Constructing media images of nursing: how does the media represent nurses when reporting on nurse prescribing? Do doctors dominate the discourse? One nurse observer thinks so.

Prescribing is potentially one of the most contentious issues facing nursing. The issue appears in the media from time to time and the comments broadcast and published could provide insight into representations of nurses and nursing.

A search of the New Zealand Herald (1) using the terms "nurse prescribing" and "prescribing fights" identified seven articles published in this newspaper between October 1999 and September 2005 which refer specifically to this issue. I chose the New Zealand Herald as it is New Zealand's largest daily newspaper. Because of its circulation, articles published in it have the potential to influence a substantial portion of the population.

I also chose to use only the terms "nurse prescribing" and "prescribing fights" in my search, as I believed this would be more objective. The articles were predominantly editorial comment and statements attributed to senior doctors. Examples of comments from these articles are presented and discussed in this article, and three inter-related themes are identified--competence, responsibility and competition.

This discussion is offered as one interpretation of how nurses are represented to the public and, in particular, the role the media and the medical establishment have in constructing these images.

Concept of competence

The concept of competence is central to valuing and trusting health care and practitioners. Centrally funded health care is an important part of the national psyche, as it forms one of the foundations of the egalitarian ideal on which modern New Zealand has developed since the middle of the 20th century. The concept of the welfare state originally focused on access to services for everyone. However, as economic tensions became apparent, notions of effectiveness and efficiency began to be used to evaluate services.

Discussions about effectiveness and efficiency have, in turn, led to debate about competence. Competence appears in the title of the most recent legislation developed to monitor health professionals and inform the public, ie the Health Practitioners Competence Assurance Act. Increasing attention on rights and consumerism in relation to health care also invoke notions of competence.

Questions about the competence of nurses to prescribe appear in the newspaper articles analysed. These comments particularly focus on the education of nurses, suggesting that nurses are less equipped than GPs to prescribe drugs, because they have spent less time being educated. Other comments suggest that medical training is the most appropriate form of education for prescribing; while still others indicate that doctors are concerned about the levels of skill and experience of nurses. A small number of comments in the articles supported the concept of nurse prescribing. These were generally attributed to government agencies and ministers. Positive international research and experience of nurse prescribing did not feature. The articles focused on comments either attributed to senior medical representatives or editorial comment which reflected the same perspective. "Medical Association chairman Dr Ross Boswell said independent nurse prescribing put patients at risk because nurse practitioners spent fewer years than doctors in training and supervision for prescribing drugs." (1) (July 26, 2005.)

"As a doctor, I would be most concerned to be facing prescribing without the depth of knowledge my medical training gave me." New Zealand Medical Association (NZMA) chair Tricia Briscoe. (1) (June 12, 2003.)

The length of time professionals spend in formal education does not necessarily correlate with their level of competence. The phenomenon of graduate-entry programmes in medical schools is a good example of this. There is evidence that doctors who qualify having completed shorter, graduate-entry programmes, are no less able than their peers who complete longer programmes. (2)

New approaches in education

Recent developments in higher education see curricula being designed around learning outcomes. (3) The required knowledge and skirts are defined and the teaming process is designed to assist students develop their understanding and apply it. Assessments provide the opportunity for students to demonstrate they have met the learning outcomes. This approach to education bears little resemblance to older notions of completing a set number of hours or years of study in order to qualify. Outcomes-based education is a far more accountable approach to supporting the development of health professionals, as those who meet the standard will pass, and those who do not, will not graduate. This approach eliminates the risk of people being awarded qualifications because they have simply served their time, as could happen within an apprenticeship model of education. It also potentially enables some to complete their qualification in a shorter time, if they have met the standard, and this is the rationale for graduate-entry programmes.

The length of time a professional spends being educated or, indeed, practising, does not relate to their competence. Prescribing is one area where practice should constantly be refined to incorporate new and changing knowledge, and this makes it all the more unwise to (ink ability to practise with the time spent being educated. Comments in these articles do not reflect any comparison between the preparation for practice doctors and nurse practitioners (NP) receive. This would be a worthy discussion, rather than simply claiming that medical education is better because it is longer and more in-depth. Evidence-based practice is one of the prevailing themes in discussions about competency in the health disciplines. However, it is essential to recognise that not all treatment can be or is based on high levels of scientific evidence. (4,5) Emerging concepts of nursing practice include notions of "being with" patients (rather than just doing things to them) and the therapeutic use of self. These developments are valuable as they help define the complexity and dynamics of nursing care (6,7) and should be incorporated into definitions of competence, alongside other more traditional notions, such as the scientific basis for decision making.

