Validation and Scope of Nurse Practitioner PracticeBy Elizabeth Rosic & Samantha Novak

NPIV, 2012

Background

NP role created in 1965 Four decades of research demonstrating:

- high quality care delivered by NP’s- care equivalent to that of physicians- pt. satisfaction often greater w NP’s- cost effective and safe care- NP’s consistently promote positive pt.

health outcomes.- Core role qualities supported by WHO

& IOM(AANP,2010) see handout

The Burlington Randomized Trial

Landmark study of nurse practitioner outcomes

Published in 1974 out of Ontario Canada 1598 families randomly allocated to physician

group (RC), or nurse practitioner group (RNP) 4 “outcome” measures 1. mortality

2. physical function 3. emotional function 4. social function

(Annals of Internal Medicine, 1974)

Burlington Trial Cont. Hypothesis: Care of the RNP would be safe & effective if

no statistical difference between outcomes from RC group.

Results: No statistical difference in any outcome! Importance of this study:

- opened up research doors that NP’s could be answer to primary care clinical demand

- Development of new RCT design (cluster randomization) w rigorous statistical methods gave results more credibility.

- Pivotal to the development of instruments (SF36) that could measure NP outcomes.

- Clinical effectiveness outcome later to be termed: EVIDENCE BASED PRACTICE

(Sackett, 2009)

MUNDINGER’S RCT

Conducted in the US from 1995-1997, published in 2000

1316 adults randomly assigned to NP (n=806) or Physician (n=510) in primary care setting

Outcomes measured: - pt. satisfaction - health status - physiologic test results - service utilization

- measured @ 6mo and 1 year(JAMA, 2000)

MUNDINGER’S RCT CONT. Results:

- No sig differences in pt. health status @ 6mo

- Physiologic test results for pts. w diabetes and asthma not different

- Satisfaction ratings the same for both 4/5 scale where 5 excellent

- No differences in health utilization

- For pts. w HTN, diastolic values statistically lower in NP group (P= .04)

- Important study d/t its RCT design, various valid measurement tools used, and vigorous statistical methods

- Collaboration of researchers from Columbia School of Nursing and College of Physicians and Surgeons

(JAMA, 2000)

MUNDINGER’S 2 YR F/U STUDY 406 pts. of original study who received

primary care from only assigned provider w at least 1 f/u visit in 2 yrs of initial visit

Consistent w findings from 2000 study: outcomes of pts. assigned to either NP or Physician are equivalent

Pts. in NP group reported high levels of satisfaction @ 2yrs.

Pts in NP group were no more likely than P group to have ER visits or hospitalizations.

(Medical Care Research & Review, 2004)

Summary of 1990-2008 Systematic Review for APN Outcomes (2011)

High Evidence Grade:1. Patient satisfaction

a. Six studies (4 RCT’s)b. Satisfaction is equivalent in NP & MD comparison groups.

2. Self-reported perceived healtha. Seven studies (5 RCT’s)b. Self-assessed health status is equivalent in NP & MD comparison groups.

3. Functional Status ADL

a. Ten studies (6 RCT’s)b. Functional status measured as ADL’s equivalent.

(Nursing Economics, 2011)

4. Glucose controla. Five studies (5 RCT’s)b. Blood glucose levels/control w NP pts. Comparable or

better than other providers.

5. Lipid controla. Three studies (3 RCT’s)b. Serum lipid levels better in NP pt. group vs. MD

group.

6. Blood pressurea. Four studies (4 RCT’s)b. BP levels w NP pt. group equivalent to MD pt. group.

7. ED or urgent care visits

a. Five studies (5 RCT’s)b. Rates of ED or urgent care visits equivalent.

8. Hospitalizationa. Eleven studies (3 RCT’s)b. NP & MD rates of hospitalization are equivalent.

9. Mortalitya. Eight studies (1 RCT)b. Mortality equivalent in NP and MD comparison group.

(Nursing Economics, 2011)

Where the research Falls Short Data available for much of the research are from

surveys by National Ambulatory Medical Care Survey, the Medical Expenditure Panel Survey, & the Community Tracking Study.

Fundamentally most of these databases reflect traditional physician care.

