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OPINION

The image of nursing: Cheap substitutes?

In the latest in our series of blogs on the image of nursing, Sandy and Harry Summers ask what a nurse practitioner is for.

Who are nurse practitioners?

Are they just cheap, inadequate substitutes for physicians, pretenders who require close supervision, or are they highly skilled professionals who combine the holistic nursing care model with more education to provide excellent, cost-effective care?

Advanced practice nursing evolved mainly to provide care to under-served populations. In the 1960s, nurses began training to perform certain work traditionally done by physicians. Advanced practice nurses (APRNs) in the United States, the vast majority of whom have at least a master’s degree, now provide care in many specialties, including primary care, anaesthesia, and midwifery. There are more than 250,000 APRNs in the US and increasing numbers in other nations. US nursing leaders plan to make the four-year doctorate of nursing practice degree (in addition to the four-year undergraduate nursing degree) the standard for all new APRNs by 2015.

Like other nurses, APRNs employ a care model that emphasises prevention, health maintenance, and overall quality of life. Because they have the skills and take the time to listen and teach, APRNs are adept at identifying subtle problems and managing serious chronic conditions.

Decades of research shows that the care of graduate-prepared APRNs is at least as effective as that of physicians. In April 2002, a meta-analysis of 34 clinical studies in the British Medical Journal indicated that patients were more satisfied with their care if it was delivered by a nurse practitioner (NP) than if by a physician. NPs read X-rays equally well, identified more physical abnormalities, communicated better, and taught patients how to provide self-care better.

More recently, in an August 2010 study in Health Affairs, the Research Triangle Institute analysed inpatient mortality and complication rates for nearly half a million hospitalisations from 1999 to 2005, comparing U.S. states where certified registered nurse anaesthetists worked unsupervised by physicians to states where they did not. The researchers found that the care of nurse anaesthetists was no more risky for patients than the care of physicians.

The media’s treatment of APRNs has been inadequate. APRNs continue to be ignored as general health experts, and the media’s relentless suggestions that practitioner care is provided only by “doctors” continue unabated in news pieces and advertising. Some press accounts have wrongly suggested that APRNs are capable only of treating minor problems, such as removing splinters and managing colds. The media often allows physicians to express uninformed criticism of APRN practice without even consulting APRNs or the relevant research.

Some news articles have reported fairly on APRNs. An excellent October 2004 Wall Street Journal article reported that nurse-run primary care practices “may be critical to the future of healthcare in the US”. The story noted that NPs’ holistic, preventative approach may be uniquely suited to an ageing population with long-term illnesses. The piece also discussed hurdles that NPs still face, including legislative limits on their autonomy and the great pay disparity with physicians doing comparable work.

Unfortunately, many more news pieces ignore or undervalue APRNs. An August 2009 article on the Western Australia news web site WAtoday was headlined “Nurse clinics are ‘supermarket medicine’”. That was the view of the only expert quoted, Australian Medical Association president Andrew Pesce, who objected to one company’s plan to open 180 pharmacy-based clinics staffed by NPs. Pesce actually suggested, with no apparent irony, that NPs were “not skilled or experienced in providing holistic care.”

In the UK, physicians have repeatedly attacked the practice of advanced practice nurses without reference to any relevant research. In the summer of 2006, anonymous physicians published op-eds in the Daily Mail and elsewhere criticising government moves allowing nurses to move into clinical roles that have traditionally been the province of physicians. Offering only anecdotes, the pieces argued that these new roles had actually undermined nursing, causing nurses to turn away from custodial care tasks that the physicians thought defined nursing.

In late 2005 Mattel, the world’s leading toy maker, released a small collectible duck doll called the Nurse Quacktitioner. Dressed in a white lab coat and a white cap with a red heart on it, the doll’s name suggested that NPs are “quacks”, incompetent healthcare providers. When physicians in the UK learned of protests about the doll, many sent letters of support to Mattel, urging the company to keep selling the doll because it would foster contempt for NPs.

Hollywood has offered few good portrayals of APRNs. ER repeatedly suggested that able nurses achieve by becoming physicians, reinforcing the wannabe-physician stereotype, even though data suggests real nurses are 100 times more likely to become APRNs. In ER’s last season, nurse character Sam Taggart did start a nurse anaesthetist programme, and there were several helpful plot lines about her career path. In December 2008 episodes, Taggart impressed senior physicians by using her growing knowledge to improve critical care.

But television healthcare portrayals are far more likely to ignore APRNs or express overt contempt. The early episodes of Private Practice included mockery of the one nurse character, midwifery student Dell Parker, with the elite surgeon character Addison Montgomery referring to “midwives” as if they were some bizarre anomaly. Dell’s duties then seemed to consist mainly of acting as a receptionist. He eventually became a midwife and occasionally played a more robust role in care, even saving a couple’s lives. But the show killed him off in May 2010 episodes that emphasised his elation at having just been admitted to medical school.

