Review of Current Healthcare Issues
If you were to ask 10 people what they believe to be the most significant issue facing healthcare today, you might get 10 different answers. Escalating costs? Regulation? Technology disruption?
These and many other topics are worthy of discussion. Not surprisingly, much has been said in the research, within the profession, and in the news about these topics. Whether they are issues of finance, quality, workload, or outcomes, there is no shortage of changes to be addressed.
In this Discussion, you examine a national healthcare issue and consider how that issue may impact your work setting. You also analyze how your organization has responded to this issue.
To Prepare:
Review the Resources and select one current national healthcare issue/stressor to focus on.
Reflect on the current national healthcare issue/stressor you selected and think about how this issue/stressor may be addressed in your work setting.
Posta description of the national healthcare issue/stressor you selected for analysis, and explain how the healthcare issue/stressor may impact your work setting. Then, describe how your health system work setting has responded to the healthcare issue/stressor, including a description of what changes may have been implemented. Be specific and provide examples.
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Growing Ranks of Advanced Practice Clinicians
Growing Ranks of Advanced Practice Clinicians
Implications for the Physician Workforce
David I. Auerbach, Ph.D., Douglas O. Staiger, Ph.D., and Peter I. Buerhaus, Ph.D., R.N.
Throughout the history of mod-ern American medicine, phy-
sicians have made up the vast
majority of professionals who di-
agnose, treat, and prescribe medi-
cation to patients. Although de-
mand for medical services has
increased markedly over the years
(and is projected to grow more
rapidly as the population ages),
the physician supply has grown
relatively slowly. Increased dele-
gation of work, new technology,
and streamlined care processes
can help practices meet patient
needs with fewer physicians, but
still require an increasing num-
ber of health professionals.1
Physician supply is constrained
in the short run by long training
times and in the longer run by
medical school capacity and the
number of accredited residency
positions. Despite a 16% increase
in graduate medical education
(GME) slots in recent years, the
Association of American Medical
Colleges (AAMC) recently project-
ed that the supply of physicians
will increase by only 0.5% per
year between 2016 and 2030.
A growing share of health care
services are being provided by ad-
vanced practice registered nurses
(APRNs), particularly nurse prac-
titioners (NPs), who make up the
majority of APRNs, and by physi-
cian assistants (PAs). NPs and PAs
provide care that can overlap with
care provided by physicians (both
in primary care and increasingly
in other specialties), and the
AAMC recognizes this overlap in
its physician-demand forecasts.
The number of NPs and PAs is
growing rapidly, in part because
of shorter training times for such
providers as compared with phy-
sicians and fewer institutional
constraints on expanding educa-
tional capacity. Residencies arent
required for APRNs though
organizations are increasingly
offering them and education
programs have proliferated: ac-
cording to the American Associ-
ation of Colleges of Nursing, the
number of NP degree programs
(masters or doctorate) grew from
282 to 424 between 2000 and
2016. Baccalaureate-prepared RNs
typically require 2 to 3 years of
graduate education to become
certified NPs. PA programs typi-
cally take 2 years and also dont
require residencies. According to
the National Center for Education
Statistics, the number of PA de-
gree programs grew from 135 to
238 between 2000 and 2016.
These dynamics will have last-
ing effects on the composition of
the health care workforce and
on working relationships among
health professionals. To take a
closer look at these trends, we
estimated the number of full-time-
equivalent physicians, NPs, and
PAs between 2001 and 2016 using
data from the U.S. Census Bu-
reaus American Community Sur-
vey, which included a roughly
0.4% sample of the U.S. popula-
tion between 2001 and 2004 and
a 1% sample between 2005 and
2016. Because the Census didnt
identify NPs until 2010, we ob-
tained data on NPs from the Na-
tional Sample Survey of Regis-
tered Nurses from 2000, 2004,
and 2008. Figures were validated
using data from health profes-
sional associations. The final data
set includes 12,887 NPs, 12,801
PAs, and 166,103 physicians.
