NP Insights
Nurse practitioners are not a consolation prize
By Tom Bartol, APRN
There are many forces trying to prove that nurse practitioners (NPs) are not qualified to practice independently, care for patients with chronic and complex illnesses, or lead a healthcare team. We are often referred to as “second rate” or a substitute for physicians now that there are not enough physicians to go around. More years of training for physicians versus NPs is a sticking point often used to back up this argument. Clearly, it takes more years of formal training to become a family physician than an NP. Does this mean that NPs are not competent or capable of providing independent care? Do fewer hours of training, in a different healthcare model, make NPs less capable of doing what we do? Just as we would look critically at a research study or at evidence-based medicine, we must closely examine these data. Is the implied conclusion valid? Just because one profession completes a certain number of training hours does not mean that another profession—with different and fewer hours of training—is not capable of a similar practice. ■ Education and training The American Academy of Family Physicians recently published a paper entitled, “Education and Training: Physicians and Nurse Practitioners.” The paper notes that a family physician undergoes 20,000 10 The Nurse Practitioner • Vol. 39, No. 11
total postgraduate hours, while an NP completes between 2,800 and 5,000 hours. No clear conclusion is drawn from this besides the obvious: Family physicians undergo at least 16,000 more hours of training than NPs.1 However, the article seems to imply that NPs are less prepared for practice. The article even quotes NP literature, a 2007 survey published in the American Journal for Nurse Practitioners, which said that of the NPs surveyed, more than half felt they were only somewhat or minimally prepared to practice after graduation. Curious, I looked up the 2007 article and read it in its entirety. What the AAFP omitted in its article was that the survey also showed that upon graduation, 93% of NPs felt they were somewhat or well prepared to manage acute disease, 89% felt they were somewhat or well prepared to manage chronic disease, and 99% said they were somewhat or well prepared to perform a differential diagnosis. Certain areas skewed the survey results downward, such as casting (85% felt minimally prepared), coding and billing (82% felt minimally prepared), suturing (68% felt minimally prepared), and X-ray interpretation (70% felt minimally prepared).2 Although many clinicians are not comfortable with these skills upon graduation, they are not skills that affect diagnosing and treating illness. The survey indicated that NP graduates did feel comfortable in areas such as decision
making and assessment, but many felt weak in certain clinical procedure skills. I did a literature search but could not find a similar survey involving medical students’ or graduating residents’ perceptions of preparation for practice for comparison. Are more years of education inherently equal to better care? Is there any evidence? The studies on patient outcomes do not validate this theory. Many studies show equivalent health outcomes between physicians and NPs and increased patient satisfaction with NPs.3,4 Is there a point of diminishing returns regarding years of education? Could it be that the types of training are different and we cannot really compare them side by side? It begs the question: Does more education mean better care and better outcomes? If that were the case, physicians or NPs with additional education, additional degrees, and additional years of training would be providing superior care. ■ The years of training How pertinent are the years of training to the end role? Consider a family practice NP’s training. From the beginning, the entire program is focused on family practice skills, both clinical and didactic. Medical education trains students to be generalists. The specialty is not declared until after graduation from medical school when the physician begins residency. Though a medical student may wish to become a family physician, www.tnpj.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
NP Insights he or she must still complete rotations in areas such as general surgery. Although interesting and educational, this training is not necessarily useful in the family practice setting. There are also many hours spent in inpatient medicine, an area many family physicians will never practice in again. In addition, family physicians undergo 3 years of residency. This is a great way to get started with practice while gaining some oversight and education. I believe NP residencies would be a useful addition to our training programs, and several have started around the country. The physician model, however, often involves long hours of hospital coverage. Do working long hours in a hospital as part of a
www.tnpj.com
residency training program improve care outcomes for the family physician? There are benefits, but are all of those hours providing a superior education? ■ Content and style With the changing face of healthcare, we must adapt educational programs to meet the evolving needs of primary care clinicians. The ability to communicate and build a relationship with a patient goes beyond knowledge. All of the years of education for any clinician will be useless if he or she cannot communicate well, listen, and draw out the important points in a patient history—many of which go far beyond the physical sciences to the psychosocial realms of a
