An Education and Career Framework for
Nurses in General Practice
Consultation Paper Questions and Response by the Australian College of Nurse Practitioners
24 December 2014
For further information and comment please contact: Chris Raftery, President
Australian College of Nurse Practitioners (ACNP) P: (02) 9016 4349
1.
In 10 years’ time, what do you want general practice in Australia to look like,
and where do you see nurses fitting into this picture?
The ACNP recognises that currently, primary health care (PHC) services are largely delivered through general practices operating in the private sector. Although public-sector community-based PHC services exist, the scope for such services is oftentimes limited due to competing funding priorities, political whim, and narrow budgetary margins. The ACNP duly recognises the first point of contact for healthcare consumers is, and should be, in the communities in which they live.
The term “general practice” is dynamic and broad in its scope – and must be in order to meet changing community and consumer requirements, as well as shifting revenue streams. Many Australians equate “general practice” as their first point of contact for healthcare. They also equate “general practice” with “general practitioners,” a profession which has established a longstanding tradition of valuable, safe and effective PHC services in their communities. But in order to sustain something that is dynamic and broad in its scope, it must maintain flexibility so that it doesn’t break. The face of general practice must be responsive and flexible. It must continue in its evolution to avoid dogma and irrelevancy. In ten years’ time, the ACNP would like to see the term “general practice” redefined to that of a “primary health care centre.” This change acknowledges the fact that PHC does not necessarily “equate” with general practitioners. A shift in focus away from a particular healthcare profession, and to that of the team, embraces principles established by the 1978 Alma Ata Declaration. In true PHC settings, there are no professions viewed as “the healthcare leader.” All professions vested in the health and safety of the community require equal footing as co-facilitators of PHC, and are equally valued in their contributions. In ten years’ time, general practices will not be “the place where I go to see the GP,” but “the place where I go to see the most qualified person to treat me.” This includes not only the disciplines of medicine, but also those of nursing, allied health and other public health professionals. This shift in focus will facilitate a more responsive and flexible system, which is able to withstand shifting funding streams and government priorities.
In order to achieve these aspirations in 10 years’ time, nurses will need adequate acknowledgement for their work by being fairly compensated for their contributions, supported through their clinical education and training, and have a formalised career progression pathway which facilitates nurses working to their full scope of practice, irrespective of practice level. Systemic barriers, which impose limitations upon a nurse’s authorised and endorsed scopes of practice, would be removed so that true measures of their valuable contribution to PHC could be explored.
2.
What do you think an education and career framework might deliver for the
general practice nursing profession, for general practice, and for the
community?
An education and career framework would contribute to greater nursing workforce capacity, consistency and capability. It would increase capacity by facilitating the entry of new nursing graduates into the PHC workforce, who would have greater opportunities to expand their knowledge of PHC, beginning with formalised undergraduate education pathways that span from the acute
hospital environment to PHC settings. This would assist with their ability to contribute an informed and influential perspective to the direction and provision of PHC services in Australia.
Such a framework would support consistency by assisting in the removal of systemic and local barriers that prevent nurses from working to their full scope of practice, through validated standards that oversee the clinical and educational governance of PHC nursing education, training and role performance. This framework would facilitate greater professional autonomy and accountability within nursing and promote advanced nursing practice. By promoting greater consistency and transparency in the role development in PHC, it is possible that government agencies, policy makers, funding bodies and service managers would have a greater understanding, expectations for, and recognition of nurse practitioners (NPs) working in PHC. This in turn may promote improved funding for PHC nursing positions, which are currently dependent upon the financial beneficence of the medical profession.
An appropriate education and career framework would contribute to a competent nursing workforce, who strives for excellence. This framework would help PHC nurses reach beyond competency and provide support in order for them to achieve the best of what their profession offers as autonomous and collaborative healthcare providers. In doing so, they would foster capability within the profession for the emergence of expert nursing clinicians who are able to lead within the PHC environment. A framework which supports capability training and assessment would create a nursing workforce able to safely and effectively respond to novel and dynamic situations encountered within PHC.
Finally, through all of the above it would contribute to greater healthcare consumer understanding, engagement and appreciation of the PHC nursing role. This in turn would increase consumer demand and utilisation of PHC nursing services, which may decrease PHC expenditures due to the provision of a highly trained, efficient and expert nursing workforce.
3.
What might this framework look like? Can you describe how you see the key
stages in the education and career of a nurse in general practice?
This framework should be supported by current and evolving standards that have been, or are in the process of being, established and endorsed by relevant professional bodies. Such standards should be informed by appropriately designed and contextualised Australian research guided by an international review of the literature and supported by appropriate research methodologies.