These data were used to proj-
ect the number of NPs, PAs, and
physicians through 2030 using
methods described in greater de-
tail elsewhere.2 Briefly, our model
estimates the number of provid-
ers of various ages in each year
as a function of both workforce-
participation patterns associated
with age and estimates of differ-
ences among birth cohorts in rates
of entry into each profession,
which ref lect institutional con-
straints. Our projections assume
that age-related workforce-partici-
pation patterns will remain stable
after 2016 and that the size of
the workforce for birth cohorts
that have not yet entered the labor
force will resemble that of the
five most recent cohorts. In the
case of physicians, to better cap-
ture the expansion in medical ed-
ucation and throughput in recent
years, we assume that the size of
future cohorts will resemble the
size of only the most recent (larg-
est) cohort. In our prior work,
this model has successfully fore-
cast health care workforce trends.2
As shown in the table, between
2001 and 2010, workforce supply
increased by roughly 150,000 phy-
sicians (an increase of 2.2% per
year), 27,000 NPs (an increase of
3.9%), and 44,000 PAs (an increase
of 7.9%). Between 2010 and 2016,
the combined increase in NPs and
PAs (79,000) outpaced the increase
in physicians (58,000), although
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the NP and PA workforces were
roughly one tenth the size of the
physician workforce in 2010. Dur-
ing this period, growth in the NP
supply accelerated to nearly 10%
per year, whereas growth in the
PA supply slowed to 2.5% and
growth in physician supply slowed
to 1.1%. The number of NPs and
PAs per 100 physicians nearly
doubled between 2001 and 2016,
from 15.3 to 28.2.
We project that these trends
will continue through 2030. The
number of full-time-equivalent
physicians is expected to continue
growing by slightly more than 1%
annually, as increased retirement
rates are offset by increased en-
try, whereas the numbers of NPs
and PAs will grow by 6.8% and
4.3% annually, respectively. Rough-
ly two thirds (67.3%) of practi-
tioners added between 2016 and
2030 will therefore be NPs or
PAs, and the combined number
of NPs and PAs per 100 physi-
cians will nearly double again to
53.9 by 2030. These shifts will
probably be even more pro-
nounced in primary care, where
physician supply has been grow-
ing more slowly than in other
fields and NPs tend to be more
concentrated.
The changing composition of
the workforce will have implica-
tions for provider teams. Primary
care providers, in particular, in-
creasingly work in larger groups
of professionals with varying back-
grounds and types of training. A
2012 national survey of primary
care NPs and physicians found
that 8 in 10 NPs worked in col-
laborative practice arrangements
with physicians and 41% of phy-
sicians worked with NPs a
percentage that will probably grow
over time.3 As more states ex-
pand practice authority for NPs,
medical practices will have to ad-
just. A recent study of working
relationships between NPs and
physicians on primary care teams
in New York and Massachusetts
found that physicians, other staff,
and patients often confused the
roles and skills of various provid-
ers and that these misunderstand-
ings often led to practices under-
mining the productivity and
efficiency of NPs.4 Physicians,
NPs, and PAs will all need to be
trained and prepared for this new
reality.
Greater reliance on nonphy-
sician clinicians is unlikely to
threaten quality of care or increase
costs. There is growing evidence
that the primary care provided by
NPs and PAs is similar to that
provided by physicians, and a re-
cent national study of Medicare
beneficiaries found that the cost
of primary care provided by NPs
was significantly lower than the
cost of physician-provided care.5
As with other projections, our
findings are subject to some de-
gree of uncertainty. It is unlike-
ly that the physician supply will
grow more rapidly than we proj-
ect: the AAMC projects even slow-
er growth, the number of GME
slots is constrained, and even an
immediate expansion of medical
school capacity and training op-
portunities wouldnt substantial-
ly affect the physician supply for
many years. Growth in the NP
and PA workforces is more un-
certain. Although shorter, more
flexible training requirements for
these providers have facilitated an
unprecedented increase in new en-
trants, growth rates could fall if
demand for nonphysician provid-
ers is lower than anticipated and
job-market prospects worsen.
