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/lp/american-medical-association/primary-care-physician-perceptions-of-the-nurse-practitioner-in-the-kYpOA0D5Ba
- Publisher
- American Medical Association
- Copyright
- Copyright 1999 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.
- ISSN
- 1063-3987
- eISSN
- 1063-3987
- DOI
- 10-1001/pubs.Arch Fam Med.-ISSN-1063-3987-8-3-foc7049
- Publisher site
Abstract
ObjectiveTo evaluate factors associated with primary care physician attitudes toward nurse practitioners (NPs) providing primary care.DesignA mailed survey of primary care physicians in Iowa.Setting and ParticipantsHalf (N=616) of the noninstitutional-based, full-time, primary care physicians in Iowa in spring 1994. Although 360 (58.4%) responded, only physicians with complete data on all items in the model were used in these analyses (n=259 [42.0%]).Main Outcome MeasuresThere were 2 principal dependent measures: physician attitudes toward NPs providing primary care (an 11-item instrument) and physician experience with NPs in this role. Bivariate relationships between physician demographic and practice characteristics were evaluated by χ2tests, as were both dependent variables. Ordinary least-squares regression was used to determine factors related to physician attitudes toward NPs.ResultsIn bivariate analyses, physicians were significantly more likely to have had experience with an NP providing primary care if they were in pediatrics or obstetrics-gynecology (78.3% and 70.0%, respectively; P<.001), had been in practice for fewer than 20 years (P=.045), or were in practices with 5 or more physicians. The ordinary least-squares regression indicated that physicians with previous experience working with NPs providing primary care (P=.01), physicians practicing in urban areas with populations greater than 20,000 but far from a metropolitan area (P=.03), and general practice physicians (P=.04) had significantly more favorable attitudes toward NPs than did other primary care physicians.ConclusionsThe association between previous experience with a primary care NP and a more positive attitude toward NPs has important implications for the training of primary care physicians, particularly in community-based, multidisciplinary settings.THE MARKET-DRIVEN reorganization of the health care delivery system, with a strong emphasis on primary care networks, and the shortage of primary care providers in some areas of the United States have increased the market for nonphysician providers, such as nurse practitioners (NPs).Consequently, increasing numbers of physicians and NPs will be working together in primary care teams. The success of these health care teams will affect the quality and cost-effectiveness of the care provided.Physician attitudes toward NPs is likely to affect working relationships. In fact, studies suggest that a physician who has worked with an NP is more likely to approve of the primary care NP role.The purpose of this study was to measure the attitudes of primary care physicians toward NPs and to correlate the physician and practice characteristics with these attitudes. Of particular interest were the differences in perceptions between physicians who had previous or current experience with NPs providing primary care vs those who had no experience with NPs in this role.SUBJECTS AND METHODSWith the use of SPSS (SPSS Inc, Chicago, Ill), half (n=616) of the licensed, full-time primary care physicians in Iowa were randomly selected from the Iowa Board of Medical Examiners (IBME) list of all licensed physicians in the state. Those selected received a written survey inquiring about their experience with and attitudes toward NPs providing primary care. Primary care physicianswere defined as those who reported their area of practice as general practice, family practice, obstetrics and gynecology, general internal medicine, or pediatrics. Full-timewas defined as working more than 30 weeks per year as reported to the IBME.An initial survey and cover letter were mailed in the spring of 1994; approximately 10 days later a postcard reminder was mailed to all physicians. Three weeks after the postcard, a second survey and cover letter were mailed to all nonrespondents. Three hundred sixty physicians responded, for an overall response rate of 58.4%. However, only 259 physicians supplied information for all the variables within the model, leaving a usable response rate of 42.0%.Demographic information was collected both from the survey and from the IBME database of licensed physicians. Physical geographic