The Role of Nurse Practitioners
Jeanette Lancaster
UNIVERSITY OFVIRGINIAWade Lancaster
KINGFAHDUNIVERSITY OFPETROLEUM &MINERALS
Lisa L. Onega
OREGONHEALTHSCIENCESUNIVERSITY
Managed health care, health maintenance organizations, and other cost in different parts of the country (Lancaster and Lancaster, 1993). Several economic realities will influence the future
containment measures driven by the private sector in conjunction with
scope and type of health care provided in the United States
Congressionally funded initiatives are serving as the guiding forces in
(U.S.) (Callan, 1992): (1) the continuing shift of health-care
health-care reform in the United States. Within this move toward
restruc-costs to employers; (2) decreased federal support; (3)
pres-turing health-care services, the role of nurse practitioners is expanding
sures for employers to either reduce or contain health-care
and evolving. Nurse practitioners provide high-quality, cost-effective, and
costs; (4) increased consumer knowledge; (5) malpractice
comprehensive primary care services. Increased use of nurse practitioners
threats and costs; and (6) continuing escalation of hospital
in disease preventions, illness management, and health education is one
and provider charges.
way of meeting the health-care needs of the U.S. population. Artificial and politically imposed barriers to effective utilization of nurse
prac-titioners should be removed. Innovative strategies for more effective use
The Need for Health-Care Reform
of nurse practitioners must be identified and implemented. J BUSN RESEconomic Needs
2000. 48.207–212. 2000 Elsevier Science Inc. All rights reserved.
National health-care reform, a major goal of the Clinton ad-ministration, failed for a number of reasons. Two primary reasons for the failure were (Pearson, 1996) as follows.
N
ever before has U.S. society undergone such dramatic 1. Special interest groups continually switched theirpoliti-and pervasive changes in health care as those cur- cal positions.
rently occurring. The national report, U.S. Depart- 2. A few groups, such as the American Medical Association ment of Health and Human Services: Healthy People 2000, (AMA), and some insurers who have become powerful
National Health Promotion and Disease Prevention Objectives and wealthy from the existing system, had a vested (1991), outlined numerous changes in the fabric of U.S. soci- interest in maintaining the status quo.
ety that influence health-care needs and emphasize the
impor-As a result of the failure of governmental efforts to institute tance of change in health-care delivery. The most significant
national health-care reform, the private sector along with Con-changes that are revolutionizing U.S. society are outlined in
gressionally funded innovations are leading this movement. Table 1 (AACNHealthy People 2000 Task Force, 1992).
Controlling costs is the major impetus for restructuring the Consumers, employers, providers, and third-party payers health-care system. Managed care and health maintenance cannot afford the increasing costs of health care and are dissat- organizations are the primary methods being used to reduce isfied with inconsistencies in the quality of health-care services expenditures (Mahoney, 1988; National Advisory Council on
Nurse Education and Practice, 1994; Pearson, 1996).
Address correspondence to Jeanette Lancaster, Ph.D., R.N., F.A.A.N., Dean
Service Needs
and Professor, School of Nursing, University of Virginia, McLeod Hall,Char-lottesville, VA 22903, USA. Health-care reform is needed to resolve the problems of
inac-Mailing address for Wade Lancaster is P.O. Box 443, Dhahran, 31261,
Saudi Arabia. cessibility, high cost, and fragmentation of health-care
ser-Journal of Business Research 48, 207–212 (2000)
2000 Elsevier Science Inc. All rights reserved. ISSN 0148-2963/00/$–see front matter
Table 1. Significant Changes Revolutionizing American Society
Cultural and ethnic diversity with increased immigration
Changing family structures with more single parent households
An infant mortality rate of 10 deaths for every 1,000 live births
Epidemic communicable illnesses such as AIDS and increasing numbers of drug-resistant strains of “old diseases” such as tuberculosis
Economic disparity
In 1992, about 60 million U.S. citizens were uninsured or underinsured. Aging of the population
In 1988, 12.4% of the population were 65 years old or older; however, by the year 2030, that percentage will almost double.
Increased numbers of chronically ill and disabled U.S. citizens
In 1989, 14.1% of U.S. citizens suffered from one or more chronic illnesses.
