How To Prescribe Medicinal Products

Volume 3 Number 1 June 2010 Nurse practitioners in western australia The Nurse Practitioner Series A series produced by the Nursing and Midwifery Office Department of Health, Western Australia HP10462 NOV 10

Volume 3 Number 1 June 2010 Nurse practitioners in western australia The Nurse Practitioner Series A series produced by the Nursing and Midwifery Office Department of Health, Western Australia 1

Nurse practitioners in Western Australia The Nurse Practitioner Series The Nurse Practitioner Series. ISBN 978-0-9804129-6-3 The Nursing and Midwifery Office publishes and distributes The Nurse Practitioners Series. The primary purpose of the series is to promote the development of the nurse practitioner role in Western Australia. Copies of The Nurse Practitioners Series are available from: Nursing and Midwifery Office Department of Health 189 Royal Street East Perth Western Australia Australia 6004 www.nursing.health.wa.gov.au Volume 3 Number 1 June 2010 Department of Health Western Australia 2010 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 those of the Nursing and Midwifery Office, Department of Health Western Australia, the Co-Editors, or the Editorial Board. Design and Layout: Nursing and Midwifery Office, Chief Nurse and Midwifery Officer, Adjunct Associate Professor Catherine Stoddart. 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. 2

Table of Contents Aim 2 Co-Editors 4 Editorial Board 5 Editorial 6 A Snapshot of Australian Nurse Practitioners Extended Practice Activities 8 Glenn Gardner, Anne Gardner, Sandy Middleton, Phillip Della and Anna Doubrovasky Nurse and Midwife Medicinal Product Prescribing: A New Initiative for Ireland 16 Elizabeth Adams, Annette Cuddy, Maureen Flynn, Rose Lorenz and Clare MacGabhann Nurse practitioner Programs: The Need for Giving Good Advice 30 Joyce M. Hendricks and Vicki Cope Nurse Practitioners Emergency Services: A Western Australian Perspective 35 Bronwyn Nicholson Power, policy and politics their interaction in evaluating nurse practitioner implementation 42 Phillip Della and Huaqiong Zhou Nurse Practitioner David Charlton Discusses His Journey of Becoming a Nurse Practitioner 49 Nurse Practitioner Fran Lee Discusses Her Journey of Becoming a Nurse Practitioner 51 Nurse Practitioner Leah Hansen Discusses Her Journey of Becoming a Nurse Practitioner 55 Nurse Practitioner Mary Dodds Discusses Her Journey of Becoming a Nurse Practitioner 58 Guidelines for Contributors 62 3

Nurse practitioners in Western Australia The Nurse Practitioner Series Co-Editors Adjunct Associate Professor Catherine Stoddart BSc (Nursing), MHSc, MBA, Winston Churchill Fellow Chief Nurse and Midwifery Officer Department of Health, Western Australia Adjunct Associate Professor Catherine Stoddart is the Chief Nurse and Midwifery Officer of Western Australia. In this role, she sets the strategic direction for the nursing and midwifery professions of Western Australia. She completed her Hospital Based Diploma of Nursing at Royal Perth Hospital. Since graduation has held executive management roles and senior clinical nursing positions at Sir Charles Gairdner Hospital. Catherine has held positions in both the State and Commonwealth Governments and more recently as the Executive Director of Nursing across WA Country Health Service and the Regional Director for the Kimberley. In 2009, Catherine was appointed to the position of Adjunct Associate Professor at Curtin University in recognition of her leadership in the Nursing profession in Western Australia. Catherine is a Winston Churchill Fellow and reviewed models for isolated nursing practice in Alaska and Canada looking particularly into indigenous communities. This experience has fuelled her passion for improving indigenous health and contributing to the global health agenda. 4

Professor Phillip Della RN RM BAppSc MBus PhD Head of School School of Nursing and Midwifery Curtin University Western Australia Professor Phillip Della has had extensive experience in policy development, analysis and evaluation. This includes the areas of public policy; the political process and the policy legislative intersect. In his previous role as the Chief Nursing Officer of Western Australia he led the Western Australian Nursing and Midwifery legislative-policy reforms including the introduction of the Nurses and Midwives Act 2006, the Nurses and Midwives Regulations 2007 and the Nurses Amendment Act 2003 that introduced nurse practitioners into Western Australia. Professor Della has also extensive experience in policy and evaluation research within the healthcare area and has recently conducted policy reviews for New South Wales Health and was a member of the Irish Commission into Nursing. Professor Della was appointed as Head of School of Curtin University of Technology s School of Nursing and Midwifery in February 2008. His research interests are healthcare reforms, organisational culture and patient outcomes. His current research activities include evaluation of the nurse practitioner role in Australia and clinical handover which together amount to over $5 million of competitive external funding. 5

Nurse practitioners in Western Australia The Nurse Practitioner Series Editorial Board Professor Dianne Wynaden RN RMHN MHN B.AppSc (Nursing) PGDip(HSc) MHSc(HSc) PhD MACMHN Professor (Mental Health)/Minimal Risk Ethics Coordinator School of Nursing and Midwifery, Member of the Curtin Health Innovation Research Institute, Curtin University of Technology Research Consultant, Fremantle Mental Health Services Fremantle Hospital and Health Service Research Consultant, State Forensic Mental Health Services and Adjunct Senior Research consultant, Fremantle Hospital Ms Annette Fraser RN, BSc (Nursing), RM A/Principal Nursing Officer, Department of Health, Western Australia Dr Vicky Brown RN., M.Sc., PG Dip Hlth.Prom., BAppSc., PhD Clinical Nurse Manager, Orthopaedic Ward, Fremantle Hospital Health Service Dr Beverly Scott RN NP BAppSc(Nurs), PGDipClinSpec(Nurse Practitioner), MAppSc(D)(ScEd), PhD, FRCNA Nurse Practitioner, Brightwater At Home and Clinical Nurse Consultant, Brightwater Group Technical Editor Ms Huaqiong Zhou RN, MCN, BSc (Nursing) Research Officer, School of Nursing and Midwifery, Curtin University of Technology, Western Australia and Clinical Nurse, Surgical Ward, Princess Margaret Hospital for Children, Western Australia 6

Editorial Welcome to this edition of the Nurse Practitioner Series which presents discussion on the progress of nurse practitioners and the development of advanced practice. This edition commences with a snapshot of Australian Nurse Practitioners and their scope of practice. This article is timely as it presents findings drawn from the AusPrac Study. The article presents the range of diagnostics and referrals that nurse practitioners are making. As we move to the new era of restrictive access to Medicare Benefit Scheme (MBS) and the Pharmaceutical Benefit Scheme (PBS) for nurse practitioners it highlights valuable information on what is actually happening in clinical practice. The second article in this edition has international favour and has been written with Irish favour. Nurse and midwife prescribing has been introduced to the Irish Health Service as a whole systems approach. The introduction has required legislative, regulative and clinical practice change. This article overviews the introduction of this new initiative into Ireland. The third article returns to Western Australia and provides an overview of advice registered nurses should consider before commencing a nurse practitioners education program. The Western Australian favour continues in the remaining articles which presents information of the development of nurse practitioners in Western Australia. Included in these articles is an overview of the interplay between power, policy and politics of the implementation of nurse practitioners it should be remembered that major achievements have been made since the commencement only seven years ago. The work of nurse practitioners in emergency service is presented and highlights the barriers and obstacles that prevent full utilisation of these practitioners in health services delivery. Interviews with four nurse practitioners present their journey on becoming a nurse practitioner. The interviews are real live experiences which includes the defining time when they choose to take a path to become a nurse practitioner, why they choose their speciality areas and the goals they want to achieve. Nurse practitioners in Western Australia are making a real difference to patient care across a wide range of settings. Their work is acknowledged by health services and by the patients they care for assess, diagnosis and treat every day. It is now in the realm of the policy makers and funders to remove artificial barriers that are prevent the full utilisation of their services to provide the full of scope of care that nurse practitioners have been educated to delivery. Unless these barriers are removed nurse practitioners will continue to practice with limitations. Professor Phillip Della Head of School School of Nursing and Midwifery Curtin University of Technology Western Australia 7

Nurse practitioners in Western Australia The Nurse Practitioner Series A Snapshot of Australian Nurse Practitioners Extended Practice Activities Professor Glenn Gardner RN PhD Director of the Centre for Clinical Nursing Royal Brisbane and Women s Hospital and Queensland University of Technology Brisbane, Australia Professor Anne Gardner RN BA MPH PhD Professor of Nursing Tropical Health James Cook University and Townsville Health Service District Townsville, Australia Professor Sandy Middleton RN BAppSc (Nursing) MN PhD Professor of Nursing Research St Vincents and Mater Health, Sydney Director, National Centre for Clinical Outcomes Research (NaCCOR) Nursing and Midwifery, Australia Australian Catholic University Sydney, Australia Professor Phillip Della RN RM BAppSc MBus PhD Professor of Nursing Head of School of Nursing & Midwifery Curtin University of Technology Perth, Australia Anna Doubrovsky BSc(Hons) MPH Project Coordinator Australian Nurse Practitioner Project Queensland University of Technology Brisbane, Australia Keywords: Nurse practitioner, clinical audit, prescribing, extended practice 8

Introduction The Australian Nurse Practitioner Project (AUSPRAC) was initiated to examine the introduction of nurse practitioners into the Australian health service environment. The nurse practitioner concept was introduced to Australia over two decades ago and has been evolving since. Today, however, the scope of practice, role and educational preparation of nurse practitioners is well defined (Gardner et al, 2006). Amendments to specific pre-existing legislation at a State level have permitted nurse practitioners to perform additional activities including some once in the domain of the medical profession. In the Australian Capital Territory, for example 13 diverse Acts and Regulations required amendments and three new Acts were established (ACT Health, 2006). Nurse practitioners are now legally authorized to diagnose, treat, refer and prescribe medications in all Australian states and territories. These extended practices differentiate nurse practitioners from other advanced practice roles in nursing (Gardner, Chang & Duffield, 2007). There are, however, obstacles for nurse practitioners wishing to use these extended practices. Restrictive access to Medicare funding via the Medicare Benefit Scheme (MBS) and the Pharmaceutical Benefit Scheme (PBS) limit the scope of nurse practitioner service in the private health sector and community settings. A recent survey of Australian nurse practitioners (n=202) found that two-thirds of respondents (66%) stated that lack of legislative support limited their practice. Specifically, 78% stated that lack of a Medicare provider number was extremely limiting to their practice and 71% stated that no access to the PBS was extremely limiting to their practice (Gardner et al, in press). Changes to Commonwealth legislation is needed to enable nurse practitioners to prescribe medication so that patients have access to PBS subsidies where they exist; currently patients with scripts which originated from nurse practitioners must pay in full for these prescriptions filled outside public hospitals. This report presents findings from a sub-study of Phase Two of AUSPRAC. Phase Two was designed to enable investigation of the process and activities of nurse practitioner service. Process measurements of nurse practitioner services are valuable to healthcare organisations and service providers (Middleton, 2007). Processes of practice can be evaluated through clinical audit, however as Middleton cautions, no direct relationship between these processes and patient outcomes can be assumed. Methodology Study population In Phase One of AUSPRAC, nurse practitioners who completed a national survey were invited to submit an expression of interest to participate in Phase Two. The majority (n=144) of nurse practitioners in Australia at that time registered to participate. From this pool a process of stratified random sampling by state and geographical location (metropolitan or non-metropolitan) selected 37 nurse practitioners who were invited to participate in this phase of the Project. Phase Two involved two separate but related studies, firstly, work sampling research that collected activity data from 30 of the invited 37 nurse practitioners around Australia and, secondly, case study research that involved collection of a range of data on the organisational and service impact of the nurse practitioner role. The case study component of Phase two recruited 11 nurse practitioners from the 9

Nurse practitioners in Western Australia The Nurse Practitioner Series 37 who were invited to participate in Phase two studies. Data was collected between September 2008 and August 2009. The case study included collection of data from the nurse practitioners, other health care professionals in their team and patients. The sub-study reported here is drawn from data collected from consenting patients health care records relating to nurse practitioner service. Consecutive patients of the nurse practitioners were invited to enrol in the study and the first ten patients to consent were included. In some cases, it was not possible to secure the enrolment of ten patients within the data collection period and thus the total number of patients was 96. Instrument and Data Analysis The instrument used in this study was adapted from a generic tool used for chart abstractions from a sample of patients in the ACT Nurse Practitioner Trial (ACT Health and the Nurses Board of the ACT, 2003 p138). Data from patient charts were collected retrospectively for a 30 day period. The sample included 96 data sheets. Information collected included presenting issues, number of visits, diagnostic investigations, therapeutic interventions, prescribed medications, and referrals recommended by the nurse practitioner. A descriptive analysis of the data was performed using Microsoft Excel 2007 (Microsoft, Redman, WA, USA). Ethics This study was approved by the Human Research Ethics Committees of all participating Universities and hospitals where this research was undertaken. Results and Discussion Assessment of extended practice in nurse practitioners was performed on data abstracted from clinical notes of 96 patients of 11 nurse practitioners. These nurse practitioners were recruited nationwide, two each from Victoria, Western Australia and New South Wales; and one from Queensland, South Australia and the Australian Capital Territory. Nine of the nurse practitioners worked in a hospital setting and two worked in the community. Nurse practitioner service models included Emergency (2), Rural and Remote (2), Mental Health, Orthopaedics, Sexual Health, Women s Health, Chronic Disease (2) and Neonatal. Diagnostic Investigations Over half the patients (52%) in the study received at least one diagnostic investigation during the study period. There were on average 2.2 diagnostic investigations per patient. The number of investigations requested was relevant to the model of nurse practitioner service with a range of 0 to 5.9 investigations per patient. Two nurse practitioners did not request any diagnostic investigation for their patients enrolled in the study within the study timeframe. The common types of diagnostic investigations requested are shown in Figure 1. Most requests from nurse practitioners were for haematology and biochemistry. Histology was not requested and only one request for cytology was made. The use of serology, microbiology and radiology diagnostic investigations were highly dependent on the type of nurse practitioner model. Serology investigations were limited to two of the nurse practitioners in the study and only four nurse practitioners requested radiology. 10

