medical nurse practitioner

8/3/2019 Medical Nurse Practitioner

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M A R K E T I N GA N D PRKBIOTICBV FO R T H EM E D I C A L N U R S E P R A C T I T I O N E R

Douglas FugateDillard Tinsley

This article discusses the development ofmarketing programs for the Medical Nurse Prac-titioner (MNP ). The role of, and the barriers to,marketing, as they ap ply to the independentnursing practice, are examined. The authorscritically analyze the selection of target markets,the characteristics of these market segments andthe importance of marketing promotions in re-gard to the MNP concept.

Doukas Fugate is an Assistant Professor of Marketing atWestern Kentucky University. He received his Ph.D. from theUniversity of Missouri-Columbia. Doug's articles have appearedin the Pittsburgh State Untversity Business and Econom icReview, the Management Review and a variety of other publi-cations.Dillard Tinsley is a Professor of Marketing at Stephen F.Austin Un iversity. He received his D.B.A. from Texas Tech andhas published extensively to include the Joumal of Purchasingand Materials Mana gement, Akron Business and Econom ic

Review. Joumal of Small Business Management and tof Business Communications.

Tb e nursing profession bas a long stand inberitage of providing care and counsel to tbe itbe injured, and tbe infirm^ normally undtbe supervision of a pbysician. In recent yeartbis traditional relationsbip between nurses anpbysicians bas been subjected to a critical bcautious reexam ination. In particular, manbelieve tbat nurses can be trained to, and sboulbe allowed to, treat certain medical problemw itbo ut direct pbysician con trol. One sucbeliever was a nurse, Lucille Kinlein, wbo wafounder of one of tbe most successful independent nursing practices in tbe United States. Sband otbers like ber, some using tbe title of nurspractitioner (NP), bave attempted to redefintbe boundaries of tbeir nursing practice and tcontro l tbeir practice obligations. Not suprisingly, tbis practice of "medicine" by nurseis a controversial issue witbin, and outside, tbnursing vocation. Wbile tbe majority opinioappears to support tbe probibition of medicaacts by nurses, tbere are many willing to recognize tbe existence of overlapping functions between pbysicians and trained nurses (mostlregistered nurses witb graduate degrees and/ospecialized trainin g). Tbe re is also a willingnesto " sb are " certain duties witbin a controllebealtb care environment. Even witb somewbalimited support, tbis amended nursing systemnow encompasses a range of over 100 accepte

The term "practice of professional nursing" means thperformance for compensation, of any acts in the observationcare and counsel of the ill, injured, or infirm or in the maintenance of health or prevention of illness of others based


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Marketing for the Nurse Practitioner / 9diagnoses covering more than 37 areas of diag-nostic nomenclature (Nursing Clinics of NorthAmerica, 1979).

A number of these diagnoses are medicalacts as traditionally defined by most state nurs-ing practice statutes. Even though some wouldprefer to call these acts "expanded" or "ad-vanced" nursing roles, there is no apparent be-havioral difference between nursing diagnosisand treatment, and medical diagnosis and treat-m ent. Fo r lack of a mo re precise term , the ap-propriately trained and certified nurse wholegally practices these medical acts with orwithout a physician/sponsor is hereafter identi-fied as a medical nurse practitioner (MNP).The term MNP would include, among others,several categories of nurses who are currentlyin independent or traditional employmentpractice as nurse practitioners, e.g., pediatricand psychiatric, and nurse clinicians.

A number of behavior and political changeshave accelerated the evolution of independentnursing prac tice. The general public has becom emore concerned about the cost and quality ofprimary health care, as well as more aware thathealth maintenance and preventative medicine aredesirable alternatives to health care treatment.To this extent, "Independent practitioners areriding the wave created by increased consumerawareness of client need to participate in healthcare decision, and the increasing popularity ofself care idea s" (Edm unds , 1980). Regulatorybodies have also recognized that the nursing pro-fession can be more responsive to, and more re-sponsible for, basic hea lth care conc erns. Todate, several states have authorized the provisionof adjunct m edical care by nurses. Oth er stateseither have established, or have under consider-ation, laws that would permit nurses to usestandard diagnosis and treatment protocols asmay be authorized by regulatory health boards(Leitch, et al, 1978).

