Nurse practitioners advance against the odds

Pioneers tell of obstacles to innovation

More than a decade after their tentative introduction to the NSW health system, nurse practitioners are growing in number and confidence.

Pilot projects started in 1994 and NPs were officially accepted into the health system five years ago.

There are now 70 authorised NPs and two midwife practitioners. A further 20 nurses are in transitional positions and working towards authorisation by the NSW Nurses and Midwives Board. About 70 nurses are studying NP post-graduate courses.

NPs are controversial because they extend the nursing role into the diagnosis and treatment of diseases, ordering diagnostic tests, accepting referrals and referring patients to other health professionals.

Early NPs who pioneered the role met strong opposition and found the going tough. Some still do, while others say their personal battle for acceptance is over.

Ten pioneer NPs have told their stories to neonatal RN Jann Foster, who is researching the nurse practitioner movement in NSW for her PhD at the University of Western Sydney School of Nursing.

‘The pioneers met many obstructions, though these have tended to decrease over time,’ Jann says. ‘One of them told me: “The battle’s over for me – I’ve finally won”.’

Jann warns, however, that the pioneers’ experience indicates the creation of a NP-friendly health system will be a marathon, not a sprint. Major obstacles remain.

In an interview with The Lamp, Jann drew on her research with pioneering NPs to discuss lessons from their experiences. Some of the barriers faced by early NPs are identified in the following excerpts from the interview.

Public scepticism

‘The public generally still see nurses in the roles they performed 20 years ago. Most people are unaware that nurses’ roles have changed in response to the changing needs of the health care system brought about by such things as new technology, faster turnover of patients, and the greater incidence of chronic disease. The public still see us as being supervised by doctors and this is reinforced by images through TV programs such as All Saints.

Lack of provider status

‘NPs are legally able to prescribe medication but have no access to the pharmaceutical Benefits Scheme (PBS) that subsidises the cost of prescriptions. This is a major problem for the community.

‘Patients must pay more for a NP’s prescription than one written by a doctor. NP patients in remote areas may be forced to choose between paying extra for a prescription or travelling hundreds of kilometres to see a GP.

‘The PBS issue also affects NPs in emer-gency departments. When they prescribe a drug the hospital – rather than the federal government – has to cover the cost. Some NPs who have run out of their meagre stocks of medications after just a few days, have been told by their hospital, ‘That’s it, we have no funding for more medications.

‘NPs are sometimes given starter packs to get a patient started on a course of antibiotics. The patient then has to see a doctor to get another script in order to finish the course. Some patients have used the starter packs then stopped the medication – with all the ramifications of not finishing a course of antibiotics.

‘In the US, where the NP movement is far more advanced, NPs undertook an aggressive lobbying campaign among legis-lators and finally won provider status in 1997.

Doctor resistance

‘The Australian Medical Association continually claims that NPs offer a second-class service. The AMA puts out more press releases attacking the concept of NPs the more they see NPs gaining a foothold.

‘Many NPs said they were acutely aware of the responsibility of being pioneers, and felt if they did anything wrong it would be seized on by the doctors.

‘NPs work within clinical guidelines which have been a major area of contention. Initially, the process of developing the guidelines was laborious, partly because it involved the AMA, which is opposed to the very concept of NPs who aren’t supervised by doctors. Some doctors attempt to limit NPs’ practice by opposing their clinical guidelines.

Relations with other nurses

‘The introduction of NPs alters working relationships within health care teams, including relations between NPs and other nurses. Some NPs identified a lack of trust from nursing colleagues who questioned their expertise.

‘For example, some nurses insisted on verifying orders written by an NP with a doctor, thereby undermining the confidence and effectiveness of the NP.

‘NPs said they constantly had to explain their roles to other nurses. They needed to explain that a NP is an expansion of nursing practice rather than a move into a medical practitioner’s role. In other words, working from a nursing model not a medical model. ‘They had to combat the view that the only people who should be diagnosing or ordering diagnostics or prescribing medication, are doctors. ‘NP positions initially received special funding. However, some Area Health Services eliminated vacant part-time senior nursing positions in the process of creating NP positions. Or they replaced a CNC position with an NP position, which created tension between nurses.

Key role of managers

‘Health care managers play a critical role in developing sustainable NP roles. Yet in the early days, minimal thought was given to the importance, needs and role of managers in successfully introducing NPs.

Managers of NPs need support themselves. They rely on support networks to share insights, information, experiences, challenges and difficulties.

Some pioneer NPs experienced amazing obstruction from some managers. One patient on their way to see a NP told the manager, ‘I’m here for a consultation with the NP’ and the manager replied, ‘Over my dead body!’

‘NPs also met obstruction from managers in developing clinical guidelines. For example, being told the Area Health Service could only afford one guideline – for example, for the pill or the morning-after pill, but not both.

‘One of the early NPs was asked by her area management to define how much of her time was spent as a NP and how much as a RN. This showed a complete lack of understanding of the NP role.

‘If managers don’t fully understand what the role is it is very hard for them to know how to use the NP properly.

Lack of support and resources

‘Many of the NPs were not accustomed to developing clinical guidelines, they had to learn that for themselves.

‘One nurse authorised to work as a NP never managed to take up the position because she could not get her clinical guidelines up and running – there was just no support. Another NP in a small country town suffered so much obstruction she’s no longer working as a NP, and no one has replaced her.

‘Pioneer NPs reported that a lack of office space, facilities and resources had a detrimental affect on their practice. More than one NP had to share a room and conduct consultations with patients while other staff were present.

‘A lack of space was identified as leading to increased patient waiting times, wasted clinician time and a decrease in NP-patient interaction time.

‘NPs were forced to search for a phone to return calls, many did not even have their own desks and had insufficient storage for confidential documents.’

Evolving role

Jann stresses that while these barriers were identified by pioneer NPs, the role will continue to evolve over time.

‘Today nurses who succeed in becoming NPs have more support available to them, and many of the issues raised have been, or continue to be addressed,’ Jann says.