Major changes are unlikely, how-
ever, given the expected increases
in demand for care, growing use
of team-based and interprofes-
sional practice, and the fact that
Provider Group No. of Full-Time Equivalents Average Annual Growth (%)
2001 2010 2016
2030
(projected) 20012010 20102016
20162030
(projected)
Physicians 711,357 862,698 920,397 1,076,360 2.2 1.1 1.1
Nurse practitioners 64,800 91,697 157,025 396,546 3.9 9.4 6.8
Physician assistants 44,282 88,047 102,084 183,991 7.9 2.5 4.3
* Based on data from the American Community Survey (ACS) and the National Sample Survey of Registered Nurses. Estimates
for NPs in 2001 are interpolated on the basis of data from the 2000 and 2004 surveys. Full-time equivalents are defined on the
basis of reported usual weekly hours worked and a 40-hour workweek for NPs and PAs and a 50-hour workweek for physicians.
NPs include a small number of certified nurse midwives who were not separately identified in the ACS because of their small
numbers. PAs in the ACS reporting an associates degree or less education were excluded. All estimates are based on sample
weights provided in each survey.
Historical and Projected Numbers of Physicians, Nurse Practitioners, and Physician Assistants.*
P E R S P E C T I V E
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NPs disproportionately serve ru-
ral and underserved populations,
whose needs would otherwise go
unmet.
Despite these uncertainties, it
is clear that patients will continue
to encounter more NPs and PAs
when they seek care. The shifting
composition of the health care
workforce will present both chal-
lenges and opportunities for med-
ical practices as they redesign
care pathways to accommodate
new payment methods, new in-
centives regarding quality of care,
and the demands of an aging
population.
Disclosure forms provided by the authors
are available at NEJM.org.
From the Center for Interdisciplinary Health
Workforce Studies, College of Nursing,
Montana State University, Bozeman (D.I.A.,
P.I.B.); the Department of Economics, Dart-
mouth College, Hanover, NH (D.O.S.); and
the National Bureau of Economic Research,
Cambridge, MA (D.O.S.).
1. Bodenheimer TS, Smith MD. Primary
care: proposed solutions to the physician
shortage without training more physicians.
Health Aff (Millwood) 2013; 32: 1881-6.
2. Staiger DO, Auerbach DI, Buerhaus PI.
Comparison of physician workforce esti-
mates and supply projections. JAMA 2009;
302: 1674-80.
3. Donelan K, DesRoches CM, Dittus RS,
Buerhaus P. Perspectives of physicians and
nurse practitioners on primary care practice.
N Engl J Med 2013; 368: 1898-906.
4. Poghosyan L, Norful AA, Martsolf GR.
Primary care nurse practitioner practice
characteristics: barriers and opportunities
for interprofessional teamwork. J Ambul
Care Manage 2017; 40: 77-86.
5. Perloff J, DesRoches CM, Buerhaus P.
Comparing the cost of care provided to
Medicare beneficiaries assigned to primary
care nurse practitioners and physicians.
Health Serv Res 2016; 51: 1407-23.
DOI: 10.1056/NEJMp1801869
Copyright 2018 Massachusetts Medical Society.Growing Ranks of Advanced Practice Clinicians
The Graduate Nurse Education Demonstration
The Graduate Nurse Education Demonstration
Implications for Medicare Policy
Linda H. Aiken, Ph.D., R.N., Joshua Dahlerbruch, B.S.N., Barbara Todd, D.N.P., and Ge Bai, Ph.D., C.P.A.
Despite decades of public and private investment, the United
States continues to have a short-
age of primary care capacity.
Only 2699 graduating U.S. medi-
cal students about 17% of
graduates from allopathic and
osteopathic schools matched
with primary care residencies in
2016.1 Studies show that nurse
practitioners (NPs) provide high-
quality primary care that is satis-
factory to patients, improves ac-
cess to care in underserved areas,
and may reduce costs of care.
But although Medicare spends
more than $15 billion annually
on graduate medical education
(GME),2 including training for pri-
mary care physicians, it spends
very little on clinical training
for NPs.