Even with these changes, there are still manydifficulties to overcom e. Tebe rg repo rted tha ther greatest difficulties in setting up a pediatricnurse practitioner clinic came from mothers andphysicians reluctant to accept MNP managementof illness, from resistance from fellow nurses and

ancillary nursing personnel, and from legal con-fusion related to the MNP's role in hospital lia-bility, insurance payments, and lawful practice(1980).

At this point, the full implications of currentnursing and non-nursing developments are notyet appa rent. However, it does appear tha t, ata minimum, there is a legal and social mandatefor nursing practice reforms which would alterthe traditiona l physician-centered role of nursing.

The Role of MarketingAs with any new service offered to the pub-

lic, the provider must be concerned with themarketing functions of appropriate positioningand prom otion of the service. Ad m ittedly,there have been a number of articles which ap-proach the in dep end ent nursing practice as abusiness. However, most of them use a distri-butive approach and con cen trate on such ele-ments as building cash flow, layout, s^tart-upcapital, and other natural business classifi-cations (Edm unds, 1980; Agree, 1974; Drayeand Ste tson , 1975). There is little in the liter-ature which addresses target marketing for theindependent nursing practice or independentMNP. It is the position of the authors that theMNP must favorably influence potential users'perceptions and preferences regarding this formof health care provision, as well as favorablyinfluence perceptions and preferences of healthcare environment participants, whose cooper-ation is essential. The MNP who wishes to succeedin his or her role must market both the personand the concept of the independent practice.

Barriers to Marketingthe Independent Nursing Practice

The initial barrier to marketing the MNPmay be prohibitive state laws that do not allowa nurse to practice nursing or medicine in a non-physician supervised setting. Once these laws


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10 / JHCM, VoL 1 , No. 2 (Spring, 19 81)are repealed, bowever, tbere may be some re-sistance by MNP's to market tbemselves be-cause of tbe tendency for professionals to resista strong business orien tation . Tbis resistance isgenerally attributed to tbe following factors:

1. Disdain of Commercialism Few pro-fessionals like to tbink of tbemselves asbusinessmen. Many sbow bostility toany su^estion tbat tbey are motivatedby money, ratber tban service to tbeirclien ts. Discussion of fees is usuallydistasteful to tbem;

2. Association Codes Ethics Professionalassociations bave erected stringent rulesagainst comm ercial bebavior. Adver-tising, direct solicitation, and referralcomm issions bave been ban ned . Pro-fessional firms tend to adbere to certain"stand ards of good practic e" wbicb limit,to some extent, tbe use of effectivemarketing or sales tecbniques;

3 . Equating Marketing with Selling Be-cause of tbe bars or bans against selling,professional service firms sbow littleinterest in tbe subject of marketing, bav-ing made tbe error of equating market-ing w itb selling. Ma rketing is much moretban selling (Kotler and Connor, 1977).

Overcoming tbe resistance to marketing on tbepart of tbe individual M NP may prove to be adifferent task. How ever, mo re damaging op-position may come from tbe otber participantsin tbe bealtb care community (Sullivan, et al,1978 ). In tbe past, labora tories bave refused toperform tests requested by MNPs, and diagnosticspecialists bave been unco ope rative. Hospitalsmay even deny patient-visiting privileges to tbeMNP (Steel, 1978). Studies indicate tb at pbysi-cians refer patients to nurse practitioners to amucb lesser degree tban would be expected ontbe basis of pbysicians' stated attitudes (Con-nelly, et al, 197 9). In otber instance s, pbysi-cians bave initiated steps to restrict tbe activi-t ies of nurse practi t ioners t b r o u ^ amendmentsto state laws tbat govern medicine (Maulescb,1978).Tbe otber important source of resistance

can come from tbe consumers, or clients, tbemselves. Inno vation and ado ptio n studies consistently suggest tbat new service forms come into widespread usage only after tbe relativeadvantage of tbe service bas been establisbed bycredible resource persons. Unless MNPs can convince influential persons tbat tbey can providecertain needed services as, or even more, effectively tban pbysicians, tbis nursing innovationmay never become widely adopted by tbe generapublic. Two marketing tools comm only used toovercome tbese difficulties are: (1) segmentation, wbicb is used to divide tbe market intobomogeneous need sets or target markets, and(2) marketing promotions, wbicb can be usedto inform and persuade members of tbe selectedtarget markets.