Professionals are entrusted by society with particular expertise and are afforded responsibilities in relation to it. The concept of responsibility appears, in these articles, as medicine seeming to assert its right to judge and have oversight over the practice of nurses. Sometimes this responsibility relates to being accountable for the act of prescribing. In other instances, medical practitioners are presented as being responsible for maintaining public safety. The most extreme of these comments imply it is irresponsible to allow nurses to prescribe, as this would put the public at risk.

"... nurses already prescribed antibiotics to treat urinary tract infections, for instance, but discussed each case with a doctor, who took overall responsibility." (1) Dr Ross Boswell. (July 26, 2005.)

"The Medical Association said the move, [nurse prescribing] set out in legislation making its way through Parliament, would threaten public health and damage team work between health professionals. " (1) (June 30, 2000.)

"Doctors fear more people will die from wrong treatment when nurses are allowed to independently prescribe." (1) (October 7, 1999.)

There is a history in Western nations of medicine being afforded the responsibility of deciding what is acceptable. "Particularly in Western medicine, patients have been socialised to view their medical caregivers as omniscient dispensers of both medication and medical wisdom". (8)

Medicine has assumed the rote of arbiter of what is safe and appropriate health care. This extends to making declarations about public safety and risk. However, people are becoming increasingly well informed about health care and their rights and options, and this challenges the omniscience of medicine.

Health care is constantly changing. The act of prescribing medicines and the central rote they play in modern medical practice is open to debate and critique. Research into pharmacogenetics suggests that people only benefit from medications if they are equipped with the genetic codes necessary to effectively metabolise the chemicals contained within them. Significant proportions of the population have been found to tack the ability to gain full effect from various types of medications. (9) The notion of placebo has also been called into question. Some researchers argue that the fundamental belief that placebos are inert is problematic. (10) This is a challenge to the view that medicine is scientifically sound, as the placebo effect is one of the primary principles on which knowledge of effectiveness of medications is built. It is conceivable that prescribing medications may not be the pre-eminent form of medical treatment and primary health care in the future.

It is no longer appropriate for medicine to assert or be afforded the rote as the most informed and, therefore, powerful health professional group. Other professional groups are defining and developing their practice and the public is becoming more informed and articulate about choices in health care.

Competition

Professional groups have areas of expertise and practice. The ongoing development of disciplines and scopes of practice creates situations where practitioners in different disciplines may encroach on the territory of others. It is important for disciplines to maintain their territory in order to retain their identity.

A number of comments in the articles analysed could be seen to represent concerns about competition between medicine and nursing. Some of these give a sense of hierarchy between nurses and doctors, possibly suggesting that if the power dynamic is maintained, and doctors remain in control, then it would be acceptable for nurses to prescribe.

Nurse prescribing is also represented as a way of addressing health workforce issues and therefore useful, as tasks are moved between the two professional groups. Nurses are presented as helpers who are useful to assist medicine in its superior role.

"Especially in rural New Zealand where we have a shortage of health providers, the expansion of the nursing role is going to be a very positive thing for the patients in that area--as long as the nurses and doctors in that area work together to provide good care." (1) NZMA chair, Peter Foley. (September 13, 2005.)

"General practitioners have traditionally been the heart of primary care, with nurses as their helpers. The Government wants to change this so that the two work as part of a team, with nurses commonly taking a more prominent role than now." (1) (July 26, 2005.)

"GPs, for their part, hove felt bruised and neglected by changes, such as their virtual exclusion from maternity care. Their representatives are opposed to the proposal to expand nurse prescribing rights." (1) (July 26, 2005.)

Professional groups maintain their power in society by protecting their professional cultures. These cultures incorporate language, rituals and rules. (11) Some groups may be identified by their limited membership and clear rules for belonging while, in other cases, class and gender divisions have been used to define and maintain territory. (12)

Maintaining territory

The military, law and medicine are examples of professional groups that have a particular culture, and which actively socialise their members. One of the ways of maintaining the territory of a professional group is to ensure the boundaries where that group meets other disciplines are protected. Prescribing rights may be seen as one of those boundaries for medical practitioners in New Zealand. It is therefore not surprising that medicine would take exception to other professional groups encroaching on its territory and even employ shock tactics, such as predicting imminent public danger, to defend it. This is particularly significant in the light of territory being "lost" in relation to maternity care in New Zealand.

Various stereotypes of nurses have developed over time. (13) These include nurses as "angels of mercy" or authoritarian matrons. The idea of nurses as "helpers" for doctors corresponds with another stereotype, the handmaiden. Such images present nursing as being inferior to medicine while also being closely linked to, and therefore, dependent on it.

