Clinical Governance for Nurse Practitioners in Queensland

Transcription

1 Office of the Chief Nursing Officer Clinical Governance for Nurse Practitioners in Queensland A guide

2 Clinical Governance for Nurse Practitioners in Queensland: A guide Queensland Health Office of the Chief Nursing Officer Clinical Governance for Nurse Practitioners in Queensland: A Guide ISBN The State of Queensland Copyright protects this publication. However, the Queensland Government has no objection to this material being reproduced with acknowledgement, except for commercial purposes. Permission to reproduce for commercial purposes should be sought from: Senior Administrative Officer Policy Branch Queensland Health PO Box 48 Brisbane 4001 Preferred citation: Queensland Government 2011 Clinical Governance for Nurse Practitioners in Queensland: A guide Queensland Government, Brisbane An electronic version of this document is available at

3 Foreword At this exciting time in the history of nursing in this country, national health reform has provided opportunities for nurse practitioners to lead the way in specialist nursing care delivery. Nurse practitioners are acknowledged as essential to the health care system not only for the responsive care they are able to deliver to patients, but also the benefits that patients can now access under Medicare Australia. Nurse practitioners are highly specialised, skilled and competent clinicians. However, their full potential is yet to be realised. I am confident this will occur as increasingly they take their place in a broader range of health care settings. Members of the nursing profession are responsible now more than ever for advancing the role of the nurse practitioner and ensuring professional standards are maintained. The benefits of the nurse practitioner role need to be supported by research and evidence to more effectively inform health care policy and service development at the local, state and national level. This document Clinical Governance for Nurse Practitioners: A guide supports nurse practitioners to practise in the capacity at which they are authorised, legislated and competent. The document can be used in any setting where nurse practitioners may be employed, including the public and private sectors. The revised Drug Therapy Protocol for Nurse Practitioners and condition for an approved Practice Scope is more relevant to contemporary nurse practitioner practice. It recognises that the nurse practitioner role is dynamic and responsive to the needs of clients and employers. This change represents new opportunities for nurse practitioners to expand their role in the current health care environment. Clinical Governance for Nurse Practitioners in Queensland: A guide Pauline Ross Chief Nursing Officer Queensland Health 1 1

4 Contents Introduction 4 1. Overview 4 2. Purpose 5 3. Application 5 4. How to use this guide 5 5. Conflict with legislation 6 6. Updates 6 Section 1. Understanding the role 8 1. Overview 9 2. Guideline Definitions 9 3. What is a nurse practitioner? First and foremost a nurse Extended practice National nurse practitioner competency framework Working autonomously and collaboratively Is a practice nurse the same as a nurse practitioner? Professional regulation Protection of title Eligibility 13 Section 2. Developing a model of care Overview Guideline The model of care Consultation Clarifying the service need Clarifying the clinical nursing role Defining the practice scope of the nurse practitioner Describing the practice environment, clinical service and clinical service measures Practice scope approval Publication Review 23 Section 3. Right person, right skills, safe practice environment Overview Guideline Nurse practitioner candidates Definition Employment as a nurse practitioner candidate Clinical internship or supported clinical practice Clinical supervision and mentoring Nurse practitioner endorsement Credentialing and defining the scope of clinical practice Definition Credentialing principles Adopting Queensland Health s policy Outcomes 30 Section 4. Extended clinical practice Overview Guideline Continuing professional development Prescription of medicines Statutory authority Drug Therapy Protocol for Nurse Practitioners 33 2

5 4.3 Components of prescribing Prescribing competency framework List of personal or preferred drugs (P-drugs) Supplementary prescribing Quality use of medicines (QUM) Use of blood and blood components Regulation Prescribing blood and blood components (blood transfusion) Diagnostic services Pathology Pathology services Quality use of pathology AUSLAB Pathology Management System Private pathology Diagnostic services Diagnostic imaging Diagnostic imaging Requests Diagnostic Radiography Protocol Diagnostic interpretation Medicare and the Pharmaceutical Benefits Scheme National health care system Medicare Benefits Schedule (MBS) Pharmaceutical Benefits Scheme (PBS) Repatriation Pharmaceutical Benefits Scheme (RPBS) Eligible nurse practitioner Delegation, referral and clinical handover Issuing certificates General principles Workers Compensation Certificates Centrelink Fair Work Act 2009 (Commonwealth) Reportable deaths Cause of death certificate Healthcare-related deaths 51 Contents Section 5. Clinical audit and review Overview Guideline Quality assessment framework Outcomes 54 Summary 55 Governance checklist 56 References 57 Appendices 58 Appendix A: Templates Practice Scope of the Nurse Practitioner 58 Appendix B: Audit tools 64 Contact details 67 Figures Figure 1: Principles of governance 7 Figure 2: Critical success factors for the nurse practitioner role 9 Figure 3: Comparison across nursing roles 18 Figure 4: Practice scope of the nurse practitioner (example) 20 Figure 5: Four components to prescribing 34 Figure 6: SBAR tool

6 Introduction 1. Overview Queensland is the fastest-growing State in Australia, with population growth nearly double the national average. Our health system is contending with a growing and ageing population, high birth rates, increasing cases of mental illness and preventable disease, and an unacceptable gap in Indigenous life expectancy. Nurse practitioners are one of a number of roles introduced in Queensland to deliver innovative and flexible health care solutions to meet the needs of individuals, families and communities. The nurse practitioner role was formally introduced in Queensland in 2006, following a successful trial of practice conducted in 2005 in a number of Queensland Health facilities. Nurse practitioners are now well integrated statewide across public and private sectors in a range of metropolitan, regional, rural and remote health services. This document reflects the contemporary health care landscape and legislative change underpinning the role of the nurse practitioner. It also reflects the recognition of the importance of the role in improving access, and delivering quality, dependable health care for all Queenslanders. 2. Purpose This guide has been developed as a practical tool to provide clear and concise information about the implementation and governance of the nurse practitioner role in Queensland. The goal is to assist health administrators, nurse practitioners and their employers to understand the critical success factors necessary to realise the full potential of the nurse practitioner role. This guide outlines fundamental good practice for the governance of the nurse practitioner role and makes explicit the standards to which all nurse practitioners and their employers should aspire. The intent is to: assist the growth and development of a flexible and responsive nurse practitioner workforce based on a culture of innovation, learning and continual improvement support health service planning and integration of new models of care resolve the recurrent and persistent barriers that prevent nurse practitioners from realising their full potential protect patient safety through clinical governance provide a framework for continuous quality improvement, which supports evaluation of health services provided by nurse practitioners. 4

7 3. Application The principles within this document apply to all nurse practitioners in Queensland, irrespective of the context and health service setting in which they practise. They are relevant for public and private sector health services, as well as private practice settings. Introduction Nurse practitioners and their employers have a professional and regulatory responsibility to apply these underlying principles. The Clinical Governance for Nurse Practitioners in Queensland: A guide may also be used to assist regulators, such as the Nursing Midwifery Board of Australia (NMBA), the Chief Health Officer and any other statutory bodies, such as the State Coroner, Health Quality and Complaints Commission and the Courts, in reviewing the decisions and actions of nurse practitioners and their managers. 4. How to use this guide This guide is presented in five sections, that deal with the key concepts of nurse practitioner models of care (see also figure 1 on page 7). Section 1: Understanding the role Lack of understanding about nurse practitioners is a recurrent theme and a persistent barrier to full implementation of the role. The purpose of this section is to clarify the nurse practitioner role and identify the critical success factors that are essential to realising the full potential of nurse practitioner models of care. Section 2: Developing a model of care Each model of care must be defined and clearly articulated to inform health consumers (patients/clients), nurses, medical practitioners, pharmacists, health care administrators and other health professionals about the nurse practitioner s role. This section provides guidance on developing innovative health care solutions based on health service planning principles, defining the scope of clinical practice of each position, and identifying the service capability of the health service setting in which a nurse practitioner is engaged (the practice scope). Section 3: Right person, right skills, safe practice environment The scope of clinical practice of each nurse practitioner is specific to the context of practice and is determined by the clinical specialty in which the nurse practitioner is educated, competent and authorised to practise. This section provides guidance on clinical supervision and mentoring for nurse practitioner candidates, endorsement as a nurse practitioner, and an overview of credentialing and defining the scope of clinical practice of the individual nurse practitioner. Section 4: Extended clinical practice A nurse practitioner is educated and authorised to function autonomously and collaboratively in an advanced and extended clinical role. This includes 5

8 Introduction undertaking roles and responsibilities not ordinarily associated with nursing, including prescribing medication, ordering and interpreting diagnostics. This section provides guidance on the extended practice privileges that are available to nurse practitioners. Section 5: Clinical audit and review Clinical audit is an important tool for continuous quality improvement for all clinicians. Safety and quality of nurse practitioner service must be evaluated against indicators that are relevant to the clinical service and patient outcomes. This section provides guidance for auditing a nurse practitioner model of care. 5. Conflict with legislation For completeness, this guide must be read and understood with the laws, codes and regulations that apply to nurse practitioners at both a state and federal level, and with the nationally accepted clinical practice standards that are relevant to each nurse practitioner s specialist area of clinical practice. In the event of conflict or overlap between these principles and the requirements of relevant Commonwealth and State legislation, the requirements of the legislation prevail over the principles, to the extent of the conflict or overlap. 6. Updates The contents of this document will be updated over time. Individuals looking for guidance and support about nurse practitioner governance should ensure that they refer to the most recent edition of this publication, plus any other national guidance, legislation and directives that may have been subsequently produced. More information is available from the following sites: Office of the Chief Nursing Officer Nursing and Midwifery Board of Australia Australian Nursing and Midwifery Accreditation Council Australian College of Nurse Practitioners Clinical Guidelines Portal Medicare Australia Workers Compensation Regulatory Authority National Prescribing Service Royal College of Nursing Australia Health Quality and Complaints Commission

9 Figure 1: Principles of governance Section 1 1. Understanding the role Respect and recognition Innovation Collaboration Introduction Autonomy Role clarity Safety and quality Outcome Supportive clinical environment which values nurse practitioners Section 2 2. Developing a model of care Health service need Clinical nursing scope Service capability Outcome Defined practice scope for nurse practitioner solution Section 3 3. Right person, right skills, safe practice environment Nurse practitioner candidate Endorsed nurse practitioner Outcome Competent nurse practitioners provide quality care in safe service environments Section 4 4. Extended clinical practice Prescribing Diagnostics Radiography Pathology Outcome Extended practice privileges are appropriate and necessary to practise nursing within the regulatory framework Section 5 5. Clinical audit and review Outcome Continuous quality improvement in nurse practitioner models of care 7

10 Section 1 Understanding the role SECTION 1 Understanding the role 1. Overview To address structural pressures on the health system and to better meet changing health care needs of the population, the National Health Workforce Strategic Framework identified a clear requirement to develop new and innovative models of care for health care service delivery recognising that: the accepted limits of existing professional roles may need to evolve opportunities exist to explore the flexibility of the workforce, including innovative approaches to skill mix and new workforce roles, and changes to scope of practice (AHMC, 2004). Nurse practitioners have existed in some countries for more than 40 years and there is consistent published evidence that this role is a positive innovation in health workforce reform. The nurse practitioner role is ideally suited to meet the challenges of an ageing population and the increasing prevalence of chronic disease and preventable illnesses requiring lifelong health care. Despite this, implementation of the nurse practitioner role in Australia has been a protracted process. In particular, lack of understanding about the nurse practitioner role is a recurrent theme and a persistent barrier to full implementation and utilisation of the role. The purpose of this section is to explain the nurse practitioner role, differentiating the practice of nurse practitioners from advanced practice nurses, medical practitioners and other health professionals. In addition, this section identifies the critical success factors that are essential to realising the full potential of nurse practitioners. 8

