Queensland Nurse Practitioner implementation guide

Queensland Nurse Practitioner implementation guide

Queensland Nurse Practitioner implementation guide Queensland Health Office of the Chief Nursing Officer Queensland Nurse Practitioner: implementation guide. The State of Queensland 2008. Copyright protects this publication. However, the Queensland Government has no objection to this material being reproduced with acknowledgement, except for commercial purposes. Permission to reproduce for commercial purposes should be sought from: Chief Nursing Officer Office of the Chief Nursing Officer Queensland Health PO Box 48 Brisbane 4001 Preferred citation: Queensland Government 2008 Queensland Nurse Practitioner: implementation guide. Queensland Government, Brisbane An electronic version of this document is available at: http://www.health.qld.gov.au/ocno

Foreword The development of the nurse practitioner role in Queensland has now entered a new phase where we will begin to see the nurse practitioner role and workforce numbers expanding. I welcome this implementation guide which will underpin the process of service planning and reform. Nurse practitioners will continue to be a valuable resource to support the delivery of sustainable health services. The nurse practitioner service is a well established and evidence informed model that is innovative and collaborative with the potential to deliver a range of services and treatments to individuals, families and communities, across all ages, illness profiles and geographical contexts in response to emerging population health needs. There is a committment to the growth and expansion of the role of nurse practitioners across the State with the provision of funding for scholarships and position development from my office. This guide is designed to support health services to ensure that nurse practitioners function to their optimum level during the candidate phase of their educational and practice development through to endorsement, service delivery and practice evaluation. It is important therefore that nurse practitioners function to their level of educational preparation and their legislative scope of practice. Their ability to provide high quality health care must be recognized and fully supported. Pauline Ross Chief Nursing Officer Queensland Health November 2008

Purpose of the guide This nurse practitioner implementation guide is a comprehensive resource package and toolkit that will provide a single source of information about nurse practitioners and nurse practitioner service in Queensland. The guide provides detailed information, guidelines and policy to inform the planning, development and implementation of a nurse practitioner position. It is designed to inform, guide and advise health service planners, nursing, medical and allied health clinicians and the community. The guide is made up of four sections, each dealing with a specific aspect of the nurse practitioner role and service. Together, the sections make up the complete nurse practitioner implementation guide. Section 1: The overview provides an introduction to and outline of the service imperatives, research background and legal framework for the development and implementation of the nurse practitioner role in Queensland. This section is designed as a prelude, introducing the essential context for each of the subsequent sections. Section 2: Information for clinicians provides essential information on the nature of the nurse practitioner role and how this role fits within the nursing career pathway in Queensland. The section also explains how the role fits within the multidisciplinary clinical team, as well as defining specific processes and requirements for nurse practitioner education, authorisation and regulation. Section 3: Establishing a nurse practitioner position is an important reference and an authoritative resource for the deliberations, planning and processes involved in setting up a nurse practitioner position. This section will be particularly useful for service planners and nurse clinicians. Section 4: Governance and evaluation of nurse practitioners includes recommendations for the governance process at the facility level. Additionally, guidelines are provided for auditing and evaluating a nurse practitioner service. 2

Contents Foreword Chief Nursing Officer...1 Purpose of the guide...2 Section 1 Overview...4.1 Introduction...4.2 Background...4.3 Nurse practitioner legislation framework...7 Section 2 Information for clinicians...8 2.1 Description of the core role...8 2.2 Nurse practitioner competencies...8 2.3 Differentiating between nurse practitioners and advanced practice nurses...10 2.4 Differentiating between nurse practitioners and practice nurses...12 2.5 Nurse practitioner education...12 2.6 Nurse practitioner endorsement...13 Section 3 Establishing a nurse practitioner position...16.1 Context: Health service planning...16.2 Steps in planning a nurse practitioner position...15.3 Steps in developing a nurse practitioner...19.4 Steps in implementing the nurse practitioner role...23 Section 4 Governance and evaluation...26 4.1 Governance...26 4.2 Evaluation...27 Section 5 Appendices...29 Terms of Reference for a District Nurse Practitioner Steering Committee...30 2 Nurse practitioner Drug Therapy Protocol...32 Health Management Protocol/Drug Therapy Protocol Guide...34 4 Health Management Protocol checklist...40 5 Diagnostic Radiography Protocol...42 References...43

Section 1 Overview 1.1 Introduction The challenges facing health service providers are considerable and relate to pressure from a growing and ageing population, increasing chronic disease in the community, rapid development of health technologies, potential workforce shortages and increasing costs, which are not necessarily matched by increases in the health funding base. Health care consumers also face challenges, such as managing and understanding the growing body of information about health, disease and treatment options; managing complex self-care and self-medication regimes; interfacing with multiple care teams across treatment for chronic and co-morbid disease, and issues of timely and coordinated access to health service. It is in this context that Queensland Health designed the strategic plan and reform agenda for health service 2007-2012 (Queensland Health 2005; 2007). These documents report an intent to develop a high quality and sustainable health service that is responsive to the changing needs of the Queensland community. Furthermore, the strategic direction of this service agenda is to build health services around the needs of consumers and the communities in which they live. Reforming the health workforce is integral to this plan. Accordingly, the workforce reform priority of the Queensland Health Statewide Health Service Plan includes the following aims: to develop a framework to determine the best utilisation of workforce skills and labour to meet service demand to develop a workforce to support service reforms. New directions in health service emphasise multidisciplinary, collaborative team approaches to care, in acknowledgement of the fact that no single health care provider or service model can adequately meet the complex requirements of the 21st century health care consumer. The nurse practitioner is a model of workforce reform that adds a new type of clinical service to the multidisciplinary team. The nurse practitioner service is a well-established model. It is innovative and accessible, and contributes to the development of new service models which are able to respond to changing and emergent population health needs. Many polls have demonstrated that nursing offers a service to health care that is valued and respected by the community. In this way, the nurse practitioner is able, while working within a multidisciplinary team, to see to completion an episode of care in the patient s health service experience. 1.2 Background The 21st century health care environment is characterised by dramatic changes in service demand. The well-known factors stimulating this demand include those related to consumer demographic, technological development and community expectation. The Australian health care system is under pressure, and health service improvement and workforce redesign are on the agenda of governments and service providers. 4

This pressure of health service is particularly urgent in areas of rapid population growth and increasing demand. Estimates in Queensland indicate that, within the next 10 to 15 years, the State s population will expand by between 31 and 37 percent, with a forecast doubling of current population figures by 2051 (Queensland Health 2004). In South East Queensland, the impact of this rapid growth is already exerting pressure on health services (Queensland Health 2005). Additionally, this increase in demand has been paralleled by a concomitant shortage of qualified and experienced health care professionals(productivity Commission 2005; Queensland Health 2004). Finding solutions to health service and workforce issues requires reexamination of existing service models, roles and responsibilities and the creation of new roles to reduce duplication and service gaps (Productivity Commission 2005; Duckett 2005). Workforce redesign has been advocated as one way of achieving these reforms, with the primary aim being to enhance community access to high-quality, safe, efficient, effective and financially sustainable health services (Gardner et al. 2004). Governments, health service providers, academics and observers agree that traditional models, roles and discipline boundaries are not adequate to meet current service pressures. There is a call to revitalise the health workforce and develop innovative care delivery models. Nurses have been an essential part of health service delivery for over 150 years. Throughout this time, nursing service has evolved and adapted to meet the changing needs of the community. Additionally, nurses make up a significant percentage of the health workforce and are therefore well positioned to make a significant contribution to service improvement through innovation in role development and scope of practice. The role of nurse practitioner is a collaborative, team-based, innovative one, with the potential to deliver a range of services and treatments to individuals, families and communities, across all ages, illness profiles and geographical contexts. The nurse practitioner role offers both a new model and level of health care provision, and is an important and ready response to calls for reform of health care systems. The role of the nurse practitioner is underpinned by a nursing model of practice, and incorporates some tasks traditionally performed by doctors. The role therefore sits across the boundaries of two disciplines. Nursing service that includes this blend of disciplines is offered at a lower cost, and there are indications that it improves access and timeliness of health care for under-serviced and marginalised populations. In Australia, there is a nationally agreed definition for nurse practitioner. This definition was developed from research commissioned by the Australian Nursing and Midwifery Council (Gardner et al. 2004) and subsequently accepted by state nurse registering authorities, including the Queensland Nursing Council. Nurse practitioner definition A nurse practitioner is a registered nurse educated and authorised to function autonomously and collaboratively in an advanced and expanded clinical role. The nurse practitioner role includes assessment and management of clients using nursing/midwifery knowledge and skills and may include but is not limited to: 5

