Nurse Practitioners and Medical Practice: Opposing Forces or Complementary Contributions?
PURPOSE. The medical profession in Australia has expressed concern about the expansion of nursing practice into areas that are traditionally the domain of medicine. Particular apprehension is raised in relation to the prescription of medications. This paper will consider and critique the argument that the standard of care provided by a nurse practitioner would be of lesser quality than that provided by a medical practitioner.
CONCLUSIONS. Despite the medical profession's opposition for nurse practitioner roles, there is little evidence suggesting that the quality of services offered by a nurse practitioner would be inferior.
PRACTICE IMPLICATIONS. Available evidence suggests that care and treatment from nurse practitioners in primary health care is equal to that provided by medical practitioners.
The development of nurse practitioner (NP) roles in Australia has not been without controversy. Strong opposition has been voiced by the medical profession, in particular, on the basis that NPs do not have the educational preparation or clinical expertise to provide a standard of care and treatment equivalent to that provided by their medical colleagues (Australian Medical Association [AMA], 2005a). The aim of this paper is to challenge this assumption, specifically in relation to the mental health field, by considering the educational preparation of mental health NPs in Australia in comparison to general practitioners.
A national study of the health and well-being of Australians conducted in the late 1990s found that only a small proportion of people experiencing a mental illness received medical care or treatment for the illness (Henderson, Andrews, & Hall, 2000). Those receiving care were almost five times more likely to be receiving that care from a general medical practitioner than from a qualified psychiatrist (Henderson et al.). For this reason, it is important to consider how mental health nurses might compare to general practitioners in terms of the educational preparation for the treatment of people experiencing a mental illness.
This paper commences with an overview of the development of NP roles in Australia; the attitudes of medical practitioners to NPs is then discussed. A comparison between the educational preparation of NPs and medical practitioners is presented and subsequently supported by an overview of the research regarding outcomes of NP care. This paper concludes with a consideration of the implications of this topic for NP practice. After considering these aspects, it is concluded that the educational preparation of mental health NPs is not inferior to that of general practitioners, and indeed may even compare favorably.
Background to the Introduction of NPs to Australia
In order to understand the current controversy surrounding the introduction of NP roles to Australia, it is important to provide an overview of the NP movement. The first steps toward the inception of the NP role in Australia began in New South Wales in the early 1990s (Jamieson & Williams, 2002). During the subsequent years, most jurisdictions have passed legislation enabling the introduction of NPs. Since the regulation of the nursing profession in Australia is the responsibility of state and territory governments, the progress of NP developments varies from one jurisdiction to the next, with some states having already appointed NPs (e.g., New South Wales, Victoria, and South Australia) and others still in the developmental phase.
Despite variations, most jurisdictions require master's-level preparation for NPs with specific subjects in pharmacology. The NP roles include practices that are usually the exclusive domain of medicine—most notably this involves prescribing. However, it may also include referral to specialists, ordering of diagnostic tests and procedures, admission and discharge rights under the Mental Health Act, and issuing certificates for absence from work.
NP positions encapsulate exciting and autonomous roles for contemporary health care. While NP practice is now well established in Canada and the United States, NP positions are much less developed in countries such as Australia (Furlong & Smith, 2005). This process is complicated and hampered by the lack of uniformity between the states and territories of Australia (Driscoll, Worrall-Carter, O’Reilly, & Stewart, 2005; Gardner & Gardner, 2005; Jamieson & Williams, 2002).
NP positions are progressing at different rates and through different structures throughout the states and territories of Australia (Driscoll et al., 2005; Gardner & Gardner, 2005). New South Wales currently boasts the largest number of NPs, with more than 60 nurses now legally authorized to practice in this capacity. Eight of these NPs have specialist expertise in mental health (Wand & Fisher, 2006).
The nursing profession has generally embraced the development of NP roles as representing a career path that encourages nurses to remain in the clinical practice arena rather than pursuing what might be perceived as a more fulfilling career in another field (Clinton & Hazelton, 2000). However, realistically, workforce shortages have probably been a stronger determinant than professional aspirations (Gardner & Gardner, 2005).
The widespread shortage of medical practitioners in all fields including mental health has prompted the consideration of workforce redesign and subsequent expanded practice roles for nursing (Australian Health Ministers’ Conference, 2004). This phenomenon mirrors the experiences of other nations. For example, the introduction of the NP role in the United States arose as a solution for the shortage of medical officers due to the influence of the Vietnam War, and difficulties in attracting medical officers to rural areas and to suburbs with a population characterized by lower socioeconomic status (Morton, 1999; Torn & McNichol, 1996).
