Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7341.819 (Published 06 April 2002) Cite this as: BMJ 2002;324:819
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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.
Competing interests: No competing interests
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
Competing interests: No competing interests
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.
Competing interests: No competing interests
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).
Competing interests: No competing interests
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.
Competing interests: No competing interests
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.
Maimonides Medical Center,
Brooklyn, NY USA
Arthur Rifkin M.D.
Long Island Jewish Medical Center-Hillside Hospital ,
Glen Oaks, NY USA
John Horiszny M.D.
Red Hook, NY USA
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)
Competing interests: No competing interests
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 .
Competing interests: No competing interests
Re:Can NPs really replace the primary care physician?
I am a student NP and agree that NPs cannot replace GPs. But collaborative care can be fruitful in the healthcare system and reduce costs, but not cheaper care. Eventhough NPs have no comprehensive knowledge of pharmacology like MDs, they can surely prescribe appropriate medications for their patients with their knowledge. They are not dummies in preventive medicine. Basically, nurses work with critical thinking.
Next, we all should stop arguing and doing research among GPs and NPs. There are many more research needed in how to provide comprehensive healthcare and to improve our healthcare system in rural communities.
Competing interests: None declared
Competing interests: No competing interests