the direct referral of clients to other health care professionals prescribing medications ordering diagnostic investigations. The nurse practitioner role is grounded in the nursing profession s values, knowledge, theories and practice, and provides innovative and flexible health care delivery that complements other health care providers. The scope of practice of the nurse practitioner is determined by the context in which the nurse practitioner is educated, competent and authorised to practise. Internationally, the nurse practitioner has been associated with health service improvement for over 40 years and was first implemented in Australia in 1998 (Gardner et al. 2004). Nurse practitioner service has been extensively researched, with investigations on patients acceptance and satisfaction safety (Fischer, Steggal & Cox 2006) and effectiveness of service (Laurand, Sergison & Sibbald 2003), cost effectiveness (Sakr et al. 1999) and descriptions of service models (MacLellan, Gardner & Gardner 2002; O Keefe & Gardner 2003; Considine, Martin & Smit 2006). Consequently, over the years since the inception of the role, thousands of articles evaluating, describing and arguing the relativities of the nurse practitioner role have been published in medical, nursing and allied health journals. In addition to this international body of literature, several Australian national health workforce inquiries have recommended development of the nurse practitioner role to support Australian health service improvement. These include the Productivity Commission s Australia s Health Workforce Position Paper (2005), the report from the Australian Health Workforce Advisory Committee, Health workforce planning and models of care in emergency departments (2006), The National Review of Nurse Education 2002 and the National Nursing and Nurse Education Taskforce. In Queensland, a trial of practice for nurse practitioner service was conducted in 2002/2003 (see reference list). The trial of practice involved advanced practice nurses working in the role of nurse practitioner in four settings one acute care and three rural and remote care models. The inquiry methods for this project involved collection of both qualitative and quantitative data from chart audit, interviews, survey and case study review to evaluate the four models. This trial built upon similar projects in NSW (NSW Health Department 1995) and the ACT (ACT Government 2002). The findings from the Queensland project were consistent with those in other states, and demonstrated improved access, safety of practice and patient and health practitioner satisfaction with the clinical care of these advanced practice nurses working in the nurse practitioner role. In February 2004, the Queensland Government made a commitment to change the relevant legislation to allow the full implementation of the nurse practitioner role in Queensland. Furthermore, the government announced, as part of an election commitment, its intention to establish annual scholarships supporting education and training for a Queensland nurse practitioner workforce. 6

1.3 Nurse practitioner legislation framework Legislative changes were effected to provide the legal framework for nurse practitioner authorisation and practice in Queensland. In 2004, amendments were made to the following Acts and Regulations: The Nursing Act The Nursing Act 1992 enables nurse practitioner title protection in Queensland. The mechanism for title protection in the Act is 3A which sets out penalties for people who claim to be authorised in an area of nursing (in this case a nurse practitioner) if the licence is not endorsed by Council allowing them to use this title (s.77d). The relevant sections are 77 and 77D, covering authorisation in an area of nursing and penalties for unauthorised use of the title nurse practitioner. Part 4 of the Act deals with the accreditation of courses leading to the eligibility to apply for authorisation. Regulation of the nurse practitioner role Legislation Section 77, Part 3A and Part 4 of the Nursing Act 1992 provide the basis for the regulation of nurse practitioner practice in Queensland. The Queensland Nursing Council may authorise an individual in an area of nursing, if the person is a holder of a qualification recognised by Council (s.77). In February 2008, Council published a Policy on the Regulation of Nurse Practitioners in Queensland, making a clinical masters degree for nurse practitioners the qualification required for this authorisation. Education providers seeking to offer a nurse practitioner masters course that will lead to nurse practitioner authorisation will need to have the course accredited by Council in accordance with Part 4 of the Act. The Health Act 1937 Radiation Safety Act 1999 Workers Compensation and Rehabilitation Act 2003 Subordinate legislation: Health (Drugs and Poisons) Regulation 1996 Amendments to the Drugs and Poisons Regulation of the Health Act 1937 were approved by Governor in Council on Thursday 16 December 2004. The Health (Drugs and Poisons) Amendment Regulation (No.1) 2004 allows for nurse practitioners, endorsed as such by the Queensland Nursing Council, to prescribe and give written and oral instructions for the administration/supply of medications according to a Drug Therapy Protocol. Subordinate legislation: Radiation Safety Regulation 1999 Amendments to Schedule 3A (Authorised Persons) of the Radiation Safety Regulation 1999 allow nurse practitioners to request plain film diagnostic radiography under the diagnostic radiography protocol. The Diagnostic Radiography Protocol outlines the conditions under which a nurse practitioner may request plain film x-rays. Amendments to this Act are currently in the planning phase. If enacted, these amendments will allow nurse practitioners to provide work cover certificates under the conditions specified. 7

2.1 Description of the core role In 2003/2004 as the nurse practitioner role was gaining momentum in Australasia, the Australian Nursing and Midwifery Council, in collaboration with the Nursing Council New Zealand, determined to establish national and trans-tasman standards for nurse practitioner service. To achieve this, the joint bodies commissioned a research project entitled The Nurse Practitioner Standards Project (Gardner et al. 2004). The aims of the project were to conduct research that would inform: a description of the core role of the nurse practitioner core competency standards for the nurse practitioner in Australia and New Zealand standards for education and program accreditation for nurse practitioner preparation, leading to registration/authorisation. The findings from this study have been adopted by the Queensland Nursing Council and provide the basis for the Council s regulation of education and authorisation for nurse practitioners in Queensland. The Nurse Practitioner Standards Project investigated nurse practitioner models throughout Australia and New Zealand and the findings established generic features of nurse practitioner service. The core role of the nurse practitioner in Australia is characterised by three areas of practice: dynamic practice, professional efficacy and clinical leadership (see Table 2.1). The practice is dynamic in that it involves the application of high-level clinical knowledge and skills in a wide range of contexts. The nurse practitioner in the role demonstrates professional efficacy, enhanced by an extended range of autonomy, supported by legislated privileges. The nurse practitioner is a clinical leader with a readiness and an obligation to advocate for their client base and their profession at the systems level of health care (Gardner et al. 2004). As an outcome of this study, there is now a nationally agreed definition for nurse practitioners in Australia. This definition provides the basis for legislative processes which protect the title of nurse practitioner in Australian States/Territories and in New Zealand. 2.2 Nurse practitioner competencies These three practice standards provide the basis for nurse practitioner competency and education standards. There are nine nurse practitioner practice competencies. These nine competencies build upon standards and codes that are requirements for advanced nursing practice, namely: National Competency Standards for the Registered Nurse Code of Ethics for Nurses Code of Professional Conduct for Nurses Advanced Nursing Practice Competency Standards. The nurse practitioner competency standards are: 8

Standard 1 Dynamic practice Competencies 1. Conducts advanced, comprehensive and holistic health assessments relevant to a specialist field of nursing practice 2. Demonstrates a high level of confidence and clinical proficiency in carrying out a range of procedures, treatments and interventions that are evidence-based and informed by specialist knowledge 3. Has the capacity to use the knowledge and skills of extended practice competencies in complex and unfamiliar environments 4. Demonstrates skills in accessing established and evolving knowledge in clinical and social sciences, and the application of this knowledge to patient care and the education of others. Standard 2 Professional efficacy Competencies 5. Applies extended practice competencies within a nursing model of practice 6. Establishes therapeutic links with the patient/client/community that recognise and respect cultural identity and lifestyle choices 7. Is proactive in conducting a clinical service that is enhanced and extended by autonomous and accountable practice. Standard 3 Clinical leadership Competencies 8. Engages in and leads clinical collaboration that optimises outcomes for patients/clients/communities 9. Engages in and leads informed commentary and influence at the systems level of health care. In summary, the nurse practitioner role is a model of extended practice that builds upon existing nursing codes and standards as well as the competencies of advanced practice nursing. The relationship between the professional and practice base of the advanced practice nurse, the nurse practitioner standards and nurse practitioner competencies is illustrated in Figure 2.1. 9

