The Legislative Case Study Nursing Essay

Courtney Allford

School of Health Sciences

Introduction

A nurse practitioner is a registered nurse educated to a master’s degree level and authorised to function autonomously and collaboratively in an advanced and extended clinical role. (Government of Western Australia, 2013, para 1). The introduction and development of the profession has varied significantly all over the country, with changes occurring to the role regularly. The purpose of this assignment is to outline the historical data and the legislative developments of the Nurse Practitioner whilst contrasting this with other countries. Throughout the paper I will also discuss the legislation that lead to PBS and MBS access for Nurse Practitioners. To conclude I will discuss the socio-political factors opposing the development and implementation of the role whilst providing an evidence based rebuttal of the opposing parties viewpoints.

The role of the nurse practitioner is diverse and includes comprehensive assessment and management of clients in a variety of health care settings. The Nurse Practitioner uses their advanced nursing knowledge and skills to determine necessary referral of patients to other health care professionals as well as having the ability to prescribe medications and order diagnostic investigations (Government of Western Australia, 2011). According to the Australian College of Nurse Practitioners, (2009) "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" (para 5). The scope of practice of the nurse practitioner is clearly defined and is determined by the environment they are authorised to practice in (Australian College of Nurse Practitioners, 2009). The Nurse Practitioner is responsible for developing and following clinical protocols to guide their clinical decision making and assist them in determining effective treatments (Hyde, 2013, page 10).

It was identified that nurses, as professional practitioners are under-utilised in their capacity. This was said to be due to entrenched hierarchies and traditional roles. The induction of the nurse practitioners in Australia has been extremely arduous compared to other developed countries (Nurse Practitioner Association Australia, 2008, p7). However since 2010 when the first Nurse Practitioner was endorsed, Australia now has endorsed Nurse Practitioners in all states and territories (Australian Government of Western Australia, 2011, p9).

The development of the Nurse Practitioner originated in October 1990 in New South Wales due to a shortage of doctors particularly in remote and rural areas. The purpose of developing the Nurse Practitioner role was to fill the gaps in the health care system and to improve nurse retention by providing an improved clinical career pathway (Driscoll, Worrall-Carter, O'Reilly & Stewart, 2005, p.143). The first Nurse Practitioner Committee convened in 1990 where key stakeholders developed pilot projects to critically analyse the Nurse Practitioner models. In 1998, the Nurse Practitioner framework was circulated, and in December 2000, the first two Nurse Practitioner’s were Authorised to practice in Australia (Australian College of Nurse Practitioners, 2012, para 1).

In South Australia, the first nurse practitioner project was endorsed in 1999. South Australia differed to other states and territories in Australia and developed the role in review of the literature supporting the benefits of the Nurse Practitioner role. In December 2002, South Australia endorsed their first Nurse Practitioner (Driscoll, Worrall-Carter, O'Reilly & Stewart, 2005, p145).

Western Australia endorsed their first Nurse Practitioner in June 2003, followed by the Australian Capital Territory (ACT) in 2004. Victoria endorsed their first Nurse Practitioner in December 2004, and adopted an advanced nursing framework Nurse Practitioner model, which was focused on advanced nursing practice and decision making. Queensland endorsed their first Nurse Practitioner in July 2006 followed by the Northern Territory in September 2008 (Australian College of Nurse Practitioners, 2012, para 1).

In March 2003 the Australian College of Nurse Practitioners was formed and in March 2004, the Nurse Practitioner legislation amendment act 2003 was passed. This act established the legislative framework for the Nurse Practitioner role. In November 2005, the Australian Nursing and Midwifery Council endorsed Nurse Practitioner definitions and competency standards. These standards were implemented individually by each state and territory’s nursing and midwifery registration authorities (Australian College of Nurse Practitioners, 2012, para 1).

Under the National Law, the Nursing and Midwifery Board of Australia (NMBA) is responsible for the regulation of both the nursing and midwifery professions with support and collaboration by the Australian Health Practitioner Regulation Agency (AHPRA). AHPRA is the national registration authority that was developed in July 2010. Their purpose was to standardise the regulation and registration of health professionals and to eliminate individual state and territory regulatory policies (ACT Health, 2008 p.13).

The Board has developed and approved not only the registration standards that Nurses and Midwifes must meet, but also codes, guidelines and competency standards that form the Professional Practice Framework that outlines the requirements determining the professional practice of nurses and midwives in Australia (Nursing and Midwifery Board of Australia, 2010, p1)

Nurse Practitioners are regulated through the National Scheme under the authority of the Nursing and Midwifery Board of Australia (NMBA). The NMBA Board has developed national registration standards for endorsement of nurse practitioners. These registration standards outline the requirements for endorsement as a Nurse Practitioner (Nursing and Midwifery Board of Australia, 2010, p1). To practice in any state or territory in Australia the nurse practitioner must be endorsed by the NMBA and practice within a designated Nurse Practitioner area (Government of Western Australia, 2013, p10).

