Nurse Practitioners and the Problem of Discounting

¶ … Martin, P.D. And Hutchinson, S.A (1999) "Nurse Practitioners and the problem of discounting." Journal of Advanced Nursing. 29(1), pp. 9-17.

Critical evaluation of the research of the article

This article presents a critique of the current state of the health care industry, from the point-of-view of a nurse practitioner. It notes that, because of the limits of managed care, more primary care practitioners and primary care institutions are turning to nurse practitioners to provide primary care giving for patients. Although this shift has been beneficial to many patients, given that nurse practitioners are, if not equally competent, at times even more efficient than physicians in diagnosing, treating, providing patients with satisfactory treatment, and follow-up, there is the potential for the abuse of this system, from the point-of-view of the nursing practitioner. (Brown and Grimes, 1993, cited in Martin & Hutchinson, 1999, 10).

Research problem -- its purpose and question or hypothesis

Thus, the central question is, is such an evaluation of the current state of care a fair and a just one from the point-of-view of nursing as a profession? Are nursing practitioners being abused because of the current state of the health care profession? The hypothesis or tentative assumption behind the study is yes. But if so, exactly how is this occurring? Why is it occurring? And how can the system be remedied to make the current modalities of providing care more beneficial to nursing practitioners, without compromising patient care?

Review of the currently existing literature

It has been suggested in the past that despite the efficacy of NPs, quite often nurse practitioners have been subject to the practice of 'discounting,' defined by the study as the practitioners being taken advantage of, in the care scenario, in such a fashion that their professional and personal integrity is belittled. This results not only in hurt feelings upon the part of the practitioner. It also results in the practitioner's ability to dispense care being compromised, and the patient's resultant health being put into jeopardy needlessly.

Discounting" can include everything from the nursing practitioner being ignored to being openly, verbally abused. (Martin & Hutchinson, 1999, 12) Nurses have reported being ignored, or even their most mundane and basic care-giving activities being questioned and belittled in a degrading manner. (Martin & Hutchinson, 1999, 12)

Theoretical/conceptual framework of the study

The framework of the study was more experiential in nature than it is statistical or data based. Its theoretical framework was designed so that, through a relatively small sampling of nurses, crucial experiential data might be accrued that is of use in determining how discounting occurs 'in the field.'

Research design

Twenty-four NPs were studied from the state of Florida, twenty of who were female, and twenty-one of who were white. Two African-American women also were represented. All had master's degrees in the nursing field. (Martin & Hutchinson, 1999, 10) It was hoped that this gender balance would be representative of the nursing field, and even though the majority of the practitioners were white, the presence of non-white staff members would provide some insight into how race as well as gender functioned in the care setting.

Sampling method/data collection

Data collection techniques included in-depth, open-ended interviews with the subjects that were observed and recorded through auditory and visual means, as well as document review and observation of the interviews by third parties.

Procedures/ethics

The experiences of nurses specific to their profession were recoded anonymously, so that their standing in their profession would not be compromised. As much as what they could recount, verbatim, was recorded as it fell beneath certain subject headings, such as the issue of being ignored, so that these issues could be highlighted in the presentation of the study, without the sense of narrative flow of particular incidents being compromised, or a sense of unfairness being conveyed upon the institution or physicians being described.

Presentation of data and data analysis

Data analysis was conducted through the constant comparative method, the fundamental method of data analysis in generating theories in the field. (Martin & Hutchinson, 1999, 11) Interviews began with level one coding, in other words, were open ended, and then proceeded to level 2, or interviews conduced through the paradigms of conceptual frameworks of the field. "Triangulation" across the data analysis, including multiple interviews, was included to ensure reliability.

Nurses reported being ignored, belittled, and constantly questioned in ways that compromised their ability to give effective care. Their competence and presence was stigmatized at the convenience of physicians. (Martin & Hutchinson, 1999, 13-14) Perhaps most unconscionably, they frequently reported being blamed, simply because of their status as a nurse practitioner, rather than as someone dispensing care and providing their judgment. Scapegoating and being rendered invisible have obvious gender related issues to the health care profession as a whole. Even when patients were satisfied, nurses were blamed or disregarded. (Martin & Hutchinson, 1999, 14)

Moreover, the very status of 'nurse practitioner' was belittled in the context of care situations, perhaps most gallingly in the nurses being misidentified in their status and profession. "I am not a physician extender," stated one nurse, proud of her profession. (Martin & Hutchinson, 1999, 15)