Comparing HMO physicians' attitudes towards NPs and PAs

This study examined the attitudes of physicians working in health maintenance organizations toward the use of nurse practitioners and physician assistants. It also explored some of the underlying reasons for these attitudes: effect upon quality of care, risk of malpractice, role threat and gender bias. The setting was a health maintenance organization serving 270,000 members. The data were derived from a survey of physicians' attitudes and behavior. Physicians from internal medicine, pediatrics and obstetrics-gynecology were the study population. Internists and pediatricians had favorable attitudes toward both nurse practitioners and physician assistants. Obstetrician-gynecologists had somewhat less favorable attitudes. Physicians in all three specialties favored nurse practitioners more than physician assistants. Physicians felt that nurse practitioners were more likely to increase the quality of care and less likely to increase the risk of malpractice. Nurse practitioners were not seen as a greater role threat. Some gender bias appeared to be present, but it did not appear to constrain the use of nurse practitioners. Large, multi-specialty, prepaid group practice health maintenance organizations may be favorable settings for nurse practitioners and physician assistants to practice primary care.     

Gender and the attribution of the nurse practitioner and physician status

The purpose of this study was to discover whether sex-role sterotypes were used to identify members of two professions, nurse practitioners and physicians. Participants reported whether they believed a videotaped health care provider was a physician or a nurse practitioner. Results showed that male providers tended to be identified as physicians, whereas female providers tended to be identified as nurse practitioners. Findings indicate that understanding and enactment of the nurse practitioner and physician roles are still affected by gender issues and that both physicians and nurse practitioners remain subject to the force of sex-role stereotypes.     

Emergency Physicians' Attitudes Toward the Emergency Nurse Practitioner Role: Validation Versus Rejection

A qualitative grounded theory approach was used in this study, which examined the attitudes of a group of emergency physicians toward collaborative practice with emergency nurse practitioners. Interviews were conducted with five physicians who were not currently working with nurse practitioners. Responses were coded, and a substantive theory model of dependent collaboration emerged. The physicians supported the emergency nurse practitioner role on the grounds that it be supervised in the traditional fashion by the physician. Concerns regarding education, trust, liability, and capability were identified. Deficits in knowledge regarding training and the role/function of nurse practitioners were also identified.     

Skill mix change between physicians,nurse practitioners,physician assistants,and nurses in nursing homes: A qualitative study

Nursing home physicians face heavy workloads, because of the aging population and rising number of older adults with one or more chronic diseases. Skill mix change, in which professionals perform tasks previously reserved for physicians independently or under supervision, could be an answer to this challenge. The aim of this study was to describe how skill mix change in nursing homes is organized from four monodisciplinary perspectives and the interdisciplinary perspective, what influences it, and what its effects are. The study focused particularly on skill mix change through the substitution of nurse practitioners, physician assistants, or registered nurses for nursing home physicians. Five focus group interviews were conducted in the Netherlands. Variation in tasks and responsibilities was found. Despite this variation, stakeholders reported increased quality of health care, patient centeredness, and support for care teams. A clear vision on skill mix change, acceptance of nurse practitioners, physician assistants, and registered nurses, and a reduction of legal insecurity are needed that might maximize the added value of nurse practitioners, physician assistants, and registered nurses.     

Family physician/nurse practitioner: stories of collaboration

AIMS: This paper presents the experiences of nurse practitioners and family physicians working in collaborative practice at four Canadian rural primary care agencies. It focuses on the qualitative segment of a larger study examining the impact of an educational intervention on interprofessional practice. BACKGROUND: Growing awareness of the importance of health promotion and disease prevention, the increased complexity of community-based care, and the need to use scarce human healthcare resources, especially family physicians, far more efficiently and effectively, have resulted in increased emphasis on primary healthcare renewal in Canada. Key to primary healthcare renewal is care delivery through interdisciplinary teams that include nurse practitioners. METHODS: Narrative analysis, a form of interpretive analysis that respects the integrity of the stories told by participants, was chosen as the strategy to examine the narrative data gathered in two sets of interviews with the nurse practitioners and family physicians. The study was undertaken during 2000. RESULTS: Thirteen family physicians and five nurse practitioners with diverse educational backgrounds and varied experience with collaboration participated in the qualitative component of the study. A number of issues related to working in a shared practice were identified in nurse practitioner and family physician interviews across the research sites. The themes identified in participants' stories included issues related to the scope of practice, emphasizing the importance of role clarity and trust, the ideological difference regarding disease prevention and health promotion, differences in perceptions about the operation of collaborative practice, and the understanding that collaborative relationships evolve. CONCLUSIONS: The placement of nurse practitioners and family physicians in a common clinical practice without some form of orientation process does not produce collaborative practice. Educational strategies related to role expectations are necessary to facilitate the development of care delivery partnerships characterized by interdependent practice.     