patient’s life experience. Content and style of training hours can be more important than the number of hours. Healthcare and medicine are constantly changing. It is important to learn how to learn. What is taught in school or training is just the beginning of learning. No matter how many years of training someone had, it is essential to change and grow with the everevolving knowledge base. Is it what we learn in school, or is it learning how to continue to learn that offers the most benefit? Memorizing more information may not make a difference in a few years as that information changes. Is it the knowledge that is most important or, in the healthcare field, is it just as
The Nurse Practitioner • November 2014 11
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
NP Insights important to know how to gather the information, communicate with patients, motivate patients, and build relationships with patients? Years of studying science may not lead to the development of these critical skills or to the ability to grow with new information. ■ A unique profession I have seen NPs sell themselves short as second to physicians. We must not use physicians as the standard when talking about healthcare providers. The term “midlevel” providers, a term I think should be retired, does just this because it implies physicians are the “high-level” providers. It also implies there is a “low-level” provider, someone below the midlevel provider. NPs are not in the middle of anything. We are a unique profession, based on nursing, on health, and on caring. We do many of the same things physicians do. Our roles may be similar, but how we do what we do and the underlying philosophy of what we do is different. It does not follow the medical model of “taking care” of patients but, rather, we “care for” our patients. The relationship with our patients is at the heart of what we do. We are all high-level providers, all healthcare providers. We have different roles, different ways of doing things, but we all strive to do it at a high level, not a mid or low level. Be careful and clear when describing your NP role. I have heard some say NPs do about 80% of what physicians do. This again makes physicians the standard. Many of us do things physicians do not. What we do really varies based on our training and experience. As NPs, we must not quantify ourselves in relation to physicians except to say that we do many of 12 The Nurse Practitioner • Vol. 39, No. 11
the same things and that our roles are similar. NPs are not a consolation prize, a second-rate solution to the shortage of primary care physicians. We were here before the physician shortage, doing great work, offering an alternative, not a secondary choice because physicians were not available. We are another choice for healthcare consumers. Shortage or not, we have something unique and special to offer. Patients choose us every day. ■ Evidence and optimal outcomes There is no evidence that says more years of education results in better clinical outcomes. There is also no evidence that says less years of a different type of education results in inadequate knowledge and skills to practice primary care independently. NPs want to work together with physicians and other members of the healthcare team. We are one component with something unique to offer. We ask questions of physicians, and many physicians ask questions of NPs. We do this because we want to give the best healthcare to our patients. The most competent clinician will likely tell you there is always more to learn. Inherently, we have no data indicating how years or hours of training alone relate to quality of care or outcomes. We must not sell anyone short. We must all work as a team, not trying to be better than or to demonstrate our own competence over someone else. Our goal is simply to give competent care. We must all work together to learn and grow, to build up our colleagues, not tear them down. Our professions, our roles, our individual styles and our knowledge can complement each other. We will continue to hear the statements that NPs do not have
adequate training and that we are secondary to physicians. Some fear that NPs are trying to take over the role of physicians. NPs do not want to be physicians; we love being nurses. Maybe independent practice is not really the word to use. NPs want and need to practice interdependently with all members of the healthcare team. “Autonomous” practice may be a better descriptor, working together in a way where our practice is not encumbered and restricted, where we can practice to the full extent of our training. We do not need to compare hours of training. We need to look at the skills we have and the outcomes we have seen with our patients. We must not sell ourselves short. We must eliminate words that describe our profession in relation to physicians or any other healthcare providers. We must be proud of our training, proud to be NPs in a unique profession with a role to play in transforming our ailing system and putting the health and the care back into healthcare! REFERENCES 1. Education and Training: Family Physicians and Nurse Practitioners. 2014. http://www.aafp.org/ dam/AAFP/documents/news/NP-Kit-FP-NPUPDATED.pdf.. 2. Hart AM, Macnee CL. How well are nurse practitioners prepared for practice: results of a 2004 questionnaire study. J Am Acad Nurse Pract. 2007;19(1):35-42. 3. August 2008-SUPPORT Summary of systematic review: do nurse practitioners working in primary care provider equivalent care to doctors? 2014. http://apps.who.int/rhl/effective_practice_and_ organizing_care/SUPPORT_Task_shifiting.pdf. 4. Lenz ER, Mundinger MO, Kane RL, Hopkins SC, Lin SX. Primary care outcomes in patients treated by nurse practitioners or physicians: two-year follow-up. Med Care Res Rev. 2004;61(3):332-351. Tom Bartol is an Advanced Practice Registered Nurse at Richmond Area Health Center, HealthReach Community Health Centers, Richmond, Me. The author has disclosed that he has no financial relationships related to this article. Questions or comments? E-mail [email protected] DOI-10.1097/01.NPR.0000452979.76805.c5
www.tnpj.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Nurse practitioners are not a consolation prize
