The Nurse Practitioner Series

The Nurse Practitioner Series The Nurse Practitioner Series A series produced by the Office of the Chief Nursing Officer Department of Health, Western Australia in collaboration with the School of Nursing and Midwifery Curtin University of Technology Volume 1 Number 1 March 2004 1

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The Nurse Practitioner Series The Nurse Practitioner Series A series produced by the Office of the Chief Nursing Officer Department of Health, Western Australia in collaboration with the School of Nursing and Midwifery Curtin University of Technology Volume 1 Number 1 March 2004 3

The Nurse Practitioner Series. ISBN 0-9751225-2-5 The Office of the Chief Nursing Officer publishes and distributes The Nurse Practitioner Series. The primary purpose of the series is to promote the development of the nurse practitioner role in Western Australia. Copies of The Nurse Practitioner Series are available from: Office of the Chief Nursing Officer Department of Health 189 Royal Street East Perth Western Australia Australia 6004 www.nursing.health.wa.gov.au Volume 1 Number 1 March 2004 Department of Health Western Australia 2004 This work is copyright. It may be produced in whole or part for study or training purposes subject to the inclusion of an acknowledgement of the source and no commercial usage or sale. Reproduction for purposes other than those indicated above requires the written permission of the Department of Health Western Australia, 189 Royal Street, East Perth, Western Australia 6004. Disclaimer The opinions expressed within are the authors and not necessarily those of the Office of the Chief Nursing Officer, Department of Health Western Australia, Curtin University of Technology, the Editors, or the Editorial Board. Design and Layout: Office of the Chief Nursing Officer, Michelle Cabrera 4

The Nurse Practitioner Series Aim The primary aim of The Nurse Practitioner Series is to promote and disseminate information on approaches, activities, theory and research relating to the role and the implementation of nurse practitioners in Western Australia. Table of Contents Aim 5 Editor 7 Editorial Board 8 Editorial 11 Leading Opinion - Reflection: Personal Characteristics of Potential Nurse Practitioners Phillip Della 13 Nurse Practitioners in Western Australia - Policy to Legislation Phillip Della and Elizabeth Adams 17 Overview of the Guiding Framework for the Implementation of Nurse Practitioners in Western Australia Elizabeth Adams 21 Regulation of Nurse Practitioners in Western Australia Cynthia Witney 27 A Synopsis of Nurse Practitioner Education in Western Australia 31 Jennie Sharp The First Nurse Practitioner Students Conference: Dimensions of the Nurse Practitioner Role - New Paths of Practice Angelica Orb 33 5

Abstracts from the Proceedings of the First Students Conference Program 34 A new scope of practice for Western Australian nurses 34 The expanding role of the haematology clinical nurse specialist 35 Examples from the field - the extended role 36 Implementation of a potential nurse practitioner role into Armadale Health Service Emergency Department a clinical perspective 37 Moving from clinical nurse specialist to nurse practitioner in wound management for an acute care setting 38 Perceptions of the nurse practitioner role from nurses, clinicians, patients and other consumers 39 Accessibility - the critical thread 40 Leading the way - implementing the role of the nurse practitioner 41 Cost effectiveness and nurse practitioners 42 Nurse practitioner within child and adolescent mental health services - a benefit rather than a burden 43 Collaborative practice in the clinical setting - nurse practitioners and physicians 44 Nurse practitioner - autonomous, independent and/or collaborative practice? 45 Current issues surrounding nurse prescribing 46 Nurse practitioner education - what level? 47 Nurse Practitioner Sponsorship Information 49 Guidelines for Contributors 51 6

The Nurse Practitioner Series Editor Dr Phillip R Della PhD RN FRCNA RM Cert QMA B App Sci Grad Dip Man MBus Chief Nursing Officer Department of Health, Western Australia Dr Phillip Della is currently the Chief Nursing Officer with the Department of Health, Western Australia. He has extensive and broad nursing experience in areas of clinical specialisation, nursing management, research and development. Phillip has directed a number of strategic developments in nursing including areas of workforce development, nurse practitioner legislation and professional enhancement. Phillip has worked as a management consultant and academic, lecturing in health service management and nursing management, and holds an Adjunct Senior Teaching Fellow position with the School of Public Health, Department of Health, Policy and Management, Curtin University of Technology. Co-editor Ms Elizabeth Adams RGN Cert(ODN) BNS(Hons) Dip(Mgt) Dip(Counselling) Dip(Phy & Chem) PGDip(Stats) MSc Manager Strategic Development (Nursing) Office of the Chief Nursing Officer Department of Health, Western Australia Elizabeth Adams is currently the Manager of Strategic Development for Nursing and Midwifery with the Office of the Chief Nursing Officer, Department of Health, Western Australia. Previously she worked with the Chief Nursing Officer in the Department of Health and Children in Ireland as a Nurse Research Officer on a national Study of Nursing and Midwifery Resource. Prior to this, she was a theatre superintendent in a large tertiary referral hospital (Mater Misericordiae Hospital, Dublin). In 2003, Elizabeth became the first student of the School of Nursing and Midwifery, University of Dublin, Trinity College Ireland, to be awarded a Masters Degree in Science through Research. She has been recognised nationally and internationally for her research skills and was the first national and, subsequently European, winner of the Klinidrape and European Operating Room Nurses Association Research Nursing Foundation. 7

Editorial Board Dr Angelica Orb BNurs DipEd MEd PhD RN MACE ALPHA CHI Senior Lecturer Research Fellow Freemasons Centre into Aged Care Services School of Nursing and Midwifery, Curtin University of Technology Angélica Orb is the former Head of the School of Nursing, Curtin University of Technology and Director of the undergraduate nursing program. Angélica s PhD was in ethics with a focus on professional aspects of the nursing profession. She was involved in the development of Curtin s Guiding Ethical Principles and has a seat on various ethics committees. Angélica is a member of Sir Charles Gairdner Hospital Ethics Committee and the Sigma Theta Tau International Honor Society of Nursing. She has a particular interest in ageing, culture and qualitative research. Angélica supervises Master and PhD students and teaches qualitative research. She is the former Honorary Consul of the Republic of Chile. Dr Carol Piercey BAppSc PGDip(HSc) MSc PhD RN FRCNA Lecturer School of Nursing and Midwifery, Curtin University of Technology Dr Carol Piercey is a lecturer at the School of Nursing and Midwifery at Curtin University of Technology. She is involved in both the undergraduate and postgraduate arenas. Her work in the postgraduate area includes the nurse practitioner program and conducting an adult rehabilitation course in conjunction with Royal Perth Hospital, where Carol has an Adjunct Appointment. Carol also has a Joint Appointment with the Quadriplegic Centre in Shenton Park. She has extensive experience in accident and emergency, operating room and rural nursing. Her research interests include the history of nursing and adult education. 8

The Nurse Practitioner Series Ms Jennie Sharp BSc(Nsg) RN RM MRCNA PhD candidate Coordinator Nurse Practitioner Program School of Nursing and Midwifery, Curtin University of Technology Jennie Sharp is the Coordinator of the nurse practitioner program at Curtin University of Technology in Western Australia. She has been involved with the Western Australian nurse practitioner movement since its inception in 1998. Her background is in remote area nursing, midwifery, research and education. She has extensive experience in curriculum development, proposal writing and research design. Jennie is an Honorary Research Fellow with the Women & Infants Research Foundation, King Edward Memorial Hospital, and an Adjunct Research Midwife at King Edward Memorial Hospital. Her PhD work focuses on the perinatal care of illicit drug-using mothers and their infants. Mr Robin Moon RN RMHN RM BHSc(Nsg) Grad Dip Bus(Mgt) Grad Cert Men s Hth MRCNA RNP candidate Robin Moon is currently employed as a Clinical Nurse in the Emergency Department of Swan District Hospital. He has extensive clinical nursing experience within a wide range of clinical areas in rural and metropolitan healthcare facilities. Robin is currently enrolled as a nurse practitioner candidate at Curtin University of Technology. 9

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The Nurse Practitioner Series Editorial Welcome to the first of The Nurse Practitioner Series. This practice-based academically-referenced series provides a forum to profile the development of the nurse practitioner role in Western Australia. The purpose of the series is to provide professional and academic debate into the development of this advanced nursing role, including its policy and legislative framework, educational preparation and practice development. Establishing the legislation and policy for the introduction of nurse practitioners in Western Australia has been one of the most rewarding parts of my nursing career. Progress to date has included the registration of the first nurse practitioners by the Nurses Board of Western Australia and the awarding of 37 sponsorships to nurses to enable them to commence the Postgraduate Diploma in Clinical Specialisation (Nurse Practitioner) at Curtin University of Technology. It is now important that the work continues to ensure nurse practitioners are established in a wide range of clinical settings. The next major step will be the designation of areas for nurse practitioners to practice. In this first issue contributions have been received from nurses from the Department of Health, the Nurses Board of Western Australia, Curtin University of Technology and those enrolled in the first postgraduate nurse practitioner course in Western Australia. Articles from these contributors were invited to both acknowledge their work and provide an overview of the development of the nurse practitioner program. Future issues will contain articles that are either submitted or invited and the series will be published biannually. All articles will be subject to review by at least two members of the Editorial Board to ensure that they add to the nursing profession s body of knowledge and the emergent nurse practitioner role. While the focus will remain on Western Australia, articles will be invited and accepted from national and international nurses who have made significant contributions to the development of the nurse practitioner role. In this issue, an overview of the Guiding Framework for the Implementation of Nurse Practitioners in Western Australia (2003) has been provided by Ms Elizabeth Adams, Manager Strategic Development, Department of Health. Elizabeth has been the driving force behind the development of the framework and has spent many long hours researching, developing, writing and publishing the final report. I thank and congratulate her on her outstanding achievement on behalf of the Western Australian nursing profession. Also in this issue, Mrs Cynthia Witney, Nursing Adviser (Registration and Education), Nurses Board of Western Australia provides an overview of the nurse regulatory requirements and Ms Jennie Sharp, Lecturer, Curtin University of Technology profiles the education course. In addition, the abstracts from the Proceedings of the First Student Conference Program are published. I would like to take this opportunity to commend The Nurse Practitioner Series to you in the knowledge that it will become a valuable resource in the development of this new role. I also wish to thank my colleagues on the Editorial Board who helped to make this part of the vision for nurse practitioners a reality. Dr Phillip R Della Chief Nursing Officer 11

