MARKETING AND PRKBIOTICBV FOR THE MEDICAL NURSE PRACTITIONER

Tbe nursing profession bas a long standing beritage of providing care and counsel to tbe ill, tbe injured, and tbe infirm^ normally under tbe supervision of a pbysician. In recent years, tbis traditional relationsbip between nurses and pbysicians bas been subjected to a critical but cautious reexamination. In particular, many believe tbat nurses can be trained to, and sbould be allowed to, treat certain medical problems witbout direct pbysician control. One sucb believer was a nurse, Lucille Kinlein, wbo was founder of one of tbe most successful independent nursing practices in tbe United States. Sbe and otbers like ber, some using tbe title of nurse practitioner (NP), bave attempted to redefine tbe boundaries of tbeir nursing practice and to control tbeir practice obligations. Not surprisingly, tbis practice of "medicine" by nurses is a controversial issue witbin, and outside, tbe nursing vocation. Wbile tbe majority opinion appears to support tbe probibition of medical acts by nurses, tbere are many willing to recognize tbe existence of overlapping functions between pbysicians and trained nurses (mostly registered nurses witb graduate degrees and/or specialized training). Tbere is also a willingness to "sbare" certain duties witbin a controlled bealtb care environment. Even witb somewbat limited support, tbis amended nursing system now encompasses a range of over 100 accepted
The term "practice of professional nursing" means the performance for compensation, of any acts in the observation, care and counsel of the ill, injured, or infirm or in the maintenance of health or prevention of illness of others based <HI knowledge and application of the principles of biological, phyacal and social science. The foregmng shall not be deemed to include acts of diagnosis or prescription of therapeutic or corrective measure. Statutory Regulation of the Scope of Nursing Practice, National J(rint Practice Commission 1975.

Douglas Fugate Dillard Tinsley

This article discusses the development of marketing programs for the Medical Nurse Practitioner (MNP). The role of, and the barriers to, marketing, as they apply to the independent nursing practice, are examined. The authors critically analyze the selection of target markets, the characteristics of these market segments and the importance of marketing promotions in regard to the MNP concept.

Doukas Fugate is an Assistant Professor of Marketing at Western Kentucky University. He received his Ph.D. from the University of Missouri-Columbia. Doug's articles have appeared in the Pittsburgh State Untversity Business and Economic Review, the Management Review and a variety of other publications. Dillard Tinsley is a Professor of Marketing at Stephen F. Austin University. He received his D.B.A. from Texas Tech and has published extensively to include the Joumal of Purchasing and Materials Management, Akron Business and Economic Review. Joumal of Small Business Management and t of Business Communications. Jouniid ot Hedth On Marketmg VoL 1, No. 2 (Spr^, 1981), pp. 8-14

Marketing for the Nurse Practitioner / 9 diagnoses covering more than 37 areas of diagnostic nomenclature (Nursing Clinics of North America, 1979). A number of these diagnoses are medical acts as traditionally defined by most state nursing practice statutes. Even though some would prefer to call these acts "expanded" or "advanced" nursing roles, there is no apparent behavioral difference between nursing diagnosis and treatment, and medical diagnosis and treatment. For lack of a more precise term, the appropriately trained and certified nurse who legally practices these medical acts with or without a physician/sponsor is hereafter identified as a medical nurse practitioner (MNP). The term MNP would include, among others, several categories of nurses who are currently in independent or traditional employment practice as nurse practitioners, e.g., pediatric and psychiatric, and nurse clinicians. A number of behavior and political changes have accelerated the evolution of independent nursing practice. The general public has become more concerned about the cost and quality of primary health care, as well as more aware that health maintenance and preventative medicine are desirable alternatives to health care treatment. To this extent, "Independent practitioners are riding the wave created by increased consumer awareness of client need to participate in health care decision, and the increasing popularity of self care ideas" (Edmunds, 1980). Regulatory bodies have also recognized that the nursing profession can be more responsive to, and more responsible for, basic health care concerns. To date, several states have authorized the provision of adjunct medical care by nurses. Other states either have established, or have under consideration, laws that would permit nurses to use standard diagnosis and treatment protocols as may be authorized by regulatory health boards (Leitch, et al, 1978). Even with these changes, there are still many difficulties to overcome. Teberg reported that her greatest difficulties in setting up a pediatric nurse practitioner clinic came from mothers and physicians reluctant to accept MNP management of illness, from resistance from fellow nurses and ancillary nursing personnel, and from legal confusion related to the MNP's role in hospital liability, insurance payments, and lawful practice (1980). At this point, the full implications of current nursing and non-nursing developments are not yet apparent. However, it does appear that, at a minimum, there is a legal and social mandate for nursing practice reforms which would alter the traditional physician-centered role of nursing.

