Insurers' contracting policies on nurse practitioners as primary care providers: the current landscape and what needs to change

A national survey showed that most insurance companies refuse to credential nurse practitioners as primary care providers in nurse-managed health centers. These prohibitive policies, along with weak federal and state laws, threaten the long-term sustainability of nurse-managed health centers as safety-net health care providers and limit the ability for nurse practitioners to become an accepted primary health care source in the United States. Interviews with national managed care organizations revealed that these companies' current business practice and policies are unlikely to change without regulatory change at state and/or federal levels.     

Job satisfaction of nurse practitioners: an analysis using Herzberg's theory

The current sociopolitical and economic forces affecting health care may lead to job dissatisfaction among nurse practitioners, according to results of a South Carolina study. A mailed survey that consisted of the Index of Job Satisfaction and the Minnesota Satisfaction Questionnaire--Short Form was used to test Herzberg's dual-factor theory of job satisfaction. A response rate of 90 percent was attained, with a final sample of 132 nurse practitioners and midwives. Consistent with the predictions of Herzberg's model, intrinsic factors served as sources of job satisfaction, while extrinsic factors were the primary sources of job dissatisfaction. Nurse practitioners in the sample reported a moderate amount of satisfaction with their "overall jobs." Suggestions are provided for ways both nurse practitioners and health administrators can enhance job satisfaction.     

Insurers' contracting policies on nurse practitioners as primary care providers: two years later

A national survey showed that nearly half of all major managed care organizations in the United States refuse to credential nurse practitioners as primary care providers. In nurse-managed health centers throughout the country, nurse practitioners provide primary care to underserved populations with similar outcomes to primary care physicians. Insurers' prohibitive credentialing and reimbursement policies reduce these centers' capacity for growth and, in turn, threaten the long-term sustainability of a key component of the health care safety net. Two years after conducting a national survey of insurers' credentialing and reimbursement policies regarding primary care nurse practitioners, researchers returned to the subject matter and found that many of the same financial barriers to nurse-managed health center sustainability still exist. Although some progress had been made since 2005, this progress did not appear to be attributable to regulatory changes or renewed enforcement of existing laws.     

Well-being Content in Nurse Practitioner Curricula: Facilitators and Barriers

The challenges and stressors of primary care require nurse practitioners to balance patient demands with their own health and well-being. Academic institutions have a responsibility to promote health and well-being among all students, with the goal of their continuing these activities after graduation. Results of this project describe the current state of well-being content integration in the curriculum of a hybrid family nurse practitioner program and identify potential barriers and facilitators of curriculum refinement. Findings provide direction regarding the next steps required to implement well-being content into didactic and workplace learning environments of primary care programs.     

The Community Medical Alliance: an integrated system of care in Greater Boston for people with severe disability and AIDS

The Community Medical Alliance in Boston has adapted principles of prepaid managed care to redesign service delivery for people with severe physical disability and with late-stage AIDS. Experience to date suggests that the flexibility of capitation can be used to substantially shift care from its usual hospital focus to clinicians in home and community settings, especially nurse practitioners, with a high degree of patient satisfaction and without apparent compromise in quality. Instead of limiting access, managed care can use prepayment to support early interventions, coordination, and the development of services specifically designed to meet the needs of the target population.     

Primary care ... where?

Corporate-based nurse managed centers are not the national norm. More prevalent is the use of an occupational health or physician-directed medical model of care. The author describes how a 14-year-old primary care center at a North Carolina computer software company is just "business as usual" when viewed in the context of the company's philosophy, goals, and culture. Included are considerations for nurse practitioners interested in the successful transplantation of this primary care model to other settings.     

Employment and salary characteristics of nurse practitioners

Nurse practitioners provide high-quality, cost-effective care to health care consumers, yet they continue to experience low economic compensation and salary compression. The nursing literature is limited with respect to data regarding salaries, benefits and trends in compensation for nurse practitioners. In order to provide baseline data for nurse practitioners to use in negotiating compensation benefits and packages, 459 certified nurse practitioners in North Carolina were surveyed regarding demographic and employment characteristics and job satisfaction. Of the 83 percent who responded, nearly two-thirds earned less than $30,000 per year. Benefits and salary adjustment for certification are reported, and techniques for compensation negotiation are discussed. Although information obtained is specific to North Carolina, geographic similarities may be apparent.     

Canada's health care system provides lessons for NPs.

