Chapter 43. Advanced Practice Registered Nurses: 

The Impact on Patient Safety and Quality 

Eileen T. O’Grady 

Background 

This chapter will define the role of advanced practice nurses (APNs), review a selected 

sample of the literature regarding what we know about APNs and patient safety/quality, and 

describe the research gaps and limitations. Advanced practice registered nurse is a term used to 

encompass certified nurse-midwife (CNM), certified registered nurse anesthetist (CRNA), 

clinical nurse specialist (CNS), and nurse practitioner (NP). Advanced practice nursing is 

broadly defined as nursing interventions that influence health care outcomes, including the direct 

care of individual patients, management of care for individuals and populations, administration 

of nursing and health care organizations, and the development and implementation of health 

policy.1 In 2004, the number of registered nurses (RNs) prepared to practice in at least one 

advanced practice role was estimated to be 240,461, or 8.3 percent of the total RN population. As 

noted in figure 1 below, the largest group among the APNs was NPs, followed by CNSs. The 

APN movement has been growing exponentially with APNs employed in every health care 

sector. According to the Bureau of Labor Statistics,2

 the demand for APNs is expected to 

continue to increase over the next decade and beyond, as the need and demand for effective 

health care increases, especially in rural, inner-city, and other underserved areas. 

Figure 1. Registered Nurses Prepared for Advanced Practice, March 2004 

Source: 2004 National Sample Survey of Registered Nurses, U.S. Department of Health and Human Services, Health Resources 

and Services Administration. http://bhpr.hrsa.gov/healthworkforce/reports/rnpopulation/preliminaryfindings.htm. 

Direct clinical practice is a core competency of any APN role, although the actual skill set 

varies according to the needs of the patient population.3

 APNs build on the competence of the 

1 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

RN skill set and demonstrate a greater depth and breadth of knowledge, a greater synthesis of 

data, increased complexity of skills and interventions, and significant role autonomy. The APN is 

prepared to assume responsibility and accountability for health promotion and the assessment, 

diagnosis, and management of patient problems, including the use and prescription of 

pharmacologic and nonpharmacologic interventions.4

Advanced Practice Nurses Evolve to the Doctoral Level 

The American Association of Colleges of Nursing envisions all APN master’s-level 

programs will evolve to a doctorate of nursing practice (DNP) by 2015.5

 This evolution to the 

doctoral level for APN education stems from the three Institute of Medicine (IOM) reports, Too 

Err is Human,

6

 Crossing the Quality Chasm,7 and Health Professions Education: A Bridge to 

Quality,

8

 which emphasized widespread problems related to patient safety and called for 

dramatic restructuring of traditional health professions education. These reports recommended 

all health professionals should be educated to deliver patient-centered care as members of an 

interdisciplinary team, emphasizing evidenced-based practice, quality improvement, and 

informatics. It was emphasized that the best-prepared senior-level nurses should be in key 

leadership positions and participating in executive decisions. Complex practice and delivery 

system demands create a mandate to expand the clinical education and leadership capacity of 

APNs. Graduates of DNP programs are expected to use advanced communication 

skills/processes to lead quality improvement and patient safety initiatives in health care systems. 

Research Evidence 

Certified Nurse-Midwife 

CNMs are licensed health care practitioners educated in the two disciplines of nursing and 

midwifery. They provide primary health care to women of childbearing age, including prenatal 

care, labor and delivery care, care after birth, gynecological exams, newborn care, assistance 

with family planning decisions, preconception care, menopausal management, and counseling in 

health maintenance and disease prevention. CNMs attend more than 10 percent of the births in 

the United States; 96 percent of these are in hospitals.9

What we know. MacDorman and Singh10 used logistic regression models to examine 

differences between CNMs and physician-delivered births in infant perinatal mortality on all 

singleton vaginal births between 35 and 43 weeks gestation in the United States (n = 810,790) in 

1991. After controlling for all social and health risk factors, the CNM risk of infant death was 19 

percent lower, neonatal mortality was 3 percent lower, and low-birth-weight infants were 31 

percent fewer than with the physician-delivered babies. The mean birth weight was 37 grams 

heavier for the CNM-attended births. The researchers concluded that CNMs provide a safe and 

viable alternative to maternity care in the United States, particularly for low- to moderate-risk 

women. The retrospective study design could not address the inherent selection bias of mothers 

who choose midwives versus mothers who choose physicians to assist with delivery. 

Rosenblatt and colleagues11 compared a random sample of records of Washington State 

obstetricians, family physicians, and CNMs for low-risk women over a 1-year period (n = 

1,322). The researchers found that CNM patients were less likely to receive continuous fetal 

monitoring and had lower rates of labor induction, epidural injections, and caesarean sections 

2 
Role & Impact of Nurse Practitioners

and overall used fewer resources. The researchers concluded that overall, in Washington State, 

low-risk patients of CNMs received fewer obstetrical interventions than similar patients cared for 

by family physicians or obstetricians, especially lower cesarean rates and resource use. There 

was no controlling for maternal risk factors such as maternal age and birth weight in this study, 

and the degree of selection bias in pregnant women choosing a CNM versus a physician could 

have influenced these results. 

Oakley and colleagues12 compared the pregnancy outcomes (n = 1,181) of low-risk pregnant 

women cared for by either an obstetrician or a CNM. After controlling for maternal risk and 

selection bias, the nurse-midwife group had statistically significant fewer infant abrasions, 

perineal lacerations, and complications; higher satisfaction with care; and lower hospital and 

professional fee charges. The researchers concluded that important significant differences were 

found between the CNMs and obstetricians and that CNMs are contributing significantly to 

lowering maternity care costs and improving maternal outcomes of low-risk women. 

While most of the research on CNM quality covered low-risk women, Davidson13 explored 

the effectiveness of CNM care for high-risk women. Outcomes of high-risk women cared for by 

CNMs in an inner-city hospital (n = 803) were compared with all women who delivered in the 

United States in 1994. The comparison suggests that CNMs can provide safe care to women with 

high-risk conditions. The single site of the study sample and lack of a controlled pair group make 

generalizability of these findings difficult. 

Nurse Anesthetist 

A CRNA is a registered nurse who is educationally prepared for and competent to engage in 

the practice of nurse anesthesia. CRNAs administer approximately 27 million anesthetics in the 

United States each year, practice in every setting where anesthesia is available, and are the sole 

anesthesia providers in more than two-thirds of all rural hospitals.14 CNRAs can also administer 

every type of anesthetic and provide care for every type of surgery or procedure, from open heart 

to cataract to pain management. CRNAs are both responsible for and accountable to others for 

their individual professional practices. In addition, CRNAs are capable of exercising independent 

professional judgment within their scope of competence and licensure.3

 CRNAs provide 

anesthetics to patients in collaboration with surgeons, anesthesiologists, dentists, podiatrists, and 

other qualified health care professionals. When anesthesia is administered by a nurse anesthetist, 

it is recognized as the practice of nursing and is not a medically delegated act.14

What we know. In 1988, the Centers for Disease Control and Prevention (CDC)15 conducted 

a pilot study to explore anesthesia outcomes. The study concluded that anesthesia-caused 

mortality and severe morbidity were too low to warrant a broader study. The CDC found that 

precise estimates would require studying 290 hospitals and would cost $15 million over 5 years, 

which was not deemed feasible. According to the IOM,6 it is estimated that death occurs only 

once for every 200,000–300,000 anesthetics administered. This low incidence of error makes 

studying the safety of CRNAs as a distinct provider group extremely difficult as it would require 

an enormous number of study subjects. 

