Practise makes perfect

The emergence of nurse practitioners in Australia has profoundly changed the nursing profession, Flynn Murphy reports.

An article published in the British Medical Journal begins with the question: “Nurse or minor medical practitioner?”

It continues: “There is a real risk of the establishment of a new form of unqualified practice [due to an] increasing tendency for both nursing associations and private persons to employ nurses who are not only allowed, but apparently in many places encouraged, to prescribe and administer drugs, to treat minor injuries, and generally to act as minor medical practitioners.”

The article is dated April 1, 1911. But the century-old mentality is familiar to many of today’s nurses, as the debate over their responsibilities and scope continues to rage.

The Australian medical profession has over the past two decades seen the gradual emergence of nurse practitioners (NPs) – senior nurses who can prescribe certain medications, plan patient care, and treat minor ailments without the need to involve a physician.

Of more than 330,000 nurses and midwives registered in Australia, only 657 are nurse practitioners. They mostly work collaboratively with doctors and allied health professionals, though in some instances – assisted by a recent legislative change that lets them access Medicare – have started their own nurse-led clinics.

Professor Glenn Gardner from Queensland University of Technology’s School of Nursing and Midwifery worked on Australia’s first national census of nurse practitioners in 2007, and the follow-up in 2009. The surveys were funded by an Australian Research Council grant.

Gardner said nurse practitioners improve the community’s access to healthcare and their advent is particularly important in the context of an ageing population. “Today we have a lot more chronic disease – people are living with disease rather than dying from disease, and there’s a lot more need for monitoring and ongoing care which doesn’t require the medical training that doctors require.

“There will never be enough money to provide the kind of healthcare the community needs, so we have to think of doing it smarter.”

Doing it smarter is something that nurse practitioner Helen Gosby said can be achieved by health reform that makes greater use of NPs. She said with a stretched health system, not only can they increase efficiency by taking the strain off emergency departments, but training NPs makes the most of skills that already exist in the system.

“The mentoring opportunities are great. We are senior nurses, and the NP role lets the system hold on to the people that used to go off into education and management – taking their knowledge with them. With this position we are actually keeping them with the patients,” said Gosby, who works in paediatric emergency at the Children’s Hospital at Westmead.

Gosby told Nursing Review she was inspired to become one of Australia’s first NPs after seeing the effectiveness of the role in the US, where it has been operating for decades. She has three decades’ experience as a nurse, and 10 as a nurse practitioner, and is president of the Australian College of Nurse Practitioners.

While the majority of NPs are employed in the public sector in acute care, they are increasingly moving into primary health, and to a lesser degree, starting their own practices. While the federal Department of Health has no specific data on the subject, anecdotal evidence suggests specialisation is on the increase as NPs drift towards specialised roles in the community and in private practices.

“We are seeing more nurse practitioner-led clinics, like the Revive Clinic in Western Australia, and the SmartClinics in Queensland. The next big push is getting them into the aged care sector,” Gosby said.

Associate Professor Rhian Parker from the Australian Primary Health Care Research Institute (APHCRI) told NR she was consulting on a $19 million federal health program, led by the University of Canberra, to expand the role of nurse practitioners working in aged care, announced in the last federal budget.

For community and private practice NPs, these moves would not have been possible without legislative changes that took place on November 1, 2010, which allowed NPs access to the Pharmaceutical Benefits Scheme (PBS) and to Medicare.

A survey of NPs in 2009 showed lack of access was an overwhelming concern for them; at the time 91 per cent felt limited by their lack of access to Medicare, and 89 per cent by their incapacity to prescribe under the PBS.

Since then, 63 per cent of Australian NPs have registered with Medicare, according to the latest statistics from the Department of Health. Of these, 282 NPs were issued a PBS prescriber number only, and 132 had both a Medicare provider number and a PBS prescriber number.

The development of the np role in Australia has been piecemeal. In the UK, US and Canada, NPs have been a crucial part of the system for more than 50 years. Here, the first Nurse Practitioner Committee was convened in NSW in 1990. Pilot projects were launched in 1994, with trial programs in several states to follow, and the Nurses Amendment (Nurse Practitioners) Act was introduced in 1998. But it wasn't until December 2000 that the first Australian nurse practitioners - Jane O'Connell and Sue Denison - were authorised.

