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DEVELOPMENT OF A SURVEY TO DETERMINE - 7
RERCERTIONS 0F PHYSICIANS 0F COLLABORATIVE -_
RRACTICE ARRANGEMENTS NITR ADVANCE PRACTICE _ 
NURSES IN PRIMARY CARE ‘ ‘ '

SchOiaréyPrOjectforthRDegTeéOTMISINI .
MICHIGAN STATE UNIVERSITY 4 , '
OIANEN. ANDERSON  

‘ 1998”" ‘

 

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6/01 cJCIRC/DateDuopGS-pJ 5

 

DEVELOPMENT OF A SURVEY TO DETERMINE PERCEPTIONS OF
PHYSICIANS OF COLLABORATIVE PRACTICE ARRANGEMENTS
WITH ADVANCE PRACTICE NURSES IN PRIMARY CARE

BY

Diane H. Anderson

A SCHOLARLY PROJECT
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
MASTER OF SCIENCE IN NURSING
College of Nursing

1998

ABSTRACT
DEVELOPMENT OF A SURVEY TO DETERMINE PERCEPTIONS OF

PHYSICIANS OF COLLABORATIVE PRACTICE ARRANGEMENTS
WITH ADVANCE PRACTICE NURSES IN PRIMARY CARE

BY

Diane H. Anderson

Advance practice nurses are crucial to providing
health care in the current primary care system. A
collaborative arrangement between advance practice nurses
(APNs) and physicians has many benefits both financially and
professionally for both disciplines, as well as clients and
families; however, APN's remain underutilized in
collaborative practice arrangements with physicians for a
host of reasons. Therefore, the purpose of this project is
to develop a survey to determine physician perceptions of
collaborative practice arrangements with advance practice
nurses in primary care. Information regarding the character
of barriers to collaborative practice as perceived by

physicians is critical to identifying strategies to overcome

those barriers.

ACKNOWLEDGMENTS

I wish to thank my project chairperson, Jacqueline
Wright, RN, MSN, as well as Brigid Warren, RN, MSN, and
Georgia Padonu, RN, DrPh, project members for their support
in the completion of my work. Your expertise and
encouragement were greatly appreciated.

A very special thank you to my son Matt. This is the
fulfillment of a goal for the both of us. And to Linda
Rollins and Char Firos, my friends for life, I could not

have completed this without your encouragement and support.

Thank you all.

iii

TABLE OF CONTENTS

INTRODUCTION . . . . .

BACKGROUND OF THE PROBLEM .

LITERATURE REVIEW . . . . . . .
Definition of Key Concepts .
Advanced Practice Nurse
Primary Care . . . . . .
Collaborative Practice .
Physician Perceptions .

Conceptual Framework . . . . .
Relevance and Relationship

Survey Development . . . .
Target Group . . . . .
Evaluation . . . . .

Implications for Advance Practice Nurses

Practice . . . . . .
Education . . . . .
Research . . . . . .

LIST OF REFERENCES . . . .

APPENDICES

Appendix A: Cover Letter
Appendix B: Survey . .

iv

0 O O O O
O O O O O
O O O O O
O O O O O
O O O O O
O O O O O
O O O O O
O

to the Project

12
15
17

18
22

25
25
28

29
29
29
30

31

35
36

LIST OF FIGURES

Page
Figure 1: Model for a Process of Nurse-Patient
Interaction I O O O O O O O O I O O O O O O O 23
Figure 2: Adaptation to King's model for the
nurse-physician interaction process in
collaborative practice . . . . . . . . . . . . 25

INTRODUCTION

BACKGROUND OF THE PROBLEM

Despite aggressive attempts to contain health care
costs since the early 1980's, advance practice nurses have
come under scrutiny in primary care. Research supports that
nurse practitioners are successfully employed in a wide
variety of health care structures--from settings supervised
by physicians, to collaborative practice with other
practitioners, to solo practice (McGarth, 1990; Mundinger,
1994). One goal of collaborative practice is to improve
health care services while defining professional standards
of practice (Sebas, 1994). Advance practice nurses
recognize the need to define the standards of practice that
might conceivably change negative attitudes and perceptions
based on a lack of direct experience or knowledge by
physicians and the public.

Research has also supported the premise that
collaborative practice between advanced practice nurses and
physicians significantly increase access to care for the
underserved populations as well as impact the increasing
cost of providing health care (Fagin, 1990). Unfortunately,
inaccurate stereotypes and beliefs of the role and scope of
practice of the advance practice nurses by physicians is one
barrier to utilization of advance practice nurses (Sebas,
1994). Increased utilization necessitates that the role and
scope of practice of the advanced practice nurse become
clarified. The identification of physician perceptions of

1

advance practice nurses is an essential first step towards
the purpose of advancement of the APN role in primary care
and collaborative practice. The purpose of this project is
to develop a survey to determine physician perceptions of
advance practice nurses in collaborative practice
arrangements in primary care.

