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Clinical Excellence for Nurse Practitioners, Volume 9, Number 3, 2005
A Historical Review of the Nurse
Practitioner Role in Australia
Andrea Driscoll, MEd, MNursing, CCC, BNursing, RN
Linda Worrall-Carter, PhD, BEd, RN, CCC
Jan O'Reilly, MHealth Ed & Promotion, Cardiothoracic Cert, BNursing, RN
Simon Stewart, PhD, Grad Dip Ad Ed, BNursing, RN
ABSTRACT
Internationally, the nurse practitioner role has been shown to be cost-effective, safe, and instru-
mental in improving patient outcomes. The nurse practitioner role in Austraha is in its infancy.
Major stakeholders such as the nurses' boards and state departments of health throughout Australia
were contacted to identify major policies and discussion papers. Database searches were conducted
in CINAHL and EBSCOhost. Disparity between states exists in all facets of the nurse practitioner
role,
especially in definition of the role, scope of practice, educational qualifications, and specialized
functions. Access to Medicare funding is unobtainable, resulting in inequity of access to health ser-
vices for disadvantaged communities. The State Nurse Practitioner Taskforce Reports highlight the
disparity between the role of nurse practitioner in each State of Australia and has led to fragmenta-
tion of the role at a national level. There is a need for consistency, which could be achieved if it were
coordinated by a national nursing body with a voice in national health policy development and
implementation.
Keywords: nurse practitioner; health policy; nursing policy; advanced practice; Australia
T
he International Council of Nurses (2003) defines
a nurse practitioner as "a registered nurse who
has acquired the expert knowledge base, com-
plex decision-making skills and clinical competencies
for extended practice, the characteristics of which are
shaped by the context and/or country in which s/he is
credentialed to practice" (p. 2003). Nurse practitioner
roles have been emerging at an international level since
the 1960s, but have only recently been developed in
Australia. The nurse practitioner movement is slowly
spreading across Australia, with three states and one
territory, Victoria, New South Wales (NSW), Australian
Capital Territory (ACT), and South Australia, accepting
applications from registered nurses for nurse practi-
tioner status. In 1998, the first state (New South Wales)
Health Registration Act (1991) was amended to incor-
porate the nurse practitioner role, signifying legitimiza-
tion and recognition of the advanced practice role of
nurse practitioners, including the right to prescribe,
order diagnostic tests, and write referrals to other health
professionals. Six years later, there exists disparity in
the nurse practitioner role between states and fragmen-
tation at a national level, despite federal and state
reviews of nursing advocating national cohesion and
leadership for the nursing profession (National Nursing
Education Review Team, 2001). Thus, this article will
discuss the historical development of the role, both
internationally and nationally, and highlight the dispar-
ity between state nurse practitioner taskforce reports in
Australia.
Copyright © 2005
NPACE®
Published by Springer Publishing Company, Inc.141
142 • Clinical Excellence for Nurse Practitioners • Vol 9 No 3
BACKGROUND
Advanced nursing practice roles have been developed
internationally since the early 20th century. Nurse prac-
titioner roles fall under the umbrella of advanced nurs-
ing practice. International research has shown that
nurse practitioners have improved patient outcomes
and that patients are satisfied with the care they provide
(David, 1994; Sakr et al., 1999; Sherwood, Brown, Fay, &
Warden, 1997;Touche-Ross£f
Co.,
1994;
Wilkinson, 1995).
These findings are supported by a more recent system-
atic review of the nurse practitioner roles in a primary
health care setting (Horrocks, Anderson, & Salisbury,
2002).
Abrief summary of the development of the nurse
practitioner roles in the USA and UK follows, as the
nurse practitioner roles were first developed and estab-
lished within the health care systems in these countries.
United States of America
The nurse practitioner movement began in the USA in
the 1960s. The first nurse practitioner program was
developed by Silver and Ford in 1965 and operated at the
University of Colorado (1967). Initially developed due to
a shortage of primary care doctors in disadvantaged com-
munities, the nurse practitioner role soon proved bene-
ficial in the provision of effective, safe, and accessible
health care (Brown & Grimes, 1995; Dunn, 1997). Con-
sequently, nurse practitioners were gradually accepted
into the mainstream of health care services (Edmunds,
2003;
Winson & Fox, 1995), such that by 1997, over
42,000 nurses were registered as nurse practitioners in
the USA (American Nurses Association, 1997a).
In the USA, nurse practitioners are credentialed in
each state rather than nationally, resulting in variability
in educational qualifications, role responsibilities, and
level of autonomy and authority (International Council
of Nurses, 2000). Nurse practitioners have legislative
authority to prescribe in 49 states of the USA and have
been granted reimbursement by Medicare (American
Association of Colleges of Nursing, 1998; American
Nurses Association, 1997b; Pearson, 2005).
One of the confusing issues surrounding the nurse
practitioner role is the use of nomenclature. In the USA,
there are a variety of advanced practice roles; however,
the boundaries among the roles have become blurred.