The Role of Marketing

As with any new service offered to the public, the provider must be concerned with the marketing functions of appropriate positioning and promotion of the service. Admittedly, there have been a number of articles which approach the independent nursing practice as a business. However, most of them use a distributive approach and concentrate on such elements as building cash flow, layout, s^tart-up capital, and other natural business classifications (Edmunds, 1980; Agree, 1974; Draye and Stetson, 1975). There is little in the literature which addresses target marketing for the independent nursing practice or independent MNP. It is the position of the authors that the MNP must favorably influence potential users' perceptions and preferences regarding this form of health care provision, as well as favorably influence perceptions and preferences of health care environment participants, whose cooperation is essential. The MNP who wishes to succeed in his or her role must market both the person and the concept of the independent practice.

Barriers to Marketing the Independent Nursing Practice

The initial barrier to marketing the MNP may be prohibitive state laws that do not allow a nurse to practice nursing or medicine in a nonphysician supervised setting. Once these laws

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are repealed, bowever, tbere may be some resistance by MNP's to market tbemselves because of tbe tendency for professionals to resist a strong business orientation. Tbis resistance is generally attributed to tbe following factors: 1. Disdain of Commercialism Few professionals like to tbink of tbemselves as businessmen. Many sbow bostility to any su^estion tbat tbey are motivated by money, ratber tban service to tbeir clients. Discussion of fees is usually distasteful to tbem; 2. Association Codes Ethics Professional associations bave erected stringent rules against commercial bebavior. Advertising, direct solicitation, and referral commissions bave been banned. Professional firms tend to adbere to certain "standards of good practice" wbicb limit, to some extent, tbe use of effective marketing or sales tecbniques; 3. Equating Marketing with Selling Because of tbe bars or bans against selling, professional service firms sbow little interest in tbe subject of marketing, baving made tbe error of equating marketing witb selling. Marketing is much more tban selling (Kotler and Connor, 1977). Overcoming tbe resistance to marketing on tbe part of tbe individual MNP may prove to be a different task. However, more damaging opposition may come from tbe otber participants in tbe bealtb care community (Sullivan, et al, 1978). In tbe past, laboratories bave refused to perform tests requested by MNPs, and diagnostic specialists bave been uncooperative. Hospitals may even deny patient-visiting privileges to tbe MNP (Steel, 1978). Studies indicate tbat pbysicians refer patients to nurse practitioners to a mucb lesser degree tban would be expected on tbe basis of pbysicians' stated attitudes (Connelly, et al, 1979). In otber instances, pbysicians bave initiated steps to restrict tbe activities of nurse practitioners t b r o u ^ amendments to state laws tbat govern medicine (Maulescb, 1978). Tbe otber important source of resistance can come from tbe consumers, or clients, tbemselves. Innovation and adoption studies consistently suggest tbat new service forms come into widespread usage only after tbe relative advantage of tbe service bas been establisbed by credible resource persons. Unless MNPs can convince influential persons tbat tbey can provide certain needed services as, or even more, effectively tban pbysicians, tbis nursing innovation may never become widely adopted by tbe general public. Two marketing tools commonly used to overcome tbese difficulties are: (1) segmentation, wbicb is used to divide tbe market into bomogeneous need sets or target markets, and (2) marketing promotions, wbicb can be used to inform and persuade members of tbe selected target markets.

Selection of Target Markets

Tbe marketing concept is based upon identification and fulfillment of consumers' needs. Since many need sets exist, it is often necessary to divide tbe total market into more bomogeneous segments. Probably tbe best segmentation approacb for tbe MNP market is tbat of "benefits s o u ^ t . " Tbose segments tbe MNP is able, and cbooses, to serve become tbe target market(s) for tbat MNP. A review of nursing literature identifies tbe following needs areas as wellsuited for MNP performance: Coordination of an individual's or a family's bealtb care needs; Provision of less expensive bealtb care; Provision of more flexible delivery of bealtb care needs; Provision of more empathy, or greater personal attention, in tbe delivery of healtb care; Provision of specialized ambulatory or outpatient bealtb care; Provision of outpatient counseling and bealtb education. Since it is quite unlikely that no one MNP would provide all of t h ^ e service, selection of specific service segmente should reflect die training, inter-

