American nurse authors, Browne and Tarlier were referring to the United States health sector when they wrote:
As politicians and policy-makers call on NPs to resuscitate an overburdened healthcare system that is increasingly affected by neoliberal policies and agendas, NPs must aim to provide primary care in ways that mitigate the impact of health and healthcare inequities using critical social justice approaches. (2008 p. 88).
This quote speaks to the very heart of nursing’s agenda for establishing the NP role in New Zealand and our concerns as we watch the implementation gaining pace.
The good news as we approach 400 NPs in New Zealand is that there are now that many NPs out there who are already demonstrating that the education and clinical training they have received has prepared them well for the role. Anecdotal reports of patient feedback are more than gratifying and bear out the international literature which consistently reports high levels of patient satisfaction and no problems with patient safety. NPs are making valuable contributions across the whole sector now but most particularly in primary health care and aged care where the need continues to increase.
Our goals in establishing NPs in New Zealand were multiple. At the simplest level it was recognised back in 1998, when the role was first mooted, that the NP role was a highly cost-effective way of delivering a high level of service to a wide range of patients in a wide range of settings. It was acknowledged that the NP would take on a number of tasks and activities that had more typically been in the realm of medicine or medical practitioners. It was also acknowledged that the acquisition of the extended skill set would increase the range of practice and allow people with a foundational preparation in nursing to manage the full episode of care for a wide range of patients.
Inevitably health bureaucrats and perhaps the public have interpreted the NP as a cost effective substitute for a medical practitioner. And in many ways that is of course true. But our final goal was a great deal more ambitious and focused on the nursing attention to comprehensive holistic assessment, health literacy, patient education, health maintenance and patient empowerment through attention to those factors. The strength of the NP role as it was anticipated was to extend those characteristics of practice to patients in the course of consultation and management of presenting problems. Such work takes time and is challenged by the tyranny of the acute and the time pressures which characterise general practice and many other settings especially when driven by a profit agenda.
The American authors quoted above speak to a very similar concern emerging in New Zealand which is the tendency to expect NPs to work in the manner of quickfire appointments thus reducing the opportunity to work with the people who most need it, in a manner which does more than band aid a presenting problem. Talking with NPs reveals their distress; despite being paid salaries considerably below the expectations of a GP they are often required or expected to “process” the same number (or very close to) as the throughput of a GP.
Stories abound from the front line:
Today I saw a 49-year-old Maori Male – has had chesty cough – cold and flu symptoms for 16 days – could not afford to come in as owed some money – did not want to get hassled by reception. He was very sick and clearly had had these symptoms for a long time as on assessment I noticed that he had marked clubbing of his fingers. He was the kind of man who you needed to get as much done in one visit as you could as he would not be back; as he left my consultation I had no sense of providing the level of care for which I have prepared.
Or another NP: “Saw a 16-year-old Maori female, booked into a 15-minute consult, wanting the ‘Jab’. Said she was with her first boyfriend, not able to talk to mother about contraception, just wanted the “jab” as that was what she had heard her friends talk about. Reported previous unprotected intercourse. I asked myself where to start. I need to develop a relationship with this young lady, and address issues of consent, alcohol, smoking, STI, pregnancy – urine HCG – cloudy urine? and discussion about other choices needed. Do I complete everything today versus get her back? Do I refer her to PHO sexual health funding but having plucked up courage to come today will she go again and to someone else? Is this a wasted opportunity to make a significant difference to her future?
We remain as a discipline committed to the fullest notion of primary health care and not primary or first contact medical care. There is a continued call to reduce or hold back the tsunami of need present in the epidemic of long term conditions, the unacceptable lack of equity and the diseases of despair that are crippling young people. NPs and RNs are a highly cost effective form of service delivery and must be granted the time, space and autonomy to deliver the exact type of care and approach for which they are educated and which can stem the flow of misery and suffering and the constant blow out of health service costs. Nurse Practitioners’ time is indeed comparatively inexpensive and the investment will pay considerable dividends in the long term. As one United States commentator noted, a nurse practitioner is a great deal more than a consolation prize.
Browne, A.J. & Tarlier, D.S. ( 2008) Examining the potential of nurse practitioners from a critical social justice perspective. Nursing Inquiry, 15 (2) 83-93