Valuing the paradigm of nursing: Can nurse practitioners resist medicalization to transform healthcare?

Abstract

A lay person commented recently to one of us that ‘seeing how nurse practitioners were so clever why didn't they rename themselves as something other than a type of nurse’. A sobering comment indeed, but one that has, on occasions, been uttered by nurse practitioners (NPs) themselves from around the world. In this editorial, we would like to tease out the thinking behind such notions and consider the implications for our discipline. In doing so, we draw essentially on the New Zealand experience of NP establishment but believe these ideas have international significance. In New Zealand, the NP is a separate legislated scope of practice from registered nurse. Nurse practitioners must graduate from an approved clinical master's programme, having at least 4 years of experience as a registered nurse in their area of practice. They autonomously (or in teams) deliver the full episode of care including diagnosis, management, prescribing and referral as needed, without recourse to guiding protocols or supervision. There are currently well over 500 registered NPs working across a wide variety of clinical settings. Approximately 60% are working in what can broadly be defined as primary health care. International evidence has provided surety that NPs deliver health outcomes at the very least equivalent to general practitioners (family or primary care physicians) and across several parameters, including mortality, long-term condition management, and patient satisfaction they deliver superior outcomes (Laurant et al., 2018). Yet through this research, the discourse of ‘substitution’ tends to dominate. While we see such evidence as central to informing the public and health sector of the safety of NP practice, the notion that NPs are direct substitutes for physicians, we believe, is becoming problematic, particularly across mainstream primary care practices. Too often, NPs are being asked to work in the same model of care as general practitioners through 15-min appointments and oftentimes limited (by organizational edicts) to only one patient issue per consultation. To see NPs as simply a replacement for general practitioners will do nothing to improve the health outcomes and persisting inequities present in specific populations in multiple countries. Instead, we need to envisage the NP workforce as offering a model of care that extends biomedicine by embracing the nursing paradigm to transform primary healthcare services. The nurse practitioner movement was first mooted in New Zealand in 1998 following a Ministerial Taskforce on Nursing. The aim of the Taskforce was to chart how to realize the full potential of nursing at a time when the demands on health services were growing, coupled with escalating costs; the population ageing; and there was greater awareness of the need to address perpetuating health inequities. The Taskforce was further motivated by the United States experience where NPs had been working for about 40 years with strong efficacy data and, since that time, other countries had, or were beginning, to launch the role. By expanding your knowledge and skills into medicine, and thereby acquiring some of that control, you can in fact expand into nursing… Less medicine when mixed with more nursing, is probably better medicine (or to translate, better health care)… By expanding into medicine you will need - more than ever before - to increase your consciousness of what nursing is all about’. (Bates, 1974, p. 686) The principal impetus for NP establishment in New Zealand was to improve access to health services by creating advanced practice nurses who could lead the care for a much wider range of patients. The intent was they remained embedded in a nursing team while working collaboratively with other health professionals across the sector. As such they would contribute a nursing paradigm of care grounded in achieving social justice and health equity (Browne & Tarlier, 2008), with the ability and authority to diagnose and prescribe. Nurse practitioners were seen as creating a flexible, affordable and available workforce which would expand service provision especially for underserved, Indigenous and priority populations (including Māori and Pacific in the New Zealand context) and rural communities. Early research on the role was conducted between New Zealand and Australia (Carryer et al., 2007) revealing that the Australasian model of NP practice was firmly grounded in nursing and resistance to medicalization was strong. Early implementation of the NP role was based in knowing that to suggest certain tasks were forever to be performed by medicine was to be rigid and inflexible and a recipe for the cumbersome and costly health system that failed to address significant consumer need. More recent research has affirmed early assumptions that an advanced nursing role with an extended toolbox of skills does indeed engender high levels of patient satisfaction and increased enablement of patients (Frost et al., 2018) leading to higher levels of patient engagement and empowerment. The role of the NP was thus seen firmly as an extension of nursing, aligning with World Health Organization global goals for primary health care. As such NPs take their grounding in primary health care, with a focus on cultural safety, social determinants, health literacy, wellness and the fundamental notions of holism, into their consultations. We have previously argued that over 100 years of commitment to the hegemony of biomedicine throughout health systems has done little to reduce inequity nor to deliver essential primary health care in the face of ever rising health costs and an epidemic of long-term conditions (Kooienga & Carryer, 2015). Added to this the complexity of systems grounded in neoliberal policy agendas has created a fragmented and competitive health arena in which NPs must work (Adams & Carryer, 2021). While the extant models of care may serve some people brilliantly, others fall through the cracks, either through lack of affordability or lack of appropriate service. Instead, if NPs stay true to a philosophy of nursing that embraces a person/family-centred