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Personal Life-Saving Experience With Clinical Nurse Practitioner
- S. J. STEINBERG (5 April 2002)
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American excellence in nurse practitioners
- wayne a johnston (5 April 2002)
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Nurse Practitioners Model Message
- Bill Misner Ph.D. (6 April 2002)
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Customer Satisfaction is all important?
- Andrew P Mimnagh (6 April 2002)
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Comparison between nurse practitioners and GPs should be viewed with caution
- Steven B Nimmo (7 April 2002)
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Longer consultations more satisfying - what a surprise
- Adrian K Midgley (7 April 2002)
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Nurse Practioners Model Care Givers
- Bill Misner Ph.D. (7 April 2002)
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Law currently precludes a full investigation
- Carolyn Buppert (7 April 2002)
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Can NPs really replace the primary care physician?
- Rahul Gupta, Seema Gupta, MD (8 April 2002)
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Let us play the right roles!
- Nikhil C Kaushik (8 April 2002)
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Another systematic review
- Richard Costello (10 April 2002)
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English
- Joseph McEvoy (10 April 2002)
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These findings could be interpreted differently.
- Matthew Howse (11 April 2002)
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How innocent are investigations?
- T. Grant Phillips (12 April 2002)
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different interpretations
- ian d nesbitt (12 April 2002)
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Can nurse practitioners provide equivalent care to G.P.s
- Ian O'Connor (18 April 2002)
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Nice Review
- Yvette Marie Petti (19 April 2002)
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Enhanced Primary Care
- Stephen F Wilson (19 April 2002)
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Is less education better?
- Thomas F. Heston (19 April 2002)
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Re: Let us play the right roles!
- david o. mabe, 167 Macarthur St. Asheboro, NC 27203 (20 April 2002)
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It's all about responsibility.
- Peter W Bibawy (29 April 2002)
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Some Concerns
- William Rifkin M.D., Arthur Rifkin M.D and John Horiszny M.D. (2 May 2002)
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Np's do not want to replace
- Jeanne L. Scotland (2 May 2002)
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Not accounting for the most important variable in consultations (time) skewes results.
- Andreas K Demetriades (10 May 2002)
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Other Key Considerations
- Linda D. Johnson (26 June 2002)
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Re: Can nurse practitioners provide equivalent care to G.P.s
- Helen Santry (1 August 2002)
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Re: Re: Can nurse practitioners provide equivalent care to G.P.s
- Phylls du Mont (2 October 2003)
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Collaboration or the future
- Helen Gray (15 June 2009)
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NP request more tests
- Cherryl A Tahvanainen (10 August 2009)
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S. J. STEINBERG, Science journalist New York, NY, USA
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Madam & Sirs: It occurs to me that perhaps my personal experience with the vital, life-or-death importance of a good, conscientious clinical nurse practitioner may help illuminate this issue. A few years ago, my mother, then in her late 80s -- and until then in rather decent health -- was thrown into the hospital by medication that her neurologist had misprescribed. This assault to her system was soon compounded by a certain disastrously improper treatment in the ICU, such that she was needlessly propelled by that ICU event into cardiac arrest; in plain language, she was now dead. Fortunately, they immediately worked on her, and she was soon revived -- but that became the beginning of a months-running in-hospital series of battles with hospital-acquired life-threatening pneumonias and related illnesses that continually put her at the edge of death. Through these illnesses, she was fortunately put under the direct care of a highly conscientious and dedicated clinical nurse practitioner, who made it her business to personally oversee my mother, know as much as possible about my mother's condition -- and to do everything possible to see to it that my mother -- despite her advanced age -- would pull through and recover. This wonderful nurse practitioner often had to do hard battle with the doctors, to assure that my mother's level of care would not be cut -- something that, despite my mom's condition, apparently was a frequent aim of some of the doctors and the department-head: all too often, with what seemed to be disregard of the criticality of my mother's condition, these doctors -- who had barely any contact with my mother -- were saying that extensive care was no longer needed and that my mom should be (with almost no advance notice) sent to a regular ward. Had they succeeded in prematurely making that move, I am certain that my mon would not have survived; but this nurse practitioner would have none of it: she did constant battle with the doctors and the department-head over their efforts to accede more to bureaucratic goals than to seek to heal their patients. She pushed hard to assure that my mom would not be thus consigned to an accelerated demise. It was a running battle. But fortunately, this nurse practitioner knew, first-hand, the details of my mother's condition in great detail, and had a close personal perspective on my mom as well, including my mom's medical condition and something else that these detached, almost never-appearing doctors could never know: my mom's optimistic outlook, her courage through horrible adversity, and her strong will to live -- vital informational elements of which these cold, impersonal doctors and department-head -- with their cursory, infrequent contact with me or my mother -- were personally unaware. Rather, while this nurse practictioner was convinced that my mother could survive