If I may address the somewhat one sided nature of this debate by mentioning issues from the other side.

Where research has looked at equivalence of care between ENPs and SHOs it has tended to judge outcomes by a scientific paradigm. Engebretson, J. (1997). A multiparadigm approach to nursing. Advances in Nursing Science, 20(1), 21-33 makes some worthwhile points in that nurses expanding their practice move away from a pure scientific paradigm to a multiparadigm approach incorporating science within an holistic approach. ("Holistic theories are global, espouse a transcendental view of humans, and are committed to not viewing subject matter as an accumulation of parts"). 
If patients are seen as the carrier of a condition requiring diagnosis and treatment of that diagnosis then based purely on diagnosis and treatment SHOs and ENPs are equivalent but ENPs are more expensive because of increased length of consultations. If however you take the attitude that the extra length of consultation adds value by allowing a deeper understanding of the person as a whole then ENPs could be said to be more cost effective. Bear in mind that a significant number of ED attendees (in some departments possibly the majority) do not have a disease that medical treatment will significantly affect. In these patients an holistic approach to them as a person will obviously be of more benefit than a pure diagnosis centred approach.
This way of looking at it also moves away from the idea of "ENPs work to protocols". ENPs incorporate protocols but their holistic approach moves further away from the disease/ pathway/ protocol driven way of working than the usual way of doctors working does.
F. C Donald and C. McCurdy. Review: nurse practitioner primary care improves patient satisfaction and quality of care with no difference in health outcomes. Evid. Based Nurs., October 1, 2002; 5(4): 121 - 121. at first seems to have a strange title (how can you claim to improve quality of care if you don't improve outcomes- surely to a patient it is outcome not process that matters) but if you move to judging quality of care by its effect on the patient as a whole rather than by its effect on the disease it is more understandable.

Going back to a pure scientific paradigm, several studies have shown statistically significant improved patient satisfaction with NPs. This is fairly weak evidence though- it is not generally found in studies in EDs. A criticism of it is that the studies have tended to be in settings where NPs have had longer consultation times than doctors and have had relatively low return rates. It would be reasonable to suspect a selection bias in these cases with patients with the time to fill in satisfaction forms tending to be those who preferred longer consultations. Again, though, this is thing worth putting into your cost/ benefit analyses.

Another point worth considering is the effect on doctors of use of NPs. There is almost an assumption that use of NPs will reduce the workload of doctors with total workload remaining the same. If this is the case and you take a disease centred approach to quality, then you could argue that use of NPs costs slightly more for the same service. Some studies however have shown an increase in total workload with the use of NPs. It could be argued in these cases that NPs are meeting a previously unmet need and increasing quality.

Overall the idea that switching from SHOs to ENPs results in a similar service at higher cost is over simplistic.

Matt Dunn


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