons will recommend the use of chest wall protective equipment if the child will be participating in contact sports such as football.

1. Due to associated psychosocial and physical conditions, pectus patients may need referrals to other subspecialties to ensure that aspects of their care can be attended to holistically.
2. Pain throughout treatment/correction of pectus anomalies should be treated effectively with a multimodal approach, which may include, but is not be limited to: NSAIDs, cryoanalgesia, gabapentin, non-opioid analgesics, sparing use of opioid analgesics, and other non-pharmacologic comfort measures.
3. Pectus carinatum should be treated with a brace. Operative intervention for pectus carinatum bracing should only be considered for rare carinatum anomalies or those who have not effectively been able to be treated with a brace despite following a prescribed brace regimen.
4. Conservative postoperative activity restrictions should be advised following repair of pectus excavatum which include refraining from contact activities that have the potential to cause a blunt force injury to the chest.

References:

Dekonenko, C., Dorman, R. M., Duran, Y., Juang, D., Aguayo, P., Fraser, J. D., … Peter, S. D. S. (2019). Postoperative pain control modalities for pectus excavatum repair: A prospective observational study of cryoablation compared to results of a randomized trial of epidural vs. patient-controlled analgesia. Journal of Pediatric Surgery. doi: 10.1016/j.jpedsurg.2019.09.021

Dekonenko, C., Dorman, R. M., Pierce, A., Orrick, B. A., Juang, D., Aguayo, P., … Holcomb, G. W. (2019). Outcomes Following Dynamic Compression Bracing for Pectus Carinatum. Journal of Laparoendoscopic & Advanced Surgical Techniques, 29(10), 1223–1227. doi: 10.1089/lap.2019.0171

Kelly, R.E., & Martinez-Ferro, M. (2020). Chest Wall Deformities. In G. Holcomb, J. Murphy, & S. St. Peter (Eds.), Holcomb and Ashcraft’s Pediatric Surgery (7th ed.), (pp. 302-331). Philadelphia, PA: Elsevier Health Sciences.

Krille, S., Müller, A., Steinmann, C., Reingruber, B., Weber, P., & Martin, A. (2012). Self- and social perception of physical appearance in chest wall deformity. Body Image, 9(2), 246–252. doi: 10.1016/j.bodyim.2012.01.005

Graves, C., Idowu, O., Lee, S., Padilla, B., & Kim, S. (2017). Intraoperative cryoanalgesia for managing pain after the Nuss procedure. Journal of Pediatric Surgery, 52(6), 920–924. doi: 10.1016/j.jpedsurg.2017.03.006

Martinez-Ferro, M., Fraire, C., & Bernard, S. (2008). Dynamic compression system for the correction of pectus carinatum. Seminars in Pediatric Surgery, 17(3), 194–200. doi: 10.1053/j.sempedsurg.2008.03.008

Millspaugh, D. (2019, October). The opioid-pain nexus: Safe opioid prescribing at the cultural moment. 25th Annual Advanced Practice Nursing Conference. Oral presentation conducted at the 25th Annual Advanced Practice Nursing Conference at Children’s Mercy Park, Kansas City, KS.

Parrado, R., Lee, J., McMahon, L.E., Clay, C. Powell, J. Kang,...Bae, J. (2019). The use of cryoanalgesia in minimally invasive repair of pectus excavatum: Lessons learned. Journal of Laparoendoscopic & Advanced Surgical Techniques, 29(10), 1244-1251.

Steinmann, C., Krille, S., Mueller, A., Weber, P., Reingruber, B., & Martin, A. (2011). Pectus excavatum and pectus carinatum patients suffer from lower quality of life and impaired body image: A control group comparison of psychological characteristics prior to surgical correction. European Journal of Cardio-Thoracic Surgery. doi: 10.1016/j.ejcts.2011.02.019

Sujka, J., Benedict, L.A., Fraser, J.D., Aguayo, P., Millspaugh, D.L., & St. Peter, S.D. (2018). Outcomes using cryoablation for post-operative pain control in children following minimally invasive pectus excavatum repair. Journal of Laparoendoscopic & Advanced Surgical Techniques, 28(11), 1383-1386.

Tocchioni, F., Ghionzoli, M., Messineo, A., & Romagnoli, P. (2013). Pectus excavatum and heritable disorders of the connective tissue. Pediatric Reports, 5(3), 15. doi: 10.4081/pr.2013.e15

Effective Date: 2020
Originated by: APSNA Chest Wall Anomaly Special Interest Group
Adopted by: APSNA Board of Directors
Original approval: July 2020

COMPETENCY BASED TRANSITION TO PEDIATRIC SURGICAL NURSING PRACTICE

Purpose:

The purpose of this position statement is to address competency-based transition-topractice programs for pediatric surgical nursing and disseminate to key stakeholders.

APSNA Position

The American Pediatric Surgical Nurses Association, Inc. (APSNA) believes and endorses the American Nurses Association’s (ANA, 2014) statement on professional role competence in that the public has a right to expect nurses to demonstrate competence throughout their careers. The nursing profession must shape and guide any process for assuring nurse competence. Regulatory bodies define minimal standards for regulation of practice to protect the public. The employer is responsible and accountable to provide an environment conducive to competent practice. The nurse is individually responsible and accountable for maintaining competence. Assurance of competence is the shared responsibility of the profession, regulatory bodies, employers, individual nurses, and other key stakeholders. Competence is definable, measurable, can be evaluated, and context determines what competencies are necessary.

Background

It is the responsibility of a professional organization to develop practice competencies. Competencies delineate the unique aspects of a particular area of practice and provide a model for entry into that practice.

