Commentary on An evaluation of a community aged care nurse practitioner service. Journal of Clinical Nursing 14, 1202–1209

Authors

  • Debbie Kralik PhD, RN,

  • Katherine Trowbridge M Nrs Sc, RN ,

  • Anne Maddock BN, MSc, RN, RM


Debbie Kralik, Associate Professor, University of Adelaide, Senior Research Fellow, School of Nursing and Midwifery, University of South Australia, RDNS Research Unit, GPO Box 247, Glenside, South Australia, 5065. E-mail: dkralik@bigpond.net.au

This paper brings into debate many of the issues around the development and implementation of the Nurse Practitioner (NP) role in Australia. Not since the transition of nursing education to the tertiary sector in the early 1980s has there been an innovation in Australian contemporary nursing that has created the level of discussion, debate and examination that has been evident during the exploration and implementation of the NP role ( Department of Health Services 2002). Nursing is under the microscope as Edmunds (2000), an American academic and NP proposed that no other group of health-care providers has been so carefully evaluated and researched as the NP.

It is clear in Allen and Fabri's paper that the role of the NP is in its infancy and continuing to carve a niche in the Australian healthcare system. Broadly, NPs are registered nurses who have advanced and extended education and clinical experience in a defined area of health care. They are experienced nurses with the necessary nursing education that enables them to use the full scope of nursing practice to provide consumers (individuals, families, groups and/or communities) with health services (Government of South Australia 2004). The NP role is an expansive one as they have a high level of expertise, autonomous in practice, initiate and develop nursing policy change, provide vision and professional leadership, contribute to the advancement of nursing knowledge, identify and facilitate research, demonstrate social and political awareness and provide pragmatic and purposeful interventions that benefit health consumers (Department of Human Services 1999). To date, there are eight NPs in South Australia.

Research has demonstrated that NPs can provide safe and effective health care in a variety of settings and are able to work collaboratively within a healthcare team to provide high quality, advanced, cost effective and extended care (Geyman 1977, Trnobranski 1994, Way et al. 2001, Lenz et al. 2002, Laurant et al. 2004). They can enhance existing services and provide a service where none exist. The NP's role extends beyond the usual scope of nursing practice. The skills and practices often associated with a NP are:

  • advanced clinical assessment;
  • interpretation of pathology and diagnostic tests, including diagnostic imaging;
  • implementing and monitoring therapeutic regimes;
  • prescribing pharmacological interventions;
  • initiating and receiving appropriate referrals;
  • admitting and providing clinical privileges within acute facilities such as space in outpatient clinics (Department of Human Services 1999).

What are the issues? Debate continues amongst many Australian medics; some who have a conservative attitude to the role, others who support the role in the context of a primary health care and complementary team relationship approach with general practitioners, whilst other outspoken medics will not support the introduction of NPs (Gunn 1998, RACGP 1999, Usher 2005, Laurant 2005). The scope of medical practice appears threatened. Indeed the Laurant (2005) paper drew comparisons between the role of NPs and medicos. Does the NP role complement nursing or is it an extension of medicine? Clearly, in the criteria for the NP role, the emphasis is on the expansion of nursing practice and a complement to medicine rather than an invasion of medicine. The emphasis on the difference and goals of the two disciplines in relation to patient care requires firm commitment. The NP role will be irretrievably harmed by adoption of a medical model of care. It is clear that the authors of this paper believe the role of NPs to complement that of medicine rather than be subsumed within it. Herein lies an important issue; however, as Australian nurses embrace the NP role, there are few benchmarks to work from or experienced people to mentor them and hence it may be medics/physician or other health professionals who often perform the mentoring role. Neither the nurse nor the physician alone is adequately prepared to address the range of client needs (Geyman 1977). ‘Each is in command of a separate body of knowledge, although there is a shared scientific base of preparation and overlap in some functions’ (Geyman 1977 p. 936). This issue is directly related to the Governance Structure required for overseeing the quality and safety of practice of NP. The clinical governance structure for NPs would not be seen as separate from the normal structure evident in an organization; however, some organizations may not have established such processes such as clinical risk assessment and review, clinical protocol development, mentorship and support, clinical and admission privileges and ‘upskilling’ and maintenance of extended skills and knowledge. Has the tertiary sector taken up the challenge here? Currently, the tertiary sector has developed Masters Programs for preparation of NPs but do not have professional development follow-up programs.

The second issue is that of the need for marketing the NP role. Measures that can facilitate the development of individual nurse practitioners include: effective communication and negotiation regarding the introduction of their role, both into organizations and acceptance into the local community, marketing knowledge to ‘sell’ the role, communication expertise to promote longevity of the role, clearly defined and documented role descriptions, clarification regarding areas of risk and liability and organizational and professional support. Allen and Fabri's paper present some thorough and interesting research that highlights a need for further trials of community models to support NPs to further develop ‘others’ understanding of benefits to the role. The focus appears to be proof of ‘value for money’ and bottom line savings for community organizations to have a NP on staff. It can be difficult to measure the effectiveness or impact of NPs because quality of life can be attributed to multiple variables and health worker contact. Not every intervention can be reduced to dollars. The challenge here is to develop further an evaluative framework that can measure quality of life, and be inclusive of emotional, educational and physiological outcomes. These outcomes may then lead to extra government funding for NP services within the community, which to date has been a stumbling block for potential community NPs within South Australia.

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