- Email: [email protected]
The evolution of the neonatal nurse practitioner role in Australia: A discussion paper
Journal of Neonatal Nursing xxx (xxxx) xxx–xxx
Contents lists available at ScienceDirect
Journal of Neonatal Nursing journal homepage: www.elsevier.com/locate/jnn
Review
The evolution of the neonatal nurse practitioner role in Australia: A discussion paper Amy Forbes-Coea,b,∗, Jennifer Dawsona,c, Anndrea Flinta,d, Karen Walkera a
Australian College of Neonatal Nurses, Australia The Townsville Hospital, Queensland, Australia c The Royal Women's Hospital, Melbourne, Australia d Redcliff Hospital, Brisbane, Australia b
A R T I C LE I N FO
A B S T R A C T
Keywords: Nurse practitioner Neonatal nurse practitioner Role evolution Role development Role sustainability Education Leadership Research
Aim: The neonatal nurse practitioner role originated in the 1960's in the Unites States from a short fall in physicians. This occurred because of changes in medical training which reduced time in specialist areas and in conjunction, the demand for neonatal care increased due to the survival of premature babies and advances in specialised care. The aim of this review is to identify the discrepancies between roles and responsibilities, highlight the challenges NNP face and explore possible role development opportunities to make the position sustainable. Method: Current review of the literature (MESH TERMS – neonatal and/or nurse practitioner, Australia) revealed fourteen published articles and government documents identifying requirements for endorsement and standards for nurse practitioner practice. Result: Neonatal nurse practitioners spend most of their time delivering direct patient care regardless of the clinical setting, however elements of research, education and leadership are still incorporated within clinical practice. Alongside the clinical role, antenatal counselling, facilitation of communication amongst the multidisciplinary team and parents, prescribing, ordering diagnostic tests have all became core components to define the scope of the NNP. However, as the role has expanded NNP must adapt to changes to continue to be recognised as a valuable member of the multidisciplinary team especially as registered nurses start to take on extended roles. Conclusion: The senior clinical role of the neonatal nurse practitioner continues to evolve. There are challenges to be overcome, however there are now more than thirty neonatal nurse practitioners in Australia and together the possibilities for expansion of their role are limitless. This can only be of benefit to our babies, their families and the nursing profession.
1. Introduction/background The Nurse practitioner (NP) role has been well established over the last five decades beginning in the United States of America (1960s), United Kingdom (1980s), Australia (1995) and most recently Canada and New Zealand (2000) (Fry, 2011). The Neonatal Nurse Practitioner (NNP) role originated in the 1970's in the Unites States from a short fall in physicians. This shortfall occurred because of changes in medical training which reduced time in specialist areas and in conjunction, the demand for neonatal care increased due to the survival of premature babies and advances in specialised care (Farah et al., 1996). This was mirrored in Australia thirty-years later and initially developed in Newcastle, North of Sydney before expanding to Townsville, North
∗
Queensland and Adelaide, South Australia all regional areas that found it difficult to attract medical trainees and junior doctors. The development of this role was embraced by nurses who desired more responsibility and autonomy in their clinical setting. However, legal endorsement of the role and standards of practice were not established until the turn of the century and in 2009 the Australian Federal Government committed nearly AU$60 million to expand the role of the NP throughout healthcare systems, generating an urgent need for a clearer understanding of the evolution of NP practice in Australia (Middleton et al., 2011). The nursing and midwifery board of Australia (NMBA) define Nurse Practitioners as “working as an advanced practice nurse endorsed by the NMBA who has direct clinical contact and practice within their
Corresponding author. Australian College of Neonatal Nurses, Australia. E-mail address: [email protected] (A. Forbes-Coe).
https://doi.org/10.1016/j.jnn.2020.01.008 Received 19 September 2019; Received in revised form 24 December 2019; Accepted 17 January 2020 1355-1841/ © 2020 Published by Elsevier Ltd on behalf of Neonatal Nurses Association.