Differences in physician attitudes towards patient-centredness: across four medical specialties

Aims: There is limited study on patient‐centred attitudes with regards to the patient–physician relationship in physicians. The objective of this study was to examine and compare physician attitudes toward patient‐centredness in four different medical settings. Methods: The present study utilised a cross‐sectional survey design and purposive sampling to recruit physicians from a single academic medical centre via face‐to‐face interviews. Patient‐centred attitudes of physicians specialising in surgery, oncology, obstetrics and gynaecology and primary care (N = 78) were compared on the Patient–Practitioner Orientation Scale (PPOS) using an independent one‐way analysis of variance (ANOVA). The four medical specialties comprised the four levels, with role orientation (patient‐centred orientation vs. doctor‐centred orientation) as the dependent measure. Results: A significant level of difference (p < 0.001) was found between the four specialisations: oncologists were found to have the highest level of patient‐centeredness, followed by obstetricians & gynaecologists and primary care physicians, with surgeons being the least patient‐centred among specialisations sampled. Conclusion: These data are the first from the South‐East Asian region to demonstrate differences in physician attitudes between medical specialties. Our findings prompt further investigation and confirmation as to whether physicians with particular attitudinal traits are attracted to any particular specialties of medicine, or if physician attitudes are acquired through professional experience and training. In addition, this study offers better insight into the attitudinal differences of physician between medical specialities.     

Physician receptivity to nurse practitioners: a study of the correlates of the delegation of clinical responsibility.

A survey to measure physician receptivity to nurse practitioners was conducted in North Carolina in 1973. All North Carolina physicians were asked to rate a list of 35 clinical tasks of varying levels of difficulty and responsibility according to their willingness to delegate these tasks to nurse practitioners. Using eight items from this list that were good discriminants of physician attitudes towards delegating responsibility, task delegation scores were correlated with physician characteristics and their responses to questions about recruitment, training, reimbursement, and willingness to hire nurse practitioners. Thirty-four per cent of the respondents would hire a nurse practitioner, whereas 52% approved of the concept but would not hire one. Physicians who had previously worked with a nurse practitioner were more willing to hire one and had a higher task delegation score. Sixty-eight per cent of respondents would share their load with nurse practitioners in their offices, while 6% would have them work in satellite clinics away from the physicians' offices. Most physicians wanted their own nurse trained as a nurse practitioner in a program that combined a didactic course at a medical center with on-the-job training. The authors conclude that there is a potential demand for nurse practitioners in North Carolina and that the training program must prepare the nurse practitioners for the tasks physicians are willing to delegate to them.     

Interprofessional simulation-based education program: A promising approach for changing stereotypes and improving attitudes toward nurse–physician collaboration

An effective working relationship between physicians and nurses is enhanced by fostering positive perceptions and collaborative attitudes between the two professions. This brief paper examines the effect of an interprofessional simulation-based communication education program in enhancing medical and nursing students' perceptions of each other's profession and their attitudes toward nurse–physician collaboration. Pretest–Posttest design was conducted on 96 medical and nursing students who demonstrated the existence of professional stereotypes in the baseline data. This study showed that by promoting open communication, shared information and decision-making, mutual respect, and trust during the interprofessional simulation training, a positive transformation on the stereotypes and attitudes toward nurse–physician collaboration can be achieved.     

Characteristics of patient visits to nurse practitioners and physician assistants in hospital outpatient departments

Many authors have described differences between nurse practitioners and physician assistants. Most studies have compared physician with nonphysician providers' practice. Few studies have compared nurse practitioners and physician assistants, and none has used a national data base. This exploratory, atheoretical research examined which of the following characteristics predicted patients being seen by nurse practitioners and physician assistants: patient and hospital demographics, diagnosis, diagnostic/screening services, therapeutic services, and disposition of the visit. The data set used for analysis was the 1992 National Hospital Ambulatory Medical Care Survey. Based on a multistage probability design yielding national estimates for patient visits in hospital outpatient settings, the National Hospital Ambulatory Medical Care Survey showed that there were 2,847 weighted patient visits to either nurse practitioners or physician assistants (4.6 million patient visits using national estimates). Results of multivariate logistic regression suggest that nurse practitioners were the most likely nonphysician provider for outpatients receiving more health promotion and counseling (therapeutic) services and for those needing women's and children's services. Outpatients in rural areas predicted visits to physician assistants. As more nonphysician providers enter the work force, the results of this research may assist with understanding the utilization of nurse practitioners and physician assistants in primary care.     