Figure 2.1 Progression from advanced practice nursing to nurse practitioner competencies Nurse practitioner competencies Dynamic practice Assessment and diagnosis Therapeutics and procedures Complex practice Evidenced-based practice Professional efficacy Nursing model of practice Respect for culture and choice Autonomy and accountability Clinical leadership Clinical collaboration Systems-level leadership Nurse practitioner standards Dynamic practice Professional efficacy Clinical leadership Advanced practitice nursing Registered nurse competency standards Advanced practice nurse competencies Code of Professional Conduct for Nurses Code of Ethics for Nurses 2.3 Differentiating between nurse practitioners and advanced practice nursing roles Advanced practice nursing roles include titles such as clinical nurse specialist, clinical nurse consultant, educator, nurse unit manager and nurse researcher. The nurse practitioner competencies build upon and extend advanced practice nursing standards and codes. This does sometimes cause confusion for other health disciplines, for patients and within the nursing profession itself. Health service planners seeking to incorporate nursing into innovative service models need clarity in differentiating the service profile and potential of advanced practice and nurse practitioner roles. Having the right clinician for the right health care service at the right time for the right price is an essential principle of health service reform. 10

Research has been conducted in Queensland aimed at providing a framework to distinguish the nurse practitioner from other advanced practice roles in nursing (Gardner, Chang & Duffield 2007). The research analysed the practice profile of a sample of advanced practice nurses from a range of hospitals in South East Queensland, against published research based models. The findings clearly identified one specific model (Ackerman et al. 1996). This model identified the service parameters of advanced practice nursing as follows: direct comprehensive care support of systems education research professional leadership. Having identified the parameters of advanced practice nursing, information is now available for design of an operational framework to distinguish, identify, establish and evaluate advanced and extended nursing positions. This framework is illustrated in the following table. Service model Advanced Practice Nurse (APN) Consultant/clinician Broad-based service profile Nurse Practitioner (NP) Direct clinical care Focused clinical service Role parameters/standards APN based on the Strong Model Direct comprehensive care à highly developed skills and knowledge to inform service coordination, care delivery and direction of care. Support of systems à optimising patients utilisation of, and progression through, a health service. Education à patients, communities, clinicians and students. Research à creating and supporting a culture of inquiry. Professional leadership à professional activity and dissemination of expert knowledge to the public and the profession. No national consistency for practice standards. Legislative structure APN Title not protected Expanded practice: Highly developed autonomous practice profile as an RN within the requirements of the (relevant) Nurses Act NP in Australia based on ANMC NP Standards Dynamic practice à highly developed skills and knowledge for direct clinical practice in complex environments. Monitors and adopts evidence base for practice. Professional efficacy à autonomous practice that includes diagnosis, prescribing medication, request for diagnostic tests and referral to other health professionals. Promotes and engages a nursing model of practice. Clinical leadership à critique and influence at systems level of health care. Promotes and engages in collaborative team-based practice. Conforms to ANMC national standards for practice. NP Title protected in Australia and New Zealand Extended practice: Authorisation to practice as a nurse practitioner with legal provisions to diagnose, prescribe medication, order diagnostic tests and refer to other health professionals Table 2.2 Operational framework Advanced Practice Nurse (APN) and Nurse Practitioner (NP) roles (Gardner, Chang & Duffield 2007) 11

2.4 Differentating between nurse practitioners and practice nurses Another nursing role that is sometimes confused with the nurse practitioner is practice nurse. This confusion arises primarily because of similarity in nomenclature rather than similarity of roles. A practice nurse is a registered nurse or an enrolled nurse who is employed by a doctor or group of doctors in general practice. The practice nurse works under a delegated authority model where practice is supervised by, and extends the work of, a medical practitioner. The practice nurse role is designed to complement and assist the work of the general practitioner. General practice nurses help doctors see more patients and spend more time with patients who have chronic or complex illnesses but they do so as part of the general practice team under the supervision of a general practitioner (AMA 2005). Watts et al (2004) categorised the work practice nurses undertook into four different, but overlapping, responsibilities: clinical care, which involved clinically based procedures and activities clinical organisation, which involved activities that required management, coordination and administration practice administration, which required providing administrative support to general practice as a business enterprise integration, which required development of effective communication channels within general practices and between practices and other organisations and individuals. In this respect, the practice nurse model resonates with the nurse practitioner model. Both draw from a nursing model of clinical practice, and both models are designed to use nursing expertise in front-line health service reform. While sharing these features, however, there are also significant differences between these roles in terms of purpose of service and service outcome. The nurse practitioner works in a collaborative, rather than delegated, relationship with other health care professionals. The nurse practitioner has a legislated scope of practice which supports autonomous delivery of a complete episode of care to a single patient or group of patients in a specific field of clinical care. Additionally, in Queensland, the nurse practitioner title is protected, identifying the clinician using that title as having a nurse practitioner master s degree qualification. The title indicates that the practitioner meets practice standards that conform to prescribed competencies and has authority to practise in a health service environment with a practice profile circumscribed by specific health management protocols. 2.5 Nurse practitioner education In Queensland, progression from a graduate nurse to a nurse practitioner takes approximately nine years. The experience required to achieve nurse practitioner status includes a mix of clinical experience, clinical specialisation and leadership and postgraduate education. One of the recommendations from the Nurse Practitioner Standards Project (Gardner et al. 2004) was that the minimum award level for an accredited program for nurse practitioner education be a masters degree. The Queensland 12

Nurse practitioner masters degree Nursing Council has adopted this recommendation meaning that gaining primary endorsement as a nurse practitioner in Queensland requires successful completion of a Queensland Nursing Council-accredited nurse practitioner masters degree. A masters degree leading to nurse practitioner endorsement will have met the following Queensland Nursing Council standards for graduate outcomes: a competency-based curriculum, with learning outcomes based on the Australian Nursing and Midwifery Council nurse practitioner competencies a curriculum structure that includes a clinical internship with mentored experiential processes summative assessment that includes a comprehensive portfolio of learning and practice experiences that demonstrates: - attainment of nurse practitioner competencies - practice in advanced nursing practice - clinical leadership. A nurse who is undertaking a nurse practitioner program has the title of nurse practitioner candidate. This title serves several purposes. It differentiates, on the basis of the potential for QNC endorsement, the student of nurse practitioner studies from those of other advanced practice nursing courses. Furthermore, it is also recognition of the clinical role these nurses undertake in their internship, as they work into the nurse practitioner role and hence engage in supervised extended practice activities. Queensland health care facilities have well-established links with universities offering nurse practitioner masters programs. Queensland health care facilities nursing and medical staff members are involved in teaching the theoretical components of these programs. Medical and nursing staff in Queensland health care facilities make up the clinical support teams for nurse practitioner candidates. The role and structure of the nurse practitioner clinical support team is further explored in Section 3.3. 2.6 Nurse practitioner endorsement An important and authoritative source of information on this topic is the Queensland Nursing Council Policy on the regulation of nurse practitioners in Queensland 2008. In brief, to be eligible for endorsement as a nurse practitioner in Queensland, a registered nurse must demonstrate the following: experience in advanced nursing practice in a leadership role successful completion of a Queensland Nursing Council-accredited nurse practitioner masters program. 13

