Expanded Roles for Advanced Practice Nurses
This backgrounder responds to arguments in a December 1993 report by the American Medical Association's Board of Trustees which questioned the qualifications of advanced practice nurses (APNs) for independent practice. The following pages also clarify and correct other recent statements in the medical press concerning APNs' educational preparation, competencies, and roles.
Quotes indicated with "(AMA)" are from the AMA Board of Trustees report or its accompanying talking points. Other quotes are from additional sources or are rephrased from statements commonly made by organized medicine. All quotes are referenced; citations from AMA are referenced in Roman numerals.
Prepared typically in master's-degree programs, APNs are advanced registered nurses who include four categories of providers:
1) nurse practitioners who deliver front-line primary and acute care in community clinics, schools, hospitals, and other settings, and perform such services as diagnosing and treating common acute illnesses and injuries, providing immunizations, conducting physical exams, and managing high blood pressure, diabetes, and other chronic problems;
2) certified nurse-midwives, who provide prenatal and gynecological care to normal healthy women, deliver babies in hospitals, private homes, and birthing centers, and continue with follow-up postpartum care;
3) clinical nurse specialists, who provide care in a range of specialty areas, such as cardiac, oncology, neonatal, pediatric, and obstetric/gynecological nursing; and
4) certified registered nurse anesthetists, who administer more than 65 percent of all anesthetics given to patients each year and are the sole providers of anesthesia in approximately one-third of U.S. hospitals.
In at least 45 states, advanced practice nurses can prescribe medications, while 16 states have granted APNs authority to practice independently without physician collaboration or supervision.
-- Studies have shown repeatedly that advanced practice nurses give care of equal or better quality than comparable care by physicians, and at lower cost. (see Section 2)
-- If not advanced nurses to meet the mounting need for primary care, then who? Physicians? Evidently not, projections say. (see Section 6) -- The name of this issue is health care reform, not medical reform. Medicine is neither the only health care profession, nor even the largest. Americans will never realize greater access to care and lower costs if policymakers continue to define health care according to the needs and interests of only one profession. (see Sections 3, 6, 8)
-- The question is not whether APNs should be providing primary care -- they already do and have been for years -- but if they should be doing so independently. The overwhelming evidence to date is yes. (see Sections 2, 3)
(AMA): "Nurses are not qualified by their education and training to practice as independent practitioners to meet the broad spectrum of needs of patients....Nurses' education does not prepare them to serve as the first point of contact for all the patient's medical and health care needs." i
-- Studies have shown repeatedly that, within their level of training, nurse practitioners provide quality, cost-efficient treatment of common acute illnesses and management of minor chronic disorders.1 In fact, a study published recently in the New England Journal of Medicine found that nurses are as competent as physicians in performing a common endoscopic screening test for colon cancer. 2
-- Advanced practice nurses (APNs) are being prepared typically in master's degree programs, and, in the case of nurse practitioners, are often team-trained alongside medical students sharing the same course work, patient rounds, and other on-site clinical experiences.
-- APNs have either a master's or doctoral degree or a certificate requiring up to two years of additional clinical training. The vast majority of nurse practitioner programs (more than 90 percent) confer the master's degree.3 -- Even after accounting for methodological limitations of some of the studies it reviewed in 1986, the congressional Office of Technology Assessment (OTA) concluded that the quality of care by nurse practitioners, certified nurse-midwives, and physicians was equivalent for comparable services, based on the "weight of the evidence" for both process measures (adequacy of patient assessment and prescribing practices and level of patient compliance) and actual outcomes (improvement in patients' conditions and resolution of acute problems).4
In all, 10 studies in OTA's review found that the quality of care by nurse practitioners and physicians was equivalent, while 14 studies reported differences. Of those 14, however, 12 found that the quality of care by NPs -- particularly in communication with patients and preventive care -- was higher than that for physicians.5
-- Physicians do not have a monopoly on health care knowledge, nor are they the only qualified independent providers of health care. It does not take 11 years of medical training to competently immunize a child, treat an ear infection or sore throat, give a physical exam, or even manage diabetes or high blood pressure. APNs not only are providing this level of care, but can be prepared at almost one-fifth the cost of expensive and prolonged medical education.
-- Patients with complicated cases or serious conditions that cannot be handled by an APN are referred to a primary care or specialist physician, in the same way that physicians refer complicated cases to specialists.