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Leading Opinion The Nurse Practitioner Series Reflection: Personal Characteristics of Potential Nurse Practitioners Dr Phillip Della PhD RN FRCNA RM Cert QMA B App Sci Grad Dip Man M.Bus Chief Nursing Officer Department of Health, Western Australia Abstract Introduction The development of the nurse practitioner role in Western Australia has now entered the next major phase. While the legislation, policy, education and regulatory frameworks have been completed, the designation of areas of practice will raise questions on what will be the characteristics that will lead to successful implementation. It is important that the nurse practitioner role is clinically-focused and recognises nursing experience. Nurses who choose a career path as a nurse practitioner will need to demonstrate a common sense approach to this new role, accept responsibility and be aware of their limitations. Consultation, collaboration and communication will all be required to ensure successful implementation of the nurse practitioner role. Nursing literature increasingly reports on the growing importance of nurse practitioners in the delivery of health care. While the nurse practitioner movement in Australia is a relatively new role for nurses, the international formation can be traced back to the 1960s, when nurse practitioners were introduced into the primary health care setting in the United States of America (USA). Canada followed the USA experience in the 1970s and in both countries the development of nurse practitioner programs have been in response to limited access to health care services in specific areas. It has, however, been reported that in the 1980s a decrease in nurse practitioner program numbers occurred as a result of an increase in the medical workforce (Wilson, 2003). This turn-around again occurred in the early 1990s when the number of nurse practitioners was increased, again in response to limited access for clients to health care services in specific areas. Increasingly in Australia attention has been given to the roles that nurse practitioners can undertake in the delivery of health care. While this attention has occurred on a national level, the adoption of the nurse practitioner role has varied between jurisdictions. It is generally accepted that New South Wales (NSW) has led the development of the nurse practitioner role. Other states including Victoria, South Australia and Queensland have undertaken pilot studies on the role of nurse practitioners. 13

The development of the nurse practitioner role in Western Australia commenced in 1998 with the formation of the Nurse Practitioner Steering Committee. This committee devised its terms of reference and in 1999 developed the nurse practitioner model for Western Australia. In 2000, the Steering Committee published the Remote Area Nurse Practitioner Report that recommended a framework for legislation, education, practice and evaluation. The Office of the Chief Nursing Officer continued the legislative process, and the Nurses Amendment Bill was introduced in 2002 and came into effect on 9 April 2003. This paved the way for the first nurse practitioners to be registered in Western Australia in October 2003. It is important that the next major steps in the implementation of the nurse practitioner program will be the development of clinical protocols and designation of practice areas and settings. Personal Characteristics While the Guiding Framework for the Implementation of Nurse Practitioners in Western Australia (2003) provides a resource for the necessary establishment of the organisational requirements, a focus must be given to the characteristics of future nurse practitioners. The framework identifies that nurse practitioners will have autonomy in clinical practice, display professional and clinical leadership and initiate and coordinate research. A study conducted by Davis, Johnson and Werdegar (2000) identified that the profile of nurse practitioners in California was as follows: the majority were in their early forties; most were female; most were engaged in primary health care, especially in under -serviced areas, with other major practice areas including emergency care, inpatient wards, outpatients, school-based clinics, community care and nursing homes; and most were educated in California. Given these demographics, it is important that a review of the individual characteristics be undertaken. The importance of this review does not only relate to nurses wishing to become a nurse practitioner, but also to managers of health services. Reay, Golden-Biddle and Germann (2003) identified three major challenges for managers of nurse practitioners: the need to clarify the reallocation of tasks; managing the altered working relationships within the team; and continual management of the team in an evolving situation. It will also be important for health service managers to select nurses with the right characteristics to ensure that they are successful in the advanced role. Nurse practitioners will require extensive and broad clinical nursing experience and have a common sense approach to the delivery of health care. They will also need to demonstrate the ability to accept responsibility, know their limitations and have the willingness to ask for and seek help. In the Western Australian model, nurses enrolling in the postgraduate nurse practitioner course are required to have at least three years of post- 14

The Nurse Practitioner Series registration clinical nursing experience, at least two of which were within a specialty setting. This requirement will ensure that nurse practitioners completing the course will have at least four years experience and a similar length of clinical experience as suggested by Sakar et al (1999). It should be remembered that this would be considered to be a minimum requirement. Roberts-Davis and Read (2001) identified that while there are similarities in advanced nursing practice roles for clinical nurse specialists and nurse practitioners, there are also differences. The differences relate to the additional competencies needed for the nurse practitioner role, which include the knowledge and skills required to make clinical assessments, diagnose and determine nursing and medical management of a patient and to evaluate the outcome of management. In addition, nurse practitioners will be able to prescribe a range of medications and order investigations to assist them in their management of patients. The notion that a nurse practitioner should have a common sense approach is related to the need to demonstrate sound judgement and not judgement simply based on specialised knowledge. While specialised knowledge is essential for a nurse practitioner, a common sense approach is required as its tenets include sound and practical understanding with quality application (Bache, 2001). The characteristic of responsibility is related to the need for nurse practitioners to be able to give an account of one s actions. This will ensure their actions can be trusted and depended upon. Nurse practitioners will be responsible for their decisions, which must be based on rational thought and action. It is also important that nurse practitioners will seek guidance and know their personal and professional limitations. Demonstration of this characteristic will include the individual nurse practitioner practising within their own knowledge base and seeking assistance as required. The boundaries of the nurse practitioner s role must be clearly identified, as there is potential for role confusion. This potential role confusion is especially associated with clinical nurse specialists. Initially, nurse practitioners and clinical nurse specialists will have similar clinical experience and backgrounds. Consultation, collaboration and communication will all be required to ensure successful implementation of the nurse practitioner role. It is important that nurse practitioners can inform other staff of the emergent role including the scope of practice, agreed clinical protocols and referral patterns. Thus, excellent communication skills should be a core competency for nurses considering career advancement in the role of nurse practitioner. 15

Conclusion While the development of the nurse practitioner role is relatively new in Australia, on an international scene it has had a 40-year history of development. Given this length of development, it can be accepted that nurse practitioners will add value to the delivery of health care in Western Australia, especially in areas where there is limited access to service delivery. It is important that this new emergent role in Western Australia is progressed in a collaborative framework to ensure that all health care professionals understand and accept the role. This will make sure that all who consult and receive care from a nurse practitioner will benefit. Nurses who accept the challenge to become nurse practitioners will need a common sense approach, accept responsibility and be willing to seek help when needed. They will also need to demonstrate excellent communication skills and have advanced clinical nursing experience. The development of nurse practitioners must be built on professional nursing competencies to ensure the credibility and success of the role. References Bache, J. (2001). Establishing an emergency nurse practitioner service. Emergency Medicine Journal, 18(3), 186-189. Davis, G., Johnson, G., & Werdegar, D. (2000). Nurse practitioners, physician assistants and certified nurse midwives in California: A report by the offi ce of statewide health planning and development and the centre for California health workforce studies at the University of California. San Francisco: The University of California. Department of Health Western Australia, Office of the Chief Nursing Officer. (2003). Guiding framework for the implementation of nurse practitioners in Western Australia. Perth: Department of Health Western Australia. Reay, T., Golden-Biddle, K., & Germann, K. (2003). Challenges and leadership strategies for managers of nurse practitioners. Journal of Nursing Management, 11(6),396-403. Roberts-Davis, M., & Read, S. (2001). Clinical role clarification: Using the delphi method to establish similarities and differences between nurse practitioners and clinical nurse specialists. Journal of Clinical Nursing, 10(1), 33-43. Sakar, M., Angus, J., Perrin, J., Nixon, C., Nicholl, J., & Wardrope, J. (1999). Care of minor injuries by emergency nurse practitioners or junior doctors: A randomised controlled trial. Lancet, 354(9187), 1321-1326. Wilson, D. (2003). Nurse practitioners: the early years (1965-1974). Retrieved December 20, 2003, from http://www.mnpa.us/history/history_to_print.html 16

