Nurse Practitioner-Led Clinics Fill Gap in Patient Care
- The rising number of nurse practitioner-led clinics is supported by evidence of a positive impact on patient satisfaction and outcomes.
- A growing physician shortage has created a gap between demand and supply that was highlighted during the pandemic.
- The American Medical Association is fighting against full-practice authority, despite strong evidence that nurse practitioners provide quality care.
There is mounting scientific evidence that advanced practice registered nurses (APRNs) have a positive impact on patient satisfaction and outcomes. This has led to a rising number of nurse practitioner-led clinics in states where nurse practitioners (NPs) have full-practice authority.
Kevin Lee Smith, DNP, FNP, FAANP, is the chief nurse practitioner officer at The Good Clinic, a chain of nurse practitioner-led healthcare clinics that emphasize patient engagement, wellness, and convenience.
The COVID-19 pandemic highlighted many healthcare disparities and inequities. Among them are gender, age, race, and socioeconomic challenges with access to care. The growth of NP-led clinics helped to answer this need in rural and urban areas.
"There is a growing shortage of primary care physicians in the U.S. due to a preference to practice specialty care," Smith says. "Primary care providers also experience a high degree of burnout and turnover due in part to a lack of face-to-face time with patients."
With primary care facing many challenges, the increasing number of clinics has had a positive impact on patient care and an overall influence on the nursing profession.
Nurse Practitioner-Led Care Demonstrates Positive Outcomes
Falling numbers of primary care physicians led to the establishment of the Minneapolis-based Good Clinic, a nurse practitioner-driven model that emphasizes wellness and continuity of care. The Good Clinics are a response to patients needing more than an urgent care physician to manage their chronic illnesses.
Patients can spend more time with a healthcare practitioner, and they are given a safe space to ask uncomfortable questions. The goal in the NP-led practice is to build lasting relationships and support patient's goals. Smith describes this as a process that is less transactional and more relational.
"We think the growing numbers of NPs in the field of primary care is a wonderful opportunity to increase access to healthcare and provide a more person-centered, holistic experience for the patient," Smith says.
Data show this care model improves patient outcomes and patient satisfaction, both of which are critical to health and wellness. One systematic review of the literature from 15 studies across several countries, including the U.S., found that clinics led by APRNs can increase access to care, improve patient satisfaction, and have a positive impact on health outcomes.
The data was gathered between 2006 and 2016. Examples of behavioral changes that led to improved health include quitting smoking, improved self-care, and safer sex practices. Two studies measured cost-effectiveness and both showed savings.
The researchers quote Cheryl Fattibene, chief nurse practitioner officer at the National Nurse-Led Care Consortium, which represents nurse-managed health clinics in the U.S. She believes the biggest challenge to the expansion of nurse practitioner-led clinics is the pushback from the American Medical Association (AMA).
She points to the differences in treatment modalities: identifying and treating a disease for physicians versus the APRNs' focus on wellness and prevention. She believes that continuing in the current way is taking healthcare in the wrong direction.
Physician Groups Fighting Change
Nurse practitioner-led clinics are operational in states where nurse practitioners have full-practice authority. This means they have the right under the law to prescribe, diagnose, and treat patients without physician oversight or supervision.
The American Medical Association has been working for over 30 years to stop full-practice authority in the U.S. Their argument is that "patients deserve care led by physicians" and their "advocacy efforts have safeguarded the practice of medicine by opposing nurse practitioner … attempts to inappropriately expand their scope of practice."
In June 2022, the AMA claimed a coalition of 108 national, state, and specialty medical societies that have influenced 70 bills introduced in state legislatures. In November 2020, the American Association of Nurse Practitioners published an open letter that criticized the organization's stance, writing that "NP-delivered care is irrefutable."
The fight to oppose full-practice authority for nurse practitioners does not appear to be based on data. Instead, the AMA cites their data that show expanding nurse practitioner authority does not equal expanding healthcare access.
