Family Nurse Practitioner - Exploring the Differences:
A NZ / US Dialogue

Jenny:
Through my role as Professor of Nursing at Massey University and executive director of the College of Nurses, I have been a long time champion of the development of the Nurse Practitioner role in NZ. It has been a very useful experience to spend considerable time with Dr Sarah Kooienga who is a Family Nurse Practitioner teaching at Massey University in the management of Lifelong Conditions postgraduate paper and living here in New Zealand for the past 4 months. Sarah has been a Family Nurse Practitioner for the past 20 years, predominantly providing primary care services in Community Health Centers, which are part of the small public health sector in the United States. As well she has practiced in Urgent Care/Walk In Care, secondary school based settings and a university health care center. Sarah is also faculty at Oregon Health and Science University Portland, Oregon since 2004 teaching both in a classroom and clinical settings. She received her PhD in 2006, her dissertation focus was Mexican American families experience of Type 2 diabetes, based on a 10 year clinical practice with Spanish speaking Latinos in the United States. Sarah has been involved with the development of the Nurse Practitioner role in Canada, working with the College of Registered Nurses of British Columbia (B.C.) in the development of the OSCE (Observed Standardized Clinical Exam) for NP licensure. She currently serves as an examiner involved in testing of all NP applicants in the province of B.C. and has provided consultation to universities in B.C. in their Family Nurse Practitioner (FNP) programs.

Our goal in writing this article shortly before Sarah’s return to the U.S. was to try and tease out some of the perceived differences in NP practice in the two countries and to move some way to understanding a seeming reluctance or difficulty in employing U.S NPs in NZ. Workforce shortages in this country mean that enquiries by nurses with many years of practice experience as NPs should be warmly welcomed but U.S NPs tell us that it does not always feel like that. The article takes the form of questions raised by Jenny and answered by Sarah with additional dialogue and a comparison made of the various NP competencies across the U.S. NZ . Canada and Australia in table form.

Jenny:
How do you see the differences between the North American Nurse Practitioner role and the New Zealand NP role?

Sarah:
I believe the differences lie in 3 areas, history of the role, competencies and scope(area) of practice. The history of the role in the United States was that it was initially a primary care role developed to meet unmet needs predominantly in paediatric and family based care. The first nurses who were encouraged and sought further education and expansion of their clinical practice were community or public health nurses. Their clinical practices involved developing advanced assessment, diagnosing and management skills in the areas of well-child, acute illness both pediatric and adult and family based care. These nurses functioned within a less formalized nursing structure and usually in a more multidisciplinary team approach (Baer, 2003). Whereas in New Zealand it seems to me early Nurse Practitioner pioneers were more likely to be nurses who functioned as specialists within the secondary or tertiary care sector, their practice evolving to take a broader role within an existing speciality role and part of an existing nursing structure.

The nurse practitioner role in the United States has evolved over the past 40 years from only a primary care role to encompass speciality functions such as acute care NPs and Neonatal NPs. However, the vast majority of nurse practitioners in the United States are employed in primary care settings. The majority of Nurse Practitioner education programs have maintained a primary care focus. All competencies for nurse practitioner practice and education programs are based in primary care with speciality focus layered upon that foundation(NONPF, 2002). Looking to Canada, nurse practitioners are currently being educated and licensed as primary care clinicians in the majority of the provinces-(CNA, 2002)

Sarah and Jenny:
Our dialogue led us to compare the current NP competencies across NZ, the US, Australia and British Columbia in Canada in the form of a table. It is notable that the Australian competencies, inititally developed for NZ and Australia have only been adopted in Australia and it is also notable that the NZ competencies have recently been separately reviewd and revised.

I

Current NP competencies across NZ, the US, Australia and British Columbia in Canada

Sarah:
Competencies have been developed in most countries to dictate nurse practitioner education, licensure and practice. If one compares and contrasts the North American and Australian competencies to the New Zealand competencies, some similarities emerge. Shared understanding exists around the importance of an expert practitioner and the need to practice in a multidisciplinary environment. The prescribing function is emphasized in both sets of competencies. The need for leadership as part of a professional role is emphasized as well.

While both the British Columbian( Canada), Australian and United States competencies are clearly clinically focused, New Zealand competencies appear to be less so. Competencies addressing diagnosing, management, prescribing and health promotion and disease prevention are seen as essential for both North American and Australian nurse practitioners.