-- Organized medicine has often cited education in an attempt to discredit other health professions who seek to practice, and receive financial reimbursement, independent of physician supervision. And nursing is not the first target. The AMA report falsely states that advanced nurses do not have sufficient education to provide independent care, as APNs do not have "medical training" -- a claim organized medicine has made (and lost) in court cases in attempts to restrain, for example, independent mental health services by psychologists.
(AMA): "Certification [of nurses] is voluntary and does not require either a baccalaureate degree or a master's degree to qualify for the examination for certification in advanced practice." ii
-- With one exception, all national professional organizations that certify nurse practitioners require nurses to have a master's degree or post-master's certificate from a nurse practitioner program in order to sit for a certifying exam. Currently, the National Certification Corporation for Obstetrics, Gynecologic, and Neonatal Nursing Specialties does not require a master's degree for its certification exam for Ob/Gyn nurse practitioners.6
-- Except for a small number of certificate programs, the vast majority of certified nurse-midwives have been trained in master's-degree programs.
-- The American Nurses Association's American Nurse Credentialing Center, the only certifying body for clinical nurse specialists, requires a master's degree for certification.
(AMA): "Only 40% of nurses in advanced practice have master's degrees." iii
-- Currently the vast majority of APNs -- nurse practitioners, certified nurse- midwives, clinical nurse specialists, and nurse anesthetists -- are being prepared in master's-degree programs, with only a small number in post-master's or other certificate programs requiring up to two years of additional clinical training.
Many APNs educated in earlier years received their training in certificate programs. However, the increasing demands of health care and the dramatic expansion of graduate nursing education have moved the focus of APN education into master's-degree programs.
-- Contrary to AMA's figures, the master's degree has been earned by 68 percent of all current APNs employed in nursing -- including those trained in earlier years. 7 For APNs being prepared now, however, master's-degree education has become the standard.
Of all APNs, nurse practitioners and certified nurse-midwives provide the majority of primary care. Of these, more than 90 percent of NPs and the vast majority of CNMs are currently being prepared in master's-degree programs.
(AMA): "The commonly accepted definition of primary care incorporates a much broader range of skills and knowledge than nurse practitioners are able to provide." iv -- "Primary care no longer requires the level of training that it once did. As biomedical knowledge has grown, basic medical education has been truncated. The gap in competence between the specialist and the primary care physician has increased....As the scope of medical care has grown, so has the scope of nursing care, and in primary care there is substantial overlap in practice between physicians and nurse practitioners," an overlap noted in numerous studies.8
You can't equate a master's degree with a medical degree.
-- Nursing has never equated the two. But such statements reveal the false view by many physicians that MDs are the only qualified health care providers. Medicine is neither the only health care profession, nor even the largest. The movement of the health system is away from institutionally-based, physician-dominated care to more front-line primary and preventive care throughout the community, and delivery by a wider choice of providers, such as nurse practitioners and certified nurse-midwives.
Meaningful health care reform will never get out of the starting gate until policymakers move beyond the narrow mind-set that sees health care as only "medicine."
-- But clinical practice has shown that master's degrees are sufficient health care degrees. In at least 45 states, advanced practice nurses can prescribe medications, while 16 states have given APNs authority to practice independently without physician collaboration or supervision.9
Moreover, years ago, few nurse practitioners worked in acute-care settings in hospitals. Now, more hospitals (whose boards are largely physician-controlled) are recognizing the skills and benefits of nurse practitioners who are managing patient-care units and handling several of the clinical duties of medical residents.
If nurses want to practice medicine, there's always medical school. -- Let's not confuse the issue. APNs and other nurses provide quality health care through nursing, not medicine, which is the domain of physicians. Nurses are intent on practicing nursing to its full potential, without the antiquated, burdensome, and unnecessary restrictions that medicine seeks to place on it in the professional self-interest of medicine, not the consumer. Nurses have never stood in the way of physicians' ability to practice medicine. Now, however, many in organized medicine are attempting to stand in the way of nurses' ability to practice nursing to its full capacity.
(AMA): "There is no basis in fact to establish that nurses practicing independently would deliver quality of service equal to or better than physicians." v
-- The evidence is in, if organized medicine chooses to acknowledge it. But despite their ability to provide a broad range of health services independently, nurse practitioners, for example, are constrained from doing so because of restrictive state laws and regulations. As a result, studies measuring the effectiveness of fully independent NP practice have been limited.