With increasing economic pressures, swaying public opinion and new government policies rationing health care resources, nurses in Canada are again challenging physicians for room to practice as nurse practitioners. Although the last Canadian nurse practitioner program was discontinued in 1983, and it was argued that the death of the role was inevitable in Canada's health care system, nurse practitioners have not vanished. Social plans in the United States are drawing heavily on the Canadian model of universal access and a government-funded health care system, and dramatic changes are taking place in Ontario's health care system. Now more than ever it is important that nurse practitioners understand Canada's health care system, why the NP role in Ontario has not been highly successful, and why the time is right for reintroduction of nurse practitioners into Ontario's health care system.     

Non-nurse college graduates: a new resource for future nurse practitioners

Non-nurse college graduates are admitted to the master's of science in nursing (MSN) degree program at the University of Tennessee, Knoxville (UTK). Over the years, a majority of these non-traditional students have chosen the family nurse practitioner clinical concentration. The purpose of this study was to compare non-traditional and traditional family nurse practitioner (FNP) graduates in terms of academic and career-development characteristics. The study population consisted of all 91 (48 non-traditional and 43 traditional) UTK FNP graduates from 1981 to 1986. Little difference was found between the two groups' academic success in the program, self-perceptions of clinical preparedness for practice, current participation in the workforce, and self-perceptions of acceptance from administrators, other nurses and physicians in current work settings. Several notable differences between the two groups were found. The non-traditional FNP graduates had higher Graduate Record Examination (GRE) mean scores. More non-traditional than traditional FNP graduates were employed initially as nurse practitioners. Similarly, more non-traditional FNP graduates were currently employed as nurse practitioners in primary health care settings. Fewer non-traditional FNP graduates expressed satisfaction with their initial or current nursing positions. In regard to career goals, however, more of the non-traditional FNP graduates stated their intent was to be functioning as nurse practitioners in the future. Non-nurse college graduates with an interest in health care are a rich resource from which to recruit practicing nurse practitioners for the future.     

Nurse practitioners: a comparison of rural-urban practice patterns and willingness to serve in underserved areas

PURPOSE: To determine nurse practitioners' (NPs) practice patterns and willingness to practice in underserved areas in both rural and urban settings in a largely rural state. DATA SOURCES: A census of all NPs holding a Pennsylvania license and providing addresses in Pennsylvania or one of the contiguous states was conducted in 1996. The ZIP codes of practice sites were matched with 1990 census data. CONCLUSIONS: Nurse practitioners in rural areas are more likely than their urban counterparts to provide primary care in primary care practice settings, they see more patients per week, and they are more likely to be the principal provider of care for a higher percentage of their patients. Experience with managed care contracts is greater for urban NPs as is their willingness to practice in urban underserved areas. Rural NPs were more willing to practice in rural underserved areas than their urban counterparts. IMPLICATIONS FOR PRACTICE: Access to primary care continues to be a concern in rural areas. The increasing market penetration of managed care and the deficit of primary care providers in rural environments may lead to increased opportunities for NPs in the rural health care delivery system.     

Education for differentiated role development for NP and CNS practice: one nursing program''s approach

Development of nurse care providers who best meet the public's health care needs is imperative. Some nurses believe the functions of nurse practitioners and clinical nurse specialists should be combined. However, the experience of the authors' nursing program argues otherwise. Two graduate nursing tracks, family nurse practitioner and rural health specialist, were developed to meet the health care needs of rural populations. Although the two tracks share expected competencies and areas of expertise to some extent, differences in practice are apparent in identified domains of practice and terminal competencies. Family nurse practitioner practice focuses on assessment, diagnosis, and management of health and illness conditions of individuals and families across the life span. Clinical nurse specialist practice incorporates traditional roles of client assessment, monitoring and coordination of care, outcome assessment, and client, family, and community education, with a new focus on case management strategies. These differences are important to care delivery in the managed care era.     

The effect of structural empowerment and perceived organizational support on middle level nurse managers' role satisfaction

BACKGROUND: The restructuring of Canadian health care organizations during the past decade has reduced the visibility of nursing leadership. This has resulted in job conditions that have disempowered nurse managers and influenced their ability to create positive work environments, mentor potential nurse leaders, and gain satisfaction in the leadership role. These conditions threaten the retention of a cadre of high quality nurse leaders in today's chaotic health care setting. OBJECTIVE: The purpose of this study was to examine the relationship between structural empowerment and perceived organizational support and the effect of these factors on the role satisfaction of middle level nurse managers. METHOD: A secondary analysis was conducted as part of a larger study of 126 middle level nurse managers working in Canadian acute care hospitals, randomly selected from the Ontario provincial registry. Eighty-four nurse managers responded to a questionnaire mailed to their home addresses. RESULTS: Structural empowerment was positively associated with middle level nurse managers' perceived organizational support. The combination of empowerment and perceptions of organizational support were significant predictors of middle level nurse managers' role satisfaction. CONCLUSIONS: The findings support R.M. Kanter's (1977, 1993; Men and Women of the Corporation. Basic Books, New York) contention that empowering work conditions have an impact on employees' feelings of support and sense of accomplishment at work. Positive perceptions of organizational support may play an important role in retaining current middle managers, and possibly attracting future leaders to management positions.     