11 2. Guideline Figure 2 outlines the critical success factors that are essential to realising the full potential of nurse practitioner models of care. Figure 2: Critical success factors for the nurse practitioner role Patient-centred Safety and quality Collaboration Autonomy Role clarity Innovation Respect and recognition Supportive environment Full potential Section 1 Understanding the role 2.1 Definitions Respect and recognition Innovation Role clarity Autonomy Collaboration Safety and quality A supportive environment is required which respects and recognises nurse practitioners as one of the most highly qualified and experienced registered nurses within the health care system who are: competent, capable and authorised by law to make informed and autonomous decisions about preventative, diagnostic and therapeutic care individually liable and accountable, under professional regulation and civil and criminal law, for their decisions and actions. Access to health services can be improved by integrating innovative and flexible patient-centred models of nurse practitioner care across the full continuum of health care, providing a seamless transition for patients as they move across health service settings. The clinical parameters of each nurse practitioner model of care must be clearly defined and articulated to assist health consumers, nurses, medical practitioners, pharmacists, health care administrators and other health professionals to understand the nurse practitioner role. To achieve their full potential, nurse practitioners require the autonomy to exercise their professional judgement within the parameters of evidencebased care in the clinical specialty in which they are educated, competent and authorised to practise. The relationship between all health care professionals involved in the care of the patient must be underpinned by mutual respect. Clear communication in which the different disciplines pool their specialised knowledge and expertise, and engage in collective action to optimise health outcomes. A robust framework is required to protect the health and safety of the patient and the community by ensuring only competent nurse practitioners provide extended clinical services, and that these services are provided within environments that support safe service delivery. 9

12 Section 1 Understanding the role 3. What is a nurse practitioner? A nurse practitioner is a registered nurse educated and authorised to function autonomously and collaboratively in an advanced and extended clinical role. The nurse practitioner role includes assessment and management of clients using nursing knowledge and skills and may include, but is not limited to, the direct referral of patients to other health care professionals, prescribing medications and ordering diagnostic investigations (ANMC, 2006). Nurse practitioners are clinical leaders who influence and progress clinical care, policy and collaboration through all levels of health service. They provide innovative and flexible health care delivery that complements other health care providers. Nurse practitioners were formally introduced in Queensland in 2006 and are now well integrated statewide across public and private sectors in a range of metropolitan, regional, rural and remote health services, and clinical settings including: emergency care (adult/paediatric) acute pain management (adult/paediatric) mental health (adult) respiratory disease (adult) wound management neonatal services cystic fibrosis (adult/paediatric) chronic heart failure heart transplant recipients inflammatory bowel disease (adult) palliative care (adult/paediatric) aged care (altered cognition) type 1 and type 2 diabetes mellitus sexual and reproductive health chronic kidney disease (including dialysis) urology services (adult) primary health care cancer services (adult/paediatric) rural and remote substance use disorders. 3.1 First and foremost a nurse A nurse practitioner is first and foremost a registered nurse, with expert skills in the assessment, diagnosis and management of a person s health needs within a particular population group, or a specialist field of nursing practice. Nurse practitioners support patients and their families across the full continuum of health care to integrate the best strategies for the promotion and restoration of health, prevention of illness, and care of the ill, disabled and the dying person. Nurse practitioners are not medical substitutes. Although they use some skills from medicine and other health professions (such as dietetics and physiotherapy), their role is firmly grounded in the nursing profession s values, knowledge, theories and practice. 10

13 3.2 Extended practice The practice of nurse practitioners is an extension of advanced practice nursing. Nurses practising at an advanced level may be educationally prepared at post-graduate level and may work in a specialist or generalist capacity. However, the basis for recognition of advanced practice is the high degree of knowledge, skill and experience that is applied within the nurse-patient/ client relationship to achieve optimal outcomes, through critical analysis, problem-solving and accurate decision-making (ANMC 2006). Nurse practitioners are educationally prepared at post-graduate level and have specialist knowledge and skills with authority to use extended practice privileges to make informed and autonomous decisions about preventative, diagnostic and therapeutic management. In Australia, this is underpinned by professional regulation which protects the title of nurse practitioner and through state legislation, authorising nurse practitioners to prescribe, use plain film diagnostic radiography and issue Workers Compensation certificates. Section 1 Understanding the role The nurse practitioner is a leader in all dimensions of nursing practice, and provides health service leadership from the perspective of a senior clinician. The nurse practitioner leads through any number of roles, including researcher, clinical teacher, case co-ordinator and spokesperson, and in this capacity may take responsibility for assisting the public, policy-makers and other health care professionals to understand the nurse practitioner role to influence care delivery systems (ANMC, 2006). 3.3 National nurse practitioner competency framework The Australian Nursing and Midwifery Council s (2006) National Competency Standards for the Nurse Practitioner identify the parameters of nurse practitioner practice. These standards are outlined here. Standard 1 Dynamic practice that incorporates application of high-level knowledge and skills in extended practice across stable, unpredictable and complex situations Competency 1.1 Competency 1.2 Competency 1.3 Competency 1.4 Conducts advanced, comprehensive and holistic health assessment relevant to the specialist field of nursing practice Demonstrates a high level of confidence and clinical proficiency in carrying out a range of procedures, treatments and interventions that are evidence-based and informed by specialist knowledge Has the capacity to use the knowledge and skills of extended practice competencies in complex and unfamiliar environments Demonstrates skills in accessing established and evolving knowledge in clinical and social sciences, and the application of this knowledge to patient care and the education of others 11

14 Section 1 Understanding the role Standard 2 Professional efficacy whereby practice is structured in a nursing model enhanced by autonomy and accountability Competency 2.1 Competency 2.2 Competency 2.3 Applies extended practice competencies within a nursing model of practice Establishes therapeutic links with the patient/client/ community that recognises and respects cultural identity and lifestyle choices Is proactive in conducting clinical service that is enhanced and extended by autonomous and accountable practice Standard 3 Clinical leadership that influences and progresses clinical care, policy and collaboration through all levels of health service Competency 3.1 Competency 3.2 Engages in and leads clinical collaboration that optimises outcomes for patients/clients/communities Engages in and leads informed critique and influence at the systems level of health care 3.4 Working autonomously and collaboratively To achieve their full potential, nurse practitioners require the freedom to exercise professional judgement within the parameters of evidence-based care and the scope of their extended competence. This does not mean that nurse practitioners function in isolation. Collaboration is integral to their practice. It is fundamental good practice for nurse practitioners to make the care of the patient their primary concern, communicating effectively with other health care professionals caring for the patient, acknowledging and respecting the contribution of all health care providers. Successful collaboration in a multidisciplinary environment requires that: nurse practitioners actively participate as senior members and/or team leaders of the relevant multidisciplinary team the different disciplines share patient information with each other and engage in planning and prioritising patient care through collective action, by pooling their specialised knowledge and expertise to achieve a common goal. The National Health (Collaborative arrangements for nurse practitioners) Determination 2010 outlines the kinds of collaborative arrangements that may be established by eligible nurse practitioners for patients to claim rebates under the national health scheme. 3.5 Is a practice nurse the same as a nurse practitioner? 12 No. A practice nurse is a registered nurse or an enrolled nurse who is employed by, or whose services are otherwise retained by, a general medical practice to provide a range of primary health care services as the delegate, or on behalf, of a medical practitioner. This includes the: Generalist Practice Nurse Model a clinical support role in which the practice nurse undertakes clinical duties as the delegate of a medical practitioner

15 Advanced Practice Nurse Model providing clinics and other health services on behalf of a medical practitioner in diabetes, asthma, women s health (including Pap smears, breast checks and family planning advice) and health promotion, including immunisation, smoking cessation and weight loss. The medical practitioner, under whose supervision the clinic or health service is provided, retains responsibility for the health, safety and clinical outcomes of the patient. In both cases, the medical practitioner retains overall responsibility for coordination of patient care. Conversely, a nurse practitioner employed by, or whose services are otherwise retained by a general medical practice, retains overall responsibility for their patient s care. As such, the nurse practitioner is free to exercise autonomy in clinical decision-making within the parameters of evidence-based care, the limits of their clinical competence, and in collaboration with the patient s nominated medical practitioner and other health professionals involved in the care of the patient. Section 1 Understanding the role 4. Professional regulation 4.1 Protection of title The title of nurse practitioner is protected by an endorsement under Section 95 of the Health Practitioner Regulation National Law Act 2009 (Qld) (the national law). It is an offence for a nurse, midwife or any other person to hold themselves out as a nurse practitioner unless they hold a current endorsement from the Nursing and Midwifery Board of Australia (NMBA). It is not appropriate for a registered nurse with endorsement to practise as a nurse practitioner, or to use the authority and title of this endorsement, if this is beyond the scope of the position in which the nurse is employed. 4.2 Eligibility To be eligible for endorsement to practise as a nurse practitioner, the NMBA National Registration standard for endorsement of nurse practitioners (2010) requires that a registered nurse must be able to demonstrate all of the following: (a) general registration as a registered nurse with no restrictions on practice (b) advanced nursing practice in a clinical leadership role in the area of practice in which he or she intends to practise as a nurse practitioner, within the past five years, complemented by research, education and management (c) competence in the Australian Nursing and Midwifery Council s (2006) National Competency Standards for the Nurse Practitioner (d) completion of the requisite Master s qualification approved by the NMBA. Additional registration standards relevant to the nurse practitioner include: Nursing and Midwifery Criminal History Registration Standard Nursing and Midwifery Recency of Practice Registration Standard 13 13

16 Section 1 Understanding the role Nursing and Midwifery Professional Indemnity Insurance Registration Standard Nursing and Midwifery Continuing Professional Development Registration Standard To ensure the good standing of the nursing profession, nursing practice is also governed by professional codes endorsed by NMBA, including: (a) Code of professional conduct for nurses in Australia (2008), ANMC (b) Code of ethics for nurses in Australia (2008), ANMC The NMBA is responsible for the regulation of professional nursing practice and protection of the public, ensuring nurses demonstrate acceptable standards of practice. Links to relevant codes and standards can be found at 14

17 SECTION 2 Developing a model of care 1. Overview Innovation in the nurse practitioner role lies in the reconstruction of traditional professional identities and autonomous practice boundaries. The nature of nurse practitioner work involves a combination of nursing care, diagnostic activities and intervention-based treatments, including the use of medicines. Some of these activities have traditionally been limited to the realm of medical practice (Gardner, Gardner & O Connell, 2010). Section 2 Developing a model of care These innovations have led to recurrent confusion over the role, responsibility, accountability, scope of clinical practice and professional boundaries of nurse practitioners. There is also limited awareness that extensions to practice are supported by legislation. A significant underlying cause is that there is no single nurse practitioner model of care. Models of care are tailored to the specific context of the health care service and unique consumer populations, with extended practice privileges linked to the role and position of the particular clinical specialty in which the nurse practitioner is educated and competent. It is essential that the practice scope of each nurse practitioner model of care is well defined with clarity about the clinical parameters of the position. 2. Guideline The scope of clinical practice of each position and the service capability of the health service setting, in which a nurse practitioner is engaged, that is, the practice scope, must be defined and clearly articulated. This serves to inform health consumers, nurses, medical practitioners, pharmacists, health care administrators and other health professionals about the nurse practitioner s role, and should not to be confused with the individual s scope of practice. 15

18 Section 2 Developing a model of care 3. The model of care 3.1 Consultation The impetus to establish a nurse practitioner position may come from one of a number of sources, including a nurse clinician, medical officer or health service administrator. Regardless of the initial source, a consultative and collaborative approach is vital to realising the full potential of the nurse practitioner role and ensuring sustainability. For a health service to incorporate a nurse practitioner role into a service delivery model, there must be consideration of key health service planning principles, supported by clinical and executive champions. A service-based working group should be formed, including, at least, a medical specialist, registered nurse and a pharmacist, to facilitate the establishment of the role. Other health professionals who may be a part of the health service where the nurse practitioner role is being implemented, including radiology, pathology services and allied health, should be included where possible. The scope and function of a working party or steering committee consisting of key stakeholders will: provide professional guidance to enable implementation of the nurse practitioner role, in accordance with legislation and professional regulation monitor the implementation phase and progress of the nurse practitioner role ensure clinical safety and quality outcomes for the nurse practitioner role to inform future service development. 3.2 Clarifying the service need The following triggers will assist in identifying the opportunities to improve access to healthcare and service delivery: Is there a change in the demographic profile of the consumer population? Examples include: population growth increase in the elderly population in the community increase in young families in the community increase in service demand (e.g. chronic illnesses, primary health care). Are there increased waiting times or waiting lists for service in: clinics outpatients community services emergency services. Are there marginalised community groups that do not access traditional health services, for example, clients with health problems related to: mental health sexual health substance abuse disorders homeless individuals or groups. 16