The American Nurses Association defines advanced
nursing practice as a clinical role that requires a gradu-
ate degree in nursing. Nurse practitioners in clinical
roles function in a multidisciplinary environment
requiring a high level of autonomy and expert knowl-
edge and skills, including comprehensive patient assess-
ment, diagnosis, and treatment of potential health
problems (McLoughlin, 1992). An example of the con-
fusing nomenclature is that between a clinical nurse
specialist (CNS) and nurse practitioner. Both roles fall
under the advanced practice umbrella, and advanced
assessment skills, competencies, and knowledge are
similar in both roles. Furthermore, the boundaries
between CNS and nurse practitioner roles have become
blurred as nurse practitioners move into the acute care
setting and CNSs move into primary care (Bates, 1970;
Dunn, 1997; Patterson & Haddad, 1992).
United Kingdom
The nurse practitioner role was developed in the UK
based on work by Barbara Stillwell (1982) and Barbara
Burke-Masters
(1986).
Barbara Stillwell worked as a nurse
practitioner in general medical practices in Birmingham,
while Barbara Burke-Masters worked autonomously for a
voluntary organization for single homeless men in Fast
London (South West London Strategic Health Authority,
2002).
As a result, the nurse practitioner role was intro-
duced in the early 1980s (Read, Roberts-Davis, & Gilbert,
1998).
As in the USA, the nurse practitioner role in the
UK was developed due to a shortage of doctors and a
need to improve accessibility to health services in disad-
vantaged communities (Harris & Redshaw, 1998; Hor-
rocks et al., 2002).
As in the USA, the boundaries between nurse practi-
tioner and CNS are also blurred in the UK. In the UK, a
GNS is a nurse with in-depth specialist knowledge con-
cerning a specific group of patients, while a nurse prac-
titioner has been described as an autonomous doctor
substitution role (Victorian Government Department of
Human Services, 2000). Gonfusion persists with the
nomenclature as the titles of nurse practitioner,
advanced practitioner, and advanced nurse practitioner
are interchangeable, with little consistency being shown
in their use (United Kingdom Gentral Gouncil, 1998).
One of the interesting issues in the UK is that the
title of "nurse practitioner" is not protected. This has
resulted in no specific standards or training programs
for nurse practitioners (Grumbie, 2001; Le Mon, 2000;
MulhoHand, 2001; United Kingdom Gentral Gouncil,
1998).
The lack of minimum education qualifications
for nurse practitioners has resulted in a shift in the nurs-
ing model toward a biomedical model focusing on tech-
nical and medical aspects of patient care (Barton,
Thorme, &
Hoptroff,
1999; Walsh, 1999a; Walsh, 1999b).
It is important to protect the title of "nurse practitioner"
because this ensures that nurses using the nomenclature
are authorized by the relevant nurses
board,
which means
they have met strict criteria, including postgraduate
Driscoll et al. • Nurse Practitioners in Australia • 143
qualifications (usually at the master's level), evidence of
advanced clinical competence, and demonstrated clini-
cal experience (Australian Gapital Territory Nurse Prac-
titioner Steering Gommittee, 2002).
METHODS
A review of policies concerning nurse practitioners in
Australia was undertaken in 2002. GINAHL and EBSGO-
host databases were searched using the following key
words: "nurse practitioner," "advanced practice," and
"Australian nursing policies." Seven state or territory
nursing boards and six state departments of health
throughout Australia were contacted to identify major
policies and discussion papers concerning nurse practi-
tioners in Australia. Drawing on the review of literature,
we will discuss the historical development of the nurse
practitioner role in Australia. This is followed by a com-
parative analysis of the New South Wales, Victorian, and
South Australian state government Nurse Practitioner
Taskforce Reports and the Australian Gapital Territory
Nurse Practitioner Taskforce Report, which stipulate
the regulation, role, and scope of practice of nurse prac-
titioners in the respective states and territory.
HISTORICAL DEVELOPMENT OE THE NURSE
PRACTITIONER ROLE IN AUSTRALIA
The nurse practitioner movement first began in Aus-
tralia in New South Wales. Figure 1 provides a timeline
outlining the historical development of the nurse prac-
titioner role in Australia. This development is briefly
discussed in the following text in relation to three Aus-
tralian states—New South Wales, Victoria, and South
Australia—and one territory—the Australian Gapital
Territory.
New South Wales
Similar to the UK and the USA, New South Wales was
experiencing a shortage of doctors in the late 1980s in
underserviced communities, especially those in rural
and remote areas. Goncurrently, the retention of expe-
rienced nurses was at a critically low level (Harris &
Ghaboyer, 2002; Turner, 2001). Nurses indicated that
one of the reasons they were leaving the profession was
an inadequate clinical career structure (Harris & Gha-
boyer; NSW Department of Health, 1995; Turner). The
nurse practitioner role would help solve the nursing
1990 Role of nurse practitioner first discussed in New South Wales at conference of New South
Wales Nurses Association and a Task Force established
1992-1995 10 pilot nurse practitioner projects established
1998 New South Wales Nurses Act (1991) amended to incorporate nurse practitioner
Victoria established a nurse practitioner taskforce
1999 Victoria Phase 1 nurse practitioner project: 11 nurse practitioner projects funded
South Australia funded first nurse practitioner project
2000 Victoria Amendments to Nurses Act (1993) incorporating nurse practitioner
New South Wales first nurse practitioner appointed
2001 Victoria Phase 2 nurse practitioner project: 18 nurse practitioner models funded
Australian Gapital Territory funded four nurse practitioner models
2002 South Australia Nurses Act (1999) amended to incorporate nurse practitioner
South Australia first nurse practitioner appointed
2003 Victoria Phase 3 nurse practitioner project: four nurse practitioner models funded
Queensland: implemented four nurse practitioner projects
Gurrently, at the time of
writing.
