A snapshot of Australian nurse practitioners’ extended practice activities

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.

Clients’ understanding of the role of nurse practitioners

Introduction: Nurse Practitioners (NPs) have an emerging role in the Australian healthcare system. However, there remains a dearth of available data about public understanding of the NP role. ---------- Aim: To evaluate clients’ understanding of the role of the NP and their satisfaction with education received, quality of care and NP knowledge and skill. ---------- Method: All authorised NPs working in a designated NP position in Western Australia and those working in three area health services in New South Wales (NSW) were invited to recruit five consecutive clients to complete the self-administered survey. ---------- Results: Thirty two NPs (NP response rate 93%) recruited 129 clients (client response rate 90%). Two thirds of clients (63%) were aware they were consulting an NP. The majority rated the following NP related outcomes as ‘excellent’ or ‘very good’: education provided (89%); quality of care (95%); and knowledge and skill (93%). Less than half reported an understanding that NPs could prescribe medications (40.5%) or interpret X-rays (33.6%). Clients of NPs practising in a rural or remote setting were more likely than those in an urban setting to have previously consulted an NP (p=0.005), and where applicable would to prefer to see a NP rather than a doctor (p=0.022). ---------- Discussion: Successful implementation and expansion of the NP role requires NP visibility in the community. Despite high levels of satisfaction more awareness of the scope of the NP role is required.

Changing to learner-centred education : challenges experienced by nurse educators in Taiwan

This paper reports the challenges experienced by nurse educators in changing a teacher-centred, content-driven approach to teaching and learning to a learner-centred, process-driven approach within a School of Nursing in Taiwan. While a general movement towards a learner-centred approach was achieved, the curriculum transformation process was complex and inevitably slow with many challenges. First the study is outlined, with the key challenges experienced by the participating nurse educators explicated and illuminated with excerpts drawn from the research data. This is followed by a discussion of possible reasons for the challenges and how they were overcome and the transition process from teacher-centred to learner-centred education facilitated.

Effectiveness of nurse-led preoperative assessment services for elective surgery : a systematic review

Background--The admission and assessment of patients for elective procedures is a task faced by all healthcare organisations that provide elective surgical services. Several different strategies have been used to facilitate the management of these tasks. Nurse-led preadmission clinics or services have been implemented in many health services as one of these management strategies; however their effectiveness has not been established. Objectives--The objective of this review was to examine the available research on the effectiveness of nurse-led elective surgery preoperative assessment clinics or services on patient outcomes.--Results--Of the 19 included articles, there were 10 audits of patient and hospital data, 3 surveys or questionnaires, 3 descriptive studies, 1 action research design, 1 prospective observational study and 1 RCT. Five of ten studies reporting data on cancellations rates found that nurse-led preadmission services reduced the number of day-of-surgery cancellations. Non-attendance for surgery was also reduced, with nine studies reporting decreases in the number of patients failing to attend. Eight studies reporting data on patient or parent satisfaction found high levels of satisfaction with nurse-led preadmission services. Three of four studies investigating the effect of the nurse-led preadmission service on patient anxiety found a reduction in reported anxiety levels. Three studies found that preoperative preparation was enhanced by the use of a nurse-led preadmission service.--Conclusions--While all included studies reported evidence of effectiveness for nurse-led preadmission services on a wide range of outcomes for elective surgery patients, the lack of experimental trials means that the level of evidence is low, and further research is needed.--Implications for practice--Nurse-led preadmission services may be an effective strategy for reducing procedural cancellations, failure to attend for procedures, and patient anxiety, however currently the evidence level is low.

Overcoming challenges to collaboration: Nurse educators’ experiences in curriculum change

This article describes challenges to effective collaboration encountered by nurse educators as they transformed a unit within a school of nursing in Taiwan. This study introduced collaborative action research as a vehicle for curriculum change. Although the team achieved positive outcomes in transforming a unit, the collaborative process was complex with four major challenges: meaning, time, work culture, and conflicting views. This article provides an overview of the study, and the major challenges posed by working together are expounded and illustrated with excerpts drawn from the study data. Possible reasons for the challenges, how these challenges were overcome, and facilitation of the collaborative process are discussed.