The Nurse Practitioner Series Nurse Practitioners in Western Australia - Policy to Legislation Dr Phillip Della PhD RN FRCNA RM Cert QMA B App Sci Grad Dip Man MBus Ms Elizabeth Adams RGN Cert(ODN) BNS(Hons) Dip(Mgt) Dip(Counselling) Dip(Phy & Chem) PGDip(Stats) MSc Office of the Chief Nursing Officer Department of Health, Western Australia Introduction Legislation Establishing the role of nurse practitioners in Western Australia required a vision that defined the strategic direction of nursing and midwifery, underpinned by a policy cognisant of the political environment. The concept of implementing nurse practitioners into the Western Australian health care system can be traced back more than 20 years. However, it was not until 1997 that serious attention was placed on achieving this goal, and in 1998 Phase One of the Nurse Practitioner Project commenced. A Steering Committee chaired by Her Honour Judge Kennedy was established by the Commissioner of Health and included representatives from the nursing, medical and legal professions, and consumers. The Steering Committee developed the operational framework in 1999, published the Remote Area Nurse Practitioner Report (2000) and provided the drafting framework for the proposed legislation. Phase Two of the project was launched in October 2001 and articulated the expansion of the scope of the nurse practitioner project. The expansion removed the restrictions limiting the role only to remote areas of practice. The new scope allows nurse practitioners in Western Australia to practice in a wide range of practice settings across all specialities and in all areas of the State. In November 2002, the Nurses Amendment Bill 2002 was introduced into the Legislative Assembly and then to the Legislative Council. Legislative changes allowing nurse practitioners in Western Australia to practice in designated areas came into effect on 9 April 2003. The legislative changes, including amendments to seven Acts and one regulation, address education, registration and the development of a structural framework to allow nurse practitioners to practice in designated areas. These changes are briefly outlined as follows: The Nurses Act 1992 (amended) provides for registration, accreditation of education programs and protection of the nurse practitioner title. The Medical Act 1894 (amended) provides exceptions for nurse practitioners to provide certain services. The exception applies only in circumstances where nurse practitioners are practicing in a designated area. 17

The Misuse of Drugs Act 1981 (amended) provides a defence to a charge of possession or use of a prohibited drug if prescribed by a nurse practitioner. The offence of obtaining prohibited drugs by fraudulent behaviour is extended to cover obtaining the drug from a nurse practitioner. The Pharmacy Act 1964 (amended) allows a pharmacist to supply a drug on the prescription of a nurse practitioner and allows a nurse practitioner, acting in the course of that profession, to dispense medicine or drugs. The Poisons Act 1964 (amended) allows a nurse practitioner, while lawfully practicing as a nurse practitioner, to supply poisons in Schedule 1 and Schedule 4. Provision is made for regulations to be made that allow the Director General of the Department of Health to designate an area of practice. The Poisons Regulations 1965 (amended) allows the Director General of the Department of Health to designate areas in which a nurse practitioner may possess, use, supply or prescribe poisons in accordance with the requirements of the Poisons Act. The nurse practitioner is allowed to procure Schedule 4 poisons to the extent that this is required for employment. The Radiation Safety Act 1975 (amended) allows a nurse practitioner to request the holder of a license under the Act to undertake diagnosis or therapy. The amendments do not permit a nurse practitioner to conduct X-rays, other diagnosis or therapy unless they also have undergone the appropriate training and hold the appropriate licence. The Road Traffi c Act 1974 (amended) provides a defence when driving under the influence of drugs alone, if the drugs were prescribed by a nurse practitioner. The framework outlined in the legislation has two distinct processes: the registration of nurse practitioners with the Nurses Board of Western Australia and the designation of an area of practice by the Director General of Health. Registered nurse practitioners can only practice in an area designated by the Director General of Health. The scope of practice of a nurse practitioner in a designated area is governed by the Nurses Act 1992 (as amended), the Poisons Act 1964, and clinical protocols approved as part of the designation of an area under the Poisons Regulations 1965, the Nurses Code of Practice 2000 and the Nurse Practitioner Code of Practice to be issued by the Nurses Board of Western Australia. Designated areas are not limited to geographical location or clinical specialty. The health service/organisation must apply in writing to the Director General of Health with a business case, job description, and clinical protocols. The clinical protocols must be developed in partnership and collaboration with the health care team in the health service/organisation. Once the clinical protocols are developed by the health service/organisation, using the best available evidence, they must be approved by an external review panel consisting of an appropriate multi-disciplinary team of experts prior to submission to the Director General of Health. In summary, legislation allows registered nurse practitioners working in designated areas to prescribe Schedule 1 and 4 medications, order routine 18

The Nurse Practitioner Series pathology and diagnostic imaging tests (Department of Health, 2003). Detailed information on the legislation that allows nurse practitioners to practice in a designated area is available from the State Law Publisher (www.slp.wa.gov.au). Conclusion Registered nurse practitioners in Western Australia are now in a position to work in and manage a designated clinical area. This model fosters intellectual creativity and innovation in patient care practices and is based on the contribution of the multi-disciplinary team in the delivery of patientcentred care. References Department of Health Western Australia, Office of the Chief Nursing Officer. (2003). Guiding framework for the implementation of nurse practitioners in Western Australia. Perth: Department of Health Western Australia. Health Department of Western Australia. (2000). Remote area nurse practitioner project. Perth: Health Department of Western Australia. Nurses Board of Western Australia (2000). Nurses Code of Practice 2000. Perth: Nurses Board of Western Australia. Western Australian Government. Medical Act 1894. Perth: Government Printer. Western Australian Government. Misuse of Drugs Act 1981. Perth: Government Printer. Western Australian Government. Nurses Act 1992. Perth: Government Printer. Western Australian Government. Pharmacy Act 1964. Perth: Government Printer. Western Australian Government. Poisons Act 1964. Perth: Government Printer. Western Australian Government. Poisons Regulations 1965. Perth: Government Printer. Western Australian Government. Radiation Safety Act 1975. Perth: Government Printer. Western Australian Government. Road Traffi c Act 1974. Perth: Government Printer. 19

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The Nurse Practitioner Series Overview of the Guiding Framework for the Implementation of Nurse Practitioners in Western Australia Ms Elizabeth Adams RGN Cert(ODN) BNS(Hons) Dip(Mgt) Dip(Counselling) Dip(Phy & Chem) PGDip(Stats) MSc Office of the Chief Nursing Officer Department of Health, Western Australia Abstracts Introduction The 9 th of April 2003 marked a major milestone in the history of the nursing profession in Western Australia when the legislation to allow nurse practitioners to practice in designated areas came into effect. This concluded many years of work by the Offi ce of the Chief Nursing Offi cer that transformed a vision for establishing nurse practitioners in Western Australia into a reality. The next phase for the Chief Nursing Offi cer was to focus on handing over the concept of nurse practitioners to the nursing profession to allow the role to be developed in partnership and collaboration within the health services/ organisations and in response to patient needs and service demands. The Offi ce of the Chief Nursing Officer is cognisant of the fact that the nurse practitioner role nationally and internationally has developed in many and diverse ways which has subsequently led to a lack of understanding and confusion about the role. In Western Australia, the approach to developing the nurse practitioner framework took into consideration national and international experience, and used it to infl uence the evolution of a clear framework for nurse practitioner practice. This paper outlines the Guiding Framework for the Implementation of Nurse Practitioners in Western Australia (2003) published by the Offi ce of the Chief Nursing Offi cer for the nursing profession and health services/ organisations, detailing the role of nurse practitioners in Western Australia. The Office of the Chief Nursing Officer has published the Guiding Framework for the Implementation of Nurse Practitioners in Western Australia (Department of Health, 2003a), which provides essential information for health services/organisations and the nursing profession on the development of nurse practitioners in the State. The guiding framework provides a background on the development of the policy, which led to the legislative changes that now allow registered nurse practitioners to practice in designated areas. It addresses the core concepts and principles, details the educational requirements and opportunities and describes the two distinct processes to establish the new role: registration and designation of an area. In addition, the document outlines an approach to develop the clinical protocols that will define the scope of practice in the designated area and provides the foundation of an evaluation framework. 21

The following five principles guided the Office of the Chief Nursing Officer in planning the strategic direction for the development of the framework for the nurse practitioner role in Western Australia: Equity: Everyone should have a fair opportunity to attain full health potential. This means that health inequalities are targeted and patients are treated according to need by nurse practitioners. Client focused: It is important that the provision of services take into account the needs and preferences of the community. Nurse practitioner service delivery must accommodate differences in patient preference and encourage decisionmaking. Involvement of consumers as partners in planning and evaluation to promote openness and accountability is paramount. Quality: This means that evidence-based standards are set in partnership and collaboration with health care professionals and the consumer, and are externally validated. Commitment to continuous quality improvement should be embedded into the delivery of care by nurse practitioners and health services/organisations. Accountability: Financial, professional and organisational accountability is incorporated in the principle of quality. Evaluation models must demonstrate that available resources are used efficiently and effectively. Consistency: A coherent and collective approach to the delivery of nursing and midwifery services within the health system is vital. This approach should be based on the concept of synergy that indicates approaching a task with collective wisdom will lead to attaining a better outcome that will contribute to nursing s body of knowledge. In developing the guiding framework, it was important to identify the attributes of a nurse practitioner that collectively distinguish and define the role in Western Australia. Consideration was given to the development of nurse practitioners nationally and internationally. The National Council for the Professional Development of Nursing and Midwifery in Ireland (2001) identifies four core concepts of a nurse practitioner: autonomy in clinical practice; professional and clinical leadership; expert practitioner; and researcher. These four core concepts have been adopted by the Office of the Chief Nursing Officer to outline the essential elements and form the foundation on which the development of the nurse practitioner role is based in Western Australia. 22

