Legacy Initiative

Legacy Column -  by Norm Keltner
The Gift Nurse Practitioners Gave Nursing Education

“When there is food on the table there are many problems. When there is no food on the table there is one problem”. Chinese proverb.

I love this proverb. Before I am finished with this essay, I will torture it (the proverb) so much that it may be unrecognizable per the example I will use. But the thought has power thus I proceed. First, however, I start with background.

I have published quite a few times over my professional lifetime- books, chapters, articles, etc. But I have also had a few papers rejected. In fact, the very first paper I attempted to publish was rejected quickly. Of course, this was in the days of sending a typed manuscript in the mail and waiting for mailed reply. I used to say that it was rejected before I got back to the house. The paper focused on psychosurgery. I worked in a state hospital for many years before teaching and I had met many patients who had had a lobotomy. Well, in my first teaching position, I was seeing a patient who had psychosurgery years before and the visible scars to prove it. I had always found the subject interesting though it was pretty much rejected as a treatment several years before I started in the field. I thought her story was interesting and worth telling. But, alas the editor did not.

I had another paper I labored over but decided not to submit. I think it might have ruined my career. I entitled it ‘The Nurse Pontificator’. In this never read opus I pondered the central weakness of nursing education, at least from my lofty vantage point of having worked in a state hospital for many years. That is, many of the nurses teaching future nurses had little clinical experience themselves. It reminded me of the old practice of ‘Indulgences’ in which you could  sort of pay ahead for future sins. But in the case of nursing education, if you could earn a high enough degree, no one would question your clinical deficiencies. So for many years academic nursing was full of people who had solid academic degrees but little time spent in hospitals taking care of sick people. The irony, of course, was that these same people were in positions to make decisions about what nurses really needed to know. I always suspected that was the reason for the onslaught of non-clinical courses that enabled an ADN grad to become what was called a professional nurse (BSN), e.g. research, management, leadership, professional ethics, cultural issues, etc. All of these could be taught without time in the hospital. In fact, these courses could be taught by non-nurses.

Well, I did not submit it. Although I don’t think I was wrong, it was probably too harsh. After all, the system rewarded educators for activities that often minimized clinical efforts.

“Don’t Make The Porch Bigger Than The House”

I have violated this principle too. I heard a minister once say that an older preacher had told it to him. That is, don’t make the introduction longer than the message you are presenting. So with that violation in tow, back to the original ancient aphorism. For many years nurses argued for and defended the position that they were capable clinicians and could be trusted to prescribe medications plus plan and take greater responsibility for patient care. While I am sure that I will contort the Chinese proverb to fit here, I remember that being the singular issue for many very competent nurses for a long time. It was their one problem as it were. After many years the responsibility was won.

But as with the proverb, once there was plenty of food (nurse practitioners were legally recognized for their abilities), other problems arose. The first I will mention was both a problem for the NP and a blessing for academia. People teaching nurses to become nurse practitioners needed to be clinically relevant themselves. To wit, they had to practice. Of course, this is the exact opposite of what I had described many years earlier. And, while it is a blessing, many of the nurse educators I know are stretched very thin between their own patients, teaching responsibilities, and the publishing that helps improve practice and also helps them progress in their respective academic systems. A further problem, in my view, is that responsibility in the nurse practitioner world does not stop at the end of the day. Let me explain. Before I became a nurse practitioner I used to work a couple shifts per week on the psychiatric unit. I did this because (pick only 1 answer): A) I am noble and wanted to hone my clinical skills. B) I had 3 kids that needed to go to college. Well the thing that always crossed my mind at the end of the shift after I had reported to the oncoming nurse was this- “I’m done and I don’t have to think about this until next week” and that felt good because I never felt “done” in my academic life.

Well, this brings us back to the nurse practitioner role. You are not done and that can be taxing. That prescription written 5 months ago can come back if things do not go well. It can come back even if someone else or even a whole other mental health system has taken over the care for the patient in question. So, the one problem solved multiplied into other problems that need to be resolved: ongoing competency, cultural relevancy, balancing the needs of a patient for your time and the needs of your hiring agency for you to see more patients (i.e. write more prescriptions), and so on.

The title, states that NP programs gave a gift to nursing education. From my perspective they did. It helped all of re-recognize the need to remain clinically relevant. This does not mean that I think every nurse should be a nurse practitioner. Far from it. I am a fan of nurses. I love to be around nurses who know what they are doing. And I respect the heck out of them. Neither do I suggest that all NP programs are excellent. I have heard the same stories some of you have heard. I am simply stating that nurse practitioner is another role but I am ascribing some positive changes in academia to this role.

(Posted July 2018)

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