Nurse-led telephone interventions for people with cardiac disease : A review of the research literature

Background: Nurse-led telephone follow-up offers a relatively inexpensive method of delivering education and support for assisting recovery in the early discharge period; however, its efficacy is yet to be determined. Aim: To perform a critical integrative review of the research literature addressing the effectiveness of nurse-led telephone interventions for people with coronary heart disease (CHD). Methods: A literature search of five health care databases; Sciencedirect, Cumulative Index to Nursing and Allied Health Literature, Pubmed, Proquest and Medline to identify journal articles between 1980 and 2009. People with cardiac disease were considered for inclusion in this review. The search yielded 128 papers, of which 24 met the inclusion criteria. Results: A total of 8330 participants from 24 studies were included in the final review. Seven studies demonstrated statistically significant differences in all outcomes measured, used two group experimental research design and valid and reliable instruments. Some positive effects were detected in eight studies in regards to nurse-led telephone interventions for people with cardiac disease and no differences were detected in nine studies. Discussion: Studies with some positive effects generally had stronger research designs, large samples, used valid and reliable instruments and extensive nurse-led educative interventions. Conclusion: The results suggest that people with cardiac disease showed some benefits from nurse-led/delivered telephone interventions. More rigorous research into this area is needed.

Clinical education for nephrology nurse practitioner candidates in Australia : a consensus statement

Objectives: To develop recommendations for the clinical education required to prepare Australian Nurse Practitioner candidates for advanced and extended practice in nephrology settings. Methods: Using the Delphi research technique a consensus statement was developed over a nine month period. All endorsed and candidate Nephrology Nurse Practitioners (NNP) were invited to participate as the expert panel. The Delphi research technique uses a systematic and iterative process. The expert panel were asked to generate a list of items which were then circulated to all NNPs. They were asked to determine their degree of agreement or disagreement with each statement using a 5-point Likert scale There was opportunity for free-text comments to be provided if desired. Results from each round were collated; the document was refined and circulated to the experts for a subsequent round. Consensus was demonstrated after three Delphi rounds. Results: The consensus statement comprises four components explaining the role and membership of the mentorship team, the setting and location of NNP clinical education, learning strategies to support the NNP, and outcomes of NNP clinical education. Demographic questions in the final survey revealed information about the qualifications, years of experience, and practice location of Australian NNPs. Conclusions: The consensus statement is not prescriptive but it will inform NNP candidates, university course providers and mentors about the expected extended nephrology specific clinical education that will enable the NNP to provide advanced nursing care for patients regardless of the stage of chronic kidney disease (CKD) and the practice setting.

Fitting in : a pervasive new graduate nurse need

Aim: This qualitative study aims to provide insight into how Australian New Graduate Nurses (NGNs) experienced their transition to acute care nursing practice. Method: Nine NGNs each participated in three in-depth interviews conducted across their first year of practice. Constant comparative analysis was used to identify the emergent themes. Findings: The desire to fit in (establishment of secure social bonds) with ward staff is an important element of NGN transition experiences. Fitting in was about feeling one's self to be part of a social group, and participants made it clear that their perceptions of their success in establishing secure and meaningful social bonds in each new ward was extremely important for their sense of being as NGNs. Current NGN Transition Programmes (NGNTPs) involve multiple ward rotations, increasing the demand for the NGN to fit in. Thus participants were engaged in a deeply personal transition experience that was not necessarily aligned with multiple ward rotations. Conclusions: Although NGNTPs have the word “transition” in their title, it may be that current programmes are more focussed on organisations’ desire to “orient” NGNs to working within the acute care setting than facilitating personal transitions to practice. Further investigation of the impact of NGNTPs on NGNs and the associated multiple ward rotations is required.

