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Nurses and physicians attempt to define collaboration and practice roles
JULY 1995, VOL 62, NO 1 LEGISLATION
Nurses and physicians attempt to define collaboration and practice roles rganized nursing and medicine continue to debate how nurses and physicians should interact. The American Nurses Association (ANA) believes that nurses need to be valued more as colleagues who have clear expertise in many areas and who do not always need physician supervision. The American Medical Association (AMA) believes that physicians and nurses should work together but that physicians should remain the leaders because they have more training and expertise. These two groups are working together to find common ground by defining collaboration, discussing independent practice standards for nurses, defining primary care and the need for additional primary care providers, and discussing whether nurses are qualified to provide primary care. Several state legislatures already have decided that nurses are cost-efficient, capable primary care providers and have, therefore, approved expanded nursing practice roles. DEFINING COLLABORATION Both the ANA and the AMA agree that physicians and nurses need to work as a team, but the ANA believes that collaboration does not always mean physician supervision. Advanced practice nurses (APNs) collaborate with, consult with, and refer patients to other health care providers, including physicians, when appropriate. Their practice patterns should not be prescribed by law,
according to the ANA. The AMA insists that every team needs a leader and that only a physician can fill that role-a position the ANA steadfastly opposes. The AMA states that it will continue to seek a compromise with nurses, however.’ The AMA and ANA have established a mutually agreedupon definition of nurse-physician collaboration, although both groups agree that many points of contention remain between the groups.? The nurses believe the definition needs to focus more on “working interdependently” with “shared values and mutual acknowledgment and respect for each other’s contribution.” The AMA Council on Medical Services proposes that the the term integralion rather than the term collaboration be used and that integration focus on “mutually agreed-upon guidelines” that reflect each group’s qualifications. One model offered for collaboration is the nurse-physician primary care team. Under this plan, nurses with additional clinical training would work with physicians to provide primary care. The team concept is predicted to be especially effective in rural and underserved areas because neither the physician nor the nurse practitioner (NP) would have to be on call constantly, and both would have a colleague with whom to interact. The issue that arises with teams is that of liability. Physicians are wary of such arrangements, arguing that they would be 107 AORN JOURNAI,
giving up control while retaining liability for the nurses’ actions. Nurse practitioners argue that they have the same amount of professional liability coverage as physicians and a much lower incidence of malpractice suits.j INDEPENDENT PRACTICE Nurses want unnecessary physician supervision removed as a barrier to their full scope of practice. One of the most controversial and defining aspects of independent practice is the ability to write prescriptions. Nearly all 50 states authorize NPs to write prescriptions, although the states differ widely in the degree of autonomy they grant. Only 21 states and Washington, DC, allow NPs independent prescriptive authority, and only 15 states allow NPs authority to prescribe controlled substance^.^ Of the states in which nurses have independent prescriptive authority, most limit that authority to rural areas and/or outpatient services, according to the ANA, which believes that such restrictions are arbitrary and should be abolished. An RN who is qualified to write a prescription in a rural community health center is equally qualified to do so in an urban setting. Some physician groups believe that it is acceptable for APNs to have prescriptive authority; however, they believe that it should be under the supervision of physicians, who would monitor nurses and devise protocols for them.5
JULY 1995, VOL 62, NO I
DEFINING PRIMARY CARE Primary care can be defined as preventive, diagnostic, therapeutic, and rehabilitative services that are oriented toward providing first-contact care and continuing relationships as well as coordinating other health services.6Primary health care is basic, initial health care for general complaints. It involves providing continuous, comprehensive, family-centered care; managing current health care needs; preventing future problems; and referring to specialists when appr~priate.~ Primary care services include physical examinations, screenings, immunizations, prenatal care, and treatment of acute and chronic illnesses. Because primary care practitioners tend to focus on the health care needs of “the whole patient” rather than on specific organ systems or diseases, primary care providers often are credited with keeping health care costs under control by preventing i l l n e s ~ . ~ Refining the definition of primary care is one task of the Institute of Medicine (IOM). An IOM panel is exploring the need for different practitioner mixes in various settings and developing a strategic plan for increasing the US health care system’s emphasis on primary care.y The IOM is addressing the opportunities for and challenges of placing greater emphasis on primary care. The provisional definition of primary care adopted by the 10M is that
