Nurse practitioners, physicians disagree on primary care roles

Nurse practitioners, physicians disagree on primary care roles
Nurse practitioners, physicians disagree on primary care roles

Nurse practitioners (NP) and physicians still disagree on many scope-of-practice issues, despite agreeing on the broad idea that NP roles should expand to help meet increasing demands for primary care services, study results indicate.

Specifically, 82% of NPs believe they should be able to lead medical homes vs. 17% of physicians, and 64% of NPs believe they should be paid equally for providing the same clinical services compared with just 4% of physicians, Peter Buerhaus, RN, PhD, director of the Center for Interdisciplinary Health Workforce Studies at Vanderbilt University in Tennessee, and colleagues reported in New England Journal of Medicine.

Although 60% of NPs working in collaborative practices indicated they provided services to complex patients with multiple conditions, only 23% of physicians in such practices agreed that NPs provided those services.

"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 others' contributions," Buerhaus said in a press release. "I am concerned that these large gaps in perceptions will inhibit efforts to redesign care deliver and to improve the productivity and configuration of the primary care workforce."

Debate among NPs, PAs and physicians regarding appropriate roles is nothing new, but specific data on the differences between primary care NPs and physicians is lacking. To further explore these ideas, Buerhaus and colleagues mailed surveys to a random sample of nearly 2,000 U.S. primary care clinicians. The final analysis included responses from 467 NPs and 505 physicians.

The majority of both groups -- 96% of nurse practitioners and 76% of physicians -- agreed with Institute of Medicine (IOM) recommendations stating that NPs "be able to practice to the full extent of their education and training," the researchers found.

However, just 76% of NPs reported they were doing so. State restrictions, hospital regulations, and the type of work setting were the main factors NPs reported as limiting their scope of practice.

The two groups also agreed that increasing the supply of primary care NPs would improve the timeliness of and access to care and that both professions provided a wide rage of services in collaborative practices.

But when it came to specific policies regarding scope of practice, NP and physician attitudes differed significantly on nearly every measure:

  • 66.1% of physicians agreed that they provided a "higher quality of examination and consultation" than NPs, whereas 75.3% of NPs disagreed with this statement
  • Among those working in collaborative practice, 88.9% of physicians agreed that NPs "typically defer certain types of patient care services and procedures to the primary care physician" compared with 61.3% of NPs (P<0.001)
  • 43.8% of physicians believed more complex patients were primarily handled by physicians vs. 21.1% of NPs
  • 11.2% of physicians vs.15.2% of NPs believed specific diagnoses or disease groups were primarily handled by physicians
  • 19.1% of physicians vs. 36.8% of NPs reported physicians handled procedures and postoperative care

"We had hypothesized that, since primary care physicians and nurse practitioners had been working together for so many years, that collaboration would lead to more common views about their roles in clinical practice," study researcher Karen Donelan, ScD, EdM, of the Mongan Institute for Health Policy at Massachusetts General Hospital said in a press release. "The data reveal disagreements about fundamental questions of professional roles that need to be resolved for teams to function effectively."

The study also identified several demographic differences between NPs and physicians. NPs were significantly more likely to be female, be older and have worked fewer years on average than physicians, and were less likely to identify as a member of a racial or ethnic minority.

In terms of work environments, NPs were nearly twice as likely to report working in a collaborative practice than physicians -- 80.9% vs. 41.4%, respectively.

Differences in professional education, theoretical perspectives and practice environments likely contribute to the seemingly polarized viewpoints of NPs and physicians, the researchers acknowledged.

They called for more innovation in interprofessional education programs for primary care clinicians regarding curriculum, training and demonstration of competence, as well as more research regarding the economic implications of expanding NP roles and responsibilities.

"Patients need health care teams that work in concert," Donelan said. "We need to look at models of successful collaboration and understand how good teams function effectively and efficiently."

References

  1. Donelan K et al. N Engl J Med. 2013;368(20):1898-1906.
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