This is the author-version of article published as:
Gardner, G and Carryer, J and Gardner, A and Dunn, S (2006)
Nurse Practitioner competency standards: findings from
collaborative Australian and New Zealand research. International
Journal of Nursing Studies 43(5):pp. 601-610.
Accessed from http://eprints.qut.edu.au
Copyright 2006 Elsevier
Title: Nurse Practitioner competency standards: findings from collaborative
Australian and New Zealand research
Authors: * Glenn Gardner RN, PhD FRCNA
Professor of Clinical Nursing
Queensland University of Technology and Royal Brisbane and Women’s Hospital
Jenny Carrier RN, PhD FCNA(NZ) MNZM
Professor of Nursing
Massey University and Mid Central District Health Board
Anne Gardner RN, PhD MRCNA
Associate Professor in Nursing
Deakin University and Cabrini Health
Sandra Dunn RN, PhD FRCNA
Professor of Clinical Nursing Practice
Flinders University and Flinders Medical Centre
Contact Author: * Professor Glenn Gardner
School of Nursing
Queensland University of Technology
Victoria Park Road
Kelvin Grove, Queensland 4059
Phone: +61 7 3636 5395
Fax: +61 7 3636 1557
This project was sponsored by the Australian Nursing and Midwifery Council and the
Nursing Council New Zealand. We also wish to acknowledge the contribution of the nurse
practitioners and the nurse practitioner course coordinators in Australia and New Zealand
who all generously gave of their time to participate in the study.
Background: The title, Nurse Practitioner, is protected in most jurisdictions in Australia
and in New Zealand and the number of nurse practitioners is increasing in health services in
both countries. Despite this expansion of the role there is scant national or international
research to inform development of nurse practitioner competency standards.
Objectives: The aim of the study was to research nurse practitioner practice to inform
development of generic standards that could be applied for the education, authorisation and
practice of nurse practitioners in both countries.
Design: The research used a multi-methods approach to capture a range of data sources
including research of policies and curricula, and interviews with clinicians. Data were
collected from relevant sources in Australia and New Zealand
Settings: The research was conducted in New Zealand and the five states and territories in
Australia where, at the time of the research, the title of nurse practitioner was legally
Participants: The research was conducted with a purposeful sample of nurse practitioners
from diverse clinical settings in both countries. Interview and material data were collected
from a range of sources and data were analysed within and across these data modalities.
Results: Findings included identification of three generic standards for nurse practitioner
practice namely, Dynamic Practice, Professional Efficacy and Clinical Leadership. Each of
these standards has a number of practice competencies, each of these competencies with
their own performance indicators.
Conclusions: Generic Standards for nurse practitioner practice will support a standardised
approach and mutual recognition of nurse practitioner authorisation across the two
countries. Additionally these research outcomes can more generally inform education
providers, authorising bodies and clinicians on the standards of practice for the nurse
practitioner whilst also contributing to the current international debate on nurse practitioner
standards and scope of practice.
Key words; Nurse practitioner, capability, practice competencies, practice standards
What this paper adds
What is already known on this topic?
• • Development of the nurse practitioner role around the world has been dogged by
inconsistency in terms of role definition.
• • There is no evidence in the literature of the development of research-informed
competency standards for the nurse practitioner.
• • The literature on practice competencies is scant with most of the information being
related to competencies for advanced practice or clinical nurse specialist roles and
few of these are informed by empirical research.
What do we now know as a result of this study?
• • The competency framework that defines the expectations of nurse practitioner
practice is structured across three generic Standards namely, Dynamic Practice,
Professional Efficacy and Clinical Leadership.
• • In addition to this competency framework, nurse practitioner practice must
accommodate a wide range of practice environments, deal with complexity and non-
linear reasoning in health-care and draw upon creative and non-standard solutions to
achieve optimal outcomes for the client.
• • Nurse Practitioner Standards also need to be informed by an approach to evaluation
of the clinician that can accommodate the above characteristics. A useful model to
achieve this orientation is that related to the notion of capability
In Australia, responsibility for nurse regulation resides with the nursing regulatory authority
in each, of the eight states or territories. Across Australian states and territories there are over
30 separate Acts related to the regulation of nursing practice, for example, Nurses Acts,
Controlled Substances Acts, Mental Health Acts and Public Health Acts. The Australian
Nursing and Midwifery Council (ANMC [at the time of the research the Council was titled
the Australian Nursing Council]) is the peak national organisation through which the
Australian states and territories formally negotiate consistent national standards for the
regulation of nursing practice.
