COMMON CONCERN

Geriatric Nurse Practitioners:How Are They Doing?

Employers see markedlyimproved patient care,and GNPs reporthigh job satisfaction.

THERESA ROGERSLOYA METZGERLAURIE BAUMAN

From 1977 to 1982, The New YorkHospital-Cornell Medical CenterSchool of Continuing Education forNurses offered a one-year certifi­cate program to prepare practicingregistered nurses for the role of ger­iatric nurse practitioner (GNP) .The goal was to extend the scope ofnursing practice by preparingnurses to function in complementa­ry roles with physicians and othersin delivering primary health careservices to the aged.

The program provided an 18­week semester of theory and clini­cal practice-five full days a weekin the classroom or on clinical as­signments-followed by a seven­and-one-half month supervisedwork experience (internship) in aparticipating health care facility oragency.

The internship included a returnday every two weeks to the medical

Theresa Rogers, PhD, is senior research as­sociate a nd adjunct associate professor ofsociology and Loya Metzger, PhD, is re­search associate, Columbia University,New York, NY. Laurie Bauman. PhD. isresearch associate, Memorial Sloan-Ketter­ing Cancer Center, New York. NY.

The program they describe was supportedby Gr ant Number 2 D24 NU 00047.Health a nd Services Administrat ion, Dept .of Health and Human Services.

center for seminars, case confer­ences, and individualized instruc­tion. Faculty made on-site visits tohelp students and their supervisorsachieve the internship objectives.

Six classes of students were en­rolled and 72 nurses-3 men and69 women-eompleted the pro­gram. Their average age was 40,and they ranged in age from theearly twenties to the mid-fifties. Atotal of 39 held a bachelor's or mas­ter's degree in nursing; 16, an asso­ciate arts degree; and the remain­ing 17, a diploma from a hospitalschool of nursing.

This article highlights the em­ployment experiences of the grad­uates of the program, using datafrom mail questionnaires and inter­views with each person before andafter training. The first question­naire was sent to the 59 members ofthe first five classes six months af­ter graduation; 55 completed thequestionnaire. In April 1982, a fol­lOW-Up questionnaire was mailed tothese same nurses (two could not belocated) in order to obtain up-to­date information about present po­sition, sources of job satisfaction,and salary. Members of the sixthclass were not included becausethey had not completed the intern­ship at the time the questionnaireswere mailed.

To evaluate the performance andimpact of graduates on the healthcare facilities where they were em­ployed, a questionnaire was alsomailed to (or telephone interviewconducted with) the person we willcall their employer. This term isused loosely. This person was

usually the collaborating physician,but practitioners at visiting 'nurseservices were assessed by the nurs­ing supervisor or the agency direc­tor, whoever was more familiarwith the practitioner's work. Thesedata were collected after each prac­titioner had been employed aboutsix months; employer assessmentswere obtained for 47 of the 59 ger­iatric nurse practitioners.

Job Satisfaction

Most of the practitioners are em­ployed in one of four types of healthcare facilities : ambulatory careclinics; long-term care facilities;hospital inpatient services; and vis­iting nurse services. Two are in pri­vate practice with physicians andtwo are faculty members of schoolsof nursing. In all of the settings,practitioners are working primarilywith patients over 65 years old.

GNPs report many sources of jobsatisfaction, as listed in the table,but providing care for geriatric pa­tients is the most important, fol­lowed by their relationships withcolleagues-other nurses, physi­cians, and nursing supervisors. Amajority of them are pleased withvarious aspects of their jobs sixmonths after graduation, but howsatisfied are they after a longertime? The answer is that although43 percent of graduates are "ex­tremely" or "very" satisfied withtheir jobs six months after certifi­cation, three-quarters say they arethat satisfied after one to four yearsin the practitioner role.

It is understandable that this newposition is difficult at first. Practi-

Differing perspectives on a problem that nurses share with other caregivers.

