Peter MacCallum Institute, Melbourne, Vic
Advanced nursing practice roles – in particular the role of the nurse practitioner, are becoming recognised as valuable and necessary in the increasingly complex health care systems of countries such as the USA, Canada, the United Kingdom and most recently Australia1,2,3,4. Political and social change, economic factors, the escalating cost of health service delivery, advances in research and technology impacting on medical practices, professional developments in the disciplines of medicine and nursing, and increasing consumer expectations have combined to facilitate the development and acceptance of these roles as the traditional boundaries between the health professions are reviewed, rethought and modified5,6,4,7. Essentially, the evolution of the nurse practitioner role has been an attempt to improve interdisciplinary health service delivery. The initiative is a response to individual and community demand for: improved access to health services, and increased diversity and flexibility of models in health care2.
In Australia, the introduction of the nurse practitioner role is at various stages. All States are in the process of either: establishing working parties, conducting feasibility studies, or implementing this new and rapidly evolving role2,8,9. The purpose of this paper is to provide an overview of one nurse practitioner pilot project conducted in the field of cancer nursing. The Peter MacCallum Cancer Institute (PMCI) participated in the Victorian State Government Nurse Practitioner Taskforce Models of Practice initiative, and aimed at further developing and extending an oncology nursing role, that of the Haematology Clinical Nurse Consultant.
The nurse practitioner is “at the apex of clinical nursing practice”10. Nurses in advanced practice must be highly educated, have post registration qualifications, and possess expertise in their specific area of practice which may include both individual and community health, in primary and acute care settings 11,12,13,4,2. In addition to traditional nursing role responsibilities nurse practitioners may: take histories, conduct physical examinations, order, perform and interpret diagnostic imaging and pathology tests, prescribe pharmacological agents, treatments and non pharmacological therapies, approve absence from work certificates, refer to specialists, and admit and discharge patients14,10,2.
As well as demonstrating high levels of clinical decision-making, nurse practitioners integrate education, consultation, administration, research, health policy development and clinical and professional leadership into their role. It is also essential that they function in collaborative and collegial relationships with other health professionals and in partnership with patients and communities11,12,13,4,2.
In Victoria, the focus of the nurse practitioner role is on the complementary nature of advanced nursing practice, rather than medical substitution. The advanced knowledge, skills and competencies of the nurse practitioner are simply tools that ensure safe, effective and expert practice in an expanded conceptualisation of clinical nursing10,2.
The PMCI Haematology Team’s long held belief that the patient is the central focus of health care practice informed our approach to the project. Several significant driving factors influenced its development:
Integral to the success and sustainability of an advanced nursing practice role was the procurement of an agreed need, and support for the role from key leadership positions in the organisation at executive, divisional, and departmental levels15.
The PMCI Haematology Nurse Practitioner Project addressed several of the critical policy issues being explored by the Victorian Nurse Practitioner Taskforce (VNPT): scope of practice; education and credentialling; and best practice12,15.
Acknowledged as a core member of the Interdisciplinary Haematology Team, the HNP maintains a practice field that includes the total care continuum and involves the entire range of patients referred to the Haematology Unit. The HNP’s primary practice setting spans across the Institute Outpatient facilities and encompasses the Inpatient Haematology Ward as required. Therefore the model provides integrated care, horizontally, within the inter-disciplinary team, and vertically, across the care continuum15.
Continuity of service provision and the availability of a constant caregiver are essential components of the model, as haematological malignancies often follow chronic trajectory paths in which care is complex, crosses several health care settings and involves a number of care providers. A real potential for fragmentation of care exists15.
The HNP’s scope of practice encompasses conventional areas of nursing practice that are provided at an advanced level. Where the scope of practice enters the realm of medical substitution, practice boundaries may be distinguished in the areas of advanced health assessment, diagnostic and clinical management. Though still managing complex clinical situations that require highly sophisticated clinical judgment, nursing practice in the areas identified above, will be limited to focused physical assessments, standard and routine investigations, and the management of common and non-complicated haematological conditions and or clinical problems15.
Thus in an acute care setting patients present with a range of problems that are essential for the HNP to correctly assess, intervene and/or refer on appropriately for resolution of some or all of the patient needs. Therefore at times the nurse works independently whilst on other occasions the nurse consults closely with the Haematology Consultant and works highly collaboratively. Clearly there is a degree of fluidity in this model however the HNP’s educational preparation and experience will inform practice in order that the HNP may differentiate when autonomous nursing practice is appropriate, and identify high-risk populations within the haematology patient population that require consultation, collaboration/co-management, or referral15.
While the development of advanced competencies in oncology nursing remains the brief of the Cancer Nursing Society of Australia, the need for identification of appropriate areas of competency, for the requirements of the project, led to adoption of the work of the North American Oncology Nursing Society Statement on the Scope and Standards of Advanced Practice in Oncology Nursing16.
