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Clark, Steven Siegloff --- "Prescribing power and the power to prescribe: nurse practitioners in rural and remote Australia" [2000] AltLawJl 10; (2000) 25(1) Alternative Law Journal 29

Prescribing Power and the Power to Prescribe

Nurse practitioners in rural and remote Australia.

Steven Siegloff Clark[*]

The crisis in rural health care has been of major concern for many years. In spite of overly generous incentive packages, doctors still refuse to serve rural and remote communities in the numbers needed. One response is to empower nurses in those communities to fulfil a larger role.

In a move to provide more services to neglected rural areas, the NSW State government has enacted the Nurses Amendment (Nurse Practitioners) Act 1998 (NSW) which provides for recognition and accreditation of Nurse Practitioners in NSW. The legislation provides for Nurse Practitioners to be given limited prescribing privileges.

Experiences in the United States and Britain

The first Nurse Practitioner program in the United States of America was established in 1965 in response to health care reforms, including the development of new models of care incorporating advance practice nursing. By 1991 Nurse Practitioners in the USA had prescribing privileges in 36 States, with enabling legislation pending or to be introduced in the rest.[1]

It was recognised that Nurse Practitioners have more time to work with patients than do doctors, and nurses suggest that they have a more holistic and preventive approach to health care than doctors, who tend to ‘view the patient as a bagful of organs’.[2]

The American Medical Association has expressed concern about doctors losing control over nurses, and argues that nurses do not have the necessary depth of education to make clinical decisions. In response, nurses argue this supervisory relationship only increases doctors’ liability and nurses are quite capable of referring cases beyond their expertise to medical practitioners.[3]

Britain is particularly interested in streamlining health care services.[4] Community nurses there were given limited prescribing rights in 1994 through a process similar to that enacted in NSW; legislation was considered an acknowledgment of practices that had existed for many years (that is, wound diagnosis and treatment).

British studies report that ‘feelings of increased status and autonomy were mentioned by many nurses now that they could work independently of the GP and were seen to be taking responsibility for decisions made’. Patients reported higher satisfaction with health care services as they were no longer required to seek out a medical practitioner for prescriptions for simple drug preparations having already been treated by the community nurse.[5]

Research in NSW

During the 14 months to the end of 1995, ten projects were undertaken across NSW, in remote and rural areas with identified need. One remote area was in fact in metropolitan Sydney, a homeless men’s centre in which doctors would not work. Other projects included Urana, a developing Multi-Purpose Service, and Wilcannia, a remote Aboriginal centre.

The final report found that the projects were highly successful. Reference committees at the individual project level and for the final report included representatives from nursing organisations, the Australian Medical Association (AMA), independent doctors, and consumer organisations. They were unanimous in their recommendations, including an amendment to the legislation to create the role of the Nurse Practitioner.

Having supported the projects and the subsequent report, the NSW Branch of the AMA then came out against the proposed Nurse Practitioner role, as some members began to express concern about loss of power.

Nurse Practitioners in NSW

The Nurses Act 1991 (NSW) was amended by inserting s.19A to enable any registered nurse to apply to the Nurses Registration Board ‘for authorisation to practise as a Nurse Practitioner’. The Board can only authorise a person who has ‘sufficient qualifications and experience to … practise as a Nurse Practitioner’, and authorisation is for a period ‘not exceeding 3 years’.

Under s.78A the Director-General of the NSW Department of Health may approve guidelines for the functions of Nurse Practitioners; the guidelines can address anything the Director-General considers appropriate, and they may have different application to different Nurse Practitioners. Breaches of the guidelines may lead to disciplinary action.

For accreditation as a Nurse Practitioner in NSW, a registered nurse must have post-registration qualifications enabling them to practise as an expert in their chosen speciality, and must be involved in ongoing professional development. They must also demonstrate 5000 hours in a current advanced practice role, meeting the competencies of an advanced nurse clinician and the standards of their chosen specialty.

Further, they must have the skills and knowledge relevant to the privileges associated with the specific context of the practice in question. Importantly, these include clinical assessment and pharmacological knowledge.[6]

Although any nurse registered in NSW may apply for accreditation as a Nurse Practitioner, they will not be able to practise as a Nurse Practitioner in the public sector except in an approved Nurse Practitioner position.

Only the Director-General of the Department of Health, NSW, has the authority to grant positions with the title of Nurse Practitioner, and only after an extensive consultation process to establish a ‘local agreed need’. Only approved Nurse Practitioner positions can require incumbents or applicants to have Nurse Practitioner accreditation.[7]

This limits the potential for educational institutions to teach specific Nurse Practitioner skills, because graduates would not be able to use that advanced knowledge in practice unless and until they were appointed to a designated position. This limits how nurses can acquire advanced skills, and how they can gain the experience needed to meet the requirements of Nurse Practitioner accreditation.

Restrictions on prescribing

Nurse Practitioners may prescribe such poisons or restricted substances within the guidelines, but they cannot be authorised to prescribe drugs of addiction as defined in the Poisons and Therapeutic Goods Act 1966.