By Tom Bartol, APRN
There are many forces trying to prove that nurse practitioners (NPs) are not qualified to practice independently, care for patients with chronic and complex illnesses, or lead a healthcare team. We are often referred to as “second rate” or a substitute for physicians now that there are not enough physicians to go around. More years of training for physicians versus NPs is a sticking point often used to back up this argument. Clearly, it takes more years of formal training to become a family physician than an NP. Does this mean that NPs are not competent or capable of providing independent care? Do fewer hours of training, in a different healthcare model, make NPs less capable of doing what we do? Just as we would look critically at a research study or at evidence-based medicine, we must closely examine these data. Is the implied conclusion valid? Just because one profession completes a certain number of training hours does not mean that another profession—with different and fewer hours of training—is not capable of a similar practice. ■ Education and training The American Academy of Family Physicians recently published a paper entitled, “Education and Training: Physicians and Nurse Practitioners.” The paper notes that a family physician undergoes 20,000 10 The Nurse Practitioner • Vol. 39, No. 11
total postgraduate hours, while an NP completes between 2,800 and 5,000 hours. No clear conclusion is drawn from this besides the obvious: Family physicians undergo at least 16,000 more hours of training than NPs.1 However, the article seems to imply that NPs are less prepared for practice. The article even quotes NP literature, a 2007 survey published in the American Journal for Nurse Practitioners, which said that of the NPs surveyed, more than half felt they were only somewhat or minimally prepared to practice after graduation. Curious, I looked up the 2007 article and read it in its entirety. What the AAFP omitted in its article was that the survey also showed that upon graduation, 93% of NPs felt they were somewhat or well prepared to manage acute disease, 89% felt they were somewhat or well prepared to manage chronic disease, and 99% said they were somewhat or well prepared to perform a differential diagnosis. Certain areas skewed the survey results downward, such as casting (85% felt minimally prepared), coding and billing (82% felt minimally prepared), suturing (68% felt minimally prepared), and X-ray interpretation (70% felt minimally prepared).2 Although many clinicians are not comfortable with these skills upon graduation, they are not skills that affect diagnosing and treating illness. The survey indicated that NP graduates did feel comfortable in areas such as decision
making and assessment, but many felt weak in certain clinical procedure skills. I did a literature search but could not find a similar survey involving medical students’ or graduating residents’ perceptions of preparation for practice for comparison. Are more years of education inherently equal to better care? Is there any evidence? The studies on patient outcomes do not validate this theory. Many studies show equivalent health outcomes between physicians and NPs and increased patient satisfaction with NPs.3,4 Is there a point of diminishing returns regarding years of education? Could it be that the types of training are different and we cannot really compare them side by side? It begs the question: Does more education mean better care and better outcomes? If that were the case, physicians or NPs with additional education, additional degrees, and additional years of training would be providing superior care. ■ The years of training How pertinent are the years of training to the end role? Consider a family practice NP’s training. From the beginning, the entire program is focused on family practice skills, both clinical and didactic. Medical education trains students to be generalists. The specialty is not declared until after graduation from medical school when the physician begins residency. Though a medical student may wish to become a family physician, www.tnpj.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
NP Insights he or she must still complete rotations in areas such as general surgery. Although interesting and educational, this training is not necessarily useful in the family practice setting. There are also many hours spent in inpatient medicine, an area many family physicians will never practice in again. In addition, family physicians undergo 3 years of residency. This is a great way to get started with practice while gaining some oversight and education. I believe NP residencies would be a useful addition to our training programs, and several have started around the country. The physician model, however, often involves long hours of hospital coverage. Do working long hours in a hospital as part of a
www.tnpj.com
residency training program improve care outcomes for the family physician? There are benefits, but are all of those hours providing a superior education? ■ Content and style With the changing face of healthcare, we must adapt educational programs to meet the evolving needs of primary care clinicians. The ability to communicate and build a relationship with a patient goes beyond knowledge. All of the years of education for any clinician will be useless if he or she cannot communicate well, listen, and draw out the important points in a patient history—many of which go far beyond the physical sciences to the psychosocial realms of a
