重视护理范式:开业护士能否抵制医疗化以改变医疗保健?

2021
11/24

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NursingResearch护理研究前
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“看到执业护士如此聪明,为什么不将自己重新命名为护士以外的其他人”。

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A lay person commented recently to one of us that ‘seeing how nurse practitioners were so clever why didn't they rename themselves as something other than a type of nurse’. A sobering comment indeed, but one that has, on occasions, been uttered by nurse practitioners (NPs) themselves from around the world. In this editorial, we would like to tease out the thinking behind such notions and consider the implications for our discipline. In doing so, we draw essentially on the New Zealand experience of NP establishment but believe these ideas have international significance.

In New Zealand, the NP is a separate legislated scope of practice from registered nurse. Nurse practitioners must graduate from an approved clinical master's programme, having at least 4 years of experience as a registered nurse in their area of practice. They autonomously (or in teams) deliver the full episode of care including diagnosis, management, prescribing and referral as needed, without recourse to guiding protocols or supervision. There are currently well over 500 registered NPs working across a wide variety of clinical settings. Approximately 60% are working in what can broadly be defined as primary health care.

International evidence has provided surety that NPs deliver health outcomes at the very least equivalent to general practitioners (family or primary care physicians) and across several parameters, including mortality, long-term condition management, and patient satisfaction they deliver superior outcomes (Laurant et al., 2018). Yet through this research, the discourse of ‘substitution’ tends to dominate. While we see such evidence as central to informing the public and health sector of the safety of NP practice, the notion that NPs are direct substitutes for physicians, we believe, is becoming problematic, particularly across mainstream primary care practices. Too often, NPs are being asked to work in the same model of care as general practitioners through 15-min appointments and oftentimes limited (by organizational edicts) to only one patient issue per consultation. To see NPs as simply a replacement for general practitioners will do nothing to improve the health outcomes and persisting inequities present in specific populations in multiple countries. Instead, we need to envisage the NP workforce as offering a model of care that extends biomedicine by embracing the nursing paradigm to transform primary healthcare services.

The nurse practitioner movement was first mooted in New Zealand in 1998 following a Ministerial Taskforce on Nursing. The aim of the Taskforce was to chart how to realize the full potential of nursing at a time when the demands on health services were growing, coupled with escalating costs; the population ageing; and there was greater awareness of the need to address perpetuating health inequities. The Taskforce was further motivated by the United States experience where NPs had been working for about 40 years with strong efficacy data and, since that time, other countries had, or were beginning, to launch the role.

From the outset, those of us who drove the establishment of the role were mindful of the pivotal statement made by the American physician Barbara Bates, who wrote the first physical examination textbook for NP students. She noted:

By expanding your knowledge and skills into medicine, and thereby acquiring some of that control, you can in fact expand into nursing… Less medicine when mixed with more nursing, is probably better medicine (or to translate, better health care)… By expanding into medicine you will need - more than ever before - to increase your consciousness of what nursing is all about’. (Bates, 1974, p. 686)

The principal impetus for NP establishment in New Zealand was to improve access to health services by creating advanced practice nurses who could lead the care for a much wider range of patients. The intent was they remained embedded in a nursing team while working collaboratively with other health professionals across the sector. As such they would contribute a nursing paradigm of care grounded in achieving social justice and health equity (Browne & Tarlier, 2008), with the ability and authority to diagnose and prescribe. Nurse practitioners were seen as creating a flexible, affordable and available workforce which would expand service provision especially for underserved, Indigenous and priority populations (including Māori and Pacific in the New Zealand context) and rural communities.

Early research on the role was conducted between New Zealand and Australia (Carryer et al., 2007) revealing that the Australasian model of NP practice was firmly grounded in nursing and resistance to medicalization was strong. Early implementation of the NP role was based in knowing that to suggest certain tasks were forever to be performed by medicine was to be rigid and inflexible and a recipe for the cumbersome and costly health system that failed to address significant consumer need. More recent research has affirmed early assumptions that an advanced nursing role with an extended toolbox of skills does indeed engender high levels of patient satisfaction and increased enablement of patients (Frost et al., 2018) leading to higher levels of patient engagement and empowerment.

