 |
|
Primary Care Physician Perceptions of the Nurse Practitioner in the 1990s
Mary L. Aquilino, PhD, RN, CS, FNP;
Peter C. Damiano, DDS, MPH;
Jean C. Willard, MPH;
Elizabeth T. Momany, PhD;
Barcey T. Levy, PhD, MD
Arch Fam Med. 1999;8:224-227.
ABSTRACT
| |
Objective To evaluate factors associated with primary care physician attitudes toward nurse practitioners (NPs) providing primary care.
Design A mailed survey of primary care physicians in Iowa.
Setting and Participants Half (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 Measures There 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  2 tests, as were both dependent variables. Ordinary least-squares regression was used to determine factors related to physician attitudes toward NPs.
Results In 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.
Conclusions The 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.
INTRODUCTION
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).1-3 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.4-7 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 METHODS
With 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 physicians were defined as those who reported their area of practice as general practice, family practice, obstetrics and gynecology, general internal medicine, or pediatrics. Full-time was 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.8
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  >.6), indicating they were likely to be measuring the same construct (=.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 2 statistics. P values 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.
RESULTS
Table 1 shows 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*
|
|
|
Forty-two percent of the physicians had worked with an NP providing primary care services. The 2 analyses 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)
|
|
|
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)*
|
|
|
COMMENT
These 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.3, 9-10 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.11-13 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.14 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.
AUTHOR INFORMATION
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.
From the College of Nursing (Dr Aquilino), the Health Policy Research Program (Dr Damiano), Public Policy Center (Ms Willard and Dr Momany), and the Department of Family Medicine (Dr Levy), The University of Iowa, Iowa City.
REFERENCES
| |
1. Aiken LH, Salmon ME. Healthcare workforce priorities: what nursing should do now. Inquiry. 1994;31:318-329.
ISI
| PUBMED
2. Mullan F, Rivo ML, Politzer RM. Doctors, dollars and determination: making physician work-force policy. Health Aff (Millwood). 1993;12(suppl):138-151.
3. Pew Health Professions Commission. Primary Care Workforce 2000: Federal Policy Paper. San Francisco, Calif: UCSF Center for the Health Professions; 1994.
4. Banahan B, Sharpe T. Attitudes of Mississippi physicians toward nurse practitioners. J Miss State Med Assoc. 1979;20:197-201.
PUBMED
5. Sharpe T, Banahan B. Evaluation 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.
ISI
| PUBMED
6. Johnson R, Freeborn D. Comparing HMO physicians' attitudes towards NPs and PAs. Nurse Pract. 1986;11:39-49, 53.
PUBMED
7. Louis M, Sabo C. Nurse 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.
PUBMED
8. Butler MA, Beale CL. Rural-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.
9. Duluth's medical school launches interdisciplinary rural program. Rural Health News. 1997;4(1):6.
10. Speakers call for community-based primary care training: conference report: Third National Primary Care Conference. Prim Care Weekly. 1997;3(10):1.
11. Nichols L. Estimating the cost of underusing advanced practice nurses. Nurs Econ. 1992;10:343-351.
PUBMED
12. Prescott P. Cost-effective primary care providers. Int J Technol Assess Health Care. 1994;10:249-257.
PUBMED
13. Record J, Schweitzer S. Potential 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.
14. Miller S, King T, Lurie P, et al. Certified nurse-midwife and physician collaborative practice. J Nurse Midwifery. 1997;42:308-315.
PUBMED
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
Barriers to developing the nurse practitioner role in primary care--the GP perspective
Wilson et al.
Fam Pract 2002;19:641-646.
ABSTRACT
| FULL TEXT
|
