They Take Nursing One Step Further -- Nurse Practitioners Focus On Prevention, Health Promotion

Maddy Wiley always wanted to be a nurse. She wanted to take care of patients. But she yearned to do more than traditional nursing allowed.

"I wanted to be in areas dealing with patients before they got sicker, doing health prevention and health promotion." she said. "(And) I wanted more control over what I did for patients and when and how I saw them."

So when she returned to get her master's degree after two years as a registered nurse, she enrolled in a graduate program designed for nurse practitioners. She now has her own family health practice in Kent where she sees 15 to 18 patients a day.

"What I see that I'm doing as a (family) nurse practitioner is providing a different approach to the health-care system," said Wiley, whose Health Connections practice also has two other licensed nurse practitioners. "Instead of just dealing with a sore throat or cold, I look at the whole system: the environment, the family and the patient themselves and how that impacts their health."

The idea of expanding the role of nurses got a boost in the mid-1960s, according to Barbara Safriet, associate dean of law at Yale, who has written about nurse practitioners. She noted that Medicare and Medicaid made more people eligible for health care; the number of primary-care physicians began declining; the women's movement encouraged more gynecological and obstetrical services and a desire for women to provide them; and the return of medical corpsmen from Vietnam resulted in the creation of physician assistant positions, which demonstrated that non-physicians could do medical tasks.

Today, nurse practitioners are registered nurses with advanced nursing and clinical education and training. They usually carry the designation of Advanced Registered Nurse Practitioner (ARNP). They focus on the prevention of illness and the promotion and maintenance of health, as well as performing functions usually done by primary-care physicians: diagnosing, ordering tests, conducting physical exams, prescribing some medications and dealing with some acute and chronic illnesses.

As Safriet noted in the Yale Journal of Regulation, the Office of Technology Assessment of the U.S. Congress reported that "within their area of competence, NPs (nurse practitioners) . . . provide care whose quality is equivalent to that of care provided by physicians."

Their specialties include family/adult health, geriatric/elder care, nurse midwifery, women's health, pediatric/child care and psychiatric/mental health. Nationally, more than 23,000 nurses have the title nurse practitioner.

As of Sept. 15, there were 1,803 advanced nurse practitioners in the state, 1,097 of whom can write prescriptions, according to the Washington State Board of Nursing. Their salaries can range from $30,000 to more than $50,000, depending on the specialty. And they operate in a variety of settings, ranging from private offices to hospitals.

Swedish Medical Center, for example, has nine nurse practitioners. They collaborate with physicians in taking care of senior citizens. They do physical exams, prescribe medicine, and educate patients at clinics set up in retirement homes and on visits to nursing homes.

"What this method of care does is increase contact with patients and increase patient satisfaction, patient care . . . and for the frail elderly, it's really important," said Deborah Kearnes, a family nurse practitioner and director of Senior Health Services at Swedish.

Marty McClelland, geriatric nurse practitioner who works at Horizon House, a retirement home in downtown Seattle, said people feel more comfortable dealing with nurses than with doctors.

"Patients sometimes can be intimidated talking to a doctor who has time constraints and may have to leave," she said. "As nurses we have more time, and that gives us a big advantage (in dealing with patients)."

And because of the low reimbursement for medical services that doctors receive for treating nursing-home patients, nurse practitioners serve a valuable function there, said Dr. John Addison, who specializes in geriatrics at the James and Minor Clinic.

"The nurse practitioner works well as a physician extender," Addison said. "It adds a big dimension to health care.

They also help fill a gap, said Dr. Robert Hauck, a pediatrician who works at Group Health's Northgate Clinic.

"Looking at it from a purely pragmatic point of view, we're facing a crisis in health care, and part of it is lack of doctors," he said. "There are not enough (doctors) and they are not distributed well geographically . . . and it's getting worse while we talk. One of the things nurse practitioners do is help alleviate some of this terrible shortage."

Hauck believes nurse practitioners work best when they work with physicians as part of a team. "They are one more person who can show concern for a family," he added.

