Journal of the New Zealand Medical Association, 14-March-2003, Vol 116 No 1170
General practitioners’ perceptions of the nurse practitioner role: an exploratory study
This study forms part of a larger research project on forces influencing the development of innovative roles in primary healthcare nursing in the Northland District Health Board (NDHB) of New Zealand. The New Zealand Primary Health Care Strategy sees primary healthcare nursing as crucial to the implementation of the strategy.1
The nurse practitioner (NP) role, which originated in the United States (US), is now recognised as an enhanced nursing role working in partnership with clients, rather than just an extended nursing role with delegated medical tasks.2 A recent systematic review of research comparing nurse practitioners and doctors at first point of contact in primary care, demonstrates a higher level of client satisfaction with care provided by an NP than that provided by a doctor, with no difference in client health outcomes. However, it was found that NPs had longer consultations with clients and it was not possible to carry out an economic analysis of differences in costs.3 The authors concluded that increasing access to NPs can promote high-quality care and client satisfaction in the primary healthcare context.3
General practitioner (GP) attitudes towards advanced roles for primary healthcare nurses appear to be changing. US research found that 49% of physicians were willing to hire an NP and 47% were favourable towards the concept of an NP.4 A later study demonstrated that the more knowledgeable a physician is about the NP role, the more receptive the physician is to hiring an NP.5 Research in the UK shows that GPs are prepared to delegate to practice nurses in an extended role as well as to NPs.6 However, a US study on the perceptions of physicians towards NPs found that most doctors believe nurses should work under the direct supervision of doctors rather than in an independently collaborative manner.7 These findings have implications for the introduction of the NP role in New Zealand. The inability of nurses in New Zealand to treat, prescribe and order laboratory and diagnostic tests independently has been identified as a barrier to timely, accessible and cost-effective healthcare.8 The Ministry of Health proposes that NPs will work in independent practice or in collaborative care delivery models with GPs.9 As key stakeholders in the delivery of primary healthcare services in Northland, GPs have the potential to influence the development and introduction of NP roles. It is essential that the perceptions and concerns of GPs are identified to highlight areas of potential conflict or misunderstanding. The aim of the research was to explore perceptions of GPs in the NDHB regarding the NP role, and to identify their knowledge of and perceived problems with that role, and their experience of nurses in advanced practice.
A survey was adapted from the ‘Survey of General Practice Physicians’ Opinions Concerning the Family Nurse Practitioner’ developed by Radke.10 Questions assessed GPs’ perception of role functions, potential problems with utilising an NP, and GPs’ source of knowledge of the NP role. As the NP role is only just being introduced to New Zealand, GPs were asked about their experience of nurses who utilise ‘advanced knowledge and skills within a specialist scope of practice.’ The final questions asked GPs for information on their demographics, organisation and funding, as well as their perception of GP shortage in their community, the potential impact of the NP on enhancing care, and their opinion of working with and employing an NP. In New Zealand, the title Nurse Practitioner is legally protected and can only be used by nurses meeting the requirements of the Nursing Council of New Zealand. GPs were asked to read the following role description of an NP before completing the questionnaire:
‘Nurse Practitioners are expert in their field and use advanced knowledge and skills within their specialist scope of practice. Nurse Practitioners are educated through a clinically focused masters degree programme and must meet the competencies set out by the nursing council. These include being able to articulate and advance the scope of their nursing practice, showing expert practice and working collaboratively with other disciplines as well as across settings. Competencies also include demonstration of leadership and consultancy in nursing, active development and influence on policy and nursing practice and demonstration of research activities surrounding nursing practice. Nurse Practitioners may or may not choose to be nurse prescribers (Nursing Council of New Zealand, 2001).’
Content validity was promoted by consulting nurses with experience in research and primary healthcare nursing, a researcher with expertise in developing questionnaires, and a GP. Of the 108 questionnaires posted, 47 of the 50 returned were included in the data analysis. Approval was obtained through the ethics committees of the University of Technology, Sydney, Australia, and Northland Polytechnic, Whangarei, New Zealand. Excel® was used to analyse the data and descriptive statistics used to summarise quantitative data. An approach recommended by Dey was used to carry out content analysis of qualitative data using Microsoft Word®.11
The GPs were asked about their perceptions of the functions of the NP role. Responses ranged on a five-point scale from ‘highly favourable’ to ‘highly unfavourable’, with a middle category of ‘uncertain’. The question on the health teaching role of the NP was rated most favourably with no unfavourable responses. Also rated favourably were making home visits, participating in evaluation of care, and obtaining health histories. Rated least favourably were questions on prescribing medications under the Nurses Act, ordering routine laboratory tests, and performing a physical examination.