19 Is there a gap in the current health service, for example: rural and remote communities outreach of services to community centres preventative and maintenance services for chronic illness hospital/community interface services specialty fields with scarce medical resources. Are there organisational quality or performance indicators that need to be met that the nurse practitioner could assist the service to achieve? ACHS indicators State performance indicators National clinical benchmarks and standards. Identifying one or more of these opportunities in the current health service will provide the foundation and focus for service improvement, and inform the features of the proposed nurse practitioner model. Section 2 Developing a model of care 3.3 Clarifying the clinical nursing role Having identified the service improvement model, it is useful at this point to consider if a nurse practitioner is the most appropriate nursing role to address the changing needs of the service. In certain situations, for example, an advanced practice nurse may be more likely than a nurse practitioner to achieve specific goals of service improvement. An advanced practice nurse demonstrates highly developed practice as either a generalist or within a specialist field, whereas a nurse practitioner is an advanced practice specialist nurse, educated and authorised to practise nursing in a way that is different from other advanced practice nursing roles. See figure 3, page 18. The extended practices of nurse practitioners include, but are not limited to, advanced and comprehensive health assessment, diagnostics, prescribing, and direct referral of patients to other health professionals. Advanced practice nursing provides the necessary preparation for the nurse practitioner role, and provides a foundation to progress to the next step in the clinical career pathway as a nurse practitioner

20 Section 2 Developing a model of care Figure 3: Comparison across nursing roles Registered Nurse Advanced Practice Nurse Nurse Practitioner Legislation Title protected General registration as a nurse Nomenclature Registered nurse Education Bachelor of Nursing Title not protected No specialist registration for nursing Wide variety of nomenclature clinical nurse specialist clinical nurse consultant advanced practice nurse practice nurse Bachelor of Nursing While not essential, a postgraduate qualification in a clinical nursing specialty is recommended Title protected Endorsement under s.95 national law Nurse practitioner Bachelor of Nursing Postgraduate qualification in a clinical nursing specialty Approved Masters degree in nurse practitioner studies Clinical experience Career usually commenced in a graduate nurse program General or specialist experience 2 to 4 years post-registration 10 to 12 years post-registration Scope of practice ANMC (2005) National Competency Standards for the Registered Nurse General and specialist clinical activities in direct patient care Administration of medication Model of care Limited autonomy Collaboratively supports the therapeutic interventions of other health team members For example: ANF (2005) Competency Standards for the Advanced Registered Nurse Advanced clinical activities in area of clinical nursing specialty Limited initiation and supply of medications under protocol Initiation of requests for plain film diagnostic radiography (Does not include interpretation of films) All driven by protocols Increased autonomy in area of clinical nursing specialty Collaboratively supports the therapeutic interventions of other health team members ANMC (2006) National Competency Standards for the Nurse Practitioner Advanced nursing practice in area of clinical nursing specialty plus expanded clinical activities including: advanced patient assessment ordering and interpretation of diagnostic investigations and pathology differentiating a diagnosis establishing management plan direct referral to other health professionals selecting and prescribing appropriate medication Highest level of autonomy in area of clinical nursing specialty Freedom to exercise professional judgement within parameters of evidence-based and collaborative care in clinical nursing specialty in which they are educated, competent and authorised 18

21 Mandatory requirement The Drug Therapy Protocol for Nurse Practitioners states the circumstances in which, and the conditions under which a nurse practitioner may prescribe, give a written or oral instruction, supply and administer a stated controlled or restricted drug or poison under the Health (Drugs and Poisons) Regulation The practice scope is a condition of the Drug Therapy Protocol for Nurse Practitioners. 4. Defining the practice scope of the nurse practitioner A new Drug therapy Protocol for Nurse Practitioners took effect in Queensland from the 31 January This protocol outlines new conditions under which a nurse practitioner may prescribe, give a written or oral instruction, and supply and administer a stated controlled or restricted drug or poison. Section 2 Developing a model of care In order for nurse practitioners to prescribe and act under the new protocol in Queensland, a Practice Scope of the Nurse Practitioner (practice scope) must be completed and approved. 4.1 Describing the practice environment, clinical service and clinical service measures The practice scope of the nurse practitioner position must be well defined and documented with clarity about the: (a) health service setting (b) service capability of the health service setting or accreditation standard (c) clinical specialty of the nurse practitioner model of care (d) scope of clinical practice of the nurse practitioner position (clinical parameters within which the nurse practitioner may use their extended practice privileges to make informed and autonomous preventive, diagnostic and therapeutic decisions). Figure four outlines the following information which must be included in the practice scope for each nurse practitioner position. The practice scope is a condition under the Health (Drugs and Poisons) Regulations 1996 (Sections 67(4), 175(5) & 263(5) and the Drug Therapy Protocol for Nurse Practitioners. More than one nurse practitioner may be included in the practice scope document

22 Section 2 Developing a model of care Figure 4: Practice Scope of the Nurse Practitioner (example) The following provides an example of suggested information to be included in the Practice Scope of the Nurse Practitioner: Office of the Chief Nursing Officer Practice scope of the Nurse Practitioner page 1 Queensland Health facility The Practice Scope of the Nurse Practitioner is a condition of the Drug Therapy Protocol for Nurse Practitioners in Queensland. The Practice Scope refers to the Position in which the nurse practiotioner is employed (not the individual nurse practitioner). As such, more than one nurse practitioner may practice within the defined Practice Scope. The Drug Therapy protocol applies to all registered nurses who: hold a current endorsement as a nurse practitioner under the Health Practitioner Regulation Law Act 2009; and are engaged in practice as a nurse practitioner in Queensland. The authorising legislation for the Drug Therapy Protocol is the Health (Drugs and Poisons) Regulation 1996 The approved practice scope will be published on the Queensland Health internet site. Practice environment Facilities/ facility where nurse practitioner position is located <name of employer or operator of facility/business in which the nurse practitioner is located> Name of Health Service <name of health service, employing entity or trading name> Health Service address <the location/s where the nurse practitioner service will be provided or based> Health Service setting <the healthcare setting or practice environment where the nurse practitioner service will be provided or based> Clinical Service capability <service level description of the facility in which the nurse practitioner service is provided, or accreditation standard of the health service> Clinical service Specialist area of clinical nursing practice <specialist area of clinical nursing practice or focus of nursing activities> Target population for service <target population, characteristics of health consumers and key demographics> Major diagnostic areas and types of clinical presentations managed autonomously by the nurse practitioner service <types of clinical areas and clinical presentations which are the focus of the nurse practitioner service> Please note: The nurse practitioner will provide life saving measures as appropriate and refer when outside of the practice scope of the nurse practitioner position Queensland Health 20

23 Prescribing arrangements (eligibility for PBS) Exclusions: A nurse practitioner must not prescribe, give a written or oral instruction or supply or administer medicines (1) that have not been approved by the Therapeutic Goods Administration (2) outside the terms of the manufacturer s product information ( off label ) unless sufficient evidence to demonstrate safety. Prescribing blood and/or blood products Procedural activities required for the clinical service page 2 <prescribing should be based on quality use of medicines principles, with consideration to high-risk prescribing groups and specific guidelines, including List of Approved Medicines, PBS restrictions for nurse practitioners> <prescription of whole blood and/or blood components is a requirement of the position and the target population> <procedural activities to be undertaken by the nurse practitioner for the designated clinical service> Included c Excluded c Section 2 Developing a model of care Key clinical practice guidelines utilised by the nurse practitioner <evidence-based guidelines that guide prescribing, and may cover the assessment, management and follow-up of patients, including the recommended drug therapy> Clinical service audit (annual requirement) Evidence that the nurse practitioners clinical practice and the use of medicines is audited annually by an interdisciplinary team Clinical audit activities <evidence of review of practice and demonstration that use of medicines is evidence based including: audit/compliance with PBS requirements, case reviews, data abstraction tools or instruments, patient satisfaction surveys> * For the purpose of the Health (Drugs and Poisons) Regulation 1996 and may be required to be produced to an inspector under section 153N of the Health Act Queensland Health Note: Refer to the complete three-page Practice Scope of the Nurse Practitioner templates in the appendices. The public and private sector Practice Scope templates are also available at

24 Section 2 Developing a model of care 4.2 Practice scope approval Public sector health service Save and complete the practice scope template online, and print the completed document for sign-off by the approving entity. Once approved, the document will need to be submitted to the Office of the Chief Nursing Officer (OCNO), Queensland Health, for publication, in accordance with the conditions outlined in the Drug Therapy Protocol for Nurse Practitioners. Should any additional information be required before publishing the document, a representative from OCNO will advise accordingly The practice scope must be approved by the approving entity, which is dependent on the health service context, outlined below. Where the nurse practitioner is engaged in a public sector health service operated by Queensland Health the chief executive officer of the health service district, local hospital network or statewide health service under the Health Services Act 1991, in which the nurse practitioner is engaged is the approving entity. Licensed private health facility Where the nurse practitioner is engaged by a private hospital or day surgery licensed under the Private Health Facilities Act 1999 the chief executive of the private health facility in which the nurse practitioner is engaged is the approving entity. Employment in private practice Where a nurse practitioner is otherwise employed under a contract of employment or a contract for services a health practitioner who is the employer, or a delegate of the employer, and holds current registration under the Health Practitioner Regulation National Law Act 2009 with no conditions or undertakings is the approving entity. Self employed practice In all other cases, an interdisciplinary team including at least a registered nurse, a medical practitioner and a pharmacist, who each hold current registration under the Health Practitioner Regulation National Law Act 2009 with no conditions or undertakings is the approving entity. Further information about this process is available on the Queensland Health website or by contacting OCNO, Queensland Health. 4.3 Publication A copy of each approved practice scope must be submitted to Queensland Health, OCNO for publishing, within 10 business days of the first approval and each re-approval. This should coincide with scheduled meeting dates for the Queensland Nurse Practitioner Advisory Committee (QNPAC). A nurse practitioner is not permitted to act under the Drug Therapy Protocol for Nurse Practitioners until OCNO, Queensland Health, acknowledges receipt of the approved practice scope. 22

25 4.4 Review The approved practice scope document will be published on the Queensland Health website, in accordance with the conditions of the Drug Therapy Protocol for Nurse Practitioners. A copy of each approved practice scope must be made available to any person immediately upon request. The practice scope for each nurse practitioner position must be reviewed and re-approved by the approving entity at least every three years, or when new clinical services, procedures or other interventions are being introduced into the nurse practitioner position. Section 2 Developing a model of care 23 23

26 Section 3 Right person, right skills, safe practice environment SECTION 3 Right person, right skills, safe practice environment 1. Overview The scope of clinical practice of each nurse practitioner is specific to the context of practice and is determined by the specialty in which the nurse practitioner is educated, competent and authorised to practise. The NMBA does not define a nurse practitioner s scope of practice. This is self-regulated and guided by the Australian Nursing and Midwifery Council s (ANMC) National Framework for the Development of Decision-Making Tools for Nursing and Midwifery Practice (2007). The NMBA s function is to regulate the nursing and midwifery profession and set the standards for practice, including the nurse practitioner role. This function is distinctly different from an employer s responsibility to manage an individual s fitness for employment through clinical governance mechanisms, such as credentialing. In particular, the NMBA does not: ensure the individual has the correct skills and qualifications for the defined position define the clinical services, procedures or other interventions for which a nurse practitioner is competent to practise autonomously verify the quality of health services provided by a nurse practitioner consider the capability of the employer or health service facility to reasonably support the practice of the nurse practitioner. In common with all other health professionals, the relevant laws, codes and standards that are unambiguous in their requirement that nurse practitioners have a professional duty only to practise where they are competent to do so, and not engage in any activities that may put patients, or other members of the public, at unwarranted risk of harm. Failure to comply may lead to disciplinary action, civil litigation and/or criminal prosecution being taken against the nurse practitioner. Despite this requirement, the Queensland Health Systems Review (2005) and the Queensland Public Hospitals Commission of Inquiry (2005) highlighted that there is a small percentage of all health professionals who cannot be relied on to practise within their level of competence. Both reviews clearly demonstrated that a robust clinical governance framework is essential to ensure health services are provided only by competent practitioners in environments that support safe service provision. 24

