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Docs, Nurses Disagree Over Expanded Nurse Roles

By Alvin Tran

May 15th, 2013, 5:00 PM

As nurse practitioners lobby to expand their authority and scope of practice in many states, a New England Journal of Medicine study released Wednesday documents a deep chasm between how doctors and nurses regard the issue.

The study found the two groups overwhelmingly agreed that nurse practitioners should be able to practice to the full extent of their schooling and training. But doctors were less likely to concur that advanced practice nurses should lead medical homes, which deliver team-based, coordinated care to patients. Only 17 percent of the 505 primary care physicians  surveyed agreed with that notion, compared to 82 percent of the 467 nurse practitioners surveyed.

The two groups also disagreed about whether nurse practitioners should be paid equally for providing the same health services. More than 64 percent of nurse practitioners agreed with the idea of equal pay, as opposed to less than 4 percent of doctors.

The debate over the role of nurse practitioners has intensified as a result of concerns over a shortage of doctors as an estimated 25 million people gain insurance under the health care law.  Nurse practitioners argue they can fill some of those needs if they are granted greater scope of practice.

That debate is reflected in the study’s finding about the groups’ conflicting views about the quality of care provided by doctors versus nurse practitioners. When researchers asked whether they felt the quality of care provided by physicians in exams and consultations was higher than that provided by nurse practitioners, more than 66 percent of doctors agreed, while 75 percent of nurses disagreed.

“We’ve done a lot of comparative surveys with health professionals but we’ve just never found gaps this big,” said Dr. Karen Donelan, an assistant professor of medicine at the Harvard School of Medicine and the study’s lead author. “When we get on the ground and we survey the people actually doing the work and working together, we see some of those professionals come closer together. We didn’t observe that here.”

Donelan pointed out that most nurse practitioners in the study — approximately 75 percent — said they are already practicing to the full extent of their training. Survey respondents who did not have this opportunity blamed their limited practice on state restrictions, hospital regulations and work setting.

During an interview, Donelan also said she was surprised by the level of disagreement in regards to the quality of care, since previous research findings have suggested little variation in the work done by  nurse practitioners and primary care doctors.

During a February 2013 interview, David Hebert, the CEO of the American Association of Nurse Practitioners, described the safety concerns raised by physicians as a “total red herring,” and added that “nurse practitioners have been practicing safely and providing great outcomes for decades.”

In March, the president-elect of the American Academy of Family Physicians, Reid Blackwelder, emphasized his support for a more collaborative approach between the two clinician groups, noting their roles are not interchangeable.

Differences aside, Donelan’s study shows that the majority of practitioners in both groups agreed that increasing the number of nurse practitioners would improve timeliness of care. However, less than a third of doctors said such an increase would boost safety or effectiveness of care.

Nurse practitioners, on the other hand, overwhelmingly felt such an increase would improve care. Close to 81 percent, for example, thought the growth would improve access to health care for the uninsured and 77 percent said it would result in lower health care costs.

“As a team, this kind of inter-professional disagreement is not a good thing when we’re trying to achieve better teamwork,” Donelan said. “The conflict over roles has got to be worked out so that it’s clear for patients when they get their care.”

Moving forward, she said she hopes that both doctors and nurse practitioners will acknowledge their differences and bridge the gaps that keep them from working together.

30 Responses to “Docs, Nurses Disagree Over Expanded Nurse Roles”

  1. ME says:

    Ashley, by that mentality then nobody would need primary care in the first place. We all would have a slew of speciallists at our disposal! Insurance would just be THRILLED about the money they are paying out for care of things that are easily managed by primary care. Heck, speciallists are the primary reason theres a primary care shortage…the moneys better and they only need to focus on a very small select group of patients.

    Regardless of the pushback, there are already three states that give full autonomy to NPs and this trend will likely continue.across the country. NPs and PAs across the US are getting more rights as they continue to prove that they are capable of both exceptional patient care and assumption of liability. When I get my license, I will work my butt off to get the clinical experience needed for the profession. But once I feel comfortable enough in my clinical practice, I will be there in the ranks ready to pick up the primary care shortages.

  2. James says:

    Are you sending your loved family member to a NP, PA, or a doctor with hundreds of thousands of more hours and training not to mention the intuitive understanding of biochemistry and pharmacology…….. Yea that’s what I thought

  3. Karen says:

    Angil: you are absolutely right. Nurses provide better hospice care than anyone in the world. I am glad that you have taught physicians to draw blood, start IV’s and do dressing changes, but in this world where the physician is being asked to see more and more in less and less time, drawing bloods, starting IV’s, and doing dressing changes are just not a good utilization of physician time. Every residency is different and some may actually incorporate that into their teaching plan. For the most part, it isn’t a valuable utilization of time. I can’t see asking the neurosurgeon to start iv’s or draw bloods when he has specialized skills that are best served elsewhere.
    As far as the GP’s diagnosing dementia, what would your work up be? Perhaps you are relating this to one case you saw, but I don’t believe this is typical of all GP’s. I do think that a good portion of the diagnosis of dementia is not in “testing” but in doing a thorough physical and neurologic exam. Following this, “tests” can be ordered. It takes 4 years of neurology residency to become a board certified neurologist. It takes 3 years of family medicine to become the “GP”. Of course, this follows 4 years of medical school and 4 years of college. After residency, the individual must pass boards and yearly reviews.