Nurse practitioners made extensive use of pathology requests, however it is not possible to determine the reason why they were used for example assessment for diagnosis, monitoring of chronic conditions or screening of vulnerable populations. Figure 1: Diagnostic investigations requested by nurse practitioners (n=211 investigations) Referrals Nurse practitioners made referrals for 63.6% of patients in the study (see Figure 2) and all nurse practitioners in the study referred patients to other professionals and agencies. Rates of referral varied amongst the nurse practitioner models, from 1.6 referrals per patient down to less than 0.2 referrals per patient. Figure 2 lists the types of referrals made. One fifth of the nurse practitioner referrals were to a general practitioner and all these referrals were made by nine of the 11 participating nurse practitioners. Most of the referrals (85%) to medical specialists were made by three nurse practitioners, who referred 20% of the patients in the study. Another three nurse practitioners made only one referral to a medical specialist during the study period. All nurse practitioners who referred patients to medical specialists were based in a hospital setting. Forty percent of patients were referred to allied or other health professionals. These included social workers, occupational therapists, physiotherapists, dentists, sexual health counsellors, pharmacists and wound care nurses. Over 10% of patients were referred to other agencies such as interpreter services, osteoporosis metabolic clinic, diabetes unit, community nursing service, hospital emergency. 11

Nurse practitioners in Western Australia The Nurse Practitioner Series Figure 2: Referrals recommended by nurse practitioners (n=81 referrals) Therapeutic Interventions Overall 93.8% of patients received a therapeutic intervention from a nurse practitioner, averaging 3.7 interventions per patient in the 30 day period. The maximum number of interventions for one patient was 33, and eight patients received at least 10 interventions in the study period. Therapeutic interventions were classified as procedural, counselling and education, monitoring, social assistance, provisions with aids, hospital administration and others (Figure 3). Most common were counselling and education interventions. All nurse practitioners provided counselling and education, with 86.5% of patients receiving this type of therapeutic intervention (with a range of 4.3 to 0.5 interventions per patient). Procedural interventions were also frequent and were performed on 43.7% of the patients; however three nurse practitioners did not perform any procedural interventions (range from 0.0 up to 3.1 procedures per patient). Only 5 nurse practitioners provided social assistance interventions and only seven nurse practitioners documented that they had monitored patients. Provision of aids and hospital admission of patients was rare. 12

Figure 3: Therapeutic interventions performed by nurse practitioners (n=358 interventions) Prescription of Medication Just under 45% of patients received medication from a nurse practitioner, averaging 0.62 prescriptions per patient. During the study period, 59 prescriptions for medication were produced by the participating nurse practitioners. All but one nurse practitioner prescribed medications, with a range of 0-1.6 prescriptions per patient. Table 1 list all medications recommended by the nurse practitioners during the study. They are classified according to their drug group. Most prescriptions were for antibiotics, narcotic analgesics and antifungals. Nine of the participating nurse practitioners were hospital based and thus were not restricted by the lack of access to PBS provider numbers in prescribing medication for their patients. 13

Nurse practitioners in Western Australia The Nurse Practitioner Series Table 1: Medications prescribed by nurse practitioners (n=59 prescriptions) Drug Group Number of Prescriptions Antibiotics 11 Narcotic analgesia 9 Antifungals 5 Respiratory stimulant 4 Anti-anxiety agents 2 Antidepressants SSRI 2 Antiemetics, antinauseants 2 Immunoglobulin tetanus 2 Non-steroidal anti-inflammatory agents 2 Topical corticosteroids 2 Vaccine Gardicil 2 Vitamin folate 2 Anaesthetic 2 Anti-diarrhoeal 1 Antihypertensive 1 Antipsychotic agents 1 Antiviral 1 Beta-adrenergic blocking agents 1 Dextrose 1 Hormone contraceptive 1 Hypoglycaemic agents 1 Mineral iron 1 Sedatives, hypnotics 1 Topical hormone 1 Topical ocular anti-infective preparation 1 Limitations Drawing conclusions and generalisability from the findings of this study is subject to the limits of retrospective chart audits. It is not possible to comment on whether the use of these extended practice services was appropriate in terms of safety and effectiveness, other than that they occurred. Also, as most of the nurse practitioners (82%) in this study worked within the financially benign context of a hospital setting, the lack of their access to PBS and MBS appeared to have no financial consequence for their patients. Consequently this study, with its major focus on nurse 14

practitioner service conducted within the financially protective confines of the public hospital setting masks the real significance of restrictions to practice for this reformative model of health service. Conclusions This study has provided a snapshot of the documented actions of a sample of nurse practitioner service. The findings from this study are useful in demonstrating the extended practice activities of a sample of Australian nurse practitioners. However these findings need to be read in the context of the holistic practice of nurse practitioners and the variability of service across difference specialist models. The nurse practitioners in this sample readily referred patients to other clinicians and agencies; primarily used counselling and education as treatment modalities and whilst almost all nurse practitioners in the study prescribed medication these prescriptions were for less than 50% of their patients. These findings are tentative but provide a good basis to inform further research into nurse practitioner service and resource usage. References ACT Health 2006, Nurse Practitioners in the Australian Capital Territory: The Framework, Canberra ACT Health and the Nurses Board of the ACT. (2002). The Act Nurse Practitioner Project Final Report of the Steering Committee, Melbourne. Gardner, A., Gardner, G., Middleton, S., Della, P. (2009). The status of Australian Nurse Practitioners: Findings from the first national census. Australian Health Review, 33(4), 679-689. Gardner, G., Carryer, J., Gardner, A., & Dunn, S. (2006). Nurse practitioner competency standards: findings from collaborative Australian and New Zealand research. International Journal of Nursing Studies, 43(5), 601-610. Gardner, G., Chang, A., & Duffield, C. (2007). Making nursing work: breaking through the role confusion of advanced practice nursing. Journal of Advanced Nursing, 57(4), 382-391. Middleton, S. (2007). Audit or research? Should nurse practitioners participate in these types of evaluation and what is the difference between them? The Nurse Practitioner Series, 2(1), 26-32. 15

Nurse practitioners in Western Australia The Nurse Practitioner Series Nurse and Midwife Medicinal Product Prescribing: A New Initiative for Ireland Adjunct Associate Professor Elizabeth Adams RGN, Cert (ODN), BNS (Hons), Dip (Mgt) Dip (Counselling), Dip (Phy and Chem), PGDip (Stats), MSc Director of Nursing and Midwifery and Deputy Nursing Services Director Office of the Nursing Services Director, Clinical Care and Quality Directorate, Health Service Executive Ms. Annette Cuddy RGN, RM, PG Cert (Facilitation), BSc, MSn Assistant Director of Nursing and Midwifery Office of the Nursing Services Director Clinical Care and Quality Directorate, Health Service Executive Ms. Maureen Flynn RGN, RNT, PGDip (Stats), Dip (Hospital and Community Infection), Dip (Research Methods), Dip (Hospital and Health Service Administration), Dip (Teaching Methods), MEd, MSc Assistant Director of Nursing Office of the Nursing Services Director, Clinical Care and Quality Directorate, Health Service Executive Ms. Rose Lorenz RGN, RM, PGDip (Clinical Practice), PGDip (Human Resource Mgt) Assistant Director of Nursing and Midwifery Office of the Nursing Services Director, Clinical Care and Quality Directorate, Health Service Executive Ms. Clare MacGabhann RGN, RM, HDip (Mgt), MComm (Government and Public Policy) Assistant Director of Nursing and Midwifery Office of the Nursing Services Director, Clinical Care and Quality Directorate, Health Service Executive Abstract The introduction of nurse and midwife prescribing in Ireland is an important and significant new initiative in the Irish Health Service which has implications not just for nurses and midwives, but for the healthcare system as a whole, in particular for patients and service users. In 2007 the Act and associated Regulations were signed into law. Nurse and midwife prescribing is underpinned by a twin-track approach encompassing amending Irish legislation and the introduction of new professional regulations. This dual framework enables a registered nurse or midwife, who has completed an approved six month post-registration education programme, has the appropriate clinical experience, is registered with the Irish Nursing Board (An Bord Altranais) as a Registered Nurse Prescriber, and has authority from the health service provider that employs them, to prescribe a range of medicinal products within their scope of practice. 16

This article sets out the national processes used in the introduction of nurse and midwife medicinal product prescribing in Ireland from inception, to legislative changes, educational preparation, governance arrangements, registration requirements and clinical practice outcomes. The critical success factor was the introduction of a standardised approach applied in a systematic manner in each health service provider with the ongoing support of the Office of the Nursing Service Director within the Irish Health Service Executive. The change management process was finalised with the commissioning and completion of an independent external evaluation of the first two years experience of nurse and midwife prescribing in Ireland. Overall, the evaluation found that the extension of prescriptive authority to nurses and midwives has been a positive development, particularly for the impact that it has had on patient care and also on the professional development of nurses and midwives. Key Words: Change Management, Collaboration, Legislation, Medicinal Products, Registered Nurse Prescriber, Role Expansion Introduction Nurse and midwife medicinal product prescribing is one of the key initiatives of the Irish Minister of Health and Children, Mary Harney, Teachta Dála (TD) (Member of Parliament). There are now over 160 nurses and midwives with prescriptive authority employed in the health services. This has real potential to enhance the efficiency and responsiveness of the health services for patients and service users. The initiative endorses the Government s policy for the expansion of nursing and midwifery roles. This article provides the background on how this was achieved. Background In October 2005, the Irish Minister for Health and Children identified the introduction of nurse and midwife prescribing as a high priority. A number of national and international trends were identified as supporting the extension of prescriptive authority to nurses and midwives in Ireland: Social and demographic change (e.g. ageing population) Changing services configuration for patients with increased specialisation of services (e.g. diabetes, asthma, oncology) Value for money Implementation of the European Working Time Directive A greater focus on community services. The nursing and midwifery professions were well prepared to respond to the Ministers direction in that a national pilot study (conducted over a three and a half year period) which rigorously evaluated the potential for the introduction of nurse prescribing had just been completed by the statutory bodies with responsibility for nursing and midwifery (An Bord Altranais and the National Council for the Professional Development of Nursing and Midwifery, 2005). 17

Nurse practitioners in Western Australia The Nurse Practitioner Series Legislation Primary legislation, the Irish Medicines Board (Miscellaneous Provisions) Act allowing for the introduction of independent nurse and midwife prescribing in Ireland, was introduced in May 2006. In November that year, the Department of Health and Children established a national steering group the Resource and Implementation Group on Nurse and Midwife Prescribing to advise on the regulations to be drafted and to oversee the rollout of nurse and midwife prescribing on a national basis (Office of the Nursing Services Director, Department of Health and Children, An Bord Altranais, National Council for the Professional Development of Nursing and Midwifery, 2007).. The subsequent regulations The Medicinal Products (Prescription and Control of Supply (Amendment) Regulations 2007 and the Misuse of Drugs (Amendment) Regulations 2007 were signed into law in May 2007 specifying the requirements/conditions for prescribing of medicinal products by nurses and midwives. These, together with the Irish Nursing Boards Nurses Rules 2007 form the basis on which nurse and midwife prescribing became a reality in 2007 (An Bord Altranais, 2007a). A number of conditions must be satisfied for prescribing authority. They are summarised as follows: The nurse/midwife must be employed by a health service provider in a hospital, nursing home, clinic or other health service setting (including any case where the health service is provided in a private home) The medicinal product is one that would be given in the usual course of service provided in the health service setting in which the nurse/midwife is employed The prescription is issued in the usual course of the provision of that health service The An Bord Altranais registration number (also known as the Personal Identification Number (PIN)) must be stated on the prescription. In addition, the 2007 regulations allow a health service provider to determine further conditions for the prescriptive authority of the nurse or midwife. A new schedule setting out restrictions and conditions for RNPs to prescribing certain controlled drugs was established for Ireland. This new schedule referred to as Schedule 8 names the specific controlled drugs that certain nurses and midwives, who are RNPs, may prescribe relevant to their scope of practice and area of work. The stipulations and particular conditions for prescribing are detailed in the Misuse of Drugs (Amendment) Regulations 2007. Dual Framework for Nurse and Midwife Prescribing Independent nurse and midwife prescribing in Ireland is underpinned by a twin-track approach encompassing amending Irish legislation and the introduction of new professional regulations. This dual framework enables a registered nurse or midwife, who has completed an approved six month post-registration education programme, has the appropriate clinical experience, is registered with An Bord Altranais as a RNP, and has authority from the health service provider that employs them, to independently prescribe a range of medicinal products within their scope of practice. 18

Post Registration Education Programme A six month education programme Certificate in Nursing (Nurse and Midwife Prescribing) funded by the Health Service Executive (HSE) was developed in 2007 and is provided by the School of Nursing, Royal College of Surgeons in Ireland and the Catherine McAuley School of Nursing and Midwifery, University College, Cork with over 100 places available every six months. The course comprises three modules taught at degree level. The curriculum is approved by the Irish Nursing Board (An Bord Altranais) and must meet their published Education Requirements and Standards (2007b). The first cohort of 42 nurses and midwives graduated in November 2007 and the seventh cohort commenced the programme in Spring 2010. Health Service Provider Participation and Entry Criteria Before admission to the programme of education and training to be a RNP, there are a number of minimum entry requirements that a nurse or midwife must fulfil. The nurse or midwife must already be registered in one of the divisions of the Nurses Register (general, psychiatric, children s, intellectual disability, midwife, public health nurse); they must have at least three years postregistration clinical experience; and the equivalent of one year full-time experience in their specific area of practice. There should also be demonstrable evidence of further education and a competent level of information technology literacy. In addition, there are site requirements for the nurses or midwives place of employment and practice, which must support nurses or midwives education and practice as a RNP. A site declaration form must be submitted by the nurses employer, confirming an organisational policy for nurse prescribing, appropriate risk management systems, access to a Drugs and Therapeutics Committee, a named mentor for each nurse, a prescribing site coordinator, and a commitment to continuing education for nurse prescribers (see Table 1). Table 1: Essential Criteria for Health Service Provider Participation Safe management an organisational policy for nurse and midwife prescribing an ability to safely manage and quality assure prescribing practices risk management systems in place and processes for adverse event reporting, incident reporting, reporting of near misses and reporting of medication errors. Education and practice development obust and agreed collaborative practice agreements a named medical practitioner/mentor who has agreed to develop the collaborative practice arrangements appropriate mentoring arrangements with a named medical mentor commitment to continuing education for staff supporting the prescribing initiative. 19