Nursing has a history of existing within the limitations medicine has placed upon it. Florence Nightingale is said to have been careful to ensure nurses did not encroach on the territory of medical practitioners. (13,14) There is evidence that the lines between the roles of nurses and doctors stemmed from competition for territory and were entrenched in doctor-run, hospital-based education of nurses. This led to medicine holding views about what nurses were capable of or were suited to, and established rules of professional etiquette. "... nurses were cautioned to suggest absolutely no treatment or diagnosis and to advance no opinions". (15)

Nursing has worked hard to develop its own areas of expertise, scholarship and education, and therefore define itself as a profession. While nursing may find itself in a position of being judged by medicine, it is important to appreciate that nurses have a higher professional profile than some other groups of hearth practitioners. Nursing has been observed to align itself with medicine in the critique of other less established groups of practitioners and in so doing, has demonstrated its own professional sovereignty. (16) The criticisms levelled between professional groups generally relate to evidence about outcomes of treatment and whether or not the treatment modality is based on sound science.

As nursing becomes brave enough to articulate and defend its practice beyond the concepts of hard science, it is important not to impose judgements on other professional groups which reflect the scientific and territorial debates that have been levelled at nursing by medicine. Nursing needs to be sensitive to other groups of practitioners, as it considers its own territory and potential competition for scopes of practice.

Conclusion

This small sample of articles published in New Zealand's largest daily newspaper over a six-year period gives some insight into messages the public receives about nurse prescribing. Three themes emerged--competence, responsibility and competition.

One interpretation of the comments contained in these articles is to see medical practitioner groups defending their status and desire to define and control nursing practice. The media has the power to select the information conveyed and, in these instances, appears to have demonstrated a bias towards the medical community's perspective.

Health care is changing dramatically as consumer knowledge and choice increase and groups of health practitioners, not previously recognised, begin to be noticed and become more organised.

In addition, the traditional response of asserting that groups of recognised health professionals can base their claims for legitimacy on scientific evidence is open to question. Some of those scientific principles are being debated, the actual level and quantity of evidence needed to support practice are questioned and professional groups claim their practice is much more than just purveying science.

Nursing must make sure it doesn't subject other groups of practitioners to the same treatment it has received from medicine.

This article was reviewed by Kai Tiaki Nursing New Zealand's practice article review committee in October 2006.

References

(1) The New Zealand Herald. APN News & Media: Auckland.

(2) Roife, I. E., Ringland, C. & Pearson, S-A. (2004) Graduate entry to medical school? Testing some assumptions. Medical Education; 38, 778-786.

(3) Allan, 3. (1996) Learning outcomes in higher education. Studies in Higher Education; 21: 1, 93-209.

(4) Ellis J., Mulligan I., Rowe J. & Sackett D. L. (1995) Inpatient general medicine is evidence based. A-Team, Nuffield Department of Clinical Medicine. The Lancet; 346: 8972,407-10.

(5) Naylor, C. D. (1995) Grey zones of clinical practice: Some limits to evidence-based medicine. The Lancet; 345: 8953, 840-3.

(6) Hines, D. R. (1992) Presence: Discovering the artistry in relating. Journal of Holistic Nursing; 10, 294-305.

(7) Meehan, T. C. (1998) Therapeutic touch as a nursing intervention. Journal of Advanced Nursing; 28, 117-125.

(8) Ragan, S. I., Beck, C. S. & White, M. D. (1995) Educating the patient: Interactive learning in an OB-GYN context. In G. H. Morris & R. 3. Chenail (Eds), The Talk of the Clinic (pp. 185-207). Hillsdale, N.1: Lawrence Erlbaum.

(9) Spear, B. B., Heath-Chiozzi, M. & Huff, 3. (2001) Clinical application of pharmacogenetics. Trends in Molecular Medicine; 7: 5, 201-204.

(10) Moerman, D. E. & Jonas, W. B. (2002) Deconstructing the placebo effect and finding the meaning response. Annals of Internal Medicine; 136: 6, 471-476.

(11) Schein, E. H. (1992) Organizational culture and readership (2nd ed). San Francisco: Jossey-Bass.

(12) Hall, P. (2005) Interprofessional teamwork: Professional cultures as barriers. Journal of Interprofessional Care, S1, 188-96.

(13) Bridges, J. M. (1990) Literature review on the images of the nurse and nursing in the media. Journal of Advanced Nursing; 15,850-4.

(14) Dixon, J. (1990) ... And the nurses were deafening in their silence. Nursing Praxis in New Zealand; 5: 3, 4-11.

(15) Stuart, M. (1992) Half a loaf is better than no bread: public health nurses and physicians in Ontario 1920-1925. Nursing Research; 41: 1, 21-27.

(16) Kelner, M., Wellman, B., Boon, H. & Welsh, S. (2004) Responses of established healthcare to the professionalization of complementary and alternative medicine in Ontario. Social Science and Medicine; 59,915-930.

Susan Shaw, RN, BN, DipTchg, MEd Admin, was a principal lecturer at Auckland University of Technology, working in academic and staff development, and working as an RN in the private sector, when she wrote this article. Over the last year she was on leave from AUT.