By Debra Wood, R.N.

Jane Dixon

hen you're down with the flu or sick with an infection, you want to see your doctor immediately. More often than not, though, there's a several-day wait that could outlast your symptoms. When this occurs, many doctors' offices will offer an earlier appointment with a nurse practitioner. And if they don't, you should ask for one.

Kerry Hillard did just that about a year ago, and she's glad. The young woman made her first appointment at Columbia Advanced Practice Nurse Associates (CAPNA), a primary-care facility staffed by master's-prepared nurses and faculty members of the Columbia University School of Nursing, in New York.

"I like the fact that they spend a lot of time with you," Hillard says. "[With nurse practitioners,] you don't feel rushed, because they are very attentive."

And besides giving plenty of time and attention, nurse practioners give high-quality care. A recent study reported in the Journal of the American Medical Association (JAMA) found nurse practitioners' quality of primary care equaled that provided by physicians. In the study, emergency-room patients were randomly assigned for follow-up either to nurse practitioners or to physicians associated with Columbia University. Patients in both groups were equally satisfied with their care and had similar improvements in their health.

"We give the patient the opportunity to look at alternative approaches to care and to try those approaches they feel will work for them," said Bob Smithing, a nurse practitioner with 19 years of experience.

Lead author Mary Mundinger, Dr.P.H., dean of Columbia's nursing school, attributes the similarities to two things. "Primary care training for the two disciplines is very much alike, and the skills learned in baccalaureate nursing education provide expertise in health education and health promotion," she explains. And as for the common concern about being rushed through appointments, Mundinger concurs with Hillard: "Nurses tend to spend more time with patients."

What exactly is a nurse practitioner?

Nurse practitioners are registered nurses with additional education and training in their field of expertise. Most hold a master's degree. A 1996 government survey determined that approximately 71,000 nurses were educated as nurse practitioners, with 50,000 in practice. During a typical office visit, they do everything a doctor does: determine what's wrong, order medications, refer to specialists, and counsel patients. Many work in rural regions or in communities with limited health-care access. More than a third practice in physicians' offices.

Each state's Nurse Practice Act determines how much autonomy nurses have in treating patients and prescribing medications. In some states, nurse practitioners work collaboratively with physicians, though not necessarily at the same location. In others, nurse practitioners can practice independently. Medicare and many insurance plans cover the visits, just as they would a physician's services.

Mundinger suspects with their current degree of prescribing authority, nurse practitioners can handle most primary care situations. "Clearly physicians know more about complex illness detection and management, but in today's system those patients are cared for by specialists," Mundinger says.

The American Medical Association (AMA), however, believes that primary care should be a collaborative effort, with the physician responsible for care and nurse practitioners working under doctors' direction. "We believe this issue revolves around protecting the quality of health care by assuring that patients receive care from the professional with the appropriate training and expertise," said AMA President Randolph D. Smoak Jr., M.D. "The ability to provide basic services must not be misinterpreted as sufficient criteria for a nurse practitioner to assume an ongoing responsibility for the overall health care of an individual patient."

How care differs

And while their level of autonomy varies between states, nurse practitioners across the country are trained to give individualized care, with an emphasis on prevention and an eye to the "big picture" of a patient's life. "We give the patient the opportunity to look at alternative approaches to care and to try those approaches they feel will work for them," said Bob Smithing, a nurse practitioner at FamilyCare in Kent, Washington, with 19 years of experience.

Indeed, various studies show that nurse practitioners are more apt than doctors to adapt treatment plans and wellness strategies to patient preferences; suggest stress-management, parenting, and other self-help activities; and order less costly services that prove equally effective. "Nurse practitioners know more about how to access community resources," Dr. Mundinger says. "They are the prevention specialists."

To promote healthy lifestyles, CAPNA nurse practitioners explain to patients like Hillard how emotions, diet, and lack of physical activities can contribute to illness.

"If you're stressed, [a nurse practitioner will] talk to you about that and ask how you are feeling about things like your love life or your job," Hillard explains. Or, she says, the nurse might "ask about your exercise habits and give you suggestions about how you can improve." These suggestions, she says, have increased her awareness about how her decisions affect her health.

Looking for more than a pharmaceutical answer to primary-care conditions, nurse practitioners help patients make healthy choices and enrich the health care experience.

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