A ‘Nurse Practitioner’ (NP) has been defined as “a registered nurse with the capability to practice autonomously and collaboratively with other health professions” (Mosby’s Dictionary of Medicine p. 2010). NPs must complete a , Master’s degree in education, as approved by the Nursing and Midwifery Board of Australia (Australian Nursing Federation 2011). [you need to signal that you are going to review the history and development of NPs] The role of a NP is to provide cost effective care and safe accessible treatment and to improve of health care and patient outcomes (Australian College of Nurse Practitioners, 2012).[I’ve moved this text to the start of your introduction]
An overview of the development of the role of NPs is as follows. [you can use your own words but you need a signal here!] In October 1990, the first NP committee convened in New South Wales (Australian College of Nurse Practitioners,2012) and this committee contributed to the establishment of f the NP role in Australia in1 2001 (Australian College of Nurse Practitioners 2012; Taylor 2007). In the United States and England the role has been in existence since the 1960s (N3ET2 2006 p. 1). Since 2001 (?), NPs have been slowly spreading all over Australia (Driscoll et al. 2005, p. 141) and the role now exists in all states and territories (Australian College of Nurse Practitioner s, 2012).
Diverse skills, experience and qualifications are all vital components in meeting the clinical requirements to be endorsed as a NP by the Nursing and Midwifery Board of Australia (Nursing and Midwifery Board of Australia, 2011). For example [give some examples to elaborate on this sentence Chauvy.] These nurses have advanced and extended roles compared to other registered nurses, particularly within the endorsed areas of their scope of practice (Australian Nursing Federation 2011; Nursing and Midwifery Board of Australia 2011). To illustrate … [elaborate a bit on these roles, endorsed areas, different scopes of practice here.]
Despite the contribution made by NPs, barriers exist in Australia which prevent these nurses from providing the full care for which are trained (Taylor 2007). Some of these obstacles include the limited access to a provider number,; the restricted right to prescribe (find a better reference please!!!) and to write referrals (Driscoll et al. 2005, p. 141). [Chauvy, don’t forget the opposition of the AMA as we discussed!]
This essay will review the growing clinical career pathway of NPs, the autonomy and limitation within the scope of practice experienced, and will provide an overview of the benefits NPs bring to the health system in Australia.
Clinical Career Path
In order to qualify as a NP, the applicant needs to meet the requirements issued by the Nursing and Midwifery Board of Australia (2011), as specified in the ‘Guidelines on endorsements as a nurse practitioner’ (Nursing and Midwifery Board of Australia 2011). These requirements are as follows:
Firstly, the applicant must already be a ‘registered nurse’ (Nursing and Midwifery Board of Australia 2011) and must not have any record of unsatisfactory professional performance or unprofessional conduct (Nursing and Midwifery Board of Australia 2011). Secondly, the applicant must have three years or equivalent experience in advanced practice. These three years or equivalent experience must be acquired within six years from lodging the application (Nursing and Midwifery Board of Australia 2011). Lastly, the applicant must have completed the study of ANMAC [explain] accredited and Nursing and Midwifery Board of Australia (2011) approved NP program at Masters Level. The Heath Practitioner Act 2009 only permits the use of the protected title ‘NP’ by those meeting all of the above requirements (Australian Nursing Federation 2011).
After complete the Master’s degree, some health authorities provide internships in Victoria. For example, Wintle, Newsome and Livingston (2011) report that Eastern Health provides such internships, and these assist NPs in meeting the Nursing and Midwifery Board of Australia national competencies. The focus is of these competencies is to ensure the development of clinical assessments; diagnostic skills; knowledge of pharmacology; analysis of medical treatment, medication management and clinical leadership – all of which assist in the preparation for endorsement as an NP3. However, recent research suggests that the endorsement process remains problematic and is not consistent across different jurisdictions in Australia.