The role of the NP was thus seen firmly as an extension of nursing, aligning with World Health Organization global goals for primary health care. As such NPs take their grounding in primary health care, with a focus on cultural safety, social determinants, health literacy, wellness and the fundamental notions of holism, into their consultations. We have previously argued that over 100 years of commitment to the hegemony of biomedicine throughout health systems has done little to reduce inequity nor to deliver essential primary health care in the face of ever rising health costs and an epidemic of long-term conditions (Kooienga & Carryer, 2015). Added to this the complexity of systems grounded in neoliberal policy agendas has created a fragmented and competitive health arena in which NPs must work (Adams & Carryer, 2021). While the extant models of care may serve some people brilliantly, others fall through the cracks, either through lack of affordability or lack of appropriate service. Instead, if NPs stay true to a philosophy of nursing that embraces a person/family-centred and collaborative approach in a social justice framework, they offer the opportunity for transformational change to healthcare delivery (Carryer & Adams, 2017).

Despite medicine's vital but narrow, contribution to health outcomes, it is accorded enormous prestige, power and high levels of public recognition and deference. In addition, medicine is also rewarded with high levels of remuneration and assumptions of leadership of healthcare teams. Certainly, the health bureaucracy seems unable to let go of searching for old solutions to new and growing problems in health service delivery. Similarly New Zealand media write endless stories about the rapid decline in general practitioner (primary care physician) numbers while firmly resisting constant requests to tell the good news story of the rise of NPs. A singular focus on biomedical solutions will not address pressing challenges in primary healthcare delivery. As Dillard-Wright and Shields-Haas (2021) so eloquently argue, ‘Ignoring holistic health and well-being to focus on singular medical tasks and disease processes is reductive, violent, and contrary to humanization as a disciplinary focus for nursing’ (p. 199).

Historically, much has been written about the oppressed group status of nursing as a discipline (see for example Roberts, 1996). One feature of oppressed groups is a tendency for members to seek escape and recognition through allegiance to a related group with greater power and status. In doing so they seek to divest their alignment with the oppressed group. The pull for NPs to align with medicine and to move away from their nursing heritage is thus potentially compelling. Such a move would, however, be completely antithetical to the essential value of the role which rests with the unique combination; a strong background in nursing extended together with the addition of various medical skills and tasks previously under the jurisdiction and professional domain of medicine.

It is our hope that the temptation for NPs to move away from nursing is resisted at all costs. We remain firmly committed to the original intent of the role establishment. While being respectful of the contribution and immense value of medicine we return to their limited contribution to comprehensive health outcomes. In addition, medical professionals’ high levels of remuneration mean that access to even the most basic primary care needs can be expensive and out of reach for many of the people who need it most, in turn leading to a greater burden of morbidity and hospitalizations. One major reason for the 2021 health reform process occurring in New Zealand is the inequitable access to care. Despite, ostensibly, a universally accessible and publicly funded healthcare system, access to what is mostly physician-led primary care remains a user-pays model (Goodyear-Smith & Ashton, 2019). NPs through the nature of their practice and their duality of approach offer the best hope for improving equity, affordability, access and sheer availability of services.

Beyond the immense value to patients there are other tangible advantages to the NP role. The presence of NPs as senior members of the nursing workforce has the potential to expand the public perception of nursing not only through their clinical acumen, but also through their engagement with local communities to identify health need and deliver culturally appropriate services. Positively promoting the visibility of nursing will help shift away from the enduring notions of handmaidens, heroes and angels (Dillard-Wright & Shields-Haas, 2021). Further, the role of NP acts as a catalyst for promising new graduates to remain in nursing with aspirational clinical career goals. The role itself has many miles to run in breaking down artificial service delivery boundaries (such as between general practice and community services; or between primary and hospital services) and delivering increasingly nurse-led services. We see the NP role as perfectly designed to span historical service boundaries, and though these boundaries may serve funders, planners and providers well, they make life complex and confusing for patients and result in reduced access to care. The need for better integration of care delivery has been much touted but remains elusive in current service delivery models.