primary care is the provision of integrated, accessible heulth c‘crr~services by clinicians who are accountahle,for addressing a large majority of personal
Hospitals will have difficulty recruiting primary care providers well into the twenty-first
health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.io The five critical assumptions that serve as the basis for this definition are that R primary care will be the logical foundation of an effective health care system because it addresses a majority of the health care problems in the population; 111 primary care will be essential to achieving quality care, patient satisfaction, and the efficient use of resources; R personal interactions (eg, trust, partnership between patients and clinicians) will remain central to primary care; R primary care will place stronger emphasis on health promotion and disease prevention and care of the chronically ill, especially among elderly patients who have multiple problems; and R the trend toward integrated health care delivery systems will continue.“ THE NEED FOR ADDITIONAL PRIMARY CARE PROVIDERS In 1930, 80% of all physicians worked in primary care practices. Only 30% of all physicians today practice in primary care, and a maldistribution of primary care 108 AORN JOURNAL
physicians has intensified the shortage of primary care in rural and inner-city areas.’* Some experts predict that medicine one day will be completely specialized, leaving primary care to nurses. They argue that unless NPs are given expanded rolea, generalist physicians will not be able to meet the growing demand for primary care. Such predictions remain open to debate, however, as medical students begin to show new interest in primary care.’? With the demise of comprehensive health care reform, some experts predict that the demand for primary care providers will not rise significantly. An independent study that simulated projected growth of managed care, based on health maintenance organizations staffing patterns, concluded that the supply of primary care providers would be adequate through the turn of the century.I4 Many groups, including the A M A , disagree, predicting that hospitals will continue to have difficulty recruiting primary care physicians until well into the twenty-first century.ls The Council on Graduate Medical Education agrees. As the 37 million uninsured Americans are gradually integrated into the system, more primary care providers will be needed to provide care for them. The Council estimates that it will take until the year 2040 to recruit and educate enough primary care physicians to meet the health care demands of these individuals.Ih As a result of these predictions, the federal government continues to encourage other primary care professionals, including physician assistants, NPs, certified nurse
JULY 1995, VOL 62, NO 1
midwives (CNMs), and other clinicians to work with physicians to meet staffing needs. The Clinton administration hopes to ease this transition by expanding the scope of practice for some of these groups, particularly NPs.”
ARE NURSES QUALIFIED TO FILL THE PRIMARY CARE PROVIDER ROLE? The ANA estimates that NPs can provide 60% to 80% of all primary care services, and the US Office of Technology Assessment (OTA) agrees with the 80% figure.18The AMA disagrees with the suggestion that NPs could handle up to 80% of what primary care physicians do, saying the OTA report fails to recognize that physician expertise is most needed at the “front end” (ie, the diagnostic stage) of the medical assessment process.19 Further, the AMA contends that NPs lack necessary medical knowledge and expertise to practice independently. While NPs can have as little as six years of higher education, physicians have 11 years or more. Moreover, notes the AMA, RN education, the basis for entry into NP programs, varies widely, as does NP education.20 The ANA disagrees, stating that the practices of NPs have been evaluated since 1965 and that when measures of diagnostic certainty, management competence and comprehensiveness, quality, and cost are used, virtually every study indicates that the primary care provided by nurses is equivalent or superior to that provided by physicians.21Organized medicine says that studies have not proven that APNs are just as qualified as physicians to provide primary care, as organized nursing claims.
