The trial identified the broad potential of the nurse practitioner role, its breadth and limitations, and its impact on selected health services in the Australian Capital Territory. Data from individual models were compared highlighting generic elements, and formed the basis for the development of the scope of practice for the Australian Capital Territory nurse practitioner models.
This study has validated a research-based, iterative process for initial development of nurse practitioner scope of practice for any Australian specialization.
Importantly, the study concluded with the scope of practice as a finding, rather than commencing with it a priori. Although general areas of health care need and under-servicing were identified at the outset, the process tested both the expansion and parameters of the roles. These databases contain citations from different subsets of available publications and different time periods and thus the citation count from each is usually different.
Some works are not in either database and no count is displayed. The count includes downloads for all files if a work has more than one. Although general areas of health care need and under-servicing were identified at the outset, the process tested both the expansion and parameters of the roles. Abstract Aims: The aim of this paper is to report a trial to investigate the feasibility of the nurse practitioner role in local health service delivery and to provide information about the educational and legislative requirements for nurse practitioner practice.
Publication types Research Support, Non-U. Until very recently, establishment of nurse practitioner services in other Australian states and territories has been heavily influenced by specific under-servicing, most noticeably in rural and remote areas, due to lack of medical practitioner services NSW Health Department , South Australian Department of Human Services , Health Department of Western Australia , Offredy , Victorian Government Department of Human Services Turner and Keyzer raise the issue of the nurse practitioner role being defined in terms of absence of medical staff and taking on minor medical roles.
In these cases, nurse practitioners have started with previously developed protocols and formularies that directed their practice. A fundamental flaw in this process is that the source of these protocols and formularies is not rigorous exploration of need but a set of pre-judged standards. The inhabitants of the ACT have been described as an affluent, urbanised population with consequent easy access to health care.
This might suggest little need for a new level of health service. The ACT study challenged these assumptions and demonstrated that nurse practitioner levels of service augmented existing health care and satisfied unmet needs for several sectors of the community. This study evaluated nurse practitioners in a health care service well-endowed with medical staff, both specialist and GPs, and nonetheless demonstrated that there is a place for nurse practitioners.
Importantly, the roles were not particularly defined by the three factors often cited as the way that nurse practitioners push the boundaries of nursing practice, namely investigating, referring and prescribing. Each candidate used only one or two of these extensions to practice as a defining feature of the model. The roles were developed very clearly within a nursing rather than a medical framework. This occurred because the clinical protocols that defined the scope of practice were very explicitly developed over the course of the trial, rather than being set down in advance.
The iterative development process of protocols in the ACT trial ensured that each challenge to current nursing practice was examined and discussed by nurses and other members of a multidisciplinary team from both a clinical and research perspective.
All extensions to practice were justified on the grounds of clinical health care needs only if there were data to support their inclusion. Thus, interpretation and analysis of the data from each nurse practitioner service revealed patterns of clinical practice that could be systematized into key areas of clinical service for each model that completed the trial Table 4. These areas defined the scope of practice for each model and, more specifically, informed the development of clinical protocols and medication formularies.
The clinical protocols extended advanced practice nursing as described for Australia Australian Nursing Federation to the nurse practitioner level of practice and clearly marked the parameters of the role see Figure 1 for an example of a clinical protocol from this trial.
The concept of extension to a new level has been discussed in a companion paper Gardner et al. Thus, the clinical protocols with accompanying medication formularies forged flexible guidelines within which the nurse practitioners would provide autonomous clinical service. The trial participants included patients with chronic health problems, episodic illness and health maintenance issues.
Patient surveys strongly indicated that nurse practitioner services were highly acceptable to these community members see ACT Government , MacLellan et al. The findings indicated that nurse practitioner services improved access to health care.
This was either through offering a new service, as with the sexual health model, or improved and timely coordination of care, as provided by the wound care and mental health models. Furthermore, the findings indicated that nurse practitioner services were provided within a nursing model of care with judicious and appropriate use of diagnostic and therapeutic resources.
