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Alternative Law Journal |
Steven Siegloff Clark
Steven Siegloff Clark is a final year
graduate student in law at Flinders University, Adelaide.
The author would like to thank Lesley Hills Siegloff for her
expert assistance in research for this article. Lorelei Siegloff was invaluable
during the early drafting of the article.
The crisis in rural health care has been of major concern for many years.
In spite of overly generous incentive packages, doctors still refuse to serve
rural and remote communities in the numbers needed. One response is to empower
nurses in those communities to fulfil a larger role.
In a move to provide more services to neglected rural areas, the NSW State
government has enacted the Nurses Amendment (Nurse Practitioners) Act
1998 (NSW) which provides for recognition and accreditation of Nurse
Practitioners in NSW. The legislation provides for Nurse Practitioners to be
given limited prescribing privileges.
The first Nurse Practitioner program in the United States of America was
established in 1965 in response to health care reforms, including the
development of new models of care incorporating advance practice nursing. By
1991 Nurse Practitioners in the USA had prescribing privileges in 36 States,
with enabling legislation pending or to be introduced in the
rest.[1]
It was recognised that Nurse Practitioners have more time to work with
patients than do doctors, and nurses suggest that they have a more holistic and
preventive approach to health care than doctors, who tend to ‘view the
patient as a bagful of
organs’.[2]
The American Medical Association has expressed concern about doctors losing
control over nurses, and argues that nurses do not have the necessary depth of
education to make clinical decisions. In response, nurses argue this supervisory
relationship only increases doctors’ liability and nurses are quite
capable of referring cases beyond their expertise to medical
practitioners.[3]
Britain is particularly interested in streamlining health care
services.[4] Community nurses there
were given limited prescribing rights in 1994 through a process similar to that
enacted in NSW; legislation was considered an acknowledgment of practices that
had existed for many years (that is, wound diagnosis and treatment).
British studies report that ‘feelings of increased status and
autonomy were mentioned by many nurses now that they could work independently of
the GP and were seen to be taking responsibility for decisions made’.
Patients reported higher satisfaction with health care services as they were no
longer required to seek out a medical practitioner for prescriptions for simple
drug preparations having already been treated by the community
nurse.[5]
During the 14 months to the end of 1995, ten projects were undertaken
across NSW, in remote and rural areas with identified need. One remote area was
in fact in metropolitan Sydney, a homeless men’s centre in which doctors
would not work. Other projects included Urana, a developing Multi-Purpose
Service, and Wilcannia, a remote Aboriginal centre.
The final report found that the projects were highly successful. Reference
committees at the individual project level and for the final report included
representatives from nursing organisations, the Australian Medical Association
(AMA), independent doctors, and consumer organisations. They were unanimous in
their recommendations, including an amendment to the legislation to create the
role of the Nurse Practitioner.
Having supported the projects and the subsequent report, the NSW Branch of
the AMA then came out against the proposed Nurse Practitioner role, as some
members began to express concern about loss of power.
The Nurses Act 1991 (NSW) was amended by inserting s.19A to enable
any registered nurse to apply to the Nurses Registration Board ‘for
authorisation to practise as a Nurse Practitioner’. The Board can only
authorise a person who has ‘sufficient qualifications and experience to
... practise as a Nurse Practitioner’, and authorisation is for a period
‘not exceeding 3 years’.
Under s.78A the Director-General of the NSW Department of Health may
approve guidelines for the functions of Nurse Practitioners; the guidelines can
address anything the Director-General considers appropriate, and they may have
different application to different Nurse Practitioners. Breaches of the
guidelines may lead to disciplinary action.
For accreditation as a Nurse Practitioner in NSW, a registered nurse must
have post-registration qualifications enabling them to practise as an expert in
their chosen speciality, and must be involved in ongoing professional
development. They must also demonstrate 5000 hours in a current advanced
practice role, meeting the competencies of an advanced nurse clinician and the
standards of their chosen specialty.
Further, they must have the skills and knowledge relevant to the privileges
associated with the specific context of the practice in question. Importantly,
these include clinical assessment and pharmacological
knowledge.[6]
Although any nurse registered in NSW may apply for accreditation as a Nurse
Practitioner, they will not be able to practise as a Nurse Practitioner in the
public sector except in an approved Nurse Practitioner position.
Only the Director-General of the Department of Health, NSW, has the
authority to grant positions with the title of Nurse Practitioner, and only
after an extensive consultation process to establish a ‘local agreed
need’. Only approved Nurse Practitioner positions can require incumbents
or applicants to have Nurse Practitioner
accreditation.[7]
This limits the potential for educational institutions to teach specific
Nurse Practitioner skills, because graduates would not be able to use that
advanced knowledge in practice unless and until they were appointed to a
designated position. This limits how nurses can acquire advanced skills, and how
they can gain the experience needed to meet the requirements of Nurse
Practitioner accreditation.
Nurse Practitioners may prescribe such poisons or restricted substances
within the guidelines, but they cannot be authorised to prescribe drugs of
addiction as defined in the Poisons and Therapeutic Goods Act
1966.
