Innovations
An Underutilized Resource: Nurse Practitioners in the ED
The reality of today’s health care delivery system is that an increasing amount of care administered in the nation’s emergency departments (ED) is not urgent or emergent. More and more, ED patient populations are comprised of individuals — some without insurance who have nowhere else to go and some with insurance who do not have a primary care doctor — are presenting with conditions that don’t require the expertise of physicians.
For this reason, more hospitals are considering the advantages of using nurse practitioners (NPs) in their EDs. With graduate level education and clinical training beyond that of a registered nurse, NPs practice in a wide array of settings, including clinics, hospitals, EDs, urgent care sites, private physician or NP practices, nursing homes, schools, colleges, and public health departments. They are licensed to provide a variety of services, including ordering, performing and interpreting diagnostic tests such as lab work and x-rays; diagnosing and treating acute and chronic conditions (e.g. diabetes, high blood pressure, infections, and injuries); prescribing medications and treatments; and counseling patients to manage their healthcare.
According to the American Academy of Nurse Practitioners (AANP), there are approximately 125,000 practicing NPs nationwide who provide primary care and specialize in everything from gerontology to oncology to mental health. An additional 6,000 new NPs are being trained each year at more than 325 colleges and universities
The Role of Nurse Practitioners
Heidi Bray, a board certified Family Nurse Practitioner, works at Olympia, Washington-based Providence St. Peter Hospital, which currently uses five NPs and three physician assistants (PAs) in the ED, employed through the physician-owned Olympia Emergency Services.
“For all intents and purposes — from the patient’s perspective — our clinical role is nearly indistinguishable to that of physicians,” Bray says of the NPs in the practice.
There are some significant differences between the role of physicians and NPs, most notably in the approach to patient care. “I think the NP model of care is more holistic than the medical model, and patients respond well to that in the ED,” Bray says. “The medical model tends to be more concrete, more focused on pathology. I think most NPs practicing in the ED — while facing time demands and efficiency concerns — continue to assert unique skills in patient education and in working with the family rather than focusing on medical concerns alone.
There is also a vast difference in salaries between NPs and physicians. The lower salaries paid to NPs vis-à-vis the services they provide and the fact that they’re less expensive to insure are two major reasons they’re attractive to EDs. In 2007, the AANP published a report on “Nurse Practitioner Cost-Effectiveness” that noted the median total compensation for primary care physicians in 2004 ranged from $130,000 to $208,700, while the median salary for NPs across all specialties who practiced full-time was $71,000.
According to Bray, NPs are more prone to ask, “who is this person, where do they come from and what do they do? What does the family and home life look like? Often those concerns are quite relevant to their presenting complaint, and I think sometimes our physician colleagues are not as well tuned in to these issues. NPs do a good job of getting a more comprehensive picture of the individual and helping them plan for whatever their post-hospital experience will be. It may be working with an elderly person who lives alone, has broken their arm, and needs help figuring out what will be involved in getting their groceries in the door. Or parents who bring in a sick child and have three others at home. We examine preventative measures, and provide them with concrete information about how their one child’s illness could affect the others
As a result of this mindset, says Bray, NPs can help EDs rectify what she considers one of their biggest shortcomings, which is their lack of familiarity with community partners and care coordination. Bray earned her Doctor of Nursing Practice (DNP) in June 2009 at the University of Washington, and as part of her doctoral work she conducted a community project in which she identified providers of charity care in Thurston County, Washington, where Providence St. Peter Hospital is located. Bray tells of an uninsured carpenter she treated in the ED at St. Peter who was in his mid-twenties and had broken his dominant hand. Over the course of two months he returned to the ED three times for splints and pain medication, but was never able to afford a visit to an orthopedist for surgery. The fracture never healed, and the young man lost his job and ultimately his apartment because he could not work. Because of Bray’s study of community partners, she was able to locate a county-based program that donated orthopedic care and, after “ten minutes of paperwork,” the young man was enrolled and received free surgery. He’s now working again “and doing quite well,” she notes.
Expanding the use of Nurse Practitioners in the ED
So what are the major impediments to the use of NPs in EDs? Louise Kaplan, an associate professor at Washington State University in Vancouver, WA, attempted to find out with a pilot study five years ago.
“As an educator of family NPs, I was aware that my students and colleagues were very interested in working in EDs but that many hospitals in Washington State and the Portland, Oregon, area were not employing them,” she explains. To gain insight on this issue Kaplan interviewed four ED managers at area hospitals. “There seemed to be a very simple explanation,” says Kaplan, which was that “most hospitals have contracts with providers groups to supply the professional services in the EDs. The provider groups that are physician-owned and controlled were making the decision about the use of NPs rather than the hospitals.”
“From the interviews that we did with nurses,” Kaplan continues, “they felt that physicians had less familiarity with the scope of practice of NPs. They typically used physician assistants (PA) because that was a model they were comfortable with. Additionally, PA licenses are directly linked to the physicians themselves, so they felt there was more oversight and control. There were also some questions as to whether or not the physicians would have liability for the NPs; however, in Washington and Oregon there is a fully autonomous practice for NPs.”
“The lobbying efforts of medical associations oppose the expansion of authority for NPs,” notes Kaplan. “They can influence lawmakers. It’s a turf battle. Because we tend to earn less money, we are often not in a position of owning our own practices; so many NPs are employees of a physician group. There’s also an element of socialization: if you are living in a state with supervised NP practice, it becomes normalized.” Led by AANP, The American College of Nurse Practitioners and the National Organization of Nurse Practitioner Faculties, “NPs across the country are working very hard to gain fully autonomous practice in all 50 states and to promoting NPs as vital components of the health care system,” Kaplan says.
“I think that physicians need to be open to the fact that NPs can be excellent colleagues and work collaboratively to provide appropriate care for patients,” she adds. “Also, more research is needed to investigate why ED physician groups resist hiring NPs. Staffing NPs in the ED can serve to reduce waiting times, reduce overcrowding and increase patient satisfaction.”
The Future of Nurse Practitioners
Strengthening the case for NPs in the ED is a movement over the past five years among nursing academics to implement the DNP, a doctoral level degree focused on bolstering the clinical training of advanced practice nurses to meet the increasingly complex needs of patient care.
“It’s a doctoral degree that is clinically oriented rather than research-focused,” explains Bray. “The hope is that by 2015 all nursing practitioners will be educated at the doctoral level rather than the master’s level.”
An Underutilized Resource
Ultimately, NPs just want to get in the door of the ED to show what they can do.
“We have the potential to improve efficiency and bring a spirit of holistic care into the ED,” says Bray. “I think as we continue and do our good work, the resistance from physicians is going to fall away.”
Heidi Bray, DNP, ARNP, Providence St. Peter Hospital, Olympia, Washington
Louise Kaplan, PhD, ARNP, Assistant Professor, Washington State University, Vancouver, Washington
