Myth: Seeing a nurse practitioner instead of a doctor is second-class care

by admin admin | Jun 01, 2010
This is an update of the popular 2002 article, which shows that research clearly and consistently demonstrates nurse practitioners can provide care that is safe, effective and comparable to a GP in a range of situations.
PDF version (335 KB)

Myth busted November 2002
Myth busted again! June 2010

Nurse practitioners are becoming familiar figures on the Canadian healthcare scene. Now licensed in all provinces and territories, the workforce doubled from 800 in 2004 to 1,626 in 2008.[i] Despite the growth and evolution of the profession, there is some lingering confusion about when and where they are qualified to work and the quality of care they can provide. A perception exists that seeing a nurse practitioner instead of a doctor is second-class care, best suited for times and places where a doctor is unavailable.

Research suggests otherwise. There is a large and growing body of evidence that shows nurse practitioners deliver care as well as their physician counterparts - sometimes more effectively. And while the autonomy of and substantial overlap in scope of practice between the two professions is recognized as occasional sources of tension,[ii,iii] there are examples of effective collaboration.[ iv,v]

Nurse practitioners in Canada

Nurse practitioners first appeared in Canada in the 1960s in response to shortages of primary care physicians in rural and remote areas. They were the subject of renewed interest in the 1990s, as part of efforts to improve access to primary healthcare in a context of deepening shortages of doctors as well as growing demand for services arising from older Canadians, chronic illnesses and mental health problems.

Nurse practitioners work in settings such as community health centres, home-care agencies, northern health centres, public health units and family practice units or physician offices and, more recently, in long-term care settings and emergency departments. They are trained and educated to conduct health assessments, perform a variety of medical procedures, prescribe drugs, and diagnose and manage common illnesses and injuries through ordering and interpreting diagnostic tests.[vi] They also have expertise in health promotion and preventive care.

Because they have comprehensive skill sets and may cost the health system less than primary care physicians,[ vii,viii] nurse practitioners are often a component of primary healthcare reform strategies.[ ix] For example, in order to increase patient access to primary healthcare, clinics are being developed with physicians functioning primarily in a consulting role to the nurse practitioner.[ x] In British Columbia, nurse practitioners have been integrated into traditional fee-for-service practices. In Ontario, 26 clinics led by nurse practitioners are being introduced in communities with physician shortages.

Tried and true

Since a pioneering study of nurse practitioners in Burlington, Ontario, in 1974,[xi] at least 28 randomized controlled trials have been conducted, predominantly in the United States, the United Kingdom and Canada. These studies have consistently shown that nurse practitioners are effective, safe practitioners and can positively influence patient, provider and health-system outcomes. A 2002 review of scientific studies compared nurse practitioners and physicians providing first-contact care to patients in primary healthcare settings and found that patient health outcomes were equivalent.[xii] Nurse practitioners tended to spend more time with patients and order more tests, but no differences were found in the number of prescriptions, return visits or referrals to specialists.

The evidence that nurse practitioners are making a difference in the Canadian healthcare system is accumulating. One study found their inclusion in primary healthcare teams in four different primary healthcare models in Ontario was associated with high-quality chronic disease management.[ xiii] In addition to improved patient outcomes, one Canadian study found when nurse practitioners were added to an emergency department, patients were more than twice as likely to be seen within wait-time benchmarks, their length of stay was cut in half and the proportion of patients leaving without being seen was down by one-third.[ xiv]

The proof is in the patient

The patient's perspective is critical when it comes to healthcare. The previously mentioned 2002 review of studies found that patients who saw a nurse practitioner reported higher levels of satisfaction and better quality of care in comparison to the care provided by physicians.[ xii] Studies also indicate that patients appreciate their communication style and the extra time spent.[xv,xvi] Patients tend to be more satisfied with the type of advice provided, too.[ xvii] For example, nurse practitioners tend to ask more questions and offer more information and options than physicians.

A growing body of evidence suggests Canadians are highly satisfied with care provided by nurse practitioners. A 2009 Harris/Decima poll of 1,000 Canadians[xviii] found that:

  • one in five has been treated by a nurse practitioner
  • a majority would like to see the role expanded
  • greater than three in four would be comfortable seeing one in lieu of their family doctor and
  • four in five feel that expanding their roles would be an effective way of managing healthcare costs (although it should be noted that there is a paucity of evidence on their cost-effectiveness relative to physicians in Canada).