Please cite this article as: Amy Forbes-Coe, et al., Journal of Neonatal Nursing, https://doi.org/10.1016/j.jnn.2020.01.008
Journal of Neonatal Nursing xxx (xxxx) xxx–xxx
A. Forbes-Coe, et al.
Table 1 Shows the diversity of the nurse practitioner role and current percentage working in each speciality (Middleton et al., 2011). Renal
13%
Oncology and Palliative care
9%
Community and Primary Health Continence, women's health and urology Mental health Age care and Rehabilitation Generalise and Remote Paediatrics Cardiac
12% 12%
Wound Management Diabetes
7% 5%
12% 11% 11% 11% 9%
Pain Management Hepatology ICU Liaison Other
4% 2% 2% 20%
Table 2 Australian Health Practitioner Regulation Authority (APHRA) approved university courses for the Master of Nursing – Nurse Practitioner (Australian Health Practitioner Regulation Agency, 2007). Name of University/State Queensland Queensland University of Technology. The University of Queensland New South Wales Charles Sturt University University of Newcastle University of Sydney
scope under the legislative protected title ‘nurse practitioner’ under the national law” (Nursing and Midwifery Board of Australia, 2016). This document highlights the appropriate supplementary education required to achieve endorsement including advanced health assessment, management of clients, pharmacology for prescribing, ordering therapeutic or diagnostic investigations and research in both an autonomous and collaborative context (Nursing and Midwifery Board of Australia, 2016). However, in Australia there are still discrepancies between NNP roles and responsibilities. Although difficult to find contemporary data regarding the specialisation of Nurse Practitioners and currently not recorded by our registering body; Australian Health Practitioner Regulation Agency (AHPRA), Middleton documented in 2011 the majority of NP worked and specialised in emergency nursing (30%) with only a small percentage working within the neonatal intensive care (5%). Table 1. The evolution of the role of NNP has been slow to develop and currently we are unable to accurately report the number of endorsed NNPs because individual specialities within the role of nurse practitioners are not recorded. This means that the impact of the NNP role is unknown across Australia.
University of Technology Sydney Wester Sydney University Northern Territory Charles Darwin University South Australia Flinders University University of South Australia Victoria La Trobe University Monash University University of Melbourne Western Australia Curtin University Edith Cowan University
Duration of course
Non-Core components
2 years PT 2 years PT 1.5 years FT or 3 years PT 2 years 2 years FT or 3 years PT 3 years PT
With a restrictive electives list Direct Neonatal Elective
3 years PT
Mental Health
2 years
One elective subject
1.5 years FT 1.5 years 2 years 3 years PT 2 years PT 3 years PT
Indigenous and Social health
1.5 years FT or 3 years PT
important to note that these requirements are the minimum and clinical experience throughout neonatal intensive care environments should be paramount, from the extremely preterm infant through to surgical/ cardiac conditions and variety is vital to develop the necessary advanced clinical expertise. The three years working within an advanced clinical role within your speciality needs to be completed by the time the individual seeks endorsement and has completed an approved program of study to gain endorsement, which could be completed as a full or part-time program (Nursing and Midwifery Board of Australia, 2016). Universities also require a letter of support acknowledging 500 hours of supervised clinical practice and governance. There are fourteen universities which offer a Master of Nursing/Science – NP and one specifically focused on mental health. Course length can vary one year full-time through to three years part-time (see Table 2). An approved program is a Masters of Nursing/Science – Nurse Practitioner and is recommended to include three components; 1. Nursing theory and research, 2. Generic advanced nursing practice – pathophysiology, assessment and pharmacology, 3. Specialist nursing subjects unique to the clinical settings (Strodtbeck et al., 1998). Courses currently conducted within Australia are generic courses except for Newcastle who offers specific neonatal modules as an elective component this is reflected in Table 2.
2. Method Little is published on the role in the Australian context. Current review of the literature (MESH TERMS – neonatal and/or nurse practitioner, Australia) revealed fourteen published articles. These articles discussed the nurse practitioner internationally and within Australia, the role of the nurse practitioner but not specifically the neonatal aspect these were reported as case reviews and the neonatal environment. All articles were published between 2002 and 2014. 2.1. Evolution of the Australian model Initially NNPs provided assessment and treatment plans for neonates from admission to discharge and were described as functionally equivalent to a junior doctor, with the additional skill required for advanced procedures. This model was modified in different clinical settings and recently, has been expanded to include post-natal wards, special care nurseries, discharge planning, community settings and growth and development clinics (Robson et al., 2002). This was observed with great interest from the nursing profession. The role proved its success quickly expanding to Queensland and South Australia. Requirements at the time for nurses in the NNP role was to have a post-graduate certificate in neonatal nursing and five years’ experience within the speciality of practice. However, the current requirements for endorsement have evolved over the years and now accept a minimum of three years working in an advanced practice role. The nursing and Midwifery board (NAMB) currently require completion of a master's in nursing/science – nurse practitioner, registration as a division one nurse in Australia, have three to five years post registration experience and a graduate certificate in your speciality. It is
2.2. Defining the role of the nurse practitioner A nurse practitioner is an advanced practice nurse endorsed by the Australian governing body to work within their scope of practice which is influenced by the clinical settings in which they are employed as long as they are educated, competent to perform and permitted by law (Nursing and Midwifery Board of Australia, 2013). Insert Fig. 1. The NP role is clinically focused incorporating research, education, plus leadership and applying these three domains throughout clinical practice. Whereas, the core standards can be applicable to define the extended role of an NP from a registered nurse to a nurse practitioner but can still be interpreted to a new or experienced nurse practitioner. Standard one, focuses on assessment using diagnostic capability 2