Medicare has contributed to
the cost of training nurses since
its inception, but NP programs
didnt exist when Medicare was
enacted and such funding streams
were established. Modernizing
Medicares payment policies for
nurse training is highly relevant,
given the recent success of the
Graduate Nurse Education (GNE)
Demonstration.3 The $200 million,
five-site Centers for Medicare and
Medicaid Services (CMS) demon-
stration authorized under the
Affordable Care Act showed that
offering payments to Medicare
providers enabled more of them
to participate in clinical precept-
ing of advanced practice regis-
tered nurses (APRNs) and result-
ed in a substantial increase in
the number of new APRN gradu-
ates. More than 60% of training
took place in community-based
settings, and primary care NPs
accounted for most of the growth
in the number of new graduates.
The GNE Demonstration doc-
umented the success of a new
model of organizing and paying
for graduate nurse education in-
volving consortia of hospitals
and health systems, community
partners, and university nursing
schools managed by a single
Medicare hospital hub. Such con-
sortia were originally proposed
in 1997 by the Institute of Medi-
cine (now the National Academy
of Medicine) as a strategy for in-
creasing community-based train-
ing for physicians, but were not
implemented until the GNE Dem-
onstration. Of the five demonstra-
tion networks, three were state
or regional consortia covering
greater Philadelphia, the Texas
Gulf Coast, and Arizona. In great-
er Philadelphia the largest con-
sortium the Hospital of the
University of Pennsylvania served
as the designated hub for a re-
gional network that included all
health systems and hospitals in
the area, more than 600 com-
munity-based providers, and all
9 local university nursing schools
involved in training APRNs. This
model has many advantages. For
Reproduced with permission of copyright owner. Further reproduction
prohibited without permission. Removing restrictions on nurse practitioners scope of practice
in New York State: Physicians and nurse
practitioners perspectives
Lusine Poghosyan, PhD, RN, FAAN1, Allison A. Norful, PhD, RN, ANP-BC2, & Miriam J. Laugesen, PhD3
ABSTRACT
Background and purpose: In 2015, New York State adopted the Nurse Practitioners Modernization Act to remove
required written practice agreements between physicians and nurse practitioners (NPs) with at least 3,600 hours of
practice experience. We assessed the perspectives of physicians and NPs on the barriers and facilitators of policy
implementation.
Methods: Qualitative descriptive design and individual face-to-face interviews were used to collect data from
physicians and NPs. One researcher conducted interviews, which were audio-taped and transcribed. Twenty-six
participants were interviewed. Two researchers analyzed the data.
Results: The new law has not yet changed NP practice. Almost all experienced NPs had written practice agreements.
Outdated organizational bylaws, administrators and physicians lack of awareness of NP competencies, and phy-
sician resistance and lack of knowledge of the law were barriers. Collegial relationships between NPs and physicians
and positive perceptions of the law facilitated policy implementation.
Conclusions: Policy makers and administrators should make efforts to remove barriers and promote facilitators to
assure the law achieves its maximum impact.
Implications for practices: Efforts should be undertaken to implement the law in each organization by engaging
leadership, increasing awareness about the positive impact of the law and NP independence, and promoting rela-
tionships between NPs and physicians.
Keywords: Nurse practitioners; scope of practice; primary care; policy.
Journal of the American Association of Nurse Practitioners 30 (2018) 354360, 2018 American Association of Nurse Practitioners
DOI# 10.1097/JXX.0000000000000040
Background
Physicians, nurse practitioners (NPs), and physician
assistants currently provide the bulk of primary care in
the United States (U.S.) to meet the demands of an
aging population and expansion of insurance coverage
(Agency for Healthcare Research and Quality, 2014; Col-
will, Cultice, & Kruse, 2008; DeVol & Bedroussian, 2007;
Patient Protection and Affordable Care Act of, 2010). One
projection suggests an additional 52,000 physicians will
be needed by 2025 to meet the primary care demand
(Petterson et al., 2012); however, the supply of these
providers is expected to decrease (Association of Medical
Colleges Center for Workforce Studies, 2015). Conversely,
NP workforce is expected to grow. In 2013, NPs comprised
about 19% of the U.S. primary care provider workforce,
and the number of NPs will increase by 93% by 2025
(Health Resources and Services Administration, 2016),
potentially expanding the primary care capacity (Auer-
bach, et al., 2013; Green, Savin, & Lu, 2013).