Still, the evidence to date shows consistently that the quality of care by nurse practitioners is equal to, and at times better than, comparable care by physicians. 10
Moreover, in studies reviewed by the congressional Office of Technology Assessment (OTA), certified nurse-midwives managed normal pregnancies safely and as well as or better than physicians. In addition, low-risk patients of CNMs delivered fewer low birth-weight infants, and had shorter inpatient stays for labor and delivery than did similar patients of obstetricians. 11
-- Despite the methodological flaws of some of the studies it reviewed in 1986, OTA found that nurse practitioners can deliver as much as 80 percent of the health services, and up to 90 percent of the pediatric care provided by primary care physicians, at equal to or better quality, and at lower cost.12 In fact, in 12 studies, OTA found that the quality of care by NPs -- including communication with patients, preventive actions, and reductions in the number of patient symptoms -- was higher than that for physicians.13
-- Some of the methodological problems encountered in OTA's review were small sample sizes, comparison with house staff physicians instead of experienced physicians, evaluation of only one practice setting, and use of nonrandomized study populations. Still, the results of "well-conducted, randomized, controlled trials that are valid within their own designs," together with findings from other studies, allowed OTA to draw some generalized conclusions. 14 -- In fact, nurses' more extensive training in community-based care may make APNs more adept than physicians in particular aspects of primary care. For example, nurses are more likely to talk with patients and tailor medical regimens to a patient's preferences, family situation, or environment. Nurses are also more likely to provide disease-prevention counseling and health promotion activities, and to know about and use community resources such as nutrition programs, stress-reduction classes, and self-help groups.15
(AMA): "Measuring quality of care is an inexact science because quality encompasses both tangible and intangible components." vi
-- If so, then medicine can't claim with "exactness" any higher quality care than is provided by other health professions.
(AMA): "An estimate that APNs can substitute for 80 percent of the services provided by physicians was synthesized from research conducted under conditions in which APN care was supervised by physicians." vii
-- Again, let's not confuse the issue. Major studies that have compared nurse practitioners with primary care physicians have focused on the NP's initial, independent decisions about diagnosis and treatment, not on a supervising physician's confirmation of those decisions. These initial judgements were made even in cases where NPs worked in settings in which their decisions were confirmed by physicians before being implemented.16
(AMA): "The claim that APNs can independently substitute for a high proportion of physician services is not supported by evidence." viii
-- In a national demonstration program, school nurse practitioners could manage independently 87 percent of health problems of students in school clinics. 17
-- Given the true, limited nature of supervision -- which often entails little more than a physician's signature on an insurance reimbursement form -- APNs in effect already practice independently in most cases.
For example, whether employed by a physician or working in collaborative or independent practices, NPs examine patients, elicit information about symptoms and medical history, and make diagnoses and treatment decisions. Even in collaborative practices with physicians - which the AMA report encourages -- a nurse practitioner is not required to obtain a physician's approval before providing care within the NP's scope of practice. 18
-- In a recent study, even physicians themselves -- including internists and pediatricians participating in a large HMO -- have reported that they could safely delegate more office visits to nurse practitioners than they already do. 19
-- "Today, many states still specify that physicians must supervise the practice of APNs. Yet medical school curricula rarely include nutritional, psychosocial, patient teaching, minor illness management, and health promotion content. APN education is based on these concepts. Legislatively specifying that physicians must supervise APNs, whose knowledge is based on content foreign to many physicians," is in itself a contradiction 20
-- Many states that require MD supervision of APNs allow advanced nurses to practice independently in certain settings, such as inner-city community health centers or rural areas, with the rationale that these sites are "medically underserved." "If unsupervised APNs are competent to practice there, where MDs do not or will not, they are competent to practice here, where MDs do practice." 21
"If APNs, practicing autonomously, can effectively care for rural and poor inner-city patients -- relatively high-health-risk populations whose economic or social status often results in poor nutrition, low birth-weight babies, and the like -- why cannot these same providers practice in suburban or urban areas without MD supervision?" 22
(AMA): "The call for independent nursing practice comes from a relatively small section of the nursing community, as most nurses in practice acknowledge the need to work with a responsible supervising physician who is immediately available for consultation or direct intervention." ix
-- There are no data to support such claims. In fact, most major nursing organizations have called for the removal of legislative and regulatory barriers that prevent advanced practice nurses from practicing autonomously to the full scope of their capabilities. Moreover, a recent survey of 2,000 registered nurses by the American Nurses Association found that 97 percent believe nurses are not being used to their full potential in the U.S. health system. More than 70 percent believe nurses should practice in independent, autonomous roles.23
Nurses who recognize the need to work with a physician are merely acknowledging what APNs already do -- consult with physicians to refer serious or complicated cases which advanced nurses are not trained to handle.
