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Doctors & Hospitals
by Peter Jaret, October 5, 2010
When Douglas Peterson called to make a doctor's appointment recently, he was given a choice. He could see the doctor in three weeks, or a nurse practitioner the next day.
"I had a couple of questions about a medication I was taking," says Peterson, 61, a business consultant in northern California. "I made an appointment with the nurse."
He's not alone. In doctor's offices, walk-in clinics, emergency rooms and long-term care facilities throughout the country, nurses are increasingly the front line of primary care — the healthcare professionals we're most likely to see first when something ails us.
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Nurse practitioners, who have advanced degrees and specialized training, examine patients, diagnose diseases, order tests and, in some areas, even write prescriptions. Some 250 clinics around the country are staffed entirely by nurse practitioners. Even where nurses work closely with doctors, they are taking on a growing range of roles and responsibilities.
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That's how it should be, many experts say. "Nurse practitioners can deal with about 80 percent of the problems that show up in primary care settings," says Marla Salmon, ScD, RN, FAAN, dean of nursing at the University of Washington. "Allowing advanced practice nurses to do what they do well improves efficiency and increases access to health care. And when nurse practitioners encounter a problem they can't deal with, they can refer patients to the appropriate doctor."
In a report released today called "Leading Change, Advancing Health," the Institute of Medicine and the Robert Wood Johnson Foundation outline the many ways in which nurses are key to solving many of the challenges facing health care. "Given their education, experience, and unique perspectives and the centrality of their role in providing care, nurses will play a significant role in the transformation of the health care system," the report states.
For many years nurse practitioners have helped make up for a growing shortage of primary care and geriatric physicians. They'll continue to play that role as health care reform brings coverage and access to more Americans.
But the contribution of nurses goes beyond filling in when doctors aren't available. Nurse practitioners can play a key role in improving the quality of health care for older patients with chronic illnesses. "Nurses are positioned across the health care system to provide high quality health care, increase access to health care services, and keep costs down," notes the Center to Champion Nursing in America, an initiative of AARP, the AARP Foundation and Robert Wood Johnson Foundation.
The rise of advanced practice nursing
Nurse practitioners are part of a larger category called advanced practice registered nurses, which also include nurse anesthetists, nurse midwives and clinical nurse specialists, who often work in acute care. Advanced practice nurses have education and training beyond that of standard registered nurses. (Unlike RNs, all of whom have college degrees, licensed practical nurses, or LPNs, graduate from accredited nurse training programs that are not part of college or university degrees. Physician assistants, commonly referred to as PAs, perform some of the functions of a nurse practitioner, such as examining patients and diagnosing illness, but they typically work directly under a doctor's supervision.)
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.
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."
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."
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)
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