2/6/02

Nurse Practitioners:Nurse Practitioners:A (Not So) New Role in Health CareA (Not So) New Role in Health Care

Kathleen Dracup, RN, FNP, DNScDean and ProfessorSchool of Nursing

University of California, San Francisco

2/6/02

Who are Advanced Practice Nurses?Who are Advanced Practice Nurses?

• Masters prepared Registered Nurses:– Nurse practitioners (NP)– Clinical nurse specialists (CNS)– Combined (NP/CNS)– Certified Nurse Midwives (CNM)– Certified Nurse Anesthetists (CNA)

2/6/02

Clinical Nurse Specialist 54,374 27.7%

Nurse Practitioner

88,186 44.9%

Nurse Anesthetist

29,844 15.2%

Nurse Midwife 9,232 4.7%

NP and CNS 14,643 7.5%

RNs prepared for APNRNs prepared for APN

DHHS, March 2000

2/6/02

History of the Nurse PractitionerHistory of the Nurse Practitioner

• Social phenomena of the 1960’s provided impetus for NP movement– Shortages of pediatricians and family practice MDs– Lack of primary health care for rural areas and

urban poor– Escalating health care costs– RNs desire to attain autonomy

• 1st NP program – 1965 @ U of CO as a research program

2/6/02

19711971

• HEW proposed definition of primary care:– A person’s first contact in any given episode of

illness with the health care system that leads to a decision of what must be done to help resolve the problem

– Responsibility for the continuum of care (maintenance, evaluation, management)

– MDs & RNs should share responsibility for primary care

2/6/02

NPs todayNPs today• NPs practice independently (i.e., without MD

supervision or collaboration) in the majority of states

• In all states, NPs have independent prescribing authority

• Reimbursement for primary care services:– Medicaid/MediCal/MediCare Part B

– Commercial insurance

• Hospital admitting privileges

2/6/02

NumbersNumbers

• 103,000 NPs in U.S.

• 9,500 NPs in California

• Graduates of UCSF NP programs from 1989-1999 = 1,000

2/6/02

Is a PA like an NP?Is a PA like an NP?

• PA– “Physician extender”

– Must practice under supervision and license of MD

– MD is liable for acts of PA under their direction

• NP– Complements MD

– Functions under own license

– Education is more extensive

– Scope of practice is broader

2/6/02

Viva la difference!?Viva la difference!?

Training

Licensing

Medical vs. Nursing Model

Scope of practice

2/6/02

TrainingTraining

• M.D.– B.S. (pre-med)

– Medical School (4 yrs)

– Internship (1yr)

– Residency (varies)

• Nurse Practitioner– B.S. (Nursing/RN)

– Masters Degree (2-3 yrs)• didactic/clinical (internship)

– other specialty training (varies)

2/6/02

LicensingLicensing

• MD– medical Board exam

– specialty exams

• APN– nursing Board exam

– NP exam/certification

2/6/02

Model of CareModel of Care

MD

• “medical model”• curing

RN

• “nursing model”• caring

2/6/02

Scope of PracticeScope of Practice• NP – Nurse Practice Act

– Primary health promotion– Disease prevention– Assessment/diagnosis and management of

common illness and chronic stable conditions

– Use of ‘standardized procedures’– Expanded roles for specialty care

2/6/02

NPsNPs• “NPs may order, conduct, and interpret

appropriate diagnostic and laboratory tests and prescribe pharmacologic agents, treatments, and non-pharmacologic therapies. Educating and counseling individuals and their families regarding healthy lifestyle behaviors are key components of NP care”

Porcher, F. K. (1996). Advanced practice nursing (179- 187)

2/6/02

Patient education and counselingPatient education and counseling

0%2%4%6%8%

10%12%14%16%18%20%22%24%

nutritional exercise growth &development

smokingcessation

weightreduction

familyplanning

NPMD/DO

Moody et al, NP, 1999, 24(3):94-103

2/6/02

Comparison of top fiveComparison of top fiveNP & MD principal diagnosesNP & MD principal diagnoses

• MD– Hypertension

– Normal pregnancy

– Acute upper respiratory infection

– Otitis media

– Health exam

• NP– Health exam– Hypertension– Routine child health – Otitis media– Acute upper respiratory

infection

Moody et al, NP, 1999, 24(3):94-103

2/6/02

Common diagnostic or screening testsCommon diagnostic or screening tests

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Blood Pressure Urinalysis Vision/hearing pap smear

NPMD/DO

Moody et al, NP, 1999, 24(3):94-103

2/6/02

What counts: Patient outcomesWhat counts: Patient outcomes

• NPs can effectively treat 90% of all pediatric patients and 80% of all adult patients. Outcomes are equal to or better than care by physicians.

» (Office of Technology Assessment, 1987)

2/6/02

What counts: Patient outcomesWhat counts: Patient outcomes

• NYC 2000 patients randomized to MD or NP serving as primary care provider– Little or no difference in health status, disease

specific physiologic measures, patient satisfaction, resource utilization (Mundinger et al, JAMA, 2000)

2/6/02

More outcomesMore outcomes• Meta-analysis of 38 studies comparing NP/CNM and

MD (Brown & Grimes, ANA, 1993)– Number and cost of drugs similar between MD and APN– More lab tests ordered by APN but cost 8% less– Patient knowledge similar– APNs received higher scores on

• Resolution of pathologic conditions• Patient satisfaction• Functional status• Patient compliance

– Average number of visits similar but fewer hospitalizations for patients seen by APNs

2/6/02

Cost/BenefitCost/Benefit• Reduced educational opportunities for Reduced educational opportunities for

residentsresidents

• Reduced interaction of physician with Reduced interaction of physician with patient/familypatient/family

• Reduced hospital length of stayReduced hospital length of stay

• Fewer complicationsFewer complications

• Improved patient satisfactionImproved patient satisfaction

• Less litigationLess litigation

2/6/02

Patients and their healthcare providerPatients and their healthcare provider

2/6/02

Patients’ Active Involvement in Care Patients’ Active Involvement in Care (n = 27 patients with heart failure)(n = 27 patients with heart failure)

At the most recent physician visit,5 asked doctor about other medications they could take for heart

failure3 brought written information to the visit2 wrote questions on paper and took to the visit

0

10

20Very ActiveActiveSomewhat ActiveNot Very ActiveNot At All Active

How Active Are You In Making Decisions with Your Doctor about Your

Health Care

How Active Would You Like to be in Making

Decisions with Your Doctor about Your Health Care Bennett, ‘PUMP-UP’

2/6/02

Patients and their healthcare providerPatients and their healthcare provider

• More patient control• More emotional display by both MD and patient

• More effective information gathering by patients

• More conversation by patients relative to the MD

= better health status (functional & subjective) at follow-up

Kaplan, Greenfield, Ware. Med Care 1989

2/6/02

Make the most of your visitMake the most of your visit• Be prepared!

– Bring list of medications, treatments, concerns, questions; know your family history

• Don’t be afraid to talk. The more you ask, the better your health.

• If you are nervous, say so.• Don’t feel rushed. If you have a question, ASK IT.

If you don’t understand something, ASK.• Participate in decisions, especially major ones.

Negotiate decisions if need be.

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