and recover given proper care and time, it became clear that these doctors' goal often was not so much to focus on my critically ill mother's welfare but instead, more importantly, to find a way of moving her out of the Progressive Care Unit as quickly as possible so that a YOUNGER PERSON could take that same PCU bed. My mom's survival, it soon became clear to me, was not their primary goal -- bureaucratuc needs and perhaps internal politics and hospital economics, not "heal the patient", had taken priority. Fortunately for my mother and me, this nurse practitioner had a deep personal sense of commitment to the welfare of her patients (especially my mom), was also brilliant in her field, and, to top it off, had "guts": when she believed in something -- such as my mom's need for care and my mom's capability to survive and recover with that proper care -- she refused to let anything (such as in-house hospital politics) or anyone (such as bureaucracy-goaled doctors) escape the power of her arguments. She fought relentlessly and fought hard -- a true champion for her patients. And fortunately, as I personally witnessed it on many occasions, she won those battles. She saved my mother's life. If not for her, my mom would have been gone in a short time. Instead, despite the myriad life-or-death onslaughts to my mom's health during that hospital-stay -- which lasted for two months -- and despite the doctors' frequent admonitions that "Your mother will never survive" or "Your mother will never survive the week" or "Your mother will never leave the hospital" -- my mother finally recovered, got her strength back, and, happily, came home. If not for that clinical practitioner nurse, my mom would never have survived. THAT, in my experience, is how important a GOOD practitioner nurse can be. -- S. J. Steinberg New York, NY, USA |
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wayne a johnston, CRNA Colorado 81301
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The fine research of Horrocks et al again demonstrates what Americans have experienced in anesthesia care for 120 years: superior quality of care from nurses. Two thirds of all anesthetics in the US are delivered by Certified Registered Nurse Anesthetists, half of all hospitals in the US rely exclusively on CRNAs, and no scientific study to date has been able to detect any difference in quality of care between anesthesia delivered by CRNAs or that delivered by anesthesiologists. How can this be? The most basic reason, from my personal experience of almost 40 years, appears to be that CRNAs bring to their anesthesia practice a strong tradition of hands-on care and close observation of the patient, while physicians in their training somehow are taught that hands- on care equates with manual labor, and they abhor that. Kudos to our British colleagues and to the BMJ. Perhaps CRNAs could help shorten your waiting lists for surgery? |
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Bill Misner Ph.D., Research Private Industry ECAPS INC.
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Today's Physician is continually over-reaching to meet a multiple time-consuming tasks that may deprive the patient of the patient-centered care demonstrated by the Nurse Practitioners in this paper. In a treatment evironment where an appropriate triage protocol is closely supervised by the physician, delegated to Nurses, Physician Assistants, and Nurse Practitioners, treatment outcome presents the highest standard of care efficiently to all the patient population. That Nurse Practioners take more time to treat and resolve each patient's complaint sends a much- needed message to clincians to delegate treatment by either standard triage or medical professional specialty. Once a treatment team is reorganized in this manner, the physician team supervisor may have a better opportunity to also devote more time to patients whose care requires the most in terms of time, testing, and treatment protocols. I have no competing interests in this subject arena. Bill Misner Ph.D. |
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Andrew P Mimnagh, Principal General Practice Eastview Surgery Waterloo Merseyside L22 4QD
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I am gratified to see such a sound overview on this topic but must point out that "Patient Satisfaction" is a notoriously unreliable assessment of standard of care provided. The Medical profession has long been aware of the importance of a bedside manner but has been driven from bedside manner by scientific observation of outcomes, and the sad fact that a generation of revered Doctors with impeccable bedside manners included several with appalling standards of objective practice, who where likely to practice poorly for extended periods because their patients where very satisfied with them and unlikely to complain.As the profession contemplates clinical governance and professional assessment as a way of improving standards should we not advise our nursing colleagues of the fallacy of assuming care is good if patients like it and bad if they do not like it? I suspect our nursing colleagues are some way behind us in this matter, the ideal is effective care delivered in a manner liked by the patients, and too many published articles on Nurse practitioners display or even attempt to display evidence of clinical outcomes.Let us not suggest "Patient satisfaction" is the prime clinical determinant, nor "outcome measures" alone justifies arrogance and brusque behaviour, but admit that the complex multifaceted assessment of our colleagues we all make asindividuals as to how we regard their standard of care provision has not yet produced an effective universally accepted validated scale with relative quantification of the merits of desirable qualities. |
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Steven B Nimmo, General Practitioner Barton Surgery, Horn Lane, Plymstock, Devon PL9 9BR
