Up Close & Personal
Nurse practitioners come into their own as the field grows and grants them more authority, autonomy and job satisfaction

By Heather Stringer
November 25, 2003

Kristin Chaussee, MSN, FNP, RNCS, wanted a job with more responsibility, and she got it. The North Dakota nurse practitioner regularly detects sexually transmitted diseases such as genital warts in teen girls-a virus that can cause cervical cancer if not treated in its early stages.

Chaussee, who opened a teen clinic in Bismarck, N.D., is well-liked not only by her young patients, but also by parents who are grateful for a health professional who will take the time to teach their children about STDs. As a nurse practitioner, Chaussee is among a group of health care professionals that is quickly gaining popularity among patients as well as physicians.

For patients, nurse practitioners usually can offer more time than doctors to talk about a patient's health problems and explain the details of a condition. For doctors, NPs can ease patient load pressures by seeing certain types of cases, which frees up doctors to focus on cases that require their type of expertise.

Although the number of NPs has more than doubled nationwide in the past 10 years, nurses say that pioneering a new field has its challenges. One source of frustration is that rules about writing prescriptions and collaborating with doctors vary from state to state. NPs in some states are quickly elevating to the level of running their own practices, while in other states progress is slow, as NPs battle medical associations that are resistant to giving them more authority.

Even though nurse practitioners in some states are eager for more responsibility, most agree that the field has gained much ground since it began in the mid-1960s.

"People who graduate now have no idea what it was like in the 1960s or 1970s," said Susan Wysocki, NP, RNC, president and CEO of the National Association of Nurse Practitioners in Women's Health. "When I first was asked to attend an NP program, I literally did not know what an NP was."

Today, NPs are commonly seen in specialties such as women's health, family practice and pediatrics, although they are moving into more areas of medicine. In 1997, NPs won a major victory when the Balanced Budget Act passed. This legislation stated that Medicare would allow NPs to be reimbursed directly. Previously, Medicare billed the physician who collaborated with the nurse.

Now, 13 states allow NPs to prescribe drugs without physician involvement, and these states even permit nurse practitioners to prescribe controlled substances, according to an article in The Nurse Practitioner.

Victories such as these are possible in part because an increasing number of nurse practitioners in the field can lobby for more authority. About 88,000 NPs were practicing in the United States in 2000, compared to only about 43,000 in 1992, according to the National Sample Survey of Registered Nurses. Another powerful lobbying tool has been patient satisfaction ratings of NPs.

"We've had a long history of having to document our expertise and come up with the data to show that patients do accept us," said Joan Stanley, Ph.D., CRNP, director of education policy at the American Association of Colleges of Nursing. "Many of us have been involved in the movement for a long time. All the studies have shown patient satisfaction with nurse practitioners, and that the care provided is just as good or better than physicians'. None of the studies has shown dissatisfaction with NP practice."

Turf battle

Although the high patient satisfaction rates are ideal for lobbying legislators for more authority, some nurses acknowledge that these studies may be threatening to some doctors. Georgia, for example, is the only state that does not give NPs any prescriptive authority. Myra Carmon, Ed.D., CPNP, RN, associate professor of nursing at Georgia State University and president of the Georgia Nurses Association, said the medical association in Georgia is powerful and not supportive of giving NPs more responsibility.

"We have been at the capital for many years trying to get prescriptive authority," Carmon said. "We feel like the current policy decreases access to care because it slows things down."

NPs in Georgia need to have the doctor sign off on a prescription, or the nurse calls it in under the doctor's name, Carmon said.

Jeanne Findlay, MN, CPNP, RN, who has worked as an NP for 20 years, faced similar barriers when she moved from New York to Maryland. As a nurse practitioner in New York, she could go on rounds and admit patients, but she didn't have these privileges when she moved to Maryland. This has changed in Maryland within the last three years, but doctors are slow to encourage NPs to set up their own practices, she said.

"They don't want you setting up your own shingle," Findlay said. NPs in Maryland need doctors to sign agreements stating their collaboration arrangement. She said that technically, NPs are allowed to set up their own practices if they have a written agreement with a collaborating doctor, but she said NPs would be hard-pressed to find doctors who will sign the agreement if the nurse wants to practice in a different location.

Taking the time

For Noelle Gibson, MN, CPNP, RN, the unspoken understanding between physicians and nurse practitioners is different. She works in Oregon, where NPs can set up their own practices and clinics, and there is no requirement to collaborate with a physician.

"In my experience, it's been very positive working with doctors," Gibson said. "They seem very thankful that we can spend more time with patients that need more time."

Ideally, doctors and nurse practitioners can have a symbiotic relationship, Wysocki said. NPs can see many of the patients who have more routine conditions, and this leaves doctors more time to treat patients who need a specialist.

"For the majority of things that people have, patients need somebody to teach them to take medication correctly, monitor their treatment plan or do normal health screenings," she said. "None of those things necessarily needs a specialist."

She said patients need a specialist for more complicated cases. Although this system could potentially seem to set up NPs to deal with more mundane health problems, Wysocki said this is not the case.

"For the most part, it's a highly satisfying profession," she said. "You are making independent decisions. There's just a great degree of satisfaction if a patient says 'I never understood that before.' I have had that happen. That feels really good."

Barbara Dehn, MS, NP, RN, agrees that autonomy and time to teach patients makes her job satisfying. She specializes in women's health and works with a group of doctors in Mountain View, Calif.

Dehn performs first trimester pregnancy ultrasounds, gynecologic ultrasounds and also works with infertility cases. She also does a lot of first pelvic exams for girls because these patients appreciate a health professional who can take more time for what seems like a frightening new experience.

Sometimes, doctors even refer patients to Dehn because they know she works well with sensitive patients. A doctor recently referred a patient to her who struggled with depression and suicidal thoughts. Dehn asked the patient to complete a questionnaire to determine if the woman was having panic attacks, obsessive-compulsive disorder or depression.

"After she finished the questionnaire, I just let her talk," Dehn said. "Then I asked open-ended questions." Dehn ultimately prescribed an antidepressant, suggested a therapist and asked the patient to come in for a follow-up visit three days later.

"I love working with women, and I feel like I am in that stage where I am practicing the art of nurse practitioning," she said. "The challenging thing is to recognize the fear behind the questions that come up for patients. When a patient can't verbalize the fear, I try to recognize the fear. It's seeing beyond the obvious."

Nurse practitioners are fighting for the right to use this kind of expertise in all states, and although there is still a long road ahead in certain parts of the country, Mary Knudtson, NP, a consultant for the American College of Nurse Practitioners, has hope that NPs will continue to gain ground.

"My dream would be that we are independently licensed and directly reimbursed, and that we would have an independent scope of practice," she said. "We've made tremendous progress and continue to make progress. We just need to do one thing at a time."

Contact Heather Stringer at heather_stringer@yahoo.com