What's the difference between a nurse practitioner and physician assistant? Click here to learn more.
Typically teammates in patient care, physicians and a group of highly educated nurses are at odds over whether those nurses should practice independently in Nebraska.
Nurse practitioners — nurses with master's degrees or doctorates — are rapidly increasing in number in Nebraska, Iowa and nationwide.
As the population of elderly Americans grows, as federal law gives more people access to insured care and as numbers of primary care doctors rise at a sluggish pace, nurse practitioners say they can help plug a gap in American health care.
At issue is the degree to which nurse practitioners may operate free of physician oversight. Nurse practitioners in Iowa and 15 other states already have autonomy. Those in Nebraska do not.
For the patient, more nurse practitioners could mean better access to care in rural areas and shorter waits in cities. But some physicians warn that independence for nurse practitioners could compromise quality.
The head of the Nebraska Medical Association says nurse practitioners should be overseen by a collaborating doctor, as is required by Nebraska law. Nurse practitioners cannot diagnose diseases and treat patients as effectively as physicians, who have more years of education and training, Dr. Chuck Gregorius said.
Nurse practitioners are “trying to get by legislation what physicians have earned by education,” said Gregorius, a Lincoln anesthesiologist and president of the physicians' association.
Katie O'Keefe, nurse practitioner curriculum coordinator at Creighton University, said it's not that nurse practitioners always want to go it alone without collaborating with physicians. But nurse practitioners are trained and experienced in seeing common medical problems such as colds, asthma, pneumonia, strep throat, ulcers, sprains and simple broken bones, she said.
They refer complex cases beyond their scope to specialists, as would a family physician. “When it comes right down to it, there's more than enough patients to be seen,” O'Keefe said.
Although nurse practitioners generally focus on primary care, they may work in oncology clinics, urology clinics and other places in which they collaborate with physicians and other health-care providers.
Doctoral programs providing nurse practitioners with additional education and training are sprouting throughout the nation. Creighton University began offering one in 2008 and the University of Nebraska Medical Center last year. Clarkson College in Omaha plans to launch one next year. The University of Iowa has had one since 2007 and Allen College in Waterloo, Iowa, started a program last year. Nebraska Methodist College in Omaha is planning to offer one in the future.
Nurse practitioners in Iowa have had the right to function independently since the 1980s. This grew from the “need for more primary care providers in Iowa, and particularly in some of our more rural areas,” said Rita Frantz, dean of nursing at the University of Iowa.
Dr. Robert Lee, president of the Iowa Medical Society, said he believes nurse practitioners work best when collaborating with physicians. Lee said the state allows nurse practitioners to independently perform nursing functions and not medical functions, but there are no clear guidelines on what that means.
The Iowa Medical Society and other organizations sued nursing groups in 2010 after nurse practitioners began supervising fluoroscopy, an imaging technique that sometimes requires high doses of radiation.
The medical society won in lower court. The case has gone to the Iowa Supreme Court.
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Differences between nurse practitioners, physician assistants
Although the two function similarly on a daily basis, there are differences.
» Nurse practitioners typically have attained a master's degree in nursing and have worked as registered nurses.
» Physician assistants typically have obtained undergraduate degrees with a science major, such as biology, chemistry or anatomy.
» Nurse practitioners increasingly have doctorate degrees in nursing practice.
» Physician assistants increasingly have master's degrees to prepare them for their professions.
» Nurse practitioners are trained in a nursing “model,” or from a nursing perspective. This means their training emphasizes health promotion, holistic strategies (dealing with the whole and with integrated systems rather than parts), chronic-disease management and patient education.
» Physician assistants learn the medical “model,” which involves treating, curing and preventing disease, relieving pain, and improving and preserving health.
» Nurse practitioners may practice independently in 16 states and Washington, D.C. Elsewhere they are required to have some form of collaborative arrangement, as described in their respective state laws, with a physician. Many nurse practitioners and nurse organizations seek autonomy in other states, such as Nebraska.
» Physician assistants generally accept that they work under a physician. They don't function independently in any states.
» Nurse practitioners and physician assistants generally are paid at 85 percent of the physician fee when the patient is covered by Medicare.
“We would really like them to work collaboratively,” Lee said of nurse practitioners.
Pat Coyle-Rogers, director of Clarkson's graduate nursing program in Omaha, said nurse practitioners already have the skill to practice without physician oversight.
“I would love to see us follow Iowa's example and have independent practice,” said Coyle-Rogers, who has a doctorate in education.
Richard Haecke, 85, used a walker last month as he moved through the UNMC Physicians clinic in Plattsmouth, Neb., to see nurse practitioner Thomas Strawmier. Strawmier has seen Haecke and his wife Phyllis several times and has become their main health care provider.