Nurse practitioners in Western Australia The Nurse Practitioner Series Organisation a firm commitment by hospital/organisation board, or Chief Executive Officer or medical director/chairperson of medical board to support the introduction of the initiative access to a drugs and therapeutics committee arrangements in place to oversee the introduction of a new practice in prescribing and ensure local evaluation a named individual with responsibility for the initiative locally and for liaison with the education provider and the national Resource and Implementation Group on Nurse and Midwife Prescribing ability to comply and ensure data input for the Nurse and Midwife Prescribing Data Collection System provision for the nurse/midwife prescriber to access to a computer, email and internet for data input to the Nurse and Midwife Prescribing Data Collection System (Monitoring System) Audit and evaluation a mechanism to audit the introduction of nurse and midwife prescribing practice. Source: Office of the Nursing Services Director, Health Service Director (2008a, page 91) Developments in the Education Programme In response to the needs of service providers, the programme has been further developed within the School of Nursing in the Royal College of Surgeons in Ireland to incorporate the use of blended learning, which includes face to face lectures combined with computer- mediated teaching through the use of an online classroom. The online component of the blended learning programme is delivered through voice recorded presentations, teaching videos and interactive tutorials and quizzes. This material can be accessed by students at any time which is convenient for them. It is not necessary for students to be online at specified times. A discussion forum is facilitated throughout the course, allowing for student-tutor interaction, student-student interaction and tutor-student interaction. The offline component of the programme is delivered through face to face tutorials utilising video conferencing facilities and this supports and enhances the online material. This new model of delivery is further enhanced through the use of an electronic portfolio (epnm) for nurses and midwives. Students can use this epnm to register their competencies, submit assignments, reflect on career experiences and gather evidence of continuing professional development. This facility allows the programme to be delivered at three regional sites across the country with lectures and tutorials being video conferenced from the college (Watson, 2009). This new approach to course organisation reduces attendance of students in college from 26 days to 13 days. 20

Registration with the Irish Nursing Board The professional regulatory framework for nurse or midwife prescribing is established through the Irish Nursing Boards Nurses Rules 2007, which allows for the creation of a division of the register for nurse prescribers. This Register is publicly accessible on the Nursing Board website http:// www.nursingboard.ie where it can be easily checked if a nurse or midwife is a RNP. The procedural requirements for registration are set out in Figure 1. Figure 1: Pathway for Application to Register with the Nursing Board as an RNP Source: Office of the Nursing Services Director, Health Service Executive (2008a, page 47) Collaborative Practice Agreement One of the key documents relating to registration and prescribing governance is the Collaborative Practice Agreement (CPA) (An Bord, Altranais, 2007c). This is a written agreement drawn up between the RNP, medical practitioner(s), approved by the health service provider/employer, outlining the parameters of the RNP s prescriptive authority, i.e. their scope of practice. It contains a general description of the practice setting to include population and conditions for which the RNP has responsibility, as well as a list of specific medications (by generic name) and/or categories of medications that the RNP is authorised to prescribe. The CPA is underpinned by the principles of professional accountability, responsibility, competence and clinical governance. It also provides a template for the development, audit and evaluation of the RNP s prescribing practices within the healthcare setting. CPAs must be reviewed and renewed annually, and are considered null and void on the termination and or movement of employment for which they were originally intended. The CPA also states a commencement date for prescriptive authority and is a prerequisite to registration with the Irish Nursing Board as a RNP. 21

Nurse practitioners in Western Australia The Nurse Practitioner Series Process of Preparing and Implementing the Change The HSE Office of the Nursing Services Director, guided by the Resource and Implementation Group on Nurse and Midwife Prescribing was responsible for: i) implementing the plan for the roll out of nurse and midwife prescribing across the public health services; ii) establishing clinical governance structures to support appropriate and safe nurse and midwife prescribing and iii) developing an overarching mechanism for the evaluation of the initiative. The initiative evolved as a collaborative model of working at national, regional and local levels involving all key stakeholders. A national standard implementation framework was established by the Office to ensure the initiative was implemented in a systematic and consistent manner that is underpinned by the best available evidence. Support provided to Health Service Providers To support health service providers the Health Service Executive appointed a Director of Nursing and Midwifery and four Assistant Directors to drive forward and implement the prescribing initiative. The team published a Guiding Framework for the Implementation of Nurse and Midwife Prescribing in Ireland in December 2008(a), underpinned by a vision statement, nine principles, four phases for change management and fifteen steps for implementation (see Figure 2). Figure 2: Guiding Framework for the Implementation of Nurse and Midwife Prescribing Source: Office of the Nursing Service Director, Health Service Executive (2008a, page 16) The steps and their phase within the project management lifecycle are clearly identified and guide each health service provider approaching the introduction of nurse and midwife prescribing for the first time (see Figure 3). While presented sequentially they are in fact approached as a continuous, overlapping process in which all of the steps and stages are interrelated and influence each other. 22

Figure 3: Steps in the Introduction of Nurse and Midwife Prescribing Source: Office of the Nursing Service Director, Health Service Executive (2008a, page 19) 23

Nurse practitioners in Western Australia The Nurse Practitioner Series To support the standardised approach to implementation and cognisant of the significant workload involved for health service providers the Office of the Nursing Service Director developed a number of supporting mechanism and publications (see Table 2). Table 2: Supporting Material developed by the Office of the Nursing Services Director A Guiding Framework for the Implementation of Nurse and Midwife Prescribing in Ireland (2008a) A National Nurse and Midwife Prescribing Minimum Dataset (2008a, page 50) A web based Nurse and Midwife Prescribing Data Collection System (2008c) A patient information leaflet: Nurse and Midwife Prescribers How they Care for You (November 2008b). Translated into French, Spanish, Chinese, Russian, Polish, Arabic and Irish (February 2010) An electronic communication mechanism for ongoing support for Prescribing Site Coordinators entitled Irish-PSC-eNetwork (launched in December 2008) An electronic communication mechanism for ongoing support for registered nurse prescribers entitled Irish-RNP-eNetwork (launched in December 2008) Information on Application Guidelines for the Nurse and Midwife Prescribing Initiative (January 2009) National Policy for Nurse Medicinal Product Prescribing in the Intellectual Disability Sector (February 2009a) National Policy for Nurse and Midwife Medicinal Product Prescribing in Primary, Community and Continuing Care (September 2009b) National Policy for Nurse and Midwife Medicinal Product Prescribing in Acute Hospitals (October 2009c). Source: accessible at http://www.hse.ie/eng/about/who/nursing_services/practicedevelopment/ Prescribing_of_medicinal_products/ Drugs and Therapeutics Committee The existence of a multidisciplinary Drugs and Therapeutics Committee, within each health service provider, is one of the key governance structures that should be in place to support the introduction of nurse and midwife prescribing. Since the introduction of the nurse and midwife prescribing initiative, 33 new committees have been established. Numbers of Registered Nurse Prescribers The first Registered Nurse Prescribers (RNPs) registered with An Bord Altranais at the end of January 2008. There are currently 160 RNPs registered (35 practising in Primary Community and Continuing Care and 124 in the acute hospital sector with one from a private organisation). The number of RNPs continues to rise on a monthly basis (see Figure 4). There are now 133 candidates preparing for registration and 112 students in college. A total of 405 candidates have been funded centrally by the Office of the Nursing Services Director to complete the six month post-registration education programme. 24

Figure 4: Incremental Increase in Registered Nurse Prescribers Source: An Bord Altranais, 31 March 2010 (unpublished) One of the focuses of the initiative is on nurse or midwife lead clinics and chronic disease management. Table 3 provides details of the various clinical areas where the current RNPs are employed. The largest numbers are from emergency departments (n=24), care of the older person (n=19), midwifery (n=12) and diabetic services (n=11). 25

Nurse practitioners in Western Australia The Nurse Practitioner Series Table 3: Clinical Areas of Practice of Registered Nurse Prescribers Clinical Area No of RNPs No of RNPs Emergency Department 24 Chest Pain 1 Care of the Older Person 19 Children s 1 Midwifery 12 Children s Emergency Dept 1 Diabetes 11 Children s Oncology/Haematology 1 Midwifery Delivery 8 Children s Respiratory 1 Mental Health 8 Coloproctology 1 Cardiology 4 Colposcopy 1 Intellectual Disability 4 Cystic Fibrosis 1 Neonatology 4 Ear Nose and Throat 1 Orthopaedics 4 Epilepsy 1 Renal Care 4 Gastroenterology 1 Cardiac Rehabilitation 3 General Medicine 1 Heart Failure 3 Genitourinary 1 Intensive Care 3 Lung Cancer Coordinator 1 Oncology 3 Midwifery Lactation 1 Pain Management 3 Midwifery Community 1 Rheumatology 3 Midwifery Continence Advisor 1 Cardiothoracic 2 Migraine 1 Children s Pain Management 2 Occupational Health 1 Dermatology 2 Ophthalmology 1 Home Care Mental Health 2 Palliative Care 1 Midwifery Diabetes 2 Peritoneal Dialysis 1 Respiratory 2 Stroke Rehabilitation 1 Sexual Health 2 Urodynamics 1 Tissue Viability 2 Vaccinations 1 Breast Care 1 Cardiac ICU 1 Private Sector - General Practice 1 Total Number of RNPs 160 Source: Office of the Nursing Services Director, Health Service Executive 31 March 2010, unpublished 26

Monitoring the Introduction of Nurse and Midwife Prescribing in Ireland Recognising the need for robust monitoring of the new service provision, the Resource and Implementation Group developed a National Nurse and Midwife Prescribing Minimum Dataset for Ireland (Office of the Nursing Services Director, 2008d). The minimum dataset contains twelve items of information that are collected in a standard way on every prescription written by a RNP. As eprescribing is not commonly available in Ireland and in order to provide for an effective and user friendly way for the information to be collected the Office of the Nursing Service Director commissioned the development of a web-based monitoring system. The Nurse and Midwife Prescribing Data Collection System accessible at https://www.nurseprescribing.ie is used by individual RNPs; prescribing site coordinators and directors of nursing and midwifery; and relevant staff within the Office of the Nursing Services Director. At any time standardised reports or adhoc queries can be prepared by system users at, local health service provider, HSE area, or national level. During the 26 months (25 January 2008 to the 31 March 2010) RNPs reported 19,941 prescribing episodes for 15,966 individual patients involving 28,108 items. Over 369 types of medicinal products were prescribed during the period. National Independent Evaluation of the Nurse/Midwife Prescribing Initiative In 2007 when introducing the initiative the Minister for Health and Children gave a commitment to conducting a review of the Regulations for nurse and midwife prescribing two years following their implementation. Following a competitive tendering process the contract was awarded to a collaborative research team from University College Dublin and took place over six months from January to end June 2009 (Drennan et al, 2009). The purpose of the evaluation was to examine the effectiveness of the introduction of nurse and midwife prescribing and to establish if the model adopted in Ireland achieved the stated objectives in terms of quality, patient safety, communication and patient/client benefits and satisfaction. The evaluation took into account the views of key stakeholders, including employers, nurses and midwives (including prescribers and nonprescribers), the medical and pharmacy professions, regulatory bodies and patients and clients. Clinical stakeholders were of the opinion that nurse and midwife prescribing impacted positively on patient outcomes such as patient satisfaction and compliance. Overall, the evaluation found that the extension of prescriptive authority to nurses and midwives has been a positive development, particularly for the impact that it has had on patient care and also on the professional development of nurses and midwives. From the perspective of nurse and midwife prescribers it has increased their autonomy, increased levels of job satisfaction, ensured better use of their skills and ultimately has allowed them to provide holistic care to patients. Irish patients are highly supportive and accepting of nurse prescribing which reduces waiting times and facilitates patients in accessing treatment that previously they may have had to wait for. It is evident that overall there is support for nurse and midwife prescribing from those surveyed from the nursing, midwifery, medical and pharmacy professions. The report demonstrated that the model for nurse and midwife prescribing for Ireland was safe and effective. The independent evaluation team made ten recommendations which provide clear direction for the further roll out of independent nurse and midwife prescribing across Ireland. Key recommendations include matters related to the regulations, education, registration, prescribing practice and future 27

Nurse practitioners in Western Australia The Nurse Practitioner Series developments of nurse prescribing in Ireland. The report identified the standard on how nurse and midwife prescribing can be audited on an ongoing basis with the development of measurement tools specific to the Irish context and environment. The report of the evaluation and the recommendations were accepted and launched by the Irish Minister for Health and Children on the 9 October 2009. Conclusion Nurse and midwife prescribing has been received positively in all areas where it has been introduced and the numerous benefits are now recognised. These include improved services to patients and service users through reduced waiting times and utilising the skills of nurses and midwives more effectively. Prescriptive authority has enabled nurses and midwives to provide holistic episodes of care more efficiently. Nurses and midwives with prescriptive authority can meet patient needs in a timely manner leading to better patient outcomes. The timely and effective implementation of the initiative underpinned by a national, structured, consistent approach in partnership with relevant personnel at all levels within the health services has resulted in the introduction of over 160 Registered Nurse Prescribers within 26 months with a further 245 on the pathway to registration. References An Bord Altranais and National Council for the Professional Development of Nursing and Midwifery (2005). A Review of Nurses and Midwives in the Prescribing and Administration of Medicinal Products. Dublin: An Bord Altranais and the National Council for the Professional Development of Nursing and Midwifery. An Bord Altranis (2007a). Nurses Rules 2007. Dublin: An Bord Altranais. An Bord Altranais (2007b) Requirements and Standards for the Education programme for Nurses and Midwives with Prescriptive Authority. Dublin: An Bord Altranais. An Bord Altranais (2007c). Collaborative Practice Agreement for Nurses and Midwives with Prescriptive Authority. Dublin: An Bord Altranais. Drennan J., Naughton C., Allen D., Dyde A., Feele P., O Boyle K., Treacy P., Butler M. (2009) Independent Evaluation of the Nurse and Midwife prescribing Initiative. Dublin: University College Dublin. Health Service Executive and The National Federation of Voluntary Bodies Providing Services to People with Intellectual Disability (2009a). National Policy for Nurse Medicinal Product Prescribing for Intellectual Disability Services. Dublin: Health Service Executive Health Service Executive (2009b). National Policy for Nurse and Midwife Medicinal Product Prescribing in Primary Community and Continuing Care. Dublin: Health Service Executive. Health Service Executive (2009c). National Policy for Nurse and Midwife Medicinal Product Prescribing in Acute Hospitals. Dublin: Health Service Executive. 28

