Objective: To describe self-reported NP practice patterns and perceived educational needs and plans of a national sample of NPs.
Design: National survey, with mailed follow-up
Population: Acute, adult , family, geriatric, and pediatric NPs credentialed through American Nurses Credentialing Center. Random sample of 6584 were sent questionnaires and 2241 usable responses were returned (34%)
Concept studied: 1) NP Practice patterns: autonomy, scope of practice, and reimbursement; 2) receipt of formal and informal training in select aspects of advanced practice and practice management; 3) perceived need for additional training and; 4) plans for additional education.
Methods: Investigator-developed semi-structured questionnaire was pre-tested then mailed in November 2001. Postcard reminder was sent two weeks later. Frequency distributions were generated for all items.
Findings: The mean age of respondents was 47.7 years, and they were disproportionately female (94.4%), and white non-Hispanic (92.5%). The vast majority hold masters degrees (91.4%), and 51.8% of them completed their masters since 1992. Respondents have been practicing as an NP for an average of 9.6 years and 90.3% currently provide direct patient care as an NP: 46.4% in office-based settings and 21.8% in hospital-affiliated clinics. Fifty-six percent state that they work in a collaborative practice and 18.1% practice independently. Almost half (49.1%) write prescriptions with no limitations imposed on them, and an additional 32.7% write their own prescriptions with the exception of narcotics. Only 15.5% hold hospital admitting privileges, and 63.2% of those with admitting privileges characterize them as "courtesy" and not full. Less than half (42.7%) are reimbursed directly for their services, and of those, 7.8% receive the same reimbursement as physicians for all contracts, and 24.9% receive the MD rate for some contracts. Main barriers to expanded NP practice were identified as (in order of decreasing frequency): low salary, lack of public knowledge of NPs, restrictions on prescriptive authority, lack of positions for NPs, and lack of admitting privileges.
Respondents report having learned differential diagnosis, disease management, and primary care management of patients in formal educational programs, and few want additional training in these topics. However, many other aspects of NP practice were reportedly learned informally on the job: telephone triage and management, negotiating specialist collaboration, commercial insurance billing and documentation, and quality assurance. The topics that respondents were most interested in learning more about included (in decreasing order): selection of information technology to support practice, getting credentialed with commercial companies, use of information technology, commercial insurance billing and documentation requirements, Medicaid billing and documentation, and managing or admitting patients in the hospital.
Nearly 15% expect that their professional opportunities as an NP will require additional formal education in nursing. However, 10.1% are considering working in another field besides nursing, while 9.3% are considering retiring in the next five years.
Conclusions: Although an overwhelming majority of NPs have prescriptive authority, few practice independently in full scope practice. Collaborative practice patterns with MDs are the norm. Currently, formal education programs are providing the basis for patient diagnosis and management, but more advanced competencies and practice management must be learned informally on the job. NPs identify learning needs related to information technology, and the complexities of interfacing with the insurance industry.
Implications: Current educational programs are not addressing, and cannot realistically be expected to include, advanced content needed for practice management, and cross-site and independent practice. A more advanced level of formal clinical education should be considered as an alternative to on-the-job training. A clinical doctorate with a standardized curriculum can provide the consistently high quality education needed for the independent full-scope NP practice that the law allows.
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