Today, more than ever before, the potential for nurses to improve the quality of life for patients in primary care settings is well documented and acknowledged (Ventulato et al, 2006). This has necessitated many countries, especially in the developed world, to develop mechanisms through which nurses are encouraged to specialize in their areas of interest with the understanding that such a trend would impact positively on healthcare delivery to millions of people who are in constant need of services (Dunn et la., 2010).
Healthcare policy analysts are constantly reminded of the need to not only have an adequate nursing workforce supply to cater to present and future healthcare needs, but to ensure that a specialized nursing workforce is solidly put in place to attain equitably and quality health outcomes, and patient access to healthcare services, irrespective of geographic constraints (Hogan et al., 2007).
The Australian government, aware of the urgent need to enhance the delivery of services and quality of care to all Australians, has put in place frameworks and policies that encourage nurse specialization and retention (Warburton et al, 2009). One of the areas that have received due attention and consideration is the Nurse Practitioner (NP). Indeed, policy documents, as demonstrated by (Turner et al, 2007), indicate support for advanced practice and the independence of NP.
But while the pathways to NP are well established, it is the view of many that the current structure and the process of authorization have some constraints that hinder the progress and success of nurses. It is known that the consequent recognition of NPs has also been challenging as nurses struggle to understand their role and responsibilities within the current practice and healthcare system. This paper attempts to critically evaluate the pathways to NP in Australia, and how the current structure hinders nurses’ progression with a view to offer practical solutions that can be implemented to solve the gridlock
Since its inauguration in the decade of the 1960s in the U.S., Nurse Practitioners (NPs) positions have been created in other countries in response to the impulsion for putting in place cost-cutting solutions and capabilities to offer specialized services in the managed care environment. Furlong & Smith (2005) suggests that the progression of NP was critically influenced by transformations in healthcare delivery, financial limitations, and consumer demand.
With the evolution of NP, concerned stakeholders led by governments soon realized that these positions required state-regulated entry to practice, mostly due to the fact that the holders of the positions were actually engaged in the provision of human services (Fealy et al., 2009), thus the need to set minimum requirements, policies and implement regulatory standards through which professionals could be evaluated to authentically determine their capabilities to practice. According to Furlong & Smith (2005), the challenges involved in authorizing or recognizing nurse practitioners in any professional capacity without instituting standards for advanced nursing practice have been well documented by many scholars. These requirements heralded the introduction of the pathways to the NP.
The role of the NP came into the fore in Australia in the 1990s, but it has remained a challenge to regulate the practitioners largely due to the fact that the country is constituted as a federation of states and territories, encompassing both state and federal legislatures, with a distinct independent regulating and registering agency for each member state (Garner et al., 2008). Indeed, Turner et al (2007) decries that, “…whilst the NP seemed the solution to health budget rationalization the actual implementation process [has been laden] with political debate and professional boundary changes which has spanned a number of decades” (p. 39).
This debate has demonstrated a discursive orientation in which nurses, upon successfully fulfilling all the requirements set by relevant bodies, believe they have the independence and right to practice but are held back by a multiplicity of rules to the effect that establishing the role for NP in some countries is still a challenge. This paper specifically aims to discuss and critique the structural challenge arising from the policy of autonomy for the NP and its impact on the nursing practice and profession.
Pathways to Nursing Practice
According to the Health Professions Licensing Authority (Northern Territory), “…a Nurse Practitioner is a registered nurse educated to function autonomously and collaboratively in an advanced and extended role” (HPLA, 2010, p. 1). The NP role comprises of assessing and managing client health problems using nursing knowledge and expertise. Specifically, the NP may work autonomously to direct referral of clients to other healthcare experts, prescribe or recommend medications to patients, and order medical procedures such as diagnostic investigations. The NP “…role is grounded in the nursing profession’s values, knowledge, theories and practice and provides innovative and flexible healthcare delivery that complements other healthcare providers” (HPLA, 2010, p. 1).
NPs are increasingly being introduced and allowed to practice autonomously in all the states and territories of Australia (RCNA, 2008), and positive outcomes have been reported and documented especially in terms of bringing affordable health services closer to the people. This, according to the Government of South Australia (2005), has a multiplier effect since it does not only heighten consumer satisfaction but also brings about positive health outcomes for consumers.