“I have a lot of confidence in Tom there,” Phyllis Haecke said. “What I like is he uses words I can understand.”
Richard Haecke's feet were so swollen that he couldn't wear shoes. The retired farmer sat in Strawmier's office with his hands on his thighs. Strawmier said the swelling in his feet could indicate a heart problem, kidney problem or some other difficulty.
“You feel well?” Strawmier asked.
“I feel good all the time,” Haecke said.
Strawmier, 39, has a nurse practitioner master's degree and is considering pursuing his doctorate. He was a registered nurse for 13 years and has worked as a nurse practitioner for two years, first in Missouri Valley, Iowa, and now in Plattsmouth.
He saw few differences in his Iowa and Nebraska practices because he collaborated with a physician in Iowa, just as he does in Nebraska.
Dr. Mary Gallagher Jansen, Strawmier's collaborating physician at the Plattsmouth clinic, reviews his patient charts, but he doesn't go to her for advice on every patient. If he has a challenging case or questions, he consults her.
Strawmier would like to function independently at some point but doesn't feel he has the experience to do that yet. It might take three more years or so, he said, but he eventually would love to have his own primary care practice in a rural area.
Strawmier consulted with his partnering doctor on Richard Haecke's case. She agreed that more blood work and followup were in order.
In North Platte, Dr. Michael Trierweiler and nurse practitioner Kelley Hasenauer became full business partners in a new clinic begun last month. The business arrangement, the two say, appears to be the only one of its kind in Nebraska.
Trierweiler and Hasenauer had worked together before in North Platte, and Hasenauer obtained her doctorate of nursing practice in Kansas City, Mo., last year. She also worked briefly as a faculty member at the University of Nebraska Medical Center. Although Trierweiler will be her collaborating physician, he said there will be cases on which he consults her, too. He said he respects what she brings to the clinic.
The controversy over independence for nurse practitioners isn't as intense in western Nebraska, he said, because the shortage of primary care providers there is severe.
A lobbyist for the Nebraska Nurse Practitioners Association said she expects the association to push for independence next year.
“It remains our top legislative goal,” Cora Micek said.
The Nebraska Medical Association will resist that effort. Dr. Richard Blatny Sr., chairman of the association's commission on legislation, said it's inappropriate for nurse practitioners to seek independence at a time when experts are calling for partnerships and teamwork through the “medical home” initiative and other concepts.
Blatny, of Fairbury, Neb., and Gregorius said they have patient safety concerns about nurse practitioners working independently.
“Nursing plays a very, very important part in health care,” Gregorius said. “We couldn't do without them.” But getting a master's degree or doctorate over two or three years, he said, doesn't compare to four years of medical school, four years in residency training and frequently more time in specialty training.
“I'm sorry. The basis is not there. It's not,” he said of nurse practitioners working autonomously. “Their basis is nursing, not medicine.”
Studies done from 1990 to 2008 of the quality of care given by nurse practitioners and other advanced practice nurses, such as certified nurse midwives, were reviewed last year by a panel for “Nursing Economics.” The panel reported that those nurses “provide effective and high-quality patient care (and) have an important role in improving the quality of patient care in the United States …”
Some of the nurse practitioners in the dozens of studies practiced independently and some collaboratively, said Robin Newhouse, a professor in the University of Maryland School of Nursing. Newhouse was the lead author in the report.
National physician organizations generally agree that a primary-care shortage exists and will worsen as baby boomers grow old.
Dr. Glen Stream, president of the American Academy of Family Physicians, said nurse practitioners can help fill the gap. But the Spokane, Wash., doctor and his organization argue it should be done in a collaborative role with physicians.
He predicted the question of autonomy won't go away. “My opinion is, it's going to get to be a bigger issue,” Stream said.
Sixteen states grant independence to nurse practitioners, including Iowa, Wyoming and Colorado.
Meanwhile, huge numbers of nurse practitioners are pouring out of colleges. About 155,000 now practice in the United States, up from 82,000 in 2001.
From 2001 through 2010, the numbers of nurse practitioners more than doubled to 893 in Nebraska, and practically doubled to 1,197 in Iowa, according to the American Academy of Nurse Practitioners.
The number of physician assistants, who work with physicians in a somewhat similar manner to nurse practitioners, also has risen. Some 83,000 practiced in 2010, up from 40,000 in 2000, according to the American Academy of Physician Assistants.
Patricia Clinton, an assistant dean at the University of Iowa College of Nursing, said nurse practitioners will continue to fight for the right to practice independently.
“This is not a new battle,” Clinton said. “We are not trying to practice anything more than we are educated and clinically trained to do.”
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