The status of Australian nurse practitioners : the second national census

Objectives. To profile Australian nurse practitioners and their practice in 2009 and compare results with a similar 2007 census. Methods. Self-administered questionnaire. Results. Atotal of 293 nurse practitioners responded (response rate 76.3%). The majority were female (n = 229, 81.2%); mean age was 47.3 years (s.d. = 8.1). As in 2007, emergency nurse practitioners represented the largest clinical specialty (n = 63, 30.3%). A majority practiced in a metropolitan area (n = 133, 64.3%); a decrease from 2007. Consistent with 2007, only 71.5% (n = 208) were employed as a nurse practitioner and 22.8% (n = 46) were awaiting approval for some or all of their clinical protocols. Demographic data, allocations of tasks, and patterns of practice remained consistent with 2007 results. ‘No Medicare provider number’ (n = 182, 91.0%), ‘no authority to prescribe using the Pharmaceutical Benefits Scheme’ (n = 182, 89.6%) and ‘lack of organisational support’ (n = 105, 52.2%) were reported as ‘limiting’ or ‘extremely limiting’ to practice. Conclusions. Our results demonstrate less than satisfactory uptake of the nurse practitioner role despite authorisation. Barriers constraining nurse practitioner practice reduced but remained unacceptably high. Adequate professional and political support is necessary to ensure the efficacy and sustainability of this clinical role.

E-portfolios : developing nurse practitioner competence and capability

Objective: This paper aims to integrate nurse practitioner literature on competence and capability with post graduate and nursing literature on e‑portfolios in order to demonstrate the potential merits of e‑portfolios in nurse practitioner education for competence and capability development. Primary Argument In the Nurse Practitioner Standards Project, competence and capability were proposed as key criteria to assess candidates in nurse practitioner educational courses. Portfolios have traditionally been used to demonstrate competence in nursing and are integral to nursing education as well. An examination of the portfolio and electronic portfolio literature in postgraduate nursing education and professional practice indicates that these portfolios fall under two main structures, each with different purposes: 1) A spinal column structure, with evidence and reflective pieces aligned to competency standards or course objectives, for the purposes of meeting prescribed competencies, professional development planning and showcasing evidence for authorisation or potential employers; and 2) A cake mix structure, which consists of a reflective narrative tying evidence together, which enables a greater focus on personal learning journeys, reflection and the development of personal qualities. Finally, evidence from the general nursing literature suggests the complexity of e‑portfolios in assessment and evaluation can be overcome by using qualitative research methods. Conclusion: To meet the competence and capability needs of nurse practitioners, portfolios could be used, for competence and showcasing and for learning and capability. Further research would be useful to refine and explore the use of e‑portfolios to meet the needs of NP candidates and their educators, clinical mentors, authorisation personal and employers. The current evidence on nurse practitioner education, competence, capability and e‑portfolios points to the integration of the use of an e‑portfolio into current nurse practitioner curriculum models to meet the unique needs of nurse practitioner candidates.

Improving access to quality clinical nurse teaching : a partnership between Australia and Vietnam

Until recently, standards to guide nursing education and practice in Vietnam were nonexistent. This paper describes the development and implementation of a clinical teaching capacity building project piloted in Hanoi, Vietnam. The project was part of a multi-component capacity building program designed to improve nurse education in Vietnam. Objectives of the project were to develop a collaborative clinically-based teaching model that encourages evidence-based, student-centred clinical learning. The model incorporated strategies to promote development of nursing practice to meet national competency standards. Thirty nurse teachers from two organisations in Hanoi participated in the program. These participants attended three workshops, and completed applied assessments, where participants implemented concepts from each workshop. The assessment tasks were planning, implementing and evaluating clinical teaching. On completion of the workshops, twenty participants undertook a study tour in Australia to refine the teaching model and develop an action plan for model implementation in both organisations, with an aim to disseminate the model across Vietnam. Significant changes accredited to this project have been noted on an individual and organisational level. Dissemination of this clinical teaching model has commenced in Ho Chi Minh, with further plans for more in-depth dissemination to occur throughout the country.

An action research approach for the professional development of Vietnamese nurse educators

Nurse education in Viet Nam is undergoing substantial reform. In order to facilitate the change, in 2007 the Viet Nam Nurses Association formed a collaborative partnership with the School of Nursing and Midwifery at an Australia university. This collaboration gave rise to the Viet Nam Nursing Capacity Building Project under the leadership of Professor Genevieve Gray, funded by the Atlantic Philanthropies. The new four year competency based nursing curriculum frame is expected to be implemented in September 2011 following approval by the Viet Nam Ministry of Education. The focus of this paper is the Teaching Fellowships Program, an initiative of the Viet Nam Nursing Capacity Building Project, developed to help meet the challenges associated with leading and dealing with the curriculum change. The paper explores the development of the program and justifies an action research approach, illuminates key issues, and briefly refers to changes to the next fellowship program.