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Editor - Horrocks et al report that nurse practitioners in primary care have higher levels of patient satisfaction than doctors with no difference in short-term health outcomes (1). However their conclusions should be viewed with caution. Many of the studies included in their meta -analysis had methodological flaws. Some were subject to selection bias, had low sample size and were not double blinded. Some studies had high refusal rates and there is no information on the percentage of patients requesting to transfer to a doctor. The studies looked only at patients requesting same-day appointments for minor illnesses. These patients may differ from the general population and it is not possible to extrapolate the results to other areas of primary care (2). It is acknowledged that the nurse practitioners had longer consultations and length of consultation is a good predictor of patient satisfaction (3). General Practitioners working to tight timescales need to develop a high degree of medical efficiency. However shorter consultations with high technical medical efficiency are related to poorer communication and less patient satisfaction (4). The authors did not adjust the odds ratios for duration of consultation to demonstrate the strength of the effect. Many general practitioners find patients requesting urgent appointments for minor illnesses very frustrating and this may adversely affect patient satisfaction. The influences on GP’s attitudes to these patients are complex (5) and may include length of service and burnout. Nurse practitioners are relatively new additions to the primary care team and the influences on their attitudes may be different. Perhaps most importantly of all time and quality pressures on GPs are completely different and include other commitments such as paperwork and home visits. This is therefore a comparison between chalk and cheese. The only conclusion that can be drawn is that this subset of patients prefer longer consultations with healthcare workers with fewer time constraints. However it would be interesting to repeat the studies in ten years time when perhaps nurse practitioners may also be offering seven minute appointments, are bogged down in paperwork and have half a dozen house calls to do at the end of surgery. Steven Nimmo General Practitioner Barton Surgery, Horn Lane, Plymstock, Devon PL6 8NN Reference List (1) Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working jn primary care can provide equivalent care to doctors. BMJ 324, 819-823. 2002. Ref Type: Generic (2) Neal RD, Wickenden G, Cottrell D, Mason J, Rugiano J, Clarkson P et al. The use of primary, secondary, community and social care by families who frequently consult their general practitioner. Health Soc Care Community 2001; 9(6):375-382. (3) Campbell SM, Hann M, Hacker J, Burns C, Oliver D, Thapar A et al. Identifying predictors of high quality care in English general practice: observational study. BMJ 2001; 323(7316):784-787. (4) Goedhuys J, Rethans JJ. On the relationship between the efficiency and the quality of the consultation. A validity study. Fam Pract 2001; 18(6):592-596. (5) Morris CJ, Cantrill JA, Weiss MC. GPs' attitudes to minor ailments. Fam Pract 2001; 18(6):581-585. |
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Adrian K Midgley, GP Exeter EX1 2QS
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The most obvious conclusion to draw from this study is that if the length of consultation is 3.6 minutes longer, patients will be more satisfied. This is, oddly enough, what GPs have been saying for some time. The increase in satisfaction extends to both parties to the consultation, not just the patient so it seems a good idea. So shall we equalise satisfaction by equalising the length of consultation, while of course seeing every patient who requests it and doing so rapidly? The obstacle here seems only to be the insufficient numbers of both doctors and nurses which, again is hardly a new surprise, and the BMA and GPs have been telling successive governments and passing echelons of health service administrata for no less than a dozen years. Whether satisfaction is the end point we should be aiming for, even if is bilateral, is of course another matter. A patient who attends desiring a particular treatment will b satsified if he departs with it, whether it is an antibiotic or quack nostrum for a cough, an unecessary and poorly evidence-based operation or an exposure to radiation whcih will not rule in or out any diagnosis nor guide treatment. In a fee for service organisation, or one in which the driving force is a need to score highest in paitnet satisfaction, behaviour is distinctly different from those where either evidence-based of finance-based drivers are applied. Having enough people involved to provide useful services in reasonable working conditions is the sensible aim, and I do not think the conclusions of this paper are born out by its subject matter, nor that it advances this aim. |
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Bill Misner Ph.D., R & D Director ECAPS INC.
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Physicians are often cast into a role that imposes demands time- consuming tasks known to deprive patients of the quality of care demonstrated herein by Nurse Practitioners. In a treatment environment where an appropriate triage protocol is closely supervised by the physician, delegated to Nurses, Physician Assistants, and Nurse Practitioners, treatment outcome presents the highest standard of care efficiently to all the patient population. A brief look through the literature expansively demonstrates this suggestion: --With the increased emphasis on accountability, cost, and quality in health care, models of care delivery are being restructured. Stutts examined the planning, implementation, and evaluation of a model of care delivery for neonates based on customer, staff nurse, nurse practitioner, and attending physician perceptions of care and their suggestions for improvement. [1] --Nurse-based intervention has been observed to reduce chronic NSAID usage and costs in primary care resulting cost-effective outcome when maintained in long term fashion. This intervention package could be readily applicable to primary care. [2] --Based on the distribution of admitting diagnoses, a subset of patients was identified that could be removed from routine care by residents and could instead be cared for by non-physician providers (i.e., physician assistants and nurse practitioners) using clinical pathways. The cohort was large enough to reduce the number of patients per resident to within national accreditation guidelines, and to provide faculty with more time available for teaching. [3] The fact that increased quality of care results when Nurse Practitioners are directed to resolving patient complaints sends a wonderful message to clinicians. Treatment quality and quantity improves when standard triage methods are recruited when the physician becomes the medical team-supervisor and treatment authority is delegated to Nurse Practioners. Such a practice affords the physician a better opportunity to focus on specific patients whose quality of care may depend on more of the physician's time and personalized treatment presence. I have no competing interests in this subject area. Bill Misner Ph.D. REFERENCES [1]-Stutts A. Developing innovative care models: the use of customer satisfaction scores. J Nurs Adm. 2001 Jun;31(6):293-300. [2]-Jones AC, Coulson L, Muir K, Tolley K, Lophatananon A, Everitt L, Pringle M, Doherty M. A nurse-delivered advice intervention can reduce chronic non-steroidal anti-inflammatory drug use in general practice: a randomized controlled trial. Rheumatology (Oxford). 2002 Jan;41(1):14-21. [3]-Abrass CK, Ballweg R, Gilshannon M, Coombs JB. A process for reducing workload and enhancing residents' education at an academic medical center. Acad Med. 2001 Aug;76(8):798-805. |