THE COST ISSUE One purported advantage to using NPs to augment and/or deliver primary care services is cost. Nursing leaders say that the cost of seeing an NP is approximately 20% to 40% lower than the cost of
Primary care provided by nurses is equivalent or superior to that provided by physicians.
is seeing the formation of managed care networks around major hospitals, one medical center granted NPs admitting privileges.26 The decision was based on a major “paradigm shift,” further blurring the line between what nurses and physicians do. Oregon. Oregon NPs have had independent prescriptive authority since 1979, and contrary to physicians’ fears, there was no great rush of nurses into private practice and no quality crisis as well as no increase in patients’ complaints about N F S . ~ ~
South Dakota, Texas, and Wyoming. These states are
addressing supervision of nonphysician providers.28 Tennessee. When the state implemented TennCare, a demonstration program that is attempting to privatize Medicaid, progress seeing a physician?* Nurse practiwas slowed when hundreds of tioners cost less to educate than Tennessee physicians dropped out physicians, and they earn less of the state’s largest managed care money. In fact, the direct educaplan because private participation tional costs for NPs are about one was tied to treating TennCare fifth of those for phy~icians.~~ The patients. Tennessee attempted to OTA said 1985 educational costs make up for sparse physician parfor physicians were $86,100 and ticipation by expanding NPs’ educational costs for NPs were scope of practice soon after the $14,600 family practice physicians earn about $100,000 per year, program was implemented.29 Washington, DC. In Washingwhile primary care NPs typically ton, DC, APNs can practice withearn $45,000 to $50,000 per year.” out collaborating with physicians or having written protocol agreeINDIVIDUAL STATES DEFINE ments, due to an amendment by NURSING PRACTICE ROLES the city council. The amendment Although federal legislation is allows NPs, CNMs, certified regnot likely to improve the situation istered nurse anesthetists, and clinfor APNs much in the immediate future, several states are taking the ical nurse specialists to provide their services without physician initiative and implementing scope collaboration or protocol agreeof practice changes that increase m e n t ~Local . ~ ~ medical society nurses’ responsibilities. Alabama. Alabama APNs were officials want Congress to repeal the changes, warning that local granted authority to prescribe health care will evolve into a twoschedule 111 and V medications and schedule I1 as appr~priate.~~ tiered system if the ruling is New York. In New York, which allowed to stand: wealthy, insured 109 AORN JOURNAL
JULY 1995, VOL 62, NO 1
patients will continue to be treated by physicians, while uninsured, poor patients will have to seek care primarily from less-well-educated nurses. Physicians claim the amendment gives nurses the right to practice medicine, although nursing officials say that because nurses are not educated to practice medicine, and the law requires that APNs practice within the scope of their education and training, the physicians’ claims are grossly exaggerated. Physicians also find irony in the timing of nursing’s push for independent practice. They cite ANA’s protests alleging that hospitals are endangering patient care by replacing RNs with aides as a cost-saving device, while nurses at the same time are doing the same thing by
trying to push NPs as a low-cost alternative to physicians.3’ WlSCOnSln. Wisconsin has established special programs to encourage the use of NPs and other primary care providers in rural areas. A 1992 rural task force report called for expanding programs to health care professionals, in addition to primary care physicians, to meet the health care needs of the rural population. Both of these programs complement existing programs that deal with primary care physician^.^^
CONCLUSION Physicians are not ready to give up their claim to primary care, just as nurses are not ready to give up certain practices to unlicensed assistive personnel. Physicians are alarmed about
NOTES 1. L Page, “Nurses, physicians reconsider relationships,” American Medical News, 5 Dec 1994,39. 2. J L Smith, “The primary question,” Health Systems Review 27 (May/June 1994) 17. 3. L Page, “Some nurses moving toward independence, wider practice,” American Medical News, 21
March 1994,35-36. 4. V T Betts, “Removing practice barriers,” (PointKounterpoint) Health Systems Review 27 (Mdy/June 1994) 18. 5. L Page, “Delegates grapple with nurses’ role in primary care,” American Medical News, 19 Dec 1994,8. 6. Smith, “The primary question,” 12. 7. Betts, “Removing practice barriers,” 18. 8. Smith, “The primary question,” 13. 9. F Kostreski, “Consensus sought on defining primary care,”AHA News, 12 Dec 1994,3. 10. M Edmunds, “IOM hearing on primary care,” (Inside Washington)NPnews 3 (JanuaryPebruary 1995) 1I. 11. Ibid. 12. Smith, “The primary question,” 12. 13. Page, “Nurses, physicians reconsider relationships,” 36. 14. J P Weiner, “Forecasting the effects of health reform on US physician workforce requirement,” Journal of the American Medical Association 272 (July 20, 1994) 228. 15. Smith, “The primary question,” 13.