27 2. Guideline The fundamental aim for applying a consistent credentialing framework to health professionals is to: reduce harm to patients and improve the safety and quality of health care through regular review of clinical performance and professional development activities extend the traditional concepts of credentialing and defining scope of practice to incorporate the concept of a strong, mutual relationship, between employing or contracting organisations and each health practitioner, centred on the safety and quality of health care (ACQSHC, 2004). 3. Nurse practitioner candidates 3.1 Definition The training and development of nurse practitioner candidates is essential for ensuring sustainability of the nurse practitioner role in Queensland, and ensures succession planning for these specialist roles and continuity of services. Section 3 Right person, right skills, safe practice environment A nurse practitioner candidate is a registered nurse undertaking an accredited university Masters program leading to endorsement as a nurse practitioner with the NMBA. The nurse practitioner candidate may be employed in a designated position established by the employer. The term nurse practitioner candidate recognises the extended clinical practice role these registered nurses undertake as part of the clinical component/requirement of the Masters program. The focus of the nurse practitioner Masters program is to transition the registered nurse professionally to competently undertake the responsibilities of the nurse practitioner role, engaging in supervised extended clinical practice and formalised skill development in the nursing specialty in which they intend to practise. 3.2 Employment as a nurse practitioner candidate While some individuals undertaking the Masters program leading to endorsement as a nurse practitioner are not employed as nurse practitioner candidates, there is currently capacity within some Queensland nursing career structures for employment as a nurse practitioner candidate. Specific criteria apply to be appointed to such a position, and the organisation must have funding and infrastructure to support this developmental position. 3.3 Clinical internship or supported clinical practice A nurse practitioner is required to exercise high-level clinical decisionmaking skills in the diagnosis and management of clients in a clinical nursing specialty

28 Section 3 Right person, right skills, safe practice environment The preparation of the nurse practitioner candidate requires the integration of academic theory with clinical practice, as well as the mastery and application of advanced clinical assessment, diagnostic skills, knowledge and competence in pharmacotherapy and other treatment modalities. The clinical internship or supported clinical practice is based on an immersion approach to clinical learning. It involves any nurse practitioner learning experience, including simulated environments or clinical placements, that assist students to put theoretical knowledge into practice within the clinical setting. This should not be limited to the hospital setting. Consideration should also be given to general practice, remote and rural health clinics and community care environments. This supported immersion approach to clinical learning for the nurse practitioner candidate has been demonstrated to be instrumental in testing both the parameters and expansion of the nurse practitioner role, and effective for achieving learning outcomes, while ensuring patient safety (Gardner, Gardner & Proctor, 2004). Each university curricula has particular learning requirements. The nurse practitioner candidate must be provided with formal documentation from the university outlining the specific academic and clinical practice (internship) requirements for the particular nurse practitioner Masters program. Employers are encouraged to employ nurse practitioner candidates in an advanced practice role in the clinical nursing specialty in which they intend to practise as a nurse practitioner. An example of this arrangement may be a minimum of 0.4 full-time-equivalent, or a block placement for a defined period of time. Local arrangements may differ from these examples, and registered nurses considering entry to the Masters program leading to endorsement as a nurse practitioner should discuss the options and opportunities with their employer or local nursing management team, and refer to local policies relevant to these arrangements. 3.4 Clinical supervision and mentoring Medical support, clinical teaching and mentorship are essential for effective skills development for the nurse practitioner candidate. Equally important is an adequate teaching and learning framework, with clarity in crossdisciplinary communication of the required learning experiences for nurse practitioner competency development and assessment outcomes. The candidate should negotiate with the health service to establish an appropriate clinical support team for the duration of the Masters program. This team provides teaching through supervision, monitoring and review of the extended practice aspects of the nurse practitioner candidate s role. The clinical support team also participates in the candidate s formal university assessment process. The clinical support team should be drawn from within the multidisciplinary service, be relevant to the nominated clinical speciality, and include at least a senior, experienced registered nurse and a clinician with appropriate expertise and experience, such as a medical specialist or nurse practitioner, as the primary clinical mentor. It should also be acknowledged that clinical supervision and mentoring is in addition to the usual clinical work arrangements of the mentor, and as a result, may impact upon the time available for the mentor to undertake usual clinical activities and responsibilities. 26

29 Supervision and mentoring principles: The following five principles will assist the clinical support team, the clinical mentor and the nurse practitioner candidate to collaborate in achieving a successful and productive clinical internship: 1: Clear communication Clear communication between the university and the clinical support team, in particular, the clinical mentors, must be established for teaching and learning requirements for the Masters program. This will be in the form of a learning contract or handbook that includes the following information: description of the clinical and leadership competencies to be achieved and relevant timeframe learning objectives for competencies and skill acquisition practice activities and performance expectations specific to the learning objectives assessment requirements and reporting structures information on contingencies for management of candidates who are not meeting the requirements of the program. 2: Hands-on clinical teaching and coaching The nurse practitioner internship includes requirements for competency development in physical examination, clinical reasoning, procedures and other activities related to extended practice in a specialty field. Section 3 Right person, right skills, safe practice environment Adequate opportunity for observation and supervised practice of these skills and activities is essential to a comprehensive and successful clinical internship and the professional development of a competent clinician. 3: Surveillance of clinical performance 4: Skilled mentors It is important that processes are in place for monitoring the performance of the candidate throughout their program of study. Scheduled reviews will ensure quality patient outcomes and the development of a competent work-ready clinician. This review process can be linked to formal performance appraisal and development processes, formal university requirements for assessment, or may be a part of regular clinical audit, peer review or review of data pertaining to the nurse practitioner candidate caseload. Through the processes described above, the clinical mentor and other relevant team members will review the candidate s assessment and management plan for patients episodes of care. This activity will provide a forum for: teaching and learning formative assessment identification of further learning requirements. The clinical mentor is an essential component of the nurse practitioner internship. Mentor teaching is central to the process of the nurse practitioner developing the skills, knowledge and clinical reasoning necessary for transition to the nurse practitioner role

30 Section 3 Right person, right skills, safe practice environment 5: Observance of legal structures The role of the clinical mentor is to establish a learning partnership with the nurse practitioner candidate to assist the candidate to apply clinical knowledge and to build clinical expertise in extended nursing practice for their specialist field. This will depend on the mentor having the specific skills, attitudes and commitment to the student, and a good understanding of the nurse practitioner role and service model. The purpose of supported learning is to enable the candidate to deepen and extend their knowledge and practice skills by working into the role of a nurse practitioner. The clinical mentor will meet some of the requirements for the extended practice aspects of the candidate s practice, as delegated. This specifically relates to prescribing restrictions, requesting diagnostic tests and referring patients to other health professionals. Strategies to achieve clinical learning outcomes in these activities can be negotiated between the candidate and the clinical mentor. These might include established practices such as: standing orders for medication protocols for registered nurses to initiate pathology and diagnostic imaging real-time case conferences led by the candidate shadowing the candidate to monitor clinical decision-making graduated responsibilities. Decisions about these strategies will be made on the understanding that the candidate must practise within the legislated parameters of nursing practice (for the registered nurse) and that practice extending beyond this scope must be monitored and supported by a medical practitioner, and where possible, an endorsed nurse practitioner. 3.5 Nurse practitioner endorsement When a nurse practitioner candidate completes the requirements of the Masters education program and can demonstrate the competency requirements for endorsement as a nurse practitioner by the NMBA, there is no automatic appointment to a nurse practitioner position. Appointment to a nurse practitioner position is a decision for an employer, subject to health service planning, funding allocation, creation of a position and a merit-based selection process. It is not appropriate for a registered nurse with endorsement to use the authority and title of this endorsement, and practise as a nurse practitioner, if this is beyond the scope of the position in which the nurse is employed at that time. Information on the endorsement process for nurse practitioners is available on the NMBA site at 28

31 4. Credentialing and defining the scope of clinical practice Mandatory requirement Nurse practitioners must be credentialed, and their scope of clinical practice defined by a process consistent with the: Australian Commission For Quality and Safety In Health Care (ACQSHC) (2004) National standard for credentialing and defining the scope of clinical practice (the National Standard) Health Quality and Complaint Commission s (2010) Credentialing and scope of clinical practice standard (the HQCC Standard) Credentialing and Defining the Scope of Clinical practice for Nurse Practitioners in Queensland Health Policy and Implementation Standard 4.1 Definition The fact that a person holds qualifications as a nurse practitioner should not be regarded as entitling that person to unrestricted practice in any health service setting. In particular, due regard must be given to whether: the nurse practitioner s qualifications or experience are confined to a particular area of practice practice restrictions may be required with consideration to the clinical service capability and resources available within a hospital or other health service setting (e.g. some procedures cannot be performed effectively without certain pathology or radiology services) Section 3 Right person, right skills, safe practice environment there is sufficient volume of patients to maintain a nurse practitioner s skills and competence (irrespective of workforce availability). This process is known as credentialing and defining the scope of clinical practice. Credentialing refers to the formal process used by an employer to verify the qualifications, experience, professional standing and other relevant professional attributes of health practitioners for the purpose of forming a view about their competence, performance and professional suitability to provide safe, high-quality health care services within specific organisational environments (ACSQHC, 2004). Defining the scope of clinical practice (formally known as clinical privileges) follows on from credentialing and involves delineating the extent of an individual health practitioner s clinical practice within a particular organisation, based on the individual s credentials, competence, performance and professional suitability, and the needs and the capability of the facility to support the practitioner s scope of clinical practice (ACSQHC, 2004). This is in addition to professional self-regulation and individual accountability for clinical judgement that are an integral part of clinical governance. 4.2 Credentialing principles The national standard is based on the following principles: credentialing and defining the scope of clinical practice are organisational governance responsibilities that are always conducted to maintain and improve the safety and quality of health care services 29 29

32 Section 3 Right person, right skills, safe practice environment processes of credentialing and defining the scope of clinical practice are complemented by health practitioner registration requirements and individual professional responsibilities that protect the community effective processes of credentialing and defining the scope of clinical practice benefit patients, communities, health care organisations and nurse practitioners credentialing and defining the scope of clinical practice are essential components of a broader system of organisational management of relationships with health practitioners reviewing the scope of clinical practice should be a non-punitive process processes of credentialing and defining the scope of clinical practice depend for their effectiveness on strong partnerships between health care organisations and professional colleges, associations and societies processes of credentialing and defining the scope of clinical practice must be fair, transparent and legally robust. 4.3 Adopting Queensland Health s policy Queensland Health s policy for credentialing and defining the scope of clinical practice for nurse practitioners may be adopted by non-government organisations. The Queensland Health Implementation Standard may be adapted and customised where necessary, provided consistency with the national standard is maintained. A supporting policy and implementation standard for Credentialing and Defining Scope of Clinical Practice for Nurse Practitioners in Queensland Health will be available in Outcomes The following five outcomes should be achieved: 1. Every nurse practitioner is credentialed and their scope of clinical practice defined and documented before commencing practice with one of the following (the approving entity): (a) where the nurse practitioner is engaged in a public sector health service operated by Queensland Health the chief executive of the health service district, local hospital network or statewide health service under the Health Services Act 1991, in which the nurse practitioner is engaged (b) where the nurse practitioner is engaged by a private hospital or day surgery licensed under the Private Health Facilities Act 1999 the chief executive of the private health facility in which the nurse practitioner is engaged (c) where a nurse practitioner is otherwise employed under a contract of employment or a contract for services a health practitioner who is the employer, or a delegate of the employer, and holds current registration under the Health Practitioner Regulation National Law Act 2009 with no conditions or undertakings (d) in all other cases, an interdisciplinary team including at least a registered nurse, a medical practitioner and a pharmacist, who each 30