In New Zealand there is a single nursing regulatory authority, the Nursing Council of New
Zealand, with responsibility for national regulation of nursing practice. The powers and
duties of the Nursing Council New Zealand are similar to those of the Australian state and
territory nursing regulatory authorities, but at a national level. Functioning of the Nursing
Council New Zealand and national nursing policy development in New Zealand is facilitated
by a national approach to nursing regulation.
In Australia and New Zealand the nurse practitioner is a new and unique level of health-care
provider. Development of the nurse practitioner role has been driven in part by the health-
care reform agenda. As described by the ANMC and Nursing Council New Zealand, the
shifting boundaries caused by health-care reform have created impetus for development of
new models of health-care, but have also created some uncertainty regarding the boundaries,
models of care and rights and responsibilities of nurse practitioners. The title, nurse
practitioner, is now protected in most Australian states and in New Zealand with its role
benefiting from significant development over a relatively short period of time. However the
role is still evolving in both countries.
The Trans Tasman Mutual Recognition Act 1977, as its title implies, includes the
requirement that registration in Australia and New Zealand be mutually recognisable. In
February 2002 the ANMC and Nursing Council New Zealand formally committed to
collaborative development of the nurse practitioner role under a Memorandum of
Cooperation. This research was conducted to develop standards for nurse practitioner
practice and education. The study was commissioned jointly by the two organizations and is a
result of this Memorandum of Cooperation. This paper will report on these research findings.
Numerous papers have been published in health-care journals on the topic of nurse
practitioners but there is scant published research relating to nurse practitioner competencies.
To investigate this topic the research team conducted a specific review of the literature. The
keywords used for the search included: nurse practitioner, advanced practice nurse, scope of
practice, nursing role, competency standards. The electronic data bases explored included
CINAHL, Medline, PubMed and HighRisk. No hand search was undertaken as nurse
practitioner literature was distributed widely in the nursing and related health literature. The
reference lists of papers were scanned manually to find other literature not identified in the
electronic search. The main search was limited to the past six years of publication (Jan 1999–
Dec 2004 inclusive).
Development and progress of the role
Nurse practitioners have had a presence in health-care delivery in some countries since the
1960s, more recently emerging in Australia and New Zealand. There is considerable
international literature to support the introduction of a nurse practitioner level of service with
studies demonstrating that the nurse practitioner delivers health-care that is valued by the
patient, (Kinnersley et al., 2000; Venning et al., 2000) and has a positive effect on patient
outcomes (Brown and Grimes, 1995; Sakr et al. 1999; Gardner, A and Gardner, 2005). A
systematic review of nurse practitioner service in primary care demonstrated that nurse
practitioners provide care equivalent to doctors at first point of contact with patients
(Horrocks et al. 2002). Furthermore, the review indicated that patients were more satisfied
with care by a nurse practitioner and that the care was of a high quality. Whilst we propose
that the benchmark of medical care does not by definition indicate quality, the research is a
useful addition to other, patient-focused outcome indicators. It also appeared that better use of
nurse practitioners could improve primary health-care access (Donald and McCurdy, 2002).
Despite these positive findings, the development of nurse practitioner services around the
world has been dogged by inconsistency in terms of role definition, level of legislative
control and funding issues (Pearson and Peels, 2002).
In Australia and New Zealand anticipation about the promise of nurse practitioner practice
has arisen in part from the sets of statements, sometimes called competency statements or
competency standards, about advanced practice. These statements have been developed by
professional and regulatory organisations (Australian Nursing Federation, 1997; Nursing
Council of New Zealand, 2001; Royal College of Nursing Australia, 2000) and are similar to
some used overseas (American Nurses Association, 2002; Carroll, 2002).
