Nurse practitioners in Australia: strategic errors and missed opportunities

Urgent reform is required to make nurse practitioners responsive to Australian health needs and priorities

The Australian nurse practitioner (NP) movement was envisioned as an innovative solution to challenges in Australian health care. But more than a decade after the first NPs were authorised, growth has been slow and there is a real risk that they will fade into obscurity. Enrolment in some NP courses is plummeting, few new NP positions are being created, and nearly a third of NPs remain in their previous nursing positions despite completing a course.1 The nursing profession may blame this situation on opposition from doctors, but the NP movement has made strategic errors and missed many opportunities to create a flourishing workforce today. Without an uncompromising examination of these factors, the Australian NP role will continue on its troubled trajectory.

Nurse practitioners as clinical specialists

The Australian NP role originated as a career pathway for nurses who wished to formalise their advanced clinical skills.2 Essentially, a specialist nurse (clinical nurse consultant [CNC]) with expertise in an area such as colorectal cancer screening, remote health or sexual health would complete postgraduate studies leading to authorisation to practise as an NP.3 The NP title was borrowed from the advanced nursing practice role in the United States. Although Australian researchers often support their assertions with evidence from the US experience, the comparison is not apt, because NPs in the US originated as primary care providers.4 The NP role in Australia most closely resembles that of the American clinical nurse specialist.5

It is not clear whether, as a whole, health services have benefited from converting CNCs to NPs. In theory, given that they are able to prescribe some medications, order a limited number of diagnostic tests and perform some procedures, NPs provide an essential service that could not be achieved by a CNC or other health professional. However, more than 10 years after the inception of the NP movement, it is not known whether this is true in practice. The cost-effectiveness and patient outcomes of CNCs (and other specialist nurses) have not been compared directly with those of NPs.

Missed opportunities

During the early years of the Australian NP movement, primary care featured prominently on the agenda. Nursing leaders sought to formalise the high degree of skill and autonomy of rural and remote area nurses. In Western Australia, remote area nurses could apply to be NPs if they carried out similar functions to an NP rather than being required to undertake any formal educational preparation.6 However, beyond this early recognition, there was no substantive attempt to develop or evaluate rural and remote NPs, or to build a generalist university curriculum that would prepare graduates for remote practice. Interestingly, an American consultant who visited WA in 2004 foresaw poor sustainability among NP specialists and challenged the WA movement to align itself strategically with primary care.5 However, the momentum moved away from primary care, and subsequent role development occurred primarily in acute subspecialties. A 2009 study showed that only 5% of Australian NPs worked in remote practice.1

The NP movement also failed to align itself with the priorities identified by health policymakers. For example, the early NP curriculum was developed from interviews with NPs7 rather than from existing concepts such as the National Health Priority Areas8 or the key initiatives from Australia's primary health care strategy.9 Using the National Health Priority Areas as a basis for curriculum and practice could have kept the NP role responsive and sustainable. Similarly, the Practice Nurse Incentive Program provided support for an expanded role for nurses in general practice, which could have been an opportunity for NPs to move into primary care — especially since it provided loading for rural and remote areas.10 If the NP movement had been more proactive and aligned with health priorities, an NP incentive program for general practice could have been proposed instead. It is not clear why these opportunities were missed. Perhaps the NP movement devoted its efforts to creating a place for itself at the top of the nursing hierarchy instead of reforming health service delivery in a broader sense.

NPs did not present themselves as solutions to the maldistribution of health professionals that Australia has always faced. Health Workforce Australia (HWA) was created in 2012 to plan solutions to workforce shortages in the health sector.11 It provided funding for nurse, midwife and doctor training, but did not fund NP education or clinical placements. In fact, HWA did not propose educating more NPs in its Health workforce 2025 report and did not include them on its clinical advisory panel.11 Moreover, a major HWA initiative to improve emergency department productivity and decrease waiting times was directed at emergency department nurses not NPs.12 This failure to influence national policy development and health reform threatens the sustainability of NP education and practice. It could make the role irrelevant. A major report declared the NP role to be a failed solution to the ongoing shortage of doctors in remote areas and proposed introducing physician assistants instead.13 Perhaps the lack of a flexible NP workforce explains the emergence of new roles such as physician assistants, extended-care paramedics12 and pharmacist prescribers.14

New roles require robust evaluation

Ongoing evaluation of the Australian NP role has not been robust enough to justify its continued progression. Much of the research uses the NPs themselves as the data source.15 Not surprisingly, these studies identified NP needs (not client or health service needs), such as a desire for more autonomy or a need for access to Medicare reimbursement. Evaluation of NP practice has focused on factors such as patient16 or colleague17 satisfaction rather than on key indicators such as cost savings, increased productivity or improved efficiency. Research reporting patient outcome data has not shed light on whether NP outcomes are superior to those for CNCs following standing orders. Even clinical ability has not been investigated rigorously — an NP research toolkit suggested that researchers should ask patients if “the NP seemed informed and up-to-date”.18

If the role is to be sustainable, NPs should perform activities that are not incorporated in other health professionals' scope of practice (or that can be done with the most efficiency by NPs). Work-sampling research has shown that NPs spend most of their time on meetings and administration, and far less time on history-taking and physical assessment.19 This indicates that Australian NPs are not primarily clinical service providers (as they are in countries with a thriving NP workforce, such as the US). It also indicates that there may not be a substantive difference between a CNC and an NP. Unless more rigorous evidence emerges that the NP role adds value to a health service, employers will find it difficult to justify using clinical specialists to spend most of their time on non-clinical activities.

The way forward

The Australian NP movement is at a crossroads. If NPs are to become sustainable and integral parts of the health system, innovation and reform are urgently required. The NP's place in the nursing hierarchy should be re-examined. Perhaps the CNC role could be developed in a way that formalises specialist nursing practice rather than converting it to an NP role. In order to produce NPs with skills that can adapt to changing health needs, they should be educated according to a generalist framework based on national priorities. If NPs want to advance, they should demand a seat at the policy table and provide a voice for their patients. Further, NP research should move beyond self-examination and patient-satisfaction surveys. Evidence of cost-effectiveness, quality of care, efficiency and productivity will be required to sustain the role. Direct comparisons between CNCs and NPs must be made if employers are to support new NP positions. Above all, if the NP movement is to progress, NPs must demonstrate that they provide flexible solutions to the highest priority health concerns in Australia.