The Acute-Care Nurse Practitioner

Judy Rashotte

• Publisher: AU Press
• Year: 2013
• ISBN:
  9781927356289
• Topic: Medicine
• Subtopic: Nursing

From the moment it was first proposed, the role of the nurse practitioner has been steeped in controversy. In the fields of both nursing and medicine, the idea that a nurse practitioner can, to some degree, serve as a replacement for the physician has sparked heated debates. Perhaps for that reason, despite the progress of the nurse practitioner movement, NPs have been reluctant to speak about themselves and their work, and their own vision of their role has thus remained largely invisible. Current research is dominated by instrumental and economic modes of discourse and tends to focus on the clinical activities associated with the role. Although information about demographics, educational preparation, position titles, reporting relationships, and costs of care contribute to our understanding, what was missing was an exploration of the lived experience of the nurse practitioner, as a means to deepen that understanding as well as our appreciation for their role.

The Acute-Care Nurse Practitioner is based on in-depth interviews with twenty-six nurse practitioners working in acute-care settings within tertiary-care institutions all across Canada. Employing a hermeneutic approach, Rashotte explores the perspectives from which NPs view their reality as they undergo a transformational journey of becoming—a journey that is directed both outward, into the world, and inward, into the self. We learn how, in their struggle to engage in a meaningful practice that fulfills their goals as nurses, their purpose was hindered or achieved. In large part, the story unfolds in the voices of the NPs themselves, but their words are complemented by descriptive passages and excerpts of poetry that construct an animated and powerful commentary on their journey. Poised between two worlds, NPs make a significant contribution to the work of their colleagues and to the care of patients and families. The Acute-Care Nurse Practitioner offers an experiential alternative to conventional discourse surrounding this health care provider's role.

Chapter 1

Being Called To Be More

A journey of a thousand miles must begin with a single step.
— Lao Tzu

Why do nurses decide to become NPs? What initiates or precipitates their journey? What are they looking for? What might they be running away from or toward? What more do they want? How do they know when to start out?

Certainly, the call to be an NP is not always clearly heard or understood at first, and for many the destination is also unclear. Some nurses take the leap without a moment’s hesitation, while others lag behind, watching the experience of others and then following their lead. For some, the desire to be an NP is driven by a vague pull toward something more. Not quite satisfied with who they are as nurses or what they are currently doing, they are willing to test new waters and set sail for destinations unknown, unsure of what they are looking for but hoping that it will be revealed along the way. Nevertheless, knowing what they value and what they no longer want becomes their North Star. For others, setting out on the journey begins with a dream: they are motivated to pioneer the NP role and continue to be fortified during the journey by reflecting on what it could mean to patients or nursing. Their reflections bring them to a new consciousness of nursing; they are almost able to feel a new relationship with it.

“Joan” worked as a CNS in a program whose patient population had outgrown the number of staff members that could effectively provide the complex clinical service needed. It came to her attention that the provincial government was looking to fund programs that would deliver health care in innovative ways. Joan used this external call as the opportunity to submit a proposal for a five-person interdisciplinary team — composed of a physician, an NP, a social worker, a pharmacist, and a clinic nurse — that would deliver one-stop care to the patients in the program. She lobbied across the institution for the NP position, with herself in the role, seeking support from the service’s clinical team members including the medical and administrative directors. In her own words, what Joan really wanted to do “was to be able to marry the kind of things that are called physician practice, things that the physicians are felt to be responsible for, and bring them into [her] nursing practice” and “really focus in on a certain group of individuals who [she] felt were falling through the cracks in our health care system.” The new program received funding, and the group, with Joan as NP, provided holistic care for the province’s entire specific patient population (approximately 900 people) from 2001 on.

For nurses like Joan, the dream of being an NP is fairly detailed: they are weaving careers from their dreams, setting out to find or create a nursing role that is the perfect fit. As weavers of their roles, some nurses first create a mental picture of their destiny as NPs — a vision of who they want to be and what they want to accomplish. They select the patterns, colours, and textures of their lives in this role. It is up to them to judge how pleased they are and to decide what changes are needed in order to create their desired role. Being a pioneer makes this creation possible, and the vision becomes the sextant used to navigate their journey.

This is not to say that the nurses’ dreams or desires include a navigational chart, or even what the exact destination will look like. Yet whether they are visionaries or seekers, as they struggle to find a place within their clinical program, organization, and profession as NPs, they find that their desire for more is what they need to help them deal with the tensions and turbulence they experience throughout their journey. The constant refocusing and reflecting on what first called them to the NP role in the first place helps them to visualize the difference that they wish to make, the people whom they want to help, and the goals that they hope to achieve. Ultimately, their desire for more helps them determine when they have reached their personal destination of being an NP.