2.6.1 Mutual recognition of interstate and trans-tasman endorsed nurse practitioners Legislation in Australian States and Territories provides for mutual recognition whereby nurse practitioners who are endorsed as such in other Australian jurisdictions or in New Zealand will be eligible to practise as a nurse practitioner in Queensland. For further information about nurse practitioner endorsement through mutual recognition, contact the Queensland Nursing Council at registrations@qnc.qld.gov.au Addendum As this Queensland Nurse Practitioner Implementation Guide is developed and made available to the professional and consumer communities in Queensland, the Australian Nursing and Midwifery Council, along with other health professional groups, are working towards national registration for health care professionals. At the time of production, this agenda is in progress. Therefore endorsement processes described in this document are relevant to the conditions at the time, namely State- and Territory-based endorsement with well-established mutual recognition processes. 14

Section 3 Establishing a nurse practitioner position 3.1 Context: Health service planning 3.1.1 District Nurse Practitioner Steering Committee The nurse practitioner in Australia is a service innovation and is integral to the health workforce reform agenda in Queensland. A key objective of workforce reform is to enhance community access to high quality, safe, efficient, effective and financially sustainable health services. This is achieved through facilitating the development of health workforce models that maximise the contribution and efficiency of the available health workforce. Establishing a nurse practitioner position is part of a strategic service reform agenda for a specific consumer population, necessitating a collaborative and planned approach. The following pages provide an important and an authoritative resource for the deliberations, planning and process involved in setting up and implementing a nurse practitioner position. An important element of the preparation and implementation of a nurse practitioner position is the District Nurse Practitioner Steering Committee. This committee is responsible for enacting and implementing nurse practitioner service at district level. The District Nurse Practitioner Steering Committee will play a central role in developing and approving nurse practitioner service models and in maximising sustainability of these roles. Each district will establish one or more committees, according to local need, and establish terms of reference (see Appendix 1 for recommended District Nurse Practitioner Steering Committee Terms of Reference). The remainder of this section will cover the three phases involved in establishing a nurse practitioner position, namely: preparation, education and implementation. Full attention to and achievement of each of these phases will enable successful progression to the next. 3.2 Steps in planning a nurse practitioner position Step 1 Consultation within the health service The impetus to establish a nurse practitioner position may come from one of a number of sources such as a nurse clinician, the medical director or the nursing director of a specific service. Regardless of the initial source, a consultative, collaborative approach is vital to establishing and sustaining the nurse practitioner role. While consultation is an essential first step, interdisciplinary collaboration will be important to each of the successive steps. The following points will assist an individual or team in this early preparatory phase. It is important to: a) Gain initial interest and cooperation from the nursing and medical directors of the service. This initial interest may be tentative, subject to the full development of a case for service reform. b) Identify champions, sponsors and stakeholders at clinical, service and management levels. 15

Step 2 Clarify the service need c) Establish a small service-based working group with medical and nursing membership to progress the initiative at service level and advance it to district level. The second step in the preparation phase is to clarify the need for service reform. The following triggers will assist the service team working group to identify service improvement needs and solutions. a) Is there a change in the demographic profile of the consumer population? Examples include: population growth increases in the elderly in the community increase in young families in the community increase in service demand, e.g. chronic illnesses, primary health care. b) Is there increased waiting time or waiting lists for service in: clinics outpatients community services emergency services other waiting lists? c) Are there marginalised community groups that do not access traditional health services, for example, clients with health problems related to: mental health sexual health drug and alcohol abuse homeless individuals or groups? d) Is there a gap in the current health service, for example: rural and remote communities outreach of services to community centres preventative and maintenance services for chronic illness hospital/community interface services specialty fields with scarce medical resources? Identifying one or more of these issues in the current health service will provide the basis for directions in service improvement and inform the features of the proposed nurse practitioner model. Step 3 Clarify the relevant clinical nursing role for service improvement The nurse practitioner is one type of advanced practice nursing role. Having identified the service improvement model, it may now be useful to consider if a nurse practitioner is the most appropriate role to address the changing needs of the service. In certain situations, for example, an advanced practice nurse may be more likely than a nurse practitioner to achieve specific goals of service improvement. An advanced practice nurse demonstrates highly developed practice as either a generalist or within a specialist field, whereas a 16

nurse practitioner is an advanced practice specialist nurse, educated and authorised to practise nursing in a way that is different from other advanced practice nursing roles. Advanced practice nursing provides the necessary foundation to progress to the next step in the clinical career pathway of a nurse practitioner. Figure 3.1 provides information about this difference in terms of the type of service model and the nature of the clinical practice required. Working through this decision-making process may assist service planning teams to identify the most appropriate nursing role to meet changing service needs. Identify clinical service need Direct clinical care Clinical service is focused on patient care Autonomous as part of a health service team What service model Consultant/clinician/ proceduralist Broad service profile/ procedure clinic Autonomous in nursing practice Activities/procedures determined by medical team member Direct clinical care in a specific specialist field Responsible for patient s complete episode of care through to resolution or referral Practice includes diagnosis, prescribing medication and initiating nursing and other specialist interventions Nature of clinical practice Specialist or generalist Consultant, clinician or proceduralist Nursing component of patient s episode of care, case management or delegated procedures Nurse practitioner Advanced practice nurse Figure 3.1 Decision-making processes to determine type of nursing role 17

Step 4 Develop a business case for consideration at district level The business case is a one-off, start-up document that will be used by the service team to demonstrate justification of the proposed nurse practitioner service model and to seek funding support or demonstrate funding availability. The business case will be submitted to the District Nurse Practitioner Steering Committee for deliberation. Approval of the business case by the CEO confirms district executive support for the service model. The sponsor for the business case will be the Director of Nursing for the service, and completion of the business case will in part draw upon the information gathered in the previous steps. Step 5 Recruit nurse practitioner or nurse practitioner candidate Standard processes should be followed for recruitment of an endorsed nurse practitioner to the new position. If the service is seeking to provide a nurse practitioner training position, an open merit selection process should be followed to recruit a nurse practitioner candidate. Selection will be based on the following minimum eligibility criteria. These criteria meet the requirements for university entrance and endorsement eligibility. The candidate will: be registered as a nurse with the Queensland Nursing Council have achieved the academic pre-requisite relevant to the specific university such as undergraduate degree (or equivalent), training in the specialty field, graduate certificate or graduate diploma have a minimum of five years full-time equivalent clinical experience as a registered nurse, of which at least three have been achieved in the relevant speciality be employed in an advanced practice nursing role for the duration of the course have access to a clinical support team in the service be committed to undertaking a Queensland-based, Queensland Nursing Council-accredited nurse practitioner masters degree. It must be noted that, for the successful candidate who completes their course and gains nurse practitioner endorsement, according to current Government Certified Agreement, there is no automatic progression to be appointed to a nurse practitioner position. Open merit selection processes will be followed to fill a subsequent nurse practitioner position. These five sequential steps in the process of planning to establish a nurse practitioner position for a specific health service are summarised in Figure 3.2 18

Step 1 Step 2 Step 3 Step 4 Step 5 Consultation Initial interest Identify champions Establish working group Identify service need Service gaps Increased demand Poor access Clarify nursing model Nature of service model Nature of clinical care, clinical practice Develop business case Justify proposed NP model Establish funding source District level approval Recruit clinician Authorised NP OR NP candidate Open merit selection for NP candidature and NP position Figure 3.2 Summary of the planning process for a nurse practitioner position 3.3 Steps in developing a nurse practitioner A nurse practitioner will be required to exercise high-level clinical decision-making skills related to diagnosis and management for clients in a specialty field. This practice must be informed by appropriate education and clinical experience. A full account of nurse practitioner education requirements is provided in Section 2.6. Consistent with the standards for nurse practitioner education as set out by the Australian Nursing and Midwifery Council and the Queensland Nursing Council, all Queensland-based university courses for nurse practitioners training incorporate a clinical internship. Steps in developing a nurse practitioner clinician must involve full integration of theoretical and clinical learning. To achieve this integration, the clinical service environment and the multidisciplinary service team will play a major role in supporting and mentoring the candidate. The following steps will guide the candidate and the service team in preparing for and implementing the clinical internship. 19