-- The AMA report confuses the meaning of "independent." Simply because nurses consult with or refer complex cases to physicians does not mean that APN services are dependent. Independent does not mean "isolated" nor lacking physician or other provider referral or back-up, any more than it means that primary care physicians work without referral to cardiologists or other specialists. 24
-- Nurses are not the only group calling for independent APN practice. To meet the mounting need for primary care delivery, a report by the Pew Health Professions Commission urges doubling the number of nurse practitioner graduates by the year 2000. The majority (82 percent) of all NPs practice in primary care settings, and unlike physician assistants, NPs "can be licensed to practice independently thus enabling them to work in underserved areas," the report says. 25
Moreover, practice restrictions -- such as lack of prescriptive authority and requirements for on-site supervision -- are an impediment to independent practice and impact where NPs are able and willing to serve, the Pew report warns. In fact, the Commission says, requirements for supervision can "promote redundancy" when physicians supervise tasks already within the scope of an NP's competency. 26
(AMA): "Quality medical care requires that a physician be responsible for the overall care of each and every patient." x
-- No one challenges this statement. Quality medical care calls, of course, for the knowledge and skill of the medical professional -- the physician. But quality health care doesn't always.
The name of the current debate isn't medical reform; it's health care reform. Medicine is neither the only health care profession, nor even the largest. As such, medicine doesn't own health care, but is only one essential part of it. What Americans need is improved access to quality, independent health care services that professionals other than physicians are qualified to provide.
(AMA) "There is no convincing evidence that nurses are the most cost-effective health care providers....There is little empirical evidence that independent nurses in advanced practice are more cost-effective than the existing delivery system." xi
-- Legal and regulatory constraints on nurse practitioners and certified nurse-midwives in many states have limited the numbers of studies of fully independent practice. In fact, comparative data on the costs and efficacy of physicians' services are "strikingly" insufficient.27
-- No one has claimed that nurses are the most cost-effective provider. Still, the fact that nurses are cost-effective is undeniable.
Repeatedly, studies have shown that nurse practitioners and certified nurse midwives are cost-effective providers of quality health care.28 "The evidence to date confirms the cost-effectiveness of these providers, given the diversity of the populations they serve, often as substitutes for physicians"; their high productivity; the fact that their care produces equal or sometimes better outcomes, and perhaps more quickly, given their patients' better compliance to care regimens; the substantially lower cost of their training; and the additional benefits of increased consumer choice and satisfaction.29
(AMA): "If patients view the services provided by nurse practitioners or clinical nurse specialists as distinct from medical care, it is unlikely that medical care consumption will fall. In that event, payments to APNs would simply be an add-on to current health expenditures." xii
-- This argument is self-defeating. Payments that organized medicine wants to restrict from APNs would no doubt go to the increased numbers of primary care physicians that organized medicine is working to provide. At the very least, medical school graduates themselves will be "add-ons" to health expenditures by generating higher medical care consumption once they enter practice.
-- The AMA report wrongly attempts to make independent primary care and reimbursement off limits to anyone but physicians, when data show other providers actually reduce costs.
In one study, costs per episode were 20 percent less when nurse practitioners provided initial care than when physicians did.30
Moreover, in a recent analysis of 38 studies, the average cost per visit for patients of NPs was $12.36, compared to $20.11 for physician patients. Researchers suggest that the comparatively lower salaries of NPs may have contributed to these findings. 31
-- A recent study estimated that not using nurse practitioners to their full potential costs the nation nearly $9 billion a year due to scope-of-practice restrictions and other "denied access" for consumers that is keeping the cost of basic health care inflated. 32
-- Physicians who seek to restrict APN practice may claim the issue is one of education, professional qualifications, or the quality of patient care. But the real issues are economics and medicine's goal of retaining a monopoly over health care delivery.