The Nurse Practitioner Series Education to Registration Designation Nurse practitioners are required to exercise higher levels of judgement, discretion and decision-making in the clinical setting. Therefore, appropriate preparation, education and demonstrated competence to practice, and formal recognition of such competence, is integral to the success of the role of nurse practitioner. The nurse will need to complete postgraduate studies, which have been approved by the Nurses Board of Western Australia in order to register as a nurse practitioner and practice in a designated area in Western Australia. The legislation allows nurse practitioners in Western Australia to practice only in an area that has been designated by the Director General of Health as holder of the Poisons Regulations 1965, regardless if the site is public or private. The Director General of Health will designate these areas, on the written advice of the Chief Nursing Officer. Designation is not limited to a clinical specialty or geographical location. For example, it may include acute care, aged care facilities, remote areas or isolated communities within Western Australia. The ability to designate areas according to need is a unique opportunity for employers, health care professionals, policy makers and the nursing profession to review service delivery and develop new models of care based on innovative practice that is responsive to service demands and patients needs. The health service/organisation applying for an area to be designated must provide a business case, job description and clinical protocols. The business case must include evidence of need, resources, funding, assurance to provide quality service demonstrated by expected outcomes, and a commitment to audit and evaluate the role and service delivery against the Western Australian Clinical Governance Guidance (Office of Safety and Quality in Health Care, 2003b). In committing to the clinical governance framework, employers have a responsibility to ensure that there are systematic mechanisms in place to assist nurse practitioners to promote and develop quality activities. Health services/organisations must ensure the protection of established high standards, promote and support a learning environment and assure that clinical decisions are based on currently available evidence of effectiveness (Office of Safety and Quality in Health Care, 2003a). Clinical Protocols The legislation requires that the Chief Nursing Officer, Chief Medical Officer and the Executive Director of Population Health, approve clinical protocols prior to designation of an area by the Director General of Health. The clinical protocols are an essential component of the business case that must be developed by a multi-disciplinary team and peer reviewed prior to submission to the Director General of Health (Department of Health, 2003a). 23

Clinical protocols must be developed to assist nurse practitioners to make appropriate decisions about patients specific clinical needs. They are designed to aid nurse practitioners to assess and implement the current best evidence into practice to ensure the optimal and appropriate outcome for their patients. The purpose of these clinical protocols is to cover the areas of advanced practice now permitted under the nurse practitioner legislation. In addition to the guiding framework, the Office of the Chief Nursing Officer has published the Western Australian Nurse Practitioner Business Case and Clinical Protocol Templates (2003), which is a generic template to assist health services/organisations to apply in writing to the Director General of Health for an area to be designated (Department of Health, 2003b). Evaluation A key priority of the Office of Safety and Quality in Health Care, Department of Health (2003) is to develop consistent policies and standards to enable the effective development and coordination of a system-wide framework for clinical governance across the health sector. The Office of the Chief Nursing Officer requires that nurse practitioners and the health services/organisations applying for an area to be designated adopt the clinical governance framework. The Office of Safety and Quality in Health Care (2003b) states that clinical governance is the term applied to collecting all the activities that promote, review, measure and monitor the quality of patient care into a unified and coherent whole. The principles of ensuring accountability and safeguarding optimal standards of nursing care, based on continually improving service quality and creating opportunities for clinical excellence, can be achieved through the clinical governance framework. In Western Australia, the model for clinical governance is based on four pillars: clinical performance and evaluation; professional development and management; clinical risk; and consumer value. Under each pillar is the identification of expected clinical outcomes, standards and policies, data and information sources, and clinical practice improvement systems (Office of Safety and Quality in Health Care, 2003b). Incorporating the clinical governance framework has many advantages for patients, the health service, the employer and the nurse practitioner. It provides a clear framework promoting an open and inclusive culture that reflects the fundamental principle of collaboration and partnership underpinning the model for nurse practitioners in Western Australia. It ensures that all practice and service delivered is committed to quality and continuous improvement. It provides a standardised framework for nurse practitioners to evaluate, audit and research their practice under the four pillars of the clinical governance model. Designated areas in which nurse practitioners will practice will be varied and diverse. Embracing the clinical governance framework will provide a foundation from which practice can be compared and benchmarked throughout the State, nationally and internationally (Department of Health, 2003a). 24

The Nurse Practitioner Series Conclusion References Implementing the role of the nurse practitioner is a unique opportunity for the nursing profession in Western Australia to work within legislation that supports an advanced level of clinical practice never before attainable in the State. Nurse practitioners will be health care providers practising in designated areas such as ambulatory, acute and long-term care settings. Nurse practitioners will practice autonomously, but in collaboration and partnership with other health care professionals to diagnose, treat and manage patients health problems. They will serve as patient advocates and health care researchers, promote health and disease prevention, and provide teaching and counselling to individuals, families and groups. This care will be delivered by appropriately prepared nurses, who are registered as nurse practitioners with the Nurses Board of Western Australia and employed to practice within designated areas of Western Australia. Department of Health Western Australia, Office of the Chief Nursing Officer. (2003a). Guiding framework for the implementation of nurse practitioners in Western Australia. Perth: Department of Health Western Australia. Department of Health Western Australia, Office of the Chief Nursing Officer. (2003b). Western Australian nurse practitioner business case and clinical protocol templates. Perth: Department of Health Western Australia. National Council for the Professional Development of Nursing and Midwifery Ireland. (2001). Framework for the establishment of advanced nurse practitioners and advanced midwife practitioner posts. Dublin: National Council Ireland. Office of Safety and Quality in Health Care. (2003a). Introduction to clinical governance A background paper. Information Series No. 1.1. Perth: Department of Health of Western Australia. Office of Safety and Quality in Health Care. (2003b). Western Australian clinical governance guidelines. Information Series No. 1.2. Perth: Department of Health of Western Australia. Office of Safety and Quality in Health Care. (2003c). Western Australian strategic plan for safety and quality in health care 2003 2008. Perth: Department of Health of Western Australia. Western Australian Government. Poisons Regulations 1965. Perth: Government Printer. 25

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The Nurse Practitioner Series Regulation of Nurse Practitioners in Western Australia Mrs Cynthia Witney MHA Grad Dip Admin(Health) Dip Teach(Nursing) SNCert RN MRCNA Manager of Registration and Education Nurses Board of Western Australia A nurse practitioner is a registered nurse educated to function in an advanced clinical role. The scope of practice of the nurse practitioner will be determined by the context in which the nurse practitioner is authorised to practice and will include legislative authority not currently within the scope of nursing practice [National Nursing Organisations October 2000]. The role of the nurse practitioner has been under development and trial in most Australian states and territories over the past decade. New South Wales registered the first nurse practitioner in 2001, followed closely by South Australia in 2002, and Western Australia in 2003. In Western Australia, the Nurses Amendment Act 2003 protects the title of nurse practitioner by restricting the use of the title to only those persons entered as nurse practitioners on the register of the Nurses Board of Western Australia. The Act included a six-month savings and transition clause to allow nurses to apply for registration as nurse practitioners, if they had practised as nurses in designated remote area nursing posts during the 3 years prior to the introduction of the nurse practitioner legislation. The clause expired in October 2003. In preparation for the registration of nurse practitioners in Western Australia, the Board convened a peer review panel to develop standards for the nurse practitioner role, criteria for accreditation of nurse practitioner courses, processes and procedures for registration, and assessment of applications from remote area nurses. Members of the panel included a practising remote area nurse with many years experience at a designated remote area nursing post, a general practitioner with considerable remote area practice experience, a nurse academic with extensive experience in intensive care nursing, a nurse manager with many years experience in accident and emergency nursing, a mental health nurse with mental health practitioner status, a consumer representative, the Registrar/Chief Executive Officer of the Board and the Manager of Registration and Education. During the transition phase, 22 nurses applied for nurse practitioner registration. The rigorous process for determining eligibility for registration included appraisal of the applicant s curriculum vitae and professional practice portfolio relevant to nurse practitioner practice and the Professional Practice Standards for Nurse Practitioners in Western Australia. Employer verification of practice was also required and in some instances applicants were interviewed by the panel. To date, 13 remote area nurses have been registered as nurse practitioners in Western Australia. Following registration, each nurse practitioner and her/his employer is required to apply to the Department of Health for approval of a designated area of practice in Western Australia. Effective from October 2003, nurses seeking registration as nurse practitioners must successfully complete a nurse practitioner course accredited by the Board. Currently, Curtin University of Technology offers the Postgraduate Diploma in Clinical Specialisation (Nurse Practitioner), the only accredited course leading to registration. Interstate and overseas nurse practitioner applications for registration are considered on an individual basis. 27

