What is in a name: advanced practice of what?


In her response to the 30th anniversary republication of Lorentzon and Hooker's (1996)JAN editorial in which they claimed that ‘it is welcome news that the UKCC is now seeking ways of embracing the nurse practitioner role’ (p. 651), Schober (2006) makes it clear that this has become a ‘global phenomenon’ (see DiCenso & Matthews 2005 for a recent Canadian report). Indeed, much has been made of the ‘new nurse’ that was slowly emerging over the last half of the twentieth century as reflected in titles such as New Skills for a New Age: Preparing Nurses for the 21st Century (Gatzke & Ransom 2001), Educating nurses for the 21st Century (Bartels 2005) and Changing Times, Evolving Issues (Tanner 2006). The age of ‘Nightingale angels’ is coming to an end (Gordon & Nelson 2005). While this is probably a good thing, the ‘new nurse’– the advanced, autonomous, expert, professional armed with a sophisticated knowledge base – is no less problematic.

Thompson and Watson (2006) have suggested that ‘we panicked and gave away tasks which we thought were beneath us and turned our attention to bettering ourselves by being like other professions’ (p. 125), notably medicine. Nurse Practitioners, it is argued, ‘provide ‘‘something different’’ compared with the service given by a general practitioner’ (Lorentzon & Hooker 1996, p. 649) but, they asked, ‘what is this magic something?’ (p. 649). Indeed, Chiarella (2006) in her response to Lorentzon & Hooker's (1996) Editorial did not ask (a) what is advanced practice? and (b) why do we need it? (doctor shortages are not a good reason). Perhaps this is asking too much given that we really do not know what nursing is even after half a century of theorising about it (Clarke 2006). I am inclined to agree with Clarke (1991) that ‘there is no such thing as nursing, no uniqueness in the mix but, instead, an occupation comprised a range of activities directed towards qualitatively different ends’ (p. 39). And I suspect, if only we can suppress the modernist in us long enough to accept ambiguity for the sake of something more important, that this is its great strength – lacking a stable ideology.

Yet we can perhaps suggest what it is that nursing is not and, with that, maybe initiate a critical perspective of the idea of advanced practice. Nursing is not medicine. By this I do not mean that medicine is ‘bad’ and nursing is then ‘good’. Indeed, this is a trite view, however strangely comforting it might be to some at times. What I do mean by this assertion is that medicine is a stable, largely epistemological, ideology: moreover, one that is becoming evermore problematic. ‘(M)edicine's finest hour is the dawn of its dilemmas’, contended Porter (1998, p. 718), continuing: ‘Today, with ‘‘mission accomplished’’, its triumphs are dissolving’. Prior to the 20th century, medicine was largely palliative: as Porter (1998) asserts, ‘for centuries medicine was impotent and thus unproblematic’ (p. 718). Yet the ‘ideology of cure’ (Garland-Thomson 2002) has now substituted powerful intervening potential for impotent palliation and, indeed, it has succeeded, literally, beyond imagination. ‘The success is, however, accompanied by a just as undeniable story of disappointment, crisis and medicalization…benefits and side-effects of medical intervention are of the same root…technological objectivation of diseases’ (Fredriksen 2003, p. 287). Indeed, Scott and Conn (1987) have diagnosed an apodictic case of scientific medicine as a socio-political failure. This is due, in large part, to its ideological inability to establish networks of communicative relationships (a Bakhtin dialogism) for the purpose of health, although it certainly knows a lot about bodies and perhaps about minds. Medicine steadfastly maintains its modern project, undeterred by its limitations, side effects and iatrogenic (clinical, social and cultural) outcomes.