and collaborative approach in a social justice framework, they offer the opportunity for transformational change to healthcare delivery (Carryer & Adams, 2017). Despite medicine's vital but narrow, contribution to health outcomes, it is accorded enormous prestige, power and high levels of public recognition and deference. In addition, medicine is also rewarded with high levels of remuneration and assumptions of leadership of healthcare teams. Certainly, the health bureaucracy seems unable to let go of searching for old solutions to new and growing problems in health service delivery. Similarly New Zealand media write endless stories about the rapid decline in general practitioner (primary care physician) numbers while firmly resisting constant requests to tell the good news story of the rise of NPs. A singular focus on biomedical solutions will not address pressing challenges in primary healthcare delivery. As Dillard-Wright and Shields-Haas (2021) so eloquently argue, ‘Ignoring holistic health and well-being to focus on singular medical tasks and disease processes is reductive, violent, and contrary to humanization as a disciplinary focus for nursing’ (p. 199). Historically, much has been written about the oppressed group status of nursing as a discipline (see for example Roberts, 1996). One feature of oppressed groups is a tendency for members to seek escape and recognition through allegiance to a related group with greater power and status. In doing so they seek to divest their alignment with the oppressed group. The pull for NPs to align with medicine and to move away from their nursing heritage is thus potentially compelling. Such a move would, however, be completely antithetical to the essential value of the role which rests with the unique combination; a strong background in nursing extended together with the addition of various medical skills and tasks previously under the jurisdiction and professional domain of medicine. It is our hope that the temptation for NPs to move away from nursing is resisted at all costs. We remain firmly committed to the original intent of the role establishment. While being respectful of the contribution and immense value of medicine we return to their limited contribution to comprehensive health outcomes. In addition, medical professionals’ high levels of remuneration mean that access to even the most basic primary care needs can be expensive and out of reach for many of the people who need it most, in turn leading to a greater burden of morbidity and hospitalizations. One major reason for the 2021 health reform process occurring in New Zealand is the inequitable access to care. Despite, ostensibly, a universally accessible and publicly funded healthcare system, access to what is mostly physician-led primary care remains a user-pays model (Goodyear-Smith & Ashton, 2019). NPs through the nature of their practice and their duality of approach offer the best hope for improving equity, affordability, access and sheer availability of services. Beyond the immense value to patients there are other tangible advantages to the NP role. The presence of NPs as senior members of the nursing workforce has the potential to expand the public perception of nursing not only through their clinical acumen, but also through their engagement with local communities to identify health need and deliver culturally appropriate services. Positively promoting the visibility of nursing will help shift away from the enduring notions of handmaidens, heroes and angels (Dillard-Wright & Shields-Haas, 2021). Further, the role of NP acts as a catalyst for promising new graduates to remain in nursing with aspirational clinical career goals. The role itself has many miles to run in breaking down artificial service delivery boundaries (such as between general practice and community services; or between primary and hospital services) and delivering increasingly nurse-led services. We see the NP role as perfectly designed to span historical service boundaries, and though these boundaries may serve funders, planners and providers well, they make life complex and confusing for patients and result in reduced access to care. The need for better integration of care delivery has been much touted but remains elusive in current service delivery models. There is good reason however to be cautious about ‘integration’ of the NP role into an existing medically dominated healthcare system (Delvin et al., 2018). As with the discourse of substitution, there is a risk that NPs and their work become subsumed into extant models of reductionist biomedical care. The focus on inter- and intra-professionality risks the loss of identity for all but medicine, who will continue to assume leadership of the clinical space, as well as the nature and direction of service delivery. On the other hand remaining at the margins of the system enables NPs to be critical of the domination (Browne & Tarlier, 2008) and from this position appreciate the system as a whole, as well as the healthcare needs of those on the periphery (Delvin et al., 2018). Delvin et al. argue that NPs need to take a philosophical perspective to describe what nourishes and defines them, their true nature and ability, and ultimately, how they express their authenticity in practice. Role definition, they say, is crucial. Dillard-Wright and Shields-Hass (2021) argue that across the globe, health systems are struggling not just with the COVID-19 pandemic but with fiscal and workforce sustainability. It is clear that a transformative approach to leadership and practice is long overdue. Nurse practitioners closely aligned to their origins in nursing hold critical potential to be this transformation if they are able to resist the medicalization of their role. We hope that NPs as our most senior clinicians will indeed remain closely aligned with their roots in nursing. We hope that NPs will not be seduced by the multiple rewards offered to medicine and will remain focused on the value of their nursing approach to practice. Aside from the value to issues of nursing identity and recognition it is patients, families and communities who will have the most to gain. None.

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