Trends in the supply of physician assistants and nurse practitioners in the United States

In 2001 an estimated 103,612 nurse practitioners (NPs) and physician assistants (PAs) were in clinical employment in the United States. The roles of PAs and NPs in providing comparable physician services are similar; they differ in that NPs are predominantly in primary care, while PAs are divided between primary and specialty care. PA and NP education processes also differ in the student pool and trends in the output. The combined number of graduates totaled 11,585 in 2001. However, the annual number of NP graduates is declining, while the number of PA graduates is increasing. These observations have implications for the future in the types of patients they see and the degree of health care services they provide.     

Knowing the nurse practitioner: dominant discourses shaping our horizons

Abstract   The purpose of this paper is to examine the various discourses, particularly the dominant instrumental and economic discourses that have brought the phenomena of the nurse practitioner (NP) into being. It is proposed that NPs have been constituted as an object of nature and therefore understood metaphorically as a tool or instrument within the health care system to be used efficiently and effectively. Heidegger's philosophical analysis of the question concerning technology is used to argue that our current ways of knowing the NP through these discourses, with their emphasis on calculative logic, have resulted from our modern view of the essence of technology. It is also argued that there is now a need to shape our horizons concerning the NP in new and different ways. There is a need to engage in dialogical forms of research in order to evoke the richness and depth of what it means to be an NP, that is, to reveal the other modes of expression by which we define ourselves, understand others and nursing.     

Effects of a geriatric nurse practitioner on process and outcome of nursing home care.

We compared measures of quality of care and health services utilization in 30 nursing homes employing geriatric nurse practitioners with those in 30 matched control homes. Information for this analysis came from reviews of samples of patient records drawn at comparable periods before and after the geriatric NPs were employed. The measures of geriatric nurse practitioner impact were based on comparisons of changes from pre-NP to post-NP periods. Separate analyses were done for newly admitted and long-stay residents; a subgroup of homes judged to be best case examples was analyzed separately as well as the whole sample. Favorable changes were seen in two out of eight activity of daily living (ADL) measures: five of 18 nursing therapies; two of six drug therapies; six of eight tracers. There was some reduction in hospital admissions and total days in geriatric NP homes. Overall measures of medical attention showed a mixed pattern with some evidence of geriatric NP care substituted for physician care. These findings suggest that the geriatric NP has a useful role in nursing home care.     

A nurse practitioner-led farmers' health service: setting up and evaluating a UK project

ABSTRACT: The farming community in the UK have significant unmet health-care needs that have traditionally remained invisible. The project that is the subject of this paper is an attempt to improve access to health care for farmers and make their needs visible. It is based in an upland area of England and involves two nurse practitioners (NPs) and two support workers who provide health care for the farming community. The main targets of the project are farm accidents, mental health and occupational diseases. The NPs visit farms, on request, for consultations and also attend auction marts, agricultural shows and other farmers' meetings. Evaluation is by a telephone follow-up interview with a sample of clients seen by the N P, who will be compared with a group from a similar area who do not receive the service. A farm accident survey is underway, case notes are being audited and the NPs are keeping a reflective diary as further sources of data.     

Context of care or provider training: the impact on preventive screening practices

BACKGROUND: While MD adherence to U.S. Preventive Services Task Force guidelines has been found to be uneven, nurse practitioners (NPs) and their adherence to guidelines have not been closely examined. METHODS: A retrospective chart review of new patients (n = 1339) in an NP primary health care center, four MD primary health care centers, and one private NP practice. Screening and counseling were compared for NPs and MDs. RESULTS: When patient populations, resources, and administrative policies were similar in the NP and MD primary health care centers, NPs were more likely than MDs to perform primary prevention; however, MDs were more likely to document the delivery of secondary prevention screening. Private practice NPs' performance was more congruent with practice guidelines than either NP or MD primary health care center providers. Private practice NPs were more likely to perform screening, assessment, and counseling. CONCLUSIONS: When context, patient population, and productivity requirements were the same, NPs and MDs differed in their use of preventive measures, and not as expected. When NPs are not constrained by productivity requirements, and when their patient population has more resources and higher expectations, NPs perform better than their primary care center counterparts, particularly in secondary prevention and assessment and counseling.     