Journal of Neonatal Nursing xxx (xxxx) xxx–xxx
A. Forbes-Coe, et al.
Fig. 1. Shows how education, research and leadership is couched within the clinical domain which is divided into four standards of practice (Nursing and Midwifery Board of Australia, 2013).
sick newborn babies (Hussey, 2008; Presly and Bernardo, 2006; Smith, 2005). Alongside the clinical role, antenatal counselling, facilitation of communication amongst the multidisciplinary team and parents, prescribing, ordering diagnostic tests have all became core components to define the scope of the neonatal nurse practitioner. However, as the role has expanded throughout Australia the core scope has been adapted to suit the individuals neonatal and even maternity working environment. An example of two completely different job descriptions are highlighted between an obstetric and non-obstetric level three nursery it is requested to have two years’ experience in an obstetric hospital as an endorsed NNP prior to working within a non-obstetric unit, which leads us to consider the diversity and flexibility of the NNP. The role of the NNP must adapt to changes in healthcare service provision to continue to be recognised as a valuable contribution to the multidisciplinary team especially as registered nurses start to take on extended roles. A nurse practitioner can extend their scope of practice by undertaking retrievals, research or even initiate early discharge/follow up clinics.
(Nursing and Midwifery Board of Australia, 2013). Further explanation of the standard confirms the clinician must complete comprehensive, relevant and holistic health assessment is conducted through timely diagnostic investigations to inform clinical decisions and applies results to formulate diagnoses (Nursing and Midwifery Board of Australia, 2013). Standard two reflects an NP to plan care and engage with others to ensure the translation of evidence into practice. Nurse Practitioners educate and support others, consider the quality of medicines or therapeutic interventions in planning care and refers or consults to provide optimal outcomes for the person receiving the care (ref). Standard three states, prescribes and implements therapeutic interventions as indicated whilst maintaining a relationship with the people at the centre of care and practices in accordance with federal, state and territorial legislation and professional regulation (Nursing and Midwifery Board of Australia, 2013). The final standard, four, evaluates outcomes and improves practice, which is not only the NPs practice, but advocates for and participates in or leads systems to support safe practice, partnership and professional growth (Nursing and Midwifery Board of Australia, 2013).
3.1. Strengths and limitations of NNP role 3. Results There are many strengths which make the nurse practitioner role one of the most sought after senior clinical role for neonatal nurses. One of the roles greatest strength is the provision of autonomy for patients whilst maintaining stability and continuity of care in the work environment, which prompted the expansion of this role (Johnson, 2002). Initially during a time of high turnover of medical registrars, NNPs provided stability within the workforce allowing support and education to both medical and nursing staff (Hussey, 2008; Presly and Bernardo, 2006; Smith, 2005). The literature also highlights the opportunity this role gives employers to attract, develop and retain skilled neonatal nurses (Jones and Webster, 2019; Schell et al., 2016). The diversity of an NNPs experience working within the clinical setting can contribute
Neonatal nurse practitioners spend most of their time delivering direct patient care regardless of the clinical setting, however elements of research, education and leadership are still incorporated within clinical practice. Fig. 1 documents the four standards but each of these standards are reflected under the umbrella of clinical practice (Australian Health Practitioner Regulation Agency, 2007). Four clinical practitioners nearly a decade ago undertook extended practice to enhance their knowledge and completed procedural training enabling them to; initiate resuscitation of a newborn, intubate a neonate, insert umbilical catheters, peripheral and central lines, conduct lumbar punctures, insert or aspirate chest drains and undertake retrievals of 3
Journal of Neonatal Nursing xxx (xxxx) xxx–xxx
A. Forbes-Coe, et al.
nurse practitioners we need to identify individual specialities upon registration to create a target network.
to a more dynamic and stable workforce which has benefits for the babies and their families and the role provides a previously unavailable clinical career pathway at a senior nursing level (Hussey, 2008). There are, however, some identified challenges and limitation to the role. NNPs have no Medicare provider number unless working within a private practice, thus when making referrals they must always be countersigned by a medical practitioner (Middleton et al., 2011). As AHPRA does not identify who is an NNP or individual clinical areas where NPs practice, it restricts the ability to identify and collaborate with colleagues. One of the main limitations of the current role is the ongoing requirement to work a rotating 24-h roster, which is generally not required in other disciplines at this senior level. Another limitation is that only a medical practitioner can certify death (State of Queensland, 2017) which can be challenging for NNPs undertaking neonatal retrievals.