(AMA) "It is irrational to jeopardize patient safety or quality of care by allowing unsupervised [nurses to] practice." xiii
-- AMA has no data to substantiate a charge of increased risk by advanced nurses who are practicing independently within their education and scope of practice. Evidence to date indicates that the quality of care by advanced practice nurses is at least equal to, and sometimes better than, comparable services by primary care physicians.
-- Is it more "rational" to give exclusive domain over independent care to a field that, according to the latest federal estimates, has fewer than 100 primary care physicians per 100,000 population in major metropolitan areas and less than 50 in rural areas of fewer than 25,000 citizens? 33
-- Arguments in AMA's report are too little too late. The report stakes an exclusive claim to a field that organized medicine has largely abandoned. The AMA cannot justify restricting advanced nurses from serving as front-line, first points of contact for primary care, when medicine neither can produce enough future physicians to provide that care, nor has demonstrated a willingness so far to be on the front lines in sufficient numbers providing it.
-- If not advanced nurses to deliver primary care, then who? Physicians? Evidently not. In 1992, nearly two-thirds of the nation's physicians were specialists34 -- with that number expected to climb to nearly 70 percent by the year 2000 35 That same year, the nation will be facing a shortage of 35,000 generalist physicians and a surplus of 115,000 specialist MDs, according to federal estimates.36 Meanwhile, the vast majority of medical graduates continue to enter subspecialty fields.37 Relying solely on physicians to deliver independent primary care is not only irrational, but jeopardizes the health system's ability to meet basic public need.
-- The AMA report would deny advanced practice nurses the independence to practice in expanded roles for which they are fully skilled and qualified. At the same time, the report claims for physicians exclusive rights to independent primary care at a time when the current and projected supply of such physicians is severely inadequate.
Even if half of all U.S. medical graduates were to enter primary care -- a goal some experts believe is unattainable -- that number may not be reached until at least the year 2020.38 The exploding need for accessible health care simply cannot wait.
-- Although the AMA supports universal access to health services, its report also claims medicine's exclusive right to independent primary care. With so few primary care physicians, how can there be "universal" access when medicine clearly doesn't have enough practitioners to treat the primary care universe?
(AMA): "The public expects that access to nurses means access to physicians; the demand is for physician services, not the lesser educated nurse services." xiv
(AMA): "Nurse care is acceptable to the public only if physician access is blocked for any reason." xv
-- A recent Gallup poll, which allowed consumers to choose freely between care from a physician or from a nurse, found that the overwhelming majority of consumers (86 percent) would be willing to receive their basic or primary care from an advanced practice nurse. Only 12 percent said they would be unwilling to receive physical exams, prenatal care, immunizations, or treatment for colds and infections from an RN who has master's-degree training.39
-- A recent opinion survey by pollster Peter Hart found that the general public respects nurses more than any other health care provider -- 70 percent for nurses compared to 12 percent for physicians.40
-- Moreover, according to the Hart survey, more than half of Americans (54 percent) think that registered nurses are not being given responsibilities equal to their abilities.41
(AMA): "Patients in rural areas, as a principle, have a right to fully trained medical care personnel as do those in other locations, and should not be surrendered to second level of care because of location." xvi
(AMA): "The inner-city areas...and the rural underserved require the learning and experience of physicians perhaps more than other populations. A two-tiered system of care would not meet the health needs of these communities." xvii -- These statements fly in the face of current reality, given medicine's own limited record of rural and inner-city practice.
-- Even within medicine, there already exists a two-tiered system of care -- with primary care physicians on the front line referring serious or complicated cases to specialists. Advanced nurses who refer patients to specialists would not be instituting a change, but merely doing what they and physicians already do.
(AMA): "Organized nursing is now asserting that the practice of registered nurses is capable of being extended into medical practice by replacing physician services by independent advanced practice nurses." xviii
-- Advanced practice nurses are not extending into medicine, but are already in health care delivery, providing services within their scope of practice which AMA's own report lauds as "essential" and "high-quality." xix
In fact, if anyone is "extending" RNs into medicine, it's medicine itself. Though they do so inaccurately, physicians and the AMA report often refer to APNs as "physician extenders" who provide needed primary care and, increasingly, acute care in hospital settings. xx
-- The question is not whether advanced practice nurses should be providing primary care...they already do and have been for years. The real issue is whether APNs are capable of doing so independently. The overwhelming conclusion of the evidence to date is yes.
