Submission on Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill

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1 Nurse Practitioners New Zealand A division of the College of Nurses Aotearoa (NZ) Inc PO Box 1258 Palmerston North 4440 p: w: Date: 6 October 2015 Submission on Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill Written submission to Health Committee, Select Committee Services from Nurse Practitioners New Zealand (NPNZ). Prepared on behalf of NPNZ by Carol Slight, Nurse Practitioner NPNZ Executive Member Jane Jeffcoat Nurse Practitioner Chair NPNZ For Mental Health Nurse Practitioners NZ Mark Baldwin, Nurse Practitioner Secretary NPNZ Statement of Intent The Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill is a consequential legislation giving effect to the Health Practitioners Competency Assurance Act NPNZ make this submission for the explicit purpose of enabling Nurse Practitioners to work toward the full extent of their scope of practice within the Act. The amendments will not change the Nurse Practitioner scope, in fact they will make practice more transparent, reducing the need for work around solutions where the Nurse Practitioner delivers the care only to require a Medical Practitioner to sign a form, which contributes to unnecessary administration, delays and patient burden. 1

2 is open to all New Zealand registered Nurse Practitioners. We are a division of the College of Nurses Aotearoa. We have 122 members of approximately 145 Nurse Practitioners in New Zealand (as at Sept 2015). Our aims are to: 1. Promote excellence in advanced clinical nursing through practice, education and research 2. Enhance capacity of the Nurse Practitioner practice in New Zealand 3. Provide Nurse Practitioner leadership for legislation, regulation and policy development 4. Provide resource and consultation for healthcare practice in New Zealand Nurse Practitioners (NPs) are registered by Nursing Council under the Health Practitioners Competency Act Nurse Practitioners work within a specific area of practice incorporating advanced clinical knowledge and skills into their care. They work both independently and in collaboration with other health practitioners to provide expert care within different health care settings. They can assume full clinical responsibility for the care and treatment of patients within their area of expertise. The Nurse Practitioner role was introduced in 2001 to provide alternatives to the traditional health care model and provide an effective and efficient model of health care in a time of increasing pressure on the health care system both primary, secondary and tertiary. Research has shown that Nurse Practitioners have delivered on these expectations. Nurse Practitioners have been unable to work to the full extent of their full scope of practice and capabilities due to restrictions within law that limit our abilities to assume full care and treatment of patients. The intention of combining skills and knowledge, once the sole domain of medicine, with advanced nursing practice to create the Nurse Practitioner scope of practice was to provide an effective and efficient alternative model of health care delivery which would enable greater substitution between groups, thereby promoting efficiency and flexibility in the use of valuable resources in times of predicted doctor shortages and where resources and therefore the public s access to healthcare are limited. This submission is based on the principle and intent of the development of the Nurse Practitioner role in New Zealand; that it become an integral intermediary health role within the health system and be utilised in the broad way it was intended. The changes made through the Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill will ensure that the Nurse Practitioner role is utilised in all aspects of health care in line with the competencies and training of the scope, decreasing the risk of underutilisation of the Nurse Practitioner role. This submission is in support of the amendments of seven Acts identified in the Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill. The members of NPNZ have been consulted in the preparation of this submission. 2

3 We wish to make the make the following comments. Part 1 Amendments to Accident Compensation Act 2001 We support the proposal to amend the clause 7(3)(b), 7(5) and 13(1)(b) from Medical Practitioner to lead Health Practitioner. This recognises that Nurse Practitioners with their expert clinical knowledge and skills assess, diagnose and independently manage patients who require treatment or rehabilitation under the Accident Compensation Act. The amendments recognise the independent care that Nurse Practitioners provide. In some areas, particularly rurally, Nurse Practitioners are an important component to overall health care delivery and lead clinical care. What Nurse Practitioners do in practice, is safe and efficient and is accepted. The change just legitimises practice and is therefore more transparent. Nurse Practitioners as Healthcare Practitioners currently take the lead role in managing patient care. A number of Nurse Practitioners describe their daily roles in Primary Health and Emergency settings completing ACC 45 and 18, time off work, ordering orthotics as the lead carer as would a Medical Practitioner. Part 2 Amendments to Burial and Cremation Act 1964 At present, within the Burial and Cremation Act 1964, there is restriction in who can certify death. The amendments proposed amend this from a doctor s certificate to a certificate of cause of death. These changes recognise that Nurse Practitioners have a clinical lead role in the care of patients during an illness and should therefore be the expected Health Practitioner to provide a certificate of cause of death. In rural and isolated environments and in aged residential care there is often delay in the certification of death because of lack of access to a Medical Practitioner. This delay results in distress for the bereaved. In aged residential care and Hospice care, Nurse Practitioners lead the care of residents, particularly in palliative care situations. When there is a death the Nurse Practitioner must rely on a GP colleague who may not have been involved in that persons care to complete the death and cremation certification. Amendments to the Act enabling Nurse Practitioners to provide certificate of death and cremation would improve continuity of care and ensure that the deceased are certified in a timely manner. Increasingly cultural and religious considerations demand urgency in certifying death as burial and cremation is time critical for an ever increasing number of New Zealanders. We support the amendments to all the sections identified within the Burial and Cremation Act 1961 from doctors certificate to certificate of death and the amendments that allow the practitioner certifying death to be either a Medical or Nurse Practitioner. 3

