Bureaucratic landscape a chance to make a difference

EVALUATING the guidelines governing nurse practitioners (NPs) in women's health in a major area health service recently, a medical expert complained that they were "discriminatory" because the practitioner did not see male patients.

The nurse practitioner works in a small town. She offers a wide range of healthcare to women, many of whom have not accessed the available medical services for years due to embarrassment or ignorance. She is presently booked up until next year.

The doctor who made the comments seems to have missed the irony of complaining about a health care worker specialising in women's health in an age where we are divided up into minute body parts when it comes to medical specialists.

But such is the state of play when nurse practitioners in this country seek to have their practice guidelines approved by doctors.

A recognition that collaboration can't be legislated was one of the lessons Donna Diers brought to the inaugural Australian Nurse Practitioners Association Conference in Canberra recently. Diers is a nurse and a professor from Yale University who delivered the opening address in what was a historical event for nursing and nurses.

After a rocky and delayed start we now have nurse practitioners appointed in four states and the ACT, and legislation being completed in the NT and other two states. But Australian NPs are still regulated and legislated to within an inch of their lives. They are the only specialist clinicians required to reapply for authorisation in another five years, despite the rigour of initial registration.

Diers went on to provide an illuminative analysis of why Australian nurses have had such a tough time compared to their colleagues in the US or Canada. The problem, she argues, is that nurse practitioners emerged here closely on the heels of the movement of nurse education into the university sector, which in itself caused a major disruption to traditional century-old health hierarchies.

In its position paper Australia's Health Workforce published in September, the Productivity Commission cites the "entrenched customs and practices including the maintenance of traditional professional barriers" within our present health workforce as barriers to reform.

While such barriers have been written about before, the Productivity Commission's paper maps out a new national landscape (albeit bureaucratic) for a system which has the potential to more effectively and appropriately use the expertise of available health workers to meet the changing needs of society well into the future. Presently our system's inflexible practices reduce job satisfaction and staff retention, but most significantly they reduce choice for individual patients.

The proposal in the commission's paper to transfer primary responsibility for allocating the quantum of funding available for university based education and training of health workers from the education portfolio to that of the health portfolio must be given serious consideration.

After all, preparing a physiotherapist, a nurse or a doctor is very different to preparing an arts graduate. And universities are not interested in ensuring workforce numbers. Their agendas are about bringing in external dollars to boost their dwindling share of federal funding for education.

Nursing, unlike medicine, is not attractive on this score. At least the federal health department has a primary responsibility to ensure a sustainable workforce for health.

The growth of the nurse practitioner movement is testament to those early nurses who were willing to stand their ground against what was sometimes quite overt undermining by doctors. In one country town, the GP asked his patients to choose between him and the nurse practitioner, although they were providing quite separate and different practices. In another, the nurse was told if she remained as a community nurse he would support her – but if she applied for NP status he would not collaborate.

Diers, who has watched from afar as we have moved towards the validation of the NP role, spoke of the "lonely splendour" in which such roles were first established. While such early days were difficult, we are now in a new era of acceptance and collegiality with our medical colleagues, many of whom have set up NP roles.

The Productivity Commission report has brought this advanced practice role into the context of the overall workforce. The report highlights the limited consideration in Australia of "major job innovation possibilities, particularly on a national systematic and timetabled basis". We now have a backdrop on which to outline new approaches to workforce design, education and legislation. Let's hope we can utilise a once-in-a-lifetime opportunity to make a difference.

by Professor Judy Lumby - Executive Director of the College of Nursing.

Article from www.theaustralian.news.com.au