Physician perceptions of nurse practitioners: a replication study

Purpose: To replicate and update findings from an earlier study on the perceived incentives of physicians to work with nurse practitioners (NPs).
Data sources: Four hundred and three questionnaires were mailed to NPs who distributed them to their collaborating physicians.
Conclusion: Physicians ranked "accessibility to health care" and the "quality of care" as equally important and more important than "physician satisfaction" and "economic incentives." The findings were consistent with findings from the earlier study; however, the original study demonstrated a much clearer distinction among the four groups of incentives.
Implications for practice: These findings imply that collaboration between physicians and NPs is maturing as NPs move into more arenas in health care.     

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.     

Health Problems Encountered by Nurse Practitioners and Physicians in General Medicine Clinics

Distribution of health problems encountered by nurse practitioners and physicians in general/adult medicine clinics was studied. Proportional samples by clinics were selected from a total of 13,039 patient visits made to four clinics during an 18-week period in 1978. A Patient Encounter Form was used as the instrument and the ICD-9-CM as the coding system. Results showed that (a) 25.1% of the 13,039 patient visits were made to the nurse practitioners and 74.9% to the physicians, (b) 23 frequently reported health problems constituted more than 50% of all health problems seen by both provider groups, and (c) health problems with V codes constituted less than 30% of all health problems seen by both provider groups. Many similarities in health problems seen by nurse practitioners and physicians may indicate that nurse practitioners in the general/adult medicine specialty are used more to substitute for physicians in managing selected health problems than to complement medical practice.     

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.     

Urgent care medicine and the role of the APP within this specialty

The field of urgent care medicine offers an additional medical pathway for patients who have immediate, but non-life-threatening, medical concerns. Urgent care medicine offers a more varied set of resources and services than a physician office setting, with more flexible hours. This gives patients an opportunity to not have to go to the emergency department for non-emergent care. As a newer specialty within the medical field, certain roles of healthcare providers other than physicians are becoming established, including the advanced practice provider (APP). An APP is a nurse practitioner or a physician assistant, who is licensed to treat under the supervision of a physician. Nurse practitioners’ (NP) and physician assistants’ (PA) role in urgent care is often seen as an effective, lower cost option to manage common acute minor illnesses seen in the community. Benefits to utilizing APPs in urgent care include decreasing costs to both the patient and health system, enhancing the physician's ability to see more patients, and decreasing wait times, all while continuing to maintain high standards of care. The goal of the authors within this publication is to discuss urgent care as a specialty and further explore the role of advanced practice providers within this setting.     

Urinary tract infections in the elderly: a survey of physicians and nurses

The purpose of this study was to identify, in the presence of significant bacteriuria, the symptoms that determine and conditions that affect whether a physician will begin antibiotic treatment in the elderly; 2 physician groups were studied: geriatric physicians and family practice/internal medicine physicians. We also sought to compare these results to symptoms and conditions that determine nurses' decisions to begin assessment for urinary tract infections (UTIs) in this population. We also sought to determine the importance these 3 groups placed of monitoring asymptomatic bacteriuria for specific elderly patient populations. Quantitative questionnaires were sent to a convenience sample of 1900 physicians and nurses. Sixty-eight of the 300 geriatric physicians (23%), 113 of the 1000 family practice or internal medicine physicians (11%), and 192 of the 600 nurses (32%) returned surveys. Results showed differences between physician groups and nurses concerning whether cloudy and malodorous urine were symptoms of a UTI. This survey also found that physicians consider patient conditions to a greater extent than nurses do in their decisions regarding UTIs. Geriatric physicians appear to be less likely to monitor asymptomatic bacteriuria in any elderly patient population. Finally, we found that with regard to monitoring asymptomatic bacteriuria, both physician groups and the nurse group gave the greatest support for monitoring among elderly who have difficulty presenting symptoms of a UTI.     

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.     

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.     

The hazards of practising emergency medicine

Emergency physicians work in a unique environment which provides the full gamut of emotions — tension, excitement, depression, joy, anger, feat.…. The challenges of the profession are simultaneously extremely rewarding and personally hazardous, and while the specialty is still new and rapidly developing, attention must be paid to the long-term effects of such a life style on its practitioners. This is of significance both on a personal level to each emergency physician, and also to emergency medicine as a whole. In terms of the longevity of the specialty, we need to both attract young doctors with their enthusiasm and innovative ideas, and to retain more senior practitioners with their accumulated wisdom and experience. This article outlines some of the hazards of the practice of emergency medicine in the hope that more attention can be given to alleviating these stresses.     

Who wants to work in geriatrics: Findings from a national survey of physicians and nurse practitioners

BackgroundAs the United States population is aging, there is a chronic shortage of geriatrics- and gerontology- trained clinicians despite a variety of incentives. With primary care clinicians also in short supply, health systems are trying to cope with the increasing demand for care for older adultsPurposeThe purpose of this study was to examine respondents' willingness to recommend their career to others and beliefs about changes necessary to enhance the supply of appropriately prepared cliniciansMethodsThis study used a national survey of a stratified sample of 276 physicians and 134 nurse practitioners working in primary care and geriatric practices.FindingsAmong nurse practitioner respondents, 29% would "definitely" recommend a career as a geriatrician vs. seventeen percent of physicians; thirteen percent of physicians would "definitely" recommend a career as a nurse practitioner specializing in adult/gerontology vs. 42% for nurse practitioners. Those trained in geriatrics were more likely to recommend a career in the field.DiscussionNurse practitioners and physicians differ in their willingness to recommend careers in in gerontology and geriatrics, but less than a majority would strongly recommend careers in either specialty. Based on clinical reports, substantial reforms in payment and reimbursement for services may be necessary to bolster the geriatric field's attractiveness, and better prepare the workforce to care for older adults.     

