Nurse Practitioner Role: Current Trends and Preferred Future

For a straightforward description of today's nurse practitioner, one convenient starting point is the International Council of Nurses, which defines the "nurse practitioner / advanced practice nurse" as a registered nurse who has acquired an "expert knowledge base," holds a Master's degree, and whose expanded practice role is shaped "by the context and/or country in which she/he is credentialed to practice."

Cheryl Stegbauer, a faculty member and nurse practitioner (NP) with thirty years of experience, delves deeper into the NP's role in shaping contemporary healthcare. "Most of the medical profession and patients" may understandably "scratch their heads about how the NP role is defined" (Nelson, 2004), Stegbauer observes. "Because the NP approach is holistic, patients like the increased attention afforded by NPs, and doctors appreciate the value of a symbiotic relationship that can improve patient care in their practices."

NPs "fill a critical gap," Stegbauer continues, since there is a "critical shortage of doctors" in many rural and inner-city communities, and physicians in those areas are often stretched too thin to be fully effective.

That said, it is the purpose of this paper to go well beyond the obvious need for competent nurses and NPs, the gaps in adequate healthcare services presently being filled by NPs, and the critical skills and talent NPs bring to the table. As Sheila Grossman and Theresa M. Valiga argue throughout their book, the new and pivotal issues revolve around nursing leadership. Their book offers 52 separate categories of "leadership" in its index, along with many additional sidebar leadership points found under further headings and subheadings. The information that provides the seeds for cogent answers to this paper's guiding questions — "So What?", "Now What?", "Who Cares?", and "Who Should Care?" — is found throughout that text. That information, combined with an analysis of what an NP must do to prepare for a preferred future, constitutes the substance and direction of this paper.

The Grossman/Valiga book is carefully structured: each of the ten chapters opens with clearly defined learning objectives and closes with critical thinking exercises and self-assessment quizzes. In Chapter Two ("The New World and New Leadership"), the authors begin to reframe healthcare by noting that 85 percent of nursing executives surveyed reported that their institution had "already gone through" or was "in the process" of going through serious redesign. This is a productive launching point for the first guiding question: "So what?"

So what if serious redesign, "retooling" (in the authors' words), and rethinking are currently reshaping how nurses perform their duties and how healthcare advances new ideas to better serve the public? So what if this era is a "new age of healthcare" (p. 27), and so what if there is a dire need to change the mistaken perception that "leadership" and "management" are synonymous? The two concepts should not be conflated, and this book provides clear guidelines for moving beyond that tired and inaccurate assumption.

So what if "many nurses are not prepared for the role they will need to assume" as healthcare seeks to better serve the ill and injured? So what if the nursing profession is moving from the "Scientific Age" — with its focus on planning, patient acuity, "using formulas to provide staff coverage," and "following bureaucratic procedures and policies" — into what the authors call the "New Science Age," which emphasizes "empowerment of all" and teamwork, among other dynamics?

What this book takes pains to express is that those not asking "Now what?" remain stuck in an old system that views management staff as the true leaders and everyone else as followers. The "now what?" vision in this book positions future NPs as individuals who no longer merely carry out medical orders but instead develop the leadership skills necessary to work within the "chaotic" environment that exists in healthcare facilities. "Now what?" also means using "our imaginations and being more in tune with the idea that there is more to our work than assessing, planning, implementing, and evaluating," the authors assert on page 33.

The authors argue repeatedly that the future of nursing will be shaped through leadership development at the individual level — a notion dramatically different from leadership at the corporate, executive, or even middle-management level. The leadership called for by "now what?" entails shedding the rigid old notions about "stability" (doing what you are told) and protecting the "status quo" (p. 35). The choice is stark: either move forward into an exciting and progressive period in which independent, critical thinkers are empowered to give better care to patients, or remain an industry populated by "sheep," "yes people," and "alienated followers" who are eager to take orders but reluctant to engage in teambuilding and strategic learning.

"Who cares" whether a new style of leadership — embraced and practiced especially by NPs — leads to more efficient healthcare services? The families of the sick and dying care. The public cares. Those injured in automobile accidents or from gunshot wounds care. If a critically important decision must be made immediately, if a patient is severely injured and his survival must be addressed at once, and there is no physician nearby, the NP certainly "cares" that he or she has solid leadership training and strong independent skills in order to save that life.

Those who believe in and strive to communicate the importance of both leadership and followership — the art of learning from leaders and providing vision and energy to them, rather than simply becoming their clones — are the answer to the question "Who should care?" They do care. The vitality and professional satisfaction that leaders and followers derive from grateful families of patients lend credence to much of what this book delivers in terms of laying out the dynamics for change so desperately needed in the healthcare industry.

Prior to discussing a preferred future in specifics, there are some points raised in an article published in Nursing and Health Care Perspectives (Ketefian, 2000) that deserve attention. The author, critiquing the Grossman/Valiga book, acknowledges that it is "an effective teaching and learning tool" presented in an "accessible manner," but raises the question of how the practice of "developing leadership at the individual level" can also "enable the nursing profession as a body to demonstrate more effective leadership in the public arena." This is a highly appropriate question. Ketefian, a professor and director of Doctoral/Postdoctoral Studies and International Affairs at a major university's School of Nursing, follows it with the observation that "it is not clear how collective and group leadership follows from the individual level."

At a time when polls and surveys show that the public "holds the highest respect for nursing as a profession," Ketefian (EdD, RN, FAAN) continues, "nursing finds itself without much influence in shaping both institutional and public policy." She asks pointedly how this can be explained.

Ketefian raises a second concern — regarding possible gaps in the book's treatment of the "real world" of nursing — by noting that the Grossman/Valiga text does not address "developing leaders from among members of underrepresented groups, and what the unique circumstances and challenges may be." Ketefian calls this "a missing component" and observes that "it is not clear that we do a good job of devoting attention and mentorship to the large number of nurses from minority groups."

Reading the Grossman/Valiga book is a valuable exercise in learning and self-challenge; but without the additional stimulus of Dr. Ketefian's critique, one might assume that the book had covered all the bases. It had not — though no single text can. The appropriate response is to continue refreshing and rededicating efforts toward wider, deeper knowledge.

A personal preferred future begins with keeping an open mind and heart toward all things relating to healthcare — both those being served and those doing the serving. That future also requires developing a sharp and critical eye toward all laws and regulations affecting the work of NPs, as well as toward what independent observers, experts, and professionals from within the field have to say about the present condition and future of nursing.

Leadership and Followership: One essential component of that future is knowing the importance of when and how to lead, and when and how to follow — and understanding the difference between the two. The timing of one's assertiveness is crucial to becoming a nursing "leader." Part of that leadership means taking into account, at any given moment, the needs and aspirations of underrepresented groups within the healthcare field — the minorities that Dr. Ketefian identified as the "missing component" in the Grossman/Valiga framework.

Leadership encompasses all the obvious elements — making decisions, assigning responsibilities, and taking calculated risks — but it also means taking a young aspiring nurse under one's wing, offering encouragement when her career is not progressing as expected, and actively supporting her development.

Followers, too, must demonstrate innovation, cooperation, and the ability to "hold up our end of the bargain" (p. 52) when the work demands it. When working alongside a healthcare aide who may not yet be fluent in English, "holding up one's end of the bargain" means offering a helping hand, attempting to learn some of her language, and sharing accessible ways for her to build language skills in return.