4 Part 3 Amendments to Children s, Young Persons, and their Families Act 1989 We support the amendments to the Children s, Young Person s and their Families Act 1989 that recognise the role that Nurse Practitioners have in managing children, young people and their families. We support the amendments to change the wording from Medical Practitioner to Health Practitioner. Nurse Practitioners are able to assess, diagnose and treat a broad range of conditions within their scope of practice and these include children and young persons with their families. It is important to recognise that Nurse Practitioners may be the lead practitioner in the care and management of patients and therefore without the amendments proposed in this Bill Nurse Practitioners are not able to work fully to the extent of their knowledge and skills. A number of Nurse Practitioners describe how they are called upon by Child Youth and Family Services to provide clinical examinations and care to children under CYFs care in their practice setting. They may be the only Health Practitioner available at the time or able to provide a service in a timely manner or in sensitive cases of where consideration of Practitioner gender may be appropriate. Part 4 Amendments to Holidays Act 2003 We support the proposal to amend Section 68 Proof of Sickness or Injury of the Holidays Act 2003 from Medical Practitioner to Health Practitioner. Nurse Practitioners have assumed full clinical responsibility of patients but have been unable to provide patients with proof of sickness or injury. At present the Act specifies Medical Practitioner. This has led to Medical Practitioners who have had no input into the care and management of patients being asked to provide proof of sickness or injury. This is unacceptable practice and should be able to be provided by the lead clinician. We support the change to Health Practitioner to allow for suitably qualified Health Practitioners to be able to provide proof of sickness or injury. Many rural Nurse Practitioners describe completing off work certificates rather than Medical Certificates as another work around. Nurse Practitioners are recognised as lead carers in many areas and business accepts off work certificates related to sickness or injury from them. Part 5 Amendments to Land Transport Act 1998 The amendments to change the Land Transport Act 1998 from Medical Practitioner to Health Practitioner recognise the changing health care environment in New Zealand. We support the changes to the wording within the amendments from Medical Practitioner to 4

5 Health Practitioner which recognises advanced clinical skills that Nurse Practitioners have that enable them to perform the tasks dealt with within the Land Transport Act The current Land Transport Act 1998 states that only medical doctors and optometrists are able to certify persons fit or unfit to drive based on their physical or mental condition. The supported amendments change the wording from Medical Practitioner and Optometrist to Health Practitioner. This recognises that Nurse Practitioners have the expert clinical knowledge and skills to provide this certification of patients. At present all driving licence issues are dealt with by Medical Practitioners and Optometrists even if they are not the lead clinician responsible for the patient who may complete the assessment but have another Health Practitioner sign off. NPNZ supports amending the wording in sections 60, 64, 72, 73, 74, 75, 76, 79, 99, 100, 100A and 209 from Medical Practitioner to Health Practitioner. In some clinical settings a Nurse Practitioner or a Registered Nurse is the lead clinician on duty/on call. Currently parts of the Blood Specimen Medical Certificate can be completed by Health Practitioners other than Medical Practitioners but Part A and D require a Police employee, Medical Practitioner or Medical Officer to complete. Part B requires a Medical Practitioner in charge of person s care to complete. Many Nurse Practitioners describe delays while waiting for a Medical Practitioner to sign the form for a person they haven t been clinically involved with. This may cause delays particularly within the acute and rural contexts when Medical Practitioners are not immediately available or at a distance. It is important to stress that access to blood sampling is time critical and delays may affect the ability to prosecute or provide protection to the public. Part 6 Amendments to Mental Health (Compulsory Assessment and Treatment) Act 1992 NPNZ support the changes to the Mental Health (Compulsory Assessment and Treatment) Act However the current amendments do not address a number of other sections of the Act which we request be considered within the Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill. The Mental Health (Compulsory Assessment & Treatment) Act 1992 (MHA) was last reviewed in This was prior to the introduction of the Nurse Practitioner Scope of Practice (2001), or Health Practitioners Competency Assurance Act 2003 and therefore has a number of sections 8 (b), 10 and 11 which relate to certificates of preliminary assessment now out of date within current health workforce practice. Mental Health Act: Responsible Clinician Role Section 7 of the MHA allows for the Responsible Clinician role to be fulfilled by other appropriately trained and competent practitioners. The..Responsible Clinician, who shall 5