location, provided by the IBME, was defined by means of a 9-level urban-rural county identification code developed by the US Department of Agriculture.The primary dependent variable in this study, physician attitudes toward NPs, was created as a composite score based on 11 statements about NPs that were answered by means of a 5-point Likert-type scale (strongly disagree to strongly agree). These attitudinal questions were developed by members of this research team based on published research and studies conducted with Iowa physicians. For the purpose of analysis, items in the scale were coded so that the least positive attitude toward NPs scored a 1 and the most positive scored a 5. These items had a high internal consistency (Cronbach α>.6), indicating they were likely to be measuring the same construct (α=.87).Bivariate analyses were used to find associations between previous experience working with an NP and physician characteristics. In addition, the association between experience working with an NP and physician attitudes was evaluated for each attitudinal question by means of χ2statistics. Pvalues less than .05 were considered statistically significant.Ordinary least-squares regression was used to evaluate the factors associated with the composite attitudinal scale score. Independent variables included in the regression were self-reported experience working with an NP, as well as physician characteristics and demographics, including age, sex, area of practice, type of degree (MD or DO), years in practice at the current location, urban-rural location, and number of physicians in the practice. One market variable, the ratio of primary care physicians to population in the county of the physician's practice, was also included in the regression. This ratio was calculated by taking the number of physicians in the county who met the criteria for full-time primary care over the county population as reported in the 1990 census.RESULTSTable 1shows the demographics of the respondents, as well as the association between previous experience working with an NP and physician characteristics. Of the 259 respondents, 82.6% were male, the mean age was 47 years, and 61.8% were family practice physicians. Respondents reported an average of 14 years of practice at their current location and saw an average of 30 patients a day.Table 1. Physician and Practice Characteristics Related to Experience Working With a Nurse Practitioner*CharacteristicsExperience Working With a Nurse PractitionerTotal (N=259)No Experience (n=150)Experience (n=109)Age, y (χ23=4.49, P=.21)<3512 (44)15 (56)27(10)35-4461 (56)47 (44)108(42)45-5437 (57)28 (43)65(25)≥5540 (68)19 (32)59(23)Sex (χ21=0.41, P=.52)Male122 (57)92 (43)214(83)Female28 (62)17 (38)45(17)Area of practice† (χ24=24.12, P<.001)Family99 (62)61 (38)160(62)General20 (69)9 (31)29(11)Internal medicine20 (74)7 (26)27(10)Pediatrics5 (22)18 (78)23(9)Obstetrics/gynecology6 (30)14 (70)20(8)Degree (χ21=0.39, P=.53)MD123 (59)86 (41)209(81)DO27 (54)23 (46)50(19)Years in practice† (χ24=9.72, P=.05)<1064 (54)54 (46)118(46)10-1942 (51)40 (49)82(32)20-2926 (79)7 (21)33(13)30-3914 (67)7 (33)21(8)≥404 (80)1 (20)5(2)Practice location (χ27=7.21, P=.41)Metropolitan 250,000-1 million36 (58)26 (42)62(24)Metropolitan <250,00032 (46)37 (54)69(27)Urban ≥20,000, near metropolitan9 (64)5 (36)14(5)Urban ≥20,000, far from metropolitan25 (69)11 (31)36(14)Urban 2500-19,999, near metropolitan15 (62)9 (38)24(9)Urban 2500-19,999, far from metropolitan26 (59)18 (41)44(17)Rural <2500, near metropolitan3 (60)2 (40)5(2)Rural <2500, far from metropolitan4 (80)1 (20)5(2)No. of full-time physicians in practice† (χ24=10.59, P=.03)133 (65)18 (35)51(20)2-466 (63)38 (37)104(40)5-728 (56)22 (44)50(19)8-107 (29)17 (71)24(9)≥1116 (55)13 (45)29(11)*Data are given as number (percentage).†Statistically significant (χ2, P<.05).Forty-two percent of the physicians had worked with an NP providing primary care services. The χ2analyses showed that physicians in pediatrics and obstetrics-gynecology were significantly more likely to have had experience with an NP (78% and 70%, respectively) compared with those in family practice (38%), general practice (31%), or general internal medicine (26%). Physicians who had worked with NPs also were significantly more likely to have been in practice for fewer than 20 years and were more likely to be in practices with 5 or more physicians. Geographic location, physician type (MD vs DO), physician age, and sex were not significantly related in bivariate relationships to having experience with NPs.Physicians