A comparative analysis of nurse and physician characters in the entertainment media

The results of a large body of research have yielded findings supportive of the view that the mass media have a decisive effect on the formation of public attitudes and behaviours. This study reports the results of a content analysis of 670 nurse and 466 physician characters portrayed in novels, motion pictures and prime-time television series, published or produced from 1920 to 1980. When compared with media physicians, media nurses were consistently found to be less central to the plot, less intelligent, rational, and individualistic, less likely to value scholarliness and achievement and exercise clinical judgement. Moreover in television series nurse characters were depicted as valuing service to others and being helpful to patients less, and as being lower in nurturance and empathy than physician characters. An analysis of these data over time points to a steady and unmistakable decline in the mass media entertainment image of nurses while physician characters have remained consistently high or shown improvement. The implications of this image gap are discussed along with the need for image reshaping efforts which might direct public demand for more collegial and productive 'real world' nurse-physician roles and interprofessional relationships.     

Nurse practitioner, nurse midwife and physician assistant attitudes and care practices related to persons with HIV/AIDS

Although multiple studies of nurses' attitudes toward people living with HIV/AIDS (PLWAs) can be found in the literature, little is known about the attitudes, beliefs and practices of nurse practitioners (NPs), certified nurse midwives (CNMs), and physician assistants (PAs). A survey including a 21-item AIDS Attitude Scale measuring the constructs of Avoidance and Empathy was sent to 1,291 NPs, CNMs and PAs in Louisiana, Arkansas and Mississippi to describe their attitudes and care practices related to PLWAs. Respondents who were more comfortable treating PLWAs had significantly lower avoidance scores and significantly higher empathy scores than respondents with lower comfort levels in providing care. Greater than 80% of respondents indicated that they would provide health care to HIV-infected individuals. Respondents who referred HIV/AIDS patients for all care did so primarily due to lack of experience with HIV and the availability of more experienced providers. Avoidance and empathy scores were not found to be significantly associated with referral for care. This study suggests that this group of providers has relatively low avoidance and high empathy toward PLWAs and is willing to care for HIV-infected individuals.     

The public's view of physicians' assistants and nurse practitioners: a survey of Baltimore urban residents.

This study of public attitudes toward physicians' assistants and nurse practitioners finds that the public regards the two groups of health workers as remarkably similar. A telephone survey of 2,583 households in the Baltimore, Maryland, metropolitan area indicates that about half the population have heard of a PA or NP, though only 4 per cent report receiving care from such workers. In this urban sample, respondents accepted the principle that important medical care functions can be delegated, as long as the PA or NP is considered assistant to the physician. The public reported more acceptance of tasks performed by nurse practitioners than by physicians' assistants, though the differences are small.     

Physicians' perceptions of physician–nurse collaboration in Japan: Effects of collaborative experience

Studies of physician–nurse relationships have focused mainly on nurses' perceptions. Few studies have explored physicians' perceptions and related factors. This study had two aims: to describe physicians' perceptions of physician–nurse collaboration in Japan by focusing on attitudes toward collaboration and collaborative practice and to examine the effect of physicians' experiences related to collaboration on their perceptions of collaboration. A cross-sectional survey was conducted. Of the 520 physicians from four hospitals, 248 completed the survey. The survey included the Jefferson Scale of attitudes toward physician–nurse collaboration, the collaborative practice scales, learning experiences related to collaboration with nurses and experiences of joint activities with nurses. Multiple regression analysis revealed that learning experiences in undergraduate and out-of-hospital education and experiences of joint committee work were significantly associated with higher collaborative practice scores. Although participants' attitude scores had a strong association with practice scores, there were no variables significantly associated with the attitude score. This study supported the importance of education in undergraduate courses and suggested that it should be ongoing after qualification. Joint activities other than daily practice, such as continuous quality improvement, might also be effective. Factors that improve physicians' attitudes toward collaboration should be further explored.     

Increased autonomy for nurse practitioners as a solution to the physician shortage

In this paper, the author addresses decreased access to health care in underserved areas and the shortage of primary care physicians and how nurse practitioners (NPs) can fill this void. In order to make up for the lack of primary care doctors, NPs need to be politically involved in fighting for their autonomy; specifically, they must work toward removal of the statutory requirement that NPs practice in collaboration with a physician. NP associations need to increase membership, encourage members' political involvement, and move legislative agendas to bring about change. Although this paper focuses mainly on New York, it does highlight NP legislative agendas and how they were used to fight for autonomy in other states.     

Who is a nurse practitioner? Processes of care and patients' and physicians' perceptions.

