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PHYSICIAN PERCEPTION OF THE FAMILY NURSE PRACTITIONER ROLE
AND THE WILLINGNESS TO HIRE
By

Suzanne Ivkovich

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTERS OF SCIENCE IN NURSING

College of Nursing
1997

ABSTRACT

PHYSICIANS PERCEPTION OF THE FAMILY NURSE PRACTITIONER ROLE
AND THE WILLINGNESS TO HIRE
By

Suzanne Ivkovich

As the managed care environment evolves in the health care system, the financial
risk shifts from the payers to the providers. Providers will need to find new and creative
ways to provide efficient, cost-effective, quality care. Though multiple studies over the
past 20 years have shown that nurse practitioners provide cost-effective, quality care,
their acceptance into the primary care arena has been limited. The purpose of this study
was to provide descriptive information about the physician knowledge and perception of
the family nurse practitioner role which would influence the physician willingness to hire.

A questionnaire that assessed physician knowledge of the family nurse
practitioner role was hand delivered to 53 primary care physicians in a southwest county
of Michigan. Descriptive, AN OVA, and correlation studies demonstrated that the more
knowledgeable the physician is about the nurse practitioner role, the more willing the
physician is to hire a nurse practitioner. Future endeavors to increase physician's

experience and knowledge of the nurse practitioner role were discussed.

ACKNOWLEDGEMENTS

I wish to gratefully acknowledge the

support and encouragement of my chairperson,

George Allen. His patience and realism was deeply appreciated.
Gratitude is also due Patty Peck and Brigid Warren
for their constructive assistance.
I would also like to thank my husband, Paul,

and my children, Jack and Kathleen,

for their unending support and encouragement

in a very challenging time.

iii

TABLE OF CONTENTS

LIST OF TABLES ............................................................................................................... v
LIST OF FIGURES ............................................................................................................ vi
INTRODUCTION ............................................................................................................... 1
THEORETICAL FRAMEWORK ....................................................................................... 5
Conceptual Definitions of the Variables ................................................................. 5
Conceptual Framework ........................................................................................... 6
REVIEW OF THE LITERATURE ..................................................................................... 8
METHOD .......................................................................................................................... 13
Design .................................................................................................................... 13
Operational Definitions ................................. - ........................................................ 14
Sample ................................................................................................................... 15
Field Procedures .................................................................................................... 15
Protection of Human Subjects ............................................................................... 15
Assumptions/Limitations ....................................................................................... l6
RESULTS/FINDINGS ...................................................................................................... 1 7
Data Analysis ......................................................................................................... l7
Findings in Relation to the Model ......................................................................... 25
Findings in Relation to the Literature .................................................................... 25
DISCUSSION .................................................................................................................... 26
Implications for Practice ....................................................................................... 27
Implications for Education .................................................................................... 27
Implications for Future Research .......................................................................... 28
Summary ............................................................................................................... 29
APPENDICES
Appendix A: Radke and Wright Physician Questionairre ................................... 30
Appendix B: Updated Physician Questionairre ................................................... 36
Appendix C: Introduction and Consent Letter ..................................................... 40
Appendix D: UCRII-IS Approval Letter ............................................................... 42
LIST OF REFERENCES .................................................................................................. 44

iv

Tablel .

Table 2.

Table 3.

Table 4.

Table 5.

Table 6.

LIST OF TABLES

Analysis of Physician Type in Regards to Actual versus Potential

Returns ........................................................................................... 18
Frequency and Percentage of Physician Practice Setting ......................... 19
Summary Statistics of Physicians' Perception of the NP .......................... 19

Frequency Percentages for Section 2:

Perceived Problems Utilizing NP ................................................. 21
ANOVA Results ....................................................................................... 23
Correlation Results .................................................................................. 23

Figure 1.

Figure 2.

Figure 3.
Figure 4.

Figure 5.

LIST OF FIGURES

An Adapted Conceptual Framework for Physician-Nurse
Practitioner interaction ................................................................... 7

The Process of Physician-Nurse Practitioner interaction

Utilizing King's Theory of Goal Attainment .................................. 8
Physician Perception of NP Role ............................................................... 20
Physician Perception of Problems utilizing NPs ....................................... 20
Physician Overall Perception of NPs ........................................................ 22

vi

INTRODUCTION

By the year 2000, an estimated 36 million Americans will be 45 to 54 years of age
(Kennedy, 1993) and 30 to 40% of traditional hospital admissions will shift to outpatient
encounters due to a change in demographics, technological advances, and payor pressure
(Satinsky, 1995). In 1993, 13.9% of the Gross National Product (GNP) was devoted to
health care and the rate of increase was greater in the health care sector than in other
sectors of the economy (Nighswander, 1994). According to Hickey (1996), the health
care industry is ranked the fourth major industry in the United States and an estimated 37
million Americans do not receive some level of health benefits as a condition of
employment or through a government subsidy program (p. 4). These factors have
influenced the development and evolution of the managed care environment in the health
care system.

Traditionally, hospitals and physicians provided care and were paid on a fee-for-
service basis. The payers paid minimal attention to appropriateness of service, let alone
to cost, quality, and efficacy (Satinsky,l995). The rising percentage of the GNP devoted
to health care is evidence of this trend. According to Satinsky, managed care exists as a
response to the fear of national health care reform through President Clinton's National
Health care proposal. This fear has provided the impetus for many states, insurers, and
many providers to make their own changes. Satinsky (1995) writes that managed care is
considered a type of health insurance plan designed to provide a wide range of health care
delivery at a reduced cost without compromising quality of care. There is an obligation

to manage that is shared among providers, consumers, and payers. Satinsky (1995) goes

1

on to describe the shift in financial risk from the insurers to the providers of health care
delivery which develops an "internally driven, but externally sensitive standards for
delivering high-quality, cost effective care" (p. 127). In this position, many physicians are
conflicted with the ethical issue of providing quality care in a cost-effective manner.

Examples of managed care plans are health maintenance organizations (HMOS),
preferred provider organizations (PPOs), point-of-service (POS) plans, and managed fee-
for-service plans. In a managed care environment, the financing and delivery of health
care are likely to come together in integrated systems. Completely integrated systems
have not come to most parts of the country but many markets are in a transitional stage of
development. According to Satinsky, there are four common characteristics in the
process of integration: vertical integration in which different levels of care are combined
into a seamless continuum of care; payment by capitation in which the provider receives
payment based on cost per member per month; emphasis on low-cost/ high-quality
services; and rationing of resources in which the provider becomes the gatekeeper to
provision and management of care (p.132). Satinsky continues that there are two
important ways in which a mature managed care environment contrasts with a non-
managed care market "(1) competition is among integrated financing and delivery
systems, not individual components, and (2) health plans and employers use many
strategies to contain health care cost while ensuring quality of care" (p.133). As the
integrated system evolves, the critical issue to their success will be the ability to capture,
share, and manage information from all parts of the system.

In 1995, Holland Community Hospital, in Holland, Michigan, appointed a design
team to evaluate its degree of integration in the health care market. The design team
findings indicated that the health care environment of the Holland area was at Stage II of
development on a scale from Stage I (least integrated) to Stage V ( most integrated). The
team proposed plans to help the integration process progress. The team re-evaluated the

market again in 1996 to find that the area had progressed to a Stage III of integration.

In September 1996, Arbor Associates developed a strategic medical staff plan for
Holland Community Hospital (Arbor Associates, Inc., 1996). The study included a
current (1996) needs evaluation and year 2001 needs projection for primary care
physicians in the Holland community. All results were stated in terms of full time
employment of physicians. For the purpose of the study, nurse practitioners (NPS) and
physician assistants (PAS) were assumed to be the equivalent of 0.75 of a full time
physician, except in the obstetrics-gynecology practice, in which the equivalent was 0.5.

The 1996 findings showed that there were 66 full time primary care physicians in
the designated area, which supported a population of 133,586. According to Arbor
Associates, the area could support 67 primary care physicians at that time. Projected
primary care physician requirements for the year 2001 were also developed. Physician
supply was adjusted to reflect retirement of primary care physicians in the future. The
need and net need figures were shown as a range based on two different scenarios of the
relative roles of primary care physicians as managed care continues to grow in western
Michigan. Scenario I was developed as a reference point for the minimum number of
primary care physicians needed based on the assumption that the demand for office visit
volume of primary care physicians in the Holland will be relatively unaffected by
increases in managed care. Scenario II, in contrast, provided the opposite end of the
range based on the assumption that as the health care market shifts from fee-for-service to
managed care, there would be a 20 to 30 percent reduction in referrals from primary care
physicians to specialists. Under scenario I, a total of 74 primary care physicians would
be required in the year 2001, or a net increase of 18 additional full time physicians.
Scenario II would require a total of 84 primary care physicians, or 28 more doctors than
are currently in practice. This is an increase of 27 to 42 percent in just five years. With
managed care and various alternative delivery systems increasing, the most cost-effective
mix of provider types should compliment the various patient populations. The objective
of any managed care plan is to manage use and price by controlling the type, level, and

frequency of treatment by restricting the level of reimbursement for services. Current

changes in the health care market have provided the impetus to hire mid level
practitioners, especially family nurse practitioners (FNPS). In the Holland area, the next
five year time period could provide the perfect opportunity to increase the utilization of
the FNP.