6 be. b) some other registered health professional who, in the opinion of the Director of Area Mental Health Services, has undergone training in, and is competent in, the assessment, treatment, and care, of persons with a mental disorder. Mental Health Nurse Practitioners are currently assuming the Responsible Clinician (RC) role for people receiving compulsory assessment and treatment under the MHA as the competencies of the Nurse Practitioner role encompass the skills required to perform this duty. As defined in Section 2, Nurse Practitioners are in many instances the clinician in charge of the treatment of that patient. It logically follows that if Nurse Practitioners have the assessment skills for the Responsible Clinician role that those same assessment and diagnostic skills would be applicable to the preliminary assessment of proposed patients in Sections 8b; 10 and 11. Section 8B. Medical Practitioner s certificate to accompany application for assessment This submission supports that the term Medical Practitioner/officer in Section 8B is amended to include Health Practitioner and furthermore in section 2 that Nurse Practitioner in relation to the MHA be defined as A Nurse Practitioner with an area of practice of Mental Health Section 9. Assessment examination to be arranged and conducted This submission supports that the term Medical Practitioner/officer and Psychiatrist in Section 9 is amended to include Health Practitioner as it is within the Nurse Practitioner competencies to assess and diagnose. Section 10. Certificate of preliminary assessment Section 9(3) of the Act describes the qualifications necessary to perform an assessment examination. The person must be a Medical Practitioner who is either a psychiatrist approved by the DAMHS or, if no psychiatrist is reasonably available, some other Medical Practitioner who is suitably qualified to conduct the assessment examination in the opinion of the DAMHS. This submission supports that the term Medical Practitioner/officer in Section 10 is amended to include appropriately qualified Health Practitioner, that being a Nurse Practitioner within the Mental Health area of practice. Section 11. Further assessment and treatment for 5 days It should be noted that from subsection (3) of Section 11 all references relating to the person in charge of the patient reverts to the term responsible clinician, as defined in section 2 and this is a role Nurse Practitioners are currently legally entitled to, and do, undertake. It is worth noting that subsequent sections, which also restrict a person s liberty, refer to responsible clinician in Sections 12, 13, 14, 29 and 30. 6

7 This submission supports that the term Medical Practitioner relating to section 11 is also amended to include Responsible Clinician as it is within the Nurse Practitioner scope of practice competencies to assess and diagnose. There are various other sections in the MHA that make reference to Medical Practitioner relate to the assessment process, and would require changing in relation to the proposed changes: Section 38; 45(4)(d); 50(1); 59(2); 60 (b); 69; 109; 110; 134, which would require amendment to replace Medical Practitioners with Health Practitioners. Paradox in Practice due to the MHA being enacted prior to the NP role Nurse Practitioners are restricted from working to the full extent of their scope of practice and therefore under-utilised in regard to the MHA due to the MHA being enacted and subsequently reviewed, prior to the conception of the Nurse Practitioner role. As a result Medical officers with little experience in mental health are authorising Section 8b and 10 assessments often under the guidance of Mental Health Nurse Practitioners. In conclusion, by enabling Nurse Practitioners to assess under Sections 8b and 10 of the Mental Health (Compulsory Assessment and treatment) Act 1992 it will: Offer a more responsive service; It will streamline how proposed patients are being assessed, for example, a high percentage of the Mental Health Nurse Practitioners are providing services in rural areas where there is limited access to Psychiatrists and it is often difficult to access a GP quickly. The ability of the Nurse Practitioner to complete Sections 8B and 10 will allow for a more responsive and timely interventions to people in rural areas. Offer assessment by the most appropriate clinician Will offer an alternative to Medical Practitioners who may have limitations in their level of expertise in the assessment and diagnosis of mental disorders compared to Mental Health Nurse Practitioners. Utilise the Nurse Practitioner role broadly as was intended and to their full scope of practice. Part 7 Amendments to Misuse of Drugs Act 1975 We support the amendments within the Misuse of Drugs Act 1975 and can report that amendments since July 2014 have greatly improved Nurse Practitioners ability to provide for the care of patients in a number of practice settings including Palliative care. However there remain some sections within this Act as well as others that continue to limit the ability of Nurse Practitioners to work to the full extent of their scope of practice which are highlighted in Part 8. 7