Medical Practitioners’ Attitudes Toward Expanded Practice Roles for Nurses
The AMA has clearly articulated opposition to the expansion of nursing roles into areas that are traditionally the domain of medicine, such as prescribing medication and referring to medical specialists. The AMA position that NPs are doctor substitutes has been expressed through an official position statement (AMA, 2005a) and via the media (Pollard, 2006a). In response, the Premier of the Australian state of New South Wales accused the AMA of fighting an old turf war (Pollard, 2006b).
The AMA's position statement (AMA, 2005) highlights a list of expanded practice roles that are not the traditional role of the nurse, including formulating medical diagnoses, referring to specialists, ordering diagnostic tests, prescribing medications, and admitting and discharging. It can hardly be coincidental that these are exactly the areas of expanded practice into which nurses must progress in order to be authorized as NPs.
The AMA (2005b) also released its policy statement on general practice nurses who work alongside general practitioners in primary care. The statement clearly articulates the role of the general practice nurse as complementary to that of the general practitioner, but that general practice nurses “must not work independently of general practitioners.” An earlier press release by the AMA (2005c) argues:
It would be consigning patients in areas of workforce need to inferior health care. The State Governments endorsing independent nurse practitioners are looking for an easy, and vastly inferior, solution—which is also an irresponsible and dangerous path to follow.
It is likely that the concern of the AMA, that NPs equate to inferior medical treatment, has been exacerbated because the impetus for the NP role has been fueled by workforce shortages. An inquiry into the Health Workforce in Australia (Commonwealth of Australia, 2005) urged the government to consider expanding the practice of a number of health professionals, including nurses, to address workforce shortages. In light of this discourse, NPs can readily be interpreted as substitute doctors.
A review of the literature suggests there is not one homogenous view addressing this controversial issue. Some evidence suggests expanded roles are not welcomed by the medical profession (Badger & Nolan, 1999) and are sometimes met with active resistance (Wittig, 2001). Wittig describes attempts by the American Medical Association to prevent the expansion of nursing and other nonmedical professions into areas of practice previously regarded as the sole domain of doctors. These attempts have included political lobbying and biased reporting of research findings (Wittig). Wittig cites a claim from the AMA News that “these days we have forces at work to deconstruct our profession of medicine, break it down into little pieces, and parcel it out for others to do” (p. 38).
On the other hand, some of the AMA's assertions have been questioned by Australian doctors with direct experience of working with NPs (Gunn, 1998). Gunn contends that the AMA has no evidence for its assertions and that they simply ignore reality. He further argues that, far from taking doctors’ jobs, NPs will improve doctors’ working conditions by allowing them to concentrate on cases that require their medical training.
Following the November 2005 announcement by the UK Health Secretary of the extension of full prescribing rights to nurses and pharmacists, the UK press reported reactions from the respective professional organizations (Carvel, 2005). The Guardian reported that officials at the Royal College of Nursing were jubilant while the British Medical Association (BMA) was outraged, contending that patient safety would be compromised because only doctors have the necessary skills and training in diagnosis and prescribing (Carvel).
While the extension of nurse prescribing in the United Kingdom met with opposition and outrage from the BMA (2005), it has been cautiously welcomed in an editorial of the prestigious and influential British Medical Journal (Royal Australian and New Zealand College of Psychiatrists [RANZCP], 2005). Avery and Pringle (RANZCP) note that there is encouraging evidence that nurse prescribers do prescribe appropriately and within their levels of competence, but they call for further, rigorous research and longer training programs to prepare nurses for independent prescribing.
It is entirely appropriate that medical practitioners question the capacity and ability of NPs to provide an optimal standard of medical care for the consumers of medical services. With this in mind, doctors have a responsibility to challenge the educational preparation of NPs to ensure it meets the standards necessary to provide this level of care. The nursing profession shares this concern and strives for quality educational programs for NPs. This will be considered later in this paper.
In relation to mental health, the RANZCP, the professional body for psychiatrists in Australia and New Zealand, has no official policy position on NPs or expanded nursing practice roles. However, in its submission to an inquiry into mental health, the RANZCP advocated for the establishment of mental health NP roles to provide services to indigenous people (RANZCP, 2005).
