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Patient Knowledge of Nurse Practitioners

What does the public know about these healthcare professionals?

There is a lack of patient understanding surrounding the role of nurse practitioners (NPs) in primary care when compared to physicians and physician assistants (PAs). This leads to a false perception that NPs may be less capable of diagnosing and managing the treatment of individuals. Patients are generally unwilling to see NPs and prefer physicians when they are given a choice.1 This is due to patient perception and not related to established evidence that nurse practitioners provide the same or better level of quality care.2 More specifically, patients prefer to consult with a medical doctor for more serious symptoms, and feel more comfortable consulting nurse practitioners for minor symptoms, education, and reassurance.3 The purpose of our study is to increase the understanding of the role, educational requirements and scope of practice of NPs in select clinics in New York State while optimizing patients' comfort level regarding the care provided by NPs.

Review of Literature

NPs are a population of healthcare providers increasing dramatically in the healthcare arena, in areas including, but not limited to, doctors offices, hospitals, and acute care clinics.3-4 It is well documented in multiple studies that NPs provide equal or better quality of care when compared to PAs and MDs.2,5 There is an overall patient satisfaction with the care of NPs.6

So why are patients unwilling to be seen by a NP for all medical needs? Despite evidence of equal quality of care by NPs, patients are more likely to choose a MD provider when given a choice between a PA, NP and MD.1There is preference for a MD when dealing with medical aspects of care3, whereas for educational and routine aspects of care, some patients either preferred the NP or had no preference for either. A variety of different providers possess an indistinguishable image, i.e. white coat and stethoscope, similar to that of a senior physician.1

How is the patient truly to know the difference between providers when many times they appear identical? A lack of differentiation among the prestigious white coats can cause confusion.

There are comparable patient outcomes in the setting of randomly assigned patients to either NPs or MDs at equal levels of responsibility.7 Additionally, evidence reveals profound awareness of the role of a NP, a high level of satisfaction with the care and evidence that NPs positively affect the patient experience.8 Patients felt confident in the care received by NPs and appreciative of their level of expertise.9 Patients also felt that their individual best interests were completely considered.9

There is an equal level of satisfaction by patients among both MDs and NPs, but a necessity of patient education regarding the differences of various healthcare providers.10 This is again related to a preconceived perception of what they feel the specific provider is capable of, and how they perceive the care actually received thereafter.10 It is suggested that more research focusing on NP competence would support the movement toward positive provider perception. Through the use of educational tools, along with further research, the role of NPs has the potential to become more understood by patients.

Methods

We conducted this research as Columbia University students within the family nurse practitioner program, at 5 different locations in N.Y.C. and Long Island, N.Y., which service the healthcare needs in high volume primary care clinics. Instructions and surveys were provided to anonymous subjects while they were in the waiting room. The subjects were explained the purpose of the survey, and that no medical information will be used for the research. The instructions were provided to each subject without any bias. Patients were informed to take a pretest survey and a posttest survey.  

Prior to the posttest an informational pamphlet provided by the Nurse Practitioner Association in New York State was included for them to read. The survey itself consisted of two parts-pre-assessment which aimed to measure patients' existing view of the role of nurse practitioners and a posttest survey, which assessed their understanding after reading the pamphlet. After reading the pamphlet, the posttest survey was used to measures their perception on the role of NPs, as well as their willingness to be seen by NPs in the future.

Results

A total of 41 patients (n = 41) in New York State within five different primary care settings were surveyed. Participants surveyed comprised of 16 males and 25 females. The age of the participants surveyed ranged from 21-68 years old with a mean age of 38.75 (one unreported). It was found that 76% of the participants stated they had an understanding of the role of a NP before reading the educational pamphlet. When asked specific questions about NP specialties, practice settings, and scope of practice, an average of 85% of the participants showed an understanding of these combined aspects. More specifically, when questioned where a NP can work, 80% of participants answered that a NP could work in a hospital, doctor's office, outpatient clinic or a school. As for specialty areas, 83% of participants answered this correctly.  Questions referring to the scope of practice of a NP revealed 93% of participants answered that a NP could diagnose illnesses, prescribe medication, perform physical exams and interpret lab tests.  However, when asked if one would prefer to see a NP, physician, or indifferent, only 12% stated that they preferred to see a NP, 49% stated they preferred to see a physician, and 39% patients reported they were indifferent.

SEE ALSO: NPs Implement an On-Site Health Clinic for Employees

Overall, after reading the given educational pamphlet 75% of participants reported the pamphlet increased their understanding of the role of a NP and 80% said they would be more willing to see a NP.  Out of the participants who originally stated they were only willing to see a physician, 77% percent stated their knowledge of the role of a NP increased, and 77% stated they were more willing to see a NP as their primary care provider.

Discussion

The patient population in this study was aimed to reflect the racial demographic of N.Y. state. According to the Census data, N.Y. State's population is consists of 66.4% White, 15.5% Black, 17.3% Hispanic, and 5.9% Asian11. Our study was comparably representative of such diversity.

The pretest of participants revealed general baseline knowledge of educational requirements and scope of practice of a NP. Despite this self-proclaimed understanding, patients were more likely to choose a physician for their medical care if given the choice. This is in line with previous literature where patients reported to be generally unwilling to see NPs, and would rather see a physician1,3. Considering the pretest results of NP role understanding, along with existing literature revealing high levels of satisfaction and patient outcomes with NPs2, the demonstrated unwillingness to be seen by a NP is surprising.

Some participants elaborated on their choices and based this decision on education alone:

"Although NPs have extensive medical training, a physician has or should have more. So I think the NP is a follow-up to a physician's diagnosis." 