It is contemplated that Nurse Practitioners would be authorised to prescribe drugs which relate to the specific needs of their practice, such as asthma medications, pain killers, antibiotics, stomach ulcer drugs and anti-nausea drugs. Medications for more serious conditions would be prescribed by a medical practitioner.

Nurse Practitioners practise under ‘standing orders’; they do not have prescriber numbers. Standing orders are put in place by registered doctors, and may include limited medication prescription to be authorised within 24 hours after administration.

Funding and accreditation

The NSW scheme has been designed to mollify medical practitioners scared of losing power to nurses. It creates positions in country and remote areas only, where there is a clear a lack of medical practitioners, rather than being recognition of the advanced skills of the nurses.

Having practised in the role of Nurse Practitioner and received the accreditation of that role, once the incumbent resigns from the designated position they are no longer allowed to refer to themselves as a Nurse Practitioner. In fact they are no longer accredited for the title. The legislation recognises the position and not the nurse.

The relevant Area Health Service is responsible for funding the position and overseeing compliance with policies and procedures. Nurse practitioners are not remunerated at levels approaching that of an equivalent rural or remote medical practitioner. This makes them an attractive option for Area Health Services struggling to provide adequate services on tight budgets.

Some nurses are concerned that the Nurses Board as a registration body is not the appropriate organisation for accreditation. The Royal College of Nursing, Australia is considered by some to be the more appropriate body for the development and implementation of credentials pertinent to advanced practice nursing. This would accord with the practice of accreditation of specialists within the medical profession, such as by the Royal Australian College of Surgeons.

The power and the passion

The Nurse Practitioner Amendment has led to some extraordinary hostility in the rural health community. A demarcation dispute has arisen within parts of the medical community. The debate about prescribing power and nurses has been ongoing for some years, with support and dissent from all sides, but has boiled over in the face of this new legislation.

According to the AMA’s Position Statement on Nurse Practitioners, released in 1994, medical education and training are prerequisites for medical practice. The AMA says that nurses and Nurse Practitioners’ lack of medical education and training precludes them, other than under medical supervision, from requesting pathology tests, making medical diagnoses, requesting X-rays or other investigations, prescribing medication, referring patients to specialists, deciding on the hospital admission and discharge of patients.[8]

This presumes that nurses in advanced practice do not, indeed cannot, acquire medical education and training to qualify them to perform a limited range of medical tasks. This cannot be true; it must also be possible for a nurse with several years experience working in an advanced role to learn these skills.

The Rural Doctors Association has proved the most outspoken critic of this legislation. They have used similar rhetoric to the AMA, but have been more emotive in their language. For example: ‘We now have the ridiculous situation where nurses can order investigations and medication but young fully qualified doctors cannot’.[9]

The concern is about loss of doctors’ revenue and loss of control over nurses. In current professional practice, doctors and nurses work in collaboration.[10] The NSW pilot projects included a homeless men’s centre in metropolitan Sydney, identified as an area of need precisely because doctors would not work there. Rather than being an issue of clinical competency, this dispute is about demarcation of roles and what medical practitioners perceive to be the proper role of nurses. The notion that nurses only follow doctors’ orders is no longer acceptable, nor relevant in practice.

Doctors do not ‘permit’ nurses to do anything: it is the law that does. For doctors to say that it is ‘permissible’ for a nurse to perform a limited range of medical functions, especially in health care settings where medical practitioners don’t want to go, is condescending and derogatory of the role of nurses in the health care system.

Nurses do more than follow the directions of medical practitioners. They make clinical decisions, and are trained to do so. Medical practitioners are not present 24 hours a day on wards, in hospices or in other continuous care environments. Nurses are, and must therefore be able to make clinical decisions and act on them.

Even when a medical practitioner is required, usually in emergencies, nurses must act to ensure the doctor has a patient to treat on their arrival. Every senior nurse has years of experience, often more than the doctor in attendance, and it is not uncommon for doctors to rely on advice from nurses in the course of their diagnosis and subsequent treatment.

Nurses are legally responsible for their actions, and have been sued for negligence. They have an ethical and professional responsibility to act in the best interests of their patient and are responsible to the patient, not the doctor. Nurses can refuse to follow treatment plans they consider not to be in the patient’s best interests.[11] This is viewed by some doctors as a control issue, rather than a difference of professional opinion.

Support for the legislation

The Doctors Reform Society supports advanced practice nurses having the capacity to prescribe.[12] The Society demonstrates a better knowledge of the current literature and practice of Nurse Practitioners in Australia and overseas than does, say, the AMA. It recognises that far from undermining doctors, Nurse Practitioners free up doctors’ time, enabling them to focus on more serious cases and patients requiring higher levels of medical expertise. The existing collaboration between advanced practice nurses and medical practitioners, especially in rural areas, reduces costs and improves standards of care for the patients.

The biggest supporters of the legislation are nurses’ organisations and State governments. Nurses are enthusiastic about the opportunity to receive recognition for advanced practice. State governments are enthusiastic about reduced health care costs and provision of extended services in rural and remote areas.