NPs’ drive for independent practice, but they have endorsed a plan to cooperate with nurses in health care teams. Perhaps if nursing addresses the educational requirements for APNs and develops standards, the medical community will have more confidence in nursing’s ability to provide quality primary care. Regardless of what organized medicine believes about nurses’ ability to provide quality care, states are moving ahead and approving expanded practice roles for APNs. Nurses can use these opportunities to prove their ability by example, as in Oregon, and to increase acceptance in the community as the qualified, cost-effective health care providers they are. LYNN HOLLADAY A V E R Y ASSOCIATEEDITOR
16. Betts, “Removing practice baniers,” 18. 17. Smith, “The primary question,” 13. 18. Ibid, 16. 19. J Green, “Are they qualified?”AHA News 30 (May 30, 1994) 7. 20. Page, “Some nurses moving toward independence, wider practice,” 35-36. 21. Betts, “Removing practice barriers,’’ 19. 22. Ibid. 23. Smith, “The primary question,” 16. 24. Ibid. 25. T Gaffney, State Legislative Quarterly Update (memorandum, Washington, DC: American Nurses Association, May 2, 1995) 2. 26. Page, “Nurses, physicians reconsider relationships,” 36. 27. Page, “Some nurses moving toward independence, wider practice,” 36. 28. Gaffney, State Legislative Quarterly Update, 2. 29. Smith, The primary question,” 12, 14. 30. “D.C. council eases practice rules, but is subject to vote in Congress,” Legislative Network for Nurses 12 (Jan 25, 1995) 11; B McCormick, “D.C. doctors, nurses square off over practice privileges,” American Medicul News, 1 Mdy 1995,6. 31. McCormick, “D.C. doctors, nurses square off over practice privileges,” 7. 32. M Edmunds, “State news,”NPuews 3 (J‘anuary/ February 1995) 14.
110 AORN JOURNAL
Nurses and physicians attempt to define collaboration and practice roles rganized nursing and medicine continue to debate how nurses and physicians should interact. The American Nurses Association (ANA) believes that nurses need to be valued more as colleagues who have clear expertise in many areas and who do not always need physician supervision. The American Medical Association (AMA) believes that physicians and nurses should work together but that physicians should remain the leaders because they have more training and expertise. These two groups are working together to find common ground by defining collaboration, discussing independent practice standards for nurses, defining primary care and the need for additional primary care providers, and discussing whether nurses are qualified to provide primary care. Several state legislatures already have decided that nurses are cost-efficient, capable primary care providers and have, therefore, approved expanded nursing practice roles. DEFINING COLLABORATION Both the ANA and the AMA agree that physicians and nurses need to work as a team, but the ANA believes that collaboration does not always mean physician supervision. Advanced practice nurses (APNs) collaborate with, consult with, and refer patients to other health care providers, including physicians, when appropriate. Their practice patterns should not be prescribed by law,
according to the ANA. The AMA insists that every team needs a leader and that only a physician can fill that role-a position the ANA steadfastly opposes. The AMA states that it will continue to seek a compromise with nurses, however.’ The AMA and ANA have established a mutually agreedupon definition of nurse-physician collaboration, although both groups agree that many points of contention remain between the groups.? The nurses believe the definition needs to focus more on “working interdependently” with “shared values and mutual acknowledgment and respect for each other’s contribution.” The AMA Council on Medical Services proposes that the the term integralion rather than the term collaboration be used and that integration focus on “mutually agreed-upon guidelines” that reflect each group’s qualifications. One model offered for collaboration is the nurse-physician primary care team. Under this plan, nurses with additional clinical training would work with physicians to provide primary care. The team concept is predicted to be especially effective in rural and underserved areas because neither the physician nor the nurse practitioner (NP) would have to be on call constantly, and both would have a colleague with whom to interact. The issue that arises with teams is that of liability. Physicians are wary of such arrangements, arguing that they would be 107 AORN JOURNAI,
