Issue 2 / 24 January 2011

THE nurse practitioner (NP) role has for some time been part of the hospital environment — particularly in emergency departments and hospital diabetes clinics.

But the NP is a very new player in the PBS/MBS-funded primary-care world, with changes announced last November giving NPs limited access to the PBS and the MBS.

The NP role and its optimal linkage with general practice have received broad and sometimes sensational attention in the media since then.

The RACGP has been actively working with key stakeholders, including medical colleges, medical indemnity insurers, NPs and government to ensure that this change has no impact on the optimal continuity of care and quality use of medicines for patients.

While the stakeholder focus early in 2010 was on the legislative framework for the role, this has now turned to the implementation reality in Australian primary care.

Our two major areas of member concern lie in extended duty-of-care responsibilities and medication misadventure.

GPs are concerned about the receipt of isolated pathology or radiology results ordered by NPs, which trigger duty-of-care obligations and confusion about who is following up.

One solution involves the return of the  results, in the first instance, only to the NP who ordered them.

The NP would then, in accordance with legislated principles of practice, MBS requirements and patient consent, provide the GP with a timely written summary of diagnosis, investigation results, intervention and management plans and proposed follow-up.

This approach would address concerns expressed in a number of states without increasing GP workload, fragmenting care or adding to GP risk.

The College is currently collecting member feedback on this proposal.

NP prescribing is autonomous and will not necessarily involve GP input before prescription, even in the elderly or those with complex co-morbidity, unless the NP requires clarification, or a formal collaborative arrangement exists.

Preventing fragmentation of prescribing and its attendant risks, and ensuring a quality use of medicines framework will clearly require ongoing work with all parties in 2011.

The College’s framework on non-medical prescribing will provide an excellent starting point.

The College has also invited the Australian College of Nurse Practitioners to nominate a primary care member to work with them, medical defence organisations and the AMA in developing collaborative care templates for general practice.

Current issues involving the NP role include:

•    developing a collaborative arrangement template that meets the needs of GPs, indemnity providers, nurse practitioners and patients

•    clarifying and addressing the ill-defined linkage with the patient’s GP outside these arrangements

•    clearly defining the clinical role of the “nominated medical practitioner”, raised in the legislation

•    assessing the ability of primary care NPs to deal with the vast number of ill-defined primary care presentations likely to present across the full range of age groups and clinical conditions when they have a much shorter and less intense training period than general practitioners

•    assessing risks to patients, particularly the elderly and those with multiple co-morbidities, of fragmented prescribing in non-collaborative arrangements

The College is keen to work closely with the many nursing, medical indemnity and government stakeholders involved, to ensure a safe, productive and accessible model of care with primary care nurse practitioners.

Formal collaborative arrangements providing clear definitions of roles and responsibilities, clinical handover, quality use of medicines and decision support will be essential.

Professor Claire Jackson is the president of the Royal Australian College of General Practitioners and Professor in General Practice and Primary Health Care and Head of the Academic Discipline of General Practice at the University of Queensland.

Posted 24 January 2011

6 thoughts on “Claire Jackson: Defining the nurse practitioner role

  1. Hugh Nelson says:

    Specialists commonly request lab tests with electronic courtesy copies going to the GP. This is valuable for future reference and minimal GP input is required for the report to become part of the patient’s electronic clinical record. Is it possible to clarify legally that the liability and duty of care remains with the referring practitioner? (If not, we should stop the specialists from sending copies). Can the same not apply to nurse practitioners?

  2. Robert Khoo says:

    If only the RACGP could be as caring and sympathetic towards non-VR GPs as they are towards nurse practitioners!
    If the RACGP truly represents general practitioners, they should be telling the government in no uncertain terms to stop devaluing the GP’s role by allowing NPs to play doctors. They have spent years discriminating against their fellow colleagues, the non-VR GPs, and yet they are inviting the NPs “to develop collaborative care templates for general practice”!
    Gutless hypocrits!

  3. Sue Jamieson says:

    GPs and other members of the medical fraternity need to take a long hard look at themselves and stop seeing nurse practitioners as a thereat to them If they are comfortable in their own skills and practise within the medical model (which is NOT the B all and end all of healthcare models)they would be able to embrace the skills and expertise that a speialised NP could bring to their practise. Combining a medical with a nursing model can only enhance the overall care of the patient (remember them?). The days of the nurse being the doctor’s handmaiden are well and truly over, and their high level of education should be proof enough of this. In my area of employment, I work with 10 GPs and I have the highest level of expertise and qualifications, and yet they are not threatened as they see me as a health care provider equal. It is time for the dinosaurs to retire …or change occupation. We are not going away:)