Sampling schemes may inconsistently capture unique skills and care of nonphysician practice.

Improved methodology to measure specific APN care. Data sources such as Medicare/Medicaid have limited

applicability to NP’s since care often billed under physician.

More research geared to factor APN’s into workforce planning.

More collaborative research w AMA, ACP etc.(Health Services Research, 2007)

OAAPN

“Research studies over the last thirty-five (35) years have documented that CNPs provide high-quality, cost-effective care with a high

level of patient satisfaction. The same research shows that at least 80% of primary care office

visits are managed equally as well by a primary care physician or nurse practitioners.”

(2011)

Definition of an NP Licensed independent practitioners. “A registered nurse who has acquired the expert

knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which would be determined by the context in which s/he is credentialed to practice.” (ICN, 2011)

1. Practice autonomously and in collaboration with health care professionals to assess, diagnose, treat and manage the patient's health problems/needs.

2. Serve as health care researchers.

3. Order, conduct, supervise, and interpret diagnostic and laboratory tests

4. Prescribe both pharmacologic and non pharmacologic therapies.

5. Educate patients. (AANP, 2010)

Definition Cont.

Education primarily based on the Nursing Model

o Designed to provide holistic and preventive care with an emphasis on health promotion and disease prevention.

o Promote patient advocacy for mutually agreed upon treatments and optimal health outcomes.

o Focus on patients' conditions as well as the effects of illness on the lives of the patients and their families and attempt to incorporate cultural relativism in treatments and recommendations.

o Make patient education priorities.

(AANP, 2010).

Where can we be utilized??

In a variety of healthcare settings and can assume a variety of roles in each type of setting.

Manage patients of all ages depending on certification. Rural, urban, and suburban communities in a variety of settings;

• home healthcare, clinics, emergency rooms, urgent care, private offices, schools, colleges, public health, or private NP run offices.

Able to work in a variety of specialties; •acute care, adult health, family health, pediatrics, gerontology, neonatal, women’s health, psych, oncology, dermatology, neurology, endocrinology, GI, occupational health etc.

(OAAPN, 2011; OBN, 2011)

NP Scope of Practice (SOP)

Nurse practitioners perform services as authorized by a state's nurse practice act which vary state-to-state. -11 states permit NPs to practice independently.

-27 require NPs to practice collaboratively with an MD.

-10 require direct MD supervision.

-NPs in all states can prescribe, limitations vary.

-42 require national certification as part of licensure.

-Just over half require a master’s degree.

(Christian, Dower & O ’Neil, 2007)

Ohio SOP-pearson report Defined by state law and national certifying bodies National certification required by Ohio Board of Nursing. Required to practice in collaboration with a physician or

podiatrist and develop a written Standard Care Arrangement (SCA) prior to practicing.

1. NPs with prescriptive authority must have chart reviews at least semi-annually

2. Physicians must continuously be available to communicate with the NP. 

3. Must be kept current and available upon request at each site of practice.

4. BON must be notified of any change within 30 days after the change takes place.

Nothing in the Ohio Nursing laws and rules prohibits a nurse from using the term “Dr”, however, the Medical law and rules (ORC 4731.34) do prohibit the use of this title or similar titles if used to represent the person as engaged in the practice of medicine and surgery.

(Pearson Report, 2012).

OHIO SOP Cont

The Committee on Prescriptive Governance (CPG) under the OBN establishes a Formulary that is annually reviewed and is available http://www.nursing.ohio.gov/practice.htm.

Drugs are categorized as; may prescribe, may prescribe with additional parameters, may not prescribe, physician consultation or physician initiation.

Senate Bill 83, introduced to the House in 2009 allows NPs, CNSs, and CNMs to prescribe Schedule II controlled

substances according to their Formulary after completing a 6 contact course specific to schedule II prescribing. 

Must have CTP # given by the OBN and name on pad, do not need MDs name.

DEA for controlled drugs.

(Pearson Report, 2012).

Ohio SOP Cont.

An NP with a CTP issued by OBN may keep drug samples as long as its within the state formulary and the amount does not exceed a 72 hour supply (or the smallest commercially available sample size).No language that specifically mandates and refers to NPs as reimbursable providers by all 3rdparty payers.Currently Aetna, Paramount and United Health Care recognize independent NPs as PCPs.All non-independent NPs continue to bill indirectly under a physician provider number.   (Pearson Report, 2012).