These findings were supported by data from clinical reviews of nurse practitioner services and the patterns of these services. Thus, in addition to meeting an identified health care need, nurse practitioner services were safe and effective.
The findings illustrated the diverse health care needs that nurse practitioners can meet. For example, the trial included services for marginalized groups such as non-English-speaking brothel workers; for national health priority groups such as mental health and aged care the latter in the wound care model ; and across both acute and primary care services.
This level of diversity replicated findings from other Australian states and internationally Hegney , Sherwood et al. In particular, the study demonstrated that nurses can combine the roles of therapist and high-level case manager.
Given the nature of working as part of a collaborative team, these 'referrals' might more properly be described as consultations undertaken as part of the integrated care provided for these patients with complex health care needs.
Case management responsibilities as part of a nurse practitioner role have been usefully developed where the health problem is potentially chronic, complex, or long-term Forsyth et al.
However, protocol requirements of an experimental design were inconsistent with the range of factors that impinged on the practice settings involved in this project. Additionally, there was no identified scope of practice for the nurse practitioner level of service in the ACT, nor was there legal authorization and protection of such practice at the time.
Until the role of the nurse practitioner is fully explored, described and legitimized, an experimental research approach is neither possible nor meaningful. Therefore, observational analytic methods were most appropriate for this study and contribute to the empirical research base of the nurse practitioner scope of practice Black Three researchers were employed by one of the funding bodies and so impartial steering committee members undertook some independent monitoring responsibilities.
Clinical review of candidates was an integral part of the ongoing teaching process by clinical support team members. Academic rigour was ensured by the final assessment being undertaken by an independent review panel. A further limitation to the project arose from a degree of resistance from sectors of the medical profession to the concept of nurse practitioner. Whilst this resistance was not universal, it did limit the scope of the project to those areas where medical support was available.
The trial has provided research-based, iterative processes for development of clinical protocols that define the scope of practice for diverse nurse practitioner models. Although general areas of health care need and under-servicing were identified at the outset, the process tested both the expansion and parameters of the roles applicable for any Australian specialization. The nurse practitioners provided health care as members of multidisciplinary teams comprising medical, nursing, and allied health professionals.
While the results cannot be generalized in terms of research design, they have robust transferability to other health care settings and contexts. Furthermore, the systems and processes established in this trial have been demonstrated to be effective and apposite to inform health policy deliberations. The steering committee overseeing the project recommended that the nurse practitioner be recognized as a legitimate and autonomous health care provider; local health authorities support the development of nurse practitioner models of practice; legislation relating to registration, prescribing, referrals, and use of diagnostic processes be amended to enable a nurse practitioner level of service; and local health authorities sponsor and support evaluation research into nurse practitioner services.
When nurse practitioners become incorporated into ACT health services a sustained evaluation programme will be needed. Consistent with recommendations from other Australian nurse practitioner trials, future research should encompass a range of methodological approaches to investigate specific practice outcomes and include a cost effectiveness analysis.
We wish to acknowledge the contribution and dedication of the four nurse practitioner candidates and those involved in their clinical support teams; and the other members of the investigating team, Sue Alexander, Frank Bowden, and Margaret Proctor.
We also acknowledge the support of Robert Cook, Carina van Diermen, and Philippa Keating in the preparation of this manuscript. Nursing Times 97 20 , Australian Nursing Federation, Melbourne. British Medical Journal , Cited by: 8 articles PMID: J Law Med Ethics , 42 1 , 01 Jan Cited by: 3 articles PMID: J Adv Nurs , 70 5 , 20 Oct Cited by: 9 articles PMID: Nurse Educ Pract , 13 5 , 06 Oct Cited by: 4 articles PMID: Nurse Educ Today , 33 5 , 02 Jun Cited by: 0 articles PMID: To arrive at the top five similar articles we use a word-weighted algorithm to compare words from the Title and Abstract of each citation.
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