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Carolyn Buppert, Attorney, Law Office of Carolyn Buppert 1419 Forest Dr., Suite 205, Annapolis, MD 21403 USA
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In the U.S., 42 of the 50 states require nurse practitioners to work "in collaboration with" physicians. And, Federal law governing reimbursement under Medicare also requires a collaborative arrangement. The UK has its own barriers to nurse practitioner practice. So, research on nurse practitioners' performance when not "working in a team supported by doctors" will not be forthcoming until laws are changed. Any recent efforts in the U.S. to change state laws have been met with vigorous opposition from the American Medical Association and state medical societies. However, because the vast majority of primary care visits (in the U.S., at any rate) are for acute minor illnesses, increased employment of nurse practitioners would seem irresistable to law and policy makers in the future. |
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Rahul Gupta, Internist & Primary care physician Florala Memorial Clinic, 718 E. 5th Avenue, Florala, AL 36442-0219, Seema Gupta, MD
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Horrocks et al (1) have concluded a few ambitious points in their review which are worth discussing further. Firstly, they mention the lack of difference in health outcomes between NPs and physicians. Most of the trials included in their review are short term trials which were inherently not designed to determine the health outcomes of chronic diseases like diabetes, asthma and hypertension which may take decades to advance. Secondly, they highlighted higher patient satisfaction by NPs. As is well known and elementary knowledge that patient satifaction, although important, is not a reliable measure of the standard of care. Thus, it certainly has no role to play in the complicated process of the ability to diagnose and provide relevent medical care. It has also been demostrated that patient satisfaction correlates strongly with patient adherence(2). Finally, more time spent with patients as well as more tests ordered by nurse practitioners proves their inability to carry out the diagnosis and subsequent care in a time limited and efficient manner. Increasing shortages in primary care delivery facing developed nations leads us to consider this fundamental question of how to provide cheaper care. This is central to the evolution of the nurse practitioner concept in the United States. We struggle to deal with issues of costs of health professional training, resource utilization, as well as the safety of health care. It is naive to consider the fact that the expert services through the several years of training from a physician can be matched by 24 months of training of a registered nurse in all aspects. Certainly, if this were true, we would have shut down physicians in the primary care world years ago and MDs would only be in speciality fields. The role of the nurse practitioner is not to be compared with or to replace the physicians but, rather, to increase the access to quality health care for many patients whose health care needs are within the limited scope of the training of the NP. Unfortunately, a few of us go far and beyond this simple goal and attempt to bring comparison when none exists. We have no competing interests. Reference: 1)Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ 2002;324:819-823 (6 April). 2)Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Pract. 1998;47:213-220. |
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Nikhil C Kaushik, Consultant Ophthalmic Surgeon North East Wales Trust Hospital, Wrexham, North Wales LL13 7TD
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This is a fascinating study indeed. People are always more satisfied by personal attention and opportunities to talk. We can all do that.In these days of evolving roles for professionals, doctors can regain lost grounds by playing as Nurse Practioners. So GPs coluld be given an additional honorary title of Nurse Practitioner. This way they will be able and indeed allowed to spend more time with their patients. This will solve all the problems of the NHS and restore happiness all around that has been eludiung us so far. |
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Richard Costello, Senior Lecturer DUBLIN 9
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I am sorry to see that the BMJ continues its descent into the banal world of "systematic reviews". These are not projects of any research value, they diminish the value of reasonable trials and add confusion. I am to conclude that there is no need to see a GP when a nurse is just as good ? |
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Joseph McEvoy, Retired nephrologist. San Clemente CA 92673
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Surely the title of this article should be ".... provide care equivalent to doctors." I presume you do not mean that the only people nurse practitioners treat are doctors. |
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Matthew Howse, Research Registrar Dept of Nephrology, Royal Liverpool University Hospital, Liverpool L7 8XP
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This article has been a very heavily 'spun' in its interpretation. Nurse practitioners spend longer with patients and order more tests with no difference in health outcome measures compared to GPs - this is portrayed positively. This could be reworded as 'nurse practitioners see fewer patients, make fewer clinical diagnoses, use more resources for no difference in health outcomes compared to GPs.' Most investigations involve at least a tiny risk and so cannot be seen as a good thing in themselves. Although patient satisfaction was higher in the patients seen by the nurses this alone is not a valid outcome. At the risk of sounding flippant handing patients £20 as they arrive would improve satisfaction but would not improve longevity. Additionally this area would be subsequent bias - GPs who are have NPs will be enthusiastic about them and pass this enthusiasm on to patients. Few NPs have been in post for 20 years or more and so the onset of disillusionment has not yet come in contrast to the GPs to whom they are compared. All doctors should be keen for all the help they can get from any source and this includes NPs. This study however does not provide us with additional information and the way it has been 'spun' will only decrease moral further. Matthew Howse |