Unhealthy lifestyle choices
In 1990, 27% of U.S. citizens smoked cigarettes, 51% drank alcohol, 6.4% used illicit drugs, and 26% were overweight.
vices. Problems in accessing health care are often associated report noted that previous efforts to reform the health-care system have failed. The challenge now is to reform the system with geographic location, lack of health-care providers, high
health-care costs, and inadequate health insurance coverage. by changing the way health professionals are educated. The Pew Commission urges schools to emphasize interdisciplinary There are too many specialists and too few primary care
pro-viders in the U.S. health-care system. Because of their extensive training in community-based sites as well as in acute care facilities. Their report supports training in health promotion, training and current financial rewards, physicians often prefer
utilizing their skills in specialty areas. In fact, only three out primary care, rural settings, and encourages an emphasis on the health of the community, as well as the individual. of every 10 physicians practice in primary care, and in 1992
a mere 14.2% of all medical school graduates planned careers One component of health-care reform may be the expan-sion of the role of nurse practitioners in health-care delivery. in primary care (Prescott, 1994). The Council on Graduate
Medical Education estimates that the shortage of primary care However, many people are unfamiliar with the purposes and functions of nurse practitioners. The movement to utilize mid-physicians could be 35,000 in 2000, increasing as much as
80,000 by 2020 (Aiken and Salmon, 1994). This trend toward level nurse practitioners began about 30 years ago (1960s) and has been unevenly accepted across the country. Nurse medical specialization has left approximately 15% of U.S.
citizens lacking access to primary health care (Fitzgerald, practitioners are registered nurses who have advanced educa-tion and clinical training in a primary care field, such as adult, Jones, Lazar, McHuch, and Wang, 1995).
To provide basic services for all U.S. citizens, increased family, geriatric, pediatric, psychiatric, school, or women’s health. Studies indicate that they provide high-quality, cost-numbers of health-care professionals in primary care are
needed. Preventive measures and vigilant management of ex- effective care; a unique and comprehensive approach to health care; and care that results in a high level of patient satisfaction isting health problems at the primary care level decrease cost
and improve efficiency. Furthermore, needs for health educa- (American Academy of Nurse Practitioners, 1988; Lancaster and Lancaster, 1993). Because nurse practitioners have a tion, health promotion, and disease prevention are increasing
as the focus of health care shifts from illness to wellness. strong history of working collaboratively with other providers, they are in a key position to facilitate restructuring of the Finally, an increasing number of chronically ill and elderly
individuals accentuate the need for managed care and case health-care system. Nurse practitioners can make particularly important contributions by (Aiken and Salmon, 1994): management services (The Pew Health Professions
Commis-sion, 1991).
1. improving primary care availability; 2. improving care of the underserved; 3. redesigning the role of public health; and
Nurse Practitioners
4. restructuring hospitals. Nurse practitioners are a new type of health-care provider
designed to meet these economic, societal, and service
health-care needs. The Pew Health Professions Commission (1991),
Barriers to Effective Use
incorporating the skills and knowledge of 27 interdisciplinaryof Nurse Practitioners
public and private experts, developed a national Agenda forauthor, Barbara Safreit (1992), concluded that the root of the practitioners offer promise for immediate as well as long-term improvement in the health-care system (Aiken and Salmon, health-care problem is that there really isno systemin the U.S.
1994; National Advisory Council on Nurse Education and Prac-health-care system. The word “system” connotes organization,
tice, 1994; Safreit, 1992). coordination, and a considered structure; however, these
qual-ities currently are absent in the over-all scheme of U.S. health-care services. Moreover, the current focus is oriented toward
Nurse Practitioners
medicine, not health, and it focuses on cure, not care (Fagin,1992; Safreit, 1992). According to Safreit, U.S. consumers are
as One Aspect of Health-Care Reform
begging for a rational health-care system that will addressAs has been noted, nurse practitioners are playing a vital role these basic concerns.