To answer questions about surgical patients’ safety with regard to CRNAs versus 

anesthesiologists, Pine and colleagues16 studied 404,194 anesthesia cases across 22 States. Risk 

adjustment was conducted for case mix, risk factors, hospital characteristics, geographic 

location, and surgical procedure. The study found no statistically significant difference in the 

mortality rate for CRNAs and anesthelogists working together versus working individually. 

There was no statistically significant difference between hospitals staffed by CRNAs (without 

3 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

anesthesiologists) versus hospitals in which anesthesiologists provided or directed the anesthesia 

care. The researchers concluded that, based on the surgical procedures included in the study, 

inpatient surgical mortality is not affected by whether the anesthesia provider is a CRNA or an 

anesthesiologist. 

Anesthesia-related accidents are infrequent, largely due to systemic quality improvements in 

applied technology, anesthetic agents, multimodal pain management, and development and 

adoption of practice guidelines in the broad field of anesthesiology over the last 40 years. The 

dramatic decrease in anesthesia-related deaths since 1960 may be largely attributable to the 

disciplinewide sharp focus on safety issues such as increased vigilance during long operations 

and rapid response teams. The pulse oximeter, standardization of equipment, and changes in 

education, including the use of simulation, have also contributed to threshold improvement in 

patient safety. In fact, anesthesia as a health care discipline is an exemplar case study of how 

local but complex, high-risk, dynamic patient care has noticeably reduced its error rate6

 (p. 164). 

The administration of anesthesia is built on a foundation of sound safety principles and has been 

a strong leader in creating systems built around patient safety. 

Clinical Nurse Specialist 

The CNS is an expert clinician in a specialized area of nursing practice. The specialty may be 

a population (e.g., pediatrics), a setting (e.g., critical care), a disease (e.g., cardiovascular or 

mental health), or a type of problem (e.g., wound or pain). CNSs are engaged in direct clinical 

practice; function as consultants in their area of expertise; provide expert coaching and guidance; 

interpret, evaluate, and participate in research; provide clinical and professional leadership; 

collaborate; and employ ethical decisionmaking.3

What we know. In 2001, a randomized controlled clinical trial by Brooten, Youngblut, and 

colleagues17 looked at prenatal, infant (194) and maternal (173) outcomes where half of the 

prenatal care was delivered in the home by CNSs. Results found that the group cared for in the 

home by CNSs experienced fewer fetal/infant deaths, fewer preterm infants, fewer prenatal 

hospitalizations, and fewer rehospitalizations compared to the control group. Researchers 

concluded that the CNS prenatal home care saved 750 hospital days or about $2.5 million 

dollars. 

Topp, Tucker, and Weber18 conducted a retrospective chart review on 491 hospitalized 

congestive heart failure patients over a 12-month period. Results indicated that length of stay and 

hospital charges were significantly less in patients who were case-managed by a CNS. 

Naylor and colleagues19 conducted a randomized clinical control trial with 276 patients and 

125 caregivers to show the effects of a comprehensive discharge planning protocol. The 

discharge planning protocol was specifically designed for elderly medical and surgical patients 

and implemented by a gerontological CNS. From the initial discharge until 6 weeks after 

discharge, the medical intervention group had fewer readmissions, fewer total days of 

rehosptilization, lower readmission charges, and lower charges for all health care services after 

discharge compared to the control group and the surgical intervention group. 

Brooten, Kumar, Brown, and colleagues20 conducted a randomized clinical trial on the 

effectiveness of CNS home care on the early hospital discharge of very low-birth-weight infants 

(n = 79). The researchers found that hospital costs were 27 percent less than for the control 

group. The researchers concluded that early hospital discharge for very low-birth-weight infants 

was safe with CNSs conducting home followup care. 

4 
Role & Impact of Nurse Practitioners

Nurse Practitioner 

NPs are registered nurses who are prepared, through advanced education and clinical 

training, to provide a wide range of preventive and acute health care services to individuals of all 

ages. NPs take health histories and provide complete physical examinations; diagnose and treat 

many common acute and chronic problems; interpret laboratory results and x-rays; prescribe and 

manage medications and other therapies; provide health teaching and supportive counseling, with 

an emphasis on prevention of illness and health maintenance; and refer patients to other health 

professionals as needed.21 Hughes and colleagues22 have categorized the 40-year history of NP 

research into succinct eras, chronicling the evidence base on NPs, by far the largest of all of the 

four APN roles. The current era is characterized by strategies to combat rising costs and tensionbuilding between NPs and the medical profession. The authors provide keen insight into why 

benchmarking NP care against physician care may have taken us to the end of that research road. 

What we know. Lambing and colleagues23 sought to build the evidence base for NP 

effectiveness in the acute care setting. They conducted a descriptive, comparative research 

design on 100 randomly selected hospitalized geriatric patients and a sample of 17 professional 

providers who staffed 3 hospital units over a 1-month period. The researchers found that the 

patients of NPs were older and sicker at the time of discharge and that readmission and mortality 

rates were similar amongst NPs and physicians. The researchers concluded that NPs provide 

effective care to hospitalized geriatric patients, particularly to those who are older and sicker. 

Mundinger, Kane, and colleagues24 conducted the most definitive research on NPs and 

quality by exploring the outcomes of care in patients randomly assigned either to a physician or 

to a nurse practitioner for primary care after an emergency or urgent care visit. The NP practice 

had the same degree of independence as the physicians, making this study unique. Patient 

interviews and health services utilization data were used on a total of 1,316 patients, and it was 

determined that the health status of the NP patients and the physician patients were comparable 

at initial visits, 6 months, and 12 months. A followup study conducted in 200425 showed that 

patients 2 years later confirmed continued comparable outcomes for the two groups of patients. 

No differences were identified in patient outcomes such as health status; physiologic measures; 

satisfaction; and use of specialists, emergency room, or inpatient services. The researchers 

concluded that NP care and physician care was comparable. 

A study by Avorn and colleagues26 used a sample of 501 physicians and 298 NPs who 

responded to a hypothetical scenario regarding a patient with epigastic pain (acute gastritis). 