New South Wales has 11 authorized nurse practitioners and has advertised
40 nurse practitioner positions; South Australia has
1
authorized nurse practitioner; Victoria has none but is
accepting applications; and Queensland, Western Australia, Tasmania, and the Northern Territory are not
in a position to begin accepting applications at this stage and are currently submitting amendments to their
respective Nurses Acts.
Figure 1. Historical timeline outlining the development of the nurse practitioner role in Australia.
144 • Clinical Excellence for Nurse Practitioners • Vol 9 No 3
retention crisis through the creation of an additional
clinical career pathway. Nurse practitioners would fill
the gap in health service delivery that was being caused
by a shortage of doctors in the rural areas given that the
role was viewed as a substitute doctor role (NSW Depart-
ment of Health; Turner). However, legislation and reg-
ulations prevented nurses from prescribing medications
and ordering diagnostic tests, although anecdotally,
advanced practice nurses were already ordering diag-
nostic tests outside the legislative boundaries.
The role of the nurse practitioner was first discussed
in 1990 at the annual conference of the New South
Wales Nurses Association (NSW Department of Health,
1995).
After the conference, a task force was established
by the chief nursing officer to consider the issues of
nurse practitioners.
During the period of 1992 to 1995 in New South
Wales, pilot projects were implemented to investigate
nurse practitioner models, such as primary care, in the
rural and metropolitan health areas. Evaluations of the
projects were positive (NSW Department of Health,
1995).
During the process of negotiations between the
New South Wales Department of Health and represen-
tative groups from the nursing and medical professions,
a compromise was reached concerning geographical
area of practice. Consequently, the nurse practitioner
models were restricted to rural and remote areas (NSW
Department of Health). Employment of nurse practi-
tioners in rural and remote New South Wales was
deemed to be cost beneficial by the health care system
and resulted in greater consumer access to the health-
care system (NSW Department of Health).
In 1998, the New South Wales Health Registration
(1991) was amended to incorporate the role of nurse
practitioner (NSW Nurses Registration Board, 2000). The
importance of this is discussed later in this article. In
New South Wales, each local health board must
acknowledge the need for a nurse practitioner in their
area. All local stakeholders, including consumers, hos-
pitals,
community health centers, and the medical pro-
fession, are required to agree on a need for a nurse
practitioner (NSW Health Department, 2000;
NSW
Nurs-
es Registration Board). The local health board then
determines the duties of the nurse practitioner and sub-
mits a proposal to the New South Wales Department of
Health. If there is consensus, the proposal goes to the
New South Wales Nurses Board for authorization, and
the position is advertised. However, the New South
Wales Nurses Board can authorize the creation of a
nurse practitioner position regardless of whether or not
there is a position available. In such a case, the position
is authorized with the provision that the medication pre-
scribing formulary and ability to initiate diagnostic tests
is determined according to the specific duties of the
nurse practitioner proposal from the local health board
(NSW Nurses Registration Board). An authorized nurse
practitioner is unable to practice as a nurse practitioner
until she/he is employed in that position (NSW Nurses
Registration Board).
Other Australian states and territories have found the
New South Wales nurse practitioner role to be too
specif-
ic because of its restriction to public rural and remote
areas and also the process of the authorization of nurse
practitioner
positions.
Victoria, the Australian Gapital Ter-
ritory, and South Australia have not restricted the nurse
practitioner role geographically or sectorially, and so
nurse practitioners operate in public and private health
care sectors as well as in rural and metropolitan areas.
Victoria
In July 1998, while the Nurses Act (1991) was being
amended in New South Wales, the Victorian Department
of Human Services (DHS) established its nurse practi-
tioner taskforce to examine the process of introducing
the nurse practitioner role. The taskforce consisted of
representatives from the Australian Nurses Federation,
Royal Gollege of Nurses Australia, Nurses Board of Vic-
toria, Australian Medical Association (AMA), Victorian
Nurse Practitioner Forum, Department of Human Ser-
vices (DHS) Health Workforce Sector and Rural Health,
Royal Australian Gollege of General Practitioners
(RAGGP), Ministerial Advisory Gommittee on Nursing,
Victorian Gouncil of Peak Nursing Organisations, and
staff from La Trobe University (Victorian Government
Department of Human Services, 2000). Unlike in New
South Wales, the implementation of the nurse practi-
tioner role in Victoria was not based upon substitution
of medical care in underserviced communities, but on
the development of an advanced nursing framework
that focused on advanced nursing practice and decision-
making to ensure that the needs of the patient and com-
munity were met (Victorian Government Department
of Human Services).
In March 1999, 11 nurse practitioner models were
funded under Phase One of the Nurse Practitioner Pro-
ject and launched by the Victorian Minister for Health.
These models included: primary health care, operating
theater, emergency, women's health (2 models), pedi-
atric,
neonatal, hematology, wound care, psychiatric,
and homeless person's program (Department of Human
Services [DHS], 1999). Twelve months later, each of the
nurse practitioners, in the models, participated in an
external evaluation undertaken by the University of
Melbourne. At the time of this writing, the Phase One
Driscoll et al. • Nurse Practitioners in Australia • 14S
Evaluation had been completed but was being withheld
by the DHS. The broad findings of the first phase were
published, including the number of clients utilizing the
service, the country of birth of participants, and clients'
and colleagues' perceptions of the service (DHS, 2001).
