Nurse Practitioners in New Zealand

Myths about Nurse Practitioners

Myth: You may not get the best care from a nurse practitioner
Fact: Nurse Practitioners are authorised, educated and prepared to provide comprehensive care in a safe, modern way.

Although Nurse Practitioners are relatively new in New Zealand, some countries, including the United States of America and Canada, have had Nurse Practitioners for up to 40 years. The Australian Nurse Practitioner role was introduced in 2001; the English Nurse Practitioner has different training from that required in New Zealand and is not regulated.1

Nurse Practitioners are registered nurses with advanced educational preparation and experience who are authorised to practise in an expanded nursing role in clinical settings as diverse as hospitals and aged care facilities, as well as in the community.

In addition to further education and advanced clinical nursing practise, Nurse Practitioners have developed the skills and knowledge to expand their role to include things that may have been ‘traditionally’ performed by other health professionals, such as prescribing medications and ordering diagnostic tests.

The introduction of Nurse Practitioners in New Zealand has taken quite a while and planning their introduction involved many different groups, including doctors, nurses, consumers and educators.

The nursing profession is very proud of its first Nurse Practitioners - this is another exciting role for nurses in the New Zealand health system. Of course, while many nurses will practise at an advanced level, not every nurse will want, or be able to be a Nurse Practitioner. However, those who do will be breaking new ground as opportunities to practise at this level continue to open up and challenge old boundaries.

As often happens with new jobs, there is some confusion and uncertainty about the role.^1,2,3,4 Also, there are some differences compared with the Nurse Practitioner role in other countries and so it is important to have the facts about Nurse Practitioners in New Zealand.
Myth: Nurse Practitioners are ill equipped to provide advanced patient care
Fact: Nurse Practitioners — a highly qualified role

Nurse Practitioners are registered nursesⁱⁱ who have gone on to achieve a high level of formal education as well as considerable nursing experience and expertise within a clinical specialty or setting.

Nurse Practitioners practise at a more advanced level than many other nurses. While having many years of experience in a particular area may mean that a nurse is seen as senior or an expert, and some nurses have titles that reflect their experience and more advanced practise (such as nurse specialist or nurse consultant), this is not the same as being a Nurse Practitioner.

Arguably, what differentiates a Nurse Practitioner is an ability to make complex decisions about what care is needed for an individual patient or population of patients, drawing on their education and experience. As with all nurses, midwives, doctors and allied health professionals, Nurse Practitioners are always accountable for the care they provide.

In New Zealand, ‘Nurse Practitioner’ is a protected titlei. This means that a registered nurse needs to be authorized by the Nursing Council of New Zealand to call themselves a Nurse Practitioner. Only nurses who have achieved the required levels of education and experience can be registered and practise as a Nurse Practitioner. In New Zealand, we can be confident that when someone calls themselves a Nurse Practitioner they have been prepared to provide that level of care or service.

A clinical Masters Degree from an approved university programme, or demonstrated equivalence, is one of the requirements for Nurse Practitioners.

All nurses seeking registration as a Nurse Practitioner must demonstrate that they have the necessary experience and education to meet the Nursing Council competencies for Nurse Practitioners. This ensures that Nurse Practitioners are qualified to do things such as examine patients and order necessary tests to determine what may be wrong. They can then use their knowledge of diseases to decide the best treatment or therapy, including prescribing medicines if needed. Those Nurse Practitioners who have also been registered to prescribe medications independently have had pharmaceutical and prescribing education. They have been assessed clinically and examined by a panel of experts. The legislation establishing the Nurse Practitioner prescribing was enacted in September 2005.

Nurse Practitioners can also admit and discharge clients and in many cases can refer to specialists. Nurse Practitioners are valuable members of collaborative health teams, working alongside other health professionals to ensure patients or clients receive the best care available.

Nurse Practitioner practise has a focus on health promotion, early intervention in disease processes, and health maintenance as part of their holistic approach to health care. They work to reduce the risks of developing diseases, and to reduce the impact of any disease.

Like all registered nurses, Nurse Practitioners do not need to be supervised by others when they are providing the care or services that they are competent, educated and authorized to provideⁱⁱⁱ. However, like other health professionals, while a nurse is preparing to become a Nurse Practitioner, they may call on other nurses or members of the team to teach them and monitor their progress.
Myth: Nurse practitioners are trying to replace doctors
Fact: Nurse Practitioners – another way to help meet New Zealander’s health needs

As we as a nation get older, we will need more help and use more of the health system’s resources and aged care services. There is a lot of concern about how we are going to meet this need in the future when we already have workforce and skill shortages.

