Public
Health Briefs
The Family Planning Nurse Practitioner: Concepts and Results of Training MIRIAM MANISOFF, RN, MA, LEE W. DAVIS, MD, MSPH, HAROLD A. KAMINETZKY, MD, AND PHYLLIS PAYNE, RN
The Need The report of the Commission on Population Growth and the American Future1 points out that even with adequiate financing for fertility-related services, delivery systems will still encounter a shortage of physicians. It recommends that programs be created to train additional doctors, nurses, and paraprofessionals and the development of new patterns of utilization for them. Family Planning deals primarily with normal healthy women, but its success depends in large measure on patient understanding, cooperation, and the development of good rapport between patient and provider. Nurses are thus uniquely suited to assume greater responsibility in family planning and, while in short supply, they are far more numerous and more widely available than are physicians. The use of nurse-midwives2 and of non-nurses3'4 as providers of family planning services has been advocated. There is no doubt that the nurse-midwife, properly trained, can be effective. However, although their number is increasing they are in even shorter supply than the physician. The non-nurse, while potentially unlimited in numbers, requires at least double the time to be trained, and must usually be limited to the technical aspects of family planning.
General Concepts In 1972, a program to train nurses as Family Planning Nurse Practitioners was begun under the joint sponsorship Ms. Manisoff is Director, Professional Education, Planned Parenthood-World Population, 810 Seventh Ave., New York, NY
10019; Dr. Davis is Associate Professor for Allied Health Profes-
sions, and Dr. Kaminetzky is Professor and Chairman, Department of Obstetrics and Gynecology, New Jersey Medical School; Ms. Payne is Assistant Coordinator, Family Planning Nurse Practitioner Training Program, Planned Parenthood-Essex Count. Address reprint requests to M. Manisoff at PP-WP. Based on a paper presented at the 101st Annual Meeting of the American Public Health Association, November 4-8, 1973, San Francisco, CA, and revised August, 1975 for publication in the Journal. 62
of the Obstetrics and Gynecology Department of New Jersey Medical School, Planned Parenthood-World Population, and Planned Parenthood-Essex County. The basic concept and approach of this training program was that the family planning nurse practitioner to be produced would be concerned with and have the ability to analyze, plan for, implement, and evaluate many aspects of a family planning services program and not be simply a medical technician or a limited physician-surrogate. The family planning nurse practitioner was seen as a deliverer of all family planning services to normal patients, with medical backup and supervision for specific pathology and management problems. The training was directed toward making possible the delegation of as much decision-making authority as possible from the physician to the practitioner. Based on these concepts, specific training objectives for the program were
developed.
The Program Each class consists of ten trainees, the limiting factor being the provision of adequate clinical experience with appropriate supervision. Selection criteria include a position or definite promise of employment in a family planning program after training, and a commitment from the program's medical director to allow the trainee to function in the expanded role and to provide the appropriate medical supervision for this expanded role functioning. The course is 12 weeks of full-time study, consisting of approximately 1/3 didactic and 2/3 clinical experience. Lectures are given by full-time faculty members of the New Jersey Medical School, by the staffs of Planned ParenthoodWorld Population and Planned Parenthood-Essex County, and by selected consultants. Clinical supervision is provided by both physicians and nurses. The first two weeks are devoted almost entirely to didactic sessions in order to introduce the basic medical and nursing knowledge necessary for participation in clinical pracAJPH January, 1976, Vol. 66, No. 1
PUBLIC HEALTH BRIEFS
tice. The students are introduced to the pelvic examination through the use of a life size plastic pelvic model and by doing examinations on each other, with medical supervision. Clinical experience is provided in both free-standing and hospital-based clinics, thus exposing the students to different delivery settings and to varied techniques. Students participate in both medical and nursing activities in the clinics, while they continue to attend classes covering additional components of the curriculum. Class time in relation to clinic time decreases as the program progresses. Students are expected to prepare a term paper in an area of interest to them.