in health-care reform. Settings in which nurse practitioners 1. Can I get care (access)? work are varied and include (National Advisory Council on 2. How good will it be (quality)? Nurse Education and Practice, 1994); ambulatory care, home 3. How much will it cost (affordability)? health care, nursing home or extended care facilities, hospitals, student health services, and prisons. It is estimated that nurse Opposition to the use of midlevel providers such as nurse
practitioners can perform 75 and 90% of the activities pro-practitioners has been fostered by physicians. Over a decade
vided by primary care physicians (Lancaster and Lancaster, ago, in 1981, the AMA House of Delegates resolved to
elimi-1993; Prescott, 1994). These basic services include (National nate federal funding for the training of nurse practitioners and
Advisory Council on Nurse Education and Practice, 1994): recommended that the AMA advise hospital administrators to
promotion and maintenance of health, prevention of illness allow only physicians to do admission histories and physical
and disability, basic care during acute and chronic phases of examinations. The AMA House of Delegates has resolved to
illness, guidance and counseling of individuals and families, oppose any attempts to empower nurse practitioners in
be-referral to other health-care providers and community coming unsupervised primary medical care providers and
re-sources, and nurse-midwifery services when appropriate. ceiving reimbursement for their services. One reason for the
In contrast to physicians, the majority of whom are special-AMA’s strong opposition to nurse practitioners is concern that
ists, 82% of all nurse practitioners are in primary care settings. the current gap between nurse practitioners’ and physicians’
Many of these advanced practice nurses work in rural or salaries will close (Safreit, 1992). To illustrate, in 1992 the
underserved areas. They provide care within their areas of median wage for family practice physicians and internists was
competence at levels equal to or better than that provided $100,000 and for pediatricians is was $98,037; however, the
by physicians. In addition, as a result of decreased salaries, median wage of nurse practitioners was $43,680 (Prescott,
decreased educational costs, reduced numbers of malpractice 1994). With the expanding role of advanced practice nurses,
claims, and increased patient compliance, nurse practitioners physicians fear that this salary disparity will be reduced as
can promote savings in the health-care delivery system. In the public recognizes its overvaluation of physician services
fact, it has been estimated that if used to their potential, nurse and undervaluation of nurse practitioner services (Prescott,
practitioners could save eight billion dollars annually (Pew 1994; Safreit, 1992). In addition, physicians recognize that
Health Professions Commissions, 1994). the cost of educating nurse practitioners is significantly below
the cost of educating physicians. In 1985, the annual cost of
educating a nurse practitioner was estimated to be $14,600;
Services Provided
whereas, the annual cost of educating a physician was $86,000by Nurse Practitioners
(Prescott, 1994). Physicians fear that the public will refuse topay these educational costs when, in many cases, nurse prac- Nurse practitioners serve as cost-effective gatekeepers in a com-titioners can provide the same quality of care at less expense. plex, fragmented, and highly specialized health-care system. Significant barriers to practice also exist, because each state They are committed to health promotion and disease preven-determines its own rules and regulations for practice. Some tion; community-determined and community-based care; the states are highly restrictive and prohibit prescriptive authority; use of appropriate health-care technology; the use of appro-whereas, others allow for practice with physician supervision priate care personnel; and collaboration among health-or under the umbrella of nurse/physician-determined proto- care professionals and between the health sector and other cols, including agreed upon prescriptive authority. In addi- public sectors, such as social welfare, utilities, environment, tion, some states prevent public and private third-party payers housing, and transportation (Stanhope and Lancaster, 1992). from reimbursing services performed by nurse practitioners Specific services that nurse practitioners provide are listed in (Prescott, 1994; Safreit, 1992). Table 2 (American Academy of Nurse Practitioners, 1988).
Table 2. Services Provided by Nurse Practitioners
Delivering individualized care focusing not only on health problems but also on the effects that health problems have on individuals and their families
Obtaining medical histories, performing physical examinations, and ordering and interpreting such diagnostic studies as laboratory findings and X-rays
Diagnosing and treating such common health problems as respiratory infections and minor injuries
Diagnosing, treating and monitoring such chronic diseases as arthritis, diabetes, and hypertension
Prescribing and recommending prescriptions for medications and other treatments
Providing prenatal care and family-planning services
Delivering such well-child care services as health screening and immunizations
Providing such health maintenance care as annual physical examinations and explaining details of health problems, medications, and other topics to help people fully understand how to care for themselves
Encouraging positive health behaviors and self-care skills by giving people the information they need to make healthy lifestyle choices and health-care decisions
Collaborating with physicians and other health-care professionals to provide interdisciplinary health services
Charging competitive fees that are covered by some health insurance programs in a number of states
Integrating patients into their communities by involving family, friends, and neighbors in the plan of care, when appropriate
old with advanced cancer of the breast with metastases to prehensive study of their effectiveness was released in 1986 by the U.S. Office of Technology Assessment (OTA). This the lumbar and sacral vertebra, weight loss, confusion, and
chronic brain syndrome, illustrates how nurse practitioners study, “Nurse Practitioners, Physician Assistants, and Certified Nurse Midwives: A Policy Analysis,” assessed the contributions act as gatekeepers and effectively provide managed care
ser-vices. Care provided by the nurse practitioner included coordi- of these three groups of health-care providers in meeting the nation’s health-care needs. The report concluded that, within nating Miss E.’s care through communication with the
oncolo-gist, radiolooncolo-gist, housing authority supervisor, brother and their scope of practice, nurse practitioners provide high-qual-ity care equivalent to that provided by physicians. In addition, sister-in-law, county protective services, and dial-a-ride.