In seizing the opportunity to become an NP, nurses perceive possibilities for who they can be as nurses and what they can bring to their nursing practice that they may not have seen in any other nursing role. They have found only a partial fit with who they want to be as nurses but are hopeful that the NP role will offer a perfect fit. Being in direct clinical practice is an integral part of that fit. For at the heart of being an NP is, as one NP noted, “the opportunity to work with patients, hands on, all the time.” For nurses already in patient-care roles (e.g., bedside or transport nurses), the NP role offers the possibility of being more in clinical practice without requiring that they leave the profession. For those who have been away from hands-on care, becoming an NP offers the possibility of returning to that which they love and miss but combining it with the opportunity to include more of that which they have found in other nursing roles (e.g., administrative leadership or education).

The desire for more is inherent in the reasons for initiating the journey to become an NP. “Kerry,” a neonatal NP, had worked in a variety of settings over the course of her twenty-five-year nursing career — obstetrics, pediatrics, public health — intertwined with various stretches back at school. Yet, she had always come back to the neonatal area. She had pioneered a neonatal transport program and she loved the autonomy that it provided. The attraction was the critical thinking needed on transport, the ability to put the pieces of the puzzle together. Kerry loved making a diagnosis, finding the solution, and working collaboratively with her medical colleagues. But she realized that she was still not fully satisfied; she wanted more. The transport role had whet her appetite for the possibilities of what more she could be and do as a nurse, what more she was capable of, and what more she could offer to the patients. She discovered possibilities within herself for being as a nurse that she liked and desired, and she chose to bring them into the light. When the prospect arose for her to pioneer the NP role, she felt that it provided the opportunity for her to learn more, maximize her potential, and contribute and make a broader difference to patients, their families, and nurses at the bedside. At the same time, it would complement who she already was as a nurse.

There are five dominant forces for being called to be more: being more connected, being more in control, being more visible, being more challenged, and being able to make more of a difference. Rarely is only one of these forces involved in the process.

Being More Connected

Being connected, physically and emotionally, to patients and families is a strong force for becoming an NP. “Laura” had worked in a cardiology clinic where she enjoyed being recognized as an arrhythmia expert. She also cherished the freedom bestowed upon her by the physicians to detect and diagnose pacemaker dysrhythmias and to reprogram them as necessary to fix the problem. However, she felt that she had become very technical in her nursing role. Laura felt a loss of nursing and so returned to an inpatient bedside nursing role in which she could feel more connected to the patients and their families. Yet in this role she felt the loss of self-sufficiency and recognition that she had formerly experienced. Consequently she was searching for something more when an NP program at the local university opened its doors. Laura knew immediately that it was what she wanted to do. Others similarly described being in clinical management or clinical educator positions as being too far away from patients. As one NP noted, the role opened the possibility of “being able to combine teaching with team leadership and a bit of research, while allowing me to stay close to the patient. This is a good fit for me. It gives me all of the things that I think are important about nursing.”

Establishing meaningful connections with patients and their families and being involved in a personal way is at the heart of caring and commitment in nursing. Bishop and Scudder (1990) found that even if individuals are not initially attracted to nursing for this reason, the sense of connectedness becomes embedded in their personal sense of nursing if they choose to remain in the profession. “Abby” recalled how restless she had become in her work as a clinical educator, in large part because she was afraid she had begun to move too far away from the bedside. The driving force behind her decision to pioneer the NP role had been to be more personally connected with patients and families, while still being able to connect with and make a difference to her immediate nursing colleagues in the education component of the role. In addition, she could make larger systemic changes within nursing, something that she had experienced as an infection-control nurse. As Abby continued in her reflections, she revealed the circular nature of her nursing journey: “It’s fascinating to go back and look at where your career path has taken you and the steps that you took that you weren’t sure where they were going to lead, but in fact, in hindsight, do lead up to you integrating those skills.”

Having worked as a candy striper during her adolescence, Abby had been drawn to the sciences. But even at that time, she knew she would not enjoy the episodic nature of their patient-care service: “I didn’t want to be in a position of just popping in and popping out. I wanted to actually understand and develop relationships with people over a longer period of time.” Instead, nursing provided her with the opportunity to be with patients and families over a longer duration and to be immersed in learning the sciences. However, the traditional bedside nursing role had ultimately not been challenging or autonomous enough for her — hence the sojourns in other nursing roles that took her away from hands-on clinical practice, the only alternatives at the time. The creation of the NP role finally offered Abby the possibility of being intellectually challenged in the multiple dimensions of nursing, while at the same time being more intimately connected with patients and families over long periods.

Being More in Control

Majestic eagle
In gilded cage, her wings clipped
Her spirit sundered.