Marketing for the Nurse Practitiono- / 11 est, and experience of the particular MNP. This selection should also reflect the needs of the particular target market chosen. attractiveness of utilizing MNPs in such positions may be enhanced by the growing governmental concern with job-site primary health care and safety. Non-medical organizations may also be interested in the MNP's advisory services, such as coordination of health maintenance needs and health care education. These could be provided to employees under a fringe benefit plan. The fact that such services improve employee health provides economic returns to the organization in terms of lowering lost time, sick pay, and other associated costs besides the general loss of productivity associated with less-thanhealthy workers. Ambulatory, or outpatient, services provided by an MNP might also reduce rehabilitation costs and insurance premiums for the firm. The possibilities of positioning the MNP in this market will be greatly influenced by the demonstration of cost-benefit savings and the participation of third parties (e.g., insurance company, labor unions) in the industrial setting. In considering ultimate consumers as target markets, it is important to recognize economic circumstances (income) and behavioral characteristics. Because those with high income can afford physicians and the set of professionals who support them, they are probably not strong candidates for MNP services. The wealthy can receive the best care from the present system. Lower-income persons, to some extent, receive social welfare aid that also provides them access to traditional medical services and they often have a shorter planning horizon. The lowerincome also tend to be less innovative in respect to new services. By default, this leaves many middle-class consumers who often finance all, or a portion, of their medical services and who face increasing price pressures from inflation. Lower cost primary health care and preventative measures may be very attractive to this group. In addition, they are likely to be fairly well-educated, have longer planning horizons, be more health conscious about themselves and their children, be less tradition-bound, and be found in geographic concentrations. In one Illinois study.

Characteristics of Selected Target Markets

The MNP can work jointly with physicians and medical organizations, or he/she can independently serve the patients that these professional sources recommend. The latter situation greatly simplifies the MNP's marketing problems especially that of gaining acceptance by the general public. In either case, the MNP receives the benefit of generalized legitimacy as a participant in a physician-initiated client relationship. In selecting cooperating physicians, the MNP should realize that the physicians most likely to utilize their services or refer patients are recent medical school graduates, physicians who already delegate many tasks to traditional nursing staffs, and certain specialists (pediatricians, orthopedists, opthalmologists, and internists) (Fottler, et al, 1978). In one study, the service that physicians were most likely to refer to independently practicing MNPs were in-home health care (50%), counseling about an illness (43%), emotional counseling (21%), conducting self-care classes (22%), and provision of health maintenance activities (17%) (Davis, etal, 1979). This evidence suggests that the MNP may have to offer services which are consistent with physicians' expectations. If the MNP does not wish to be limited primarily to the situations described above, non-medical organizations may be an attractive alternative target market. The MNPs can serve non-medical institutions with many of their skilled services. Many organizations especially in manufacturing presently hire physicians and nurses to be at their plants during operating hours. The MNP may be able to replace physicians in some of these facilities. In many instances, the MNP can provide greater specialization and a wider range of services than regular professional nurses. The

12 / JHCM, VoL 1, No. 2 (Spring, 1981)

receptivity to tbe MNP concept was quite bi (61%) among a cross section of county residents. In tbis situation, tbe respondents viewed tbe MNP as a complement to pbysician-provided services and primarily responsible for bealtb promotion and prevention services. Tbose most unlikely to possess positive attitudes were tbose under stress, tbose baving pbysical symptoms, and tbose in worry-inducing situations (Pender and Pender, 1980). Admittedly, most MNP successes bave been acbieved in areas wbere pbysicians were not practicing. However, tbis may be a function of natural monopoly instead of effective segmentation. Tbe middle class may well be b i ^ y receptive to tbe MNP, given tbe quality of service, tbe bigb level of information, and an acceptable risk level. It is tbe responsibility of tbe MNP to use marketing communications to integrate tbemselves in tbe community, as well as secure tbe cooperation of otber key bealtb care community participants, e.g., pbysicians, laboratories, insurance companies, and bospitals. groups wbo migbt be interested in an informative program on tbis innovative medical practice. Personal contacts witb local pbarmacies migbt also prove fruitful because tbeir employees bave direct, or indirect, contact witb tbe ill and are often consulted for advice. Advertising to consumers by tbe MNP could be risky because of potential bostile reactions by otber medical professionals. Most advertising (otber tban Yellow Pages listings) continues to be controversial among tbose in tbe medical field. Beyond tbis, tbe MNP is a position wbose ultimate public role and acceptance is still open to question. Advertising to consumers would likely belp to confirm, or even develop, tbe medical professionals' resistance to tbe idea of MNPs. Even institutional advertising, wbicb would be directed to educating tbe general public about tbe MNP concept, migbt cause negative reactions. Tberefore, advertising sbould be carefully studied by MNPs to determine its effects on otber medical professionals.