patient’s life experience. Content and style of training hours can be more important than the number of hours. Healthcare and medicine are constantly changing. It is important to learn how to learn. What is taught in school or training is just the beginning of learning. No matter how many years of training someone had, it is essential to change and grow with the everevolving knowledge base. Is it what we learn in school, or is it learning how to continue to learn that offers the most benefit? Memorizing more information may not make a difference in a few years as that information changes. Is it the knowledge that is most important or, in the healthcare field, is it just as
The Nurse Practitioner • November 2014 11
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
NP Insights important to know how to gather the information, communicate with patients, motivate patients, and build relationships with patients? Years of studying science may not lead to the development of these critical skills or to the ability to grow with new information. ■ A unique profession I have seen NPs sell themselves short as second to physicians. We must not use physicians as the standard when talking about healthcare providers. The term “midlevel” providers, a term I think should be retired, does just this because it implies physicians are the “high-level” providers. It also implies there is a “low-level” provider, someone below the midlevel provider. NPs are not in the middle of anything. We are a unique profession, based on nursing, on health, and on caring. We do many of the same things physicians do. Our roles may be similar, but how we do what we do and the underlying philosophy of what we do is different. It does not follow the medical model of “taking care” of patients but, rather, we “care for” our patients. The relationship with our patients is at the heart of what we do. We are all high-level providers, all healthcare providers. We have different roles, different ways of doing things, but we all strive to do it at a high level, not a mid or low level. Be careful and clear when describing your NP role. I have heard some say NPs do about 80% of what physicians do. This again makes physicians the standard. Many of us do things physicians do not. What we do really varies based on our training and experience. As NPs, we must not quantify ourselves in relation to physicians except to say that we do many of 12 The Nurse Practitioner • Vol. 39, No. 11
the same things and that our roles are similar. NPs are not a consolation prize, a second-rate solution to the shortage of primary care physicians. We were here before the physician shortage, doing great work, offering an alternative, not a secondary choice because physicians were not available. We are another choice for healthcare consumers. Shortage or not, we have something unique and special to offer. Patients choose us every day. ■ Evidence and optimal outcomes There is no evidence that says more years of education results in better clinical outcomes. There is also no evidence that says less years of a different type of education results in inadequate knowledge and skills to practice primary care independently. NPs want to work together with physicians and other members of the healthcare team. We are one component with something unique to offer. We ask questions of physicians, and many physicians ask questions of NPs. We do this because we want to give the best healthcare to our patients. The most competent clinician will likely tell you there is always more to learn. Inherently, we have no data indicating how years or hours of training alone relate to quality of care or outcomes. We must not sell anyone short. We must all work as a team, not trying to be better than or to demonstrate our own competence over someone else. Our goal is simply to give competent care. We must all work together to learn and grow, to build up our colleagues, not tear them down. Our professions, our roles, our individual styles and our knowledge can complement each other. We will continue to hear the statements that NPs do not have
adequate training and that we are secondary to physicians. Some fear that NPs are trying to take over the role of physicians. NPs do not want to be physicians; we love being nurses. Maybe independent practice is not really the word to use. NPs want and need to practice interdependently with all members of the healthcare team. “Autonomous” practice may be a better descriptor, working together in a way where our practice is not encumbered and restricted, where we can practice to the full extent of our training. We do not need to compare hours of training. We need to look at the skills we have and the outcomes we have seen with our patients. We must not sell ourselves short. We must eliminate words that describe our profession in relation to physicians or any other healthcare providers. We must be proud of our training, proud to be NPs in a unique profession with a role to play in transforming our ailing system and putting the health and the care back into healthcare! REFERENCES 1. Education and Training: Family Physicians and Nurse Practitioners. 2014. http://www.aafp.org/ dam/AAFP/documents/news/NP-Kit-FP-NPUPDATED.pdf.. 2. Hart AM, Macnee CL. How well are nurse practitioners prepared for practice: results of a 2004 questionnaire study. J Am Acad Nurse Pract. 2007;19(1):35-42. 3. August 2008-SUPPORT Summary of systematic review: do nurse practitioners working in primary care provider equivalent care to doctors? 2014. http://apps.who.int/rhl/effective_practice_and_ organizing_care/SUPPORT_Task_shifiting.pdf. 4. Lenz ER, Mundinger MO, Kane RL, Hopkins SC, Lin SX. Primary care outcomes in patients treated by nurse practitioners or physicians: two-year follow-up. Med Care Res Rev. 2004;61(3):332-351. Tom Bartol is an Advanced Practice Registered Nurse at Richmond Area Health Center, HealthReach Community Health Centers, Richmond, Me. The author has disclosed that he has no financial relationships related to this article. Questions or comments? E-mail [email protected] DOI-10.1097/01.NPR.0000452979.76805.c5
www.tnpj.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