The DHS (2001) concluded that the Phase One External
Evaluation "yielded insights rather than conclusions,
and preferable alternatives rather than clear pathways"
(p.
3). It is disappointing that there was not more infor-
mation released, as the evaluation seemed to increase
the mystification rather than clarify processes and out-
comes. Furthermore, the results of the internal evalua-
tions of
8
of the 11 nurse practitioners in the models are
also unavailable (DHS, 2001).
In early 2000, the final report of Victoria's nurse prac-
titioner taskforce was released (Victorian Government
Department of Human Services, 2000). The report out-
lines a framework for the introduction of the nurse
practitioner role in Victoria. The Australian Medical
Association (AMA) acknowledged that nursing practice
has changed and that there was an increase in knowledge
and expertise in specialist areas. However, the Australian
Medical Association disagreed with nurse practitioners
prescribing drugs, initiating diagnostic tests, providing
referrals to medical specialists, and having admitting priv-
ileges.
Their reasons ranged from inadequate educational
preparation to the potential for unsafe prescribing and
fragmentation of the health care system (Victorian Gov-
ernment Department of Human Services, 2000).
Amendments to the Victorian Nurses Act (1993) to
incorporate the nurse practitioner role were passed in
November 2000. At the time of this writing, changes to
the Drugs, Poisons and Gontrolled Substances Act (1981)
to incorporate the nurse practitioner role are being made.
South Australia
In South Australia, the first nurse practitioner project was
endorsed in 1999. This state differed from New South
Wales and Victoria in that it acknowledged the literature
endorsing the benefits of a nurse practitioner role. On
the basis of the literature. South Australia amended the
legislation and regulations regarding the Nurses Act
(1999) and Drugs, Poisons and Gontrolled Substances Act
(South Australian Department of Human Services, 1999).
The recommendations from the State's Nurse Practition-
er Project Report were published in October 1999, and
were based on a review of international and national lit-
erature and consultations with key stakeholders (South
Australian Department of Human Services). South Aus-
tralia has endorsed its first nurse practitioner in care of
patients diagnosed with heart failure.
Australian Capital Territory
In March 2001, the Australian Gapital Territory funded
trials of four nurse practitioner models: sexual health,
wound care, mental health, and primary care and
health promotion (Australian Gapital Territory Nurse
Practitioner Steering Gommittee, 2002). These trials fin-
ished in December 2001, and the final report was
released in July 2002. At the time of this writing,
amendments were still being made to the Nurses Act
and the Drug, Poisons and Gontrolled Substances Act.
Goinciding with the gradual introduction of nurse
practitioners throughout Australia was the release of
state and territory government nurse practitioner task-
force reports. These reports stipulated the regulatory
boundaries and defined the role of nurse practitioners
in their respective state or territory.
DISCUSSION
In this section, we undertake a comparative analysis of
each state and territory government taskforce report of
the nurse practitioner role according to their definition
of a nurse practitioner, scope of practice for a nurse
practitioner, educational qualifications required to be
a nurse practitioner, and specialized functions of a
nurse practitioner. Table 1 provides an overview of the
analysis.
Definition and Defining Features
of a Nurse Practitioner
Several issues have hindered the development of the
nurse practitioner role in Australia, and the most
signif-
icant of these is a lack of consensus on the definition of
a nurse practitioner (Barton et al., 1999; Reveley, 2001),
a problem complicated by the development of the GNS
role (Reveley; Roberts-Davis & Read, 2001). Interna-
tionally, the blurring of the boundaries within the
advanced nursing practice umbrella has further con-
tributed to the confusion. Some authors have suggested
that there is an overlap in the nurse practitioner and
GNS roles (Roberts-Davis & Read), while others have
suggested that the two roles are conceptually and fun-
damentally different and should be recognized as two
distinct entities (Reveley). The literature indicates that
boundaries between nurse practitioners and GNSs in the
USA are almost nonexistent (Dunn, 1997; Fenton &
Brykczynski, 1993; Patterson & Haddad, 1992). Both are
considered to be advanced practice roles, and much of
the knowledge and many of the skills and competencies
they require are shared depending upon the particular
setting and clinical situation (Victorian Government
146 • Clinical Excellence for Nurse Practitioners • Vol
9
No 3
TABLE 1. Gomparison of Key Elements of Nurse Practitioner Policy in New South Wales, Victoria, South
Australia, and Australian Gapital Territory Nurse Practitioner Taskforce Reports
Key ElementsNew South WalesVictoriaSouth AustraliaAustralian
Gapital Territory
Year of implemen-
tation of the nurse
practitioner role
Definition of nurse
practitioner (as cited
in relevant policy)
Scope of practice
and health care
sector
1998
Advanced practice
with the character-
istics defined hy
context of practice
Initially only rural
and primary care.
Gurrently specialist
areas.
Private and
puhlic health care
sector.
2001
Advanced practice
skills and knowledge,
educator, counseling,
manager, admini-
strator, quality
improvement
Specialist areas.
Private and public
health care sectors
2002
Advanced practice,
educator, mentor,
research,
autonomous
Specialist areas.
Private and public
health care sectors
2002
Extended practice in
autonomous assess-
ment and manage-
ment of clients
Specialist areas.