4. Conclusion It is an exciting time for neonatal nursing in Australia as this senior clinical role of NNP continues to evolve. There are challenges to be overcome, however there are now more than thirty endorsed NNPs in Australia and together the possibilities for expansion of their role are limitless. This can only be of benefit to our babies, their families and the nursing profession. Thus, however this is only a reflection on nurse practitioners within Australia and it is a position that has been established globally since 1960's. This then leads to further research to identify if international nurse practitioners have the same diversity within their role and what extended skills are considered to advance your knowledge when you are already working as a senior nurse without stepping over the line to the medical position because as nurse practitioners we should remain grounded in nursing.
3.2. Sustainability of the neonatal nurse practitioner As the role of neonatal nurses is expanding to incorporate some of the procedural, diagnostic and clinical skills typical of the NNP role (Presly and Bernardo, 2006), for the NNP role to also evolve, NNPs must start to develop their skills by taking on extended roles to continue to be competitive within the work place. The diversity of the current NNP roles, enables some extended roles to already occur in single centres leaving scope for expansion, however there are other skills and areas which can be considered. A recent paper from the UK highlights the need for NNPs to have a career pathway as they are hypothesising that NNPs work in diverse roles adapted to their current clinical setting (Jones and Webster, 2019). Throughout NICUs the use of clinician performed ultrasound is increasing in popularity. Traditionally the medical practitioners undertook a certified course, this could change in the future enabling NNPs to perform ultrasound in the unit and on retrievals (Raftery, 2013). Outpatient activity is also another possible role undertaking neurological and developmental assessments of infants using tools such as the General Movements Assessments (Einspieler and Prechtl, 2005) and the Bayley Scales of Infant and Toddler Development (Vohr et al., 2012). NNP led clinics could also be developed allowing the continuity of care from the clinical unit to home, supporting families to an even greater extent. As leaders in their clinical field it is extremely important for NNPs to be involved in clinical trials or research to maintain an evidence-based focus within their scope of practice. They also need to be proactive to ensure that they are included in managerial decisions, clinical governance and contribute to policy directions for neonatal units. Lastly, negotiation between universities and clinical areas must be initiated to assist in providing educational programs for NP preparation which should include leadership, negotiating change, self-care/motivation and conflict resolution. The financial burden for neonatal nurses to undertake masters study courses should not be underestimated; thus, it is important to provide funding and employment to support potential candidates to ensure sustainability of this important clinical roles. (MacLellan et al., 2017). Nevertheless, to be able to support and educate nurse practitioner candidates as well as experienced endorsed
References Australian Health Practitioner Regulation Agency, 2007. Approved Programs of Study Masters of Nursing Nurse Practitioner. Einspieler, C., Prechtl, H.F.R., 2005. Prechtl's assessment of general movements: a diagnostic tool for the functional assessment of the young nervous system. Ment. Retard. Dev. Disabil. Res. Rev. 11 (1), 61–67. Farah, A.L., Bieda, A., Siho, S., 1996. The history of the neonatal nurse practitioner in the United States. Neonatal Netw. J. Neonatal Nurs. 15 (5). Fry, M., 2011. Literature review of the impact of nurse practitioners in critical care services. Nurs. Crit. Care 16 (2), 58–66. Hussey, L., 2008. Neonatal nurse practitioner. Aust. Nurs. J. 16 (5), 47. Johnson, P.J., 2002. The history of the neonatal nurse practitioner: reflections from 'under the looking glass'. Neonatal Netw. J. Neonatal Nurs. 21 (5), 51–60. Jones, T., Webster, K., 2019. Recognising the need for a career pathway for advanced neonatal nurse practitioners. Infant 15 (3), 104–106. MacLellan, L., Higgins, I., Levett-Jones, T., 2017. An exploration of the factors that influence nurse practitioner transition in Australia: a story of turmoil, tenacity, and triumph. J. Am. Assoc. Nurse Pract. 