Awkward! GP college retracts position paper on NPs but paternalism concerns remain

Many have asked the bigger question as to why the RNZCGP is trying to describe and compare GPs to NPs in the first place?

It was a typical Tuesday evening when I heard the familiar “ping” from my email account.

A new message had arrived from a friend, who is a GP. I read the words “I was almost too afraid to send this you. I feel ashamed by it”.

“This should be interesting” I thought while raising an eyebrow. Putting my iced water down, I double clicked onto the four-page PDF document. It was written by the RNZCGP and it provided a “position statement” on nurse practitioners.

“Oh dear” I thought.

“Oh dear” was indeed accurate. It was more than a position statement. It seemed to provide the RNZCGP perspective on what constitutes a nurse practitioner’s role comparative to that of a GP. Sadly, the document was inaccurate, appeared to be misinformed and projected a role that was nothing like the actuality of the NP role.

In 1967 psychiatrist Leonard Stein conceptualised the Doctor-Nurse game.

He deemed that in order for a registered nurse to gain respect and acceptance by a doctor, they needed to play a game: The Doctor-Nurse game. Players assumed roles dictated by their profession.

The game, however, is not like draughts or even Scrabble. Registered nurse players use lines such as “yes, doctor” or “may I hold the door open for you, doctor” or “here, have my chair, doctor” or “did I mention that I polished your stethoscope while you were at lunch?”.

Interestingly, this phenomenon extended into the way a registered nurse phrased their sentences to doctors. Ultimately, this was in a manner that reinforced subordinance and promoted medical superiority.

For example, “Oh doctor, I wonder if the patient’s leg is looking a little red. What do you think, doctor?”

The registered nurse may have even made an extra effort to use medical words that the doctor would understand. This would then help them to be “ticked off” as being “a good nurse” and gain the doctor’s respect.

When we consider this gaming lens, one thing that is very different now is that NPs are not registered nurses. They do not arrive with a subtle and historic socialised pastime banter of “I am just a nurse”.

Nor do they view doctors as the only ones to make the overall decisions or hold the overall responsibility. This is because they themselves are in a role as a lead care provider.

The responsibility of what a NP does, the decisions they make and the care they provide sit solely with them. Not a doctor. Their legal authority and responsibility under the Health Practitioners Competency Assurance Act 2003 dictate they are autonomous and capable of providing comprehensive healthcare.

NPs are blended between medical and nursing sciences so they can work in an autonomous role; they are not advanced registered nurses.

This fact can create a very delicate space between medicine and nursing. This fragile space can at times manifest into a type of patch protection and this can be expressed in varied forms in the workplace, in healthcare systems and in the public arena.

It is reasonable to assume that this description has the capability to make a solely trained medical doctor uncomfortable. It may even lead someone’s mind down the garden path to bigger questions around what this may mean within a team.

One is not more, or less, than the other and, importantly, the difference creates an opportunity to learn from one another and be innovative together. But, if these concepts are causing your insides to twist, fear not. You can Google the location of a drive-through vaccine clinic near you.

Many GPs are exemplary in truly collaborating with NPs. Many get it. Some get it so much that their mind moves on progressively to concepts such as the development of a primary care college that values all primary care roles' contribution without hierarchy and includes all, even community pharmacists.

Yet sceptics who live along some grapevines reveal it is hard to let go of how it was. It may be challenging for some doctors to no longer be the only one who can be the head of the team.

There may be a tendency to view “nurses” as all the same in the nursing profession, with a few who have “some special advanced skills”. However, NPs are completely different from registered nurses and are very different to registered nurses with special advanced skills, who, by the way, we call clinical nurse specialists or rural nurse specialists.

Nurse practitioners are not replacement doctors, rather practitioners with a different perspective in their own right.

As I reflect on all of this, I recall a fascinating discussion I found myself in after a presentation on hierarchy in healthcare. I posed the suggestion to the audience that the nursing profession has a hierarchical structure that is similar to that of medicine; based on knowledge and clinical context.

It provided for some spicy debate during Q&A time and several GPs in the audience explained the challenges faced when interacting with hospital doctors.

It emerged that GPs felt their choice to work in primary care versus being a cardiothoracic surgeon or sports physician was greeted with hints of being “less”. This is an important point to consider as we watch NP numbers increase in primary care. We need to avoid the temptation to project “lesser”; “different” is better.

Perhaps it may also help to understand that it is likely many GPs and possibly many medical students may not clearly know the content of the nursing curriculum in both undergraduate and postgraduate education.

They may not realise that, even at undergraduate level, student nurses are rigorously taught about ethics, law, clinical reasoning, pharmacology, pathophysiology and competent clinical assessment skills.

When I was a course coordinator in an undergraduate nursing degree programme, student nurses frequently voiced concerns that doctors did not appear to understand their role, their knowledge and their skills.

I asked a rural GPSI one day: “How do you decide if you can trust a registered nurse?” They answered: “By their ability to speak in medical terms and present accurate information to me about a patient.”

“Are you aware of what registered nurses are taught in their degrees?” I continued. “Oh ‘nursey caring’ type stuff. I don’t need to know because all the responsibility sits with me.”

This is interesting food for thought as the tide changes around “who” the overall responsibility is able to now sit with. It is problematic if doctors work alongside registered nurses for their entire careers and have no idea what nurses and, likewise NPs, are educated in.

What I can tell you (from the perspective of a lecturer who works within the national NP training practicum internship year) is that I am yet to encounter one medical clinical mentor who holds the title of GP, GPSI, SMO or consultant that has ever highlighted to me that a NP intern is not skilled enough to work as a lead care provider and be part of their medical team.

It is usually the polar opposite.

Now more than ever, we need to consider the possibility that we may have blind spots or have been socialised into having unconscious biases toward the people we work alongside in healthcare.

Yes, it is reassuring to many that the RNZCGP has been responsive and retracted their position statement. As we await the revised version, hope is held that the rewriting will be undertaken in collegial collaboration with a professional body that represents NPs.

Let us pause to remember some of the important values that exist within New Zealand society such as kindness, inclusion, collectiveness, collaboration and good faith.

Ultimately, it matters what you think, what you say, what you write and what you print. In leadership and governance of professional groups, we all have a responsibility to lead by example and step toward change so that others feel brave enough to let go, follow, and embrace.

Chelsea Willmott works in rural general practices around Southland and Otago. She works as a rural nurse practitioner in general practice, emergency and PRIME. She is also a senior lecturer, clinical advisor and academic at Victoria University in the NP Training Programme intern year.