By Debra Wood, R.N.
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
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
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,"
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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