AARP magazine sends mixed messages on nursing roles
January 2015 – Recently AARP The Magazine has published items explaining the roles of various health professionals, especially nurse practitioners (NPs). In the August / September 2014 edition, the magazine ran a short but excellent piece by Sylvia Smith, “Nurse Practitioners Fill the Gap.” The item focuses on NPs’ work to provide care for underserved populations, which is particularly important amid discussion of a physician shortage. The piece rejects the claims of some physicians that NPs should not be permitted to practice without undue restrictions, as they can now in almost half of U.S. states. The item might have mentioned the wealth of research showing that NP care is at least as effective as physician care. In the edition of the magazine for December 2014 / January 2015, there was a short slideshow, “Who’s Who in Your Doctor’s Office.” In that feature, Candy Sagon and Sarah Barchus explain the roles of some of the major types of current health professionals. The slideshow seems to list professionals according to their perceived importance and length of training: physician, physician assistant (PA), nurse practitioner, medical student, registered nurse, and technician. The brief descriptions of NPs and nurses provide some helpful information. Unfortunately, the apparent hierarchy in the slideshow—which places not only physicians but even medical students above nurses—and the descriptions do not convey a fair or accurate sense of the value of nurses in patient care.
Filling the gap
The earlier piece is “Nurse Practitioners Fill the Gap: A smart way to help fix health care shortages.” The article’s frame story is that of Utah NP Danielle Pendergrass (right), who opened a women’s health clinic a year and a half earlier in rural Price, Utah. The item notes that before that time, many women in the area had not seen a physician for years—the nearest obstetrician-gynecologist was reportedly 60 miles away. Pendergrass’s patient load quickly reached 3,300. Pendergrass, “who recently earned a doctorate in nursing,” explains how difficult it is to recruit physicians to rural Utah and says that she is “filling the gap.” The rest of the piece is the larger context. The article explains that about 60 million people in the U.S. have limited access to health professionals, especially in rural areas with no physicians and urban areas where people rely on hospital emergency departments for primary care (meaning the uninsured, of course). In addition, the piece says that there are fewer physicians overall, with physician groups predicting a shortage in coming years. The piece relies on Susan Reinhard, senior vice president of the AARP Public Policy Institute, which includes the Center to Champion Nursing in America. Reinhard says NPs are the solution. The article explains that NPs are RNs with a master’s or doctorate who “are trained to diagnose and treat illnesses, give physicals, prescribe medicine and refer patients to specialists.” Over one third of U.S. states allow NPs to “do the work they’ve been trained to do.” But the rest impose restrictions such as physician oversight, which Reinhard says creates needless paperwork and travel; patients must go to existing physician practices when NPs would practice closer. AARP is pushing for change, although the American Medical Association has resisted, arguing that physicians have more training and experience and that “increasing the responsibility of nurses is not the answer to the physician shortage.” The piece concludes: “For the more than 180,000 nurse practitioners in the U.S., it is.”
This article has many helpful features. It explains the basic nature of NPs, including their advanced educational credentials, and the critical role they can play in U.S. health care, particularly for underserved populations. The example of Pendergrass is a good one, showing that NPs really are operating and prospering on their own; it’s not just theoretical. And the piece directly confronts physician resistance to NP care, while rightly giving a brief statement of the physician argument. In that regard, the piece might have pointed to the decades of research showing that NP care is at least as effective as physician care. More broadly, the piece might have noted that NPs are not just “filling gaps,” but are in fact a good choice for anyone who values a holistic, preventive focus in primary care.
And otherwise manage patient care
The more recent “Who’s Who” piece is a slideshow about the roles of some types of health professionals now working in outpatient care. It says that “back in the day, there were doctors and nurses,” but now “a plethora of health care professionals may be caring for you.” The first slide is labeled “Behind the Coat,” and it shows a physician’s white coat. Slide 2 shows an Asian male physician, in a suit with the long white coat. The description says that “physicians are still the ones in charge — and those with the most training, as indicated by the length of their white coats, the longest of any health care professionals,” noting that physicians have 3-7 years of training after medical school. Slide 3 shows an African-American male PA in a suit and white coat, stating that PAs can diagnose and prescribe, that they “typically have a master’s degree plus 2,000 hours of training with patients while in PA school,” and that their white coat is a little shorter than a physician’s. Slide 4 offers healthy living tips. Slide 5 shows a white female NP, dressed in a kind of slacks and blouse outfit and an even shorter white coat. The text notes that an NP “has a master’s degree, which includes 500 to 700 hours of direct patient care during nursing school. NPs can do much of what doctors do, including diagnose you and prescribe medications.” Slide 6 shows a seemingly Asian female medical student, in a knee length skirt outfit and high heels. The text says that such students wear “a hip-length white coat” and “can take a medical history, but the prescribing of meds or diagnostic tests needs approval from a supervising physician.” Slide 7 shows an African-American male RN wearing solid-color scrubs, with a stethoscope and clipboard. The text: “Certified and licensed by the state, RNs administer meds, provide care and otherwise manage patient care. The iconic nurse’s cap all but disappeared by the 1980s, as more men became nurses and there was a switch to unisex scrubs.” Finally, slide 8 shows a white female technician in scrubs, and the text notes that they perform routine tests and many have “an associate’s degree in clinical laboratory science.”
It is commendable to try to provide a quick guide to the nature and roles of some of the major groups of health professionals, and there is some helpful information here. The images and text also promote diversity to some extent. However, the obvious ranking conveyed by the slide show order and some of the specific descriptions are troubling. No one in medicine should be placed above anyone in nursing, since nursing is an autonomous profession of equal importance. Perhaps the most unfortunate notion is that a medical student would rank more highly than a registered nurse. Turning briefly to the specific descriptions, it is important to note that physicians are not “in charge” in a clinical sense, although they may own outpatient practices that employ nurses. In inpatient settings, nurses report to senior nurses, not physicians. Physicians do not necessarily have more health training than nurses with graduate degrees.
In addition, PAs certainly do not have more training than NPs, who have 6-8 years of university education in nursing and often years of clinical practice as RNs before they become NPs. PAs may receive more clinical hours in their masters programs than NPs do in their masters programs. But most NPs have already received 1,000 or more hours of clinical training as part of their undergraduate nursing programs, followed by far more clinical practice as RNs before they enter graduate school. By contrast, a PA’s undergraduate degree may not even be in a scientific field, and PAs cannot practice autonomously. The text should also have noted that NPs increasingly have doctorates, not just masters degrees.
The RN image and description highlight the slowly growing role of men in nursing, which is good. But we wish the description had mentioned registered nurses’ years of university education and the difference they make in patient outcomes. We were struck by the final phrase: “…and otherwise manage patient care.” Yes. But most readers will need more to understand the central role nurses play in that care.
We thank AARP for its efforts to educate the public about the value of nurse practitioners.