And nurse practitioners are very good listeners, so when patients don't understand something, they can explain it to them, said Barbara Wallace, a nurse practitioner in Boston with a doctorate in human development and psychology.

"Basically, we speak the language of the consumer. We're definitely advocates for the patient and family when it comes to health care," said Wallace, who acts as a consultant to nurse practitioners in Washington state.

Nancy Lockett, a pediatric nurse practitioner at Group Health's Northgate Clinic, likes the wellness orientation she's engaged in. After working in the neonatal area for five years, Lockett said, "It's a much nicer focus to see children grow and to help families improve (their physical well-being)."

The opportunity to help counsel families appeals to Lynn McGlocklin, a pediatric nurse practitioner at Group Health on the Eastside.

"We can be totally focused on the parenting issues, limit setting, all the normal growth and development stuff," she said. "We can offer anticipatory guidance that allows parents to feel confident as they go through developmental stages."

By working with families in that way, nurse practitioners can help them take responsibility for and manage their own care, said Keela Marshall, a registered nurse practitioner for Group Health in Factoria. Marshall stressed that people need to learn they have certain rights in the health-care system and that most nurse practitioners act as patient advocates.

They also try to push the limits of nursing, said Susan Caverly, a psychiatric/mental health nurse practitioner. She views the role of nurse practitioners as innovators in the health-care field in terms of their practice.

"Nurse practitioners are on the cutting edge of nursing, developing nursing as a discipline as far as it can go," said Caverly, who can offer both psychotherapy and prescribe certain medications to help those with psychiatric disorders. "We're the wave of the future."

This approach to health care, with nurse practitioners assuming a greater role in the process, makes the nursing profession more attractive, Wallace said.

"For people checking out career paths, nursing is the career of the future . . . because it's extremely satisfying . . . because the population is aging . . . and you can make a very good living," she said.

Kris Barnes, a registered nurse who is involved with nurse practitioners as part of her work at the Washington State Nurses Association, sees the concerns about access to health care as an opportunity for nurse practitioners. "There is a growing need for nurse practitioners to help solve the health access problem," she noted.

Both the University of Washington in Seattle and Gonzaga University in Spokane offer master's degree programs designed for those who want to be nurse practitioners and have baccalaureate degrees.

The UW's School of Nursing offers graduate work for those who want to be nurse practitioners in family health, pediatrics, geriatrics and women's health. The two-year program now has about 80 students enrolled.

"In the last few years we have not been able to fill all the jobs that are out there. We hear about huge needs in certain areas, and we anticipate there will be lots of openings," said Phyllis Arn Zimmer, a family nurse practitioner, assistant coordinator of the family nurse practitioner program at the UW and president of the national organization of nurse practitioners faculties.

Gonzaga's program for nurse practitioners is unique, said Jim Pittman, who has a doctorate in nursing and is the coordinator of the family nurse practitioner courses. The program is set up not only for on-campus study but also can be taken off-campus.

"Nurses can take courses off campus and then come on campus three or four times each semester," Pittman said. "So a lot of students can do the program without having to uproot themselves. The distance format helps rural nurses to stay where they are and still get their degree. And that helps maintain health care in that area."

Nurse practitioners like to point out that although they can carry out a number of medical tasks also done by doctors, they have a different role.

"We are not physicians," Arn Zimmer said. "(Nurse practitioners) blend nursing strategies of care with ability to utilize assessment and management in a physician role. We blend health promotion with illness management."

Nurse practitioners draw on their background as nurses and focus on teaching and health promotion, using the best of both medicine and nursing to take care of people on a day-to-day basis, said Bob Smithing, a family nurse practitioner at Health Connections.

"The difference between medicine and nursing, in simplest terms, is that physicians focus on diseases, how to identify and cure them," he said. "Nurses focus on people and how to care for them in illness and in health. Sometimes it's referred to as care-cure dichotomy. Nurse practitioners try to bridge that gap. They take from the cure in medicine but at the same time they hold onto the care component of nursing."