Nursing Praxis in New Zealand Vol. 18 No. 2 2002 Page 33

ADVANCED NURSING PRACTICE - EVOLUTIONOR REVOLUTION?

Sandra Richardson, BA, Dip.Soc.Sci., Dip.Heal.Sci.(PG)Nurse Researcher, Christchurch Hospital Emergency Department

Abstract

This article has been written to challenge the seemingly unquestioning acceptanceof changing roles in New Zealand nursing. It is evident in nursing history that anumber of issues, such as community versus hospital services and generalistversus specialist practice, tend to resurface in a cyclic manner. Characteristicsthat are currently associated with ‘advanced’ nursing roles can be recognisedwhen the origins and development of nursing in New Zealand are traced. Thisgives rise to speculation that changes to nursing scope of practice are not somuch revolutionary as evolutionary, and can perhaps be viewed as a reclaimingrather than a redefining of nursing roles.

Introduction

There is considerable interest in thearea of 'advanced' practice roles fornurses, both nationally andinternationally. A number ofdescriptors have been applied to theseprojected nursing roles often, in theirmultiplicity, more confusing thanenlightening. The phrase 'advancedpractice' tends to be used as anumbrella term encompassing many ofthe sometimes conflicting definitionsassociated with the concept. NewZealand (NZ) nursing appears to beembracing the re-conceptualisation ofthe scope and practice of nursing thatthese roles imply.

Historically nursing in New Zealand,as elsewhere, has been influenced bypolitical, social and cultural factorsas they emerge within itsenvironment. This has resulted in a

Key Words: advanced practice, nursing boundaries, New Zealand nursing history.

range of interpretation and variedimplementations of the advancednursing role (Denner, 1995; Scott,1996; Sheehy & McCarthy, 1998).Central to the concept of advancedpractice is the notion of change thatextends or expands existingboundaries, suggesting thatinnovation, revolution andreconstruction are part of thisprocess. In contrast to this view, ananalysis of nursing in early NewZealand suggests an alternativehypothesis namely that, rather thanpushing against the boundaries ofother professions, nursing is in factreclaiming elements associated withearlier nursing roles.

Richardson, S. (2002). Advanced nursing practice- evolution or revolution? Nursing Praxis in NewZealand, 18(2), 33-41.

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nursing practice. Magennis, Slevinand Cunningham (1999) undertook alimited study of nurses’ attitudesabout expanded and extendednursing practices. While generallypositive in their responses, the nursessurveyed nevertheless identified aperceived increase in vulnerabilityregarding the possibilities ofexploitation, litigation andfragmentation of the basic nursingrole.

Unlike such professions as medicineand law, the core elements andessential definition of nursing remainssubject to debate. Henderson (1991)postulates that the need to definenursing will remain a perennialproblem, “... because conditionschange from one era to the next andchange with the culture, or thenature, of a society” (p.6). This raisesthe question of why nursing is sodifficult to define, and what effectfailure to articulate its fundamentalpurpose and function has on thecredibility of the claim to‘professionalism’. Nursing has beenrepresented in a variety of waysthroughout history, and thediscourses that have arisen aroundthese definitions remain influentialtoday. The discourse ofprofessionalism, for example, isevident in the rhetoric of nursingorganisations and in the focus ondeveloping such roles as the NursePractitioner (Nursing Council, 2000).Despite this emphasis, the influenceof the ‘nursing as vocation’ discourseis still evident in references to nurses‘putting their patient first’, and linkswith concepts of self-sacrifice andmoral goodness as ascribed to theearlier Nightingale nurses.

The problem of definition

Within NZ interest in the advancedpractice concept has been shown byindividual nurses, professionalnursing organisations, and at apolitical level (e.g. Ministry of Health,1998; Jacobs, 1998; Litchfield, 1998;Nursing Council of New Zealand,2000.). Yet, despite the considerabledegree of interest, a central tensionremains. There is no clear, generallyaccepted definition or understandingof the term ‘advanced practice’.Instead several descriptions(Christensen, 1999; Litchfield, 1998;Ministry of Health, 1998; NENZ, 1998;Nursing Council of New Zealand,1999, 2000) are being consideredcurrently. The specifics of roledescription and implications in termsof professional boundaries continueto be debated. The development ofadvanced nursing practice has beenlinked with the concepts of enhancedprofessional standing and greaterautonomy for nurses (O’Malley,Cummings & King, 1996). Milstead(1997) goes further, asserting that theadvanced nurse practitioner has animportant political role, arguing that“if ANPs do not exercise the influenceinherent in the role, professionalnursing practice will revert to thedependent, handmaiden status of theearly 20th century” (p.12). He goeson to identify the importance of ANPsbecoming involved in shaping andsetting public policy, operating at anational as well as a local level.

