Acceptance of Nurse Practitioners and Physician Assistants in Meeting the Perceived Needs of Rural Communities

ABSTRACT Nurse practitioners and physician assistants have provided a partial solution to the shortage of primary care services in medically underserved rural areas. This paper describes the results of a study exploring community acceptance of nurse practitioners and physician assistants in rural medically underserved areas. Community acceptance in the context of this study implies not only satisfaction with care received, but also willingness of the community to support NP/PA practice through its infrastructure and encourage members to initially seek and continue to receive care from an NP or PA. Five focus groups were conducted in each of five rural medically underserved communities. The two most pervasive findings were the lack of previous exposure to NPs and PAs and the general belief that NPs and PAs would be accepted in these communities if certain conditions could be met. The theme of conditional acceptance included both personal and system factors. Personal factors included friendliness, competence, willingness to enter into the life of the community, and the ability to keep information confidential. System factors considered critical for acceptance included service type, integration with the existing health care system, cost, geographic proximity, and availability. The results of this study offer insight into community attitudes and suggest marketing strategies for those who plan to introduce NP or PA services into rural communities.     

Physician assistant and nurse practitioner utilization in U.S. emergency departments, 2010 to 2017

BackgroundPhysician Assistants (PAs) and Nurse Practitioners (NPs) are widely utilized in United States (US) Emergency Departments(EDs). We sought to characterize ED PA and NP utilization and practice characteristics in US EDs 2010–2017.MethodsA retrospective, secondary analysis of the Center for Disease Control's National Hospital Ambulatory Medical Care Survey was performed. National estimates of ED visits involving PAs/NPs alone (PA/NP), PAs/NPs with physician involvement (PA/NP+), or physician only (PHYS) were analyzed for patient demographics and hospital characteristics.ResultsBetween 2010 and 2017, 1 billion US ED visits occurred. 8.4% (±4.2%) of visits were seen by a PA/NP, and 11.8% (±4.5%) by a PA/NP+; 76.3% (±7.2%) by PHYS. There was an increase in utilization by PA/NP observed in 2016. PA/NP acuity was highest for semi-urgent/nonurgent (53.2%, ±8.6%). PA/NP see the minority of ambulance arrivals [5.4% (±1.2%)] and admit less patients overall [1.6% (±0.7%)]. Less laboratory [53.6% (±10.0%) vs. 67.0% (±6.2%)] and radiographic [38.0% (±7.0%) vs. 51.6% (±4.6%)] studies were performed during PA/NP only vs. PHYS visits. PA/NP visits were most common for patients 25–44 years old (yo) (31.1%, ±5.5%) and 0–15 yo (23.9%, ±4.7%). Most PA/NP visits result in a length of stay (LOS) between 1 and 1.9 h (33.4%, ±5.7%) compared to most PHYS visits resulting in a LOS greater than 3 h (40.3%, ±3%).ConclusionsFrom 2010 to 2015, PA/NP utilization remained stable until an increase in 2016. There was a decrease in 2017. Various PA/NP patient characteristics are significant compared to PHYS. PHYS continue to see most ED patients.     

Training of nurse practitioners and physician assistants to perform screening flexible sigmoidoscopy

PURPOSE: To describe the colorectal cancer-screening program at Harvard Vanguard Medical Associates, a large multispecialty medical group, in which nurse practitioners (NPs) and physician assistants (PAs) perform screening flexible sigmoidoscopies. DATA SOURCES: Scientific literature, consensus statements and guidelines, and the protocol utilized to train NPs and PAs to perform flexible sigmoidoscopy. Data from 9,500 screening procedures are presented. CONCLUSIONS: In comparison with gastroenterologists, trained NP and PA endoscopists perform screening flexible sigmoidoscopy with similar accuracy and safety but at lower cost. IMPLICATIONS FOR PRACTICE: Screening flexible sigmoidoscopy performed by NPs and PAs may increase the availability and lower the cost of flexible sigmoidoscopy for colorectal cancer screening.     

Nurse practitioner and physician assistant satellite health centers. The pending demise of an organizational form?

A national cohort of 44 rural satellite health centers originally staffed by nurse practitioners (NPs) and physician assistants (PAs) was studied in 1975 and resurveyed in 1979 and in 1984 to examine the viability of this type of health-care delivery organization during a period of significant growth in the nation's physician supply. Twelve of these practices had ceased to function, although eight have been replaced by physician practices. Of the remaining 32, 14 have physicians on their staffs and 18 remain staffed only by NPs and PAs. Those centers staffed by physicians experience greater patient utilization, charge more for office visits, have larger budgets, and generate more of their budgets from fees for services and therefore appear to be more organizationally stable than centers staffed only by NPs and PAs. Although broader studies are needed for substantiation, these findings suggest that the period when NP/PA-staffed satellite health centers were important organizations for delivering care to previously underserved rural communities may be ending.     