The first physician-nurse collaborative team of Drs.
Henry K. Silver, a physician, and Loretta C. Ford, a nurse,
broke new ground in the 1970's with the inception of a
pediatric nurse practitioner certificate program that
expanded the skills of professional nursing through advance
education (McGrath, 1990). In a 1993 publication A_Ezimazy
£are_2:imez the W.K. Kellogg Foundation announced that of
2.2 million registered nurses in the United States, more
than 100,000 are considered advance practice nurses.
Advance practitioners deliver expert care, manage patients
and their families, teach, consult, research, and identify
the needs of patients within the environment in which they
practice (Madden et al., 1994). Further, APN's provide care
that emphasizes early interventions and the ongoing
management of patient health status (Schaffner et al.,
1995). Advance practice nurses are employed in specialties
such as mental health, oncology, or cardiology, as health
educators, or in primary care settings with emphasis on
common chronic conditions such as diabetes and hypertension
(Sharp, 1994). The federal government has estimated that by
the year 2000, 200,000 advance practice nurses will be
required to meet the growing health care demands that

2

includes increased client acuity and advance technology, but
fewer health care dollars (Nuccio et al., 1993). Data
supports that advance practice nurses either independently
or collaborative can provide a variety of high quality
services that impact client outcomes in a cost effective
manner (Drunk, 1992).

Advance practice nurses are underutilized in
collaborative practice arrangements with physicians.
Barriers to full utilization may be hindered by physician
beliefs, inaccurate perceptions, or lack of knowledge. The
purpose for this project is the development of a survey that
identifies physician perceptions of the advance practice
nurse and collaborative practice arrangements in an attempt
to isolate new data to support future actions and outcome
goals.

LITERATURE REVIEW

The following section will define the key concepts of:
1) advanced practice nurse; 2) primary care; 3)
collaborative practice; and 4) physician perceptions to
provide a structure upon which this scholarly project is
developed. The key variables will be defined by a focused
review of the literature in which each concept is discussed.

Definition of Key Concepts
AW

In 1992, the American Nurses Association at the

Congress of Nursing Practice approved the following

definition of advance clinical practice:

Advance practice nurses have a graduate degree in
nursing. They conduct comprehensive health
assessments, demonstrate a high level of autonomy
and possess expert skills in the diagnosis and
treatment of complex responses of individuals,
families, and communities to actual or potential
health problems. They formulate clinical

decisions to manage acute and chronic illness and

promote fellness. Nurses in advance practice

integrate education, research, management,
leadership and consultation into their clinical

role and functions in collegial relationships with

peers, physicians, professionals and others who

influence the health environment (Berger et al.,

1996, p.250).

From a historical perspective, the advanced practice
nurse (APN) movement began in the mid 1960's consequently
from the shortage of primary health care physicians. In
1965, the first short term practitioner certificate based
program commenced at the University of Colorado, in
conjunction with a nurse-physician team, Loretta C. Ford,
RN, and Dr. Henry Silver (Mundinger, 1994). Before the mid-
1970's there were more than 500 certificate programs to
educate nurses as primary care providers (Koch et al.,
1992). At present there are more than 100,000 advanced
practice nurses provide access to health care throughout the

country and the number continues to increase.

Advanced practice nurse education has shifted focus
from a diploma based model to a graduate level education in
colleges and universities. Focus is placed on nursing
theory, holistic patient management, health promotion, and
disease prevention (El-Sherif, 1995). Core curriculum for
the education of advanced practice nurse programs has
similarities throughout the country. Emphasis is placed on
pharmacology, primary care, physician assessment, nutrition,
and the taking of history. Among all the curricula there is
little variability from program to program. Rooted in
nursing theory, the APN role, which evolved from a medical
component, provides an evolved educational foundation to
fully evaluate and treat clients (Forbes et al., 1990).

Support for advance practice nurses in primary care is
reflected in literature (Brown et al., 1995; Genet et al.,
1995; Koch et al., 1992; Kerekes et al., 1996). The safety,
cost effectiveness, and high quality of care provided by
advance practice nurses in primary care is also well
documented (Ethridge, 1991; Boyle & Jennings, 1993; Shamian
et al., 1994; Shay et al., 1996). Support and visibility of
the advance practice nurse has increased and, therefore,
public awareness, but barriers continue to block full
utilization of highly educated and qualified APN primary
care providers. Reimbursement of services provided by
advance practice nurses by third party payers is one such
barrier that has come under investigation. Research and
evaluation studies over the years has provided a base for
professional practice, a data base for political arenas, and

5

health policy influence to minimize such barriers to advance
practice (Jacox, 1987).