29 (3), 149–156. Middleton, S., Gardner, A., Gardner, G., Della, P.R., 2011. The status of Australian nurse practitioners: the second national census. Aust. Health Rev. 35 (4), 448–454. Nursing and Midwifery Board of Australia, 2013. Nurse Practitioner Standards for Practice. pp. 7. Nursing and Midwifery Board of Australia, 2016. Registration Standard: Endorsement as a Nurse Practitioner. Presly, P., Bernardo, J., 2006. Working life: neonatal nurse practitioners rule!. Aust. Nurs. J. 13 (10), 25. Raftery, C., 2013. Nurse Practitioner Succession Planning: Forward Thinking or Just an After-Thought? Australian Health Review: A Publication of the Australian Hospital Association, vol. 37. pp. 585–587 5. Robson, A., Copnell, B., Johnston, L., Harrison, D., Wilson, A., Ramudu, L., et al., 2002. Overseas experience of the neonatal nurse practitioner role: lessons for Australia. Contemp. Nurse: J. Aust. Nurs. Prof. 14 (1), 9–23. Schell, G.J., Lavieri, M.S., Jankovic, F., Li, X., Toriello, A., Martyn, K.K., et al., 2016. Strategic modeling of the neonatal nurse practitioner workforce. Nurs. Outlook 64 (4), 385–394. Smith, J., 2005. Focus on a unit. The nurse practitioner role comes to North Queensland. Infant 1 (4), 108. State of Queensland, 2017. Birth, Deaths and Marriages Registration Act 2003. Strodtbeck, F., Trooter, C., Lott, J.W., 1998. Coping wth transition: neonatal nurse practitioner education for the 21st century. J. Pediatr. Nurs. 13 (5), 272–278. Vohr, B.R., Stephens, B.E., Higgins, R.D., Bann, C.M., Hintz, S.R., Das, A., et al., 2012. Are outcomes of extremely preterm infants improving? Impact of Bayley assessment on outcomes. J. Pediatr. 161 (2), 222–228 e3.
4
Contents lists available at ScienceDirect
Journal of Neonatal Nursing journal homepage: www.elsevier.com/locate/jnn
Review
The evolution of the neonatal nurse practitioner role in Australia: A discussion paper Amy Forbes-Coea,b,∗, Jennifer Dawsona,c, Anndrea Flinta,d, Karen Walkera a
Australian College of Neonatal Nurses, Australia The Townsville Hospital, Queensland, Australia c The Royal Women's Hospital, Melbourne, Australia d Redcliff Hospital, Brisbane, Australia b
A R T I C LE I N FO
A B S T R A C T
Keywords: Nurse practitioner Neonatal nurse practitioner Role evolution Role development Role sustainability Education Leadership Research
Aim: The neonatal nurse practitioner role originated in the 1960's in the Unites States from a short fall in physicians. This occurred because of changes in medical training which reduced time in specialist areas and in conjunction, the demand for neonatal care increased due to the survival of premature babies and advances in specialised care. The aim of this review is to identify the discrepancies between roles and responsibilities, highlight the challenges NNP face and explore possible role development opportunities to make the position sustainable. Method: Current review of the literature (MESH TERMS – neonatal and/or nurse practitioner, Australia) revealed fourteen published articles and government documents identifying requirements for endorsement and standards for nurse practitioner practice. Result: Neonatal nurse practitioners spend most of their time delivering direct patient care regardless of the clinical setting, however elements of research, education and leadership are still incorporated within clinical practice. Alongside the clinical role, antenatal counselling, facilitation of communication amongst the multidisciplinary team and parents, prescribing, ordering diagnostic tests have all became core components to define the scope of the NNP. However, as the role has expanded NNP must adapt to changes to continue to be recognised as a valuable member of the multidisciplinary team especially as registered nurses start to take on extended roles. Conclusion: The senior clinical role of the neonatal nurse practitioner continues to evolve. There are challenges to be overcome, however there are now more than thirty neonatal nurse practitioners in Australia and together the possibilities for expansion of their role are limitless. This can only be of benefit to our babies, their families and the nursing profession.