There is debate regarding theimplications of adopting a wider scopeof practice. In taking on a widerscope, other practice elements may belost, altering the basic nature of

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One debate concerning advancednursing practice can be seen in termsof two competing discourses - thoseof nursing as an ‘art’ and as a‘science’. This debate can also beframed in terms of expanded versusextended practices, with the term‘extended’ linked to the discourse of‘nursing as science’, and that of‘expanded’ to the discourse of ‘nursingas art’. The extended role is describedby Davis (1992) as one “... notincluded in basic nurse training, andcomprises tasks normally undertakenby a doctor, but which may bedelegated to a nurse who has receivedappropriate training and has beenassessed competent” (p.37).Similarly, ‘nursing as a science’involves a focus on the value oftechnical competence and skill level,drawing on the bio-medical model andsuch attributes as objectivity andefficiency. The expanded role can bedefined as involving “... a more holisticapproach to the development of thenurse’s role: expanding their rolearound the needs of the patient,rather than simply taking ondelegated medical tasks” (Davis, p.37).While this is a rather simplisticdichotomy, such generalisationsindicate the wide spectrum of nursingpractice.

In any study of history cycles are likelyto be observed, and nursing historyis no exception. It is commonlysuggested that the mistakes of thepast are being repeated, but it canalso be argued that there is anopportunity to reclaim the successesof the past. There are a number ofrecurring issues specific to thenursing workforce, including shifts infocus regarding practice bases and the

skills and knowledge needed tosupport these.

Within NZ, the issues associated withchanging professional expectationsare becoming increasingly evident inthe reconfiguration of nursingaspirations and public perceptions.The movement towards ‘advancednursing practice’ is one that can beseen as rooted in the historicaldevelopment of nursing - NZ nurseshave often shown innovation andflexibility in their roles and scope ofpractice. Nurses in the past havedemonstrated responsiveness to thesocial mandate they hold, developingservices that reflect the changingneeds of society. The ability toaccommodate such changes is evidentin the emergence of uniquely NZsolutions such as the Nurse MaudeDistrict Nursing Service, Plunket andKaritane services. Debate aboutautonomy and independence inpractice is often linked to advancednursing practice, yet closerexamination of the ‘handmaidens’ ofthe past working in such roles as‘back blocks’ district nurses andnative nurses shows that thesewomen had considerableindependence in their practice.

Influences shaping NZ nursing

Following the introduction of thewelfare state, NZ has been viewed asa centre of innovation and forwardthinking. The colonial heritage, whiledecried for its impact on theindigenous peoples of NZ (Cheyne,O’Brien & Belgrave, 1997; Rata, 1986;Walker, 1986) also gave rise to a socialframework within which a respect forthe unconventional, and a valuing of

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initiative was evident (Cheyne, O’Brien& Belgrave, 1997; Rattray, 1961).While, despite their enfranchisement,the role of women in society remainedconstrained, there were opportunitiesto move outside the traditionalframework of western societies. TheNZ nursing culture continued to berefined and re-focused as a result ofinfluences from colonialism, socialexperimentation and, more recently,the gradual acknowledgement of thevalues and aspirations of the TangataWhenua (indigenous people).

The first of the ‘Nightingale’ nursesarrived in NZ in 1883, bringing withthem the values and morals, as wellas the clinical and theoreticalknowledge, that formed the basis oftheir training (Burgess, 1984;Rodgers, 1985). These nursestransposed the structure and purposeof nursing as it had developed in theUnited Kingdom, and the perceivedefficiency and effectiveness of theirpractice soon saw this emulated in thecolonies. There were few formallytrained nurses in NZ prior to thisperiod, although nursing actions wereevident as described in the historiesand biographies of this period(Rodgers, 1985; Rattray, 1961).

Nightingale is seen as a seminalinfluence on nursing practice, and thewidely acknowledged founder ofmodern nursing. She determined thestructure and ethos of Westernsecular nursing practice andeducation, significantly influencingpublic health beliefs and introducingthe concept of the ‘trained’ nurse(Selanders, 1998). Prior toNightingale’s involvement, nursingwas a disreputable, menial

occupation, poorly paid and poorlyrespected. Commonly recognisedcaricatures such as that of ‘SaireyGamp’ portrayed by Dickens wereaccepted as accurate representationsof the contemporary state of nursing.Nightingale’s description of nursing(cited in Bowman, 1967, p.19) wasthat it was undertaken by those “tooold, too weak, too drunken, too stolidor too bad to do anything else”. InNZ, early state provided nursing carewas not dissimilar, with hospital staffconsisting of a Master and Matrontogether with any additional help thatcould be found. These untrainedpersonnel were not held in highregard, and hospitals were seen as aplace of last resort, a refuge for thepoor and indigent. Lambie (1947)describes the type of women employedas “uneducated, rough and oftenuncouth in their conduct and this wasreflected in the state of the wards andthe care of the patients” ( p.3). It wasnot until the late 1870s that the firstregulations regarding nursingstandards were introduced.Requirements for nurses working atChristchurch Hospital were identifiedas follows: “Nurses must be able toread and write, they must treat thesick with kindness, see that allpatients are in bed after the doors arelocked and put the gas down onretiring to rest” (Buchanan, 1951,p.69).