Selection of Target MarketsTbe marketing concept is based upon identi-

fication and fulfillment of cons um ers' needs.Since man y n eed sets exist, it is often necessaryto divide tbe total market into more bomogene-ous segments. Probably tbe best segmentationapproacb for tb e MNP market is tbat of "bene-f its so u ^ t . " Tbose segments tbe MNP is able,and cbooses, to serve become tbe target mar-ket(s) for tb at MNP. A review of nursing litera-tur e identifies tb e following n eed s areas as well-suited for MNP performance:

Co ordin ation of an individual's or afamily's bealtb care needs; Provision of less expensive bealtb care; Provision of m ore flexible delivery ofbealtb care needs; Provision of mo re em path y, or greaterpersonal attention, in tbe delivery ofhealtb care; Provision of specialized am bu latory oroutpat ient beal tb care; Provision of ou tpa tien t counseling andbeal tb educat ion.

Since it is quite unlikely th at n o o ne MNP wouldprovide all of t h ^ e ser vi ce , selection of specificservice segmente sho uld reflect d ie training, inter-


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Marketing for the Nurse Practitiono- / 11est, and experience of the particular MNP. Thisselection should also reflect the needs of the par-ticular target market chosen.

Characteristics of SelectedTarget MarketsThe MNP can work jointly with physicians

and medical organizations, or he/she can in-dependently serve the patients that these pro-fessional sources reco m m end . The latter situa-tion greatly simplifies the MN P's m arke ting pro-blems especially that of gaining acceptance bythe general public. In either case, the MNP re-ceives the benefit of generalized legitimacy asa participant in a physician-initiated client re-lationship.

In selecting cooperating physicians, the MNPshould realize that the physicians most likely toutilize their services or refer patients are recentmedical school graduates, physicians who al-ready delegate many tasks to traditional nursingstaffs, and certain specialists (pediatricians,orthopedists, opthalmologists, and internists)(Fo ttler, et al, 1978). In one study, the servicethat physicians were most likely to refer toindependently practicing MNPs were in-homehealth care (50%), counseling about an illness(43%), emotional counseling (21%), conductingself-care classes (22%), and provision of healthma intenance activities (17%) (Davis, et al , 1979).This evidence suggests that the MNP may haveto offer services which are consistent with phy-sicians' exp ectation s. If the MNP does not wishto be limited primarily to the situations des-cribed above, non-medical organizations may bean attractive alternative target market.

The MNPs can serve non-medical institu-tions with many of their skilled services. Manyorganizations especially in ma nufacturingpresently hire physicians and nurses to be attheir plants during operating hours. The MNPmay be able to replace physicians in some ofthese facilities. In man y instances, the MNP canprovide greater specialization and a wider rangeof services than regular professional nurses. The

attractiveness of utilizing MNPs in such positionsmay be enhanced by the growing governmentalconcern with job-site primary health care andsafety.

Non-medical organizations may also be in-terested in the MNP's advisory services, such ascoordination of health maintenance needs andhealth care edu catio n. These could be pro-vided to employees under a fringe benefit plan.The fact tha t such services improve em ploye ehealth provides economic returns to the organi-zation in terms of lowering lost time, sick pay,and other associated costs besides the generalloss of productivity associated with less-than-heal thy workers. Am bulatory, or outpat ient ,services provided by an MNP might also reducerehabilitation costs and insurance premiumsfor the firm. Th e possibilities of positioningthe MNP in this market will be greatly influ-enced by the demonstration of cost-benefitsavings and the participation of third parties(e.g., insurance company, labor unions) inthe industrial setting.