The professional standards for nurse practitioner practice have been developed and are listed below. All documents relevant to the registration of nurse practitioners are available through the Board website www.nbwa.org.au. Professional Standards for Nurse Practitioner Practice The nurse practitioner demonstrates advanced level triage/prioritisation skills through: Early detection of subtle physiological signs and symptoms within context of presentation; Priority interview questioning to extract appropriate patient presenting complaint and history; Accurate determination of patients acuity and initiation of clinical intervention; and Ability to distinguish between life-threatening situations and non-emergent patient presentations in a singular or multiple patient context and planning appropriate care. The nurse practitioner demonstrates advanced level of practice in health assessment through: Expert knowledge and application of mechanisms of injury and precursors to ill health; Expert detection of physiological/psychological abnormalities through a systematic physical assessment including primary and secondary assessments; and Expert social, spiritual and cultural assessment within the context of the presenting complaint/ detected abnormalities. The nurse practitioner demonstrates advanced level of practice in diagnosis through: Judicious and prioritised ordering of pathology and radiological investigations based on informed preliminary diagnostic assumption/s; Interpretation of pathology and radiological results with consideration to informed preliminary diagnostic assumptions; and Determination of probable or definitive diagnosis/es and planning of further investigative tests/ interventions as appropriate. The nurse practitioner demonstrates advanced level of practice related to accountability through: Identification and initiation of wellness interventions utilising a broad range of resources; Compliance with relevant legislation, standards, codes of practice and competencies consistent with the nurse practitioner role; and Documentation of case management for either singular or multiple patient groups. 28

The Nurse Practitioner Series The nurse practitioner demonstrates advanced level of practice in therapeutic management through: Implementation of prioritised treatment regimes based on diagnosis and abnormalities detected from health assessment; Implementation of multiple therapeutic regimes concurrently; Awareness of therapeutic scope including limitations and determination of appropriate and timely referral; and Clinical practice, which is evidence-based, relevant and current. The nurse practitioner demonstrates ability to evaluate practice at an advanced level through: Revision of therapeutic interventions based on ongoing evaluation of clinical outcomes; Identification of alternate treatment/care options and systematic investigation of their relevance to achieve improved outcomes; and Identification of potential adverse outcomes and implementation of proactive strategies to achieve risk minimisation. The nurse practitioner demonstrates advanced level of pharmacology knowledge through: Knowledge of specific pharmaceuticals required within the area of practice; Understanding and application of appropriate drug selection and therapeutic monitoring within scope of practice; and Understanding of amendments to Poisons Act 1965 relevant to the role of the nurse practitioner. Mrs Cynthia Witney MHA Grad Dip Admin(Health) Dip Teach(Nursing) SNCert RN MRCNA Manager of Registration and Education Nurses Board of Western Australia Cynthia has worked in the challenging area of regulation for the past two years and has 26 years experience as a nurse in a number of contexts including education, management, school health and rehabilitation consultancy. Her previous position was as Quality Manager at Barwon Health, Geelong, Victoria. Cynthia has an abiding interest in the quality of education for nurses and hopes to complete a doctorate focusing on this topic in the not too distant future. 29

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The Nurse Practitioner Series A Synopsis of Nurse Practitioner Education in Western Australia Ms Jennifer Sharp BSc(Nsg) RN RM MRCNA PhD candidate Coordinator Nurse Practitioner Program School of Nursing and Midwifery, Curtin University of Technology The Steering Committee of the Remote Area Nurse Practitioner Project, which was convened in 1998, established the foundations for an education program to prepare nurse practitioners in Western Australia. One of the recommendations from that committee was that nurse practitioner aspirants must complete an appropriate postgraduate diploma, accredited by the Nurses Board of Western Australia. Originally, the focus of the nurse practitioner project was on introducing nurse practitioners only into designated remote areas. However, in 2001 the scope of the project was expanded, which removed the restrictions limiting the role to remote area nurses. Expanding the scope to include a diverse range of specialty fields of practice had implications for education and curriculum development. The Department of Health s commitment to the education of nurse practitioners in Western Australia is substantial. In 2002, the Department of Health called for tenders for an education program to prepare nurse practitioners, offering 60 full-time-equivalent scholarships over three years. Curtin University s School of Nursing and Midwifery was successful in winning that tender with an innovative curriculum proposal. The development of the curriculum employed a collaborative and consultative process with key stakeholders and content experts. It was considered that a generic curriculum, which allowed students to relate the theoretical concepts to their field of clinical practice (Reveley & Walsh, 2000), was a feasible model. The philosophy underpinning this decision was that the commonalities across the spectrum of nursing are greater than the differences (Reveley & Walsh, 2000). The resultant program was the Postgraduate Diploma in Clinical Specialisation (Nurse Practitioner), which has been accredited by the Nurses Board of Western Australia. The Postgraduate Diploma includes a spectrum of topics to facilitate the professional socialisation and clinical expansion of nurse practitioners. The units of study include professional issues, pharmacology and pharmacotherapeutics, diagnostics, leadership, research and an innovative clinical internship. The internship is completed in the student s area of specialisation under the preceptorship of medical practitioners and faculty staff. It was felt that the internship was essential for the acquisition of higher-level knowledge and skills required for nurses to function at an expanded level of practice. The internship also provided an avenue for the evaluation of knowledge and skill synthesis as well as the assessment of clinical competence (Price et al., 1992). Criteria for entrance into the program were set in accordance with the recommendations from the Steering Committee of the Remote Area Nurse Practitioner Project (Health Department of Western Australia, 2000), the Nurses Board of Western Australia and the University. Applicants must have a minimum of three years postregistration clinical nursing experience with at least two years in a specialty field of practice. Post-registration education in the student s field of practice is desirable and is considered in the selection process. Students enter the program with extensive clinical experience and a high level of expertise. However, as students embark on the process of acquiring the new role of nurse practitioner, through education and then 31

implementation, they may experience role transitions (Brykczynski, 2000). The shift from expert to novice experienced during their role development, coupled with the rigor of the program, can be challenging for some students. However, the aim of the theoretical component of the program is to facilitate the professional socialisation, expand the student s knowledge, increase their level of inquiry, and develop complex problemsolving skills. The clinical internship facilitates the synthesis of theory into practice and provides a supported environment for the implementation of the new role. Support during the role transition in the work environment will be an important strategy of the implementation of the nurse practitioner role. The education program for the preparation of nurse practitioners was implemented at Curtin University of Technology in July 2003 and there are 60 students currently enrolled. It has taken six years from the inception of the Remote Area Nurse Practitioner Project in early 1998 to this phase of implementation. Nurse practitioners will face challenges as they cross professional boundaries into areas of practice that have not previously been recognised or acknowledged within the scope of nursing practice (Buppert, 1995). The educational preparation offered by Curtin University of Technology will prepare students with the professional skills and knowledge to be able to meet this challenge, expand their professional boundaries and provide better health services to clients. A career pathway for clinical nurse experts has been created with the introduction of the role of nurse practitioner in Western Australia and the development of an education program to meet the needs of this cohort. References Brykczynski, K. A. (2000). Role development of the advanced practice nurse. In A. B. Hamric, J. A. Spross & C. M. Hanson (Eds.), Advanced nursing practice: An integrated approach (2nd ed., pp. 107-134). Philadelphia: W. B. Saunders Company. Buppert, C. K. (1995). Justifying nurse practitioner existence: Hard facts to hard figures. Nurse Practitioner, 20(8), 43-48. Health Department of Western Australia. (2000). Remote area nurse practitioner project report 2000. Perth: Author. Price, M. J., Martin, A. C., Newberry, Y. G., Zimmer, P. A., Brykcznski, K. A., & Warren, B. (1992). Developing national guidelines for nurse practitioner education: An overview of the product and the process. Journal of Nursing Education, 31(1), 10-15. Reveley, S., & Walsh, M. (2000). Preparation for advanced nursing roles. Nursing Standard, 14(3), 42-45. 32

The Nurse Practitioner Series The First Nurse Practitioner Students Conference: Dimensions of the Nurse Practitioner Role - New Paths of Practice Dr Angelica Orb BNurs DipEd MEd PhD RN MACE ALPHA CHI Senior Lecturer Research Fellow Freemasons Centre into Aged Care Services School of Nursing and Midwifery, Curtin University of Technology The first Nurse Practitioner Students Conference was held on 18 November 2003, at the School of Nursing and Midwifery, Curtin University of Technology. The purpose of the conference was to provide students with a forum where the following objectives could be achieved: Provide an avenue for students participation in conferences; Identify the main issues associated with the role of the nurse practitioner; and Recognise the importance of professional gathering as a means of personal and professional growth. As the first student conference of this kind in the Postgraduate Diploma in Clinical Specialisation (Nurse Practitioner) program, it was considered that embarking upon the development of the conference and preparing a book of proceedings was an opportunity to provide an important snapshot of the current issues and concerns identified by nurse practitioner candidates in Western Australia. A variety of topics presented at the conference related to the role of the nurse practitioner and highlighted critical issues such as professional boundaries and accountability. Presenters discussed issues related to designated areas, legal concerns, education and prescribing authority. Students also provided an insight into the politics and nature of the role of nurse practitioners. The presentations were a challenging experience for students, who made an extraordinary effort to present papers of a high standard. This worthwhile experience was shared with key members of nursing and health authorities, who have supported the introduction of the nurse practitioner program in Western Australia. This exciting and stimulating conference gave students the opportunity to reflect on their personal challenges as future nurse practitioners and raised their awareness of their political role. It also gave students the opportunity to reflect on the importance of establishing different models of care for patients and families, as well as reinforcing the importance of their collaborative role in the health care team. The future role of appropriate education for nurse practitioners and the need for research was also highlighted. These points were also reinforced by the keynote speaker, Dr Phillip Della, who emphasised the legal implications attached to the role of nurse practitioner in Western Australia. The conference set the seeds for the professional development of nurse practitioners, which has already been materialised in this edition of The Nurse Practitioner Series. Subsequent conferences will challenge future students and foster a broad view of the professional role of nurse practitioners. 33