Within NZ opportunity to stretch andeven breech some of the traditionalboundaries constraining women insociety was apparent, and influencedthe way in which nursing developed.This is illustrated in the work of GraceNeill, trained under the Nightingalesystem, who became the first female

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assistant Inspector for theDepartment of Hospitals, Asylumsand Charitable Aid (Neill, 1961). Herduties included inspecting the varioushospitals, during which she becameaware of a considerable disparity innursing standards. This, togetherwith her interest and involvement inthe activities of the InternationalCouncil of Nurses, led to hersupporting the establishment of aState Examination for Nurses. In1901 NZ passed the first registrationact for nurses in the world. Thisspecified a course of three yearsduration, culminating with the StateExamination and entry to the Registerfor successful participants. Neillexpanded the interests of the state,identifying the role of central co-ordination and regulation in regard tothe provision of nursing relatedservices. The place of the political, aswell as the professional, agenda inshaping the role of the nurse wasbecoming formally vested in thefunctioning of the state.

The introduction of registration fornurses was seen by many as providinga professional base, but thisconceptual shift regarding the roleand place of nursing in society wasnot universally accepted. Sargison(1993) suggests “some doctors werewary of ‘overtrained’ nurses whomight threaten their prestige, andsome parliamentarians fearedprofessional examinations mightundermine the ‘womanly instinct’ fornursing” (p.19). The concept ofovertrained nurses is still evident incontemporary society. The fear of'advanced' nursing roles resulting insome form of mutant mini doctor hasbeen well articulated in the nursing

literature (Shepherd, 1993; Denner,1995; Mitchinson & Goodlad, 1996).There is a tendency to question therelevance of some aspects of nursingknowledge and skills. Rather thanquestioning the appropriateness ofspecific elements of nursing alsocommon to other professions, anacknowledgement of the influence ofthe conceptual and practiceframeworks within which these occurhighlights their significance when partof nursing practice. As the nursingprofession focuses on thedevelopment and recognition ofprofessional attributes, the value ofspecific nursing knowledge and theunique nature of the nurse patientinteraction is emphasised. The publicand members of the health care teamneed an understanding of thedistinctive nursing contribution.Equally, nurses themselves need toclearly articulate what it is about theirpractice that is unique and valuable.

The expected range of duties and workconditions associated with earlynursing positions required a degreeof flexibility and adaptability. EllenDougherty became the world’s firstRegistered Nurse. She studiedchemistry at Wellington PublicHospital so that “when she wasappointed Matron of the PalmerstonNorth Hospital she was well equippedfor her own responsibilities, and didher own dispensing. In an emergencyshe could operate, amputate and setbroken limbs” (Rattray, 1961 p.30).Conditions in the colony remainedprimitive for some time, with nursingstaff having to deal with a range ofenvironmental hazards andlimitations. One English trainednurse, Miss Blackley, arrived for work

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at New Plymouth Hospital in 1886,where she found

there was neither bathroom, washhouse nor mortuary. Everythinghad to be carried to the wards byway of the kitchen or frontentrance. There was aninadequate supply of runningwater. Operations were performedat night by candlelight in themen’s lavatory, where the only tapwas installed (Rattray, 1961,p.30).

The value placed on willingness,flexibility and initiative continuedduring the early 1900s, anddifferences between the new breed ofcolonial nurses and those from the‘home countries’ were becomingincreasingly evident. The followingcomments were written in responseto a British Journal of Nursingeditorial, which outlined some of theconcerns and shortcomings identifiedwith nursing work in the colonies.The British Journal noted that “lifein a well-appointed nurse’ home withits comfort, clockwork regularity andsufficiency of service is not goodpreparation for roughing it in thecolonies” (anon. 1912, p.93). Inresponse to this comment, the NewZealand Nursing Journal notes “it hascertainly been found that someEnglish nurses working in thecolonies appear to expect a great dealof waiting upon ... colonial nurses atHome have been commended for theirreadiness to put their hands toanything” (anon. 1912, p.94.)

Specialist or Generalist?

Specialisation in nursing practice isnot a new concept. Nightingale herselfnoted that “a nurse should do nothingbut nurse. If you want a charwoman,

have one. Nursing is a speciality”(Skretkowicz, 1992, p.65). Earlymovements aimed at providingadvanced education for nurses in NZwere also structured along specialtylines, with courses initially designedto provide for nurses working in publichealth, administration and education(Lambie, 1947; Burgess, 1984).