Statement of Problem

The Holland area is in the midst of integration into a managed health care system.
As this system moves toward a mature managed care environment, the financial risk
shifts from payers to providers. The implications of this shift for primary care are
extremely complex. According to Swartz and Brennan (1996), the physician is no longer
the independent decision maker guided solely by medical knowledge and a code of ethics.
Physicians are dramatically impacted by the managed care system. The insurance
companies are placing tighter restrictions on physician practice, a new and uncomfortable
situation for the physician. This means physicians will need to find new and creative
ways to provide efficient cost-effective, quality care to the community. Many studies
have provided information regarding how NPs are cost effective, provide quality care,
and have positive outcomes with patient satisfaction (Brown & Grimes, 1993; Office of
Technology Assessment, 1986). If it is true that NPs provide quality cost-effective care
and that the managed care environment emphasizes cost-effectiveness, why has the entry
of NPs into the primary care arena been so limited? It is this author's belief that the
physician still plays a key role in the hiring process and success of NPs in the health care
system. How the NP role is viewed by the physician within the current health care
market is thus vitally important.

The purpose of this study is to provide descriptive information about the
physician's knowledge and perception of the NP role which would influence the
physician's willingness to hire. The more positive the perception the physician has of the
NP role, the more willing the physician will be to hiring a NP. The information obtained
in this study would provide a base for developing a more effective marketing program for

NPs. Therefore the following questions will be addressed.

Research Questions

The research questions are:
(1) What is the physician's perception of the role of the FNP?
(2) What do physicians perceive as problems in utilizing the FNP in practice?
(3) What is the prior physician knowledge or experience with FNPs?
(4) What is the relationship of physician demographics to physician perception of the

FNP role?
(5) What is the relationship of physician perception of the FNP role and the willingness

to hire?

Research Hypothesis

The more positive the perception of the role of the FNP, the more willing the

physician will be to hire a FNP.
THEORETICAL FRAMEWORK
Conceptual Definitions of the Variables
The key variables to be discussed are perception and willingness to hire.
According to King (1992), perception is "each person's representation of reality" (p.145).
Perception is a process in which data that is obtained through the senses and from
memory is organized, interpreted, and transformed. This process of human interaction
with the environment influences behavior, provides meaning to experience, and
represents the individual's image of reality. Thus, the physician's perception of the role of
the NP is based on past and present knowledge and experience with the NP role.
Willingness to hire is based on a decision making process which is founded on the

perception of the individual making the decision. King (1992) defined decision making
as "a dynamic and systematic process by which goal-directed choice of perceived
alternatives is made and acted upon by individuals or groups to answer a question and to
attain a goal" (p.132). Kahneman, Slovic, and Tversky (1982) describe decision-making
as an individual's initial framing of the problem, which is dependent on how the problem

is presented, the person's present mood, the ability to imagine alternatives, past

experience, perceived effect on current life-style, and whether the decision outcome will
be a win or a loss for the person. Decision-making is thus a cognitive process based on
the individual's interpretation or framing of the situation. Therefore, the decision to hire
a NP is directly related to the physicians perception, both positive and negative, of the NP
role. The decision is a process by which the physician assesses the current situation and
the possible alternatives based on previous life experiences, current physical state, and
current information available. The physician then evaluates the possible outcomes, and
makes a decision which is believed to be the most appropriate.

Conceptual Framework

The conceptual framework utilized in this study is King's theory of goal
attainment (King, 1981,1992). The theory is written to describe nurse-client interaction
but can be considered as the interaction between any two individuals. According to
George (1995), King's theory of goal attainment is generalizable to any dyadic nursing
situation and therefore can include the interaction between the NP and the primary care
physician. For the purpose of this paper, the dyadic relationship will pertain to the nurse
practitioner and the primary care physician.

King's theory is derived from an open systems framework and consists of three
systems, personal, interpersonal, and social, which are in continuous exchange with their
environment. The personal system involves the individual and is based on the concepts
of perception, self, body image, growth and development, time, learning, and Space. The
interpersonal system involves dyads, triads, or small and large groups. The concepts
relate to role, interaction, communication, transaction, and stress. The social system is
composed of family, school, social organizations, and health care delivery systems. The
concepts are organization, power, authority, status, decision making, control, and role.
Figure 1 illustrates the three open interacting systems, which are distinctly unique but not
separate. The broken lines represent openness and permeability that allow interaction to

take place within the other systems. The arrows represent the integration of systems to

one another. All three systems can be seen interacting within the NP and physician

relationship.
If ----------------- ~--~\'
I MSW PM “I l
I s. rim) Authority in the I
I ( Work place I
I_ __________________ I
l 1W8)“: :
I (am .91 > I
I r---r----\ I
. Peru-d8”: |
I Plum , I am I I I
l Nun: practitioners I I I
I Clint: Nurse practitioner I I
I I Client: I
I I L_-_-J ' I
I I I
I l I I
I k ____________ J l
I I
I I
k _____________________ J

Figure 1. An adapted conceptual fiamework for physician-nurse practitioner interaction.
(From King's Conceptual Framework for Nursing (King, 1992, p.20).)

Each individual has their own perception of themselves and the situation based on
current and previous life experiences. When the NP and the physician interact with each
other, their communications and transactions are influenced by their perception of their
roles. The social system also influences the relationship by dictating the organization,
power, and authority. Within this theory and the current health care system, physicians
have the power and authority to make the decision whether to hire a NP into a private
practice. This decision is based in part on the physician's knowledge or perception of the
role of the NP. An inaccurate perception will directly impact the communication,
interaction, and transaction between the NP and the physician. Ultimately, an inaccurate
perception will result in an inability to reach a common goal. This- relationship is
illustrated in Figure 2. Perceptual congruence increases the chance of mutual goal setting

and congruent role expectations thus avoiding role conflict, confusion, and stress.

Physician's Perception
history
knowledge
demographics

Interaction ——> Transact ———> Goal
willingness to
hire

NP's Perception
history
knowledge
demographics

Figure 2. The process of physician-nurse practitioner interaction utilizing King's theory of
Goal attainment (King, 1 992, p.21).
REVIEW OF THE LITERATURE
Managed Care and Physician Practice
Numerous Studies have been conducted that have evaluated the effect of the
managed care system on physician practice(Freund et al., 1989; Hillman, et al., 1989;
Lurie et al., 1992; Clement et al., 1994; Lurie et al., 1994; Miller & Luft,1994; Greenfield
et al., 1995). In general, these studies showed a consistently lower cost in the managed
care system with an equal or better quality than in the fee-for-service arena. Processes
and outcomes in managed care systems have been better or the same for patients with
diabetes and blood pressure control (Greenfield et al,1995), urinary tract infections and
pelvic inflammatory disease (Carey & Weis,1990), and care for patients with chronic
mental illness (Lurie et al., 1992). In studies of care and outcome in the elderly, there is
little difference between managed care and fee-for-service systems with regard to rate of
functional decline (Lurie et al., 1994), number of outpatient visits to providers per year
(Clement et al., 1994), or one year outcomes of patients with congestive heart failure
(Retchin & Brown, 1991). The two major limitations of these studies are I) that most of
the studies are already more than three years old, and with rapid reorganization growth

theie results are already outdated, and 2) most studies have evaluated relatively short

term outcomes, even when dealing with chronic illnesses like diabetes and congestive
heart failure.
Nurse Practitioners in Primary Health Care

Many studies have been conducted evaluating the efficacy of NPs in the
ambulatory setting. Most notably are Brown and Grimes (1993) meta-analysis and the
study by the Office of Technology Assessment (OTA) in 1986. Brown and Grimes found
that NPs provided more health promoting activities, scored higher on quality of care
measures, achieved higher patient satisfaction and compliance, and spent more time per
visit than their physician counterparts (none of whom were in managed care). The OTA's
1986 policy analysis of NPS, PAS, and certified nurse midwives also found that NPs were
more accessible and cost effective and had higher patient satisfaction ratings than
physicians. These studies were done over a decade ago however, and have limited impact
in today's health care system. New studies of the impact of the NP in the current health
care system are currently underway and will likely provide information regarding the
impact of the NP in an integrated health care system.

Physicians' perceptions of the NP role in Managed Care

There exist very few published research studies conducted solely to assess the
physician's perception or attitude toward the NP. Some studies have combined
physicians' perceptions along with patients' perceptions, acceptance, and quality
outcomes (Betancourt, et al., 1996; Olzack & Carrico, 1995). Other studies have
examined the incentives managed care provides physicians to hire NPs (Bezjak, 1987) or
the attitudes of HMO physicians toward the use of NPS and PAS (Johnson & Freebom,
1986). Only two studies could be found that actually evaluated the physician's perception
of the NP and their willingness to hire (Radke, 1977; Louis & Sabo, 1994).