These standards should be used for the clinical and educational governance of specialty PHC nurses. Nurses would receive formalised education on PHC principles during their undergraduate and postgraduate educational programs and, after completing clinical rotations in the hospital environment, be offered specialty placements working in PHC settings.
An appropriate framework might be supported by King’s work defining specialty practice (S. J. King, Ogle, & Bethune, 2010); namely, that specialty PHC nursing be based on the following:
• a core body of nursing knowledge, which is continually being expanded and refined • is national it its geographic scope
• subscribes to the overall purpose, functions and ethical standards of nursing
• requires the application of focussed knowledge and skill sets
• supported by a demand and need for PHC nursing in the community
• expertise is gained through various combinations of experience, formal and informal education programs, which include but not limited to continuing education and professional development This framework should acknowledge the beginning nurse through to expert roles such as the nurse practitioner, as described by Benner (Benner, Tanner, & Chesla, 2009). It might incorporate existing models which are being contextualised to the development and operationalisation of advanced nursing practice roles in Australia, as with Gardner’s work using the Strong Model (G. Gardner, Chang, & Duffield, 2007). This model uses the domains of direct comprehensive care, support of systems, education, research, publication and professional leadership to inform the differences between the advanced practice nurse and nurse practitioner roles. Incorporating this contextualised model would allow for greater expression of advanced practice nursing within PHC environments.
This framework should facilitate and further explore capability teaching and learning approaches for PHC nurses, as discussed in works by Gardner, Gardner and O’Connell (A. Gardner et al., 2014; A. Gardner, Hase, Gardner, Dunn, & Carryer, 2008; G. Gardner, Carryer, Dunn, & Gardner, 2006; O'Connell, Gardner, & Coyer, 2014). This will ensure not only a competent PHC nursing workforce, but one that facilitates the expansion of capability-trained nurses in PHC.
PHC settings should be offered incentives such as grants and other forms of financial incentives to undertake the clinical education and training of these nurses, so they are not placed at a financial disadvantage. Primary Health Networks could serve as a facilitator for PHC nurse training, and could help promote a national approach to the provision of PHC nursing services. A centralised and national approach for PHC education would provide credibility and consistency in training requirements and outcomes, further improving the perception of the capability of the PHC nurse.
4.
What are the likely stumbling blocks (barriers and challenges) for developing
and implementing an education and career framework for nurses in general
practice?
The shift of traditional hierarchical paradigms to support a nursing career and education framework, which values and supports the full breadth of the nursing profession, will be difficult. There is a great deal of resistance to nurses working to their full scope of practice by various bodies, including nursing. This resistance primarily revolves around the preservation of tradition and resistance to true innovation under the guise of concern for safety and efficacy. Appropriate change management strategies should be employed to ensure a positive outcome for this project.
There is great uncertainty about the NP role in general practice, which may directly affect this framework when applied to nurse practitioners. Currently, NPs working in PHC are primarily supported by general practitioners in their independent professional practice, a requirement for their formalised clinical education and training. There is no financial incentive for general practitioners to train NPs, who are dependent upon the goodwill of their colleagues to assist them in reaching their potential as expert nursing clinicians. There is evidence to suggest that medical professionals might inadvertently limit the scope of practice of NP students due to perceived conflicts of interest and
protection of traditional hierarchies (Barton, 2006). An appropriate education and career framework would facilitate collegiality, in-depth understanding of the breadth and depth of nursing roles, establish clear and transparent expectations for nursing education and training, and support positive practice environments, all while mitigating for this possibility.
There are many accredited Australian nursing programs that do not appear to have adequate and/or formalised relationships that support the education and training of nurses working in PHC settings, such as general practices. Facilitation of these professional and educational relationships would enhance a PHC nursing education and career framework. However, with enhanced relationships comes expense. With current NP clinical training models, the expense of training falls upon the private practice and/or nursing student, as opposed to the educational institution. There has been a disproportionate allocation of funding supporting the clinical education and training of medical students in PHC, as opposed to nursing. The expenses associated with the education and training of PHC nurses can be prohibitive, especially considering the significant discrepancies in nursing salaries which exist between the public and private health sectors. Although students should be accountable for their own education, a nursing education and career framework would underscore the need for financial support through the use of PHC nursing scholarships and career development funds.
Finally, a barrier to the development of innovative education and career frameworks is perpetuated by unjustifiably ignoring lessons learnt by our international colleagues. For example, education and/or career frameworks established by our North American colleagues have traditionally been placed in the “apples vs. oranges” basket, and these differences have not been fully appreciated during local service planning. We feel there are valuable lessons to be learnt by truly understanding the principles which inform a PHC education and career framework in all countries vested in the exploration of that which is PHC nursing.
