La Responsabilidad en el Sistema Educativo

My study is predicated on the evidence that NPs are a highly competent and cost-effective workforce who use advanced clinical and decision-making skills to examine, diagnose, and prescribe in a way that, until recently, was solely under the jurisdiction of medical practitioners (J. C. Bauer, 2010; Fisher, 2010; Group & Roberts, 2001; Pirret, Neville, & La Grow, 2015). Over the past two decades a body of research has been analysed and presented in systematic reviews comparing care provided by NPs and doctors demonstrating, at the very least, equivalence (Dierick-van Daele, Metsemakers, Derckx, Spreeuwenberg, & Vrijhoef, 2009; Horrocks, Anderson, & Salisbury, 2002; Laurant et al., 2005; Martínez- González et al., 2014; Mundinger et al., 2000; Newhouse et al., 2011; Swan et al., 2015). Some examples of key research are presented below, including utilisation of NPs, process of care, patient outcomes, and cost effectiveness.

In relation to consultation types, a retrospective cross-sectional analysis compared NPs, physician assistants (PAs), and physicians for primary care encounters with patients who were part of the Veterans Health Administration in the US (P. A. Morgan, Abbott, McNeil, & Fisher, 2012). In 2010, 10.6 million primary care encounters with patients took place and were analysed. Of those encounters, 19.2% were with NPs. Nurse practitioners, physician assistants (PAs), and physicians were found to fill similar roles. While the patient complexity score was slightly higher for physicians, the researchers noted that these differences were small. Additionally, physicians saw equal numbers of less complex patients. Importantly for the development of the NP workforce, they concluded that this “challenges the prevailing notion that NPs and PAs see patients who are less medically complex than those cared for by physicians” (P. A. Morgan et al., 2012, p. 4).

39 Research comparing the work of NPs to doctors or physicians has been ongoing for several decades. Particularly notable was a randomised controlled trial (RCT) conducted between 1996 and 1997 on 3397 adults in primary care settings assigned to either NP or physician care, which found patient outcomes were comparable (Mundinger et al., 2000). A two year follow up on 406 of those patients again found no difference in health status or use of specialist or hospital usage (Lenz, Mundinger, Kane, Hopkins, & Lin, 2004). Since then, various systematic reviews have been conducted. Newhouse et al. (2011) reviewed studies undertaken between 1990 and 2008 comparing advanced practice nursing care to care provided by physicians. Specifically, for NPs a total of 37 studies (fourteen RCT trials and 23 observational studies) were reviewed that examined patient outcomes. Overall, a high level of evidence was found that demonstrated NPs provide at least equivalent care to physicians.

With regard to prescribing, a systematic review of 35 studies compared nurse and physician prescribing and found that nurses prescribe in similar ways to physicians in relation to patients, their diagnosis, medication types, and dose (Gielen, Dekker, Francke, Mistiaen, & Kroezen, 2014). In terms of clinical outcomes, only tentative conclusions could be drawn due to the low methodological quality of the study designs. However, taking this into consideration, clinical outcomes were the same or better for NPs. Perceived quality of care was similar or better for nurses compared to physicians, and patients treated by nurses were just as satisfied or more satisfied. The argument sometimes made that NPs prescribe more medications than doctors was not demonstrated in the review.

With the increase in number of NPs, particularly in the US, studies with large numbers and increasing statistical power are being conducted. A recently published retrospective cohort study in the US of 345,819 older adults with diabetes receiving Medicare, compared the care provided by NPs with primary care physicians (Kuo et al., 2015). The researchers found that care from a NP was associated with a lower risk of hospitalisation for conditions that could

40 be defined as preventable. They concluded that primary care provided by NPs was at the very least comparable to that provided by general physicians.