However, many states have developed their own pathways to NP, though there are marked similarities especially in terms of basic qualifications for authorization, time-frames, and the roles that a practitioner is allowed to engage in upon accreditation (Dunn et al, 2010). The Northern Territory, for instance, have developed three pathways for registered nurses (RNs) who wish to be officially authorized to practice autonomously as NPs. The first pathway is for RNs who are certified, registered or sanctioned to practice as NPs by another Australian Nursing and Midwifery Board (HPLA, 2010). It is imperative to note that RNs registered or authorized by the New Zealand Nursing and Midwifery Board can also benefit from this pathway.
The second pathway for NP in the Northern territory is for RNs who have successfully “… completed a masters program accredited by the Nursing and Midwifery Board of the Northern Territory as leading to authorization as a Nurse Practitioner” (HPLA, 2010, p. 3). The third pathway is for RNs who are already engaged at an advanced practice level and voluntarily aspire to become endorsed as NPs but have not finished a clinically-oriented master’s program which is normally recognized by the NMB of the Northern Territory. In South Australia, the Nurses Board of South Australia (NBSA) is the authorizing agent for NPs.
Applicants are required a develop a portfolio that clearly identifies the NP band and Area of practice, commence a peer review, and attend a compulsory interview conducted by the board (NBSA, 2009). Other states and territories have their own routes of entry and eligibility criteria for the pathways to NP.
Identifying and Discussing the Challenge
It can be clearly established that although each state and territory in Australia have clearly defined pathways to NP, the role for the NP is still vaguely explained, not mentioning the fact that it “…does not have the autonomy that the nursing profession intended it would have and has merely shifted the profession’s sphere of influence within the existing models of care” (Turner et al., 2007, p. 39).
In the state of South Australia, the policy is clear that the NP’s role goes beyond the normal scope of nursing to include: clinical evaluation or assessment; interpretation of diagnostic examinations; implementing, administering, and monitoring therapeutic procedures, prescribing or recommending pharmacological methodologies, and instituting or receiving referrals (Government of South Australia, 2005). Other states and territories have clearly defined roles for the NP.
Many analysts, however, are of the opinion that the roles are mere rhetoric of policy since they do not fit within the current healthcare structure in Australia (Turner et al, 2007). Indeed, the authors note a huge gap between what official policies from nursing boards say about the role for the NP and the reality of implementation. Also, gaps exist in experiences of RNs working towards NP approval and endorsement and those already endorsed to practice (Dunn et al, 2010).
This is largely brought by the fact that Australian states and territories have approached the concept of role development for the NP differentially, with variations to the laid down rules, frameworks, guidelines, and procedures for authorization (Turner et al., 2007). The above have overbearing ramifications not only to the Australian nurses, but also to their practice. For instance, RNs spend a lot of time and resources to get authorization to practice autonomously or collaboratively, yet many end up not receiving the independence they so deserved due to role ambiguity and role conflict occasioned by healthcare structures in many Australian states and territories. As such, it can be safely argued that the role of NP do not fit into the current healthcare structure.
By and large, the contradictory role expectations of the NP at local health level are fuelled by deviating viewpoints and perceptions from various stakeholders (Turner et al, 2007). According to the authors, “…the perceptions of the NP role are further confused by an acceptance that the education and experience of NPs prepares them for the role which can provide the same services as that of doctors” (p. 41). This again points towards the idea of weak policies that have failed to cut a niche for the NP in Australia. The idea of developing the NP was informed by the need to bring quality and cheap health services closer to the consumers (Jennings et al., 2008), but the policies developed so far have inarguably failed to inspire the independence required for the NP to practice.
As demonstrated by Glenn et al (2007), the differing perceptions and viewpoints about the role of the NP have been so pronounced to a point of altering the perceptions of health consumers about the true role of the NP. This has obvious negative ramifications for the NPs in that they may end up loosing trust with consumers; not mentioning the fact their role remains largely unknown to the population. As such, NPs will always be incapable of realizing the independence that has been legitimatized by the various state or territorial policies unless their roles are clearly cut within the current healthcare structure.
The confusion of role expectations for the NP has led many individuals and organizations to mistake or substitute NPs for medical officers or doctors (Fact Sheet 1, n.d.). While it has been mentioned before that the main purpose of introducing the role of the NP was to assist in meeting the healthcare needs of the population, NPs cannot in anyway be substituted for doctors or medical officers although some stakeholders think that this is the case.