5.
What are the likely facilitators for developing and implementing an education
and career framework for nurses in general practice?
We feel the following will facilitate the development of an innovative, relevant and sustainable education and career framework for nurses working in PHC:
• Current and future Standards for Practice for the Registered and Enrolled Nurse • Current and future Standards for Nurses working in General Practice
• Current and future Nurse Practitioner Standards for Practice
• Future Clinical Practice Standards for Nurse Practitioners working in the Primary Health Care Meta-specialty (A. Gardner et al., 2013; Queensland Health, 2014)
• Partnerships with other professional bodies vested in PHC
• Appropriate funding for the education and training of nurses across the spectrum of their scope or practice in PHC
6.
Can you describe how you would see a nurse moving on from one stage to
another in such a framework?
• Pre-registration familiarisation in the PHC setting
• Post-registration commencement in the PHC setting
• A clear and transparent pathway for nursing in the PHC setting from new beginner, novice, competent, proficient, expert
• Facilitation of nursing programs vested in PHC postgraduate studies
• Facilitation of the advancement from entry-level nursing positions to nursing consultant positions, including nurse practitioners, in PHC settings
7.
What are the key issues you see in relation to the assessment of nurses'
capabilities, and how could these be addressed in the development of the
education and career framework?
Nursing assessment has traditionally been based upon competency, and not capability frameworks. Competency training is used to establish minimum standards of practice and is heavily endorsed by the VET sector. It does not promote excellence or the full use of a nursing professional’s ability. Capability, on the other hand, takes competent professionals and teaches them how to respond safely, effectively and efficiently to novel situations with existing knowledge. Competency is fine for undergraduate nurses, but as you move up the ladder of expertise in nursing, one must focus on capability teaching and learning approaches within the framework. It encapsulates concepts of knowing how to learn, working well with others, creativity, and high self-efficacy (A. Gardner et al., 2008).
A key issue in the development of an education and career framework for nurses in PHC is the fact that didactic learning is vastly different from that of clinical learning and teaching. Unlike other professions, healthcare professionals require a significant portion of their education and training to be undertaken in the clinical environment. Appropriate governance structures must be secured in PHC to ensure clinical assessment and training is performed expertly and appropriately.
8.
How do you see the ideal role of nurse practitioners in general practice, and
how could the framework facilitate the development of this role?
Since November 2010, when legislation was enacted that allowed NP access to the Medicare Benefits Schedule and Pharmaceutical Benefits Scheme, NPs working in PHC have been growing steadily. Recent data taken from the ACNP member database reveals it represents approximately 50% of endorsed NPs in Australia. Thirty-five percent of its membership are endorsed NPs who work in PHC. A recently published case study illustrates one way the NP role is being used in general practice. Although it is a paper discussing financial modelling, it provides insight into the profession’s ability to provide diverse generalist and specialty PHC services in a general practice environment (Helms, Crookes, & Bailey, 2014). There are other exemplars of the varied roles NPs perform in general practices which have been previously published, and are also equally applicable (J. King, Corter, Brewerton, & Watts, 2012).
The ideal role of the NP in PHC is one who compliments, not replicates, existing services. Confusion around “complimentary service” has perpetuated the belief by some health professionals that nurses cannot share the same skill sets and abilities as others. The ACNP holds the position that this is not necessarily the case, and is practically demonstrated by the skills shared by NPs and medical
practitioners. These skills are prescribing, diagnosing, ordering and interpreting diagnostic tests. The knowledge and theories which inform the development of those skills are simply different. This may mean that PHC NPs practice with a specialty skillset (such as cardiology, diabetes, women’s health) but it may also mean they have generalist expertise and are flexible in their ability to treat common preventative, acute and chronic conditions in the PHC environment. Their practice is informed and applied by nursing knowledge and expertise.
It is the opinion of the ACNP that the answer to many of the issues faced in PHC (access, affordability, continuity of care, etc.) could be addressed by ensuring the education and career framework fosters nurses working in general practice to become nurse practitioners. Currently, throughout Australia, there are nurse clinicians working in an advanced capacity in general practices. Their skills, knowledge and expertise affords them the ability to perform advanced physical and mental health assessments, analysis of results, the independent provision of lifestyle modification programs, and other skills which provide valuable services in the communities in which they live. Due to financial and logistical barriers which preclude a nurses’ ability to enhance their education and training to become a NP, these nurses are stymied when it comes to ordering diagnostic tests, prescribing medications, and making referrals to specialists. The net effect is patient inconvenience due to the need to refer back to medical colleagues, which results in increasing health system costs.