Currently in New Zealand, the whole workforce is expected to increase by 105,000 over the next five years, 21,000 per year, but by 2031 the numbers will be decreasing. At the same time, the ageing of the population is expected to increase the demand for health, community and aged care services6. The serious national shortage of health workers, including doctors and nurses, means that we need to rethink how to get the best from the people we have working in health.

Figure. Projected Population and Workforce by selected age-groups, 2006-2026²²



Of course, over time all jobs change in their design and performance criteria. Skills once performed by a group of workers change, are no longer needed or are done by others in the team. This happens in health care too; once only doctors took blood pressure readings, today you can buy a monitor from a pharmacy and use it yourself at home.In July 2006 there are 25 Nurse Practitioners practising as Nurse Practitioners within New Zealand7. They work in a variety of specialty areas which include: whanau ora and high dependency services, aged care, mental health and intellectual disability, neonatal care, wound care, adult urology, diabetes, adult respiratory care and pain management.

As the Nurse Practitioner role develops, there will be many more nurse practitioners working in increasingly diverse settings; with many different communities and teams and in many different roles.

Nurse Practitioners provide one answer to a growing problem in health care efficiency and effectiveness. Both in New Zealand and overseas, the Nurse Practitioner role has been introduced to complement and improve access to services and health care outcomes for consumers, not simply to replace other workers.

While the Nurse Practitioner role is relatively new to New Zealand, there is growing recognition and evidence around the world of the significant contribution nurse practitioners make to health care delivery. In Canada, for example, research confirms that nurse practitioners work very well in a range of situations and provide much needed care in rural and remote communities, where they diagnose, prescribe and refer patients9.

Sometimes in trying to explain new roles, comparisons are made that over-simplify and may even add to the confusion. Headlines that describe nurse practitioners as ‘super-nurses’ or ‘hybrid doctors’ are not accurate.

Nurse Practitioners are, first and foremost, nurses – they are not trying to be doctors, they are providing nursing care that is consistent with the needs of New Zealanders, our modern health system and with their high level of education and preparation.

Some legislative changes will need to be made In New Zealand before the Nurse Practitioner can function in the way their training enables them to. For example, Nurse Practitioners cannot access the Medical Benefits Scheme (MBS) or the Pharmaceutical Benefits Scheme (PBS). This means if a Nurse Practitioner writes someone a script to be filled at a community pharmacy, the client would have to pay the full price.

Similarly, without access to the MBS, those using Nurse Practitioner services in the community would have to pay and could not get a rebate. Issues like this have fuelled the debate about the Nurse Practitioner role as a threat to the ‘business’ of others^18,19 and have contributed to the current situation where Nurse Practitioners are largely employed in public hospitals where they can work in ways that accommodate these restrictions to some extent²⁰.
Myth: Nurse practitioners provide ‘second rate’ care
Fact: Studies confirm value of Nurse Practitioner role

Nurse Practitioners bring a nursing perspective to the care and support they provide. They focus on the whole person and on how people respond to illness, such as what medications they are taking, what treatments they have tried and what is most important to their health.

Nurses with these skills are needed across the spectrum of health, illness and ageing. Many studies have looked at the Nurse Practitioner role in settings where there are problems or delays for people seeking services, such as primary care, aged care or in the care of those with chronic diseases like diabetes, heart failure and respiratory diseases. In other countries the Nurse Practitioner role developed to help address the inequalities and inequities in underserved populations or to address gaps in the health care available.

Given the recent addition of the Nurse Practitioner to the New Zealand health care workforce, there are few New Zealand based studies reported in the literature. We can, however, look to overseas studies that describe the positive impact of the role.

Some overseas studies:
A recent UK analysis of more than 30 different trials and studies in a primary care setting concluded that ‘increasing availability of nurse practitioners in primary care is likely to lead to high levels of patient satisfaction and high quality care’¹³.

Another UK study has found that ‘Nurse practitioner-led care for stable patients within a chronic chest disease clinic is safe and as effective as doctor-led care’ and ‘There was significant additional patient satisfaction with some aspects of nurse practitioner-led care and better patient compliance with antibiotic therapy.’¹⁴

Evaluation of an aged care nurse practitioner service¹⁵ in Melbourne found that nurse practitioners provided a high quality of nursing care and positively affected the physical and psychological wellbeing of those they were seeing; improved their quality of life, and assisted with practical details of their care, such as supplies, providing health education and advocacy.

An audit of 100 patients of a nurse practitioner-led colorectal cancer screening clinic in South Australia revealed ‘service and procedural outcomes that compared favourably with other colorectal screening services as well as a high level of patient satisfaction’¹⁶.
Myth: Nurse practitioner is just another name for practice nurses.
Fact: Practice nurses are different from Nurse Practitioners

Some people get Nurse Practitioners confused with practice nurses – but they are different. It may be the similarity in titles that has led to confusion or it may be because overseas (unlike New Zealand) many Nurse Practitioners work in general practice.

