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. 2002 Jul 20;325(7356):166.

Can nurse practitioners provide equivalent care to GPs?

Nurses and doctors working together can complement each other

Catherine Baraniak 1
PMCID: PMC1123683  PMID: 12130620

Editor—Horrocks et al consider whether nurse practitioners working in primary care can provide equivalent care to doctors.1 It has reinforced much of my experience as a nurse running a general practice under the auspices of a personal medical services pilot.

My practice has been open for three and a half years and operates the philosophy that patients should be seen by the most appropriate person to help them. On average, 65% of patients choose to see the nurse and a small proportion of those require referral back to a general practitioner.

Concerns for patient satisfaction arose from my need to ensure the acceptability of a nurse led service to patients. By establishing a mechanism to listen to patients' concerns about their health and including patient representatives in the management of the practice, we have developed a service with a high standard of patient satisfaction.

Some may argue that patient satisfaction is a fickle concept that is impossible to measure and that such commercial concepts have no place in healthcare provision. Using the general practice assessment survey's patient satisfaction questionnaire, our patients showed that they felt valued and commented that they thought that nurses made better listeners and had more time than doctors. In reality, this perceived time factor issue is not the case in my practice, as the nurse often sees more patients than the doctor and the doctor tends to spend more time with the patients than the nurse. This is not surprising as he tends to see important medical problems for most of his surgery. Patients also expressed confidence in the nurses' clinical abilities and are surprised that such a system has not been thought of before.

Whether this has anything to do with nurses versus doctors, I am not sure. Patients feel that they can relate better to a nurse as an equal. For this reason they may be able to communicate their needs more readily. Underneath the titles is the concept that the professional with the right skill should be the person the patient sees. Nurses and doctors working together can complement each other, generating an environment where patients receive prompt, competent care and staff enjoy job satisfaction.

References

  • 1.Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ. 2002;324:819–823. doi: 10.1136/bmj.324.7341.819. . (6 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2002 Jul 20;325(7356):166.

More studies of these nurses' technique are needed

Ian O'Connor 1

Editor—Horrocks et al state in the title of their systematic review that its focus is the role of nurse practitioners in primary care.1-1 They concede that ambiguity exists over the definition of a nurse practitioner yet go on to include studies involving nurses working in hospital departments.1-2–1-4

Before large sums of money are thrown at such projects, it would be wise to compare like with like. In addition, policy implementers ought to consider several other points not covered by Horrocks et al's review.

Firstly, general practitioner registrars in their final three months of training have a minimum of four years of postgraduate work experience, yet are deemed unfit to practise without first passing various elements of summative assessment. Nurse practitioners are not required to have their video consultation technique checked.

Secondly, if nurse practitioners wish to be considered as independent practitioners then they need to have their own comprehensive indemnity, so that litigation stops with them, rather than their employing practice.

Thirdly, during employment of a nurse practitioner on a three month trial basis, doctors at my practice asked our trainer to review each of the nurse practitioner's surgeries, as he would with a general practitioner registrar. The trainer thought that little insight was shown into why specific questions, investigations, or drugs were used. The basic understanding of the pathology and pharmacology lagged far behind the automated efficiency of following guidelines.

There certainly seems to be an evolving role for nurse practitioners, but future studies must clearly document the context in which patients are seen. There must also be some form of assessment of nurse practitioners' consultation technique, similar to that in general practice.

References

  • 1-1.Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ. 2002;324:819–823. doi: 10.1136/bmj.324.7341.819. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-2.Hoekelman RA. What constitutes adequate well-baby care? Pediatrics. 1975;55:313–326. [PubMed] [Google Scholar]
  • 1-3.Saker M, Angus J, Perrin J, Nixon C, Nicholl J, Wardrope J. Care of minor injuries by emergency nurse practitioners or junior doctors: a randomised controlled trial. Lancet. 1999;354:1321–1326. doi: 10.1016/s0140-6736(99)02447-2. [DOI] [PubMed] [Google Scholar]
  • 1-4.Cooper M. Glasgow: Accident and Emergency, Glasgow Royal Infirmary; 2001. An evaluation of the safety and effectiveness of the emergency nurse practitioner in the treatment of patients with minor injuries: a pilot study. . (Typescript.) [Google Scholar]
BMJ. 2002 Jul 20;325(7356):166.

Nurse practitioners increase access to quality health care for many patients

Rahul Gupta 1, Seema Gupta 1

Editor—A few points in Horrocks et al's systematic review are worth discussing further.2-1

Firstly, they mention the lack of difference in health outcomes between nurse practitioners and doctors. Most of the trials included in their review are short term trials not designed to determine the health outcomes of chronic diseases such as diabetes, asthma, and hypertension, which may take decades to advance.