33 hold current registration under the Health Practitioner Regulation National Law Act 2009 with no conditions or undertakings. 2. The approving entity has used a process for credentialing and defining scope of clinical practice of nurse practitioners that is consistent with the Credentialing and Defining the Scope of Clinical Practice for Nurse Practitioners in Queensland Health, the national standard and the Health Quality Complaints Commission (HQCC) standard. 3. The defined scope of practice of each nurse practitioner is appropriate and consistent with: the clinical services capability of the health service setting the practice scope of the position in which the nurse practitioner is engaged the individual s qualifications and competence any conditions imposed by, or undertakings made with, the NMBA or any other regulator. 4. The approving entity reviews the credentials and scope of clinical practice of each nurse practitioner within a period not exceeding three years, or when circumstances change affecting the individual nurse practitioner. 5. The approving entity has a process to support the restriction or suspension of any nurse practitioner s scope of clinical practice within the health service setting. Section 3 Right person, right skills, safe practice environment 31 31

34 Section 4 Extended clinical practice SECTION 4 Extended clinical practice 1. Overview A nurse practitioner is a registered nurse educated and authorised to function autonomously and collaboratively in an advanced and extended clinical role. The nurse practitioner role includes assessment and management of clients using nursing knowledge and skills and may include but is not limited to, the direct referral of patients to other health care professionals, prescribing medications and ordering diagnostic investigations (Australian Nursing and Midwifery Council, 2006). 2. Guideline 1. Nurse practitioners must only use those extended practice privileges that are appropriate and necessary to practice nursing within: the practice scope of the position in which the nurse practitioner is engaged their education, competence and defined scope of clinical practice. 2. Nurse practitioners must establish and maintain collaborative arrangements with all health professionals involved in the care of the patient, based on inter-professional respect, effective communication and collective action to optimise health outcomes. 3. Continuing professional development Under the national law, which governs the operations of the national boards and Australian Health Practitioner Regulation Authority (AHPRA), all registered health practitioners must undertake continuing professional development. Continuing professional development is the means by which members of a profession maintain, improve and broaden their knowledge, expertise and competence, and develop the personal and professional qualities required throughout their professional lives (Nursing and Midwifery Board of Australia (NMBA, 2010)). All nurse practitioners must meet the NMBA continuing professional development standard, and are required to demonstrate competence in relation in their context of practice and endorsement. Mandatory requirements set down by the NMBA to maintain registration as a registered nurse and endorsement as a nurse practitioner includes completion of at least: (a) 20 hours of continuing nursing professional development per year (b) 10 hours per year of education related to their endorsement as a nurse practitioner. 32

35 Nurse practitioners must also keep written documentation of continuing professional development that demonstrates evidence of completion of the requirements set down by the board on an annual basis. 4. Prescription of medicines 4.1 Statutory authority Provisions within the Queensland Health (Drugs and Poisons) Regulation 1996 authorise nurse practitioners to the extent necessary to practise nursing to obtain, possess, administer, supply and prescribe medicines. Section 4 Extended clinical practice 4.2 Drug Therapy Protocol for Nurse Practitioners The Drug Therapy Protocol for Nurse Practitioners is certified by the Chief Executive, Director-General, Queensland Health under the Health (Drugs and Poisons) Regulation It is a condition of the Drug Therapy Protocol for Nurse Practitioners that a nurse practitioner may only prescribe, give a written or oral instruction, supply and administer the controlled and restricted drugs or poisons that are necessary to practise nursing within the defined nurse practitioner model of care in which the nurse practitioner is engaged to practise. A copy of the Drug Therapy Protocol for Nurse Practitioners and supporting information sheets are available through the Queensland Health site Mandatory requirement Practice scope of the nurse practitioner position must be defined for a nurse practitioner to act under the Drug Therapy Protocol for Nurse Practitioners. The Drug Therapy Protocol states the circumstances in which, and the conditions under which, a nurse practitioner may prescribe, give a written or oral instruction, supply and administer a stated controlled or restricted drug or poison under the Health (Drugs and Poisons) Regulation Components of prescribing Nurse practitioners use evidence-based guidelines to facilitate decisionmaking for prescribing medications. They are not directed by rigid protocol- based prescribing, but have comprehensive knowledge of pharmacology and pharmacokinetics related to a specific field of clinical practice. There are essentially four components to prescribing (Coombes, 2007). Refer to figure 5 on page

36 à Section 4 Extended clinical practice Figure 5: Four components to prescribing 1. Information-gathering: medication history, adverse drug reactions, medicine-taking behaviour, adherence presenting complaints, history of presenting complaint current problems relevant signs symptoms pathology results guidelines, protocols, pathways à 2. Clinical decision-making diagnosis consider ideal therapy balance risks and benefits of drugdrug, drug-patient, drug-disease actual/potential problems consider economical/availability of therapeutic options select drug, form, route, dose, frequency, duration à 4. Monitor and review: review control of signs and symptoms review adherence review patients outcomes consider need for therapy to be tailored to patient, continued or ceased reflection by prescriber and peer feedback à 3. Communicate decision as an instruction to (generate order): other medical staff/prescribers to continue and monitor (including discharge) nursing staff to administer or supply pharmacy staff to review and dispense or arrange supply patients and carers to administer 4.4 Prescribing competency framework The following prescribing competency framework (incorporating the consultation, prescribing safely and effectively, and prescribing in context ), describes the knowledge and skills required for prescribing. The consultation Clinical and pharmaceutical knowledge The nurse practitioner has up-to-date clinical and pharmaceutical knowledge relevant to own area of practice, including: understanding the medical conditions being treated, their natural progress and how to assess their severity understanding different non-pharmacological and pharmacological approaches to modifying disease or conditions; promoting health, desirable and undesirable outcomes; and how to identify and assess them understanding the mode of action and pharmacokinetics of medicines, how these mechanisms may be altered (e.g. by age, renal impairment) and how this affects dosage 34

37 understanding the potential for unwanted effects (e.g. allergy, adverse drug reactions, drug interactions, special precautions and contraindications), and how to avoid or minimise, recognise and manage them maintaining an up-to-date knowledge of products in the Australian Medicines Handbook (AHM), List of Approved Medicines (LAM), and other formularies (e.g. doses, formulations, pack sizes, storage conditions, costs) understanding how medicines are licensed, monitored (e.g. adverse drug reaction reporting) and supplied applying the principles of evidence-based medicine, clinical and costeffectiveness understanding the public health issues related to medicines use appreciating the misuse potential of medicines. Section 4 Extended clinical practice Establishing options (involving carers, parents and/or advocates where appropriate) The nurse practitioner reviews diagnosis, generates treatment options for the patient and follows up treatment within the scope of the clinical management plan, including: taking and/or reviewing the medical and medication history, and undertaking a physical examination, where appropriate views and assesses the patient s needs holistically (i.e. psychosocial, physical) accessing and interpreting all relevant patient records to ensure knowledge of the patient s management reviewing the nature, severity and significance of the diagnosis or clinical problem requesting and interpreting relevant diagnostic tests considering no treatment, non-drug and drug treatment options (including referral and preventive measures) assessing the effect of multiple pathologies, existing medication and contraindications to treatment options assessing the risks and benefits to the patient of taking or not taking a medicine (or using or not using a treatment) selecting the most appropriate medicine, dose and formulation for the individual patient, and prescribing appropriate quantities monitoring effectiveness of treatment and potential side-effects establishing, monitoring and making changes within the scope of the clinical management plan, in light of the therapeutic objective and treatment outcome ensuring that patients can access ongoing supplies of their medication. Communicating with patients (involving carers, parents and/or advocates where appropriate) The nurse practitioner establishes a relationship based on trust and mutual respect, sees patients as partners in the consultation, and applies the principles of concordance, including: ensuring that the patient understands and consents to be managed by a prescribing partnership, in accordance with local arrangements listening to and understanding patients beliefs and expectations 35 35

38 Section 4 Extended clinical practice understanding the cultural, language and religious implications of prescribing adapting consultation style to meet the needs of different patients (e.g. for age, level of understanding, physical impairments) dealing sensitively with patients emotions and concerns creating a relationship that does not encourage the expectation that a prescription will be written explaining the nature of the patient s condition and the rationale behind, and potential risks and benefits of, management options enabling patients to make informed choices about their management negotiating an outcome to the consultation that both patient and prescriber are satisfied with encouraging patients to take responsibility for their own health and selfmanage their conditions giving clear instructions to the patient about their medication (e.g. how to take or administer it, where to get it from, possible side-effects) checking the patients understanding of, and commitment to, their treatment. Prescribing safely and effectively Prescribing safely Prescribing professionally The nurse practitioner is aware of their own limitations, does not compromise patient safety and justifies prescribing decisions, including: knowing the limits of their own knowledge and skill, and working within them knowing how and when to refer back to, or seek guidance from, the independent prescriber, another member of the team or a specialist only prescribing a medicine with adequate, up-to-date knowledge of actions, indications, contraindications, interactions, cautions, dose and side-effects knowing about common types of medication errors and how to prevent them making prescribing decisions often enough to maintain confidence and competence keeping up to date with advances in practice and emerging safety concerns relating to prescribing understanding the need for, and making, accurate and timely records and clinical notes writing legible, clear and complete prescriptions that meet legal requirements checking doses and calculations to ensure accuracy and safety. The nurse practitioner works within professional, regulatory and organisational standards, including: accepting personal responsibility for their own prescribing in the context of a shared clinical management plan, and understanding the legal and ethical implications of doing so 36

39 Improving prescribing practice using professional judgement to make prescribing decisions based on the needs of patients and not the prescribers personal considerations understanding how current legislation affects prescribing practice prescribing within current professional and organisational codes of practice or standards keeping prescription pads safely, and knowing what to do if they are stolen or lost. The nurse practitioner actively participates in the review and development of prescribing practice to improve patient care, including: reflecting on their own performance, with the ability to learn and change prescribing practice sharing and debating their own, and others prescribing practice (e.g. audit, peer group review, etc.) constructively challenging colleagues inappropriate practice understanding and using tools to improve prescribing (e.g. review of prescribing analysis and cost tabulation [PACT], prescribing data and feedback from patients) reporting prescribing errors and near-misses, and reviewing practice to prevent recurrence developing their own networks for support, reflection and learning establishing multi-professional links with practitioners working in the same specialist area taking responsibility for their own continuing professional development. Section 4 Extended clinical practice Prescribing in context Information in context The nurse practitioner knows how to access relevant information, and can critically appraise and apply information in practice, including: understanding the advantages and limitations of different information sources using relevant, up-to-date information, both written (paper or electronic) and verbal critically appraising the validity of information (e.g. promotional literature, research reports, etc.) when necessary applying information to the clinical context (linking theory to practice) using relevant patient record systems, prescribing and information systems and decision-support tools regularly reviewing the evidence behind therapeutic strategies. The health care system in context Note: Most of these points apply more generally The nurse practitioner understands and works with local and national policies that impact on prescribing practice, and sees how their own practice impacts on a wider health care system, including: understanding the framework of supplementary prescribing and how it is applied in practice 37 37