The development of the patient/provider relationship is key to understanding the NP role in North America. National Organization of Nurse Practitioner Faculty (NONPF) competencies stress the importance of relationship based care, evidenced in competency #2- patient/nurse practitioner relationship, as well in the development of teaching /coaching function in partnership with clients/patients. In the development of the therapeutic patient/nurse practitioner partnership, nurse practitioners need to manage and negotiate an ever complex health care system, monitor and ensure quality and develop cultural understanding to serve the needs of increasingly diverse patient groups(NONPF, 2002). The relationship development is part of the health promotion competency for B.C. nurse practitioners, in relationship development , the nurse practitioner engages in partnership with therapeutic communication, appropriate rapport, respect and empathy,negotiates priorities for health care and understands the experience of the patient/client –College of Registered Nurses-British Columbia (CRNBC, 2003). In the Australian competencies in which competencies are structured under Standards 2-Establishing therapeutic links with patient/client /community that recognise and respect cultural identity and lifestyle choices (Gardner, Carryer, Dunn, & Gardner, 2004). In reviewing the New Zealand nurse practitioner competencies, the negotiated relationship with clients/patient is barely mentioned In summary, the North American and Australian nurse practitioner competencies emphasize clinical practice and see the development of excellent advanced nursing clinicians as paramount.

The New Zealand NP competencies stress the importance of a change agent at both a local and national level, the need for research activity by the nurse practitioner, and the promotion of nursing leadership and consultation to other nurses. Excellent clinical practice is emphasized but to a lesser degree. Clinical practice is stated in a more general manner as “articulating a specific area of nursing practice and its advancement” http://www.nursingcouncil.org.nz/competenciesnp.pdf rather than” focusing on safe, organized, systematic and accepted approaches to assessment, diagnosis, and treatment if applicable”which are more primary care concepts (CRNBC, 2003).

Certainly, the broad NZ nurse practitioner competencies are important to advancing nursing practice in a country such as New Zealand but do not easily fit into a very clinically focused nurse practitioner’s world view. A nurse practitioner coming from North America may find it difficult to have a program of research or the ability to enact significant change at a local or international level. Leadership may have occurred at clinic level or within a health care system. For example, nurse practitioners may have been involved in quality assurance activities such as morbidity and mortality review which would have changed clinical practice at an organizational level, impacting day to day clinic life. An experienced North American FNP provides consultancy to her peers who are probably physicians, not nurses and probably not within a formalized nursing structure. A North American NP would have read the literature around best practices and evidenced based practice but would not have the opportunity to contribute directly to research.

Jenny:
New Zealanders will, I think, be stunned to find that the role appears less clinical here but your comments are interesting because in the recent review of NZ competencies many of us gave the feedback that the focus on leadership, research and teaching needed to take a back seat to the focus on clinical expertise. Some people argued that it was too much to expect of someone who was starting out as an NP and gave no space for the beginning NP to really focus on clinical expertise.

Sarah:
Competencies for Nurse Practitioners in New Zealand are written and interpreted as the highest standards of excellence rather than the beginning level of competence. I believe this causes difficulties for both New Zealand nurses desiring roles as primary health care nurse practitioners as well as for expert North American Family nurse practitioners seeking to become licensed in New Zealand as nurse practitioners.

Jenny:
We should now discuss the issue of what you call “scope of practice” and we now call “area of practice” given that being an NP in NZ is in itself a scope now under the HPCA (2003). We have had a number of debates about the narrowness or broadness of the NP role and people hold differing views about the nature of specialty. Indeed it could be said that there is now a widespread myth in NZ and in nursing itself that the NP role is a specialist role. Quite a few nurses this year have even told me that “they cannot decide what disease to choose to specialize in!!” which is so far from what we ever intended.

Sarah:
The questions of scope of practice remains challenging for nurse practitioners across North America and New Zealand. For nurse practitioners in or coming to New Zealand, scope (area of practice) is defined broadly-.

Nurse practitioners are expert clinicians who work within a specific area of practice incorporating advanced knowledge and skills. They practise both autonomously and in collaboration with other health care professionals to assess, treat and manage people’s health problems. (Nursing Council New Zealand)cite source

Jenny:
While area of practice in NZ is theoretically determined against a population group and not deliberately specialist in practice many candidates find themselves struggling to determine the nature of that population group and many have emerged with narrower and sometimes disease focused areas opf practice.

