Evolving Role of the Nurse Practitioner in Australia - Essay Example

Evolving Role of the Nurse Practioner in Health Care Systems in Australia and Number Term and Year Besides the background, essential features and barriers to the development of the nurse practitioner’s role, the legal framework and the significance of the work of the nurse practitioner will be discussed. The prevailing socio-economic environment in Australia, and the N.P.’s role based on greater critical awareness, for the provision of socially responsive health care will be examined. Evolving Role of the Nurse Practioner in Health Care Systems in Australia Introduction Over the past few 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 people in 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 value of nurse practitioners will be fully realized only when they also focus on advocating for changes to the social and economic conditions that are at the root of many of the medical conditions they will be required to manage. This paper proposes to analyze the development of the role of the nurse practitioner in Australia from a socio-political perspective. Discussion 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). 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 (N.P.), practice privileges, and protection of the N.P. title in five states: New South Wales, South Australia, Victoria, Capital Territory and Western Australia (Appel & Malcolm, 2002; Gardner, 2004). The remaining states are currently working towards nurse practitioner role development and legislative change (Browne & Tarlier, 2008). Evolving Role of Nurse Practitioner The four key conditions which facilitate and rationalize the implementation of nurse practitioner roles are: advanced level educational preparation, typically a master’s degree in nursing, legislation to confer and protect the title N.P., and formal systems of licensure and credentialing; a scope of practice that includes activities that used to be carried out exclusively by physicians; including diagnosing, prescribing medication, referring patients to other professionals, and in some jurisdictions admitting patients to hospital; providing a direct point of entry to the health care system for case management, diagnosis, treatment, prevention and in some cases palliative care (Browne & Tarlier, 2008). 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 Carryer et al (2007) found from empirical evidence that the core role of the nurse practitioner consisted 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, a new level of health service is being implemented through professional orientation and legislative protection. 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. These 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. 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. 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). Moreover, the political climate of the region also needs to be taken into consideration. The main features of contemporary neoliberal policies are increasing forms of privatization, outsourcing method of provision of public services, increased partnership between public and private, reduction in social welfare, unemployment and childcare benefits, decreased public spending on health care, decreased governmental regulation, and increased emphasis on individual responsibility and self-reliance. Current neoliberal policy that is related to the work of nurse practitioners, is the resultant inequities within the country and the community. “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 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: This 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. 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 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). In the prevailing sociopolitical environment in Australia and other countries, the N.P. role has to emphasize greater social responsiveness in the context of primary care practice. From a critical social justice perspective, it is necessary that nurse practitioners’ roles and practice will need to be founded on greater critical awareness, to ensure that those who are the most vulnerable to the effects of increasing inequities receive socially responsive health care. Hence, nurse practitioners must be prepared to participate in formulating policies and thereby influence social and political trends that form the basis for inequities. In this area, “there is vast room for improvement and innovation in the role development of NPs” (Browne & Tarlier, 2008). 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.. 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 health care. For nurse practitioners to remain committed to health as a basic social value, they will need to know the current political and economic climate influencing social determinants in health inequities, particularly for those who are vulnerable to inequities. Hence, nurse practitioners should be prepared not only to provide health care for the socially disadvantaged and those living in poverty; but also work towards providing relief from adverse social and economic conditions. Nurse practitioners need to develop socially responsive approaches to practice, leadership and policy, in order to deliver “high quality clinical services and promote social justice in health-care” (Browne & Tarlier, 2008). References ADGP (Australian Divisions of General Practice). (2005). Nurse practioner in general practice – position statement. Retrieved on 19th September, 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. Retrieved on 19th September, 2008 from: http://www.anmc.org.au/docs/Publications/Competency%20Standards%20for%20the%20Nurse%20Practitioner.pdf Appel, A.L.M. & Malcolm, P. (2002). The triumph and continuing struggle of nurse practitioners in New South Wales, Australia. Clinical Nurse Specialist, 16(4), 203-210. Browne, A.J. & Tarlier, D.S. (2008). Examining the protection of nurse practitioners from a critical social justice perspective. Nursing Inquiry, 15(2), 83-93. Carryer, J., Gardner, G., Dunn, S. & Gardner, A. (2007). The core role of the nurse practitioner: practice, professionalism and clinical leadership. Journal of Clinical Nursing, 1818- 1825. DHS (Department of Human Services). 1999. Nurse practitioner project final report. Department of Human Services, Adelaide. Retrieved on 19th September, 2008 from: https://www.library.health.sa.gov.au/Portals/0/nurse-practitioner-project-1999.pdf Gardner, G.E. 2004. Issues in nurse practitioner developments in Australia. Cancer Forum, 28(3), 132-134. Gott, M. (2000). Nursing practice, policy and change. Oxford: Radcliffe Publishing. Kelly, N.R. & Mathews, M. (2001). The transition to first position as nurse practitioner. Journal of Nursing Education, 40, 156-162. Lincoln, P.E. (2000). Preparing CNS and NP role activities: a replication. Clinical Nurse Specialist, 14, 269-277. McGee, P. & Castledine, G. (2003). Advanced nursing practice. Australia: Blackwell Publishing. Mundinger, M.O., Kane, R.L., Lenz, E.R., Totten, A.M., Tsai, W.Y, et al. (2000). Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial. Journal of the American Medical Association, 283(1), 59-68. NSW (New South Wales) Health Department. (1998). Nurse practitioner review: stage 2. Sydney: NSW Health Department. Offredy, M. (2000). Advanced nursing practice: the case of nurse practitioners in three Australian states. Journal of Advanced Nursing, 31, 274-281. Pearson, A. & Peels, S. (2002). The nurse practitioner. International Journal of Nursing Practice, 8: S5-S10. QUT (Queensland University of Technology). (2004). Report to the Australian Nursing Council. Nurse Practitioner Standards Project. Retrieved on 20th September, 2008 from http://www.anmc.org.au/projects/past_projects.php#NP Rural Doctors Association of Australia Ltd. (2003). Rural and remote nursing practice policy. Retrieved on 20th September, 2008 from http://www.rdaa.com.au/uploaded_documents/Nursing_Practice_Policy_final_aug_03__-_with_logo.pdf Turner, C., Keyzer, D. & Rudge, T. (2007). Spheres of influence or autonomy? A discourse analysis of the introduction of nurse practitioners in rural and remote Australia. Journal of Advanced Nursing, February 2007, 38-46. Read More