Student Evaluation The program has trained 80 students in eight classes from its inception to 1975. Thirty more students were in training during 1975. The 80 students have ranged in age from 22 to 61, the median being 35.8 years. Thirty-one students had baccalaureate or higher degrees; 45 were graduates of hospital or diploma schools of nursing; and four were graduates of two-year Associate Degree nursing programs. Eighteen of the 80-over 20%-have been from minority groups. Thirtytwo students were from health departments; 20 from Planned Parenthood Centers; 12 from hospital based programs; 12 from community based health programs; two from student health services in colleges; and two from private group practice. Twenty-six states and the District of Columbia have been represented. Trainees are evaluated in three broad areas during training-didactic knowledge, by means of interval examinations and a comprehensive final written examination; clinical experience, by an enumeration of the number of pelvic examinations and their accuracy and by specific experience records in each procedure; and clinical expertise (i.e. overall ability in patient management) by the supervising clinicians' evaluation and by a final oral examination.
Observations on Training Process and Outcomes The training program essentially prepared outpatient gynecologic practitioners with special expertise in family planning. The addition of an obstetrics module would yield a well-prepared obstetric-gynecologic out-patient nurse practitioner. The point to be emphasized is to make the training as well-rounded and complete at each level as time and money will permit, so that as much decision-making as possible can be delegated. The choice of a program length of 12 weeks, rather than a shorter period, in our experience is justified not only in terms of the extent and variety of clinical experience necessary to produce a well-rounded practitioner (rather than a technician), but also because more time is necessary to allow for the "maturing" of the trainee's skill and the development of her ability to synthesize the components of patient management. Students uniformly show a desire to concentrate initially on technical aspects such as the pelvic examination, IUD AJPH January, 1976, Vol. 66, No. 1
insertion, etc. But the importance of proper, comprehensive searching history-taking, not simply the filling out of a history form, is constantly stressed. While many nurses feel they already know how to do this, our experience has shown that much additional training is required. The same is true of patient teaching. Frequently nurses must unlearn much that they have been doing and acquire new and better skills in both areas. The early involvement by the student's home agency in planning for her return and utilization is of paramount importance in her successful integration in the expanded role. To this end, key people in each agency are invited to visit the program and are provided with suggested Job Descriptions, Standing Orders, Curriculum Outline, and Training Objectives.* After the students have been back at their agencies for three months, they are asked to complete a questionnaire as a basis for evaluating the effect of the training. This is usually followed by a site visit, including interviews with the trainees and their medical and nursing supervisors to gain first hand knowledge of the factors included in the questionnaire responses. Of the 80 nurses who have completed the program, all but five had added the patient management role to their functions after training. Four of these were among the first 30 nurses trained. Patient acceptance by physicians has been enthusiastic, especially those who have observed the nurse practitioner in action. Some doctors were somewhat slower to accept her new role completely and placed limitations on her practice, e.g., no initial examinations on new patients, and IUD insertions only with the doctor present. No medical catastrophes due to poor nurse practitioner judgment have been reported, nor have any lawsuits been initiated. Acceptance by other nurses appears to be a problem in some instances, although many graduates report good reception and understanding of their new role. The strong and unanimous expression of increased job satisfaction by the graduates appears based on the fact that they feel well prepared for their expanded role, and that they have more decision-making responsibility. The opportunity to do total patient care and do it well is a source of deep personal gratification. Salary increases-or their absence-is the most consistent area of dissatisfaction reported. Nurses in county health departments were least likely to have received any increases, compared with nurses from hospitals, planned parenthood, or community health agencies. The absence of new title categories in health departments to cover the nurse practitioner was frequently cited as an obstacle in providing such increases. In all instances, employing agencies were able to document specific improvements in the efficiency and/or effectiveness of their services directly related to the contributions of the family planning nurse practitioner. One final observation is that the proliferation of programs of widely varying lengths and approaches,5 as well as *Available on request from senior author 63
PUBLIC HEALTH BRIEFS
on-the-job training by individual physicians outside of formal programs-all purporting to prepare the family planning nurse practitioners-indicate a need for the eventual standardization and accreditation of training programs and the national certification of the various nurse practitioner categories.