-- Moreover, this issue is about delivering needed primary care, not replacing physicians. Only about one-third of U.S. physicians now practice in primary care.42 You can't replace a provider who, for so many communities, simply doesn't exist.
(AMA): "Some [hospital] programs have used nurse practitioners to extend resident physician services......Because residents hours are long, two nurse practitioners have to be hired to substitute for one resident; each nurse practitioner is paid considerably more than resident stipends, making the use of NPs as physician extenders very costly in this setting." xxi
-- Another self-defeating argument. "The resident hours are long, now, at 80+ hours per week. When adjusted for a 40-hour [full-time-equivalent] work week, the institution would have to hire two residents to replace the 80-hour/week resident, just as it would have to hire two APNs. The users of APNs as resident substitutes have consistently noted the tremendous increase in service stability, smoothness of operation and efficiency when APNs are utilized. As the number of APNs utilized as resident replacements continue, we anticipate these trends to continue, as well." 43
(AMA): "Physicians and nurses have separate roles that complement each other in practice; but it would hardly be feasible to abandon patients solely to the care of nurses, no matter how willing they may be to assume this role." xxii
-- Given the interdisciplinary nature of health care knowledge and delivery today, it's inconceivable that any discipline could be expected to provide all essential services solo.
Assigning patients to the exclusive care of nurses is as unrealistic and against the public interest as patient care provided solely by physicians, in cases where the services of a nutritionist, physical therapist, or psychologist would do better.
"Nurses must be part of the health care team, where doctors would always be the 'captain.'" 44
-- Nursing has always been an advocate of collaboration. It is irresponsible for any practitioner in primary care to not collaborate through consultation and referral, so that expertise that may surpass the knowledge of nurses or physicians can be used for the benefit of the patient.
-- The AMA is correct in calling for increased collaboration. But even in truly collaborative practices, physicians and nurse practitioners share authority equally. NPs are not required to first seek the physician's approval before providing care within their scope of practice. 45
-- Both partners in a collaborative practice are equally autonomous, with physicians providing medical care and nurses delivering needed nursing care. In these cases, the "captain" may not always be the physician. If the nurse has more knowledge and professional competence in a particular type of care, he or she has final authority.46 For example:
What if a team is focused on patient education, prevention, or helping patients adopt healthy lifestyles? Should a physician (whose disease-focused training seldom included these concepts) head that team? Or should a nurse (for whom such concepts are a central hallmark of nursing education)?
Similarly, what about a team aimed at improving patients' diet and nutrition? Should a physician (whose medical school training includes little content on nutrition) head that team? It could be argued that a nurse could be the team leader (nutrition is a staple of nursing education). However, in many cases, even a nurse would not be as qualified as the most knowledgeable professional in this area, a registered dietician.
-- Physicians should be the primary provider of care for complex, medically unstable conditions, or for care outside of an advanced nurse's capabilities. But for routine primary care where skills are equal, NPs and physicians should provide care equally and independently. -- Collaborative practices of nurses and physicians not only provide more comprehensive services than care by a nurse or physician alone, but produce more satisfied patients "who are less likely to be litigious. Indeed, if their care includes nursing services (counseling, teaching, and an explanation of therapy and the need for compliance), true negligence and harm are likely to occur less often." In fact, the more comprehensive the practice, the more competitive it will be. 47
(AMA): "Replacing physicians with unsupervised nurses who have less diagnostic and treatment management training would clearly increase medical risk to the patient and entail costly burdens of additional care with corresponding productivity losses. Significant costs to patients in the form of added uncertainty, pain, and suffering would also result. Additionally, there may be implications for expanded liability." xxiii
-- The AMA report produces no data to substantiate such claims, which are based on fear, not facts. Public policy should not be based on what may or may not occur in the future, but on what we know to be hard fact today. All major studies to date have found that advanced nurses such as nurse practitioners -- in making their own initial, independent diagnoses and treatment decisions -- provide high quality care equal to or better than comparable care by physicians.
-- In reality, malpractice claims against nurses are dramatically low. In 1992, figures from the federal National Practitioner Data Bank reported less than one (.3) malpractice claim per 1,000 registered nurses compared to 33 claims per 1,000 physicians.48
"[Nurse practitioners] may not always appreciate the seriousness of a clinical problem and may fail to refer the patient to someone more expert." 49
-- So might a physician. Clearly, there are no data to document that physicians always catch every complication.