Irish Medicines Board (Miscellaneous Provisions) Act, 2006 (Commencement Order) 2007. Dublin: Stationery Office. Irish Medicines Board (Miscellaneous Provisions) Act, 2006. (Section 16 l (ii)). Dublin: Stationery Office. Medicinal Products (Prescription and Control of Supply) (Amendment) Regulations 2007. Statutory Instruments No 201 of 2007. Dublin: Stationary Office. Misuse of Drugs (Amendment) Regulations 2007. Statutory Instruments No. 200 of 2007. Dublin: Stationary Office. Office of the Nursing Service Director, Health Service Executive (2009). Information on Application Guidelines the Nurse and Midwife Prescribing Initiative. Dublin: Office of the Nursing Services Director, Health Service Executive. Office of the Nursing Services Director, Health Service Executive (2008a). Guiding Framework for the Implementation of Nurse and Midwife Prescribing in Ireland. Dublin: Office of the Nursing Services Director, Health Service Executive. Office of the Nursing Services Director, Health Service Executive (2008b). Patient and Service User Information Leaflet: nurse and midwife prescribers how they care for you. Dublin: Office of the Nursing Services Director, Health Service Executive. Office of the Nursing Services Director, Health Service Executive (2008c). Nurse and Midwife Prescribing Data Collection System. Dublin: Office of the Nursing Services Director, Health Service Executive. Office of the Nursing Services Director, Health Service Executive, Department of Health and Children, An Bord Altranais, National Council for the Processional development of Nursing and Midwifery (2007) The Introduction of Nurse and Midwifery Prescribing in Ireland: An overview. Dublin: Health Service Executive. Watson, C. (2009) Certificate in Nursing (Nurse/Midwife Prescribing). Dublin: Royal College of Surgeons in Ireland. 29

Nurse practitioners in Western Australia The Nurse Practitioner Series Nurse Practitioner Programs: the need for giving good advice Dr Joyce Marie Hendricks RN, RM, PhD, FRCNA Research and Higher Degree Coordinator Edith Cowan University Joondalup, Western Australia Vicki Cope RN, RM, BA Grad, Dip Ed, MHS (Nursing) FRCNA Nursing Pathways Coordinator Edith Cowan University Joondalup, Western Australia Abstract This commentary paper provides descriptive information on the expanding scope of the Nurse Practitioners role to encompass state and national healthcare frameworks and directives. It discusses an approach to student application for nurse practitioner courses which is guided by an active career counselling standpoint on behalf of the university academic. This structured career advice to potential nurse practitioners ensures that the potential student is central to decisions related to personal career paths and goal achievement. Overall the nurse practitioner program at Edith Cowan University is innovative in that each applicant, despite e-admission processes, meets with the course coordinator to strategise the best way forward in the exploration and advancement of career planning. Key words: Nurse Practitioner, career planning, structured advice Introduction In the contemporary healthcare landscape the role of Nurse Practitioner (NP) is now an accepted phenomenon. Most recently the discussion paper titled Towards a National Primary Health Care Strategy (Department of Health and Ageing, 2009) has identified the role of the NP as central to the framework that targets; health promotion and intervention, rural areas and the improvement of the general health of the population. Nurse Practitioners are an essential part of that healthcare service (Roxon, 2008). This represents a shift in thinking related to the role of the NP, a role that may be said to pragmatically align with the acute care sector with for example, renal, emergency, and wound care specialist units where the NP works within a medicalized system of health care. This medicalisation of the NP role may curtail the growth of this professional group and numbers prepared for these acute care roles may overtake the available positions. Della, et al. (2007) asserted that NP numbers are increasing incrementally, from 230 nationally at June 2007 to the same amount now being prepared within one state alone in 2009. Are too many nurses entering into a NP program that cannot be employed to the level of their registration upon exit from that NP program? Are there re-registration programs in place for these NP s when they are unable to maintain competence as they have not been employed as such due to the lack of NP positions? 30

These important issues are still to be addressed. The bottom line is that if the role of the NP remains acutely focused, and is not strategically pursued and clearly identified in the healthcare sector to be responsive to national directives and healthcare frameworks, nurses may continue to fill the void rather than to expand their practice and be employed to the level of their registration and expertise (Della, 2007). Contemporary health care frameworks require the endorsement of NP s in specialist areas of nursing historically not considered as such, for example, generalist nursing streams, practice nursing, community nursing, primary health care and rural and remote nursing (WHO, 2008). This expansion in the scope of practice to encompass new areas of nursing practice means that University NP preparation programs must be responsive to State and National health directives to ensure that NP competencies meet the demands and requirements for primary healthcare, health promotion and preventative medicine (ANMC, 2006). Further this change in health care focus is compounded by nursing shortages and the aging population of both health professionals and their clientele. These compounders necessitate an educational program for NP s which seeks to encompass the potential for their widening scope of practice whilst concurrently providing the practitioners with expert knowledge and skills and clinical leadership behaviours that are required to meet the demands of a dynamic client population and healthcare environment (Roxon, 2009). Universities do not have a formal role in the design of strategic plans of healthcare services nor in the budgetary allocation for NP s within those services, rather the University has a role in providing informed choices to potential students. Both the healthcare services and the tertiary providers should have the specific intent of providing a nursing workforce which bridges the gap between the need for tertiary intervention and primary healthcare (Reel, 2004). In order to address this gap, Universities have a role to maintain the number of NP students and to prepare those students to expect to be employed in response to workforce and consumer requirements, to be endorsed within this role, and to meet the individual nurse s desire for employment so that they are renumerated for their study, skill and expertise (Sullivan, 2003). University courses therefore must meet the demands of the profession, workforce needs and the individual needs of the student (Gardner, 2007). Tertiary education providers must not only be accountable for providing the student with an education but also in assisting those students to have a higher than average chance of finding the level of employment equal to their registration and expertise (Stanley, 2005). This paper will focus upon ECUs Master of Nursing (Nurse Practitioner) program and highlights the responsibility of providing career advice and counselling to nurses who seek to enter the role of Nurse Practitioner. The ECU Master of Nursing (Nurse Practitioner) Program The ECU Master of Nursing (Nurse Practitioner) program was revised in 2007 and the program continues to be offered in conjunction with the School of Nursing and Midwifery at Flinders University in South Australia so as to make the best use of academic expertise within both universities (Glover, Churchouse, Saunders & Rudd, 2007). The program combines a strong focus on clinical skills development with advanced theory-to-practice topics specifically designed to meet the demands of the professional, regulatory and political contexts in which graduates will practise. It is suitable for candidates working in advanced practice nursing roles in a wide range of health care settings and is reflective of changes on the focus of healthcare delivery. 31

Nurse practitioners in Western Australia The Nurse Practitioner Series Places in the course are offered subject to availability of appropriate clinical support and mentoring in the workplace environment. All applicants are required to hold a Bachelor s degree in Nursing or equivalent, be registered as a nurse, and hold a current practising certificate. In addition, students require written support from their employing facility and their clinical facilitators who act as clinical mentors. The role of the clinical mentor is to assist, guide and assess students in clinical development, for example, with patient interviews and examinations, specialised physiology and pathophysiology, diagnostic tests, therapeutics including pharmacotherapeutics, and other areas relevant to the clinical specialty; and to act as contact for other members of the health care team, providing information about, and perhaps advocacy for, the students evolving clinical role. Therefore, students are required to identify that they are employed in a clinical area that is able to provide them with a supportive environment and resources to practice and develop their extended clinical knowledge and skills with the view to employment as a NP within that facility upon completion of the course. The ECU Master of Nursing ( Nurse Practitioner) program is a 240 credit point or eleven unit award designed to develop specialist practice with a focus on clinical leadership, health promotion and an integration of evidence based nursing. The specialist streams offered within the award include: critical care, intensive care, coronary care, high dependency; paediatrics, paediatric intensive care, advanced nursing, chronic disease management, post anaesthesia care, peri operative, orthopaedic, gerontology, dementia care, palliative care, oncology, mental health, and general practice nursing. Student learning is developed and assessed using the spiral curriculum model where theoretical, clinical and practical perspectives are introduced and revisited throughout the duration of the course. Students are required to have a minimum of three to five years experience of their chosen speciality. This ensures that the program remains clinically rigorous, intellectually challenging and relevant to contemporary practice. The program is offered externally by coursework, fully online in response to student feedback, which was an innovation first offered in 2008 to address the requirements of a predominantly female workforce who are working, rearing family and studying too, and it uses a variety of virtual and online teaching modalities with virtual classroom technology and simulation. The on-line nature of the program ensures that students can work from home, maintaining work life balance, whilst remaining in a workforce so that they are paid and can still work strategically with managers to identify positions which are conducive to practitioner roles and therefore plan a career as a NP to ensure future employment. The following discusses the importance of career counselling and guidance in assisting potential NP s in meeting career goals. Career advice Counseling and career advice is important to maintaining the success of the NP program at ECU. Often requests for information come from nurses who have little clinical experience or nurses with experience who are looking for options to expand their educative and skill base. Here university academics have a role in providing educative and career counseling in order to ensure that the best possible outcome is achieved for all. Central to ECU s postgraduate nursing education philosophy is personal growth and building job market value for the individual nurse which entails enhancing and developing the potential to become a nurse leader. The changing work environment has opened new avenues for individuals 32

to think creatively, to keep up with current trends, and to investigate and make sound and informed career decisions based on trends within healthcare and to prepare themselves for new challenges. Determining the critical needs of each student assists in planning the best unit options for them, and any extra learning based activities which may also need attention. The ECU program academics, through individual interview and discussion with applicants, ensure that the potential NP has a repertoire of portable skills, and is positioned in respect to organizational and workforce needs. Academic counseling places the students needs at the centre of discussions, and empowers the student to make his or her own career and life decisions, and to have final control over the critical variables which impact upon personal and professional growth. That is whether to undertake more study and/or whether to take action for higher performance and increased nursing accountability and responsibility. The University here can provide valuable education, skill based training, support and clinical mentorship which may also influence those personal career decisions (Kaye, 2003). As the supply and demand of nursing skills and experiences fluctuate in relation to changes in workforce needs, students require flexibility with their career choices and future directions. Careers generally have a cycle made up of four steps: exploration, advancement, maintenance and decline (Walsh & Osipow, 1988, p.5). Career advice is particularly important in the stages of exploration and advancement where the student initiates discussion about role development and seeks expert advice from the university academic. Central to this discussion is career security. In creating career security, students are encouraged to take complete ownership and responsibility for their own career management. This awareness requires energy, enthusiasm and confidence and is only achieved by having a complete picture of self and a planned direction as to future goals and aspirations. This University assists the student in developing awareness and confidence by encouraging students to take an active role in their study options and by matching the student with an individualised study path. This active strategy of involvement with the career advice of students has seen the increased enrolment within the program by at least 50% and points to the need for, and the importance of, career planning and goal setting. Initial evaluation of active career counselling has demonstrated that expected and desired outcomes of the student being prepared have reflected their personal goals. High completion rates of students suggest that career advice given was appropriate with positive student and industry feedback attesting to this. Student satisfaction and quality assurance via standard university processes have indicated continued improvement in the student learning experience in this course and the positive influence of career advice and counselling. The next step forward is to formally evaluate ECU s NP s in the workforce in relation to career guidance and goal achievement. Conclusion This paper has discussed the ECU Master of Nursing (Nurse Practitioner) Program. It has highlighted the need for developing practitioners in response to industry requirements and the changing trends in state and national healthcare directives. In particular this paper has highlighted the academics role in providing individualised career advice within the context of the Nurse Practitioner Program. Moreover the need for student-centred advice which focuses on long term job security is most important. The paper has pointed towards formal evaluation of structured career advice for goal attainment with graduates in the future. 33

Nurse practitioners in Western Australia The Nurse Practitioner Series Acknowledgements The ECU Master of Nursing (Nurse Practitioner) course information can be found on the University website at: www.snmpm.ecu.edu.au References Department of Health and Ageing. (2009). Towards a National Primary Health Care Strategy: A Discussion Paper from the Australian Government. Retrieved May 26, 2010, from http://www.health.gov.au/internet/main/publishing.nsf/content/d66fee14f736a789ca2574e30017 83C0/$File/DiscussionPaper.pdf. Australian Nursing and Midwifery Council. (2006). National Competency Standards for the Nurse Practitioner. Canberra: Australian Nursing and Midwifery Council. Della, P.R. (2007). The nurse practitioner journey: What has been achieved and what is next. The Nurse Practitioner Series, 2(1), 8-12. Della, P.R., Fielding, K., Hagen, D., Hagendorf, M., Harford, E., Kerr, K., et al. (2007). National progress on nurse practitioner numbers. The Nurse Practitioner Series, 2(1), 33-37. Gardner, G. (2007). Research challenges for an emergent nursing service. The Nurse Practitioner Series, 2(1), 13-18. Glover, P., Churchouse, C., Saunders, L., & Rudd, C. (2007). Two is better than one: a model in joint collaboration to achieve excellence for the nurse practitioner. The Nurse Practitioner Series, 2(1), 51-55. Kaye, B. (2003). Fast-Track Mentoring: Engage Your Top Talent. Executive Excellence, 20(5), 8-9. Reel, S. (2004). The West Australia Nurse Practitioner Project: An American Perspective. The Nurse Practitioner Series, 1(2), 25-30. Roxon, N. (2008). Speech to the Australian Nurse Practitioners Conference Nurse Practitioners their role in a modern health system Melbourne 28 October 2008. Retrieved May 26, 2010, from http://www.acnp.com.au/news-events/speech-to-the-australian-nurse-practitioners-conference/ print.html. Roxon, N. (2009). Speech to the Royal College of General Practitioners Melbourne-1 October 2009. Retrieved May 26, 2010, from http://www.health.gov.au/internet/ministers/publishing.nsf/content/ sp-yr09-nr-nrsp011009.htm?opendocument&yr=2009&mth=10. Stanley, J. (2005). Moving toward a new vision of nurse practitioner education. The Journal of Nurse Practitioner, November/December, 209-212. Sullivan, M. (2003). The new subjective medicine: taking the patients point of view in healthcare and health, Social Science and Medicine, 56, 1595-1604. Walsh, W.B., & Osipow, S.H. (1988). Career Decision Making. New Jersey: Lawrence Erlbaum Associates. WHO. (2008). World Health Report 2008: primary health care-now more than ever. Geneva: WHO. Retrieved May 26, 2010, from http://www.who.int/whr/2008/whr08_en.pdf. 34

