My experiences working with nurse practitioners in palliative care teams, drug and alcohol units, sexual health clinics, correctional centres and Aboriginal health services have been positive. I have never felt they were competing for my job or undermining my authority. Rather, there have been tremendous opportunities to work as a team and assist each other in areas of difficulty.

I currently work a couple of sessions per week with a full-time nurse practitioner in a clinic for homeless young people. She attends counselling and supports clients both within and outside the clinic. It would be impractical to employ a medical practitioner full-time for these tasks. She also performs basic examinations, immunizations, sexual health screens and Pap smears. Young people needing medical assessment and treatment are identified and if I am unavailable these clients are taken to local GPs.

It is difficult for me to understand why the AMA is involved in a demarcation dispute with nurse practitioners. Spokespeople for the AMA have contended that nurse practitioners will provide an inferior service made more costly by mistakes, and that they cannot be effective because a nurse's training is to make observations not judgments. However, where is the evidence to support these assertions?

Far from providing an inferior service, a range of studies suggest that suitably trained and assisted nurse practitioners can perform as well as, if not better than, doctors in diverse areas. These include studies allowing nurse practitioners to prescribe the potentially hazardous drug warfarin (1), and research with nurses providing ongoing management of asthma, diabetes, palliative care and even rheumatology patients (2).

The assertion that nurses cannot make judgments simply ignores reality. Nurses routinely make judgments and management decisions. These do not only concern nursing care but also judgments such as when to call a doctor, give p.r.n. medication or treat arrhythmias in CCU.

Could the true concern not be that nurse practitioners will be incompetent but rather that they might provide a better service than doctors in certain situations?

The medical profession should not feel insecure, regardless of whether the nurse can take a better Pap smear (3). The nursing profession does not want our [the medical profession's] jobs. Presumably what nurses do want is a greater range of career choices, a little more autonomy and status, and some different responsibilities whilst still having medical backup available.

Nurse practitioners offer opportunities for us [the medical profession] to concentrate our attention on the tasks which most require medical training. Most doctors are busy, particularly those working in areas of need, and increasing the availability of nurse practitioners offers the chance to improve our own working conditions. Many rural GPs have recognized this and are lobbying, with success, for the AMA and colleges to soften their stances against more diverse roles for nurse practitioners.

Nurses are prepared to work in areas, both geographical and clinical, that are inadequately serviced by doctors. This is why any battle against their employment in underserviced areas should be lost.

Nurse practitioners will only be widely utilized in areas which the medical profession is failing to adequately service. Therefore there are few circumstances where, rather than being a help, they could be construed to be a threat to the basic workload of doctors.

One potential circumstance involves the long waiting lists for certain procedures in public hospitals. Whether acknowledged or not, having a public hospital service inferior to the private one is financially advantageous for visiting specialists because it ensures more people go privately.

At present governments go along with this because they are committed to low-tax low-spend policies and prefer to wear the resultant political flak concerning public waiting lists. However future governments could sideline these specialists by employing other staff for specific procedures.

Fred Hollows was able to train health workers in a developing country to do cataract surgery during a war. A government may eventually train a few dozen GPs, optometrists or nurse practitioners to do the same job here, if public hospital waiting lists remain unacceptable.

However these situations will only develop where the medical profession fails to provide a readily accessible service for the entire community.

Greater involvement of nurse practitioners and other non-medical health professionals can only improve our [the medical profession's] working conditions, benefit our patients and increase our job satisfaction. If our remuneration were not largely fee-for-service perhaps this would be more widely recognized.

(1) "The role of the rheumatology nurse practitioner in primary care: an experiment in the further education of the practice nurse" Grahame R; West J Br J Rheumatol 1996 Jun;35(6):581-8
(2) "Comparison of oral anticoagulant control by a nurse-practitioner using a computer decision-support system with that by clinicians" Vadher et al Clin Lab Haematol 1997 Sep;19(3):203-7
(3) "Cervical cancer screening performed by a nurse. Evaluation in family practice."  Thommasen et al Can Fam Physician 1996 Nov;42:2179-83

Written by Dr Andrew Gunn
Published in the DRS column of Australian Doctor 13 March 1998