1. Introduction/background The Nurse practitioner (NP) role has been well established over the last five decades beginning in the United States of America (1960s), United Kingdom (1980s), Australia (1995) and most recently Canada and New Zealand (2000) (Fry, 2011). The Neonatal Nurse Practitioner (NNP) role originated in the 1970's in the Unites States from a short fall in physicians. This shortfall occurred because of changes in medical training which reduced time in specialist areas and in conjunction, the demand for neonatal care increased due to the survival of premature babies and advances in specialised care (Farah et al., 1996). This was mirrored in Australia thirty-years later and initially developed in Newcastle, North of Sydney before expanding to Townsville, North
∗
Queensland and Adelaide, South Australia all regional areas that found it difficult to attract medical trainees and junior doctors. The development of this role was embraced by nurses who desired more responsibility and autonomy in their clinical setting. However, legal endorsement of the role and standards of practice were not established until the turn of the century and in 2009 the Australian Federal Government committed nearly AU$60 million to expand the role of the NP throughout healthcare systems, generating an urgent need for a clearer understanding of the evolution of NP practice in Australia (Middleton et al., 2011). The nursing and midwifery board of Australia (NMBA) define Nurse Practitioners as “working as an advanced practice nurse endorsed by the NMBA who has direct clinical contact and practice within their
Corresponding author. Australian College of Neonatal Nurses, Australia. E-mail address: [email protected] (A. Forbes-Coe).
https://doi.org/10.1016/j.jnn.2020.01.008 Received 19 September 2019; Received in revised form 24 December 2019; Accepted 17 January 2020 1355-1841/ © 2020 Published by Elsevier Ltd on behalf of Neonatal Nurses Association.
Please cite this article as: Amy Forbes-Coe, et al., Journal of Neonatal Nursing, https://doi.org/10.1016/j.jnn.2020.01.008
Journal of Neonatal Nursing xxx (xxxx) xxx–xxx
A. Forbes-Coe, et al.
Table 1 Shows the diversity of the nurse practitioner role and current percentage working in each speciality (Middleton et al., 2011). Renal
13%
Oncology and Palliative care
9%
Community and Primary Health Continence, women's health and urology Mental health Age care and Rehabilitation Generalise and Remote Paediatrics Cardiac
12% 12%
Wound Management Diabetes
7% 5%
12% 11% 11% 11% 9%
Pain Management Hepatology ICU Liaison Other
4% 2% 2% 20%
Table 2 Australian Health Practitioner Regulation Authority (APHRA) approved university courses for the Master of Nursing – Nurse Practitioner (Australian Health Practitioner Regulation Agency, 2007). Name of University/State Queensland Queensland University of Technology. The University of Queensland New South Wales Charles Sturt University University of Newcastle University of Sydney
scope under the legislative protected title ‘nurse practitioner’ under the national law” (Nursing and Midwifery Board of Australia, 2016). This document highlights the appropriate supplementary education required to achieve endorsement including advanced health assessment, management of clients, pharmacology for prescribing, ordering therapeutic or diagnostic investigations and research in both an autonomous and collaborative context (Nursing and Midwifery Board of Australia, 2016). However, in Australia there are still discrepancies between NNP roles and responsibilities. Although difficult to find contemporary data regarding the specialisation of Nurse Practitioners and currently not recorded by our registering body; Australian Health Practitioner Regulation Agency (AHPRA), Middleton documented in 2011 the majority of NP worked and specialised in emergency nursing (30%) with only a small percentage working within the neonatal intensive care (5%). Table 1. The evolution of the role of NNP has been slow to develop and currently we are unable to accurately report the number of endorsed NNPs because individual specialities within the role of nurse practitioners are not recorded. This means that the impact of the NNP role is unknown across Australia.
University of Technology Sydney Wester Sydney University Northern Territory Charles Darwin University South Australia Flinders University University of South Australia Victoria La Trobe University Monash University University of Melbourne Western Australia Curtin University Edith Cowan University
Duration of course
Non-Core components
2 years PT 2 years PT 1.5 years FT or 3 years PT 2 years 2 years FT or 3 years PT 3 years PT
With a restrictive electives list Direct Neonatal Elective
3 years PT
Mental Health
2 years
One elective subject
1.5 years FT 1.5 years 2 years 3 years PT 2 years PT 3 years PT
Indigenous and Social health
1.5 years FT or 3 years PT
important to note that these requirements are the minimum and clinical experience throughout neonatal intensive care environments should be paramount, from the extremely preterm infant through to surgical/ cardiac conditions and variety is vital to develop the necessary advanced clinical expertise. The three years working within an advanced clinical role within your speciality needs to be completed by the time the individual seeks endorsement and has completed an approved program of study to gain endorsement, which could be completed as a full or part-time program (Nursing and Midwifery Board of Australia, 2016). Universities also require a letter of support acknowledging 500 hours of supervised clinical practice and governance. There are fourteen universities which offer a Master of Nursing/Science – NP and one specifically focused on mental health. Course length can vary one year full-time through to three years part-time (see Table 2). An approved program is a Masters of Nursing/Science – Nurse Practitioner and is recommended to include three components; 1. Nursing theory and research, 2. Generic advanced nursing practice – pathophysiology, assessment and pharmacology, 3. Specialist nursing subjects unique to the clinical settings (Strodtbeck et al., 1998). Courses currently conducted within Australia are generic courses except for Newcastle who offers specific neonatal modules as an elective component this is reflected in Table 2.