Nurse Practitioners Emergency Services: A Western Australian perspective Bronwyn Nicholson NP, RN, MHS (Nurse Practitioner), BSc (Nursing), HBDip (Nursing), RCN, ACNP Nurse Practitioner (Emergency Services), Emergency Department, Joondalup Health Campus, Western Australia Abstract This commentary paper provides insights into the Nurse Practitioner Emergency Services (ENP) role from a Western Australian perspective. Significant numbers of patient presentations to Western Australian Emergency Departments are of the non urgent type, mostly as a result of poor access to primary health care via a General Practitioner. ENPs are able to examine and treat significant numbers of these patients independently freeing up Medical Officers to attend to other patients. Limiting ENPs to the management of these non urgent cases however, fails to utilise the full potential of the ENP. The transition from senior Emergency Department nurse to ENP is challenging. Full responsibility for clinical decisions and the impact they will have on patients, rests with ENPs. It can take quite some time for ENPs to be confident with this responsibility. ENPs are not required to rotate to different departments or hospitals. As a result, they are usually consistent members of the Emergency Department team, resulting in benefits for patients and other team members, including Medical Officers. Despite the negative public stance of the Australian Medical Association regarding independent Nurse Practitioners, Medical Officers who are working alongside ENPs have fully embraced the role. Studies reflecting the outcomes of the ENP service, including patient satisfaction, are needed in this state. Work also needs to be undertaken to remove the legislative constraints to the full potential of the ENP role in Western Australian Emergency Departments. Despite the many challenges, the ENP role is evolving into a necessary service to the Western Australian community. Key Words: Nurse Practitioner, minor injuries, emergency department, constraints, waiting times Introduction The role of the Nurse Practitioner in Emergency Departments is not a new concept. Countries such as the United Kingdom, Canada and the United States of America have utilised the Nurse Practitioner role in Emergency Departments for several decades (Henrick & Appleyard, 2001: Byrne, Richardson, Brunsdon, & Patel, 2000: Chang et al, 1999). In Western Australia the role is evolving with the first Nurse Practitioners commencing practice in 2006. It might be expected that Nurse Practitioners working in Western Australian Emergency Departments would share similar experiences to their colleagues working in other locations worldwide, but do they? This paper examines the Western Australian experience and highlights some of the insights gained by the author over the three years since the commencement of the role. 35

Nurse practitioners in Western Australia The Nurse Practitioner Series Management of Minor Injuries and Illness In Western Australian Emergency Departments, significant numbers of patient presentations are classed as minor injuries and illness and thus non-urgent. These presentations are most likely a result of patients experiencing difficulty in accessing primary health care via a General Practitioner. When confronted with unexpected health problems, often the only option for patients is to attend the Emergency Department. As most of the presenting conditions of these patients are not considered an emergency, they often wait long periods of time for assessment and treatment, as patients with more urgent health care needs are attended to first. The introduction of streaming these non urgent patients to a dedicated area with dedicated staff, often called Fast Track, has helped considerably in these patients obtaining health care in a timely manner. Due to a lack of primary health care services in the community, it is the author s belief that the Fast Track stream within Western Australian Emergency Departments has evolved into a necessary service to the community. The Nurse Practitioner Emergency Services (ENP) is helping to staff the Fast Track areas. In this role the ENP can be most fiscally efficient. Numerous studies have shown the ENP to be effective, productive and cost effective in managing non urgent cases in Emergency Departments in other countries (Davidson & Rogers, 2005; Sakr et al, 2003; Horrocks, Anderson, & Salisbury, 2002). The ENP is able to examine and treat significant numbers of these non urgent patients independently. This process not only reduces waiting times to be attended to, but also reduces treatment times for this group of patients while freeing up Medical Officers to attend to other patients. The provision of additional resources such as ENPs, help relieve some of the congestion experienced in the Emergency Departments. Consequently, in most Western Australian Emergency Departments, ENPs spends the majority of their time managing minor injuries and illness. It is the author s belief that the skills of ENPs are not fully utilised however, by limiting ENPs to the management of minor injuries and illness. There are numerous patient presentations that can be safely managed by ENPs utilising appropriate clinical guidelines and collaborative input from Medical Officers. Often these presentations are more complex cases. They may require more input from Medical Officers and often involve more investigations than those of non urgent patients. Consequently the length of stay in the Emergency Department for these more complex patients is often longer. Rostering more than one ENP on a shift regularly allows the high throughput of patients to continue through the Fast Track, while rotating another ENP through the main department. ENPs working in the main department are then able to regularly attend to more complex cases, maintaining their assessment and diagnostic skills in the management of more complex conditions. There is also potential for ENPs, with appropriate training, to assist with more complex procedures such as relocating dislocated shoulders, or the reduction of certain fractures. Impact on Length of Stay There have been numerous studies published discussing the benefits of the ENP role including a decreased length of stay for patients managed by ENPs (Byrne et al, 2000; Fry, Thompson, & Chan, 2003; Cooper, Lindsay, Kinn, & Swann, 2002; McMullen, Alexander, Bourgeois, & Goodman, 2001; Rogers, Ross & Spooner, 2004). One Australian study has reported decreased waiting times and length of stay for patients with minor injuries or illness when Nurse Practitioners are working in the Emergency Department (Jennings et al, 2008). The role of the ENP is quite a unique nursing 36

role in that both the assessment and diagnosis of the patients health care problems along with the nursing care are undertaken by the ENP. This process can expediate the patient s journey through the Emergency Department in contrast to the traditional method of management where the patient is seen by a Medical Officer, a diagnosis is made and care prescribed. Often the patient then has to wait for the nurse to be available to carry out the care. This process can result in significant delays, especially when resources are limited, increasing the patient s length of stay within the Emergency Department. Patient Satisfaction and Health Care Advice Numerous studies have shown that patients are satisfied with the role of the ENP (Wilson & Shifaza, 2008; Organ, Chinnock, Higgison, & Stanhope, 2005; Cooper et al, 2002; Byrne et al, 2000; Chang et al, 1999). There are no published Western Australian studies however, examining patients satisfaction with the care received by ENPs. Anecdotally the authors experience has been a very positive acceptance of the ENP role by patients. Research in this area is needed in Western Australia to confirm anecdotal evidence. A number of international studies comparing ENPs to Medical Officers found that ENPs were more likely to provide patients and their families with discharge information and health advice. Furthermore, suggested resources for patients to gain additional information, equipping them to better manage their own health care, were more often provided by ENPs (Byrne et al, 2000; Cooper et al, 2002). The author believes these findings result from the additional time ENPs spend with patients, as they undertake the assessment and diagnosis of health problems, along with the required nursing care. The additional time spent completing these tasks enables the development of a good rapport. Consequently, patients develop confidence in the ENPs management of their condition and become comfortable enough to ask questions. This additional time also provides the opportunity for ENPs to share health information and health care advice with patients and their families. The provision of health care advice and information along with a holistic approach and a commitment to evidence based best practice, ensures ENPs provide safe and high quality health care to their patients (Cooper et al, 2002; McMullen et al, 2001). Transition from Nurse to ENP The role of ENPs has provided a career path for senior Emergency Department nurses who wish to remain in a clinical role within nursing. The transition from Senior Emergency Department nurse to ENP can be very challenging. Experienced nurses working in Emergency Departments develop excellent patient assessment skills as a result of undertaking these tasks for many years. The transition to ENP requires the additional skills of diagnosis and establishing management plans for the Emergency Department patients. Full responsibility for these clinical decisions and the impact they will have on patients, rests with ENPs. It is the authors experience that it can take quite some time for ENPs to be comfortable with this responsibility. It can take as long as a year to stop deliberating over clinical decisions long after the patient has been discharged. This view is shared by other ENPs. One colleague stated that taking responsibility for their patients can be the hardest adjustment to make in this new role (M. Smith, personal communications, 5 September, 2009). Accepting responsibility for clinical decisions becomes easier as ENPs develop confidence in managing the same presenting conditions repetitively. ENPs may deliberate over the management 37

Nurse practitioners in Western Australia The Nurse Practitioner Series of their third sprained ankle but when managing a sprained ankle for the thirtieth time, they will not question their management decisions. Consistent Member of the ED Team ENPs are usually a long term member of the Emergency Department team. There is no rotation to other hospitals or departments, unlike their medical colleagues. Consequently ENPs manage high numbers of similar, non urgent cases resulting in them becoming highly competent in the management of minor injuries and illness. Competency is enhanced, in many cases, by the fact that ENPs have been making similar assessments for years in the course of their work before formalising their training. Medical Officers are recognising ENPs high levels of competence in managing minor illness and injuries. It is the author s experience that senior ENPs are often utilised as resource people for Medical Officers, who seek advice regarding the management of certain injuries such as fractures and wounds. Furthermore, training for Emergency Department nurses in wound closure and plastering is facilitated by ENPs. Medical students also seek out ENPs to supervise and enhance their skills in plastering, splinting and wound management and closure. A further advantage of ENPs being consistent members of the Emergency Department team is in the professional relationships they develop with senior Medical Officers within specialty referral teams, in both the public and the private sector. Due to the nature of the presenting conditions that ENPs manage, the same specialty referral teams are used consistently. The frequent communication with senior Medical Officers within these teams leads to the development of good professional relationships. ENPs gain knowledge of what the management preferences are for the individual specialty referral teams and the patient s benefits from this consistent approach. Some referral teams provide written feedback regarding patient outcomes. This process provides an opportunity for reflection and education for the referring ENPs. Feedback may take several months to be forthcoming by which time many of the Medical Officers may have been rostered to other areas or hospitals, missing out on this valuable feedback. Legislative Constraints Despite the numerous benefits in having a Nurse Practitioner working within the Emergency Departments as discussed above, the ENP role is constrained by legislation in certain areas. The decision made by the Federal Government to include Nurse Practitioners in the budget for access to the Medicare Benefits Scheme and the Pharmaceutical Benefits Scheme in late 2010 will make a significant difference to patients. They will be able to receive reimbursement for tests ordered and medications prescribed by Nurse Practitioners. There is still much work to be undertaken however, as Workers Compensation and Motor Vehicle Insurance legislation does not include Nurse Practitioners. Patients presenting to the Emergency Department under the Workers Compensation Act require a Medical Officer to sign First or Progress medical certificates. Despite ENPs examining and treating these patients, Medical Officers need to attend Workers Compensation patients for administrative purposes only. This process delays the discharge of these patients resulting in an increased length of stay within the Emergency Department. 38

Motor Vehicle Insurance legislation states ENPs are not able to examine patients admitted under this legislation (Government of Western Australia, 2006). If a Medical Officer is not working in Fast Track when patients are admitted under this legislation, these patients will need to be directed back to the main department to be managed by a Medical Officer. Priority is necessarily directed to the acute and emergency conditions in the main department and as a result these re-directed patients often wait long periods of time to be assessed and treated. ENPs celebrate the change in legislation allowing access to the Medicare Benefits Scheme and the Pharmaceuticals Benefit Scheme. They look forward to changes to the Workers Compensation and Motor Vehicle Insurance legislation allowing them to completely manage the care of these patients. Medical Support for the Role Although ENPs celebrate the reduction in constraints to their role, other sections of the health sector have not responded positively. There have been numerous reports in the media regarding the negative response from the Australian Medical Association towards independent Nurse Practitioners in general, but access to these schemes in particular (Australian Medical Association, 2008; Australian Medical Association, 2005; Australian Medical Association, 2009). In contrast to this public stance by the Australian Medical Association, the authors experience has been one where Medical Officers have embraced the ENP role. Senior Medical Officers in particular have been very supportive in the professional development of ENPs. In addition, consultants in specialties such as radiology and pathology have been supportive in providing valuable advice regarding the development of clinical practice guidelines for ENPs. Outside of the Emergency Department, medical support for the role has been shown by several consulting specialists who have facilitated formal education sessions for Nurse Practitioners across WA along with informal teaching sessions in their relevant fields. Such support from senior Medical Officers helps to equip ENPs to work independently within their scope of practice, while seeking collaborative input from Medical Officers when their patients fall outside their scope. Discussion With increasing demands on emergency department services in Western Australia, the introduction of nurse practitioners to the emergency department team is one strategy being utilised to improve patient flow through the busy departments. As discussed above, ENPs are able to treat and discharge a specific group of patients independently and in doing so reduce the waiting times and length of stay for this group of patients. With the advent of the four hour rule being applied to Western Australian Emergency Departments over the coming year, 98% of emergency department patients will be expected to be treated and discharged, or admitted to a ward within four hours. By reducing waiting time and length of stay for the cohort of patients they manage, ENPs improve patient flow through the department and assist the departments to meet their expected targets. The full potential of the ENP role is not being realised however, while the role is constrained by legislation. By not including NPs within the Workers Compensation and Motor Vehicle Insurance legislation, significant delay in the care of this group of patients who have minor injuries occur. This delay can impact significantly on patient flow through the Emergency Departments for this group of patients. 39

Nurse practitioners in Western Australia The Nurse Practitioner Series Along with increased patient flow through the Emergency Departments, patients treated and managed by the ENP benefit from receiving timely health care. Furthermore, the provision of health care information and advice along with the extra time spent with the patients results in higher levels of satisfaction with the care that the patients receive. As discussed previously the staff also benefit from having ENPs working in their department through the provision of a local resource person to consult for advice and a consistent approach to the management of minor injuries and illness. Consideration needs to be given however, to the potential to develop ENPs into experts in the management of minor injuries and illness at the expense of their other acute care skills. Senior nursing staff within the Emergency Department may also benefit from this alternative career choice. The introduction of the ENP role has offered an alternative career path for senior nurses allowing them to advance their education while remaining in a clinical role with direct patient care. The transition from senior Emergency Department nurse to ENP, a significantly different role to any other previous nursing roles, is challenging and can elicit high stress levels. It can take considerable time for the novice ENP to adjust to the changes in what is required from them to effectively work in this new role. Much support is required for the novice NP as they adjust to the levels of responsibility that they carry for their clinical judgement and decision making. The valued support from medical colleagues along with that of the experienced ENPs is vital in assisting the nurses while they make this transition. Conclusion Anecdotally it appears that ENPs in Western Australian Emergency Departments share similar experiences to those in other countries. Studies reflecting the outcomes of the ENP service, including patient satisfaction, are needed in this state to confirm anecdotal evidence. Work also needs to be undertaken to remove the legislative constraints to the full potential of the ENP role. Despite the many challenges, the ENP role in Western Australia is evolving into a necessary service to the Western Australian community. References Australian Medical Association. (2005). AMA Position Statement: Independent Nurse Practitioners. Retrieved from http://www.ama.com.au/node/2099 Australian Medical Association. (2008). AMA Position Statement: Health Workforce Reform. Retrieved from http://www.ama.com.au/node/3306 Australian Medical Association. (2009). AMA Response to nurse practitioner and midwife legislation. Retrieved from http://www.ama.com.au/node/4841 Byrne, G., Richardson, M., Brunsdon, J., & Patel, A. (2000). Patient satisfaction with emergency nurse practitioners in A & E. Journal of Clinical Nursing, 9, 83-93. Chang, E., Daly, J., Hawkins, A., McGirr, J., Fielding, K., Hemmings, L., et al. (1999). An evaluation of the nurse practitioner role in a major rural emergency department. Journal of Advanced Nursing, 30, 260-268. Cooper, M., Lindsay, G., Kinn, S., & Swann, I. (2002). Evaluating Emergency Nurse Practitioner Services: a randomised controlled trial. Journal of Advanced Nursing, 40, 721-730. 40