Table 1. GPs’ responses to the question, ‘Please tick the one response that indicates how you personally feel about the nurse practitioner performing each of the following functions.’
fav=favourable; unc=uncertain; unfav=unfavourable
The most uncertainty concerned prescribing medications under the Nurses Act. One third of GPs indicated that overall they felt uncertain about the concept of the NP. Table 1 summarises the GP responses to questions on role functions.
The second question asked about the anticipated problems and factors influencing the development of the NP role. An analysis of responses indicates that overall GPs foresee ‘some’ to ‘few’ problems with the utilisation of an NP (Table 2). The question relating to patients’ acceptance of the NP was viewed most positively. The remaining seven items were rated more negatively. The item the GPs perceived to be most problematic was funding of NP services. Table 2 outlines the GPs’ response to potential problems.
Table 2. GP responses to the question, ‘Please indicate your perception of the following potential problems in the utilisation of a nurse practitioner. Tick the one response which is most representative of your belief.’
Other concerns GPs mentioned included confidence in competence, skills and knowledge base, NPs being used as a cheap option by the Government, competition affecting income and workload, increased after-hours workload, fragmentation and duplication of services, confusion over role and professional boundaries, repeat of experience with midwives and nurses not wanting to take on the role and training required.
When asked about their knowledge of the NP role, GPs indicated they have knowledge of and have read about the NP role and most had discussed this with colleagues. The majority had experience of a nurse who ‘utilises advanced skills and knowledge within a specialist scope of practice.’
One question concerned demographics, practice settings, organisation structure, capitation, GP shortage, NP service, and willingness to employ or work with an NP. A shortage of GPs in their community was noted by 57%; 70% indicated that the services of an NP would enhance the delivery of healthcare in their community; 64% said they would be willing to employ an NP; and 86% indicated a willingness to work in collaboration with an NP.
One doctor experienced in working with NPs overseas stated, “They allow me to expand my practice and care for more clients...This could be a way for New Zealand and Northland to deal with the shortage of care providers.” Some comments referred to politics or the Government as the key driver of the NP role. It was also apparent that GPs are confused over the proposed role and legal status of the NP. Some GPs indicated that if nurses wanted to be doctors, they should go to medical school.
These findings indicate that although the overall perception of GPs regarding the NP role is favourable, there is a degree of concern about some role functions including prescribing, undertaking physical examinations and ordering laboratory tests. These functions could be seen as those traditionally belonging to the domain of the medical profession. GPs felt most favourably towards those functions that have traditionally been part of the nursing role, such as health teaching, home visiting, taking a health history, and evaluating quality and effectiveness of care. The list of role functions included in the questionnaire is not prescriptive or complete. For example, many NPs may elect not to be nurse prescribers. The focus of the NP role will not be on role functions but rather on a scope of practice. NPs will define their own scope of practice according to their area of expertise.12 If the NP has to carry out those role functions traditionally associated with medicine they will be well prepared to do so, but the emphasis will be on health promotion and disease prevention.9 The scope of practice will also be developed to meet client needs.9
Uncertainty regarding the concept of the NP and concern over legal problems and demands on doctor time indicate some role confusion regarding the NP’s scope of practice and the boundaries between the GP and NP roles. NPs will be legally accountable for their own practice or malpractice. In addition, while it appears that GPs believe that NPs would enhance services, it seems that there is still a problem with doctors’ acceptance of the NP. Comments indicate that this could be due to a perception that NPs will be in competition with doctors or will replace GPs. A concern was expressed about a repeat of the experience with midwives. This is valid in view of the fact that after midwives were enabled to provide independent care and claim reimbursement there was a reduction in the number of GPs providing maternity care.13 It is estimated that NPs can manage up to 90% of the care currently provided by doctors working in primary care.14 In this study, 57% of GPs felt there was a GP shortage in their area, therefore it is unlikely that NPs will replace current GPs in Northland. However, the fact remains that NPs can deliver some of the care currently provided by GPs. Clients should be able to access the health professional best able to meet their health needs in the most cost-effective manner.1
GPs indicated that funding was the most problematic issue. GPs have traditionally been the lead providers in primary healthcare.15 Although funding arrangements will change towards capitation for population groups, only 30% of GPs indicated that they receive capitated funds of some sort. This highlights the reliance of GPs on traditional fee-for-service funding systems for part of their income. It is proposed that new captitated funding arrangements will enable the direct funding of nursing and other services through the proposed Primary Health Organisations (PHOs).1
The comments and concerns listed by the GPs highlight the stress, uncertainty and confusion they experience in these times of rapid change in the primary healthcare system. Role confusion and frustration were evident from comments that, “If nurses want to be doctors, they should go to medical school.” Professional role boundaries will change and create further uncertainty and challenges to professional identity. Williams found that as role boundaries change, there is increasing uncertainty in professional identity for doctors as well as nurses.16
While GPs indicated that they have knowledge of the NP function, incorrect assumptions indicated that more education is required to fully inform GPs about the NP role and how NPs will fit into the context of primary healthcare in the NDHB. Areas in which GPs displayed a requirement for further information were nurse prescribing, legal issues, and funding.