— Mika Yoshimoto (2008, p. 6)

Some nurses are strongly attracted by the possibility of finally having both increased responsibilities and the autonomy to act in their clinical practice. In other words, they seek to have control over their practices, which they feel has been missing from or has eluded them in their role as bedside nurses. Indeed, the frustrations with practice limitations and the inability to experience their own potential in the traditional bedside nursing role has led many nurses to consider either applying to medical school or leaving the health care field altogether. However, the NP role offers them the opportunity to remain rooted in the nursing profession, in direct clinical practice, in a position that holds the promise that they can have more independence and more control over the decisions about patient care, including the treatment plan and the way in which the care can be delivered. Greater knowledge and skill, combined with the authority to use all of their abilities more holistically, potentially enables nurses to make a greater difference, a finding equally expressed by a group of American primary-care NP pioneers in the mid-1960s and throughout the 1970s (Brown and Draye, 2003). One NP explained her attraction to the role:

At the time I was in a staff role and I wanted to do something different. . . . The focus wasn’t on delivering the best patient care, it was on who has the appropriate title to do X amount of care. Just one example: a patient has a headache. As a nurse you’ve certainly got the knowledge and expertise to know they need Tylenol but you can’t give them Tylenol until you call the physician to get an order for plain Tylenol. I found that kind of thing incredibly frustrating because it wasn’t a matter of the nurse not having the knowledge and expertise; it was the role limitations, the barriers to optimal practice. So the patient’s suffering while you’re jumping through these hoops to get something that the nurse should be able to deliver. . . . So I thought to myself, I either jump ship or go into medicine, which didn’t really appeal to me because I love nursing. . . . And I finally decided that . . . I was going to stick it out but I would do my masters preparation, which would give me the background to have more options. And at that time the NP role had been piloted at [hospital] . . . they were trying new territory . . . and I decided that it might just fit for me.

Suzanne Gordon’s journalistic work, Nursing Against the Odds (2005), passionately describes the health care systems that severely restrict what nurses can do without a doctor’s order, which both creates problems and reinforces status and power hierarchies between nurses and physicians, a deadly catch-22 situation. She described this situation from the physician’s perspective:

Every night, a thousand times a night, all over the country, nurses are calling doctors reporting that a patient has a fever and asking doctors what they should do about it, or asking the doctor whether they should give the patient Tylenol. And every night, doctors are berating nurses for calling them up and bothering them, because they are reporting a fever, and the doctors are thinking to themselves, “Why are you so stupid that you are asking me whether you should give Tylenol?” (p. 48)

Akin to wanting more control is the desire for more flexibility. Wanting to be more involved in all aspects of the patient’s care (“the social, the emotional, helping patients cope with the stressors, the medical care”), liking the flexibility in meeting the patients’ needs, and appreciating the additional responsibility and accountability results in nurses being attracted to a role in which they believe they will be able to direct care in collaboration with physicians. Moreover, they are drawn to the possibility of being able to spend time with patients and their families.

Being More Visible

It was about diagnosing and coming up with the solution and being able to really work collaboratively and build those partnerships with our medical colleagues. . . . And I felt as a nurse that one of the opportunities to present itself would be to become a neonatal nurse practitioner. . . . Well I guess, it’s like that power, not power, but the sense of fulfilment that you have at the bedside when you work together . . . being part of the team in terms of how could I, as a nurse practitioner, be more part of . . . working collaboratively with making that plan . . . but working with the nurse, working with the whole team in how we can make a difference, but really being part of that discussion.

Becoming an NP is also about the call to be more visible: the search for a more collaborative practice, of being able to contribute more to the team and to experience the feeling of being truly valued, all inherently speak to this. Nurses who become NPs want to have their voices heard and to be recognized and acknowledged for their own agency. They are frustrated with being viewed as “just a nurse” (an implication that nurses are engaged in insignificant work) or “just temporarily borrowing the doctor’s agency” (Gordon, 2005, p. 50). NPs view their role as an opportunity to be affirmed and recognized for what they know and do, rather than having their actions attributed to the physician. For instance, “Sally,” in her role of transport nurse, was tired of the evasive and roundabout language that demonstrates deference to physicians. She no longer wanted to play the doctor–nurse game of arriving at the identification of the problem or plan of care without venturing on the medical territory of diagnosis, treatment, or prescribing:

So you have an air leak happening and the baby’s telling you what symptoms he’s having; you’re looking at an X-ray that’s telling you, this baby has a pneumothorax. And the parents are asking me, “Well why are you putting that needle in the chest?” And so, you’re going, “Well he has symptoms that are suggestive of a hole in his lung, an air leak.” No. He’s got a pneumothorax. It’s a diagnosis. It just boggles my mind to try and get the wordsmithing around just to stay within the scope of nursing.

Gordon (2005) observed that even in settings in which nurses can change ventilator settings, wean patients off inotropic agents, insert catheters, and initiate intravenous fluid therapy, after which they get the physician (resident) to write an order, the treatment interventions are presented on rounds in such a way that the nurse seems to have acted on the physician’s behalf. As these participants confirmed, it is common to hear staff physicians inform new residents that nurses know their preferences. All of this reinforces what physicians admit that they have been taught through informal or formal lessons and socialization: “The nurse is stupid, because she uses dumb language, makes dumb suggestions, and doesn’t know anywhere near what the physician knows” (Gordon, 2005, p. 49). Nurses “have no real agency of their own” (p. 50).

The term doctor–nurse games was coined by Leonard Stein (1967) to refer to the implicit or explicit relationships of power between physicians and nurses and the social game played by both parties to maintain that balance. Such “games” conceal nurses’ mastery of their knowledge and skills and their importance to patients. Nurses remain barely visible to physicians, exc...