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Letter to the Editor

  • As the general public slowly recognizes the nurse practitioner as a primary care provider, society has a right to question whether or not the profession is in keeping with their own unique code of ethics.

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Advanced Nursing Practice In The 21st Century: Do We Want To Be Right or Do We Want To Win?

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Ruth M. Harris, Ph.D, RN, C-ANP


Because cost containment is a priority in our rapidly changing American health care system, the prestigious Pew Health Professions Commission (1995) has predicted a greater role for nurse practitioners (NPs) in the delivery of primary care. Factors favoring a broadened scope of NP responsibility for primary care include: (a) the pressing need to contain the nation's ever-escalating health care costs, (b) the present window of opportunity for advanced nursing practice, and (c) the need to use fewer resources more effectively. Because ours is a market-driven health care system with a growing surplus of physicians, NPs increasingly find themselves in direct competition with physcians for the same primary care jobs. Hence, market-driven (rather than identical) pricing of services is necessary if NPs are to compete successfully with medically trained providers of primary care.

The brain has two functions: One is to be right and the other is to survive and sometimes we give up the latter. (Old Chinese proverb)

Citation: Harris, R., (June 10, 1998). "Advanced Nursing Practice In The 21st Century: Do We Want To Be Right or Do We Want To Win?" Online Journal of Issues in Nursing. Vol. 3, No. 1, Manuscript 2. Available:

The Pressing Need to Contain Costs

In the last decade, our country's health care costs have grown faster than any other aspect of the economy (DeLeon, Frank, & Wedding, 1995). Health care expenditures currently exceed 14% of the Gross Domestic Product (GDP). The comparable percentage only 3 decades ago was less than 6% of the GDP. DeLeon et al. (p. 493) concluded:

If the current system continues unchanged, health care will consume over 16% of the GDP by the year 2000 and between 27% and 43% of the GDP by the year 2030. Simply stated, the U. S. economy cannot afford continued prolonged expenditures at this rate; thus, effective cost-containment strategies clearly have become of primary and dominant importance. [italics added]

There is consensus that the trillion dollar American health care system is undergoing fundamental change. The Health Professions Commission of the Pew Charitable Trusts (1995) issued an 83-page report on what impact this change is likely to have on the nation's 10 million health care workers. Most relevant to nursing is the Commission's expectation that as many as half of the nation's hospitals will close, resulting in a surplus of 200,000 to 300,000 nurses. The Commission also predicted a surplus of 100,000 to 150,000 physicians, as the demand for specialty care shrinks.

Among the recommendations for nursing, the Commission urged the "expansion of the number of masters level nurse practitioner training programs by increasing the level of federal support for students" (p. vi).

Most relevant to nursing is the Commission's expectation that as many as half of the nation's hospitals will close, resulting in a surplus of 200,000 to 300,000 nurses.

At the same time, the Commission advised a 10-20% reduction in the size and number of basic nursing programs, this reduction is to be accomplished by "closings in associate and diploma degree programs" (p. vi).

Despite the projected loss of nursing positions due to the coming loss of hospital beds, the Pew Health Professions Commission (1995) expects that nursing will make "important primary care settings as nurse practitioners and nurse-midwives are permitted wider ranges of practice" (p. 48). But will such nursing gains be thwarted if the surplus physician-specialists (estimated at 100,000 to 150,000) retrain in sizable numbers for primary care? That is, there is the distinct possibility that nurse practitioners (NPs) and physicians trained or retrained for primary care will be in direct competition for the same positions.

There is growing dissatisfaction that our trillion dollar expenditure for health care "is not producing the level of return that we expect" (Pew Health Professions Commission, 1995, p. 7). In other words, patients, politicians, and the general public want more bandage for the buck. In the past two decades, other social services and industries have been forced to retrench, in terms of such practices as downsizing and stagnant wages. The Commission concluded that, in similar fashion, the health care sector now faces the necessity "of doing more work, of higher quality, less expensively, and more appropriately " (p. 7).

The Transformation of Health Care as a Window of Opportunity for Advanced Nursing Practice

Evidence-Based Decision Making as a Window of Opportunity for Advanced Nursing Practice

The Pew Health Professions Commission (1995) decried the fact that our current health care system is largely "governed and managed by opinion" (p. 8) ; the Commission recommended that the system be changed so decisions are based largely on evidence. Evidence-based practice "is sweeping medicine in the United States, Canada and Britain, widely hailed as the crucial, long-sought link between research and practice" (Zuger, 1997, p. sc1). This approach may merely seem like good common sense, until one realizes that much of health care is art rather than science (Hilts, 1997). Many health care experts estimate that half of all surgical operations and other medical procedures "remain without strict scientific evidence of their efficacy and safety" (Hilts, 1997, p. wk5). Of great importance to nursing, widespread reliance on evidence-based strategies would appear to make possible an enlargement of the NPs' ranges of practice.