Nurse practitioners in primary care

OBJECTIVES: Recent policy emphasizing the role of primary care has increased the workload of general practitioners (GPs) while simultaneously placing nurse practitioners (NPs) as key providers in the delivery of health care. There is need to examine the latter's work practices. The purpose of this article is to explore the role and practice of NPs in general practice. METHODS: DESIGN: Thirty-six semi-structured interviews with GPs, NPs, receptionists and patients were analysed. SETTING: Four general practices in south-east England. MAIN OUTCOME MEASURES: Data from semi-structured interviews relating to allocation, prescribing and referral practices of NPs in primary care. RESULTS: These include the differences in presenting problems of patients seen by GPs and NPs, prescribing and referral practice and legal issues of the nurse practitioner. A wide range of practice is reported. CONCLUSION: This study highlights the variation in how patients are allocated for NP consultation and in NP autonomy, prescribing and referral, which raises issues for clinical governance of protocols and risk management.     

Advanced nurse practitioners and physician assistants: what is the difference? Comparing the USA and UK

With the reduction in junior doctors' hours and fewer doctors being trained in the UK, there is a need for other types of health-care practitioners to fill the gap. This article describes some of the background to the present situation and delineates two types of roles, the advanced nurse practitioner and the physician assistant, for consideration as alternatives to address the present and growing shortage of doctors.     

Primary care physician perceptions of the nurse practitioner in the 1990s.

OBJECTIVE: To evaluate factors associated with primary care physician attitudes toward nurse practitioners (NPs) providing primary care. DESIGN: A mailed survey of primary care physicians in Iowa. SETTING AND PARTICIPANTS: Half (N = 616) of the non-institutional-based, full-time, primary care physicians in Iowa in spring 1994. Although 360 (58.4%) responded, only physicians with complete data on all items in the model were used in these analyses (n = 259 [42.0%]). MAIN OUTCOME MEASURES: There were 2 principal dependent measures: physician attitudes toward NPs providing primary care (an 11-item instrument) and physician experience with NPs in this role. Bivariate relationships between physician demographic and practice characteristics were evaluated by chi 2 tests, as were both dependent variables. Ordinary least-squares regression was used to determine factors related to physician attitudes toward NPs. RESULTS: In bivariate analyses, physicians were significantly more likely to have had experience with an NP providing primary care if they were in pediatrics or obstetrics-gynecology (78.3% and 70.0%, respectively; P < .001), had been in practice for fewer than 20 years (P = .045), or were in practices with 5 or more physicians. The ordinary least-squares regression indicated that physicians with previous experience working with NPs providing primary care (P = .01), physicians practicing in urban areas with populations greater than 20,000 but far from a metropolitan area (P = .03), and general practice physicians (P = .04) had significantly more favorable attitudes toward NPs than did other primary care physicians. CONCLUSIONS: The association between previous experience with a primary care NP and a more positive attitude toward NPs has important implications for the training of primary care physicians, particularly in community-based, multidisciplinary settings.     

Role disagreement in primary care practice

To measure the extent of disagreement on roles between nurse practitioners (NPs) and physicians working together and to look for characteristics of joint practices that are associated with disagreement, patient vignettes were sent to 15 NP/M.D. dyads, and both M.D.s and NPs were asked how appropriate it would be for them and for their co-practitioner to provide care for the problem presented in each vignette. Measures of disagreement on patient care roles were developed by comparing responses within the dyad. For all practices, there was moderate agreement on roles, and this agreement seemed to favor a complementary practice. Disagreement on the NP's role was most often in the direction of NP feeling capable of providing more care than the M.D. felt she could provide. Various factors, such as job satisfaction, age differences between providers, and training level of the NP, were associated with the disagreement that was found. Some disagreement on roles exists between NPs and M.D.s practicing together. Resolution of these differences may lead to greater job satisfaction and more effective interaction between providers.The authors are with the University of North Carolina, Chapel Hill where Dr. Davidson is an Assistant Professor of Medicine in the Division of General Medicine and Clinical Epidemiology, Dr. Earp is an Assistant Professor of Health Education in the School of Public Health and Dr. Fletcher is Co-Chief of the Division of General Medicine, Associate Professor of Medicine and Clinical Epidemiology, and Director of the Robert Wood Johnson Clinical Scholars Program. Reprints may be obtained from Richard Alan Davidson, M.D., M.P.H., Department of Medicine, 3041 Old Clinic Building, University of North Carolina, Chapel Hill, North Carolina 27514. This work was presented at the American Federation for Clinical Research Meetings, May, 1980. This project was supported in part by the Robert Wood Johnson Clinical Scholars Program. The authors would like to acknowledge the assistance of David McKay in the planning of this study.     