Nurse Practitioner Competencies
Historically, competency assessment has applied to manual work where academic learning
and intelligence testing were not relevant to occupation performance (Winter and Maisch,
1996). They became important in the vocational education sector in the early nineties in
Australia through a drive to formulate measurable industry standards for work practices
(Keating, 1994). This subsequently influenced the adoption of this approach in Australia by
nursing (Sutton and Arbon, 1994) as well as other professions. Competency benchmarks are
used in Australia for nursing undergraduate education and regulation through the ANMC
competencies. In the same way, Nursing Council New Zealand competencies are used for
undergraduate nurse education and advanced and specialist competencies are used for
postgraduate programs. In the UK competency training and assessment is integral to
undergraduate nurse education (UKCC, 1999) where formal assessment of clinical
competency has replaced the previous episodic task assessment and the more recent
continuous clinical assessment (Watkins, 2000) approaches.
In a systematic review of clinical competence assessment Watson and colleagues (2002)
concluded that there was almost universal acceptance of the need for assessment of clinical
nursing competence but that reliability and validity of assessment methods remain vexed and
could not be found in the published literature. Assessment of clinical competence was
identified as a particular issue when trying to distinguish between different levels of
competence (Girot, 2000). Nonetheless, without a superior alternative, regulatory authorities
are looking to demonstrate safe standards for nurse practitioner practice by use of
In relation to nurse practitioner standards there is no evidence in the literature of the
development of research-informed competency standards. The literature on competency for
this level of clinical practice is scant with most of the competency information being related
to advanced practice competencies or clinical nurse specialist competencies. The research
outcomes reported in this paper therefore provide an essential basis for application,
discussion and advancement of generic nurse practitioner competency standards.
In addition to the international relevance of this study, in Australasia mutually agreed
competency standards will ensure that there is a consistency in the preparation and
authorisation of nurse practitioners. Given the longstanding mutual recognition agreements
between Australian states and territories and between Australia and New Zealand, this
research has the potential to standardise nurse practitioner education and practice between
these jurisdictions and to inform the international movement in standardisation of the nurse
The competencies reported in this paper were developed from a research project that was
commissioned by the ANMC and Nursing Council New Zealand. The primary aim of the
project was to develop national/trans-Tasman competency standards for the recognition and
education of nurse practitioners in Australia and New Zealand. It is beyond the scope of this
paper to fully report the analytical and interpretive processes that describe the research
findings. The reader is directed to the ANMC report (Gardner et al 2004) for details of the
research results. However in order to contextualise the competencies that are reported here as
research outcomes, we will briefly describe the research process that was used for the study.
The methodology for this study needed to draw upon data relating to current practices,
established processes across a range of jurisdictions, documentary evidence, unpublished
literature and the experiential aspects of the nurse practitioner level of service in different
geographical and clinical contexts of practice. Accordingly, the research design incorporated
a multi-methods approach. A range of data collection tools was developed and a variety of
data sources was used. This incorporated research of policies and curricula, and survey and
interviews with academics and clinicians. Data were collected from relevant sources in New
Zealand and the five states and territories in Australia where, at the time of the research, the
title of nurse practitioner was legally protected. The data relating to the development of a
competency framework was primarily drawn from in-depth interviews with authorised and
practising nurse practitioners and published and grey literature related to nurse practitioner
The in-depth interviews with nurse practitioners were conducted to gain information on the
practice experiences of nurse practitioner work. This included a report of a de-identified case
study that represented for that participant an exemplar of nurse practitioner service. The
interview focused on the clinical and experiential dimensions of management for the
patient/client in the case study. These interviews were audio recorded and transcribed to
produce text data. These data were analysed to gain understanding of the core role of the
nurse practitioner as perceived and reported by these clinicians, and included both deductive
and inductive methods. An inductive process was used to order the data according to
recognised patterns within each interview then these data were aggregated across the data set
according to identified storylines. The storylines were then collated into several conceptual
categories. The text data was further reviewed to identify textual samples that best captured
the storylines in the analytical framework.
Relevant university ethical approval for the study was secured. Informed consent was
obtained from all interviewee participants. As far as possible, the identity of individuals who
participated in the study has been protected.
The objective of this research was to develop core standards that could inform nurse
practitioner competencies for education and practice. The first step in developing these
standards was to draw upon the research findings to describe the core role of the nurse
practitioner, the characteristics of this core role establish the thread that continues through to
define the generic standards and practice competencies.