In considering ultimate consumers as targetmarkets, i t is important to recognize economiccircumstances (income) and behavioral charac-teristics. Because those with high incom e canafford physicians and the set of professionalswho support them, they are probably not strongcand idates for MNP services. Th e we althy canreceive the best care from the present system.Lower-income persons, to some extent, receivesocial welfare aid that also provides them accessto traditional medical services and they oftenhave a shorter planning horiz on. Th e lower-incom e also ten d to be less innovative in respectto new services.By default, this leaves many middle-classconsumers who often finance all , or a portion,of their medical services and who face increas-ing price pressures from inflation. Low er costprimary health care and preventative measuresmay be very attractive to this grou p. In ad-dition, they are likely to be fairly well-educated,have longer planning horizons, be more healthconscious about themselves and their children,be less tradition-b oun d, and be foun d in geo-graphic concentrations. In one Illinois study .


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12 / JHCM, VoL 1 , No . 2 (Spring, 19 81 )receptivity to tbe MNP concept was quite bi(61%) among a cross section of cou nty residents.In tbis situation, tbe respondents viewed tbeMNP as a complement to pbysician-providedservices and primarily responsible for bealtbpromotion and prevention services. Tbose mostunlikely to possess positive attitudes were tboseunder stress, tbose baving pbysical symptoms,and tbose in worry-inducing situations (Penderand Pender, 1980).

Admittedly, most MNP successes bave beenacbieved in areas wbere pbysicians were notpracticing. How ever, tbis may be a function ofnatural monopoly instead of effective segmen-tat ion. Tbe middle class may well be b i ^ yreceptive to tbe MNP, given tbe quality of ser-vice, tbe bigb level of information, and an accep-table risk level. It is tbe respon sibility of tbeMNP to use marketing communications to inte-grate tbemselves in tbe community, as well assecure tbe cooperation of otber key bealtb carecommunity participants, e.g., pbysicians, labora-tor ies, insurance companies, and bospitals.

groups wbo migbt be interested in an informative program on tbis innovative medical practice. Personal contacts witb local pbarmaciemigbt also prove fruitful because tbeir employeebave direct, or indirect, contact witb tbe ill anare often consulted for advice.

Advertising to consumers by tbe MNP coulbe risky because of p otential bo stile reactions botbe r medical professionals. Most advertisin(otber tban Yellow Pages listings) continues tbe controversial among tbose in tbe medicafield. Beyond tbis, tbe MNP is a position wbosultimate public role and acceptance is still opeto question. Advertising to consumers woullikely belp to confirm, or even develop, tbmedical professionals' resistance to tbe idea oMNPs. Even institu tion al advertising, wb icwould be directed to educating tbe generapublic about tbe MNP concept, migbt causnegative reactions. Tberefore, advertising sboulbe carefully studied by MNPs to determine iteffects on otber medical professionals.

M arketing Promo t ion sIf tbe target markets are pbysicians, medical

organizations, or non-medical institutions, tbeMNP's marketing promotions sbould be mostlypersonal in presentation. All approacbes to mem-bers of tbese target markets sbould be bigb-ly educative in natu re. An understand ing of tbeMNP concept must be empbasized, and tbe mes-sage sbould be framed in terms of tbe benefitseacb target m arke t wou ld receive. Fo r pbysi-cians, tbe message may be structured around tbeadvantages of easing pbysicians' cbronic pro-blems of time sbortages, scbeduUng, and coordi-nation of patient care. Fo r otber group s, it islikely tbat tbe cost-benefit approacb would bemost appropriate.

If tbe MNP decides on tbe consumer targetmarket, advertising and personal selling can botbbe utilized. Personal selling is possible tbro ug btalks by tbe MNP to women's clubs, scboob, ser-vice organizations, cburcbes, and other such

Gaining AcceptanceTbe cost of studies tbat analyze tbe impac

of MNP marketing programs on otber medicaprofessionals, as well as target markets, is too expensive for a single MNP. A lso, effective mark eting programs may be expensive to formulate andexecu te. Tbis impbes tbe need for MNPs twork togetber a need tbat would be facilitateby an MNP professional asso ciation. A professional association is also an appropriate agencyfor resolving tbe questions tbat MNPs may bavin tbeir own minds about tbe desirability omarketing.