-- Physicians and advanced nurses alike may fail to detect a more serious disorder by not referring to a specialist. Still, studies show that nurse practitioners not only refer cases to specialists at the same rate as family physicians do, but in some cases, nurses refer more frequently.50
-- Though it does so inaccurately, the AMA report says nursing hasn't provided convincing evidence that APNs can provide quality, accessible, cost-efficient care in the absence of physician supervision. But the report also hasn't provided any convincing evidence that APNs can't.
-- The AMA report contains many "may's" and "might be's," "likely's" and "possibly's," but fails to substantiate its major claims: For example:
"Unsupervised APNs may utilize more inputs per unit of medical service provided than APNs in collaborative practices. As physician direction and oversight is reduced, APNs might order more diagnostic tests, prescribe more drugs, and utilize more medical supplies per patient or per office visit." xxiv
-- In fact, a recent analysis of 38 studies found that nurse practitioners and physicians prescribe drugs at equivalent rates. While NPs did order slightly more laboratory tests (for 36 percent of their patients compared to 30 percent by physicians), the cost of the tests was slightly lower (8 percent) for the nurses. Researchers suggest that "nurses order with more frequency, less costly tests." 51
Regarding medical supplies, a review of 15 studies found that certified nurse-midwives used less analgesia, anesthesia, and intravenous fluid, and performed less fetal monitoring and forceps deliveries than did physicians.52
-- The AMA report also provides a series of contradictory conclusions: For example:
"The APNs who work with residents and attendees in hospitals represent a true collaborative approach where the nurse is used as a physician extender." xxv (later in the same section...) "Each nurse practitioner is paid considerably more than resident stipends, making the use of NPs as physician extenders very costly in this setting." xxvi
1 For a review of studies, see Safriet, Barbara J., "Health Care Dollars and Regulatory Sense: The Role of Advanced Practice Nursing," Yale Journal on Regulation, Summer 1992, pp. 426-440.
2 Maule, William Forest, "Screening for Colorectal Cancer by Nurse Endoscopists," New England Journal of Medicine, January 20, 1994, pp. 183-187.
3 National Organization of Nurse Practitioner Faculties, National Directory of Nurse Practitioner Programs, 1994.
4 Office of Technology Assessment, Health Technology Case Study 37: Nurse Practitioners, Physician Assistants, and Certified Nurse Midwives: A Policy Analysis (OTA STUDY), Congress of the United States, December 1986, p. 5-6, 25.
5 OTA STUDY, see note 4, p. 21.
6 Morgan, Walter A. and Joann Trolinger, "The Clinical Education of Primary Care Nurse Practitioner Students," Nurse Practitioner, April 1994, p. 62.
7 Public Health Service, The Registered Nurse Population: Findings from the National Sample Survey of Registered Nurses, Division of Nursing, U.S. Department of Health and Human Services, March 1992, calculation based on data reported on pp. 19-21, 56.
8 Mundinger, Mary O., "Advanced Practice Nursing -- Good Medicine for Physicians?", New England Journal of Medicine, January 20, 1994, p. 212.
9 Pearson, Linda J., "Annual Update of How Each State Stands on Legislative Issues Affecting Advanced Nursing Practice," Nurse Practitioner, January 1994, p. 17.
10 Safriet, Barbara J., see note 1, pp. 426-440.
11 OTA STUDY, see note 4, p. 23.
12 OTA STUDY, see note 4, p. 39.
13 OTA STUDY, see note 4, p. 21.
14 OTA STUDY, see note 4, p. 18.
15 Mundinger, Mary O., see note 8, p. 212.
16 Mundinger, Mary O., see note 8, p. 211.
17 Safriet, Barbara J., see note 1, p. 435, citing Robert J. Meeker et al, "A Comprehensive School Health Initiative," IMAGE: Journal of Nursing Scholarship, vol. 18, p. 86, (1988).
18 Mundinger, Mary O., see note 8, p. 211.
19 OTA STUDY, see note 4, p. 43, citing Johnson, R.E., Freeborn, O.K., Lee, G., et al., "Delegation of Office Visits in Primary Care to PAs and NPs: The Physicians' View," Physician Assistant, January 1985, pp. 159-169.
20 Pearson, Linda J., see note 9, p. 13.
21-22 Safriet, Barbara J., see note 1, p. 453-454.