However, the ability of NPs to care for patients has
been limited by state-level scope of practice (SOP) reg-
ulations that determine the services NPs provide. Nurse
practitioner state-level scope of practice laws vary across
states. In 2017, 22 states and the District of Columbia au-
thorize NPs to deliver care according to their competen-
cies (Robert Wood Johnson Foundation, 2017). The
remaining states impose restrictions, including the re-
quirement of NPs to have supervisory or collaborative
relationships with physicians. Some states require NPs to
1Columbia University School of Nursing, New York, NY 2Columbia
University School of Nursing, Columbia University Medical Center
Irving Institute for Clinical and Translational Research 3Department
of Health Policy & Management, Columbia University Mailman School
of Public Health
Correspondence: Lusine Poghosyan, PhD, RN, FAAN, Columbia
University School of Nursing, 630 W. 168th Street, Mail Code 6, New
York, NY 10032. Tel: 212-305-7081; Fax: 212-305-0722; E-mail: [emailprotected]
columbia.edu
Received: 9 August 2017; revised 30 October 2017; accepted
20 November 2017
354 June 2018 Volume 30 Number 6 Journal of the American Association of Nurse Practitioners
Qualitative Research
2018 American Association of Nurse Practitioners. Unauthorized reproduction of this article is prohibited.
have such relationships both for delivering care and
prescribing medication and services, other states impose
restrictions only on one aspect. The Federal Trade Com-
mission, the National Governors Association, and the
National Academy of Medicine have criticized these laws
and recommend removal of these restrictions to improve
access to care (Federal Trade Commission, 2014; Institute
of Medicine, 2010; National Governors Association, 2012).
Indeed, states granting NPs greater SOP authority expe-
rience expanded health care utilization (Kuo, Loresto,
Rounds, & Goodwin, 2013; Xue, Ye, Brewer, & Spetz, 2016).
In 2015, New York State (NYS) implemented the Nurse
Practitioners Modernization Act (New York State De-
partment of Education, 2015). The law removed the re-
quired written practice agreement between NPs and
physicians for experienced NPs with more than 3,600
hours of practice. New NPs with less than 3,600 hours of
practice still are required to have this agreement. The
outdated policy requiring NPs to have a written practice
agreement with physicians limited NPs ability to in-
dependently care for their patients and practice in un-
derserved areas with shortage of primary care physicians.
This policy change aimed to promote NP independent
practice and address the misdistribution of primary care
services across NYS by allowing experienced NPs to
practice independently in underserved areas (Center for
Health Workforce Studies, 2013). In this study, we
assessed the perspectives of physicians and NPs on the
barriers and facilitators of implementing the NP Mod-
ernization Act 18 months after the policy adoption.
Methods
We used a qualitative descriptive design as described by
Sandelowski (2010) to collect data from physicians and
NPs because we know little about the laws implementa-
tion. Participants were recruited through purposive
snowball sampling (Sandelowski, 2007). We contacted
several practices in NYS, through our professional network
in primary care, and informed practice managers or
providers about the study and asked for assistance with
recruitment. Both managers and providers distributed
flyers about the study which included information about
studys risks and benefits, and the contact information of
the researchers. Participants were eligible for inclusion if
they practiced as a primary care NP or physician and spoke
and understood English. Interested participants contacted
the researchers to schedule a convenient time and place
(e.g., primary care office) for the face-to-face interview.
Using the snowball sampling method, we also asked par-
ticipants to refer colleagues as potential participants.
One researcher (AN), an experienced NP in NYS with
expertise in qualitative designs, conducted all interviews
using a semistructured interview guide that allowed for
probing for additional information. The researcher kept
a reflexivity journal prior to and during the interviews to
reduce bias. We developed the questions from existing
evidence. Interviews started with questions regarding the
practice, participants roles, and then about the NP
Modernization Act. Table 1 presents key questions.