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T. Grant Phillips, Asistant Director Washington Hospital Family Practice Residency Program
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With regards to the results of the “Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors”, certain conclusions need to be considered at more than face value. One conclusion was drawn that quality of care was equivalent, but the NP’s ordered more investigations. It would be interesting to note whether these additional investigations were beneficial or harmful to the patients or whether they merely increased expense and discomfort. Unnecessary testing can lead to other unnecessary tests and inappropriate treatments, so on, and patients might benefit or be harmed. Since this issue was not settled, the conclusion that care was equivalent is in question. |
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ian d nesbitt, consultant anaesthetist newcastle ne2
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If this study shows anything (a dubious presumption), it is that nurse practitioners are less efficient than doctors- they take a longer time and request more (expensive) investigations to obtain the same outcome. And this is despite the support of medical practitioners. The authors acknowledge that none of the studies in this paper were adequately powered to detect an effect on rare but serious outcomes, and follow up was insufficient to make any meaningful analysis of useful outcomes. Other limitations of this publication include the marked heterogeneity of results in the trials analysed (even after compensation for confounding factors), an inability to make any economic analysis, and the fact that nurses only saw patients with simple problems. As Dr Howse states, patient satisfaction is gratifying, but hardly a useful outcome measure of significant health benefit. Patients are more satisfied with private health care facilities because they get better food, a private room with TV, and so on. That doesn’t make them any healthier in real terms. When one compares apples and pears, one finds they are not the same. Hardly a surprise. I do hope that the authors intend a follow up study of patients seen by doctors under the same conditions as patients seen by nurse practitioners. Perhaps then we will see if any differences in outcomes exist. As for the comment on 5th April about nurse anaesthetists delivering higher quality care than physician anaesthetists, there is absolutely no evidence to suggest that is the case. Undoubtedly, nurse anaesthetists provide a high quality service in many parts of the world, but to state that they are better than physician anaesthetists is not only arrogant, but wrong. Yours in irritation
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Ian O'Connor, General Practitioner Oldcastle Surgery, Bridgend, Mid Glamorgan, CF31 3ED
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Can Nurse Practitioners provide equivalent care to G.P.s? EDITOR – Horrocks et al. state in their title, that the focus of their review, is the role of Nurse Practitioners in Primary care [1 ] . They concede that ambiguity exists over the definition of a Nurse Practitioner, yet go on to include studies involving nurses working in Hospital departments [2, 3, 4]. Before large sums of money are thrown at such projects, it would be wise to compare like with like. In addition, ‘Policy Implementers’ aught to consider several other points, not covered by the above review: - 1. A G.P. registrar in their final 3 months of training, has a minimum of 4 years of post-graduate work experience, yet is deemed unfit to practise, without first passing various elements of Summative Assessment. Approved video consultative technique is not a criteria needing to be passed, to be a Nurse Practitioner. 2. If Nurse Practitioners wish to be considered as independent Practitioners, then they need to have their own comprehensive indemnity, so that litigation stops with them, rather than their employing practice. 3. During employment of a Nurse Practitioner on a 3-month trial basis, we asked our Trainer to ‘Hot’ review each of the Nurse Practitioner’s surgeries, as he would a G.P. registrar. The trainer felt that there was little insight into why specific questions/investigations/drugs were used. The basic understanding of the pathology and pharmacology, lagged far behind the automated efficiency of following guidelines. Whilst there certainly seems to be an evolving role for Nurse Practitioners, it is important that future studies clearly document the context in which patients are seen, and that there is some form of assessment of Nurse Practitioner consultation technique, similar to that seen in General Practice. Ian O’Connor, General Practitioner, Oldcastle Surgery, South St.,
Bridgend, South Wales, CF31 3ED. T
References: 1. Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ 2002; 324: 819-823. 2. Hoekelman RA. What constitutes adequate well-baby care? Pediatrics 1975; 55: 313-326. 3. Saker M, Angus J, Perrin J, Nixon C, Nicholl J, Wardrope J. Care of minor injuries by emergency nurse practitioners or junior doctors: a randomised controlled trial. Lancet 1999; 354: 1321-1326. 4. Cooper M. An evaluation of the safety and effectiveness of the emergency nurse practitioner in the treatment of patients with minor injuries: a pilot study. Glasgow: Accident and Emergency, Glasgow Royal Infirmary, 2001.( Typescript.) |
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Yvette Marie Petti, Certified Adult Nurse Practitioner 49017
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As a certified adult NP for over 10 years and as an Rn for nearly fifteen years, I enjoyed reading your article. I would like to challenge the nursing and the medical communities to stop "re-inventing the wheel" on this issues. Literature dating from the early seventies documents not only the safety and efficacey of care delivered by nurse practitioners, but it also addressed the level of satisfaction within the profession and from patients as to the care received by nurse practitioners. Can we move onto more qualitative research in the area of clinical intervention and standardization of medical/advanced practice guidelines among medical schools and nursing schools. This will take us farther than re-validating what we as a society already know from research based evidence? Thank you.