Davidson, J., & Rogers, T. (2005). A lesson from the UK? Australasian Emergency Nursing Journal, 8, 5-8. Fry, M., Thompson, J., & Chan, A. (2005). Patients regularly leave emergency departments before medical assessment: A study of did not wait patients, medical profile and outcome characteristics. Australian Emergency Nursing Journal, 6, 21-26. Government of Western Australia. Office of the Chief Nursing Officer: Nurse Practitioner Information Sheet 1 (2006). Retrieved from http://www.ocno.health.wa.gov.au/practitioner/docs/ NursePractitionerInformation%sheet%201.pdf Henrick, A., & Appleyard, J. (2001). Clinical nurse specialists and nurse practitioners: Who are they, what do they do, and what challenges do they face? In J. McCloskey Dochterman, & Kennedy Grace, H (Ed.), Current Issues in Nursing (6th ed.). St Louis: Mosby. Horrocks, s., Anderson, E., & Salisbury, C. (2002). Review: nurse practitioner primary care improves patient satisfaction and quality of care with no difference in health outcomes. Evidence Based Nursing, 5, 121. Jennings, N., O Reilly, G., Lee, G., Cameron, P., Free, B., & Bailey, M. (2008). Evaluating outcomes of the emergency nurse practitioner role in a major urban emergency department, Melbourne, Australia. Journal of Clinical Nursing, 17, 1044-1050. Retrieved from doi: 10.1111/j.1365-2702.2007.02038.x McMullen, M., Alexander, M., Bourgeois, A., & Goodman, L. (2001). Evaluating a nurse practitioner service. Dimensions of Critical Care Nursing, 20, 30 34. Organ, K., Chinnock, P., Higgison, I., & Stanhope, B. (2005). Evaluating the introduction of a paediatric emergency nurse practitioner service. Emergency Nurse, 13, 8-11. Rogers, T., Ross, N., & Spooner, D. (2004). Evaluation of a see and treat pilot study introduced to an emergency department. Accident and Emergency Nursing, 12, 24-27. Sakr, M., Kendall, R., Angus, J., Saunders, A., Nicholl, J., & Wardrope, J. (2003). Emergency nurse practitioners: a three part study in clinical and cost effectiveness. Emergency Medicine Journal, 20, 158-163. Wilson, A., & Shifaza, F. (2008). An evaluation of the effectiveness and acceptability of nurse practitioners in an adult emergency department. International Journal of Nursing Practice, 14, 149-156. Retrieved from doi:10.1111/j.1440-172x.2008.00678.x 41

Nurse practitioners in Western Australia The Nurse Practitioner Series Power, policy and politics their interaction in evaluating nurse practitioner implementation Professor Phillip Della RN RM BAppSc MBus PhD Professor of Nursing, Head of School of Nursing & Midwifery, Curtin University, Perth, Western Australia Huaqiong Zhou RN, MCN, BSc (Nursing) Research Officer, School of Nursing and Midwifery, Curtin University, Perth, Western Australia; Clinical Nurse, Surgical Ward, Princess Margaret Hospital for Children, Western Australia Abstract Despite political bipartisan support for the development of nurse practitioners in Western Australia the legislative process was stalled at times as a direct result of political lobbying. The power of lobbying groups cannot be underestimated in the development of public policy. Groups who have real or perceived political power can change or even stop the development of good public policy. This may be achieved without empirical, valid or sound evidence. The legislative framework for the introduction of nurse practitioners in Western Australia was examined to assess the influence of political lobbying on public policy development. The results of the research study does suggest that the work needs to be continued in establishing the nurse practitioner role and further research on the scope of practice is required. In order for nurse practitioners to gain influence in health policy an understanding of politics and power must be understood. Nurse practitioners may gain a influence in the health policy arena through a number of avenues including direct lobbying, supporting professional organisations or research and publication. Key Words: Nurse Practitioner, Power, Policy and Practice Introduction The introduction of nurse practitioners in Australia has both a political and professional agenda. Evaluating the intersection of these agendas provides an insight into the influences they have had and will continue to have on shaping public policy and legislation. While at times these agendas may align they do originated from different thinking. It is this different thinking that has both assisted and restricted the development of the nurse practitioner in their role and scope of practice. While from a nursing view the agenda has been embedded in enhancing the values and goals of the profession the political agenda has been a workforce replacement agenda. The political agenda of workforce replacement which focuses on providing greater access to care has led to organisations outside the nursing profession to openly criticise the nurse practitioner movement. The power of organisations and associations outside nursing cannot be underestimated in the policy and legislation debate. Powerful dominant groups have been very successful in gaining political support to provide policy and legislation restrictions to nurse practitioner practice. The 42

imposed restrictions have occurred despite extensive evidence that nurse practitioners provide safe and quality patient care. Organisations opposed to the introduction of nurse practitioners have relied on anecdotal or hearsay evidence and have rejected the published evidence which supports that nurse practitioners are clinically safe, well accepted by patients and are cost effective in practice. Thus, the political influence of these groups cannot be underestimated in shaping public policy through legislation. Rather than accept the restrictive nature of political influences the nurses and their leaders must look for opportunities to advance their profession. Public policy debate on nurse practitioners in Australia can be traced through the public record of parliaments in the Hansard. The Hansard provides a rich electronic database of parliamentary proceedings and in Western Australia is published on the Parliament of Western Australia s website as www.parliament.wa.gov.au. Hansard is not a verbatim transcript but a full report in the first person. In addition to the Hansard record, the media statements of political parties and professional associations also provide a record of the political influences. Together these data sources provide documented information that can be evaluated to assist our understanding of why things happen and to help shape the future in which nurse practitioners can influence the political agenda. In many ways the nurse practitioner movement may be viewed as an innovation that has enhanced the nursing profession and the general health of the community. Ford (1992) clearly states that the nurse practitioner movement is one of the finest examples where nurses have seized the opportunity to advance their own professional agenda and realize the potential to improve access to health care. Despite early gains in the development the full potential of nurse practitioners in Australia has not been realised. This may be considered a wasted resource. Given both the innovation and limitation aspects of the implementation of nurse practitioners, research into the policy and political aspects is warranted. Diers (2004, p60) supported the notion of nurses becoming more involved in policy based research and this view is represented in the following quote: Policy related research might well become a new subfield within nursing research, a field in which the clinical wisdom we have worked so hard to gather through our clinical work and research may inform and test health policy. Research Method A historical research method was applied which aimed to uncover the sequence of events that led to the current legislation that governs nurse practitioners practice in Western Australia. This approach allowed for evaluation of the rationale why events happened and not just a log of what happened (Leedy & Ormrod, 2010). The primary source of data was the Western Australian Parliament Hansard which was accessed electronically from http://www.parliament.wa.gov.au/web/newwebparl.nsf/iframewebpages/hansard+search. Data containing information and statements regarding nurse practitioners was extracted from the Hansard database from 2000 to 2008. A total of 67 Hansard transcripts were accessed. Data was exported to Microsoft Word to allow content analysis. 43

Nurse practitioners in Western Australia The Nurse Practitioner Series Discussion Initial content analysis of the Western Australian Government Hansard during the development of nurse practitioners revealed that a large amount of debate, including agreement and disagreement, occurred. During the parliamentary sittings from the year 2000 to 2008 the term nurse practitioner was used 1,126 times. This was subsequently divided into the following: Table 1: Number of times the term nurse practitioner was mentioned in the Western Australian Parliament Hansard Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 Nurse Practitioner 48 10 666* 161 6 48 128 15 44 * The high nurse practitioner term count in 2002 related to the introduction of the Nurses Amendment Bill into the Western Australian Parliament. On 9 April 2003 the Nurses Amendment Act 2003 came into effect (Department of Health Western Australia, office of the Chief Nursing Officer, 2003). The 67 transcripts were then subjected to content analysis, a total of five themes and two subthemes emerged from the data. The themes were labelled as follows: Regulation and Policy Development and approval of nurse practitioner positions Area Health Services Commitment Education Support and Development of transitional positions Scope of Practice Issues and Concerns Regulation and Policy The Regulation and Policy theme was mentioned 672 times and related to areas such as the introduction of the proposed legislation, the bipartisan support and the support of the nursing profession for the introduction of nurse practitioners in Western Australia. It was noted at this early stage of the nurse practitioner debated that confusion with practice nurses emerged. The following quote illustrates this point: The extended model to which I referred demonstrated that if the nurse practitioners or practice nurses call them what we will regularly screened and tested people in the first place As the debate progressed, political point scoring featured with both the government of the day and the opposition claiming credit for the proposed introduction of nurse practitioner legislation in Western Australia. While this may have been viewed as a negative it actually worked in favour of the role establishment as bipartisan support was achieved. However, confusion on this advanced nursing role remains with models such as medical assistants appearing in the transcripts. 44

The need for Codes of Practice emerged in the transcripts which were stated to regulate the practice of nurse practitioners. Further areas debated included designated areas of practice, implementation frameworks and speciality areas of work. The introduction of the amendments to other health related Acts also caused debate and, while largely supported, did at times cause disagreement about the nurse practitioner scope of practice. The Acts that were amended during the introduction of the Nurses Amendment Bill 2002 were: Nurses Act 1992 Medical Act 1894 Misuse of Drugs Act 1981 Pharmacy Act 1964 Poisons Act 1964 Poisons Regulations 1965 Radiation Safety Act 1975 Road Traffic Act 1974 Development and approval of nurse practitioner positions A sub-theme of the Regulation and Policy was the Development and approval of nurse practitioner positions which were specifically referred to 124 times. This sub-theme was related to the development and approval of positions. The areas that were addressed included the business planning, services to be developed and the employer responsibly. The need to define the Business Planning for the establishment of nurse practitioners caused numerous debates around the number of positions and how these were being funded. While bipartisan support continued there was a tension emerging in the debate around the number of nurse practitioners and the location that they would practice. A general trend was for the Opposition Members of the time to call for the establishment of nurse practitioners in rural/remote areas. At times the focus was more on the rural area needs for medical services than an advanced nursing role. Support for the overall principle of the establishment of the nurse practitioner role continued. The following quote illustrates this debate: The introduction of the position of nurse practitioner in recent years is a welcomed change. It is particularly relevant and helpful in the more remote parts of Western Australia. While the importance of sound legislation and regulation supports the development and sustainability of the nurse practitioner role, local area management commitment, especially in the areas of resources, is also required. 45

Nurse practitioners in Western Australia The Nurse Practitioner Series Area Health Services Commitment to the Expansion of the role of Nurse Practitioners Analysis of the transcripts revealed that the Area Health Service Commitment to the Expansion of the role of Nurse Practitioners theme was referred to some 269 times. The areas referred to include the expansion of health services, clinical practice areas, funding, resourcing and role differentiation between doctors and nurse practitioners. It is important that health care executives understand the difference in roles and scope of practice to ensure this new role is sustainable in the future. In order to support the enhancement of this advanced nursing role post graduate education was required. Education The education theme was mentioned some 45 times and the debate focused on the length of the course, the number of nurses who would receive funding to undertake the course and the rural area. In general, bipartisan support was provided for education of nurses to undertake and, before funded, to complete nurse practitioner university courses. The difference in the debate still remained around the rural area with members calling for a period of time to be spent in the rural area. The following quote illustrate this point: he or she will require a certain number of years of rural experience before registered as a nurse practitioner. Given the level of debate and the bipartisan support for the establishment of post graduate nurse practitioner courses the Department of Health issued, on behalf the Government, a tender for the development and delivery of courses. It was noted in the Hansard the Department of Health awarded a tender to a university and funded 20 full-time positions for three years. Support and Development of transitional positions A sub theme of Support and Development of transitional positions emerged in the parliamentary debate which occurred on 19 separate times. This theme included the issues of the transitional positions and the funding for these positions. It was noted that the nurse practitioner course would include clinical diagnostics, pharmacology, research, leadership and professional foundations. The combination of these units addressed the scope of practice area. Scope of Practice The scope of practice theme occurred some 37 times and the debate related to formulary, the schedule of drugs to be prescribed and limitations of practice. Of interest two distinct positions were adopted, those in favour of a restrictive formulary and others who wanted a non-restrictive approach. While the area of a non-restrictive approach was presented on a number of occasions the formulary approach was adopted. The nursing profession supported the adoption of a non-restrictive formulary and the parliamentary support for this position is illustrated as follows: 46

but unless we give nurse practitioners the ability to prescribe under the pharmaceutical benefits scheme, the legislation will not work. The formulary approach was adopted and the legislation restricted nurse practitioners to prescribing Schedules 1 to 4 from a clinical protocol. In the debate those supporting the restrictive approach suggested that opening prescribing schedule to nurse practitioners was not required. The following quote illustrates this point:.. but I do not believe that opening up schedule 4 carte blanche is needed to support the extension of nurse practitioner legislation access to schedule 8 drugs We would not want them to be able to dispense drugs that are used for the purpose of drug abuse, such as physeptone or methadone Issues and Concerns Issues and concerns were raised in the debate and in this area the influence of external lobby groups emerged. The theme Issues and Concerns were mention some 87 times and related to doctor substitution, nurse practitioner competencies and criticism by the medical profession. To illustrate this point the following statement was made: The Australian Medical Association has the view that if we endorse nurse practitioners, as a practitioner will set up opposite me in direct competition to me The criticism of some in the medical profession against the introduction of the nurse practitioner became a focus at times during the parliamentary debate which caused delays in the passage of the legislation. In addition to the Hansard record the medical media statements at that time also call for the nurse practitioner legislation to be a least weakened or stopped. The position adopted often could be traced to the misunderstanding of the role of practice nurses compared to that of nurse practitioners. Conclusion Parliamentary debate on the establishment of nurse practitioners in the Western Australian Hansard illustrates the difficulty in establishing new advanced health roles. In many ways nurses seized the opportunity to advance their professional standing, however, this advancement was not achieved without conflict. Often the conflict emerged from those outside the nursing profession without evidence to support their position. The Hansard record presented these views which endeavoured to either stop or weaken the nurse practitioner legislation. While the introduction of nurse practitioner legislation received bipartisan support the evaluative approach used in this research highlighted the differences in the parliamentary debate. The differences emerged as confusion between the role of nurse practitioners and that of the practice nurse. Given this confusion, a restrictive nature on the scope of practice emerged especially in the area of prescribing medications. The restrictive nature also included statements from the Australian Medical Association. In order for the nursing profession to engage further in the shaping of health policy, nurses and the profession must gain a better understanding of the areas of politics and power. Nurses can influence the shaping of health policy but they need to be more visible in their approach. 47

