Evaluation of family practice nurse deployment in urban medical practice in Newfoundland

Chambers, Larry W.(Larry William) (1978) Evaluation of family practice nurse deployment in urban medical practice in Newfoundland. Doctoral (PhD) thesis, Memorial University of Newfoundland.

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Abstract

The Family Practice Nurse Education Program of Memorial University of Newfoundland was established to prepare experienced, diploma- and degree-holding nurses to assume an expanded nursing role in primary health care settings. The topic of this thesis is the evaluation of the impact of six graduates of this program on private medical practices in St, John's and Corner Brook, Newfoundland. The evaluation component of the family practice nurse project began in 1973 with the development of instruments to measure the family practice nurse’s impact on the effectiveness of patient care, patient and health professional satisfaction, quality of care, practice service output and organization, and financial aspects of the practices. -- Effectiveness of Patient Care: In order to assess the effectiveness and safety of the primary care provided by a family practice nurse, a randomized clinical trial was conducted in one of the St. John's practices between June 1975 and May 1976. Before and after the trial, standardized measurements of physical, social, and emotional function were administered by lay interviewers to 572 patients who received conventional care by the family physician and to 296 patients who received care mainly from the family practice nurse. At the start of the study, statistical analyses revealed the comparability of the two groups of patients with respect to all three health outcome measurements. At the end of the study, the health outcomes of the two groups of patients were found comparable. These results corroborate the evidence derived from other controlled trials that family practice nurses/nurse practitioners provide effective care. -- Satisfaction: Satisfaction and acceptance of family practice nurses was found high for patients, physicians and allied health professionals. -- Quality of Patient Care: Quality of patient care standards were maintained after the introduction of family practice nurses. Before and after evaluations were achieved by using the indicator condition method. Minimal explicit process criteria for the management of patients with 12 indicator conditions and the use of 14 drugs were approved by an ad hoc peer group of community physicians. These criteria were applied to the practices using a single blind design and abstracting unaltered medical records. A standardized score for each practice was used to compare management of indicator condition scores and clinical use of drug scores before and after attachment of the family practice nurses. For each of the indicator conditions and the drugs assessed similar levels of adequacy were observed between study periods. These explicit (objective) audit results agreed with the implicit (subjective) assessments of the family practice nurses by their physician colleagues. -- Practice Service Output and Organization: The addition of a family practice nurse to an urban medical practice increased service output in four out of six cases. Physician/family practice nurse teams were studied using daily logs of family practice nurse activity, physician claims to the provincial Medical Care Plan, time study sheets, and function delegation questionnaires. Practices using family practice nurses had a mean increase of 14% in the number of patient services during the first year of family practice nurse attachment; the mean increase for all physicians in the province was 9%. The number of patients in the six study practices changed only slightly while services per patient increased by 15%. Family practice nurses provided total care in 4% of office services, and participated with physicians in a further 26%. -- No consistent changes were noted in the age and sex of patients seen or in the amount of time the physician spent in the office. -- Financial Aspects: Estimated losses were experienced by four of six fee-for-service family physicians in a study of revenues generated and expenses incurred by the six family practice nurses who had held salaried positions for one year in private medical practices. Daily service diaries were used to make annual estimates of family practice nurse generated revenues. Data from these diaries were linked by computer to yearly physician service data maintained by the provincial Medical Care Plan. -- During the year of family practice nurse attachment, the six physicians experienced a mean increase in gross Medical Care Plan revenue of $11,350 with an additional extimated mean increase of $2,690 when solo family practice nurse services were included. Physicians' subjective appraisals and actual financial statements from the practices were used to estimate annual expenses related to the employment of the family practice nurses. The first procedure indicated average costs of employment were $14,700 and the other $19,770. -- The estimated physician losses in net income, though real, were not substantial given (1) this was the first year of the family practice nurse attachment, (2) the purposes of the family practice nurse attachment were exploratory to determine the family practice nurse's role in the practice and not primarily to demonstrate the profitability of employing family practice nurses, (3) the fee-for- service method of payment on the whole discourages delegation of tasks and allocation of time for teaching, factors not present with physicians on salary.

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