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The final part of the thesis consists of four chapters. Part two surveyed one hundred years of nursing in the 20th century; part three is concerned with the context of nurse practitioner development in the 21st century. Reintroducing Foucault’s notion of governmentality, chapter eight begins by examining the business model of general practitioner proprietorship in the context of a new government regime, introduced with the PHC Strategy (Ministry of Health, 2001b). It is argued, the for-profit imperative of GP ownership continues to view PHC as curative medicine, constraining the expansion of nursing practice into population health and the nurse practitioner, as a potential business competitor, into assessment, diagnosis and prescribing practices.

Chapter nine examines the basis for medical resistance to the introduction of prescriptive privileges for nurse practitioners and the protracted journey of negotiations that took place to bring about the necessary legislative change. Of interest are the disciplinary practices used by a group of specialist physicians to curtail nurse practitioner autonomy and independence by limiting prescriptive powers.

Chapter ten foregrounds the representations of New Zealand nurse practitioners as a new and more liberating mode of subjectivity. Foucauldian theoretical tools of ‘techniques of the self’ are introduced as a mechanism by which nurses engage in new techniques of self-governance. Nurse practitioners actively constitute themselves as safe prescribers, collaborative practitioners and as trustworthy colleagues, ushering in hope for a new normalcy towards trust between the two professional groups. As a new mode of subjectivity, the nurse practitioner identity is not defined by the truth claims of others – as nursing has (Papps, 1997) – but by a nursing discourse and nursing practices informed by multiple forms of knowledge, only one of which is medicine.

The final chapter to the thesis is the conclusion and draws together the main arguments presented throughout parts two and three. The limitations of the study, implications for further research and suggestions for the future are discussed.

Chapter 8: Medical privilege

Introduction

“It’s turf, turf, turf,” says Art Caplan, a University of Minnesota medical ethicist …“The resistance is dressed up in language about inadequate training, inappropriate preparation and lack of skills, but the bottom line is that it’s a fight over turf. Authority and prestige are the issues”. Further, he adds, “rattling in the background are the bones of about 100 years of sexism, in which nurses were basically mistreated, under appreciated, taken for granted and viewed by too many doctors as being third-rate citizens doing fourth-rate jobs” (cited in Cimons, 1993 June 28, p. 1). This chapter examines the dominance of medicine in the delivery of health services in New Zealand. The privileged position of medicine dates back to the late 19th century practice of professional men in independent practice charging, at their discretion, a fee for service (Belgrave, 1991). As state funding streams developed under the welfare state during the 1940s, only medical practitioners were eligible for payment, as by omission, policies excluded non-physician providers from reimbursement (see Fairman, 2003). Legislative state practices, too, have privileged medicine with particular powers in relation, for example, to public health (Health Act, 1956), access to medicines (Medicines Act, 1981), provision of death certificates (Coroners Act, 1988) and sick certificates (Holidays Act, 2003). Together they form a network of power to construct a discourse of medical ownership that is sanctioned by the state (Freidson, 1970).

New interpretations of health and service delivery introduced under the PHC Strategy (2001) in many respects challenged the privilege of medicine and positioned nurses as the largest and often most appropriately prepared workforce to expand into areas such as population health and primary health care. But it is argued new nursing ventures are constrained by the business model of primary medical care delivery and discourses related to profitability. Advanced nursing roles into areas beyond the direct gaze of medicine, along with the permeability of boundaries between the professions of nurse practitioner and general practitioner, represent a competitive threat to the monopoly and profitability of the business model.

Whereas part two of this thesis concerned autonomy as a discourse in relation to the expansion of nursing practice, this chapter first considers the autonomy engendered as a practice of neoliberalism in the governance of health service provision in New Zealand and secondly, autonomous nursing practice as fait accompli. The discussion is focused on primary and not secondary or tertiary care services, because the nurse practitioner role is potentially most threatening to the jurisdiction of general practitioners rather than specialists, excepting the anaesthetists (examined in chapter nine).

Foucault’s (1991b) notion of governmentality will be used throughout the chapter to illustrate the range of techniques available for governing. Government has as its purpose “the welfare of the population, the improvement of its condition, the increase of its wealth, longevity, health etc.” (Foucault, 1991b, p. 100) and to achieve those ends an ensemble of disciplinary techniques (surveillance, examination and normalisation), domination and government of others and the self may be used. Domination may be the end effect, but the means by which this is achieved is not, in the first instance, by force, although that is a possibility. The PHC Strategy is a government technique that locates responsibility for the welfare of the population through the provision of health services with DHBs, PHOs and health practitioners, in both morally responsible and economically rational ways. Governmentality, therefore, harnesses and directs these groups, including nurses, towards particular behaviours that coincide with a government programme. As previous primary care identities disintegrate with new forms of organisations such as PHOs, new modes of subjectivity are produced that are linked to governmental technologies (Lemke, 2000); an example discussed in this chapter, is the state sponsored initiative integral to the success of the Strategy that introduced the nurse practitioner role.

This chapter, therefore, examines the relations of power engendered by the introduction of the PHC Strategy, between physicians and the state, and physicians and nurses. General practitioner ownership is highlighted as the context in which nurses aspiring to become nurse practitioners must find an interstice in which to practise, between conventional medical and nursing role boundaries.