Nurse practitioners in Western Australia The Nurse Practitioner Series The establishment of nurse practitioners in Western Australia is one example of where a strong evidence based approach to public policy achieved a positive outcome. References Department of Health Western Australia, Office of the Chief Nursing Officer (2003). Guiding framework for the implementation of nursing practitioners in Western Australia. Perth: Department of Health Western Australia. Diers, D. (2004). Speaking of Nursing Narratives of practice, research, policy and the profession. Boston: Jones and Bartlett Publishers. Ford, L. (1992). Advanced nursing practice: Future of the nurse practitioner. In L. Aiken & C. Fagin (Eds), Charting nursing s future: Agenda for the 1990s (287-302). Philadelphia: J.B. Lippincott Company. Leedy, P., & Ormrod, J. (2010). Practical research: Planning and design (9th ed). Boston: Pearson Education International. 48

Nurse Practitioner David Charlton Discusses His Journey of Becoming a Nurse Practitioner Tell us about your nurse practitioner career thus far. I have been registered as a NP since 2009. My current position as NP Rottnest Island Nursing Post commenced in January 2010. As the first NP on the island I am in the process of developing and establishing the role. Was there a defining time when you decided to take the path to becoming a nurse practitioner? Yes, when I commenced at RINP in 2005 I saw the potential for the development of the current nursing positions to one that could encompass the NP role. Nurses at RINP work at an advanced skills level within an isolated environment and the NP role I could foresee would totally enhance the delivery of care. Furthermore, a study undertaken in 2002 (Downie et al) recommended the development of the NP role at Rottnest as soon as the WA legislation permitted so from that time establishment of the NP role had been a goal of the organisation. To achieve your goal to become a nurse practitioner why was post graduate education important? The postgraduate course through Curtin University provided the essential professional framework of study as well as the ability to gain an internationally recognised qualification. Why did you choose your area of specialty? I have lived and worked in rural settings in WA for 10-12 years and have gained much experience working in isolated settings. Rottnest offers a rural experience whilst being only 20km from the Fremantle. Working on Rottnest requires an ability to work independently and autonomously and these are both criteria I enjoy. How did your nursing career unfold to allow you to advance to becoming a nurse practitioner? I initially registered as a mental health nurse and then qualified as a registered general nurse with experiences in emergency care and intensive care settings. Following emigration to Australia I undertook a number of short contracts in isolated settings within WA. It was evident that if I wished to work in smaller rural settings I would need to gain my midwifery qualification, which I undertook in Scotland. Upon returning to WA I completed my nursing degree and then returned to work in WA Country Health as a Director of Nursing/Health Service Manager for approximately 10 years. Whilst working in the rural setting, legislative changes to allow nurses to register as NP s was enacted and I began to think that this would be an ideal pathway to allow for career advancement without the requirement to focus on a purely administrative role. What do you enjoy most about being a nurse practitioner? The ability to work autonomously and to deliver care to patients from their initial presentation all the way through to discharge. Working within a legislative framework also provides 49

Nurse practitioners in Western Australia The Nurse Practitioner Series What are the rewards and challenges in your nurse practitioner role? The rewards related to the NP role are many but include the knowledge that I am working independently and in collaboration with colleagues within my own rights as an autonomous practitioner. The challenges include ensuring that the general public has a sound understanding of my role as well as the role of the NP in general. Developing a professional relationship with medical colleagues is one that requires ongoing attention, though I believe as the NP role becomes more established this will become easier. Do you feel that is important for someone to be passionate about the nursing care in order to be a successful nurse practitioner? I believe that any NP should have the best outcome for the patient as their ultimate aim. As a NP there is a greater emphasis upon these outcomes the onus is upon the NP to ensure this occurs. I have been nursing for over 30 years and my new NP role has reaffirmed my commitment and energy towards nursing as a profession. The role empowers nurses in their ability to provide nursing care to patients in a way which was not previously achievable. When is it a good time to commence your nurse practitioners studies? I believe a nurse should have experience of 3-4 years within their chosen speciality before embarking upon the NP career path. What are your thoughts on succession planning for the nurse practitioner role in your specialty? Future planning has already commenced. Current nursing staff have been encouraged to commence NP studies. A new staff member has just enrolled in NP studies. If new nursing staff are employed the support to undertake NP studies will be offered. Are you mentoring other nurses in you specialty are to advance to the nurse practitioner role? Yes one current staff member undertaking NP studies and as a qualified NP I see it as my role to assist and support that person in any way possible. What do you hope the nurse practitioner role in your area of expertise will look like in 5 years time? The goal for the future would be that all nurses employed at the Rottnest Island Nursing Post will be NP s. The service would be a model of care for many other similar rural health services. Do you have any advice for a registered nurse thinking of becoming a nurse practitioner? Ensure you are committed to study! Gain the support of your current employer and ask them what support mechanisms are in place to assist you. Touch base with a NP from a similar area of practice and gain feedback regarding the role and expectations of the position. Ask that person if they would be willing to be a support/ mentor during your studies. Enquire about financial support from the Health Department or Commonwealth at an early stage. Once formal studies commence develop a small network of fellow students (3-4) and try to meet up in person if possible. If working in isolated health settings the ability to communicate with others is a crucial Any other comments you would like to make? Good luck! 50

Nurse Practitioner Fran Lee Discusses Her Journey of Becoming a Nurse Practitioner Tell us about your nurse practitioner career thus far. I have been working as an NP since Aug 2007. I have loved the challenge and it has been challenging at times! It has been a very steep learning curve. The more I learn the more I realise how much more there is to learn. I know that this will never stop but it is exciting learning new things. There has been steady increase in recognition of my skills and abilities by the Urology team. It has been more difficult to make in-roads into other specialties but individually there have been many satisfying encounters with registrars and consultants who are grateful for my input into planning patient care especially in the emergency department. I have met many more people in the hospital HSSD, theatre and waitlist staff, to name a few, but I have lost contact with others. I don t recognize many nurses now there have been many changes. And I am not out and about as I used to be. I am still recognised in some areas though and that is nice. Was there a defining time when you decided to take the path to becoming a nurse practitioner? Yes there was. I had been a CNC for Continence for about 8 years starting a continence service at Bentley Hospital from scratch and then developing a hospital wide service at Fremantle Hospital - and while I thoroughly enjoyed this challenge when the legislation was passed to allow the NP role to develop, my role has been designated as an area that would be suited to the NP role. A colleague asked me if I was interested and I didn t give it second thought and just said yes! I look back now and I amazed that it was such a quick decision that led me to this point. A very good decision though. To achieve your goal to become a nurse practitioner why was post graduate education important? For a role such as this there is much to learn and there is a need to be taken seriously. Qualifications are needed to perform this very important role. In-depth study relating to the specialty is always ongoing but there is a lot more than that to learn. Pharmacology, pharmacotherapeutics, diagnostics and development of the role are just some of the important components of study that will encourage the medical fraternity to take us seriously. For the partnership of doctor and nurse practitioner to work the doctors need to know that have a good knowledge base and that we are competent and safe with our patients. We are not doctors but we certainly have the ability to manage some patients that have previously been the realm of the doctor. However we have to recognise that this group of health professionals have studied long and hard to get to where they are now they will a constant challenge for us. 51

Nurse practitioners in Western Australia The Nurse Practitioner Series Why did you choose your area of specialty? I fell into this specialty by taking a opportunity while I was working at Mt Henry hospital (an aged care rehabilitation hospital now gone) - to take part in a short continence course which was run by the hospital and then when I had completed this the continence adviser resigned and I took another opportunity and applied for the position. That was about 1990 and I have been in the area ever since albeit in a slightly different direction continence to urology which does encompass both. How did your nursing career unfold to allow you to advance to becoming a nurse practitioner? I have had a variety of experiences in nursing. I thought I would always be a midwife but juggling family and shift work was very difficult in the days when set part time work was very difficult to get no allowances made for children back then!! I worked in aged care while my children were young and increased my hours as they grew only working full time when my youngest child was 17. The role of continence adviser gave me the opportunity to develop the role along with my knowledge and skills and rise to CNC and from there to NP. What do you enjoy most about being a nurse practitioner? Enjoy is a strange word to describe this position as it is so challenging! But yes I do enjoy it because it is involves continual learning. There is no time for complacency! I enjoy the autonomy but also the support of the urologists and other medical officers. My days are unpredictable, never mundane. I enjoy the teaching that comes with the position ward staff to assist with a cystoscopy and then be able to see inside a bladder. To show what a urethra looks like if nurses force a catheter. I enjoy being a resource for the interns and RMOs. What are the rewards and challenges in your nurse practitioner role? Rewards are many patient satisfaction is very important and sorting out patient problems is wonderfully satisfying. Being able to perform a flexible cystoscopy and insert a urinary catheter over a guide-wire can result in quick patient discharge from the emergency department. I enjoy the ability to follow a patient from initial point of contact, through to discharge from hospital and follow-up post hospital stay. It is very satisfying when a patient can be discharged promptly because of my intervention. Removing a ureteric stent via cystoscopy makes a patient very happy no more discomfort! Being in integral part of the urology team is very satisfying. Having the support of the hospital is vital and I am very thankful for that. Challenges are constant making the right decision about patient care. Being able to remove a ureteric stent when it is difficult to grasp is nerve wracking. Days are never long enough for all that there is to do. There is always something more to learn although that is a positive rather than a challenge. 52

Do you feel that is important for someone to be passionate about the nursing care in order to be a successful nurse practitioner? I think that passion is very important. There is a lot of study to get through and then a steep learning curve as the role is defined. This takes large amounts of energy and time which if it were not for the passion might result in reduced effort. It also needs passion to develop the role to its full potential. The path can be tricky and you need to find your way through to get the result that you want. There are many different health professionals that you need to negotiate with so that the role reaches it optimum level this can be challenging. And the passion can get you through on a bad day. When is it a good time to commence your nurse practitioners studies? I think that this will be an area of debate in the future. There will be a tendency for nurses to rise through the ranks in their area of specialty and head straight for the NP role but I think maturity is very important also. Life experiences teach us and help us in our practice. Negotiating with patients, relatives, health professionals and others can be fraught at times and often needs a mature person to deal with the problem. More importantly there is much to learn in any specialty and it takes time to do that. What are your thoughts on succession planning for the nurse practitioner role in your specialty? Succession planning is very important to maintain the role. The effort required to set up the service provided by the NP is huge and shouldn t be allowed to disappear. This is definitely a role that has a positive impact on urology waitlists and is one that is imminently suitable for career progression. Are you mentoring other nurses in you specialty are to advance to the nurse practitioner role? Yes. There are currently 4 candidates in continence and urology although practices vary depending on location. What do you hope the nurse practitioner role in your area of expertise will look like in 5 years time? I hope there are more of them. I hope that the urologists are more accepting of them at present the role of the NP is not wholly supported by the urology fraternity as a whole. There are only about 4-5 designated Urology NPs in Australia/New Zealand and we all do very different things and this very much depends on individual urologists. For them to come to an agreement that all NPs can do the same would be great for all concerned. I hope that it is integral to the specialty and continues to be supported by the hospital. Do you have any advice for a registered nurse thinking of becoming a nurse practitioner? I think that nurses should be reminded that there is a no quick path to NP. It is a hard slog and the experience of ward nursing can never be underestimated. It is much better to gets lots of experience and increase expertise/skills/knowledge generally and then as a specialty before moving upwards. It is not just about having a title and making more money. With that comes enormous responsibility. 53

Nurse practitioners in Western Australia The Nurse Practitioner Series Any other comments you would like to make? Our biggest challenge will be the doctors and the AMA. We do need to educate the community. I am aware of all the publicity about NPS but many do not know who or what we are although they are very thankful for out care. 54

Nurse Practitioner Leah Hansen Discusses Her Journey of Becoming a Nurse Practitioner Tell us about your nurse practitioner career thus far. Commenced a full time NP position with an independent private NP clinic 14 months ago, providing primary healthcare to all persons 2 years and older and corporate health assessments and seasonal flu vaccine programs. My knowledge and clinical skills have certainly developed ten fold since graduating in 2006 I can t remember how to think like an RN now; without progressing to full clinical evaluation and autonomous diagnosis with prescribing pathology or required medicines as clinically indicated. Was there a defining time when you decided to take the path to becoming a nurse practitioner? Yes, frustrated at the access to patient support, patient education and follow up related to preventative and proactive care I knew I could do more and hungered for more knowledge and wanting to contribute more to ease the workload of my medical colleagues. A friend of mine was going to enrol and invited me to attend a presentation by Sally have forgotten her name from the USA on the role of NPs in the States and describing how the role could work in WA I was mesmerized and soon found myself enrolling. To achieve your goal to become a nurse practitioner why was postgraduate education important? As an CN / CNS / CNM / CNC you have expert knowledge and clinical skills related to your specialty, undertaking the post grad studies was one of most challenging and rewarding studies I have undertaken. I learned to acknowledge and respect the differences between the nursing and medical models, my clinical skills developed beyond the nursing model but within the art of nursing, my knowledge base, critical thinking and analysis became more scientific and evidence based the more I learned the more I needed to learn. Why did you choose your area of specialty? Primary Health Care is the basis of all health care if we can educate, assess and intervene early the long term healthcare costs are reduced. To facilitate early detection and treatment of many insipid asymptomatic health concerns through opportunistic health evaluation. How did your nursing career unfold to allow you to advance to becoming a nurse practitioner? I was very fortunate to have had excellent nursing and medical mentors who were leaders in their field with superior clinical knowledge and a willingness to share their wisdom of expert proactive care and challenged me to think outside the box and question care delivery, regardless of the discipline. I would listen to the consultants teaching the registrar s this began my advanced education if I new some of the medical knowledge imagine how much better my nursing care and interpretation of clinical data would be how I could further enhance my nursing care and contribute to my team more effectively. There were also senior nursing persons who were mentors by not challenging the nursing concerns of health care delivery and failing to see the future benefits and opportunities of the progression of nursing roles. 55

