Nurse Practitioners

1. 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, DNSc
Dean and Professor
School of Nursing
University of California, San Francisco

2. 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)

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 2/6/02
Viva la difference!?Viva la difference!?
Training
Licensing
Medical vs.
Nursing Model
Scope of
practice

10. 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)

11. 2/6/02
LicensingLicensing
• MD
– medical Board exam
– specialty exams
• APN
– nursing Board exam
– NP exam/certification

12. 2/6/02
Model of CareModel of Care
MD
• “medical model”
• curing
RN
• “nursing model”
• caring

13. 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

14. 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)

15. 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
smoking
cessation
weight
reduction
family
planning
NP
MD/DO
Moody et al, NP, 1999, 24(3):94-103

16. 2/6/02
Comparison of top fiveComparison of top five
NP & 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

17. 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
NP
MD/DO
Moody et al, NP, 1999, 24(3):94-103

18. 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)

19. 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)

20. 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

21. 2/6/02
Cost/BenefitCost/Benefit
• Reduced educational opportunities forReduced educational opportunities for
residentsresidents
• Reduced interaction of physician withReduced 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

22. 2/6/02
Patients and their healthcare providerPatients and their healthcare provider

23. 2/6/02
Patients’ Active Involvement in CarePatients’ 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 failure
3 brought written information to the visit
2 wrote questions on paper and took to the visit
0
10
20
Very Active
Active
Somewhat Active
Not Very Active
Not 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’

24. 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

25. 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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