Neither House nor Grey’s Anatomy has ever included an APRN in any significant role. In a January 2010 episode of Grey’s, the heroic neurosurgeon Derek Shepherd did suggest that another surgeon’s follow-up visits with a post-surgical patient were “easy” and a waste of her time because a “nurse practitioner can do this”.

Actually, Dr McDreamy, graduate-prepared nurse practitioners can do quite a lot, and do it at least as well as physicians. APRN-directed care offers not only a way to enhance access to care for underserved populations, but also an advanced hybrid practice model that could change the future of healthcare for everyone.

Readers' comments (15)

  • Now this is an excellent article.

    Your definition of Nurses as highly skilled professionals is pretty spot on. Nurses now who have advanced to the Nurse Practitioner role or simialar are educated up to the level of a physician if not more so.

    Questions of inadequacies or stereotypes of 'quacks' are easily countered with academic qualifications that can match or even supersede a physicians, never mind the mountain of journals and academic studies that prove the level of care we can and do provide.

    Regardless of Physicians opinions, or the publics for that matter, in terms of clinical skill, education and qualification levels patient care and accountability, the Nurse practitioner is the future of healthcare.

    We are not Doctors in any way shape or form, I personally find the term 'wannabe Doctor' quite insulting. We are advanced professionals in our own right, employing a different medical paradigm to the 'medical model' that Doctors use. Both of theses ideologies, the medical model and the Nursing model, complement each other very well, but they are different. There is room for both in the modern NHS, as we perform different, if intertwining roles.

    The problem is that Nurse practitioners, and the Nurses who are working up to that level are not given the levels of respect, status or pay that we deserve given the levels of skill, education, accountability and responsibility that Nurses have now. The general public by and large do not even realise the level that advanced Nurses practice at, and that needs to change. But even worse than that, the managers and trusts DO know and understand the level we practice at, and STILL refuse to give us the status or pay we deserve. In that respect they ARE treating us as 'cheap alternatives', and that needs to stop. Now.

    What is needed now is a consolidation of the Nurse training and advanced Nursing Masters and Doctorates, and for them to become the standard norm. There should also be a push for a status and pay levels to match that of a physicians at the advanced Nursing levels. Image as always is important in this respect, but I fear more drastic action will be needed. We should strike if necessary to achieve this.

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  • Eight years training? Why don't those that want to do this just train to become doctors. They can then introduce all of those afore mentioned wonderful attributes into the medical profession and leave nursing to those that want to be nurses.
    Mike, how many times are you going to say that we should go on strike before you actually do something about it? You appear to be all mouth and qualifications but no action.

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  • Keep calm all of you!! I adore my job as a nurse practitioner-I know I am a cheap alternative but not sub-standard-I bring all of the attributes of an excellent nurse skilled in holistic care and have nicked the good bits of medicine to use in my patient care-what more could you ask for -except of course more money and recognition-but the more people and patients I see and treat the better the public will know how we work-word of mouth is very powerful.

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  • Anonymous | 20-Dec-2010 10:03 am you have missed the point completely.

    Nurses are not Doctors, we do not want to be. We are a completely seperate profession in our own right, offering medical and Nursing care and treatment to our patients, albiet the fact that our professions do intertwine a lot. Eight years actually covers the length of time it takes to get an academic Doctorate and then some, by consolidating these into specific and universal Nursing qualifications we will have a professional pathway that Nurses can follow right up to the top. That way Nurses will not only be AS qualified as a Doctor, we will academically be more so; and furthermore we will be able to offer NURSING care using the Nursing and Medical models, at the same level as a Doctor does now.

    That is a very strong argument in my opinion to increase our pay and status.

    Finally, what the hell do you expect me to do about it in the face of such apathy in the profession and moronic comments such as yours. Instead of stating I am 'all mouth and no action', why don't you help me garner support for strike action? The poll on NT not so long back showed that a large number of Nurses were ready to strike, but had so much apathy to deal with. Writing to local MPs has led nowhere, our so called unions are pathetically useless, NT itself does very little in terms of organising petitions, lobbying unions/parliament etc, so come on then, put your money where your mouth is and do something yourself!