In December, 1986, a significant research study,
(Jacox, 1987) commissioned by the United States Senate and
published by the Congressional Office of Technology
Assessment analyzed federal policy on direct and third party
payment of advance practice nurse providers. Additionally,
the quality and cost of care provided by advance practice
nurses was examined. The policy analysis members consisted
of external contractors and a twenty member advisory board
that included nurses, physicians, economists, businessmen,
consumers, and health policy analysts. The study analyzed
advance practice roles in the health care market, coverage
and direct payment practices for health care service by
third party payers, and finally potential benefits of
increased utilization. The study findings, based upon
extensive review of literature and data, supported that care
provided by advance practice nurses is cost effective and
beneficial to the public by increasing access to care and
decreasing cost of that care. The study further recommended
changes in societal and public policies to increase the
potential benefits and remove financial barriers for
advanced practice.

In the United States occupational licensure, which
includes all professional licensing, is left to individual
states. Individual certification as advanced practice
nurses by a state certificate provides a separate title, a
defined scope of practice, and self responsibility for

6

actions. In a 1980 publication Nursing: A Social Policy
Statement, the American Nurses Association supported advance
practice nursing recognition through national associations
rather than at the state level. As a result of this action
stratification of advance practice level of education is
recognized by all states at the graduate level, yet a
singular method of certification and therefore legal
practice recognition is lacking (Mezey et al., 1993).

The public may be more informed about the physician
assistant (PA), a health professional who works under direct
supervision of a physician. A large proportion of PA
programs offer baccalaureate degrees upon completion of a
course of study of less than two years. The PA, unlike the
advance practice nurse, is not an independent practitioner,
but performs technical tasks that free the physician for
more complex functions (Lombess, 1994).

Originally, APN educative programs were certification
based. Currently, most programs are offered at the graduate
level and the National Counsel of the State Boards of
Nursing recommends masters' degree preparation for advance
practice as well as a requirement to sit for national
certification exams (Wilson, 1994). Advance practice nurse
programs focus on primary care with the development of
highly developed assessment skills to fully evaluate and
treat a variety of clients (Forbes et al., 1990). The
advanced practice nurse is educated at the masters level and

certified as expert in a specialty area.

Of the 2.2 million registered nurses currently licensed
in the United States 25,000 nurse practitioners in mostly
collaborative arrangements in primary care provide cost
effective care to diverse populations (Sharp, 1994). The
evidence to support advance practice nurses in the evolving
health care market is supported by studies such as The
Office of Technology Assessment (1987) which provided
research data supportive to advance practice nursing in
public policy. Further studies are necessary that can
expand nursing opportunities in collaborative practice
arrangements in particular and to promote the validity that
advance practice nurses in the primary care market is
economically sound. The development of a survey to
determine physician perceptions of advance practice nurses
in primary care and collaborative practice arrangements
would increase the knowledge of advance practice role and
therefore increase utilization by physicians and the public.

When looking at the multiple roles within the domain of
the advanced practice nurse, there are a number with
application to this project and will be further defined.
These subroles include assessor, clinician, collaborator,
case manager, and educator.

Assessgz_391e. Webster's dictionary (1983) defines an
assessor as one who defines the worth or importance of
something (p.36). Advance practice nurses function as
primary health care providers usually within a specific
group of physicians and clients. Advance practice nurses
have advanced knowledge in assessment and diagnosis, as well

as pharmacology, health promotion, and disease prevention.
Advance practice nurses are strong client advocates, as well
as pharmacology, health promotion, and disease prevention.
Advance practice nurses are strong client advocates, as well
as accountable for high quality, cost effective care (Berger
et al., 1996). Therefore, the subrole of assessor is one
aspect that defines the role of the advance practice nurse.

Clinician_Rgle. The clinician possesses the ability to
formulate nursing diagnoses and to provide direct primary
care based on sound theory and advanced clinical judgment to
clients and their families in a variety of health care
settings to promote self care capabilities, maintain health
while preventing complications, develop coping skills, and
manage disabilities (NUR 501 syllabus).

Research demonstrates that benefits and barriers to
health care defined individually, which necessitates an
individualized assessment, interventions, goals, and
outcomes (Frenn et al., 1998). The advanced practice nurse
educated at the master's level exercises clinical judgment
with the focus of practice on patient-client-family in a
clinical setting. Advance practice nurses possess the
knowledge, skills, and abilities to provide health care in
the current primary care setting.

£911aboratgr_3gle. Fagin (1992) defined collaboration
as a relationship of interdependence that requires the
recognition of complimentary roles. Recently cost
constraints, provider competition, managed care, early
hospital discharges and privatization of care has provided a

9

renewed interest in nurse-physician collaborative practice
(Arslanian-Engoren, 1995).

Historically, the utilization of advance practice
nurses has met with strong resistance from the American
Medical Association. Recent changes in health care reform
has increased recognition of advance practice nurses as
collaborators by hospital administrators, insurance
companies, and the public (Sharp, 1994). Increased
recognition has promoted advanced practice nurses in the
interdependent role within the medical community.

Case_nanagement_3gle. The case management role is a
patient care delivery that focuses on the achievement of
specific outcomes within designated time frames and
appropriate use of resources. The case manager must have
excellent communication skills. Communication, negotiation,
and collaboration are beneficial characteristics of the
advance practice nurse to coordinate multidisciplinary
collaboration within a specific time frame (Lynn-McHale et
al., 1993).

