Why the angst about nurse practitioners? The advent of the nurse practitioner has created a sense of unease within some parts of the profession. Is it justified?
The interview struck a chord with many nurses and a number wrote letters expressing their disappointment that Eckhoff's applications were turned down. The letters express a range of views but a number of common threads are evident: that primary care, in which Eckhoff works, is an ideal site for NPs; that nurses who want to advance academically and those who want to remain in practice, learning through on-the-job study, should be equally valued; that nurses who have been working at an advanced level of practice for years, some of whom have been called NP, are feeling frustrated and disillusioned; that the NP role may create divisions within the profession; that those driving advanced nursing practice are out of touch with the reality of clinical practice. Rarely has an article provoked such debate. Eckhoff also received many personal, positive responses to the article.
There is also anecdotal evidence from NZNO staff about the unease and anxiety among some nurses about the role. So what is it about the NP role that has created this sense of unease, if not downright threat, in some parts of the profession?
Nursing Council chair Annette Huntington is a little bemused. "Levels of roles in nursing are not new. The NP is just another level of practice. When the clinical nurse specialist was introduced, was there the same debate about it driving a wedge between nurses? It is another role in many roles within nursing but it is the most advanced clinical role we have at this time. For nurses in the clinical area, it maybe a role they want to aim for."
Referring to the need for masters-level education or equivalence for the NP role, Huntington said the qualification was not set "by a small, elite group of educators. We looked at international NP models and a masters education is set as the appropriate preparation for that particular role."
What does concern her is the cost of tertiary education generally. "It is a significant cost for all students and nurses doing masters papers are part of that community."
Huntington was not involved in the development of the NP role, which grew out of the Ministerial Taskforce on Nursing. NZNO had withdrawn from the taskforce before the publication of its report in 1998. In the report the idea of an advanced nurse practitioner was raised. The report stated the key difference in the advanced NP role and nurses who were operating as NPs at that time lay "in the educational preparation for the role". The report said use of the title NP needed to be clarified, particularly in relation to advanced and specialist roles. (1)
Huntington says the role was developed through the profession and the Nursing Council was required to regulate it to ensure public safety. The Nursing Council brought together an "appropriate group of people" to draft competencies and set standards for the institutes that would provide education for NPs. Because the NP was a new development, the first applicants did experience some delays "but we had to ensure the process was robust and fair".
Some of the initial problems experienced by applicants have now been addressed. "We now have a monthly report to the council's education committee on every contact with the applicant and performance measures around time. I have confidence in the process and the speed with which it can be carried out. But it can't be a rapid process, as it must be managed in a fair and just manner. The Nursing Council is not wanting to stop nurses becoming NPs. We are there for public safety."
There is now the Nurse Practitioner Advisory Committee, NPAC-NZ, of representatives from a range of nursing organisations. "That group was not there initially for those first applicants."
The committee acts in an advisory and support role to aspiring NPs. Nine nurses have been trained as mentors to support people through the application process. One mentor, NZNO professional nursing adviser Faith Roberts, said the mentor role had been developed because applying to become an NP was a difficult process." It is outside nurses' experience and nurses have never been particularly good at asking for help. This is a way of providing formal support and of helping nurses accurately represent their practice and experience on paper."
Roberts hopes that once this role is cemented in for NPs, it can be expanded for all levels of nursing.
Up until 2010, NP applicants can be awarded equivalence. The applicant has to demonstrate "accumulation of knowledge and expertise equivalent to a master's degree". Huntington said some nurses believed equivalence meant "a lot of clinical experience. But that is not the case. In a master's degree nurses have to think about their practice in a way that is reflective and critical and have evidence to support their clinical decisions. That's what nurses going for equivalence have to demonstrate--how they think about their clinical experiences."
Equivalence was approved by educators, not clinical specialists. "It involves issues to do with education. It would he highly inappropriate for clinical specialists to determine equivalence."
Huntington understands that not all nurses will want to become NPs. "Nurses make considered decisions about what they want to do in their professional lives. It will suit some to become NPs and it won't be in the career planning of others."
