Here is the study:
In the early 1960s, the faculty at the University of Colorado's Department of Pediatrics came up with an idea for a new health profession - the nurse practitioner - a registered nurse with advanced academic and clinical experience, who could work independently or as part of a health care team. By 1965, the university had created the first training program for nurse practitioners. Today, almost 40 years later, New York City's Columbia University School of Nursing is working toward a new goal for this field: a Doctor of Nursing Practice (DrNP) degree program.
Nurse practitioners (NPs) normally collaborate with a supervising physician, who assists them in addressing any questions or problems the nurses might encounter. Most NPs work in primary care, but their practices also encompass other specialties. The DrNP degree will help current nurse practitioners (NPs) advance their independent nursing skills by providing more extensive training. "Developing this degree program is about assuring quality," says Mary O'Neil Mundinger, RN, DrPH, a major force behind this project. "Right now, there are no training programs for nurse practitioners addressing in a formal, standardized way the expanded skills that our nurses have taken on over the past decades."
There are other nursing doctorates already in existence. The University of Kentucky grants a Doctor of Nursing Practice (D.N.P.) degree geared toward leadership development. In addition, some universities confer a research-focused nursing Ph.D., but Columbia University's proposed DrNP degree would be the first program specifically tailored to nurse practitioners seeking to refine independent and advanced nursing skills in primary care.
Comparing NP and Physician Services
The process of developing the proposed DrNP program took nearly a decade. In 1993, the faculty at Columbia University's College of Physicians and Surgeons noticed it lacked enough primary care physicians to staff the medical center and asked the university's nursing school faculty to take over two primary care sites. These clinical sites, located at what is now New York-Presbyterian Hospital/Columbia Presbyterian Center, provided health care for the area's low-income Dominican families.
"We agreed to take over the two clinical practices with the condition that the hospital would support us in doing a research study to show the effects, costs, and outcome of our treatment on the patients we served," says Dr. Mundinger. Prior to this study, there had been more than 100 other published clinical studies that indicated no gap in the quality of treatment provided by NPs and the care provided by physicians. But the results of the studies were criticized as invalid because "they weren't part of the gold standard in scientific study design," according to Dr. Mundinger.
In an effort to come up with definitive answers, the nursing school faculty put together a randomized clinical trial using identical clinical locations. "We had the same geography, same square footage, same support staff," says Mundinger. "The difference was that the providers in one site were physicians and the providers in the other sites were my faculty."
The nursing faculty was given admitting privileges to the university hospital "to reduce the variables in the study," Dr. Mundinger explains. Preparation for the trial took approximately one-and-a-half years, and the trial itself was carried out over a two-year period. When the trial was completed, the faculty performed an analysis of the data, and the results indicated there was no gap in the quality of services provided by the nurse practitioners and the physicians.
In 1997, Columbia's School of Nursing opened its first practice in midtown Manhattan for commercially insured patients. The practice was so successful, the school opened an additional practice, and it still holds admitting privileges to the university's medical center.
"In the New York metropolitan area, the primary care practice base is not as robust as other areas of the country on the physician side," explains Thomas Morris, M.D., Columbia University's vice president for Health Sciences, vice dean of College Health Sciences, and vice dean of the College of Physicians and Surgeons, "Advanced practice nurses have identified a natural niche which they are able to fill quite well."
Columbia University's medical faculty has been supportive of the nursing school's efforts, according to Dr. Morris. "The form of advanced practice nursing, and the collaborative efforts between the nurses and members of the medical staff, has varied from one department to another, but it has been tailored to meet the needs of both levels of providers," he notes.
The study's final results, published in the January 2000 Journal of the American Medical Association (JAMA), found that in an ambulatory care situation, patients treated by either nurse practitioners or physicians had comparable outcomes. An editorial in the same JAMA issue however, questioned the study's external validity, or its ability to apply to "other study sites and other populations of patients."
Invading the Realm of PCPs
Since nurse practitioners first entered the scene in 1965, they have gradually taken on responsibilities that were once under the exclusive purview of primary care physicians (PCPs). Some physicians are disturbed at this trend and question whether patients are receiving the same quality of care under nurse practitioners. Perry Pugno, M.D., M.P.H., director of the division of medical education at the American Academy of Family Physicians, a national organization representing family doctors, argues that PCPs have more years of training under their belt, and are more capable of providing quality care than NPs.
"It's well recognized that nursing education does not include the same number of curriculum hours and patient contact time that physician education does," Dr. Pugno says, stressing that PCPs go through four years of medical school and at least three residency years before they practice. If the DrNP program gets approved, he says, NPs pursuing primary care roles would undergo a maximum of four years of graduate education, compared to the seven years primary care physicians go through.
"Since this proposed program appears to be an educational program with substantially less training than what primary care physicians receive, representing NPs as equivalent to PCPs would be disingenuous, and would result in lowering the quality of care provided," says Dr. Pugno.