They were able to request additional information before recommending treatment. If adequate 

history taking was performed, the provider would have learned that the patient ingested aspirin, 

coffee, and alcohol, and was under a great deal of psychosocial stress. Compared to NPs, the 

physician group was more likely to prescribe a medication without seeking the relevant history. 

NPs, in contrast, asked more questions, obtained a complete history, and were less likely to 

recommend prescription medication. This study suggests that NP-delivered care may be superior 

to that of physicians when a diagnosis is history dependent. 

5 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Summary of APN Research on Quality 

A selected sample of research on APNs and quality and safety was conducted because much 

of the APN research lacked randomization, had sample sizes too small to be generalizable to the 

national health care system, or was not relevant to quality or safety. The summary of the 

preceding research samples suggests that APN*

-delivered care, across settings, is at least 

equivalent to that of physician-delivered care as regards safety and quality. In the case of the 

CNSs, it appears that CNSs demonstrate competence and cost savings as case managers for 

patients transitioning from acute care to home care. Overall, however, the study designs and 

sample sizes are too limited to draw conclusions that are generalizable to the United States 

population. Widely accepted methodological techniques and research best practices outlined in 

the report of the Agency for Healthcare Research and Quality (AHRQ), Evidence Report to Rate 

the Strength of Scientific Evidence27 (see Table 1), have not been applied to the emerging 

research on APN practice and quality. Methodologic quality has been defined as the extent to 

which all aspects of a study's design and conduct can be shown to protect against systematic bias, 

nonsystematic bias, and inferential error. Not met were certain design elements in the preceding 

APN research design, conduct, or analysis that have been shown through empirical work to 

protect against bias or that are long-accepted practices in epidemiology and related research 

fields. These research evaluation criteria include quality, quantity, and consistency that are wellestablished variables for characterizing how confidently one can conclude that a body of 

knowledge provides information on which clinicians or policymakers can act. As the research on 

APN and quality evolves over time, the rigor of the research and its capacity to influence policy 

will improve. 

Table 1. Important Domains and Elements for Systems To Grade the Strength of Evidence 

Quality: The aggregate of quality ratings for individual studies, predicated on the extent 

to which bias was minimized. 

Quantity: Magnitude of effect, numbers of studies, and sample size or power. 

Consistency: For any given topic, the extent to which similar findings are reported using 

similar and different study designs. 

These studies are also limited in looking specifically at patient safety as a subset of health 

care quality. According to Crossing the Quality Chasm,

7

 the American health care system is in 

need of fundamental change because health care frequently harms and fails to deliver its 

potential benefits. The preceding literature compared APNs to physicians within the context of a 

health care system that is not necessarily patient safety focused. Comparing APN to physician 

outcomes was an important validation of APN practice as these professions evolved. Given the 

current mandate for fundamental system change, new research questions on APN practice as they 

relate to patient safety have emerged. Most outcome studies to date have focused on acute care 

 

*

 No studies comparing CNSs to physicians have been conducted. 

6 
Role & Impact of Nurse Practitioners

nurse staffing and nursing-sensitive outcomes such as decubitus ulcers.28 The research to 

measure APN outcomes with valid tools has yet to be developed. 

While the summary of research related to the safety and quality of APNs validates them as 

competent and comparable to physicians in many aspects, more research is needed to reduce 

errors and enhance patient safety. Threshold improvement cannot be accomplished without 

interdisciplinary practice approaches—which are going to require revolutionary change to flatten 

the educational and cultural silos between medicine and nursing education.29 It is crucial that 

APNs are separated out as distinct provider types in all interdisciplinary research and 

administrative and clinical datasets. It has taken the nursing profession decades to untangle 

nursing’s unique role and value within the hospital and decouple professional registered nursing 

from the “hotel costs” of a hospital stay. RNs have historically been characterized as a cost 

center rather than a highly valued revenue source within hospitals. If all professional nursing 

activity was billed for separately, such as is done with physician care, nursing’s value would not 

have to be debated. As the evidence base on interdisciplinary teams is built, APNs must not 

become invisible on the health care team. Building a research portfolio on APN practice will 

require adherence to methodological quality that explores APN practice within an 

interdisciplinary context. Practice Implications—Barriers to APN Practice 

Lack of Collaboration 

Health professionals work together in small groups providing care, be it oncology, the 

operating room, end of life, or primary care. These team members, however, are educated in their 

health professional silo and likely have little knowledge of their team members’ skill sets. The 

IOM report, To Err is Human,

6

 suggested that health professionals should be educated in teams 

using evidenced-based methods employed in aviation such as simulation and checklists. People 

make fewer errors when they work in teams because it forces processes to be planned and 

standardized, forces team members to have a clear role and to look out for one another, noticing 

errors before they become an accident. In an effective interdisciplinary team, members come to 

trust one another’s judgments and attend to one another’s safety concerns. 

In no uncertain terms, the IOM declares that most care delivered today is done by teams of 

people, yet training often remains focused on individual responsibilities, leaving practitioners 

inadequately prepared to enter complex settings. The silos created through training and 

organization of care impede safety improvements.6

The Quality First report highlighted “... the need for clinicians to develop a broader systems 

perspective. Specifically, the commission states that ‘... in health care organizations, much of the 

learning is aimed at improving individual physicians learning to become better physicians, 

nurses learning to become better nurses, rather than learning how the system as a whole can 

improve.’”30 Irrespective of health care setting, there is a high premium placed on medical 

autonomy and perfection and a historical lack of interprofesional cooperation and effective 

communication.6

Learning and working in a true interdisciplinary context is a requirement for improved 

patient safety, and the silo systems in place now are viewed as wholly inadequate. It is the space 

between the disciplines that may create the most opportunity for patient safety improvement. The 

following quote expresses the opportunity created in this interdisciplinary space as John Brown, 

an information technology leader, discusses how his company lost the commercial market share 

on the world’s first personal computer solely due to a lack of interdisciplinary collaboration: 

7 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

First of all, we were fundamentally noncollaborative, there was surprisingly little 

cross-disciplinary work. There were turf wars and physicists, for example, were 

not allowed to talk to computer scientists . . . To me the white space between 

fields is the place to explore. . . . If you get multiple disciplines together working 

around the root of a problem, it pulls you out of your own discipline and fuses 

different points of view that lead to a reframing.31 

Exemplars in collaborative models have demonstrated quality and safety improvements in 

two divergent settings, acute and chronic care. The Rapid Response Team (RRT)—known by 

some as the Medical Emergency Team (MET)—is a team of clinicians who bring critical care 

expertise to the patient’s bedside (or wherever it is needed) in the acute care setting. The concept 

is relatively simple: create a small but powerful team experienced at assessing patients’ 

symptoms and make that team continuously and readily available to any provider who wants a 

second opinion about a patient, particularly a patient showing signs of potential decline, as 

patients often exhibit signs and symptoms of physiological instability for some period of time 

prior to a cardiac arrest.32 

Another model, the Chronic Care Model, also has great potential to improve health care 

quality by employing a team of providers to apply a high standard of scientific evidence to 

groups of patients with a chronic illness.33 Yet the role of providers, the community, and patients 

with chronic care needs can be unclear and at times disjointed. 