Step 1 Preparing the clinical learning environment and infrastructure Queensland health care services have well-established links with all of the Queensland universities that offer nurse practitioner courses, and will continue to work with these universities to achieve high quality, consistent clinical education experiences. Guiding principles for the internship The internship is conducted as part of the candidate s clinical role as an advanced practice nurse and is based on an immersion approach to clinical learning. This has been demonstrated as effective in nurse practitioner clinical learning (Gardner & Gardner 2004). The candidate will need to be working into the role of nurse practitioner through this workplace-based internship for at least 50 percent of a full-time role. The candidate will undertake monitored clinical activities that are an extension to the role of a registered nurse, and include referral of patients to other health care professionals, requesting diagnostic tests, diagnosing and performing specific interventions. The candidate is unable to prescribe medication until they are endorsed as a nurse practitioner and have an approved health management protocol. However, the candidate will observe the process over the duration of their candidature. It is advisable that the candidate is allocated one day a week as supernumerary for mentored clinical learning and self-directed observation. The candidate and nursing service director will negotiate with the multidisciplinary team to establish a clinical support team for the duration of the internship. This team provides teaching through supervision, monitoring, supporting and reviewing the extended practice aspects of the candidate s role. The clinical support team will be drawn from the multidisciplinary service team as relevant and include at least a senior, experienced nurse and a clinician with appropriate expertise and experience, such as a medical specialist or nurse practitioner. Step 2 Conducting mentored clinical teaching and review for nurse practitioner internship Medical support, clinical teaching and mentorship are essential for effective skill development for the nurse practitioner candidate. Also important is an adequate teaching and learning framework, with clarity in cross-disciplinary communication of required learning experiences for nurse practitioner competency development and assessment outcomes. Queensland Health, in collaboration with participating universities, provides the following principles to assist the clinical support team, the clinical mentor, and the nurse practitioner candidate to collaborate in achieving a successful and productive clinical internship for the nurse practitioner candidates in the service. 20

Principles for successful clinical teaching and mentoring Clear communication Clear communication between the university and the clinical support team and clinical mentor about teaching and learning requirements for the internship. This will be in the form of a framework or handbook that includes the following information: description of the clinical competencies to be achieved and relevant time frame learning objectives related to competencies and skill acquisition practice activities and performance expectations specific to the learning objectives assessment requirements and reporting structures information about contingencies for management of candidates who are not meeting competency levels. Hands-on clinical teaching and coaching Regular clinical practice reviews The nurse practitioner internship includes requirements related to competency development in physical examination, clinical reasoning, and procedures and other activities related to extended practice in a specialty field. Adequate opportunity for observation and supervised practice of these activities is essential to a comprehensive and successful clinical internship. The candidate will be required to provide patient care, using nurse practitioner competencies for specific and complete episodes of care. Through weekly clinical practice reviews, the clinical mentor and other relevant team members will examine and review the candidate s assessment and management plan for patients in these episodes of care. This activity will provide a forum for: teaching and learning formative assessment identification of further learning requirements. Skilled mentors Observance of legal structures The nurse practitioner clinical mentor is an essential component of the internship. Mentor teaching is central to the process of the nurse practitioner developing the skills, knowledge and clinical reasoning necessary for competency development. The role of the clinical mentor is to establish a learning partnership with the nurse practitioner candidate in order to aid the candidate to apply clinical knowledge and to build clinical expertise in extended nursing practice for the specialist field. This outcome is dependent upon the mentor having the specific skills, attitudes and commitment to the internship. The purpose of the internship is to enable the candidate to deepen and extend their knowledge and practice skills by working into the role of a nurse practitioner. The clinical mentor will meet the legal requirements for the extended practice aspects of the candidate s practice. This specifically relates to prescribing restrictions, requesting diagnostic tests and referring 21

patients to other health professionals. Strategies to achieve clinical learning in these activities can be negotiated between the candidate and the clinical mentor. These might include established practices such as: standing orders for medication real-time case conferences led by the candidate shadowing the candidate to monitor decisions in these areas graduated responsibilities. Decisions about these strategies will be made on the understanding that the candidate must practice within the legislated parameters of nursing practice and that practice extending this scope must be monitored and supported by a medical practitioner. Step 3 Nurse practitioner education scholarships The final step in developing a nursing practitioner is application for scholarship support. Through the Office of the Chief Nursing Officer, Queensland Health offers nurse practitioner course fee scholarships to successful applicants. In an effort to support and enable the effective development of a nurse practitioner workforce in Queensland Health, the Office of the Chief Nursing Officer has identified five priority areas to support nurse practitioner education in the short- to medium-term. The selection of these priority areas has been informed by the best available evidence on current service need and workforce projections, both local and national. Targeted areas of speciality for the development of nurse practitioner roles are aligned with the following National Health Priority areas. The area must: have potential for health gains and improved outcomes for consumers pose a significant burden of disease have the support of all jurisdictions and agreement from Australian, State and Territory Governments to collaborate (Australian Government Department of Health and Ageing, 2002). The five priority areas for development of the nurse practitioner role in Queensland are: aged care chronic disease rural, remote and isolated practice mental health emergency medicine. The development of nurse practitioner roles is open to all clinical speciality models, some of which will have priority status in gaining an education scholarship. In the short- to medium-term, models that meet merit selection criteria and also conform to these identified health service areas will gain priority in selection. However, scholarship support does not exclude models outside these clinical service priorities. The three sequential steps in the process of developing a nurse practitioner are summarised in Figure 3.3 22

Step 1 Step 2 Preparing the learning environment Immersion learning Working into the role Supernumerary time Clinical support team Clinical teaching and review Clear communication Clinical practice reviews Skilled mentors Legal structures for extended practice learning Step 3 Education Scholarships Course fee support Service priority areas Figure 3.3 Summary of the process for developing a nurse practitioner 3.4 Steps in implementing the nurse practitioner position 3.4.1 Health Management Protocol and Drug Therapy Protocol A nurse practitioner who is endorsed to practise by the Queensland Nursing Council has legal authority to prescribe, give a written or oral instruction, supply and administer the controlled and restricted drugs that are listed in the Queensland Hospitals Standard Drug List under the conditions contained within the Drug Therapy Protocol (DTP). The provisions of the DTP require that a Health Management Protocol (HMP) is developed and approved by the Queensland Nurse Practitioner Advisory Committee (QNPAC). See Nurse Practitioner Drug Therapy Protocol (Appendix 2) 3.4.2 Process for development and approval of a HMP/DTP The Office of the Chief Nursing Officer maintains a repository that will hold all HMP/DTPs that have been granted final approval by QNPAC and are specific to nurse practitioner service models. These approved protocols can be downloaded from the OCNO website, and can be adopted and modified to be used as the basis of development for future HMP/DTPs. All HMP/DTP s must be submitted to QNPAC for final approval and it is the responsibility of the QNPAC chairperson to sign and date any approved protocols for the duration of a maximum of two years from the date of QNPAC approval, or sooner. Each district is responsible for ensuring that the full approval process is completed, prior to the implementation of a HMP/DTP within any of their service areas. A HMP/DTP guide and checklist has been developed that reflects the requirements of the 2006 nurse practitioner drug legislation. These 23

documents have been approved by QNPAC and are for use by districts to support the development of HMP/DTPs to ensure that all components of legislative requirements are met. A completed checklist is to be forwarded with every HMP/DTP submitted to QNPAC for final approval (see Appendices 4 and 5). It is the responsibility of the nurse practitioner and the multidisciplinary service team to identify the parameters of the nurse practitioner model, based upon their service planning model. From this, the team will either: a) adopt and modify an approved HMP/DTP from the repository held at the OCNO, and progress the document through to District endorsement and then onto QNPAC for final approval, as per the condition stated in the Nurse Practitioner- Drug Therapy Protocol Appendix 3, paragraph 5.1 b) develop a new HMP/DTP and progress this through to district endorsement and then onto final approval of QNPAC prior to implementation. 3.4.2.1 Completing the HMP/DTP template Figure 3.4 illustrates the process of development, selection and final approval of a nurse practitioner HMP/DTP. 3.4.3 Nurse practitioner clinical work requirements The nurse practitioner is a systems level innovation, the inclusion of a new type of clinician to a service team. This means that the practice field needs to be prepared to ensure successful implementation of a nurse practitioner position. New relationships need to be established, new processes implemented and changes made to some existing policies. The specific preparation needs will vary according to the nurse practitioner model and the service context. The following list is related to the clinical work requirements that may need attention when implementing a nursing practitioner position. 3.4.3.1 Pharmacy Collaborate with the Pharmacy Director to coordinate nurse practitioner prescribing in your service area. Discussion should include the required sharing of details regarding the nurse practitioner model and the service model to be implemented. Agree on specific pharmacy arrangements for the dispensing of prescriptions (considering that nurse practitioners do not currently have prescriber numbers) to ensure that patients are not financially disadvantaged because of issues surrounding Pharmaceutical Benefits Scheme (PBS). Provide the pharmacy with a copy of the Nurse Practitioner-Drug Therapy Protocol (Appendix 2) and a copy of the finally approved QNPAC HMP/ DTP for the relevant service model. 3.4.3.2 Imaging Collaborate with the Director of Medical Imaging to coordinate nurse practitioner imaging requests, in line with the Diagnostic Radiography Protocol (see Appendix 5). 24

