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

Mapping workforce configuration and operational models in Australian emergency departments: a national survey

Objective Hospital emergency departments (ED) in Australia and internationally have been experiencing increased demand, resulting in reduced hospital quality, impaired access and adverse health outcomes. Effective evaluation of new ED service models and their effect on outcomes is reliant on baseline measures of the staffing configuration and organisational characteristics of the EDs being studied. The aim of the present study was to comprehensively measure these variables in Australian EDs. Methods Australian hospital EDs with 24-h medical and nursing cover were identified and invited to participate in the study. Telephone interviews were conducted with nursing or medical department managers to collect data related to hospital characteristics, ED workforce and training and ED service and operational models. Results Surveys were completed in 87% of the population sample (n = 135). Metropolitan EDs were significantly more likely to retain higher full-time equivalents (FTEs) in several medical (staff specialist, registrar, resident and intern) and nursing (nurse practitioner (NP), nurse educator, nurse unit manager and registered nurse) positions. NPs were employed by 52% of Australian EDs overall, but this ranged from 40% to 75% depending on jurisdiction. The most commonly used operational models were FastTrack teams (72% of EDs), short-stay/observational unit (59%) and patient liaison models for aged care (84%) and mental health (61%). EDs that employed NPs were significantly more likely to use FastTrack (P = 0.002). Allied health services most frequently available within these EDs were radiology (60%), social work (69%), physiotherapy (70%) and pharmacy (65%). Conclusions The present study has established a baseline measure of the staffing configuration and organisational characteristics of Australian EDs. What is known about the topic? EDs are overcrowded due, in part, to the combined effect of increased service demand and access block. Innovative service and workforce models have been implemented by health departments aiming to improve service and performance. National uptake of these service and workforce innovations is unknown. What does this paper add? The present study is the most comprehensive to date profiling Australian EDs covering hospital characteristics, workforce configuration, operational models and NP service patterns and practice. What are the implications for practitioners? Information from the present study will assist health service planners to evaluate workforce and service reform models, and to monitor trends in emergency service development. </jats:p

Diagnostic Accuracy of Fine Needle Biopsy for Metastatic Melanoma and Its Implications for Patient Management

The use of fine needle biopsy (FNB) for the diagnosis of metastatic melanoma can lead to the early removal and treatment of metastases, reduce the frequency of unnecessary surgery, and facilitate the staging of patients enrolled in clinical trials of adjuvant therapies. In this study, the accuracy of FNB for the diagnosis of metastatic melanoma was investigated. A retrospective cohort study was performed with 2204 consecutive FNBs performed on 1416 patients known or suspected to have metastatic melanoma. Almost three-quarters (1582) of these FNBs were verified by either histopathologic diagnosis following surgical resection or clinical follow-up. FNB for metastatic melanoma was found to have an overall sensitivity of 92.1% and a specificity of 99.2%, with 69 false-negative and 5 false-positive findings identified. The sensitivity of the procedure was found to be influenced by six factors. The use of immunostains, reporting of the specimen by a cytopathologist who had reported >500 cases, lesions located in the skin and subcutis, and patients with ulcerated primary melanomas were factors associated with a significant improvement in the sensitivity of the test. However, FNBs performed in masses located in lymph nodes of the axilla and FNBs that required more than one needle pass to obtain a sample were far more likely to result in false-negative results. FNB is a rapid, accurate, and clinically useful technique for the assessment of disease status in patients with suspected metastatic melanoma

The Australian nursing workforce survey toolkit

The nursing workforce is an essential, complex and multi-layered component of health service organisations. Nursing service leaders and policy makers need to understand the structure and service potential of their workforce to effectively plan and optimise nursing resources in line with organisational goals. To date, these service leaders have been reliant upon staff records or population level knowledge from published research to inform their decision making and service planning. The Australian Nursing Workforce Survey Toolkit will enable nursing service leaders to develop real time, reliable knowledge of the practice profiles and service potential of the nursing workforce in their organisation or jurisdiction

The work of nurse practitioners

Aim: This paper is a report of a study of variations in the pattern of nurse practitioner work in a range of service fields and geographical locations, across direct patient care, indirect patient care and service-related activities. Background. The nurse practitioner role has been implemented internationally as a service reform model to improve the access and timeliness of health care. There is a substantial body of research into the nurse practitioner role and service outcomes, but scant information on the pattern of nurse practitioner work and how this is influenced by different service models. --------- Methods: We used work sampling methods. Data were collected between July 2008 and January 2009. Observations were recorded from a random sample of 30 nurse practitioners at 10-minute intervals in 2-hour blocks randomly generated to cover two weeks of work time from a sampling frame of six weeks. --------- Results: A total of 12,189 individual observations were conducted with nurse practitioners across Australia. Thirty individual activities were identified as describing nurse practitioner work, and these were distributed across three categories. Direct care accounted for 36.1% of how nurse practitioners spend their time, indirect care accounted for 32.2% and service-related activities made up 31.9%. --------- Conclusion. These findings provide useful baseline data for evaluation of nurse practitioner positions and the service effect of these positions. However, the study also raises questions about the best use of nurse practitioner time and the influences of barriers to and facilitators of this model of service innovation

Efficacy of incontinence-associated dermatitis intervention for patients in intensive care: Open-label pilot randomized controlled trial