Betancourt, Valmocina, and Grossman (1996) utilized three questionnaires to
evaluate the patient's perception of the NP role, the physician's perception of the NP role,
and the knowledge the patient and the physician have with regard to the NP role. Both

physicians and patients had positive perceptions of the NP role but each had different

IO

limiting factors regarding role performance capabilities. The item that scored lowest on
the physicians questionnaire was the ability to prescribe medications. The study did not
report which states this questionnaire was completed in nor whether the NP had
prescriptive authority there.

A study by Olzack and Carrico (1995), two clinical nurse specialists from a
obstetrics-gynecology practice surveyed their patients and the physicians they worked
with concerning their satisfaction with NP services. Of the thirteen physicians responded,
eleven (85 %) stated they were satisfied with the care that was administered and would
refer family and friends. Even though twelve (92%) of the physicians felt the NP made
appropriate referrals and performed thorough assessments, only ten (77%) felt the
assessment skills were effective. The authors state that the organization used the terms
"clinical nurse specialist" and "nurse practitioner" synonomously. The organization was
described as a main facility that supported three satellite facilities, which were staffed
with three nurse midwives and ten NPS, who worked with ten physicians. The total
number of questionnaires sent to physicians was never stated, so that the reader has no
way of determining whether the thirteen who responded were a fair representation of the
potential population. If it was a small percentage of the population, more could be
implied by the fact that a high number of physicians did not respond to the questionnaire.
This study was limited by the small number of respondents and could be skewed
secondarily due to any relationships between the NP and the respondents.

A 1987 study by Bezjak concerned physicians' motivations to form associations
with NPs. The study explored NP-associated incentives in relation to year of physician
graduation from medical school, physician specialty, and the type of practice. The
physician subjects were recruited through a process where NPs practicing in Arizona
identified their physician counterparts. Of the eighty-eight physician/N P associations so
identified, 63 (72%) responded within one month to the mailed survey. The survey
contained four areas of study: accessibility, physician satisfaction, economic benefit, and

quality of care, and its results indicated that physicians perceived an increased

ll

accessibility to their services and improved quality of their care as being the most
important incentive to hire a NP.

Johnson and Freebom (1986) assessed the attitudes of physicians working in
HMOs toward the use of NPs and PAs. Data for this study were collected in 1977, in the
early evolution period of NP history. Physicians were surveyed from internal medicine,
pediatrics, and obstetrics-gynecology in a HMO serving 270,000 members. The
percentage of respondents per specialty was as follows; internal medicine 69%,
pediatrics 84%, and obstetrics-gynecology 94%. The organization employed 21 NPs (16
females and 5 males) and 14 PAS which were all male. Overall, internists and
pediatricians had more favorable attitudes toward NPs and PAs than did the obstetrics-
gynecology physicians. Physicians from all three groups favored NPs more than PAs and
felt that NPs were more likely to increase the quality of care and less likely to increase
the risk of malpractice. Besides the fact that this is a very old study, the article does not
provide information regarding the type of survey questions used nor tests run on the data
collected to verify the assumptions or to document the validity or reliability of the data.
The article stated that many of the results were not statistically significant but does not
provide the reader with supporting statistical information.

Radke (1977) developed a 43-item questionnaire to determine the physician's
perception of the FNP. This questionnaire was mailed to 239 general practice physicians
in a selected county of southern California. Of the 81 respondents(34%), 73(90%) had
heard or read about NPs and 56 (69%) had discussed the concept with other physicians or
health professionals. However, 47 (58%) had not observed a NP in practice, 60 (74%)
had not worked with a NP, and 70 (86%) had never employed or presently were not
utilizing a NP. The physicians' most favorable responses to the function of the NP were
to health teaching, obtaining a health history, counseling, making home visits, managing
routine health care, and participating in evaluation of care. The greater percentages of
unfavorable responses were for inserting intrauterine devices and performing physical

exams. Many physicians had an unfavorable response to prescribing medications but also

12

had a comparable number of favorable responses. Forty (49%) of the physicians were
willing to consider hiring a FNP as compared to 38 (47%) who were not willing to hire.
Areas of uncertainty were identifying behavioral problems, managing commonly
occurring acute illnesses and managing stabilized, chronic diseases. This study is twenty
years old and most likely out of date; however, it does provide important information
concerning physicians' previous attitudes.

Louis and Sabo (I994) assessed the need for and willingness to hire NPS, as
viewed by nurse practitioners, nurse administrators, and physicians. Questionnaires were
sent to all licensed physicians (N = 1,800), all state certified NPs (N = 120), and the top
nurse administrators (N = 86) in the state of Nevada. The study had a return rate of 21%
overall with 79% of the nurse administrators, 35% of the NPS, and 18% of the physicians.
Overall, the respondents saw a need for NPs (74%) yet only 50%, including the NPS,
wished to hire a NP. Over 20% of the respondents, including some NPs, indicated the
need for more information about NPs before committing to hire. Seventy-six percent of
all respondents had experience with NPs; however 75% of those respondents saw a need
for NPs and only 55% indicated a desire to hire. Twenty-three percent of the physician
group expressed a need for more information about NPs. These findings suggest that, if
professionals need more information about NPS, the public also needs more information
about services provided by NPs.

Summary of Literature Review

The major focus of this study was to describe the physician's perception of the NP
role and the physician's willingness to hire. The nearest study that has been done to
evaluate this was twenty years old when advanced practice nursing was in its infancy not
to mention the beginning of the managed care concept. Much has changed since that time
and will continue to change. For this reason, more current studies need to be conducted
to evaluate the physician's perception of the NP role and how the two roles interact. A
clearer understanding of the physician's perception of the NP will better serve the NP in

future interactions. The purpose of this study is to provide more descriptive information

[3

regarding the physician's perception of the NP role which will aide the NP in
employment.
METHOD
Design

This study was a non-experimental design in which a self selected convenience
sample of primary care physicians completed a one-time survey. The purpose of the
study was to provide the NP with information to better understand the physician's
perception of the NP and then compare those perceptions to their willingness to hire a
NP. The information obtained then provides the NP with concrete areas of role
incongruence, information which can then be used to create planned change of the
physician's perception of the NP. The survey required approximately ten minutes to
complete and was given to primary care physicians in Ottawa County, Michigan, that
were affiliated with the three hospitals in that county (Holland Community Hospital,
Zeeland Community Hospital, and North Ottawa Community Hospital). The primary
care physicians were defined as physicians practicing in family practice, pediatrics,
obstetrics-gynecology, or internal medicine.

Permission was obtained to employ a 43-item questionnaire developed and
copyrighted by Karen J. Radke and Edith Wright (Appendix A). The questionnaire was
developed to include statements of function considered to be representative of those
performed in the ambulatory health setting which could be performed by the NP. The
questionnaire was updated to include the current description of a FNP and to include
primary care physician demographics to enhance the study findings (Appendix B).

Five-point Likert type scale items are used in Section I of the questionnaire
(questions 1-21) to assess the physician's perception of the FNP performing each
function. The categories range from "Highly Favorable" (5) to "Highly Unfavorable" (1)
and include a category of "Uncertain" (3). Section II of the questionnaire (questions 22-
29) assesses perceived problem areas or barriers the physician might anticipate when

employing a FNP. This section uses four-point Likert scale items ranging from "no

l4

problem at all" (4) to "many problems" (1). Section III (questions 31-35) inquires about
the physician's source of knowledge of and experience with FNPs. Physicians were asked
to respond "yes" (1) or "no" (0) to the questions stated. SectionIV (questions 36-47)
provides demographic information and also the critical question, "Would you ever be
willing to consider hiring a Family Nurse Practitioner?" Given the age of the original
survey and the evolution of the NP role, this question was changed. The author felt that
this question, in the way it was written, would not evoke a significant number of "no"
answers and would thus limit the sensitivity of the instrument. This question was
changed into three questions regarding hiring a FNP now, in 1-2 years, or in 2-5 years.
The response to each remained "yes" or "no". The physician was allowed space below
Section I and Section II for any additional comments.
Operational Definitions Of the Variables

The physician's perception of the FNP role was operationally defined by survey
questions 1-35, which included areas of role definition, perceived utilization problems,
and previous knowledge or exposure to NPs. The first section evaluated the physician's
perception of the NP role. This variable was Operationally defined by the summation of
items 1 through 21 with scores ranging from 21 (highly unfavorable) to 105 (highly
favorable). The second variable was the physician's perceived problems in utilizing a NP
and was operationally defined by the summation of items 22 to 29 ranging from 8 (many
problems) to 32 (no problems at all). The last section evaluated previous knowledge or
experience to NPs. It was defined by items 31 to 35 with a summation ranging from 0
(all no) to 5 (all yes). The total range of scores for the physician's perception was from
29 to 142.