Private and public
health care sectors
Minimal educational
qualifications
Prescribing rights
Diagnostic tests
Referrals
Admitting
privileges
Dependent upon
qualifications and
experience and/or
master's degree
Yes with limited
formulary specific
to context of
practice
Yes specific to
context of practice
Allowed to refer
only to outpatient
clinics, allied health
professionals, and
community health
centers
No
Master's degree
Yes with limited
formulary specific
to context of
of practice
Yes specific to
context of practice
Referrals to be
coordinated by the
patient's general
practitioner in
consultation with the
nurse practitioner
Recommends
No minimal
qualifications
Yes with limited
formulary specific
to context of
practice
Yes specific to
context of practice
Yes
Must apply to the
Nursing & Midwifery
Glinical Privileges
Advisory Gommittee
(at the Department
of Human Services)
and if granted, to
individual hospital
boards
Master's degree
Yes with limited
formulary specific
to context of
practice
Yes specific to
context of practice
Yes
No
Department of Human Services, 2000). However, in
Australia there is a clear boundary between nurse prac-
titioner and GNS due to the extension of practice of
nurse practitioners concerning prescribing, writing
referrals and, in some states, admitting privileges. Glar-
ification of the titles continues to be debated interna-
tionally; however, there is general consensus that the
nurse practitioner role is the most significant of the
advanced practice roles (Reveley).
In Australia the defining features of a nurse practi-
tioner differ between the states and territory govern-
ment nurse practitioner taskforce reports. The defining
Driscoll et
al.
• Nurse Practitioners in Australia • 147
features of the Australian Gapital Territory and South
Australian nurse practitioner are intentionally very
broad and fiexible, while Victoria stipulates the activi-
ties within each of the broad characteristics of the nurse
practitioner (see Table 1). The Victorian Nurse Practi-
tioner Taskforce Report is prescriptive, with little lati-
tude for variations (Victorian Government Department
of Human Services, 2000). The South Australian Nurse
Practitioner Taskforce Report states that the defining
features of a nurse practitioner exhibit fiexibility to
encourage diversity of the role in order to meet the
needs of the client and community; in addition, it
described the defining features of a nurse practitioner
within the context of need, setting, education, and
autonomy (South Australian Department of Human Ser-
vices,
1999). In the Australian Gapital Territory Nurse
Practitioner Taskforce Report, the definition of a nurse
practitioner is vague, with no mention made of educa-
tor, mentor, or researcher, although it does emphasize
practice at an advanced level (Australian Gapital Terri-
tory Nurse Practitioner Steering Gommittee, 2002).
However, in order to practice at an advanced level,
nurses must keep up to date with the latest research
and undertake research themselves in their area of clin-
ical expertise. Advanced clinical nursing practice incor-
porates application and utilization of the latest evidence
to ensure that advanced clinical practice is evidence-
based.
Playing the roles of mentor and educator is an impor-
tant part of being a nurse practitioner. It is important for
nurse practitioners to foster, encourage, and develop
junior nurses so they may continue on a career pathway
toward an advanced level of nursing practice. Anecdo-
tally, it seems that in clinical nursing, there are very few
clinical nursing mentors. One of the important aspects of
the nurse practitioner role is the potential for nurse prac-
titioners to fill the mentoring gap that currently exists in
nursing. The International Gouncil of Nurses (2003)
incorporates "research," "mentor," and "education" in
their defining features of
a
nurse practitioner.
The only congruence between the states in the defi-
nition of nurse practitioner is that a nurse practitioner
operates at an advanced level of practice. However, it
could he argued that this is a grossly inadequate defini-
tion of
a
nurse practitioner.
Protection of Title
All of the state nurse practitioner taskforce reports have
noted success in securing legislation that protects the
title of nurse practitioner. Such legislation ensures that
no other nurse can use the title of nurse practitioner,
and that those working as nurse practitioners have met
strict criteria developed by the regulatory nurses'
boards, including postgraduate qualifications, evidence
of advanced clinical skills, and significant experience
(Australian Gapital Territory Nurse Practitioner Steer-
ing Gommittee, 2002). Nurse practitioners also have a
legal responsihility to adhere to regulatory safeguards
and laws to support consumer confidence in the role.
Scope of Practice
All of the nurse practitioner taskforce reports have a
similar scope of practice for nurse practitioners, which
include their having no geographical or sectorial restric-
tions (see Table 1). The defined scope of practice is
intentionally very broad and nonprescriptive. However,
in reality, a different picture emerged that has only
recently begun to change. For example, in New South
Wales, nurse practitioners were initially restricted to
working in rural and remote areas, and their role was
that of primary care nurse rather than involving one
area of specialization, such as sexual health, diabetes,
wound management, or hematology (NSW Health
Department, 2000; NSW Nurses Registration Board,
2000).
Authorization as a nurse practitioner in New
South Wales was also restricted not only to rural and
remote areas but to six areas of practice: high depen-
dency, mental health, rehabilitation, community health,
maternal and child health, and medical/surgical nurs-
ing (NSW Nurses Registration Board). However, in 2001,
New South Wales commenced employing nurse practi-
tioners in acute metropolitan public hospitals in various
speciality areas, such as in accident and emergency
departments (Armstrong, 2001). Nurse practitioners in
South Australia, the Australian Gapital Territory, and
Victoria, according to the nurse practitioner taskforce
reports, will he employed in any geographic area, and
their scope of practice will be limited to an area of spe-
cialization (Australian Gapital Territory Nurse Practi-
tioner Steering Gommittee, 2002; South Australian
Department of Human Services, 1999; Victorian Gov-
ernment Department of Human Services, 2000).