The nurse practitioner originated in the USA in the 1960’s. Like New South Wales and Victoria it was initially developed due to the shortage of doctors in underserviced areas. The role of the Nurse Practitioner supplementing the doctors proved beneficial, and they were seen to provide effective, safe, and accessible health care to the American population (Brown & Grimes, 1995, p337). Unlike Australia, nurse practitioners in the USA are registered in each individual state. This has seen a significant variation in educational qualifications, roles and responsibilities and a significant variation in the level of autonomy and authority that the Nurse Practitioner has was obvious. (Driscoll, Worrell-Carter, O’Reilly & Stewart, 2005, p 142). To date the Nurse practitioner has legislative authority to prescribe in 49 states of the USA and have also been granted reimbursement by Medicare (National Governors Association, 2002, p 444).

Similar to that of the USA, New South Wales and Victoria, in the UK, the nurse practitioner role was developed in the early due to the doctor shortage in particular areas (Horrocks, Anderson & Salisbury, 2002, p 821). A significant issue that the Nurse Practitioner faces in the UK is that the title nurse practitioner is not protected. As a result of this there are no specific standards or dedicated post graduate tertiary qualifications (Driscoll, Worrell-Carter, O’Reilly & Stewart, 2005, p 142). Australia differs in this respect as the nurse practitioner is a protected title which means the registered nurse requires authorisation by the specific regulatory body in the individual state/territory to practice (Nurse Practitioner Association Australia, 2009, p 10).

In Canada, the Nurse Practitioner role was developed in 1967 again to provide support to remote areas of the country (DiCenso et al., as cited in Driscoll, Worrell-Carter, O’Reilly & Stewart, 2005, p 142). Canadian Nurse Practitioners must also practice in collaboration with the multidisciplinary team and work within their scope of practice and within the Canadian Nurse Practitioner Core Competency Framework. Similar to Australia and the US, they also have the ability to prescribe medications and order diagnostic tests (College of Nurses of Ontario, 2011, p 4).

New Zealand endorsed their first Nurse Practitioner in 2001, to augment the general practitioners within the country (Waikato District Health Board, 2009, para 3). The Nurse Practitioner practices both independently and in collaboration with the multidisciplinary team to not only promote health and prevent disease, but they also have the ability to order, conduct and interpret diagnostic tests and prescribe medications (Nursing Council of New Zealand, 2008, para 1).

The Medicare Benefit Scheme (MBS) is an Australian Government initiative that outlines the Medicare benefit schedule that provides eligible health practitioners to a comprehensive list of the Medicare services subsidised by the Australian government (Australian Government- Department of Health and Ageing, 2013, para 1). The Pharmaceutical Benefits Scheme (PBS) is administered by the Department of Human Services and gives all Australian residents and eligible overseas visitors access to the prescription medications subsidised by the Australian Government (Medicare Australia, 2013, para 1).

The Nurse Practitioner Association Australia, (2009) para 10, suggested that there was a disjoint between state and national legislation surrounding nurse practitioners access to the Medical Benefits Scheme and the Pharmaceutical Benefits Scheme. This thereby limited their authority to practice and overall limiting the benefits to the patient.

On 1 November 2010, the Health Legislation Amendment (Midwives and Nurse Practitioners) bill 2012 was passes to enable eligible nurse practitioners and midwives access to some Medicare Benefits Scheme (MBS) listed items as well as access to a variety of medications under the Pharmaceutical Benefits Scheme (PBS) (Australian Government – Medicare, 2012, para 1). As a result of this change several other pieces of legislation including Health Insurance Act 1973, the Medical Indemnity Act 2002, the Medicare Australia Act 1973 and the National Act 1953 were also amended (Australian Government Comlaw, 2012 p 38-43). This legislation has been a significant breakthrough in the development of the Nurse Practitioner role and the overall benefit to the Australian community.

According to the (Australian Government – Department of human services, 2012, para 3), to be eligible for a Medicare provider number the Nurse Practitioner must;

Be registered under the National Registration Accreditation Scheme, and be endorsed as a nurse practitioner by the Nursing and Midwifery Board of Australia, OR be notated as an eligible midwife by the Nursing and Midwifery Board of Australia, AND be in private practice to access MBS services.

For a Nurse Practitioner to be eligible for a PBS prescriber number they must "Be registered under the National Registration Accreditation Scheme, AND be endorsed as a nurse practitioner by the Nursing and Midwifery Board of Australia, OR be notated as an eligible midwife who is qualified to prescribe by the Nursing and Midwifery Board of Australia" (Australian Government – Department of human services, 2012, para 4).

Prior to this legislation being past Nurse Practitioner experienced barriers in enabling them to provide the required level of care to their full potential. The main reason for this is that the patients that were utilising the services of a Nurse Practitioner were forced to pay full price for medications and services. These barriers made the public believe that the Nurse Practitioner was second rate care and the Nurse Practitioner role was significantly under valued (National Nursing and Nursing Education Taskforce, 2006, p 3).

