Your views and letters

What Is in a name: Advanced practice of what?

5A response to the JAN 30th anniversary Editorials on Advanced Practice Nursing issue 55.3
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
reected in titles such as New Skills for a New Age: Preparing
Nurses 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 nest 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 of
cure (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 medicalizationbenets 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 scientic
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 biomedi-
cine 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 dene it. Moreover, one that I think is a potentially better
socio-politics of health, which is to say that health is a socio-
political issue. As Foucault (1980) put it, the political ques-
tionis truth itself (p. 133). Or to phrase it more helpfully, the
idea that the disinterested pursuit of scientic 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
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were, with which to practice (advanced or any other) is making a
serious mistake 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 advanced things 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 this
advanced 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 and
Nelson (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, specic 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 veried.
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 difcult (or even impossible) to dene comprehensively,
may nevertheless withstand the vagaries of economic 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 epistemo-
logical 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
References
Bartels J.E. (2005) Educating nurses for the 21st century. Nursing
and Health Science 7, 221225.
Chiarella M. (2006) Advanced nursing practice. Journal of Advanced
Nursing 55(3), 276277.
Clarke L. (1991) Ideological themes in mental health nursing. In
Ethical Issues in Mental Health (Barker P. & Baldwin S., eds),
Chapman & Hall, London, pp. 2744.
Clarke L. (2006) So what exactly is a nurse? Journal of Psychiatric
and Mental Health Nursing 13, 388394.
DiCenso A. & Matthews S.2005) Report on the Integration of
Primary Health Care Nurse Practitioners into the Province of
Ontario. Retrieved from http://www.health.gov.on.ca/english/
public/pub/ministry_reports/nurseprac03/nurseprac03_mn.html
on ?? ???? 200? 1
Drummond J. (2003) Care of self in a knowledge economy: higher
education, vocation and the ethics of Michel Foucault. Educational
Philosophy and Theory 35(1), 5769.
Foucault A. (1980) ?????. In Power/Knowledge: Selected Interviews
and Other Writings, 19721977 (Gordon C., ed.), Pantheon, New
York, pp. ????. 2
Fredriksen S. (2003) Instrumental colonisation in modern medicine.
Medicine, Health Care and Philosophy 6, 287296.
Garland-Thomson R. (2002) Integrating disability, transforming
feminist theory. National Womens Studies Association Journal
14(3), 132.
Gatzke H. & Ransom J.E. (2001) New skills for a new age: preparing
nurses for the 21st century. Nursing Forum 36(3), 1317.
JAN Forum
2 2007 The Author. Journal compilation 2007 Blackwell Publishing Ltd
Gordon S. & Nelson S. (2005) An end to angels: moving away from
the virtue script toward a knowledge-based identity for nurses.
American Journal of Nursing 105(5), 6269.
Illich I. (1999) Limits to Medicine: Medical Nemesis, the
Expropriation of Health. Marian Boyars, London.
Latour B. (1994) ?????. In We Have Never been Modern (Porter C.,
ed.), Harvard University Press, Cambridge, pp. ????. 3
Lorentzon M. & Hooker J.C. (1996) Nurse practitioners, practice
nurses and nurse specialists: whats in a name? Journal of
Advanced Nursing 24, 649651.
Parsi K.P. & Geraghty K.E. (2004) The bioethicist as public
intellectual. The American Journal of Bioethics 4(1), W17W23.
Perron A., Fluet C. & Holmes D. (2005) Agents of care and agents of
the state: bio-power and nursing practice. Journal of Advanced
Nursing 50(5), 536544. 4
Porter R. (1998) The Greatest Benet to Mankind: A Medical
History of Humanity. W. W. Norton & Company, New York.
Rorty R. (2004) Forward. In Knowledge and Civilization House
Divided Comparing Analytic and Continental Philosophy (Allen
B., ed.), Westview Press, Colorado, pp. viix.
Schober M. (2006) Advanced nursing practice: an emerging global
phenomenon. Journal of Advanced Nursing 55(3), 275276.
Scott R.T. & Conn S. (1987) The failure of scientific medicine: Davis
Inlet as an example of sociopolitical morbidity. Canadian Family
Physician 33, 16491653.
Smith R. (2002) Reviews: limits to medicine. Medical nemesis: the
expropriation of health. British Medical Journal 324, 923.
Tanner C.A. (2006) Changing times, evolving issues; The faculty
shortage, accelerated programs, and simulation. Journal of
Nursing Education 43(3), 99100.
Thompson D.R. & Watson R. (2006) Professors of nursing: what do
they profess? Nurse Education in Practice 6, 123126.
Ubbes V.A., Black J.M. & Ausherman J.A. (1999) Teaching for
understanding in health education: the role of critical and creative
thinking skills within constructivism theory. Journal of Health
Education 30(2), 6772, 135.
JAN Forum
2007 The Author. Journal compilation 2007 Blackwell Publishing Ltd 3
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