The major sub-roles of a nurse practitioner – direct clinical practice, education, consultation and research – are demonstrated by these competencies. Emphasis is placed on providing clinical and professional leadership; advancing nursing practice to the “cutting edge” through education and research; and, contributing to the development of health policy in the interests of patients and health services15. This framework also provided some direction for the educational preparation of the nurse practitioner.
Major emphasis was placed on the development of an education program. It was designed to build on a requisite post registration qualification in oncology and extensive clinical experience in haematology nursing to further develop context based clinical knowledge, skills and attitudes relevant to the specialist area of haematology and necessary for advanced practice15.
This clinically-driven accelerated program consisted of 12 modules conducted over the 12 months of the project. Supernumerary status was accorded the candidate to assist in progressing through the accelerated program. The total period was the equivalent of 0.6 of an effective full time (EFT) position or 32 weeks distributed over the duration of the project15.
The module areas included were: advanced counselling; advanced nursing practice; cannulation; clinical decision making; diagnostic imaging; diagnostic pathology; microbiology and infectious diseases; pharmacology; physical assessment and history taking; rehabilitation; and transfusion medicine. A range of acknowledged experts across disciplines participated in the provision of lectures and tutorials: Haematology Consultants and Pathologists, Medical Physicians, Senior Medical Scientists, Pharmacists, Clinical Nurse Consultants, Clinical Nurse Specialists, Radiologists, University Faculty, Nurse Educators-Intensive Care/ Oncology; Haematology Nurse Manager. Teaching strategies, in varying combinations across the modules, comprised: formal lecture presentation, one-on-one tuition, observational placement and self-directed learning. In addition, medical and nursing supervision was provided throughout the clinical placement/practicum15.
Selected procedures, investigations and management decisions that could be well defined by appropriate and clearly documented best practice guidelines, were identified and developed as clinical protocols. These involved: bone marrow biopsy, diagnostic imaging and pathology, pharmacology, and transfusion medicine. A limited formulary was also developed from which the HNP was able to select and nurse-initiate medications contingent on medical authorisation15.
Responsibilities were accepted by the HNP in a graded manner commensurate with the ability of the nurse practitioner to perform at the desired level. Ongoing assessment of the HNP’s skills base to assess competency and determine degree of allocation of responsibility was performed. Mastery over practice and achievement of an advanced level of performance in all role competencies is a variable and dynamic process that develops over time. Meanwhile, it was critical that the education program produce a safe and effective practitioner. Thus initial competency (entrance level-nurse practitioner) was rigorously assessed through a combination of written and oral examinations and clinical assessment15.
In the future it is anticipated that this program may represent one major component of a clinical Master’s Degree of Nursing that would provide a global view on health and advanced nursing practice and prepare the candidate for clinical and professional leadership15.
A collaborative model of practice was identified as most suitable for the establishment of an advanced practice role in haematology nursing. Such a model of practice may be thought of as an interdisciplinary partnership or joint practice17. The professional relationship between the HNP and haematology medical staff in particular is highly collaborative.
Collaborative relationships require certain fundamentals to ensure productive alliances and the creation of an environment in which collaboration is valued and practised.
These include: shared values, a common purpose, mutual trust and respect, and effective interpersonal communication and negotiation skills. The diverse and complimentary knowledge, skills, experience and resources each participant brings to the collaborative effort must be understood and valued. Then, each team member may participate in a synergistic alliance that maximises the contributions of each participant and improves the quality of assessment, decision-making, problem solving, and choice of intervention. Subsequently a comprehensive health service is produced that could not be achieved by individuals alone18,17, 19.
Following completion of the PMCI Haematology Nurse Practitioner Project in May 2000, a limited, local evaluation demonstrated high levels of stakeholder satisfaction, and an overwhelming positive response to the role. On a broader scale recommendations enclosed in the final report of the Victorian Nurse Practitioner Taskforce to progress the implementation of the nurse practitioner role in Victoria were received favourably by the State Government2. Consequently the Institute has given a firm commitment to continue this role that continues to evolve, and is currently the subject of research that aims to further explore the nature and scope of practice in advanced haematology nursing.
The PMCI Haematology Nurse Practitioner Project as part of the Victorian Government initiative is contributing to a national consideration of the nurse practitioner role. New South Wales, the first to formally establish the nurse practitioner role, has: defined scope of practice, set educational and credentialling standards, developed legislation necessary for practice extension and introduced regulatory measures. Victoria now joins with South Australia and moves into an implementation stage whilst the remaining States continue in various phases of role exploration9,8,20,2.
The evolving nurse practitioner role offers enormous potential within a dynamic health system, to provide enhanced, collaborative interdisciplinary care, which is patient focused and responsive to the myriad needs of the oncology patient.