Not all physicians share Dr. Pugno's view, however. Richard Cooper, M.D., former dean and current head of the Health Policy Institute of the Medical College of Wisconsin, believes that the quality of care offered by NPs is comparable to the care provided by physicians. He also thinks the competition between NPs and PCPs is not cause for concern. "There is no question that nurse practitioners' work overlaps very broadly the workscope of primary care physicians, but that's not entirely the case," says Dr. Cooper. "PCPs tend to treat patients with higher acuity, more complex diseases, and engage in a greater range of tasks and procedures. On the other hand, many patient care responsibilities of PCPs deal with things such as well-baby exams, upper-respiratory infections, mild hypertension, patient education, and nutrition. Many of these things are readily performed and done on a daily basis by NPs."
Competition between NPs and PCPs already exists, Dr. Cooper says, and is probably here to stay. "After all, there's competition among physicians as well," he notes. If this program gets approved, he says, the difference will be that doctors will then compete with NPs who have more years of training in their field.
A higher level of training for nurse practitioners is something that is long overdue, according to the supporters of the DrNP program. "The more sophisticated you make the knowledge base of the clinicians, the higher the level of practice that is achieved. This provides the opportunity to produce very sophisticated clinicians," says Polly Bednash, Ph.D., executive director of the American Association of Colleges of Nursing (AACN), a national organization representing university and four-year-college education programs in nursing.
"The health care system today is so complex that we need the most sophisticated clinicians possible," says Dr. Bednash.
Michael Whitcomb, M.D., senior vice president of the AAMC's division of medical education, also agrees that today's health care academic environments must match professional changes and expectations. "When these advanced practice nurses set up their independent clinics, the faculty at Columbia's school of nursing realized that many of the responsibilities and skills they acquired were things learned by virtue of having been out in practice settings, not things learned during their formal education," Dr. Whitcomb explains. "The faculty concluded that the standards of the educational process leading to this kind of advanced independent nursing practice weren't high enough. This proposed educational program [addresses this problem] by having standards that are high enough to prepare the nurses for independent practice."
Professionals in most fields try to improve their own academic and career standards, and advanced nursing practice shouldn't be an exception, says Dr. Cooper. "It wasn't that long ago when physicians entered practice right out of medical school," he says. "Having a three-year residency is a relatively recent phenomenon. The nursing profession is driving this [push for more years of clinical training] just as the medical education establishment drove medical education to where it is today." Because nurse practitioners hold the highest level of independence of all nursing practices, Dr. Cooper thinks it is inevitable that there will be more programs like the one Columbia is proposing.
But critics also argue that programs emphasizing nurses' independent practice may exacerbate the country's current nursing shortage by redirecting nurses from hospital sites into private practice. "This kind of program does two things to worsen the nursing shortage," says Dr. Pugno. "First, if successful, it would draw people away from other areas of nursing into this doctoral program. Second, it gives the mixed message to young people interested in other nursing careers that being a nurse, as opposed to an NP, isn't big enough."
Dr. Mundinger believes the opposite is true. "Finally, there is credibility to the fact that nursing practice at its highest level merits a doctorate degree," she says. "This can add luster to the attraction of entry-level jobs because it turns this profession into one that goes just as far, and does just as much intellectually, to merit a doctoral degree as the other health professions."
Dr. Cooper also doubts this program could aggravate the nursing shortage. "There are 3.5 million nurses in America," says Dr. Cooper. "In a few years, there will be 100,000 master's level trained nurse practitioners. So one can predict that there might be, at the doctoral level, approximately 25,000 nurse practitioners. These 25,000 NPs out of a total of 3.5 million nurses won't make a big difference."
Nurses choosing to participate in such a program could still be useful hospital staff regardless of the program's emphasis on independent nursing skills, says Christiana Care Health System's president and CEO Charles M. Smith, M.D., a member of the AAMC's Council of Teaching Hospitals administrative board. Graduates of this proposed program could become "sophisticated clinical managers," Dr. Smith believes.
"Because of their training, such nurses might be able to better understand how a hospital's clinical nursing structures could be revised and modified so that more effective use of nursing resources can take place," he says. "Someone who understands well the clinical delivery of a type of care is in the best position to figure out how that might be changed in order to effectively use nursing resources. Ultimately, this could even have an impact on reducing the demand of nursing resources."
In addition to the nursing shortage problem, the prospect of a physician shortage adds another dimension to this discussion. In a Health Affairs article published last January, Dr. Cooper warned readers of a potential physician shortage. Citing that article, Dr. Bednash says that the entrance of better-trained nurse practitioners in the scene could help alleviate this potential problem.
Regardless of whether or not the above prediction materializes, Dr. Bednash believes health care professionals should keep their minds open to innovation and experimentation in their area. "All health professionals share the common goal of having the best health care system possible in this country," says Dr. Bednash. It should be in the interest of health care professionals to be innovative and to make sure the best care is given to the greatest number of people possible, she believes. "This isn't a zero-sum game; there's enough work for everyone, and we should figure out how to best use the finite resources of health professionals to give the best care to the greatest number of people."
