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Understanding the Unique Training and Value of Nurse Practitioners

In this podcast, Pradeep Manudhane, MD of Phoenix Rising Behavioral Health, interviews Jessica Giddens-Whelan, DNP, BA, APRN, FPMHNP-BC, RN-BC of Holon Inclusive Health System, to better understand the role NPs play in the primary care setting and explore areas of need which NPs could fill.

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Transcript:

[0:00] Pradeep Manudhane, MD: Hello, I’m Dr. Pradeep Manudhane, and I am a psychiatrist.

Jessica Whelan, DNP: I’m Dr. Jessica Giddens-Whelan, and I am a family psychiatric mental health nurse practitioner.

Dr. Manudhane: Nurse practitioners play a central role in healthcare delivery in primary care settings. In fact, approximately 70% of nurse practitioners work in primary care.1 They are vital members of the patient care team and help ensure the timely delivery of high-quality, evidence-based treatments and services.

But despite this, NPs are not being fully utilized in the primary care setting.2 Too often, NPs are tasked with roles and responsibilities that are more appropriate for other providers, like medical assistants.3 Or they may be constrained in their scope of practice, which, in the hospital setting, limits their autonomy.4 As a result, there are opportunities for nurse practitioners to contribute more to primary care. This may be especially important when it comes to mental health care, given that NPs are increasingly playing a key role in mental health diagnosis and treatment in primary care settings.5

Today, we will tackle this issue by discussing the value of including nurse practitioners in your primary care team and the unique training that makes them an asset.

[1:22] Dr. Manudhane: So, let’s start by talking about the experience and value of nurse practitioners in primary care. One of the main factors that jumps out at me is the diversity of training. Nurse practitioners not only have advanced training and certification, but they are also exposed to a wide range of interventions, techniques, theories, and patient populations.

Dr. Giddens-Whelan: That’s right. NPs are not trained in a “medical model” but rather in a “nursing model.”6 The medical model of sickness is focused on the biological causes of pathology and the treatment of that pathology. Physicians as well as physician assistants are trained in the medical model. The nursing model means that our training encompasses far more than diagnosis and treatment. While this is certainly part of what we learn, our training also includes things like assessment and screening, disease prevention, and health education.7 Our training also draws on a variety of theoretical models, practice frameworks, care models and interventions.8

As a result, we perform many different healthcare services, including preventive care, coordinated care, management of chronic illnesses, and prescription of medications—including, in some states, for controlled substances. We also take on roles that fall outside of direct patient care—things like collecting data for quality monitoring and reporting purposes.7

Because NPs have to be well versed in liaising across all areas of medicine, I have found myself involved in all sorts of roles, from providing interventions for specific illnesses, to broadly managing a patient’s overall health by providing in-home case management, and even addressing a patient’s social or emotional health.9 We have a unique hands-on and bedside approach as well as a focus on patient advocacy that is not part of the medical model.

Beyond being able to perform so many different tasks, NPs in primary care settings produce just as effective and safe patient and clinical outcomes as physicians—and in some cases have done so at lower costs. On top of that, patients have reported being happy with the care they receive from nurse practitioners, which is of course a critical part of quality care.8,10,11

[3:46] Dr. Manudhane: I think there is a tendency to compare physicians and physician assistants to nurse practitioners, but it’s kind of an apple-oranges thing, isn’t it? We all complement one another, but we aren’t directly comparable because our training is different, and thus our perspectives on patient care is different. I think that is really evident when we think about holistic care. Can you talk a bit about that?

Dr. Giddens-Whelan: Sure. Holistic care means taking into account not just the patient’s physical health but also their environment, emotional state, cognitive health, economic status, social functioning, and spiritual well-being.12 Holistic care also means working in partnership with patients to provide a comprehensive, person- centered service.13 This differs from the medical model of care because, as we were saying, that approach is primarily centered on the illness, it’s biological cause, and its treatment.6

Holistic, person-centered care is an important part of NP training and practice.13 The nursing model has taught many of us to look at the big picture, not just the patient’s illness. We learn to evaluate the patient’s environment, their family system, lifestyle, social network, work life, and other non-medical factors that may impact one’s health or well-being.

