May 16, 2013

Study finds disagreement on the role of primary care nurse practitioners

While physicians and nurse practitioners agree on general principles, survey reveals differences on specific policies

(Vanderbilt University)

Primary care physicians and nurse practitioners significantly disagree on some proposed changes to the scope of nurse practitioners’ responsibilities, according to a New England Journal of Medicine study released today.

The study, led by investigators from the Vanderbilt University School of Nursing (VUSN), Vanderbilt Institute for Medicine and Public Health and Massachusetts General Hospital (MGH), comes at a time when the U.S. health system is facing both an increasing demand for primary care services and a worsening shortage of primary care physicians.

One broadly recommended strategy to combat the problem has been to increase the number and the responsibilities of nurse practitioners.

Peter Buerhaus, Ph.D., R.N.

“It is unsettling that primary care physicians and nurse practitioners, who have been practicing together for several decades, seem so far apart in their perceptions of each other’s contributions,” said co-author Peter Buerhaus, Ph.D., R.N., director of the Center for Interdisciplinary Health Workforce Studies and the Valere Potter Professor of Nursing at VUSN.

“I am concerned that these large gaps in perceptions will inhibit efforts to redesign care delivery and to improve the productivity and configuration of the primary care workforce,” he said.

The study survey was mailed to a national random sample of nearly 2,000 primary care clinicians — evenly divided between physicians and nurse practitioners — and responses were received from 467 nurse practitioners and 505 physicians.

The majority of both groups — 96 percent of nurse practitioners and 76 percent of physicians — agreed with the Institute of Medicine recommendation that nurse practitioners “be able to practice to the full extent of their education and training.”

The two groups disagreed significantly on whether an increase in the supply of nurse practitioners would improve patient safety and the effectiveness of care and health costs. One-third of physicians responded that such an increase might have a negative effect on safety and effectiveness.

“We were surprised by the level of disagreement reported between these two groups of professionals,” said Karen Donelan, Sc.D., Ed.M., of the Mongan Institute for Health at MGH, lead author of the report.

“We had hypothesized that, since primary care physicians and nurse practitioners had been working together for many years, collaboration would lead to more common views about their roles in clinical practice. The data reveal disagreements about fundamental questions of professional roles that need to be resolved for teams to function effectively,” she said.

A strong majority (82 percent) of nurse practitioners believed they should be able to lead medical homes — practices using a team-based model to deliver coordinated patient care — but only 17 percent of physicians agreed.

Additionally, 64 percent of nurse practitioners agreed they should be paid equally for providing the same services, compared with only 4 percent of physicians.

Sixty percent of nurse practitioners in collaborative practices indicated they provided services to complex patients with multiple conditions, but only 23 percent of physician in such practices responded that those services were provided by nurse practitioners.

Study co-author Robert Dittus, M.D., MPH, Albert and Bernard Werthan Professor of Medicine, associate vice-chancellor for Public Health and Health Care and director of the Institute for Medicine and Public Health, said he hopes the study will provide information needed for thoughtful discussion among nurse practitioners and physicians and encourage a focus on working more closely together in both training and practice to understand each provider’s capabilities and roles.

Robert Dittus, M.D., MPH

“Such roles are likely to evolve over time as primary care is practiced more in a team concept than a one-on-one provider to patient-only model,” Dittus said. “The roles for many of the team providers, including nurse practitioners, are likely to change as such providers gain expertise and experience over time, and thus the confidence and trust of the entire provider team.”

The two groups did agree that increasing the supply of primary care nurse practitioners would improve the timeliness of and access to care, and respondents working in collaborative practices indicated that both professions provide a wide range of services in their practices.

The study was supported by grants from the Gordon and Betty Moore Foundation, the Johnson & Johnson Campaign for Nursing’s Future, and the Robert Wood Johnson Foundation.