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Workplace climate proves crucial to NPs’ practice effectiveness

Organization and culture in healthcare settings often impede the full utilization of nurse practitioners, meaning state laws expanding scope of practice might not be sufficient to relieve the nation’s primary care crisis, according to a small study.

A research team led by Lusine Poghosyan, RN, PhD, assistant professor at the Columbia University School of Nursing in New York City, investigated how the workplace environment in primary care settings affects NPs’ ability to deliver quality care and practice independently. Study results came from 16 NPs practicing in Massachusetts, where state health reform increased demand for primary care and subsequent legislation recognized NPs as primary care providers.

The results, published in the Journal of Professional Nursing, suggest that gains made through legislative reform can be neutralized by the formal and informal practices in place at healthcare organizations. For example, the study cited instances where NPs were not allowed to see new patients or even conduct physical assessments.

The researchers also investigated the level of support and resources available to NPs, who reported they often were denied the same level of personnel support and operational resources provided to physicians — including medical assistants and administrative staff — and sufficient exam room space. NPs interviewed for the study also said their role was poorly understood by senior leadership, contributing to a sense of deprecation, isolation and poor relations with administrative personnel.

This lack of understanding of the NP role also emerged as a contributing factor to what the study describes as NP “invisibility.” Study results consistently found that administrative personnel lacked an awareness of the NP role and competences, further aggravating the fragmented communication between NPs and administrative staff and keeping NPs out of the decision-making processes within the primary care practice.

Billing and data collection systems are a key factor in NP invisibility, the study found. Massachusetts law requires third-party payers to recognize NPs as primary care providers. However, the study cited examples where data used to capture productivity and quality of care measurements often masked the contribution of NPs because physicians were listed as the provider of record. Most health organizations list physicians as the provider of record because Medicare pays about 15% less for services that are billed by an NP, Poghosyan said in a news release.

Listing NPs under the physician name on the patient record hinders NPs from getting timely access to patient information and hinders their ability to develop a care plan and track quality measures, according to the news release. In addition, the report points out attributing NP care to physicians can lead to missed opportunities for measuring the benefits of care delivered by multidisciplinary teams, a strategy envisioned under health reform as a tool for improving quality and cutting costs.

The implications of the study make clear that enacting expanded scope-of-practice legislation for nurse practitioners is necessary, but not sufficient, to effectively strengthen the delivery of primary care.


Administrators should clearly define ways for NPs to be included on the decision-making committees that govern the daily operations of the healthcare setting workplace, the authors recommend. To achieve better outcomes and reduce cost, healthcare practice sites should provide adequate access to resources to assure efficient use of NP time and skills. Also, to encourage NP visibility as care providers and promote their professional practice, organizational and policy structures should be created to demonstrate the contributions of NPs to patient care and foster continuous contact with patients.

Time may help improve the experiences of NPs in primary care, the study suggests. Most NPs reported that the longer they worked with physicians, the more the MDs trusted them and gave them autonomy to practice independently. Administrators who had past experience working with NPs had better knowledge about NP roles and competencies.

Study abstract:


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By | 2014-01-10T00:00:00-05:00 January 10th, 2014|Categories: National|0 Comments

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