The Institute of Medicine’s (IOM), Future of Nursing (2010) report mandated the following:

• The nursing profession must adopt a framework of continuous, lifelong learning that includes basic education, residency programs, and continuing competence. P. 60
• It should be noted that “competencies” here denotes not task-based proficiencies but higherlevel competencies that represent the ability to demonstrate mastery over care management knowledge domains and that provide a foundation for decision-making skills under variety of clinical situations across all care settings. P. 229
• Competence at the specialty level will not be assessed or regulated by boards of nursing but rather by the professional organizations. P. 358
• Preparation in a specialty area of practice is optional but if included must build on the APRN role/population-focus competencies. P. 364
• Competency in the specialty areas could be acquired either by educational preparation or experience and assessed in a variety of ways through professional credentialing mechanisms (e.g., portfolios, examinations, etc.). p. 365

APSNA developed its strategic plan in 2015, using the IOM’s Report as a guide for strategic direction. Using 4 key messages from the IOM, APSNA determined that nurses working in pediatric surgical settings must be able to practice to the full extent of their education regardless of setting. APSNA furthermore identified the Pediatric Nursing Scope and Standards (2015) as the overarching framework for practice. A task force was developed to lead this strategic goal. The task force was asked to build from these scope and standards and develop competencies specific to nurse practitioners (NP) who practice in pediatric surgery settings; this would provide insight to the practice of NPs in the pediatric surgical areas of service. These competencies may be utilized to integrate them into education, preceptorship, and membership orientation to the organization and practice of pediatric surgery nursing.

The competencies in this document are intended to support the NP pursuing employment in pediatric surgery. In addition, these competencies along with the core competencies for all NPs, the population-focused NP competencies, and the advanced practice-nursing core curricula are intended to guide the preparation of NPs who plan to specialize in pediatric surgical care. The competencies provide a model for professional NPs upon entry into pediatric surgical care practice, but do not prescribe a scope of practice. As the practice of NPs in pediatric surgery care evolves, the requirements for competency will change. These competencies will be reviewed and updated periodically to reflect scientific advances and evidence-based practice changes in NP practice in pediatric surgery care.

References

American Nurses Association. (ANA). (2015). Pediatric nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: American Nurses Association.

American Nurses Association. (ANA). (2014). Professional role competence. Retrieved February 4, 2017, from http://nursingworld.org/MainMenuCategories/Policy-Advocacy/Positionsand-Resolutions/ANAPositionStatements/Position-Statements-Alphabetically/ProfessionalRole-Competence.html

Emergency Nurses Association. (ENA). (2008). Competencies for nurse practitioners in emergency care. Retrieved on January 29, 2017, from https://www.ena.org/practiceresearch/Practice/Quality/Documents/NPCompetencies.pdf

Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: The National Academic Press.

National Council of State Boards of Nursing. (NCSBN) (2008). Consensus model for APRN regulation: Licensure, accreditation, certification & education. Retrieved January 30, 2017, from https://www.ncsbn.org/Consensus_Model_for_APRN_Regulation_July_2008.pdf

National Organization of Nurse Practitioner Faculties. (NONPF). (1995-2014). Domains and core competencies of nurse practitioner practice. Retrieved January 30, 2017, from http://www.nonpf.com/displaycommon.cfm?an=1&subarticlenbr=14

February, 2017

Task Force Members:

Brittney K. Anderson, DNP, CPNP, Children’s Hospital Orange County, Orange, CA
Neil Ead, MSN, CPNP, Hasbro Children’s Hospital, Providence, RI
Monique Jenkins, PhD, ARNP, FNP-BC, Maimonides Medical Center, Brooklyn, NY
Raquel Pasarón, DNP, ARNP, FNP-BC, Chair, Nicklaus Children’s Hospital, Miami, FL
Laura Saksa, MSN, CPNP, Cleveland Clinic, Cleveland, OH

FIREARM INJURY PREVENTION

Description

The following statement was developed by the Trauma Special Interest Group (SIG) of the American Pediatric Surgical Nurses  Association, Inc. (APSNA, Inc.) and approved by the APSNA, Inc. Board of Directors.

APSNA Position

1. APSNA, Inc. is committed to protecting children and teens from harm caused by firearms.
2. Firearm violence is a public health crisis and APSNA, Inc. supports a public health approach to prevention (Center for Gun Violence Solutions; Office of the U.S. Surgeon General, 2024).
3. If present in the home, firearms should be stored unloaded and locked, with ammunition locked away separately (Lee et al., 2022).
4. Firearm injury prevention should be part of standard education for healthcare professionals (Barron et al., 2022; Rickert et al., 2022).
5. APSNA, Inc. opposes efforts that seek to prohibit healthcare workers from firearm safety counseling in the clinical setting (Lee & Curfman, 2017).
6. We recommend suicide screening at every healthcare encounter for any patient 12 years or older (AAP, 2017).
7. It is best practice for the pediatric trauma team to coordinate the care of patients with firearm injuries as part of a broader multidisciplinary team, such as pertinent surgical services, an injury prevention team, social work, psychology, rehabilitation services, and child life specialists.
8. APSNA, Inc. supports legislation that enforces safe firearm storage.
9. APSNA, Inc. supports mandatory background checks for anyone purchasing a firearm. APSNA, Inc. also supports legislation aimed at closing the “Charleston Loophole,” which allows the firearm sale to move forward after three business days, even if the background check has not resulted.
10. APSNA, Inc. supports legislation that prohibits the sale or transfer of mass capacity firearms or homemade firearms (i.e., “ghost guns”).
11. APSNA, Inc. supports legislation that seeks to limit concealed carry of firearms in high-risk areas, such as schools, churches, and parks.
12. APSNA, Inc. supports publicly funded firearm take back programs.
13. APSNA, Inc. supports extreme risk protection laws (i.e., “Red Flag Laws”), which allow families or healthcare providers to petition the court for temporary restriction of an individual's access to a firearm.
14. APSNA, Inc. supports the development of smart guns and gun safety features, which require biometric authorization for use.
15. APSNA, Inc. supports participation in research that is focused on efforts to decrease the incidence of morbidity and mortality related to firearms.