Dr. Manudhane: I think you really see this when you talk about the “nursing diagnosis”, which is like the diagnosis of the entire picture. The medical diagnosis is really focused on the disease, but the nursing diagnosis is focused on the patient as a whole, their family and community, and his or her response to the medical issue.14 A nursing diagnosis might include things like “imbalanced nutrition” or “impaired social interactions” or even “spiritual distress.”14,15

Dr. Giddens-Whelan: I think having both types of providers—those who are trained in the medical model and make medical diagnoses, like physicians and PAs, as well as nurse practitioners giving nursing diagnoses—helps make a primary care setting well-rounded. All three types of providers are important, and although they have different training backgrounds, they can provide similar services.7,16

[6:03] Dr. Manudhane: One other point we want to touch on more is the way in which nurse practitioners help fill gaps in primary care. You started to talk about it a bit earlier. That’s certainly a value you bring to the table that needs to be better leveraged. What can you tell us about that?

Dr. Giddens-Whelan: Well, we have seen in primary care settings that they are experiencing physician shortages, along with a growing number of healthcare patients—many of whom have chronic conditions.4 So there’s a real supply-demand problem here. But nurse practitioners can certainly play a role in alleviating this.

Dr. Manudhane: In what ways can nurse practitioners help address this gap?

Dr. Giddens-Whelan: Like we were saying earlier, nurse practitioners can take on a wide variety of clinical roles. They can operate independently or as part of an interdisciplinary, collaborative team. They can work bedside, and they can work in management. They’re also more likely than primary care physicians to work in rural settings and with underserved populations. So nurse practitioners might be able to help address gaps in health equity as well.

I think all of this underscores why increasing our access to patients is so critical. We are bound by whatever Scope of Practice laws are in our state and in our organization, but there are data showing that, in states with more restrictive Scope of Practice laws or where federal regulations and statutes limit what we can do, our ability to provide the most effective and efficient care is limited. This is especially true in rural settings and other underserved areas where NPs often practice, and limits to scope of practice can lead to delays in patient care.4

Also, I want to call out that these guidelines and access barriers contribute to the myth that we aren’t qualified to work autonomously or that we are “lesser” providers somehow. This is not true.4 We’re just a different type of provider.

Dr. Manudhane: Absolutely. And I think part of the problem is also that many physicians just aren’t aware of what a nurse practitioner's true scope of practice is or full range of competencies are, so there are some learning gaps that obviously need to be filled there.3,4 But hopefully conversations like these can help get the ball rolling.

Dr. Giddens-Whelan: Certainly. I would also add that nurse practitioners can help fill the need for better mental health care provision in primary care settings by helping with screening, educating patients about their mental health symptoms and treatment options, and providing referrals to mental health specialists as needed. In some cases, NPs even serve as case managers or care coordinators for patients with mental health struggles.17

Dr. Manudhane: That’s a good point and an important one given how common mental disorders are in primary care populations. Somewhere between 14% and 22% of primary care patients are estimated to have depression.18 Further, in primary care settings, about 21% of patients screen positive for bipolar disorder yet a majority of those individuals never received a bipolar disorder diagnosis previously.19,20 Rather, many primary care patients with bipolar disorder are misdiagnosed with and treated for major depressive disorder.18,21,22

Dr. Giddens-Whelan: But we know mental disorders in primary care tend to be underdiagnosed, likely in part because of the lack of mental health specialists, like psychiatrists, located in primary care as well as difficulties primary care providers may experience in accessing outside mental health specialists.3,23

Consequently, other primary care providers are likely going to need to be engaging in mental health screening, diagnosis, and treatment.23 Including nurse practitioners on your primary care team might help with problems like the need for better mental health screening and earlier identification of psychiatric symptoms and disorders.3 Moreover, assessing your primary care patients’ mental health is a form of holistic care in that you’re looking beyond their physical state and exploring additional needs they may have related to things like their emotional wellbeing, functioning, relationships, and quality of life. All of this underscores why nursing education and postgraduate programs really need to increase their focus on helping nurse practitioners understand, recognize, and manage mental disorders, particularly in the primary care setting.17

[10:41] Dr. Manudhane: Well, I want to thank my colleague Jessica for leading this informative and eye-opening discussion.