There are similarities in access to a nurse practition-
er in the public sector and the private sector (i.e., for
patients with private health insurance) of the Australian
health care system. All of the nurse practitioner task-
force reports stated that nurse practitioners will not be
restricted in terms of the sectors they can work in. The
Victorian Government Department of Human Services
(2000) and New South Wales Department of Health
(1995) Nurse Practitioner Taskforce Reports, however,
do not allow nurse practitioners to write referrals to pri-
vate medical consultants, with the result that they have
restricted access to the private health-care system. Also,
148 • Clinical Excellence for Nurse Practitioners • Vol 9 No 3
none of the nurse practitioners in any of the states have
access to the Medicare rebate. In the Australian health
care system, patients are reimbursed a predetermined
amount of medical expenses by the federal government,
known as the Medicare rebate. In Australia, patients
who visit nurse practitioners are unable to claim the
Medicare rebate (no reimbursement by the federal gov-
ernment is available), and the patients have to pay full
fees for diagnostic tests and visits to the nurse practi-
tioner (Australian Gapital Territory Nurse Practitioner
Steering Gommittee, 2002; NSW Department of Health;
South Australian Department of Human Services, 1999;
Victorian Government Department of Human Services).
Thus,
it would be cheaper for private and public
patients to visit a medical consultant and obtain reim-
bursement from Medicare than to have a consultation
with a nurse practitioner. The South Australian Depart-
ment of Human Services (2002) stated that "this system
should not place nurse practitioners' clients at any cost
or choice disadvantage" (p. 1). Paradoxically, stopping
nurse practitioners from having access to Medicare
funding will result in inequity of access to health ser-
vices in rural and remote communities that are disad-
vantaged hy doctor shortages, as many patients will he
unable to afford to visit a nurse practitioner and there
may be no other alternative when it is cheaper to visit
the doctor despite the shortage of doctors in rural and
remote areas. The nurse practitioner role was initially
developed in New South Wales due to a shortage of doc-
tors in rural and remote disadvantaged communities.
However, the debate continues concerning access to
Medicare funding despite nurse practitioners in the USA
being granted access (American Association of Golleges
of Nursing, 1998; American Nurses Association, 1997b;
Pearson, 2005).
Educational Qualification for the
Nurse Practitioner Role
The advanced practice role of the nurse practitioner
requires that postgraduate educational preparation and
continued professional development courses be devel-
oped. In order to ensure that an advanced level of com-
petency is achieved, maintained, and improved,
potential nurse practitioners must have an advanced
level of clinical practice and postgraduate educational
qualifications to support and extend their clinical prac-
tice.
Universities in Australia are developing postgradu-
ate courses aimed at preparing registered nurses for the
nurse practitioner role.
In Australia, similar to the USA, nurse practitioners
are endorsed in each state and not at a national level.
which has led to inconsistency in role definition, educa-
tional qualifications, and level of authority and autono-
my. The Victorian Government Department of Human
Services (2000), NSW Department of Health (1995), Aus-
tralian Gapital Territory Nurse Practitioner Steering
Gommittee (2002), and South Australian Department of
Human Services (1999) Nurse Practitioner Taskforce
Reports differ as to what level of minimum educational
qualification is appropriate for a nurse practitioner (see
Table 1). There are no specific minimum qualifications
or training programs for GNSs or nurse practitioners in
the UK (United Kingdom Gentral Gouncil, 1998). In the
USA, a master's degree is the minimum requirement for
GNS
status, and the American Association of Golleges of
Nursing aims for all nurse practitioners to have a simi-
lar minimum qualification (Woods, 1997). The Interna-
tional Gouncil of Nurses recommends a master's degree
for nurse practitioner status (International Gouncil of
Nurses, 2003). The New South Wales Department of
Health report (1995) is situated in the middle of the field
in this respect in that applicants must demonstrate
extensive clinical knowledge in their scope of practice
and/or an approved master's degree in conjunction with
extensive clinical experience. The Victorian Govern-
ment Department of Human Services and Australian
Gapital Territory Nurse Practitioner Steering Gommit-
tee reports stipulate a minimal education qualification
at the master's level given that graduate certificates/
diplomas are not recognized internationally (Victorian
Government Department of Human Services). The Vic-
torian Government Department of Human Services
report stipulated that the level of practice required of a
nurse practitioner must be advanced, highly developed,
and equivalent to a master's program; in addition, exten-
sive clinical experience is required. In contrast to this,
the South Australian Department of Human Services
report does not stipulate any mandatory qualifications.
The South Australia Nurse Practitioner Taskforce
Report emphasizes the importance of clinical experience
and recognition of prior learning and discussed a study
by Hegney (1997) about rural nurses. The report stated
that Hegney found "it was unacceptable for nurses to
work in advanced roles without adequate education and
training" (p. 30). Yet the South Australian Department of
Human Services report fails to stipulate minimal educa-
tion qualifications for a nurse practitioner.
