The Evolution of Nurse Practitioners, Memes and the Science of Chaos'

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The Evolution of Nurse Practitioners, Memes and
the Science of Chaos.

• Dr Mike Walsh
• Reader in Nursing St Martins College
• mh.walsh_at_ucsm.ac.uk

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Evolution and the NP

• Understanding of how the NP role has evolved so
  far can help us guide its future development
• Evolutionary theory can act as a powerful analogy
  or model to guide us in this endeavour
• This also requires a grasp of Chaos Theory

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Problems

• Review the issues which have held back the
  general development of nursing practice
• Obviously inequalities in power and the complex
  politics of health care together with economic
  factors are very important
• Other factors include

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Nursing Research

• Too much emphasis on qualitative research
• Need to redress balance with more quantitative
  research which produces generalisable evidence
  about cause and effect i.e. OUTCOMES!
• Is there a problem with nurses and maths/
  statistics?

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Education

• Pre-registration education lacks sufficient
  science in UK
• Advanced practice nurses will be judged by the
  standard of the post not by the standard of a
  reasonable nurse. Incorporating medical skills
  into practice means you will be judged by the
  standard of a reasonable doctor.

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Protocols

• Protocols are a useful quality tool, but
• Protocols are no substitute for a repertoire of
  scientific knowledge combined with psychosocial,
  interpersonal skills and professional
  accountability.
• Lead to a quick fix and avoiding the need for
  education ? understanding

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Boundaries

• Inter-professional boundaries are potential zones
  of conflict which inhibit practice development
• Expanding universe of health care however means
  there need not be boundary conflict as there is
  more than enough work to be done for all of us!

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Boundaries Chaos

• In a dynamic system what happens next depends
  upon what happened last.
• They have fractal boundaries which can never be
  fully resolved into a clear cut dividing line for
  all cases
• Fuzzy boundaries are the natural order of things,
  so why not in health care?
• Rigid adherence to boundaries is artificial and
  therefore inhibits care

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Evolution Nurse Practitioners

• So far we have set the context within which NP
  evolution has taken place. A changing environment
  with competition between species and turf wars.
  One species, the nurse, has problems such as a
  lack of scientific education but is succeeding in
  evolving as a Nurse Practitioner. So why?

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Evolutionary Niches Nursing

• Small animals may successfully survive hostile
  environments by forming a relationship with a
  bigger more powerful animal that benefits both
• However they are restricted in their evolution by
  dependence upon the more powerful animal.
• Florence Nightingales legacy to nursing?

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Dawkins The Selfish Gene

• The successful gene readily replicates itself
  conferring a survival advantage upon the organism
  that is the carrier.
• Genes are neither good nor bad, they just do not
  care, they merely replicate some more
  successfully than others which then die out.
  Hence the term selfish gene

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Dawkins and Memes

• Memes are bits of culture (eg. ideas) that act in
  the same way as genes.
• Successful memes are those which have fecundity
  ie. are readily copied and so spread rapidly.
  They also confer an advantage upon their
  adherents.
• Humans are the just the physical hosts which
  allow the memes to get around

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Example Nurses and Pain Relief

• Meme Nurse knows better than patient
• Fecundity as student nurses imitate and learn
  from RNs in practice. Students not taught
  adequately the physiology of pain
• Confers advantage upon nurse as reinforces
  his/her power and status.
• As a result this is a successful meme

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Nurse Practitioners as a Meme

• NPs are an idea that has spread throughout USA
  and is now spreading through the nursing
  population globally
• If a successful meme is one which is readily
  copied and spread, why did the NP meme achieve
  this in the USA?
• Why is this happening in the UK?
• Where next?

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NPs as a Meme

• Successful memes also confer an advantage upon
  their adherents which contributes to their
  success.
• What advantages has the NP meme conferred on RNs
  in the USA and increasingly in the UK?
• What advantages are there in other parts of the
  world?