Willingness to hire is operationally defined by questions 43, 44, and 45 on the
survey, which directly ask whether the physician would hire a family nurse practitioner

now, in 1-2 years, or in 2-5 years.

l5

Sample

The questionnaire was delivered to a convenience sample of primary care
physicians located in Ottawa County, Michigan. The primary care physicians included
obstetrics and gynecology, internal medicine, pediatrics, and family practice physicians
that were actively affiliated with the three community hospitals (Holland Community
Hospital, Zeeland Community Hospital, and North Ottawa Community Hospital) and
their primary office was located in Ottawa County. This excluded physicians whose
primary office was in another county and who did not have active privileges. Since all
the physicians practice in close proximitry, all were similarly effected by managed care.

Field Procedures

The following procedures were implemented in this study:

1. An envelope containing an introduction and consent letter (Appendix C) and
the questionnaire was personally delivered to each physician's office. Offices with one or
two physicians received a self addressed stamped envelope to return the completed
survey. Offices with three or more physicians received a large manila envelope to hold
the completed surveys and the author returned on a designated date to collect them. It
was believed that this would increase the number of respondents without compromising
confidentiality. Voluntary consent was determined by the completion and return of the
survey.

Protection of Human Rights

The rights of all subjects involved in this study were protected in accordance with
the Michigan State University Committee on Research Involving Human Subjects.
Approval #97-487 was obtained from the committee prior to initiating any data collection
(Appendix D). Voluntary consent to participate in the study was indicated by completion
and return of the survey, as indicated in the introduction and consent letter (see Appendix
C). Anonymity was maintained by providing self addressed stamped envelopes for the

return of surveys given to practices with only one or two physicians. Larger practices

16

were provided a manila envelope to place the completed forms which were collected
together at one time by the surveyor.
Assumptions
The following were identified as assumptions for the purpose of this study:
1. Self-reported data given by subjects was accurate to the best of their knowledge.
2. The surveys were completed alone without consulting another individual and thus the
data are independent.
3. The sample comes from populations of the same variance.
4. The subjects practice within an integrated health care system.
Limitations

The results of this study are limited by several methodological flaws. The sample
was made up of a small group of physicians in western Michigan. Given the varying
degrees of managed care integration in communities across Michigan and the country, the
results of this study could not be generalizable to a larger population.

After the questionnaires were collected, it became obvious that the return rate was
greater for the questionnaires that were mailed back as opposed to being personally
picked up by the author. One contributing reason for this could be that the author did not
call the group practices the day before the established pick up date to remind the
physician. It is believed that it would have been easier and possibly yielded a greater
number or responses if all the questionnaires had been returned by mail.

There was some difficulty in locating physicians' offices. Some listed addresses
according to the hospital register were not up to date and the author was unable to find
three physician offices. It must also be noted that the survey was done in the middle of
the summer and the author was informed at many of the offices the some of the
physicians were on vacation during a portion or all of the time period allotted for the
survey response. This limited the number of responses and should be considered if

another study were to be conducted.

17

Other threats to external validity include physicians who may have given socially
acceptable responses because of perceptions that the author was a supporter of all that
was included in the questionnaire. The author has also worked professionally with many
of the physicians surveyed, so that their answers may have been biased. This kind of bias
due to physician knowledge of NPs was the major finding of this study.

Threats to internal validity involved confusion related to two specific areas of the
questionnaire. The first area concerned the year that the physician graduated from school.
Since the question was written to include both the MD and the DO, some respondents
simply circled one or the other but did not give the year of graduation. It can only be
assumed that either the question was not read carefiilly or that there was confusion
regarding the question. The second area of concern dealt with questions 43, 44, and 45.
These questions involved the decision to hire a FNP now, in
1-2 years, or in 2-5 years. Some physicians responded yes to hiring a FNP now but left
the next two questions blank. Other physicians answered yes to all three questions. In
discussion with some of the physicians, there appeared to be confusion as to how to
answer these questions when they had just hired a FNP within the last six months.
Further clarification of these questionswould help future studies.

RESULTS/FINDINGS
Data Analysis

Statistical analyses of the data were done with the SPSS/PC+ computer program.
Descriptive and summary statistics were provided as a basis to understand the distribution
of the physician types.

1. Analysis of varience (ANOVA) was used to compare the physician groups
with respect to knowledge of the descriptive NP role (Section I).

2. ANOVA was used to compare the physician groups with respect to perceived
problems in utilization of the NP (Section II).

3. ANOVA was used to compare the physician groups with respect to prior

knowledge or experience with a NP (Section III).

18

4. ANOVA was used to compare the physician groups with respect to total
knowledge of the NP role (Total Sections I, II, & III).

5. Correlations were computed to test for a relationship between physician type,
years since physician graduation, perception of NP role, and willingness to hire now and
in the future.

A total of 90 surveys were delivered to primary care physicians in Ottawa County,
Michigan, which broke down to 17 OB-GYN (19%), 39 Family Practice (43%), 12
Pediatricians (13%), and 21 Internal Medicine (23%). Of these surveys, 53 (59%) were
returned. These frequencies and percentages can be found in Table 1. Analyzing each
physician type with respect to actual versus potential returns, the internal medicine group
had the highest return rate (71%). It is of interest to note that the family practice group
was the largest potential sample group but had the lowest percentage of returns.

«.0‘, 4.1-. ' I 'I l-I 0‘ uti‘ 0‘ 0a .--. V . .O‘Io. 1‘ .u

Erratum Lenten!
OB-GYN 9 17 52% 17.0% 19.0%
Family 20 39 , 51% 37.7% 43.3%
Pediatrics 8 12 67% 15.1% 13.3%
Internal Med. 15 22 71% 28.3% 24.4%
Other 1 1.9
Total 53 90 100 100

Demographic information demonstrated that 89% of the physicians surveyed were
males, with a mean number of years since graduation of 17 years. Within the sample, the
breakdown of physician group practice showed that 43% of physicians are in a group
practice of 2-4 physicians, 36% practiced in a group of 5 or more physicians and 21% are

in solo practice. The physicians' practice settings are shown in Table 2.

C. O O
20' '9. ' a“ ’ 'Ie". l 2| 0. ‘ ' I.’

Kaine Emmy Bergen!
Private 49 92.5%
Federal 2 3.8%
Other 2 3.8%
final 5 3 1 00%

The next area to be analyzed related to the physicians' knowledge of each of the
three sections of the survey that pertain to the NP role. Summary statistics can be found
in Table 3, in which all physician groups were evaluated for each section of the
questionnaire pertaining to the NP role (Sectl, Sect2, Sect3) and the total of all the
sections (Totalsc). The mean of each section was used to determine the physician's
knowledge or perception of each area. Section I totals are illustrated in Figure 3, along

with the mean for that section.

IIIZS S"EE1"'E . E11113

Standard

Ema-bk Min m I I I I I. D . . B l. l .1.
Sectl:
MD perception of NP role 50 105 86.57 87.5 1 1.66 .9274
Sect2:
Perceived Utilization Problems 13 31 21-03 19-65 4-43 .8511
Sect3:
Previous Knowledge/experience 0 5 4'04 5 1-33 -7774
Totalsc:

66 137 111.40 111 16.08 .7909

Total score for three sections

Research question # I asked: What is the physician's perception of the role of the

FNP? This schematic view illustrates the more favorable view the physicians toward

FNP roles.

 

Eammhl: anmabl:
I l | | l l
21 42 63 84 {87.5} 105

Figure 3. Physician perception of NP role. (Mean response in braces)

Closer evaluation of the frequencies of each individual question in section 1
yields very interesting data. As stated earlier, the questions in this section are answered
in S-point Likert scale items ranging from highly favorable to highly unfavorable. The
majority of questions had distribution over all possible answers with the concentration of
answers being either favorable or highly favorable. Two questions were answered as
either favorable or highly favorable by all respondents. These questions pertained to the
NP obtaining. a health history and providing health teaching (questions 9 and 4
respectively). The most controversial question in this section had to do with insertion of
intrauterine devices. Of the respondents, 23% viewed this as a highly favorable function
of the FNP role while 14% viewed this as highly unfavorable and 44% were uncertain.
The last question of this section asked the physician about their overall feelings of the
FNP concept. None of the respondents answered highly unfavorable. The majority
answered this question "favorable" (43%) with "highly favorable" next (32%) and
"uncertain" third at 19%.

Research question # 2 asked: What do physicians perceive as problems in
utilizing the FNP in practice? Analysis of responses to Section II of the questionairre
shows that, overall, then physicians see few to some problems in utilizing the FNP in
practice (see Fig.4).

