Although nurse practitioners continue to provide care to many underserved communities, they're also at work in suburban doctor's offices and major medical centers, in hospitals and long-term care facilities around the country. "When I started as a nurse practitioner in the 1970s, there were 7,000 of us," says Eileen Sullivan-Marx, PhD, CRNP, FAAN, who is now an associate dean at the University of Pennsylvania School of Nursing. "Today there are 160,000. The profession has become mainstream."
"Frankly, it's a waste of time and money to require a nurse practitioner to get a doctor's signature to order a blood test or send a patient to physical therapy."
An uneasy alliance
Although nurse practitioners have come to play so vital a role, disagreement about expanding their scope of practice remains.
"Nurses are critical to the health care team, but there is no substitute for education and training," states American Medical Association board member Rebecca J. Patchin, M.D., in the organization’s response to the October 5 Institute of Medicine report. "Physicians have seven or more years of postgraduate education and more than 10,000 hours of clinical experience, most nurse practitioners have just two-to-three years of postgraduate education and less clinical experience than is obtained in the first year of a three year medical residency."
Differing views also exist at the state regulatory level, which determines what care nurse practitioners can and can't provide. Some states require nurse practitioners to work directly under a doctor's supervision. Others allow them far greater autonomy. Some states allow nurse practitioners to write a full range of prescriptions. Others don't.
Many of the regulations that limit nurses responsibilities date from before the rise of advanced practice nursing, says Sullivan-Marx. "Until the laws change, they will go on limiting the contribution that nurse practitioners can make."
Not surprisingly, professional nursing organizations would like to see more uniform state regulations and greater autonomy for advanced practice nurses across the country. So would many nursing professionals. "Frankly, it's a waste of time and money to require a nurse practitioner to get a doctor's signature to order a blood test or send a patient to physical therapy," says Tara Cortes, PhD, RN, FAAN, executive director of the Hartford Institute for Geriatric Nursing at New York University College of Nursing.
The Institute of Medicine report concurs."Restrictions on scope of practice and professional tensions have undermined the nursing profession's ability to provide and improve both general and advanced care," it states. The report calls on both states and insurance companies to change regulations so that patients can choose from a range of providers, including advanced practice nurses, to meet their health needs.
Uniform regulations would also make it easier for the general public to understand exactly who nurse practitioners are and what they do.
Again not surprisingly, physicians groups still emphasize the overriding importance of doctors. "Patients with complex problems, multiple diagnoses, or difficult management challenges will typically be best served by physicians working with a team of health care professionals, that may include nurse practitioners and other non-physician clinicians," the American College of Physicians emphasized in its 2009 position paper on nurse practitioners.
Especially at a time when the landscape of medical care is changing rapidly, such turf battles are likely to continue. But as doctors and advanced practice nurses increasingly work side by side, there's also a growing sense of trust and collaboration.
Nurse practitioner Eileen Sullivan-Marx knows that first hand. For a time she shared a private practice with her husband, a pediatrician. "Sometimes patients wanted to see me. Sometimes they preferred to see him," she remembers. "The choice wasn't always what you'd expect, either. My husband treated lots of female patients. I did most of the routine physicals for the volunteer firemen in town. Patients are pretty good at deciding who they want to see for a particular problem."
In an ideal world, most patients would have that choice. "Doctors and nurses come to medicine with different skills sets, different approaches," says Connie Ulrich, PhD, RN, FAAN, associate professor of bioethics and nursing at the University of Pennsylvania School of Nursing. The work of advanced practice nurses complements the work of doctors, she maintains, vastly improving the quality of health care. "All of us have the same thing in mind, after all, which is what's best for the patient."
Peter Jaret is a frequent contributor to AARP publications and is the co-author, along with National Geographic photographer Karen Kasmauski, of Nurse: A World of Care (Emory University Press 2008)