Challenges remain on the nurse practitioner journey: a nurse who is journeying towards nurse practitioner registration shares some observations and ideas she has gleaned along the way.

The leading causes of death in New Zealand for people aged 19 and older are predominantly lifestyle related, ie they are preventable. (1) (See Table 1.) It is in the area of prevention and early detection that nurse practitioners (NPs) could make a major contribution to the health of New Zealanders.

In other countries, NPs have been shown to improve the quality and quantity of life experienced by the individuals, families and communities they serve. (2,3,4) NPs have also been shown to practise in a cost-effective manner. (5,6,7,8) Therefore, it seems reasonable to expect that NPs in New Zeland would have the same or similar outcomes.

Almost 10 years ago, the report of the Ministerial Taskforce on Nursing suggested a new type of health practitioner, the NP, who would help ensure available, acceptable, affordable, equitable health care. (9) The role was included in the vision for the primary health care strategy. (10)

The then Minister of Health Annette King wrote in 2002: "Nurse practitioners advocate for health promotion and disease prevention, looking beyond treating the ailment to consider non-medical interventions, and to encourage self-care. They will be able to diagnose health problems and, if they choose, prescribe medications. Nurse practitioners will have the opportunity to practise as part of a primary health care team, to lead specialty focused clinics in community settings, or to establish independent primary health care nursing practices that offer o range of assessment, diagnostic, treatment and support services and clinically manage caseloads in acute settings. (10)

In 2000, the Nursing Council announced it would begin the registration process for the advanced nursing scope of the NP. The Council identified seven practice areas and a variety of potential populations. (11) In December the next year, the Council had registered New Zealand's first NP.

At the time of publication, there were 45 NPs around the country, with 26 as registered prescribers. Many of these NPs practise in narrow and specialised areas. How did the concept of a health care team member, helping meet the needs of a broad range of clients in a wide range of settings, become a list of 45 NPs predominantly working in acute care practices?

As a nurse on the NP pathway and preparing a portfolio for registration, I have observed two variables that may explain the stow growth and development of the NP role in New Zealand. The first variable is establishing competence with the Nursing Council, and the second is finding an NP position.

Proving competence

Nurse practitioner applicants must prove to Nursing Council they are competent in the Council's six designated competencies. However, along the way, they must also prove competence to support staff, colleagues, managers, patients, patients' families, clinical associates and academic supervisors. Potential NPs prove competence in a variety of ways--designing new documents, coming up with innovative ideas about changing some long-standing practice, creating teaming contracts, changing their minds and creating something else. Yet at the end of it all, the question remains: Are these nurses actually competent to be entry-level NPs? Having spent sometime during the last few months with NPs and others on the way to becoming NPs from all over the country, I am not sure that proving competence is a consistently applied principle. It seems to me that, unless the area of practice is extremely narrow, the NP applicant will not be able to prescribe, at least not at the first attempt. This means greater expense, which dampens one's sense of worth and, indeed, reads one to question what exactly is being asked of potential NPs, and will this process ever become transparent? It also raises the question of how the vision of the Ministry of Hearth for the NP is being articulated within the nursing profession and regulating body. To avoid appearing merely critical of the NP registration process, I recognise the rigour, dedication and diligence the Council has brought to the gargantuan task of creating a process for registering individuals in the NP scope of practice. I also believe the portfolio is an excellent toot and should be maintained in some form.

Recommendations and observations

That said, I would like to present some observations and recommendations regarding the registration process, as it currently stands. The recommendations are designed to read to a more consistent approach to the process, remove a barrier to practice and ensure public safety.

1) The portfolio is an excellent tool, when constructed properly, with a focus on criteria that address the practice of an entry-level NP. That is, the criteria should reflect an acceptable minimum Level of clinical skills required to enter safe NP practice.

2) An entry-level NP should be encouraged to focus on the precise application of advanced clinical skills in their specific area of practice. The portfolio of the first-time applicant should document the education, experience and rigorous evaluations of the applicant by trusted senior practitioners in nursing and medicine. This would ensure the NP has the education, experience and support of a mentor.

3) Registration as an NP should automatically include prescribing within their practice specialty. To demonstrate prescribing competence, the NP applicant should be able to document a course of study including pharmacology and pharmacotherapeutics. The applicant should be able to identify medications they feet competent to prescribe and submit documentation of actual use, white under the mentorship of a prescribing professional, or document the need for the medications in their practice.