The research shows that many physcians usually rely on a combination of habit and casual intuition, rather than basing their decisions on firm evidence that a given treatment is the best possible approach for their patients. On the other hand, NPs or doctors who practice evidence-based nursing or medicine search the existing computer databases or the health care literature for the best treatment. Evidence-based strategy capitalizes on the fact that the results of about 1,000,000 prospective, randomized controlled trials have been reported in the last 30 years (Zuger, 1997). Moreover, there now exist additional huge outcomes databases which contain analyses of results from medical histories of thousands of patients taking myriad tests and treatments.

Sackett, a physician, is a founder of the evidence-based movement. He concluded that existing databases can answer almost 80% of medical (and presumably nursing) queries, in an average of 30 seconds per question. Thus, a NP with a computer and modem can find relevant data within minutes (Zuger). Of course, evidence-based practice of nursing or medicine may not be everyone's cup of tea. But for those who view health care largely as an art, Sackett countered with the remark that "art kills"(in Zuger, p. sc7, 1997). The Pew Health Professions Commission (1995, p. 8) concluded:

As paradoxical as it may seem, it is rational discourse and evidence-based deliberation that have the potential to help form a more humane system and to lead to the more efficient use of resources that mitigate against crass schemes of health care rationing.

Comparing Care Provided NPs and MDs

In a review appearing in The New England Journal of Medicine, Mundinger (1994, p. 211) concluded :

When measures of diagnostic certainty, management competence, or comprehensiveness, quality, and cost are used, virtually every study indicates that the primary care provided by nurse practitioners is equivalent or superior to that provided by physicians.

Even research conducted by MDs or other non-nurses yield data showing NPs (as compared to MDs) to be the better practitioner (Buppert, 1995). Buppert also stressed the necessity of providing hard data on how NPs can provide comparable or superior services less expensively than MDs do. Such facts and figures appear to be the best answer to the ubiquitous query of lawmakers, insurers, and hospital administrators: Why should anyone prefer an NP over an MD?

Marla Salmon, former director of the Division of Nursing for the U.S. Department of Health and Human Services, stated that NPs "can do about 60 to 80 percent of what a primary care physician does"and at a much lower cost (Anthony, 1994, p. 27). Other experts estimate an even higher percentage. For example, Sinclair (1997, p. 219) concluded that "it has been documented that NPs can effectively provide 80-90% of the primary care services now provided by physicians," at a lower cost and with comparable or superior outcomes.

Importance of Image in Advancing the Role of NPs

The Columbia Journalism Review recognizes that nursing is the largest professional group in our health care system, that nurses actually deliver the most health care, and therefore nurses "may know best how and where the system does and doesn't work" (p. 14, Hoyt, 1991). Nevertheless, when the organization "Nurses of America" content analyzed health care articles in the three major American newspapers (The New York Times, The Washington Post, and the Los Angeles Times), they found nurses were quoted least frequently (1.1%) among the 12 groups used in the analysis; this rate was lower than that for nonprofessional health care workers (1.5%). The physicians' rate was 32.4% (Hoyt, 1991). Obviously nurses need to work harder to get better recognition in the press.

Turf Wars. The reader gets a sense of deja vu when comparing New York Times headlines in 1993 and 1997. On November 22, 1993, the headline read: "Advanced Nursing Practices Are Invading Doctors' Turfs." Four years later (November 2, 1997), the headline was: "Nurses Treading on Doctors' Turf." Thus, the evolution of nursing to meet 21st century health care needs is regarded by some as akin to an alien invasion.

Even as we approach the end of the century, many nurses continue to be marginalized and psychologically discounted by their medical colleagues (Martin & Hutchinson, 1997). The growing surplus of physicians guarantees that organized medicine will become an even more formidable opponent of nursing's efforts to expand its role. The American Medical Association (AMA) is a highly experienced, knowledgeable, powerful, and respected organization with millions of dollars to spend on lobbying and public relations.

Organizations like the AMA "are furiously attacking" what they consider to be nursing's encroachment into areas beyond its level of expertise (Freudenheim, 1997, p. D4). Thus, nursing must continue to be an effective promoter and defender of the profession's right to expand its practice, knowing that organized medicine is determined to thwart this competition.

Organizations like the AMA "are furiously attacking" what they consider to be nursing's encroachment into areas beyond its level of expertise. Thus, nursing must continue to be an effective promoter and defender of the profession's right to expand its practice, knowing that organized medicine is determined to thwart this competition.