OBJECTIVE To determine the feasibility of an adequately powered trial testing a long-acting cyanoacrylate skin protectant to prevent incontinence-associated dermatitis in critically ill patients. METHODS This open-label pilot randomized controlled feasibility study was conducted in the adult ICU of an Australian quaternary referral hospital. Patients were allocated to either an intervention group or a control group (usual care). The intervention was the application of a skin protectant (a durable, ultra-thin, transparent, waterproof, no-removal barrier film). Data collected by trained research nurses included demographic and clinical variables, skin assessment, and incontinence-associated dermatitis presence and severity. Data were analyzed using descriptive and inferential statistics. RESULTS Of the 799 patients screened, 85% were eliminated because of a short ICU stay or other exclusion criteria. The mean proportion of patients not meeting any of the exclusion criteria was 22% on each screening day. Protocol fidelity was followed for 90% of intervention participant study days. Retention of participants was 86% (31 participants out of 36), 15 in the intervention group and 16 in the control group. Enrolled patients had a mean age of 59 years, 50% were obese, 67% were male, and 36% were smokers. Two patients (11%) in the intervention group developed incontinence-associated dermatitis, compared with three (17%) in the control group. CONCLUSIONS This study reports no significant findings between the two groups. Difficulty in recruitment and feasibility issues might be overcome with changes to inclusion criteria and study design.</p

An interventional skin care protocol (InSPiRE) to reduce incontinence-associated dermatitis in critically ill patients in the intensive care unit: A before and after study

Aim This study aimed to test the effectiveness of a bundle combining best available evidence to reduce the incidence of incontinence-associated dermatitis occurrences in critically ill patients. Methods The study used a before and after design and was conducted in an adult intensive care unit of an Australian quartenary referral hospital. Data, collected by trained research nurses, included demographic and clinical variables, skin assessment, incontinence-associated dermatitis presence and severity. Data were analysed using descriptive and inferential statistics. Results Of the 207 patients enrolled, 146 patients were mechanically ventilated and incontinent thus eligible for analysis, 80 with 768 days of observation in the after/intervention group and 66 with 733 days of observation in the before group. Most patients were men, mean age 53 years. Groups were similar on demographic variables. Incontinence-associated dermatitis incidence was lower in the intervention group (15%; 12/80) compared to the control group (32%; 21/66) (p = 0.016). Incontinence-associated dermatitis events developed later in the intensive care unit stay in the intervention group (Logrank = 5.2, p = < 0.022). Conclusion This study demonstrated that the use of a bundle combining best available evidence reduced the incidence and delayed the development of incontinence-associated dermatitis occurrences in critically ill patients. Systematic ongoing patient assessments, combined with tailored prevention measures are central to preventing incontinence-associated dermatitis in this vulnerable patient group

Does education level influence the practice profile of advanced practice nursing?

Background Advanced practice nursing is recognised globally as central to meeting this community need. Whilst there is increasing recognition that advanced practice nurses should be educated to at least a master degree level, there is scant evidence on the influence of higher education on the practice profile of advanced practice nursing. Aim To investigate the relationship between level of education and domain practice scores of nurses in advanced practice roles. Methods The validated Advanced Practice Nursing Role Delineation (APRD) tool was used to measure the practice profile of advanced practice nurses at different postgraduate education levels, across five domains of nursing practice activities. A cross-sectional electronic survey of nurses was used. Findings APNs with higher degrees performed at a higher level across all five domains of the APRD tool compared to those who did not hold a higher degree. This was highly significant for the domains of Research and Leadership, followed by the Optimising Health Systems and Education domains, but not significant for the Direct Care domain. Discussions Questions are often raised about the benefits of investing in nurses’ education, particularly the need for a higher degree for advanced practice nurses. APNs with higher degrees have a different emphasis in their role activities than those without a higher degree. This difference could be significant given current global health challenges. Conclusion Higher education changes the practice profile of APNs. Those with higher education are more likely to be involved in research and leadership with knowledge integration across all practice domains

Identifying advanced practice: A national survey of a nursing workforce

Background The size and flexibility of the nursing workforce has positioned nursing as central to the goals of health service improvement. Nursing's response to meeting these goals has resulted in proliferation of advanced practice nursing with a confusing array of practice profiles, titles and roles. Whilst numerous models and definitions of advanced practice nursing have been developed there is scant published research of significant scope that supports these models. Consequently there is an ongoing call in the literature for clarity and stability in nomenclature, and confusion in the health industry on how to optimise the utility of advanced practice nursing. Objectives To identify and delineate advanced practice from other levels of nursing practice through examination of a national nursing workforce. Design A cross-sectional electronic survey of nurses using the validated Advanced Practice Role Delineation tool based on the Strong Model of Advanced Practice. Participants Study participants were registered nurses employed in a clinical service environment across all states and territories of Australia. Methods A sample of 5662 registered nurses participated in the study. Domain means for each participant were calculated then means for nursing position titles were calculated. Position titles were grouped by delineation and were compared with one-way analysis of variance on domain means. The alpha for all tests was set at 0.05. Significant effects were examined with Scheffe post hoc comparisons to control for Type 1 error. Results The survey tool was able to identify position titles where nurses were practicing at an advanced level and to delineate this cohort from other levels of nursing practice, including nurse practitioner. The results show that nurses who practice at an advanced level are characterised by high mean scores across all Domains of the Strong Model of Advanced Practice. The mean scores of advanced practice nurses were significantly different from nurse practitioners in the Direct Care Domain and significantly different from other levels of nurse across all domains. Conclusions The study results show that the nurse practitioner, advanced practice nurse and foundation level registered nurse have different patterns of practice and the Advanced Practice Role Delineation tool has the capacity to clearly delineate and define advanced practice nursing. These findings make a significant contribution to the international debate and show that the profession can now identify what is and what is not advanced practice in nursing