Despite the differences between the nurse practi-
tioner taskforce reports concerning minimal education
qualifications, all of them agree that authorized nurse
practitioners must gain credentialing in the area of their
professional practice according to the standards and
competencies determined hy their professional nursing
Driscoll et al. • Nurse Practitioners in Australia • 149
body (Australian Gapital Territory Nurse Practitioner
Steering Gommittee, 2002; NSW Department of Health,
1995;
South Australian Department of Human Services,
1999;
Victorian Government Department of Human Ser-
vices,
2000). The New South Wales report went one step
further, stipulating that nurse practitioners must be cre-
dentialed and reapply for authorization to practice as a
nurse practitioner every 3 years (NSW Nurses Registra-
tion Board, 2000). At the time of writing, the Victorian
Government Department of Human Services Taskforce
was waiting for the outcomes of
a
report from the Gom-
monwealth Department of Health and Aged Gare estab-
lishing a national framework for credentialing of
advanced practice nurses.
Specialized Functions of the Nurse Practitioner
Not only is there debate about the level of qualification
but there are strong and debatable issues relating to the
nurse practitioner role concerning prescribing rights,
ability to order diagnostic tests and write referrals, and
admitting rights (see Table 1).
Prescribing Rights. All of the nurse practitioner
taskforce reports recommended that nurse practition-
ers be given prescribing rights. In New South Wales
amendments have heen made to the appropriate legis-
lation, such as the Drugs, Poisons and Gontrolled Sub-
stances Act, granting nurse practitioners prescribing
rights to a limited formulary. At the time of writing,
none of the nurse practitioner legislation allowed
unlimited prescribing rights (NSW Department of
Health, 1995; South Australian Department of Human
Services, 1999). In Victoria, amendments have been
made to the Nurses Act (1993) hut not the Drugs, Poi-
sons and Gontrolled Substances Act (1981). Ghanges
will not be made to the Victorian Drugs, Poisons and
Gontrolled Substances Act (1981) until clinical practice
guidelines have been established and there is agree-
ment from medical and nursing bodies that the clinical
practice guidelines and accredited training will provide
support for safe prescribing of drugs (DHS, 2001). In
South Australia, nurse practitioners must apply to the
Nurses Board for prescribing rights to a limited formu-
lary appropriate to their scope of practice.
Anecdotally, there have been instances in which a
nurse practitioner in one state is able to prescribe med-
ications, while another nurse practitioner from another
state but in a similar specialty can only authorize med-
ications that are readily available in pharmacies with no
prescription. Throughout the implementation of the
nurse practitioner role, the Australian Medical Associa-
tion has been supportive of nurse practitioners titrating
medications according to a strict protocol that has been
prescribed by a medical practitioner, but not supportive
of nurse practitioners prescribing medications (Victori-
an Government Department of Human Services, 2000).
In each of the states where nurse practitioner endorse-
ment has been approved, the majority of medications
on the nurse practitioner's drug formulary list are ones
that are readily available in pharmacies without a pre-
scription; however, nurse practitioners are able to
titrate prescribed medications. Anecdotal evidence indi-
cates that nurses already titrate medications according
to a strict protocol prescribed by the patient's medical
practitioner.
In all of the states studied, prescribing rights are lim-
ited to a predetermined formulary according to the
nurse practitioner's scope of practice. In New South
Wales, a nurse practitioner may be authorized to prac-
tice prior to gaining employment as a nurse practition-
er. In such cases, the limited formulary is determined
according to the scope of practice, when approval for
employment of a nurse practitioner is granted by the
Director-General in the NSW Health Department (NSW
Health Department, 2000). However, in Victoria and
South Australia, nurse practitioner applicants must have
approval from their employer for extended practice
(including predetermined drug formulary) prior to
endorsement (Nurses Board of Victoria, 2001). In all
states,
clinical guidelines and/or protocols for the limit-
ed nurse's formulary will be developed, at the time of
their nurse practitioner application, based upon the
nurse practitioner's scope of practice.
Diagnostic Tests. In the area of ordering diagnostic
tests,
all of the states have approved nurse practitioners
to initiate diagnostic tests from a specified formulary
according to their scope of practice. The Victorian Nurse
Practitioner Taskforce Report recommended that guide-
lines be developed allowing nurse practitioners to initi-
ate diagnostic tests appropriate to the scope of practice
(Victorian Government Department of Human Services,
2000).
Referrals. The Australian Medical Association has
been successful in negotiating a limited formulary of
prescribing drugs and diagnostic tests for nurse practi-
tioners. It could be argued that the Australian Medical
Association has blocked nurse practitioners from access-
ing the Medicare system, providing referrals to special-
ist services, and admitting privileges (in Victoria and
NSW).
In Victoria, the Australian Medical Association
successfully argued that referrals to medical specialists
should be coordinated through a general practitioner,
ensuring that the medical profession remain gatekeep-
ers to the private and public health-care systems and
ISO • Clinical Excellence for Nurse Practitioners * Vol 9 No 3
those general practitioners are perceived by the public
as coordinators of care and key providers of primary
health care (Victorian Government Department of
Human Services, 2000). This sentiment was echoed in
the Victorian Government Department of Human Ser-
vices report in which general practitioners were consid-
ered the primary coordinators:
General Practitioners have been the traditional providers
of referrals to medical specialists for patient/clients in the
community, providing coordinated patient care in the
community, (p. 50).