Brimblecombe and Hulatt (2005) discuss the implications of a review of psychiatrists’ roles within UK mental health services. This review, brought about because of increasing workloads and a chronic shortage of psychiatrists, resulted in a proposal to reduce psychiatrists’ caseloads, give them direct clinical responsibility for selected complex cases, and shift their responsibility for other service users to other clinicians, including mental health nurses. This will mean that, rather than holding diffuse responsibility for numerous patients, psychiatrists will act as consultants to mental health nurses who will have more autonomy but also more responsibility and accountability (Brimblecombe & Hulatt). Brimblecombe and Hulatt argue that this development is consistent with developments in other areas of health care in the United Kingdom where senior nursing roles are being established and nurses are assuming leadership responsibility in disease management.
The perspectives of mental health nurses and psychiatrists were explored using focus groups to explore the introduction of supplementary prescribing in an acute psychiatric hospital setting (Jones, 2006). A major theme to emerge from Jones's qualitative study was that the introduction of supplementary prescribing was viewed by both nurses and psychiatrists as influencing the power relationships between the two professions. The direction of this perceived influence differed between the participants. Some saw an opportunity for nurses to influence the psychiatrists’ prescribing decisions and to replace junior doctors, regarded as often being poorly skilled and inexperienced. Others saw the psychiatrist as gaining more control over nurses’ work.
Overall, psychiatrists and nurses viewed supplementary prescribing as a positive development, with potential to improve collaborative working relationships between the professions and improve standards of care for mental health service users (Jones, 2006). Jones also found that psychiatrists were supportive of transferring more responsibility, leaving them with more time to concentrate on patients with complex assessment and treatment needs. Some of the psychiatrists also saw nurse prescribing as a way of overcoming problems with junior doctors who had little experience in psychiatry but were less controllable than nurse supplementary prescribers.
A review of the literature highlights examples where the implementation of NP roles has been favorably received by medical practitioners. The settings included primary care (Carr, Armstrong, Hancock, & Bethea, 2002), accident and emergency (Fisher, Steggall, & Cox, 2006; Griffin & Melby, 2006; Wand, 2004), and acute inpatient medical unit (Vazirani, Hays, Shapiro, & Cowan, 2005). These studies revealed some differences between medical practitioners’ attitudes toward the roles that NPs should undertake; there was a common acceptance that the NP role provided some benefit to the overall delivery of health care.
Clarin (2007) observes that despite the positive advancement in the relationship between NPs and medical practitioners, five main factors pose barriers to the achievement of a truly collaborative relationship: lack of knowledge of the NP scope of practice, lack of knowledge of the NP role, negative attitudes, lack of respect, and communication. Clearly these factors are interdependent, and communication about the NP role and scope of practice is likely to be effective in overcoming the negative attitudes and lack of respect. An increased understanding of the educational preparation of NPs is likely to make a positive contribution to overcoming these barriers. The educational preparation of NPs in mental health in Australia is presented in the following section and should reassure medical practitioners regarding the competence of nurses in relation to medication prescription.
Furthermore, an enhanced knowledge and understanding of the structure of and boundaries to the NP role represents a necessary precursor to establishing more collegial and collaborative relationships with medical practitioners and NPs and overcoming negative attitudes toward these roles.
Furthermore, an enhanced knowledge and understanding of the structure of and boundaries to the NP role represents a necessary precursor to establishing more collegial and collaborative relationships with medical practitioners and NPs and overcoming negative attitudes toward these roles. For example, medical practitioners are likely to be reassured by the knowledge that NPs tend to value their nursing backgrounds and are not seeking the ability to prescribe medications as a means to become more like medical practitioners. Communication is an important key, and disseminating evidence of the competence of NPs in prescribing medication should be a component of any communication strategy.
Educational Preparation for Prescribing Medication in Mental Health: A Comparison Between NPs and Medical Practitioners
Discussion of the ability of nurses to undertake expanded practice roles in a safe and appropriate manner requires consideration of the educational preparation that permits both doctors and NPs to legally prescribe medication in Australia. To become a medical practitioner in Australia, the most common approach is to complete a double degree (MBBS or Bachelor of Medicine/Bachelor of Surgery); normally this requires 5 years of full-time study (Monash University, 2007).