giving up control while retaining liability for the nurses’ actions. Nurse practitioners argue that they have the same amount of professional liability coverage as physicians and a much lower incidence of malpractice suits.j INDEPENDENT PRACTICE Nurses want unnecessary physician supervision removed as a barrier to their full scope of practice. One of the most controversial and defining aspects of independent practice is the ability to write prescriptions. Nearly all 50 states authorize NPs to write prescriptions, although the states differ widely in the degree of autonomy they grant. Only 21 states and Washington, DC, allow NPs independent prescriptive authority, and only 15 states allow NPs authority to prescribe controlled substance^.^ Of the states in which nurses have independent prescriptive authority, most limit that authority to rural areas and/or outpatient services, according to the ANA, which believes that such restrictions are arbitrary and should be abolished. An RN who is qualified to write a prescription in a rural community health center is equally qualified to do so in an urban setting. Some physician groups believe that it is acceptable for APNs to have prescriptive authority; however, they believe that it should be under the supervision of physicians, who would monitor nurses and devise protocols for them.5
JULY 1995, VOL 62, NO I
DEFINING PRIMARY CARE Primary care can be defined as preventive, diagnostic, therapeutic, and rehabilitative services that are oriented toward providing first-contact care and continuing relationships as well as coordinating other health services.6Primary health care is basic, initial health care for general complaints. It involves providing continuous, comprehensive, family-centered care; managing current health care needs; preventing future problems; and referring to specialists when appr~priate.~ Primary care services include physical examinations, screenings, immunizations, prenatal care, and treatment of acute and chronic illnesses. Because primary care practitioners tend to focus on the health care needs of “the whole patient” rather than on specific organ systems or diseases, primary care providers often are credited with keeping health care costs under control by preventing i l l n e s ~ . ~ Refining the definition of primary care is one task of the Institute of Medicine (IOM). An IOM panel is exploring the need for different practitioner mixes in various settings and developing a strategic plan for increasing the US health care system’s emphasis on primary care.y The IOM is addressing the opportunities for and challenges of placing greater emphasis on primary care. The provisional definition of primary care adopted by the 10M is that
primary care is the provision of integrated, accessible heulth c‘crr~services by clinicians who are accountahle,for addressing a large majority of personal
Hospitals will have difficulty recruiting primary care providers well into the twenty-first
health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.io The five critical assumptions that serve as the basis for this definition are that R primary care will be the logical foundation of an effective health care system because it addresses a majority of the health care problems in the population; 111 primary care will be essential to achieving quality care, patient satisfaction, and the efficient use of resources; R personal interactions (eg, trust, partnership between patients and clinicians) will remain central to primary care; R primary care will place stronger emphasis on health promotion and disease prevention and care of the chronically ill, especially among elderly patients who have multiple problems; and R the trend toward integrated health care delivery systems will continue.“ THE NEED FOR ADDITIONAL PRIMARY CARE PROVIDERS In 1930, 80% of all physicians worked in primary care practices. Only 30% of all physicians today practice in primary care, and a maldistribution of primary care 108 AORN JOURNAL
physicians has intensified the shortage of primary care in rural and inner-city areas.’* Some experts predict that medicine one day will be completely specialized, leaving primary care to nurses. They argue that unless NPs are given expanded rolea, generalist physicians will not be able to meet the growing demand for primary care. Such predictions remain open to debate, however, as medical students begin to show new interest in primary care.’? With the demise of comprehensive health care reform, some experts predict that the demand for primary care providers will not rise significantly. An independent study that simulated projected growth of managed care, based on health maintenance organizations staffing patterns, concluded that the supply of primary care providers would be adequate through the turn of the century.I4 Many groups, including the A M A , disagree, predicting that hospitals will continue to have difficulty recruiting primary care physicians until well into the twenty-first century.ls The Council on Graduate Medical Education agrees. As the 37 million uninsured Americans are gradually integrated into the system, more primary care providers will be needed to provide care for them. The Council estimates that it will take until the year 2040 to recruit and educate enough primary care physicians to meet the health care demands of these individuals.Ih As a result of these predictions, the federal government continues to encourage other primary care professionals, including physician assistants, NPs, certified nurse
JULY 1995, VOL 62, NO 1
midwives (CNMs), and other clinicians to work with physicians to meet staffing needs. The Clinton administration hopes to ease this transition by expanding the scope of practice for some of these groups, particularly NPs.”
