Expanding the Role of the Nurse: Nurse Practitioners and Case Managers

ABSTRACT: This paper discusses the impact of health trends on the structure of nursing organisations and the function and education of the professional nurse. It is argued that these changes are promoting a demand for autonomous nursing practice in the form of nurse practitioners and nurse case managers. The challenge to the profession is viewed in terms of making current health policies work for the achievement of professional goals, rather than against them.     

The delivery of a minor injuries telemedicine service by Emergency Nurse Practitioners

We conducted a retrospective review to assess the potential for Emergency Nurse Practitioners (ENPs) to deliver telemedicine advice for minor injuries. Over a one-year study period, 835 patients from 15 minor injury units in community hospitals presented to the minor injuries telemedicine service and were seen via videoconferencing by a doctor at the Aberdeen emergency department. A case review showed that overall, ENPs were considered capable of treating 470 of 788 new presentations (60%). If children under 14 years of age and shoulder injuries were excluded, this figure rose to 84%. Assessment of all minor injuries via a telemedicine network by medical staff is unnecessary. An ENP-led service offers a realistic and attractive alternative.     

The content of care provided by Family Nurse Practitioners

The content of care provided by 30 graduates of the UCLA Primex (Family Nurse Practitioner) program was examined. An encounter form similar to that used in the National Ambulatory Medical Care Survey was employed to code patients' complaints. These practitioners had been specifically trained to provide care for ambulatory patients. Data were collected one year after the completion of the university didactic phase of the program. We found that Primex practitioners spent more time with patients, more often employed traditional nursing functions, and more often used medical investigative procedures, such as x-rays and laboratory tests than did the physicians in the NAMC survey. Although the types of problems seen varied according to the organizational setting, these nurse practitioners were more often assigned routine health examinations and less often saw certain kinds of acute health care problems than had been anticipated in their training; 116 different types of symptoms or problems were presented, with a total of 1,170 encounters.The authors are with the UCLA Primex Program; Dr. Lewis is Professor of Medicine and Dr. Linn is Associate Researcher in the Department of Medicine, University of California at Los Angeles, Los Angeles, California 90024. This work was supported by grant HS-00985 from the National Center for Health Services Research.     

Physician Assistants and Nurse Practitioners as a Usual Source of Care

ABSTRACT:  Purpose: To identify characteristics and outcomes of patients who use physician assistants and nurse practitioners (PA/NPs) as a usual source of care. Methods: Cross sectional analysis using the telephone and mail surveys of the Wisconsin Longitudinal Study (WLS), a prospective cohort study of Wisconsin high school graduates and selected siblings (n = 6,803). Findings: Individuals from metropolitan (OR = 0.40, 95% CI = 0.29-0.54) and micropolitan (OR = 0.65, 95% CI = 0.44-0.95) areas were less likely to utilize PA/NPs than participants from rural locations. Participants without insurance or with public insurance other than Medicare were more likely than those with private insurance to utilize PA/NPs (OR = 1.71, 95% CI = 1.02-2.86). Patients of PA/NPs were more likely to be women (OR = 1.77, 95% CI = 1.34-2.34), younger (OR = 0.95, 95% CI = 0.92-0.98) and have lower extroversion scores (OR = 0.81, 95% CI = 0.68-0.96). Participants utilizing PA/NPs reported lower perceived access (β=−0.22, 95% CI =−0.35-0.09) than those utilizing doctors. PA/NP utilization was associated with an increased likelihood of chiropractor visits (OR = 1.57, 95% CI = 1.15-2.15) and decreased likelihood of a complete health exams (OR = 0.74, 95% CI = 0.55-0.99) or mammograms (OR = 0.65, 95% CI = 0.45-0.93). There were no significant differences in self-rated health or difficulties/delays in receiving care. Conclusions: Populations served by PA/NPs and doctors differ demographically but not in complexity. Though perceived access to care was lower for patients of PA/NPs, there were few differences in utilization and no differences in difficulties/delays in care or outcomes. This suggests that PA/NPs are acting as primary care providers to underserved patients with a range of disease severity, findings which have important implications for policy, including clinician workforce and reimbursement issues.     

Nurse practitioner effectiveness: a review of physician-nurse comparison studies.

