In a proactive PR plan, an NP organization would seek to generate articles or television pieces about NPs or to showcase the expertise of NPs, not in response to some attack on NPs, but as a regular, systematic promotion of NPs. For example, an NP organization might arrange for an article to appear in the local newspaper giving an NP’s advice for staying well in flu season. The article serves three purposes: keeps NPs in the news in a positive light, demonstrates the information an NP can offer, and gives people useful information. The article satisfies the needs of NPs, the needs of readers, and the needs of newspaper editors to run informative articles.

A message about NP expertise in primary care could be disseminated on television, in newspapers and magazines, at health fairs, by word of mouth, and through advertising. It is generally agreed that television stories and newspaper articles are an effective way of getting a message to a large segment of the population with little expenditure.

When developing a PR plan, NPs need to keep in mind that newspapers and television station owners need readers (or viewers) and advertisers. An NP may not be able to offer to a newspaper advertisers but can offer readers if the NP is providing information on a topic of interest to many people. Health, and particularly primary care, is interesting to many people.

To generate an article in a newspaper or website, the following things have to happen:

A statewide media campaign would involve something like sending a news release to every newspaper in the state once a month. When the process described above is done 12 times a year and multiplied by 50 or 100 newspapers, it is close to a full-time job.

Each NP organization and each private practice needs a person designated to handle PR. PR services may be purchased or performed by a volunteer NP. Obviously, a volunteer is less expensive, will know more about NPs than a PR professional, and will be motivated. However, a volunteer probably will have a job as an NP, and the volunteer PR efforts may not get the regular attention that is needed. Further, when NPs organize into associations and there is a treasury, it makes sense for all NPs to share in contributing to PR efforts, and that is best done by purchasing PR services rather than imposing on one NP to do the work.

Public relations is reactive when it is in response to a particular event or criticism. For example, if a physicians’ group came out with a statement that only physicians should be PCPs, the rebuttal of an NP organization would be reactive.

The keys to effective reactive PR are speed and a consistent and logical message. Therefore, NP organizations should have a set of “talking points” ready for use in the event that a speedy reaction is needed. Talking points are a PR method for ensuring that a spokesperson for a group has something to say and that the message is consistent with the group’s goals. For examples of talking points for NP organizations, see Appendix 13-B.

Hall et al. set up audit criteria, with input from the practitioners being studied, and then audited charts of 426 MDs and NPs in 16 ambulatory care practices.² The researcher looked at eight tasks: (1) follow up of a low hematocrit to detect patients with anemia caused by colorectal cancer or other serious gastrointestinal disease; (2) screening for cancer using breast examination and Pap smears in women; (3) follow up of a high serum glucose to detect and treat diabetes; (4) monitoring of patients on digoxin to detect drug toxicity or symptomatic relapse; (5) follow up of a positive urine culture to treat persistent bacteriuria; (6) compliance with the American Academy of Pediatrics standards for screening and immunization of infants; (7) assessment of the risk of dehydration in children at the start of an episode of gastroenteritis; and (8) monitoring and follow up of children with otitis media to detect and treat failure to resolve the middle-ear effusion.

The findings: NPs’ performance was comparable or superior on seven of the eight tasks. Female MDs were better at cancer screening for women, but male MDs were worse at this than NPs. The sample of male “nonphysicians” was too small to make any generalizations about and was therefore excluded from the results.

Salkever et al. compared NPs and MDs on cost and effectiveness.³ To study costs, Salkever paid observers to time NP and MD visits with patients. The research team then analyzed costs of office space, costs of follow-up visits, and costs of ancillary services and drugs ordered by the providers. To study effectiveness, the researchers randomly surveyed patients regarding problem severity and changes in problem status after treatment. The researchers then computed the cost per episode of care for two conditions, sore throat and otitis media.

The findings: NPs were 20% less costly in their care.⁴ NPs were at least as effective as MDs at resolving the problem.^3,p152

Avorn et al. asked 799 MDs and NPs to consider the following case vignette and answer two questions:⁵

Questions: What more do you want to know? What would you do?

The findings: Nurses were far more likely to collect more historical information about the patient before deciding upon therapy. The NPs asked an average of 2.6 questions about the patient as opposed to 1.6 for physicians. A third of physicians (and 19% of NPs) chose to initiate therapy without any additional information. Nurses were far more likely to ask about the patient’s diet and psychosocial information (but less likely to ask about alcohol intake). NPs were more likely to suggest nonprescription approaches to therapy, such as a change in diet or counseling to help the patient deal with stress. NPs were far less likely than physicians (20% versus 63%) to recommend a prescription drug.⁶ NPs were much less likely to state that a prescription drug would be the single most effective therapeutic intervention for this patient (12% versus 46%).⁷

No analysis of cost of therapy was done. However, when the cost of MDs’ treatment plan—prescription medication, but no counseling about unhealthy lifestyle—is compared with NPs’ treatment plan—no prescription, but counseling regarding aggravating factors—the NPs’ treatment plan certainly shows itself to be the more economical approach to care.

Medical Economics, a magazine written for physicians, conducted a survey of patient satisfaction with NPs and MDs.⁸ Patients were as satisfied with NPs as with physicians.

Harrocks et al. systematically reviewed randomized controlled trials and prospective observational studies and found that patients were more satisfied with care by a nurse practitioner, that there were no differences in the health status of patients treated by nurse practitioners versus medical doctors, and the quality of care was in some ways better for nurse practitioner consultations.⁹

Mundinger et al. conducted a randomized trial comparing outcome measures for care provided by nurse practitioners and medical doctors. Among other things, Mundinger
found a statistically significant difference in the diastolic value of patients treated for hypertension by nurse practitioners. Nurse practitioners’ patients had a lower diastolic blood pressure after treatment than physicians’ patients.¹⁰

A survey study (N = 3257) comparing OB-GYN practices that used nonphysician providers with physician-only practices found that patients preferred the “collaborative” practices.¹¹ Of the nonphysician providers, 45% were NPs, 19% were midwives, 16% were PAs, and 9% were CNSs. Reasons for preferring practices with nonphysician providers were:

Patients felt that nonphysicians were less rushed in their care. However, patients believed that physicians provided more complete information.

For a quick reference to substantive arguments supporting NP practice and citations for the arguments, see Exhibit 13-1.