POLICY BRIEF
NURS 450
March 2015
Should Nurse Practitioners Be the Primary Care
Providers for Patients in the Rural Setting?
A glance at rural healthcare providers
In the United States, there is a lack of primary care providers in rural settings. Only 10% of
physicians practice in the rural setting although almost 25% of the American population lives in
the rural setting (National Rural Health Association). This creates an issue for the patients living
in this setting. They will not receive the diagnosis, treatment, education, and health maintenance
needed to optimize their health status. Although, recruiting efforts are being made to entice
physicians to these rural areas, it is important to keep in mind that Family Nurse Practitioners are
a possible solution to this issue. Nurse practitioners are able to diagnosis, educate and assist in
maintaining the rural populations’ health. They can provide the basic care a family physician
would in rural America.
Too few physicians
For years the number of medical students who have wanted to practice Family Medicine has
vastly declined (American Academy of Family Physicians, AAFP, 2015).The physicians who do
wish to practice Family Medicine have no desire to practice in rural America. The health of rural
Americans will decline if more primary care physicians refuse to treat patients in this setting.
Nurse Practitioners are responding to this decline by becoming the primary caretakers in many
cases (Mahar, 2013).
Nurse Practitioners (NP) are advanced practice nurses (APN) with training to diagnose, treat,
and sometimes prescribe medications to patients. Autonomy legislation is different for each state
and changing consistently.
Some states currently allow a NP to diagnose, treat and prescribe patient medications without
supervision of a physician. Others allow the NP to diagnose and treat, but not prescribe under
physician. In the remaining states, the NP either has to be directly or indirectly be supervised by
a physician (National Conference of State Legislators, 2015). This practice can repress the nurse
practitioners training and hinder the healthcare of the rural community by not having enough
primary care physicians.
American Medical Association
There are barriers to nurse practitioners becoming the primary caregiver. The American
Medical Association (AMA) is one organization that does not support nurse practitioners
practicing independently. They state that nurse practitioners do not have the training and
education needed to administer primary care. Furthermore, the AMA states “With a shortage of
both nurses and physicians, increasing the responsibility of nurses is not the answer to the
physician shortage,” (Patchin, 2010).
Education
Rural America is seeing a shortage of family medicine
physicians and nurse practitioners can help fill this void by
provided primary care services. Although physicians have more
time training, the extra training is considered specialty training.
Nurse practitioners are trained to perform as primary care givers
(Fairman, 2011). These services include wellness prevention
services, diagnosis, management of uncomplicated acute illness,
and chronic diseases. These are services a primary care physician would provide.
Nurse practitioners can also fill the void of physicians more quickly than young physicians
can. According to Cassidy, the average nurse practitioner takes six to seven years completing
their degree, including their undergraduate degree. The typical physician completes his or her
training in eleven to twelve years (Cassidy, 2013). The American Medical Association argues
that these additional years of training are important to optimize patient care. However, Fairman
argues that these additional years of training for physicians are specialized training years and that
nurses are trained to attend to patients for basic care services.
The American Medical Association also argues that during the seven years of additional
education, physicians have more than 10,000 hours of clinical experience and that nurse
practitioners do not have that much (Patchin, 2010). No one can argue that physicians do not go
through a grueling training experience with over 80 hour work weeks. However, some nurse
practitioners have more experience entering their program than physicians know. For example,
Mahar cites that the University of Michigan’s average student entering the nurse practitioner
program has 7 years of hands-on clinical experience (2013). If these nurses worked full time, 36
hours a week, for all 7 years, they would have worked over 10,000 hours. This time was most
likely spent collaborating and learning from trained physicians.
Why Nurse Practitioners?
Currently, there are over 6,000 nurses who operate independent practices (Mahar, 2013).
These nurses have the ability to diagnose, manage illnesses, treat illnesses and prescribe
medications. Some physicians have argued that nurse practitioners order more unnecessary test.
However, in 26 studies, it was found that the treatment and prescription practices were near
equal between a nurse practitioner and a physician. In fact, nurses were found to order fewer lab
test and less expensive procedures (Cassidy, 2013).
When a nurse is learning in nursing school, they are taught to be compassionate to the patient.
This practice carries over into a nurse practitioners daily practice. Nurse practitioners are found
to have a higher level of patient satisfaction. This is partly because they are better with patient
follow-up; more time is spent in consultations, and a better provision of screening (Cassidy,
2013).
Recommendations
The Institute of Medicine (IOM) recognizes the need for primary care givers in rural
American. They have taken a stand for nurse practitioners to practice independently of
physicians. However, the IOM does not support independent NP’s without having
recommendations to ensure adequacy. These recommendations include expanding Medicare
covering, extending Medicaid reimbursement for providing similar services, an implementation
of an APN residency program, and doubling the amount of nurse doctorates by 2020. These
recommendations will make the APN more competent and able to provide better quality of care
to patients (Institute of Medicine, 2010).
If physicians and lawmakers do not take to the idea of nurse practitioners performing the roles
of a primary care giver, rural Americans will go a long time without seeing a health care provider
and become sicker. As Fairman rightly stated, “We are not arguing that nurse practitioners are
substitutes for these physicians, but rather that we should consider how primary care services can
be more effectively provided to more people with the use of the full primary care workforce.”
Physicians and lawmakers need to consider the nurse practitioner to help fill the void of primary
care physicians in a rural setting. This means more independence and overall better care for the
patient.
References
American Academy of Family Physicians. (2002). Rural practice, keeping physicians in
(position paper). Retrieved from http://www.aafp.org/about/policies/all/rural-practicepaper.html
American Association of Nurse Practitioners. (2013). [Graph illustration of how much
independence each state has for nurse practitioners]. Retrieved from
http://ctmirror.org/2014/02/11/malloy-let-nurse-practitioners-in-ct-work-independentlyof-doctors/
Cassidy, Amanda. (2012, October 25). Nurse practitioners and primary care. [Web log
comment]. Retrieved from
http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=79
Fairman, J.A., Rowe, J.W., Hassmiller, S., and Shalala, D.E. (2010). Broadening the scope of
nursing practice. New England Journal of Medicine, 364. Retrieved from
http://www.nejm.org/doi/full/10.1056/nejmp1012121
Institute of Medicine. (2010, November 17). The future of nursing: Leading change, advancing
health, report recommendations. Retrieved from http://www.iom.edu/Reports/2010/TheFuture-of-Nursing-Leading-Change-Advancing-Health/Recommendations.aspx
Mahar, Maggie. (2013, April 3). A doctor confides, “My primary doc is a nurse.” [Web log
comment]. Retrieved from http://www.healthbeatblog.com/2013/04/a-doctor-confidesmy-primary-doc-is-a-nurse/
National Conference of State Legislators. (2015). Meeting the primary care needs of rural
America: Examining the role of non-physician providers. Retrieved from
http://www.ncsl.org/research/health/meeting-the-primary-care-needs-of-ruralamerica.aspx
National Rural Health Association. (2007). What’s different about rural health care? Retrieved
from http://www.ruralhealthweb.org/go/left/about-rural-health/what-s-different-aboutrural-health-care
Patchin, R.J. (2010, October 5). AMA responds to IOM report on future of nursing. Retrieved
from http://www.ama-assn.org/ama/pub/news/news/nursing-future-workforce.page