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NP Meme and Fecundity

• 1. Increasingly necessary for delivery of health
  care (shortages of medical staff)
• 2. Nurses seen as responsible reliable by
  managers (Accountability)
• 3. Patients like nurses
• 4. Legitimising what has gone on for years so it
  has common sense appeal

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NP Meme and Fecundity (2)

• 5. NP role very attractive to nurses feeling
  frustrated and held back by health service
  politics / tradition. Can realise their true
  potential.
• 6. University educational provision
• 7. Communication channels, conferences,
  international visits, journals, books etc

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Spreading the Meme

• If these ideas are right, then to spread the NP
  meme into your area, these 7 points should form
  the basis of your strategy Consider the following
  approaches

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Exploiting Fecundity

• 1. Politicians / Managers need NPs for delivery
  of the health care agenda
• 2. Nurses are accountable professionals
• 3. Popular with patients, consumer satisfaction
• 4. Stress the safety of NP practice
• 5.Job satisfaction for RNs
• 6. Build strong educational links with
  universities
• 7. Read, talk, attend conferences and visit areas
  where NP practice is up and running

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NP Meme Advantages

• NP qualification confers advantage upon the nurse
  as it ? attractiveness to employers
• Managers (achieve targets)
• Doctors (makes their work more satisfying,
  improves patient care)
• Patients (Holistic approachable RN)

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Nursing Models A Failed Meme

• An example of a failed meme because
• Lacked fecundity as they were not readily copied
  due to lack of connection with reality and the
  very difficult language/ concepts involved in
  many of them
• Failed to confer any advantage upon the would be
  user in practice

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Memes Practice Development

• Memetics offer explanations of why some new ideas
  are rapidly adopted
• Why other new ideas fail to be adopted and fade
  away
• Some beliefs and practices, despite contradictory
  evidence, refuse to go away.

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Complexity Theory

• Complexity is the study of macroscopic
  collections of such units that are endowed with
  the potential to evolve in time
• (Coveney and Highfield 1997)
• The result is known as an emergent property

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Complexity Continued

• The whole is greater than the sum of the parts
• Relationships between things is more important
  than the things themselves
• Reductionist approach fails to see the big
  picture, what happens when the pieces are put
  back together and interact with each other
  (Holism)

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Chaos

• Chaos is part of complexity theory
• Sensitive dependence upon initial conditions
  feedback characterise dynamic systems
• Result apparently chaotic unpredictable
  behaviour but within, lie rules which have to be
  discovered deterministic chaos

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Chaos in 1758

• For want of a nail the shoe was lost
• For want of a shoe the horse was lost
• For want of a horse the rider was lost
• For want of a rider the battle was lost
• For want of a battle the kingdom was lost
• Benjamin Franklin 1758.

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Chaos and Healthcare

• Healthcare is a dynamic system, so is the health
  of each person as what happens next depends upon
  what happened last
• Predicting the effects of change is therefore
  very uncertain and hazardous
• Action Research methodology crucial to get rapid
  feedback on effects of change such as
  implementing NP roles.

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Complexity Practice Development

• Complexity implies we have to look far beyond the
  immediate bits we are going to change and look at
  the inter-relatedness of everything involved. A
  NP project will take on a life of its own as
  emergent properties evolve from the initial
  changes made.
• Totality of change will usually be different than
  what was envisaged

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Chaos and Change

• Outcomes are difficult to predict unless the
  rules governing deterministic chaos are known.
• Complexity and Chaos suggest always expect the
  unexpected and be prepared for this, close
  monitoring (action research) of NP role
  development is therefore essential.

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Summary

• Well known problems conspire to hold back nursing
  development
• Yet the NP has succeeded in an often hostile
  environment and is now spreading
• A memetic analysis suggests why
• Memes as a future NP research agenda?

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Research Principles

• Any new theory must
• Explain things better than existing or rival
  theories
• 2. Lead to testable predictions that turn out to
  be correct when tested.

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Further Information

• An electronic version of his presentation is
  available from Mike Walsh, email address below
• mh.walsh_at_ucsm.ac.uk