The Institute of Medicine has recognized that increasing the number of NPs in primary care can help address quality-of-care issues and increased demand for services. In a recent qualitative study, researchers surveyed 16 members of the Massachusetts Coalition of Nurse Practitioners to determine the current state of the NP workplace climate. Most worked full-time; the settings were varied: physicians' offices, group practices, primary care offices associated with hospitals or academic centers, and community health centers.

The authors identified five themes they deemed important to the soundness of the NP work environment: relationships with physicians, independent practice and autonomy, professional visibility, organizational support and services, and the relationship with the administration. Most (though not all) NPs reported collegial relationships with physicians. The NPs' level of autonomy varied because of differing policies in the practices, some of which contradicted and were more restrictive than Massachusetts state law requires. NPs commonly reported a lack of understanding of their roles and competencies within their practices, particularly among administrators, leading to diminished professional visibility (similarly, the NPs were also not well represented within their practices' administrations). For example, most NPs reported that their practices don't bill NP visits as primary care visits despite the Massachusetts law recognizing NPs as primary care providers. Although a significant number of NPs in the study reported receiving adequate support and resources, some said that they have access to fewer resources than physicians do.

Convenience sampling limits extrapolation of the results to the entire state, and responses would certainly vary in other states because of differing state policies. Nevertheless, the authors believe that administrators, researchers, and policymakers wishing to improve working conditions of NPs should be aware of these five facets of the work environment. Such awareness will aid in supporting NPs in the provision of high-quality care and ameliorate the current shortage of health care providers.

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