Advanced Nursing Practice in Australia - Essay Example

The Development of Advanced Nursing Practice and the Evolving Role of the Nurse Practioner in Australia Introduction Over nearly two decades, there is continued debate about developments in advanced nursing practice, its impact on healthcare delivery, and implications on the role of the nurse practitioner. This evolution in advanced nursing practice in Australia and other countries is because of increasing demands on the health care system and changes in the delivery of health care which include the growing cost of acute health care; the increasing number of specializations in health care; the greater avoidance by medical practitioners of particular client groups such as rural and remote communities, those with chronic illness, and low socio-economic groups; and the extensive upgrade of nursing education and training. These factors fuel the development and extension of the scope of nursing practice and the consequent increase in the allocation of clinical discretion, responsibility and autonomy to nurse practitioners (Pearson & Peels, 2002). The nurse practitioner is defined as “a registered nurse with appropriate accreditation who practices within the professional role. The nurse practitioner has autonomy in the work setting and has freedom to make decisions consistent with his/ her scope of practice, and the freedom to act on those decisions” (NSW Health Department, 1998). This paper proposes to discuss the developments in advanced nursing practice and the role of the nurse practitioner in Australia. Discussion By the turn of the century after several years of struggle and conflict with the medical profession to crystallize the importance of the nursing role in health care, legal recognition was proclaimed for nurse practitioners in New South Wales, Ausrtralia. This brought about legislation, authorization, acceptance and implementation of the advanced professional role and status of nurse practitioners (Appel & Malcolm, 2002). Advanced Nursing Practice and the Evolving Role of Nurse Practitioner The nurse practitioner role was initially developed in the area of primary health care, with nurses implementing complete and direct management of health care. In the primary care sector they are providers of care in their own right; they work in collaboration with general practitioners, carrying out preventative care, health education, screeing and counselling. This essentially means that rather than perform as a doctor substitute, nurse practioners in the primary care setting have their own case load, and they retain the autonomy to admit, discharge and refer from and to their caseload. “The role is clearly health focused, patient centred, and theoretically informed” (Cahill, 1999: 11). Thus it is observed that a nurse practitioner accepts responsibility for the delivery of healthcare services that were previously associated with the modes of practice associated with medical practitioners. The Background to the Role of Nurse Practitioner: The unique features of delivering health care services in Australia combined with the relevant modes in other countries form the basis for the development of the role of nurse practitioner, which is a new concept. The specific features which impact health care delivery in Australia are: geographical isolation, unequal distribution of health services particularly between remote and rural areas compared to inner urban areas, difficulties attracting and retaining doctors in remote and rural areas, and the poor record in the provision of health services to the Indigenous population (QUT, 2004; McGee & Castledine, 2003). The Nurse Practitioner Standards Project found that nurse practitioners in Australia and New Zealand work across a range of clinical settings including many speciality areas of health care and provide specific health service to particular populations. Extensive amendments of the health care Acts and regulations were required to be made, for implementation of the nurse practitioner role. “The Acts and regulations are set by parliament and provide the broad legal framework within which the nurse practitioner may practice” (ADGP, 2005: 2). Nursing regulatory bodies located in the states and territories are responsible for authorisation and endorsement for nurse practioner. Several factors including compliance with legislative process established through relevant Acts and regulations impact the requirements for authorisation which vary between different jurisdictions. State health authorities are also responsible for approving nurse practitioner guidelines and protocols, and approving positions within the state health system. Potential candidates for nurse practitioner must satisfy a diverse range of authorisation criteria including level of education “which is usually required at master’s degree or equivalent, advanced clinical practice, collaborative arrangements, professional leadership and development, and evidenced based practice” (ADGP, 2005: 2). Renewal of nurse practitioner authorisation is required in all jurisdictions, ranging from an interval of one to five years, and random audits may also be performed. Essential Features in the Role of Nurse Practitioner: The ADGP (2005) has formulated the following requirements in the role of nurse practitioner: 1) Models for supporting the establishment of nurse practitioner’s roles in primary care should complement and support the role of the general practitioner. 2) In order to improve the existing health care provision and increase the access to primary care for all consumers, multidisciplinary models of care will be advanced, consequently impacting the evolution of the role of nurse practioner in general practice. 3) It is essential to determine and define the exact range of practice of the nurse practitioner in genera practice, in order to adequately meet the primary health care needs of the local population. 4) Where community need is identified, it is important that funding models for general practice should provide support for the engagement of nurse practitioners. 