Are Nurse Practitioners The Solution To Indiana’s Physician Shortage?

More nurse practitioners are stepping up to meet the needs of Hoosier patients as Indiana grapples with a shortage of primary care doctors.

Nurse practitioners and other advanced practice nurses go through extended education and training so they can treat patients similar to medical doctors. Whereas nurses provide a supportive role in the doctor’s office, nurse practitioners can oversee wellness visits, order tests, diagnose illnesses and prescribe medicine.

"I think there's still a knowledge deficit about our role," said Lu Sclair, a nurse practitioner with Indiana University Health Southern Indiana Physicians in Martinsville. "We're looked at, I think, consequently, as somewhat of an inferior element."

By 2020, Indiana is predicted to have 500 fewer primary care doctors than needed to treat its growing and aging population, according to the Robert Graham Center, an independent research unit affiliated with the American Academy of Family Physicians. By 2030, that deficit will increase to more than 800.

There’s a lot driving this pending shortage of primary care doctors who are often the first line of defense in preventing serious health complications. Medical degrees are expensive, and jobs in primary care don’t pay as well as specialty practices. So a lot of doctors end up working in cities and specializing. Nurses who go back to school, on the other hand, earn a pay bump when they move into advanced practice in primary care.

But some nurse practitioners say advanced practice nurses in Indiana are limited by outdated teaching methods and government regulations that tie them to a physician required to oversee their work. Now, organizations like the Coalition of Advanced Practice Nurses of Indiana are pushing to give nurse practitioners full prescribing ability.

"That is a huge barrier," said Kathleen Kent, a certified nurse practitioner and clinical assistant professor at the Indiana University School of Nursing.

Primary care in rural communities

Rural areas are hit hardest by the physician shortage, Kent said. New doctors can graduate from medical school hundreds of thousands of dollars in debt, and working at a primary care clinic in rural Indiana won't quickly pay off their student loans.

Advanced practice nurses, however, often earn their degrees after spending years as nurses in underserved communities. These are communities where they will return to work as nurse practitioners, certified nurse midwives and clinical nurse specialists.

"If we can get our students out there and get them educated in that community, they'll be more likely to practice in that community when they graduate," said Carol Clark, family nurse practitioner program coordinator at the IU School of Nursing. "There is no reason why they wouldn't be able to jump right in and take care of patients."

Steps in the right direction

Clark and Kent said their colleagues could do more to help fill the gaps in care left by fewer primary care doctors if they had more control over their practices.

In Indiana, advanced practice nurses are required to have written collaborative practice agreements with physicians in their specialties. A doctor, as part of that agreement, reviews some of the nurse practitioner's charts to ensure proper prescribing and diagnosing.

This means advanced practice nurses and doctors often end up clustered in cities, while rural areas are left without coverage. This was true for Kent. She said had difficulty finding a collaborating physician while working in rural Indiana as a nurse practitioner in pediatrics.

"Therefore, I wouldn't be able to prescribe," she said. "Until we start making primary care a priority, it's going to be very hard to keep providers in those rural systems."

Advocates celebrated two "big step(s) in the right direction" toward prescribing authority this year, Kent said. New laws allow advanced practice nurses and physician assistants to sign treatment forms that detail preferences for life-sustaining treatments for people with serious illnesses, such as orders not to attempt resuscitation during a heart attack.

The term advanced practice nurse was also legally changed to advanced practice registered nurse, a title that advocates say better reflects the education needed and the authority of nurse practitioners.

A new teaching model

While Indiana has only two medical schools, at least half a dozen colleges and universities around the state have advanced practice nursing programs. Students can also earn their advanced degree online. But the way advanced practice nurses are taught and trained isn't as effective as it could be, Kent and Clark said.

Before they are licensed, advanced practice nursing students must spend between 500 and 600 hours in a clinical setting. The many advanced practice nursing programs compete for limited clinical spots. And traditionally, the teaching model has been one student to one teacher, also called a preceptor.

"It’s a really great way to learn, but it's also very resource intensive," Kent said.

Kent, Clark and Sharon Riesner, also faculty at the IU School of Nursing, researched how pairing two nursing students with one preceptor might be a better teaching model.

The researchers found that students, who often come into advanced education with a strong background in nursing, learned as much from each other as they did the preceptor. Their findings were published this year in the Journal for Nurse Practitioners.

"Everyone comes to the table with different skills and different knowledge," Kent said. "We learn every single day in health care because it is a dynamic field."

Sclair has been a nurse practitioner for 13 years. In that time, she said she's seen a resurgence of health care issues like diabetes, high blood pressure and cardiovascular disease. These are illnesses that can often be managed with lifestyle changes and prevented with education by health care workers like nurse practitioners. Sclair said she and other nurse practitioners can fill gaps in education to lessen the burden these patients put on the health care system.

"We're here to be teachers and mentors to our patients and to be, as much as we can, advisors and healers for them," Sclair said.

This story was produced by Side Effects Public Media, a news collaborative covering public health.