11o lien Sam: M
Emblems Emblems Emblems Emblems

I | l ‘ | |
32 24 {21} 16 8

Figure 4. Physician perception of problems in utilizing NPs. (Mean response in braces.)

21

Table 4 shows the percentages for each question and answer in Section II.

10“ ’0.‘t " ‘le" 0 ‘ OI ' " ‘_V'! '_tt‘u '

No Problems Very Few Some Many Problems
#22. Patients 1 1.3 28.3 47.2 13.2
#23. Physicians 1.8 43.4 49.1 5.7
#24. Other RNs 13.5 40.4 40.4 5.7
#25. Quality 17.6 60.8 17.6 4.0
#26. Legal 11.5 55.8 25.0 7.7
#27. Interference 23.5 49.0 21.6 5.9
#28. Funds 6.2 57.1 26.5 10.2
#29. MD Demand 7.8 49.0 37.3 5.9

The first two columns of Table 4 are more positive (few to no problems); the last two
columns are more negative (some to many problems). The areas that were perceived as
having predominantly none to few problems with utilization of the FNP were Quality
(78%), Legal (67%), and Interference with the physician-patient relationship (73%). The
areas perceived as having a more negative relationship were patient's acceptance (60%),
and physician's acceptance (55%). All other areas were slightly more positive. It was
interesting that the area that the physician views as being the most problematic was that
of the patient's acceptance of the F NP. Numerous studies that actually assessed the
patient's perception of the NP (Betancourt etal., 1996; Brown, S., & Grimes, D., 1993;
OTA, 1986; Guyther, J ., & Sabo, J ., 1982) have found just the opposite.

Research question # 3 asked: What is the physician's prior knowledge or
experience with family nurse practitioners? Analysis of Section III responses show that
the vast majority of the physicians surveyed had experienced working with a NP in 4 out
of 5 possible ways. The results are obviously skewed to the right with a mean of 4.04
and a median of 5 as a result of the scoring of the "yes" and "no" answers.

The total of all three sections can be visualized in a similar manner as before. The

overall scores depicted on a line with placement of the surveys mean score.

29 56 82 {111.4} 112 142
Figure 5. Physician overall perception of the NP. (Mean shown in braces.)
Figure 5 shows that the overall score was a favorable perception Of the FNP by all
physician typescombined.

Section IV of the questionairre provided descriptive information regarding
physician type which was discussed earlier. The section also provided more information
regarding the physician's perception of the health care environment along with their
willingness to hire. Seventy three percent of the responding physicians did not feel there
was a shortage of general practitioners in this community. The physicians responded at a
rate of 69% that the services of a FNP would enhance the delivery of health care in their
practice setting. In response to the question of hiring a FNP now, in 1-2 years, or in 2-5
years, the physicians marked "yes" in 42%, 49%, and 61% respectively. Thus it would
appear that the willingness to hire may increase over the next 5 years. This could be
interpreted a number of ways. Since the majority of physicians did not feel there was a
shortage of health care providers in the area, it stands to reason that the physicians would
not be looking to increase the number of providers to their area. Another possibility
could be that the physician may have recently hired another provider in the last 6 to 12
months, thereby financially affecting their decision to hire a FNP. Another impact on the
decision could be the current reimbursement constraints by insurance companies and the
government for FNP services. But what are the reasons for the increased percentages for
hiring in the next 1 to 5 years? This could be related to future population growth
predicted to the area, retirement of physicians within the time period, stabilization of
current financial status, or better insurance reimbursement anticipated in that time period.

Further questions to illuminate the reasons for waiting were not asked.

23

Analysis of variance was then conducted utilizing first the non-parametric
Kruskal-Wallis test and then confirming the results with parametric ANOVA testing.
Since the results were the same for each variable in both the Kruskal-Wallis and the
ANOVA and the ANOVA is considered the more powerful of the two tests, the results of
the ANOVA testing are shown in Table 5. The results show that there is no statistically
significant difference between the scores and the physician type. Thus, the different
physician types have similar amounts of knowledge and acceptance of the NP role. As a
note, the p-value for physician type and Section II (Perceived Utilization Problems) was
.07. Examination of the means underlying this nearly significant trend suggests that the

internal medicine physicians viewed greater problems in utilizing NPs.

WM

Mariam: 13.513.115.119 Halli:- 5121111193111
Sectl:

MD Perception of NP Role 2065 9335 NO
Sect2:

Perceived Problems Utilizing NP 23002 0737 N0
Sect3:

Physician's Knowledge/ experience of NP '6760 6119 N0
Totalsc:

Total of all sections 5571 .6949 No

Correlations were computed to test for relationships between variables, including
each section, type of physician, and willingness to hire now and in the future. Results are

shown in Table 6.

W15

Gradyrs Q39 Q43 Q44 Q45 Q46
:IDtherception of NP role .0980 -. 1463 .5496 .4455 .4576 .1964
szgived Problems Utilizing NP .1215 -.2673 .4900 .4239 .4761 .1240
ls’fiitSPiCian Knowledge opr -.0539 -.2070 .4761 .1446 .1 159 .3126
Totalsc:

Total Ofall sections .1036 -.2399 .6046 .4241 .4542 .2175

24

Gradyrs refers to the number of years since the physician graduated from medical school.
A Pearson's r was used with this data because the years since graduation is an interval
scale. Q39, Q43, Q44, Q45, and Q46 refer to questions 39, 43, 44, 45, and 46
respectively in the questionnaire. Spearman's rho correlations were used to evaluate the
relationship between these questions and each section of the survey. This data answers
research questions # 4 and #5: What is the relationship of physician demographics to
physician perception of the FNP role and what is the relationship of physician perception
of the FNP role and the willingness to hire? As seen in Table 6, there is no statistical
relationship between the physician's perception of the NP and the year the physician
graduated from school or the type of physician practice. Question 43 asks, " Would you
or your group hire a Family Nurse Practitioner now?". For the purposes of this study, any
Spearman rho figure greater than 0.5 was considered of practical significance (values
greater than 0.5 are statistically different from 0.). With a Spearman rho value of .60,
there is a positive relationship between hiring a FNP now and the physician's perception
of the FNP (totalsc). In reviewing the breakdown of physicians' perceptions of NPS, the
strongest relationship is Section I relating to the specific role characteristics. This could
be due to the fact that this is the largest section of the survey and therefor would carry
more impact to the overall score. Section II and III are also positively correlated but not
as strongly as SectionI and the total score section. There is less of a relationship with
questions 44, 45, and 46, which relate to future hiring of a FNP and the employment of a
PA.

In summary, there is a significant positive relationship between the physician's
perception of the NP and the willingness to hire. Though only 42% would hire a FNP
now, the percentage increased to 61% in 2 to 5 years. Perceived problems in utilizing the
FNP relate to patient acceptance of the FNP. The specific role that produced the widest
spread of opinion and the highest negative response had to do with the insertion of an

intrauterine device.

25

Findings in Relation to the Model

The findings of this study were consistent with the conceptual model. In King's
theory of goal attainment, each individual has a perception of self which then interacts
with others in order to form the concepts of role, interaction, and transaction of the self
and of others in the dyad or triad. The physician's perception of the NP role is based on
the past and the present knowledge and experience. As seen in Figure 2, past experience
could be included under the history and knowledge component that influences the
physician's perception. The results of the study concur that the past experience with NPs
was more of an influence on willingness to hire than the demographics.

Section II of the survey found that the strongest perceived barrier to utilization of
the FNP by the physician was that of the patient's acceptance of the FNP. King's theory
emphasizes the need for accurate perceptions of each role (physician, NP, and patient) in
order to have positive interaction and transactions which directly impacts goal attainment.
Many studies (Betancourt etal., 1996; Brown, & Grimes, 1993; OTA, 1986; Guyther, &
Sabo, 1982) have found that patients have a positive perception of the NP and the
physician's misconception regarding this could definitely affect the interaction between
the physician and the FNP. Thus, the FNP needs to evaluate the accuracy of the
physician's knowledge of the F NP role and educate the physician in areas that are weak or
inaccurate. An inaccurate perception would directly impact the communication,
interaction, and transaction between the physician and the FNP and thus the hiring of a
FNP.

