Shifting patterns of practice: nurse practitioners in a managed care environment.

The purpose of this qualitative study was to uncover patterns across nurse practitioner (NP) experiences that contribute to understanding their perceptions of managed care, how it affects daily practice, and how NPs respond to a changing managed care workplace. In-depth interviews were conducted with 14 NPs representing primary care, specialty, and independent practices. Over an 18-month period, data collection and analysis occurred simultaneously using standard methods of purposive sampling, constant comparison, memoing, and member checks. This study illuminates the tension NPs experience between a business and a professional ethic and the strategies they use to reconcile this difference with core nursing values. Type of setting, workplace dynamics, and length of time in practice contributed to variation in NP perspectives. Keywords: values; dual agency; nurse-patient relationship; work environment; nurse practitioners Over the past 10 to 15 years, managed care has seen increased growth in the United States health care delivery system. Market penetration of this form of care varies regionally; 74% of Americans employed by firms with more than 200 workers now belong to managed care health plans (Gaffney, 1997). Nurse practitioners (NPs) have expanded their numbers significantly since the 1980s, the same time period when managed care began to dominate health care. The well-documented positive outcomes of NP care in the primary care setting, along with less costly salaries in comparison to physicians, make NPs attractive to managed care administrators. The literature on managed care speaks from business, social science, and health care perspectives and raises structural, socio-political, and ethical concerns. Communication and dialog on these issues of managed care are essential to establishing the NP's place in this system. MANAGED CARE AND NP PRACTICE Research on the effect of managed care on NP practice is limited. In a Delphi survey to explore perceptions of NPs and clinical nurse specialists (CNSs) regarding the influence of managed care on their practice, Harrison (1999) found that increased autonomy may diminish NPs' perceived threats from managed care; however, NPs viewed resource issues as affecting the quality of patient care. The expansion of the NP role to extend beyond primary care was viewed positively, but encroachment upon NP practice by other disciplines, employers, and managed care administrators indicated a need for vigilance. Exclusion of NPs on managed care organization (MCO) provider panels has been discussed as a barrier to NP practice. A survey on the credentialing of NPs by MCOs found that a large percentage of NPs had never applied for MCO panel status (Mason et al., 1999). This decision was influenced by the behavior of employers or administrators. The presence or absence of support from coworkers or superiors was also a major finding influencing NP role performance regardless of setting in a study conducted by Hupcey (1993) 6 years earlier. Ethical issues related to managed care are cited frequently in the theoretical literature (Pellegrino, 1999; Randel, Pearson, Sabin, Hyams, & Emanuel, 2001; Wurzbach, 1998). A survey to explore whether managed care raised ethical conflicts for NPs in the delivery of patient care (Ulrich, Soeken, & Miller, 2003) found that the majority of NPs reported moderate to extreme concerns with managed care and 80% reported bending the rules to benefit patient care. Interestingly NPs in HMOs had significantly lower ethical concern scores and perceived more favorably the ethical climate at the worksite than NPs in other types of practice settings. On the other hand, physicians who practiced in higher HMO penetration areas had decreased their stance of undivided loyalty to the patient (Sulmasy, Bloche, Mitchell, & Hadley, 2000). Results of these studies lend support to the premise that differences in state policy as well as administrator and employer support may influence managed care arrangements with NPs. …