It is contemplated that Nurse Practitioners would be authorised to
prescribe drugs which relate to the specific needs of their practice, such as
asthma medications, pain killers, antibiotics, stomach ulcer drugs and
anti-nausea drugs. Medications for more serious conditions would be prescribed
by a medical practitioner.
Nurse Practitioners practise under ‘standing orders’; they do
not have prescriber numbers. Standing orders are put in place by registered
doctors, and may include limited medication prescription to be authorised within
24 hours after administration.
The NSW scheme has been designed to mollify medical practitioners scared of
losing power to nurses. It creates positions in country and remote areas only,
where there is a clear a lack of medical practitioners, rather than being
recognition of the advanced skills of the nurses.
Having practised in the role of Nurse Practitioner and received the
accreditation of that role, once the incumbent resigns from the designated
position they are no longer allowed to refer to themselves as a Nurse
Practitioner. In fact they are no longer accredited for the title. The
legislation recognises the position and not the nurse.
The relevant Area Health Service is responsible for funding the position
and overseeing compliance with policies and procedures. Nurse practitioners are
not remunerated at levels approaching that of an equivalent rural or remote
medical practitioner. This makes them an attractive option for Area Health
Services struggling to provide adequate services on tight budgets.
Some nurses are concerned that the Nurses Board as a registration body is
not the appropriate organisation for accreditation. The Royal College of
Nursing, Australia is considered by some to be the more appropriate body for the
development and implementation of credentials pertinent to advanced practice
nursing. This would accord with the practice of accreditation of specialists
within the medical profession, such as by the Royal Australian College of
Surgeons.
The Nurse Practitioner Amendment has led to some extraordinary hostility in
the rural health community. A demarcation dispute has arisen within parts of the
medical community. The debate about prescribing power and nurses has been
ongoing for some years, with support and dissent from all sides, but has boiled
over in the face of this new legislation.
According to the AMA’s Position Statement on Nurse Practitioners,
released in 1994, medical education and training are prerequisites for medical
practice. The AMA says that nurses and Nurse Practitioners’ lack of
medical education and training precludes them, other than under medical
supervision, from requesting pathology tests, making medical diagnoses,
requesting X-rays or other investigations, prescribing medication, referring
patients to specialists, deciding on the hospital admission and discharge of
patients.[8]
This presumes that nurses in advanced practice do not, indeed cannot,
acquire medical education and training to qualify them to perform a limited
range of medical tasks. This cannot be true; it must also be possible for a
nurse with several years experience working in an advanced role to learn these
skills.
The Rural Doctors Association has proved the most outspoken critic of this
legislation. They have used similar rhetoric to the AMA, but have been more
emotive in their language. For example: ‘We now have the ridiculous
situation where nurses can order investigations and medication but young fully
qualified doctors
cannot’.[9]
The concern is about loss of doctors’ revenue and loss of control
over nurses. In current professional practice, doctors and nurses work in
collaboration.[10] The NSW pilot
projects included a homeless men’s centre in metropolitan Sydney,
identified as an area of need precisely because doctors would not work there.
Rather than being an issue of clinical competency, this dispute is about
demarcation of roles and what medical practitioners perceive to be the proper
role of nurses. The notion that nurses only follow doctors’ orders is no
longer acceptable, nor relevant in practice.
Doctors do not ‘permit’ nurses to do anything: it is the law
that does. For doctors to say that it is ‘permissible’ for a nurse
to perform a limited range of medical functions, especially in health care
settings where medical practitioners don’t want to go, is condescending
and derogatory of the role of nurses in the health care system.
Nurses do more than follow the directions of medical practitioners. They
make clinical decisions, and are trained to do so. Medical practitioners are not
present 24 hours a day on wards, in hospices or in other continuous care
environments. Nurses are, and must therefore be able to make clinical decisions
and act on them.
Even when a medical practitioner is required, usually in emergencies,
nurses must act to ensure the doctor has a patient to treat on their arrival.
Every senior nurse has years of experience, often more than the doctor in
attendance, and it is not uncommon for doctors to rely on advice from nurses in
the course of their diagnosis and subsequent treatment.
Nurses are legally responsible for their actions, and have been sued for
negligence. They have an ethical and professional responsibility to act in the
best interests of their patient and are responsible to the patient, not the
doctor. Nurses can refuse to follow treatment plans they consider not to be in
the patient’s best
interests.[11] This is viewed by
some doctors as a control issue, rather than a difference of professional
opinion.
The Doctors Reform Society supports advanced practice nurses having the
capacity to prescribe.[12] The
Society demonstrates a better knowledge of the current literature and practice
of Nurse Practitioners in Australia and overseas than does, say, the AMA. It
recognises that far from undermining doctors, Nurse Practitioners free up
doctors’ time, enabling them to focus on more serious cases and patients
requiring higher levels of medical expertise. The existing collaboration between
advanced practice nurses and medical practitioners, especially in rural areas,
reduces costs and improves standards of care for the patients.