Be-because nurse practitioners typically function within an ap-cause of multiple factors, including disarray of the health-care
proved area of competence, few problems arise with their system, unfamiliarity with the system, physical and sensory
performing tasks associated with medical practice. Research limitations, and general decrease in functioning, often it is
on the role of nurse practitioners is summarized in Table 3. nearly impossible for elderly patients to manage their complex
Thus, although nurse practitioners are currently underuti-care alone. Thus, frequently either a family member has to
lized in the health-care system, studies show that they are help them “navigate” and “negotiate” their way through the
cost-effective primary health-care providers. Nurse prac-system, or that patient ends up missing needed health care
titioners are educated for collaborative practices; they are not and social services. Ultimately, without preventive primary
meant to replace physicians throughout the health-care sys-care services, the patient often either ends up in the emergency
tem, but rather to provide primary care and to manage patients room or hospitalized. The managed care approach described
with chronic illness. Nurse practitioners are ideally suited to above enabled Miss E. to continue living independently in
be the first person that the patient sees in the health-care the community (Donovan, 1984) and illustrates the
compre-system, providing referrals to physicians as needed. hensive and integrated health care that nurse practitioners
provide.
The Future Role of
Evaluation of
Nurse Practitioners in
Nurse Practitioner Effectiveness
the Health-Care System
com-Table 3. Research on the Role of Nurse Practitioners
A review of 26 studies comparing the performance of nurse practitioners to physicans identified that nurse practitioners recieved higher scores than physicians on the following variables: amount and depth of discussion reguarding child health care, preventive health, wellness promotion, advice, therapeutic listening, and support offered to patients; completeness of patients’ histories and follow-up on history findings; completeness of physical examination and interviewing skills; and patient knowledge about the treatment plan given to them by the health care provider (American Academy of Nurse Practitioners,Quality of Service, Undated).
A review of 15 studies showed that between 75 and 80% of all adult primary care services and up to 90% of all pediatric primary care services could be performed in a cost-effective, high-quality manner by nurse practitioners (American Academy of Nurse Practitioners,
Quality of Service, Undated).
A review of several studies revealed that the quality of care based on proper diagnosis, treatment, and patient outcomes provided by nurse practitioners is as high as the care rendered by physicians for the range of skills that nurse practitioners are trained to use (American Academy of Nurse Practitioners,Quality of Service, Undated).
The American Nurses Association’s meta–analysis of cost effectiveness and clinical outcomes showed that, on average, physicians spend 16.5 minutes with patients at a cost of $20.11; whereas nurse practitioners spent 24.9 minutes with patients at a cost of $12.36. In addition, nurse practitioners have been rated better at communicating with their patients than were physicians (Fitzgerald, Jones, Lazar, McHugh, and Wang, 1995).
In 12 studies, OTA found that the quality of care by nurse practitioners, including communication with patients, preventing actions, and reductions in the number of patient symptoms, was higher than that of physicans (American Association of Colleges of Nursing, 1995).
Fallon Healthcare System, a multispecialty group in Massachusetts, evaluated the cost effectiveness of a nurse practitioner/physician team in long-term care facilities. The 1992 fiscal utilization data for nursing home patients revealed significantly lower rates of emergency room transfers, hospital lengths of stay, and speciality visits for patients covered by the teams than for patients covered by physicians only. Over-all costs were 42% lower for patients receiving care by the team than for those recieving care by a physician only (Burl, Bonner, and Rao, 1994).
creasing numbers of elderly individuals, and the shift from increase access to high-quality services, while reducing health-care costs.
illness to wellness, the role of nurse practitioners may easily be expanded. Increased numbers of nurse practitioners may
We express our appreciation for the editorial comments and suggestions of
be incorporated into the health-care system in innovative ways
Elizabeth Tornquist. Adapted from a 1993 paper presentation at the American
(AACN Board of Directors Final Report of the Pew
Commis-Association for Advances in Health Care Research.
sion, 1992). Consumers, business persons, policy makers, physicians, and nurses who are concerned about health-care
reform must lobby for, identify, and create new strategies for
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