The case management role of the advance practice nurse
suggests case coordination across community and hospital
settings to collaborate with other health care
professionals. Literature strongly links advance practice
and case management to cost savings, as promoting
collaborative health care, and beneficial for clients, their
families, physicians, and institutions (Lynn-Mcflale et al.,
1993; Walton et al., 1993). Case management models describe
methods for advance practice nurses to provide quality, cost

10

effective health care to specific populations within a
particular institution. Advance practice nurses, role
models with initiative, management, organizational and
communication skills are supported with data as improving
client care, enhancing quality of life for clients and
families, while containing health care costs (Rheaume et
al., 1994).

Educator_Role. The advance practice nurse is in a
unique role to provide education through interaction.
Collaboration with physicians, with clients, families, and
with other professionals increases empowerment of the
advance practice nurse in the health care system. Graduate
level education provides core competencies for the
responsibility of the advance practice role of educator.
Advance practice nurses are proactive in the education of
clients and families in the management of their own health.
Further, when clients are knowledgeable regarding goals and
outcomes of interactions they become active participants in
the health care system.

Advance practice nurses assume a leadership role in
promoting and providing education within a specific area of
practice and to a particular population. Advance practice
nurses demonstrate expertise in developing and implementing
teaching to diverse clients as well as integrate research
into guidelines for care, policies, and procedures (Berger
et al., 1996).

The role characteristics of assessor, clinician,
collaborator, educator, and case manager describes the

11

inter-related roles of the advance practice nurse. Graduate
level education is essential to the implementation of each
of these roles. The development of a survey to determine
physician perceptions of advance practice nurses would
measure the significance of these roles and to potentially
increase utilization by physicians.

W

In 1994 primary care was defined by the Institute of
Medicine as *the provision of integrated, accessible health
care services by clinicians who are accountable for
addressing a large majority of personal health services by
clinicians who are accountable for addressing a large
majority of personal health services, developing a sustained
partnership with patients, an practicing in the context of
family and community” (Schouttz et al., 1997). In addition,
primary care embodies the principles of equitable
distribution, appropriate technology, a focus on health
promotion, and disease prevention, community participation,
and a multisectorial approach to improve health for the
population.

With the enrollment of 130 million beneficiaries,
managed care is the predominant mode of health care for
privately insured consumers in the United States. Data
confirms the aging of the population at a rapid rate and
that less than 1% of clients accounts for 30% of health care
costs (Malloy, 1997). As the population rapidly ages in the
decades ahead, there will be a disparity of both monies and
services towards the elderly generation. Primary care is

12

the delivery of personal health care in the community
setting across all age spans and populations.

There is, in addition, a paradigm shift to disease
management which attempts to control the costs of chronic
diseases such as asthma, congestive heart failure, and
diabetes through education, home care support, and a
collaborative or consultant role with a nurse. Health
promotion and consumer education allows clients to become
partners in cost containment. The consumer is not passive,
but rather a partner in health promotion (Fagin, 1992).

Advance practice nurses are taking positions to become
proactive in the primary care market. Opportunities exist
to increase visibility by becoming active in workshops,
committees, and publishing. Advance practice nurses have
been identified as health care providers who can improve
client and family outcomes in a fiscally responsible way
(Kane et al., 1991; Ethridge, 1991).

It is the data that supports outcomes that forms the
foundation for legitimizing advance practice nurses while
defining and affirming capabilities within the primary care
health system. In a meta-analysis of advance practice
nurses and the impact on both primary care roles and
outcomes Brown et al. (1995), in a one year period collected
published and unpublished data relating to advance practice
nurses. Inclusion criteria included an intervention, then
data derived from care provided in the geographic areas of
United States and Canada with a control group within a
managed care system, a measure of the impact of the

13

intervention, a specific experimental, quasi-experimental,
or ex post facto design, and finally data that allowed
calculations and direction of effect size. Ultimately, the
study supported that advance practice nurses have greater
client compliance with treatment recommendations, a higher
degree of client satisfaction, and resolution of
pathological conditions (Brown, 1995).

Kerekes (1996) provides data that supports the use of
nurse managed primary care centers for community based,
accessible care focused on those particular needs of the
elderly and poor. A grant application was written to the
Disadvantaged Minority Health and Improvement Act of 1990
requesting funds for the provision of first contact,
comprehensive, longitudinal, and coordinated primary care to
a disadvantaged population. Demographics of the population
for the funding were; nearly one half of a population of
1,612 residents were younger than age 17, had female head of
households, racially mostly black, with an average weekly
income of less than one hundred dollars. The health care
delivery model consisted of comprehensive, continuous, cost
effective health care that was promoted by the residents
themselves. Results concurred that primary care provided by
advance practice nurses was more cost effective, accessible,
with fewer hospital admissions, and with shorter lengths of
stay when hospitalized and ultimately an improved health
status.