Satisfaction with Nurse Practitioners and Intent to Adhere to Plan

This study explored perceptions of satisfaction with care from nurse practitioners (NPs) and intent to adhere to health plan. A convenience sample of 118 participants was included. The Perception of Satisfaction with Care from NP instrument was used to measure components of satisfaction and overall satisfaction after the visit. Most participants intended to adhere to the plan by the NP. The clients’ perceptions of overall satisfaction with care and intent to adhere to health recommendations were high. Nursing implications include to develop benchmarks for quality of care and promote care provided by NPs. The adapted instrument, Perception of Satisfaction with Care from NP, is reliable and can be useful for students.     

Nurse practitioners in accident and emergency departments: reflections on a pilot study

This paper reflects on the conduct of a pilot study which was intended to prepare the ground for a randomized, controlled clinical trial of the assessment and treatment of patients with minor injuries by nurse practitioners or senior house officers (junior doctors) in an accident and emergency department. The authors believe that such reflection makes a useful contribution to the growing debate about methodology in health services research. Following a brief literature review on nurse practitioners, the intended research design is explained. The authors then describe how observation in the chosen department led to a change in design, involving trial use of patient-kept diaries as a means of assessing outcome. Despite promising results from the third diary exercise, doubts remained about the validity of the relationship between process and outcome. The small number of patients managed by nurse practitioners compared to the greater number managed by junior doctors posed difficulties for randomization; similarities in pathways of care for patients managed by the two staff groups made it unlikely that differences in outcome could be demonstrated. These problems led to abandonment of the plan for a clinical trial at that point, but the authors believe that further exploration of the idea is desirable.     

An evaluation of the nurse practitioner role in a major rural emergency department

The purpose of this pilot study was to investigate whether nurse practitioners are able to provide a level of primary health service applicable to remote/isolated settings in wound management and treatment of blunt limb trauma. It was hypothesized that there would be no significant difference in the quality of care, or the level of client satisfaction, provided by the medical officers and the nurse practitioners in the study. Two groups participated in the study, nurse practitioners and medical officers. The study used a randomized trial design. Data were collected using quantitative and qualitative methods. Two hundred and thirty-two clients participated in the study. Of this number 63 were supervised cases in the pilot trial. In the randomized trial participants were distributed between nurse practitioners and medical officers (n = 169), of which 91 were randomized to medical officers and 78 to nurse practitioners. Telephone interviews were conducted to evaluate client satisfaction. The majority of study participants were surveyed for client satisfaction (n = 132). This represents approximately 78% of the randomized sample and multivariate analysis was carried out on the data. Study results indicate that there were no significant differences between the two groups in relation to client satisfaction. Very positive outcomes of treatment were consistent across groups in the study. The study also found that there was strong support for the role of the nurse practitioner in the rural emergency setting. Recommendations include further research to measure the efficacy of nurse practitioners utilizing the selected competencies in remote/isolated settings.     

Wait time and satisfaction with care and service at a nurse practitioner managed clinic

PURPOSE: To examine the relationships among the various times patients wait for health care and patient satisfaction with nurse practitioner (NP) care and the service component of care in a NP developed and managed clinic. DATA SOURCES: Forty-seven patients (78% response rate) responded anonymously to a 15-item questionnaire that measured satisfaction with NP care and an additional 15 items that measured satisfaction with the service component of care. Actual clock times were recorded on a flow sheet that corresponded to the system of care at this clinic. CONCLUSIONS: Using Pearson Product-Moment Correlation, there were no statistically significant relationships among various wait times and the measures of satisfaction. IMPLICATIONS FOR PRACTICE: Patient satisfaction with NP care is an important indicator of quality of care. Although satisfaction was not related to wait times, NPs must be respectful of the amount of time that patients wait for health care.     

Nurse Practitioner Political Strength Through Unification

If nurse practitioners are to achieve their goal of serving as the principal providers of primary health care and having a major voice in health policy decisons, they must increase their political effectiveness. Of all the problems that nurse practitioners face today, this is one of the most serious. This article identifies some of the reasons why nurse practitioners have failed to achieve maximum political effectiveness, such as lack of national stancardization of the role, titling confusion, and the lack of research to demonstrate that the nurse practitioner is the most appropriate and cost effective primary health care provider. Next, the consequences of the above are explored. Finally, some solutions are proposed, the most important of which is the establishment of a strong national nurse practitioner organization to serve as the voice of all nurse practitioners.