Geriatric Nursing Janu ary/February 198451

COMMON CONCERN

tioners must demonstrate theirnewly acquired skills and at thesame time gain the acceptance andrespect of physicians, nurses, ad­ministrators, and patients. Perhapsmost d ifficult of all , beginningpractitioners lack confidence. With

Satisfaction of GNPswith Their Job'

. Aspects of Percentthe Job satisfied

Type of patient 96served

Relationship with 82non-GNP nurses

Relationship with 75physician(s)

Phys ical demands 75Relationship with 69nursing supervisor

Variety of 68activit ies

Amount of war\( 64required

Emot ional demands 62Availability of 59facilities andbackup necessaryto provide goodpatient care

Pay and benefits 56

Administrative 55climate

Geographic location 50

Proportion of time spent 42on nonprofessional tasks

• The number of respondents ranges from42 to 52 for individual items_ Some itemsdid not apply in every woO< selting and afew GNPs did not answer every item.

Six months alter certili<:ation. <43 percent ofGNPs were "very" or "axtremely" satisfiedwith the ir jobs; 75 percent were that sat is-lied alter one to four years' work with olderpatients.

experience, they overcome theseinitial fears and begin to truly en­joy their new responsibilities.

When asked, "What about yourjob is most satisfying?" two out ofthree said working with patients,either because they prefer clinicalnursing or because they find thatimproving the quality of patient

52 Geriatric Nursing JanuaryfFcbruarv 100 A

care is so gratifying.I find it ex trem ely satisfyingthat th e patients [manage re­main in stable condition long­er and require fewer hospitaladmissions than before.

The remaining one-third consid­er other aspects of their work par­ticularly satisfying: its increasedresponsibility, autonomy, and chal­lenge, and the personal gratifica­tion they derive from using theirskill s.

I find the challenge extreme­ly satisfying. Each client'sproblems are unique and ad­justing m edical tr eatment toeach life-style allows me tobe creative.

I don 't feel like a handmaid­en to physicians any longer.Now I ha ve a true share inth e medical responsibility forthe patient . I make decisions;I am not just following or­ders.

An especially telling indicator ofjob satisfaction is turnover, and 60percent of the practitioners have re­mained at the facility where theywent to work after graduation. Atleast half of those who changedjobs volunteered that a key consid­eration in the ir decision to do sowas the desire to use their newskills to a greater extent than hadbeen possible in their previous posi­tion . One put it this way:

All my efforts to carve therole were thwarted and I ha vesimply not been able to ex-:pand my role. Hence, I amleaving. If I cannot be uti­lized as a practitioner, then Icannot remain here..

Salaries

In April 1982, the average an­nual salary of these practitionerswas $22,658, with a range from$19,922 if employed in outpatientclinics to $24,650 for those in pri­vate practice with a physician.

The number of years a nurse has

been employed as a practitioneralso influences salary level. Thegraduates of the first three classesaverage $23,562 as compared to$21,014 for Classes 4 and 5. Butthe number of years a nurse hasbeen employed at the same facilityis not related to salary level.

Impact on Health Care Facilities

GNPs have the potential to im­prove the quality of patient care,but many factors can limit their cf­fcctiveness. Will patients acceptGNPs or will they prefer' a physi­cian? Will staff nurses appreciatethe practitioner role or will there beconflict and competition? Willphysicians have confidence in thepractitioner's skills and judgmentor will they block a collegial role inpatient care?

These are the key questions weasked the GNPs' employers, andtheir answers reveal that practi­tioners do indeed have a strong pos­itive effect on the facilities a t whichthey work. To be specific, four outof five employers reported that pa­tient care improved significantlywith a practitioner on the staff, interms of six specific criteria:

• quality of patient assessments• quality of medical manage­

ment• amount of patient education

provided• proportion of patients given to­

tal assessments• amount of attention given to

secondary problems and symptoms• continuity of care.The improvement mentioned

most frequently is the increasedquality of patient assessments; thissuggests that when a nurse practi­tioner' is on the staff, more ' thor­ough care is ava ilable to patients.Moreover, although every practi­tioner was judged to have improvedthe quality of patient care, fewerthan one-fourth of the employershad anticipated that practitionerswould be so effective. Instead, rea­sons such as reducing the physi­cian's caseload, providing inservice

Three-quarters of the GNPs said they were "very"or "extremely" satisfied with their jobs afterworking for one to four years with older patients.

training to other nurses, and per­forming specific nursing tasks wereanticipated as the main benefits ofhiring a practitioner.