who had experience with NPs had significantly different responses from those without experience on 6 of the 11 attitudinal items (Table 2). Physicians who had worked with an NP were more likely to disagree that NPs provide lower-quality primary care than physicians. However, they were more likely to agree that hiring an NP would attract new patients to a practice, that NPs should be allowed to prescribe commonly used drugs, that patients would be accepting of an NP, that NPs bring a different yet positive dimension of care to a practice, and that employing an NP would increase a physician's time for activities other than patient care.Table 2. Attitudes Toward Nurse Practitioners (NPs) by Previous Experience With an NP Providing Primary Care (N=259)Statements Regarding NPsExperience With NPs*% of Respondents†Strongly DisagreeNeutralStrongly Agree12345Employing an NP to provide primary care increases a physician's chance of being sued for malpractice more than hiring a staff nurse (χ2=6.85, P=.14)No Yes7 1719 1836 3429 239 8NPs should be allowed to practice independently in underserved areas (χ2=1.31, P=.86)No Yes35 3734 2813 1511 147 7NPs provide lower-quality primary care than physicians‡ (χ2=19.54, P=.001)No Yes3 1520 2139 2519 2819 12Hiring an NP can attract new patients to a practice‡ (χ2=12.02, P=.02)No Yes9 517 1242 3728 324 15Use of a lower-cost NP is unfair to other physicians in the area (χ2=5.25, P=.26)No Yes10 1728 2943 4313 97 3NPs can provide 80% or more of the primary care services of a physician (χ2=3.61, P=.46)No Yes23 1733 3424 2416 164 9NPs should be allowed to prescribe commonly used drugs‡ (χ2=11.94, P=.02)No Yes40 2317 1613 1824 325 12Patients are willing to accept seeing an NP for some of their primary care‡ (χ2=19.37, P=.001)No Yes6 213 1733 1742 456 19NPs bring a different yet positive dimension of care to a physician's practice‡ (χ2=21.21, P<.001)No Yes9 310 1442 2734 385 19Employing an NP would increase a physician's time for activities other than patient care‡ (χ2=11.66, P=.02)No Yes9 617 1932 3339 284 15NPs are needed to improve access to primary care services in rural areas (χ2=7.15, P=.13)No Yes15 615 1531 3231 348 14*No, n=150; yes, n=109.†Percentages may not total 100% due to rounding.‡Statistically significant (χ2, P<.05).Responses to these 11 attitudinal items were combined to create an attitudinal scale score for each respondent, which was used as the dependent variable in the multivariate analysis. The ordinary least-squares regression showed that physicians having previous experience working with NPs providing primary care had a significantly more positive attitude toward NPs (Table 3). Physicians practicing in urban areas with populations greater than 20,000 but far from a metropolitan area were also more likely to have a positive attitude toward NPs compared with physicians in metropolitan areas with populations less than 250,000. Physicians in obstetrics-gynecology had significantly more favorable attitudes toward NPs than family practitioners did. Other variables, including age, sex, physician type (MD vs DO), years in practice, and practice size, were not significantly related to physician attitude.Table 3. Factors Significantly Affecting the Attitudes of 259 Physicians Toward Nurse Practitioners Providing Primary Care (Ordinary Least Squares Regression)*DescriptionRegression Coefficient (SE)Standardized Regression Coefficient (β)PExperience with a nurse practitioner providing primary care (experience coded as 1)−0.2600 (0.1029)−0.1687.01Obstetrics-gynecology specialization (family practice=0)0.3738 (0.1838)0.1312.04Sex (male=0)−0.1419 (0.1292)−0.0707.27Urban ≥20,000, far from metropolitan0.3444 (0.1589)0.1566.03*Adjusted R2=0.04; regression coefficient for constant=3.0028. Variables tested that were not significantly related to physician attitudes were specialization in general practice, pediatrics, or general internal medicine; type of degree (MD, DO); age; sex; years in practice at current location; primary care physician–population ratio; practice size; and practice location (metropolitan >250,000, urban ≥20,000 near metropolitan, urban ≥20,000 far from metropolitan, 2500-19,999 near metropolitan, 2500-19,999 far from metropolitan, rural near metropolitan, rural far from metropolitan).COMMENTThese results indicate that physicians have supportive attitudes toward NPs. Not surprisingly, physicians who had worked with NPs had a more positive attitude toward the role of the NP and the NP's ability to enhance the provision of primary care services than those