Conclusions This experience confirms that (1) Family Planning Nurse Practitioner training objectives can be met in 12 weeks; (2) the need for this type of nurse practitioner is unequivocally present; (3) when properly trained and utilized she is well accepted by patients and colleagues; and (4) she
can improve and expand services in many, diverse real world situations.
REFERENCES 1. Report of the Commission on Population and the American Future. New York, New American Library, 1972 2. Majzlin, G. and Kohl, S. G., Family planning by nurse midwives: A significant concept in family planning program development. Advances in Planned Parenthood, Volume VII, 62-65, 1971 3. Ostergard, D., Broen, E. M., and Marshall, J. R., The family planning specialist as a provider of health care services. Fertility and Sterility, Vol. 23, #7 4. Ostergard, C. M., and Ostergard, D. R., Are R.N.'s the best family planning specialist recruits? Journal of Nurses Association of ACOG, Volume 2, #1, January/February, 1973 5.... Non-Physicians trained to provide medical family planning care. Family Planning Digest, Volume 2, #4, pp. 1-6, July 1973
Task Delegation to Physician ExtendersSome Comparisons JOHN K. GLENN, MSE, PhD, MSPH JAY GOLDMAN, DSc Studies of task delegation offer insights into the change process that appears to be occurring on the part of physicians who desire to use physician extenders effectively. Task analysis often is used as the mechanism to describe both the anticipated as well as actual roles of physician extenders. Over the past ten years, two principal types of physician extenders have been developed. The first type would include physician assistants, exemplified by the Duke University Physician Associate Program and by various Medex programs. The second type would include nurse practitioners, represented by an assortment of training programs and job titles. Extensive studies of "what physician extenders do" in practice are only beginning to be published.'-9 The American Society of Internal Medicine (ASIM) obtained data on 3,425 members in 1969 concerning their attitudes toward anticipated task delegation to physician extenders.10 The study reported here was conducted by the authors in eight medical practices and combines both anticipated and actual task delegation analyses. It used a task questionnaire aimed at the physician in which the sampling of tasks is identical to that used in the ASIM study. Both physician assistants and nurse Dr. Glenn is Assistant Professor, Department of Community Health and Medical Practice, School of Medicine, and Dr. Goldman is Professor and Chairman, Department of Industrial Engineering, College of Engineering, The University of Missouri, Columbia, MO 65201. At the time the study was made, Dr. Glenn was Special Research Fellow, National Center for Health Services Research, United States Public Health Service. Address reprint requests to Dr. Glenn at the University of Missouri-Columbia. This paper was submitted to the Journal in March, 1975. 64
practitioners are included in the sample of actual task delegation practices.