The biggest supporters of the legislation are nurses’ organisations
and State governments. Nurses are enthusiastic about the opportunity to receive
recognition for advanced practice. State governments are enthusiastic about
reduced health care costs and provision of extended services in rural and remote
areas.
The National Rural Health Alliance includes medical, nursing and community
health organisations with members in rural and remote area health care services.
It has endorsed the development and recognition of advanced practice roles for
rural and remote services. The Alliance has emphasised the need for
collaboration between health professions, adequate education and training for
nurses, the need for uniform provisions for advance practice across Australia,
and clear guidelines, policies, or protocols to assist Nurse Practitioners
exercising prescribing
privileges.[13]
While other States have yet to legislate for Nurse Practitioners, Victoria,
South Australia and Tasmania are currently undertaking Nurse Practitioner
trials, and Western Australia has recently indicated that they will have trials
in the near future.[14]
These projects are independent of the NSW projects in definition and
detail. A major concern of the nursing profession is the lack of national
uniformity in defining the role of the Nurse Practitioner and how that role
translates across State boundaries. The NSW legislation is written such that a
Tasmanian trained and accredited Nurse Practitioner, for example, would find
themselves in breach of the Act should they attempt to transfer their practice
to NSW.
Towards the end of 1998 several hundred nurses were involved in private
practice in South Australia. Services offered include diabetes education,
primary health, occupational health and training, child health, case management,
complementary therapies and women’s health. For the past 20 years Family
Planning Australia has provided Nurse Practitioner training in sexual and
reproductive health. Most of their graduates work as Nurse Practitioners in
rural and remote SA and NT.[15]
Until recently there has been little formal recognition of these advance
practice roles.
South Australia is actively developing communication and collaboration
between health professions, and recognises that many nurses are already working
in advanced practice roles.[16] In a
move towards formal recognition, the SA Human Services Division
(formerly the Health Commission) has established the ‘Nu Prac’
Project, involving three pilot projects with strong support from government, the
pharmaceutical industry, hospitals, and health care organisations. The Project
is informed by Nurse Practitioner projects in NSW and overseas, and is broader
in scope than the NSW model.
The pilots are focused on epilepsy management in the community, palliative
care in nursing homes and hostels, and cervix screening in rural areas, and have
proved extremely successful to date.
There has been a mixed reaction to the recognition of Nurse Practitioners
in NSW. Some medical practitioners feel threatened by the role, others are more
open to it. Governments recognise the cost-benefits and possibilities for
extending health services into rural and remote areas which Nurse Practitioners
can offer.
Nurses have been working in advanced practice roles, particularly in rural
and remote areas, for some time. The opportunity to prescribe a limited range of
medications enhances their services, and improves the efficacy and efficiency of
health care services overall.
Recognition and development of these roles, and the specialised skills of
the nurses who perform them, is both timely and appropriate.
References
[1] Office of the Chief Nurse,
The Nurse Practitioner Role in the South Australian Health System, South
Australian Health Commission, 1998, p.1; ‘What is a Nurse
Practitioner?’ (1991) Nurse Practitioner
News.
[2] Gentry, Coral,
‘Nurse Practitioners Fill Primary Care Gap’, St Petersburg
Times, 2 June 1993, p.663.
[3]
Gentry, above, p.663.
[4] Luker,
K., Austin, L., Hogg., C., Ferguson, B. and Smith, K., Nurses Prescribing: The
Views of Nurses and Other Health Care Professionals, (1997) 2(2) British
Journal of Community Health Nursing
69.
[5] Luker and others, above,
p.71.
[6] NSW Department of Health,
Nurse Practitioner Services in NSW, NSW Department of Health, 1998,
p.2.
[7] Meppem, J., Chief Nursing
Officer, NSW Department of Health, NSW Nurse Practitioner — Some
Facts, 11 November 1998.
[8]
Australian Medical Association, Position Statement, ‘Nurse
Practitioners’, 1994.
[9]
White, Geoff, National President of RDA, in a facsimile to G. Gordon, CEO of
National Rural Health Alliance, 25 March 1998, in response to the NRHA’s
media release re nurses diagnosing and
prescribing.
[10] Breen, K.,
Plueckhahn, V. and Cordner, S., Ethics, Law and Medical Practice, Allen
& Unwin, 1997, p.166.
[11]
Breen and others, above,
p.166.
[12] Gunn, Andrew,
‘Nurse Practitioners Are a Benefit Not a Threat’, Doctors’
Reform Society of Australia column, Australian Doctor, 13 March
1998.
[13] National Rural Health
Alliance, Advanced Nursing Practice, Rural and Remote, in SA Department of Human
Services, Nurse Practitioner Project Newsletter 2, March
1999.
[14] Robertson, Jeanette,
Nurse Practitioner Project in Western Australia, in SA Department of Human
Services, Nurse Practitioner Project Newsletter 2, March
1999.
[15] Office of the Chief
Nurse, The Nurse Practitioner Role in the South Australian Health System,
South Australian Health Commission, 1998,
p.2.
[16] Averis, A., Brown, J.
and White, D., Nurse Practitioners: What’s Happening in South
Australia? Office of the Chief Nurse, SAHC, 1997, p.5.