In 2009, the Australian Medical Association (AMA) prepared the senate inquiry about Nurse Practitioners. In that submission they outlined many factors that they saw as significant issues with the implementation of the Nurse Practitioner role. They believe that the medical model of care is far more superior to the Nurse Practitioner model. The medical model of care is a General Practitioner led and focussed model with a Practice Nurse working for the General Practitioner. They believe that this model ensures collaborative practice and eliminates the development of a two tier effect on the health system. They also believe that it enables the Practice Nurse to utilise their skills by complementing the work of the doctor. Within this model the doctor continues to provide the overarching care and is entirely responsible and accountable for the patient outcomes (AMA, 2005, p3)

The Nurse Practitioner Association of Australia, (2009, p3) have outlined that the role of the Nurse Practitioner is not to replace the role of the General Practitioner, it is primarily to complement their role. One of the key differences between the doctor and the Nurse Practitioner is that the nurse practitioner "Is grounded in the nursing profession values, knowledge, theories" (ANMC, 2006, page 1). The Nurse practitioner is equipped with a higher degree of autonomy which provides them with the authority to not only determine practice but also to be more accountable for the care they provide by utilising a higher level of clinical decision making (The Australian Nurse Practitioner Association of Australia, 2009, p 10).

The Australian Medical Association have also suggested that the role of the Nurse Practitioner would place a significant amount of financial strain on the country as well as fragmenting care and increasing the risk of adverse patient outcomes (AMA, 2005, page 4). However, there is minimal evidence to support that the nurse practitioner provides a more costly and inferior service. In contrast studies suggest that adequately trained nurse practitioners can perform if not as well as, but better than doctors in some areas. (Gunn, 2008, para 8). Other studies have shown that the relative costs of Medical Professionals and Nurse Practitioners are similar (Hollinghurst, Horrocks & Anderson, 2006 p 531)

In 2009, the Australian Medical Association (AMA) suggested that the Midwives and Nurse Practitioner Bill provided insufficient detail on key areas. Those key areas included the definition and scope of practice of the Nurse Practitioner as well as the details of collaboration with the medical profession. Amendments were made to the bill in response to the AMA’s recommendations to ensure that all necessary key areas were included to ensure it was robust enough to govern the profession (Pesce, 2009, p3)

The Australian Medical Association (AMA), (2005, p1) believe that chronic disease management in the current population is on the rise and in order to treat these patients the practitioner requires "the exercise of significant judgement that goes well beyond the application of "technical skill"…..The required skills in these circumstances lie with the general practitioner, which are developed through many years of medical school, prevocational medical training, the GP training program and ongoing professional development activities. (Pesce, 2009, p 5). Another statement made by the president of the Australian Medical Association Dr Mukesh Haikerwal, (2005, p1) was that you can’t make up the expert skills and experience plus all the years of study and training that is required to become a doctor.

In contrast, the Nurse Practitioner is also a very highly skilled profession with initial Registered Nursing undergraduate degree training as well as up to four years of rigorous post graduate academic and clinical training, such as Masters in Nurse Practitioner. The core units for a Masters in Nurse Practitioner post graduate masters include but are not limited to advanced health and physical assessment, advanced diagnostics and pharmacology, (Hughes, 2010, 260). With this extensive training the Nurse Practitioner obtains the required knowledge and skill to practice safely as an endorsed Nurse Practitioner.

The Australian Medical Association (AMA), (2005, p5) have argued that they believe that they should not have the legal responsibility for errors or omissions in patient outcomes when caused by nurse practitioners that they do not have control over. The Australian Nurse Practitioner Association supported this statement and agreed that the Nurse practitioner is a complementary service, which

enhances collaboration with the multidisciplinary team (Hughes, 2010, p260).

As outlined in the Health Legislation Amendment (Midwives and Nurse Practitioners) 2010, the Nurse Practitioner renders a service in a collaborative with the medical practitioner (Parliament of the Commonwealth of Australia, 2010, p4).

Conclusion

Nurse practitioners are senior nursing professionals who work in specialty areas. They work within an extended scope of practice autonomously whilst ensuring collaboration with the multidisciplinary team including the Medical practitioner. There have been a considerable amount of legislative changes over the years to ensure that the Nurse Practitioner role is implemented and used appropriately to maximise patient outcomes. The endorsement of the Nurse Practitioners access to the MBS and PBS was seen as a significant development and has proved to have significant benefits for patients accessing the service. Some peak bodies still oppose of the implementation of the role, however there is significant evidence to support the role. This assignment focused on outlining the historical and legislative developments of the Nurse Practitioner whilst contrasting with other countries that have also endorsed the profession. It has also explored the legislation that lead to PBS and MBS access for Nurse Practitioners. Finally it discussed the socio-political factors opposing the development and implementation of the role with evidence against the opposing parties viewpoints.