Editorial

November 2007

Claiming Health

This editorial is closely derived from a paper recently presented to the NPNZ conference in Auckland on October 20th 2007.

A while ago Dr Jill Wilkinson (a member of the College) suggested to me that nurses needed to embark on a campaign to ensure that in the public’s mind the word nurse became synonymous with health.  I think she is absolutely right.  I want in this paper to consider how the medicalisation of health in the public mind and the burial of nursing behind those assumptions is critical to the issues which confront establishment of the NP role in NZ.

Last month many of us read the comments of the Auckland Medical School Dean, Professor Des Gorman, on the development of the nurse practitioner role in New Zealand.  Gorman noted that “this initial experiment has failed and we need to quickly relaunch it.  He noted that NPs were “a good idea killed by being time and cost punitive” and he also noted that NPs took just as long to train and were just as expensive to train as medical practitioners.  He further noted that he was not opposed to NPs or physician assistants and it is interesting and instructive (and even alarming) to note that he refers to these two roles interchangeably.

I want to say at the outset that I don’t necessarily disagree with Prof Gorman that there is a significant problem but I have completely different reasons for sharing his concern.  Prof Gorman’s comments neatly and explicitly capture a widely, indeed globally, held view about the nature of health service delivery and the role of nurses in that system.

I do agree with Prof Gorman completely that we should have developed the fundamentals of an employment model first.  It is a source of huge concern to me that NPs who have undertaken the demanding journey to reach NP status should find themselves not employed as an NP.  This is more than tragic; it is a mindless and inexplicable waste of precious resource and a loss of potential health gain. 

I find his assertion that NPs take as long to train as medical practitioners deeply ironic; having sat across one too many tables where medical lobby groups were asserting that NP prescribing is unsafe because NPs have not undertaken the years of training that our medical colleagues do!  They cannot have it both ways!!  I have also seen the figures clearly demonstrating that despite the nature and time taken for NP education it remains considerably less costly than medical education.

But I want to acknowledge that Prof Gorman is right to be concerned; he knows as we all do that the health system of this and many other countries faces an incomprehensible tidal wave of demand and that we seem unable to move beyond the hand wringing phase of planning for the future.  That we need a revision of the current model of health care delivery is a given and this has been well argued by the NZIER report of 2004.

How can we possibly be concerned on one hand that we will not be able to cope with the demand for health services, yet on the other hand waste existing resource.  In one area that I know of (as just one of several examples) we have an NP who has used the process of community partnership extremely effectively to set up a youth and sexual health clinic.  In four months she has accepted over 700 registrations, multiple referrals from GPs and other services and is addressing serious health problems in vulnerable young people.  Inexplicably she is working in an unpaid role and is not even funded for the relevant diagnostic tests.  I simply do not understand this but I do want, today, to salute her persistence, courage and sheer tenacity and there are others in similar circumstances.

The really interesting comment from Prof Gorman was that he believed that the starting point for developing a model for roles like NP or PA is to decide what the role of medical practitioner should be in 2020, then the next bit (deciding alternative roles like NP) should be easier.

In a last referral to Prof Gorman he also suggested that “The most successful NP models were in endoscopy or practice and experience based areas like diabetes clinic leaders and the public would get the best return for investment by having GPs at the front door of the hospital.” 

It is at this point that I must totally and fundamentally disagree with Prof Gorman.  These statements, especially those about endoscopy, suggest that the whole of health services are medical in nature and that all health encounters of importance are medical or diagnostic or relevant to hospital admission.  In addition it strongly suggests the NP role as a technical and substitutive role and interchangeable with a physician assistant.  It is this belief system that has brought us to our current impasse.  His comments suggest that the role of NPs is to complement and substitute for aspects of medical practice roles in a system in which health remains synonymous with illness and illness care.

Let’s not forget that we have had a system that runs on these grounds for well over 100 years.  Since the rise of bio-medicine we have considered the body as a machine, we have looked to medicine to lead services and we have consistently invested in increasing medical and pharmaceutical solutions to health problems.  Despite our increasing cleverness in these areas we now have an epidemic of chronic disease, and we now recognise that our current model is expensive, ineffective and unsustainable.  

Health services and current health systems are increasingly unable to address burgeoning need within current budgets and with available human resource.  A just concluded two-year research project which I have been leading explored the experience of a cohort of people with chronic illness when they accessed general practice services.  It considered a great deal more than this but the findings of this particular aspect of care were instructive.  Participants clearly and powerfully outlined a need for connection, co-ordination, information, health education, interpretation, assistance with planning, having realistic expectations and with negotiating their life in altered circumstances.  Because of the way our system is set up their first (and often only) point of contact is a busy GP whose services they essentially described as effective for managing the presenting problem but reactive in nature and not able or willing to address their personhood rather than their presenting problem.  This had strong echoes for me of similar findings in the Australasian NP standards research with which I was involved.

Here NPs described the very different way in which they interacted with patients or clients as compared to their medical colleagues.  In particular I remember one Australian NP participant who with a medical colleague visited a young mother with terminal cancer in a remote area.  She described vividly the compassionate and competent clinical consult provided by the doctor but then she went on to describe her own consult when she went back alone the next day.  Here she described her connectedness with the woman as they explored not just her physical pain but the anguish she felt about the impending abandonment of her very young children, the need to manage her dying in a way that put their needs first and her need to find a way to shield them from her anticipatory grief.

These comments are problematic because they imply that nurses and doctors are polar opposites and that we care and they don’t.  This is absolutely not the case and would be a gross oversimplification.  What I am describing is not about the individual doctors or nurses who vary enormously on both sides of the medical/nursing divide.  Rather it is about the focus of our respective education and training and our philosophical approach to practice.  It is also important to acknowledge at this point that at a personal and professional level there is mutual respect for these differing perspectives and for most NPs their medical colleagues are welcome friends and collaborators.