5) Educational courses which prepare nurse practitioners to work in primary care should incorporate work experience in the general practice setting, and knowledge inputs from the general practice speciality. 6) Those nurse practitioners who are working in specialist fields out of the general practice domain, should establish strong communicational bonds with the patient’s general practice team. Besides the above features, Carryer et al (2007) found from empirical evidence that the core role of the nurse practitioner constituted of three crucial concepts: dynamic practice, professional efficacy and clinical leadership. Nurse practitioner practice is dynamic and involves the application of high levels of clinical knowledge and skills in a wide range of contexts. The nurse practitioner demonstrates professional effectiveness enhanced by an extended range of autonomy that includes privileges granted by legislation. The nurse practitioner is a clinical leader who is obliged to advocate for the client base and for the profession at the systems level of healthcare. Thus a clearly defined description, based on research, of the core role of the nurse practitioner helps to develop educational and practice competency standards. These research findings widen perspectives in the international debate about the advanced nursing practice role; and the position of nurse practitioner to achieve a standardized approach and internationally consistent nomenclature. Thus, the unique nature is seen, of the development of a new level of health service being implemented through professional orientation and legislative protection. Extension of Role Definition of Nurse Practitioners: The perspective in nursing that nurses in specific contexts may need to extend their traditional roles in order to meet the healthcare needs of their clients effectively, is represented in the view of nurse practitioners. Meeting client needs is considered to be the priority and if necessary, should take precedence over professional disputes among nurse practitioners and medical practitioners regarding role boundaries or occupational status. Since the position of nurse practitioner has emerged from contemporary health system’s needs to deliver appropriate health care to diverse populations, it is expected of appropriately prepared and skilled nurses as nurse practitioners to accept greater responsibility for client care, and provide health care which may have earlier been outside the legitimate domain of nursing. Especially in remote and rural areas, where people are under-served with respect to health care, often nurses are the only health professionals available to the community, then nurse practitioners are required to be the providers of primary health care. Such extended nursing roles were being performed by nurses in rural settings in Australia, Canada and the United States of America, even before the concept of advanced practice and nurse practitioners had been visualized (Pearson & Peels, 2002). Turner et al (2007) conducted a study to determine the extent to which nurse practitioners are able to practice autonomously in the rural and remote setting. Autonomy refers to the ability of nurse practitioners to practise as professionals in their own right. The implementation of the role in rural and remote Australia is found to be slow, with a number of influences that hinder progress. Governmental policy documents were found to indicate support for autonomy and advanced practice. Nurses’ progress was found to be supported but also hindered by the process for authorization. “Subsequent acceptance of nurse practitioners has also been problematic as colleagues struggle to understand the role within the current healthcare system” (Turner et al, 2007: 38). Thus significant disparity was found between policy and actual implementation of nurse practitioner roles in rural and remote Australia. The nurse practitioners report a mere shift in the traditionally accepted boundaries of nurses’ roles, though policy supports their autonomous functioning as healthcare professionals. The findings from this study are relevant internationally as well as nationally, because evidence from other countries such as the United Kingdom and the United States indicate similar disparities to be present. Barriers to the Development of the Nurse Practitioner Role Lack of Adequate Education: A study was conducted by Offredy (2000) on nurse practitioners in three states in Australia: Victoria, South Australia and New South Wales, to determine the policy and legislative changes needed to firmly establish the nurse practitioner role. The researcher found that the range of services that the nurse practitioner could provide to the community was restricted by lack of adequate education. Opposition of the Medical Profession: Another reason for limitations to the role of the nurse practitioner was the opposition of the medical profession to the nurse practitioner role. This occurred especially with the introduction of the first legislation to protect nurse practitioners and officially recognise their role, in New South Wales in 1998. This legislation established that the Nurses Act was implemented in 1991 as protective legislation under which the title of nurse practitioner could be used only by those registered nurses who were accredited by the Nurses Registration Board of New South Wales. Further, the Pharmacy Act was also amended to allow prescribing rights to nurse practitioners in particular circumstances. The above legislative changes were considered to be threatening to the Australia Medical Association, whose members claimed that the provision of comprehensive patient care was possible only by medical pratitioners since they had the required training, knowledge and skills. “However, these legislative changes are necessary, not only to ensure nurse practitioners are able to make independent professional judgements, but also to ensure that nurse practitioners are working to recognized standards” (Offredy, 2000: 274). Other barriers to the development of the nurse practitioner role have been identified by Kelly & Mathews (2001) as legislative restrictions, continued existence of the unequal power relationship between physicians