Queensland University of Technology & Royal Brisbane and Women’s Hospital
The nurse practitioner level of health care is one of the most important developments in nursing in the past 30 years and marks the opportunity for significant reform in the Australian health care industry. Nurse practitioners, whilst well established in North America, the United Kingdom and parts of Europe, are a relatively recent development in Australia. The introduction of the nurse practitioner level of service is a function of state rather than national government and consequently the implementation throughout Australia has been gradual, with title protection and practice privileges now legislated in five states over a 15-year period.
Despite this rather long lead-in time, there remains confusion and uncertainty relating to the role and function of the nurse practitioner within nursing, other health disciplines and most importantly, the community of health care consumers. The aim of this paper therefore, is to reduce the confusion and uncertainty and provide information for nurses, medical and allied health professionals about this innovative level of health care.
The preparation and introduction of a new level of health care into existing systems is a complex and multifaceted undertaking. In this paper I focus on four issues that are currently influencing the progress of the nurse practitioner in Australia. These are definitional issues, the research base, Australian state and national development and role development.
There is general agreement that the introduction of the nurse practitioner as a new level of health care has been complicated by the existing nomenclature relating to advanced practice roles in nursing. Titles such as advanced specialist, clinical nurse consultant, clinical nurse specialist and advanced practice nurse are used interchangeably and at times unproblematically in the literature1,2. Contributing to this confusion is the lack of consensus internationally in the use of these terms3. While the clarification of titles is complex and may continue to be debated for some time, the consensus gradually emerging is that the nurse practitioner role is evolving and developing globally as the most significant of the advanced practice roles2.
Each state in Australia has developed and operates from a different definition for the nurse practitioner. A recent Australian study4 collated and examined these definitions and identified elements that were common to all. Following is the definition that was developed including all common elements:
A nurse practitioner is a registered nurse educated to function autonomously and collaboratively in an advanced and extended clinical role. The nurse practitioner role includes assessment and management of clients using nursing knowledge and skills and may include, but is not limited to the direct referral of patients to other health-care professionals, prescribing medications and ordering diagnostic investigations. The nurse practitioner role is grounded in the nursing profession’s values, knowledge, theories and practice and provides innovative and flexible health care delivery that complements other health care providers. The scope of practice of the nurse practitioner is determined by the context in which the nurse practitioner is authorised to practise.
There are three points in this definition that are central to understanding the nature of the nurse practitioner role.
i) Extended practice: The element that differentiates the nurse practitioner from other advanced practice roles is that the scope of practice of the nurse practitioner is subject to different practice privileges that are protected by legislation. Extended practice therefore is defined by those elements of nursing activity that call upon a legislative structure that is outside the scope of practice for the registered nurse. With a scope of practice that incorporates these extended practice activities, the nurse practitioner functions in that grey area that incorporates both medical and nursing activities.
ii) Autonomous practice The nurse practitioner engages in clinical practice with significant clinical autonomy and accountability, which incorporates responsibility for the complete episode of care. This means accepting the need to act autonomously in decision making and the follow-through in patient care. This autonomy is situated within a team approach to health service whereby the nurse practitioner works in a multidisciplinary team in a clinical partnership role to optimise patient outcomes.
iii) Nursing model: This practice is firmly located within a nursing model. That is, nurse practitioner practice is about clinical flexibility in the delivery of nursing care.
There is now an extensive body of literature relating to the nurse practitioner role and practice. However, large scale quantitative research into nurse practitioner practice is not yet feasible because the number in practice remain relatively small. There is none-the-less an emerging research-based body of knowledge to inform ongoing developments in the introduction of the nurse practitioner level of service.
Nurse practitioners have been shown to offer a beneficial service and fill a gap in health care provision, both in the primary health care and in the acute care sectors. National and international experience demonstrates that they provide a specific service that is highly regarded5-8 and in demand9,10. The specific service offered by nurse practitioners provides care to many under serviced groups such as the homeless11, women and children, the elderly12, rural and remote communities9,13 and specialist services in acute care areas14. Nurse practitioners have been demonstrated to be effective in managing common acute illnesses and injuries and stable chronic conditions12. Nurse practitioners have an emphasis on health promotion and assessment and disease prevention5. For example, a nurse practitioner working in Scotland coordinates a unique health project that seeks out homeless people, assesses and identifies their health needs and offers them assistance11. In this paper Armstrong posits that without the services of the nurse practitioner, there would be little chance of reaching this vulnerable group using conventional health services.