In May 2001, NP positions in rural NSW were authorised, followed by South Australia in December 2002. The Australian Nurse Practitioners Association was formed in NSW in March 2003, with legislation in WA to follow a month later.

One NP who has just applied for a Medicare provider number is Chris Helms. He began working at the private West Belconnen Health Co-op in north Canberra at the beginning of December, after eight months consulting with the co-op on its new NP program. He spends two days a week there, and pending the approval of his Medicare application he will spend three in public health, specialising in acute illnesses and injuries.

Helms has been a nurse for 15 years and an NP for nine. He emigrated from the US to Australia six years ago, and underwent what he called a “soul-destroying experience” to have his US accreditations recognised here.

“Having recently gained employment in the private sector, now any referrals or tests I order for my patients will be reimbursed. That means my patients will be at an advantage,” he said.

Gosby said recent advances in the powers and responsibilities of NPs had fuelled tensions between physicians and nurses.

“[Physicians] used to think [the NP role] was something coming into their turf, trying to take it over. Now a nurse practitioner can set up just like a GP, so I think that’s what a lot of the worries were. But [doctors’] resources are stretched, and they need to start looking at what’s the best for them – which patients are the best for them to manage, and which ones they can hand off.”

It’s a claim rejected by national secretary of the Doctors Reform Society (DRS) of Australia Dr Peter Davoren, whose organisation is a vocal critic of fee-for-service healthcare across the board.

Davoren said the DRS supported the development of the np role, but criticised NP-led clinics such as Brisbane’s SmartClinic, arguing a clinic without doctors is not the most efficient way to deliver healthcare to the public.

“I don’t think [NPs] are going to threaten GPs in their work, because there’s plenty of work for GPs. Our issue is that the federal government is now spending another amount of money on a fee-for-service basis, but is not necessarily going to be delivering better health services,” said Davoren.

“To be most efficient and effective, nurse practitioners should be working co-operatively with other members of a health team – medical practitioners and allied health staff.”

Helms thinks the debate is counterproductive.

“These arguments about nurses working independently or in private practices have been ongoing since the early 1900s. I think it’s counterproductive. What I know is that the care I provide for my clients is evidence-based, it’s safe, it’s effective, and like any healthcare professional when they reach the limitations of their expertise, knowledge or experience they refer them on to another healthcare professional.

“It doesn’t matter if you’re a nurse or a physiotherapist or a doctor, or some other allied health professional. When you reach the limits of your domain of knowledge you refer on.”

Professor Sandy Middleton from the Australian Catholic University, who worked with Gardner and a team of researchers on Australia’s second national census of nurse practitioners in 2009, said there could be something else at play. Middleton told NR one of the key barriers perceived by NPs was a lack of support from within the nursing profession itself.

Incorporating what at the time constituted 76.3 per cent of all NPs in Australia, Middleton’s survey showed that while 52 per cent of respondents thought a lack of organisational support was limiting their practice, an alarming 58 per cent cited a lack of support from other nurses.

“Nurse practitioners are our most senior nurses in a clinical role, and we need to examine why they feel unsupported by the nursing profession and how we can better support them. Until all of our nurse practitioners are able to work at their full capacity, we are not going to be able to fully evaluate the collective contribution that nurse practitioners make to healthcare.”

Middleton hopes to follow this up in the future and her team has just been awarded a grant to look at the role of NPs in emergency departments.

Meanwhile, what does the public think? Parker, from the APHCRI, has joined forces with Darlene Cox from the Heath Care Consumer Association to look at public attitudes to nps working in the primary healthcare setting, delivering a report to the Department of Health and Aging that awaits publication. Parker said that the responses of focus groups, and an online survey of more than 1880 people, led the pair to conclude that the public was highly accepting of nurse practitioners, particularly where they filled a gap in the workforce.

Parker and Cox have found that the public was wholeheartedly prepared to accept triaging, repeat scripts, and minor ailment treatment by NPs, though there was confusion about exactly what qualifications NPs had that separated them from registered nurses.

Parker said that about half of the respondents were willing to pay up to $20 more than the bulk billing rate to see a NP, provided they could get “timely access” to medical care, which is within about eight hours.

“[Our respondents] said ‘look, we can make a decision about when we need to see a doctor and when we can see a nurse practitioner’. They didn’t want to be forced to see anyone in particular, they just wanted to be able to make the choice.”