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.     

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.     

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.     

Interactional styles of nurse practitioners and physicians regarding patient decision making

The purpose of this study was to describe interactional styles used by nurse practitioners and physicians in their attempts to influence patients' decision making. The ethical concepts of paternalism, maternalism, and shared decision making (operationalized as command, consequence, and concordance, respectively) formed the conceptual framework for the analysis of the interactions. Videotaped interactions of 85 physicians and 42 nurse practitioners in either joint or solo practice were analyzed. Tests of a priori hypotheses using hierarchical log-linear modeling yielded the following significant results: Males and physicians in solo practice used more command statements and fewer consequence statements than females and nurse practitioners in solo practice, who used fewer command statements and more consequence statements. All groups used more command/consequence statements than concordance statements.     

Emergency medicine in Nepal: present practice and direction for future

Emergency medicine is one of the youngest recognized specialties in Nepal, and its growth in clinical practice and academic development has been challenging. In this paper, we reviewed the current state of emergency medicine in Nepal based on review of the literature, personal observations and experience, and interviews with many Nepali and foreign emergency physicians. Most hospitals in Nepal have adopted a multi-specialist approach, where emergency room physicians are primarily general practitioners/family physicians or house officers. As physicians are receiving their training via various pathways, national standards in training and certification have not been developed. As a result, the scope of practice for emergency physicians and the quality of care vary greatly among hospitals. Difficult working conditions, physician recruitment, compensation, and academic enrichment remain major challenges in the development of emergency medicine. For the sustainable development of this specialty, more international guidance and local leadership is needed to standardize the training curriculum, to provide adequate funding opportunities for academic development and to promote the overall development of the emergency care system.     

Collaborative practice: a critical theory perspective

The purpose of this critical theory study was to investigate the observed failure of nurses and physicians to collaborate, and the underlying meaning behind this failure. Using a phenomenological and participatory approach, 18 family nurse practitioners and physicians in joint practice were interviewed separately and together about their practice relationships. Transcribed interviews and data summaries were returned to the participants for review and validation. Emergent themes were analyzed using the critical theory of Jürgen Habermas. Results demonstrated that distorted communication and nonmeaningful interactions were promoted by both nurses and physicians. Elements identified as contributing to more successful collaborative practices included a willingness to move beyond basic information exchange in nurse/physician interactions, the willingness and ability to challenge distortions and assumptions in the relationship, and a belief system based on critical self-reflection.     

Patient perceptions of the specialty of emergency medicine

The study objective was to determine emergency department (ED) patients' perceptions of the specialty of emergency medicine. We surveyed a convenience sample of adult ED patients regarding their knowledge of the specialty of emergency medicine. Responses included: 22% believing that ED physicians have their own practice outside the ED; 26% of patients with primary care physicians expected to be seen by their primary care physician in the ED; 19% thought ED physicians care for patients after admission; 26% thought that ED physicians perform surgery, 62% perceived emergency medicine to be a specialty; 15% have heard of the American College of Emergency Physicians; 71% thought that ED physicians are board certified and 15% thought paramedics were ED physicians. Patients estimated ED physicians' mean annual mean salary to be $100,000 and 61% believe that ED physicians are hospital employees. In conclusion, the specialty of emergency medicine is not well understood by our patients.     

Patient satisfaction with primary care: does type of practitioner matter?

OBJECTIVE: The objective of this study was to evaluate the association of patient satisfaction with type of practitioner attending visits in the primary care practice of a managed care organization (MCO). STUDY DESIGN: We conducted a retrospective observational study of 41,209 patient satisfaction surveys randomly sampled from visits provided by the pediatrics and adult medicine departments from 1997 to 2000. Logistic regression, with practitioner and practice fixed effects, of patient satisfaction versus dissatisfaction was estimated for each of 3 scales: practitioner interaction, care access, and overall experience. Models were estimated separately by department. Independent variables were type of practitioner attending the visit and other patient and visit characteristics. RESULTS: Adjusted for patient and visit characteristics, patients were significantly more likely to be satisfied with practitioner interaction on visits attended by physician assistant/nurse practitioners (PA/NPs) than visits attended by MDs in both the adult medicine and pediatrics practices. Patient satisfaction with care access or overall experience did not significantly differ by practitioner type. In adult medicine, patients were more satisfied on diabetes visits provided by MDs than by PA/NPs. Otherwise, patient satisfaction for the combined effects of practitioner type and specific presenting condition did not differ. CONCLUSIONS: Averaged over many primary care visits provided by many physicians and midlevel practitioners, patients in this MCO were as satisfied with care provided by PA/NPs as with care provided by MDs.     

The Acute Care Nurse Practitioner in Collaborative Practice

Nurse-physician relationships remain, for the most part, hierarchical in nature. A hierarchical structure allows the person at the top, most notably the physician, the highest level of authority and power for decision making. Other health care providers are delegated various tasks related to the medical plan of care. One role of nonmedical health care providers, including nurses, is to support the medical plan of care and increase the productivity of physicians. Medical centers have house staff, usually interns and residents, who work collaboratively with the attending physicians in care delivery. At one medical center, a shortage of medical house staff for internal medicine prompted the development and evaluation of an alternative service. The alternative service utilized master prepared, certified nurse practitioners on a nonteaching service to provide care for selected types of medical patients. Physicians consulted with nurse practitioners, but retained decision-making authority concerning patient admission to the service. This paper describes the development and evaluation of an alternative service based on a collaborative practice model and the role of nurse practitioners working under such a model. Discussion includes suggestions for process guideline development for organizations that want to improve collaborative practice relationships between unit nursing staff, nurse practitioners, and physicians.