For the purpose of this project primary care will be
defined as comprehensive, longitudinal, accessible health

14

care to a diverse population who are largely underserved by

the current health care system.
Wm

Collaboration and interdisciplinary teamwork are roles
that the advance practice nurse routinely use in primary
care. Traditionally the relationship between nurses and
physicians have been hierarchical, but currently it is
evolving into one where each interacts as an equal.
Collaboration enhances the roles of who and what advance
practice nurses are, as well as enhance the credibility of
the role.

The literature supports collaborative practice. In one
phenomenological research study (Arslanian-Engoren, 1995),
the data clearly reflected that advance practice nurses who
are employed in a collaborative practice have increased
satisfaction. They also express a collegial view of
themselves as equal partners and capable of achieving
autonomy in their area of expertise in health care. The
purpose of the study was to examine the relationship between
advance practice nurses and physician in a collaborative
arrangement. Advance practice nurses were asked to verbally
describe the meaning of collaboration, based on experiences
with physicians. Analysis of the data concluded that mutual
respect and trust was evident, that the role of advance
practice is an evolutionary process, and with time collegial
relationships are established and viewed as positive.

The role of nurse practitioner was first developed in
the 1960's to provide cost effective primary care to

15

essentially vulnerable populations (Hester et al., 1996).
Nursing literature has indicated that advance practice
nurses in a collaborative practice are cost effective in the
primary care setting (Sebas, 1994). The discipline of
nursing has along tradition of working with and observing
individuals and families in the context of where they live.
Additionally to the treatment of injuries, it is the health
promotion and education components that allow collaborative
practices to be cost effective.

Documentation of collaborative practice outcomes are
defined by quality of care, quantity of interventions, and
cost or financial savings. During the 19705 and 19805 there
was limited literature on outcomes and collaborative
practice. Research in the 19908 impact studies supports
that advance practice nurse interventions prevents
rehospitalization of the chronically ill, that patients and
their families received knowledge and followed treatment
plans, and that effective management of patient care by
multidisciplinary cooperation and communication were just a
few benefits (McCaffrey-Boyle, 1995).

Collaboration occurs between health professionals with
similar interests and personal and professional maturity
levels. When these occur, five interactive processes are
possible. These themes can be described as mutual respect
and trust, which is a complex process, a collegial
relationship that respects the nursing prospective, and a
positive experience (Arslanian-Engoren, 1995). In a
collaborative arrangement, a written agreement defines

16

practice guidelines and standards of care. Between
physician and advance practice nurse a collaborative
practice agreement establishes a level of care which the
advance practice nurse agrees to, a mechanism for assessment
of that care is established, and the manner in which
conflicts are to be resolved (Sebas, 1994). Such an
agreement supports joint decision making, definition of
roles, and conflict resolution method in written form.

Fagin (1992) in her view of the relationship between nurses
as physicians has stated “collaboration is the preferable
relationship and will be even more essential for good health
care in the future (which is upon us).”

For the purpose of this project, collaborative practice
will be described as an interdependent relationship between
advance practice nurses and physicians. Barriers to
collaborative practice are inaccurate perceptions and lack
of direct experience with advance practice nurses by
physicians and the public. Changing a negative attitude
requires education and visibility (Sebas, 1994).

El . . E l'

A review of literature reveals that the study of
physicians perceptions relating to advance practice nurses
is limited. Much, however, has been published of physician
opinions of advance practice nurse relating to the medical
community and to the health care reform movement (Friedman,
1990).

Webster's dictionary defines perception as the mental
grasp of objects, through the senses, insight or intuition,

17

or the knowledge received by perceiving (p.444). Bunting
(1988) contributes the link of perception between person and
nurse, person and environment, and person and health.
Therefore, the concept of perceptions is a process of the
mind that interprets subjective input. It is imprecise,
usually based on past experience, and holds great interest
to nursing research as a concept of importance (Bunting,
1988). .

For the purpose of this project physician perceptions
will be conceptually defined as a measure of knowledge,
insight or intuition of physicians of advance practice
nurses in collaborative practice arrangements in primary
care. '

Unfamiliarity is an obstacle that advance practice
nurses themselves can rectify. Nursing literature supports
that advance practice nurses provide the care that society
needs and to be the leaders and innovators in the shaping of
the market forces that are currently shaping health care.
The development of a survey to determine physician
perceptions of collaboration with advance practice nurses
may pave the way towards meaningful co-existence and greater
professional autonomy.

Conceptual Framework

Imogene King has defined nursing as “perceiving,
thinking, relating, judging, and acting the behaviors of
individuals who come to a nursing situation to form a
relationship". Nursing is “a process of action, reaction,
and interaction where information is shared about

18

perceptions....” (King, p.2) and that nursing and
individuals interact in a social system for the purpose of
setting goals. Thus, nursing might be described as an
evolving relationship with a basis in non observational
behaviors.