There were also other arguments put forward by the
Australian Medical Association against unrestricted
nurse practitioner initiated referrals as follows:
The referral of
patients
from General Practitioners to spe-
cialists is one of the strengths of the Australian health
care system. (Victorian Government Department of
Human Services, 2000, p. 84)
Referral of patients to specialist medical practitioners
from practitioners other than the patient's general practi-
tioner may lead to unnecessary referrals, and fragmenta-
tion and loss of continuity of care, which may expose
patients to unnecessary harm without producing any
worthwhile benefits. (Victorian Government Department
of Human Services, 2000, p. 84)
In Victoria, one major reason for the Australian Med-
ical Association opposing nurse practitioner initiated
referrals, in favor of general practitioner referrals, is the
reimbursement provided hy Medicare to doctors who are
involved in the preparation and coordination of patients'
health care plans. In New South
W^ales,
nurse practition-
ers have limited referral rights according to their scope
of practice (NSW Department of Health, 1995). South
Australian nurse practitioners have no restrictions
placed on them concerning referrals to medical special-
ists'
services, but nurse practitioners are obligated to
communicate the specifics of a patient's care with the
patient's general practitioner (South Australian Depart-
ment of Human Services, 1999). In addition to unre-
stricted referrals, nurse practitioners in South Australia
have also heen granted admitting privileges.
Admitting Privileges. Nurse practitioners in South
Australia are able to apply for admitting privileges to
public hospitals through the Nursing and Midwifery
Glinical Privileges Advisory Gommittee (at DHS); if
granted, they need to apply to individual hospital
hoards, which mainly consist of the medical profession
(South Australian Department of Human Services,
1999).
Admitting privileges grant the nurse practitioner
responsibility for the patient's continuum of
care,
which
includes admitting to hospital, discharge, and follow-up
care of the patient in the community and allows the
nurse practitioner to work in private practice or as an
employee of the hospital (South Australian Department
of Human Services). New South Wales nurse practi-
tioners do not have admitting privileges. In Victoria,
the debate continues over admitting privileges, with the
Victorian Government Department of Human Services
report (2000) recommending the development of guide-
lines granting nurse practitioners admitting privileges.
The International Gouncil of Nurses stated that admit-
ting privileges are one of the specialized functions of a
nurse practitioner (International Gouncil of Nurses,
2003).
Limitations and Recommendations
This review has been limited to the state and territory
government nurse practitioner taskforce reports con-
cerning the Australian nurse practitioner role. Further
exploration is needed comparing specific nurse practi-
tioner models hetween states and territories and exam-
ining the possibility of transportability of the role
between states. It would also he interesting to compare
patient outcomes between similar nurse practitioner
models in different states and territories throughout
Australia.
CONCLUSION
As the nurse practitioner movement has progressed
through the states, implementation of the role has
hecome easier and acceptance of the role increased.
The Victorian and the Australian Gapital Territory
Nurse Practitioner Taskforce Reports expanded on the
first nurse practitioner role in New South Wales, and
South Australia expanded on the Victorian role.
However, the variations between the Victorian, New
South Wales, and South Australian nurse practitioner
taskforce reports serve to highlight the fragmentation
in nursing between states, which is a continual prohlem
for the nursing profession. The regulation of nursing
varies significantly between states, hindering discussion
of professional issues, career structure, and flexibility of
the workforce. The South Australian nurse practitioner
has been granted approval to initiate unrestricted refer-
rals and to apply for admitting privileges in the public
health care system. However, New South Wales, the
Australian Gapital Territory, and Victoria continue to
debate whether to approve the unrestricted initiation of
referrals and access to admitting privileges for nurse
practitioners. The presence of a national nursing body
would support nursing bodies in New South Wales,
the Australian Gapital Territory, and Victoria in their
struggle to achieve access to admitting privileges and
Driscoll et al. • Nurse Practitioners in Australia • 151
unrestricted initiation of referrals, and encourage
national consistency for the nurse practitioner role. A
national nursing voice in health policy development
and implementation is vital if nursing is to remain a
cohesive and progressive profession.
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Biographical Data. Andrea Driscoll is currently under-
taking her PhD and has received an NHMRC Public
Health Postgraduate scholarship. She is an expert advi-
sor to the Nurses Board of Victoria for Critical Care Nurse
Practitioners and a member of the Nurses Board of Vic-
toria Nurse Practitioner Endorsement Committee. She
also Editor of
Critical
Times (national publication of the
Australian College of Critical Care Nurses). Linda Wor-
rall-Carter is a Senior Research Fellow at Deakin Univer-
sity. She is Associate Editor of the journal Australian
Critical
Care.
Jan O'Reilly is an experienced nurse clini-
cian with postgraduate qualifications (Grad Dip. and
Masters) in cardiovascular nursing and health education
and promotion. Simon Stewart is currently the National
Heart Foundation Chair of Cardiovascular Nursing. Pro-
fessor Stewart has been awarded a number of prestigious
research awards. Professor Stewart's pioneering research
to develop the role of the specialist heart failure nurse
has been used as blueprint to apply cost-effective heart
failure services in Australia, Europe,
&'
the USA, includ-
ing establishing the Glasgow Heart Failure Nurse Liaison
Service.
Aeknowledgment. Support from a National Health &
Medical Research Gouncil scholarship is gratefully
acknowledged.
Offprints. Requests for offprints should be directed to
Andrea Driscoll, MEd, MNursing, GGG, BNursing, RN,
Deakin University School of Nursing, 221 Burwood
Highway, Burwood 3123, Victoria, Australia. E-mail: aldr
@deakin.edu.au