3.4.3.3 AUSLAB Pathology Management System 3.4.3.4 Referral pathways Nurse practitioners can gain approval as requesting officers in the AUSLAB Pathology Management System by completing the application form. The application needs to be completed, signed by the CEO and forwarded to the AUSLAB support unit. Information about AUSLAB and training support can be accessed at: http://qhpss.health.qld.gov.au/auslab/ https://qhss:8031/docs/23365r2.doc Identify clinicians and services (internal and external) likely to constitute referral networks for the nurse practitioner. Negotiate with these clinicians and services about accepting and acting upon nurse practitioner generated referrals. The NP and service team determine the scope and parameters of practice for the NP model Yes Determine if there is an approved QNPAC HMP/DTP in OCNO repository for the required NP service model No Assess suitability of HMP/DTP obtained from repository against district service model requirements No - Convene multi-disciplinary team - Define NP role and scope - Develop HMP/DTP as per HMP guide - Complete NP HMP checklist. See Appendices 4 and 5 Approval process Submit to CEO via District Director of Nursing Services /District Nurse Practitioner Steering Committee for local endorsement Submit to QNPAC for final approval and sign off by QNPAC chairperson as delegated by the Director-General, Queensland Health (include checklist, See Appendix 5) The CEO will be informed in writing that the HMP/DTP has been approved. NP is authorised to practise within approved HMP/DTP. Formulate an evaluation and HMP/DTP revision strategy and timeline. Formalise links with local pharmacy to enact HMP/DTP. See section 3.4.3.1 Pharmacy Figure 3.4 Process for the development and approval of a nurse practitioner HMP/DTP 25

Section 4 Governance and evaluation The nurse practitioner is an emerging clinical role and quality management systems need to be established to define, ensure appropriate and sound governance and monitor and evaluate the quality and effectiveness of nurse practitioner service. Stakeholders such as the general public, governments, the nursing profession and other health disciplines will be evaluating the process and outcome of new nurse practitioner roles. Service teams and nurse practitioner clinicians must incorporate a governance plan into their implementation strategy. 4.1 Governance The nurse practitioner is a clinician who is legally endorsed to provide care and treatment within a specified scope of practice. Sound governance is required to minimise risks and protect patient safety, strive to improve performance, consider all available and current evidence to make informed decisions and deliver a consistently high service to stakeholders and the wider community. Governance processes provide a framework for health care facilities to verify that the endorsed health care provider possesses the requisite knowledge, skills and expertise to manage and treat patients and to perform the clinical procedures that they are required to provide, and which the organisation is able to resource. It is the responsibility of specific health care organisations to ensure that clinical staff and visiting clinicians have met the required standards of practice and training. Nurse practitioners and their teams should be aware that the governance process for the nurse practitioner in a Queensland health care facility may involve the following as a minimum: details of clinical procedures and interventions the nurse practitioner will perform for and with patients in the course of their employment in the organisation primary source verification of a Queensland Nursing Councilaccredited nurse practitioner masters degree (or equivalent), demonstrating that the nurse practitioner met all academic and clinical learning requirements for nurse practitioner training a portfolio as evidence of nurse practitioner clinical training and clinical experience current QNPAC finally approved Health Management Protocol/ Drug Therapy Protocol direct, first-hand documentation by a supervising clinician competent in and authorised to perform the particular procedure the nurse practitioner is seeking to affirm, that the nurse practitioner is competent in that activity nurse practitioner portfolio should include documentation of education, clinical training, licensure, experience, current competence including current prescriber competence, health status, and ethical behaviour 26

verification of portfolio evidence is required to ensure that: the individual is in fact the same individual who is identified in the portfolio documents the applicant has attained the experience, qualifications and competencies as stated the evidence is current there are no challenges to any of the evidence evidence of ongoing case conferencing/clinical case reviews within a multi disciplinary team relevant to the nurse practitioner service delivery. 4.2 Evaluation The growing body of research into nurse practitioner service indicates that this service is safe, effective and positively valued by patients and other health care professionals. As the nurse practitioner role is implemented throughout Queensland, it is important that nurse practitioners contribute to this body of knowledge and to systematically collect and examine information to ensure that the service models deliver safe and effective care. Clinical audit is an important and readily available approach to achieving this. For the nurse practitioner, conducting clinical audits is an essential part of professional accountability and a core nurse practitioner competency. Additionally, auditing is a mechanism that can be used to develop and maintain the trust of consumers and colleagues in a nurse practitioner service. While a clinical audit is commonly used to improve care in specific conditions and diseases, it is also a valuable tool to use where there is a change in service models. A well-conducted audit can evaluate whether or not new approaches to a service or an area of practice meet the expected level of performance. Furthermore, a clinical audit provides a mechanism whereby quality of care can be reviewed objectively and evaluated against pre-determined service targets. Nurse practitioner models are implemented across a broad range of specialty service areas in response to consumer demand. Examples include emergency services, wound care, mental health, primary health, aged care and service models for a broad range of specific chronic illness conditions. Essentially, where there is a service gap, increased demand, a marginalised community or an emerging need, there will be the potential for a nurse practitioner model. This diversity presents challenges for developing a standardised approach to clinical service auditing. However, there are some central principles that can be followed to design a clinical audit program to suit a specific nurse practitioner service model. These relate to steps in preparation, identifying targeted service outcomes and establishing service objectives. 27

Step 1 Prepare the field Gain service and organisational level support for conducting an audit of the new service. Identify the project leader. This may be the nurse practitioner, the service director or other service clinicians. It may also come from interested colleagues in other areas, such as academics from an adjacent university or facility-based nurse researchers. Decide on audit methodology including data issues, data sources, data collection or data abstraction tools, implementation issues and costs. Using or modifying existing data collection methodologies is important in terms of maintaining efficiencies and enabling the data to be compared and benchmarked against state and national outcomes. Step 2 Identify the service objectives Auditing is a systematic review process of care or service against explicit service expectations. In planning the audit, determine a realistic level of expected service improvement. The key component of this approach to auditing is that performance is reviewed or audited to ensure that the service improvement is being achieved. Step 3 Identify outcomes to be evaluated Identify the service indicators to be evaluated. As the implementation of the nurse practitioner role is a service improvement model, this is likely to involve both established and new service indicators. Guidance to identify the indicators to be measured can be taken from the case argued in the original business plan for the position. Identify the safety indicators to be monitored. Identify the resource usage to be monitored. Identify the consumer group for service satisfaction evaluation. Establish service demand indicators. Attention to these steps of preparing the field, revisiting the service objectives and identifying the outcomes to be evaluated will provide a sound basis for evaluation of new nurse practitioner positions and the impact on service outcomes. The following may be useful resources for information on clinical auditing: A Practical Handbook for Clinical Audit. Guidance published by the Clinical Governance Support Team March 2005 <http://www.cgsupport. nhs.uk/downloads/practical_clinical_audit_handbook_v1_1.pdf> accessed 11 August 2008. The Joanna Briggs Institute for Evidence Based Nursing and Midwifery <http://www.joannabriggs.edu.au?about/home.php> accessed 11 August 2008. 28

