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Nurse Practitioners: A (Not So) New Role in Health Care

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Nurse Practitioners: A (Not So) New Role in Health Care Kathleen Dracup, RN, FNP, DNSc Dean and Professor School of Nursing University of California, San Francisco – PowerPoint PPT presentation

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Title: Nurse Practitioners: A (Not So) New Role in Health Care


1
Nurse Practitioners A (Not So) New Role in
Health Care
  • Kathleen Dracup, RN, FNP, DNSc Dean and
    Professor School of Nursing University of
    California, San Francisco

2
Who are Advanced Practice Nurses?
  • Masters prepared Registered Nurses
  • Nurse practitioners (NP)
  • Clinical nurse specialists (CNS)
  • Combined (NP/CNS)
  • Certified Nurse Midwives (CNM)
  • Certified Nurse Anesthetists (CNA)

3
RNs prepared for APN
DHHS, March 2000
4
History of the Nurse Practitioner
  • Social phenomena of the 1960s provided impetus
    for NP movement
  • Shortages of pediatricians and family practice
    MDs
  • Lack of primary health care for rural areas and
    urban poor
  • Escalating health care costs
  • RNs desire to attain autonomy
  • 1st NP program 1965 _at_ U of CO as a research
    program

5
1971
  • HEW proposed definition of primary care
  • A persons first contact in any given episode of
    illness with the health care system that leads to
    a decision of what must be done to help resolve
    the problem
  • Responsibility for the continuum of care
    (maintenance, evaluation, management)
  • MDs RNs should share responsibility for primary
    care

6
NPs today
  • NPs practice independently (i.e., without MD
    supervision or collaboration) in the majority of
    states
  • In all states, NPs have independent prescribing
    authority
  • Reimbursement for primary care services
  • Medicaid/MediCal/MediCare Part B
  • Commercial insurance
  • Hospital admitting privileges

7
Numbers
  • 103,000 NPs in U.S.
  • 9,500 NPs in California
  • Graduates of UCSF NP programs from 1989-1999
    1,000

8
Is a PA like an NP?
  • PA
  • Physician extender
  • Must practice under supervision and license of MD
  • MD is liable for acts of PA under their direction
  • NP
  • Complements MD
  • Functions under own license
  • Education is more extensive
  • Scope of practice is broader

9
Viva la difference!?
Training Licensing Medical vs. Nursing
Model Scope of practice
10
Training
  • M.D.
  • B.S. (pre-med)
  • Medical School (4 yrs)
  • Internship (1yr)
  • Residency (varies)
  • Nurse Practitioner
  • B.S. (Nursing/RN)
  • Masters Degree (2-3 yrs)
  • didactic/clinical (internship)
  • other specialty training (varies)

11
Licensing
  • APN
  • nursing Board exam
  • NP exam/certification
  • MD
  • medical Board exam
  • specialty exams

12
Model of Care
  • RN
  • nursing model
  • caring
  • MD
  • medical model
  • curing

13
Scope of Practice
  • NP Nurse Practice Act
  • Primary health promotion
  • Disease prevention
  • Assessment/diagnosis and management of common
    illness and chronic stable conditions
  • Use of standardized procedures
  • Expanded roles for specialty care

14
NPs
  • NPs may order, conduct, and interpret
    appropriate diagnostic and laboratory tests and
    prescribe pharmacologic agents, treatments, and
    non-pharmacologic therapies. Educating and
    counseling individuals and their families
    regarding healthy lifestyle behaviors are key
    components of NP care

Porcher, F. K. (1996). Advanced practice nursing
(179- 187)
15
Patient education and counseling
Moody et al, NP, 1999, 24(3)94-103
16
Comparison of top five NP MD principal diagnoses
  • MD
  • Hypertension
  • Normal pregnancy
  • Acute upper respiratory infection
  • Otitis media
  • Health exam
  • NP
  • Health exam
  • Hypertension
  • Routine child health
  • Otitis media
  • Acute upper respiratory infection

Moody et al, NP, 1999, 24(3)94-103
17
Common diagnostic or screening tests
Moody et al, NP, 1999, 24(3)94-103
18
What counts Patient outcomes
  • NPs can effectively treat 90 of all pediatric
    patients and 80 of all adult patients. Outcomes
    are equal to or better than care by physicians.
  • (Office of Technology Assessment, 1987)

19
What counts Patient outcomes
  • NYC ?2000 patients randomized to MD or NP serving
    as primary care provider
  • Little or no difference in health status, disease
    specific physiologic measures, patient
    satisfaction, resource utilization (Mundinger et
    al, JAMA, 2000)

20
More outcomes
  • Meta-analysis of 38 studies comparing NP/CNM and
    MD (Brown Grimes, ANA, 1993)
  • Number and cost of drugs similar between MD and
    APN
  • More lab tests ordered by APN but cost 8 less
  • Patient knowledge similar
  • APNs received higher scores on
  • Resolution of pathologic conditions
  • Patient satisfaction
  • Functional status
  • Patient compliance
  • Average number of visits similar but fewer
    hospitalizations for patients seen by APNs

21
Cost/Benefit
  • Reduced educational opportunities for residents
  • Reduced interaction of physician with
    patient/family
  • Reduced hospital length of stay
  • Fewer complications
  • Improved patient satisfaction
  • Less litigation

22
Patients and their healthcare provider
23
Patients Active Involvement in Care (n 27
patients with heart failure)
  • At the most recent physician visit,
  • 5 asked doctor about other medications they could
    take for heart failure
  • 3 brought written information to the visit
  • 2 wrote questions on paper and took to the visit

How Active Would You Like to be in Making
Decisions with Your Doctor about Your Health Care
How Active Are You In Making Decisions with Your
Doctor about Your Health Care
Bennett, PUMP-UP
24
Patients and their healthcare provider
  • More patient control
  • More emotional display by both MD and patient
  • More effective information gathering by patients
  • More conversation by patients relative to the MD
  • better health status (functional subjective)
    at follow-up

Kaplan, Greenfield, Ware. Med Care 1989
25
Make the most of your visit
  • Be prepared!
  • Bring list of medications, treatments, concerns,
    questions know your family history
  • Dont be afraid to talk. The more you ask, the
    better your health.
  • If you are nervous, say so.
  • Dont feel rushed. If you have a question, ASK
    IT. If you dont understand something, ASK.
  • Participate in decisions, especially major ones.
    Negotiate decisions if need be.
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