Sarah:
For nurse practitioners in the United States the issue is different., Scope can very confusing since there are 50 different states, 50 different Boards of Nursing each with a different set of regulations. Nurse practitioners often push the boundaries of their scope and then experiencie disciplinary actions by Nursing Boards. For example, geriatric nurse practitioners or pediatric nurse practitioners managing young adult’s health problem are practicing outside their scope-defined by age.

In the United States there is an understanding of scope as needing to expand and evolve. There is a move across all health care to view scope very broadly as defined by the Institute of Medicine (IOM) report-Crossing the Quality Chasm: A New Health System for the 21st Century,

All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics(IOM, 2001).]

From my perspective, nurse practitioner scope both in North America and New Zealand needs to be defined in a comprehensive and expansive manner to meet the needs of aging and increasingly ethnically and culturally diverse populations. Most specifically, primary health care is in a state of frequent and ever evolving change and nurse practitioner’s role and scope must evolve and change as well.

Jenny:
I can only entirely agree with you about the need to broaden and evolve. We need to be mindful of the manner in which medicine has increasingly focused on smaller and smaller parts of the body and more focused specialties and to consider if that has been entirely helpful. And for me the most critical thing is a constant assessement of what people need most and the ability to be flexible. In this very small country the ability to work broadly, collaboratively and to focus on consumer need has never been stronger. One issue which really concerns me about these differences is not just the challenges posed for nurses wanting to change countries but also the limits it places on the ability to do consistent international research focused on NP outcomes and building that body of knowledge which shows the contribution that the NP role makes to health service delivery.
How do you think the different way our health system is configured impacts on the situation?

Sarah:
Having a largely publicly funded system is a huge difference between New Zealand and the United States. I believe countries such as Canada and New Zealand’s healthcase system serve their population better than the U.S. system serves its people. However, I wonder if nurses are served less well under a system which puts health care access for the population its serves predominantly under the control of physicians and a government health care bureaucracy. Are nurses able to control their own destiny in such a structure?.

Medicine like all disciplines is territorial and does not embrace new roles for nurses that can overlap with physicians in spite of extensive evidence that the role would benefit patients, nurses, health care systems and even physicians themselves (Pringle, 2007).

Jenny:
Professor Donna Diers raised an interesting point when she spoke at a recent NPNZ ( Nurse Practitioners of NZ) conference. She said that NPs in the United States had flourished initially in areas of unmet need. In NZ where we theoretically have full and open access to health care for all it is too difficult or even embarrassing to publically admit the level of unmet need!

Jenny:
Why is there a seeming underlying anxiety in NZ that US NPs may follow a medical model rather than a nursing model and be “too medicalized” for the NZ practice environment?

Sarah:
Based on the World Health Organization (WHO) definition1, I believe primary health care is neither nursing nor medicine. The delivery system of primary health care which works best is a multidisplinary team approach where all members of the primary care work force, whether professionals or paraprofessionals, are equal players on the team.

Therefore North American nurse practitioners who come to New Zealand to practice will struggle since they understand themselves as primary care clinicians and have functioned in more multidisciplinary settings. The settings in which they worked would not have had an organized nursing structure. Their role may have been interchangeable with physicians and other persons in the primary care sector. These nurse practitioners may have been the only nurse in a clinic setting and therefore would not have interacted with a nursing structure and deliberatively not defined themselves as a nurse but rather a primary care clinician.

Yet, excellent advanced nursing practice, most generally, and family nurse practitioner (FNP) practice more specifically is nursing practice. It possibly cannot be easily articulated with a nursing structure or one defined nursing theoretical framework. FNP practice in North America may not be easily defined as nursing and does not lend itself well to dichotomous thinking-nursing vs. medicine, but rather situates itself within a broader multidisciplinary team approach to primary care. But for New Zealand, primary care in New Zealand will improve if nurse practitioners are fully integrated within the primary health care system since they are unique, strong members of the team.

Footnote

1. Primary health care is essential health care made universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost that the community and country can afford. It forms an integral part both of the country’s health system of which it is the nucleus and of the overall social and economic development of the community.(WHO, 1978)

Jenny:
The NZ stance has been to make the NP a senior clinical nursing role and to utilise additional previously medical tasks such as assessment, diagnosis and medical management to address disparities in access in the New Zealand health care system? As a North American FNP how difficult/easy would you find it to fit in here?

