The field of advanced practice nursing arose in the 1960s —a time when, like today, health care faced enormous challenges. In 1965, Medicare and Medicaid expanded coverage to low-income women, children, seniors and people with disabilities, dramatically increasing demand. In addition, rapid advances in medicine meant more doctors were going into specialties, creating the shortage of primary care physicians that continues today.
— Randy Faris/Corbis
In many underserved rural and poor urban areas, nurse practitioners represent the only health care providers available.
At the time, advanced practice nursing had plenty of critics. Physician groups worried that the quality of medical care would suffer, since nurses receive less training than doctors. Some professional nursing groups voiced concerns that nursing's unique role would be diluted.
Many of those concerns have been allayed. Since the early 1970s, dozens of studies have shown that the quality of primary care from nurse practitioners is equal to that of medical doctors. In a 2002 report in the British Medical Journal that reviewed 34 studies, researchers found that patients fare equally well whether they were seen by a nurse practitioner or a primary care physician. Indeed, patients were typically more satisfied with care from nurse practitioners, perhaps in part because they spent more time with patients.
One proving ground has been the Veterans Administration, which has long made extensive use of nurse practitioners. Findings reported in 2009 showed that the V.A.'s Home Based Primary Care Program, run entirely by advanced practice nurses, reduced hospital stays from 14.8 days to 5.6 days and kept many patients out of nursing homes by helping them live independently.
Some of the crucial roles nurse practitioners fill are less easy to measure but just as important, advocates say. One is providing information. "I can't tell you how often patients see the doctor and then sit down with the nurse practitioner and say, ‘Would you please explain what's going on,' " says Salmon. In their role as teachers, nurses tend to stress preventive care, encouraging patients to follow healthier lifestyles.
Nurses also provide continuity of care in an increasingly fragmented medical system. "Older patients with chronic illnesses may see a doctor once every three months," says Salmon. "In between, it's often the nurse practitioner who follows-up, who makes sure patients comply with treatment, who watches for adverse reactions or new problems."
The culture of nursing has traditionally addressed not only the physical needs but also psychological and even spiritual needs of patients. "They see the larger context," says Carol Hall Ellenbecker, PhD, RN, a professor at the College of Nursing & Health Sciences at the University of Massachusetts in Boston. "That's especially important when you're talking about older patients with chronic illnesses."
Filling the gap
In many underserved rural and poor urban areas, nurse practitioners represent the only health care providers available. When the sole physician in Mount Morris, Pennsylvania, retired in 1990, people in this rural and relatively poor community on the border of West Virginia had to travel long distances to get medical care — until nurse practitioner Mona Counts, PhD., RN, , who is now a professor of nursing at Pennsylvania State University, started the Primary Care Center of Mt. Morris.
One of her first patients was Jeanne Roush-Russell, 73. Fifteen years ago, when Roush-Russell suddenly collapsed at work, Counts was there in minutes. Bedridden after a string of surgeries, Roush-Russell receives regular home visits from Mt. Morris's nurse practitioners. "I wouldn't be able to stay at home if it weren't for them."