To be endorsed as an NP in Victoria, Australia, a nurse must complete a master's degree that includes specific pharmacology units. Entry into such a program requires a Bachelor of Nursing degree and usually at least 2 years of professional nursing experience (Deakin University, 2007; University of Melbourne, 2007). Given that the bachelor's degree can be completed in 3 years of full-time study and the master's degree in 2 years of full-time study, the NP will have at least 5 years of formal educational preparation. In addition, the nurse must demonstrate advanced clinical practice, research, and leadership, usually requiring many years of experience and additional postgraduate qualifications in a particular area of nursing specialty (e.g., mental health nursing).
It could, therefore, be argued that the preparation required for NPs is at least as extensive, both in terms of time and level of award, compared with the preparation for medical practitioners. This argument is further extended when the specialist mental health content of undergraduate medical education, which has been noted to be barely adequate (Rosenthal, Levine, Carlson, Clegg, & Crosby, 2005), is compared with that of a specialist mental health NP. This point is particularly important given the fact that the majority of medications for mental illnesses are prescribed by general practitioners rather than by specialist psychiatrists. It should also be noted that doctors are able to prescribe from the full range of available medications whereas NPs in the Australian state of Victoria are only permitted to prescribe from a limited formulary (Parliament of Victoria, 2006).
Therefore, a clear need for education of the medical profession about the authorization requirements for NPs is evident. The resistance of some members of the medical profession and its industrial and professional organizations may be lessened if they were more fully informed. Medical bodies like the AMA continue to claim that standards of care and treatment will be adversely affected if NP roles are allowed to develop (AMA, 2005a; Pollard, 2006a,b). However, strong evidence about the safety, efficacy, and consumer acceptability of NP care leads one to wonder whether such education will have any effect.
Outcomes of NP Care and Treatment
There is strong evidence from systematic reviews concluding that NPs can provide levels of primary health care that are at least equivalent to that provided by physicians (Horrocks, Anderson, & Salisbury, 2002; Kinnersley et al., 2000; Parliament of Victoria, 2006; Rosenthal et al., 2005; Shum et al., 2000; Venning, Durie, Roland, Roberts, & Leese, 2000). Large-scale studies (n = 1,815, Shum et al.; n = 1,368, Kinnersley et al.; n = 1,316, Mundinger et al., 2000) did not find any significant differences in treatment outcomes between NPs and medical practitioners. These findings were confirmed in a recent Cochrane review. Furthermore, satisfaction with care and treatment tended to be higher for patients treated by NPs in comparison to those treated by medical practitioners (Laurant et al., 2006).
However, it is important to note that this research has predominantly been conducted in primary care settings and, therefore, whether specialist mental health NPs can provide care and treatment that are equivalent to those provided by either general practitioners or psychiatrists is, as yet, unclear and should be the subject of further research. However, this research should not be clouded by unsubstantiated statements suggesting that the care and treatment provided by an NP will automatically be inferior (Clarin, 2007).
Implications for Nursing Practice
NP roles in Australia are still some way from becoming recognized roles within the healthcare workforce, particularly so within the mental health field. However, the steady growth in these positions suggests that NP roles will be an important component of the future workforce. The strength and acceptability of these roles will depend, at least in part, on the ability of the profession to demonstrate the competence and effectiveness of NPs and, therefore, defend against claims that NPs are an inferior alternative to conventional medical treatment.
The strength and acceptability of these roles will depend, at least in part, on the ability of the profession to demonstrate the competence and effectiveness of NPs and, therefore, defend against claims that NPs are an inferior alternative to conventional medical treatment.
By articulating the educational preparation of NPs, presenting research on the outcomes of NP care, and comparing these to the education of and outcomes from conventional medical care, a greater appreciation of the capacity of NPs to engage in expanded practices (most notably medication prescription) can be more fully understood and appreciated. This is particularly relevant in the mental health field, where general practitioners without specialized training in mental health currently prescribe the majority of psychotropic medications. It is hoped that this will allay the concerns of the medical profession that the quality of health care will be adversely affected by the proliferation of NP roles.
Research evidence suggests that NPs have the capacity to contribute positively to healthcare delivery in a number of fields, including mental health. To qualify as an NP, the mental health nurse requires extensive specialist education, clinical experience, and specific education pertaining to the prescription of medication. This level of preparation compares favorably to that received by general medical practitioners. Becoming more informed about the clinical and educational background of NPs is important in overcoming medical practitioners’ concerns about the standard of care and treatment NPs are able to provide.