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MARCH / APRIL 2012 :: 73(2)
Oral Health

This issue's policy forum focuses on initiatives that promote oral health and on challenges the state currently faces. Commentaries discuss new practice models and trends in dental practice, dentist workforce numbers, the East Carolina University School of Dental Medicine education model, and insurance innovation in dental coverage. Several articles focus on access to oral health care in specific populations including children, adult Medicaid recipients, and people with special needs. Original articles examine reasons for tanning bed use among community college students and evaluate the effectiveness of mailed interventions to increase colon cancer screening.


Response: Encouraging Collaboration between Physicians and Advanced Practice Registered Nurses in North Carolina

Debra Barksdale, Kristen M. Swanson

N C Med J. 2012;73(2):145-146.PDF | TABLE OF CONTENTS

To the Editor—We wholeheartedly agree with Dr. Kanaan’s point in his letter to the editor that the focus of all health care professionals should be on enhancing population health and developing innovative collaborative care models that increase access and improve the health of all North Carolinians.

However, we disagree with 2 lurking assumptions that lie behind Dr. Kanaan’s central thesis, namely that (1) care delivered by “unsupervised” nurse practitioners (NPs) will endanger interprofessional collaboration; and (2) allowing North Carolina’s advanced practice registered nurses (APRNs) to practice autonomously (in his words “practicing medicine independently”) would constitute a risk to the public.

The nursing profession has its own educational standards, skills, competencies, licensure requirements, certification mechanisms, code of ethics, and legal accountability for safe practice. It is not the intent, claim, or expectation of nurses that APRNs have the full breadth of medical knowledge across all content areas in which physicians are educated to practice. APRNs build upon baccalaureate education with 2 to 3 years of intensive graduate education that prepares them to sit for a national certification exam (above and beyond the National Council Licensure Examination for Registered Nurses) and to apply for state licensure to practice as an APRN. Whether they reside in a state that allows autonomy or one that requires supervision, driven by their own professional code of ethics, advanced practice nurses provide the highest quality of care that falls within their scope of practice.

Supervisory language assumes that only one profession has both the preparation and moral obligation to safeguard the care of the public. There are no studies that provide evidence that physician supervision of APRNs results in better care, better health outcomes, or greater protection of the public. There is, however, a growing body of evidence that APRNs provide high-quality care. Indeed, as Dr. Kanaan noted, the 2009 Cochrane report [1] concluded, with a caveat, that having found only one study with sufficient power to assess equivalency of care between NPs and physicians, the report’s findings should be interpreted with caution. That one powered study, however, did not stand alone in finding that NPs and physicians provide equivalent care. Also cited in the Cochrane review were multiple smaller studies that offered corroborating evidence. Moreover, using very strict criteria to grade the weight of cumulative evidence, the Newhouse et al review [2] provides strong substantiation for the veracity of the 2010 Institute of Medicine / Robert Wood Johnson Foundation [3] assertion that APRNs, whether practicing autonomously or supervised, provide safe, effective, and high quality patient care.

A major recommendation of the IOM / RWJF report is that nurses should be able to practice to the full extent of their education and training. The report urged the Federal Trade Commission and the Antitrust Division of the Department of Justice to “review existing and proposed state regulations concerning advanced practice registered nurses to identify those that have anticompetitive effects without contributing to the health and safety of the public. States with unduly restrictive regulations should be urged to amend them to allow advanced practice registered nurses to provide care to patients in all circumstances in which they are qualified to do so” [3].

Recently, investigators from Department of Family Medicine at the University of Washington [4] examined whether NPs from states allowing autonomous practice were more likely to practice in a rural setting. They used National Provider Identifiers to approximate where certified registered nurse anesthetists (CRNAs) (N = 35,973) and NPs (N = 106,113) practiced [4]. Compared to states in which CRNAs were denied prescriptive authority, CRNAs in states allowing greater autonomy were more likely to practice in a rural location (RR 2.0, P < .001). A similar trend towards NPs practicing in a rural setting (RR 1.5, P = .075) was discovered when comparing states allowing autonomous practice to those requiring greater supervision. It is puzzling to us why Dr. Kanaan would claim that advanced practice nurses are unlikely to care for underserved populations, remain in primary care, or practice in rural settings. In a recent review of 4 years of data from 6 North Carolina state-supported graduate programs that prepare nurses for entry into advanced practice, we discovered that more than 50% of newly graduated APRNs provide care to underserved North Carolina populations and/or work in an area where there is a health professional shortage. Nationally, approximately 140,000+ NPs, (70%-80%) work in primary care including pediatrics, adult and family health, and care of women including midwifery [5].

Supervision does not assure good health outcomes. Safe care relies on respectful collaboration between providers who willingly focus their knowledge and skills on the patient before them. The capacity of all professions to practice to the full extent of their education and training enhances access to comprehensive care that includes health promotion, illness management, care coordination, and stronger health sustaining partnerships with patients, families, and communities.

The Association of American Medical Colleges projects that by 2020 there will be 45,000 fewer primary care physicians than needed to meet the care needs of the American public [6]. A logical solution to this shortage is deployment of other health care providers who have demonstrated capacity to deliver safe, affordable, high-quality care. The number of nurse practitioners entering the workforce is projected to increase by at least 9% annually [7]. Nurse practitioners are a logical, safe, cost-effective workforce to deploy in meeting the health care needs of our state and nation.

Potential conflicts of interest. All authors have no relevant potential conflicts of interest.

1. Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, and Sibbald B. Substitution of doctors by nurses in primary care (review). Cochrane Database Syst Rev. 2004:(4):CD001271.pub2. doi: 10.1002/14651858.CD001271.pub2.

2. Newhouse RP, Stanik-Hutt J, White KM, et al. Advanced practice nurse outcomes 1990-2008: a systematic review. Nurs Econ. 2011;29(5):230-251.

3. Institute of Medicine of the National Academies. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2010.

4. Skillman SM, Kaplan L, Fordyce MA, McMenamin PD, Doescher MP. Understanding Advanced Practice Registered Nurse Distribution in Urban and Rural Areas of the United States Using National Provider Identifier Data. Seattle, WA: University of Washington; 2012.

5. Naylor MD, Kurtzman ET. The role of nurse practitioners in reinventing primary care. Health Aff (Millwood). 2010;29(5):893-899.

6. Association of American Medical Colleges. Physician Shortages to Worsen Without Increases in Residency Training. Association of American Medical Colleges Web site. Accessed April 16, 2012.

7. Steinwald, AB. Primary Care Professionals: Recent Supply Trends, Projections, and Valuation of Services. Testimony before the Committee on Health, Education, Labor, and Pensions, US Senate. Government Accountability Office Web site. Accessed April 16, 2012.

Debra Barksdale, PhD, RN, FNP-BC, ANP-BC, FAANP associate professor, School of Nursing, University of North Carolina–Chapel Hill, Chapel Hill, North Carolina, and president, National Organization of Nurse Practitioner Faculties, Washington, DC.

Kristen M. Swanson, PhD, RN, FAAN dean and alumni distinguished professor, School of Nursing, University of North Carolina–Chapel Hill, Chapel Hill, North Carolina.

Address correspondence to Dr. Debra Barksdale, School of Nursing, UNC–Chapel Hill, Carrington CB#7460, Chapel Hill, NC 27599-7460 (