Methodology The task delegation study was one part of a more comprehensive analysis of impact of physician extenders on productivity. The investigators spent an average of three days in each practice selected for the study. The sites were selected with multiple criteria in mind. Each site involving physician extenders was recommended as "having successful experience using physician extenders" by outside opinions (physicians/researchers/training programs) familiar with physician extender practices. To this extent, the selection process was biased. However, since every site approached agreed to the study, the site personnel themselves did not alter the selection criteria. All sites operated on a fee-for-service basis and all physician extenders worked with physicians immediately available to them on site in the practice. Beyond these requirements, selection was based upon variety in geographical location, size of population center, medical specialty involved, and type of physician extender. Two sites (IC, CT) were clinics within hospitals; the remainder were solo practices (WL), partnerships (GX) and members of group practices of up to five physicians (NM, NO, NP). The one site (VS) which did not use physician extenders was a rural general practice of four physicians and was included in the overall study as a conceptual control. AJPH January, 1976, Vol. 66, No. 1
Health Briefs
The Family Planning Nurse Practitioner: Concepts and Results of Training MIRIAM MANISOFF, RN, MA, LEE W. DAVIS, MD, MSPH, HAROLD A. KAMINETZKY, MD, AND PHYLLIS PAYNE, RN
The Need The report of the Commission on Population Growth and the American Future1 points out that even with adequiate financing for fertility-related services, delivery systems will still encounter a shortage of physicians. It recommends that programs be created to train additional doctors, nurses, and paraprofessionals and the development of new patterns of utilization for them. Family Planning deals primarily with normal healthy women, but its success depends in large measure on patient understanding, cooperation, and the development of good rapport between patient and provider. Nurses are thus uniquely suited to assume greater responsibility in family planning and, while in short supply, they are far more numerous and more widely available than are physicians. The use of nurse-midwives2 and of non-nurses3'4 as providers of family planning services has been advocated. There is no doubt that the nurse-midwife, properly trained, can be effective. However, although their number is increasing they are in even shorter supply than the physician. The non-nurse, while potentially unlimited in numbers, requires at least double the time to be trained, and must usually be limited to the technical aspects of family planning.
General Concepts In 1972, a program to train nurses as Family Planning Nurse Practitioners was begun under the joint sponsorship Ms. Manisoff is Director, Professional Education, Planned Parenthood-World Population, 810 Seventh Ave., New York, NY
10019; Dr. Davis is Associate Professor for Allied Health Profes-
sions, and Dr. Kaminetzky is Professor and Chairman, Department of Obstetrics and Gynecology, New Jersey Medical School; Ms. Payne is Assistant Coordinator, Family Planning Nurse Practitioner Training Program, Planned Parenthood-Essex Count. Address reprint requests to M. Manisoff at PP-WP. Based on a paper presented at the 101st Annual Meeting of the American Public Health Association, November 4-8, 1973, San Francisco, CA, and revised August, 1975 for publication in the Journal. 62
of the Obstetrics and Gynecology Department of New Jersey Medical School, Planned Parenthood-World Population, and Planned Parenthood-Essex County. The basic concept and approach of this training program was that the family planning nurse practitioner to be produced would be concerned with and have the ability to analyze, plan for, implement, and evaluate many aspects of a family planning services program and not be simply a medical technician or a limited physician-surrogate. The family planning nurse practitioner was seen as a deliverer of all family planning services to normal patients, with medical backup and supervision for specific pathology and management problems. The training was directed toward making possible the delegation of as much decision-making authority as possible from the physician to the practitioner. Based on these concepts, specific training objectives for the program were
developed.
The Program Each class consists of ten trainees, the limiting factor being the provision of adequate clinical experience with appropriate supervision. Selection criteria include a position or definite promise of employment in a family planning program after training, and a commitment from the program's medical director to allow the trainee to function in the expanded role and to provide the appropriate medical supervision for this expanded role functioning. The course is 12 weeks of full-time study, consisting of approximately 1/3 didactic and 2/3 clinical experience. Lectures are given by full-time faculty members of the New Jersey Medical School, by the staffs of Planned ParenthoodWorld Population and Planned Parenthood-Essex County, and by selected consultants. Clinical supervision is provided by both physicians and nurses. The first two weeks are devoted almost entirely to didactic sessions in order to introduce the basic medical and nursing knowledge necessary for participation in clinical pracAJPH January, 1976, Vol. 66, No. 1
PUBLIC HEALTH BRIEFS
tice. The students are introduced to the pelvic examination through the use of a life size plastic pelvic model and by doing examinations on each other, with medical supervision. Clinical experience is provided in both free-standing and hospital-based clinics, thus exposing the students to different delivery settings and to varied techniques. Students participate in both medical and nursing activities in the clinics, while they continue to attend classes covering additional components of the curriculum. Class time in relation to clinic time decreases as the program progresses. Students are expected to prepare a term paper in an area of interest to them.