Despite nursing's track record as "the primary providers of health care" (Buppert, 1995, p. 48), NPs are still in the position of having to justify their existence. As Buppert pointed out, physicians continue to take the major share of the credit for health care; they also remain the holders of the health care purse strings. NPs lack the AMA's millions for lobbying and public relations; public relations for NPs are mostly one-on-one (i.e., the satisfied client). Nevertheless, we nurses have several important things on our side: the power of numbers (2.4 million), research data that document our cause, and the nation's growing determination to cut costs in the face of the fiscal crisis in health care. These are factors to impress politicians, patients, and the general public.

Facilitating media access to nursing's expertise

How can the profession gain greater media recognition of nurses' unique qualifications as specialists in health care research and practice? Other professional organizations are perhaps more active in promoting their members as specialists who are to be recognized and quoted by the media. For example, the American Psychological Association (APA) has a media office that links any journalist doing, say, an article or TV program on a given topic, with a psychologist whose research or practice makes him or her a specialist in that topic.

The APA compiled this roster of specialists by recruiting volunteers among its membership; the list is updated each year. Thus, when Newsweek (3.2 million in circulation) was doing a cover story on rape, the journalist called the APA media office, which furnished the name/telephone number of a psychologist with relevant expertise. The journalist telephoned to interview the psychologist, who thus served as a source of information and direct quotations appearing in the article. Newsweek identified the source by name, profession, title, and institutional affiliation. Every nursing organization with members in advanced nursing practice might consider creating such a media support, if one is not already in existence.

Caveat. The author's recent experience with the media (namely, the CNN national TV news network) demonstrated how hard it may be to get recognition for nursing. I emphasized to the journalists who interviewed me the importance of mentioning both my profession and nursing school affiliation. Despite my efforts, the TV program merely identified me as "Dr. Harris," so nursing failed to get due credit. See Gallagher (1996) for a list of other ways to promote advanced nursing practice (e.g., getting free publicity by means of press releases or by creating/joining a community speakers' bureau).

Thank God for Nurse Hathaway. "E.R." is currently the nation's most popular TV program, with a viewership numbering in the double-digit millions. One of the major characters in this one-hour dramatic show is Nurse Hathaway, who serves as a most exemplary role model.

One dramatization like this (i.e., the refusal of a young, beautiful, brainy nurse to switch to medicine) is worth a thousand press releases.

The program dramatizes her enormous social and technical skills in her daily practice as well as in medical emergencies when no physician is present. The program obviously has input from nurses and its plot lines involve many current nursing issues.

For example, Nurse Hathaway (like most, if not all, Registered Nurses) is frequently insulted by being asked why she's a nurse, rather than a doctor. The implication, of course, is that a person with her ability is wasted as a mere nurse. Urged by her colleagues, Nurse Hathaway takes the medical school entrance exam, receiving scores which insure her admittance to any number of schools. However, after carefully pondering her options (and several weeks of suspense), she decides nursing practice is the preferred career. One dramatization like this (i.e., the refusal of a young, beautiful, brainy nurse to switch to medicine) is worth a thousand press releases.

Nursing recognizes the importance of how TV depicts nurses, and has exercised its First Amendment influence with the networks (e.g., informing broadcasters of how demeaning it is to the profession to depict nurses as sexpots on "The Nightingales", a series that was eventually canceled). Unfortunately, movies are relatively impervious to nurses' input, and so we have infamous depictions of characters such as the sadistic Nurse Ratched ("One Flew over the Cuckoo's Nest") and the cheerleading Nurse Hot Lips (in "M*A*S*H").


It is generally recognized that effective public relations and lobbying power are important to the growth and prosperity of any profession. The nursing profession is doing a good job in these areas. However, we nurses must redouble our efforts, as organized medicine steps up its campaign to limit NPs' roles.

Cost-Effectiveness: Implications for Advanced Nursing Practice

Cost Issues

Buppert (1995), Gallagher (1996), and Sinclair (1997) have stressed the necessity of coping with the realities of the marketplace if NPs are to expand their roles. Here is a paraphrase of some of their most cogent points: NPs have an unprecedented opportunity to become major providers of primary health care, but there are barriers. There exists strong research documentation of the NPs' cost-effectiveness and outcome-based care, but being good is not enough (Gallagher, 1996). The public, lawmakers, insurers, and health care bureaucrats must be convinced that, yes, there are valid and demonstrable reasons for, in many cases, preferring NPs over MDs (Buppert, 1995). NPs must promote their practice by using an array of marketing strategies, including pricing their services at the right level (Buppert, 1995; Gallagher, 1996; Sinclair, 1997). In summary, "the issue of cost is paramount" (Sinclair, 1997, p. 219).

