The Australian: "Rise of the super nurse"
February 12, 2005 -- Today The Australian ran a generally very good piece by Adam Cresswell about the growing role of Australian nurse practitioners (NPs) in managing chronic heart failure, a critical and costly problem in Australia. The piece does a fine job of highlighting the benefits nurses can bring to this field, especially in its focus on the positive effect of the holistic nursing "model" on patient outcomes--that is, the NPs are not simply aping physicians. However, the piece might have explored the apparent physician objections to the nurses' work in more detail, and the "super nurse" approach to NP media coverage continues to make us uncomfortable to the extent it can be read to denigrate non-NP nurses.
The article starts by suggesting that the nurses currently meeting at a heart failure conference in Sydney are well placed to change traditional views of nurses--"if those stereotypes aren't dead yet, they soon will be." (We wish we could be so confident.) The piece is largely a description of the work of three nursing leaders attending the conference: Libby Birchmore and James McViegh, reportedly Australia's only two NPs "in heart failure," and Simon Stewart, a nursing professor at the University of Queensland and the University of South Australia. These NPs can "manage the day to day treatment of patients, which means assessing their conditions, adjusting their medications, and even one day soon prescribing drugs themselves." Stewart is involved in expanding the use of nursing-centered management of heart failure and other chronic cardiac conditions in Australia, which he argues can result in better patient outcomes and ultimately lower costs. Stewart's own research has shown that the nation is in the midst of a costly heart failure "epidemic," with patients generally facing a "poor prognosis" and suffering with harsh symptoms.
But under Birchmore's "model of nursing care for heart failure," the NP contacts heart failure inpatients, makes plans for their care and visits them at home within a couple of weeks of their discharge. Birchmore's plans rely not only on a physical assessment for the clinical markers of heart failure. As she notes, "this is a nursing assessment, so it incorporates all the other traditional nursing things like bowel and bladder function, the patient's general physical state, their hygiene and whether they need some assistance. It's still using the nursing philosophy--it's looking at the total person, not just the specific cardiac issue." The piece explains that this nursing model includes teaching patients how to manage their conditions themselves, including dietary guidelines, daily weigh-ins, and regulating their diuretic medications. Birchmore notes that her home visits allow her to survey and address patient needs that may not otherwise be obvious, such as a need for physiotherapy, and to check on patient medications for potential drug interactions or duplication. She notes that this model of chronic disease management could work well for many other diseases, including diabetes and respiratory illnesses.
The piece describes evidence of "dramatic improvements" in heart failure outcomes from this model, particularly sharp drops in hospital readmissions and shorter stays for patients who are readmitted, which translates into not only better lives among patients but also significant cost savings. As Stewart's research has shown, hospital treatment accounts for the great majority of the cost of heart failure.
The piece reports that physicians' groups object to this type of expansion of nurses' roles into primary care, with the Australian Medical Association apparently opposed to "moves that would allow nurses to diagnose illnesses or prescribe drugs, except under the direct supervision of a doctor, or in rural areas too remote to support a GP." The piece might have discussed why the physicians' groups are taking this position--the obvious possibilities being concerns about safety and/or fear of competition--and their response, if any, to the research showing the model's apparent effectiveness, as well as the research from other nations showing that NP care is at least as good as that provided by physicians. In particular, the piece might have benefited from quotes from physicians. The piece notes that "governments may find the prospect of financial savings from the nursing model too compelling to resist." It might also have noted that, unlike the kind of short term cost savings that might result from simply cutting back care, these cost savings reflect better patient outcomes. Even so, the article is so unreservedly positive and uncritical about the potential benefits of NP management of such diseases that it could be accused of a lack of balance.
Another result of this "head over heels" quality is that the piece may have the presumably unintended effect, despite the excellent focus on the nursing "model" of care, of reinforcing views that non-NP nurses are not especially significant. In other words, if these NPs are "super," where does that leave the vast majority of nurses who are not NPs? A recent U.S. News & World Report feature on NPs showed how the media can fall deeply into this trap in covering NPs' very real achievements. In fact, all registered nurses are "super" because they are highly skilled, autonomous professionals who save lives and improve outcomes using the same nursing model that the NPs do.
See the article "Rise of the super nurse" by Adam Cresswell in the February 12, 2005 edition of The Australian.