2. Method Little is published on the role in the Australian context. Current review of the literature (MESH TERMS – neonatal and/or nurse practitioner, Australia) revealed fourteen published articles. These articles discussed the nurse practitioner internationally and within Australia, the role of the nurse practitioner but not specifically the neonatal aspect these were reported as case reviews and the neonatal environment. All articles were published between 2002 and 2014. 2.1. Evolution of the Australian model Initially NNPs provided assessment and treatment plans for neonates from admission to discharge and were described as functionally equivalent to a junior doctor, with the additional skill required for advanced procedures. This model was modified in different clinical settings and recently, has been expanded to include post-natal wards, special care nurseries, discharge planning, community settings and growth and development clinics (Robson et al., 2002). This was observed with great interest from the nursing profession. The role proved its success quickly expanding to Queensland and South Australia. Requirements at the time for nurses in the NNP role was to have a post-graduate certificate in neonatal nursing and five years’ experience within the speciality of practice. However, the current requirements for endorsement have evolved over the years and now accept a minimum of three years working in an advanced practice role. The nursing and Midwifery board (NAMB) currently require completion of a master's in nursing/science – nurse practitioner, registration as a division one nurse in Australia, have three to five years post registration experience and a graduate certificate in your speciality. It is
2.2. Defining the role of the nurse practitioner A nurse practitioner is an advanced practice nurse endorsed by the Australian governing body to work within their scope of practice which is influenced by the clinical settings in which they are employed as long as they are educated, competent to perform and permitted by law (Nursing and Midwifery Board of Australia, 2013). Insert Fig. 1. The NP role is clinically focused incorporating research, education, plus leadership and applying these three domains throughout clinical practice. Whereas, the core standards can be applicable to define the extended role of an NP from a registered nurse to a nurse practitioner but can still be interpreted to a new or experienced nurse practitioner. Standard one, focuses on assessment using diagnostic capability 2
Journal of Neonatal Nursing xxx (xxxx) xxx–xxx
A. Forbes-Coe, et al.
Fig. 1. Shows how education, research and leadership is couched within the clinical domain which is divided into four standards of practice (Nursing and Midwifery Board of Australia, 2013).
sick newborn babies (Hussey, 2008; Presly and Bernardo, 2006; Smith, 2005). Alongside the clinical role, antenatal counselling, facilitation of communication amongst the multidisciplinary team and parents, prescribing, ordering diagnostic tests have all became core components to define the scope of the neonatal nurse practitioner. However, as the role has expanded throughout Australia the core scope has been adapted to suit the individuals neonatal and even maternity working environment. An example of two completely different job descriptions are highlighted between an obstetric and non-obstetric level three nursery it is requested to have two years’ experience in an obstetric hospital as an endorsed NNP prior to working within a non-obstetric unit, which leads us to consider the diversity and flexibility of the NNP. The role of the NNP must adapt to changes in healthcare service provision to continue to be recognised as a valuable contribution to the multidisciplinary team especially as registered nurses start to take on extended roles. A nurse practitioner can extend their scope of practice by undertaking retrievals, research or even initiate early discharge/follow up clinics.
(Nursing and Midwifery Board of Australia, 2013). Further explanation of the standard confirms the clinician must complete comprehensive, relevant and holistic health assessment is conducted through timely diagnostic investigations to inform clinical decisions and applies results to formulate diagnoses (Nursing and Midwifery Board of Australia, 2013). Standard two reflects an NP to plan care and engage with others to ensure the translation of evidence into practice. Nurse Practitioners educate and support others, consider the quality of medicines or therapeutic interventions in planning care and refers or consults to provide optimal outcomes for the person receiving the care (ref). Standard three states, prescribes and implements therapeutic interventions as indicated whilst maintaining a relationship with the people at the centre of care and practices in accordance with federal, state and territorial legislation and professional regulation (Nursing and Midwifery Board of Australia, 2013). The final standard, four, evaluates outcomes and improves practice, which is not only the NPs practice, but advocates for and participates in or leads systems to support safe practice, partnership and professional growth (Nursing and Midwifery Board of Australia, 2013).
