The Discursive Positioning of the Advanced Nurse Practitioner in the Irish Healthcare System

Background: The Irish health service, in common with health services across the world, faces the challenge of operating within economic constraints while responding to changing demographics that increase demand for health and social care services. Within this dynamic environment, nurses, especially Advanced Nurse Practitioners (ANP), are experiencing new challenges. Whilst nursing and medicine have established systems of disciplinary practices that produce nurses and doctors within historically-contingent role boundaries, these boundaries are becoming more fluid and porous. ANPs constantly negotiate these boundaries, offering the possibility of a new and potentially more liberating identity for them within the healthcare system. Uncertainty about the ANP identity results in the full potential of the ANP role not being realised and, consequently, ANPs are underutilised. This study aims to understand how ANPs are positioned within current nursing and health systems by making explicit the discourses that construct the ANP role and how they both enable and constrain it. Methods: The study is based on a critical discourse analysis (CDA) of healthcare professionals’ language-in-use. To gain an analytic purchase on participants’ language-in-use, James Paul Gee’s Tools of Inquiry and Building Task Frameworks were employed. In addition, Barry Oshry’s Organic Systems Framework (OSF) was applied to deepen the analysis and to help identify how the patterns of relationships and processes inherent in human systems manifest in language. Data were elicited from a literature review and document analysis as well as seven in-depth interviews and four focus groups involving twenty-nine participants including twelve ANPs, two staff nurses, eight nurse managers, one director of nursing and one nursing project officer, three medical doctors and two allied healthcare professionals. Findings: Language-in-use established that ANPs add value to the healthcare system from both a monetary and non-monetary perspective and highlighted the centrality of nursing to the ANP role. Language-in-use constructs an identity for ANPs as a medical substitute, an inferior role, yet an innovative addition to the system and a threat to existing structures. Language-in-use constructs tensions between independence and autonomy, on the one hand, and collaboration and control, on the other. Findings show that when hierarchical structures and professional self-interest dominate, systemic processes and relationships are impacted, resulting in a healthcare system that is out of balance. Whilst nursing research and professional scholarship are seen as central to the ANP role, discourses related to these elements were not prevalent in this study. Instead, ANPs are busied by the demands of the clinical aspect of the role, and the ANP role itself is based around the performance of tasks that are mastered by experience rather than erudition. Conclusions: This study alerts healthcare professionals to the ways in which discourses influence opinion and frame the ANP role. To meet the demands of an ever-changing, dynamic healthcare system, it is vital that ANPs are supported and allowed to ‘advance’. When Conversations and Discourses disparage the ANP role, they should be challenged. We need to move away from positioning ANPs as a marginal and contested presence in the health system and instead see their role as making an important and necessary contribution to it. ANPs need to clearly articulate their role, the value that it adds to the healthcare system and demonstrate how it aligns with and complements other healthcare professionals’ roles. ANPs need to become more visible and vocal, and more engaged in policy formulation. They should recognise and harness the tremendous strength and rich diversity that they collectively represent. This is key to maximising the ANPs potential and strengthening their distinctive contribution to the healthcare system