The National Rural Health Alliance includes medical, nursing and community health organisations with members in rural and remote area health care services. It has endorsed the development and recognition of advanced practice roles for rural and remote services. The Alliance has emphasised the need for collaboration between health professions, adequate education and training for nurses, the need for uniform provisions for advance practice across Australia, and clear guidelines, policies, or protocols to assist Nurse Practitioners exercising prescribing privileges.[13]

Other Australian States

While other States have yet to legislate for Nurse Practitioners, Victoria, South Australia and Tasmania are currently undertaking Nurse Practitioner trials, and Western Australia has recently indicated that they will have trials in the near future.[14]

These projects are independent of the NSW projects in definition and detail. A major concern of the nursing profession is the lack of national uniformity in defining the role of the Nurse Practitioner and how that role translates across State boundaries. The NSW legislation is written such that a Tasmanian trained and accredited Nurse Practitioner, for example, would find themselves in breach of the Act should they attempt to transfer their practice to NSW.

Towards the end of 1998 several hundred nurses were involved in private practice in South Australia. Services offered include diabetes education, primary health, occupational health and training, child health, case management, complementary therapies and women’s health. For the past 20 years Family Planning Australia has provided Nurse Practitioner training in sexual and reproductive health. Most of their graduates work as Nurse Practitioners in rural and remote SA and NT.[15] Until recently there has been little formal recognition of these advance practice roles.

South Australia is actively developing communication and collaboration between health professions, and recognises that many nurses are already working in advanced practice roles.[16] In a move towards formal recognition, the SA Human Services Division (formerly the Health Commission) has established the ‘Nu Prac’ Project, involving three pilot projects with strong support from government, the pharmaceutical industry, hospitals, and health care organisations. The Project is informed by Nurse Practitioner projects in NSW and overseas, and is broader in scope than the NSW model.

The pilots are focused on epilepsy management in the community, palliative care in nursing homes and hostels, and cervix screening in rural areas, and have proved extremely successful to date.

Conclusion

There has been a mixed reaction to the recognition of Nurse Practitioners in NSW. Some medical practitioners feel threatened by the role, others are more open to it. Governments recognise the cost-benefits and possibilities for extending health services into rural and remote areas which Nurse Practitioners can offer.

Nurses have been working in advanced practice roles, particularly in rural and remote areas, for some time. The opportunity to prescribe a limited range of medications enhances their services, and improves the efficacy and efficiency of health care services overall.

Recognition and development of these roles, and the specialised skills of the nurses who perform them, is both timely and appropriate.

References


[*] Steven Siegloff Clark is a final year graduate student in law at Flinders University, Adelaide.

The author would like to thank Lesley Hills Siegloff for her expert assistance in research for this article. Lorelei Siegloff was invaluable during the early drafting of the article.

[1] Office of the Chief Nurse, The Nurse Practitioner Role in the South Australian Health System, South Australian Health Commission, 1998, p.1; ‘What is a Nurse Practitioner?’ (1991) Nurse Practitioner News.

[2] Gentry, Coral, ‘Nurse Practitioners Fill Primary Care Gap’, St Petersburg Times, 2 June 1993, p.663.

[3] Gentry, above, p.663.

[4] Luker, K., Austin, L., Hogg., C., Ferguson, B. and Smith, K., Nurses Prescribing: The Views of Nurses and Other Health Care Professionals, (1997) 2(2) British Journal of Community Health Nursing 69.

[5] Luker and others, above, p.71.

[6] NSW Department of Health, Nurse Practitioner Services in NSW, NSW Department of Health, 1998, p.2.

[7] Meppem, J., Chief Nursing Officer, NSW Department of Health, NSW Nurse Practitioner — Some Facts, 11 November 1998.

[8] Australian Medical Association, Position Statement, ‘Nurse Practitioners’, 1994.

[9] White, Geoff, National President of RDA, in a facsimile to G. Gordon, CEO of National Rural Health Alliance, 25 March 1998, in response to the NRHA’s media release re nurses diagnosing and prescribing.

[10] Breen, K., Plueckhahn, V. and Cordner, S., Ethics, Law and Medical Practice, Allen & Unwin, 1997, p.166.

[11] Breen and others, above, p.166.

[12] Gunn, Andrew, ‘Nurse Practitioners Are a Benefit Not a Threat’, Doctors’ Reform Society of Australia column, Australian Doctor, 13 March 1998.

[13] National Rural Health Alliance, Advanced Nursing Practice, Rural and Remote, in SA Department of Human Services, Nurse Practitioner Project Newsletter 2, March 1999.

[14] Robertson, Jeanette, Nurse Practitioner Project in Western Australia, in SA Department of Human Services, Nurse Practitioner Project Newsletter 2, March 1999.

[15] Office of the Chief Nurse, The Nurse Practitioner Role in the South Australian Health System, South Australian Health Commission, 1998, p.2.

[16] Averis, A., Brown, J. and White, D., Nurse Practitioners: What’s Happening in South Australia? Office of the Chief Nurse, SAHC, 1997, p.5.


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