Background

Firearm violence is a serious public health crisis in the United States (Center for Gun Violence Solutions). Firearms are the leading cause of death for pediatric patients aged 1-19 years (Goldstick et al., 2022). The Centers for Disease Control and Prevention (CDC) define firearm injury as a gunshot wound or penetrating injury from a weapon that uses a powder charge to fire a projectile including handguns, rifles, and shotguns. The CDC found that firearm-related deaths typically occur at home with a gun that is loaded and unsecured (Wilson et al., 2023). Mental health also plays an important and growing role in this public health crisis. From 2012 to 2022, suicide by firearm rose by 68% among those aged 10-14 years (CDC, 2023). Leading agencies, including the CDC, agree that these injuries and deaths are preventable (CDC, 2024).

Nurses and nurse practitioners, who constitute APSNA, Inc. membership, have an important role to play in firearm injury prevention. In the clinical setting, they can perform suicide and safe storage screening and education. They can conduct research to better understand incidence, associated factors, and effective prevention strategies. In the legislative arena, they can serve as advocates for policy initiatives that seek to prevent firearm injury and death.

Statistics and Other Facts

• From 2003–2021, a total of 1,262 children aged 0-17 years died from firearm injury (Wilson et al., 2023).
• Children aged 0–5 years accounted for 29.1% of these unintentional firearm injury deaths, followed by those aged 6–10 years (14.0%), 11–15 years (33.0%), and 16–17 years (23.9%) (Wilson et al., 2023).
• 30 million children lived in households with firearms in 2021 (Martin et al., 2024; Miller & Azrael, 2022).
• 36.1% of children of gun-owning parents lived in homes with unlocked firearms, 37.1% with loaded firearms, and 15% with at least one firearm unlocked and loaded (Martin et al., 2024; Miller & Azrael, 2022).
• The most common location for pediatric firearm injuries is a private home (Ordoobadi et al., 2024).
• 59% of children are unable to differentiate between a real and toy gun (Doh et al., 2021; Martin et al., 2024).
• 53% of children of gun-owning parents can locate where the gun is stored, while only 11% of parents believed their children could identify the location (Doh et al., 2021; Martin et al., 2024).

Studies show that most parents are receptive to firearm safety education provided in the outpatient setting, as well as changing their firearm storage behaviors (Campbell et al., 2020; Martin et al., 2024).

References:

Office of the U.S. Surgeon AAP. (2017). Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents. American Academy of Pediatrics. https://doi.org/10.1542/9781610020237

Barron, A., Hargarten, S., & Webb, T. (2022). Gun Violence Education in Medical School: A Call to Action. Teach Learn Med, 34(3), 295-300.
https://doi.org/10.1080/10401334.2021.1906254

Campbell, B. T., Thaker, S., Fallat, M. E., Foley, D. S., McClure, E., Sakran, J. V., Nasr, I. W., Ziegfeld, S., Ehrlich, P. F., Snodgrass, M., Levy, M., Naik-Mathuria, B. J., Johnson, B., Demello, A. S., Jones, S., Watters, J. M., Burke, P., Allee, L., Kozyckyj, T.,...Stewart, R. M. (2020). A Multicenter Evaluation of a Firearm Safety Intervention in the Pediatric Outpatient Setting. J Pediatr Surg, 55(1), 140145. https://doi.org/10.1016/j.jpedsurg.2019.09.044

CDC. (2023). National Center for Health Statistics Mortality data on CDC WONDER https://wonder.cdc.gov/Deaths-by-UnderlyingCause.html

CDC. (2024). About Firearm Injury and Death. Centers for Disease Control and Prevention. Retrieved December 29 from https://www.cdc.gov/firearmviolence/about/index.html

Center for Gun Violence Solutions. Johns Hopkins Bloomberg School of Public Health. Retrieved December 29 from https://publichealth.jhu.edu/center-for-gun-violencesolutions/research-reports/the-public-health-approach-to-prevent-gun-violence

Doh, K. F., Morris, C. R., Akbar, T., Chaudhary, S., Lazarus, S. G., Figueroa, J., Agarwal, M., & Simon, H. K. (2021). The Relationship Between Parents' Reported Storage of Firearms and Their Children's Perceived Access to Firearms: A Safety Disconnect. Clin Pediatr (Phila), 60(1), 42-49. https://doi.org/10.1177/0009922820944398

General, O. o. t. U. S. S. (2024). Firearm Violence: A Public Health Crisis in America. Retrieved from https://www.hhs.gov/sites/default/files/firearm-violenceadvisory.pdf

Goldstick, J. E., Cunningham, R. M., & Carter, P. M. (2022). Current Causes of Death in Children and Adolescents in the United States. N Engl J Med, 386(20), 1955-1956. https://doi.org/10.1056/NEJMc2201761

Lee, L. K., Fleegler, E. W., Goyal, M. K., Doh, K. F., Laraque-Arena, D., Hoffman, B. D., THE COUNCIL ON INJURY, V., & PREVENTION, P. (2022). Firearm-Related Injuries and Deaths in Children and Youth: Injury Prevention and Harm Reduction. Pediatrics, 150(6). https://doi.org/10.1542/peds.2022-060070

Lee, T. T., & Curfman, G. D. (2017). Physician Speech and Firearm Safety: Wollschlaeger v Governor, Florida. JAMA Intern Med, 177(8), 1189-1192. https://doi.org/10.1001/jamainternmed.2017.1895

Martin, S. A., Bishop, K., Choma, E. G., & Koepke, N. M. (2024). Pediatric Firearm Violence in America. J Pediatr Health Care, 38(3), 413-419. https://doi.org/10.1016/j.pedhc.2023.10.009