and nurses, lack of support from other nursing bodies, and the inability to effectively impact the decisions of policy making bodies. The researchers found from their study that there was lack of support to nurse practitioners from both physicians and nurses, and they were isolated from both the latter groups since they did not fit into either group. Further, the lack of clarity in the parameters of the nurse practitioner’s role with no practice guidelines and legal dimensions created additional barriers to the development of the role. Differences Between the Roles of Clinical Nurse Specialist and Nurse Practitioner: Though both the roles are those of advanced nurse practitioners and are similar in some respects, a merger of the two roles was not found to be possible because of a number of differences in the setting and focus of their practice. A continued division of the two roles and separate educational needs for each was found to be necessary. Research conducted by Lincoln (2000) found that the majority (60%) of clinical nurse specialists (CNS) were found to work in hospitals, 91.5% of them in large cities, while 75% of nurse practitioners worked in ambulatory care settings, and large numbers worked in small cities and rural areas (12.9% and 19.4% respectively). The focus of their time was also an important differentiating factor. Nurse practitioners were found to spend 74% of their time in providing direct patient care by physical examinations, prescibing medications and treatments and making referrals. On the other hand, CNS spent only 35% of their time focused on direct patient care, and their major emphasis was on education and consultation (Lincoln, 2000). The Difference Between Practice Nurse and Nurse Practitioner: The term “practice nurse” refers to a “qualified nurse who provides nursing management in the general practice setting under some degree of supervision from the employing general practitioner(s)” (Rural Doctors Association of Australia Ltd., 2003: 1). This system is meant as a collaboration between the practice nurse and the general practitioner who work as a multidisciplinary team to increase available services and to improve the quality of healthcare in general practice. In contrast to the practice nurse, the role of the nurse practitioner or advanced practice nurse is that of a specialist and autonomous advanced practice clinician providing healthcare within a defined speciality field, which may or may not within the primary care setting (Halcomb et al, 2006). The role of the nurse practitioner or advanced practice nurse includes aspects of diagnosis and treatment. In this model of nursing care, a range of predefined, protocol-driven, clinical tasks that are normally part of the functions of a physician, are undertaken by the nurse practitioner. The nurse practitioner role in general practice in the United Kingdom (Mundinger et al, 2000) has been found to be effective to some extent, with mixed success. This is different from general practice nurse role development. The difference between collaborative and independent nursing practice “confounds discussion and debate” states Halcomb et al (2006: 377). Legal Framework for the Role of Nurse Practitioner In Australia, New South Wales was the first state to have the title of nurse practitioner practitioner protected by legislation: NSW, 1998. With the help of extensive collaborative work with key stakeholders, the framework document was created to outline the policy and legislative changes that were to occur. Subsequently, the Nurses Amendment or Nurse Practitioners’ Act, 1998 was passed by both houses of NSW in 1998. The purpose of the Act was to: authorise certain registered nurses to practice as nurse practitioners by the permission of the Nurses Registration Board; allow the approval of guidelines by the Department of Health towards the supply and prescription of particular substances by the nurse practitioners; and prevent the unauthorised use of the title of nurse practitioner (Gott, 2000). Accreditation to the post of nurse practitioner is granted by the Nurses Registration Board to appropriately qualified candidates from the nursing profession. Nurse practitioners are to be specialist nurses with extensive knowledge, advanced skills and experience. They are to work collaboratively with local medical practitioners and other members of the multi-disciplinary health team. The legislation paves the way for long-term development of innovative, community-responsive best practice. Voluntary choices are encouraged on the part of nurse practitioners, and does not confine them to areas where doctors do not wish to work, and accreditation depends on individual nurse practitioners and not on employee position (Gott, 2000). The Significance of the Role of Nurse Practitioner in Australia The significance of nurse practitioners in the development of nursing for the 21st century, is observed to be immense. With radical changes taking place in the healthcare system, extensive opportunities are also opening up. In areas where demands for healthcare are greater than the availability of professionals to provide it, nurse practitioners are much needed for their expertise and skills in healthcare delivery. Overcoming challenges to their role with the help of improved education, public relations, information about their role which contributes to improved service quality and decreased costs, nurse practitioners can be well equipped to meet the challenges and opportunities that they face in the future, in the Australian healthcare system (Gott, 2000). “The evolution and recognition of the nurse practitioner role is one of the most important milestones in the history of nursing in Australia” (Australian Nurses Federation, 1999, as quoted in DHS, 1999). The introduction and development of the nurse practitioner role has proved to be crucial in providing cost effective, quality health care in remote communities as a viable alternative to healthcare given by medical practitioners. They provide a wider variety of consumer choice in healthcare. The development of the nurse practitioner role and protection of the title across Australia