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OCR for page 105
COMMENT
Loretta C. Ford, R.N., Ed.D.
Dean and Director of Nursing
University of Rochester Medical Center
March 1978
Over the past two years, the Institute of Medicine's Committee to
Study an Integrated Manpower Policy for Primary Care reviewed informa-
tive and analytical papers prepared by project staff members and grappled
with the conceptual and contextual problems of defining primary care
and setting forth recommendations for this report. Upon reviewing the
final draft of the report, I find myself, as a nurse practitioner and
educator, with certain reactions and reservations. This comment explains
those reactions and expresses concern about some of the recommendations,
particularly those dealing with the relationship of the physician to the
nurse practitioner.
Throughout the report, recognition is given to the "goodness of
fit" between the kinds of health problems for which people seek services
and the roles of non-physicians, nurse practitioners, and physician
assistants as providers of primary care. Emphasis on teamwork, equal
reimbursement, accountability for all professionals, and the need for a
data base and research to determine manpower needs are all laudable
aspects of the report.
However, there are noticeable imbalances and incongruities that I
am compelled to mention. Despite the heroic efforts of some committee
members to balance the health vis-a-vis illness content, the medical
and economic issues permeate the report without adequate consideration
for addressing the unmet needs of people. The maintenance of health,
early management of health problems designed to prevent hospitalization
or institutionalization, and the creation of incentives for self-care
received too little attention.
Incongruities also are apparent between the content of the report
and some of the recommendations. I take particular exception to Recom-
mendation #19 which singles out medical acts in delivering primary care
and specifically calls for physician supervision of nurse practitioners.
The effective domain for which professionals other than physicians are
primarily responsible, for example, nursing acts or pharmacy acts,
is not mentioned. My review of 24 state nursing practice laws, which
were changed to accommodate expanded role functions, reveals that only
two statutes have used the phrase "physician supervision."
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OCR for page 106
Primary care is a complex, problem-oriented issue that does not
lend itself to solution through the skills and controls of one disci-
pline. True interdisciplinary behavior must be learned by the providers
with an acceptable distribution of power, control, and accountability.
Some explorations of new and evolving relationships which are worthy of
continuing study are described in the publications of the National Joint
Practice Commission and the Academy of Nursing.*
In summary, my major concern is that incongruities exist between
the text of the report and some of the recommendations; this will limit
the usefulness of the report in establishing cogent public policies for
health. Instead of taking the giant steps for preparing teams of health
professionals to deliver primary care to all the people of this nation,
only small steps will be taken and token changes made. Once again, we
will experience "dynamics without change" in health policies.
*Together: A Case Book of Joint Practices in Primary Care, National
~ .-
Joint Practice Commission, editor Berton Roueche, Chicago, 1977.
Primary Care By Nurses: Sphere of ResDonsibilirv and Arrn''nt~hi ~ i For
American Academy of Nursing Annual Me
City, 1977.
Joint Practice in Primary Care: Definitions and Guidelines, National
Joint Practice Commission, Chicago, adopted September,
-106-
Representative terms from entire chapter:
practice commission