Harvey et al (2011, p.247-8) recommend that the process for becoming a NP in Australia should change, due to the difficulties of endorsement existing in different jurisdictions. The findings of this study demonstrate that different state-based regulatory policies throughout the Australian workforce affect the employment of r NPs (Harvey et al 2011, p.247-8). For example, in Victoria, along with ‘the guidelines of endorsement for a nurse practitioner’ (Nursing and Midwifery Board of Australia 2011 – do you need to repeat this ref?), the NPs who wish to prescribe medications must apply for the ‘Explanatory Statement: Nurse Practitioner Category Notion (Victoria) and have that registered against the name (Nursing and Midwifery Board of Australia 2010). In contrast, NPs in NSW … (you want to give an example to show how states differ – pick another state and show how prescribing rights vary from one to another to complete the point you are making here.)
It should be acknowledged that the Australian public are often confused about the difference between a NP and a registered nurse (RN). One distinction between a NP and a RN is in the different levels in education. The RN would be qualified in a Bachelor’s Degree in Nursing (Mosby’s Dictionary of Medicine, 2010), however the NP must also receive not only a Bachelor’s Degree in Nursing but the extended study in a Master’s Degree (Australian Nursing Federation 2006). The second difference is the level of autonomy enjoyed by NPs relative to RNs. This autonomy enables the NP to initiate treatment without the supervision of the medical practitioner, whereas the RN is under the supervision of a GP at all times (Australian Nursing Federation 2006). However, there are also some similarities among the two health professionals;both are eligible to initiate medical surgical routes and do basic nursing assessments (Oxford Reference Concise 1994, Australian Nursing Federation 2006).
Scope of Practice
The scope of practice (SoP) is the legislative framework which indicates the area of jurisdictions that the NP must work within (Baker, N 2010 p 211). NPs have a wider SoP than RNs (ANF). They can call upon the extended skills and knowledge, interpret test results and scans, perform consultations, content assessments and undertake on planning and research diagnosis (ANF). Any presentation that is out of the jurisdictions of the SoP, the NP must seek assistance of a medical practitioner (Heaps and bounds).The SoP of a NP varies across all health areas (Baker 2010 p) for example; a NP trained in emergency department (ED) as an emergency nurse practitioner (ENP) will have a different SoP to a NP trained in the mental department as a mental nurse practitioner (MNP).
To illustrate this further, the study by Lowe (2010 p) demonstrates the current SoP of an ENP at the Alfred Emergency and Trauma Centre (AETC) located in Melbourne. The AETC have established the SoP for ENPs around the model of care (MOC) (Lowe 2010 p) that was based upon the Clinical Practice Guidelines (CPG) cited in the Alfred Health website (2012). The areas in the SoP involve prescribing medications, ordering tests, diagnosing results and admitting and discharging patients (Lowe 2010 p). The assessment of minor injuries or illnesses and initiation of treatments are also part of the ENP’s SoP (Lowe 2010 p).
Lastly required at the AETC the ENP must also attend educational classes with other ED medical staff, and further additional classes that will identify the gaps between the ENP’s skill and knowledge and own professional development (Lowe 2010 p80). In comparison, Fry’s research (2011, p58) indicated that the NP in the critical care department (CCD) have separated areas which are adult, paediatric and neonate, however all three areas can fall under the same SoP. The SoP (Fry 2011, p64) involves around direct patient assessments, research of the injury or illness, complex monitoring and therapies of high intensity interventions and care focused by highly acute technology (Association of critical care 2011 p12). NPs in the CCD also follow up with post-intensive care discharge, intensive care retrieval and transfers, and follow up on outpatient care (Fry 2011, p64).
There are times a NP trained in certain an area such as a MNP, can work in a different health department for example ED. A case study by Baker (2010) based in Victoria shows a MNP working in the ED as part of a team, the Youth Early Psychosis (YEP). Bakers (2010) article shows that working as a MNP in the ED in a YEP team can work autonomy to appropriate areas. The SoP involves the combination of a NP working in the MD and ED, in this mostly around the SoP of a MNP; however it is also required for the MNP to obtain an extension of practice within the ED (Baker 2010 p 212). The additional roles within the ED include ‘fast tracking patients’ and attending to other medical concerns (Baker 2010 p 212). The MNP working within the YEP can prescribe a limited range of medication in the duration of seven days, supervise and monitor the progression of the medication, initiate other therapeutic skills and test and take further action towards the patient (Baker 2010 p).