3.1. Strengths and limitations of NNP role 3. Results There are many strengths which make the nurse practitioner role one of the most sought after senior clinical role for neonatal nurses. One of the roles greatest strength is the provision of autonomy for patients whilst maintaining stability and continuity of care in the work environment, which prompted the expansion of this role (Johnson, 2002). Initially during a time of high turnover of medical registrars, NNPs provided stability within the workforce allowing support and education to both medical and nursing staff (Hussey, 2008; Presly and Bernardo, 2006; Smith, 2005). The literature also highlights the opportunity this role gives employers to attract, develop and retain skilled neonatal nurses (Jones and Webster, 2019; Schell et al., 2016). The diversity of an NNPs experience working within the clinical setting can contribute
Neonatal nurse practitioners spend most of their time delivering direct patient care regardless of the clinical setting, however elements of research, education and leadership are still incorporated within clinical practice. Fig. 1 documents the four standards but each of these standards are reflected under the umbrella of clinical practice (Australian Health Practitioner Regulation Agency, 2007). Four clinical practitioners nearly a decade ago undertook extended practice to enhance their knowledge and completed procedural training enabling them to; initiate resuscitation of a newborn, intubate a neonate, insert umbilical catheters, peripheral and central lines, conduct lumbar punctures, insert or aspirate chest drains and undertake retrievals of 3
Journal of Neonatal Nursing xxx (xxxx) xxx–xxx
A. Forbes-Coe, et al.
nurse practitioners we need to identify individual specialities upon registration to create a target network.
to a more dynamic and stable workforce which has benefits for the babies and their families and the role provides a previously unavailable clinical career pathway at a senior nursing level (Hussey, 2008). There are, however, some identified challenges and limitation to the role. NNPs have no Medicare provider number unless working within a private practice, thus when making referrals they must always be countersigned by a medical practitioner (Middleton et al., 2011). As AHPRA does not identify who is an NNP or individual clinical areas where NPs practice, it restricts the ability to identify and collaborate with colleagues. One of the main limitations of the current role is the ongoing requirement to work a rotating 24-h roster, which is generally not required in other disciplines at this senior level. Another limitation is that only a medical practitioner can certify death (State of Queensland, 2017) which can be challenging for NNPs undertaking neonatal retrievals.
4. Conclusion It is an exciting time for neonatal nursing in Australia as this senior clinical role of NNP continues to evolve. There are challenges to be overcome, however there are now more than thirty endorsed NNPs in Australia and together the possibilities for expansion of their role are limitless. This can only be of benefit to our babies, their families and the nursing profession. Thus, however this is only a reflection on nurse practitioners within Australia and it is a position that has been established globally since 1960's. This then leads to further research to identify if international nurse practitioners have the same diversity within their role and what extended skills are considered to advance your knowledge when you are already working as a senior nurse without stepping over the line to the medical position because as nurse practitioners we should remain grounded in nursing.
3.2. Sustainability of the neonatal nurse practitioner As the role of neonatal nurses is expanding to incorporate some of the procedural, diagnostic and clinical skills typical of the NNP role (Presly and Bernardo, 2006), for the NNP role to also evolve, NNPs must start to develop their skills by taking on extended roles to continue to be competitive within the work place. The diversity of the current NNP roles, enables some extended roles to already occur in single centres leaving scope for expansion, however there are other skills and areas which can be considered. A recent paper from the UK highlights the need for NNPs to have a career pathway as they are hypothesising that NNPs work in diverse roles adapted to their current clinical setting (Jones and Webster, 2019). Throughout NICUs the use of clinician performed ultrasound is increasing in popularity. Traditionally the medical practitioners undertook a certified course, this could change in the future enabling NNPs to perform ultrasound in the unit and on retrievals (Raftery, 2013). Outpatient activity is also another possible role undertaking neurological and developmental assessments of infants using tools such as the General Movements Assessments (Einspieler and Prechtl, 2005) and the Bayley Scales of Infant and Toddler Development (Vohr et al., 2012). NNP led clinics could also be developed allowing the continuity of care from the clinical unit to home, supporting families to an even greater extent. As leaders in their clinical field it is extremely important for NNPs to be involved in clinical trials or research to maintain an evidence-based focus within their scope of practice. They also need to be proactive to ensure that they are included in managerial decisions, clinical governance and contribute to policy directions for neonatal units. Lastly, negotiation between universities and clinical areas must be initiated to assist in providing educational programs for NP preparation which should include leadership, negotiating change, self-care/motivation and conflict resolution. The financial burden for neonatal nurses to undertake masters study courses should not be underestimated; thus, it is important to provide funding and employment to support potential candidates to ensure sustainability of this important clinical roles. (MacLellan et al., 2017). Nevertheless, to be able to support and educate nurse practitioner candidates as well as experienced endorsed
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