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Your views and letters

What is in a name: advanced practice of what?

In her response to the 30th anniversary republication of

Lorentzon and Hookers (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 phenom-

enon (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: PreparingNurses 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 Practition-

ers, 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 &

Hookers (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)edicines 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 ofcure (Garland-Thomson 2002) has now substituted powerful

intervening potential for impotent palliation and, indeed, it has

succeeded, literally, beyond imagination. The success is, how-

ever, accompanied by a just as undeniable story of disappoint-

ment, crisis and medicalizationbenefits and side-effects of

medical intervention are of the same roottechnological objec-

tivation 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 bio-

medicine 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 thathealth is a socio-political issue. As Foucault (1980) put it, the

political questionis 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

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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 advancedthings 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 thisadvanced practice, and certainly the medically-controlled inter-

vention, was far less important than the formation and develop-

ment 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 relation-

ships, 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 anotherRelationism

will serve as an organon fornegotiations 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 andNelson (2005) or those extremely skilled in outcomes-based

practicewho 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 eco-

nomic rationalism. (p. 65)

As Smith (2002) commented, after a review of Illichs (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.

Clinton E. Betts BSc BScN MEd RN

Assistant Professor, School of Nursing,

Faculty of Health Sciences, McMaster University,

1200 Main Street West, Hamilton, ON,

Canada L8N 3Z5

E-mail: bettsc@mcmaster.ca

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