ARE NURSES QUALIFIED TO FILL THE PRIMARY CARE PROVIDER ROLE? The ANA estimates that NPs can provide 60% to 80% of all primary care services, and the US Office of Technology Assessment (OTA) agrees with the 80% figure.18The AMA disagrees with the suggestion that NPs could handle up to 80% of what primary care physicians do, saying the OTA report fails to recognize that physician expertise is most needed at the “front end” (ie, the diagnostic stage) of the medical assessment process.19 Further, the AMA contends that NPs lack necessary medical knowledge and expertise to practice independently. While NPs can have as little as six years of higher education, physicians have 11 years or more. Moreover, notes the AMA, RN education, the basis for entry into NP programs, varies widely, as does NP education.20 The ANA disagrees, stating that the practices of NPs have been evaluated since 1965 and that when measures of diagnostic certainty, management competence and comprehensiveness, quality, and cost are used, virtually every study indicates that the primary care provided by nurses is equivalent or superior to that provided by physicians.21Organized medicine says that studies have not proven that APNs are just as qualified as physicians to provide primary care, as organized nursing claims.
THE COST ISSUE One purported advantage to using NPs to augment and/or deliver primary care services is cost. Nursing leaders say that the cost of seeing an NP is approximately 20% to 40% lower than the cost of
Primary care provided by nurses is equivalent or superior to that provided by physicians.
is seeing the formation of managed care networks around major hospitals, one medical center granted NPs admitting privileges.26 The decision was based on a major “paradigm shift,” further blurring the line between what nurses and physicians do. Oregon. Oregon NPs have had independent prescriptive authority since 1979, and contrary to physicians’ fears, there was no great rush of nurses into private practice and no quality crisis as well as no increase in patients’ complaints about N F S . ~ ~
South Dakota, Texas, and Wyoming. These states are
addressing supervision of nonphysician providers.28 Tennessee. When the state implemented TennCare, a demonstration program that is attempting to privatize Medicaid, progress seeing a physician?* Nurse practiwas slowed when hundreds of tioners cost less to educate than Tennessee physicians dropped out physicians, and they earn less of the state’s largest managed care money. In fact, the direct educaplan because private participation tional costs for NPs are about one was tied to treating TennCare fifth of those for phy~icians.~~ The patients. Tennessee attempted to OTA said 1985 educational costs make up for sparse physician parfor physicians were $86,100 and ticipation by expanding NPs’ educational costs for NPs were scope of practice soon after the $14,600 family practice physicians earn about $100,000 per year, program was implemented.29 Washington, DC. In Washingwhile primary care NPs typically ton, DC, APNs can practice withearn $45,000 to $50,000 per year.” out collaborating with physicians or having written protocol agreeINDIVIDUAL STATES DEFINE ments, due to an amendment by NURSING PRACTICE ROLES the city council. The amendment Although federal legislation is allows NPs, CNMs, certified regnot likely to improve the situation istered nurse anesthetists, and clinfor APNs much in the immediate future, several states are taking the ical nurse specialists to provide their services without physician initiative and implementing scope collaboration or protocol agreeof practice changes that increase m e n t ~Local . ~ ~ medical society nurses’ responsibilities. Alabama. Alabama APNs were officials want Congress to repeal the changes, warning that local granted authority to prescribe health care will evolve into a twoschedule 111 and V medications and schedule I1 as appr~priate.~~ tiered system if the ruling is New York. In New York, which allowed to stand: wealthy, insured 109 AORN JOURNAL
JULY 1995, VOL 62, NO 1