The Medicare Benefits Schedule (MBS) and the Pharmaceutical Benefits Scheme (PBS) became accessible, albeit in a limited way to NPs on 1 November 2010, were governed by the Health Legislation Amendment ACT 2010 (Medicare Australia 2011). Objections to the NP role have been voiced by the AMA(cited in Taylor 2007, p 20) on the grounds that NPs “…are not adequately educated and trained in areas such as ordering pathology and diagnostic tests, making medical diagnoses, prescribing medications, referring patients to specialist and having hospital privileges”. Furthermore the PBS has constricted the prescribing rights to the NPs’ SoP in the designated state and territory (PBS). In contrast, this is a major progression in the development on expanding the SoP compared to 2008 where the Health Legislation was yet to pass (reference PBS). Dr Phillip Della (cited in Taylor 2007) supported the availability of the MBS and PBS during this time, to provide safe and quality patient care across all access and addition to realising the NPs’ full potential used to improve Australia’s health.
Medicare Australia (2011) reports that only NPs working in a private practice may obtain access to the MBS services, which refer patients to specific specialists and request of some pathology and diagnostic items. easons stated in the Department of Health WA (2011 p. 16), that under the Health Insurance Act 1973 (cited in Department of Health WA, 2011 p. 16), that NPs (or other health professionals) with pre-existing funding arrangements with the governing bodies of the Commonwealth, state or local will not be rebated by Medicare. This is because NPs working in the public sector are to provide a ‘public hospital service’, thus cannot charge a fee for treatment or care initiated to public patients (Department of Health WA, 2011 p. 16).
A ‘public hospital service’ is funded by the governing body to a public patient (Department of Health WA, 2011 p.16), and therefore MBS services are only allocated to NPs in the private sectors because patients are being charged. According to the Health Department SA (2011) fact sheet, NPs working in the private sector would be required to obtain a provider number to access to the MBS. NPs working in the public sector would use the provider number of the public hospital. Provider numbers are obtained through the Department of Health and Ageing in the Australia Government (2011). A final requirement to access the MBS, are that NPs must have professional indemnity insurance (Australian Government, Department of Health and Ageing 2011) which can be obtain through the Australian Nursing Federation (2012).
Though the initiation of the PBS (2010) was enabled for the authorised NPs to prescribe medications under the state and territory legislation, prescribing is still limited due to the SoP of the NP and state and territory rights. Medications are listed for NPs to identified which medicines are available to prescribe are located on the PBS website (Australian Government Department of Health and Ageing, 2011). NPs can also prescribe when they have a collaborative arrangement with the general practitioner (GP) under certain conditions, this usually occurs when the patient is living in a rural or remote area (Department of Health and Ageing WA, 2011, p).
The collaborative arrangement occurs in two forms continuing therapy only (CTO) model and shared care model (SCM) is shown in the Department of Health and Ageing WA (2011 p). The CTO model is when the GP has already initiated the treatment and prescription for the patient and then is continued by the NP (Australian Government 2011). The SCM is formalised agreement between both NP and GP planned to managed the treatment of the patient (Australian Government Department of Health and Ageing 2011).
According to the ANF (2011) and ACNP (2012) the role of the NPs is to provide cost effective care, provide patients in rural and remote areas treatment, improve waiting times, faster access to treatment and provide a mentorship and clinical expertise to other health professional. The framework utilized by the Department of Human Services Victoria(2000) recommends various ways in which NPs can assist in improving existing health services and patient flow in Australia (Wintle, Newsome & Livingston 2011).
To illustrate, in the emergency department(ED) based in Sunshine Hospital in Melbourne, there has been a shortage of doctors working on site especially after hours (Webster-Brain 2011 p). In 2004 a project developed by the Department of Human Services Victoria (cited in Webster-Brain 2011 p) provided the hospital funding to introduce the role of NP. Webster-Brain (2011 p) suggested that the NP was deemed to be trained in the management of minor presentations, for example minor injuries, infections, complaints and symptoms of miscarriages. The benefit of NPs being available at the ED is that action can be taken immediately and effectively (Webster-Brain 2011 p). The NP provides support in counselling to those whom just experienced a miscarriage, also to educate the emotional impact on the medical and nursing staff (Webster-Brain 2011 p).