Nurse practitioners in Western Australia The Nurse Practitioner Series What do you enjoy most about being a nurse practitioner? The ability to work autonomously within my scope of practice and make a positive life changing difference to individuals and family health. Being able to facilitate timely access to health care, opportunistic diagnosing of asymptomatic health conditions that could have detrimental consequences had they remained undiagnosed and untreated usually something that the patient did not think was worth seeing their GP for but thought they d drop in and get an opinion. What are the rewards and challenges in your nurse practitioner role? Rewards; so many positive patient outcomes from facilitating medical care, implementing new lifestyle prescriptions with positive sustained clinical and pathology results. Patient s increasing their knowledge, control and responsibility for their health issues. Challenges; misconception and acceptance of the role by some professional colleagues, consumer awareness of the role, current lack of MBS makes our service too costly for those who are financially challenged. Getting NPs to leave the hospital sector and take up PHCNP opportunities in the private sector. Do you feel that is important for someone to be passionate about the nursing care in order to be a successful nurse practitioner? Definitely, if you don t have that fire in your belly that drive for hands on nursing care, the appreciation of patient assessment and interpretation of clinical data along with the drive for continuous learning; a successful NP knows their scope of practice, acknowledges their strengths and weaknesses, able to work autonomously confidently, and has a shield impervious to negative press remarks made by other professions. When is it a good time to commence your nurse practitioners studies? When you re ready, when that fire in your belly needs to be actioned. The course is intensive and demanding you need a good knowledge and clinical experience base on which to build your developing expertise in assessment diagnosis and appropriate prescribing. What are your thoughts on succession planning for the nurse practitioner role in your specialty? Succession planning is important in every position to maintain standards and smooth transgression into a new role. At this point of time the numbers of NPs who work outside of the hospital system is very limited, attracting NPs from the public health sector to the private sector is a challenge. Are you mentoring other nurses in you specialty are to advance to the nurse practitioner role? I am currently mentoring nurses in other specialities to progress to NP level. 56

What do you hope the nurse practitioner role in your area of expertise will look like in 5 years time? MBS/PBS covering all points of NP service Standard of pay and conditions reflective of responsibility and level of education Improved respect by other professionals and requests for shared care arrangements and support Improved employment opportunities outside of the public sector Multiple published articles on positive outcomes of NP roles and impact on health GPs having NPs as part of their practice and team ACNP with the recognition, advocacy and voice equal to that of the AMA this may take 10 years. Do you have any advice for a registered nurse thinking of becoming a nurse practitioner? Once you have gained sound clinical experience go for it! Contact an NP in your specialty and develop a mentorship, once you start thinking of progressing your journey start your learning them listen to your colleagues discuss case reviews, try to understand how they came to various diagnosis, start challenging yourself to get to know every drug you administer as if you were responsible for prescribing it.. every little bit you learn now will contribute to your future pharmacology units. Question question question why why why everything about your patient s care. Any other comments you would like to make? None. 57

Nurse practitioners in Western Australia The Nurse Practitioner Series Nurse Practitioner Mary Dodds Discusses Her Journey of Becoming a Nurse Practitioner Was there a defining time when you decided to take the path to becoming a nurse practitioner? In 2002 at SCGH commenced discussing the potential roles of Nurse Practitioner which coincided with some timely changes in the legislation to permit Nurse Practitioners to practice. At that time I was in a Clinical Nurse Consultant role and a number of my colleagues in the general hospital were discussing about undertaking NP studies. This led me to consider my role as it was (as a CNC) and what would be needed to undertake a NP role. On examination I realized that many aspects of the NP role were generic to both the CNC role and the NP role. There were some aspects such as medication competence which would require further study / expertise on my part in order to become a NP. I also realized that the role of a NP in mental health had considerable potential and usefulness in the current health care environment and looked towards overseas experience with NP in mental health to gain an insight into how such a role could be used. I thus made the decision to undertake a Masters in Nursing (Nurse Practitioner) and commenced such education through the University of South Australia in 2004. To achieve your goal to become a nurse practitioner why was post graduate education important? Post graduate education was important to me to ensure that my specific learning needs and preferred mode of education were addressed. As I perform better academically through distance education and self-directed education I completed a review of all the Nurse Practitioner courses available in Australia and decided that the University Of SA met my specific needs. An incidental advantage of choosing the Uni of SA was they at that time had two well known mental health academics on staff which was to my advantage. Why did you choose your area of specialty? Despite working in general nursing for a number of years following the completion of my general training in 1978 I was looking for a new challenge in my career. In 1982 I completed a Diploma in mental health nursing and have never returned to general nursing since that time. I have found that my personality is particularly suited to this type of nursing and I have a special interest in the emotional / psychiatric aspects of illness and the impact this can have on the individual. On a lighter note I also love to hear other s stories and I love to talk. How did your nursing career unfold to allow you to advance to becoming a nurse practitioner? Commencing my training in 1975, I graduated from Sir Charles Gairdner Hospital in 1978 with a Diploma of General Nursing and continued working in the Hospital as a Registered Nurse in various Medical Specialties until 1982. In 1984 I graduated from Mental Health Services of WA with a Diploma of Mental Health Nursing and have continued to work in the mental health arena since. After the completion of my MHN training I worked for a brief time at Swanbourne Hospital and then returned to work at Sir Charles Gairdner Hospital in the Department of Psychiatry as a MH nurse in 1985. I have remained at the Hospital every since and have held a number of positions, which have included Clinical Instructor, Clinical Nurse and Clinical Nurse Specialist. I was appointed to 58

the position of Clinical Nurse Consultant in 1996. In addition, I completed a Bachelor of Science (Nursing) in 1992 at Curtin University and a Post Graduate Diploma (Nursing) in 1996 at Curtin University. I completed a Masters in Mental Health Nursing (Nurse Practitioner in 2007 through the University of South Australia and was authorised as the first Nurse Practitioner for Mental Health in WA in 2008. I currently hold the position of Nurse Practitioner Mental Health at Sir Charles Gairdner Hospital. This position provides mental health nursing expertise and support to the general hospital. Primarily nursing focused I provide support to all health professionals in the management of patients who have mental health issues which impact on patient treatment. Working closely with the consultation liaison psychiatric team and nursing staff on general wards I aim to ensure that holistic care is provided through the delivery of timely and appropriate mental health care within the hospital and ensures that appropriate psychiatric follow-up on discharge is available. As part of my role, I am also responsible for the coordination and provision of professional development for nursing staff across the hospital to assist in providing appropriate mental health care to all patients. In addition to this I maintain an interest in the professional development of other mental health nurses and provides regular input into the Area Mental Health Service Professional Development Program. What do you enjoy most about being a nurse practitioner? The most enjoyable component of being a NP is the ability to utilize expanded and advanced nursing skills in an autonomous fashion. What are the rewards and challenges in your nurse practitioner role? The biggest reward for me is the knowledge that patients with mental illness will receive MH care in a timely manner and that the appropriate care and follow-up will be available as required. Many patients with mental illness find admission to hospital a stressful time and if the NP role can make this easier for them then such a role is justified. There are a number of challenges yet to be addressed as follows; Reducing the stigma of mental illness although some improvements have occurred. Expansion of the current role of the NP role from what it currently is. Improving the acceptance of more NP roles by services and other health professionals. This includes both attitudinal changes and financial support. Do you feel that is important for someone to be passionate about the nursing care in order to be a successful nurse practitioner? I think you do need to be passionate about your patients, the care you provide and the support you are prepared to offer. I think that if you are not passionate about these things you are unable to develop a relationship with your patients and thus are unable to be empathetic or have any rapport. When is it a good time to commence your nurse practitioners studies? I believe that one needs to have considerable expertise in your specialty through clinical experience at the bedside. I think that in mental health nursing you would need to have between 5 to ten years experience at the coal face before you could consider NP studies. 59

Nurse practitioners in Western Australia The Nurse Practitioner Series If you believe that that you can improve the care provided to the population you work with by expanding your scope of practice by becoming a NP and you have the clinical expertise then you should undertake NP studies. What are your thoughts on succession planning for the nurse practitioner role in your specialty? I think it is important to consider plans for the replacement of the NP role in the short-term and the role as it will be in the future. Thus it is paramount to firstly consider; The role as it currently is. What aspects of the role can be replaced in the short-term (in the event the NP is unavailable) by another nursing position (e.g., Clinical Nurse Consultant) or medical staff (e.g. Medication prescribing) Secondly in the longer term one needs to consider the mentoring and recruitment of appropriate NP candidates and / or appropriately qualified NP s. It may also be important to consider where the position is going e.g. does the role need to change with changes in the clients or diagnostic groups. Are you mentoring other nurses in you specialty are to advance to the nurse practitioner role? I currently play an active role in encouraging nursing staff to consider the NP role as an option for their future in nursing. I have given a number of presentations across the metropolitan area to both my nursing colleagues and other health professionals to promote the role of the NP in mental health. I have specifically spoken at ACMHNs functions, NMAHS Area Mental Health Service functions and local functions with the view of educating all health professionals about the NP role. In addition to this I have also been nurturing a number of other mental health nurses to consider the NP role as a career option. What do you hope the nurse practitioner role in your area of expertise will look like in 5 years time? The current NP MH role provides a service to patients admitted to the general hospital who have a pre-existing mental illness or who develop mental health issues as a consequence of their medical illness or hospital stay. I would like to see this service expanded to include an expanded assessment and referral service to the general hospital and the development of an outpatient service which will accommodate patients who require short term mental health interventions. In addition, I would like to see other NP roles in mental health developed to include a number of other mental health sub-specialties on this site. Considerable potential exists for a NP role in the Emergency Department, MH Hospital in the Home and the NMAHS Mental health Early Discharge program. 60

Do you have any advice for a registered nurse thinking of becoming a nurse practitioner? The advice I would give to any nurse considering becoming a NP would be to; Ensure that you already have advanced clinical skills in mental health nursing and considerable experience before you undertake your NP studies Ensure that you understand the role of a NP and the related responsibilities/expectations of a NP Ensure that you understand the legal requirements of the role Expect to encounter some opposition or negative comments from some of your nursing colleagues and other health professionals Be very clear about what your role will be. Be very sure that becoming a NP is what you really aspire to and ensure that you are committed to the role. Any other comments you would like to make? None. 61

Nurse practitioners in Western Australia The Nurse Practitioner Series The Nurse Practitioner Series: Guidelines for Contributors (2010) Introduction The Nurse Practitioner Series is a peer-reviewed journal which reflects the broad interests of nurse practitioners and the nursing profession. The series will be published annually. 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: Adjunct Associate Professor Catherine Stoddart Chief Nurse and Midwifery Officer Nursing and Midwifery Office Department of Health PO Box 8172 Perth Business Centre Western Australia 6849 Email: Catherine.Stoddart@health.wa.gov.au Submission The Editors invite papers up to a maximum of 3000 words. One hard copy of the manuscript and one electronic copy must be submitted. The submitted version of hard copy and disk must be the same. If the two versions of the paper do not correspond, the electronic version will be used. The document must include all parts of the text of the manuscript including all pictures, figure and/ or table legends. 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. As such, authors are permitted to re-publish work. 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). Review of manuscript Receipt of manuscripts by the Department of Health will be acknowledged. Review of manuscripts will take an average of six to ten weeks. Covering letter 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 62

proofs in PDF format. Manuscript style 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. 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. (2010). Publication Manual of the American Psychological Association (6th ed.). Washington, DC: Author. Copyright The Nurse Practitioner Series does not hold copyright. As such, authors are permitted to re-publish work. 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. Checklist Submission Cover letter Manuscript style Page set up Abstract Key words Main text Acknowledgements 63

Nurse practitioners in Western Australia The Nurse Practitioner Series Reference Samples Electronic sources Periodicals/Journals Elsom, S., Happell, B., & Manias, E. (2009). Nurse practitioners and medical practice: Opposing forces or complimentary contributions? Perspectives in Psychiatric Care, 45(1), 9-16. Retrieved from http://web.ebscohost.com.eplibresources.health.wa.gov.au/ehost/ pdf?vid=7&hid=103&sid=b63e35d0-35a1-4586-87b1-41dd6085ea8d%40sessionmgr110 Elsom, S., Happell, B. & Manias, E. (2008). Expanded practice roles for community mental health nurses ion Australia: Confidence, critical factors for preparedness, and perceived barriers Issues in Mental Health, 29, 767-780. doi: 10.1080/01612840802129269 Podcasts Australian Broadcasting Commission. Health Report (2009, July 27). [Audio podcast]. Retrieved from http://www.abc.net.au/rn/podcast/feeds/health.xml Non-electronic sources Periodicals/ Journals 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. Poster Presentation Stow, J. (2007, May). Epilepsy Role of the nurse practitioner. Poster session presented at the Epilepsy Society of Australia Conference, Melbourne. Books Codina-Leik, M.T. (2008). Adult nurse practitioner intensive review: Fast facts & practice questions. New York: Springer Publishing. American Psychological Association. (2010). Publication Manual of the American Psychological Association (6th ed.). Washington, DC: Author. LoBiondo-Wood, G. & Haber, J. (2009). Nursing research: Methods and critical appraisal for evidence-based practice (7th ed.). Philadelphia: Mosby Elsevier. 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. 64

Illustrations and Tables Graphs, charts and tables must be supplied in an excel format. Illustrations and tables should be referred to in the text as figures or tables using Arabic numbers (e.g. 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 and Logos Any logos should be a Tiff, vector EPS or JPEG file @ 300 dpi. When supplying photographs our production area can accept original photographs or JPEG files which will need to be supplied @ 300 dpi. Copyright The Nurse Practitioner Series does not hold copyright. As such, authors are permitted to re-publish work. 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. Acknowledgements Details of sources of funding, other support, and acknowledgments should be included. Proofs 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. Copies The author will be provided with three free copies of the issue in which their manuscript/paper appears. 65

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