Consequently, no reason supports the contention that one group must be dependent and the other dependent. "Measuring NP performance against the physician (or any other group) as the gold standard is inappropriate because the philosophical approach of the NP is singular," Weiland (the NP as…section, ¶ 2) stresses. NPs offer a unique approach to health care and are independent providers of health care services. They are not physician substitutes. Weiland points out: Underutilization of NPs has been estimated to cost society approximately $9 billion annually. Indeed, the social burden of healthcare spending nears $1.9 trillion. Medicare alone spent up to $256.8 billion in 2003. Additionally, a physician shortage of 200,000 is projected by 2020, and 46.6 million people are currently without health insurance. The impact is that society is paying for nonrecognition of this resource, not just financially but by a serious lack of access to care. The role of NPs can be carried out only with full professional recognition as independent providers. (Weiland, 2008, Introduction section, ¶ 3)

Dr. Alice Running, Associate Professor, Orvis School of Nursing, University of Nevada, Lisa Hoffman and Victoria Mercer (2008), both of Department of Psychology, University of Nevada, note that due to dramatic changes in health care in the U.S. during the last decade, significant healthcare reorganization occurred. In turn, relationships with other healthcare providers have started to shift, with new roles for NPs beginning to evolve. Shifts in these relationships, possibly relate to increasing independent practice, as well as access to medications requiring licensure, and direct Medicaid and Medicare reimbursement. Consequently as numerous NPs also apply for and obtain hospital privileges comparable to those of physicians, the ensuing changes potentially affect the dynamic relationship between NPs and physicians. Research demonstrates that as NPs work in collaboration with physicians, the health care system improves in a number of ways, including improved patient access and reduced physician workloads, contributing to increased reports of physician job satisfaction. Productivity within practices has been enhanced, and patient satisfaction has increased" (Running, Hoffman & Mercer, 2008, Introduction section, ¶ 2). Although NPs, perceived as versatile and flexible, also regularly fill the gaps in specialty settings, they typically receive 40% less than physicians.

Barriers to Establishing Professional Practice

As the researcher alluded to during the proposed study's introduction, a number of factors prove detrimental NPs securing full recognition of as autonomous providers of medical care. Some of the components which thwart NPs establishing private practice environments where their services may be fully utilized not only include physician dominance and reimbursement challenges, but also federal and state rules and regulations Weiland (2008) notes a number of social and economic outcomes of nonrecognition and underutilization of NPs to include:

1. Denial of primary provider status,

2. decreased patient access to care, and

3. increased healthcare costs (Weiland, 2008, Introduction section, ¶ 3).

In the journal publication, "Shifting Patterns of Practice: Nurse Practitioners in a Managed Care Environment," Dr. Rosemary Johnson (2005), University of Southern Maine, Portland, Maine, explains how managed care affects the NPs' daily practice and ways NPs respond to a changing managed care workplace. According to findings from this study, tension between a business and a professional ethic concerns NPs as managed care values emphasize "cost containment, efficiencies, and bottom line issues" (Johnson, Discussion section, ¶ 1). Values the NP providers support, on the other hand, emphasize patient-centered holistic care. At the heart of the NP role, Johnson concludes, NP students need to be better prepared for the business side of professional practice, as well as in the ethical dilemmas that occur when one attempts to balance a business and a professional ethic.

Linda Miller Atkinson (2007), a partner in Atkinson, Petruska, Kozma & Hart, notes in the journal publication, "Who's really in charge? Physician assistants and nurse practitioners are common in health care facilities. But how much responsibility do they have? If a patient is injured, you need to find out who - the midlevel provider, the supervising doctor, the facility, or all of them - is responsible," that due to legal constraints, physicians always supervise clinically practicing physician assistants and nurse practitioners. This practice reportedly links to avoiding potentially dangerous and sometimes deadly results, such as the following:

Hospital emergency departments often delegate walk-ins to midlevel providers who are not supervised directly or consistently.