Student Evaluation The program has trained 80 students in eight classes from its inception to 1975. Thirty more students were in training during 1975. The 80 students have ranged in age from 22 to 61, the median being 35.8 years. Thirty-one students had baccalaureate or higher degrees; 45 were graduates of hospital or diploma schools of nursing; and four were graduates of two-year Associate Degree nursing programs. Eighteen of the 80-over 20%-have been from minority groups. Thirtytwo students were from health departments; 20 from Planned Parenthood Centers; 12 from hospital based programs; 12 from community based health programs; two from student health services in colleges; and two from private group practice. Twenty-six states and the District of Columbia have been represented. Trainees are evaluated in three broad areas during training-didactic knowledge, by means of interval examinations and a comprehensive final written examination; clinical experience, by an enumeration of the number of pelvic examinations and their accuracy and by specific experience records in each procedure; and clinical expertise (i.e. overall ability in patient management) by the supervising clinicians' evaluation and by a final oral examination.
Observations on Training Process and Outcomes The training program essentially prepared outpatient gynecologic practitioners with special expertise in family planning. The addition of an obstetrics module would yield a well-prepared obstetric-gynecologic out-patient nurse practitioner. The point to be emphasized is to make the training as well-rounded and complete at each level as time and money will permit, so that as much decision-making as possible can be delegated. The choice of a program length of 12 weeks, rather than a shorter period, in our experience is justified not only in terms of the extent and variety of clinical experience necessary to produce a well-rounded practitioner (rather than a technician), but also because more time is necessary to allow for the "maturing" of the trainee's skill and the development of her ability to synthesize the components of patient management. Students uniformly show a desire to concentrate initially on technical aspects such as the pelvic examination, IUD AJPH January, 1976, Vol. 66, No. 1
insertion, etc. But the importance of proper, comprehensive searching history-taking, not simply the filling out of a history form, is constantly stressed. While many nurses feel they already know how to do this, our experience has shown that much additional training is required. The same is true of patient teaching. Frequently nurses must unlearn much that they have been doing and acquire new and better skills in both areas. The early involvement by the student's home agency in planning for her return and utilization is of paramount importance in her successful integration in the expanded role. To this end, key people in each agency are invited to visit the program and are provided with suggested Job Descriptions, Standing Orders, Curriculum Outline, and Training Objectives.* After the students have been back at their agencies for three months, they are asked to complete a questionnaire as a basis for evaluating the effect of the training. This is usually followed by a site visit, including interviews with the trainees and their medical and nursing supervisors to gain first hand knowledge of the factors included in the questionnaire responses. Of the 80 nurses who have completed the program, all but five had added the patient management role to their functions after training. Four of these were among the first 30 nurses trained. Patient acceptance by physicians has been enthusiastic, especially those who have observed the nurse practitioner in action. Some doctors were somewhat slower to accept her new role completely and placed limitations on her practice, e.g., no initial examinations on new patients, and IUD insertions only with the doctor present. No medical catastrophes due to poor nurse practitioner judgment have been reported, nor have any lawsuits been initiated. Acceptance by other nurses appears to be a problem in some instances, although many graduates report good reception and understanding of their new role. The strong and unanimous expression of increased job satisfaction by the graduates appears based on the fact that they feel well prepared for their expanded role, and that they have more decision-making responsibility. The opportunity to do total patient care and do it well is a source of deep personal gratification. Salary increases-or their absence-is the most consistent area of dissatisfaction reported. Nurses in county health departments were least likely to have received any increases, compared with nurses from hospitals, planned parenthood, or community health agencies. The absence of new title categories in health departments to cover the nurse practitioner was frequently cited as an obstacle in providing such increases. In all instances, employing agencies were able to document specific improvements in the efficiency and/or effectiveness of their services directly related to the contributions of the family planning nurse practitioner. One final observation is that the proliferation of programs of widely varying lengths and approaches,5 as well as *Available on request from senior author 63
PUBLIC HEALTH BRIEFS
on-the-job training by individual physicians outside of formal programs-all purporting to prepare the family planning nurse practitioners-indicate a need for the eventual standardization and accreditation of training programs and the national certification of the various nurse practitioner categories.
