Why Physician Oversight of Onsite Nurses is Needed and Other Staffing Options

When employers choose to hire an onsite nurse directly

Employers are increasingly interested in making onsite medical expertise available to their employees. In fact, onsite clinics have emerged as a top trend for 2021 in the Business Group on Health survey, which reported onsites “have proven to be flexible enough to adapt to the evolving landscape.”¹ The evolving landscape, of course, is the COVID-19 pandemic. As of May 17, a full 480 days since the first SARS-CoV-2 infection in the United States, more than 32.9 million cases and 585,970 deaths have occurred. But the trend in new U.S. cases is down.² Even so, employers understand that onsite medical expertise offers vital support in keeping employees informed about COVID-19 vaccines3, mask safety4, and persistent symptoms the media calls “long COVID5,” but known to clinicians as “Post-Acute Sequelae of SARS-CoV-2.”

Fully staffed onsite clinics may be more than many businesses can afford, as they begin rebuilding financially after pandemic shutdowns and partial reopenings. Consequently, employers who need a less expensive alternative than a physician or require only limited services may hire an onsite registered nurse (RN). Naturally, employers may be surprised when they are told certain tests cannot be performed or vaccinations given without physician oversight or that a physician must sign-off on the standing orders of an onsite registered nurse. Why is medical oversight by a physician needed?

This article will explain the medical, financial, and legal reasons for such a requirement. In addition, employers will be introduced to other onsite staffing options involving advanced practice clinicians (APCs) where, in some instances, physician oversight is not be needed. Jeffrey Wainstein, MD, vice president of medical operations-onsite programs for Concentra®, will discuss the rising use of APCs and how their performance and medical outcomes compare to physicians.

Understanding the various medical professionals

MD, DO, PA, NP, APC, RN, and LPN is a sample of caregiver designations that can be confusing to anyone outside the medical profession. There are important differences in the education and training and, thus, in their scope of practice.

MD, DO, and PA. A doctor of medicine (MD), a doctor of osteopathy (DO), and a physician assistant (PA) all train under a medical model. Physicians (MD or DO) have about 23,000 hours of education and training, while PAs have around 3,000 hours, explains Dr. Wainstein. MDs and DOs are required to have at least four years of college, four years of medical school, an internship, and a residency – more than 10 years of education and training. A PA also has four years of college and two to three years of postgraduate education, several years of experience, but no internship or residency.⁶

NP and APC. A nurse practitioner (NP), also called an advanced practice nurse, has a master’s or doctoral degree and advanced clinical training. NPs and PAs are examples of advanced practice clinicians (APCs) because of their advanced education and training.⁷

RN and LPN (LVN in California and Texas⁸). The minimum requirement for an RN is a two-year associate’s degree in nursing or a two-year RN diploma before passing an exam. Licensed practical nurses (LPNs) and licensed vocational nurses (LVNs) need only a high school diploma or GED and to graduate from an accredited LPN/LVN program.⁹

The occupational health perspective

“On occasion, businesses will come to us and ask for a physician to sign-off on the standing orders that have been executed by their onsite registered nurse. To the employer, it seems like a simple request, but it’s more complicated than that,” says Mike Southwick, assistant vice president of diversified services for Concentra.

“Signing standing orders means that a physician assumes medical oversight of a registered nurse or other health professional. Medical oversight requires clarification of roles and responsibilities, as well as assignment of risk and a procedure for conducting chart audits and case reviews of duties performed. Also, the physician must be available for phone consultation. All of this requires the physician’s time, perhaps significantly,” says Southwick. “In addition, there needs to be a pathway in place for the physician to escalate issues if directions or instructions are not followed properly.”

The physician’s medical oversight role is especially critical in work environments due to the occupational health physician’s knowledge of job requirements and hazardous exposures. This expertise can help avoid unnecessary testing, increased costs, or inaccurate interpretation of results that could occur absent an occupational physician’s involvement.

Other staffing options offer flexibility in onsite care

Concentra, an occupational health leader with more than 40 years of experience, nearly 520 clinics, and more than 130 onsite programs nationwide, recommends that staffing models for onsite programs be based on the type of industry, the size of the eligible population, the scope of work required, and the goals the employer would like to achieve. Staffing options include onsite nurse (discussed earlier), emergency medical technician (EMT), athletic trainer, physical therapist, dietitian, health coach, physician, or advanced practice clinicians (APCs).

“The role of APCs, such as a physician assistant or a nurse practitioner, varies from state to state, depending on what they are permitted to do under state law and regulations,” says Dr. Wainstein.^10,11 “In a recent 10-year period, the number of licensed nurse practitioners almost doubled, while certified physician assistants grew from about 43,500 to more than 102,000. This is a welcome response to persistent projected shortfalls in the availability of physicians.”

Several research studies have compared the care provided by physicians and various APCs, including nurse practitioners and physician assistants. One such study published in the Journal of the American Medical Association (JAMA) found no significant difference in patient health status at six months, health services utilization at six months and one year, or measures of patient satisfaction at six months.¹²

“Based on the comparable quality of care suggested by the research and the scarcity of physicians in some regions, Concentra strongly considers APCs when determining staffing models for onsite clinics and recommends the use of physician assistants or nurse practitioners, when appropriate to the needs of the employer” says Dr. Wainstein. Nurse practitioners are allowed to practice independently without physician oversight. Other APCs generally require physician oversight, except in some states.

By promoting alternative staffing models, Concentra seeks to support employer demand for onsite care across a broader spectrum. To address cost concerns, Concentra offers five additional strategies, as explained in a new Concentra white paper. Download “Onsite Care in a Working World of Pandemic-driven Change” now to get started with onsite care.¹³

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NOTES

1. Business Group on Health Lists Top Open Enrollment Trends for 2021. Business Group on Health. Business Group on Health news release. September 29, 2020.
2. New COVID-19 Cases Worldwide. Daily Confirmed New Cases (7-Day Moving Average). Outbreak evolution for the current most affected countries. Critical Trends. Johns Hopkins Coronavirus
3. Three Essential Employer Questions Answered on COVID-19 Vaccination. Concentra.com. March 30, 2021.
4. Update on COVID-19 Mask Safety in the Workplace. March 24, 2021.
5. Vital Support for Employers Addressing Long COVID in the Workplace. March 9, 2021.
6. The difference between MD, DO, PA, and more. Blue Cross and Blue Shield of Michigan and Blue Care Network. July 20, 2018.
7. Ibid.
8. Nursing Ranks and Levels Explained. Nurse.org. May 12, 2020.
9. Ibid.
10. Physician assistant scope of practice. American Medical Association. 2018.
11. State Practice Environment. American Association of Nurse Practitioners. January 1, 2021.
12. Mudinger MO, Kane RL, Lenz ER, Totten AM, et al. Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized clinical trial. Journal of the American Medical Association (JAMA). January 2000;283(1):59-68.
13. Onsite Care in a Working World of Pandemic-driven Change. Concentra.com. April 27, 2021