THE International Council of Nurses (ICN) describes the advanced practice registered nurse (APRN) as “a registered nurse trained at the master’s level who has acquired expert knowledge base, complex decision-making skills, and clinical competencies for expanded practice. These characteristics are shaped by the context and/or country in which s/he is credentialled to practice”. This nomenclature distinguishes the APRN from the registered nurse (RN).

APRNs are capable of taking on more intricate casework and handling those cases with greater independence and discretion. APRNs are increasingly being relied on to meet the demand for primary and specialty health care practitioners, especially in rural areas and other areas underserved by physicians.

In Jamaica, there are two established categories of APRNs:

(1) nurse practitioners

(2) nurse anaesthetists

The practice of nurses administering anaesthetics commenced in Jamaica as early as the 1900s by nurses who had no formal training but were guided by their knowledge of operating theatre techniques. In 1956, the first Jamaican nurse anaesthetist was trained in the United States of America and assigned to the Spanish Town Hospital.

Nurse practitioners (NPs), on the other hand, commenced training in Jamaica in 1977 and joined the health workforce by 1978. The categories of NPs in Jamaica include:

(1) family

(2) mental health/psychiatry

(3) paediatrics.

These advanced degree nurses work parallel to medical officers in primary care facilities. NPs conduct physical examinations, diagnose, and prescribe medications.

For the purpose of this article, I will focus on this group of APRNs — the nurse practitioner.

NEED FOR A LEGISLATIVE FRAMEWORK

NPs stellar contribution to the Jamaican health sector is unquestionable. Nonetheless, the requisite legislative framework for their practice is yet to be promulgated.

This year marks 41 years of their existence in Jamaica, but how much have they achieved?

While NPs typically work alongside medical practitioners, it is not unusual to find them working alone. Besides, prescribing medications is an expectation of NPs; however, these prescriptions have to be co-signed by a medical officer. This oftentimes impacts the quality of care patients receive because, in the absence of a medical officer, NPs are not permitted to prescribe drugs even if the patient is in dire need. To combat this, the highly criticised practice of NPs issuing pre-signed prescriptions is rife in the public health sector. This practice has raised concern among key stakeholders, prompting the Medical Council of Jamaica to instruct its members to desist from such practice.

Where has this left us as a profession? Over the years, attempts have been made by successive ministers of health towards legitimising the practice of NPs. At each turn the dialogue has been thwarted by one or more key stakeholders. I believe, however, that the time is right for NPs, the regulatory body, the professional organisation, and health policymakers generally to take the necessary steps required to correct this age-old anomaly.

The increased use of NPs in a number of health care settings globally cannot go unnoticed. In the USA, the District of Columbia, Guam and 22 additional states have full practice authority for NPs, and in some instances some states have eased their scope of practice laws (American Association of Nurse Practitioners [AANP], 2019).

Of note is that some of our own Caribbean neighbours, for example, St Vincent and the Grenadines, are far advanced with their legislative machinery for NPs’ practice. What should be worrying, if not embarrassing, is that NPs from the other islands are trained right here in Jamaica. Why then is Jamaica lagging behind? Should we blame it on a health sector that is highly ‘medicalised’?

Globally, NPs’ roles were expanded in order to be responsive to the needs of people, especially in certain geographic areas (Safriet, 1992). In the USA, recent reports suggest that there are more than 270,000 NPs who are licensed to practice. This is an increase from 248,000 in 2008 and 120,000 in 2007. In Jamaica, there are approximately 45 NPs working in the public health system and approximately 20 in training. While compensation packages vary according to certification area, clinical focus and practice setting, in the USA, NPs working full-time earn approximately US$105,903 annually and average hourly rate is US$60.02 (AANP, 2019). In Jamaica, on the other hand, NPs take home less that $2 million per annum (approximately US$14,000) in some cases.

Generally speaking, Jamaica nurses continue the struggle to obtain a regulatory framework for NPs to practice. This limits their contribution to the health system. While role clarity and liability are concerns raised by some stakeholders, this has not been fully explored. These concerns have only served to delay the ratification of a legal framework within which NPs can practice.

Noteworthy, is the fact that the benefits of NPs’ work to users of the Jamaican public health system have been well established. In addition to their clinical work, NPs wear many other hats. They may be engaged at the policymaking level, in research, education, mentoring, coaching, inter alia. They have worked effectively and collaboratively with other members of the health team. NPs should, therefore, be embraced as a suitable alternative to offer medical care where needed. It is about time the lens of relevant policymakers and stakeholders be refocused.

I am aware that some work is being done, but not sufficient. For example, dialogue is ongoing between NPs and successive ministers of health to advance the legal framework to regulate their practice. Further, the Nursing Council of Jamaica is currently attempting to have the Nurses and Midwives Act (1964) repealed in order to acknowledge the practice of APRNs generally. Additionally, work by the professional organisation, coupled with public utterances by policymakers and stakeholders, suggests that the matter has obtained some traction. Traction that I hope will result in an established and ratified legislative framework.

As a country, we are now at the juncture at which we need to reorient our position on the work of NPs if the nation is to sustain the gains made in the health system. Correspondingly, if we are serious about achieving the United Nations Sustainable Development Goals, universal health coverage, and ensuring that the nation’s people have access to quality health care services generally, we need to refocus.

It is important to realise that NPs can assist to significantly reduce inefficiency in the health system while improving access to health care services to an underserved population. Time come!

Adella Campbell, PhD, JP, is an associate professor and head of the Caribbean School of Nursing at the University of Technology, Jamaica. She is the author of the recently published The Jamaican Public Health System from the 17th-21st Centuries. Send comments to the Observer or adcampbell@utech.edu.jm .