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  • Mike, you talk so much sense! As a specialist nurse, in this winter weather I'm required to work on the wards. As I've said before on this site, ward nursing is a specialism in its own right, but my patients have acute and potentially life threatening clinical needs and these can't be ignored or dealt with "another day". I end up doing my own job all evening amd typing letters (no admin support of course!) in the early hours. Using "the proper channels", writing to MP's and raising this at Government level makes no difference and I know I will be at risk if I don't comply. Again, this shows the lack of knowledge about what the NP or specialist nurse role involves and I would invite anyone who would like to understand it to spend some time at work with me - my managers have never opted to do this despite apparently having a strong view that my work and my patients are of no value when they are short of ward staff.

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  • Most Nurse practitioners are predominantly white and male and work in the "exciting" areas of nursing ITU etc

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  • Out of interest what is the route to NP qualification? It is something that has never been brought up at university. I have also seen a post on the pronurse forums that you can reach band 6 in a year of qualifying, or people claiming to have gone straight into a band 7 after qualifying. I find this a bit odd. I thought you would need to gain experience as a band 5 for a number of years before working your way up?

    As for the article, I really enjoyed reading it. How about we petition the TV bods to do a fly-on the wall, or a drama based on the nurses/NP role? One that does not paint us in such a bad light as No Angels etc. And although I LOVE Getting On...doesn't paint us as professionals, but hey its comedy.

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  • Anonymous | 31-Dec-2010 8:24 am Do you really think sexist or racist remarks are a clever way of joining in a debate?

    Sam, I can imagine getting a band 6 role within a year is impossible, you'd need a certain level of experience to even get an interview. And straight into band 7? I don't think so.

    As for the route to NP, there isn't one at the moment, not really. It's just a case of gaining experience in a field, getting extra quals (ie a Masters or Doctorate) and applying for the posts on the rare occassions they actually pop up. That is why I was saying before about a need for a consolidation of the Nurse training and advanced Nursing Masters and Doctorates to lead to this route and beyond.

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  • Having a BSc, I did a PGDip in Specialist Practice in Public Health Nursing, Health Visitor. That counts as nurse practitioner level, it's autonomous specialist practice in a nursing discipline. However along came AFC and down graded all HVs who suddenly weren't at specialist practice level after all! Never mind ER or Greys, the government manipulates the posts and the 'status' of what you train as one day, can be removed. I can't think why there's a HV shortage?

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  • Thanks to those who replied. Mike I also asked more or less the same question on another forum and the responses seemed to suggest that progression to band 6 was possible and that the person going straight to band 7 was an ex care assistant with lots of experience being hired as a care home manager.

    Equally I asked how it was possible for some NHS nurses to be earning 28k in their first year and was told it was down to overtime. From the posts I have read on here it seems to be most overtime is unpaid/farmed out to bank or agency rather than given to regular staff.

    Please note that my questions are not geared towards my finding out how to climb the greasy pole as quick as I can. I think being a band 6 after a year would be far too much responsibility for me to handle so soon. The questions are more to do with confusion at conflicting information.

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  • Sam, from newly qualified to band 6 really? Within a year? Wow, I know I wouldn't like that responsibility within a year, and I can imagine for the majority we wouldn't get an interview for band 6 after only a year.

    And I have to admit I never thought of care assistants becoming home managers at band 7. Is it just me or does anyone else find that wrong? I suppose it depends on the type of experience. I was just thinking about a newly qualified at band 5 making their way up the ladder. For many newly qualifieds, it will take a good few years to work their way up to band 6, then another couple to get to band 7. The routes to become band 7 are numerous and massively varied, so don't worry we all get confused by it. Hence my argument for a more cohesive qualification/career progression route.

    Don't get me wrong I didn't think that about you at all, I was just trying to give you the answers as I saw them.

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  • Thanks again Mike. I just know that some people reading on here may just jump to the conclusion that its another university nurse just trying to make it to management as quick as she can.

    From alot of the comments on here I am learning to be careful with my postings.

    I have also been reading a book recently written by a GP that at the and describes nurse practitioners as "jumped up" and basically there to muck things up. Combine that with the hostility from the "new nurses are too posh to wash" brigade and I am starting to wonder what the point is. I commend the nurse practitioners who shake off all the mud slinging that comes their way.

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  • Anonymous | 31-Dec-2010 8:24 am

    Rubbish!

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  • Hmm, lets see. It takes what 12 years to become a consultant physician? And even then they don't necessarily have a PhD but rather an initial BSc and some diplomas to follow.
    Now then, I have an initial clinical BSc (4yr), 2 other diplomas, (5yr), a nursing diploma (2yr) and currently studying for my MSc (3yr). Makes me a consultant too, eh? Different focus, but bloody well trained and not a cheap substitute I think.

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  • PS: Halfanurse, if you want to do NP go for it!
    'a life lived in fear is a life only half lived'.

    GP's in my area, although they won't put their hands in their pockets they do value nurse practitioners, and are surprising themselves in finding they can't imagine doing without them now.

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