  4. Dr John B. Myers says:

    A collaborative system can only work if there is collaboration, which means collaboration according to the medical model based on trust [see Myers J. Int Med J. 2006]. Duty to care or duty of care – which regards the doctor-patient relationship as sacrosanct, based on trust. Only the doctor can act as the medical advocate of the patient on being asked to become “my doctor”. Public hospital treatment plans have invaded this space as doctors are not selected by patients as occurs in the private sector, and this has allowed others, such as social workers, discharge planner, even administrators, let alone nurses to think they have the right to determine the fate of patients. So what is collaborative teamwork according to the medical model? It is where the patient’s welfare (not stakeholders’) comes first. “Stakeholders” is a word used by self-serving power brokers and those with an agenda to push, to pretend to act in the patient’s or another’s best interest – a domain that is beyond their competence to act, unless appointed to do so by the patient. That said, any nurse practitioner’s input must be by referral from the patient’s self-selected GP, be this on the advice of a recognised specialist (medical/surgical specialist or other) and with informed consent obtained from the patient, as is any referral for paramedical health care, in the best interest of patient care, between the patient’s doctor, elected on the basis of trust by the patient and the patient. In public settings, where the patient does not elect a doctor to act on their behalf, but succumbs to the system of “third party appointment”, even there the doctor’s authority to provide informed consent to treatment must prevail as he/she is ultimately responsible for the management of the patient under his/her care. Successful treatment and or rehabiliation of the patient in any setting or even occurrence of death will be recorded and details (discharge or other summary) sent to the patient’s local medical practitioner, who for ongoing treatment purposes remains as the elected medical advocate of the patient by the patient. That way the local medical doctor is aware of and can also terminate or reintroduce nurse practitioner or any other required added or supplementary care with the consent of his/her patient. Collaboration does not mean we are equals. We are not. The core team consists of the patient and his/her elected trusted medical doctor, to whom others, health workers and family may be invited. Having supplementary health professionals adds to the team already created. Within the team, whomever it is composed of – by invitation and with the patient’s consent – each has something, including the appointment as medical advocate, the other does not that can be harnessed in serving our patient’s according to their best interest. Best interest is a personal viewpoint [Myers J, int Med J 2006, 2009, 2010] also defined as “psychological and social wellbeing” [2010 Victorian Government Review of the Guardianship and Administration Act 1986] i.e. which reflects the patient’s wishes – which is not and can never be according to another’s wishes or viewpoint. Thus said, to ensure all parties collaborate in the patient’s best interest, the doctor must co-ordinate any other involvement with informed consent and expect an updated report of that agreed and invited involvement. Involvement which does not have the agreement between patient and elected and trusted medical practitioner must be considered fractious and not in the patient’s best interest. It would be timely for the government to act in the public interest by ensuring the above to ensure health delivery in the patient’s best interest. (I am a specialist geriatrician and consultant physician in internal medicine in private practice.)

  5. Dr Philip Dawson says:

    I find the debate rather confusing. Why call those doing a further 3 years post nursing qualifications a nurse “practitioner”? Are all nurses not “practitioners”? Apparently some do specialized courses enabling them to do more in public hospitals eg renal unit, cancer units. If that is what those running those units need, so be it. Others seem to be doing some kind of extra study in “general” nursing with the object of setting up clinics in the suburbs. These clinics are in some instances “stand alone”, whereas other “nurse practitioners” become practice nurses with extra study enabling extra duties. I see no need for a stand alone nurse practitioner clinic in a suburb of a large city, nor in any rural area. We already have “community nurses” and “community psychiatric nurses”.Why not add some nurses with extra abilities to these (underresourced) groups? I am sure many general practices would welcome a “nurse practitioner” to work with them, as current practice nurses are restricted by the various state nursing boards from doing things they all used to do (and still do in remote areas) eg, plaster back slabs, minor sutures, IV cannulation. And on the issue of remote area nurses – for years they have been doing lots of things their more urban counterparts aren’t allowed to, yet they don’t have a “nurse practitioner” qualification. I have asked our practice nurses (we have three full-time equivalents) and none of them want to spend 3 years doing further study. I will be disappointed if most “nurse practitioners” end up in large hospitals, large urban GP superclinics, and stand alone suburban nurse-only clinics.

  6. Sue Ieraci says:

    Nurse Practitioner workforce dynamics are subject to the same forces as any other professional role – most practitioners ARE concentrated in relatively well-staffed urban areas. This is somewhat ironic, as the role has been sold to the community as a “substitute” for doctors in areas of worksforce need. In my view, advance practice nurses can have a very valuable role in health care, but should be seen as an adjunct to current roles, not as substitutes. Because their clinical training tends to be concentrated in depth rather than breadth, the role is particularly usefulin highly specialised areas, and less so in the generalist areas. The real problem with “substitution” is the inherent restriction to scope of practice. WHile a medical practitioner is trained in depth across all the clinical sciences, nurses’ basic training does not cover the same depth, and so is not consistent across all pracitioners, with NPs gaining depth in their specific areas with experience. While there is some ideological opposition to the role amongst the medical profession, there is also some ideological promotion of it. Surely the nurses who add value to patient care and have a cost-effective role will show their own worth, without the need for idelogical arguments.

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