40 Section 4 Extended clinical practice The team and individual context understanding and working with local health care organisations and relevant agencies contributing to health improvement (e.g. social services) working within local frameworks for medicines use as appropriate (e.g. formularies, protocols and guidelines) working within the organisational code of conduct when dealing with the pharmaceutical industry understanding drug budgetary constraints at local and national levels, and discussing them with colleagues and patients understanding national frameworks for medicines use (e.g. Quality Use of Medicines, National Prescribing Service, medicines management, clinical governance, information technology strategy, etc.). The nurse practitioner works in partnership with colleagues for the benefit of patients and is self-aware and confident in their own ability as a prescriber, including: relating to the independent prescriber as an equal partner negotiating with the independent prescriber to develop and agree on clinical management plans thinking and acting as part of a multidisciplinary team to ensure that continuity of care is not compromised establishing relationships with colleagues based on understanding, trust and respect for each other s roles recognising and dealing with pressures that may result in inappropriate prescribing being adaptable, flexible, proactive and responsive to change seeking and/or providing support and advice to other prescribers, team members and support staff where appropriate negotiating the appropriate level of support for their role as a prescriber. 4.5 List of personal or preferred drugs (P-drugs) Nurse practitioners are required to develop a comprehensive list of medications that are used regularly in their practice. This will reflect the practice scope of the position in which the nurse practitioner is employed. The AMH recommends that a list of personal or P-drugs is essential for safe prescribing. Prescribers need to be confident in their ability to evaluate information about drugs and to determine their therapeutic value. Confidence is enhanced by having a personal list of preferred drugs and becoming thoroughly familiar with their use. 4.6 Supplementary prescribing Supplementary prescribing is a voluntary partnership between an independent prescriber (a doctor or dentist) and a supplementary prescriber to implement an agreed patient-specific clinical management plan with the patient s agreement (Department of Health UK 2005). 38

41 Supplementary prescribing is intended to provide patients with faster and more efficient access to medicines, and to make the best use of the clinical skills of nurse practitioners. Supplementary prescribing is primarily intended for use in managing specific long-term medical conditions or health needs affecting the patient. For example, a consultant medical practitioner in an urban area may be treating a patient who resides in remote Queensland. The consultant medical practitioner may consider a supplementary prescribing arrangement with a nurse practitioner in rural and isolated practice who is more accessible to the patient. The supplementary prescribing plan must be drawn up, with the patient s agreement, following diagnosis of the patient by the consultant medical practitioner, and consultation and agreement between the consultant medical practitioner and nurse practitioner. The nurse practitioner must be satisfied the supplementary prescribing plan is within the nurse practitioner s education, skills and competence. Section 4 Extended clinical practice The supplementary prescribing plan must be in writing and include arrangements for regular communication with the consultant medical practitioner, and regular clinical reviews of the patient s progress by the consultant medical practitioner. A copy of the plan should be made available to the dispensing hospital or community pharmacist if requested. The nurse practitioner has discretion in the choice of dosage, frequency, product and other variables in relation to medicines only within the limits specified by the supplementary prescribing plan. The plan may include reference to recognised clinical guidelines as an alternative to listing medicines individually. Any guidelines referred to should be readily accessible to the nurse practitioner when managing the patient s care. Where another health professional is the lead clinician responsible for the diagnosis and management plan, the arrangements for supplementary prescribing by the nurse practitioner must be documented in the medical record of the patient, and where practicable, the consultant medical practitioner and nurse practitioner should share the same patient record. 4.7 Quality use of medicines (QUM) When using medicines, nurse practitioners must comply with the National Policy on the Quality Use of Medicines and ensure their prescribing practice is evidence-based and in accordance with the recognised clinical standards, practices and procedures for health care in Australia. This means that a nurse practitioner must: (a) not prescribe beyond the limits of their competence and experience (b) only prescribe for a patient whom the nurse practitioner has assessed for care and there is evidence of a genuine clinical need for treatment (c) select management options wisely by: (i) considering the place of medicines in treating illness and maintaining health (ii) recognising that there may be better ways than medicine to manage many disorders (iii) identifying relevant evidence-based guidelines to support decisionmaking 39 39

42 Section 4 Extended clinical practice (d) choose suitable medicines if a medicine is necessary so that the best available option is selected by considering: the individual the clinical condition risks and benefits dosage and length of treatment any co-existing conditions other therapies monitoring considerations costs for the individual, the community and the health system as a whole. (e) understand the pharmacokinetics and pharmacodynamics when prescribing for high-risk patient groups, including: neonates (0 28 days) young infants (1 3 months) infants (3 months 2 years) children (2 12 years) pregnant women breastfeeding women patients with renal impairment patients with hepatic impairment the elderly (>65 years, or Indigenous >50 years) treatment of persons for drug dependency (AMH, 2010). (f) use medicines safely and effectively to get the best possible results by: (i) monitoring outcomes (ii) minimising misuse, over-use and under-use (iii) improving people s ability to solve problems about medication, such as negative effects or managing multiple medications. 5. Use of blood and blood components 5.1 Regulation Blood, blood components and plasma derivatives are regulated under the Therapeutic Goods Act 1989 (Commonwealth). The Health (Drugs and Poisons) Regulation 1996 applies to plasma derivatives as prescription medicines, but does not apply to the use of whole blood and blood components. The Queensland Blood Management Program (QBMP) was established in 2005 to ensure the Queensland Government meets its obligations under the National Blood Agreement. The QBMP has a statewide Haemo-vigilance System (Queensland incidents in Transfusion QiiT) that aligns with the National Haemo vigilance System managed by the National Blood Authority. More information is available at 40

43 The Australian Red Cross Blood Service provides comprehensive information for clinicians on individual blood components, the risks of transfusion, and consent. More information is available at Prescribing blood and blood components (blood transfusion) The prescribing of blood and blood components by nurse practitioners is not appropriate unless blood transfusion is within the nurse practitioner s education, competence, and defined scope of clinical practice. The authority for a nurse practitioner to prescribe blood and blood components must be expressly stated in the approved practice scope of the nurse practitioner position, and the defined scope of clinical practice of the individual nurse practitioner. Section 4 Extended clinical practice Guidelines for the administration of blood components are available from the Australian & New Zealand Society of Blood Transfusion at 6. Diagnostic services Pathology 6.1 Pathology services Nurse practitioners are authorised to use necessary pathology tests and investigations to practise nursing within the defined practice scope of the position in which the nurse practitioner is engaged. The nurse practitioner s responsibility commences with the decision to request a pathology test/investigation, and is maintained until the nurse practitioner has taken the appropriate clinical action in response to the report generated by the request. The nurse practitioner s responsibility does not cease with the transfer of the request to the pathology provider. 6.2 Quality use of pathology Nurse practitioners have a responsibility to have in place management systems to ensure requests are correctly initiated and acted upon and that pathology reports are communicated in an appropriate, clinically meaningful and timely fashion. In accordance with this responsibility, the nurse practitioner (or their employer) must have systems in place to ensure the following. (a) The informed cooperation and consent of the patient is obtained by informing the patient about the required tests and what the tests broadly involve, their foreseeable risks and benefits, and the implications of declining treatment. The information should be adapted to the patient s needs. (b) Where requesting tests or investigations for notifiable diseases, nurse practitioners should ensure the patient is aware of the nurse practitioner s reporting obligations. (c) Requests are correctly initiated by accurately completing a signed hard copy or electronic request form, including the relevant patient, clinical and test information

44 Section 4 Extended clinical practice (d) requested tests and investigations are identified using generally accepted names or acronyms. (e) Overdue reports are identified and followed up with minimum delay. (f) Pathology reports are acted on appropriately and in a timely manner. (g) In the absence of the nurse practitioner, a suitable delegate has been nominated to receive and act on the result. (h) Support staff are provided with clear and sufficient documented policies and procedures for the managing of pathology requests and reports. This should include policies covering confidentiality and privacy. Further guidance is available from the Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) produced by the Australian Government, Department of Health and Ageing AUSLAB Pathology Management System Nurse practitioners (and nurse practitioner candidates) employed by Queensland Health can apply for access as requesting officers in the AUSLAB Pathology Management System. The application needs to be approved by the relevant executive director of Nursing and forwarded to Laboratory Information Systems and Solutions, Clinical and Statewide Services. The application form and more information are available from the site of Laboratory Information Systems and Solutions at qheps.health.qld.gov.au/liss/home.htm 6.4 Private pathology Through the Medicare Benefits Schedule (MBS), the Australian Government funds private patient pathology service on fee-for-service arrangements through Medicare rebates. Eligible nurse practitioners are able to request specific services listed in the pathology services table. More information can be found on the Australian Government Department of Health and Ageing site at 42

45 7. Diagnostic services Diagnostic imaging 7.1 Diagnostic imaging 7.2 Requests A request for a diagnostic imaging examination is regarded as a referral to a specialist for a clinical opinion which will assist in the diagnosis and future management of a particular clinical problem. Nurse practitioners are authorised to request appropriate and necessary diagnostic imaging provided its use is within the scope of clinical practice of the nurse practitioner, and the use of the diagnostic imaging is not otherwise controlled or restricted by regulation. Section 4 Extended clinical practice The primary responsibilities of a nurse practitioner requesting diagnostic imaging are to: have a full knowledge of the potential benefit and detriment of the procedure be aware that many imaging tests have risks, and prevent unnecessary exposure to imaging procedures clarify the requirement for the diagnostic procedure by undertaking an accurate patient history, clinical assessment and examination provide the diagnostic imaging specialist with sufficient clinical data relevant to the request (such as relevant history, mechanism of injury, clinical signs and allergies/contraindications) and the main objective of the examination (clinical questions to be answered by performing the procedure) ensure requested diagnostic images are performed view, act upon and record the results of the diagnostic imaging studies consult or refer to other health professionals when the patient s condition requires expertise beyond their own scope of competence. 7.3 Diagnostic Radiography Protocol Under section 39A and Schedule 3A, Part 1, of the Radiation Safety Regulation 1999, a nurse practitioner, acting under a Diagnostic Radiography Protocol, is authorised to request plain film diagnostic imaging. The Diagnostic Radiography Protocol is a document certified by the Director-General, Queensland Health and published by Queensland Health, which states the circumstances in which, and conditions under which, nurse practitioners (and other registered nurses authorised to act under the protocol) may request plain film diagnostic radiography. A nurse practitioner may request plain film diagnostic radiography where the diagnostic procedure is within the scope of the position in which the nurse practitioner is engaged. Ultrasound is not regulated in the same way, and may be used as a diagnostic investigation by nurse practitioners under local service arrangements

46 Section 4 Extended clinical practice 7.4 Diagnostic interpretation The current Diagnostic Radiography Protocol dated 30 November 2006, is under review, and is available on the Queensland Health site at An imaging report provides a specialist interpretation of diagnostic images and relates the findings, both anticipated and unexpected, to the patient s current clinical symptoms and signs to diagnose or contribute to the understanding of their clinical condition. It often incorporates advice to the referring clinician on appropriate further investigation or management. Caution must be exercised when interpreting, and acting upon, diagnostic imaging that is unreported. Nurse practitioners have a general responsibility to only interpret unreported diagnostic images within their knowledge and expertise. Nurse practitioners should take reasonable precautions to ensure their interpretation is accurate and appropriate in the circumstances of the case. The nurse practitioner must have collaborative arrangements in place with a medical practitioner to review unreported images, and to follow up imaging reports when available. Where possible, communication on the findings of the report should be made with other health professionals involved in the patient s care. 8. Medicare and the Pharmaceutical Benefits Scheme 8.1 National health care system The national health care funding system provides eligible Australian residents, regardless of their personal circumstances, access to health care at an affordable, or no cost, while enabling individual choice through substantial private sector involvement in health care delivery and financing. The Australian Government s health funding includes three major national subsidy schemes: Medicare Australia s universal health care program Pharmaceutical Benefits Scheme (PBS) Federal Government 30 per cent rebate on private health insurance. 8.2 Medicare Benefits Schedule (MBS) The Australian Government Department of Health and Ageing is responsible for the Medicare Benefit Schedule (MBS) which lists the services and unique item numbers for which a Medicare benefit is payable. More information can be found on the Department of Health and Ageing s site at and Medicare Australia s site at Eligible nurse practitioners are able to provide certain services listed within the MBS provided those services are within the nurse practitioner s authorised scope of practice and level of experience and competence. 44