8 Part 8. Supplementary Considerations Amendments to Misuse of Drugs Act 1975 NPNZ endorse the submission by Nurse Practitioners from Drug and Alcohol Nurses Australasia (DANA) and request that Select Committee consider the proposed submission. Nurse Practitioners currently work in settings where they are lead carers for people with addictions completing assessments and advising on prescriptions that a Medical Practitioner who may not have the same level of knowledge in that area of practice will sign. Medicine's Act 105 B1 Nurse Practitioners have come to realise that as a proverbial door opens (due to legislative change/amendments to acts), it reveals that other doors are closed (due to regulative barriers). Nurse Practitioners are authorised prescribers and lead carers who provide clinical oversight to nurses within the Registered Nurse scope of practice. However Nurse Practitioners are unable to supervise Registered Nurse Designated Prescribers under Clause D. In addition, the Standing Orders Regulation limits Nurse Practitioners from supervising and issuing standing orders that are within our area of practice. This regulation can be problematic for Primary Health Care Nurse Practitioners where there is an emphasis by Ministry of Health for working in PHC groups. There may be no General Practitioner on site and the Nurse Practitioner is often working with practice nurses. If Nurse Practitioners are unable to sign off standing orders then it can create delays in patient care for simple issues that can be managed by standing orders. We acknowledge that Minister Coleman has announced changes to the Standing Orders Regulations that should happen with the appropriate amendments made outside of the regulatory review and we look forward to seeing the required amendment made to the Regulations in the near future. Social Security Act While not within the scope of Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill there is a need for this Act to be reviewed. At present Nurse Practitioners conduct the assessments and prepare the documents to be signed by a designated General Practitioner and they need to agree with the findings. In some cases these findings are then referred to a designated General Practitioner by WINZ for completion. The revisions need to look at the system and make this more workable for those applying for these benefits for their patients. In some instances Nurse Practitioners can complete the certification but not the examination. A simple change of wording from Medical Practitioner to Health Practitioner would overcome these barriers. Thank you for amending these seven acts that will allow Nurse Practitioners greater flexibility and ability to more effectively undertake their roles in providing patient care and 8

9 also your consideration of the supplementary points. Nurse Practitioners are ideally positioned within their areas of practice to know which of the amended acts are applicable to their practice environments. Greater access and improved health outcomes will result from Nurse Practitioners being enabled to work towards the full extent of their scope. The Health Practitioner Competency Assurance Act 2003 has set a foundation for future proofing New Zealand health workforce development and policy making. The Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill embeds the general term Health Practitioner into Legislation. If this Bill is successful it will simplify and coordinate legislation to facilitate workforce innovation and efficiency. It is safe; it does not change Health Practitioner scope of practice, just enables Health Practitioners to utilise it fully; it will improve the efficiency of the health system, reduce costs and improve access to healthcare. The Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill is an enabler to Nurse Practitioners within their existing scope of practice and as such NPNZ request that on passing the Bill there be no delay in enacting the changes. On behalf of NPNZ and the clients cared for by Nurse Practitioners in New Zealand we thank you. Sincerely, Jane Jeffcoat RN, NP, MN (Hons), FCNA (NZ) Chair, NPNZ Nurse Practitioner Taumarunui Emergency Department Waikato DHB Mark Baldwin NP, RN(Mental Health), Msc (Mental Health), PG Dip (Health Sciences) B.A. (Hons) Nursing Studies Secretary NPNZ Nurse Practitioner Southern DHB Carol Slight, RN, NP, MN (Hons), MCNA (NZ) Executive Member, NPNZ Nurse Practitioner Ophthalmology Greenlane Clinical Centre Auckland DHB 9

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