Each interviewee signed a consent form. Interviews
and data analysis were conducted concurrently (DiCicco-
Bloom & Crabtree, 2006). As interviews progressed,
participants provided information, which was further
explored in subsequent interviews. All interviews were
conducted in the participants practice office with no
others present during the interview. Interviews were
audio-taped and lasted between 25 and 45 minutes. The
interviewer took notes. Demographic and practice char-
acteristic information was also collected. Data collection
took place in the summer-fall of 2016.
Twenty-three interviews were completed initially (12
NPs and 11 physicians) and analyzed to identify codes and
themes (Miles & Huberman, 1984). To further explore the
codes and themes and develop an exhaustive de-
scription, we conducted three additional interviews with
two NPs and one physician. In alignment with qualitative
research principles (Sandelowski, 2007), data collection
ended when interviews were not producing new in-
formation. This was reached after the 26th interview.
Interview audio-recordings were transcribed verbatim
by a transcriptionist. We imported the data into the
qualitative software package, Atlas, and using iterative
content analysis (Bradley, Curry, & Devers, 2007), we an-
alyzed the data. Two researchers independently read and
reread transcripts for overall understanding and in-
ductively coded the data (Hsieh & Shannon, 2005). We
reviewed data line-by-line and when a concept became
apparent, we assigned a code. We used constant com-
parison to refine codes and had regular in-person
meetings to review discrepancies and achieve consensus.
After identifying all concepts, we linked them to develop
themes relating to barriers and facilitators of the laws
implementation. We also conducted a comparative
analysis in two groups (physicians and NPs) by retrieving
data coded with both conceptual and participant codes.
This comparison showed whether certain concepts were
Table 1. Examples of interview questions
Key Questions
Can you describe the Nurse Practitioners Modernization Act?
What does it state?
Can you talk about how your organization has adopted the
Nurse Practitioners Modernization Act?
How has the Nurse Practitioners Modernization Act impacted
your practice?
What organizational barriers exist to adopt the Nurse
Practitioners Modernization Act?
Journal of the American Association of Nurse Practitioners June 2018 Volume 30 Number 6 355
L. Poghosyan et al.
2018 American Association of Nurse Practitioners. Unauthorized reproduction of this article is prohibited.
reported differently between two groups. Findings were
shared with participants to obtain feedback. De-
mographic data were analyzed using SPSS v24.
Results
Table 2 includes information about the 14 NP and 12
physician participants. The mean age was 41 years for NPs
and 45 years for physicians. The mean years of experience
for NPs was about 7 years and for physicians was 13 years.
Twelve of 14 NPs (85.7%) were experienced NPs with at
least 3,600 hours of clinical practice. The majority of NPs
and physicians worked in practices affiliated with
hospitals or medical centers. We identified four barriers
and two facilitators toward the laws implementation
(Table 3), which emerged both in NP and physician
interviews; thus, findings are combined.
Barriers
The following barriers emerged: stagnant organizational
policy; lack of awareness of NP competencies; lack of
knowledge about the NP Modernization Act; and physi-
cian autonomy and resistance to change.
Stagnant organizational policy. Almost all NPs reported
that the law change did not affect their practice because
Table 2. Nurse practitioner (NP) and physician characteristics
Characteristics NPs (N = 14) Physicians (N = 12)
Age, mean (SD), years 41.36 (3.4) 45.78 (2.7)
Female, No. (%) 13 (93) 7 (58)
Highest degree, No. (%)
Masters 5 (36)
Post-Masters 3 (21)
MD 11 (92)
Doctorate (PhD; DNP; PhD/MD) 6 (43) 1 (8)
Years of experience, mean (SD) 7.21 (1.8) 13 (2.4)
Main practice site, No. (%)
Private practice 2 (14) 3 (25)
Academic medical center-affiliated
practice
5 (36) 6 (50)
Hospital-affiliated practice 7 (50) 2 (17)
Community health center 1 (8)
Geographical location, No. (%)
Urban 9 (64) 8 (67)
Suburban 5 (36) 3 (25)
Rural 1 (8)
Table 3. Barriers and facilitators for implementing the nurse practitioners modernization act