Given public calls for increased access to care, reduced wait times, and more services related to the aging population, chronic illnesses and mental health problems, nurse practitioners have the potential to contribute significantly to the improved delivery of healthcare in Canada.

Related CHSRF Articles

References

i. Canadian Institute for Health Information. (2010). Regulated nurses: Canadian trends, 2004 to 2008. Ottawa.

ii. Baerlocher, M.O. & Detsky, A.S. (2009). Professional monopolies in medicine. Journal of the American Medical Association, 301(8), 858-860.

iii. Closson, T. Ontario Medical Association is taking aim at wrong target, Toronto Star, October 6, 2009

iv. Canadian Medical Protective Association & Canadian Nurse Protective Society. (2005). Canadian Medical Protective Association /Canadian Nurse Protective Society joint statement on liability protection for nurse practitioners and physicians in collaborative practice . Ottawa, ON: Author.

v. Jones, L. & Way, D. (2004). Delivering primary health care to Canadians: Nurse practitioners and physicians in collaboration. Ottawa, ON: Canadian Nurses Association & Canadian Nurse Practitioner Initiative.

vi. Canadian Nurses Association. (2009). Position statement: Nurse practitioner. Ottawa, ON: Author.

vii. Dierick-van Daele, A.T., Metsemakers, J.F., Derckx, E.W., Spreeuwenberg, C., & Vrijhoef, H.J. (2010). Economic evaluation of nurse practitioners versus GPs in treating common conditions. British Journal of General Practice , 60 (570), e28-35.

viii. Venning, P., Durie, A., Roland, M., Roberts, C., Leese, B. (2000). Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care,
British Medical Journal, 320(7241), 1048-1053.

ix. DiCenso, A., Auffrey, L., Bryant-Lukosius, D., Donald, F., Martin-Misener, R., Matthews, S., et al. (2007). Primary health care nurse practitioners in Canada. Contemporary Nurse , 26 (1), 104-115.

x. DiCenso, A., Bourgeault, I., Martin-Misener, R., Kaasalainen, S., Kioke, S., Carter, N., Harbman, I., Donald, F., Bryant-Lukosius, D., & Kilpatrick, K. (2010). Utilization of nurse practitioners to increase patient access to primary healthcare in Canada - Thinking outside the box. Canadian Journal of Nursing Leadership

xi. Spitzer, W., Sackett, D., Sibley, J., Roberts, R., Gent, M., Kergin, D., et al. (1974). The Burlington randomized trial of the nurse practitioner. New England Journal of Medicine, 290(5), 251-256.

xii. Horrocks, S., Anderson, E., & Salisbury, C. (2002). Systematic review
of whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal, 324(7341), 819-823.

xiii. Russell, G.M., Dahrouge, S., Hogg, W., Geneau, R., Muldoon, L., & Tuna, M. (2009). Managing chronic disease in Ontario primary care: The impact of organizational factors. Annals of Family Medicine 4(4), 309-318.

xiv. Ducharme, J., Alder, R., Pelletier, C., Murray, D., & Tepper, J. (2009). The impact on patient flow after the integration of nurse practitioners and physician assistants in 6 Ontario emergency departments. Canadian Journal of Emergency Medical Care , 11(5), 455-461.

xv. Charlton, C., Dearing, K., Berry, J., & Johnson, M. (2008). Nurse practitioners' communication styles and their impact on patient outcomes: An integrated literature review. Journal of the American Academy of Nurse Practitioners, 20(7), 382-388.

xvi. Mundinger, M., Kane, R., Lenz, E., Totten, A., Tsai, W., Cleary, P., et al. (2000). Primary care outcomes in patients treated by nurse practitioners
or physicians: A randomized trial. Journal of the American Medical Association, 283(1), 59-68.

xvii. Seale, C., Anderson, E., & Kinnersley, P. (2006). Treatment advice in primary care: A comparative study of nurse practitioners and general practitioners. Journal of Advanced Nursing, 54(5), 534-541.

xviii. Harris/Decima. (2009). Canadians very comfortable with expanded role for nurse practitioners. Press release, August 13, 2009. Ottawa, ON: Author.

Disclaimer:

Mythbusters articles are published by the Canadian Health Services Research Foundation (CHSRF) only after review by experts on the topic. CHSRF is an independent, not-for-profit corporation funded through an agreement with the Government of Canada. Interests and views expressed by those who distribute this document may not reflect those of CHSRF. © 2010.