Appendices Appendix 1 Terms of Reference for a District Nurse Practitioner Steering Committee...22 Appendix 2 Nurse practitioner Drug Therapy Protocol...22 Appendix 3 Health Management Protocol/Drug Therapy Protocol Guide...22 Appendix 4 Health Management Protocol checklist...22 Appendix 5 Diagnostic Radiography Protocol...22 29

Appendix 1 District Nurse Practitioner Steering Committee Terms of Reference 1 Role 2 Reporting 3 Terms of Reference The District Nurse Practitioner Steering Committee (DNPSC) is a representative interdisciplinary group that reports to District CEO via the District Director of Nursing. The role of the DNPSC is to oversee the development of suitable environments and models of care to introduce and support Nurse Practitioner roles across the Health Service District in line with the current Queensland Implementation Guide for Nurse Practitioners and to provide an endorsement forum for Health Management Protocols (HMP) inline with Nurse Practitioner Drug Therapy Protocol 2006. The DNPSC reports to District CEO via the District Director of Nursing. The purpose of the DNPSC is to: 1 Provide organisational leadership for the implementation of Nurse Practitioner roles 2 Provide the strategic direction for the implementation of Nurse Practitioners across the Health Service District 3 Oversee the development of the service / business planning process guiding the implementation of new Nurse Practitioner roles 4 Review and endorse Health Management Protocols which will be submitted to the Queensland Nurse Practitioner Advisory Committee (QNPAC) for final approval prior to any use within the District 5 Identify and support the required organisational changes to enable the implementation of Nurse Practitioners. 6 Identify potential areas for establishing Nurse Practitioner positions inline with the District strategic plan. 7 Identify review and monitor the adequacy and suitability of educational support required for Nurse Practitioners and candidates across the District 8 Ensure consumer engagement and feedback is integral to Nurse Practitioner development and service delivery. 9 Explore the funding opportunities for implementing Nurse Practitioner and co ordinate submissions/tenders for new funding. 10 Receive and review regular clinical audit and evaluation reports in line with QNPAC requirements and report to QNPAC in line with key performance indicators as required. 30

4 Membership Chair: District Director of Nursing / Executive District Director of Nursing Secretary: as nominated by the Chair Members: District Senior Nursing Staff Executive Director of Medical Services (or delegate) Director of Medical Imaging (or delegate) Director of Pharmacy (or delegate) Director of Pathology (or delegate) Allied Health Representative Nurse Practitioner Nurse Practitioner candidate Division of GP / GP representative Consumer representative Clinical Governance senior representative 5 Meeting 6 Meeting frequency 1 Any person elected or appointed, as a member of the committee is entitled to one vote and in the event of an equality of votes, the Chair shall have the casting vote. 2 A quorum consists of a simple majority of voting members 3 The committee may invite any person to attend a committee meeting in order to facilitate its business. Any person so attending does not have voting rights. The DNPSC will meet quarterly at a minimum. 31

Appendix 2 Nurse Practitioner Drug Therapy Protocol Nurse Practitioner - Drug Therapy Protocol I, Uschi Schreiber, Chief Executive of Queensland Health, under the provisions of Sections 67, 175 and 263 of the Heath (Drugs and Poisons) Regulation 1996, approve the Drug Therapy Protocol Nurse Practitioner in which a nurse practitioner may prescribe, give a written or oral instruction, supply 1 and administer the controlled and restricted drug(s) contained within the Queensland Hospitals Standard Drug List under the conditions contained in this protocol. Conditions of the Drug Therapy Protocol 1. Authority to Practise 1.1. A nurse practitioner endorsed to practice by the Queensland Nursing Council may, in accordance with the provisions of the Drug Therapy Protocol (DTP), prescribe, give a written or oral instruction, supply 1 and administer those drugs listed in the Queensland Health (QH) Standard Drug List for which a Health Management Protocol (HMP) has been developed and approved. 2. Requirement for a Health Management Protocol 2.1. The nurse practitioner must have a current HMP that supports and details the clinical use, being the prescription, instruction, supply 1 and administration of drug(s) listed/contained within the Queensland Hospitals Standard Drug List. 2.2. The HMP will define the subset of medications to which the nurse practitioner has access. 3. Development of a Health Management Protocol 3.1. The HMP must be developed or adopted by an interdisciplinary team that is either: (i) appointed by the employer under whose jurisdiction the HMP will be implemented; or (ii) established by a self employed nurse practitioner. 3.2. As a minimum, the team must consist of a medical practitioner, registered nurse and pharmacist, and may include other identified professional personnel as considered appropriate. 3.3. An employer or self employed nurse practitioner may adopt relevant HMPs that have already been developed by another interdisciplinary team and approved by the Queensland Nurse Practitioner Advisory Committee. For self employed nurse practitioners, the interdisciplinary team will be responsible for endorsing the HMP for use by the nurse practitioner. 4. Content of a Health Management Protocol The HMP must contain clinical guidelines covering the clinical assessment, management and follow-up of patients, including the recommended drug therapy. The recommended drug therapy must identify: 4.1 the name, form, strength, dose and route of administration of the drug. 4.2 the duration of administration or supply of the drug. 4.3 the duration of the drug supply or prescription before follow-up is required 5. Approval, Endorsement and Renewal of a Health Management Protocol 5.1. All HMPs must be submitted to the Queensland Nurse Practitioner Advisory Committee (QNPAC) for final approval. On approval, Chairperson of QNPAC will sign and date HMP. 5.2. The HMP must be endorsed for use by: (i) the District Health Service Manager; or (ii) the Chief Executive Officer of a non-queensland Health employing authority; or (iii) the interdisciplinary team working with a self employed nurse practitioner. 5.3. The HMP shall be effective for a maximum of two (2) years from the date of QNPAC approval. 5.4. Following this period of two years or sooner if considered necessary, the HMP must be reviewed by the interdisciplinary team, approved by the QNPAC and endorsed again by the District Health Service Manager or Chief Executive Officer of a non-queensland Health Drug Therapy Protocol: Nurse Practitioner version May 2006 Page 1 of 2 32

employing authority or the interdisciplinary team working with a self employed nurse practitioner. 6. Responsibilities of Nurse Practitioners 6.1. The actions of a nurse practitioner who is endorsed by the Queensland Nursing Council in regard to the prescription, giving of a written or oral instruction, supply and administration in accordance with the provisions of this DTP, must at all times be in accordance with the HMP. 6.2. It is the responsibility of the Nurse Practitioner to apply the principles of Quality Use of Medicines and safe prescribing practices. 6.3. The following literature must be in the possession of a nurse practitioner who is practising under this DTP: 6.3.1. A copy of this Drug Therapy Protocol 6.3.2. Health Management Protocols relevant to this DTP and the nurse practitioners area of practice 6.3.3. A copy or access to a current Prescription Product Guide / MIMS and Australian Medicines Handbook 6.3.4. A copy of or access to the current Queensland Hospitals Standard Drug List 6.3.5. A copy of or access to the current Health (Drugs and Poisons) Regulation 1996. 6.4. A nurse practitioner must ensure that they have equipment and procedures for the management of an emergency associated with the use of any drugs being prescribed, supplied or administered by the nurse practitioner. 6.5. A nurse practitioner practising in accordance with the provisions of this DTP must be aware that practising within the DTP does not relieve that person of their legal responsibility or accountability for that person s actions and may not provide immunity in case of negligence. 6.6. When Consumer Medicines Information is available for a particular drug contained within a HMP, a nurse practitioner should provide this information to each person when prescribing, giving a written or oral instruction, supplying or administering the drug. 6.7. The Nurse Practitioner must cooperate with the Queensland Health Safe Medication Practice Unit (QHSMPU) and provide access to whatever records are required to conduct audits of prescribing practices. 7. Auditing 7.1. Auditing of Nurse Practitioner prescribing practices will be conducted by the QHSMPU. 8. List of Drugs 8.1. The drugs approved for use under this protocol are contained within the current version of the Queensland Hospitals Standard Drug List. Signed at Brisbane on this 16th day of May 2006. Uschi Schreiber Director-General Queensland Health 1 1 Supply For the purposes of this DTP, the term supply is limited to circumstances where NPs are working in an isolated practice area or a rural hospital that does not employ a pharmacist or if the rural hospital employs a pharmacist and the pharmacist is absent from the rural hospital at the time the drug is supplied. Drug Therapy Protocol: Nurse Practitioner version May 2006 Page 2 of 2 33