Abstracts from the Proceedings of the First Students Conference Program A new scope of practice for Western Australian nurses In Western Australia the scope of practice for nurse practitioners has been formulated and articulated through the Nurses Amendment Act 2003. However, development of policies and procedures defining and guiding the practice in specific areas of designation are still in their infancy. This paper discusses the importance of collaborative practices with all stakeholders during the development stages of these policies and procedures and how this will be translated into the work environment. Using a brief review of the history of nurse practitioners in other countries, it will be deliberated that such an approach to the development of nurse practitioners in Western Australia will lead to defining roles, acceptance and transparency of practice and ultimately to autonomy of practice. Jo Daly RN CCH BSc(Nsg) RNP candidate Jo Daly works as a clinical nurse manager in community health, having experience in school health, child health and in a community health generalist role. Her major focus is primary health care but she continues to work intermittently within a hospital setting. She has a belief that the role of nurse practitioner will enhance the delivery of health care to the community in Western Australia. 34

The Nurse Practitioner Series The expanding role of the haematology clinical nurse specialist This paper describes the developing role of the haematology clinical nurse specialist preparatory to registration as a nurse practitioner. The role of the clinical nurse specialist in haematology is to provide clinical expertise as well as emotional and informational support to a select group of patients and their families as well as ensuring the quality of nursing care. The expansion of the clinical nurse specialist role to that of nurse practitioner requires the acquisition of advanced knowledge, competencies and skills that will support the expanded more autonomous role. Practice changes that will occur during the role expansion will impact on patients, nurses and medical staff within the haematology department and will require a consultative collaborative approach if the changing role is to succeed with positive outcomes for all stakeholders. Susan Hyde RN Master candidate RNP candidate Susan Hyde is a Clinical Nurse Specialist in haematology/oncology at Sir Charles Gairdner Hospital. During her 26 years of practice in this specialised area, she has worked in cancer units in Australia, UK and the USA. As well as clinical expertise in chemotherapy administration in the outpatient setting, Susan has specialised in the nursing management of patients undergoing peripheral blood stem-cell transplants (PBSCT). She believes that the opportunity to practice autonomously, but also as part of a multidisciplinary, collaborative team can only have positive effects on patient outcomes; thereby, assisting patients to maximise their quality of life. 35

Examples from the field - the extended role This paper discusses the implications of the role of nurse practitioners in the management and care of lung transplant patients. The specific criteria and indications for lung transplant, accessing and facilitating referral to transplant centres and the clinical management of the patient post transplant are discussed. Lung transplantation is indicated for patients with chronic lung disease for whom no further medical or surgical therapy is available and survival without transplant is predicted to be 12 24 months, despite the use of appropriate medical or alternative surgical therapies. People requiring lung transplant from Western Australia need to relocate to either Melbourne or Sydney to await a suitable donor and for early post-operative care, which increases their potential for adverse outcomes. Using an interdisciplinary model of care, nurse practitioners will work in collaboration with the specialists of respiratory medicine and cardiology to appropriately select patients for transplantation and identify physical and emotional barriers that could be contraindications to transplantation. Through a nurse practitioner-led clinic, they will also offer pre and post transplantation counseling, support and monitoring. Sue Morey OAM RN BSc(Nsg) RNP candidate Sue Morey is a Clinical Nurse Consultant, Respiratory Medicine at Sir Charles Gairdner Hospital. Sue has been working in this area for 30 years. During that time she has seen the specialty develop from managing pulmonary tuberculosis, silico-asbestosis and other chronic lung diseases to one including a fl exible bronchoscopy service, the creation of an adult cystic fi brosis clinic, the formation of a respiratory failure unit using non-invasive ventilation and the initiation of a lung transplant clinic. 36

The Nurse Practitioner Series Implementation of a potential nurse practitioner role into Armadale Health Service Emergency Department a clinical perspective The benefits of an emergency nurse practitioner role have been well documented in the United Kingdom literature. The main benefits being a reduction in patient waiting times for lower acuity patients, a reduction in patient aggression and complaints, an overall improvement in the quality of service offered and a more sensible use of nursing and medical resources in busy Emergency Departments. Emergency Departments in Western Australia face similar problems, often with long and excessive waiting times for lower acuity patients, ambulance diversion, access block and high numbers of patient complaints. With the introduction of the Nurses Amendment Act 2003, a way forward was created to formally introduce nurse practitioners into designated areas across Western Australia. The author believes that one of these areas should be Emergency Departments. This paper examines the potential implementation of an emergency nurse practitioner role into the Department of Emergency Medicine at Armadale Health Service from a clinical perspective. Mike Hayward RN DipN A&E Cert BSc(Hons) MCENA MRCNA RNP candidate Mike Hayward has 16 years emergency nursing experience and has worked in emergency departments across Australia and overseas, including Royal Perth Hospital, Sir Charles Gairdner Hospital, and in Saudi Arabia and the UK. He has spent time as a Nursing Offi cer in the Australian Defence Force and has been heavily involved in trauma and cardiac resuscitation training throughout his career. His interests lie in trauma and cardiac resuscitation and the role of the emergency nurse practitioner. He has previously undertaken nurse practitioner studies in the UK, where he was employed as an emergency nurse practitioner for three years. Since 1999, he has been employed as the Clinical Nurse Specialist, Department of Emergency Medicine, Armadale Health Service. 37

Moving from clinical nurse specialist to nurse practitioner in wound management for an acute care setting The development of the nurse practitioner role in Western Australia marks a major milestone for the nursing profession. This new level of advanced nursing practice promotes a nursing model where nurses will have the education, expertise and legal authority to practice autonomously within an interdisciplinary framework. This paper outlines the historical development of the Nurse Practitioner in Australia and focuses on the change in the role dimensions from Clinical Nurse Specialist in wound management to that of Nurse Practitioner. Nurses, more than any other health professional, can have an impact on patients with impairment to their skin integrity. The value of the Clinical Nurse Specialist in wound management is well recognised; however, having the legislative authority to expand this role can only serve to improve clinical outcomes for this client group. Donna Angel RN BSc(Nsg) RNP candidate Donna Angel graduated in 1994 with a Bachelor of Nursing from Edith Cowan University. In 1997 she worked as a Clinical Nurse in Vascular Surgery, Royal Perth Hospital, and then held the position of Staff Development Nurse in this area of speciality. Currently, Donna is the Clinical Nurse Consultant in Wound Management and Vascular Surgery at Royal Perth Hospital. This role not only provides a service within Royal Perth Hospital, it also includes Telehealth linkups to rural sites for wound management advice. Donna is also the Educational Offi cer for the Western Australian Wound Management Association. 38

The Nurse Practitioner Series Perceptions of the nurse practitioner role from nurses, clinicians, patients and other consumers For a role to function well, that is, meeting the needs of all who access the service, it might well be expected that users have clear perceptions of what and how the role or service can assist them. The nurse practitioner role, a concept introduced into Australia only during the last decade, is potentially suffering from a lack of understanding by current aspirants to nurse practitioner status, other health professionals and patients accessing the services of a nurse practitioner. Stakeholders are still grappling with questions surrounding the role, status and acceptability of nurse practitioners and whether the blurring of boundaries between traditional nursing and medical roles will integrate into Australia s health care system. With questions like this not fully answered, it is clear the nurse practitioner role is still evolving and those witness to the evolutionary process exhibit confusion. Whilst those looking at the nurse practitioner role might have concerns, nurse practitioners themselves are equally concerned regarding the perception of the nurse practitioner role by stakeholders such as clinicians, health managers, patients and others. For the nurse practitioner role to gain acceptance, it is important that aspiring nurse practitioners have a clear understanding of stakeholder expectations. In an effort to put the efficacy of the nurse practitioner role into perspective, studies have been undertaken evaluating the service nurse practitioners provide from the context of collegial and patient viewpoints. This paper explores the perception and satisfaction of the nurse practitioner role from the perspective of consumers of the service. Robin Moon RN RMHN RM BHSc(Nsg) Grad Dip Bus(Mgt) Grad Cert Men s Hth MRCNA RNP candidate Robin Moon is a Clinical Nurse working in the Emergency Department at Swan District Hospital. He has an extensive nursing background with experience in rural and metropolitan healthcare facilities. Robin has postgraduate qualifi cations in midwifery, mental health nursing, business management and men s health. 39