Panel an 'artificial barrier to practice'

4) The panel examination should be abandoned. The panel is a time consuming, expensive, stress-inducing exercise in subjectivity. It is an artificial barrier to practice. The time and expense of assembling and preparing the panel to question an applicant could be better spent on ensuring the educational and experiential background of the applicant supports their application, and that individuals registered are safe practitioners in their new roles.

The above changes do not create more risk to the patients, in fact, changes such as these may Lessen risk to patients and the practitioner by ensuring the system is creating competent entry-level NPs who will have the confidence and knowledge to expand the horizons of practice and nursing knowledge.

Employment issues

Having made recommendations about the registration of NPs, the second variable regarding NP employment arises. There are reports of NPs working as volunteers or returning to their previous positions with little change in their practice or incomes, or worse, remaining unemployed or underemployed as an NP. (12)

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It is curious that so few nurses from primary care are studying to be NPs. Why aren't primary health organisations and non-governmental organisations seeking NPs to enter primary care positions? It is also curious there are so few positions for NPs within district health boards (DHBs). Currently the Canterbury District Health Board (DHB) employs no NPs and does not include NPs on its list of endorsed senior nurses for the DHB. However, the DHB is proposing to create new positions for NPs over the next five years.

All DHBs should include in their strategic plans specific NP positions in a variety of settings. The DHBs should assist in the identification of potential NPs from their staff, provide financial and clinical mentorship/supervisory support during the educational preparation of these nurses, and support the transition of the new NPs into positions within the community, outpatient clinics and the hospital.

I would like to reiterate my thanks to the Nursing Council for providing a clinical pathway for nurses to extend their skills and knowledge. While it is apparent there is excellent work being done by some DHBs, others have yet to recognise and accept the worth of the NP position to their organisations.

I wonder how much longer it will take before consumers have the opportunity to have their health needs met, not only by doctors, but also by well educated and skilled NPs, competent in preventive and early intervention health care. That's when we will start to see a major impact on the rate of lifestyle-related deaths.

* Special thanks to Mary Jo Gagan, PhD, RN, FAANP, for assistance with manuscript preparation.

References

(1) Statistics New Zealand (2002) www.stats.govt.nz Retrieved 28/10/07.

(2) Brown, S.A. & Grimes, D.E. (1995) A meta-analysis of nurse practitioners and midwives in primary care Nursing Research; 44: 6, 332-9.

(3) Cooper, M.A, Lindsay, G.M., Kinn, S. & Swann, I.J. (2002) Evaluating emergency nurse practitioner services: A randomized controlled trial. Journal of Advanced Nursing; 40: 6.

(4) Larkin, H. (2003) The case for nurse practitioners. Hospitals and Health Networks; August, 54-59.

(5) Hunter, M, Ventura, H. & Keams, P. (1995) Cost analysis of a nursing center for the homeless. Nursing Economics; 17: 1, 20-8.

(6) Jenkins, M. & Torrisi, D. (1995) NPs, community nursing centers and contracting for managed care. Journal of the American Academy of Nurse Practitioners; 7: 3, 119-23.

(7) Paez, K. & Allen, J. (2006) Cost-effectiveness of nurse practitioner management of hypercholesterotemia following coronary revascularization. Journal of the American Academy of Nurse Practitioners: 18: 9, 436-444.

(8) Spitzer, R. (1997) The Vanderbilt experience. Nursing Management; 28:3, 38-40.

(9) Ministerial Taskforce on Nursing. (1998) Report of the Ministerial Taskforce on Nursing: Releasing the potential of nursing. Wellington: Ministry of Health.

(10) Ministry of Health. (2002) Nurse Practitioners in New Zealand. Wellington: The Ministry of Health.

(11) Nursing Council of New Zealand. (2002) The Nurse Practitioner: Responding to the health needs in New Zealand. Wellington: The author.

(12) Cassie, F. (2007) Searching for a place in the system. Nursing Review; 8: 6, 5.

Gail Phillips, RN, PGDipHlth Sci (mental health), MN, is a lecturer in the School of Nursing, Christchurch Polytechnic Institute of Technology.

Table 1: Leading causes of death by age group 19 and over. (1)

LEADING CAUSES OF DEATH BY AGE GROUP

19-39           40-64                   Over 65

Motor vehicle   Heart disease           Heart disease
accident

Homicide        Lung cancer             Lung, colorectal and
                                        breast Cancer

Suicide         Cerebrovascular         Cerebrovascular disease
                disease

Injuries        MVA                     Chronic obstructive
(nonmotor)                              pulmonary disease

Heart disease   Breast and colorectal   Pneumonia/influenza
                Cancer

                Obstructive lung
                disease

                Suicide Homicide