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2012 opr
- 1. Contests of Expertisewithin Primary Care MEDICAL WORK/NURSING WORK LaTonya J. Trotter, MPH, MA OPR Notestein Seminar
- 2. PROVIDING HEALTH CARE •32 Million Primary Care • 20 Million “Less Profitable” Poor
- 3. HEALTH CARE Science Nursing Medicine Disease Clinical Decision Making
- 4. WHAT IS ANURSE PRACTITIONER? Diagnose Treat ✚ = Bachelors Masters Nurse Practitioner 4 years 2 years 650 clinical hrs
- 6. Commitment to PrimaryCare Access for uninsured and medicaid Cost effective PROFESSIONAL CLAIMS
- 7. What is anurse practitioner? Physician extender? Junior doctor? Independent Clinician Mid-level Practitioner?
- 8. How “good aDr.” is the NP? • Flynn, B C. 1974. “The effectiveness of nurse clinicians’ service delivery.” American Journal of Public Health 64(6):604–611. • Mundinger, M O et al. 2000. “Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial.” JAMA: 283(1):59–68. • Laurant, M et al. 2005. “Substitution of doctors by nurses in primary care.” Cochrane Database of Systematic Reviews (Online) (2):CD001271
- 9. What we don’tknow… • NPs may do something different, but what? • How organizations might use the NP • Role of interaction What do they do?
- 10. Hidden Population • 180,000NPs 800,000 MDs • 376,000 MDs Primary Care Specialties
- 11. Hidden Population 26 States = Autonomous 48 States = Rx Source: The 2012 Pearson Report, The American Journal for Nurse Practitioners, NP Communications LLC.
- 12. Hidden Medical Practices •Hospital • Technological Innovations • Acute Care / Cure • Outpatient / Home • Practice Innovations • Chronic Disease Management
- 13. Questions • How doNP’s practice? • How may patients be differently seen? • How are NP practices constructed through negotiation? • Spaces of difference in healthcare delivery
- 14. NP Training • NP’sare Nurses, not “Junior Doctors” – School of Nursing – Textbook audience is Nurses • Practice / Vocationally Oriented • Unique Expertise: Social Quandries
- 15. Methodology • 18 monthsof Ethnographic Observation • Community-Based Practice – Nurse-Managed – NPs are primary providers
- 16. Site • Program forAll Inclusive Care for the Elderly (PACE) • Medicaid/Medicare enrollees • Social Work, Homecare • Interdisciplinary Teams = Interaction
- 17. A Tale ofTwo Teams
- 18. “…started realizing Ididn’t want to be a hospital nurse…you really don’t have a lot of autonomy.” Blue Team NORAH, CRNP
- 19. Norah “…And once Isee how they do it— once I see how it’s managed, I’m good to go. “Like consultants rather than collaborators. I grab them when I’m stuck.”
- 20. “I never reallydid this kind of NP work, where you’re really in charge.” “PC docs refer to rheumatologists, NPs refer to medical docs” Black Team SARA, CRNP
- 21. NP Expertise • Norahwas “ideal” NP • “Whole Case” • Sarah was lacking • Failed to Invest in local expertise
- 22. Physician Role • Positioned“outside” the clinic • Physicians and NPs not interchangeable • Physician only “saw” medical concerns
- 23. Conclusions • NP Expertise of “whole case” • Medicalize the Social • “Medical competence” is not enough • Need to reorient our understanding of physician practice
- 24. Implications • Clinician shortage?Not “the” answer • Living critique of medicine • NP practices as alternatives for primary care
- 25. Acknowledgments • Elizabeth Armstrong,Mitchell Duneier, King-to Yeung • NSF Graduate Research Fellowship • Princeton’s Center for Health and Well-being