The conceptual framework for this project is based on
the work of Dr. Imogene King who originally developed her
conceptual framework while working towards a master's degree
in nursing at Loyola University in 1961. In an attempt to
develop a definitive supportive structure for nursing as a
discipline and a profession, Dr. King reviewed literature
from psychology, sociology, and nursing (Evans, 1991, p.4).
Dr. King believed that nursing is an applied science and
that;“nurses are expected to integrate knowledge from
natural and behavioral science and the humanities and to
apply knowledge to concrete situations’ CHanacharurnkul,
1989).

Dr. King's conceptual framework is based on a general
systems theory which looks upon the whole rather than the
individual parts in examining relationships. Further, the
framework postulates that the structure of the system is
determined in an indirect method by the interactions of the
individuals. Interaction provides the means to communicate
and exchange information in a meaningful way.

Imogene King within the systems framework
conceptualized that there were three interacting systems
that determined how nurses organize knowledge, skills, and
values that legitimize the function and value of nursing.

19

Personal systems are individuals as a total system, which
forms groups called interpersonal systems. Some groups with
common interests create social systems (King, p.10). The
concepts that Dr. King developed within each of the three
systems were arbitrarily placed, still the overall purpose
of the framework was to facilitate interactions between
individuals, groups, and society within a total environment
(King, 1991).

Dr. King describes that it is the complexities of human
behavior that prompted the conceptual framework. King
further determined that nursing process involves functions
of observing, measuring, synthesizing, interpreting, and
analyzing, not as each individual actions, but
simultaneously. The three systems and concepts provide a
framework that is significant to nursing and to nursing
practice (McQuiston & Webb, 1995, p.45). Dr. King's
conceptual framework is a systematic approach for
identifying independent nursing functions as well as
collaborative activities with professionals.

Dr. King conceptualized a personal system as focused on
individual human beings with relevance to concepts such as
body image, perceptions, space, self, and time. By better
understanding the individual, information on groups and
communities might be applicable (McQuiston & Webb, 1995,
p.46).

It is the interpersonal system that considers human
interactions in terms of behaviors among individuals. King
conceptualizes the process of human interaction with

20

communication, perceptions, transactions, stress, and role
as constructs of human acts (King, 1981, p.102).

Social systems are defined as.5an organized boundary
system of social roles, behaviors, and practices developed
to maintain values”. Individuals share common goals and
interests and the system exists for recognition of concerns
of both individuals and subgroups. Concepts postulated by
Dr. King within this system are authority, decision making,
organization, power, and status (Evans, 1991, p.70).

King's theory postulates that nursing has always been
about individuals and groups in a social system. Further,
nursing interaction is a form of human interaction among
individuals who come together to achieve goals
(Hanucharurnkul, 1989). Communication involves the
perception of both the sender and receiver, and according to
King's conceptual framework, brings about an environment
conducive to an exchange of information (McQuinston & Webb,
1995, p.51).

The concept of perception was significant within King's
original framework. A concept is a mental image of
something that is characteristic or generalizable. The
concept of perception, based on prior experiences, self
awareness, and personal history influences the process of
interaction. Dr. King states that behavior flows from one's
perceptions and perceptions influence behavior, that sensory
experiences provide data that transforms memory and

represents each individual's reality (Bunting, 1988).

21

Each individual communicates based on perceptions. Dr.
King's conceptual framework demonstrates that interactions,
characterized by verbal or nonverbal communication is an
exchange of information. Further, elements in communication
are a process within the interaction process for a purpose
(King, 1991). Figure 1 is a schematic visualization of

Imogene King's conceptual framework that describes her

ideas.
Wm

The concepts developed in this project will be
discussed within the conceptual framework of Imogene King.
The perception of advanced nurses and the conceptual
definitions of those role characteristics of advance
practice nurses are sustained within King's framework.
Specifically, it is the perceptions of physicians relating
to advance practice nurses that is under scrutiny. Dr. King
conceptualizes perceptions within the personal system, which
is relevant in the understanding of human beings as persons.
Perception is a central theme in King's conceptual framework
and to nursing practice and, ultimately to this project.
Communication, based on perceptions, is an elemental
connection between advance practice nurses and physicians
for the development of interactional exchange that generates
a transaction or awareness.

Perceptions, according to King are an accumulation of
knowledge over time from formal and informal sources.
Perceptions are influenced by previous knowledge of the
roles of the advance practice nurse, conceptually defined in

22

7 Feedback
Perception

Judgment

v

Nurse Action

Reaction —> Interaction —> Transaction

Action
Patient 4

Judgment

A

Perception

 

 

Feedback

Fignze_1. Model for a Process of Nurse-Patient Interaction.
(King, I. (1981). A theory of nursing: Systems, concepts,

process, p.61)

this project as educator, collaborator, case manager,
assessor, and clinician. Roles are social forces, according
to King, that influence function and provide knowledge
within social systems such as the health care system (King,
1998, p.12). The perceptual knowledge of those roles by

physicians provides both information and interaction, which

23

King conceptualizes is elemental for the understanding of
the nature of groups.