Dr. Giddens-Whelan: Thank you, Pradeep! We hope this has been helpful to you and helps your organization or clinic build a far more collaborative relationship between your physicians and nurse practitioners, which is ultimately for the betterment of your patients and your practice.

Dr. Manudhane: Thanks for joining us on NP Psych Navigator!

References

  1. NP Facts. The Voice of the Nurse Practitioner. Published online May 2021.

  2. Riegel B et al. Meeting global needs in primary care with nurse practitioners. The Lancet. 2012;380(9840):449-450.
  3. Poghosyan L et al. Removing restrictions on nurse practitioners’ scope of practice in New York State. Journal of the American Association of Nurse Practitioners. 2018;30(6):354-360.
  4. Office of the Assistant Secretary for Planning and Evaluation. Impact of State Scope of Practices Laws and Other Factors on the Practice and Supply of Primary Care Nurse Practitioners. Westat; 2015:4-30.
  5. Brown M et al. Primary care and mental health: overview of integrated care models. The Journal for Nurse Practitioners. 2021;17(1):10-14.
  6. Waddell G et al. Models of Sickness and Disability: Applied to Common Health Problems. Royal Society Of Medicine Press Ltd; 2010.
  7. Kaprielian VS et al. What Can a PA or NP Do for Your Practice? Family Practice Management. 2017;24(2):19-22. Accessed June 23, 2022. https://www.aafp.org/pubs/fpm/issues/2017/0300/p19.html#:~:text=They%20can%20help%20physicians%20enhance.
  8. Stucky CH et al. COVID 19: An unprecedented opportunity for nurse practitioners to reform healthcare and advocate for permanent full practice authority. Nursing Forum. 2020;56(1):222-227.
  9. Grant J et al. How do nurse practitioners work in a primary care setting? A scoping review. Int J Nurs Stud. 2017;75:51-57.
  10. Kippenbrock T et al. A national survey of nurse practitioners’ patient satisfaction outcomes. Nurs Outlook. 2019;67(6):707-712.
  1. Liu et al. Outcomes of primary care delivery by nurse practitioners: utilization, cost, and quality of care. Health Serv Res. 2020;55:178–189.
  2. Ventegodt S et al. Concepts of Holistic Care. Health Care for People with Intellectual and Developmental Disabilities across the Lifespan. Published online 2016:1935-1941.
  3. Kinchen E. Holistic nursing values in nurse practitioner education. Int J Nurs Educ Scholarsh. 2019;16(1).
  4. Chiffi D et al. Medical and nursing diagnoses: a critical comparison. J Eval Clin Pract. 2014;21(1):1-6.
  5. NANDA NIC NOC Diagnoses - All labels updated 2021. Nanda Diagnoses. https://www.nandadiagnoses.com/.
  6. Neprash H et al. Practice patterns of physicians and nurse practitioners in primary care. Med Care. 2020;58(10):934-941.
  7. Bennett C. Improving mental health education in nursing school. Nursing. 2021;51(9):48-53.
  8. Cho SH et al. How do nurse practitioners work in primary health care settings? A scoping review. J Psychiatry Behav Health Forecast. 2018; 1(1): 1002.
  9. Hirschfeld R et al. Screening for bipolar disorder in patients treated for depression in a family medicine clinic. The Journal of the American Board of Family Medicine. 2005;18(4):233-239.
  10. Hirschfeld R. The mood disorder questionnaire. The Primary Care Companion to The Journal of Clinical Psychiatry. 2002;04(01):9-11.
  11. Pace C et al. Addressing unhealthy substance use in primary care. Medical Clinics of North America. 2018;102(4):567-586.
  12. Love A et al. Anxiety disorders in primary care settings. Nursing Clinics of North America. 2019;54(4):473-493.
  13. National Council for Mental Wellbeing. The Psychiatric Shortage Causes and Solutions. National Council Medical Director Institute; 2018:1-20. 

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