They also cite patient preference to have physicians involved in diagnosis and treatment decisions and concern that nonphysician level care is a step in the wrong direction.
Implications of Rising Number of Nurse Practitioner-Led Clinics
The increasing number of nurse practitioner-led clinics and changes to the healthcare system have long-term implications for the nursing profession. These changes to the healthcare system were driven by inequities and disparities made evident during the pandemic.
The need for expanded roles, such as physician shortages and healthcare disparities, is well supported by data. The gap between demand and supply became more evident during the pandemic. Barriers to healthcare include:
In contrast to physician education, nursing programs address health from a holistic perspective and focus on disease prevention and health promotion. Additionally, NPs are educated in population health and the healthcare needs of a larger society.
California passed Assembly Bill 890, which increases the NP scope of practice without changing the practice authority in the state. NPs will be required to meet specific criteria to practice independently, including 4,600 hours of physician oversight.
The state hopes nurse-led clinics will help close the gap in healthcare and reduce morbidity and mortality in underserved urban areas. Many experts believe the rising number of NPs is good news for the healthcare system as a whole.
However, this growth may also contribute to the registered nursing shortage. In 2017, the increase in the number of NPs and physician assistants was greater than the number of physicians entering practice.
Nurse Practitioner-Led Clinics Guided by Collaboration and Cooperation
According to the Centers for Disease Control and Prevention, six out of every 10 adults in the U.S. have a chronic disease and four out of every 10 have two or more. The rate of chronic disease rises with age. This means that not only is the baby boomer generation retiring by 2030, but they will likely also contribute to an increasing need for healthcare to treat chronic diseases.
To care for these complex patients, nurse practitioners collaborate and cooperate with other healthcare providers, much the same way that a physician-led clinic does. Digital communication also allows near-instant access to more experienced NPs.
Nurse practitioner-led clinics often consult each other internally and may create partnerships with other specialty practices. For example, a partnership with a radiology group could help nurse practitioners quickly consult about the type of imaging that might be most beneficial on a case-by-case basis.
As in other patient care situations, nurse practitioners are quick to refer to a specialist when their patients require a higher level of care. Quality assurance and professional accountability are integral parts of a nurse practitioner-led clinic.
"What is unique about NPs is their patient education focus, experience, and holistic care approach. We want to leverage the nursing perspective that takes the whole person into account — the bio-psycho-social-spiritual being," Smith says.
Nurse practitioners are patient care providers, but they are also educators and researchers. Their knowledge and skill base can help advance policymaking activities and inform advocacy for legislative change to improve healthcare access.
Meet Our Contributor
Kevin Lee Smith, DNP, FNP, FAANP
Kevin Lee Smith is the chief nurse practitioner officer at The Good Clinic with previous experience helping to create the MinuteClinic model and providing early-stage informatics leadership at Zipnosis. Smith has also been an active primary care nurse practitioner and served in faculty positions at the University of Minnesota throughout his career.
AMA successfully fights scope of practice expansions that threaten patient safety. (1995-2022). https://www.ama-assn.org/practice-management/scope-practice/ama-successfully-fights-scope-practice-expansions-threaten
Assembly bill 890. (2022). https://www.rn.ca.gov/practice/ab890.shtml
Chronic diseases in America. (2022). https://www.cdc.gov/chronicdisease/resources/infographic/chronic-diseases.htm
Modernization of California nurse practitioner practice is overdue: Implications for nurse-led clinics. (2020).
Open letter to the American Medical Association. (2020).
Salsberg E. (2018). Changes in the pipeline of new NPs and RNs: Implications for health care delivery and educational capacity. https://www.healthaffairs.org/do/10.1377/forefront.20180524.993081/full/
Sofer D. (2018). Nurse-led health clinics show positive outcomes. https://journals.lww.com/ajnonline/fulltext/2018/02000/nurse_led_health_clinics_show_positive_outcomes.6.aspx
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