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Stephen F Wilson, Rehabilitation Physician Macarthur Health Service
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Horrocks , et al (1) have demonstrated that nurses may competently complement the work of general practitioners. However the primary health care team includes many more disciplines than doctors and nurses, such as patients consulting pharmacists for over the counter influenza remedies and physiotherapists for the diagnosis and assessment of sports and musculoskeletal injury. Also the primary health input of an occupational therapist may be the most useful intervention to prevent falls in the older patient. There is no doubt that nurses are significant care providers although I disagree with the paper’s summary which suggests that nurses should be relegated to “same day appointments for minor illness”. It is more likely that nurses should be dealing with the chronic and complex care needs of a patient with an established diagnosis where management and treatment are more important to quality of life than attendance by a GP or equivalent. The encouragement to general practitioners in Australia to develop multidisciplinary management plans for patients with chronic and complex conditions through a Commonwealth funded enhanced primary care program has placed GPs at the head of this team. Individual primary health care providers working as a multidisciplinary team have the opportunity to achieve efficiency and improved health outcomes through synergistic rather than competitive practice. References: 1.Horrocks S, Anderson E, Salisbury C, Systematic review of whether nurse practitioners working in Primary care can provide equivalent care to doctors. BMJ 2002; 819-23 |
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Thomas F. Heston, Family Physician in private practice Kellogg, Idaho, USA 83837
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The authors propose that less education is good. Nurse practitioners receive less medical education than do physicians. This fact is undisputed. Sure, with longer consultation times and same day appointments, nurse practitioners can have satisfaction rates similar to less time with a physician on a day that is less convenient. Is this really the direction we want to take medical education? |
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david o. mabe Uwharrie Medical Center, 167 Macarthur St. Asheboro, NC 27203
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What a simplistic conclusion by Dr. Nikhil Kaushik that G.P.'s need only spend more of their valuable time with patients to enhance patient satisfaction and wear the honorary badge of Nurse Practitioner. In the same manner,if Nurse Practitioners choose to pattern todays medical model and "loose ground" by playing as doctors they may be given the honorary title of General Practitioner. |
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Peter W Bibawy, GP Registrar Ryde-Isle of Wight Po30 5GB
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The evidence is clear that NP have a great and important role to play in reviving our National Health Service BUT it has to all come with a change. We need to change the way nurses think,to allow them to take more responsibility and to make more decisions.This has to be done in Nursing School not in post-graduate training for NP's . If the NHS was going to rely on NP's then they must take responsibility for decisions specially in Primary Care. I don't want to be fully responsible for my NP's decisions and management if things go wrong. I am convinced the need for ongoing support but at the end of the day ,Who will make decisions? We all stand by our clinical decisions and responsibilities and the NP should do the same. Only then, will they be an effective Doctor-like Health Proffesional that will bring the NHS forward . |
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William Rifkin M.D., Department of Medicine Maimonides Medical Center, Brooklyn NY 11219, Arthur Rifkin M.D and John Horiszny M.D.
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We wish to comment upon the systematic review of the equivalence of nurse practitioner and physicians by Horrocks and colleagues. (1) The authors report higher levels of patient satisfaction for patients of NP’s. While important, it is unclear if patient satisfaction is a valid measure of the quality of practice. Moreover, of the five trials presented regarding patient satisfaction (2-6), three ask prospective patients if it was acceptable with them to see a nurse practitioner rather than a physician. (2-4) Therefore, only those patients predisposed to be accepting of NP’s were included in the studies. The authors also report that NP’s undertook more investigations and had longer consultations. The absolute difference of less than four minutes in consultation time is of questionable clinical importance and may reflect the practice setting enjoyed by the NP’s. It is unclear if the finding that NP’s ordered more tests per patient is a marker of better or worse practice, and may inflate costs. We believe that the authors’ assertions about the quality of care are not supported by the data they present. The authors state that NP’s identified physical abnormalities more often than physicians did, without qualifying that the cited data are from 1975 and only refer to well-baby exams. (7) The observations that NP’s made more complete records, communicated better and were as proficient in the ordering and interpretation of x-ray films are based only upon patients with minor injuries seen in an emergency room. (8,9) It may not be reasonable to make the leap that such conclusions would hold true in adults, more currently, outside the ER or in more seriously ill patients. With these limitations in mind, we question the author’s ability to conclude that “NP’s can provide care that leads to increased satisfaction and similar health outcomes.” Even more dubious is the conclusion that NP’s provided care of equivalent or superior quality when compared to physicians. We do agree with the authors that the ability of NP’s to identify “rare but important health problems” needs further research. Although the authors cite some of the weakness of their data, they propose that their review supports an increased involvement of NP’s in primary care. We feel that this conclusion is out of proportion to the presented data, and that patients and policy-makers would be better served by using this review as no more than a springboard to more methodologically sound investigations. William Rifkin M.D.
Arthur Rifkin M.D.
John Horiszny M.D.
