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Nurse practitioner roles — An exercise in professionalism, safety and quality
Australian Critical Care
Guest editorial Nurse practitioner r o l e s - an exercise in professionalism, safety and quality P r o f e s s o r M a r y C h i a r e l l a • RN, CM, LLB (Hons), PhD (UNSW) FCN (NSW), FRCNA Professor of N u r s i n g i n Corrections H e a l t h , F a c u l t y of N u r s i n g , Midwifery & Health, U n i v e r s i t y of Technology, S y d n e y
Advanced practice nurses, nurse practitioners, call them what you will, there is no doubt that these issues are very much on our minds as a profession at present. The previous edition of this journal featured two articles and an editorial on advanced practice L2 and the Department of Education Science and Training (DEST) Review of Nurse Education has recommended the development of national standards for nurse practitioners ~.
integral to their work, employers have adopted a range of approaches to their performance over the years due to concerns for safety and quality. Some have insisted that all nurses be reaccredited in a particular 'extended' skill on a regular basis. This has meant that nurses might move one day from a hospital where they were accredited and skilled to perform venepuncture, to another the next day where they had to be re-accredited before they were allowed to perform the task.
Whatever the views held or the politics surrounding advanced practice and nurse practitioner roles, the fact remains that the scope of nursing practice in any given clinical setting has always been fluid. Nurses have repeatedly taken on roles, tasks and activities at work which fell, to a lesser or greater degree, outside the scope of their designated practice. Some of these have been completely new, often relating to the introduction of new drugs or new equipment in the ward or unit. Others have been tasks and roles habitually performed by other health service deliverers, such as doctors, physiotherapists, radiographers, dietitians, even cleaners.
Such a process can be demeaning for nurses, who feel that their specialist skills and expertise are not recognised. This approach was criticised by the (then) United Kingdom Central Council for Nursing, Health Visiting and Midwifery (UKCC) in 1992. The UKCC Position Statement on the Scope of Professional Practice pointed out that the traditional approach to education was that pre-registration education prepared nurses, midwives and health visitors for the necessary skills for safe practice at entry point to the profession. However, it acknowledged that "this foundation education alone ... cannot effectively meet the changing and complex demands of modern health care". Therefore the premise was (and still is in Australia today) that "any widening of that range and enhancement of the nurse's practice requires 'official' extension of that role by certification" s.
The most obvious reason for nurses to take on these activities has been for the benefit of the patient but, in their performance, nurses often report clinical satisfaction for themselves, due to increased efficiency, improved patient care and enhanced clinical interest, although there is often no financial or professional recognition for their extra work4S. In two studies, one in 1992 ~ and another in 19997, nurses described one of their greatest frustrations as waiting - particularly waiting for doctors, but also for allied health professionals and other health service providers. Whilst critical care nurses may have more frequent access to medical practitioners than ward-based nurses, it is inarguable that often nurses take on activities because they want specific services to be performed speedily, and because they believe their patients require them quickly.
The UKCC went on to say: 11. The Council considers that the terms 'extended' or 'extending' roles which have been associated with this system are no longer suitable since they limit, rather than extend, the parameters of practice. As a result, many practitioners have been prevented from fulfilling their potential for the benefit of patients. The Council also believes that a concentration on 'activities' can detract from the importance of holistic nursing care... 12. The reality is that the practice of nursing, and the education for that practice, will continue to be shaped by developments in care and treatment, and by other events which influence it. This equally applies to midwifery and health visiting.
There has been varied acknowledgement that nurses have performed such activities. Where these activities have required no further professional development (such as cleaning), little has been said. However, where further clinical and/or professional development was required, there has been a range of responses from employers and the nursing profession alike. Some technical activities have developed into specialties in their own right, recognising the special needs of the client groups as well as the specialist skills required, some examples being renal dialysis and endoscopic nursing.