Research that examines the efficacy of the nurse practitioner role has tended to compare nurse practitioner service outcomes with the outcomes of medical service6,15. This line of inquiry builds upon an assumption of the nurse practitioner as doctor replacement or substitute. The literature is now debating the usefulness of this approach6,16 and there is now a trend in nurse practitioner research towards holistic health service research. This examines how the health disciplines (including the extended practice of the nurse practitioner) complement and overlap to build better organised care practices16. I see this trend as an important and constructive direction as it is a move away from the one dimensional thinking about the nurse practitioner and recognises the potential of the nurse practitioner as a new level of care and a radical departure from the way health service is currently organised.
In Australia, nursing is regulated at state rather than national level and for this reason it is difficult to track the number of authorised nurse practitioners in the country and the influence that this level of service has on the health care system. Estimates suggest that in Australia there are currently between 50 and 80 authorised nurse practitioners, but these are not all currently employed in nurse practitioner positions. The development of the nurse practitioner role and protection of the title across Australia has been uncoordinated and diverse as the states and territories individually moved towards establishment of the nurse practitioner role. To date five jurisdictions in Australia have introduced legislation to protect the title of nurse practitioner and amended relevant legislation to legitimise extended nursing practice over the following time frame:
|New South Wales||1999|
Queensland, Tasmania and the Northern Territory are currently working towards nurse practitioner role development and legislative change.
This progress indicates that the nurse practitioner level of service is being recognised by all Australian state/territory governments as contributing to improving health service and/or delivering health care to marginalised or under serviced populations14,17. Moreover this new level of nurse is now on the national agenda.
The two recent commonwealth inquiries into nursing18,19 have both called for greater consistency across the states and territories in progressing the nurse practitioner agenda. Additionally the longstanding mutual recognition agreements between Australian states and territories and between Australia and New Zealand require a level of standardisation in role definition and educational requirements for authorisation of the nurse practitioner. Consequently the nurse practitioner role is included in the implementation brief of the National Nursing and Nursing Education Taskforce (National Nursing and Nursing Education Taskforce website). Furthermore the Australian Nursing and Midwifery Council in collaboration with the Nursing Council of New Zealand has recently sponsored the development of research-informed nurse practitioner standards for education and practice4.
In addition to contributing to improvements in health service for the community, the nurse practitioner role provides an exciting and new clinical career pathway for nurses. The nurse practitioner is an advanced practice nurse with extensive experience in a specialty field, postgraduate education and increasingly required to hold a nurse practitioner masters degree20,4. The nurse practitioner works within a defined scope of practice and model of service and is a member of a multidisciplinary team. The structure and proximity of the team is dependent upon the specific nurse practitioner model. Some examples of nurse practitioner models piloted, currently in development or currently practising in Australia include wound care, neonatal intensive care, rural and remote practice, mental health liaison, paediatric renal, neuroscience, primary health, diabetes, gerontology, child health, cardiac rehabilitation and sexual health.
In relation to cancer services, the scope for the nurse practitioner role is open and responsive to development of new and emerging clinical services. Accordingly, health service planners looking to streamline cancer services, improve access to comprehensive palliative care and/or improve case management for patients with co-morbid chronic illness are increasingly building the nurse practitioner role into the health care teams in these areas21,22.
In designing a nurse practitioner role there are factors that need to be considered to enhance the efficacy and sustainability of a new service. First the nurse practitioner is not a medical substitute. The nurse practitioner model needs to conform to a collaborative/team approach to health care that is complementary to other professional roles and central to better organisation of the clinical service. The team may look different depending on the service provided, but the nurse practitioner, like all other health care providers, operates most effectively in an overtly collaborative model. Second the role needs to be sustainable in that it does not replicate existing services. The nurse practitioner level of care is most effective when the service fills a gap in access, efficiency or quality of service for the patient population in a specific field of health care. Finally the candidate for the nurse practitioner role needs to have extensive experience in the specialty field and appropriate educational preparation.
This paper has attempted to clarify some of the issues related to the development of the nurse practitioner role in Australia. The paper has discussed what a nurse practitioner is, the progress in Australia at both state/territory and national levels and has identified factors to be considered in the design of a nurse practitioner role.
The nurse practitioner has been described as an advanced practice nurse who bridges that grey area between nursing and medicine and is emerging as a new type and level of health care clinician. They represent a new breed of health care professional in that they are not limited by traditional health discipline boundaries, their practice includes what has traditionally been viewed as medical activities within a nursing model of care and they expand clinical practice in both medical and nursing specialty areas.
7. Kinnersley P, Anderson E, et al. Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting ‘same day’ consultations in primary care. British Medical Journal. 2000; 320: 1043-1048
8. Venning P, Durie A, et al. Randomised control trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care. British Medical Journal. 2000; 320(7241): 1048-1053