1. Horrocks S, Anderson E, Salisbury, C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ 2002; 324: 819-23. 2. Venning P, Durie A, Roland M, Roberts C, Leese B. Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care. BMJ 2000; 320: 1048-53. 3. Shum C, Humphreys A, Wheeler D, Cochrane MA, Skoda S, Clement S. Nurse management of patients with minor illnesses in general practice: multicentre, randomised controlled trial. BMJ 2000; 320: 1038-43. 4. Kinnersley P, Anderson E, Parry K, Clement J, Archard L, Turton P. Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting “same day” consultations in primary care. BMJ 2000; 320: 1043-8. 5. Mundinger MO, Kane RL, Lenz ER, Totten A, Tsai W-Y, Cleary PD. Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial. JAMA 2000; 283: 59-68. 6. Winter C. Quality health care: patient assessment. MSc thesis. Long Beach CA: California State University, 1981. 7. Hoekelman RA. What constitutes adequate well-baby care? Pediatrics 1975; 55: 313-26. 8. Sakr M, Angus J, Perrin J, Nixon C, Nicholl J, Wardrope J. Care of minor injuries by emergency nurse practitioners or junior doctors: a randomised controlled trial. Lancet 1999; 354: 1321-6. 9. Cooper M. An evaluation of the safety and effectiveness of the emergency nurse practitioner in the treatment of patients with minor injuries: a pilot study. Glasgow: Accident and Emergency, Glasgow Royal Infirmary, 2001. (Typescript) |
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Jeanne L. Scotland, Acute Care NP student Foothills Medical Center
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Thank you for this review of literature. However, I would like to make two points. First is the understanding that the authors wanted to determine if the nurse practitioner could be used to substitute a physician. This concept of replacing the physician may be viewed as threatening and accentuate territoriality between the nurse practitioner and the physician. It cannot be argued that NP's carry out some technical functions that have been traditionally performed by medical colleagues. However, the role of the NP extends beyond these technical functions and simply providing a source of medical coverage. In working as collaborative team members, each discipline contributes its expertise toward optimum patient care decisions. As an advanced practice nurse, the NP contributes not only the advanced skills, but a broad foundation of nursing theory, practice, education, research and administrative duties (Hunsberger et al, 1992). Considerable overlap exists between the NP and physician in knowledge and skills but neither profession can replace the depth and breadth of the others knowledge. It is only if a team philosophy prevails that a complimentary approach to care can be realized. And secondly is the use of the outcome measure of patient satisfaction to assess the standard of care provided. Many physicians who responded to the review in the electronic journal, cautioned that patient satisfaction is an unreliable assessment of the standard of care provided, and that it has no role to play in the ability to diagnose and provide relevant medical care (Horracks et al, 2002). Some of the physician respondents go on to conclude that if they had more time with the patient, that they too could increase patient satisfaction, while others suggested that just because a patient is satisfied does not make them any healthier in real terms. The debate between the relationship between patient satisfaction and standard of care provided is perhaps the greatest difference in the paradigm thinking between nursing and medicine. Comments such as these from medical colleagues suggest that medicine tends to align with the scientific paradigm of modernity. The scientific paradigm is characterised by a parallel dualism between matter as a subject of science and nonmatter as the domain of religion, and that this split helped medicine make technological advances by utlilizing scientific reason (Engebretson, 1997). Advanced practice nurses, on the other hand, are moving toward a holistic approach to nursing. "Holistic theories are global, espouse a transcendental view of humans, and are committed to not viewing subject matter as an accumulation of parts"(Engebretson, 1997,p.22). An advance practice nurse incorporates the scientific paradigm knowledge within practice, but recognizes the limitation for explaining the human experience and the power it may hold in bringing about health or healing. Engebretson (1997) proposed a multiparadigm approach for advanced nurse practitioners that incorporated the scientific approach, within a holistic framework. The extra time the NP's in the review studies spent in consultation with patients may have been necessary to gain deeper understanding into of the person as a whole. It is thus erroneous to conclude that the NP's were merely inexperienced at collecting information compared to physicians. Patient satisfaction outcome, is therefore not frivolous but potentially pivotal to outcome measures for those practising within the nursing paradigm. And yes we are responsible for our own practice and accountible for actions. Thank you Engebretson, J. (1997). A multiparadigm approach to nursing. Advances in Nursing Science, 20(1), 21-33. Hunsberger, M, Mitchell, A., Blatz, S., Paes, B., Pinelli, J., Southwell, D., French, S., & Soluk, R. (1992). Definition of an advanced nursing practice role in the NICU: the clinical nurse specialist/nurse practitioner. Clinical Nurse Specialist, 6(2), 91-96. |
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Andreas K Demetriades, Senior House Officer University College London Hospitals Trust, WC1N 6AU
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The systematic review by Horrocks et al (1) comparing the level of care between nurse practitioners and doctors was very interesting and the authors should be congratulated for their well designed study. Results are debatably unsurprising; patients were more satisfied after consultations with nursing practitioners were longer and resulted in more investigations. Spending more time and doing more has a psychological effect on the patient. The outcomes, however, were not improved compared to the shorter and less investigation oriented consultations by doctors. This may suggest a less focused approach by the nursing practitioners, and also addresses the issue of experience, but this was difficult to standardise for. The limitations of the study are probably more interesting than the results at this stage and should be considered in future efforts. The studies included in the review were considerably heterogeneous with respect to the autonomy of the nurses involved. The background support network provided by physicians was not specified. Whether individual or team approach was employed was unclear (surely whatever the conclusions the former should be the main aim). Patients in the NHS have long complained of lack of time during consultations. Had the studies standardised for time differences, which are an integral and most inevitable part of every NHS doctor's pressure factor, would satisfaction levels still be higher in the nursing practitioner group? One wonders if the severe limitations of the study allow at all any robust conclusions. That longer consultations make happier patients is no surprise and was probably the most important factor that should have been accounted for. A similar result would probably have emerged if one had compared, without the limitations of time, final year medical students vs consultants ! Until strong studies are performed with standardisation of the time pressure factor, of the patient populations and of the target outcomes, any conclusions are weak. This should perhaps have been the main conclusion of the systematic review. As the authors suggest, further research is needed to evaluate the safety of any weak or premature findings in this potentially great initiative. A. K. Demetriades UCL Hospitals NHS Trust andreas.demetriades@doctors.org.uk 1. Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. Br Med J 2002, 324;819-823 (April 6). |