Miller, M., & Azrael, D. (2022). Firearm Storage in US Households With Children: Findings From the 2021 National Firearm Survey. JAMA Network Open, 5(2), e2148823-e2148823. https://doi.org/10.1001/jamanetworkopen.2021.48823

Rickert, C. G., Felopulos, G., Shoults, B., Hathi, S., Scott-Vernaglia, S. E., Currier, P., Masiakos, P. T., & Sacks, C. A. (2022). Development and Implementation of a Novel Case-Based Gun Violence Prevention Training Program for First-Year Residents. Academic Medicine, 97(10), 1479-1483. https://doi.org/10.1097/acm.0000000000004656

Wilson, R., Blair, J., Betz, C., Collier, A., & Fowler, K. (2023). Unintentional Firearm Injury Deaths Among Children and Adolescents Aged 0–17 Years — National Violent Death Reporting System, United States, 2003–2021. Morbidity and Mortality Weekly Report(72), 1338-1345. https://doi.org/10.15585/mmwr.mm7250a1

IMPACT OF VOLUNTEERISM

Description

Nurses are uniquely situated to coordinate and deliver health services to patients worldwide. In order to do so, nurses are tasked with improving global healthcare through increased knowledge, evidence-based clinical practice, and actions that inspire changes in healthcare delivery. Worldwide learning experiences such as attendance at international conferences, familiarity with published recommendations by pediatric and national nursing organizations and experience with medical volunteering in underserved countries are vital to understanding and supporting overall improvement in health among global communities. Research that yields evidence based practice empowers nurses to advocate for, promote, and assess the efficacy of interventions for pediatric surgical patients. Collaboration with global organizations aids in the advancement of health policy and reform (National League for Nursing, 2017).

It is well described that global health knowledge promotes a higher level of care by improving the standards of medical and surgical treatments through outreach and training in lowincome countries (Sigma Theta Tau International, 2018). As access to medical services continues to vary throughout the world, it is of the utmost importance that evolving healthcare models are based on improving the wellbeing of patients among the global population (Keeling, 2005), specifically patients requiring surgery. According to the World Health Organization, aiding other countries in gaining the resources necessary to provide surgical services is crucial, as surgery is often the only method of treating many medical conditions. Additionally, it is estimated around five billion people worldwide have limited or no access to surgical and anesthesia care that is safe, reliable and cost efficient, furthermore in some countries 9 out of 10 people do not have equipment, providers, or space to perform even very simple operations (World Health Organization, 2021).

More and more nurses and medical teams are participating in global outreach or medical missions which provide access to safe and timely treatment of medical and/or surgical conditions. It is crucial that members of the American Pediatric Surgical Nurses Association, Inc. (APSNA), who are participating in these missions or outreach, do so in the most professional, helpful, ethical manner by consulting organizational guidelines set by relevant organizations. In 2018, the American Academy of Pediatrics (AAP) Delivery of Surgical Care Global Health Subcommittee, the American Pediatric Surgical Association (APSA) Global Pediatric Surgery Committee, and the APSNA Global Health Special Interest Group, published several recommendations to be used as guidelines for missions carried out by healthcare professionals (Butler et al., 2018). Crigger (2008) clearly demands that responding to disparities and inequities in health care is a human rights issue that is a responsibility for everyone. ANA believes that it is the responsibility of the volunteer to ensure their assistance is socially responsible, is done with cultural respect and integrity and must be done in a sustainable manner for the community (ANA Ethics Advisory Board, 2019).

APSNA Position

1. Involvement in medical missions and international medical volunteering is encouraged but should be conducted following guidelines established by pediatric organizations such as AAP, APSA, and APSNA, as well encompass the ethical recommendations established by the ANA.
2. Actions that inspire worldwide changes in global health disparities can include medical volunteering, research projects, and involvement with international organizations.
3. Continuing education with an emphasis on respect for differing values, cultural variances and increased awareness of global health disparities is essential to serving the needs of all patients regardless of their geographic location or social/economic standing.
4. Participation in healthcare research guides nurses to evidence-based practice which can be utilized by global organizations to address the disparity in the quality and availability of pediatric surgical care worldwide.

Background

Even in today’s world, good healthcare continues to be largely inaccessible to millions of people globally. Many underdeveloped countries are lacking the resources and infrastructure (including basic resources such as food, water, or health care providers) needed to ensure access to even the most minimal services. In more developed countries, obstacles such as geographic distance, inequitable distribution of resources, and personal, out-of-pocket healthcare costs can prohibit access to care. This specifically affects pediatric surgical patients as children are at highest risk of mortality from preventable causes such as infection, birth defects and poor perinatal care, which can be improved by timely surgical intervention (Johnson, 2013).

Engaging nurses in continuing education to increase global health knowledge, evidencebased research, worldwide advocacy, and international partnerships will help to support the establishment of well-defined surgical guidelines, reduce health risks and improve quality of life for pediatric surgical patients. Improved collaboration among pediatric surgical providers across the globe helps identify evidence-based methods to treat surgical diseases more successfully and to improve quality of life in children and their families (Lakhoo & Msuya, 2015). Many organizations offer worldwide conferences and mentorships to bring together surgeons, nurses, and students to share their expertise.

By participating in medical missions and short-term medical volunteering APSNA members can positively impact global health for the surgical care of children. Prior to any medical volunteering APSNA members are encouraged to review the guidelines published by Butler et al. (2018). These guidelines cover recommendations for the goals and processes of medical missions, including planning, patient care, post-trip follow-up, and need for sustainable healthcare services as well as for travel and safety considerations. Finally, according to the ANA, acting with moral courage and developing moral resilience are essential for successful volunteer experiences (paragraph 4). Ongoing assessment of ethical issues and practicing according to The Code [of ethics] during all phases of the volunteer experience are critical to mitigating any potential harms. Volunteering can be a powerful means for nurses to meet their social responsibilities and expand their world views (paragraph 30) (ANA Ethics Advisory Board, 2019).

