The What's Next Health series features leading thinkers and visionaries. Stanford social scientist & innovator BJ Fogg discusses his model f...
Patricia Pittman and Benjamin Williams are co-authors of "Physician Wages in States with Expanded APRN Scope of Practice," published in the January 2012 issue of the Nursing Research and Practice. This article was the funded through the Robert Wood Johnson Foundation Initiative on the Future of Nursing.
If you listen hard to the stakeholders and try to understand where they’re coming from, the research questions that are relevant to the policy debate can pop out.”
What was the inspiration for this study—the critical knowledge gap you were trying to fill or the challenge you were trying to address?
This has been a subject of debate for over 20 years. In 2010, the Institute of Medicine report on the future of nursing recommended that advanced practice registered nurses should be able to practice to the full extent of their education and training. It was probably the most important of all of the recommendations, but politically it was very contentious. As we looked at the issue as researchers, we scratched our heads and tried to understand what the dangers were for primary care physicians, and whether there were economic interests at stake. If there were, it would be an important policy question.
Right now, the nation has too few primary care physicians, and most physicians want to go into specialty care. So policy-makers are balancing two sets of goals. They wouldn’t want the goal of allowing advanced-practice nurses to practice independently to in any way negatively affect the incentives they’re trying to create for more physicians to go into primary care. There is already has a robust evidence base on the quality and safety of scope-of-practice reforms. We viewed this study as a first step towards building an evidence base around the economics of these reforms.
In a nutshell, what were the key findings and why are they significant?
Eventually, we found that there was no smoking gun. There is no evidence thus far that these reforms negatively impact physician wages. Primary care physicians in states that reformed their scope of practice laws—and allowed advanced-practice nurses to practice independently did not have lower wages than those in states that did not. For policy-makers, I think that alleviates one of the concerns about the possible unintended consequences of these reforms.
Who did you most want this research to reach, and what influence did you hope to have?
Obviously, we wanted to reach the physicians. To the extent that they have not looked at this in a scientific manner themselves, they’d be interested in these findings. While it might not persuade them definitively, it’s one element in their thinking about the impact of these changes. It’s a first step in the direction of trying to unpack some of these questions.
The second audience is the policy community. In this country, state legislatures are responsible for establishing scope of practice laws. Often, they are not well-prepared to make these very difficult decisions that are enormously contentious—with their physicians lobbying on one side and nurses lobbying on the other—so it’s important to begin to give them better research about what the effects of these laws are.
What are a couple examples of uptake and impact you are particularly proud of thus far?
As a researcher, it’s hard to claim causality between one’s research and a policy change, but we are seeing a wave of interest in implementing scope-of-practice reforms in those states that have not yet moved on this issue. And the debates, I think, are becoming increasingly rational—and part of that is that there’s a better research base, and I think the study is one of many studies that is contributing to that.
Are there other unexpected audiences who have taken interest, and/or new audiences you did not initially think about who you feel would benefit from this research?
Within health care, there’s a lot of interesting application of the lessons from the debates about scope of practice for advanced practice nurses to other health care professions—for example, the dental sector. There are also scope-of-practice policy debates going on within social work, within psychology, within pharmacy, within physical therapy.
Each of these professions has arguments going on about what higher levels of education can do. And the assistant roles generally are pushing to be able to do more. I know, for example, that a Pew project on dental hygiene has looked at scope of practice laws for dental therapists and hygienists, and is very interested in seeing what kind of research has been done around nurses, and what the policy experience has been for them so that they can learn from it. It’s inherent in the way professions organize, that there is this ongoing debate. States are under enormous pressures from professional associations, and we continue to have this void at a national level in terms of good research and leadership, which is needed to help states make responsible decisions about these issues.
Are there any lessons from this project that will inform your future research, or that you’d share with other researchers who want to maximize the impact and reach of their work?
What was surprising for me is how, if you listen hard to the stakeholders and try to understand where they’re coming from, the research questions that are relevant to the policy debate can pop out. It’s important to keep your eyes and ears open, and think about available data to answer questions that are coming down the pike—whether they’re in the newspapers, or things you hear at conferences—and be able to stop what you’re doing and see whether it’s possible to answer these questions. Often we as researchers are looking for the big project that will sustain us for many years; this paper did not take more than a week to do. These quick-turnaround studies may not be definitive in their findings, but they’re a step towards building evidence that is relevant to important policy debates.
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