The rural nurse practitioner: a challenge and a response.

From a cohort of 525 employed nurse practitioners (NPs) who graduated between May 1975 and June 1976, 85 (16 per cent) reported practicing in rural areas. While 91 per cent of the rural NPs chose the short-term certificate programs rather than the master's degree for their NP preparation, 47 per cent had already earned a baccalaureate or master's degree prior to NP training. Family NPs comprised the most frequent specialty area chosen, followed by pediatric and adult specialties. Of the 85, 99 per cent were actually providing a broad array of primary care services to clients over a wide age range. Physicians were periodically available on site in about 80 per cent of the practices, by telephone in 97 per cent of the practices, and in 60 per cent of the practices provided additional consulation by record review. Major motivations of the NPs for entering rural practice were to participate in a creative approach to health care delivery (50 per cent of the practice setting were less than five years old), and for the opportunity for role autonomy. Over 95 per cent of these NPs and employers were satisfied with the NP role.     

An epidemiology of women's lives: the environmental risk of breast cancer

The dominant discourses of breast cancer risk are individualistic and biological, tending to emphasize personal life history, genetic predisposition and ‘lifestyle’ factors. Statutory programmes to reduce risk are correspondingly concerned primarily with early detection, and not with primary prevention of a disease whose incidence rate continues to rise in the UK and the USA. Against this, the breast cancer movement is working to emphasize the collective narrative of breast cancer aetiology, applying an ecological approach to public health protection, and basing its demands on a precautionary approach to environmental hazards. This paper considers how the breast cancer/environment movement in the US and UK asserts the legitimacy of activists’ alternative expertise, and challenges the biomedical foundation of traditional epidemiological practices. Activists’ knowledge claims are, additionally, understood as embodied, lay expertise, predicated in feminist epistemology which has argued that the personal, the subjective and the partial count, and that such situated knowledge makes for stronger science. These dimensions of the breast cancer/environment movement shape what is here termed ‘citizen expertise’, as activists present a ‘transformational vision’ of the physical, political, social and economic environments that currently contribute to breast cancer.     

Perceived Barriers to Nurse Practitioner Practice in Rural Settings

CONTEXT: Rural residents experience the same incidence of acute illness as urban populations and have higher levels of chronic illness. Overall, access to adequate rural health care is limited. Nurse practitioners (NPs) have been identified as safe, cost-effective providers in meeting these challenges in rural settings. PURPOSE: This replication study was conducted to examine NP perceptions of barriers to rural practice in Minnesota. Findings were compared to earlier studies to examine issues that have persisted over time. METHODS: A Barriers to Practice checklist was mailed to NPs from the database of the Board of Nursing of a midwestern state. Rural NPs (n = 191) identified and described barriers to practice and rated the overall restrictiveness of their practice. FINDINGS: Barriers to practice were perceived to be prevalent. Persisting barriers continued to stand in the way of full utilization of NP roles. Lack of understanding of NP roles on the part of the public and other health professionals has been particularly problematic over time. Key issues in 2001 were low salaries, lack of adequate office space, and a limited peer network. Perceived restrictiveness of the practice climate, gauged as somewhat restrictive, remained unchanged between 1996 and 2001. CONCLUSIONS: NPs have an excellent history of meeting rural primary health care needs. Enhancing the NP work environment could prove instrumental to retaining these professionals in the work force and thereby contribute to improved access and quality of care in underserved rural communities.     

Use of midlevel practitioners to achieve labor cost savings in the primary care practice of an MCO

OBJECTIVE: To estimate the savings in labor costs per primary care visit that might be realized from increased use of physician assistants (PAs) and nurse practitioners (NPs) in the primary care practices of a managed care organization (MCO). STUDY SETTING/DATA SOURCES: Twenty-six capitated primary care practices of a group model MCO. Data on approximately two million visits provided by 206 practitioners were extracted from computerized visit records for 1997-2000. Computerized payroll ledgers were the source of annual labor costs per practice from 1997-2000. STUDY DESIGN: Likelihood of a visit attended by a PA/NP versus MD was modeled using logistic regression, with practice fixed effects, by department (adult medicine, pediatrics) and year. Parameter estimates and practice fixed effects from these regressions were used to predict the proportion of PA/NP visits per practice per year given a standard case mix. Least squares regressions, with practice fixed effects, were used to estimate the association of this standardized predicted proportion of PA/NP visits with average annual practitioner and total labor costs per visit, controlling for other practice characteristics. RESULTS: On average, PAs/NPs attended one in three adult medicine visits and one in five pediatric medicine visits. Likelihood of a PA/NP visit was significantly higher than average among patients presenting with minor acute illness (e.g., acute pharyngitis). In adult medicine, likelihood of a PA/NP visit was lower than average among older patients. Practitioner labor costs per visit and total labor costs per visit were lower (p<.01 and p=.08, respectively) among practices with greater use of PAs/NPs, standardized for case mix. CONCLUSIONS: Primary care practices that used more PAs/NPs in care delivery realized lower practitioner labor costs per visit than practices that used less. Future research should investigate the cost savings and cost-effectiveness potential of delivery designs that change staffing mix and division of labor among clinical disciplines.     