As a matter of fact, confusing them with doctors or medical officers has obvious negative connotations for the practice since NPs should first and foremost be evaluated as nurses, with higher educational preparation and experience, and who have been legally approved to practice in extended clinical nursing roles, including prescribing medications, conducting clinical assessments, and ordering diagnostic investigations across the acute, aged care, and community settings (Fact Sheet 1, n.d.). As such, they have a right to practice, and should be seen and perceived as such.
However, the current structure makes the NP appear to be surpassing the traditional boundaries and assuming the role of doctors and other medical professionals. This has caused some powerful organizations such as Australian Medical Association (AMA) to employ all forms of media to emphasize that there is no place for NPs in Australia’s healthcare system (Turner et al, 2007). Again, this points to the structural problems that are so domineering that the role of the NP is almost left in abyss. According to Turner et al (2007), the AMA is of the opinion that “…the move to independent nurse practitioners would dumb down the Australian health system” (p. 41).
The same organization is on record for saying that “…Australians expect and deserve higher quality healthcare, and it would be irresponsible for any governments to pursue medical workforce solutions that offer patients less than the best possible care” (Turner et al., 2007, p. 42). Such suggestions coming from a respectable organization such as the AMA serves to not only dampen the morale and practice capabilities of the NPs, but also attempts to question the role of the NP within the existing models of care. Certainly, this is a structural problem rather than a role differentiation problem.
Evaluating the Structural Problem in Relation to its Social-Political Determinants
The social-political determinants must be well demonstrated in any attempt geared towards the development of actual roles for the NP in addition to actively entrenching them into the current healthcare structure. It should be remembered that reducing health inequities and providing quality and affordable healthcare is a priority for the Australian government (Glenn et al, 2007). As such, the nurse practitioner has a clear mandate to ensure accessibility to quality and affordable healthcare (Reutter & Kushner, 2010).
In line with the above, it is known that the health and wellbeing of individuals and of populations is primarily determined by social and political factors (Kelly et al., 2007). The structural problem discussed in this paper has obliged many NPs not to exercise their autonomy in practice, not mentioning the fact that the current structure has not functioned effectively to elaborate and entrench the role of the NP (Turner et al, 2007). This problem derives from the fact that the policies that have been put in place to cut the roles for NPs are only rhetoric and are totally different from what is happening on the ground.
The political will is very much needed if any health policies are to be implemented and remain effective so as to better serve the health needs of consumers (Reutter & Kushner, 2007; Glenn et al, 2006)). The political will must come from all interested stakeholders charged with the responsibility of delivering quality healthcare services to people. This paper has demonstrated an entrenched lack of political goodwill in establishing the role of the NPs within the current care environment, thus the confusion.
Indeed, the AMA is on record for questioning the very existence of NPs and for vehemently arguing that allowing NPs to practice as doctors is irresponsible on the part of the government due to the ‘hazards’ involved. This reveals the extent of lack of political will, which is a critical determinant in ensuring healthcare to the population. If not checked, the problem is bound to initiate more health inequity in Australia.
What do the Findings hold for the Future?
It has been revealed that there exist substantial gaps between the rhetoric of various state and territory policies governing the practice of NP on the one hand and the implementation of the NP roles in many jurisdictions of Australia on the other. While it is clearly evident that many policies support the concept of autonomy for the NP, “…the experiences of nurses indicate a mere shift in the traditionally-accepted boundaries of nurses’ roles” (Turner et al., 2007. p. 44).
The question of differing perceptions and viewpoints is predominant even for the NPs themselves by virtue of the fact that NPs chasing their approval have different perceptions of their ‘would be’ extended roles than those already in practice (Gardner et al, 2008; Beadnell, 2006). Still, with many credible organizations such as the AMA questioning the rationale behind the establishment of the role of NPs, it is clear the discipline and practice is in a serious problem of role ambiguity or role contradiction.
The value of policy to guide the development of the NP in Australia is of critical importance. The pathways to NP need to be flexible and visionary to prepare NPs for practice, but the policy must be strongly enacted to ensure survival of this important practice. Any attempts to dilute the role of the NP will be met with negative consequences especially in attempts to ensure equitable and quality delivery of health services to the Australian population (Beadnell, 2006).