In October 2009, the AMA published “Nurse Practitioners” in its Scope of Practice Data Series. Described as being a reference for legislature when considering expanding NP SOP.Referred to NPs as “limited licensure health care providers”, “physician extenders” and “non-physicians”.Frequently state and allude that patients under NP care are at risk for unsafe health practices.NPs are only successful at treating routine health problems-colds, earaches, HTN, immunizations.Petition to take away NP independence and autonomy-would like NPs to function more like a PA.“How do NPs alleviate the nursing shortage?”

NP’S RESPONSE TO THE AMAMany national organizations (AANP, ANA, ANCC, NLN) wrote a letter to Dr. Maves, CEO of the AMA.

“Nurse practitioners are fully licensed professionals who practice within their legal authority and who have established a reputation for providing safe, effective, high quality care to their patients”.State that the document contains numerous factual misrepresentations and misleading conclusions. State it was a biased report that left out studies that demonstrate safety and high quality of care provided by NPs.During a time when the nation faces a failing health care delivery system with so many unmet health care needs, the individual health care professions should make it a high priority to evaluate their own areas for improvement and ways to enhance, not further restrict, patients’ access to health care…. (Letter accessed via springboard content)

STRESSED OUT!!! Can anyone here relate????

References

American Academy of Nurse Practitioners. Quality of Nurse Practitioner Practice. (2010). Retrieved

February 1, 2012 from http://www.aanp.org.

American Academy of Nurse Practitioners. Scope of Practice for Nurse Practitioners. (2010). Retrieved

February 8, 2012 from http://www.aanp.org.

American Medical Association (2009). Nurse Practitioners. AMA Scope of Practice Data Series.

Christian, S., Dower, C., & O’Neil, E. (2007). Overview of nurse practitioner scopes of practice in the United States-discussion. The Center for Health Professionals, University of California, San Francisco.

International Council of Nurses. (2011). Nurse Practitioner/Advanced Practice Nurse: Definition and Characteristics. Nursing Matters Fact Sheets. Retrieved February 8, 2012 from http://icn-apnetwork.org/.

Lenz, E., Mundinger, M., Kane, R.L., Hopkins, S.C., and Lin, S.X. (2004). Primary Care Outcomes in

Patients Treated by Nurse Practitioners or Physicians: Two-Year Follow-Up. Medical Care Research and Review 61(3): 332-351.

Morgan, P.A., Strand, J., Ostybl, T., and Albanese, M.A.(2007). Missing in Action: Care by Physician Assistants and Nurse Practitioners in National Health Surveys. Health Services Research, 42(5): 2022-2037.

Mundinger, M.O., Kane, R.L., Lenz, E., Totten, A.M., Tsai, W., Cleary, P.D., Friedewald, W.T., Siu, A.L., and Shelanski, M.L. (2000). Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians: A Randomized Trial. Journal of the American Medical Association, 283(1): 59-68.

Newhouse, R.P., Stanik-Hutt, J., White, K.M., Johantgen, M., Bass, E.B., Zangaro, G., Wilson, R.F., Fountain, L., Steinwachs, D.M., Heindel, L., and Weiner, J.P. (2011). Advanced Practice Nurse Outcomes 1990-2008: A Systematic Review. Nursing Economics, 29(5): 230-251.

References Ohio Association of Advanced Practice Nurses. What is a Certified Nurse Practitioner? (2011).

Retrieved February 8, 2012 from http://www.oaapn.org/cnp.php.

Ohio Board of Nursing (2011). Chapter 4723: nurses. Retrieved February 8, 2012 from http://www.nursing.ohio.gov/index.htm.

Sackett, D.L. (2009). A landmark randomized health care trial: the Burlington trial of the nurse practitioner. Journal of Clinical Epidemiology: 303-28.

Sackett, D.L., Spitzer, W.O., Gent, M., Roberts, R.S. (1974). The Burlington Randomized Trial of the Nurse Practitioner: Health Outcomes of Patients. Annals of Internal Medicine, 80(137): 137-142.