During a repeat of a previous study of nurse practitioners conducted at the University of Kansas, an opportunity occurred to examine the impact of two different styles of care provided by nurse practitioners on patients and physicians with whom they worked. The two nurse practitioners involved had similar backgrounds in terms of work experience. The participated in the same training program for nurse practitioners, practice in the same environment, and cared for patients randomly allocated to one or the other practitioner. One practitioner saw her patients more often and for longer periods of time, ordered more medications, and less often sought physician consultation. She also was most optimistic regarding the impact of her services on patients' conditions. The other was more dependent upon physicians for validation of her actions. Physicians did not distinguish between the two practitioners in terms of their performance. However, patients cared for by the practitioner whose behavior suggested an integration of medical and nursing care processes saw nurses as a more common source of information about illness and demonstrated more significant shifts in preferences for services provided by nurses rather than physicians. No significant changes were noted from pretest values among patients cared for by the other nurse practitioner.     

Counseling medical patients about cigarette smoking: a comparison of the impact of training on nurse practitioners and physicians

Health providers believe that eliminating smoking is an important health promotion goal, but physicians and nurse practitioners may differ in the implementation of that belief. To determine whether nurse practitioners or physicians were more likely to counsel smokers to quit smoking, 12 internal medicine nurse practitioners (100 percent female) and 40 internal medicine physicians (30 percent female) were studied at four San Francisco Bay-area Kaiser Permanente Medical Centers, both before and after training in smoking-cessation counseling. In addition, exit phone surveys of at least 15 smokers per participant were completed as soon as possible following an office visit to the participant (269 nurse practitioner patients; 948 physician patients). It was found that nurse practitioners discussed smoking with patients more often than did physicians (64 percent vs. 50 percent; p less than 0.001), asked patients more often whether they were interested in quitting (49 percent vs. 40 percent; p less than 0.01), distributed more smoking-cessation literature to patients (37 percent vs. 25 percent; p less than 0.001) and made more follow-up appointments about smoking (36 percent vs. 19 percent; p less than 0.001). These differences in counseling behavior between the two groups were not explained by differences in patient characteristics of the two groups. The authors concluded that, given the same training, nurse practitioners are more likely to counsel smokers about quitting than are physicians.     

Factors influencing the decision to use nurse practitioners in the emergency department.

INTRODUCTION: Emergency department overcrowding is a serious problem nationwide. Of an estimated 14 million visits to hospital emergency departments, only 12.9% are considered emergent. Many emergency departments, however, employ only physicians despite the fact that nurse practitioners have a proven record of providing high quality, cost-effective care in the emergency department. The purpose of the study was to determine factors that influence the decision to use nurse practitioners in the emergency department. METHODS: Interviews were conducted with ED managers in hospitals that both employ and do not employ nurse practitioners in the emergency department. RESULTS: In this study, the primary reason that nurse practitioners were not employed by emergency departments was that physician groups with whom the hospitals contract refuse to use nurse practitioners. Emergency department managers of facilities with nurse practitioners reported high levels of satisfaction with the nurse practitioners performance. The 2 ED managers without nurse practitioners in their facility were highly supportive of having nurse practitioners in the emergency department and have advocated for hiring nurse practitioners. DISCUSSION: Education needs to occur with emergency departments regarding the value of the nurse practitioner's role to the facility. Research is needed to investigate why emergency department physician groups resist hiring nurse practitioners. Increased staffing with nurse practitioners in the emergency department can serve to reduce overcrowding, reduce waiting times, and increase patient satisfaction.     

Nominations for Excellence: Collegial Advocacy for Nurse Practitioners

This study examined physician nomination data submitted for Syntex Nurse Practitioner of the Year Awards for 1988, 1989, and 1990. The physicians identified nurse practitioner contributions to patient care, community service/outreach, and education and research. A content analysis of the text data yielded themes within four major domains that described outstanding nurse practitioners in mutual practice relationships with physicians. The domains were clinical expertise, holistic caring, patient-centered activism, and leadership. The findings in this study indicated that physicians value the contributions of nurse practitioners that enhance the quality and scope of health care for patients within a mutual practice.     

Management of Mild-to-Moderate Osteoarthritis: A Study of the Primary Care Perspective

Abstract

Objectives: Examine the knowledge, attitudes, and practice patterns of primary care clinicians regarding the management of mild-to-moderate osteoarthritis (OA). Design: Case vignette-based survey. Methods: A survey was distributed to 251 physicians, physician assistants (PAs), and nurse practitioners (NPs) in the primary care setting. The survey assessed practice patterns in the management of patients with mild-to-moderate OA, as well as attitudes toward guidelines and future educational topics that may be of benefit to the clinician. Results: We found that primary care clinicians are most likely to treat mild-to-moderate OA with an oral nonsteroidal anti-inflammatory drug regimen. Patients with initial or recurrent OA were “very likely” to be recommended to a physical therapy maintenance program. Two-thirds of respondents claimed to be unfamiliar with Osteoarthritis Research Society International guidelines for OA management. Conclusion: This study reflects the need for further education for primary care physicians, NPs, and PAs on the management of OA.