Response to "An Interpretive Study Describing the Clinical Judgment of Nurse Practitioners"

Article excerpt

"How does one describe the clinical practice of experienced nurse practitioners? This is no easy task" (p. 75). These opening sentences by Brykczynski offer us the quintessential challenge raised in this paper. After a quarter of a century of research and hundreds of studies about nurse practitioner practice, the question remains only partially answered and perpetually difficult. This difficulty persists despite the recent publication of several excellent, comprehensive, and coherent documents designed specifically to assist us in explicating our practice area. Scope of Practice of the Primary Health Care Nurse Practitioner (ANA, 1985), Standards of Practice for the Primary Health Care Nurse Practitioner (ANA, 1987), Office of Technology Assessment Case Study 37: Nurse Practitioners, Physicians Assistants, and Certified Nurse Midwives: A Policy Analysis (Office of Technology Assessment [OTA], 1986).

Similar to our colleagues in other nursing specialty areas, nurse practitioners often have some difficulty articulating an answer to the above question because it presumes a real understanding of our practice. The ability to respond, however, is not simply a "navel gazing exercise"; rather, it is of paramount importance to the survival of the specialty. This paper focuses on the contribution of Brykczynski's research to this elusive question and offers preliminary ideas about clinical implications. A paper with such depth, complexity, and far-reaching implications as this warrants attention to each of the critical issues raised. Yet, the practical constraints will delimit this analysis to clinical applications in three critical areas: role explication and interpretation, education, and quality assurance/peer review.


Responding to Brykczynski's work calls forth several dimensions of my person: the clinician, the educator, and the researcher. My initial response, however - pride - provides the first pathway to explore. The nurse practitioner client encounters described in this study reflect the best of what we can be. It is more than pride, however; it is pride with ownership. My response was comparable to reading From Novice to Expert (Benner, 1984), except this time I felt this was my practice under discussion.

While an experience of pride is a stimulus for any professional group, it is particularly important to nurse practitioners. The nurse practitioner movement was launched into a trajectory of conflict and rejection, although certainly accompanied by excitement and exploration. Most segments of both nursing and medicine were wary, and often overtly rejecting, of the existence of nurse practitioners. Medicine claimed nurse practitioner incompetence to protect its professional turf, nursing experienced anxiety about these traditional medical tasks included in the nurse practitioner role, and academia created a "second class" category for nurse practitioner education because of the perceived overriding focus on clinical application of knowledge and the development of clinical skills. While great strides have been made in physician support and collaboration with nurse practitioners, the battle over provider status promises to continue. In 1985, the American Medical Association resolved to "oppose new legislation extending medical practice to non-physician providers" (Legislative Network for Nurses, 1985).

The challenge within nursing also continues, although the form and content of the struggle has changed slightly. Primary-care nurse practitioner programs have been, for the most part, completely or at least partially federally funded. As the number of programs increases and the availability of federal dollars for such programs becomes tighter, schools of nursing have been asked to assume more, if not all, of the fiscal responsibility for their nurse practitioner programs. New debates center on the relative importance to society of educating nurse practitioners versus others in less costly advanced practice roles. …