Missing in the APN research is the notion of team-delivered care as it relates to quality. One 

study34 explored only cost implications, and not quality per se, of multidisciplinary teams of 

hospitalists, nonhospitalist attending physicians, and NPs. The study model employed NPs to 

supplement physician care and ensure continuity of care, comparing this approach for managing 

581 general medicine patients in one unit of a large academic medical center during 

hospitalization and for 30 days after discharge with usual care for 626 patients in another general 

medicine unit. The research findings indicated that reduced hospital length of stay (LOS) and 

increased hospital profits occurred in the collaborative model when compared with physicianonly care. This approach reduced the average LOS from 6 to 5 days. By reducing the number of 

hospital days after the first 4 days, which are the most profitable ones, hospital profits increased 

by $1,591 per day for each patient without increasing hospital readmission or mortality rates.34

State Regulation of APN Practice 

The 50 States and the District of Columbia have vastly different laws governing APN 

practice. The 51 nurse practice acts currently lack any clear framework or congruence amongst 

each other.35 This high degree of variation suggests that the regulatory framework for APN 

practice is not evidence-based and that States are not promulgating APN regulations with a 

coherent patient safety orientation. 

By way of example, some States employ a joint board of nursing-board of medicine to 

regulate APNs, while others require physicians and APNs to be in collaborative or even 

supervisory relationships with each other. Some States consider APN practice a medically 

delegated act and require physician, dentist, or podiatrist supervision of APNs, while other States 

require physicians to be in contact with the APN periodically throughout the week or to be 

physically within a defined radius (defined in miles) of the NP. Some States require APNs with 

doctorates to “hide” their doctoral degree credential from patients, and other States do not 

require APNs to be nationally certified to practice. These practice acts vary even within States 

8 
Role & Impact of Nurse Practitioners

(urban or rural) and can specify the types of medical conditions APNs are permitted to treat. The 

current APN regulatory environment has numerous issues that foster poor quality or impair 

patient safety. Regulatory barriers that directly impact patient safety include onerous entry into 

APN practice; cryptic scope of practice regulations; polices that restrict APN hospital and 

prescriptive privileges and impede continuity of care, the capacity of NPs to serve as primary 

care providers (NP empanelment), to receive third-party payment, or the pharmacist from 

printing the prescribing APN name on the prescription bottle, making it difficult for pharmacists 

or patients to contact the prescribing APN. The APRN Joint Dialogue Group36 of the National 

Council of State Boards of Nursing (NCSBN) recommends sole board of nursing regulation for 

APN practice and that APNs be independent practitioners with no regulatory requirement for 

supervision from another discipline across all States. Standardizing nurse practice acts will 

establish the groundwork necessary to move to a mutual recognition (interstate compact) for 

APNs. 

This high degree of variation across the States for APN regulation has spotlighted the need to 

ensure that regulation serves the public, promotes public safety, and does not present 

unnecessary barriers to patients’ access to care. Likewise, the regulatory bodies overseeing APN 

practice are slow or unable to keep pace with changes in health care. Moreover, the Internet has 

rendered geographic boundaries irrelevant, and as technology and national delivery systems 

infiltrate care delivery, these practice acts will strangle innovation. The Crossing the Quality 

Chasm report notes that State practice acts that limit nonphysician providers, e-health, and 

multidisciplinary teams act as a barrier to innovative health care because these innovations can 

help care for patients across settings and over time7 (p. 215). Crossing the Quality Chasm

recommends greater coordination and communication among professional boards, both within 

and across States, as the patchwork of NP regulations are resolved over time. 

The IOM’s Crossing the Quality Chasm recommends that regulators create an infrastructure 

to support evidence-based practice, facilitate the use of information technology, align payment 

incentives, and prepare the workforce to better serve patients in a world of expanding knowledge 

and rapid change7 (p. 5). The report stresses that if innovative programs are to flourish, 

regulatory environments will be required to foster innovation in organizational arrangements, 

work relationships, and use of technology. The 21st century health care system described in 

Crossing the Quality Chasm simply cannot be achieved in the current environment of regulation 

and oversight. The report summarizes the current patchwork of regulatory frameworks as 

inconsistent, contradictory, duplicative, outdated, and counter to best practices. Moving the 

NCSBN’s vision for APN regulation into reality across all of the States is requisite to promote 

APNs and patient safety. 

APN Invisibility 

Many polices have rendered APN practices “invisible” or established barriers that adversely 

impact accurate measurement of quality-related data. By way of example, Medicare has a policy 

that allows physician practices to bill Medicare for NP-provided services as “incident-to” the 

physician. This allows medical practices to bill for NP care through a physician, creating 

perverse incentives to make NPs invisible, as NPs are reimbursed 100 percent of the physician 

rate when billing Medicare “incident-to.” When APNs bill Medicare directly, they bill at 85 

percent of the physician rate. The cost savings of using a less expensive provider are passed onto 

the physician practice, not the patient or the payer. 

9 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Another startling example of APN invisibility is that the most comprehensive ambulatory 

care data, the National Ambulatory Medical Care Survey (NAMCS) produced by the National 

Center for Health Statistics, does not include APNs. This important national survey is conducted 

annually on the provision and use of ambulatory medical care services in the United States. 

Findings are based on a sample of visits to nonfederally employed office-based physicians who 

are primarily engaged in direct patient care. Each physician is randomly assigned to a 1-week 

reporting period. During this period, data for a systematic random sample of visits are recorded 

by the physician or office staff on an encounter form provided for that purpose. Data are 

obtained on patients’ symptoms, physicians’ diagnoses, and medications ordered or provided. 

The survey also provides statistics on the demographic characteristics of patients and services 

provided, including information on diagnostic procedures, patient management, and planned 

future treatment. APNs practicing in ambulatory care are not surveyed or discussed in the 906 

million visits to physician offices.37

In that same vein, the Center for Studying Health System Change (HSC), whose mission is 

“to inform policy makers about how local and national changes in the financing and delivery of 

health care affect people ... strives to provide high-quality, timely and objective research and 

analysis that leads to sound policy decisions, with the ultimate goal of improving the health of 

the American public.”38 HSC employs rigorous surveys and in-depth case studies and chronicles 

trends in the health care system; however, their provider surveys include only physicians. HSC 

unquestionably influences decisionmakers on all sides of the issues and guides those crafting 

health care policy in Government and private industry. More must be done to encourage thought 

leaders to think about health system change more broadly. 