who had no direct experience. Although the direction of this relationship is not known (did experience with NPs produce a more positive attitude or did physicians with a more positive attitude self-select a practice with NPs?), the former is more likely, particularly in large group practices where physicians are unlikely to choose a practice setting based solely or even principally on the practice's use of NPs.The finding that work experience produces a more positive physician attitude toward primary care NPs may have implications for the training of both physicians and NPs. Although there is an increasing number of interdisciplinary primary care training programs outside of academic health centers, many experts are calling for expanding these efforts further.Although not a new idea, the results of this study support initiatives to encourage interdisciplinary training as an effective way to begin the process of mutual understanding and respect between professionals that can continue throughout their practice careers.Collaborative practice models can enhance the quality and cost-effectiveness of health care.In a recent study of nurse-midwife and physician collaborative practice, 92% of the midwives reported conflicts caused by physicians' lack of understanding of nurse-midwifery, yet most (95%) indicated that these situations improved over time.Such improvement is likely if increased knowledge of the abilities of the midwife leads to increased physician trust.Future research should be directed at developing and evaluating education models that enhance mutual understanding among professions. Examining NP attitudes toward physicians could also suggest ways to improve working relationships between these 2 groups of providers. Efforts to describe the nature and amount of experience that physicians have had with NPs would provide additional information that would be useful in determining if these factors influence attitudes. Research is also required to determine the mix of health care providers necessary to produce high-quality, cost-effective health care. This is a difficult task, but it is critically important in our rapidly changing health care environment.LHAikenMESalmonHealthcare workforce priorities: what nursing should do now.Inquiry.1994;31:318-329.FMullanMLRivoRMPolitzerDoctors, dollars and determination: making physician work-force policy.Health Aff (Millwood).1993;12(suppl):138-151.Pew Health Professions CommissionPrimary Care Workforce 2000: Federal Policy Paper.San Francisco, Calif: UCSF Center for the Health Professions; 1994.BBanahanTSharpeAttitudes of Mississippi physicians toward nurse practitioners.J Miss State Med Assoc.1979;20:197-201.TSharpeBBanahanEvaluation of the use of rural health clinics: attitudes and behaviors of primary care physicians in service areas of nurse practitioner clinics.Public Health Rep.1982;97:566-571.RJohnsonDFreebornComparing HMO physicians' attitudes towards NPs and PAs.Nurse Pract.1986;11:39-49, 53.MLouisCSaboNurse practitioners: need for and willingness to hire as viewed by nurse administrators, nurse practitioners, and physicians.J Am Acad Nurse Pract.1994;6:113-119.MAButlerCLBealeRural-Urban Continuum Codes for Metro and Nonmetro Counties.Washington, DC: Agricultural and Rural Economy Division, Economic Research Services, US Dept of Agriculture; 1993. Staff report AGES 9425.Not AvailableDuluth's medical school launches interdisciplinary rural program.Rural Health News.1997;4(1):6.Not AvailableSpeakers call for community-based primary care training: conference report: Third National Primary Care Conference.Prim Care Weekly.1997;3(10):1.LNicholsEstimating the cost of underusing advanced practice nurses.Nurs Econ.1992;10:343-351.PPrescottCost-effective primary care providers.Int J Technol Assess Health Care.1994;10:249-257.JRecordSSchweitzerPotential effects on staffing and cost: estimates from the model.In: Record J, ed. Staffing Primary Care in 1990: Physician Replacement and Cost Savings.New York, NY: Springer Publishing Co Inc; 1979:87-114. Springer Series on Health Care and Society; vol 6.SMillerTKingPLurieCertified nurse-midwife and physician collaborative practice.J Nurse Midwifery.1997;42:308-315.Accepted for publication May 28, 1998.This study was supported in part by the Iowa Department of Human Services, Des Moines.Nancy Ridenour, PhD, FNC, Texas Tech School of Nursing, assisted with the development of the survey instrument.Reprints not available from the authors.
Journal
Archives of Family Medicine – American Medical Association
Published: May 1, 1999