The image of nursing: Cheap substitutes?
In the latest in our series of blogs on the image of nursing, Sandy and Harry Summers ask what a nurse practitioner is for.
Who are nurse practitioners?
Are they just cheap, inadequate substitutes for physicians, pretenders who require close supervision, or are they highly skilled professionals who combine the holistic nursing care model with more education to provide excellent, cost-effective care?
Advanced practice nursing evolved mainly to provide care to under-served populations. In the 1960s, nurses began training to perform certain work traditionally done by physicians. Advanced practice nurses (APRNs) in the United States, the vast majority of whom have at least a master’s degree, now provide care in many specialties, including primary care, anaesthesia, and midwifery. There are more than 250,000 APRNs in the US and increasing numbers in other nations. US nursing leaders plan to make the four-year doctorate of nursing practice degree (in addition to the four-year undergraduate nursing degree) the standard for all new APRNs by 2015.
Like other nurses, APRNs employ a care model that emphasises prevention, health maintenance, and overall quality of life. Because they have the skills and take the time to listen and teach, APRNs are adept at identifying subtle problems and managing serious chronic conditions.
Decades of research shows that the care of graduate-prepared APRNs is at least as effective as that of physicians. In April 2002, a meta-analysis of 34 clinical studies in the British Medical Journal indicated that patients were more satisfied with their care if it was delivered by a nurse practitioner (NP) than if by a physician. NPs read X-rays equally well, identified more physical abnormalities, communicated better, and taught patients how to provide self-care better.
More recently, in an August 2010 study in Health Affairs, the Research Triangle Institute analysed inpatient mortality and complication rates for nearly half a million hospitalisations from 1999 to 2005, comparing U.S. states where certified registered nurse anaesthetists worked unsupervised by physicians to states where they did not. The researchers found that the care of nurse anaesthetists was no more risky for patients than the care of physicians.
The media’s treatment of APRNs has been inadequate. APRNs continue to be ignored as general health experts, and the media’s relentless suggestions that practitioner care is provided only by “doctors” continue unabated in news pieces and advertising. Some press accounts have wrongly suggested that APRNs are capable only of treating minor problems, such as removing splinters and managing colds. The media often allows physicians to express uninformed criticism of APRN practice without even consulting APRNs or the relevant research.
Some news articles have reported fairly on APRNs. An excellent October 2004 Wall Street Journal article reported that nurse-run primary care practices “may be critical to the future of healthcare in the US”. The story noted that NPs’ holistic, preventative approach may be uniquely suited to an ageing population with long-term illnesses. The piece also discussed hurdles that NPs still face, including legislative limits on their autonomy and the great pay disparity with physicians doing comparable work.
Unfortunately, many more news pieces ignore or undervalue APRNs. An August 2009 article on the Western Australia news web site WAtoday was headlined “Nurse clinics are ‘supermarket medicine’”. That was the view of the only expert quoted, Australian Medical Association president Andrew Pesce, who objected to one company’s plan to open 180 pharmacy-based clinics staffed by NPs. Pesce actually suggested, with no apparent irony, that NPs were “not skilled or experienced in providing holistic care.”
In the UK, physicians have repeatedly attacked the practice of advanced practice nurses without reference to any relevant research. In the summer of 2006, anonymous physicians published op-eds in the Daily Mail and elsewhere criticising government moves allowing nurses to move into clinical roles that have traditionally been the province of physicians. Offering only anecdotes, the pieces argued that these new roles had actually undermined nursing, causing nurses to turn away from custodial care tasks that the physicians thought defined nursing.
In late 2005 Mattel, the world’s leading toy maker, released a small collectible duck doll called the Nurse Quacktitioner. Dressed in a white lab coat and a white cap with a red heart on it, the doll’s name suggested that NPs are “quacks”, incompetent healthcare providers. When physicians in the UK learned of protests about the doll, many sent letters of support to Mattel, urging the company to keep selling the doll because it would foster contempt for NPs.
Hollywood has offered few good portrayals of APRNs. ER repeatedly suggested that able nurses achieve by becoming physicians, reinforcing the wannabe-physician stereotype, even though data suggests real nurses are 100 times more likely to become APRNs. In ER’s last season, nurse character Sam Taggart did start a nurse anaesthetist programme, and there were several helpful plot lines about her career path. In December 2008 episodes, Taggart impressed senior physicians by using her growing knowledge to improve critical care.
But television healthcare portrayals are far more likely to ignore APRNs or express overt contempt. The early episodes of Private Practice included mockery of the one nurse character, midwifery student Dell Parker, with the elite surgeon character Addison Montgomery referring to “midwives” as if they were some bizarre anomaly. Dell’s duties then seemed to consist mainly of acting as a receptionist. He eventually became a midwife and occasionally played a more robust role in care, even saving a couple’s lives. But the show killed him off in May 2010 episodes that emphasised his elation at having just been admitted to medical school.
Neither House nor Grey’s Anatomy has ever included an APRN in any significant role. In a January 2010 episode of Grey’s, the heroic neurosurgeon Derek Shepherd did suggest that another surgeon’s follow-up visits with a post-surgical patient were “easy” and a waste of her time because a “nurse practitioner can do this”.
Actually, Dr McDreamy, graduate-prepared nurse practitioners can do quite a lot, and do it at least as well as physicians. APRN-directed care offers not only a way to enhance access to care for underserved populations, but also an advanced hybrid practice model that could change the future of healthcare for everyone.