The results of the current study were compared with two US studies that used versions of the same questionnaire. These were an early study of physicians in general practice in Southern California,4 and a more recent study of primary care physicians in Michigan.5 Although the results of these exploratory studies cannot be generalised to other populations, there are similarities. The current study indicates that GPs had increased knowledge of the NP role since the time of Radke’s original study in 1977.4 This is not surprising, given that the NP concept has appeared frequently in the international literature over the last 20 years. There were similar responses in GPs’ perceptions of the role functions of NPs and potential problems. In the current study and those by Radke4 and Ivkovich,5 health teaching was seen as most favourable and doctors’ acceptance of NPs problematic. While results cannot be generalised to a larger population of GPs, they indicate that there are doctors’ perceptions of the NP that carry over to the present day and the New Zealand setting.
The results of this study indicate that Northland GPs are favourable towards working with NPs and believe NPs can enhance care in the community. GPs as key stakeholders have the ability to positively or negatively influence the support and development of the NP role and models of care delivery. To promote support, it is essential that GPs be fully informed about the NP role and its potential positioning in primary healthcare in order to reduce uncertainty, minimise role confusion, and promote collaboration. The NDHB should explore opportunities to educate GPs about the NP role. Information on the NP role could be taken to GP practices in Northland via a regional version of the roadshow conducted by the Ministry of Health in 2002.17 The NDHB should also commission research to assess health outcomes as NP models of healthcare delivery are implemented. In addition, doctors who have worked overseas could share their knowledge and positive experiences of working with NPs, defusing any stress and uncertainty regarding this change.
Mutual respect and cooperation is required between doctors and nurses in Northland. NPs are potentially a valuable resource in the provision of primary healthcare. Overseas, medical organisations have fought the introduction of NPs and the perceived threat they present to the medical profession. Australia is currently experiencing this.18 However, this experience does not need to be repeated in Northland or New Zealand as a whole. Multiple studies have demonstrated that the NP role is one that has much to offer.3 The government supports the introduction of the NP.9 Medicine and nursing must move beyond professional lobbying and work together with consumers and other health professionals to develop NP models of care delivery to best meet the needs of their communities.
Author information: Bev Mackay, Doctor of Nursing Candidate, Faculty of Nursing, Midwifery and Health, University of Technology, Sydney, Australia and Senior Lecturer, Faculty of Health and Science, Northland Polytechnic, Whangarei
Acknowledgements: This research was funded by Northland Polytechnic. I am grateful to the GPs who took part in this study, and to the Northland District Health Board and Northland Polytechnic for their cooperation in enabling this study to be carried out. I also thank Dr Karen Radke and Edith Wright as developers of the original survey instrument. Finally, I acknowledge and thank my doctoral supervisors Drs Mary Chiarella and Sharon McKinley for their guiding influence, and editorial adviser Shiela Alexander for her contribution.
Correspondence: Bev Mackay, Faculty of Health and Science, Northland Polytechnic, Private Bag 9019, Whangarei. Fax (09) 432 0461; email: firstname.lastname@example.org
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