Exploring the roles of nurse practitioners in Fiji: a critical social theory perspective

Lindsay, David John (2008) Exploring the roles of nurse practitioners in Fiji: a critical social theory perspective. PhD thesis, James Cook University.

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Abstract

Background

Rapidly changing patterns of health service delivery, together with an increasingly globalised health workforce have strongly influenced, and also been influenced by, the development of the nursing profession. One significant outcome of these changes has been the emergence of advanced clinical practice roles, including that of Nurse Practitioners (NPs) (Pearson & Peels, 2002). Many countries around the world now utilise NPs in specialist roles within hospital or community settings, and/or in rural areas which are often under-served by medical and allied health personnel and associated primary, secondary and tertiary health care services. Considerable research has been conducted exploring the roles of NPs in developed countries such as the United States of America, Australia and the United Kingdom, yet there is a paucity of studies which focus on these roles within smaller, non-western countries such as Fiji. This study describes the unique, multidimensional role of NPs in Fiji and the vital role they play in the delivery of health care, predominantly in remote inland or small island communities. The many barriers and difficulties experienced by NPs in Fiji in the delivery of their role are described, and contextualised within the complex and at times highly unstable sociopolitical milieu that has characterised Fiji in recent years. Exploration of the NP role in Fiji has been chosen for the following reasons:

• The NP role in Fiji has only been implemented within the past decade, thus as an advanced nursing role and wider health workforce initiative, it is in its early stages of development;

• No published studies have been found that focus on the role and experiences of NPs in developing countries in the Western Pacific region;

• Research into the NP role will provide a valuable resource within Fiji and also within the broader discourse on NPs in developing countries;

• Fiji's complex socio-political and cultural climate offered a fertile context within which to explore the development of this important nursing role.

Research question

What can be learnt from NPs and key stakeholders in Fiji that will contribute to improving the professional role and function of NPs, and increase their recognition and effectiveness within the health workforce?

Aims

The main aims of this study were to:

• Describe the evolution of the NP role in Fiji, within the context of health care provision in remote areas;

• Examine the different clinical contexts in which the NPs practice and their interprofessional relationships with other members of the multidisciplinary team;

• Document the professional barriers described by the NPs in the implementation of their role and,

• Identify strategies to support the NPs and enhance their role within the health workforce in Fiji.

Methodology and method

Critical inquiry was employed as the methodology by which to explore the professional world of Nurse Practitioners in Fiji, with its emancipatory, change oriented goals and premise that relations of power, oppression, domination and inequality exist within society. Use of the case study method enabled identification of Nurse Practitioners in Fiji as the case, and informed decisions regarding data collection and use of a variety of data sources including nineteen interviews with NPs and other key stakeholders, newspaper articles, Government documents and World Health Organization reports. Utilisation of this method provided thick, multi-perspective descriptions that optimized the opportunity for me to understand the case.

Interpretive framework

Based on the view that discourse and discursive practices are situated within a broader social sphere, and with its focus on the linguistic features of a text, Fairclough's three dimensional framework for critical discourse analysis was applied to examine the sources of data used in this study. Few nursing oriented studies have specifically applied this framework, and it proved to be highly effective in assisting me to link texts with discursive and socio-cultural practices.

Findings and conclusions

This study identified that the professional world of the NPs in Fiji contains evidence of disempowerment and exploitation, which negatively impacts on the effectiveness of the role and their development as a vital component of the workforce. New models of health care delivery now exist as NPs have become established in remote communities, and also been utilised within a variety of clinical contexts in regional, peri-urban and urban settings. Significant scope of practice issues arise when NPs work outside their clinical protocols and as defined in the Nurse, Midwives and Nurse Practitioner Act, 1999. NPs in remote areas work at the nexus between traditional and allopathic approaches to medicine, though the latter (and its associated discourse) is being subjugated by the former. The NP role in Fiji comprises a truly unique blend of nursing, midwifery, public health, primary care, primary health care and health promotion. The NPs lack a professional identity and voice, and remain a relatively disparate group despite the importance of their role.

Significance

This study has demonstrated that the NPs in Fiji provide health care which uniquely blends knowledge and skills from the fields of nursing, midwifery, primary medical care, public health and health promotion. It identified that articulation of these many fields within the one role requires more substantial educational preparation, greater ongoing professional support, and a career structure that reflects the advanced nature of the role. Much can be learned by foregrounding these issues, not only for the Government, key stakeholders, professional groups and consumers in Fiji, but other countries in the Western Pacific and, indeed, beyond. Moreover, highlighting the difficulties experienced by the Fiji Government in implementing an appropriate model of health professional and health care delivery for remote areas also assists organizations involved in health policy and health workforce development, such as the World Health Organization and the many aid organizations on which Fiji relies for support. By raising awareness of the social, cultural, political, religious and historical factors that have impacted on the health workforce in Fiji, and the effects they continue to have on the NPs and the communities they serve, it is hoped that strategies can be implemented to ameliorate their effects. This study also described, for the first time, the experiences of Fijian NPs working at the interface between traditional and allopathic approaches to medicine, and the challenges this presented for the NPs and people in remote communities, in particular. This provides much needed insights into a previously unexplored dimension of the NPs role, and offers a potentially important area for further inquiry. Lastly, it is clear that a policy of Feldsherism, where mid-level practitioners are developed as a 'stop-gap' response to an acute shortage of physicians, is no longer an appropriate health workforce model in countries such as Fiji. The NPs have clearly demonstrated that they are able to provide a comprehensive, safe and sustainable level of care to rural and remote communities, and should therefore be supported and recognised for this vital role that they play within the wider health system. They are not merely doctor substitutes, but leaders and pioneers in providing a unique and legitimate level of health care that effectively addresses a broad range of health care needs in these communities. Increasingly, they are also being utilised in regional hospitals, peri-urban health centres and urban hospital and community mental health settings. This study provides important new evidence that the NPs are significantly changing the skill-mix of nurse and doctors across a broad range of practice settings, and draws attention to the urgent need for a review of their educational preparation, scope of practice, careers structure and professional development.

Item ID: 31616
Item Type: Thesis (PhD)
Keywords: Fiji; nurse practitioners; diversity of role; training; professional development; emerging role demands
Date Deposited: 06 May 2014 02:35
FoR Codes: 11 MEDICAL AND HEALTH SCIENCES > 1110 Nursing > 111099 Nursing not elsewhere classified @ 100%
SEO Codes: 92 HEALTH > 9202 Health and Support Services > 920210 Nursing @ 100%
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