Taking nursing to the limits

By MARK STORY

She - or he - is something more than a nurse, but not a doctor. The nurse practitioner, while common in the United States for more than 30 years, is a new species in New Zealand healthcare.

The role of nurse practitioner (NP) started evolving in 1998, when a ministerial taskforce on nursing supported development of the role.

Now recognised as the highest level of nursing, the job of the NP brings with it new responsibilities. Unlike the country's 50,000 registered nurses - 35,000 of whom are practising - NPs are legally able to independently refer patients to specialists, discharge patients, make diagnoses, order and interpret test results and, where authorised, prescribe medication directly, like a general practitioner.

The nurse practitioner is the most significant breakthrough since nurses received professional registration in 1901, says one of only four New Zealand-registered NPs, Mark Smith.

Smith arrived in New Zealand in the late 1980s with a degree from London's Nightingale School of Nursing. He returned to the United Kingdom during the early 1990s to complete a master of nursing degree.

He divides his time between lecturing on the University of Auckland's master of nursing programme and clinical practise - he specialises in the mental health of young people at Waikato Hospital.

Smith expects vastly improved pay for nurses at the NP level, to help staunch the massive exodus of registered nurses leaving the country for better-paid jobs overseas.

While entry-level registered nurses earn between $20,000 and $30,000, an nurse practitioner's pay is around $70,000.

But veteran NP Paula Renouf says pay is only half the issue. She says the fact that many registered nurses can do a lot more than the system allows them to is a career-stopper for many.

It's as much about improving primary healthcare as it is about pay, says Renouf, who recently returned to New Zealand after 12 years as an NP in California.

She certified as a paediatric nurse practitioner in 1992, having completed a master of science. Also a lecturer on the Auckland University master of nursing programme, Renouf recently returned home to apply her NP expertise locally. She plans to work part-time as a NP within a high school-based clinic or similar.

It takes a three-year bachelor of nursing degree and a one-year internship in a public hospital to become a registered nurse, so what else is required to become an NP?

To be admitted onto a four-year master of nursing programme, offered by six local universities, RNs must have at least two years working in a specialist area.

Even then, there's exacting assessment for NP registration. "During a five-hour interview, I had to convince the Nursing Council of my clinical skills as well as my research and supervisory skills, plus my ability to teach others," says Smith, who received his NP registration in July last year.

Once registered, NPs must operate within a clearly defined area, such as child and family health, maternal mental health or rural nursing.

Where will they make the most difference? It's in rural areas, where many GPs find it too stressful to live, that NPs will fill the biggest void, says Smith.

"Being able to deliver services directly at the client level means GPs are no longer the only gatekeepers to specialists or to prescriptions. This empowers NPs to become independent colleagues with GPs, as opposed to their subordinates."

Most NPs are expected to work in teams with GPs, but Smith foresees a time when NPs will migrate to their own private practises.

Legally, NPs could hang up their shingles tomorrow, but he says the public is taking some time to get used to the idea.

Nursing Council chief executive Marion Clark won't speculate on how many of the 700 people currently on a nursing masters programme will seek NP registration.

However, Smith expects to see more than 1000 NPs registered throughout the country in five years' time.

By 2010, he hopes that around 15 per cent of the country's registered nurses will have acquired NP status.

But based on offshore examples these projections look ambitious. After the first 20 years of NPs in the United States, just five per cent of registered nurses had become nurse practitioners.

Based on her American experience, Renouf says the desire to make local nurse practitioners researchers and teachers - as well as first class- clinicians - may put off many experienced registered nurses applying.

Having chalked-up over 36,000 patient encounters in the United States, she's convinced the strength of the NP role, as in the US, should be preventative treatment.

"Nurse practitioners will indeed fill a gap in rural primary healthcare, but there's also a golden opportunity for Asian and Pacific Island NPs to serve urban areas where there are equally gaping holes."