References

American Nurses Association’s (ANA) Ethics Advisory Board. (2019). ANA position statement: Ethical considerations for local and global volunteerism. OJIN: The Online Journal of Issues in Nursing , 25(1). https://www.nursingworld.org/~4a346d/globalassets/practiceandpolicy/nursingexcellence/ana-position-statements/social-causes-and-health-care/ethical-considerations-for-localand-global-volunteerism_final_nursingworld.pdf

Butler, M., Drum, E., Evans, F. M., Fitzgerald, T., Fraser, J., Holterman, A., Jen, H., Kynes J.M., Kreiss, J., McClain, C.D., Newton, M., Nwomeh, B., O’Neill, J., Ozgediz, D., Politis, G., Rice, H., Rothstein, D., Sanchez, J., Singleton, M., & Yudkowitz, F. S. (2018). Guidelines and checklists for short-term missions in global pediatric surgery. Pediatric Anesthesia, 28(5), 392-410. doi:10.1111/pan.13378

Crigger, N.J. (2008). Towards a viable and just global nursing ethics. Nursing Ethics, 15(1), 17-27.

Johnson, W. (2013). Surgery as a global health issue. Surgical Neurology International, 4(1), 47. doi:10.4103/2152-7806.110030

Keeling, A. (2015). Historical perspectives on an expanded role for nursing. OJIN: The Online Journal of Issues in Nursing, 20(2). doi: 10.3912/OJIN.Vol20No02Man02.

Lakhoo, K. & Msuya, D. (2015). Global health: A lasting partnership in paediatric surgery. African Journal of Paediatric Surgery, 12(2), 114-118. doi: 10.4103/0189-6725.160351.

National League for Nursing. (2017). A vision for expanding US nursing education for global health engagement [Position Statement]. vision-statement-a-vision-for-expanding-usnursing-education.pdf (nln.org)

Sigma Theta Tau International. (n.d.). “Global” health policy position statement. [Global Health] Policy Position Statement (nursingrepository.org)

World Health Organization. (n.d.). https://www.who.int/health-topics/ethics-andhealth#tab=tab_1

Effective Date: July 2021
Originated by: APSNA Global Health Special Interest Group
Adopted by: APSNA Board of Directors
Original approval: July 2021

PREVENTION OF DOG BITES IN YOUNG CHILDREN

Description

Dog bites are serious and largely preventable injuries that disproportionately affect young children. The vast majority of dog bites to children are inflicted by a family pet or familiar dog and these injuries most often occur at home (Arhant, Landenberger, Beetz, & Troxler, 2016; Garvey, Twitchell, Ragar, Egan, & Jamshidi, 2015; Reisner & Shofer, 2008). The absence of appropriate adult supervision is a significant, but modifiable risk factor for dog bite injuries to young children. Despite the magnitude of this problem and research defining the dangers, successful programs targeting the reduction of dog bite injuries to infants and small children have not been developed (Warner & Schilling, 2017).

APSNA Position

It is the position of APSNA that:

1. Childhood dog bite injuries can be prevented when parents and dog owners understand safe child-dog interactions and parents consistently provide appropriate supervision of these interactions.
2. Pediatric providers should include anticipatory guidance at well child visits to raise awareness about the risk of injury and educate parents about appropriate supervision of child-dog interactions (Warner & Schilling, 2017).
3. Anticipatory guidance to parents should include ways to improve the safety of the child’s environment such as the use of baby gates to ensure separation of the child and dog (Warner & Schilling, 2017).
4. Parents should be taught that a sleeping infant or child should never be left unsupervised in a room with a dog and children should not be allowed to put their faces in close proximity to a dog’s face (Arhant et al., 2016; Iazzetti, 1998; Rezac, Rezac, & Slama, 2015).
5. An adult caretaker should supervise all toddler-dog interactions and the child should not be allowed to approach a dog while it is eating or sleeping (Patronek, Sacks, Delise, Cleary, & Marder, 2013; Reisner & Schofer, 2008).
6. Collaboration between medical and veterinary professionals in a variety of settings will be necessary for the development of successful dog bite prevention programs.
7. The development of state based, centralized reporting systems for dog bites would aid in determining the true incidence of these injuries and help identify areas for further research and prevention.
8. Future research should examine the impact of educational programs on the rate of pediatric dog bite injuries.

Background

According to the Centers for Disease Control and Prevention (CDC), there were more than 87,000 nonfatal dog bites to children ten years of age and younger in 2014. This is a rate of 86 dog bite injuries per 100,000 children (CDC, 2003). Children under the age of five years old are at highest risk for severe and fatal injuries resulting from dog bites (Daniels, Ritzi, & O’Neil, 2009; Patronek et al., 2013) and are two to three times more likely than an adult to suffer a dog bite injury. A review of 256 dog bite fatalities in the US between 2000 and 2009 identified the most preventable incidents occurred when a young children was left alone with a dog or came into contact with a dog while unsupervised (Patronek et al., 2013). Infants and toddlers suffer the highest proportion of dog bites to the face and neck which can result in severe, disfiguring injuries requiring multiple surgical procedures and long hospital stays (Rezac, Rezac, & Slama, 2015). The physical and emotional impacts of dog bite injuries can be long-term. Child victims may develop symptoms including intense fear of dogs, reluctance to leave home, and lack of interest in routine play activities (Peters, Sottiauk, Appleboom, & Kahn, 2004). Parents and dog owners are often unaware or underestimate the risks inherent to toddler-dog interactions(Arhant et al., 2016).