Findings in Relation to the Literature

The findings of this study were fairly consistent with the limited literature
available, with the exception of physicians' perceptions of practitioner shortage in the
practice area. The physicians in this study did not feel there was a shortage of general
providers in the area, in conflict with the literature findings. Willingness to hire was
consistent with the literature but none of the previous studies differentiated between

hiring now, in 1 to 2 years, or in 2 to 5 years. Comparisons of perception of the NP role

26

yield similar results. The area of greatest conflict in this study and the literature is that of

insertion of an intrauterine device. There is no clarification as to whether this is

perceived as a problem regarding the FNP or a negative perception of the use of

intrauterine devices. The literature describes role conflict with regard to performing a

physical exam and prescriptive authority, conflicts which were not found in this study.
DISCUSSION

One important and interesting finding from the survey may play an integral part in
the hiring of the FNP. The physicians in this survey did not feel there was a shortage of
general practitioners in the area. Could this perception be a reaction to the paradigm shift
the physicians have encountered in the area over the past few years? The physicians in
the area studied have only recently become effected by the impact of managed care or
working within an integrated health care system. Managed care has forced the physician
to be accountable for all business decisions or else risk loss of income. Therefore the
physician now scrutinizes every aspect of the practice, including the decision to increase
staff. Extensive evaluation regarding the addition of another physician or a mid-level
provider will be done but only after there is a sense of need for another provider. In an
area where there is no perceived shortage of general practitioners, the FNP may be
considered either an asset or a threat to the practice. When making the decision to hire,
the physician will base that decision on past experience, the present situation, and the
perceived outcomes of that decision. This study supports the hypothesis that the more
positive perception of the FNP role, the more willing the physician will be to hiring a
FNP. Experience working with a FNP has the greatest impact on physician knowledge
and perception of what a FNP can provide to the practice.

The top two areas the physicians perceived as problems in utilizing the FNP were
the patients' acceptance of the FNP and the physicians' acceptance of the F NP,
respectively. Though the study showed that these physicians had a positive perception of
the F NP, they still felt that the FNP would not be accepted by the patient or the physician.

This appears to indicate that the physician agrees with the FNP concept but not with the

27

reality of the F NP in the workplace. The FNP is viewed as competition to the physician's
practice as opposed to being an asset to the primary care environment.
Implications for Practice

The greatest predictor of willingness to hire is the physician's previous experience
with a FNP. The FNP in practice should develop strategies to increase their experience
with various physicians. This would increase their visibility in the health care
community as well as the general public. Ways to do this include getting involved in
physician directed work teams affiliated with the local hospital, encourage and attend
inservices for all medical staff, and work with various physicians at a clinic for the
underserved community population.

The FNP also needs to find support within the profession. There are two
professional support groups located in the Holland area: a NP-PA group which meets
monthly to discuss professional issues, current job market, and ways to better market the
profession; the Journal Club of Grand Rapids is composed solely of NPs and meets on a
quarterly basis. Each meeting updates members on current issues pertaining to the
profession but also provides an inservice on various practice topics. Each group provides
a support network for the NP in practice.

Other ways to increase awareness of NPs would be to increase interaction with the
community. This could be done by volunteering on health-related committees within the
medical community and the public sector. This would increase visibility and cultivate
allies outside the nursing continuum. Every community government has various
committees that the NP could join that would help increase community awareness and
knowledge regarding the NP role.

Implications for Education

The study clearly shows the importance of previous experience between the
physician and the NP. Schools of Nursing which also have an affiliated School of
Medicine should strive toward joint education of the students as much as possible. It is

believed that some of the basic course work could be combined, both undergraduate and

28

graduate. Currently there is social interaction between the groups but a stronger
interaction, e.g., clinical and residency, would better serve the collaborative process. In
the meantime, NP students preparing for their clinical rotations should look seriously at
combining their learning experiences with established NPs and with physicians in their
area of interest. This strategy is especially important for students who plan to work in an
area in which there does not appear to be a shortage of general practitioners. Establishing
a professional relationship with a physician will increase the Odds of future employment.
Implications for Further Research

This survey provides a comprehensive appraisal of the physician's knowledge of
the NP role but does not provide adequate information regarding what information a
physician would utilize when making the decision to hire a NP. Further investigation of
the influences and criteria a physician uses when deciding to increase professional staff,
whether it would be another physician, NP, or PA, would be helpful in determining a
marketing scheme for the professional. As the health care market changes, there is a shift
from quality of care issues to financial stability which plays an important role in the
hiring process. An accurate understanding between professionals regarding the reasons
for hire may be very important in providing job security and satisfaction.

As the NP role continues to expand, so does conflicting or confusing information
regarding the role. This study attempted to assess the physicians knowledge but it did not
provide an area to evaluate the areas of actual or perceived lack of information. By
assessing the areas that the physician perceives as needing more information, the NP can
develop an educational plan.

With the increased influence that insurance companies play in health care
practices, it would be appropriate to assess the insurance industries' knowledge and
perception of the role of the NP. This could provide invaluable information that the NP
could use to promote the NP role.

More studies need to be done that evaluate the effect of managed care on health

care delivery and outcomes in relationship to cost effectiveness and care provided by the

29

physician and the NP. Evaluation of physicians' perceptions of the managed care changes
in relation to their practice and what factors influence the decision to hire more providers.
All this information would be valuable to the NP assessing the market place.

In replicating this study, it would be advisable to sample a larger population, so
that results could be more widely generalized. Further clarification should also be made
regarding the questions related to willingness to hire. For example, one might add, "If
you answered "no" to the previous question, would you hire a FNP in 1-2 years?"
Finally, providing an open response area for further explanation as to why there is an
unwillingness to hire would be helpful.

Summary

This study of primary care physicians in Ottawa County, Michigan, examined the
physician's knowledge and perception of the FNP role and their willingness to hire.
Physicians, for the most part, had a positive perception of the FNP role. The hypothesis
that the more positive perception of the role of the FNP, the more willing the physician
would be to hire, was supported by the data. Given the continually changing health care
environment, there is growing competition and confusion regarding who would provide
the most cost-effective, quality care in primary care. The NP will benefit from the results
of this study by increasing experiences with physicians since there is statistical proof that
the more knowledgeable the physician is of the NP role, the more willing the physician
will be to hire a NP.

APPENDICES

30

APPENDIX A

Radke and Wright

Physician Questionnaire

'23 Dun-ow Crescent
tairport, I! new
February 4, 1997

Dear us . Ivkovich :

Enclosed is a copy of ny survey tool regarding “General
Practice Physicians' Opinions Concerning the tanily nurse
Practitioner.“ You have ny peraission to use it as you see tit
fir your study, providing the appropriate acknowledgements are
9 ven.

when you have coapleted your study, I would appreciate
receiving a copy or an abstract regarding your tindings.

Best of everything to you as you proceed.

8i cerely,

   
   

aren J. Radke, PhD, RN
Associate Professor
University of Rochester
School of Nursing, and
Departaent ot Pharaacology a Physiology
School of Medicine and Dentistry

31

32

L11“ l‘V E R S I'T Y (D F snnwcunmxquxsnum
snxxncrummomcamoonnsnn

ROCHESTER mm...
Nove-ber 5, 1997

MEDICAL CENTER

Dear us. Ivkovich:

In previous correspondence with you I gave you permission to
use my survey tool regarding “General Practice Physicians' Opinions
Concerning the Panily Nurse Practitioner.” I also need to add that
acknowledgeaent for use of the survey tool needs to be given to
Karen J. Radke and Edith wright as developers of this particular

survey instrunent.
Wishing you the best of everything,

flu“ L”

Karen J. Radke, PhD, RN

Associate Professor of Nursing, School of Nursing
Associate Professor ot Pharnacology/Physiology,
School of Medicine 8 Dentistry

”INA-onus
lat-unflaflhdlflfll

 

33

LOMA LINDA UNIVERSITY SCHOOL OF NURSING -

Role Description of a Family Nurse Practitioner

The role assumed by nurses in the provision ofhealthservicesisunderpolngacontlnuousanddynamicchanps toward more
active and responsible participation In providing comprehensive health care to people. The Family Nurse Practitioner Is a grad-
uate ofanaccredited baccalaureate programin nursingandhashadadvancededuestlonandchniealexperisncslnthemof
obstetrics. gynecology .family planning. pediatrics, and adult udichre. Instruction is provided jointly physicians and nurses.
The additional responsibilities of the Family Nurse Practitioner are performed in collaboration with and/or underthe thesupervlsion
ofaphysicianandpenerallywlllincludethe following:

I. To continue to providelhenursingslullsofhealth healdtcounsdhgandeoordlnationof tientcarewlth

mphafisonthepmodonofhedthanddupnvenm pa

2. To acquire patient data throudi history-taking and physical meat: to analyse the data collected; and to initiate
mded action according to protocol approved by a physician.

3. To differentiate between normal and abnormal findings and to conslllt with the physician to determine what health
problems can be handled by the nurse practitioner and which problems must be referred to other resources.

4. Tocollaborate withthephysieianinesublishhrgaueamtplanfordiecllniealmanapementofdtronicand commonly
occurringacuteillness.

SURVEY OF GENERAL PRACTICE PHYSICIANS‘ OPINIONS mNCERNING
THE FAMILY NURSE PRACTITIONER

l. After reading the role description of a Family Nurse Practitioner, please checkthe mm that indicates how you
personally feel about the Family Nurse Practitioner performing each one of the following functions.