In New Zealand the Nurse Practitioner role is relatively new whereas the practice nurse has been part of the primary health care team since the 1970s. The roles and responsibilities of Nurse Practitioners and practice nurses are very different and it is important to know the difference.

Practice nurses work in general practice settings, many employed by General Practitioners^iv .

Practice nurses are mainly registered nurses, although there are a few who are enrolled nurses, but there are no formal post registration/enrolment educational requirements or professional regulations associated with practice nursing, as there are with Nurse Practitioners. Many practice nurses seek voluntary credentialing through their professional college (the New Zealand College of Practice Nurses NZNO) accreditation programme.

So, there are a lot of myths about Nurse Practitioners, but it is important to refer to the facts. Nurse Practitioners are advanced-practice nurses who are regulated, educated and prepared to provide comprehensive care in a modern, safe way.
Notes

1. Nurse Practitioner is not a protected title in the UK or in some states of the USA, this means there is no uniform regulation of education preparation or professional standards. Regulations relating to prescribing also differ, for example, prescribing by nurses is permitted in the UK and many states in the US while it is limited in New Zealand.
2. Registered nurses in New Zealand undertake a three year university degree (higher education) before being eligible to be on the Register. All nurses have to be registered with the regulatory authority the Nursing Council of New Zealand.
3. The scope of a nurse’s practice is generally taken to be that which they are educated, authorised and competent to perform.
4. There is a potential for Nurse Practitioners to practise in general practice settings in New Zealand with support for this from District Health Boards or Primary Health Organisations, however, at present, issues of funding make it difficult for a nurse practitioner to be able to operate as an independent practitioner.

References

1. Australian Government Productivity Commission (2005). The Health Workforce. Productivity Commission Issues Paper. Canberra, Australian Government. Productivity Commission.
2. Lumby, J. (2005). ‘Qualified, trained nurses can become doctors' colleagues’. Weekend Australian. Australia: 21 July.
3. Pollard, R. (2005). ‘Widening of nurses' role wins state backing’. Sydney Morning Herald, 12 December.
4. Pollard, R. (2005). ‘Wider skills allow for time to scan the big picture’. Sydney Morning Herald, 12 December.
5. NSW Health (2005). Sydney, Office of the Chief Nurse, NSW Health.
6. Demographic trends 2005, SNZ, Wellington.
7. N3ET (2005) Nurse Practitioners in Australia. Mapping of State/Territory Nurse Practitioner (NP) Models, Legislation and Authorisation Processes. Unpublished data.
8. Canadian Nurses Association (2002). Fact Sheet, Ottawa. 2005.
9. CHSRF (2002). Myth Busters: Seeing a nurse practitioner instead of a doctor is second class care. C. H. S. R. Foundation. Ottawa.
10. (2005). ‘Team work with rural flavour’. The Australian. 12 November.
11. (2005). 'Super nurses' could ease rural doctor shortage. ABC News. 23 July.
12. Cresswell, A. (2005). ‘Radical plan for doctor-nurse hybrid’. The Australian. 23 July.
13. Horrocks, S., Anderson, E. et al. (2002). ‘Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors’. British Medical Journal 324: 819–823.
14. Caine, N., Sharples, L. et al. (2002). ‘A randomised controlled crossover trial of nurse practitioner versus doctor-led outpatient care in a bronchiectasis clinic.’ Health Technology Assessment. 6(27).
15. Allen, J. & Fabri, A.M. (2005). ‘An evaluation of a community aged care nurse practitioner service’. Journal of Clinical Nursing 14(10): 1202–1209.
16. Morcom, J., Dunn, S. et al. (2005). ‘Establishing an Australian Nurse Practitioner-Led Colorectal Cancer Screening Clinic’. Gastroenterology Nursing 28(1): 33–42.
17. Allen, J & Fabri, A.M. ibid.
18. Lumby, J. (2005). ‘Nurse Practitioners make a difference, and we need them. Let nurses prescribe patients drugs and manage their illnesses’. The Weekend Australian: p19.16/17 April.
19. Stafford, A. (2005). ‘Physicians, heal thy self importance’. The Australian Financial Review: 61. 26 July.
20. Cresswell, A. (2006). ‘Busting open Medicare’. Weekend Australian. Australia: 24–25.
21. Australian Divisions of General Practice (2003). National Practice Nurse Workforce Survey 2003.
22. Craig Wright, Senior Advisor (Statistics/Epidemiology), Public Health Intelligence, Public Health Directorate, Ministry of Health

We are very grateful to the National Nursing & Nursing Education Taskforce of the Australian Health Minister’s Advisory Council for giving permission to allow the replication of the information they produced in February 2006. www.nnnet.gov.au