In order to bring into proper focus the professional responsibility and consequent accountability of individual practitioners, it is the Council's principles for practice rather than certificates for tasks which should form the basis for adjustment to the scope of practice s. The UKCC has developed six principles for practice which place the responsibility for currency, safety and quality resolutely with the registered nurse. These principles are, of course, predicated upon the UKCC system of re-accreditation, in which is implicit the expectation of currency of practice, the need for nurses to keep up
However, other skills or tasks have been seen as generic to a range of disciplines but have still been treated as specialist tasks or 'extended' roles, a longstanding example being venepuncture. Although certain nursing specialities have accepted these skills as
Volume 16 Number 1 February 2003
4
Australian Critical Care
to date in their area of practice and to provide evidence of such currency in order to re-register. The term currency is used here to differentiate it from recency of practice, whereby nurses are expected to have practised as a nurse within a specified period of time. Both these requirements vary from country to country across the Western world L A t the moment there is no uniformity in requirements for either currency or recency of practice across Australia and, unless there is, it is reasonable that employers will feel responsible for
Selection criteria All associate editors will be critical care nurses and members of ACCCN Ltd.
ensuring safety and quality in nursing practice. The debate on currency and recency of practice in Australia is ongoing, and is beyond the scope of this editorial. However, with nurse practitioner accreditation, there is the potential to address the question from the start. Most of the states and territories which are introducing nurse practitioner positions in Australia are stipulating careful criteria for accreditation and expectations of currency and recency in re-accreditation. It is anticipated that
They will be engaged in clinical, educational and or research activities directed toward the development of the discipline of critical care nursing. Excellent oral and written communication skills are necessary. Applicants will have had experience as peer reviewers.
nurse practitioners, once accredited in their speciality areas of practice, would be able to work in their advanced practice roles
Duties
without the need for further skill assessments. Such a process will provide recognition of the professional responsibility of nurses for their own safety and quality in practice, but also a mechanism of safety and quality assurance for their employers through the re-accreditation and expectation of currency and recency of practice. This is a significant step forward in both the protection of the public and the honouring and recognition of
The associate editors will be responsible for collaborating with the editor and other associate editors in order to: • maintain the standards of a professional journal, newspaper and website; • develop and expand ACCCN Ltd publications, in order to meet reader expectations; • promote ACCCN Ltd publications; • provide authors and peer reviewers with editorial support; • liaise with the editor and editorial board, and
the professional status of nurses.
REFERENCES 1.
Harris D & Chaboyer W. The expanded role of the critical care nurse: a review of the current position. Australian Critical Care 2002; 15:4. 133-137.
2.
Jamieson L, Williams LM & Dwyer T. The need for a new advanced nursing practice role for Australian adult critical care settings. Australian Critical Care 2002; 15:4. 139-145.
• develop and implement editorial policy with regard to the direction of ACCCN Ltd publications.
3.
DEST, National review of nursing education: our duty of care. Canberra: JS McMillan Printing Group; 2002, 19.
These are voluntary positions which do not attract remuneration.
4.
Chiarella M. The legal and professional status of nursing. Edinburgh: Churchill Livingstone; 2002, 157-158.
5.
Lumby J. Who cares? The changing health care system. Sydney: Allen & Unwin; 200i, i13.
6.
Employment Studies Centre of the University of Newcastle. Productivity and nurses' pay: proposal for a framework agreement Stage 2 of research project for the NSWNA. Newcastle: University of Newcastle; 1992, 39-41.
7.
Wicks D. Nurses and doctors at work: rethinking professional boundaries. Sydney: Allen & Unwin; 1999.
8.
UKCC. UKCC Position Statement on the Scope of Professional Practice. London: UKCC; 1992, 3.
9.