An alternating focus on communityversus hospital based care can alsobe seen in nursing history. This islinked not only to government policiesbut also to changing socialexpectations and technologicaldevelopments. The link betweennursing and hospital based caredeveloped following the introductionof the Nightingale training system.This system of education was basedon the apprenticeship model. Nursingstudents were to provide care withinthe hospital for minimal recompense,but also be given time for study andto receive instruction. In practice, theamount of time allocated fortheoretical education was quicklyreduced, with the nursing studentsproving a valuable commodity, andone that soon became essential to theeconomic viability of the hospitalsystem.

Following on from this earlyassociation, nursing became stronglylinked to hospital based care, in botha practical and ideological sense.Practical links included the greaterreliance on nursing actions followingthe introduction of Listerian theoriesof asepsis, which necessarily involvedgreater collaboration between doctorsand nurses. The practice links weresoon followed by ideological ones, withmedicine seen as the role model forprofessional attainment. Nursing wasincreasingly described in terms of

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‘agency’ for the performance ofmedical tasks, and nursing rhetorictook on the vocabulary and focus ofthe bio-medical model. The‘handmaiden’ image was thusreinforced, and the relationshipbetween nursing and medicineincreasingly formalised, with nursesidentified in a dependent role. As thepractice of medicine becameincreasingly specialised, so too didnursing, with a shift away from thegeneralist approach to one of specificexpertise. Ideologically, as nursesmoved to a more subservient role,oppressed group behaviour becameincreasingly evident, including thedesire to emulate the socially valuedprofessional model.

Within NZ, the shift back to acommunity focus is again apparent,and the need for nurses with a soundgeneralist base has again emerged.There is growing pressure for nursesworking in isolated and often ruralareas, to expand their practice. TheMinisterial Taskforce on Nursing(1998) identified the potential role ofnurses in improving access to healthcare services. Taken together with thegrowing difficulty of attracting GeneralPractitioners to rural areas, and thecurrent moves towards nurseprescribing, it seems likely thatadvanced practice roles may be seenas the solution to both physicianshortages and nurses’ professionalaspirations.

Nurses in colonial NZ initiallydeveloped as generalists, with adegree of independence despite thelack of formally vested autonomy.Nurses were valued within thecommunities where they worked, andwere expected to bring a range of skillsand knowledge to their practice. This

practice has changed over time,influenced by changes in medicineand health policy, and the movementtoward specialisation, largelyoccurring in the hospital setting. Inlinking nursing to the hospital system,it was inevitable that the relationshipbetween nursing and medical staffhas become more stratified, with anunderlying rigidity that is only nowbeing challenged. Shifts ineducational policies have alsomirrored this movement. As nursesfirst undertook formal education, thelink was clearly to medicine, hospitals,and specialty practice. It may besuggested that the development of thecomprehensive nursing programs,offered through polytechnics, beganto modify this focus, by moving backtoward a single, integratedregistration producing a generalistpractitioner. The on-going focus ofpost-graduate courses appears to beto return to a specialty focus.However, based on the pattern ofswings that is evident in a review ofthe past, I would suggest that theadvanced practitioner of tomorrow willcontinue the cycle, returning to acomprehensive general expertise,developing skills and attributes thatare readily transferable within a rangeof advanced settings. While there willstill be specialists within advancednursing practice, their strength willbe in critical thinking, the ability tosee the possibilities in a situation andenvisage a range of outcomes, andwith the ability to justify theirpractice.

While colonial nurses were not able toact autonomously in the sense that weuse the term today, they were requiredoften to work independently, to maketheir own decisions, and to determinethe appropriate interventions for the

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situation. It may be that as nursingbecame more closely linked tomedicine, that the options for nursingto expand became more limited, andthat nurses in fact saw the extensionof their role as the way forward, in asociety that valued the scientific,measurable and task based role. Therecognition of nursing as a separateand legitimate domain, and thegrowing base of nursing epistemologyand methodology, have opened the wayfor nurses to again expand as well asextend the scope of their practice.

Conclusion

The NZ nursing profession, like thosein many other countries, is showinginterest in the concept of advancednursing practice. There isconsiderable debate about this

movement, including issues ofdefinition, scope of practice and theneed for credentialling. A number ofattributes and attitudes are generallyassociated with practice at anadvanced level, many of which can berecognised in a review of NZ nursinghistory. As the nursing professionmoves forward, it is important not tolose sight of the past - the potentiallessons are not only those found inthe story of oppression and medicaldomination. Nurses in NZ havedemonstrated innovation andadvancement in practice, a heritageto be acknowledged and respected.The current movement towardsadvanced nursing practice is acontinuation of this legacy, althoughwhether it will be recognised as aninevitable evolution or a radicalrevolution remains to be seen.

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