Nursing never has had, and likely never will have, this kind of power for socio-political (re)organization. ‘(M)odern biomedicine is seriously challenging and changing our notions of what a human being is, of what it is to be human’ (Porter 1998, p. 668). Hence nursing has developed, hopefully, a radically different philosophy despite, or perhaps in spite of, our apparent inability to define it. Moreover, one that I think is a potentially better socio-politics of health, which is to say that health is a socio-political issue. As Foucault (1980) put it, ‘the political question…is truth itself’ (p. 133). Or to phrase it more helpfully, ‘the idea that the disinterested pursuit of scientific truth can be neatly separated from engineering, warfare, money, media and politics is pretty well dead’ (Rorty 2004, p. ix). Whoever would eschew this critical complexity for a little knowledge, epistemology as it were, with which to practice (advanced or any other) is making a serious mistake that the future shall inevitably pay the price for, if it has not already.

It is not my intention to give offence to advanced practice nurses of any kind, or their advocates. However, I did not dream of being ‘a nurse’ as a young boy, and I doubt that many boys do even today. I had something more advanced in mind. I did acquire a degree in nursing and from there I became an ‘advanced practice nurse’ working in remote north of Canada. It was not until I had been a nurse for a while that I started to become one. I tell this story not in an effort to argue against the nurse practitioner per se, but rather to argue that being a nurse is not something one simply learns, although of course teaching and learning are certainly indispensable. Being a nurse is a realization. To be sure, I had cured diseases, delivered a few babies, even saved a few lives – the advanced things that doctors are well known for. Yet it occurred to me (perhaps I had an epiphany as opposed to epistemology), as I saw these advanced efforts amount to very little with respect to the psychosocial and spiritual to say nothing of socio-political, that much of this advanced practice, and certainly the medically-controlled intervention, was far less important than the formation and development of relationships, or at any rate fundamentally dependant on that. That is, I think, the realization that is nursing and, moreover, I think that it truly is advanced. This is not to say that physicians or any other health professions do not form relationships, certainly they do. But nursing asks a very different question in my view: that being, is the purpose of a relationship primarily to accomplish some health-related goal or could the relationship be an end in itself, moreover a therapeutic end that is potentially healing in itself? This certainly does not mean that there cannot be goals, health related or not, that are part of a relationship. However, as Latour (1994) put it, ‘nothing is, by itself, either reducible or irreducible to anything else. Never by itself, but always through the mediation of another…Relationism will serve as an organon for…negotiations over the relative universals that we are groping to construct’ (p. 114).

Such negotiations are the future of nursing conceptualization and, I dare say, of nursing practice. I might even go so far as to label this advanced practice. The Advanced Practice that I attempt to foster in my teaching is less an epistemology of nursing which a knowledge/consumer economy seems to demand, be it the ‘knowledge-based identity’ of Gordon and Nelson (2005) or those ‘extremely skilled in outcomes-based practice…who will create and manage systems of care that will be responsive to the evolving healthcare needs of society’ that Bartels (2005, p. 222) recommends. The Advanced Practice that I champion is that of a critical and creative thinking nurse who sees an outcome as ‘a tentative event, specific to context, developed through the relationship of persons and circumstances’ (Ubbes et al. 1999, p. 71). Of course I am not arguing against knowledge, such would be foolish if not downright dangerous. However as Drummond (2003) put it:

The professional act of caring is not only about what can be verified. It is also about the attachment of the carer to the human condition, to a philosophy of both the individual and the collective that, while it may prove difficult (or even impossible) to define comprehensively, may nevertheless withstand the vagaries of economic rationalism. (p. 65)

As Smith (2002) commented, after a review of Illich's (1999)Limits to Medicine. Medical Nemesis: The Expropriation of Health, ‘(w)hen sick I want to be cared for by doctors who every day doubt the value and wisdom of what they do’ (p. 923). I may be wrong, but I think that nursing, with its ineluctable ambiguity, is more capable of undertaking this advanced task than medicine. For the record, I expect all of my fourth year advanced students to be (public) intellectuals rather than some kind of epistemological expert (Parsi & Geraghty 2004) and, strangely enough, they do not seem to mind for the most part.