Hlsmv 0*st
Favorable Iavorabte Uncutaln Untavorable Unfavorable

a. Makes the initial assessment of an individual’s health-illness
status when he or she enters the health care system. 'I 1 'I 1 't 1 ‘t 1 't l

b. Prescribe: medications with physician approval. I 1 t 1 t 1 t 1 I 1

c. Evaluates progress of patient with prescribed therapeutic regi-
men and adjusts medications, treatment or therapy In collabo-

rationwithphysician. (I ll ll t1 (I
d. Provides health teaching to patient and family in order to

maintain or promote health, and to prevent illness. I I t I I I t l I I
e. Perform a physical examination on individuals in any age

mup- l l l l I l I I l I
f. Recommends plan for health care to patient and family based

upon clinical findings and in consultation with a physician. I I t l t I t I I I
3. Makes home visits to do follow-up evaluations of the condition

ofthepatientandhisfamily. ‘I I ‘II ’I I ‘l I 'II

h. Initiates treatment and therapeutic regimens of commonly-
occurring. acute health problems of individuals in my age

group as authorized by a physician. t l l I I I I I I I
i. Obtains and records the patient's and family's health history. I I I I I l t I I l
j. Performs insertion of intrauterine devices. I i I l t I I 1 I I
It. Malies hospital visits to assist physician in evaluating patient's

condition. I I I I I I I I I I

I. Manages uncomplicated prenatal and postpartum care. I l I I I I l l I I

m. Identifies development and behavioral problems of children
and adolescents. I I l I I 1 r I 1 l

n. Coordinates health care of individual and family througt refer-
ral In other health professionals and/or community agencies. I l I l l 1 I l I I

PLEASE CONTINUE WITH QUESTIONS ON THE BACK OF THIS PAGE ’W'

34

0. With written Idelines makes decision regardhig when to refer
patient to a yslcian. '

p.Managea routinshealthcareofeuentlallywellindividuals.
q. Orders routine laboratory studies as indicated.

r. Maiagustabiliaed.long-tersnandchronicillneasoflndividuals
hen-snout».

nhrtici teswlthphysicianinccntlnuousevaluationofthe
qualitypand effectiveness of-health care.

LProvidescouruelingngardingthshealth-Illnessprobleneof‘

individual and families. -

u. Overall.howdom[alaboutthei=amilyNursePractitioner
Conceptatthistinte‘l

m
PM

Parrots.“ Uncertain

”I!
WW” 00'0”“...

'II
II
II

II

Midiofthefollowingareasdoyoufetlmeybeaproblenrhrtheutilisatlonofai’amilyNursePractitionerCFlilP)? Please

checkthemmwhichismostrepresentativeofyourbelief.

a. Patients‘ acceptance of FNP.

b. Physicians' acceptance of FNP.

c. Other nuraes' acceptance of FNP.

d. Quality of service rendered.

e. legal problems (licensure. malpractice, etc.).

f. Interference with physidan-patient relationship.
g. Availability of funds to cover FNP services.

h.Demandsonphysiciantimefornrpervision
of and/or consultation with FNP.

i. Other problems (list).

NORM
I‘ll

'(l
II
II

Verylow
m

Seine

m

Wheelers-a

‘il
II
II
II

arr

 

 

 

The concept of utilizing Family Nurse Practitioners in the delivery of health care is relatively new, and thus. many health
personnel are not familiar with this idea. Please indicate your source of knowledge or experience regarding Nurse Practitioners

by responding “yes” or “no” to the following items.

a. Have you read or heard about Nurse Practitioners before receiving this questionnaire?
b. Have you discussed with other physicians or health professionals the idea of Nurse

Practitioners providing health care?

c. Have you observed a Nurse Practitioner in action?

d. Have you had experience in working with a Nurse Practitioner?

e. Have you ever employed or are you presently utilizing a Nurse Practitioner?

PLEASE CONTINUE WITH QUESTIONS ON FOLLOWING PAGE

‘ltves

[Ives
(IYOS
IlVfl

[IVOS

t| |No

(Into
IINO
IINo

[INC

vvvvvvvvvvvvvvv

35

IV. Pleaseanswerthefollowingquestions:
a. Mistisyoursex?
‘l 1an.
'[ lFemale
b. hmtyardidyoureceinyourMD. degree?
c. mmmmmh:
'I lSolo
‘[ lGroupof2-4
’[ lGroupofflvsormore
d. lsyourprscticeaettingMina/an
'[ lPrivateOfIIce
'I Ilndusuy
'[ ISchoclHealth
‘[ lPublicl-lealthClinic
'[ lfiepddflealthPlanSystem

‘[ ]Other
e. be you feel there is a shortage of general practitioner sewices in your conununity? 'I I Yes 'I I "0
f. Would theservicesofa FamilyNursePractitionerenhancethedeliveryofhealthcare
inyourpraetice ? ' t iv. I IN:
g. WouldyoueverbewillingtoconsiderhiringaFamilyNunePractitioner? III!“ I INo
h. Doyou or your group presently employa physician's assistant? 1 i v. I H“

i. Hesse list any additional comments you may have about the Family Nurse Practitioner
Concept and/or this particular questionnaire.

 

 

 

THANK YOU FOR COMPLETING THIS QUESTIONNAIRE.

mans: CHECK THROUGH THE QUESTIONNAIRE T0 are sum: no oussrrous wane mssso.

© 1975 by Karen J. Radke

36

APPENDIX B

Updated Physician Questionnaire

Role Desa'iption of a Family Nurse Practitioner

The role description of a Family Nurse Practitioner as defined by the American Nurses Credentialing Center is a registered nurse with a graduate degree in
nursing who is prepared for advanced practice with individuals and families throughout the life span and across the health continuum. This practice includes
independent and interdependent decision—making and direct accountability for clinical judgment. Graduate preparation expands the comprehensiveness of the
family nurse practitioner role to include participatlon in and use of research. development and implementation of health policy. leadership. education. case
management and consultation.

SURVEY OF GENERAL PRACTICE PHYSICIANS OPINIONS CONCERNING

THE FAMILY NUR‘SE PRACTITIONER

l. mmmmmmata FMMW.WMMMMMMMH MMFMMWMMJIMM
incline.

M M
Fmallh Favorable Utartain Unfavorable Unfivorahle

I a. mmWMfimstdth-M

mumbwsieemflnbdlhmm. [ ] [ I I I I I I I
lemminnmmm. [] I] [I ' [I [l
3 c. mmdmmmmmns-

madafirstsm.mortlquyhcohbo-

manner“. I l I l I I I I I I
4 cmmmnmuhunnme

WVWW.NMWM. I I I I I l I I I I
5 e.Pn'iIrnopIrysicdwliMIlanonWieanya¢

m- I I I I I I I I I I
6 I. WMEMMNWMWW

wmmuummom. I l I I I I I I I 1
1 ammmnammdmm

dilemma-Italian. I l l I I I I I I 1
6 LMWdMWU‘M

MMWMJMnmags

Intermix-them. I I I I I I I I I l
9 Late-aardrecerdsthepetbnt'sadfifly’shadthfistm. [ l I I l I [ I l I
IoIMumdmm. I] [I II I] II

37

II I. I‘IcIesIespitdvisitstoassistphysicianinevaluafingpotient’s
attrition.

12 l. WWWMWQN.

13 n. Iantifiesdsvelopnlntandbelmioralprablsmsofclildren
“adolescents.

u n. Wammdamlwwmrda-
rdtaotiwhealthprofessiomlsatWorcomntyagercies.

IS a. Withnrittenguideiinesmaiesdscisionregardngimentarefer
Widow.

16 p. wmmmdwm individuals.
IT a. Ordersrouthebborotoryshidesosindcated.

Id r. WW.WWNMMOIWIQ
”arm.

19 s. Participateswithphysidonincontimousevaluationofthe
nralityarllefiecthemssoflealthcare.

20 t. ProndescoweelingreprdngtheIeaIIh-iilmss problemsof
Meridian-lea.

I u. OveralwadoEIseiabwttheFanilyNursePracfit'om
weeptottlistim?

II. WafthsbloningoreasdowaednuybeaproblemintleunlizationofaFanilyNurssPractitioterGNP)? Pleasecheck

38

Higidy

Favorable

[I
II

themflichhnustrspresernativeofmbellef.

22 a. Patients'arceptarceofFNP.

3 II. Physicians'occeptanceofFNP.

3‘ c. Otternurses'occeptanceofFNP.

25 d. Mafssrvlcerendersd.

26 e. WMW.W.U€.).

27f. mem.

28 g. WOIMNWFNFM.

29 It. WmWMbrcolobaraflon
MrWafianwithFNP.

30 i. Otterproilsnsaist).

i

v—av—Qr—r—‘r—nHr—‘a

H

HHHHHHH;

Favorable

Very be
problems

I

HHF‘HHH

I

I—‘HHO—‘HH

 

 

 

“EASE CWTINUE WITH QUESTIONS ON MIG ”GE »»»»ss»»»

Sane

problems

HHHU—‘Hflm

e—s

HHHHHHH

HHHHHHH

fi—Ot—‘HHQ—fluh—fi

h—O

h—l

lu—J

39

III. PleaseIMicateioursourceofbvwledgeorezperienceregardingNursePractinombyresponing'yes'or'm'totlu followingitems.

31 a. HavsyoursadorieardaboutNursePractitionersbeforereceiving
Ilismsstlannaire? I In.