Assessing the utilization and productivity of nurse practitioners and physician's assistants: methodology and findings on productivity

This article describes the research design, survey instrument and methodology employed in a national study to assess the utilization and productivity of nurse practitioners and physician assistants (NP/PAs) in primary care settings. All practices (N = 455) used in the study employed formally trained NP/PAs who treated, or were eligible to treate, Medicare patients on an outpatient basis, and included a general practitioner, family practitioner or a general internist as the supervising physician. A matched group of comparison practices were subject to the same eligibility criteria except that they did not employ NP/PAs. A comprehensive diary-type instrument focusing on patient care was used to collect detailed data on each practitioner's daly professional activities. Data are presented on the productivity of NPs, PAs and physicians as measured by seven basic variables related to patient volume, time in patient care and revenue generated. Numerous inter- and intraspecialty comparisons were made across various practice arrangements and across location variables such as rural vs. urban, remote vs. nonremote, and health care resource areas. Interpretations of the data indicate clearly that PAs are considerably more productive than NPs. However, although NPs spend more time with individual patients, the cause of this differential productivity was not revealed.     

Practical and legal implications of nurse practitioners and physician assistants in cystoscopy

Due to looming physician shortages and the increase in demand for quality medical care for the newly insured, as well as the aging Baby Boomer population, there has never been a more important time for physicians, administrators, and the public to endorse and develop the role that nurse practitioners (NPs) and physician assistants (PAs) will play in the future of medical practice. One way to begin to address this problem is by expanding investments in training, competencies, and certification for NPs and PAs in performing minor procedures, such as cystoscopy, which is currently being performed by NPs and PAs across the United States and United Kingdom safely and with consistently high quality outcomes.     

Factors associated with the use of advanced practice nurses/physician assistants in a fee-for-service nursing home practice: a comparison with primary care physicians

The purpose of this research was to examine factors associated with the use of advanced practice nurse and physician assistant (APN/PA) visits to nursing home (NH) patients compared with those by primary care physicians (PCPs). This was a secondary analysis using Medicare claims data. General estimation equations were used to determine the odds of NH residents receiving APN/PA visits. Ordinary least squares analyses were used to examine factors associated with these visits. A total of 5,436 APN/PAs provided care to 27% of 129,812 residents and were responsible for 16% of the 1.1 million Medicare NH fee-for-service visits in 2004. APN/PAs made an average of 33 visits annually compared with PCPs (21 visits). Neuropsychiatric and acute diagnoses and patients with a long-stay status were associated with more APN/PA visits. APN/PAs provide a substantial amount of care, but regional variations occur, and Medicare regulations constrain the ability of APN/PAs to substitute for physician visits.     

Use of midlevel providers in US EDs, 1993 to 2005: implications for the workforce

Objective

The aim of the study was to evaluate use of physician assistants (PAs) and nurse practitioners (NPs) in US emergency departments (EDs).

Methods

We analyzed visits from the 1993 to 2005 National Hospital Ambulatory Medical Care Survey, seen by midlevel provider (MLP), and compared characteristics of MLP visits to those seen by physicians only.

Results

From 1993 to 2005, 5.2% (95% CI, 4.6%-5.8%) of US ED visits were seen by PAs and 1.7% (95% CI, 1.5%-2.0%) by NPs. During the study period, PA visits rose from 2.9% to 9.1%, whereas NP visits rose from 1.1% to 3.8% (both P_trend < .001). Compared to physician only visits, those seen only by MLPs arrived by ambulance less frequently (6.0% vs 15%), had lower urgent acuity (37% vs 59%), and were admitted less often (3.0% vs 13%).

Conclusions

Midlevel provider use has increased in US EDs. Their involvement in some urgent visits and those requiring admission suggests that the role of MLPs extends beyond minor presentations.     

Problem-based learning and clinical practice: The nurse practitioners’ perspective

This paper reports the findings of a phenomenological study which explored the lived experience of the nurse practitioner (NP) who had been educated through a problem-based learning (PBL) approach and the meaning of that education on the NPs current clinical practice. This was accomplished through the use of in-depth interviews to gather information from 13 practicing NPs. It was found that information obtained in the PBL classroom could be directly applied to professional practice providing the NP with the skills needed for clinical decision making with a holistic viewpoint and satisfaction in clinical practice. The analysis both supports and challenges the current research on perceptions, experiences, satisfaction, and outcomes related to PBL.     