I do not need to bore a sophisticated audience with what it means to provide care and services from a nursing approach but the Australasian study strongly affirmed for me that the additional tools which NPs take on (medical diagnosis and prescribing etc) are just that – tools – and they are a matter of convenience and access and they allow a nurse to provide the full episode of care when it is appropriate or necessary.

In the Australasian standards study we found that
“NPs represent a unique form of change agent for delivering services differently in a manner giving primacy to health and human complexity whilst delivering some medical services as a means of increasing and maintaining access.  When nurses add medical tasks to their repertoire but retain a nursing focus they extend the range of their health-focused service.” (Gardner, Carryer, Gardner, Dunn, 2004)

The NZIER report mentioned previously argues that the current approach to health and disability services provision is unsustainable.  The demand is growing and the workforce is contracting and we cannot afford to waste anything.  There is consensus in the report that closer attention must be paid to occupational definitions and boundaries.  The report argues that the focus of the whole health system must change and become more firmly fixed on what the users of health services and their associated communities want, and a person- and community-centred approach is suggested.  

This speaks remarkably clearly to me of just what we were “on about” when we agreed that the NP role as already evidenced in the US was just what the health sector needed here.  Many other countries have arrived at the same decision and are actively pursuing NP roles.  Current multidisciplinary literature debating the improvement of health outcomes produces some remarkable consistency.  The universal challenges for consumers of health services include maintaining access, choice, safety, affordability and cultural comfort in contexts where distance, lack of transport, poverty, reduction of amenities and limited support services increasingly present significant challenge.  Consistently, analysis of health need (and my own research) raises the demand for co-ordination, continuity, seamlessness, attention to individual difference and the ever present need for cost effectiveness.  The dwindling resource of medical practitioners in this country is too oft-cited to need serious mention here but I suggest that is to some extent a red herring.  I think even if we did have more doctors it would not solve our problems.

The issue of unmet need is of huge importance; in the US NPs established their services with the obviously homeless and uninsured whose unmet need was clear.  Unmet need is much more widespread in NZ now but it is rendered invisible by a health service that ostensibly provides medical care for all, either free or at a very low cost but in doing so obscures or fails to acknowledge the more complex issues which block access to good health for many.

What is it that continues to frustrate the design of flexible yet well co-ordinated health services delivered in an accessible manner?  What would move us from the endless rhetoric of “new ways of working”, “right person for the right job” to actually enabling it to happen?  I think that hegemonic faith in the power of biomedicine constitutes the over-riding barrier to any real innovation in the delivery of health services. 

Fear-mongering and assertions of danger when people are cared for by NPs cleverly supports the ever-present belief that a health system is really about illness management rather than the care of people and, by default, suggests that illness management is properly the province of highly skilled and expensively prepared medical practitioners.  This belief system consistently obscures the importance of obvious solutions to health sector challenges.  The establishment of the nurse practitioner role has occurred in the crossfire of such challenges and this is exactly why it has brought us to the position whereby our processes can to some extent be correctly described as a tragic failure.

At no point has the health system actually owned the development of the role in a consistent, planned and coherent manner.  Six years from the authorisation of the first NP we are still setting up working parties, trooping to the Minister’s office and sitting up late at night writing tedious papers for the Ministry. 

We watch our best efforts disappear into the ether and we learn that we should get over our constant self-interest and focus on the needs of our patients and clients.  Just the other day a Ministry of Health person asked me in all seriousness if we had ever actually demonstrated the need for NPs.  I know that establishment of the NP role took forever in the States.  But it is not acceptable to me in an intensely globalised world to have to reinvent the wheel here and to need to relitigate the same arguments and air the same evidence.  And what is different is that the movement started in the States well before there was any awareness of the level of challenge facing us in 2007.  We do not have the luxury of time to fight for 40 years to achieve the exceedingly obvious. 

At a systems level there is the deeply held belief that all health care provision must be directly or indirectly led or overseen by medicine.  In this respect I want to acknowledge the ovular work of Barbara Saffreit and her clear analysis of the processes and consequences of medicine’s strategic creation of all health, illness and medicine as synonymous terms. 

Nurse practitioners are a vitally needed workforce development, particularly as the indicators of demand outstripping available labour supply have become urgent.  NPs are especially important, indeed critical, to managing the increasing burden of chronic illness and delivering on the goals of increasing wellness levels through effective primary health care which is proactive and planned and patient centred rather than episodic and reactive.  Nurse practitioners provide just such a new form of health service, one which combines the best of nursing with the convenience of a number of additional tasks to improve access through allowing provision of the full episode of care. 

We cannot afford to accept the notion of tragic failure as recently used to describe the ad hoc employment model currently in existence.  This threatens to slow the impetus nurses will show towards the education and authorisation process and it denies us the role models we need to provide leadership and, worst of all, it denies us a source to quickly provide outcome related research to guide our ongoing development.

In closing I want to return to Jill’s suggestion and expand it a little.  We need to appropriate and control the language of health.  We need to ensure that the discourse of the health sector is reframed to give primacy to prevention and wellness and to nurses as the navigators of people’s health journey regardless of whether or not that journey is interrupted by illness or injury.  Perhaps then the construction of employment for NPs will occur in a planned and purposeful manner.

Reference:

New Zealand Institute of Economic Research. (2004). Ageing New Zealand and Health and Disability Services: Demand Projections and Workforce Implications, 2001–2021. A discussion document. Wellington: Ministry of Health.