Chiarella M. Selected review of nurse regulation. In DEST, National review of nursing education 2002: nursing regulation and practice. Canberra: JS McMillan Printing Group; 2002, 1-92. •
II
ACCCN's website www.ACCCN.com.au I
R e m e m b e r to access the members' lounge, you will need membership number located on your membershi[
5
Volume 16 Number 1 February2003
Guest editorial Nurse practitioner r o l e s - an exercise in professionalism, safety and quality P r o f e s s o r M a r y C h i a r e l l a • RN, CM, LLB (Hons), PhD (UNSW) FCN (NSW), FRCNA Professor of N u r s i n g i n Corrections H e a l t h , F a c u l t y of N u r s i n g , Midwifery & Health, U n i v e r s i t y of Technology, S y d n e y
Advanced practice nurses, nurse practitioners, call them what you will, there is no doubt that these issues are very much on our minds as a profession at present. The previous edition of this journal featured two articles and an editorial on advanced practice L2 and the Department of Education Science and Training (DEST) Review of Nurse Education has recommended the development of national standards for nurse practitioners ~.
integral to their work, employers have adopted a range of approaches to their performance over the years due to concerns for safety and quality. Some have insisted that all nurses be reaccredited in a particular 'extended' skill on a regular basis. This has meant that nurses might move one day from a hospital where they were accredited and skilled to perform venepuncture, to another the next day where they had to be re-accredited before they were allowed to perform the task.
Whatever the views held or the politics surrounding advanced practice and nurse practitioner roles, the fact remains that the scope of nursing practice in any given clinical setting has always been fluid. Nurses have repeatedly taken on roles, tasks and activities at work which fell, to a lesser or greater degree, outside the scope of their designated practice. Some of these have been completely new, often relating to the introduction of new drugs or new equipment in the ward or unit. Others have been tasks and roles habitually performed by other health service deliverers, such as doctors, physiotherapists, radiographers, dietitians, even cleaners.
Such a process can be demeaning for nurses, who feel that their specialist skills and expertise are not recognised. This approach was criticised by the (then) United Kingdom Central Council for Nursing, Health Visiting and Midwifery (UKCC) in 1992. The UKCC Position Statement on the Scope of Professional Practice pointed out that the traditional approach to education was that pre-registration education prepared nurses, midwives and health visitors for the necessary skills for safe practice at entry point to the profession. However, it acknowledged that "this foundation education alone ... cannot effectively meet the changing and complex demands of modern health care". Therefore the premise was (and still is in Australia today) that "any widening of that range and enhancement of the nurse's practice requires 'official' extension of that role by certification" s.
The most obvious reason for nurses to take on these activities has been for the benefit of the patient but, in their performance, nurses often report clinical satisfaction for themselves, due to increased efficiency, improved patient care and enhanced clinical interest, although there is often no financial or professional recognition for their extra work4S. In two studies, one in 1992 ~ and another in 19997, nurses described one of their greatest frustrations as waiting - particularly waiting for doctors, but also for allied health professionals and other health service providers. Whilst critical care nurses may have more frequent access to medical practitioners than ward-based nurses, it is inarguable that often nurses take on activities because they want specific services to be performed speedily, and because they believe their patients require them quickly.
The UKCC went on to say: 11. The Council considers that the terms 'extended' or 'extending' roles which have been associated with this system are no longer suitable since they limit, rather than extend, the parameters of practice. As a result, many practitioners have been prevented from fulfilling their potential for the benefit of patients. The Council also believes that a concentration on 'activities' can detract from the importance of holistic nursing care... 12. The reality is that the practice of nursing, and the education for that practice, will continue to be shaped by developments in care and treatment, and by other events which influence it. This equally applies to midwifery and health visiting.
There has been varied acknowledgement that nurses have performed such activities. Where these activities have required no further professional development (such as cleaning), little has been said. However, where further clinical and/or professional development was required, there has been a range of responses from employers and the nursing profession alike. Some technical activities have developed into specialties in their own right, recognising the special needs of the client groups as well as the specialist skills required, some examples being renal dialysis and endoscopic nursing.