Physician assistants and nurse practitioners: a missing component in state workforce assessments

Due to current or predicted health workforce shortages, policy makers worldwide are addressing issues of task allocation, skill mix, and role substitution. This article presents an example of this process in the United States (US). Health workforce analysts recommend that US physician workforce planning account for the impact of physician assistants (PAs) and nurse practitioners (NPs). We examined 40 state workforce assessments in order to identify best practices for including PAs/NPs. Most assessments (about 60%) did not include PAs/NPs in provider counts, workforce projections or recommendations. Only 35% enumerated PAs/NPs. Best practices included use of an accurate data source, such as state licensing data, and combined workforce planning for PAs, NPs, and physicians. Our findings suggest that interprofessional medical workforce planning is not the norm among the states in the US. The best practices that we identify may be instructive to states as they develop methods for assessing workforce adequacy. Our discussion of potential barriers to interprofessional workforce planning may be useful to policy makers worldwide as they confront issues related to professional boundaries and interprofessional workforce planning.     

Physician assistants and nurse practitioners: a missing component in state workforce assessments

Due to current or predicted health workforce shortages, policy makers worldwide are addressing issues of task allocation, skill mix, and role substitution. This article presents an example of this process in the United States (US). Health workforce analysts recommend that US physician workforce planning account for the impact of physician assistants (PAs) and nurse practitioners (NPs). We examined 40 state workforce assessments in order to identify best practices for including PAs/NPs. Most assessments (about 60%) did not include PAs/NPs in provider counts, workforce projections or recommendations. Only 35% enumerated PAs/NPs. Best practices included use of an accurate data source, such as state licensing data, and combined workforce planning for PAs, NPs, and physicians. Our findings suggest that interprofessional medical workforce planning is not the norm among the states in the US. The best practices that we identify may be instructive to states as they develop methods for assessing workforce adequacy. Our discussion of potential barriers to interprofessional workforce planning may be useful to policy makers worldwide as they confront issues related to professional boundaries and interprofessional workforce planning.     

Strategies to promote the professional transition of new graduate nurse practitioners: A systematic review

New graduate nurse practitioner (NP) postgraduate support programs and interventions have proliferated, sparking controversy. The Institute of Medicine/National Academy of Medicine recommends residency programs for new graduate NPs; however, the NP community debates whether new graduate NPs need additional training and whether such training compromises patient access to care. This systematic review aimed to synthesize evidence regarding the effectiveness of interventions and strategies to promote the professional transition of new graduate NPs. Interventions identified in the current literature included fellowship programs and a webinar. Strategies included mentorship, experiential learning, interprofessional training, and professional socialization. The studies reviewed primarily evaluated NPs’ perceptions of the interventions’ effects on their professional transitions. The findings from this systematic review highlight challenges in evidencing postgraduate support programs. The small number of available studies underscores a critical problem for the NP community: additional evidence is needed to inform whether and how to support new graduate NPs as they transition to practice.     

Science Not Sales: Partnerships and Scientific Exchange With Industry

Parallel to the time that the nurse practitioner (NP) role evolved, pharmaceutical companies recognized the need for more scientific relationships among the academia-based physicians and researchers. The role of the medical science liaison (MSL) was first established by UpJohn in 1967, yet has grown, much like the NP role, to meet the dynamic marketplace changes in health care. To meet the true definition of being a “scientific peer,” backgrounds have become increasingly broad to include clinicians with a PhD, DNP, or physician assistant. The term “clinical practice liaison” (CPL) is used in this article, understanding that the CPL role is the same as the MSL, except that the engagement provider type is almost exclusively NPs and PAs. The CPL is not a sales representative. Rather, the CPL is a field-based professional who is strictly focused on balanced scientific and clinical exchanges.     

Nurse Practitioners’ Experiences of Moral Distress in the Continuing Care Setting

This article describes a qualitative study designed to understand nurse practitioners’ (NPs) experiences with moral distress in the continuing care setting. The findings confirm that NPs in this setting experience moral distress. These experiences are in response to tensions that arise when factors interfere with their ability to provide “good” patient care. Five themes emerged as important factors: patients, perceptions, physicians, palliation, and policies. Moral distress is a substantial issue for NPs in the continuing care setting. Further research is required to examine NP’s experience with moral distress in other settings and identify solutions to resolve and respond to this distress.     

Physician assistants in primary care. Patient assignment and task delegation

This paper reports a concurrent self-report study of 2,456 office encounters with physicians and/or physician assistants (PAs) in 16 primary care, private practices in Florida. Initial patient assignment to either a physician or PA varies according to demographic and visit-specific characteristics. Patients who are male, younger than 65 years, new patients, seeking help for acute problems, and those who are "walk-in" or "work-in" patients are more likely to be assigned to a PA. Among frequently performed procedures, physicians are more likely to perform the partial histories, partial physicals, and pelvic examinations, as well as counsel patients on diet and psychosocial problems. PAs are more likely to perform the complete physical examinations, record vital signs, conduct diagnostic tests, and perform therapeutic procedures (administer injections, change dressings, etc.). Most tasks performed by PAs receive supervision through chart review rather than direct oversight. The typical patient visit in a practice employing a PA involves the receipt of services from only one provider. Approximately 50% of patient services are performed by physicians only, while 35% of the services are performed solely by PAs, and 15% are performed by both. Most patients have received care from both the physician and the PA.