APNs are also invisible in the basic county-specific Area Resource File (ARF), a database 

containing more than 6,000 variables for each of the Nation's counties. ARF contains 

information on health facilities; health professions; and measures of resource scarcity, health 

status, economic activity, health training programs, and socioeconomic and environmental 

characteristics. In addition, the basic file contains geographic codes and descriptors that enable it 

to be linked to many other files and to aggregate counties in various geographic groupings. This 

database is used to establish Health Professional Shortage Areas (HPSAs), using criteria of 

population-to-clinician ratios. It is difficult to include APNs in the ratio as there is no uniform 

data source at the ZIP Code level on APNs. HPSA designation is important to communities 

because of the enormous funding priority they receive in more than 34 Federal programs that 

depend on the shortage designation to determine eligibility.39 About 20 percent of the U.S. 

population reside in primary medical care HPSAs, and APNs are not considered full-time 

equivalent providers in the designation because of the lack of data. Fully counting APNs could 

thus impact the distribution of Federal funds to counties.

The Federal requirement that CRNAs must be in a supervisory relationship with 

anesthesiologists creates enormous barriers to adequate measuring of patient safety data, as the 

CRNA may not be identified as a distinctive provider group, rendering CRNA-delivered 

anesthesia invisible. This policy also has a detrimental effect on rural States that cannot staff 

their hospitals with anesthesiologists; therefore, many States have opted out of the Federal 

requirement for CRNA supervision in order to meet their patients’ needs. 

These policies, in each of the preceding examples, remove or marginalize the APN from all 

administrative and clinical data systems or survey designs. This lack of inclusion in these 

national research endeavors makes it impossible to understand the full dimensions and value of 

NP practice. 

10 
Role & Impact of Nurse Practitioners

Practice Implications

The intense drive to measure quality is a deep concern for payers, regulators, and 

increasingly consumers. As data systems evolve and payers insist on “paying for performance,” a 

level of accountability and transparency will be required regardless of provider type or health 

care setting. As these quality measures are developed, the current focus seems to be entirely on 

physician-delivered care. Quality data will be embedded with health information systems, so it 

will be imperative that APNs are involved in both the development of quality measures and the 

inclusion of APN practice as distinct from that of other providers. The database on nursesensitive indicators is being built at the inpatient level of hospitals. As many APNs practice in 

settings outside of the hospital, the need to create APN-sensitive measures cannot be 

overemphasized. The Medicare objective to align quality incentives through payment creates 

enormous opportunity for APNs. As Medicare gathers the evidence on effective strategies, it will 

phase in new payment systems intended to promote transformational quality improvement in the 

health care industry. This realignment will encourage innovation and efficiency and promote 

coordination of care across time and settings.40 These activities are central to the APN function 

and have historically been undervalued and invisible in the fee-for-service model. 

Pay-for-performance initiatives are occurring outside of Government as well. Bridges to 

Excellence (http://www.bridgestoexcellence.org/) is a multistate, multiemployer coalition 

developed by employers, physicians, health care services researchers, and other experts. Its 

mission is to reward quality across the health care system. In Bridges to Excellence’s three 

program areas, physicians are targeted exclusively by certifying physicians in diabetes, cardiac 

care, and electronic office systems. The physician receives a financial bonus of up to $180 per 

year per patient treated. There are no other providers included in this program, despite the 

claimed mission to improve health care across the health care system. 

Health Services Research Field Gains Strength 

Over the last 20 years, the evolution of health services research (HSR), a distinct area of 

scholarship, has grown dramatically in both resources and influence and is currently funded 

publicly at $1.5 billion annually. HSR is important to APNs because it addresses questions that 

require observational or quasi-experimental design. This form of research includes determining 

the comparative effectiveness of interventions across a range of different settings, economic 

evaluation of different financing and organizational decisions, and qualitative designs that help 

us understand the how and why of social interactions.41 The HSR field is uniquely suited to 

exploring APN practice because it provides a mixing bowl of interdisciplinary perspectives 

working on similar problems. As HSR methods become increasingly more prestigious and 

influential, APN research must be framed within a broader HSR and patient safety context. 

Research Implications 

The rapid growth and success of the APN movement has been described as a disruptive 

innovation—in that APNs can in many ways provide the same care or better care than 

physicians, at a lower cost in a more convenient setting. This disruption has contributed to 

professional turf battles that do not promote quality and patient safety. Strong leadership to study 

11 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

innovative models on interdisciplinary team approaches that foster patient safety, including how 

to eliminate barriers to interdisciplinary education and practice, is required. 

Turning the disruption of APNs toward improved patient safety will require a more robust 

evidence base and laser beam focus by these professionals. APNs must demonstrate specific 

clinical performance and patient outcomes. To develop this research agenda, stakeholders must 

convene and map out a vigorous research agenda that distinguishes APNs in the context of 

interdisciplinary practice. APN organizations along with the governmental and private research 

enterprise must come together and build a strategic plan identifying the most critical research 

questions. This research agenda would address strategies for APN inclusion in electronic 

administrative and clinical data systems, quality measurement, cost containment, as well as 

influential surveys such as the NAMCS and HSC. As pay-for-performance initiatives are 

transformed into payment policy, it is essential that researchers include APNs in the quality 

measurement process. This research agenda must be highly relevant to address today’s health 

care problems and overcome APN invisibility; it must recognize APNs’ unique contribution and 

discipline. 

APN research must expand to an HSR orientation. This includes developing a research 

agenda that has methodological dialogue with other disciplines and fits within a framework of 

agreed-upon methods in the field of HSR. This research agenda must consistently and 

systematically translate APN research into sound health policy. Applying randomized thinking to 

nonrandomized problems is seldom useful to inform public policy because the researcher cannot 

expose a randomized group to the policy on a qualitative problem. The research must help the 

policymaker see the intended and unintended consequences that follow enactment of policies 

over time. 

The Agency for Healthcare Research and Quality (AHRQ) has emerged as the premier 

funder for HSR, and this funding source should be explored to a far greater degree by APN 

researchers. While the National Institutes of Health focus on the biomedical aspect of diseases, 

AHRQ focuses on patient outcomes, cost, use of services, access disparities, quality of care, and 

patient safety. The focus of AHRQ is becoming increasingly important as the delivery system 

undergoes transformation, driven by transparency and quality. AHRQ’s goal is to ensure that the 

knowledge gained through HSR is translated into measurable improvements in the health care 

system and better care for patients.42 This goal could be shared by members of the APN 

community by sharpening and aligning the APN research focus on systems of care. 

There are a number of informational or empirical issues lacking in the current APN evidence 

base. Future research must be independent, longitudinal, and directed to authoratitively answer 

the most urgent policy-relevant questions concerning APNs. Following are some of the questions 

that research into APN practice should address. 

Cost and Quality

• Do APNs create value for payers to improve the quality in health care? Is APN practice 

economically efficient and effective? Are APNs a competitive advantage in the health 

care marketplace? Does APN practice demonstrate a threshold improvement in lowering 

cost, reducing misuse, overuse, and errors? 