32 b.HoveyoudscuasedwithoIIerphysicionsorhealthproiessIomlsthe

ItaoI'NurseProctitionersprovidingi'eaIthccre? [ ] Yes
33c.HaveyouobservedaNmePractitIonerlnoction? [ ]Yes
3d. HaveyautndeperienceinnorfingwithaNursePracntiom? [ ]Yes
35 e.HMiouevernIponedorareyoupresemeutilinngaNursePracnfiaer? [ ]Yes

IV. Pleasrannrsrtheblouingauestions:
36a. Matiswsnt?
I I Mr I I PM
37 b. Indutyearddyoureceivewurl'lD/DOdegree?

3chrsyoudolrtgpracticrfl'm_I-iiyin:
[ ] Solo [ ]Groupof2-4 [ ]6roupoffiveorm

39d.lsyourpracticeprinenlyt
[]OB-GYN []FaninPractice []Prdonics []|nttmll'1edcine

40 e. lampractlcrsetfltha/anz

[ ] maria

I I Mum

[ ] mnemonic

[ ] Pro-raidiieaithi’lmsvstem

I I 0th
t1e. Dowufeeltlereisaslnnogeofgenemlpracfifiomrsenicesmyourcommuruty? [ ]Yes
42f. WMIIIessrviceaofaFanilyNursePracnhonererinmetledrivnyof

Ieallhmisyourpractkeserthg? [ ] Yes
43 g. WouldyauarmmlireaFaailyMrsePractimLI-fl [ ]Yes
“It. Wouldyeuoryotrmh'rraFonilyNwsePractitiorerm-Jm? [ ]Yes
‘5 i. WarldieuarwmlireoleyNursePracfimhi-Sm? [ ] Yes
46; Domammmhmwmidn'sm? [ ] Yes

47 i. ReaselktmoddtiorelcommswunnymaboutneFaflyNursePracnw
Cusptand/ortlispartiorlarqrestiomire.

 

 

 

THANK YOU FOR COP‘IPLETIM THIS QUESTIONNAIRE.

PLEA$E CHECK THROUGH THE QUESTIONNAIRE TO BE SURE no GJESTIONS WEE I‘IISSED.

EEEEE

40

APPENDIX C

Introduction and Consent Letter

Dear Potential Participant,

I am a graduate student in the College of Nursing at Michigan State University. My
studies include the completion of my master's thesis.

I am using a questionnaire to examine the physician's perception of the Family
Nurse Practitioner (F NP) and whether there is a relationship between this
perception and the willingness to hire a FNP. This questionnaire is being sent to
primary care physicians, including obstetrics and gynecology, internal medicine,
pediatrics, and family practice, with stafi privileges at Holland Community
Hospital, Zeeland Hospital, or North Ottawa Community Hospital. The
commitment involved is one-time. The questionnaire will take approximately 10
minutes to complete. Participation in this study is voluntary; you may choose to
participate or may return the unanswered questionnaire. If you choose to
participate, no information which could identify you will be asked and all responses
will be kept confidential. If you prefer not to answer any particular question, please
feel free to leave it blank. Please do answer the questions if you can and write any
comments or concerns about any question in the margin or the space provided. You
indicate your voluntary agreement to participate by completing and returning this
questionnaire.

A postage-paid return envelope has been provided for your convenience. To
analyze the information in a timely fashion, I ask that you return the questionnaire
to me by August 1, 1997. If you have any questions or would like a copy of the
summary, you may contact me at (616) 786-4951.

Thank you very much for you cooperation and assistance in this endeavor.

Sincerely; [Cf/fl/

Suzanne Ivkovich, R.N., B.S.N.

4i

42

Appendix D

UCRIHS Approval Letter

 

GTCEU‘
RESEARCH
AND
GRADUATE
STUDIES

mnnsnsi
Fax smut-rm

 

MICHIGAN STATE

UNIVERSITY

July 9. 1991

To: George D. Allen
A230 Lite Sciences Bldg.

RR: IRBI: 97-‘07

TITLE: PHYSICIAN PERCEPTION OP THE FAMILY NURSE
PRACTITIONER ROLB AND TN! NILLINGNESS TO HIRE

REVISION REQUESTED: N/A
CATEGORY: l-C
APPROVAL DATE: 07/07/97

The university Committee on Research Involving human Sub ects'lUCRIflSI

review of this project is complete. I am pleased to adv so that the

rights and welfare of the human subjects appear to be adequately

pggtected and methods to obtain informed consent are a roprsate.
refore. the UCRIHS approved this project and any rev sions listed
ve.

llllunns UCRIHS approval is valid for one calendar year. beginning.with
the approval data shown above. Investigators planning to
continue a project be nd one year must use the green renewal
form (enclosed with t a original a roval letter or when a
project is renewed) to seek u t certification. There is a
maximum of tour such expedite renewals ssible. Investigators
wishin to continue a roject beyond the time need to submit it
again or complete rev ew.

 

RIVIBIONS: UCRIHS must review an changes in ggocedures involving human
subjects. rior to in tlatlon o: t c a. If this is done at
the time o renewal, please use the green renewal form. To
revise an approved protocol at an o her time during the yoar.
send your written request to the 188 Chair, requesting revssed
approval and reterencsng the project's IRE 0 and title. Include
in your request a description of the change and any revised
instruments. consent forms or advertisements that are applicable.

normal

cannons: Should either of the following arise during the course of the
work. investigators must nota QCRIHS promptly: l1) roblema
(unexpected side effects, comp asnts. e c IDsnvolvlng uman
subjects or (2) changes an the research envsronment or new
information indicating greater risk to the human sub acts than
existed when the protocol was previously reviewed an approved.

If wo can be of any future hel , lease do not hesitate to contact us
at (517)355-2180 or FAX (517Is 2- 171.

Sincerely.

 
 
   

I
ad 3. Wright, Ph.
133 Chair

Dlflzbod

cc fame Ivkovich

43

LIST OF REFERENCES

LIST OF REFERENCES

Arbor ASSOCiatCS’ Inc- (19%)- WW
Hospital, Petoskey, Mi.

Betancourt, J .C., Valmocina, M., & Grossman, D. (1996). Physicians' and
patients' knowledge and perceptions of the roles and functions of nurse practitioners.

W6), 13-15.

Bezjak, J. E. (1987). Physician-perceived incentives for association with nurse

Practitioners. W12 (3) “'53 72 74
Brown SA &Grimes DE (1993) W

I ‘ I I" o." I I I I I ' III" .

WWW American Nurses Association Publicati,on 1-10.

Carey, T., Weis, K., & Homer, C. (1990). Prepaid versus traditional Medicaid

plans: Effects on preventative health care. LqumaLQfLJinicaLEpidgminngA; 1213-
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Clement, D.G., Retchin, S.M., Brown, R.S., & Stegall, M.H. (1994). Access and
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George, J-B-(EdJ (1995). Wan
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Greenfield, 8., Rogers, W., Mangotich, M., Carney, M.F., & Tarlov, AR. (1995).
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I[AMA_.2_’Z§_,1436-1444.

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Practitioner WWZJZ) 125-131

Hickey,J. V. ,Ouimette, R..,M &Venegoni, S. L. (1996). Admceifizacfice
WPhilwelphia Pa.: Lippincott

Johnson, R F... & Freebom, D. K. (1986). Comparing HMO physicians' attitudes
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44

45

Kahneman. D.. Slovic, P., & Tversky, A. (Eds). (1982). Judgement Under
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Kassirer, JP. (1994). What role for nurse practitioners in primary care? New

England Journal af Medicine, 3 30(3). 204-205.

Kennedy. P. (1993). Pre a ' i r he went '-first centur . New York: Random
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King, I.M. (1981). A Theerv fer Nursing. New York, NY: John Wiley.

King. I.M. (1992). King's theory of goal attainment. Nursing Science Quarterly,
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Louis, M.,& Sabo. CE. (1994). Nurse practitioners: Need for and willingness to
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Lurie, N., Moscovice, I.S., Finch, M., Christianson, J .B., & Popkin, MK. (1992).
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Miller. R.H.. Luft,H.S., (1994). Managed care plan performance since 1980: a
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Nighswander, A. (1994). Integrated health eare delivery: A blae print fer aetien.
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Olzak M. M., &Carrico. D..,J (1995). Surveying Patient and Physician
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'V‘ 'u'd't case

   

46

Swartz. K.. & Brennan. TA. (1996). Integrated health care. capitated payment
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R

nICHIc
lllllll
3 1

N STATE UNIV. LIBRARIES

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