    Are you implying that a nurse practitioner could do this better with less training both in the class and on the job? I agree, nurses start iv’s and draw bloods better than doctors – thats what is incorporated into your training.

  4. ME says:

    Technically starting IV’s and drawing blood are no longer incorporated in most nurse training. These days, its reserved for the hospitals to decide to train or not as many have moved the job to techs or IV teams. Nurses these days are getting far more education on theory, disease process, pharmacology, AND biochemistry that is expected of many doctors today. MANY of the things an MD sees in premed and med school, a NP will see in their BSN (4 years) and their MSN (2-3 years).

    For people like james to presume an MD is the only person capable of being “intuitive” in biochem and pharm is fairly short sighted. “Hundreds of thousands of hours” of training can be interpreted differently for any individual who may get their experience and technical abilities in different ways. I have over 6000 hours of clinical experience as an RN. With this comes understanding diseases my patients face, the physiologic tolls they take on the body, recognizing risks and tests that could negatively impact that disease, and making plans of care in anticipation of those risks. At this current moment, I am not trained to provide past that role. But 2-3 years of NP school will give me this training and I will be a capable provider with an additional 6000 hours of clinical experience under my belt…working full time while I go to school full time.

    People like me put just as much into our school as many MDs do (not all, but many). I chose a different path because after military service nursing made sense out the gate. Since the foundations are already being laid for NPs to fill gaps, nobody in their right mind in my shoes would consider going to med school. If you believe the NP training is that vastly different, show the difference in the curriculums…not the differences in hours worked. Because hours worked and clinical experience are the great equallizers. If we learn less than an MD, then use it in your defence. Because from where I stand, I learn nothing less than what an MD learns.

  5. Cliff Callaway says:

    ME…. You are WAY sadly mistaken about what you have learned and what you might learn in some MSN training. The biochem and pharm “intuitive” insights are far from intuitive. They are ACADEMIC bases from which MD/DO trained individuals begin their lifelong training journey. The NP path, to which this culture has understandably committed, will never come close to the training process offered in medical schools. These women and men in our med schools are fortunate to have been given superior learning ability, then have busted their collective buns to use that ability. I am reasonably sure that the severe academic demands have not diminished in the 45+ years since I was privileged to start med school. We are all aware of the explosive expansion of scientific information of the last 100 years; med students struggle to assimilate all of this that they can. Midlevel provider folks have a role, but never dream that any equivalency of note exists. Indeed, some of us really practiced medicine one year forty times, NOT forty years of experience. Your thousands of hours of experience fall into such a concept. So, challenge yourself, go get some spectacular grade points on your transcript, take the MCAT, and join us!!! You are needed.

  6. James says:

    Frankly, I dont want someone who took the easy way out in regards to their training taking care of me or a Family member. Nursing and Medicine are different professions.

  7. freda lozanoff says:

    If the mid level practitioners can do our job, then why did we bother to go to medical school?

  8. Danalexa Jimenez says:

    In California, NPs practice using standardized procedures (SPs). http://www.rn.ca.gov/pdfs/regulations/npr-b-20.pdf
    SPs clearly detail what an NP can/cannot do via protocols. Add a standardized procedure to clinical decision making systems and MDs/DOs can treat the sickest /more complex patients. It is a fallacy that every condition requires medical knowledge/expertise/experience to be resolved. We’ve sold the population a bill of good on that score. Understandably, MDs/DOs are defensive about expanding the role of NPs. Most physicians believe they are indispensable, but graveyards are full of indispensable people. Evidence shows (think Kaiser Permanente) that deploying NP & MD s competencies efficiently we can have improved population health. As a consumer, I want the best health bang for my buck.

  9. Alaska says:

    So if NP’s want to get paid the same as a doctor because they feel they are doing the same work, why hire an NP? If society is going to be paying both the same now, why not hire the physician who has more training and experience? You get more”‘cluck for your buck with the doctor.” And how is paying an NP at the same rate as a physician lowering heath care cost? Aren’t you raising it? Now society is paying more people more money? Just saying…

  10. Melissa says:

    NPs and MDs are not the same, nor should they be. I am currently pursuing my Master’s Degree in Nursing to further my role as a nurse, but I have always wanted to be a nurse and not a MD. If people want to be MDs and offer the services and skills an MD offers they should pursue that stream instead of trying to make their NP role equivalent to the MD role. That being said there are some services an Master’s prepared nurse can offer a patient or client that an MD can and just as well. I don’t think MDs should feel threatened by that. It is equivalent to how on a hospital floor a technician or a student nurse can complete skills that a nurse can. Instead of feeling threatened by the fact the tech or SN can do the same skill nurses are often grateful for the assistance. MSNs who can fill in primary care roles or specialized positions like Certified Nurse Midwives or Pediatric Practitioners can and should, however I don’t think we should assume that we have all of the skills or knowledge base an MD does and if we wanted that than we should have went to medical school, not nursing school. I don’t think having a different knowledge base, skill set and theory from MDs makes me any less of an excellent nurse.

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