has been uncoordinated and diverse, since the states and territories individually took initiatives towards establishment of the nurse practitioner role. The role of the nurse practitioner is based on the nursing profession’s values, knowledge, theories, and practice and complements that of other health care providers. The scope of practice of the nurse practitioner depends on the situation or context in which they are authorised to practice (Gardner, 2004). There are three core concepts to the role of the nurse practitioner: 1) Extended practice: The main element that differentiates the nurse practitioner from other advanced practice roles is that the scope of practice is subject to different practice privileges that are protected by legislation. Therefore, extended practice refers to those elements of nursing activity that form part of the legislative structure, outside the scope of practice for the registered nurse. Thus, the nurse practitioner operates in “that grey area that incorporates both medical and nursing activities” (Gardner, 2004: 133). 2). Autonomous practice: The nurse practitioner engages in clinical practice with significant clinical autonomy and accountability, which incorporates responsibility for the complete episode of care including decision making and follow up on patient care. This autonomy functions within a team approach to health service, the nurse practitioner being a part of the multidisciplinary team in a clinical partnership role, in order to ensure best health outcomes for the patient. 3). Nursing model: The nurse practitioner’s work is based on a nursing model, in which clinical flexibility is permitted in the delivery of nursing care. Some examples of nurse practitioner models 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” (Gardner, 2004: 133). Thus, it is observed that the nurse practitioner is an advanced practice nurse who operates mainly in the grey area between nursing and medicine. Nurse practitioners are emerging as a new breed of professionals in healthcare, since they are not limited by boundaries related to health disciplines, their practice is based on medical activities within a nursing model of care, and they expand both medical and nursing clinical speciality practice (Gardner, 2004). Nurse Practitioner Competency Standards Three generic standards that define the parameters of nurse practitioner practice have been identified, and these standards encompass nine competencies each with specific performance indicators. Standard 1 refers to dynamic practice in stable, unpredictable and complex situations that incorporates the application of high level knowledge and skills in extended practice. This includes comprehensive assessment ability based on advanced knowledge of pathophysiology and the range of human sciences integral to nursing, ability to prescribe and order investigative procedures according to address need, and continually keeping up with current practice norms. Standard 2 refers to professional efficacy in which practice is structured in a nursing model and enhanced by autonomy and accountability. The nurse practitioner applies critical reasoning to negotiate evidence and adapt care to the reality of clients in different contexts. This is achieved by establishing a climate of mutual trust and partnership with clients and whole communities where relevant. Standard 3 refers to the clinical leadership that impacts and promotes clinical care, policy and collaboration through all levels of health service. The essential elements of clinical leadership include the requirement to guide and influence care delivery systems through involvement in policy development. The nurse practitioner leads as researcher, clinical teacher, case coordinator and spokesperson, drawing from the relevant evidence bae to improve the quality and nature of services provided (ANMC, 2005). Conclusion This paper has highlighted the developments in advanced nursing practice and the role of the nurse practitioner in Australia. Nursing has a long history of responding to the health needs of communities. “The evolution of the Nurse Practitioner reflects this characteristic response of nurses to reform their practices in the light of contemporary need” (Pearson & Peels, 2002: S9). Further government legislation to strengthen and support the advanced professional role and status of nurse practitioners is essential. This will help nurse practitioners not only to contribute more fully to healthcare where their advanced expertise and skills are required, but also to rise professionally in their area of nursing practice. The development and improvement of education and training, the conceptualization of a framework of standards and competencies for nurse practitioners that are consistent throughout the country, and legislation to extend prescribing rights and referral rights to nurse practitioners are features that need to be implemented. Nurse practitioners need to take the lead in strategic planning of this developing speciality. Enhanced empowerment for leadership from academic, research and policy perspectives is essential to drive clinical practice development and the delivery of evidence-based care. It is important that the concept of autonomy in advanced nursing practice should be evaluated. Merely legitimizing the existing role of rural and remote nurses is not adequate, since the real meaning of autonomy in practice has to be defined and established (Turner et al, 2007). As part of a multidisciplinary team of healthcare professionals in urban settings, or as the single healthcare professional in rural and remote settings, autonomous practice is crucial in the role of the nurse practitioner, to fulfill their duties to the best of their knowledge and abilities. References ADGP (Australian Divisions of General Practice). 2005. Nurse practioner in general practice – position statement. Retrieved on 13th June, 2008 from http://www.agpn.com.au/site/content.cfm?page_id=8089¤t_category_code=321 ANMC (Australian Nursing and Midwifery Council). 2005. National competency standards for the nurse practitioner. 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