47 Eligibility to access Medicare benefits is determined by the Health Insurance Act 1973 (Cth) and related regulations. The Health Insurance Act 1973 can be found at Pharmaceutical Benefits Scheme (PBS) Eligible nurse practitioners are enabled to prescribe certain medicines under Commonwealth subsidy (commonly known as the Pharmaceutical Benefits Scheme (PBS)), by which the Commonwealth provides access to a wide range of medicines for all Australians. The PBS arrangements are governed by the National Health Act 1953 (Cth) and the National Health (Pharmaceutical Benefits) Regulations 1960 (Cth) which can be found at Section 4 Extended clinical practice More information about the PBS can be found at In Queensland, some Queensland Health facilities will participate in arrangements with the Commonwealth to enable access to PBS in some public hospitals. It is important that patients are not financially disadvantaged as a result of nurse practitioner prescribing. Mandatory requirement To be authorised to prescribe under the PBS, a nurse practitioner must: be authorised to prescribe medicines within their scope of practice under State or Territory law be issued by Medicare Australia with a PBS prescriber number (which must be stated in each PBS prescription written by the nurse practitioner) provide treatment in a collaborative arrangement with one or more medical practitioners. 8.4 Repatriation Pharmaceutical Benefits Scheme (RPBS) Prescribing by eligible nurse practitioners under the PBS will also apply for supply of pharmaceutical benefits under the Repatriation Pharmaceutical Benefits Scheme (RPBS). More information can be found on the Commonwealth Department of Veterans Affairs site at Eligible nurse practitioner To be eligible to access the MBS and PBS, each nurse practitioner must register with Medicare Australia for a unique Medicare provider number and PBS prescriber number for each practice location. Meaning of eligible nurse practitioner Under section 84AAI, of the National Health Act, 1953 A person is an eligible nurse practitioner if the person: (a) is a nurse practitioner (b) meets the requirements (if any) set out in a determination made under Subsection (2) of the Act

48 Section 4 Extended clinical practice The Federal Minister for Health and Ageing may, by legislative instrument, determine one or more requirements that a specified person must meet in order to be an eligible nurse practitioner for the purposes of this Act. Medicare Australia provider numbers are also allocated to enable nurse practitioners to request certain diagnostic imaging and eligible pathology services as set out in the MBS. An eligible nurse practitioner applying for a provider number must be in private practice, and services claimed under this initiative must be performed while working in a private capacity. In some circumstances, exemptions may apply. Medicare Australia has created a series of interactive elearning modules to help nurse practitioners understand their obligations under the MBS and PBS. These are available at Nurse practitioners establishing a private practice as an eligible nurse practitioner are required to obtain adequate professional indemnity insurance and are advised to seek appropriate legal and financial advice. Mandatory requirements The National Health (Collaborative arrangements for nurse practitioners) Determination 2010 specifies the kind of collaborative arrangements required for a nurse practitioner to access the MBS and PBS: (a) The nurse practitioner is employed or engaged by one or more medical practitioners, or by an entity that employs or engages one or more medical practitioners. (b) A patient is referred, in writing, to the nurse practitioner for treatment by a medical practitioner. (c) A written and signed agreement is made between a nurse practitioner and one or more medical practitioners. (d) An arrangement, recorded in the nurse practitioner s written records, is made with a named medical practitioner who has acknowledged they will be collaborating with the nurse practitioner in a patient s care. In each case, the collaborative arrangement must provide for: (a) consultation between the nurse practitioner and a medical practitioner (b) referral of a patient to a medical practitioner (c) transfer of a patient s care to a medical practitioner. A collaborative arrangement (other than the arrangement described in (d) above) may apply to more than one patient. 46

49 9. Delegation, referral and clinical handover Central to the nurse practitioner s care of the patient is clear and effective communication with other members of the health care team. Delegation, referral and clinical handover are three key areas where concise communication will provide for effective care of the patient. In some circumstances, the nurse practitioner will be required (adapted from Medical Board of Australia 2010) to: delegate specific tasks or activities to a nurse or another health care professional to provide care on the nurse practitioner s behalf while the nurse practitioner retains overall responsibility for the patient s care. Although the nurse practitioner will not be accountable for the decisions and actions of those to whom they delegate, the nurse practitioner remains responsible for the overall management of the patient, and for their decision to delegate refer a patient to obtain opinion or treatment from another health care professional. This usually involves the transfer (in part) of responsibility for the patient s care, usually for a defined time and for a particular purpose, such as care that is outside the nurse practitioner s area of expertise hand over the patient s care by transferring all responsibility to another health care professional. Section 4 Extended clinical practice Nurse practitioners have a responsibility to identify clinicians and services (internal and external to the health service) likely to constitute referral networks supporting their clinical practice. They are also required to negotiate with these clinicians and services about accepting and acting upon nurse practitioner-generated delegation, referral and handover. Nurse practitioners must ensure that: the person to whom they delegate, refer or hand over has the qualifications, experience, knowledge and skills to provide the care required sufficient information is communicated about the patient and the treatment they require to enable the continuing care of the patient it is clear to the patient, the family and colleagues who has ultimate responsibility for coordinating the care of the patient. Using a standardised approach to the handover will ensure effective transfer of information and responsibility for patient care between health professionals. There are a number of standardised tools that can be adopted to support the handover process. One example is the SBAR framework situation, background, assessment and recommendation. Refer to figure 6 on page

50 Section 4 Extended clinical practice Figure 6: SBAR tool S B A R Situation state the patient s diagnosis/reason for admission and the current problem The situation is that I have a patient (age/gender), who is (diagnosis/deteriorating/ stable). My concerns are (clear and succinct concerns). The current presenting symptoms are (clear, current and relevant symptoms and observations). Background what is the clinical background or context? By way of background (give pertinent information that may include: date of admission/presenting symptoms/medication/previous recent vital signs/test results/status changes) Assessment what do you think the problem(s) is? (Don t forget to have the current vital signs and a key problem list ready) My assessment on the basis of the above is that the patient is.. they are at risk of.. and in need of. Recommendation what are you asking the person to do? My recommendation is that this patient needs (what test/action) by (who) within (timeframe) Repeat to confirm what you have heard. (e.g. I understand that I am to. and you will ) The OSSIE Guide to Clinical Handover Improvement, The Australian Commission on Safety and Quality in Health Care (2010) provides further guidance on best practice in clinical handover to ensure patient safety and is available at Additional resources are also available at Issuing certificates Nurse practitioners are frequently required to issue certificates certifying sickness or a medical condition. Certificates are usually issued for the information of patients employers, but may also be required by insurers, and in court proceedings. The patient must be informed that ultimately it is up to the employer, insurer, magistrate or other party as to whether a certificate issued by a nurse practitioner will be accepted. Nurse practitioners must ensure they are not restricted by law from issuing the certificate. 48

51 10.1 General principles The following key points provide guidance for nurse practitioners when issuing a certificate: A certificate issued by a nurse practitioner must: be legible clearly identify the certificate is issued by an endorsed nurse practitioner as the treating health professional include the signature of the nurse practitioner, the date of issue, the nurse practitioner s registration number and the nurse practitioners practice address and contact details not contain abbreviations or medical jargon be based on facts known to the nurse practitioner. The certificate may include information provided by the patient but any clinical statements must be based upon the nurse practitioner s own observations, or must indicate the factual basis of those statements. Section 4 Extended clinical practice A certificate issued by a nurse practitioner must indicate: the date on which the examination took place whether the patient is totally incapacitated the date on which the patient is likely to be able to return to work be addressed to the party for whom the certificate is forwarded as evidence of illness (eg. employer, insurer, magistrate). Under no circumstances should the examination date: be backdated or antedated or post-dated to correspond with an existing or proposed absence from work be other than the date on which the patient attended the nurse practitioner and at which consultation a genuine medical condition was observed or was considered, in the nurse practitioner s judgement, to have been suffered in the recent past, or be for days off work for holiday or special needs. A diagnosis should not be included in a certificate without a patient s consent. A medical certificate may be issued by a nurse practitioner subsequent to a patient taking sick leave. In these circumstance, the certificate must: state the date of the examination clearly indicate whether it is based upon observations of signs and symptoms during the examination, or upon information provided by the patient which the nurse practitioner deems to be true, and cover the period during which the nurse practitioner believes the illness would have incapacitated the patient Workers Compensation Certificates Under Section 132(3)(a) of the Workers Compensation and Rehabilitation Act 2003 (Qld), a nurse practitioner, acting under the Workers Compensation Certificate Protocol, is authorised to issue a Workers Compensation certificate for a minor injury; that is an injury which does not require admission to hospital to treat the injury. The Workers Compensation Certificate Protocol is a document, co-certified by the Director-General, Queensland Health and the Chief Executive Officer, Q-Comp (Queensland s Workers Compensation Regulatory Authority), and 49 49

52 Section 4 Extended clinical practice 10.3 Centrelink published by Q-Comp, which states the circumstances and conditions under which a nurse practitioner may issue a Workers Compensation certificate. A copy of the Workers Compensation Certificate Protocol for Nurse Practitioners (21 April 2010) is available at It is a condition of the Workers Compensation Certificate Protocol that a nurse practitioner may only issue a workers compensation certificate for a minor injury: (a) where assessment of the injury is within the clinical scope of the position in which the nurse practitioner is engaged (b) for a total period of incapacity not exceeding 10 calendar days. Under the Social Security Act 1991 (Commonwealth), a Centrelink Medical Certificate can only be issued by a medical practitioner (sickness allowance, disability support pension, mobility allowance, Newstart, Youth Allowance, Parenting Payment with participation requirements or Special Benefit). However, there are other provisions under the Social Security Act 1991 that authorise a medical report to be provided by a treating health professional currently involved in the treatment of the Centrelink customer. These provisions also include reports from registered nurses and endorsed nurse practitioners (carer allowance and carer payment for adults and children). Centrelink should be contacted to clarify requirements before issuing a certificate for Centrelink s purposes Fair Work Act 2009 (Commonwealth) Under Section 12 of the Fair Work Act 2009 (Commonwealth), a medical certificate for the purposes of that Act can be issued only by a medical practitioner. This applies, for example where an employer may ask an employee for a medical certificate under sections.73, 74, 81 and 82 of the Fair Work Act 2009 ( Parental leave and related entitlements ). 11.Reportable deaths 11.1 Cause of death certificate Under Section 30 of the Births, Deaths and Marriages Registration Act 2003 (Queensland), a cause of death certificate may only be completed by a medical practitioner. This does not limit a nurse practitioner s obligation under the Coroners Act 2003 (Queensland), which imposes a duty that anyone who becomes aware of a reportable death must report it to a coroner or the police if they do not reasonably believe that this has already occurred. Failure to report is a criminal offence. 50

53 Reportable deaths are defined in Section 8(3) of the Coroners Act 2003 (Queensland) as deaths where: the identity of the person is unknown the death was violent or unnatural the death happened in suspicious circumstances a cause of death certificate has not been issued and is unlikely to be issued the death was a health care-related death the death occurred in care the death occurred in custody the death occurred as a result of police operations. Section 4 Extended clinical practice 11.2 Health care related deaths All health care-related deaths are reportable under the Coroners Act 2003 (Queensland), where: (a) the health care caused or contributed to the death, or a failure to provide health care caused or contributed to the death (b) death was an unexpected outcome of the health care being provided. For the purposes of the Coroners Act 2003 (Queensland): Health care means a health procedure or any care, treatment, advice, service or goods provided for the benefit of human health. Health procedure includes any dental, medical, surgical, diagnostic or other health-related procedure, including a consultation or giving an anaesthetic or other drug. Information for health professionals is available at