patients will continue to be treated by physicians, while uninsured, poor patients will have to seek care primarily from less-well-educated nurses. Physicians claim the amendment gives nurses the right to practice medicine, although nursing officials say that because nurses are not educated to practice medicine, and the law requires that APNs practice within the scope of their education and training, the physicians’ claims are grossly exaggerated. Physicians also find irony in the timing of nursing’s push for independent practice. They cite ANA’s protests alleging that hospitals are endangering patient care by replacing RNs with aides as a cost-saving device, while nurses at the same time are doing the same thing by
trying to push NPs as a low-cost alternative to physicians.3’ WlSCOnSln. Wisconsin has established special programs to encourage the use of NPs and other primary care providers in rural areas. A 1992 rural task force report called for expanding programs to health care professionals, in addition to primary care physicians, to meet the health care needs of the rural population. Both of these programs complement existing programs that deal with primary care physician^.^^
CONCLUSION Physicians are not ready to give up their claim to primary care, just as nurses are not ready to give up certain practices to unlicensed assistive personnel. Physicians are alarmed about
NOTES 1. L Page, “Nurses, physicians reconsider relationships,” American Medical News, 5 Dec 1994,39. 2. J L Smith, “The primary question,” Health Systems Review 27 (May/June 1994) 17. 3. L Page, “Some nurses moving toward independence, wider practice,” American Medical News, 21
March 1994,35-36. 4. V T Betts, “Removing practice barriers,” (PointKounterpoint) Health Systems Review 27 (Mdy/June 1994) 18. 5. L Page, “Delegates grapple with nurses’ role in primary care,” American Medical News, 19 Dec 1994,8. 6. Smith, “The primary question,” 12. 7. Betts, “Removing practice barriers,” 18. 8. Smith, “The primary question,” 13. 9. F Kostreski, “Consensus sought on defining primary care,”AHA News, 12 Dec 1994,3. 10. M Edmunds, “IOM hearing on primary care,” (Inside Washington)NPnews 3 (JanuaryPebruary 1995) 1I. 11. Ibid. 12. Smith, “The primary question,” 12. 13. Page, “Nurses, physicians reconsider relationships,” 36. 14. J P Weiner, “Forecasting the effects of health reform on US physician workforce requirement,” Journal of the American Medical Association 272 (July 20, 1994) 228. 15. Smith, “The primary question,” 13.
NPs’ drive for independent practice, but they have endorsed a plan to cooperate with nurses in health care teams. Perhaps if nursing addresses the educational requirements for APNs and develops standards, the medical community will have more confidence in nursing’s ability to provide quality primary care. Regardless of what organized medicine believes about nurses’ ability to provide quality care, states are moving ahead and approving expanded practice roles for APNs. Nurses can use these opportunities to prove their ability by example, as in Oregon, and to increase acceptance in the community as the qualified, cost-effective health care providers they are. LYNN HOLLADAY A V E R Y ASSOCIATEEDITOR
16. Betts, “Removing practice baniers,” 18. 17. Smith, “The primary question,” 13. 18. Ibid, 16. 19. J Green, “Are they qualified?”AHA News 30 (May 30, 1994) 7. 20. Page, “Some nurses moving toward independence, wider practice,” 35-36. 21. Betts, “Removing practice barriers,’’ 19. 22. Ibid. 23. Smith, “The primary question,” 16. 24. Ibid. 25. T Gaffney, State Legislative Quarterly Update (memorandum, Washington, DC: American Nurses Association, May 2, 1995) 2. 26. Page, “Nurses, physicians reconsider relationships,” 36. 27. Page, “Some nurses moving toward independence, wider practice,” 36. 28. Gaffney, State Legislative Quarterly Update, 2. 29. Smith, The primary question,” 12, 14. 30. “D.C. council eases practice rules, but is subject to vote in Congress,” Legislative Network for Nurses 12 (Jan 25, 1995) 11; B McCormick, “D.C. doctors, nurses square off over practice privileges,” American Medicul News, 1 Mdy 1995,6. 31. McCormick, “D.C. doctors, nurses square off over practice privileges,” 7. 32. M Edmunds, “State news,”NPuews 3 (J‘anuary/ February 1995) 14.
110 AORN JOURNAL