Concern that practitioners mightnot be competent to manage a case­load of patients proved groundless.In fact, in their first year of em­ployment, practitioners were suc­cessful beyond expectation in im­proving patient care.

Employers were not only pleasedwith the quality of patient care, butfour out of five also said that pa­tient satisfaction with care had im­proved. As one nurse employer ex­pressed it:

She represents the highestlevel of care we can provide.It is ofgreat benefit to the pa­tient, especially her knowl­edge of interactions and med­ications, observation of sideeffects and the early detec­tion of potential problems.We've probably decreased thenumber of emergency roomvisits.

A medical collaborator in a hos-pital setting said:

Patients love her. She takesmore time and her view ofthings is slightly different,She is very good at thinkingabout things like walking,bedsores, and what mighthappen when the patient goeshome. She has the total pa­tient in view as she providescare.

Only two pracuuoners wererated poorly on patient satisfaction.One employer rated the technicalperformance of the GNP well be­low average. The other instance in­volved a practitioner employed in ahospital outpatient clinic where pa­tients walk in expecting to see aphysician. In every other work set­ting, the pattern isthe opposite: pa­tients prefer a practitioner to aphysician. Practitioners explain itthis way:

After my examination pa­tients often say they never gotsuch a thorough exam from a

physician.

Patients don't feel that timeis a problem. I don't rushthem.

The use of practitioners in a staffteaching role is another distinctbenefit. Four out of five employersfound that the performance of oth­er nurses at their facility had im­proved, and one in three said thatperformance had improved signifi­cantly. This result was true even atfacilities with no formal inserviceteaching programs. It is likely thatpractitioners in these settings serveas examples and, informally andthrough consultation, strengthenthe skills of their nursing col­leagues. And, sometimes, nurses

who feel threatened by the presenceof a practitioner become "super­nurses" to prove their own worth.

The response of physicians tothese practitioners is also veryfavorable, and five out of six physi­cians reported that their satisfac­tion with their own work has in­creased as well. '

One physician was skepticalabout the ability of GNPs and re­luctantly agreed to work with apractitioner during her internship.After seeing what she could do,however, he changed his mind anddelegated part of his caseload toher. Other physicians who hadoriginally refused to sponsor thepractitioner now say that they tooshould have a practitioner!

Three-fourths of the physiciansassociated with the GNPs reportedthat practitioners had improvedtheir own performance. This no

doubt is due in part to the more ef­fective use of physician time, butthe skills and interests of the GNPapparently influence the physi­cian's behavior. Stated anotherway, gains in knowledge and per­formance accrue to medical collab­ora tors as well as to nurse practi­tioners. As one physician 'said,"Knowing she's around, I do a: bet­ter job."

Overall, these practitioners seemto be performing exceptionallywell. Nine out of 10 employers seethem as making a "valuable contri­bution"; seven said it was an "es­sential" one. Perhaps the most con­vincing piece of data is that virtual­ly all employers agree that theywould want to replace the present

practitioner with another GNP, ifthe former should leave.

Problems and Obstacles

Despite all this expressed appre­ciation, practitioners encounterseveral large obstacles as they seekto implement this new role. Twogiant barriers are the lack of finan­cial reimbursement to a facility forpractitioner services when a physi­cian is not present and regulationswhich mandate that a physician'ssignature accompany modificationof a patient order.

The nonreimbursement problemillustrates some of the complexitiesof introducing change into healthcare delivery. A GNP can be per­ceived as "exceptionally useful" bythe employing agency or physician,but when the practitioner's servicesare not income-generating, budget­ary problems sharply constrain the

Geriatric Nursing January/February 198453

CQMfv10N CONCERN

role. The net effect is poor use ofhighly skilled nurses and frustra­tion for both the facility and thepractitioner.