54 Section 5 Clinical audit and review SECTION 5 Clinical audit and review 1. Overview Clinical audit has a history reaching back to the work of Florence Nightingale in the 1800s, where she used an epidemiological method of review for monitoring rates of nosocomial infections in relation to standards of hygiene. Health services are now utilising audit as an integral part of their qualityimprovement strategies and accreditation processes (UNSW, 2009). What is a clinical audit? Clinical audit can be defined as a process that seeks to improve patient care and outcomes through a systematic review of care against explicit measures and the implementation of change in practice if needed (Dixon, 1996). Clinical audit may be used to measure adherence to evidence-based clinical practice guidelines, and is a useful way for clinicians to measure their current practice and subsequently identify any gaps. The main aim of clinical audit is to rigorously measure how well something is done and to provide feedback to improve local performance of clinical care (Middleton, 1996). Clinical audit has the potential to assure or improve direct patient care, though patients are not the only beneficiaries of the process. The clinician and multidisciplinary team benefit from: feedback on performance enhanced teamwork development of knowledge identification and minimisation of problems. The organisation benefits from: achieving cost benefits through the application of best evidence having accurate information on performance ability to demonstrate high-quality services identification and minimisation of risks. Patients benefit from: being assured that the quality of care is monitored improvements in health care delivery (Queensland Health, 2005). Quality management of clinical care is an important tool for the effective and efficient roll-out of new levels and types of health service (Drennan et al 2009), and contributes to a framework for clinical governance and ongoing development of the nurse practitioner role. It is important, therefore, that the safety and quality of nurse practitioner service is evaluated against indicators that are relevant to their clinical service and patient outcomes. An audit is an important tool to provide measurement and feedback on the process and outcome of clinical practice (Gardner, Gardner & O Connell, 2010). 52

55 2. Guideline Mandatory requirement Regular review of the safety and quality of nurse practitioner services are undertaken to evaluate the nature and performance of nurse practitioner practice, the context in which nurse practitioners work and the quality of clinical service outcomes. Responsibility for this process will need to be identified within the model, and undertaken by either a nurse practitioner, nurse researcher or other health professional. Section 20 of the Health Quality and Complaints Commission Act 2006 (Queensland) imposes a duty on all public and private sector health service providers (including nurse practitioners and their employers) to establish, implement and maintain processes to improve the quality of services they deliver, including processes to monitor the quality of the health services and protect the health and wellbeing of users of the health system. Section 5 Clinical audit and review Queensland Health Clinical Governance Implementation Standard: Clinical Audit and Review describes the minimum mandatory requirements for clinical audit and review processes. 2.1 Quality assessment framework The Donabedian Quality Assessment Framework (1997) of structure, process and outcome is an appropriate tool for review of health care services: 1. Structure Evaluation of structure includes identification of adequacy of facilities, equipment and access to diagnostic, information technology (IT) and other resources for the nurse practitioner; characteristics of support, training and development; and the extent of integration of the nurse practitioner role into the organisation of the service. Data collection tools include: survey interviews of nurse practitioners and stakeholders. 2. Process Audit of the process of care includes measuring service outcomes that are influenced by nurse practitioner service (such as wait times and other specific service key performance indicators; nurse practitioner use of resources (such as diagnostic tests, prescribing, referrals); technical competency and scope of nurse practitioner practice; availability and use of evidence-based guidelines specific to the patient group and the nurse practitioner s defined scope of clinical practice. Data collection tools include: patient chart review survey interviews of nurse practitioners and stakeholders relevant service key performance indicator records. 3. Outcome Audit of outcome of nurse practitioner service includes number of patients/clients accessing nurse practitioner service in a defined period (measurement will be relevant to the nurse practitioner model); evaluation of progress/improvement/cure of presenting condition and/or symptoms; evaluation of patient attitudes and satisfaction; improved patients knowledge and self-care competencies; recording of adverse events

56 Section 5 Clinical audit and review 3. Outcomes Data collection include: facility-based nurse practitioner patient flow data peer case review of a sample of patients chart review patient interviews. The nurse practitioner and their employer establish a framework for review and evaluation of, and continuous improvement in, the safety and quality of health services provided by the nurse practitioner. The nature and performance of each nurse practitioner s practice, the context in which each nurse practitioner works and the quality of the clinical service outcomes is reviewed by an interdisciplinary team at least every 12 months. Validated tools should be used to support this practice the Australian Nurse Practitioner Study (AUSPRAC), 2009, A State-wide Audit of Queensland Health Nurse Practitioners, Appendix B provides examples of a data abstraction instrument and a case review tool that may be adopted for auditing nurse practitioner models of care. 54

57 Summary All health practitioners are bound by regulations, processes and responsibilities. This guide and revised Drug Therapy Protocol for Nurse Practitioners aims to support the progression of the nurse practitioner role in Queensland. The positive engagement with the nurse practitioner role in the state attests to identification by service delivery areas that this new level of health care provider improves quality, timeliness and access to health care (Middleton, 2007). Further research and evidence will inform the future direction of the nurse practitioner role and help determine the impact of the role on health service delivery. Nurse practitioners are at the forefront of nursing and health care reform, and successfully negotiate the challenges head on to improve access to quality health care for Queenslanders. Summary 55

58 Governance checklist Governance checklist Nurse practitioners and their employers must be able to demonstrate the following outcomes (please tick boxes): c Use of extended practice privileges is evidence-based and in accordance with the recognised clinical standards, practices and procedures for health care in Australia. c Use of medicines by nurse practitioners complies with the Health (Drugs and Poisons) Regulation 1996 (Queensland) and the Drug Therapy Protocol for Nurse Practitioners. c Each nurse practitioner maintains a list of personal or P-drugs that are prescribed by the nurse practitioner as lead clinician. c Where another health professional is the lead clinician responsible for the diagnosis and management plan, the arrangements for supplementary prescribing by the nurse practitioner are documented in the patient s record. c Blood and blood components are not used unless specifically authorised in the approved practice scope of the position in which the nurse practitioner is engaged. c Use of diagnostic radiography complies with the Radiation Safety Regulation 1999 (Queensland) and the Diagnostic Radiography Protocol. c Issue of Workers Compensation certificates complies with the Workers Compensation and Rehabilitation Act 2003 (Queensland) and the Workers Compensation Certificate Protocol for Nurse Practitioners. c Nurse practitioners issue certificates with factual information based upon the nurse practitioner s own observations and assessment. c Patients are only referred to health practitioners who have the qualifications, experience, knowledge and skills to provide the care required. c The provision of services under the Medicare Benefits Schedule (MBS) complies with the Health Insurance Act 1973 (Commonwealth). c Prescribing of medicines under the Pharmaceutical Benefits Scheme (PBS) complies with the National Health Act 1953 (Commonwealth). c Audit processes are in place to review the prescribing practices and the services provided by nurse practitioners. c A credentialing framework will be adopted (when available) to support clinical governance arrangements. 56

59 References Australian Commission on Safety and Quality in Health Care (ACSQHC) (2010), The OSSIE Guide to Clinical Handover Improvement. Australian Council for Safety and Quality in Health Care (ACSQHC) (2004), National standard for credentialing and defining the scope of clinical practice. Australian Health Ministers Conference (AHMC) (2004), National Health Workforce Strategic Framework Sydney. Australian Nursing Federation (2005), Competency Standards for the Advanced Registered Nurse. Australian Nursing and Midwifery Council (ANMC) (2008a), Code of ethics for nurses in Australia. Australian Nursing and Midwifery Council (ANMC) (2008b), Code of professional conduct for nurses in Australia. Australian Nursing and Midwifery Council (ANMC) (2007b), A national framework for the development of decision-making tools for nursing and midwifery practice. Australian Nursing & Midwifery Council (ANMC) (2006), National competency standards for the nurse practitioner. Bowie P, Quinn P, Power A. (2009), Independent feedback on clinical audit performance: a multi-professional pilot study, Clinical Governance: An International Journal, 14(3): Coombes ID. (2007), Four Components of Prescribing, PHO thesis for the University of Queensland. Department of Health (UK) (2005), Supplementary Prescribing by Nurses, Pharmacists, Chiropodists/Podiatrists, Physiotherapists and Radiographers within the NHS in England A guide for implementation. Dixon N. (1996), Good practice in clinical audit: a summary of selected literature to support criteria for clinical audit. London: National Centre for Clinical Audit. Donabedian A. (1997), The quality of care: How can it be assessed? Arch Pathol Lab Med, 121: Drennan J, Naughton C, Allen D, Hyde A, Felle P, O Boyle K, Treacy P, Butler M. (2009), Independent evaluation of the nurse and midwife prescribing initiative, University College Dublin, Dublin. Dulko D, Hertz E, Julien J, Beck S, Mooney K. (2010), Implementation of cancer pain guidelines by acute care nurse practitioners using an audit and feedback strategy, Journal of the American Academy of Nurse Practitioners, 22: Dulko D, Mooney K. (2010), Effect of an audit and feedback intervention on hospitalized oncology patients perception of nurse practitioner care, Journal of Nursing Care Quality, 25(1): Gardner, G, Gardner, A, O Connell, J. (2010), A State-wide Audit of Queensland Health Nurse Practitioners, Office of the Chief Nursing Officer, Queensland Health. Gardner et al (2009), AUSPRAC, The Australian Nurse Practitioner Study. The Nurse Practitioner Research Toolkit. Gardner, G, Gardner, A & Proctor, M. (2004), Nurse practitioner education: a research-based curriculum structure, Journal of Advanced Nursing 47(2): Health Quality and Complaint Commission s (2010), Credentialing and scope of clinical practice standard. Jamtvedt G, Young J M, Kristoffersen D T, O Brien M A, Oxman A D. (2009). Audit and feedback: effects on professional practice and health care outcomes (Review), The Cochrane Collaboration, Issue 1. Medical Board of Australia (2010), Good Medical Practice: A Code of Conduct for Doctors in Australia. Middleton S. (2007), Audit or research. Should nurse practitioners participate in these types of evaluation and what is the difference between them? The Nurse Practitioner Series, 2(1): Nursing and Midwifery Board of Australia (NMBA) (2010), Registration standard for endorsement of nurse practitioners. Queensland Health Systems Review Final Report (2005). Queensland Health (2005), A Practical Handbook for Clinical Audit. Clinical Governance Support Team. Queensland Health (2009), Credentialing and Defining the Scope of Clinical Practice for Medical Practitioners in Queensland: A Policy and Resource Handbook. Report of the Queensland Public Hospitals Commission of Inquiry (2005). University of New South Wales (2009), Clinical Audit: A comprehensive review of literature, Centre for Clinical Governance Research. References 57 57

60 Appendices Appendix A Template: Practice Scope of the Nurse Practitioner (Queensland Health Facility) Important note: The following Practice Scope of the Nurse Practitioner templates are for information only. The electronic, interactive public and private sector templates are available from page 1 58

61 Practice Scope of the Nurse Practitioner (Queensland Health Facility) continued page 2 Appendices 59 59

62 Appendices Practice Scope of the Nurse Practitioner (Queensland Health Facility) continued page 3 60

63 Template: Practice Scope of the Nurse Practitioner (private health facility, clinic or health contractor) Important note: The following Practice Scope of the Nurse Practitioner templates are for information only. The electronic, interactive public and private sector templates are available from page 1 Appendices 61 61

64 Appendices Practice Scope of the Nurse Practitioner (private health facility, clinic or health contractor) continued page 2 62

65 Practice Scope of the Nurse Practitioner in a private health facility,clinic or health contractor continued page 3 Appendices 63 63

66 Appendices Appendix B Audit tools 64

67 Audit tools continued Appendices 65 65

68 Audit tools continued Case review NP model context Patient health issue Assessment criteria Authors judgement Evidence exemplars 1. Knowledge, skills and performance NP competencies 1 to 3 Quality of assessment Appropriate use of diagnostics Clarity of clinical decision making Appropriateness of treatment/interventions (Scope of Practice) 2. Communication and teamwork. NP competencies 5 to 7 Patient s experience of care Patient s self-care knowledge and competencies 66

69 Audit tools continued 3. Quality and safety. NP competencies 4 and 8 Patient s perception of quality of care Use of evidence to inform practice Practice consistent with scope of practice Nurse practitioner s reflection on case review Contact details for Office of the Chief Nursing Officer Office of the Chief Nursing Officer Queensland Health GPO Box 48 BRISBANE QLD 4001 Contact details [email protected] Phone: Fax:

70 68