Accessibility - the critical thread As nurse practitioners in Western Australia look to the future and the exciting possibilities of extended scope of practice, so too should they have an eye to the past. Historically, the pattern of development of the nurse practitioner role has been based on the need to provide primary health care to underserved communities. One of the threads critical to weaving a strong and vibrant pattern in the fabric of nurse practitioner care is accessibility. As a women s health nurse, this metaphor is particularly germane. Throughout time women have used tapestries to tell stories of politics, home and family life, and dreams of the future. For many years the stories of disabled women were lost to the tapestry, but recently there has been a concerted effort to include them in the complicated weave of health care services. Nurse practitioner led women s health services have the potential to increase accessibility for all women, improve patient outcomes and patient satisfaction with the services provided. Jane Akerman RN BSc BSc(Nsg) MSc(FNP) RNP candidate Jane Akerman is a Clinical Nurse Consultant in Women s Health with the East Metropolitan Population Health Unit. She runs the Women on Wellness (WOW) program offering woman-centred care to the female staff and clients of Royal Perth Hospital. Originally from Toronto, Canada, Jane has worked in the area of sexual health/ women s health for a number of years. Her time in community health has made her very aware of the barriers that many women in the community face when trying to access care. Jane has a particular interest in ensuring that women with disabilities have access to the basics of women s health, specifi cally, Pap smears and breast checks. To that end, she has developed a component of the WOW program to provide accessible service to women with a disability. 40

The Nurse Practitioner Series Leading the way - implementing the role of the nurse practitioner The process of defining and developing a formal role for nurse practitioners in Western Australia has been instigated and the implementation of such a role will begin in the near future. It is essential that nurse practitioners understand the importance of their leadership role within this process. Leadership is a commitment to the people and the organisation in which one works and a relationship between those who choose to lead and those who choose to follow. Leadership is also the art and science of envisioning, creating and shaping change. Being the lynchpin to successful change and implementation of new ideas and practices within organisations, leadership is an essential nurse practitioner role. It is critical to the success of the nurse practitioner role that the primary responsibility for leading the way lies in the hands of those undertaking the role. This process will ensure the expectations the nursing profession has of the role are fulfilled, our clients needs are protected and nurse practitioners are respected as leaders in their field. It will also ensure the longevity of the nurse practitioner role. Moreover, as the process of implementing the nurse practitioner role involves adjusting current perceptions of health care delivery and the way in which nurses view their role in society, the process inherently implies cultural change and challenges to the profession. These challenges may produce conflict and barriers to success, and effective leadership will be crucial to recognising and addressing these issues. The primary purpose of this paper is to describe a model for leadership that will enable nurse practitioners to actualise their own potential and the potential of the profession. The leadership process described in this paper will examine leadership principles used throughout history. Jane Mateer RN Grad Cert Emerg Nsg BA MA Int Sec Studies MRCNA RNP candidate In a career spanning 20 years, Jane Mateer has focused on Paediatric and Emergency Care. Most recently, she has concentrated on creating opportunities for leadership, change development and clinical teaching in the emergency environment. Jane currently works as a Clinical Nurse Consultant in Emergency at Joondalup Health Campus. 41

Cost effectiveness and nurse practitioners The aim of this paper is to evaluate the cost and clinical effectiveness of nurse practitioners. A literature review of nurse practitioners in United States of America reveals that nurse practitioners are cost effective in a wide variety of areas such as primary care, neonatal units, emergency departments and rural areas. However, studies in Great Britain do not support these findings. Nurse practitioners are cost neutral when compared to doctors in British studies. This discrepancy may have been because some of the studies were done in minor injury units where nurse practitioners reviewed patients and asked them to return for dressings and follow-up, whereas the doctors who saw patients in the emergency departments may have referred the patients back to their general practitioners. Studies in both countries concurred that patients received high quality care, which lead to increased patient satisfaction. Patients indicated that nurse practitioners communication skills and extra time spent with them was appreciated. Evidence indicates that nurse practitioners add value to consultations by including health promotion strategies to their care regime and were more likely to give advice on changing lifestyles rather than medicate, compared to their medical colleagues. Patients were more receptive to advice given by nurse practitioners than doctors and the cost benefits due to a reduction in the number of prescriptions and less hospitalisation all reflect on the cost effectiveness and advantages of employing nurse practitioners within the health care system in Australia. Anne Findley RN CCH BSc(Nsg) RNP candidate Anne Findley has been nursing for 29 years and completed her Registered Nurse, Midwifery and Health Visiting training in the United Kingdom. She worked as a health visitor in an underprivileged area in North East England before migrating to Perth in 1986. She holds a BSc(Nsg) and has worked as a child health and generalist community nurse before taking up her present position as a Visiting Nurse at Princess Margaret Hospital. 42

The Nurse Practitioner Series Nurse practitioner within child and adolescent mental health services - a benefit rather than a burden Due to the changing demands within health care, the nurse practitioner role has emerged as a result of renewed concern as to how health services could be made more accessible, flexible and effective for individuals, families and community groups. Although child and adolescent mental health is a specialty of paramount importance within our health care service, there is limited literature that explores where or how the nurse practitioner fits in within the realm of child and adolescent mental health services. The objective of this paper is to explore and describe the benefits of the nurse practitioner role within child and adolescent mental health services and how that role can be implemented to work harmoniously with other health professionals such as the clinical nurse specialist, psychiatrist, or psychologist without causing disharmony. Within this specialty, implementation of the nurse practitioner role enables nurses with extensive experience and expertise to practice their advanced skills within a scope of practice that complements rather than replaces the services provided by other health professionals. Other benefits such as reduced waiting lists, increased accessibility/flexibility to services and cost effectiveness are discussed. In terms of education, practice and research, the nurse practitioner in child and adolescent mental health services is well equipped to meet the challenges and demands of patient health care; therefore, utilising their expertise to their full potential and to the benefit of the consumer. Russell Oliver RMHN RNP candidate Russell Oliver is a Mental Health Nurse Clinician and the coordinator of the Child and Adolescent Unit based at Bentley Health Campus. The unit s main focus is to assess and treat adolescents with major psychiatric issues. Russell is responsible for the quality of care and the standard of nursing practice that is delivered to clients and families. Prior to this position, he had extensive experience as a Clinical Nurse in Adult/Acute and Community Mental Health. 43

Collaborative practice in the clinical setting - nurse practitioners and physicians The continuing development of health care practices and rising health care costs have contributed to the implementation of nurse practitioners in Western Australia. Nurse practitioners have been established in the United States of America for several decades with the first nurse practitioner commencing practice in primary care in 1965. The original goal of the nurse practitioner role was to augment services due to the perceived shortage of primary care physicians. Today, nurse practitioners have the opportunity to work collaboratively with physicians to optimise patient care. They practice in various countries and within diverse specialties. Effective collaboration between nurse practitioners and physicians has the potential to improve communication, patient care and staff and patient satisfaction. Furthermore, effective collaboration will contribute to positive health outcomes for patients. Traditional patterns of hierarchy, territorialism, role confusion and reimbursement may be impediments that limit effective collaboration and integration of nurse practitioners to practice areas. Saroja Nazareth RN BHSc MSc(Nsg) RNP candidate Saroja Nazareth has 16 years experience as a Clinical Nurse and Staff Development Nurse and has been a Hepatitis Coordinator at Royal Perth Hospital for the past five years. She qualified as a Registered Nurse in London, holds a Bachelor s degree, has postgraduate diplomas in Critical Care and Paediatrics and completed a Master s degree in 2000. 44

The Nurse Practitioner Series Nurse practitioner - autonomous, independent and/ or collaborative practice? The role of the nurse practitioner in Western Australia is still being defined and there is no doubt that the role is multifaceted. Some authors describe nurse practitioners as accountable and autonomous professionals able to make differential diagnosis using decision-making and problem-solving skills, and working collaboratively with other health care professionals. However, the word autonomy has sparked much criticism and argument within the health care sector. This paper explores the concepts of autonomy and independence. Additionally, it examines the ability of nurse practitioners to practice autonomously, as well as the tools required to facilitate the implementation of autonomous practice. Moreover, the concept of professional boundaries, interdependency and collaborative practice are discussed. Casey Light RN BSc(Nsg) RNP candidate Casey Light is the Clinical Nurse Specialist at Armadale s Satellite Dialysis Unit. Following graduation in 1977 from Royal Perth Hospital School of Nursing, she joined the Haemodialysis Unit in 1979, where she helped to set up the state s fi rst satellite dialysis unit. She then transferred to Armadale Health Service to set up a five-chair satellite dialysis unit, which expanded to a 10-chair facility in 2001 under her direction. Casey is a Member of the Renal Dialysis Reference Group and President of the Renal Society of Australasia (2002-2003). She achieved the Renal Nursing Certifi cate from the University of Sydney in 2002 and is a Curriculum Adviser and lecturer for the Department of Health s Certifi cate IV Entry Level Renal Course. 45

Current issues surrounding nurse prescribing The Nurses Amendment Act 2003, came into effect in April 2003 and brought with it legislative changes allowing the implementation of the role of the nurse practitioner in Western Australia. Traditionally, doctors prescribe, pharmacists dispense and nurses administered medications and poisons. However, recent developments in advancing nursing practice has seen a dynamic and forward thinking initiative: nurse prescribing. There has been much controversy surrounding the legislative changes allowing nurses to prescribe, and it is the intention of this paper to address three key areas. The author discusses the contentious issue of accountability and responsibility as well as quality and standards of care necessary to ensure patient safety. Finally the author explores human resource implications of nurse prescribing. The literature demonstrates that the implementation of the nurse practitioner role has been used effectively to address a diverse health climate. Candice Edmunson RN Dip Psych Nsg Dip Comm Nsg Dip A&E Nsg Dip ICU Nsg Flight Nurse BAC RNP candidate Candice Edmunson is a Clinical Nurse at Fremantle Hospital and Health Services Emergency Department. Originally from Johannesburg, South Africa where she obtained her undergraduate and postgraduate qualifi cations in nursing, she has worked almost exclusively in Accident and Emergency and Critical Care environments. Her experience and qualifi cation include that of accident and emergency nursing, trauma and cardiothoracic intensive care, prehospital emergency roadwork, and fl ight nursing. 46

