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Geriatrician and Gerontologic Nurse Practitioner Collaboration: A Necessity or Nice Idea?

1994; Wiley; Volume: 42; Issue: 4 Linguagem: Inglês

10.1111/j.1532-5415.1994.tb07501.x

1532-5415

James N. Kvale, Elizabeth McNeely, Stephanie J. Nagley,

Nursing Roles and Practices

To the Editor: Discussions of health care reform frequently include expanded use of advanced practice nurses and other non-physician health care providers. Typically, organized medicine's response has been to resist these suggestions by countering with the argument that these changes will result in deterioration of standards of care. Rather than being a part to the resistance of increased use of the non-physician provider, geriatric medicine (and older Americans) has much to gain by becoming advocates of collaborative practice. The mandate for moving to support the expanded use of advanced practice nurses (the Gerontological Nurse Practitioner (GNP)) in the care of the elderly comes primarily from our own shortcomings. The numbers of trained geriatricians relative to the increase in the population of older Americans reveal that we are falling behind in our ability to either care for an aging population or to educate the coming generation of primary care physicians to the task.1 The efficiency, cost effectiveness, and consumer satisfaction with care provided by advanced practice nurses has been well documented.2 Nursing and medicine compliment each other in providing the complex health care needed by the older person. The heterogeneity of the older adult demands a multidisciplinary approach and a collaborative relationship, which will result in better achievement of quality of life outcomes. Collaboration can achieve much more than either discipline can alone.3 The key word in this discussion is collaboration. Traditionally, professional relationships in health care have been hierarchical rather than egalitarian, with the physician in roles of power and authority. For collaboration to be effective, it must be egalitarian. Professional equity implies working together to provide care for people, with the recognition that both nurses and physicians bring areas of complimentary expertise essential to the health and well-being of the older person. Equity also implies a level of independent practice for the advanced practice nurse, with the physician participating as a consultant. Further, mechanisms for independent reimbursement for nurse-delivered health care must be included. (At present, Medicare will reimburse advance practice nurses in long-term care settings.) Without the possibility of independent reimbursement, the relationship is neither collaborative nor egalitarian. There are, potentially, other problems that may present with the expanded use of non-physicians in the delivery of primary health care. Some would argue that expanding these roles will weaken the standards of health care. American culture has the perception that use of non-physician health care providers is somehow less than optimal health care. However, studies examining consumer reaction to non-physician care have consistently demonstrated high levels of satisfaction.4 Though these studies mention an initial reticence to accept care from a advanced practice nurse or other non-physician provider, this reluctance is easily overcome by a positive experience with the allied provider and the support of the physician. Conversely, others have expressed the concern that expanding the use of non-physician providers could lead to overuse of the health care system.5 These concerns are unfounded in fact. The concept of advanced practice nursing certainly is not new. Psychiatric nurses, nurse anesthetists, and certified nurse-midwives have been an essential part of American health care for many decades. The models of collaboration they have crafted with their physician counterparts are instructive and can be adapted for use in the geriatric population. The “Tenets of the Clinical Practice Relationship” developed by the American College of Nurse-Midwives and the American College of Obstetrics and Gynecology has utility as a model for geriatrician seeking to formalize a collaborative association with GNPs. Key concepts include: (1) the use of guidelines and protocols; (2) clear explanation of the collaborative association to the patient; (3) mechanisms of peer review; (4) recognition of the skills that both the nurse and physician bring to the relationship with the patient; and (5) emphasis on the primacy of the patient's needs.6 We think most geriatricians will not disagree with any of the above. In reality, many of us probably already work in relationships that incorporate many of these concepts. We argue that the time is right in terms of population need and national politics to move toward formalized collaboration between geriatric medicine and GNPs. It should be noted that a collaborative association between geriatric nurse practitioners and geriatricians has significant educational implications. Neither discipline has a repertoire of experience of collaboration. Both, we assume, would agree that they have much to learn about working together comfortably. There are not enough opportunities for geriatric fellows or primary care residents to experience models of collaborative association. Meanwhile, nursing must also create environments that can demonstrate collaboration. Historically, medicine has found egalitarian efforts threatening. Change will be facilitated when the educators of both disciples recognize the mutual advantages of collaboration in providing care for aging Americans. The time to change is now.