• What is the most reliable, valid, and feasible approach(es) to measuring quality of care 

delivered by APNs? 

• Are there certain settings (acute care, palliative care) or content areas (obesity, cardiac 

disease) that APNs are most effective? 

12 
Role & Impact of Nurse Practitioners

• How does APN practice uniquely respond to patient preferences? 

• What are the outcomes of APN interventions targeted at changing patient behaviors and 

lifestyle? Do APNs uniquely or qualitatively employ effective strategies to promote 

health and human wholeness and prevent disease? 

• What is the most effective health care team composition for acute care? Primary care? 

Palliative care? How do we build an evidence base on interdisciplinary approaches or 

“collaboratories” to function as incubators and disseminators of team-delivered care? 

• How do State nurse practice acts enhance or create barriers to safe, effective, and 

innovative APN-delivered care? 

Medicare 

• What is the advantage to Medicare to include APNs in its pay-for-performance 

initiatives? Do APNs, as central members of the health care team, demonstrate threshold 

quality improvements? How do these findings inform Medicare’s Graduate Medical 

Education program currently targeting primarily physicians? 

• How can the cost savings on APN practice be passed onto consumers, Medicare, and 

other payers? 

Access 

• What impact do APNs have on vulnerable segments of the population? How do they 

impact the uninsured? Elderly? Children? Rural residents? How do APNs participate in 

the safety net? 

• How are access and quality of care impacted once a State has adopted NCSBNs 

regulatory vision for APN practice, which eliminates barriers to APN practice? 

• Does APN practice improve health care disparities? Do improvements benefit minority 

populations preferentially? 

Educational Issues 

• How are APNs demonstrating interdisciplinary patient safety curricula with educational 

simulation techniques for use early in professional schooling, continuing throughout 

training, and at intervals during professional practice? 

• How do APNs maintain continued competence throughout their career trajectory? 

• What would be included in a curriculum that demonstrated competency in patient safety? 

Data and Dissemination Issues 

• How can the Health Resurces and Services Administration’s National Sample Survey of 

RNs be conducted more frequently, expanded and designed to include a sample of APNs? 

How frequently should the survey be conducted in order to yield the most timely 

workforce projections? 

• How do APNs get built into the Area Resource File? 

• How can a database on APNs answer the following questions? 

o How many ANPs are there? 

o Where do they practice, what do they practice, and who do they care for? 

o What constitutes a full-time equivalent APN? 

13 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

• When do APNs enter the workforce, and when and how to they leave/retire? 

• How should APNs be included in shortage designation methodologies? 

• What would a national, integrated workforce planning initiative look like? 

• What is the best way to communicate APN-related research to the public, policymakers, 

payers, and media? 

Conclusion 

In addition to developing a robust APN research agenda, APN organizations must strategize 

to have APNs appointed to Federal and private advisory commissions that oversee or develop 

quality improvement measures. APN organizations must also identify key corporate boards and 

develop long-term strategies and political capital to get APNs appointed to those influential 

boards. This sector of the health policymaking process is increasingly influential as payers seek 

to know more about what they are getting from their health care dollar vis-à-vis pay-forperformance initiatives. 

Findings from APN research must be published in journals outside of nursing to reach a 

broader policymaking and public audience. Key policymakers as well as the public could be 

made more aware of the contributions that APNs make in reducing health care costs and 

improving access and quality of care. Achieving broader recognition, reducing APN invisibility, 

and removing barriers to APN practice will be contingent on APNs communicating 

methodologically sound APN research that produces results that are generalizable to the larger 

delivery system. 

Search Strategy 

Both MEDLINE® and CINAHL® databases were searched to locate literature for this review. 

The search terms were “advanced practice nursing,” “certified nurse midwives,” “certified 

registered nurse anesthetists,” “clinical nurse specialists,” “nurse practitioners,” “quality,” 

“safety,” and “outcomes.” For both databases, the searches were limited to research articles 

published in the English language between 1991 and 2006 and restricted to research within the 

United States. 

There were 97 articles identified in the CINAHL search and 54 identified by the MEDLINE 

search, with some duplication in the citations identified by the two databases. All abstracts were 

reviewed and most were eliminated from further consideration because they were not evidence 

based or there were methodology concerns. For example, articles about advanced practice roles, 

delivery models, theoretical papers, educational and curriculum issues, international issues, 

advanced practice nursing in defined specific populations (e.g., rural, emergency departments, 

gerontological) or diseases (e.g., sexually transmitted infection, heart disease), and all metaanalyses and studies with fewer than 70 subjects were omitted from this review. Once the 

unrelated articles were eliminated, a complete copy of each of these papers was acquired and 

read. Four professional associations were contacted to obtain the strongest research papers on the 

four APN roles (American College of Nurse Midwives, American Association of Nurse 

Anesthetists, the American Association of Clinical Nurse Specialists, and the American College 

of Nurse Practitioners). Dominant among the reasons for excluding papers were that they were 

not research based, they were short reports that were lacking essential details, or there were 

methodological concerns. 

14 
Role & Impact of Nurse Practitioners

Author Affiliations 

Eileen T. O’Grady, Ph.D., R.N., N.P., policy editor, Nurse Practitioner World News and The 

American Journal for Nurse Practitioners. E-mail: e.ogrady@verizon.net. 

References 

1. American Association of Colleges of Nursing. 

AACN position statement on the practice doctorate in 

nursing. Washington, DC: Author; 2004. 

2. Bureau of Labor Statistics, U.S. Department of 

Labor. Occupational Outlook Handbook, 2006-07 

edition, registered nurses. 

http://www.bls.gov/oco/ocos083.htm 

3. Hamric AB, Spross JA, Hanson CM. Advanced 

practice nursing: an integrative approach. 3rd ed. St. 

Louis: Elsevier Saunders; 2005. Chapter 3, A 

definition of advanced practice nursing. 

4. American Association of Colleges of Nursing. 

AACN essentials of doctoral education for advanced 

nursing practice. Washington, DC: Author; 2006. 

5. American Association of Colleges of Nursing. 

AACN doctorate of nursing practice roadmap task 

force report. Washington, DC: Author; 2006. 

6. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is 

human: building a safer health system. A report of 

the Committee on Quality of Health Care in America, 

Institute of Medicine. Washington, DC: National 

Academy Press; 2000. 

7. Institute of Medicine. Crossing the quality chasm: A 

new health system for the 21st century. Washington, 

DC: National Academy Press; 2001. 

8. Institute of Medicine. Health professions education: 

A bridge to quality. Washington, DC: National 

Academies Press; 2003. 

9. American College of Nurse Midwives. 

http://www.acnm.org/. Accessed February 15, 2007. 

10. MacDorman MF, Singh, GP. Midwifery care, social 

and medical risk factors, and birth outcomes in the 

USA. J Epidemiol Community Health 1998 

May;52(5):310-7. 