23 American Nurses Association, Survey of Membership, The American Nurse, April 1993.
24 American Nurses Association, Summary of Reports, Resolutions to be Considered at AMA Interim House of Delegates (unpublished memorandum), December 2, 1993, p. 3.
25-26 Pew Health Professions Commission, Nurse Practitioners: Doubling the Graduates by the Year 2000, University of California, San Francisco, Center for the Health Professions, April 1994, p. 1, 16.
27 Safriet, Barbara J., see note 1, p. 434.
28-29 Safriet, Barbara J., see note 1, p. 439, 434.
30 OTA STUDY, see note 4, p. 43, citing Salkever et al., "Episode-Based Efficiency Comparisons for Physicians and Nurse Practitioners," Medical Care, February 1982, pp. 143-153.
31 Brown, Sharon A. and Deanna E. Grimes, A Meta-Analysis of Process of Care, Clinical Outcomes, and Cost-Effectiveness of Nurses in Primary Care Roles: Nurse Practitioners and Nurse Midwives, American Nurses Association, December 1992, p. 3.
32 Nichols, Len M., "Estimating Costs of Underusing Advanced Practice Nurses," Nursing Economics, September-October 1992, pp. 343-351.
33 Bureau of Health Professions, Health Personnel in the United States: Eighth Report to Congress: 1991 (EIGHTH REPORT), U.S. Department of Health and Human Services, September 1992, pp. 50-51.
34 Council on Graduate Medical Education, Fourth Report - Recommendations to Improve Access to Health Care Through Physician Workforce Reform, U.S. Department of Health and Human Services, January 1994, p. 2.
35 EIGHTH REPORT, see note 33, p. 222.
36 Council on Graduate Medical Education, see note 34, p. 7.
37 Levinsky, Norman G., "Recruiting for Primary Care," New England Journal of Medicine, March 4, 1993, p. 656.
38 Council on Graduate Medical Education, see note 34, p. 7.
39 American Nurses Association, (News Release) Consumers Willing to See a Nurse For Routine 'Doctoring,' According to Gallup Poll, September 7, 1993.
40-41 Hart, Peter D., A Nationwide Survey of Attitudes Toward Health Care and Nurses, Peter D. Hart Research Associates, Inc., May 1990.
42 Council on Graduate Medical Education, see note 34, p. 2.
43 American Nurses Association, see note 24, p. 4.
44 American Medical News, "Reform Causing New Friction Between Doctors, Nurses," American Medical Association, December 20, 1993.
45 Mundinger, Mary O., see note 8, p. 211.
46-47 Mundinger, Mary O., see note 8, pp. 211, 213.
48 National Practitioner Data Base, March 1992.
49 Kassirer, Jerome P., "What Role for Nurse Practitioners in Primary Care?", New England Journal of Medicine, January 20, 1993, p. 204.
50 Brown, Sharon A. and Deanna E. Grimes, see note 31.
51-52 Brown, Sharon A. and Deanna E. Grimes, see note 31, p. 3-5.
CITATIONS FROM AMA BOARD OF TRUSTEES REPORT
i American Medical Association, "Talking Points" (Addendum) to Economic and Quality of Care Issues with Implications on Scope of Practice -- Physicians and Nurses, Board of Trustees Report I-93-95 (AMA REPORT), December 1993, p. 21.
ii AMA REPORT, p. 5.
iii AMA Talking Points, p. 21.
iv AMA Talking Points, p. 21.
v AMA Talking Points, p. 23.
vi AMA REPORT, p. 17.
vii AMA REPORT, p. 18.
viii AMA REPORT, p. 18.
ix AMA Talking Points, p. 22.
x AMA REPORT, p. 19.
xi AMA REPORT, p. 14.
xii AMA REPORT, p. 15.
xiii AMA REPORT, p. 19.
xiv-xv AMA Talking Points, p. 28.
xvi-xvii AMA Talking Points, p. 27.
xviii AMA REPORT, p. 12, 17.
xix AMA REPORT, p. 12.
xx AMA REPORT, p. 8.
xxi AMA REPORT, p. 12.
xxii AMA Talking Points, p. 30.
xxiii AMA Talking Points, p. 22.
xxiv AMA REPORT, p. 15.
xxv-xxvi AMA REPORT, p. 12.
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CONTACT: Robert Rosseter
(202) 463-6930, x231