Conclusions This experience confirms that (1) Family Planning Nurse Practitioner training objectives can be met in 12 weeks; (2) the need for this type of nurse practitioner is unequivocally present; (3) when properly trained and utilized she is well accepted by patients and colleagues; and (4) she
can improve and expand services in many, diverse real world situations.
REFERENCES 1. Report of the Commission on Population and the American Future. New York, New American Library, 1972 2. Majzlin, G. and Kohl, S. G., Family planning by nurse midwives: A significant concept in family planning program development. Advances in Planned Parenthood, Volume VII, 62-65, 1971 3. Ostergard, D., Broen, E. M., and Marshall, J. R., The family planning specialist as a provider of health care services. Fertility and Sterility, Vol. 23, #7 4. Ostergard, C. M., and Ostergard, D. R., Are R.N.'s the best family planning specialist recruits? Journal of Nurses Association of ACOG, Volume 2, #1, January/February, 1973 5.... Non-Physicians trained to provide medical family planning care. Family Planning Digest, Volume 2, #4, pp. 1-6, July 1973
Task Delegation to Physician ExtendersSome Comparisons JOHN K. GLENN, MSE, PhD, MSPH JAY GOLDMAN, DSc Studies of task delegation offer insights into the change process that appears to be occurring on the part of physicians who desire to use physician extenders effectively. Task analysis often is used as the mechanism to describe both the anticipated as well as actual roles of physician extenders. Over the past ten years, two principal types of physician extenders have been developed. The first type would include physician assistants, exemplified by the Duke University Physician Associate Program and by various Medex programs. The second type would include nurse practitioners, represented by an assortment of training programs and job titles. Extensive studies of "what physician extenders do" in practice are only beginning to be published.'-9 The American Society of Internal Medicine (ASIM) obtained data on 3,425 members in 1969 concerning their attitudes toward anticipated task delegation to physician extenders.10 The study reported here was conducted by the authors in eight medical practices and combines both anticipated and actual task delegation analyses. It used a task questionnaire aimed at the physician in which the sampling of tasks is identical to that used in the ASIM study. Both physician assistants and nurse Dr. Glenn is Assistant Professor, Department of Community Health and Medical Practice, School of Medicine, and Dr. Goldman is Professor and Chairman, Department of Industrial Engineering, College of Engineering, The University of Missouri, Columbia, MO 65201. At the time the study was made, Dr. Glenn was Special Research Fellow, National Center for Health Services Research, United States Public Health Service. Address reprint requests to Dr. Glenn at the University of Missouri-Columbia. This paper was submitted to the Journal in March, 1975. 64
practitioners are included in the sample of actual task delegation practices.
Methodology The task delegation study was one part of a more comprehensive analysis of impact of physician extenders on productivity. The investigators spent an average of three days in each practice selected for the study. The sites were selected with multiple criteria in mind. Each site involving physician extenders was recommended as "having successful experience using physician extenders" by outside opinions (physicians/researchers/training programs) familiar with physician extender practices. To this extent, the selection process was biased. However, since every site approached agreed to the study, the site personnel themselves did not alter the selection criteria. All sites operated on a fee-for-service basis and all physician extenders worked with physicians immediately available to them on site in the practice. Beyond these requirements, selection was based upon variety in geographical location, size of population center, medical specialty involved, and type of physician extender. Two sites (IC, CT) were clinics within hospitals; the remainder were solo practices (WL), partnerships (GX) and members of group practices of up to five physicians (NM, NO, NP). The one site (VS) which did not use physician extenders was a rural general practice of four physicians and was included in the overall study as a conceptual control. AJPH January, 1976, Vol. 66, No. 1