Wbatever tbe decision regarding tbe amounof marketing tbougbt appropriate by tbe MNPas a group, educational programs sbould be developed. A professional association is tbe obvious sponsor for educational promotion of tbegeneric con cept of tbe MNP. Tbis type of association can also gain acceptance in scboolscburcbes, and otber places where educationallyrelated programs can he effective.


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Marketing for the Nurae Practitioner / 13In fact, achieving acceptance for the MNP

from the various target markets, and from thegeneral public, is enhanced if the prestige thatofficial medical associations impart can be in-cluded in prom otional com mu nications. Pro-fessional MNP associations, organized on a local,state, and/or a national level, can play an impor-tant role in the success of MNP marketing pro-grams. Such formalized associations can helpestablish cooperative relationships with otherprofessional med ical associations. Credibilityof the MNP will grow in the minds of othermedical professionals if their associations acceptthe MNP as a valid concept.

Acceptance of the MNP by additional pro-fessionals in me dicin e is crucial. Ho stility ofany sort from medical practitioners can be aserious handicap, as the public probably viewsthe MNP's services as being inferior to those ofa physician or a physician-directed nurse. Whilesuch a view may not be correct, given the natureof the M NP, it is und erstan dab le. The averageperson regards the physician as the standard-setter for health care, and the MNP obviouslyis not qualified in as many different facets ofmedical practice as the physician.

If MNPs can gain the endorsements by othermedical professionals, and use them in market-ing the MNP concept, acceptance by potentialcustom ers will be facilitated. The obvious ave-nue for gaining such endorsements would bevia an MNP professional association. This impliesa marketing effort to the associations of othermedical professionals by MNP formal associa-tions. Such m arke ting efforts also pave the wayfor the individual MNP to offer his/her servicesto the target markets of physicians and medicalorgan izations, such as hospitals or clinics. Itcan also help in marketing the MNP concept andservices to non-medical organizations.

The most difficult target market for theMNP is the con sumer. In a direct consumer ap-proach, the MNP cannot draw on the prestige ofany third party such as a physician, a hospital,or a business. Educating consumers to under-stand the special talents of the MNP, and per-suading them to choose the MNP instead of tra-ditional health care sources, may take a number

of years even with the support of other medi-cal professionals. There fore, the relatively low-risk target m arkets for the MNP are physiciansand medical organizations. Acce ptance mu st begained with these target markets before approvalcan be expected from the consumer, or even non-medical organizations.

Summary and RecommendationsDevelopment of marketing programs for the

MNP presen ts difficult pro blem s. This is a ser-vice industry whose quality the public cannoteasily judge. In additio n, few persons are exper-ienced with this service; it has a high perceivedrisk factor and lacks widespread legitimization.Under these circumstances, the MNP should de-velop response models to determine which typeof exposure (personal and impersonal), messagestruc ture, and message co nte nt are mo st efficientin effecting consumer trial and adoption in eachdesignated target market.

Marketing by the MNP is also complicatedby the fact that many medical practitioners, in-cluding nurses, do not think that professionalsshould "se ll" themselves. Any attem pt at mar-keting, including segmentation and promotion,may have detrimental effects on the acceptanceof the MNP concept.

To cope with these problems, MNPs need awell-researched, sy stem atic plan for gaining ap-proval of their practice by other health careprofessionals. As this acceptance is developed,medical professionals will become more respon-sive to utilizing and recomm ending MNPs. Thiswill help in gaining generalized acceptance bynon-medical organizations and consumers, ingeneral.

