More than a dozen states have passed legislation expanding the role of nurse practitioners (NPs) so they can help fill the shortage of primary care providers in the U.S. But a new study from Columbia University School of Nursing, published in the Journal of Professional Nursing, suggests that the organization and culture in health care settings often impedes the full utilization of NPs so that state laws expanding scope of practice may not be sufficient to relieve the nation's primary care crisis.
A research team, led by Columbia Nursing Assistant Professor Lusine Poghosyan, PhD, RN, investigated how the workplace environment in primary care settings affects NPs' ability to deliver quality care and practice independently. The study was conducted in Massachusetts, where state health reform increased demand for primary care and subsequent legislation recognized NPs as primary care providers. The results suggest that gains made legislative reform can be neutralized by the formal and informal practices in place at health care organizations. For example, the study cited instances where NPs were not allowed to see new patients or even conduct physical assessments.
"Organizational policies can often trump governmental policies, keeping the contribution of the nurse practitioner unrecognized and preventing them from making the fullest contribution possible to effective patient care," says Poghosyan.
The study also investigated the level of support and resources available to NPs, who reported that they were often denied the same level of personnel support and operational resources provided to physicians, including medical assistants and administrative staff, as well as sufficient exam room space. NPs interviewed for the study also said that their role was poorly understood by senior leadership, contributing to a sense of deprecation, isolation and poor NP-administration relations.
This lack of understanding of the NP role also emerged as a contributing factor to what the study terms NP "invisibility." Study results consistently found that administrative personnel lacked an awareness of the NP role and competences, further aggravating the fragmented communication between NPs and administrative staff, and keeping NPs out of the decision-making processes within the primary care practice.
Billing and data collection systems are a key factor in NP invisibility, the study found. Massachusetts law requires third party payers to recognize NPs as primary care providers. However, the study cited examples where data used to capture productivity and quality of care measurements often masked the contribution of NPs because physicians were listed as the provider of record. Most health organizations list physicians as the provider of record because Medicare pays about 15% less for services that are billed by an NP, Poghosyan says.
Listing NPs under the physician name on the patient record makes it harder for NPs to get timely access to patient information and impedes their ability to develop a care plan and track quality measures. In addition, the report points out attributing NP care to physicians can lead to missed opportunities for measuring the benefits of care delivered by multidisciplinary teams, a strategy envisioned under health reform as a tool for improving quality and cutting costs.
The implications of the study make clear that enacting expanded scope-of-practice legislation for nurse practitioners is necessary, but not sufficient, for an effective solution for strengthening the delivery of primary care.
"Legislation is a needed to create the legal framework for nurse practitioners to practice as independent primary care providers. It's a good first step," says Poghosyan. "Health care organizations now need to be proactive in creating policies and practices conducive to NP practice."
Administrators should clearly define ways for NPs to be included on the decision-making committees that govern the daily operations of the health care setting workplace, the study recommends. To achieve better outcomes and reduce cost, health care practice sites should provide adequate access to resources to assure efficient use of NP time and skills. Also, to encourage NP visibility as care providers and promote their professional practice, organizational and policy structures should be created to demonstrate the contributions of NPs to patient care and promote continuous contact with patients.
Time may help improve the experiences of NPs in primary care, the study suggests. Most NPs reported that the longer they worked with the physicians, the more the doctors trusted them and gave them the autonomy to practice independently. Administrators who had past experience working with NPs had better knowledge about NP role and competencies.
If familiarity encourages the professional recognition of NPs, says Poghosyan, "meaningful changes in workforce climate should be put in place quickly to fully leverage the NP role in meeting the demand for effective care emerging from the revitalization of the primary care system."
Columbia University School of Nursing