King's conceptual framework supports that professional
nurses are uniquely qualified at understanding interacting
systems, and relationships of individuals and groups in any
environment (King, 1991). Therefore, an interaction between
advance practice nurse and physician to ascertain
perceptions specific to professional nursing roles relating
to primary care and collaborative practice would provide
significant information towards addressing future actions
and outcomes.

Interactions, according to King, are characterized by
values and perceptions and involves a collaborative effort
between individuals. Effective communication is a process
where information is given from one person to another. It
is a method of documenting in a systematic way the responses
and behavioral changes in individuals (King, 1991, p.75).
Figure 2 depicts an adaptation model of King's framework for
this specific scholarly project.

Imogene King's conceptual framework supports the
relevance of the project which is to obtain information from
physicians relating to perceptions of advance practice
nurses based on conceptually defined roles of nursing
practice. The conceptual framework provides the framework
for interactions which are influenced by perceptions, roles,
beliefs, and past experiences. The framework will provide a

conceptual direction in the development of the survey.

24

APN ——-> Perception

Knowledge of role of APN
Assessor
Clinician
Collaborator
Case Manager
Educator

Interaction

I

Collaborative
Practice

 

Physician ——> Perception

ve
Knowledge of role of APN C0113}, orati
Practice
Assessor
. . . Arrangements
Clmncxan

Collaborator
Case Manager
Educator

£1gnre_z. Imogene M. King. Adaptation fo King's model for
the nurse-physician interaction process in collaborative

practice.
Survey Development
The survey development will originate from concepts
from the adaptation of Imogene King's framework and relevant
findings from the review of the literature. The literature

and framework suggests the potential categories for the

25

survey. They are the following: 1) physician perceptions or
beliefs relating to APNs; 2) physicians' knowledge of the
roles of the APN and beliefs about the benefits of those
roles in the delivery of primary care; 3) physicians' past
interactions and experiences while working with APNs; 4)
physicians' beliefs and knowledge regarding collaborative
practice in primary care.

The survey designed for this project attempts to assess
and evaluate physician knowledge of the specific roles of
assessor, clinician, collaborator, case manager, and
educator which encompass the survey categories. Each
subrole has been conceptually defined as a variable from the
literature review. Additionally, each subrole is
incorporated within a category relating to physician
perceptions, beliefs, and experiences with APNs in
collaborative practice and the primary care system.

Self report is an appropriate method of gathering
information relating to perceptions and attitudes. The
strength of self report is the ability to communicate
directly on subjects, such as thoughts and beliefs, that
might be difficult to approach by any other method. Through
direct communication with a particular target group,
feelings, values, opinions, as well as retrospective and
future behaviors can be measured with an instrument.

The survey incorporates a four point Likert scale to
rank the magnitude of response in an increasing manner.
Rationale for the use of the Likert scale is the ease of
expressing an opinion on a declarative statement. The

26

response range of the scale is from 1=strongly disagree to
4= strongly agree. The response under investigation relate
to pertinent questions regarding the roles of advance
practice as well as the King's conceptual framework.

The survey questions reflect the roles of assessor,
clinician, collaborator, case manager, and educator of the
advance practice nurse as defined by the review of
literature. Imogene King's conceptual framework provides
the methodology of the interactive process involved in
obtaining perceptual knowledge and defines categories within
the survey of physicians' perceptions, beliefs, and
knowledge. Questions one and five of the survey reflects
the assessor role which correlates to the category of
physicians' knowledge of the APN roles. Questions three,
ten, and fourteen reflects the clinical role and the
category of physicians' beliefs and knowledge regarding
collaborative practice in primary care. Questions four,
six, and nine the collaborator role which reflects
perceptions about APNs. Questions seven and twelve the case
management role, and two and thirteen the educator role
which reflects physicians' beliefs of the usefulness of APNs
in primary care. King's conceptual framework provides the
process of communication for obtaining information.
Communication is an interactive function towards the goal of
mutual exchange. Survey questions eight, eleven, and
fifteen describes the interpersonal relationship between

APNs, clients, and collaborative practice arrangements

27

within King's conceptual framework and questions physicians'
past interactions with APNs.

The survey has not been tested for validity and
reliability. The purpose of a pilot study would be to test
the feasibility of the project and to obtain information
suggesting improvements. A pilot study will be accomplished
by the mailing of ten surveys to randomly selected APNs and
physicians in collaborative practice in Muskegon.
Information gathered from this initial study would guide
revisions and refinements necessary prior to the actual
implementation of the survey. Demographics relating to each
physician such as age and length of time of practice will be
included in the study.