Gaining Acceptance Marketing Promotions

If tbe target markets are pbysicians, medical organizations, or non-medical institutions, tbe MNP's marketing promotions sbould be mostly personal in presentation. All approacbes to members of tbese target markets sbould be bigbly educative in nature. An understanding of tbe MNP concept must be empbasized, and tbe message sbould be framed in terms of tbe benefits eacb target market would receive. For pbysicians, tbe message may be structured around tbe advantages of easing pbysicians' cbronic problems of time sbortages, scbeduUng, and coordination of patient care. For otber groups, it is likely tbat tbe cost-benefit approacb would be most appropriate. If tbe MNP decides on tbe consumer target market, advertising and personal selling can botb be utilized. Personal selling is possible tbrougb talks by tbe MNP to women's clubs, scboob, service organizations, cburcbes, and other such Tbe cost of studies tbat analyze tbe impact of MNP marketing programs on otber medical professionals, as well as target markets, is too expensive for a single MNP. Also, effective marketing programs may be expensive to formulate and execute. Tbis impbes tbe need for MNPs to work togetber a need tbat would be facilitated by an MNP professional association. A professional association is also an appropriate agency for resolving tbe questions tbat MNPs may bave in tbeir own minds about tbe desirability of marketing. Wbatever tbe decision regarding tbe amount of marketing tbougbt appropriate by tbe MNPs as a group, educational programs sbould be developed. A professional association is tbe obvious sponsor for educational promotion of tbe generic concept of tbe MNP. Tbis type of association can also gain acceptance in scbools, cburcbes, and otber places where educationallyrelated programs can he effective.

Marketing for the Nurae Practitioner / 13 In fact, achieving acceptance for the MNP from the various target markets, and from the general public, is enhanced if the prestige that official medical associations impart can be included in promotional communications. Professional MNP associations, organized on a local, state, and/or a national level, can play an important role in the success of MNP marketing programs. Such formalized associations can help establish cooperative relationships with other professional medical associations. Credibility of the MNP will grow in the minds of other medical professionals if their associations accept the MNP as a valid concept. Acceptance of the MNP by additional professionals in medicine is crucial. Hostility of any sort from medical practitioners can be a serious handicap, as the public probably views the MNP's services as being inferior to those of a physician or a physician-directed nurse. While such a view may not be correct, given the nature of the MNP, it is understandable. The average person regards the physician as the standardsetter for health care, and the MNP obviously is not qualified in as many different facets of medical practice as the physician. If MNPs can gain the endorsements by other medical professionals, and use them in marketing the MNP concept, acceptance by potential customers will be facilitated. The obvious avenue for gaining such endorsements would be via an MNP professional association. This implies a marketing effort to the associations of other medical professionals by MNP formal associations. Such marketing efforts also pave the way for the individual MNP to offer his/her services to the target markets of physicians and medical organizations, such as hospitals or clinics. It can also help in marketing the MNP concept and services to non-medical organizations. The most difficult target market for the MNP is the consumer. In a direct consumer approach, the MNP cannot draw on the prestige of any third party such as a physician, a hospital, or a business. Educating consumers to understand the special talents of the MNP, and persuading them to choose the MNP instead of traditional health care sources, may take a number of years even with the support of other medical professionals. Therefore, the relatively lowrisk target markets for the MNP are physicians and medical organizations. Acceptance must be gained with these target markets before approval can be expected from the consumer, or even nonmedical organizations.