This area noted in Gabrial et al (2005) that even at early pregnancy loss, practitioners need to be aware at any inappropriate or insensitive responses may cause more grief or trauma towards the patient. Thus this issue can be assisted by the NP through sensitive and supplementary counselling. According to Webster-Brain (2011 p) the successful collaborations between the medical staff, emergency physicians and NPs in the ED, resolved the problem in the lack of services and staff. A survey was conducted by Scully (2006 p) which reviewed the contributions of NPs model care on the patients at Sunshine Hospital. The findings had patients responding positively towards the NPs service and care, thus resulted in the permanent implementation of the NP position at Sunshine Hospital (Scully 2006, p).
There has been some opposition to the expansion of the role of the NP, notably from the Australian Medical Association (AMA) (cited in Taylor 2007, p). The AMA (cited in Taylor, p) does not believe that NPs are adequately trained to prescribe medication and order diagnostic tests, therefore they support limited access to MBS and PBS. Another concern from the AMA are that the role of a medical practitioner may one day be substituted by the growing occupation of NPs (Weiland et al ????). They have announced that NPs “cannot and should not replace the expertise and care provided by general practitioners.” (AMA 1994). However NPs were originally developed in the United States to provide care and utilising treatment in cases of patients in rural and remote health where a medical practitioner cannot be able to attend to (Distoll et al ???? p).
Case studies in Australia, which addressed welfare shortages in other suburbs with growing population, have proven positive (Scully 2006 p). Sunshine Hospital in Melbourne utilised the NPs to resolving the outnumbered medical practitioners and staff (Webster-Brain 2011 p), that resulted to the permanent position of the NP role is one example. In this case the AMA (cited in Taylor 2007 p.) had agreed that the shortage of medical practitioners are undeniable and is an issue. In a solution, the AMA (cited in Taylor 2007 p.) have reopposed that Australia should utilise the treatment and care provided by the NP in such areas, however with the consultation of a medical practitioner, whom carries the ultimate clinical responsibility.
The awareness of the general public about the role of NPs is limited of this stage. There is limited awareness about the position of NPs in the Australian public (Taylor 2011 p). Professor Glenn (cited in Taylor 2007 p.??) argue that the “State government needs to educate the public about nurse practitioners and how anyone on a waiting lists for category three or four could be receiving care from a health professional. The public would be appalled if they knew how ready nurse practitioners are to provide health services but are restricted by bad policy.” Taylor, M (2007) recommends that those have and are interested in the position of a NP should consider addressing barriers that requires action. Promoting Australia’s public awareness, utilising and justifying the role of a NP and involved politically to support change are a few of many factors that may alter the restriction to NPs (Taylor 2007).
In conclusion, Australia is still fairly new as a country towards role of a NP, which has been around internationally for much longer (Distroll et al 2005 p141). The NP has a higher education level at the Master’s Level which can perform specific areas within their scope of practice (Australian Nursing Federation 2006), to help out in different areas of aspects in Australia’s health system (Baker 2010 p). The process of obtaining the title and position of a ‘NP’ is based the Nursing and Midwifery Board of Australia (2011), however was indicated by Harvey et al (2011 p2478) that complications have raised difficulties through the endorsement in different state.
The Australian health systems are still in the progress of trial and error with developing and broadening of the SoP of a NP. The accessibility of the MBS and PBS by the legislation has proven to be a great step despite controversies from the AMA (cited in Taylor). Finally the value of NP have been evaluated and have successfully implemented on the Australian health system improving waiting times for patients, assist the workload for medical practitioners, and mentor and enhance communication between patient and medical staff (Webster-Brain 2011 p).
Department of Human Services Victoria (2004)
Gabrial et al (2005)