Te Puawai April 2005 - Editorial

Nurses have often placed a great deal of value on something we might loosely call the nature of nursing, or the philosophical basis or approach to care. I and many other nurses have often talked about this essence of nursing. In the recent report to the Australian and New Zealand Councils on the Nurse Practitioners Standards project, one key finding was that Nurse Practitioners might well incorporate tasks and procedures previously the province of medicine but they did so from a “nursing approach”.

All ideas and anything we talk about constantly should of course be rigorously and routinely critiqued to ensure there is any real meaning behind our most favourite and oft used expressions. A recent editorial in the British Medical Journal (330, March, 2005) caused me to reflect strongly on this issue. The editorial was entitled “Nurses as Leaders in Chronic Care”.

The editorial noted that nurses by nature of their education and role are in a position to champion the transformation of chronic care. Essentially this was based on the recognition that effective care of people with chronic disease relies on an engagement between an informed, activated patient and a prepared, proactive practice team. The editorial goes on to cite some fascinating survey findings including that doctors interrupt patient stories on average 23 seconds after they start, that half of patients leave the office not understanding what they have been told and patients are involved in decision making less than 10% of the time.

The author then cites a range of studies showing improvements in a number of critical indicators for patients receiving directed care from nurses. In addition there are now some oft-cited studies, which have shown that people with chronic conditions do better receiving structured care from nurses rather than unstructured care from GPs. One random controlled clinical trial of consultations with people with diabetes showed that nurses covered more topics in the consultation and more often mentioned diet, alcohol use, smoking and weight than did the doctors. Significantly nurse consultations were more likely to show patients taking the lead in discussing behaviour change.

In conclusion the editorial notes that despite evidence and examples of the pivotal role nurses play in improving chronic care there are significant barriers to their full utilisation. In the usual format of the BMJ there are then a number of rapid responses. One is particularly interesting as he suggests that “doctors and nurses are not chromosomally different”. He notes that he is made uncomfortable when it is suggested that one type of health professional does something better than another and suggests very sensibly that it may have more to do with the training or the structures in which practice occurs. Compellingly he notes that the ten minute consultation and 25 patient day are barriers to good care under which doctors struggle. These are valid comments but he does rather ruin his argument by concluding his letter with a declaration of competing interests in which he self describes as a doctor “paid for looking after chronic diseases”!!

That aside, there are issues of interest here. Is it the person of the nurse or doctor who makes the difference, is it the training, the philosophical approach or the structures in which practice styles are constrained? Is there really an “essence of nursing” which has a distinctive value and provides a qualitatively different kind of care? Would or could that kind of care survive if exposed to the constraints of five minute appointments - or a private business orientation?

We did note in the recently concluded Australasian Nurse Practitioner Standards project that where NPs and doctors were working alongside each other in Australian remote rural areas, under similar conditions there were marked differences. The nurses commented on their own different approach to patients; in particular their almost instinctive embracing of context, their desire to connect first with the person and then with the presenting problem and their expectation that their care would be highly individual or personalised. They felt this contrasted markedly to the approach of the doctors with whom they worked.

One essential caution here is of course the infinite nature of human variation. There are many differences within and between nurses (some most clearly do not embrace the niceties of this thing called a nursing approach), and there are many doctors who are the exception to any survey or finding about the nature of doctor/patient encounters. But the evidence is mounting in many studies that nurses and nursing do have something to offer which, when set free from an assistive role, offers a type of service which is very much needed as the chronic disease burden increases.

The incorporation of additional tasks into the framework of nursing practice offers an improved type of care and service, which was recognised by an insightful American physician 30 years ago. I keep using this quote as I believe it was incredibly visionary and even more relevant 30 years after it was made. She said

“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).

Bates I think recognised that there is something essentially different about a nursing approach and she is affirming that the inclusion of context, human variation, culture and complexity make a measurable difference to the patient/ health professional encounter. As levels of chronicity increase, the population ages, the cancer burden increases and the diabetes epidemic takes its toll, the service created by adding additional tasks to a nursing framework and approach to practice is exactly what is needed to address unmet need. The inclusion of an increased range of tasks is simply that, tasks which are tools which extend the range of service, increase accessibility and offer a much needed boost in capacity to a work force which is becoming increasingly thin in parts.

Put simply I think this means that regardless of whether nurses order diagnostic tests, prescribe and have admitting privileges, they still give primacy to focusing on the person and their need to live well with whatever ails them. Accordingly the nurse considers as a priority, the ethnicity, the values, the beliefs and the general tensions and challenges in a person’s life as equal factors in determining clinical responses to physical or mental problems. Poverty, family circumstances and the nature of relationships all impact on decision-making when a nursing approach is predominant.

So are we being “precious” when we talk about and are protective of the “nature of nursing”? Personally I don’t think so. A focus on nursing is a focus on health. A focus on health is desperately needed to counter the internalised view that health care and biomedicine are synonymous. The predominance of this view currently supports a medicalised disbursement of funding meaning that most funding has been centred around the diagnosis and immediate treatment of disease and it is much more difficult to secure adequate and appropriate funding for long term disability and the demands of living with chronic illness. Similarly, until very recently it has been hard to gain funding for primary health care unless secondary care services had leftovers. Some of this is changing and changing quite rapidly. It’s a good time to articulate and foster the particular nature of nursing. Nurses need to celebrate their proven impact on patient care and continue to drive forward an agenda based on health and a nursing approach to care and service configuration.

Bates, B. ( 1974). Twelve paradoxes: A message for nurse practitioners. Nursing Outlook 31 pp686-68.

Professor Jenny Carryer
RN PhD FCNA(NZ) MNZM
Executive Director