The findings indicate that the core role of nurse practitioner practice is characterised by three
areas of practice, each of these three areas has several components that define the practice
characteristics (Figure 1).
Com ponents of Dynam ic Practice
Clinical knowledge and skills
Practice in com plex environm ents
Currency of clinical knowledge
Dynam ic Practice
Com ponents of Professional Efficacy
A nursing m odel of extended practice
Partnerships and cultural awareness
Autonom ous and accountable practice
Com ponents of Clinical Leadership
Critique and influence at system s level of health-care
Figure 1 Core role of the Nurse Practitioner
Practice is dynamic in that it involves the application of high-level clinical knowledge and
skills in a wide range of contexts. The nurse practitioner in the role demonstrates professional
efficacy enhanced by an extended range of autonomy, including legislated privileges. The
nurse practitioner is a clinical leader with a readiness and an obligation to advocate for their
client base and their profession at the systems level of health-care. This combination of
practice areas and defining characteristics that make up the core role of the nurse practitioner
provides a strong, research-based platform for development of standards and competencies
for nurse practitioner practice.
An additional finding from this research was the recognition that the practice of the nurse
practitioner is qualitatively different from that of other roles and levels of nursing. Generic
Standards for nurse practitioner practice in Australia and New Zealand must accommodate
practice environments that range from highly technical care in large tertiary facilities to sole
clinicians who practice in isolated and remote settings. They must deal with complexity and
non-linear reasoning in health-care and draw upon creative and non-standard solutions to
achieve optimal outcomes for the client.
Our conclusion from analysis of our research data and the literature is that in addition to a
competency framework, Nurse Practitioner Standards also need to be informed by an
approach to evaluation of the clinician that can accommodate these characteristics. A useful
model to achieve this orientation is that related to the notion of capability (Stephenson and
Weil, 1992; Hase and Kenyon, 2000). According to Hase (2000) capable people are more
likely to be able to deal effectively with the turbulent environment in which they live (or
work) by possessing an all-round capacity to deal with continual change. Cairns (1997)
defined capability as ‘having justified confidence in your ability to take appropriate and
effective action to formulate and solve problems in both familiar and unfamiliar and
Hence, the competency framework that follows outlines the knowledge, skills and attitudes
of nurse practitioner practice that is located at the extended level of nursing service and also
sets a standard for capability attributes. Many of the competencies are measurable and all are
Nurse Practitioner Standards
The practice areas presented in Figure 1 readily translate to core standards and the
components of the three practice areas contribute to development of competencies for these
standards. A major strength in the reliability of these standards and their competencies is that
they were developed from a range of data sources. Initially the standards were developed
from the components in the core role and then supported and refined through information
from the literature and other data sources (for example, NSW Health Department, 1995;
Read, 2001; ACT Government, 2002)
The assumptions informing the development and use of this competency framework are as
1. The nurse practitioner is a registered nurse whose practice must first meet the following
regulatory and professional requirements for Australia and New Zealand and then
demonstrate the additional requirements of the nurse practitioner:
• • National Competency Standards for the Registered Nurse
• • Code of Ethics for Nurses
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• • Code of Professional Conduct for Nurses.
These assumed requirements serve as the foundation for the nurse practitioner competency
framework and are not repeated in the framework.
2. The Nurse Practitioner Standards build upon the extant advanced practice competency
standards that are used in Australia and those used in New Zealand. These founding standards
are not repeated in the nurse practitioner framework.
3. The Nurse Practitioner Standards are core standards that are common to all models of
nurse practitioner practice. They can accommodate specialty competencies that are designed
to meet the unique health-care needs of specific client/patient populations.
Nurse Practitioner Competency Framework
The competency framework has three Standards, each Standard has a number of
competencies and each competency has a list of measurable or demonstrable performance
indicators. These standards and the competency framework provide a clear, meaningful and
logical foundation to inform nurse practitioner practice, regulation and education.
Dynamic practice that incorporates application of high-level knowledge and skills in
extended practice across stable, unpredictable and complex situations.
This standard sets an expectation that the nurse practitioner draws upon specialist expertise for
practice in a range of contexts and demonstrates a readiness to maintain and update this clinical
expertise. Whilst the standards and competencies are generic, the four competencies that define
the expected skills and knowledge for Standard 1 can also potentially provide a framework for