More scopes of practice than the current seven would evolve. "Nursing Council is not imposing a limited number of scopes. There has to be flexibility because of a rapidly changing health environment and there is a lot of flexibility within the current scopes of practice."
Despite some initial problems, Huntington is convinced NPs will have an "enormous impact" on the health of their communities.
NZNO chief executive Geoff Annals agrees. "The NP is an excellent role that will make an important contribution to improving health outcomes."
But he has some concerns about how it is being promoted. "There is a sense among some nurses that the profession is abandoning them in some way. Nurse leaders need to be wary about the messages being given about the role. It is important to value the NP role but to do so in a way that values the whole spectrum of nursing."
He believes the feelings of angst, if not anger, the NP rule arouses for some nurses is a reflection of many nurses' low professional self esteem. "Nursing is constantly reinventing itself as something better. Nursing is very able and has huge professional worth as it stands. To evolve and build on it does not mean abandoning what we have and reinventing ourselves."
Some nurses had similar feelings with the advent of comprehensive training, a sense that those who were hospital trained would no longer be valued, he said. "We have to acknowledge some nurses are feeling threatened by the NP role. We have to ask what that means for us as a profession. We have to view ourselves in a much healthier way."
He wonders why NZNO is seen by some sectors in the profession as anti-NP. "We have consistently supported the role, although we have had significant concerns about some aspects of it. It is unfortunate the role and prescribing are wedded. The NP role is by definition broad in its scope, which doesn't necessarily lend itself to nurse prescribing. There has been a lack of focus on the nurse specialist role and their ability to prescribe. But NZNO supports the role within the whole gamut of nursing and the range of different approaches individuals have to their careers."
In practical terms, NZNO had done a great deal to develop the credentialing process, to ensure nurses' input and to get NPAC-NZ up and running, he said.
Annals has no idea how many NPs New Zealand might need. "Nurse practitioners will respond to community need."
One nurse who has done just that over more than a decade is Nelson-based founder of an independent nursing practice, Annette Milligan. Her successful practice was established and continues to build on a need for sexual health care and education, particularly for young people. An ideal candidate to become a NP, Milligan is not interested but strongly supports the role. At NZNO's College of Practice Nurses' conference in Nelson in May Milligan urged nurses to support the role. "The pathway is there now. The NP status is the gold seal of approval and that's very important when seeking funding."
Milligan said at this stage in her career she could live without NP status. "Not all nurses will want to be NPs but it is important all nurses get in behind Nursing Council and [the Ministry of Health's chief nursing adviser] Frances Hughes who worked so hard to get the NP role and nurse prescribing.."
Nursing researcher Merian Litchfield has cautioned against the way in which the role is being developed in New Zealand and suggests it "places nursing within an interventionist/curative paradigm--a medical paradigm". (2) She also lends support to the argument, voiced by some in the profession and others within medicine, that NPs will compete rather than collaborate with doctors. "Introduction of the role in the given framework is understandably interpreted by doctors as competition and assumed to be filling the vacuum created by the shortage doctors. (2)
One of the most influential drivers of NP development is executive director of the College of Nurses Aotearoa, Jenny Carryer. Responding to Litchfield's arguments, Carryer said there had been "interesting shifts in what constitutes nursing and medicine, particularly at the level of tasks and procedures.... What determines both nursing and medical practice must be regarded as historically, or context and even location specific." (3)
She maintains it will be up to pioneer NPs "to assess what their patients and clients need and to respond as creatively as they can, within the framework of legislation and certification ..." (3)
So what of those caught in the crossfire of the NP debate, who have met the Nursing Council's competencies and are now working as those pioneering NPs?
(1)) Ministry of Health (1998) Report of the Ministerial Taskforce on Nursing: Releasing the potential of nursing. Wellington: Ministry of Health.
(2)) Litchfield M. (2002) Nurse practitioner role limits the professsion. Kai Tiaki Nursing New Zealand; 8: 8, 20.
(3)) Carryer J. (2002) The nurse practitioner role: a process of evolution. Kai Tiaki Nursing New Zealand; 8:10, 23.