Pit bulls are the breed most often responsible for life-threatening dog bite injuries to children^2,6,7 including ocular injuries (Prendes, Jian-Amandi, Chang, & Shaftel, 2016), and severe injuries to the head and neck (O’Brien, Andre, Robinson, Squires & Tollefson, 2015). Most states lack a centralized reporting system for dog bite injuries(Rhea et al., 2014) and dog bite laws are the purview of individual state and local authorities.

This position statement was developed to educate health care providers about age-specific risk factors and prevention strategies for dog bite injuries in children. APSNA strongly encourages all health care providers, teachers, legislators, public safety advocates, and government officials to protect our children from dog bite injuries with the overall goal to reduce the frequency of dog bites as well as to protect our greatest resource, our children.

References

Arhant, C., Landenberger, R., Beetz, A., & Troxler, J. (2016). Attitudes of caregivers to supervision of child–family dog interactions in children up to 6 years—an exploratory study. Journal of Veterinary Behavior: Clinical Applications and Research, 14, 10-16.

Bini, J., Cohn, S., Acosta, S., McFarland, M., Muir, M., Michalek, J., & TRISAT Clinical Trials Group (2011). Mortality, mauling, and maiming by vicious dogs. Annals of Surgery, 253(4), 791–797.

Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS). [Online]. (2003). National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (producer). Available from: URL: https://www.cdc.gov/injury/wisqars/index.html. [2017, Nov, 15].

Daniels, D. M., Ritzi, R. B., & O’Neil, J. (2009). Analysis of nonfatal dog bites in children. Journal of Trauma and Acute Care Surgery, 66(3), S17-S22.

Dixon, C. A., Pomerantz, W. J., Hart, K. W., Lindsell, C. J., & Mahabee-Gittens, E. M. (2013). An evaluation of a dog bite prevention intervention in the pediatric emergency department. The Journal of Trauma and Acute Care Surgery, 75(4), S308-S312.

Garvey, E. M., Twitchell, D. K., Ragar, R., Egan, J. C., & Jamshidi, R. (2015). Morbidity of pediatric dog bites: A case series at a level one pediatric trauma center. Journal of Pediatric Surgery, 50(2), 343-346.

Golinko, M. S., Arslanian, B., & Williams, J. K. (2016). Characteristics of 1616 consecutive dog bite injuries at a single institution. Clinical Pediatrics, 56(4), 316-325. http://doi:10.1177/0009922816657153.

Iazzetti, L. (1998). Anticipatory guidance: having a dog in the family. Journal of Pediatric Health Care, 12(2), 73-79.

O'Brien, D. C., Andre, T. B., Robinson, A. D., Squires, L. D., & Tollefson, T. T. (2015). Dog bites of the head and neck: An evaluation of a common pediatric trauma and associated treatment. American Journal of Otolaryngology, 36(1), 32-38.

Patronek, G. J., Sacks, J. J., Delise, K. M., Cleary, D. V., & Marder, A. R. (2013). Co-occurrence of potentially preventable factors in 256 dog bite–related fatalities in the United States (2000–2009). Journal of the American Veterinary Medical Association, 243(12), 1726-1736.

Peters, V., Sottiauk, M., Appleboom, J., & Kahn, A. (2004). Posttraumatic stress disorder after dog bites in children. The Journal of Pediatrics, 144(1), 121-122.

Prendes, M. A., Jian-Amadi, A., Chang, S. H., & Shaftel, S. S. (2016). Ocular trauma from dog bites: Characterization, associations, and treatment patterns at a regional level I trauma center over 11 years. Ophthalmic Plastic & Reconstructive Surgery, 32(4), 279-283.

Rhea SK, Weber DJ, Poole C, Waller AE, Ising AI, & Williams C. (2014). Use of statewide emergency department surveillance data to assess incidence of animal bite injuries among humans in North Carolina. Journal of the American Veterinary Medical Association, 244(5), 597–603.

Reisner, I. R., & Shofer, F. S. (2008). Effects of gender and parental status on knowledge and attitudes of dog owners regarding dog aggression toward children. Journal of the American Veterinary Medical Association, 233(9), 1412-1419.

Rezac, P., Rezac, K., & Slama, P. (2015). Human behavior preceding dog bites to the face. The Veterinary Journal, 206(3), 284-288.

Warner, H. & Schilling, S. (2017). When interactions between young children and dogs become dangerous: A case review, Journal of Pediatric Surgical Nursing, 5(4), 15-21

Resources

Dog Bite Prevention
American Veterinary Medical Association
https://www.avma.org/public/Pages/Dog-Bite-Prevention.aspx

Family Paws Parent Education
www.familypaws.com

The Safe Kids/Safe Dogs Project
https://www.safekidssafedogs.com

Doggone Safe
http://www.doggonesafe.com

Holly Warner, and Lynne Farber, Trauma SIG
February, 2018

STOMA SITE MARKING

Description:

Pediatric colorectal surgeons and certified ostomy nurses are the optimal clinicians to select and mark stoma sites, as this skill is a part of their education, practice, and training. All providers or clinicians who are involved with pediatric surgical patients should familiarize themselves with the principles of proper stoma site selection, including placement of the stoma within the rectus abdominis muscle, use of multiple patient positions to identify appropriate stoma sites, avoidance of folds and scars, and consideration of the diaper, clothing/beltline.

The decision of where to position an intestinal stoma site should not be considered a trivial undertaking. An optimal stoma site placement can help reduce postoperative problems such as leakage, fitting challenges, need for expensive custom pouches, skin irritation, pain, and clothing concerns.