"There really isn't much of a difference between NPs and MDs except more schooling. I'd go to either one depending on severity of the issue. Obviously if it's life threatening I'd go to an MD."

"I have a finite amount of time to spend in an healthcare practice so I'd rather have continuity and see an MD that has more comprehensive and lengthy training."

The educational intervention intended to strengthen the perception of a NP's qualifications. This intervention proved successful. The post-test results showed a significant and positive change in patient perception of NP competence. Participants felt like their knowledge of the NP role increased, and they were also more willing to make a medical appointment with a NP.

Some participants directly attributed the pamphlet to their knowledge expansion:

"The brochure was informative and reassured my knowledge of NPs."

"I know more about the NP profession then I did before I read the brochure."

Voluntary participant comments after the survey offered further insight. Those who have already experienced medical care from a NP were more willing to follow up with a NP when making a medical appointment. This information was gathered only from a few participants who left comments, as this was not a direct finding in the questionnaires. However, this does correspond with the high satisfaction levels of NP-patient relationships already reported from previous literature8.

"I feel as though NPs are qualified to sufficiently care for patients from personal experience." 

"NPs have a good understanding of the medical field and I'm comfortable with them." 

"From personal experience I feel as though NPs are qualified to sufficiently care for patients."

"I have had the pleasure of being treated by NPs in the past. They were highly professional, skilled and had complete confidence in the their treatment and care."

Limitations

There were several limitations to the study. First, participants were conveniently selected from outpatient primary care clinics in NYC and Long Island, N.Y. The sample size could be expanded to represent other areas of N.Y.S. Second, the sample surveyed represented relatively urban, English speaking, literate patients. According to the U.S. Census Bureau, up to 25% of NYC's population is not fluent in English11. Further demographics, educational background and poverty level should be investigated to understand deficits in knowledge of provider roles. Third, it was difficult to determine if pretest answers adequately reflected patients' actual knowledge of the NP role before reading the pamphlet, as there was no direct observation of the sequencing of events.

Conclusion

The results of this study show that there was a greater understanding and willingness to see NPs after reviewing the educational pamphlet. By just giving a sample of patients the basic facts of who NPs are and their roles, we were able to increase the acceptance of NPs, therefore increasing the likelihood that they may choose a NP as their primary care provider. With additional study results, a more comprehensive scale of patient education can be implemented. With a greater patient understanding, NPs will be in a better position to help with the increasing health needs of our country and patients will be more willing to utilize their services.

Melissa Argenio is a cardiology nurse practitioner at Columbia Doctors. Alison Collier is a dermatology nurse practitioner at MDCS: Medical Dermatology and Cosmetic Surgery. Meggan Kent is a cardiology nurse practitioner at The Huntington Heart Center.  I-Li Lei is a nurse Practitioner at New York Presbyterian-Columbia Medical Center. Aluem Tark is a PhD student at Columbia University School of Nursing. Katie Walton is a transplant nurse practitioner at Saint Barnabas Medical Center.

References

1. Larkin, GL, & Hooker, RS. (2010). Patient Willingness to Be Seen by Physician Assistants, Nurse Practitioners, and Residents in the Emergency Department: Does the Presumption of Assent Have an Empirical Basis? The American Journal of Bioethics, 10, 1-10.

http://www.tandfonline.com.ezproxy.cul.columbia.edu/doi/full/10.1080/15265161.2010.494216#abstract

2. Stanik-Hutt, J, Newhouse, R, White, K, Johantgen, M, Bass, E, Zangaro, G, & Weiner, J. (2013). The Quality and Effectiveness of Care Provided by Nurse Practitioners. The Journal for Nurse Practitioners, 9, 492-500. http://www.sciencedirect.com/science/article/pii/S1555415513004108

3. Laurant MGH, Hermens RPMG., Braspenning JCC., Akkermans RP, Sibbald, B, & Grol RPTM. (2008). An overview of patients' preference for, and satisfaction with, care provided by general practitioners and nurse practitioners. Journal of Clinical Nursing, 17, 2690-2698.

http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2702.2008.02288.x/abstract?deniedAccessCustomisedMessage=&userIsAuthenticated=false 

4. The Nurse Practitioner Association New York State. About Nurse Practitioners [Pamphlet]. (n.d.) New York: (n.p.).

5. Horrocks, S, Anderson, E, & Salisbury, C. (2002). Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. Bmj, 24(8), 819-823.

6. Knudtson, N. (2000). Patient Satisfaction With Nurse Practitioner Service In a Rural Setting. Journal of the American Academy of Nurse Practitioners, 12(10), 405-412.

7. Mundinger, M, Kane, R, Lenz, E, Totten, A, Tsai, W, Cleary, P, & Shelanski, M. (2000). Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians: A Randomized Trial. The Journal of the American Medical Association, 283(1), 346-347.

8. Brown, D. (2007). Consumer perspectives on nurse practitioners and independent practice. Journal of the American Academy of Nurse Practitioners, 19, 523-529.

9. Hayes, E. (2007). Nurse practitioners and managed care: Patient satisfaction and intention to adhere to nurse practitioner plan of care. Journal of the American Academy of Nurse Practitioners, 19, 418-426.

10. Maul, T, Zaidi, A, Kowalski, V, Hickey, J, Schnug, R, Hindes, M, & Cook, S. (2015). Patient Preference and Perception of Care Provided by Advance Nurse Practitioners and Physicians in Outpatient Adult Congenital Clinics. Wiley Periodicals.

11. U.S Census Bureau. (2015, September 24). Quickfacts: New York, N.Y.  http://quickfacts.census.gov/qfd/states/36/3651000.html.

 

 

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