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Linda D. Johnson, RN, BSN in U.S.A. Managed Care Organization
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1. Is there a way to determine the "amount" of experience that the nurse practitioners in the studies have received? In the conclusion of "ordering 20% more tests than the physicians did" an inexperienced or new grad may be more likely to engage in this behavior than a more seasoned NP. 2. Are the clinical settings urban or rural? Thank you. |
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Helen Santry, Nurse Practitioner Clevedon Medical Centre , Old Street, Clevedon, BS21 6DG
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Editor As one of the nurse practitioners who took part in the research of Horrocks et al , I read with interest the letters on your page July 20th. In answer to some of the comments made by Dr Ian O'Connor ( letters 20th July), Yes registrars have a minimum of 4 years post graduate work, however I had 25 years wide ranging experience before undertaking the Nurse practitioner degree. I was mentored for 2 years whilst studying and took a further year to complete and publish a 15,000 word researched dissertation. I went on to join my current practice, where for the first year I was allocated to a GP trainer and followed more or less the registrars training year. 3 years on I have undertaken post graduate education in diabetes ( my original speciality) and have recently completed the extended nurse prescribing programme . I do have my own comprehensive indemnity and have, as Ian suggests, had my surgeries videoed and consultation technique checked. I do not however claim to be a GP and suggest to Ian that more support for his Nurse Practitioner may have been the key. In reply to W Rifkin et al ( letters 20th July) , Yes I do order more tests, If a patient has an URTI, I do not simply give advice and send away , but have time to take a more holistic view. If 'over forty & fat' 'fasting glucose' ( 12 new diabetics diagnosed in past 6 weeks). In the past four years a variety of other major problems from a 4 year old with diabetes to a 40 year old with cardio myopathy ( I undertake my own referrals). Do I provide care equivalent to a GP ? , Firstly I'm not and have no intention of becoming a GP, I am however a highly qualified and experienced nurse, who considers the 'whole patient' , works within a team of excellent GP's and other health professionals, who value my skills. Secondly I agree it is difficult to asses the abilities of Nurse Practitioners, as it is also difficult to asses the abilities of all GP's ( How many have videoed their surgeries?). As Gupta et al ( letters 20th July) state 'Nurse practitioners are not meant to be compared with or replace doctors' but be a complementary part of a whole team approach. Yours sincerely Helen Santry BSc Nurse Practitioner Clevedon Medical Centre, Old street. Clevedon, BS21 6DG |
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Phylls du Mont, Assistant Professor University of Tennessee, Knoxville, TN, 37931
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Among ourselves, most of us will complain about aspects of our education which seem completely irrelevant to our daily clinical practice. Yet those physicians who disapprove of physician extenders point to the length of their own training as if it had all been focused, clinically important content that they use everyday in the provision of safe patient care. And regarding the presumptive benefit of advanced training in basic sciences: any physician who has been in practice for more than 10 years or so should examine a recent HIGH SCHOOL advanced biology text if they care to be made humble about the extent of their expertise in current, basic biology. The competencies needed for effective primary care can be taught and acquired via many different pathways. In fact, one might question whether some American medical schools any longer teach some of these skills. Physician colleagues complain that many young physicans lack bedside diagnostic skills (research confirms this). It is the competencies that we should debate, not the pathways one takes to acquire them. A serious debate about the scope and definition of those competencies and about effective teaching strategies could benefit future patients. Also needed is research into best practice models for collaborative care using multidisciplinary teams. Competing interests: In so far as I teach nurse practitioners, I could be said to have a competing interest. |
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Helen Gray, Gynaecology Oncology Nurse Coordinator Flinders Medical Centre,Adelaide.Australia
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I am a Registered Nurse with over 30 years experience,having commenced in the 'old' hospital training days. Throughout those years I have seen/experienced positives/negatives from all areas of the health arena. This includes medical staff,nurses and allied health professionals. There are always going to be cases of'good'and 'bad' nurse practitioners and 'good/bad'medical practitioners. There are always going to be research papers that argue either way for the Nurse Practitioners or Medical staff. I have been concerned for the future as many nurses are retiring and there are many patients who will not receive quality care due to workforce shortages. My area is Oncology and I'm studying my Nurse Practitioner course because of the shortage of Oncologists and Oncology nurses within this area. I truly believe that as health professionals who are concerned about adequate (let alone quality) patient care we need to work together now. Yes, we can all argue the pros and cons of this paper. However,the fundamentals are -; 1/To put aside professional pettiness/bickering and try to establish a functional,knowledgeable workforce for the future.Lets embrace skill mix and encourage health professionals to address the gaps,gain increased knowledge (through recognised institutions)practice safely, and the patients hopefully will receive the benefits. 2/For health professionals to share their knowledge and expertise for 'the greater good" 3/. All of us to be aware that the health systems are under financial duress and we will all need to work 'smarter' and identify waste (that has been evident in our systems for years) 4/.Utilise and promote those nurses who have advanced skills and expertise.We can hopefully provide superior care when working together with a common purpose. This will also help to give those nurses an improved career path and use all of those years of experience for the good of the patients. We all need to work together to provide a better health system as the future is going to be very challenging !! 'The eternal optimist' Helen Gray RN Competing interests: I am a Nurse Practitioner student in Australia. My only interest is to improve our waning health system |
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Cherryl A Tahvanainen, Peri operative CN 6112
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My questions; if nurse practitioners request more tests, does this mean that the nurse practitioner is more costly than the doctor? Does the increase in tests promote more accurate diagnosis? thank you Competing interests: None declared |
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