APSNA Position:

It is the position of APSNA that:

1. Available educational guidelines have been developed to assist clinicians (especially those who are not surgeons or Wound Ostomy Continence Nurses) in selecting an effective stoma site.
2. Marking the optimal location for a stoma preoperatively enhances the likelihood of a patient’s independence in stoma care, predictable pouching system wear times, and resumption of normal activities.
3. The goal is that all children undergoing stoma placement will have preoperative stoma site marking performed

Background:

Ostomy education and stoma site selection needs be performed preoperatively for all patients if possible, including children younger than school-aged, to ensure the best possible quality of life with a stoma. It is critical for WOC nurses to understand the impact of appropriate stoma siting in the preoperative period and how it has an immediate and continued impact on a person’s quality of life, along with the quality of preoperative and postoperative education leading to fewer ostomy-related complications (Hovan, 2017). Stoma site marking can prevent leakage, skin irritation, peristomal dermatitis and fitting challenges, which can negatively impact the
psychological, physical, and emotional health of the patient and caregiver.

When marking the stoma site, it is important to consider the child’s daily routine, activities such as sports and hobbies and other activities that will impact the best possible location of the stoma.

This may help predict a pouch's wear time and ability of the patient and/or caregiver to adapt to the ostomy. By involving the patient and family, this is an opportunity for education and involvement in stoma site selection. Preoperatively marking the stoma site allows assessment of the school age, teenager, or young adult patient’s abdomen in multiple positions, which promotes selection of the optimal stoma site. It is imperative for the individual marking the site to be cognizant that a small skin surface area will impact the appliance fit after stoma creation (Mahoney, 2015). In addition, this preoperative session promotes a patient-centered approach respecting the individuality, values, and information needs of the patient and family. At least one parent should be present during the stoma siting session. The session allows time to provide information regarding ostomy management, including pouching options, and provide psychosocial support for the patient and family (WOCN, 2014). While preoperative stoma site marking is strongly encouraged, it is important to divulge that intra-operative circumstances may not allow for the optimal stoma site to be used in all situations. This is especially important to emphasize in the adolescent population and to make sure they have realistic expectations as to the final location selection of the stoma site. The final stoma site is chosen by the surgeon after the abdominal cavity is entered and the condition of the bowel is determined.

“Colon and rectal surgeons and certified ostomy nurses are the optimal clinicians to select and mark stoma sites, as this skill is a part of their education, practice, and training” (WOCN, 2014. p. 4). Since these providers are not always available, especially in emergency situations, a guideline to assist those who are not surgeons or Certified Wound Ostomy Continence nurses in selecting an effective stoma site needs to be available.

All providers and clinicians who are involved with pediatric surgical patients should familiarize themselves with the principles of proper stoma site selection, including placement of the stoma within the rectus abdominis muscle, use of multiple patient positions to identify appropriate stoma sites, avoidance of folds and scars, and consideration of the diaper or clothing/beltline.

Key Points to Consider

1. “The stoma site should be located within the rectus abdominis muscle” (WOCN, 2014, p. 4).
2. Positioning issues can include but are not limited to contractures, posture, mobility such as wheelchair confinement.
3. Activity level, sports, hobbies and family environment.
4. Physical considerations: abdominal folds, scars/suture lines, other stomas, rectus abdominis muscle, waistline, iliac crest, braces, vision, dexterity, and the presence of a hernia (WOCN, 2014).

References

Hovan, H. (2017, October 27). The importance of preoperative stoma site marking and ostomy education. Wound Source:
https://www.woundsource.com/blog/importance-preoperative-stoma-site-marking-andostomy-education

Mahoney, M. F. (2016). Preoperative preparation of patients undergoing a fecal or urinary diversion. In J. E. Carmel, J. C., Colwell, & M.T. Goldberg, M. (Eds.), Wound, Ostomy and Continence Nurses Society Core curriculum: Ostomy management (pp. 99–112).
Philadelphia, PA: Wolters Kluwer.

Wound, Ostomy and Continence Nurses Society. (2014). WOCN Society and ASCRS position statement on preoperative stoma site marking for patients undergoing colostomy or ileostomy surgery. Mt. Laurel: NJ. Author.

Effective Date: 2020
Originated by: APSNA Colorectal Special Interest Group
Adopted by: Board of Directors
Original approval: July 2020

Use of Terms Such as Mid-Level Provider and Physician Extender

Description

The terms mid-level provider (MLP) and physician extender (PE) were originally used by physicians, physician groups, medical organizations, and medical corporations to describe advance practice registered nurses (APRN) and physician assistants (PA). These terms suggest that the role of the APRN, specifically nurse practitioners (NP) and PAs are an "extension" of physician care rather than acknowledging that many are licensed independent practitioners.

The American Association of Nurse Practitioners (2015) states that “the use of terms such as ‘mid-level provider’ and ‘physician extender’ in reference to NPs individually or to an aggregate inclusive of NPs is inaccurate and misleading (paragraph 1).” The terms MLP and PE are vague and imply that APRNs are halfway or midway between something and denotes a false qualitative hierarchy.

All APRNs must complete a master's or doctoral degree program and have advanced clinical training beyond their initial professional registered nurse (RN) preparation. Didactic and clinical courses prepare nurses with specialized knowledge and clinical competency to practice in primary care, acute care and long-term health care settings. There are four types of APRNs, each with distinct educational curricula: NPs, Clinical Nurse Specialist, Certified Nurse Midwife, and Certified Registered Nurse Anesthetist. After completing the required education, an APRN must pass a national board certification exam in the specific area of focus. Scope of practice is largely established through a legislative process and varies by state. Scope of practice may also differ for the different types of APRNs within a state.

A PA is a nationally certified state-licensed medical professional who works on a health-care team with physicians and other providers. PAs must practice medicine under the supervision of a physician, with the required nature of that supervision varying from state to state. PAs have graduate medical training typically consisting of 26 months of combined classroom and clinical rotations in hospital and outpatient clinical settings; they are awarded a master’s degree upon completion. The required training for a PA consists of a broad, generalist education that prepares them to practice in primary care as well as diagnose, treat, and prescribe medicines. There are also voluntary postgraduate residency training programs that further focus PA training in a particular specialty area.