Secondly, they highlighted higher patient satisfaction among patients seen by nurse practitioners. Patient satisfaction correlates strongly with patient adherence2-2 but, though important, is not a reliable measure of the standard of care. It certainly has no part to play in the ability to diagnose conditions and provide medical care. The fact that nurse practitioners spend more time with patients and order more tests proves their inability to diagnose conditions and provide subsequent care in a time limited and efficient manner.

The increasing shortages in the delivery of primary care facing developed nations have led to the question of how to provide cheaper care. This is central to the evolution of the nurse practitioner concept in the United States. We struggle to deal with issues concerning the cost of training health professionals, resource use, and the safety of health care.

It is naive to consider that the expert services given by doctors after their several years of training can be matched by the 24 months of training of a registered nurse. If this were true we would have stopped using doctors in primary care years ago; doctors would only be in specialty fields.

Nurse practitioners are not meant to be compared with or to replace doctors. Rather, they will increase access to quality health care for many patients whose needs are within the limited scope of their training. Unfortunately, a few of us go far beyond this simple goal and attempt to make comparisons when none exists.

References

  • 2-1.Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ. 2002;324:819–823. doi: 10.1136/bmj.324.7341.819. . (6 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2-2.Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Pract. 1998;47:213–220. [PubMed] [Google Scholar]
BMJ. 2002 Jul 20;325(7356):166.

More methodologically sound investigations are needed

William Rifkin 1,2,3, Arthur Rifkin 1,2,3, John Horiszny 1,2,3

Editor—Horrocks et al report higher levels of patient satisfaction among patients of nurse practitioners.3-1 Though this is important, it is unclear whether patient satisfaction is a valid measure of the quality of practice. Moreover, of the five trials presented that looked at patient satisfaction, three asked prospective patients whether they found it acceptable to see a nurse practitioner rather than a doctor.3-2–3-4 Thus only those patients predisposed to accept nurse practitioners were included in the studies.

The authors also report that nurse practitioners undertook more investigations and had longer consultations than did doctors. The absolute difference of less than four minutes in consultation time is of questionable clinical importance and may reflect the practice setting used by the nurse practitioners. Whether the finding that nurse practitioners ordered more tests per patient is a marker of better or worse practice is unclear; it may inflate costs.

We believe that the authors' assertions about the quality of care are not supported by the data presented. The authors state that nurse practitioners identified physical abnormalities more often than doctors did, without qualifying that the cited data are from 1975 and refer only to well-baby examinations.3-5 The observations that nurse practitioners made more complete records, communicated better, and were as proficient as doctors in ordering and interpreting x ray films are based only on patients with minor injuries seen in an accident and emergency department. It may not be reasonable to make the leap that such conclusions would hold true in adults more recently, outside the accident and emergency department, or in more seriously ill patients.

With these limitations in mind, we question the authors' ability to conclude that “nurse practitioners can provide care that leads to increased satisfaction and similar health outcomes.” Even more dubious is the conclusion that they provided care of equivalent or superior quality to that provided by doctors.

We agree with the authors that the ability of nurse practitioners to identify rare but important health problems needs further research. Although the authors mention some of the weakness of their data, they propose that their review supports the increased involvement of nurse practitioners in primary care. We think that this conclusion is out of proportion to the data presented and that patients and policymakers would be better served by using this review as an indication of the need for more methodologically sound investigations.

References

  • 3-1.Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ. 2002;324:819–823. doi: 10.1136/bmj.324.7341.819. . (6 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3-2.Venning P, Durie A, Roland M, Roberts C, Leese B. Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care. BMJ. 2000;320:1048–1053. doi: 10.1136/bmj.320.7241.1048. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3-3.Shum C, Humphreys A, Wheeler D, Cochrane MA, Skoda S, Clement S. Nurse management of patients with minor illnesses in general practice: multicentre, randomised controlled trial. BMJ. 2000;320:1038–1043. doi: 10.1136/bmj.320.7241.1038. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3-4.Kinnersley P, Anderson E, Parry K, Clement J, Archard L, Turton P. Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting “same day” consultations in primary care. BMJ. 2000;320:1043–1048. doi: 10.1136/bmj.320.7241.1043. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3-5.Hoekelman RA. What constitutes adequate well-baby care? Pediatrics. 1975;55:313–326. [PubMed] [Google Scholar]

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