The issue of drawing "the linebetween practicing medicine andpracticing nursing," as it has beenphrased, is another obstacle someGNPs are experiencing.* Em­ployers concur that the problem isnot that practitioners are unwillingto assume responsibility, but ratherthat facility regulations, concernabout possible malpractice litiga­tion, and long-established practicesreserve to physicians the right to in­itiate treatment and to write pre­scriptions.

Although intended as safeguardsfor the' patient, such practicessometimes have the opposite effect.For the practitioner employed byvisiting nurse services, for instance,adequate medical backup is all toooften not available. At best thepractitioner may, at some latertime, reach the physician by phone,but this means that patients' medi­cal and nursing needs are attendedto less well and not as soon as theycould be.

Apart from the legal limitationson their practice, establishing a col­laborative relationship with physi­cians is the chief problem faced bysome GNPs, especially those em­ployed in visiting nurse services.One practitioner was outspoken:

Physicians are not available.They don't know me and Idon't know them.

Another noted that physicianbiases about treating geriatric pa­tients compound the problem.

Many physicians who dealwith the aged or chronicallyill often will not even acceptthe needfor a change in treat­ment because of the patient'sage or disease status. Mygoals are higher than theirs,

"Sullivan, J. A., and others. Overcomingbarriers to the employment and utilizationof the nurse practitioner. Am.JiPublicHealth 68:1098, Nov. 1978.

54 Geriatric Nursing January/February t984

but I'm dismissed with, Whatdo you expect at 85?

Other GNPs described their dif-ficulties with physicians this way:

I must earn the respect ofeach physician separately, bydemonstrating that my role ismuch more than that of aphysician's assistant.

Physicians don't trust a nurseuntil they have had a workingrelationship with her forsome time and get to knowher work and know she is re­liable. Practitioners gain ac­ceptance by physicians onlyin individual concrete in­stances, not in the abstract.

Practitioners who have had prob­lems working with physicians stress

GNP skills and interestaffected physicians'behavior. As one said,"Knowing she's around,I do a better job."

the importance of proving one'sskills by direct patient care. How­ever, one GNP employed by a facil­ity where there are more than 300physicians also uses her writingskills to good advantage:

I try to define my role by ac­tions rather than words, but Ishould add that my progressnotes on charts generate cu­riosity and create opportuni­tiesfor me to talk with physi­cians about particular pa­tients.

Two problems practitioners re­ported having in the first fewmonths of employment proved to beonly temporary. One is developingconfidence in their ability to makeclinical assessments and to assumeresponsibility for patient manage-

ment. Some found, for example,that they concentrated so much onusing a stethoscope or evaluatinglab results that they did not assessthe patient's condition as a whole.One practitioner ruefully told thisstory about herself:

I learned the tasks of physi­cal assessment and' historytaking but I lost track of thepatient in the beginning be­cause I was checking eachpiece so carefully. For exam­ple, one patient with migrainecame in and the doctor said,There is a subtle neurologicalfinding. I could not find itand what was it? One pupilwas larger than the other. Idid all the tasks, but I neverlooked at the patient!

The second of these transitionalproblems is developing a goodworking relationship with nursecolleagues. GNPs, expecially thosewho are the first at their facility,have found that the nurses withwhom they work can be reluctantto accept the professional role ofthe practitioner. '

At times this reluctance surfacedas rivalry, competition, suspicion,and even jealousy. Such problemshave been addressed by practition­ers meeting with the nursing staffand demonstrating the complemen­tarity of this role with those of oth­er nurses for the benefit of the pa­tient.

In sum, the full implementationof the nurse practitioner role bythese GNPs has been hampered bythe restrictive regulations and lawsthat govern nursing practice and bythe working conditions of the facili­ties where they are employed. Spe­cific problems, such as poor physi­cian backup and limited opportuni­ty to use their skills, have led tosome job dissatisfaction. But mostGNPs are enthusiastic about theirnew role, enjoy working with olderadults, and want to be in the van­guard of professionals whose prin­cipal goal is to improve the qualityof patient care. GN