11. Rosenblatt RA, Dobie, SA, Hart, LG, et al. 

Interspecialty differences in the obstetric care of lowrisk women. Am J Public Health 1997 

Mar;87(3):344-51. 

12. Oakley D, Murray, ME, Murtland, T. et al. 

Comparisons of outcomes of maternity care by 

obstetricians and certified nurse-midwives. Obstet 

Gynecol 1996 Nov;88:823-9. 

13. Davidson MR. Outcomes of high-risk women cared 

for by certified nurse-midwives. J Midwifery 

Womens Health. 2002 Jan-Feb;47:46-9. 

14. American Assocation of Nurse Anesthetists. 

http://www.aana.com/. Accessed February 15, 2007. 

15. Centers for Disease Control. Investigation of 

mortality and severe morbidity associated with 

anesthesia: Pilot study. Atlanta, GA: Author; 1988 

December 1. 

16. Pine M, Holt KD, Lou YB. Surgical mortality and 

type of anesthesia provider. AANA J 2003 

April;71:109-16. 

17. Brooten D, Youngblut JM, Brown I, et al. A 

randomized trail of nurse specialist home care for 

women with high risk pregnancies, outcomes, and 

costs. Am J Manag Care 2001 7:793-803. 

18. Topp R, Tucker D, Weber C. Effect of clinical case 

manager/clinical nurse specialist patients hospitilized 

with congestive heart failure. Nurs Case Manag 1998 

3(4):140-5. 

19. Naylor M, Brooten D, Jones R, et al. Comprehensive 

discharge planning for the hospitalized elderly. Ann 

Inter Med 1994 120:999-1006. 

20. Brooten D, Kumar S, Brown LP, et al. A randomized 

clinical trial of early hospital discharge and home 

follow up of very low birthweight infants. N Engl J 

Med 1996 (315): 934-9. 

21. American College of Nurse Practitioners. http:// 

www.acnpweb.org/. Accessed February 15, 2007. 

22. Hughes F, Clarke S, Sampson D, et al. Research in 

support of nurse practitioners. In: Mezy, MD, 

McGivern, DO, Sullivan-Marx, EM, eds. Nurse 

practitioners: evolution of advanced practice. 4th ed. 

New York: Springer Publishing Company; 2003. 

15 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

16 

23. Lambing AY, Adams DL, Fox DH, et al. Nurse 

practitioners and physicians’ care activities and 

clinical outcomes with an inpatient geriatric 

population. J Am Acad Nurse Pract 2004 16(8):343-

52. 

24. Mundinger MO, Kane RI, Lenz ER, et al. Primary 

care outcomes in patients treated by nurse 

practitioners or physicians: A randomized trial. 

JAMA. 2000:283;59-68. 

25. Lenz ER, Mundinger MO, Kane RI, et al. Primary 

care outcomes in patients treated by nurse 

practitioners or physicians: two-year follow up. Med 

Care Res Rev 2004;61:332-51. 

26. Avorn L, Everitt DE, Baler MW. The neglected 

medical history and theraputic choices for abdominal 

pain: a nationwide study of 799 physicians and 

nurses. Arch Intern Med 1991; 141:694-98. 

27. Agency for Healthcare Research and Quality. 

Systems to rate the strength of scientific evidence. 

Evidence Report/Technology Assessment No. 47. 

Rockville, MD: Author; 2002. 

28. American Nurses Association. Nursing-sensitive 

quality indicators for acute care settings and ANA’s 

safety & quality initiative. 

http://nursingworld.org/readroom/fssafe99.htm. 

Accessed February 15, 2007. 

29. Health Resources and Services Administration. 

Collaborative education to ensure patient safety. 

COGME/NACNEP. Rockville, MD: Health 

Resources and Services Administration; 2000. 

30. The President’s Advisory Commission on Consumer 

Protection and Quality in the Health Care Industry. 

Quality first: better health care for all Americans. 

Final report. Washington, DC; 1998. pp 201. 

31. Schrage M. The debriefing: John Seely Brown. 2000. 

Wired 2000 August 20; 4-7. 

32. Institute for Healthcare Improvement. Rapid response 

team record. http://www.ihi.org/IHI/Topics/ 

CriticalCare/IntensiveCare/Tools/RapidResponseTea

mRRTRecord.htm. Accessed February 21, 2007. 

33. Bodemheimer T, Wagner EH, Grumbach K. 

Improving primary care for patients with chronic 

illness: The chronic care model part II. JAMA. 

2002;288:1909-14. 

34. Cowan MS, Hays RD. The effect of a 

multidisciplinary hospitalist/physician and advanced 

practice nurse collaboration on hospital costs. J Nurs 

Adm 2006;36(2):79-85. 

35. Pearson L. The Pearson report. A national overview 

of NP legislation and health care issues. Am J Nurse 

Pract 2007;11(2):9-136. 

36. National Council of State Boards of Nursing. Joint 

Dialogue Working Group. Activities Update. 

https://www.ncsbn.org/APRN_Joint_Dialogue_Grou

p.ppt. Accessed November 8, 2007. 

37. National Center for Health Statistics. National 

ambulatory medical survey, The Centers for Disease 

Control and Prevention. http://www.cdc.gov/nchs/ 

about/major/ahcd/ahcd1.htm. Accessed February 20, 

2007. 

38. Center for Studying Health System Change (HSC). 

http://www.hschange.com/. Accessed February 14, 

2007. 

39. Health Resources and Services Administration. 

Bureau of health professions, shortage designation 

branch. http://bhpr.hrsa.gov/shortage/muaguide.htm. 

Accessed February 14, 2007. 

40. Institute of Medicine. Rewarding provider 

performance: aligning incentives in Medicare 

(Pathways to Quality Health Care Series). 

Washington, DC: National Academy Press; 2007. 

41. AcademyHealth. AcademyHealth Report, 2006 Dec; 

25 

42. Agency for Healthcare Research and Quality. AHRQ 

Strategic Plan 

http://www.ahrq.gov/about/strateix.htm. Accessed 

February 14, 2007. 
Evidence Table. Advanced Practice Nurses: Impact on Safety and Quality of Care 

Source Safety/Quality 

Issue Related to Clinical Practice 

Study Design, Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

Quality Evidence on CNMs Davidson 200213 High-risk obstetrical care Level 3. Univariate analysis on vaginal 

births after cesarean, forceps, and vacuumassisted deliveries, cesarean delivery, 5 minute Apgar score, maternal fever, and meconium stained amniotic fluid outcomes. 

High-risk mothers who received care from an urban, midAtlantic hospitalbased OB clinic during a 10-year period from 1988 to 1998, N = 803. 

Risk factors managed by CNMs compared to the national population. 