Providing enablers to enhance the ability of these nurses to become endorsed NPs might close the gaps in total patient management, improve health service efficiency, and improve the patient experience in general practices. There are over 10,000 nurses working in primary health care; imagine the advances in PHC if just a quarter of them had a clinical ladder which facilitated their education and training to become a nurse practitioner.
9.
Do you have any views on the professional recognition of nursing in general
practice, for example through a certification process?
The ACNP feels that certification has the potential to promote additional barriers to practice, which are already quite substantial. Although the certification process may contribute to greater consistency and professional recognition, it could contribute to additional professional burden if administered by professional bodies unfamiliar with the role. For example, the ACNP is involved with the development of nurse practitioner clinical practice standards for primary health care. The certification process for NPs working in PHC should therefore be overseen and administrated by the ACNP.
10. Is there anything else that should be considered at this point?
We welcome APNA’s work leading this project and look forward to our future discussions and contribution to this framework.
About the ACNP
The ACNP is the national peak professional body for Australian nurse practitioners. Our mission is to improve access to quality healthcare through the advancement of the nursing profession.
Our Vision:
• To influence healthcare policy through advocacy, consumer engagement and research • To instil nurse practitioner knowledge, competency and capability by improving access to
quality education
• To facilitate communities of professional nursing practice Our Aims:
• To provide leadership, representation and support that improves the provision of health care to the general community
• To monitor and make recommendations regarding the ongoing development of the nurse practitioner role, policy and position
• To increase the level of awareness and implementation of the nurse practitioner role • To provide forums for discussion and dissemination of information regarding nurse
practitioners
• To provide consultancy which improves the provision of health care to the general community • To support relevant nursing research
Reference List
Barton, T. D. (2006). Clinical mentoring of nurse practitioners: the doctors' experience. British Journal of Nursing, 15(15), 820-824.
Benner, P., Tanner, C., & Chesla, C. (2009). Expertise in Nursing Practice : Caring, Clinical Judgment and Ethics Retrieved from http://ACU.eblib.com/patron/FullRecord.aspx?p=423244
Gardner, A., Gardner, G., Coyer, F., Henderson, A., Gosby, H., & Lenson, S. (2013). Educating for Health Services Reform: Clinical Learning, Governance and Capability (CLLEVER 2) Study. Australian Catholic University. Canberra, Australia.
Gardner, A., Gardner, G., Coyer, F., Henderson, A., Gosby, H., & Lenson, S. (2014). Educating nurse practitioners: advanced specialty competence, clinical learning and governance (Office for Learning and Teaching, Trans.) (pp. 95). Canberra: Australian Catholic University.
Gardner, A., Hase, S., Gardner, G., Dunn, S., & Carryer, J. (2008). From competence to capability: A study of nurse practitioners in clinical practice. Journal of Clinical Nursing, 17(2), 250-258. doi: 10.1111/j.1365-2702.2006.01880.x
Gardner, G., Carryer, J., Dunn, S., & Gardner, A. (2006). Competency and capability: Imperative for nurse practitioner education. Australian Journal of Advanced Nursing, 24(1), 8-14.
Gardner, G., Chang, A. M., & Duffield, C. (2007). Making nursing work: breaking through the role confusion of advanced practice nursing. Journal of Advanced Nursing, 57(4), 382-391. doi: 10.1111/j.1365-2648.2007.04114.x
Helms, C., Crookes, J., & Bailey, D. (2014). Financial viability, benefits and challenges of employing a nurse practitioner in general practice. Aust Health Rev.
King, J., Corter, A., Brewerton, R., & Watts, I. (2012). Nurse practitioners in primary care: benefits for your practice. Australian General Practice Network: Julian King & Associates Ltd. Retrieved from http://www.acnp.org.au/images/NP_business_case.pdf.
King, S. J., Ogle, K. R., & Bethune, E. (2010). Shaping an Australian nursing and midwifery specialty framework for workforce regulation: criteria development. The International Journal of Health Planning and Management, 25(4), 330-349. doi: 10.1002/hpm.997
O'Connell, J., Gardner, G., & Coyer, F. (2014). Beyond competencies: using a capability framework in developing practice standards for advanced practice nursing. Journal of Advanced Nursing, n/a-n/a. doi: 10.1111/jan.12475
Queensland Health. (2014). Nurse Practitioner - Practice Scope. Retrieved 5 March, 2014, from http://www.health.qld.gov.au/nmoq/nurse-practitioner/practice-scope.asp