There is good reason however to be cautious about ‘integration’ of the NP role into an existing medically dominated healthcare system (Delvin et al., 2018). As with the discourse of substitution, there is a risk that NPs and their work become subsumed into extant models of reductionist biomedical care. The focus on inter- and intra-professionality risks the loss of identity for all but medicine, who will continue to assume leadership of the clinical space, as well as the nature and direction of service delivery. On the other hand remaining at the margins of the system enables NPs to be critical of the domination (Browne & Tarlier, 2008) and from this position appreciate the system as a whole, as well as the healthcare needs of those on the periphery (Delvin et al., 2018). Delvin et al. argue that NPs need to take a philosophical perspective to describe what nourishes and defines them, their true nature and ability, and ultimately, how they express their authenticity in practice. Role definition, they say, is crucial.

Dillard-Wright and Shields-Hass (2021) argue that across the globe, health systems are struggling not just with the COVID-19 pandemic but with fiscal and workforce sustainability. It is clear that a transformative approach to leadership and practice is long overdue. Nurse practitioners closely aligned to their origins in nursing hold critical potential to be this transformation if they are able to resist the medicalization of their role. We hope that NPs as our most senior clinicians will indeed remain closely aligned with their roots in nursing. We hope that NPs will not be seduced by the multiple rewards offered to medicine and will remain focused on the value of their nursing approach to practice. Aside from the value to issues of nursing identity and recognition it is patients, families and communities who will have the most to gain.

全文翻译(仅供参考)

一位外行人士最近对我们中的一个人评论说,“看到执业护士如此聪明,为什么不将自己重新命名为护士以外的其他人”。这确实是一个发人深省的评论,但有时也会由来自世界各地的执业护士 (NP) 自己说出。在这篇社论中,我们想梳理出这些概念背后的思想,并考虑对我们学科的影响。在这样做时,我们主要借鉴了新西兰建立 NP 的经验,但相信这些想法具有国际意义。

在新西兰,NP 是独立于注册护士的立法范围。执业护士必须从经批准的临床硕士课程毕业,并在其执业领域拥有至少 4 年的注册护士经验。他们自主(或以团队形式)提供整个护理过程,包括根据需要进行诊断、管理、处方和转诊,无需求助于指导协议或监督。目前有超过 500 个注册的 NP 在各种临床环境中工作。大约 60% 的人从事广义上可以定义为初级卫生保健的工作。

国际证据表明,NP 提供的健康结果至少与全科医生(家庭或初级保健医生)相当,并且跨越多个参数,包括死亡率、长期状况管理和患者满意度,他们提供了卓越的结果(Laurant 等., 2018)。然而,通过这项研究,“替代”的话语往往占据主导地位。虽然我们认为这些证据是告知公共和卫生部门 NP 实践安全性的核心,但我们认为 NP 是医生的直接替代品的概念正在变得有问题,尤其是在主流初级保健实践中。很多时候,NP 被要求通过 15 分钟的预约以与全科医生相同的护理模式工作,并且通常(根据组织法令)每次咨询仅限于一个患者问题。将 NP 仅仅视为全科医生的替代品,无助于改善多个国家特定人群中存在的健康结果和持续存在的不平等。反而,

护士从业者运动于 1998 年在护理部长级工作组之后首次在新西兰提出。工作组的目的是在对卫生服务的需求不断增长、成本不断上升的情况下,规划如何充分发挥护理的潜力;人口老龄化;并且人们更加意识到需要解决长期存在的健康不平等问题。工作组进一步受到美国经验的推动,美国的 NP 已经工作了大约 40 年,拥有强大的功效数据,从那时起,其他国家已经或正在开始发挥作用。