83% of the CNM deliverievaginal births, compared t79%. Seventy four percencesarean births delivered higher than the national avdelivery rates were considgroup (4%) compared to tOnly 12% of the CNM grocompared to the national aresearcher concludes that quality care to high-risk wo

MacDorman 199810

Birth outcomes and infant survival 

Level 3. Logistic regression on infant, neonatal, post-neonatal mortality and risk of low birth weights. 

All singleton vaginal births at 35–43 weeks gestation in the United States in 1991, N = 810,790. 

CNM care compared to physiciandelivered births. 

After controlling for medicthe risk of experiencing an lower for CNM-attended thbirths, the risk of neonatal and risk of delivering a low31% lower. National data have excellent birth outcomoderate-risk women. 

Oakley 199612 Pregnancy/ 

perinatal outcomes 

Level 3. Logistic regression analyzed outcome measures: infant and maternal outcomes, 30 clinical indicators, satisfaction with care, and monetary charges. 

At intake, all women qualified for CNM care and a convenience sample identified 710 low-risk, singleton pregnant women cared for by obstetricians and 471 cared for by CNMs in private practice.

CNM care compared to obstetrician care. 

After controlling for social multivariate analysis found ≤ 0.05) differences betweeon 7 outcome measures. vs. 4% CNM), infant remaentire hospital stay (15%O

degree perineal lacerationnumber of complications (satisfaction with care, ave($5,427 OB vs. $4,296 CNfee charges ($3,425 OB vconcluded that CNMs provmaternity care for low-risk contribute to lowering matimproving maternal outcom

17
18

Source Safety/Quality Issue Related to Clinical Practice Study Design, Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key Finding(s) Rosenblatt 199711 Patterns of obstetric care Level 3. Provider behavior pattern was the unit of analysis; outcomes included cost of prenatal and intrapartum care. In Washington State, CNM

deliver babies without an oObstetricians were more lamniocentesis in the prento family physicians (1%) Obstetricians were far mosection (15 %) than family CNMs (9%). CMNs were faugment (episiotomy, epidpatients during delivery. TCNMs have a different apthan their physician collearesources. Quality Evidence on CRNAs Pine 200316 Surgical patient safety related to type of anesthesia provider Level 3. Surgical mortality restricted to carotid endartectomies, cholecystectomies, herniorrhaphies, mastectomies, hysterectomies, prostatectomies, and knee replacements. Retrospective observation on Medicare patients, N = 404,194, from 22 States from 1995 to 1997. Anesthesia- related deaths among anesthetists vs. nurse anesthetists. There is no statistically sig

mortality rate for CRNAs aworking together or individmortality is not affected by provider is a CRNA or an 

Quality Evidence on CNSs Brooten 200117 Prenatal, maternal, 

and infant outcomes 

Level 1. Randomized clinical trial n = 173 women and 194 infants. 

1-year study period in one delivery system of women at high risk for delivering low-birthweight infants. 

Half of the study sample received prenatal care in the home by CNS while they received traditional obstetrical care. 

Group cared for in the homdeaths compared to the copreterm infants, 78% of twterm (9), control group = 3hospitalizations, 18 infant group = 24). CNS home chospital days or about $2.
19

Source Safety/Quality 

Issue Related to Clinical Practice 

Study Design, Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

Brooten 199620 Safety and cost 

effectiveness of care by CNSs. 

Level 1. Randomized clinical trial, n = 79 

patients in one system. Outcomes included hospital costs, physician fees, home followup care by CNSs. 

Very low-birthweight infants discharged from a hospital early. 

Home care followup by CNS. 

Mean hospital costs were group ($47,520 vs. $64,94physician charge was 22% group cared for in the homof home care was $576, y$18,560

Naylor 199419 Hospital transition 

to home for frail elderly 

Level 1. Randomized clinical trial; initial hospital discharge until 6 weeks after discharge. 

Medical and surgical patient and caregiver posthospital discharge outcomes and cost of care, N = 276 patients and 125 caregivers 

Comprehensive CNSdelivered discharge planning protocol. 

The medical patient group readmissions, fewer total readmission, lower readmsurgical intervention group differences with the controdischarge period. 

Topp 199818 Effect of CNS case 

management 

Level 4. Quasiexperimental comparative, correlational. Outcomes included nursing interventions, length of stay, complication rate. 

Chart review of 164 post-op total knee replacements in one delivery system. 

CNS case management 

Patients in the units with Cnursing interventions, had 

Quality Evidence on NPs Avorn 199126 Treatment 

comparisons between NPs and MDs 

Level 4. Randomized selection of MDs and NPs given a case vignette. 

501 MDs and 298 NPs were presented a case vignette. 

Hypothetical scenario involving epigastic pain 

More than one-third of the initiate therapy without see

Nearly half of all physician

prescription would be the therapy; 65% recommend

By contrast, only 19% of N

taking further history; the naverage of 2.6 questions v

These findings suggest thand were less likely to recmedication when not indiccircumstances. 
20

Source Safety/Quality Issue Related to Clinical Practice Study Design, Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key Finding(s) Lambing 200423 Acute care outcomes of frail elderly Level 4. Descriptive comparative, research using a convenience sample of providers and self report. Outcomes measures obtained from claims data include charges for length of stay, hospital readmission, and mortality rates. Random selection of 100 inpatient geriatric patients and a convenience sample of 17 professional providers who cared for them in one hospital in the Midwest over 1 month. MD vs. NP provider NP patients were older (P 

admission (P ≤ 0.001) and 

Charges for length of stay 

the physician provider grogroup had shorter stays (P and mortality rates were sgroups. The authors conceffective care to hospitalizparticularly to those who a

Mundinger 200024 NP outcomes in primary care after an urgent or urgent care visit. Level 2. Randomized clinical trial between August 1995 and October 1997 with patient interviews at 6 months after initial appointment and health services utilization. Four community- based primary care clinics ( 17 physicians) and 1 primary care clinic (7 NPs) at an urban academic medical enter, N = 1,316. NP practice with the same degree of independence as MDs, compared to MD process outcomes. No significant differences 

health status at 6 months. patients with diabetes or aFor hypertensive patients, significantly lower for NP pP < 0.04). No significant dhealth services utilization There were no differences following the initial appoinat 6 months differed for 1 (provider attributes), with 4.5 on a scale where 5 = eAuthors conclude that primNPs are comparable to Msame level of authority, reand administrative require

Lenz 200425 2-year followup of 

outcomes on patients followed by NPs and MDs 

Level 2. Randomized clinical trial (of same sample in Mundinger, 2000) 

N = 406 adults Health status, 

diseasespecific physiologic measures, satisfaction or use of specialist, emergency or inpatient services. 

Results consistent with 6-Mundinger, 2000). The bothat the quality of primary equivalent to that of MDs. 

CNM = clinical nurse midwife; CRNA = clinical registered nurse anesthetist; CNS = clinical nurse specialist; NP = nurse practiti