In terms of the nursing profession, the status quo will only serve to disillusion more RNs and curtail their desires of extending their knowledge since they are not sure whether they will get the autonomy to practice that is guaranteed by policy yet it is absent in practical implementation. When nurses don’t further their training or engage in specialization, it is the consumers who are going to lose the most in terms of quality healthcare (Barnes et al., 2006).
To conclude, the underlying principle stills remains the strengthening of the policy on autonomy and role of the NP so that the practice is comprehensively entrenched into the current healthcare structure. The importance of NPs in the provision of specialized healthcare has been well demonstrated (Dunn et al, 2008; Gardner et al, 2008). It is therefore up to the interested stakeholders, especially the governments and respective nursing boards, to work towards the actual formalization of the practice by implementing the policy at the most local level.
This will definitely alter the perceptions and viewpoints carried by various stakeholders on the role of the NP, and will also give them a bigger and clearer mandate to practice. NPs need not be seen as surpassing the traditional boundaries to assume the roles of other professionals; rather, they need to be perceived and evaluated as qualified professionals in their own right.
Barnes, L., Cheek, J., Naton, R.L., Gibert, A., Paradiso, L., & Ballantyne, A. (2006). Making sure the residents get the tablets: Medication administration in care homes for older people. Journal of Advanced Nursing, 56(2), 190-199. Web.
Beardnell, C. (2006). Putting the ‘care’ back into the aged care. Australian Nursing Journal, 13(9), 245-27. Web.
Dunn, S.V., Cashin, A., Buckley, T., & Newman, C. Nurse Practitioners prescribing practice in Australia. Journal of the American Academy of Nursing Practitioners, 22(3), 150-155. Web.
Fact Sheet 1. (n.d.). Nurse practitioner frequently asked questions. Web.
Fealy, G.M., Carney, M., Drennan, J., Tracy, M., Burke, J., O’Connell, D., Howley, B., Clancy, A., McHugh, A., Patton, D., & Sheerin, F. (2009). Models of initial training and pathways to registration: a selective review in professional regulation. Journal of Nursing Management, 17(6), 730-738. Web.
Furlong, E., & Smith, R. (2005). Advanced nursing practice: Policy, education and role of development. Journal of Clinical Nursing, 14(9), 1059-1066. Web.
Gardner, A., Hase, S., Gardner, G., Dunn, V., & Carryer, J. (2008). From competence to capability: A study of nursing practitioners in clinical practice. Journal of Clinical Practice, 17(2), 250-258.
Glenn, G., Grove, K., Dunn, S., Carryer, J., & Gardner, A. (2006). Competency and capability: Imperative for Nursing Practice Education in Australia. Australian Journal of Advanced Nursing, 24(1), 8-14. Web.
Health Professions Licensing Board. (2010). Web.
Hogan, P., Moxham, L., & Dwyer, T. (2007). Human resource management strategies for the retention of nurses in acute care settings in hospitals in Australia. Contemporary Nurse: A Journal for the Australian Nursing Profession, 24(2), 189-199. Web.
Jennings, N., O’Reilly, G., Lee, G., Cameron, P., Free, B., & Bailey, M. (2008). Evaluating outcomes of the emergency nursing practice role in a major urban emergency department, Melbourne, Australia. Journal of Clinical Nursing, 17(8), 1044-1050.
Kelly, M.P., Morgan, A., Bonnefoy, J., Butt, J., & Berman, V. (2007). Final report to World Health Organization Commission on the social determinants of health. Web.
Reutter, L., & Kushner, K.E. (2010). Health equity through action on the social determinants of health: taking up the challenge in nursing. Nursing Inquiry, 17(3), 269-280.
Royal College of Nursing, Australia. (2008). Nursing Practitioner National Network. Web.
Warburton, J., Bartlett, H., & Rao, V. (2009). Ageing and cultural diversity: policy and practice Issues. Australian Social Work, 62(2), 168-185. Web.
The Government of South Australia. (2005). Nurse Practitioner. Web.
Turner, C., Keyzer, D., & Rudge, T. (2007). Spheres of influence or autonomy? A discourse analysis of the introduction of Nursing Practitioners in rural and remote Australia. Journal of Advanced Nursing, 59(1), 38-46. Web.
Venturato, L., Kellet, U., & Windsor, C. (2006). Searching for value: The influence of policy and reform on nurses’ sense of value in long-term aged care in Australia. International Journal of Nursing Practice, 12(6), 326-333. Web.