Interdisciplinary Team-Based Management of Heart Failure

Multidisciplinary team disease management has evolved into consensus ‘best practice’ in the care of patients with chronic heart failure (CHF). The mission of disease management for patients with CHF is to shift care from the hospital to the clinic and to the home, optimize quality of care in concert with consensus guidelines, reduce admissions by 40% and improve functional status and quality of life. The Partners Heart Care program has been operational for 5 years and enrolled hundreds of patients throughout the Partners Health Care System in Boston, Massachusetts, USA. This program enrolls patients following hospital discharge in a physician-directed multidisciplinary interventional care program, run by nurse practitioners, which incorporates several levels of care dependent upon patient acuity. Following clinical stabilization and optimal titration of oral therapy in concert with consensus care guidelines, patients transition to a longitudinal care program. The primary responsibility for the clinical care of patients in all phases of the program resides with nurse practitioners and primary care physicians, with heart failure specialists serving as consultants on an as-needed basis. Data on pre-specified program outcomes such as quality of care, mortality, hospital admissions, functional status, procedure use and costs are collected prospectively and provide benchmarks for continuous quality improvement. The most critical lesson learned in development to date is the necessity of precise tailoring of the program to local patient and provider needs with local oversight and management.     

A comparative study of physicians' and nurses' conceptions of the role of the nurse practitioner.

Attempts to define the role of the nurse practitioner as a new health care provider raise questions about the traditional health care division of labor. In order to determine nurses' and physicians' conceptions of the NP's role, parallel surveys were conducted among registered nurses and primary care physicians in southeastern Pennsylvania (including Philadelphia). Respondents (679 nurses and 597 physicians) indicated their opinions on the issue of autonomy for NPs and on the issue of specific tasks appropriate to the NP's role. There were significant differences between nurses and physicians with respect to both of the issues under consideration, but there were also important differences within each of these groups. Nurses were more likely to assert that an NP might practice independently, and also had a higher conception of the NP's capabilities. Physicians who were interested in employing a nurse practitioner had opinions which were closest to those of nurses. These findings suggest that conflict between nurses and physicians might be minimal as long as the nurse practitioner movement remains relatively small, but that there may be latent conflict inherent in any large scale attempt to change the health care division of labor at the present time.     

Digital care at home: Exploring the role of smart consumer devices

In-home ‘smart’ consumer devices such as voice assistants, doorbells, thermostats, and lightbulbs have been advocated by organisations in the UK such as the RNIB, Alzheimer Scotland, and the NHS. Yet the use of these devices, which are not purposely designed as care devices and therefore are not subject to evaluation and regulation, has been neglected in the academic literature. This paper reports on a study which examined 135 Amazon reviews of 5 ‘top-selling’ smart devices, concluding that such devices are being used to supplement informal caring, albeit in different ways. The implications of this phenomena are necessary to consider, specifically the consequences for ‘caring webs’ and expectations about the future role of digital devices within the landscape of informal caring.     

维和医院护士的角色与内涵建设

目的明确护士在维和任务中应承担的角色,有针对性地研究维和护士培训评价标准,探索维和护理勤务理论研究。方法通过对护理护士角色功能阐述,分析维和护士角色定位,明确维和护士基本任务,并有针对性地提出内涵建设内容:军人角色、战场生命救护者、维和医疗活动的管理者、维和"全科技能"护理者、军事外交使者、"标准预防"的执行者。结果明确护士在维和任务中应承担的角色,进而确立对维和护士核心能力的建设标准。结论通过对维和护士角色的认识,建立一套具有可操作性的维和护理培训标准和技术考核规范,为保障对象提供安全、有效、及时的护理勤务活动。