Nurse practitioners fight for more independence, doctors resist

One of the solutions consistently offered to the problems of increasing healthcare costs and the shortage of primary care physicians is allowing advance practice registered nurses (APRNs), such as nurse practitioners, to practice independently. States considering such legislation are finding it's a hotly debated issue that often pits APRNs against physicians.

At the end of 2011, the American Academy of Family Physicians (AAFP) proclaimed the success of its Texas chapter in thwarting an attempt by that state's nurse practitioners (NPs) to push through legislation allowing NPs to practice independently.

In a story posted on its website in December, AAFP described how TAFP waged a strategic opposition campaign stressing the message that while it understands the important role of NPs, NPs just don't have enough medical training to practice and prescribe independently.

"Even in an era of financial constraint, healthcare policy and legislation should not pretend that high quality patient care will result from substituting one less-trained healthcare professional for another in the name of saving money," said Glen Stream, MD, president of AAFP. "To do so is a disservice to patients and establishes a two-tiered healthcare system that limits patients' access to comprehensive, whole-person medical care they need and pay for."

Family physicians complete seven to 20 times more clinical training than do nurse practitioners, Stream said, and the training of NPs doesn't cover diagnosis and treatment of complex patients with multiple health problems. Given that, he said, "AAFP doesn't support policies that put patient care solely in the hands of nurse practitioners."

Nurse practitioners will be the first ones to say that they are not doctors nor are they doctor replacements, however, they say, they offer high-quality care and high patient satisfaction at lower costs.

"NPs are nurses first and foremost," said Deonne Benedict, a nurse practitioner who owns Charis Family Clinic in Edmonds, Wash., one of a handful of states that allow NPs to practice and prescribe independently.

"Physicians seem to be making the same arguments they made historically against osteopaths, optometrists, chiropractors and others," said Benedict. "The fact is that we have a strong body of evidence with hundreds of studies showing that NPs provide excellent care, with high patient satisfaction and quality care outcomes.

We are educated differently, from a nursing perspective, but we are highly educated." And like their physician colleagues, Benedict noted, NPs know when it's appropriate to refer.

"What are the issues around allowing APNs to practice independently?" said Janet Selway, DNSc, ANP-BC, director of the adult gerontology nurse practitioner program and assistant professor at the Catholic University of America's nursing school. "Two words: fear and misunderstanding.

"Some of our colleagues in medicine fear that NPs are trying to be physician replacements. Rather, we highly value our nursing background and believe that our unique nursing perspective benefits the patient.

Both disciplines should focus on the patient and avoid getting bogged down in fighting over an outdated captain of the ship view."

While the medical training argument won out in Texas last year, physician groups like the AAFP may find themselves fighting an uphill battle that ultimately comes down to money. As state governments continue to feel the pressure to rein in healthcare costs, the argument that NPs can offer high quality care at lower costs is bound to get attention.

Also adding weight to the arguments of NPs is a report issued in the fall of 2010 by the widely-regarded Institute of Medicine. In "The Future of Nursing: Leading Change, Advancing Health" the IOM recommends eliminating scope of practice barriers and the expansion of the Medicare program to include coverage of advanced practice nursing services.

TAFP noted that Texas' NPs didn't use the IOM report in its 2011 legislative fight but the organization expects it will be used in the next round of the fight – 2013's legislative session.