The Nurse Practitioner Series Nurse practitioner education - what level? This paper discusses the wide range of nurse practitioner education that is available throughout the world. Educational courses and standards for the preparation of nurse practitioners vary enormously, from a few in-house study days to Master s level tertiary programs. There is currently debate in the United Kingdom about the level of qualification that nurse practitioners should possess. With the advent of the approved nurse practitioner program in Western Australia, it seems appropriate to be asking whether there should be a global uniformity in education standards and question whether nurse practitioners that are developing highly specialised roles should be educated to Master s level. In addition to a variance in educational preparation for nurse practitioners, legislation protecting the title Nurse Practitioner also varies across settings. In Western Australia the title Nurse Practitioner is protected by legislation, making it illegal to hold oneself out to be a Nurse Practitioner without appropriate preparation and registration with the Nurse Board of Western Australia. However, the indiscriminate use of the Nurse Practitioner title in other jurisdictions has the potential to undermine the value and credibility of nurse practitioners here and elsewhere. Emma Phillips RN RNP candidate Emma Phillips is a Clinical Nurse at Fremantle Emergency Department. Her experience spans fi ve years in Emergency nursing both here and in London. Prior to Emma s current appointment, she practiced at the Royal Military Academy, Sandhurst, England as a nurse practitioner. Emma also has experience in trauma and orthopaedic nursing. 47

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The Nurse Practitioner Series Nurse Practitioner Sponsorship Information Office of the Chief Nursing Officer Department of Health, Western Australia The purpose of the Office of the Chief Nursing Officer, Department of Health of Western Australia, is to promote and develop the professional role of nurses and midwives to ensure the delivery of quality nursing care that is focused on, and contributes to, achieving optimal health outcomes for the community in a changing health care environment. One aspect to this commitment is the development of the nurse practitioner role in designated areas of clinical practice. Nurse practitioners are required to exercise higher levels of judgement, discretion and decision-making in the clinical setting. Therefore, appropriate preparation, education and demonstrated competence to practice and formal recognition of such competence, is integral to the success of the role of the nurse practitioner in the designated area of practice. One pathway to apply for registration as a nurse practitioner is to complete postgraduate studies that have been approved by the Nurses Board of Western Australia. A major milestone achieved by the Office of the Chief Nursing Officer in 2002 was the awarding of the tender to Curtin University of Technology to develop and deliver the Postgraduate Diploma in Clinical Specialisation (Nurse Practitioner) for a three-year period. The Office of the Chief Nursing Officer provides 20 full-time equivalent sponsorships a year (2003 2005) to cover the fees in order to support nurses and midwives to undertake the program. The third round of sponsorship will be advertised in September 2004. Sponsorship criteria includes, but is not limited to: Registered in Division 1 of the Nurses Board of Western Australia register; Currently employed within the Government Health Industry in Western Australia; Evidence of a minimum of three years post-registration clinical nursing experience at the sponsorship application closing date. This includes one graduate nursing year and two years specialised in a clinical nursing area; Australian citizen or permanent resident of Australia; Enrolment in the Postgraduate Diploma in Clinical Specialisation (Nurse Practitioner) at Curtin University of Technology; Letter of support from the candidates Director of Nursing or equivalent; and A letter of intent to apply for a designated area from the candidate s most senior officer of the health service/organisation. Application forms and information packages will be available on www.nursing.health.wa.gov.au when the sponsorships are advertised. 49

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Guidelines for Contributors The Nurse Practitioner Series Introduction The Nurse Practitioner Series is a peer-reviewed journal that reflects the broad interests of nurse practitioners and the nursing profession. This series will be published twice a year. Papers focussing on original clinical and educational research, scholarly critique of policy and nursing issues, and clinical case reports relevant to nurse practitioners in Western Australia will be considered for publication. All correspondence relating to The Nurse Practitioner Series must be submitted to: Dr Phillip Della - Chief Nursing Officer, Department of Health 189 Royal Street East Perth 6004, Western Australia. Email: nursinginwa@health.wa.gov.au Submission Review of manuscript Covering letter Manuscript style The Editors invite papers up to a maximum of 3000 words. One hard copy of the manuscript and one copy on floppy disk/cd must be submitted. The submitted version of hard copy and floppy disk/cd must be the same. If the two versions of the paper do not correspond, the floppy disk/cd version will be used. The floppy disk/cd must include all parts of the text of the manuscript in a single file (including all figure and table legends). Floppy disk/cd or hard copies submitted will not be returned to authors. It is assumed that authors will have conformed to normal ethical aspects of authorship, investigation and copyright. The Nurse Practitioner Series does not hold copyright. The Editors will decide on the time of publication and retain the right to modify the style of a contribution. Acceptance of major changes to a manuscript will be sought from the author(s). Receipt of manuscripts by the Department of Health will be acknowledged. Review of manuscripts will take an average of six to 10 weeks. A covering letter signed by all authors must be included with the submission. This letter should state that the work has not been published elsewhere and is not being considered for publication in other journals. The letter should display the manuscript title, authors names, professional and academic qualifications, position and places of work and the address to which all correspondence and proofs should be addressed. An email address must be provided to facilitate the dispatch of proofs in PDF format. The following points outline the publication convention that must be adhered to prior to submission of the paper. Page setup: Papers should be typed on one side only of A4 paper using double spacing size 12 font Times New Roman with a margin of 2.54 cm on each side of the text. Abstract and keywords: The abstract should be on a separate page and not exceeding 300 words. Up to six keywords should be listed after the abstract. The abstract should not include references or abbreviations. 51

Main text: The main text of the manuscript should begin on a separate page. Sections within the main text should be appropriately sub-headed. Abbreviations, footnotes and appendices should be avoided. In exceptional circumstance, if an abbreviation is used, the abbreviated name should be cited in full at first usage followed by the accepted abbreviation in parentheses. Referencing of sources must adhere to the latest version of the American Psychological Association (APA) referencing style. American Psychological Association. (2000). Publication manual (5th ed.). Washington, D.C.: American Psychological Association. A smaller style helper (tips) is also available at: www.apastyle.org/stylehelper/ Reference Samples Electronic source What is a nurse practitioner? (2002). Retrieved September 10, 2002, from http://aanp.org/nurse.htm Journal articles Brooks, B., Barrett, S., & Zimmermann, P. G. (1998). Beyond your resume: A nurse s professional portfolio. Journal of Emergency Nursing, 24(6), 555-557. Buppert, C. K. (1995). Justifying nurse practitioner existence: Hard facts to hard figures. Nurse Practitioner, 20(8), 43-48. Hayes, E., Chandler, G., Merriam, D., & King, M. C. (2002). Nurse practitioners education: The master s portfolio: Validating a career in advanced practice nursing. Journal of the American Academy of Nurse Practitioners, 14(3), 119-125. Books McKenzie, S. B. (2000). Textbook of haematology (3rd ed.). Philadelphia: Lea and Febiger. Dunstan, R. (Ed.). (2001). Pocket guide to diagnostic tests (3rd ed.). McGraw-Hill: Lange Medical Books. Walsh, M., Crumbie, A., & Reveley, S. (1999). Nurse practitioners: Clinical skills and professional issues. Melbourne: Butterworth Heinemann. Book section Antonovsky, A., & Anson, O. (1976). Factors related to preventive health 52

The Nurse Practitioner Series behavior. In J. W. Cullen, B. H. Fox & R. N. Isom (Eds.), Cancer: The behavioral dimensions (pp. 35-43). New York: Raven Press. Archbold, P. (1986). Ethical issues in qualitative research. In W. C. Chenitz & J. M. Swanson (Eds.), From practice to grounded theory: Qualitative research in nursing (pp. 155-163). Menlo Park, California: Addison-Wesley. Illustrations and Tables Copyright Acknowledgements Proofs Copies Illustrations and tables should be referred to in the text as figures or tables using Arabic numbers (eg. Figure 1, Table 2) in order of appearance. They should be submitted with the manuscript but on a separate page marked with the Figure/Table number. Authors must indicate in the body of the manuscript, the most appropriate place for insertion of figures/tables. Photographs should be unmounted glossy prints in black and white. The Nurse Practitioner Series does not hold copyright. A copy of any documentation granting permission to reproduce material from other sources must be enclosed with the final version of the manuscript prior to publication. Details of sources of funding, other support, and acknowledgments should be included. Proofs will be sent to the author via email as an Acrobat PDF (portable document format) file. The author s email server must be able to accept attachments up to 1MB in size. Acrobat Reader will be required to read this file. Corrected proofs must be returned within a week of receipt. The author will be provided with three free copies of the issue in which their manuscript/paper appears. 53

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