TBIQBI_GIQDR

The target group.are all primary care physicians in the
Muskegon area. The anticipated sample size will not be
large, therefore every physician listed in the Muskegon
Medical Society as either primary care or family practice
will receive a survey. To maintain confidentiality, results
of the survey will be reported in aggregate form. Every
survey will have a cover letter explaining the nature of the

study and a request for return within thirty days and

enclosure of a return envelope.
Exaluatien

The returned surveys will be collected from the
physician subjects by mail within a thirty day period.

The Likert scale scores the strength of response to the
survey questions. Evaluation of the data involves scoring

28

data into categories to determine strength of response to
each question. Each survey questions attempts to measure
beliefs, perceptions, and knowledge of physicians towards
APNs, collaborative practice, and primary care.
Implications for Advanced Practice Nurses

Practice

The development of this survey attempts to determine
physician awareness of advance practice nurses, their
specific roles, and collaborative practice. The roles of
assessor, clinician, collaborator, case manager, and
educator are the attributes to measure physicians'
perceptions of advance practice nurses with this survey.
The survey would identify those physicians with positive
responses. These physicians might be approached for

assistance in further education of advanced practice nurses

to their peers.
Education

Based on the results of the survey, physician
perceptions and knowledge of the roles of the advance
practice nurse and in collaborative practice arrangements
would be identified by analysis of the survey responses.
The survey may also identify myths and barriers to APN
utilization.

Increasing physician awareness of the roles of advance
practice nurses and in collaborative practice arrangements
begins with communication. Strategies for increasing
communication can be developed when barriers and myths are
understood. This might be accomplished by arranging

29

collaborative meeting between APNs and physicians such as
joint continuing education forums.
Research

The survey will generate both new knowledge and new
research questions. Research on the nature of the advance
practice nurse with physicians in both collaborative
arrangements and in the primary care system continues. This
survey attempts to assess physicians' perceptions of advance
practice nurses based on past experiences, beliefs, and
perceptions. The survey measures the strength of responses
of categories and roles as perceived by physicians.
Potential future research for increasing knowledge, clearing
myths, and the collaborative arrangement between APN and
physician may be explored.

In summary, perceptions and knowledge are integral to
the collaborative practice arrangements between physicians
and advance practice nurses. This scholarly project is the
development of a survey that attempts to identify what
perceptions and knowledge are in place and what is not.

With this data, future plans for education, communication,
and information exchange will increase advance practice

nurse utilization by physicians in collaborative practice

arrangements.

30

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34

APPENDIX A

Cover Letter

Dear Dr.

I have developed a survey to better understand
physician perceptions regarding advance practice nurses in
primary care and collaborative practice arrangements as a
scholarly project for the completion of my advance practice
degree. Would you please assist me my reading and
completing a survey?

Your name was randomly selected from a list of your
peers. The survey is anonymous. It is hoped that you will
freely give your honest opinion, but you may leave some
questions blank. Please answer all the questions that you
can.

A postage paid return envelope has been provided for
your convenience. The survey should take no more than 15
minutes. To analyze the data, please return the survey

within 30 days.

Thank you very much for your cooperation and assistance

in this study.

35

APPENDIX B

Survey

The following statements attempts to better understand
physician perception of advance practice nurses and
collaborative practice arrangements. Please circle the
number corresponding to the degree of importance you

associate to your response.

 

Strongly' Disagree Strongly
Disagree A ree

 

 

l.APNs have sound assessment
skills as a primary care 1 2
provider

 

2.APNs are knowledgeable in the
proactive management of clients 1 2
and family health

 

3.The APN as a clinician with
knowledge of nursing theory and
clinical judgment benefits 1 2
collaborative practice with
physicians

 

 

4.APNs in collaborative
arrangements with physicians 1 2 3 4
share complementary roles

 

5.APNs knowledge of health
promotion and disease

prevention is cost effective in 1 2 3 4
collaborative practice

 

6.Primary care changes, cost

constraints, and managed care
are reasons for collaborative 1 2 3 4
practice with APNs

 

 

 

7.APNs in collaborative

practice achieve effective
outcomes within a cost 1 2 3 4
effective timeframe

 

8.The APNs in collaborative
practice arrangements

effectively communicate with 1 2 3 4
physicians as equals

 

9.The universal recognition of
APNs in primary care has

promoted acceptance in the l 2 3 4
medical community

 

 

 

 

 

36

 

 

Strongly
Disagree

 

10.The APN role emphasizes a
holistic approach to clients
and enhances collaborative
‘practice

Disagree Agree

Strongly
A res

 

ll.APNs and physicians in
collaborative arrangements can
be equals in the practice

 

12.Costs of health care are
reduced by the conciliative
role of APNs in collaborative
practice

 

'13.APNs demonstrate expertise
in the education of diverse
populations in primary care

 

 

14.APNs promote self care and
health maintenance of clients
which complements collaborative
practice

 

 

15.An essential factor in a
collaborative practice is the
interaction capabilities of the
e al artners

 

 

 

 

 

Questions or Comments:

Thank you.

37

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1293 02331 8383