Sarah:
I think there would be challenges for the North American nurse practitioner coming to New Zealand. There is the nuances of another version of English, different cultural understandings of health care and the patient provider relationship, living in a defined bicultural society and restrictions as part of a single payer system. Yet there would be benefits as well. It is a small country with a small population base with a great potential for uniformity of care. The potential for equal and uniform access for all members of society is very heartening. New Zealand’s health care system has successfully used physicians from other Western English speaking countries successfully so why not NPs?

Experienced U.S. educated family nurse practitioners could easily fit into the existing general practice environment here in New Zealand. Family nurse practitioners (FNPs) would offer strong clinical assessment skills and a necessary health promotion and disease prevention focus. They have been educated around principles of cultural competence and embracing diversity. The focus of many FNPs on patient centered care and therapeutic communication would enrich the primary health care practice environment in New Zealand.

Yet, I wonder how does a family nurse practitioner from North American easily slip into the existing nursing structure on NZ?. How does one take a professional identity from one country and forge a new identity in a country with such defined nursing roles? These are the challenges the expert North American Family nurse practitioners would face coming to New Zealand.

Jenny:
Can you share your perceptions of our teaching environments as I have some real concerns about our need to work really hard at increasing the rigour of our clinical teaching and the need to really address NPs ability to manage the everyday presenting problems in a general practice environment and elsewhere. We have always had a bit of a “chicken and egg” problem as we try and produce expert clinicians without always being able to use expert clinicians to do the teaching.

Sarah:
In the current University environment both in the U.S. and New Zealand, the emphasis on research funding and outputs make having a robust advanced practice nursing curriculum challenging. Advanced practice nursing faculty have many challenges maintaining teaching, a publication record and a clinical practice. I think this remains a challenge in New Zealand where the nurse practitioner role is so new.

Certainly our programs focus very heavily on teaching clinical skills and testing clinical skills in patient simulation scenarios. This emphasis is carried through into very structured testing process inherent in the OSCE which is the gateway to licensure as an NP in British Columbia.
I also believe there needs to be an internationalization of NP education where there are cross-border exchanges of educators, ideas and curriculum. This exchange can be best achieved in an environment where competencies and frameworks are consistent and the flow of expertise is valued.

Jenny:
For me one of the most critical reaons for some international consistency is the ability to generate research showing nurse practitioner client outcomes in a manner that has meaning across as many countires as possible. This has been, for me anyway, a very useful dialogue especially in reflecting the degree to which we might have perpetuated a nursing versus medicine dichotomy in the NP role in NZ. I remain convinced that we have much more to do to establish the FNP role in NZ and to assist primary health and rural nurses (whose area of practice is essentially very broad) to become nurse practitioners.

References

Baer, E. D. (2003). Philosophical and historical bases of advanced practice. In M. D. Mezey, D. O. McGivern & E. M. Sullivan-Marx (Eds.), Nurse practitioners-evolution of advanced practice (pp. 37-542). New York, NY: Springer Publishing Company.
CNA. (2002). Advanced nursing practice: a national framework. Ottawa, Ontario: Canadian Nurses Association.
CRNBC. (2003). Competencies required for nurse practitioners in British Columbia (No. pub.416). Vancouver, B.C.: College of Registered Nurses of British Columbia.
Gardner, G., Carryer, J., Dunn, S., & Gardner, A. (2004). Report to the Australian Nursing and Midwifery Council-nurse practitioner standards project: Queensland University of Technology.
IOM. (2001). Crossing the quality chasm-a new health system for the 21st century. Washington, D.C.: Institute of Medicine.
NONPF. (2002). Nurse Practitioner Primary Care Competencies in Speciality Areas: Adult, Family, Gerontological, Pediatric, Women’s Health (No. HRSA 00-0532 (P)). Rockville, MD. USA: Department of Health and Human Services (DHHS).
Pringle, D. (2007). Nurse practitioner role: nursing needs it. Nurse Leadership-CJNL, 20(2), 1-5.
WHO. (1978). Primary health care defined. Retrieved October 14, 2008, from www.who.int/topics/primary_health_care/en/