Honesty is defined as “free of deceit and untruthfulness; sincere.”1 Honestly, I had a great nursing career being a Registered Nurse (RN) for 15 years followed by 8 years of being a Nurse Practitioner (NP) before embarking on my journey to become a Physician. I will say it again, I love bedside RNs and thoroughly enjoyed my time as an NP on Physician led teams on inpatient units. In reference to the American Association of Nurse Practitioners (AANP) position statement on Educational Effectiveness titled “Clinical Outcomes: The Yardstick of Educational Effectiveness,”2 I find it somewhat less than honest. As such, this hurts the Nurse Practitioners (NPs) that are out there on the front lines on Physician led teams doing the daily grind. My former profession is being led astray and harming those NPs that are out there doing good work. This is evidenced where it says:
“In the more than 100 studies on care provided by both nurse practitioners and physicians, not a single study has found that nurse practitioners provide inferior services.”2
First of all, the source for this statement is an opinion paper and not a meta-analysis nor systemic review.3 Secondly, it is unclear as to where the notion of inferiority and superiority is coming from. Thirdly, the opinion paper itself states:
“Of more than 100 published, post- OTA reports on the quality of care provided by both nurse practitioners and physicians, not a single study has found that nurse practitioners provide inferior services within the overlapping scopes of licensed practice.”3
Which is confusing on a number of fronts. One practitioner practices medicine and the other practices nursing, so is there really overlapping scopes of practice? On one hand no because nursing is nursing and medicine is medicine, but on the other hand yes, because some of the Physician’s roles have been hijacked by the nursing profession and nurses are practicing medicine under the guise of advanced practice nursing. But taking a deeper look, this statement isn’t even referenced. This opinion paper3 further references:
“The internationally respected Cochrane Collaboration has recently produced a detailed review of this cumulative literature, citing more than three dozen objective studies that suggest patient care outcomes are similar. (The Cochrane review also suggests that nurse practitioners consistently score better on subjective measures of quality, such as patient satisfaction.)” 3,4
However, upon review of this literature summary, it states:
“The findings suggest that appropriately trained nurses can produce as high quality care as primary care doctors and achieve as good health outcomes for patients. However, this conclusion should be viewed with caution given that only one study was powered to assess equivalence of care, many studies had methodological limitations, and patient follow-up was generally 12 months or less.”4
So to summarize, the AANP Position2 statement references an opinion paper3 which references a literature summary4 which concludes:
“this conclusion should be viewed with caution given that only one study was powered to assess equivalence of care, many studies had methodological limitations, and patient follow-up was generally 12 months or less.”4
Furthermore, a 2014 literature review titled “Substitution of physicians by nurses in primary care: a systematic review and meta-analysis,”5 states in it’s conclusion:
“The available evidence continues to be limited by the quality of the research considered”……”The slowly growing number of studies, assessing substitution of physicians by nurses is still substantially limited by methodological deficiencies.”5
Another review6 which is an update to an earlier review4 lists several outcome measures but lists the evidence as a certainty level of low to low-moderate and concludes:
“The effects of nurse-led primary care on the amount of advice and information given to patients, and on whether guidelines are followed, are uncertain as the certainty of these findings is very low.”
Lastly, in the AANP statement where it states:
“In fact, these studies have shown that NPs have the same or better patient outcomes when compared to physicians.”
The actual statement was plagiarized from the opinion paper,3 but was done so incorrectly and not cited. The actual statement from the opinion paper3:
“The paper presents extensive, consistent evidence that nurse practitioners provide care of equal or better quality at lower cost than comparable services provided by other qualified health professionals.”
What’s important to note is that the opinion paper does not state comparable to physicians. This whole AANP Position Statement is a dishonest manipulation of literature. I have many other issues with this position statement such as it’s premise of not considering educational preparation in evaluating primary care, and others, but will save that for another time. Have a great day.
- Bauer, J.C. (2010). Nurse practitioners as an underutilized resource for health reform: Evidence-based demonstrations of cost-effectiveness. Journal of the American Academy of Nurse Practitioners 22 (2010) 228–231. doi:10.1111/j.1745-7599.2010.00498.x
- Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. (2005). Substitution of doctors by nurses in primary care. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD001271.
- Martínez-González et al. Substitution of physicians by nurses in primary care: a systematic review and meta-analysis. BMC Health Services Research 2014, 14:214 http://www.biomedcentral.com/1472-6963/14/214
- Laurant M, van der Biezen M, Wijers N, Watananirun K, Kontopantelis E, van Vught AJAH. Nurses as substitutes for doctors in primary care. Cochrane Database of Systematic Reviews 2018, Issue 7. Art. No.: CD001271. DOI: 10.1002/14651858.CD001271.pub3.