Private family clinics use "sign-in logs" to separate patients who need or want to see a doctor from those who can see midlevel providers, leaving this clinical decision to the patient -- the person least capable of...

In some cases, surgeons effectively abandon their patients.
In large measure, health care in prisons is provided almost entirely by PAs who are hesitant -- because of budgetary pressures -- to order testing or transport to a hospital, and whose supervision consists of having a physician review the charts weekly at most.

Specialists depend on midlevel providers for monitoring and follow-up even in complicated medical cases, expecting them to alert the specialists to drug reactions, drug toxicities, and other complications that often exceed the midlevel provider's expertise. (Atkinson, 2007, the problem section, ¶ 1-6).

Atkinson (2007) points out that each state has enacted enabling statutes to define and regulate permissible activities of midlevel providers, such as NPs, may provide. Traditionally, to regulate NPs, states define their scope of practice, require they be supervised by a licensed physician, require a particular level of written direction, and control the level of education required for licensure.

Weiland (2008) purports that organized medicine has been a stalwart in discrediting NPs as competent providers.that in order to maintain the medical profession's dominance as well as the exclusivity of their role as primary care providers, o Dr. Ford recalls a time when the American Medical Association depicted "NPs as ducks (symbolizing "quacks")..." (p. 31 (.Despite four decades of collegial collaboration and numerous compelling studies that demonstrate NPs are competent, that is, quality of care is no different from that of physicians, physicians continue to express concerns that NPs lack the training necessary to provide comparable care (Weiland, 2008, Evolution of…section, ¶ 1).

Recent Massachusetts Legislation

The article, "Legislative news," (2008) explains that Massachusetts recently began to address its primary care provider shortage by passing legislation (Chapter 305), proposed by Senate President Therese Murray, to confront issues of access, quality and transparency in health care. "The recognition of nurse practitioners as primary care providers is vital to this legislation and will immediately and dramatically increase the number of providers available to residents" (Legislative news, ¶ 1). The need for legislation such as this proves critical as a number of Massachusetts physicians do not currently accept. Some individuals seeking medical care in the state, according to the Massachusetts Medical Society, have to wait an average of 8-12 weeks to schedule a primary care appointment.

Currently, the law requires all Massachusetts health insurers to recognize NPs as primary care providers, a potential solution to the current primary care challenges Massachusetts currently seeks to resolve. Nancy O'Rourke, president of the Massachusetts Coalition of Nurse Practitioners, stresses that nurse practitioners can effectively diagnose, treat and prescribe medications in each state in the U.S. According to the Massachusetts Medical Society, recently most patients who present to a primary care practice and see a nurse practitioner deliberately chose to do so. As NPs provide care and manage chronic disease, they constitute an ideal remedy to solvingthe shortage of primary care providers not only in Massachusetts, but throughout the U.S.

Theoretical Concepts to Address Challenges

According to the Dreyfus model which Benner adapted to nursing, noted earlier in the study proposal, as an individual acquires and develops a skill, he/she passes through the following five levels of proficiency (abbreviated for the proposal):

Stage 1: Novice: Beginners have had no experience of the situations in which they are expected to perform. Novices are taught rules to help them

Stage 2: Advanced Beginner: Advanced beginners are those who can demonstrate marginally acceptable performance, those who have coped with enough real situations to note, or to have pointed out to them by a mentor, the recurring meaningful situational components

Stage 3: Competent: Competence, typified by the nurse who has been on the job in the same or similar situations two or three years, develops when the nurse begins to see his or her actions in terms of long-range goals or plans of which he or she is consciously aware

Stage 4: Proficient: The proficient performer perceives situations as wholes rather than in terms of chopped up parts or aspects, and performance is guided by maxims. Proficient nurses understand a situation as a whole because they perceive its meaning in terms of long-term goals

Stage 5: The Expert: The expert performer no longer relies on an analytic

principle (rule, guideline, maxim) to connect her or his understanding of the situation to an appropriate action. The expert nurse, with an enormous background of experience, now has an intuitive grasp of each situation and zeroes in on…