Summary and Recommendations

Development of marketing programs for the MNP presents difficult problems. This is a service industry whose quality the public cannot easily judge. In addition, few persons are experienced with this service; it has a high perceived risk factor and lacks widespread legitimization. Under these circumstances, the MNP should develop response models to determine which type of exposure (personal and impersonal), message structure, and message content are most efficient in effecting consumer trial and adoption in each designated target market. Marketing by the MNP is also complicated by the fact that many medical practitioners, including nurses, do not think that professionals should "sell" themselves. Any attempt at marketing, including segmentation and promotion, may have detrimental effects on the acceptance of the MNP concept. To cope with these problems, MNPs need a well-researched, systematic plan for gaining approval of their practice by other health care professionals. As this acceptance is developed, medical professionals will become more responsive to utilizing and recommending MNPs. This will help in gaining generalized acceptance by non-medical organizations and consumers, in general. The financial costs of marketing research and marketing programs that win acceptance by other medical professionals can be significant. These costs, when considered with the need for educational promotion of the generic concept of the MNP, imply united action by MNP formal associations. An MNP professional association can formulate relationships with otiier medical

14 /JHCM, VoL 1, No. 2 (Spring, 1981) associations and would lend a certain prestige to tbe individual MNP member. It also would provide a forum wbere MNPs could decide on tbe amount and type of marketing tbat is appropriate to tbeir professional status. Tbe marketing of professionals presents special problems. Establisbment of a new profession, wbicb may encounter resistance from tbe standard setters in bealtb care, implies tbat tbe first target market sbould be tbese standard setters. Tbe MNP wbo directly approacbes consumers is taking tbe bigb-risk approacb, botb as an individual and for tbe MNP profession.
Reports, 95 (July-August), 321-333. Sullivan, Judith A.,et al. (1978), "Overcoming Barriers to the Employment and Utilization of the Nurse Practitioner," American Journal of Public Health 68 (November), 10971103; Cherkin, Daniel C (1980), "Factors Influencing the Physician Market for Primary Care New Health Practitioners," Medical Care, 18 (November), 1107. Steel, Jean E. (1978), "Precepts for Practitioners," Nursing Outlook, 26 (August), 499. Teberg, Annabel J., et al. (1980X "Setting up a PNP (Pediatric Nurse Practitioner) Clinic," American Joumal of Nursing, 80 (August), 1487.

REFERENCES
Connelly, Shirley V., et al. (1979), "Physicians' Patient Refer, rals to a Nune Practitioner in a Primary Care Medical Clinic," American Joumal of Public Health, 69 (January), 73-75. Davis, Gail C, Linda C. Colvin, Bette Bell, and Mary Bruce (1979X "Planning for Independent Practice," Nurse Practitioner. 4 (January-February), 47. Edmunds, Marilyn (1980), "Financial Concerns for Nurse Practitioners," Nurse Practitioner, 5 (July-August), 51. Fottler, Myron D., G. Gibson and D. M. Pinchoff (1978X "Physicians' Attitudes Toward the Nurse Practitioner," Joumal of Health and Social Behavior, 19 (September), 303-311; Wineberger, Morris, James Greene and Joseph Mamlin (1980), "Changing House Staff Attitudes Towards Nurse Practitioners During Their Residency Training," American Joumal of Public Health, 70 (November^ 1204-1206. Gordon, Marjory (1979), "The Concept of Nursing Diagnosis," Nursing Clinics of North America, 14 (September), 493; see also. Classification of Nursing Diagnosis, Proceedings of the 3rd National Conference, National Group for Qassification of Nursing Diagnosis, 1980. Kotler, Philip and Richard A. Connor, Jr. (1977), "Marketing Professional Services," Joumal of Marketing, 41 (January), 71-72. Leitch, C. J., et al. (1977), "A State by State Report: The Legal Accomodation of Nurses Practicing Expanded Roles," Nurse Practitioner, 2 (November-DecemberX 9-22; TrandelKorenchuk, Datlene M. and Keith M. (1978X "How State Laws Recognize Advanced Nursing Practices," Nursing Outlook, 26 (November), 714. Mauksch, Ingeborg G., (1980), "The Nurse Practitioner Movement Where Does it go from Here?" American Joumal of Public Health, 68 (November), 1074-75. . (1980X "Missouri Nurses Protest Practice Restrictions," American Joumal o/Nursing, 80 (April) 604. Pender, Nola J. and Albert R. (1980), "Illness Prevention and Health Promotion Services Provided by Nurse Practitioners: Predicting Potential Customers," American Joumal of Public HeaUh, 70 (August), 798-803. See, for example, Edmunds, (1980): or Tenant, Forest, Karin Sorensen, Gaudine Simmons and Carmd Day (1980), "A Study of the ViaUlity of Low Cost, Fee for Service Clinics Staffed by Nurse Practitioners," Public Heabh