In order to bring into proper focus the professional responsibility and consequent accountability of individual practitioners, it is the Council's principles for practice rather than certificates for tasks which should form the basis for adjustment to the scope of practice s. The UKCC has developed six principles for practice which place the responsibility for currency, safety and quality resolutely with the registered nurse. These principles are, of course, predicated upon the UKCC system of re-accreditation, in which is implicit the expectation of currency of practice, the need for nurses to keep up
However, other skills or tasks have been seen as generic to a range of disciplines but have still been treated as specialist tasks or 'extended' roles, a longstanding example being venepuncture. Although certain nursing specialities have accepted these skills as
Volume 16 Number 1 February 2003
4
Australian Critical Care
to date in their area of practice and to provide evidence of such currency in order to re-register. The term currency is used here to differentiate it from recency of practice, whereby nurses are expected to have practised as a nurse within a specified period of time. Both these requirements vary from country to country across the Western world L A t the moment there is no uniformity in requirements for either currency or recency of practice across Australia and, unless there is, it is reasonable that employers will feel responsible for
Selection criteria All associate editors will be critical care nurses and members of ACCCN Ltd.
ensuring safety and quality in nursing practice. The debate on currency and recency of practice in Australia is ongoing, and is beyond the scope of this editorial. However, with nurse practitioner accreditation, there is the potential to address the question from the start. Most of the states and territories which are introducing nurse practitioner positions in Australia are stipulating careful criteria for accreditation and expectations of currency and recency in re-accreditation. It is anticipated that
They will be engaged in clinical, educational and or research activities directed toward the development of the discipline of critical care nursing. Excellent oral and written communication skills are necessary. Applicants will have had experience as peer reviewers.
nurse practitioners, once accredited in their speciality areas of practice, would be able to work in their advanced practice roles
Duties
without the need for further skill assessments. Such a process will provide recognition of the professional responsibility of nurses for their own safety and quality in practice, but also a mechanism of safety and quality assurance for their employers through the re-accreditation and expectation of currency and recency of practice. This is a significant step forward in both the protection of the public and the honouring and recognition of
The associate editors will be responsible for collaborating with the editor and other associate editors in order to: • maintain the standards of a professional journal, newspaper and website; • develop and expand ACCCN Ltd publications, in order to meet reader expectations; • promote ACCCN Ltd publications; • provide authors and peer reviewers with editorial support; • liaise with the editor and editorial board, and
the professional status of nurses.
REFERENCES 1.
Harris D & Chaboyer W. The expanded role of the critical care nurse: a review of the current position. Australian Critical Care 2002; 15:4. 133-137.
2.
Jamieson L, Williams LM & Dwyer T. The need for a new advanced nursing practice role for Australian adult critical care settings. Australian Critical Care 2002; 15:4. 139-145.
• develop and implement editorial policy with regard to the direction of ACCCN Ltd publications.
3.
DEST, National review of nursing education: our duty of care. Canberra: JS McMillan Printing Group; 2002, 19.
These are voluntary positions which do not attract remuneration.
4.
Chiarella M. The legal and professional status of nursing. Edinburgh: Churchill Livingstone; 2002, 157-158.
5.
Lumby J. Who cares? The changing health care system. Sydney: Allen & Unwin; 200i, i13.
6.
Employment Studies Centre of the University of Newcastle. Productivity and nurses' pay: proposal for a framework agreement Stage 2 of research project for the NSWNA. Newcastle: University of Newcastle; 1992, 39-41.
7.
Wicks D. Nurses and doctors at work: rethinking professional boundaries. Sydney: Allen & Unwin; 1999.
8.
UKCC. UKCC Position Statement on the Scope of Professional Practice. London: UKCC; 1992, 3.
9.
Chiarella M. Selected review of nurse regulation. In DEST, National review of nursing education 2002: nursing regulation and practice. Canberra: JS McMillan Printing Group; 2002, 1-92. •
II
ACCCN's website www.ACCCN.com.au I
R e m e m b e r to access the members' lounge, you will need membership number located on your membershi[
5
Volume 16 Number 1 February2003