The ongoing evidence of the equivalence of NP practice led Alison Pirret, in her doctoral research, to compare the diagnostic reasoning abilities of thirty NPs and sixteen doctors relating to a complex case (Pirret et al., 2015). Nurse practitioners and doctors, who were completing postgraduate specialist training, were given a complex case scenario with a ‘think aloud’ protocol that was used to assess their diagnostic reasoning abilities through a panel of experts. The study found that there was no statistical difference in NPs’ ability to generate diagnoses, and formulate and implement an action plan. While this study is small, it indicates the ability of NPs to work with high levels of health and medical complexity. While equivalence has been thoroughly substantiated, evaluating the cost-effectiveness of NPs is more problematic. Many studies focus on the comparisons of consultation time, basic salary costings, ordering of diagnostic tests, and follow-up and referrals. However, a thorough analysis of cost-effectiveness requires much more than this. Martin-Misener et al. (2015) undertook a systematic review of the cost-effectiveness of NPs in primary health care settings. They found there was high quality evidence to conclude that NPs provided care that was cost-effective with patient outcomes demonstrated to be at least equivalent to, or better than care provided by doctors. However, the researchers raised the need to overcome the methodological and ethical challenges for assessing cost across a whole range of parameters. Such parameters include professional expenses, overhead costs of private businesses, salary, and the long-term outcomes relating to morbidity and mortality. Such a system wide evaluation would provide clarity to health service planners challenged by rising health care costs, chronic disease, and health inequalities.

Thus the literature reveals that NPs are providing care that, across some parameters, is superior to the care provided by doctors. Martínez-González et al. (2014) undertook a systematic review comparing nurse-led care, including NPs, to care provided by physicians

41 in community, general practice, and ambulatory care settings. Twenty-four randomised controlled trials with over 38,000 participants were included in the review. With a caution regarding methodological limitations, they stated:

Our review suggested that nurse-led care is associated with higher patient satisfaction, lowered overall mortality and lowered hospital admissions…. The effect of nurse-led care on hospital admissions and mortality was particularly present in studies of ongoing care and non-urgent visits and when NPs … provided the care. [The] surprising and important finding, especially that nurse-led care could lead to reduced mortality, should be addressed in future studies. (Martínez-González et al., 2014, p. 14)

Similarly, in a smaller systematic review, researchers again concluded that advanced practice nurses, including NPs, provided safe and effective primary care, that for some measures was superior to physician-led care (Swan et al., 2015). Further, these researchers identified that advanced practice nurses in these studies provided care that was “in some ways different” (p. 403) from the care provided by physicians. This will come as no surprise to NPs who work within a model of care where the individual patient’s needs are considered within the context of family, community and environment.

The high patient satisfaction scores found throughout research on NPs, are likely a reflection of the use of a nursing model and approach to care that particularly focuses on communication strategies, advocacy and health promotion (Budzi, Lurie, Singh, & Hooker, 2010; Ploeg et al., 2013). While this ‘other’ work has been described qualitatively (for example, Tarlier & Browne, 2011), mostly NP work is described through case studies, such as Bourgeois et al. (2014a) or commentary in nursing or NP journals. It has always been a challenge for the nursing profession to clearly define what nurses do outside of the dominant biomedical discourse. The same issue persists for NPs, and leads to ongoing misconceptions from the medical profession as to what NPs do, and how their work is complementary to, a ‘value-add’, or even more appropriate than the work of doctors.

42 The ongoing drive to produce and deliver research which directly compares the work of NPs and doctors, renders invisible the ‘other’ work that NPs do. Hughes and colleagues (F. Hughes, Clarke, Sampson, Fairman, & Sullivan-Marx, 2010) referred to this as defensive research designed to demonstrate safety within the dominant paradigm of medicine. Further, NPs are being subsumed into the prevailing discourse of new public sector managerialism, where the focus is on health outputs and outcomes (Aranda & Jones, 2008). Aranda and Jones argue that such dominant discourses, prevalent in the ruling relations, leave NPs in a position of feeling both ambivalent and subordinated. It is perhaps not surprising that research which extols the models, qualities, and characteristics of the ‘other’ work of NPs, which would enhance health care provision, is limited.

While research to demonstrate comparative work and safety was a necessity earlier in the development of the NP workforce, there is a call to shift research to identify what constitutes optimal care (F. Hughes et al., 2010). There are increasing data that NPs are providing superior care across some parameters of primary health care work when compared to doctors. Carryer and Adams (2017) argued in a recent paper that having conclusively established equivalence with doctors, research now needs to focus on the value-add of NPs in primary health care (Carryer & Adams, 2017, see Appendix B):

In this paper we argue that nurse practitioners (NPs) offer the exact transformation in care that the WHO seeks. We challenge the necessity of continuing to conduct research demonstrating direct comparisons of equivalence between nurse practitioner (NP) and doctor or physician-led care, and in fact argue, using our data, that such questioning has limited the way in which NP services could be envisaged, and limited acknowledgement of their potential points of difference. (p. 2)

Nurse practitioners are the ideal workforce to provide health services to such communities, working from within a social justice framework.

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