从一开始,我们这些推动角色成立的人就注意到美国医生芭芭拉·贝茨 (Barbara Bates) 的关键言论,她为 NP 学生编写了第一本体检教材。她指出:

通过将您的知识和技能扩展到医学领域,从而获得一些控制权,您实际上可以扩展到护理领域……如果将更少的药物与更多的护理相结合,可能是更好的药物(或翻译为更好的医疗保健)……通过扩展到您将需要的药物 - 比以往任何时候都多 - 以提高您对护理的全部意识'。(贝茨,1974 年,第 686 页)

在新西兰建立 NP 的主要动力是通过创建高级执业护士来改善获得医疗服务的机会,这些护士可以领导更广泛的患者的护理。目的是让他们在与整个行业的其他卫生专业人员合作的同时,仍然融入护理团队。因此,他们将贡献一种以实现社会正义和健康公平为基础的护理模式(Browne & Tarlier,2008 年),并具有诊断和开处方的能力和权威。护士从业者被视为创造了一支灵活、负担得起和可用的劳动力队伍,这将扩大服务范围,特别是为服务不足的土著和优先人群(包括新西兰的毛利人和太平洋地区的人)和农村社区提供服务。

新西兰和澳大利亚之间对该角色的早期研究(Carryer 等人,2007 年)表明,澳大利亚的 NP 实践模式牢固地植根于护理领域,并且对医疗化的抵抗力很强。NP 角色的早期实施是基于知道建议某些任务永远由医学执行是僵化和不灵活的,并且是繁琐且昂贵的卫生系统的一个秘诀,无法满足重要的消费者需求。最近的研究证实了早期假设,即具有扩展技能工具箱的高级护理角色确实会提高患者满意度并增加患者的能力(Frost 等,2018),从而导致更高水平的患者参与和授权。

因此,NP 的作用被坚定地视为护理的延伸,与世界卫生组织的初级卫生保健全球目标保持一致。因此,NP 将他们在初级卫生保健方面的基础,重点放在文化安全、社会决定因素、健康素养、健康和整体主义的基本概念中,纳入他们的咨询中。我们之前曾指出,面对不断上升的卫生成本和长期疾病的流行,100 多年来对整个卫生系统生物医学霸权的承诺在减少不平等或提供基本的初级卫生保健方面几乎没有起到任何作用(Kooienga 和搬运工, 2015)。除此之外,基于新自由主义政策议程的系统的复杂性造成了一个支离破碎且竞争激烈的健康领域,NP 必须在其中发挥作用(Adams & Carryer,2021 年)。虽然现存的护理模式可能为某些人提供出色的服务,但其他人却因缺乏负担能力或缺乏适当的服务而陷入困境。相反,如果 NP 坚持在社会正义框架中采用以人/家庭为中心的协作方法的护理哲学,他们将为医疗保健服务提供转型变革的机会(Carryer & Adams,2017 年)。

尽管医学对健康结果的贡献至关重要但范围很窄,但它被赋予了巨大的声望、权力和高度的公众认可和尊重。此外,医学也获得了高水平的报酬和医疗团队领导的假设。当然,卫生官僚机构似乎无法放弃为卫生服务提供中新的和日益严重的问题寻找旧的解决方案。同样,新西兰媒体不断撰写关于全科医生(初级保健医生)人数迅速下降的报道,同时坚决抵制不断要求讲述 NP 崛起的好消息的要求。对生物医学解决方案的单一关注无法解决初级医疗保健服务中的紧迫挑战。饰演 Dillard-Wright 和 Shields-Haas(2021 年))如此雄辩地争辩说,“忽视整体健康和福祉而专注于单一的医疗任务和疾病过程是还原性的、暴力的,并且与作为护理学科重点的人性化背道而驰”(第 199 页)。