Barriers
Stagnant Organizational Policy
Lack of Awareness of NP Competencies
Lack of Knowledge about the NP Modernization Act
Physician Autonomy and Resistance to Change
Facilitators
NP and Physician Collegiality
Positive Perceptions of the benefits of NP Independence and the Law
356 June 2018 Volume 30 Number 6 www.jaanp.com
Removing restrictions on NPs scope of practiceQualitative Research
2018 American Association of Nurse Practitioners. Unauthorized reproduction of this article is prohibited.
the organizational bylaws were not reformed to accom-
modate the change, particularly in practices affiliated
with hospitals or medical centers. Eighty-six percent of
NPs (12 out of 14), regardless of experience, had a written
practice agreement with physicians. One NP employed in
a hospital-affiliated practice for seven years described,
The bylawsstate that you have to have a collaborating
physicianI still have a collaborating physician. She
continued, They (administrators) have not kind of come
with the times yetmy collaborating physician in
particular totally agrees with the Modernization Act and
does not feel that she needs to oversee me in any way,
shape, or form. Most NPs reported that their
organizations do not plan to change their bylaws because
of lack of advocates in the leadership to encourage
change.
Practices sold to hospitals found that new owners
were less supportive of expanding NP SOP. Hospitals not
only did not promote NP independent practice, but they
even restricted the practice of those NPs who had
a broader SOP in a standalone practice prior to the hos-
pital acquiring their practice. One NP with 15 years of
experience provided an example:
Before (hospital) took over, I was comfortable, and the
physician that owned the practice was very comfortable
with me doing initial physical examinations, doing med-
ical clearances, doing workers compensation. All that has
gone away since (hospital) bought the practice.
Physicians also confirmed that their organizations did
not conform to the law. They saw this as a reflection of
their organizations, which they perceived as out of touch
with new policies. One physician practicing with NPs for
20 years stated, I really think that the organization that
Im working for is just not up with the times. I dont think
theyre astute enough to know whats out there.
Lack of awareness of NP competencies. Most participants,
both NPs and physicians, perceived that some physicians
and administrators are not familiar with NP competen-
cies or the care NPs can deliver. One NP said, I also dont
think that all providers, like physicians, know what nurse
practitioners can do and the extent we can do it, too.
Physicians comments confirmed NPs concerns. One
physician said, Im not really sure what their (NPs)
training entails.
Physicians had conflicting views about NPs abilities
when speaking about NPs more generally compared with
NPs they worked with directly. Most physicians viewed the
quality of care of NPs in their practices positively, The
nurse practitioner that works here I feel is exceptional. So,
if she went out on her own independently, I would have
no hesitation about it. However, viewed as a group, the
same physicians perception of NPs was not as positive, I
dont feel that way across the board for most NPs.
Awareness of NP competencies and support for NP in-
dependent practice was higher among physicians who
worked with NPs; however, that awareness and support
was individualized to the NPs they worked with. Physi-
cians often perceived that these NPs are uniquely skilled
and their competencies are not generalizable to the
overall NP workforce.
Lack of knowledge about the NP Modernization Act.
Awareness of the policy change varied across the two
groups. Although most NPs were familiar with the law,
only a few physicians had heard about it. One physician
stated, I heard it is something like they (NPs) can
practice individually? Without any presence of any
doctors? Another physician said, I dont know about
NPs going independent. I have not seen that in any of my
practices.
Even though most NPs knew the law had passed, they
were not well informed about its details. One NP sum-
marized as, It is (NP Modernization Act is) basically pro-
moting NP autonomy. Also, both physicians and NPs
reported that their organizations are unfamiliar with the
law or they do not keep informed about the state policy
changes.
Physician autonomy and resistance to change. Two
physicians reported resistance toward surrendering
some of their rights despite recognizing that the laws
implementation would reduce delays for patients by
allowing NPs to bypass physician signing off on forms.
One physician provided an example, Ideally, I would
hope that we (NPs and physicians) would be completely
equal. But I know that after being in, like, 20 years of
practice where I am sort of the final say, I might have
a hard time giving up that. The same physician said,
Then you would have to sort of negotiate between the
two providers. Another physician said, not that they
(NPs) dont know and they dont have any experience, but
I