Appendix 3 Nurse Practitioner Health Management Protocol Guide Nurse Practitioner Health Management Protocol for the management of Note: The title must be inclusive of the specific target population or clinical condition(s) to be treated and the specific service area. Adult and paediatric populations must be contained within separate Health Management Protocols (HMPs). The Nurse Practitioner Health Management Protocol checklist (Appendix 4) must be completed and submitted with this document. The italic fonts within this document are to guide the information and detail that is to be added by the clinical team developing the Health Management Protocol. Table of contents Contents Page no. Glossary of terms Acronym Meaning 34

Description of health service Note: The service in which the nurse practitioner is providing care must be described. The description must be inclusive of: the service goals/purpose the model of care the collaborative relationships within the service to support NP practice. Scope of practice The nurse practitioner is responsible and accountable for making professional judgements about when the patient s condition is beyond their scope of practice and for initiating consultation with a medical officer or other member of the health care team. Note: The scope of practice is determined by a nurse practitioner s education and competency. The scope of practice of individual nurse practitioners is influenced by: the setting in which they practice the health needs of people the level of competence and experience of the nurse practitioner the policy requirements of the service provider. The scope of practice should include, target population to whom the service is delivered clinical condition(s) and severity of conditions to be treated by NP assessment and management framework that guides NP practice including assessment investigations diagnosis interventions follow up. 35

Referral The nurse practitioner role includes assessment and management of clients using nursing/midwifery knowledge and skills and may include but is not limited to: the direct referral of clients to other health care professionals prescribing medications requesting diagnostic investigations. Currently in Australia nurse practitioners do not have access to a Medicare provider number. Consequently, until this changes a referral from a nurse practitioner may cause financial disadvantage for the patient. To ensure that patients are not financially disadvantaged arrangements for private referral are as follows: Note: specific referral arrangements must be described for the nurse practitioner service The nurse practitioner should consider referral to a medical officer in the following situations: persistent signs and symptoms despite treatment symptomatic or laboratory evidence of previously unidentified, decreased or decreasing function of any vital organ or system signs of recurrent or persistent infection any atypical presentation of a common illness or unusual response to treatment a deviation from normal growth and development of an infant or child all potentially life threatening situations when a patients condition deteriorates unexpectedly. Note: add any other specific criteria relevant to your speciality. Drug therapy protocol Choice of pharmacological therapy must be guided by the Therapeutic Guidelines and the Australian Medicines Handbook, within the parameters of the Standard Drug List for Queensland Hospitals. The Consultant/General Practitioner is the lead clinician for the coordination of the patients care and thus any new medications, titration of medications and recommended discontinuation of medications must be communicated to them. The nurse practitioner must verify that the choice of drug is suitable for the patient after carefully considering the following individualised patient information: age previous allergies adverse drug reactions co-morbities such as renal and hepatic dysfunction concomitant medications for potential drug interactions pregnant and or lactating women. 36

The Queensland Health Safe Medication Practice Unit has identified specific medications and patient groups where extra precautions are necessary. These groups are listed below and must be considered carefully when selecting drug treatment to avoid adverse medication events. High risk medications drugs with a narrow therapeutic range i.e. digoxin, lithium drugs requiring specialised monitoring or interpretation i.e. therapeutic dose monitoring anticoagulants cytotoxics NSAIDS or COX-2 inhibitors opiate analgesics aminoglycosides anti-epileptics insulin IV electrolyte supplementation weekly dosing regimens i.e. methotrexate. High risk patient groups renally impaired cardiac disease liver disease transplantation mental health problems cancer paediatrics elderly pregnant and breastfeeding. Currently in Australia nurse practitioners do not have access to the pharmaceutical benefits scheme. Consequently, until this changes a prescriptions from a nurse practitioner may cause financial disadvantage for the patient. To ensure that patients are not financially disadvantaged arrangements for dispensing of the nurse practitioner prescription are as follows: Note: specific prescribing arrangements must be described for the nurse practitioner service A copy of the approved HMP/DTP must be available in the pharmacy for identification and signatory purposes. 37

Drug therapy Note: List drug groups to be utilised by NP e.g. 1. Antibiotics 2. Analgesics Drug Information must be set out as below. A new drug table as per the Australian Medicine Handbook (AMH) is required for each drug group. 1. Antibiotics Generic name Form Indications, dose schedule and duration of drug supply e.g. Amoxycillin trihydrate Capsule AMH section 5.1.8 Reference list Note: List references for HMP development 38

Endorsement and approval HMP/DTP developed and checked by Name and designation Signature Date Endorsed by DDON/Chair, District Nurse Practitioner Steering Committee Signature:... Date: / / Name:... Endorsed by: Chief Executive Officer Signature:... Date: / / Name:... Final approval Chair, Queensland Nurse Practitioner Advisory Committee Signature:... Date: / / Name:... Effective date Review date Reviewing position 39

Appendix 4 Nurse Practitioner Health Management Protocol Checklist The Nurse Practitioner Drug Therapy Protocol endorsed by the Director General of Queensland Health on 16 May 2006 states that all Health Management Protocols (HMP) must be submitted to the Queensland Nurse Practitioner Advisory Committee (QNPAC) for final approval. Prior to the presentation of a HMP to QNPAC, the HMP must have been developed by an interdisciplinary team appointed by the employer and endorsed by the Chief Executive Officer of the clinical service area. This checklist is to be used by the Health Service District as a guide to ensure that the Health Management Protocol being submitted to the Queensland Nurse Practitioner Advisory Committee is compliant with the conditions set out in the Nurse Practitioner Drug Therapy Protocol. Name of Health Management Protocol... Criteria as per DTP legislation Requirement of HMP Yes No Additional comments Does the HMP detail the clinical use being the prescription, instruction, supply (1) and administration of drugs listed in the QH Standard Drug List? Does the HMP define a subset of medications to which the nurse practitioner has access? Development of a HMP Has the HMP been developed by an appropriate expert clinical team with relevant clinical expertise? As a minimum the team must include a pharmacist, registered nurse and medical practitioner. Content of HMP Does the HMP refer to clinical guidelines outlining clinical assessment, management and follow up of patients? Does the HMP identify the recommended drug therapy: 1. Name, form, strength, dose and route of administration 2. The duration of administration or supply of the drug 3. The duration of the drug supply or prescription before follow up is required? Approval, endorsement and renewal Has the HMP been reviewed through district processes e.g. Drugs and Therapeutics committee or equivalent? Has the HMP been endorsed by CEO? Is there evidence of a planned review process within two years? Nurse practitioner responsibilities Is there evidence that the NP has access to equipment and procedures for the management of an emergency associated with the use of any drugs being prescribed, supplied or administered? 40

Requirement of HMP Yes No Additional comments Will the nurse practitioner have access to: 1. The NP - Drug therapy protocol legislation 2. The HMP relevant to area of practice 3. Current prescription product guide/mims and Australian Medicines handbook 4. Queensland Hospitals Standard Drug List 5. The current Drugs and Poisons Regulation? (1) Supply- For the purposes of the DTP, the term supply is limited to circumstances where NPs are working in an isolated practice area or a rural hospital that does not employ a pharmacist or if the rural hospital employs a pharmacist and the pharmacist is absent from the rural hospital at the time the drug is supplied. HMP/DTP developed and checked by: Name and designation Signature Date Endorsed by DDON/Chair, District Nurse Practitioner Steering Committee Signature:... Date: / / Name:... Endorsed by: Chief Executive Officer Signature:... Date: / / Name:... 41

Appendix 5 Diagnostic Radiography Protocol 42

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