从历史上看,关于护理作为一门学科的受压迫群体地位的文章很多(例如,参见 Roberts,1996 年)。受压迫群体的一个特征是成员倾向于通过效忠于具有更大权力和地位的相关群体来寻求逃避和承认。在这样做的过程中,他们试图摆脱与受压迫群体的结盟。因此,NP 与医学保持一致并摆脱其护理传统的吸引力具有潜在的吸引力。然而,这样的举动将与独特组合所具有的角色的基本价值完全背道而驰。强大的护理背景以及以前属于医学管辖和专业领域的各种医学技能和任务的增加。

我们希望不惜一切代价抵制 NP 离开护理行业的诱惑。我们始终坚守角色设立的初衷。在尊重医学的贡献和巨大价值的同时,我们又回到了它们对全面健康结果的有限贡献。此外,医疗专业人员的高薪意味着即使是最基本的初级保健需求也可能是昂贵的,而且对于许多最需要的人来说是遥不可及的,反过来又会导致更大的发病率和住院负担。新西兰进行 2021 年医疗改革进程的一个主要原因是获得医疗服务的机会不公平。尽管表面上是一个普遍可及且由公共资助的医疗保健系统,2019 年)。NP 通过其实践的性质和方法的二元性,为改善服务的公平性、可负担性、可及性和绝对可用性提供了最好的希望。

除了对患者的巨大价值之外,NP 的作用还有其他明显的优势。NP 作为护理人员的高级成员的存在有可能不仅通过他们的临床敏锐度,而且通过他们与当地社区的接触来确定健康需求并提供适合文化的服务,从而扩大公众对护理的认知。积极提升护理的知名度将有助于摆脱女仆、英雄和天使的持久观念(Dillard-Wright & Shields-Haas,2021 年))。此外,NP 的作用是促使有前途的新毕业生继续从事护理工作,并实现有抱负的临床职业目标。这个角色本身在打破人工服务提供边界(例如全科和社区服务之间;或初级和医院服务之间)和提供越来越多的护士主导的服务方面还有很长的路要走。我们认为 NP 角色完美地跨越了历史服务边界,尽管这些边界可能很好地为资助者、规划者和提供者服务,但它们使患者的生活变得复杂和混乱,并导致获得护理的机会减少。对更好地整合护理服务的需求已被广泛吹捧,但在当前的服务提供模式中仍然难以捉摸。

然而,有充分的理由对将 NP 角色“整合”到现有的以医学为主导的医疗保健系统中保持谨慎(Delvin 等,2018 年)。与替代话语一样,NP 及其工作有可能被纳入现有的还原论生物医学护理模型中。对跨专业和跨专业的关注可能会导致除医学之外的所有人失去身份,医学将继续担任临床领域的领导者,以及服务提供的性质和方向。另一方面,留在系统的边缘使 NP 能够批评统治(Browne & Tarlier,2008 年),并从这个位置欣赏整个系统以及外围人员的医疗保健需求(Delvin等人,2018 年)。德尔文等人。认为 NP 需要从哲学的角度来描述是什么滋养和定义了他们,他们的真实本性和能力,以及最终他们如何在实践中表达他们的真实性。他们说,角色定义至关重要。

迪拉德-赖特和希尔兹-哈斯(2021 年)) 认为,在全球范围内,卫生系统不仅在应对 COVID-19 大流行,而且在财政和劳动力可持续性方面苦苦挣扎。很明显,领导力和实践的变革方法早就该采用了。如果护士从业者能够抵制其角色的医学化,那么与其护理起源密切相关的护士从业者具有成为这种转变的关键潜力。我们希望作为我们最资深的临床医生的 NP 确实能够与他们在护理领域的根源保持密切联系。我们希望 NP 不会被提供给医学的多重奖励所吸引,而将继续专注于他们的护理实践的价值。除了护理身份和认可问题的价值外,患者、家庭和社区将获得最大收益。

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关键词:
care,role,医疗化,NPs,护士,护理

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