The financial costs of marketing researchand marketing programs that win acceptance byother medical professionals can be significant.These costs, when considered with the need foreducational promotion of the generic concept ofthe MNP, imply united action by MNP formalassociations. An MNP professional associationcan formulate relationships with otiier medical


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14 /JHCM, VoL 1, No. 2 (Spring, 1981)associations and w ould lend a certain prestige totbe individual MNP me mb er. It also would pro-vide a forum wbere MNPs could decide on tbeamo unt and type of marketing tb at is appro-priate to tbeir professional status.

Tbe marketing of professionals presentsspecial problems. Establisb men t of a new pro-fession, wbicb may encounter resistance fromtbe standard setters in bea ltb care, implies tbattbe first target market sbould be tbese standardsetters. Tbe MNP wb o directly approac bes con-sumers is taking tbe bigb-risk approacb, botb asan individual and for tbe MNP profession.

Reports, 95 (July-August), 321 -333 .Sullivan, Judith A.,et al. (1978), "Overcoming Barriers to

Employment and Utilization of the Nurse PractitioneAmerican Journal of Public Health 68 (November), 1091 1 0 3 ; Cherkin, Daniel C (1980), "Factors Influencing tPhysician Market for Primary Care New Health Practioners," Medical Care, 18 (November), 1107.

Steel, Jean E. (1978), "Precepts for Practitioners," NursiOutlook, 26 (August), 499.Teberg, A nnabel J., et al. (19 80X "Settin g up a PNP (PediatNurse Practitioner) Clinic," American Joumal of Nursi80 (August), 1487.

REFERENCESConnelly, Shirley V., et al. (1979), "Physicians' Patient Refer,

rals to a Nune Practitioner in a Primary Care MedicalClinic," American Joumal of Public Health, 69 (January),73-75.

Davis, Gail C, Linda C. Colvin, Bette B ell, and Mary Bruce(1979X "Planning for Independent Practice," Nurse Prac-titioner. 4 (January-February), 47 .

Edmunds, Marilyn (1980), "Financial Concerns for NursePractitioners," Nurse Practitioner, 5 (July-August), 51.

Fottler, Myron D., G. Gibson and D. M. Pinchoff (1978X "Phy-sicians' Attitudes Toward the Nurse Practitioner," Joumalof Health and Social Behavior, 19 (September), 303-311;Wineberger, Morris, James Greene and Joseph Mamlin( 1 9 8 0 ) , "Changing House Staff Attitudes Towards NursePractitioners During Their Residency Training," AmericanJoumal of Public Health, 70 (November^ 1204-120 6.

Gordon, Marjory (1979), "The Concept of Nursing Diagnosis,"Nursing Clinics of North America, 14 (September), 493;see also. Classification of Nu rsing Diagno sis, Proceedings ofthe 3rd National Conference, N ational Group for Qassi-fication of Nursing Diagnosis, 1980.

Kotler, Philip and Richard A. Connor, Jr. (1977), "MarketingProfessional Services," Joumal of Marketing, 41 (January),71-72.

Leitch, C. J., et al. (1 97 7) , "A State by State Report: The LegalAccomodation of Nurses Practicing Expanded Roles,"Nurse Practitioner, 2 (November-DecemberX 9-2 2; Trandel-Korenchuk, Datlene M. and Keith M. (197 8X "How StateLaws Recognize Advanced Nursing Practices," NursingOutlook, 26 (November), 714.

Mauksch, Ingeborg G., (1980), "The Nurse Practitioner Move-ment Where Do es it go from Here?" American Joumal ofPublic Health, 68 (November), 1074-75.

. (1980X "Missouri Nurses Protest PracticeRestrictions," American Joumal o/Nursing, 8 0 (April) 60 4.

Pender, Nola J. and Albert R. (1980), "Illness Prevention andHealth Promotion Services Provided by Nurse Practitioners:Predicting Potential Customers," American Joumal of Pub-lic HeaUh, 70 (August), 798-803.

See, for example, Edmunds, (1980): or Tenant, Forest, KarinSorensen, Gaudine Simmons and Carmd Day (1980),"A Study of the ViaUlity of Low Cost, Fee for ServiceClinics Staffed by Nurse Practitioners," Public Heabh


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medical nurse practitioner

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