Equal pay for equal work. The concept of "equal pay for equal work" is an American icon, up there with Mom, apple pie, and Santa Claus. But while NPs produce equal or better outcomes than do MDs, their "work" is different. For example, NPs typically use less invasive techniques and take more time with patients, as compared to MDs. NPs can handle most primary care situations, with estimates ranging from 60% to 90%. But that leaves from 10% to 40% of duties that must be performed by providers with medical training.

Impact of surplus physicians. Nurses must not forget those 100,000-150,000 surplus physicians (Pew Health Professions Commission, 1995) who may be directly competing for the same jobs. If pay is equal, wouldn't it make more economical sense to hire the MD instead of the NP, since the physician can perform additional services including routine surgery?

Time spent with patients. Typically, NPs (as compared to MDs) take more time with patients. If the NPs' pay is increased to the MDs' level (i.e., at least doubled), costs at least in the short run will increase. And nurses should remember that lawmakers, insurers, and health care bureaucrats are much more focused on short-run costs than on long-term improvements.

Educational preparation. As compared to the NP, the MD typically spends many more years in getting a medical degree, pays higher fees/tuition, and at graduation is in a much higher level of debt. The more costly medical preparation yields a wider range of technical skills, thereby justifying higher pay.

Savings to patients and the economy. Analysts predict that the entry of lower-cost NPs into the pool of primary care providers "is bound to put downward pressure on costs" (Freudenheim, 1997). In an era of ever-escalating health care costs, any downward pressure will benefit patients and taxpayers.

Equitable pay. If NPs demand the 6-figure salaries typically earned by MDs, they will price themselves out of the market. Most patients are still biased in favor of the physician; lower cost is one way to win them over to NPs.


Is it really higher salary that is the issue or is it NP acceptance as a viable health care provider that we want? If we continue to think in terms of individual gains, rather than what will benefit the system as a whole, we will continue to fight our battle in a conflict mode rather than a consensual mode. This will result in opposition from the insurance companies, physicians, and patients. If the nurse continues to focus on self, short term goals, and what is good "for me" rather than on long term goals and what is good for the NP profession, we may win the battle, but lose the war.

Patients like stability and are very resistant to change, so winning them over to NPs as their "doctor" may be a hard sell ... So do we want to be right or do we want to win?

NPs must (a) get politically involved (Buppert, 1997), and (b) learn to successfully negotiate the new health care system (Medicaid waivers, state policies regarding health insurance, knowledge of credentialing and compensation mechanisms under managed care) to obtain their place on provider panels (Cohen & Juszczak, 1997) to secure the power needed to become an effective player in the health care system. The NP is seeking social change in terms of: Why do patients automatically think "I need a doctor," when they are sick? How do we change that habit? What can NPs provide that physicians can't or won't? Insurance companies are very price sensitive, the customer is not. Patients like stability and are very resistant to change, so winning them over to NPs as their "doctor" may be a hard sell.

So do we want to be right or do we want to win? The 85% compromise on direct Medicare reimbursement provides one model for pricing NP services. NPs are within yards of the goal line, that is, of becoming the "doctor" for most primary care needs of patients.

Here are the Pew Health Professions Commission's conclusions about nursing (1995, p. 49):

Advanced preparation...will permit the nursing professional to develop the information background and experience base to operate more independently, work in community settings, more effectively manage the health of patients and make an even more profound contribution to health care.... In many ways nurses are the best prepared professionals to respond to the changing system. Their training focuses on the delivery of cost effective care;...they combine clinical and managerial skills; they focus on the behavioral aspect of health more than physicians; and they are effective team workers and leaders.

Thus, the experts on this Commission are urging NPs to widen their scope of practice to better meet the health care needs of 21st century patients.


Ruth M. Harris, Ph.D, RN, C-ANP

Ruth M. Harris, Ph.D, RN, C-ANP is an Associate Professor for Graduate Study and Chair of the Adult Nursing Department at the University of Maryland School of Nursing in the Department of Psychiatry, Community Health and Primary Care Nursing. As an Adult Nurse Practitioner, she teaches Physical Assessment and Advanced Diagnosis and Management to students in the Adult Nurse Practitioner and Women's Health Programs. She has been active politically to foster the advancement of nurse practitioners as accepted primary health care providers; however, she believes that to compete and for nurse practitioners to gain their share of the patients, they may have to provide a monetary incentive initially.


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© 1998 Online Journal of Issues in Nursing
Article published June 10, 1998

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