It is important and worthwhile to take a stand and educate the medical, healthcare finance, organizational and federal community regarding appropriate titles for non-physician, health-care practitioners who have advanced degrees. Ignoring or tolerating this from a futility perspective leads to significant implications to APRN workforce barriers and professional identity and satisfaction.

APSNA Position

It is the position of APSNA that:

1. The terms of mid-level provider, physician extender and similar terms in reference to APRNs and PAs is inaccurate and misleading.
2. It is important and worthwhile to take a stand and educate the medical, healthcare finance, organizational and federal community regarding appropriate titles for nonphysician, health-care practitioners who have advanced degrees.

Background

The term “mid-level practitioner” is used by the US Department of Justice’s Drug Enforcement Administration (DEA) (2021) to identify a group of health-care individuals for the purpose of monitoring controlled substances. According to the website of the DEA, Office of Diversion Control,

“Pursuant to Title 21, Code of Federal Regulations, Section 1300.01(b28), the term midlevel practitioner means an individual practitioner, other than a physician, dentist, veterinarian, or podiatrist, who is licensed, registered, or otherwise permitted by the United States or the jurisdiction in which he/she practices, to dispense a controlled substance in the course of professional practice. Examples of mid-level practitioners include, but are not limited to, health-care providers such as nurse practitioners, nurse midwives, nurse anesthetists, clinical nurse specialists and physician assistants who are authorized to dispense controlled substances by the state in which they practice (paragraph 1).”

As a result of the outcry from both APRN and PA groups regarding the use of these inappropriate terms Medicare changed its nomenclature to “non-physician practitioner” to describe APRNs and PAs (Centers for Medicare and Medicaid Services, 2013). Other terms used to reference APRNs include “limited-license providers,” “non-physician providers,” “allied health providers,” and “advance practice providers.” The latter is recently being criticized by APRNs for the purposeful removal of the identity of nursing (Anderson, 2019).

A current trend affecting this is highlighted by the American Academy of Emergency Medicine (2020) who is proactively protecting employment opportunities for board-certified emergency physicians and upcoming residents and students by creating barriers for PA practice in emergency rooms. All of these terms and initiatives are inappropriate because they appear to “question the legitimacy of APRNs as independently licensed practitioners, according to their established scopes of practice (Hoyt, 2012, p. 93).”

These terms are not interchangeable with the title NP, APRN or PA (Bishop, 2012; AANP 2015). DeCapua (2015) further delineates that these terms need to be eliminated because they 1) devalue expertise, 2), confuse patients, and 3) impede teamwork. This is further outlined in the work by Adams and Markowitz (2018) who purport that scope of practice restriction impacts labor markets because restrictive practice will deter the entry of APRNs and PAs into practice, limit collaboration and full access to care, both mandates from the Institute of Medicine (2011) 3 and does not capitalize in individual productivity and comparative advantage which tailor toward efficiency and cost reduction.

Sarzynski and Barry (2019) nicely summarize that physicians’ arguments about NP/PA quality outcomes are largely unfounded and not supported by the available literature, further recommending the following: 1) APRNs should practice to the fullest extent of their education and training, 2) all providers should be transparent about their education, training, credentials, and certification, 3) the U.S. needs to standardize state laws governing APRNs/PAs which limits access to care, and 4) physicians, APRNs and PAs must be accountable to competency-based standards specific to their scope of practice. Working with specialty organizations help to accomplish these goals.

References

Adams, E.K., & Markowitz, S. (2018). Improving efficiency in the health-care system: Removing anticompetitive barriers for advanced practice registered nurses and physician assistants [Policy brief]. https://www.hamiltonproject.org/assets/files/AM_PB_0620.pdf

American Academy of Emergency Medicine. (2020). Updated position statement on nonphysician practitioners. https://www.aaem.org/resources/statements/position/updatedadvanced-practice-providers

American Association of Nurse Practitioners [AANP]. (2015). Use of terms such as mid-level provider and physician extender [Position statement]. https://www.aanp.org/advocacy/advocacy-resource/position-statements/use-of-termssuch-as-mid-level-provider-and-physician-extender

Anderson, J. (March 29, 2019). The next person who calls me a mid-level provider… Clinical Advisor. Retrieved on February 8, 2021, from
https://www.clinicaladvisor.com/home/the-waiting-room/the-next-person-who-calls-mea-mid-level-provider/

Bishop, C. (2012). Advanced practitioners are not mid-level providers. Journal of Advanced Practice Oncology, 3(5), 287-288. 4

Decapua, M. (2015, December 30). Don’t call me "midlevel," "extender," or "nonphysician." [Online blog]. Barton and Associates. https://www.bartonassociates.com/blog/dont-callme-midlevel-extender-or-non-physician

Department of Health & Human Services. Centers for Medicare & Medicaid Services. (2013). Physician delegation of tasks in skilled nursing facilities (SNFs) and nursing facilities (NFs). https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-15-.pdf

Hoyt, S. (2012). From the editors: Why the terms “mid-level provider” and “physician extender” are inappropriate. Advanced Emergency Nursing Journal, 34(2), 93-94. https://doi.10.1097/TME.0b013e3182617a2b

Institute of Medicine (2011). The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academic Press.

Sarzynski, E., & Barry, H. (2019). Current evidence and controversies: Advanced practice providers in healthcare. The American Journal of Managed Care, 25(8), 366-368.

United States Department of Justice, Drug Enforcement Administration. (2021). Mid-level practitioners authorization by state. https://www.deadiversion.usdoj.gov/drugreg/practioners/index.html

Effective Date: March, 2022
Originated by: Strategic Plan Theme 1 Committee
Adopted by: 2021-2022 APSNA Board of Directors
Original approval: September, 2016
Reaffirmed on: March, 2022