This article discusses selected conceptual and methodological issues associated with studies evaluating nurse practitioner effectiveness by comparing nurse practitioner and physician practice. The particular areas covered include: the comparison criteria and the standards and the research methods used in these studies. Recommendations for future studies include: (1) activities representing the full range of the nurse practitioner role should be included in any comprehensive evaluation of nurse practitioners; (2) explicit criteria with adequate sensitivity should form the basis of comparisons between nurse practitioners and physicians; (3) empirically established relationships between process and outcome variables should form the basis for establishing nonarbitrary performance standards whenever possible; (4) random sampling of nurse practitioners and physicians should be used when possible. When random sampling is not possible, providers should be selected using variables known to correlate with quality of care; (5) random assignment of patients to providers is strongly recommended, taking care to use clients new to both providers; (6) use of multiple data sources is recommended to decrease the current heavy reliance on adults; (7) conclusions should point out differential findings identifying those which favor physicians, those which favor nurse practitioners, and those identifying no differences between providers.     

Nurse appraisal systems: characteristics and effectiveness

The present research surveyed Directors of Nursing regarding characteristics and effectiveness of their nurse appraisal systems. Results indicated that perceived effectiveness was influenced by process rather than technical characteristics of the system. Implications of the survey findings for the design and maintenance of a nurse appraisal system are discussed.     

Education of Physician Assistants, Nurse Midwives, and Nurse Practitioners for Rural Practice

Physician assistants, nurse midwives, and nurse practitioners have been described as a vital and unique solution to the problem of providing adequate access to high quality health care for many Americans. Each of these classifications of health care providers has been accepted as separate professions with their own standards and identities. Their curricula and educational pathways have developed into clearly distinguishable educational tracks that complement the larger disciplines of nursing and medicine. Physician assistants, nurse midwives, and nurse practitioners have been singled out in federal legislation for their potential contribution to underserved rural communities (e.g., the Rural Health Clinics Services Act of 1977 and its subsequent amendments). This designation is partly due to the fact that certified nurse midwives, nurse practitioners, and physician assistants traditionally chose to practice in rural, underserved areas, and because their skills and practice structures were well matched to the needs and resources of rural areas. That pattern of practice, however, appears to have changed and the distribution of these practitioners has begun to resemble the distribution of physicians and other clinicians with heavy concentrations in urban areas and a growing shortage in rural and underserved areas.     

The Attitudes of Rural Minnesota Family Physicians Toward Nurse Practitioners and Physician Assistants

Increased use of nurse practitioners and physician assistants has been promoted as a possible solution to the shortage of primary care providers in rural locations. If the use of nonphysician providers is to be optimized in these areas, awareness and acceptance of their capabilities by rural family physicians is essential. This study surveyed the attitudes of rural Minnesota family physicians toward the use of physician assistants and nurse practitioners. Forty-six percent of the 600 rural family physicians surveyed responded to the questionnaire. Approximately 90 percent of responding physicians indicated a high degree of confidence in the abilities of nonphysician providers in the areas of preventive and routine care; some concern was expressed about the proficiency of nonphysician providers taking call, covering the emergency room, and doing hospital rounds--activities that involve a broader base of clinical knowledge and diagnostic skills. Other concerns were an increased workload for physicians due to their assumed supervisory roles, an increase in complexity of cases seen by physicians, increased physician liability, job competition between nonphysician providers and physicians, and the lack of educational opportunities and supervisory guidelines for physicians regarding collaborative relationships. Appropriate roles for family physicians, nurse practitioners and physician assistants are not well-defined in the minds of respondents, and it appears future acceptance and practice patterns will depend on how these roles are established and accepted.     

Redesigning a School Health Workforce for a New Health Care Environment: Training School Nurses as Nurse Practitioners

ABSTRACT: Diminishing financial resources for school health dictate the most efficient possible deployment of the school health workforce. School nurses trained as nurse practitioners could help resolve the common problems of ready access to and appropriate use of primary care, early detection of potentially costly medical problems, and efficient use of school health staff. To determine how best to use existing resources to meet the increasingly varied and complex health care needs of children and adolescents, a pilot project was conducted in Denver from 1994 to 1996. With physician back-up and health aide support, school nurses were trained as nurse practitioners to provide in-school diagnostic and treatment services. Based on their evaluation study of this pilot project, the authors suggest ways to solve problems in role transition, including well-balanced training; clear role definition and assignment of responsibilities; appropriate back-up and mentoring support; and issues of sustaining long-term programs     

Safety of Aspiration Abortion Performed by Nurse Practitioners,Certified Nurse Midwives,and Physician Assistants Under a California Legal Waiver

Objectives. We examined the impact on patient safety if nurse practitioners (NPs), certified nurse midwives (CNMs), and physician assistants (PAs) were permitted to provide aspiration abortions in California.Methods. In a prospective, observational study, we evaluated the outcomes of 11 487 early aspiration abortions completed by physicians (n = 5812) and newly trained NPs, CNMs, and PAs (n = 5675) from 4 Planned Parenthood affiliates and Kaiser Permanente of Northern California, by using a noninferiority design with a predetermined acceptable risk difference of 2%. All complications up to 4 weeks after the abortion were included.Results. Of the 11 487 aspiration abortions analyzed, 1.3% (n = 152) resulted in a complication: 1.8% for NP-, CNM-, and PA-performed aspirations and 0.9% for physician-performed aspirations. The unadjusted risk difference for total complications between NP–CNM–PA and physician groups was 0.87 (95% confidence interval [CI] = 0.45, 1.29) and 0.83 (95% CI = 0.33, 1.33) in a propensity score–matched sample.Conclusions. Abortion complications were clinically equivalent between newly trained NPs, CNMs, and PAs and physicians, supporting the adoption of policies to allow these providers to perform early aspirations to expand access to abortion care.Increased access to early abortion is a pressing public health need. By 2005, the number of abortion care facilities in the United States had decreased 38% from its peak in 1982.1 Although the number has since remained stable, the proportion of US counties with no facility remains high at 87%; more than one third of women aged 15 to 44 years live in these counties.2 Additionally, a large proportion of US facilities are hospitals that perform abortions only in cases of serious medical and fetal indications or facilities that offer medical abortions only up to 9 weeks of pregnancy.2Many women face difficulties finding a facility, resulting in delayed care.3 Increasing access is critical because abortions at later gestations are associated with a higher risk of complications4 and higher costs.2 Research has also found that many women would prefer to obtain their abortions earlier5 Finally, traditionally underserved populations experience the greatest barriers to abortion care, resulting in higher rates of procedures after the first trimester.6,7In California, more than half of the 58 counties lack a facility that provides 400 or more abortions (R. K. Jones, PhD, Guttmacher Institute, written communication, November 2011). Low-income and minority women are most likely to be served by public health departments or community health centers,8 most of which do not provide abortions. These women are also more likely to be cared for by nurse practitioners (NPs) and physician assistants (PAs) than by obstetricians and gynecologists.9One potential solution to improve access is to increase the number and types of health care professionals who offer early abortion care.10–12 Increased emphasis has been placed on task sharing to better meet women’s health needs in the context of health care workforce shortages.13 In the United States, health professions are regulated through a patchwork of state regulations14,15 that determine who can perform abortions, a power reaffirmed by several US Supreme Court decisions.16–18 Currently, nonphysician clinicians can perform aspiration abortions legally in only 4 states—Montana, Oregon, New Hampshire, and Vermont. Two additional states (Kansas and West Virginia) do not limit the performance of abortions to physicians, but nonphysician clinicians have never tried to provide abortion care. Of the remaining 44 states (Figure 1), some allow nonphysician clinicians to perform medical (but not aspiration) abortions under decisions by attorneys general or health departments, and 1 state—California—passed statutory authority for that care. As part of a larger effort to limit abortion access, several states have recently promulgated laws that specifically prohibit nonphysician clinicians from performing abortions.19 For example, a 2009 Arizona law (HB 2564 and SB 1175) that precluded NPs from providing abortions resulted in the discontinuation of abortion care at several facilities that had previously been staffed exclusively by NPs.20Open in a separate windowFIGURE 1—Landscape of health professional regulation of abortion provision in the United States.Note. CNM = certified nurse midwife; NP = nurse practitioner; PA = physician assistant.Limited clinical evidence is available to inform policymakers about whether physician-only legal restrictions on abortion are evidence-based.21–24 Our study was designed to provide this evidence to policymakers; it answers the question “What would be the impact on patient safety if NPs, PAs, and certified nurse midwives (CNMs) were permitted to provide aspiration abortions in California?” (We use the term aspiration abortion to refer to what is commonly called surgical abortion because the technique does not meet the technical definition of surgery.25) We used a noninferiority design to compare the incidence of abortion-related complications between groups because we anticipated a slightly higher number of complications among newly trained NPs, CNMs, and PAs than among the experienced physicians.