Nurse Practitioners in New Zealand, Research Paper Example

My area of practice is accident and emergency care which needs thorough professional competence, presence of mind and sound decision making capabilities. Handling accident and emergency cases is always a challenging task and the decisions made at vital junctures mean a difference between life and death. In New Zealand, the patient population assigned to this section is included in triage category 3-5 which is based upon the Australasian 5 stage triage scale (Read et al, 1992). The scale has been developed on the basis of time critical interventions which are necessary in life threatening situations for patients who might be presented simultaneously in an emergency department. The Australasian triage scale defines 5 categories ranked from ATS1 to ATS 5 which are identified on the basis of the most urgent clinical feature upon presentation of the patient in the emergency department, and prescribes maximum waiting times in an ascending order from immediate in ATS 1 to 10, 30, 60 and 120 minutes in ATS 2, 3, 4 and 5 respectively (Geraci, 1994).

The patient population I deal with includes those requiring medical, surgical, orthopaedics, gynaecology, plastics, trauma and preventative care in an emergent situation. The role is well defined and demarcated to patient populations within 13 years of age and above who are presented at the clinical setting either by walking in, if they are capable of doing so, or brought by ambulance. My duties include preparing a comprehensive health history of the patient presented, his or her clinical assessment, differential diagnoses, planning of care and decisions about the necessary pharmacological and non pharmacological interventions. Interventions usually involve a multidisciplinary approach and sending the patient to appropriate generalist or specialist. My professional role requires me to be familiar and well acquainted with identifying life threatening problems in my department, and to initiate essential care immediately. My limitations in practice include ATS 1 and ATS 2 categories where immediate life threatening conditions are handled in by the physicians and patients below the age of 13 years.

In my area of practice, it is vital to establish interdisciplinary collaboration between nurses and doctors as multiple organ systems may be involved in case of trauma suffered in accidental and other injuries. Recommended procedures such as surgical interventions to arrest life threatening haemorrhage, establishment of patent airway and coma can be undertaken only by the experts and skilled technicians whose cooperation should be actively sought. The nurse shoulders the responsibility for establishing communication and coordination between the various departments and sub specialties according to the presented symptoms and patient history. Such coordination has to be achieved in specific and predefined time frames according to the triage category.

So far, nurses have relied upon delegated responsibilities for the commencement of episodic care of patients. They were merely trained for and assigned specific duties based upon instructions from the physicians and other experts. However, paucity of staff, particularly in remote areas has necessitated the need for nursing practitioners (NPs) who are empowered to exercise more procedures depending upon their qualification, experience as well as competence. Nursing practitioners are registered nurses with advanced and extended clinical roles (Gardner et al, 2008). Although the concept is novel in the Australasian region, NPs have been recognized and assigned more responsible roles in other developed countries. The recognition of NPs as an important link in the healthcare delivery system, especially in underserviced areas was initially recognized as early as the 1960s in the US (Gardner et al, 2008). At present there are 106,000 NPS in the US (American Academy of Nurse Practitioners, 2006), 1000 in Canada (Canadian Institute for Health Information, 2006) and only 140 in Australia ().

Nurse Practitioner Practice in New Zealand

The acceptance of NPs in New Zealand and the empowerment of nurses with prescribing rights have faced much resistance as well as debate during the last ten years over concerns of patient safety (Lim et al, 2009). Compared to other developed countries, the term ‘Nursing Practitioner’ came to be recognized in New Zealand relatively recently as compared to other developed countries and only at the advent of the twenty first century i.e. in 2001 (Lim et al, 2009). Nurses, in the past were not considered competent enough to exercise prescribing rights and could only play a participatory role under the guidance of a physician. The categories for NP prescribing rights gradually evolved from physician assistant prescribing to supplementary prescribing and finally independent prescribing (Lim et al, 2009). Independent prescribing for NPs has now been recognized as the preferred model in New Zealand.    Educational attainment in the form of an approved Master’s degree in the pertinent specialty as proscribed by the Nursing Council of New Zealand (NCNZ), the regulatory authority responsible for the registration of nurses is essential to qualify as a Nurse Practitioner. NCNZ’s principal purpose is to look after the health and wellbeing of members of the community by assuring that nurses are capable and fit to practice. The Nursing Council’s minimal necessities for endorsement as a nurse practitioner are: a clinically determined master’s degree or equivalent as well as 4 to 5 years of experience in a specific area of practice. The curriculum includes meeting specified levels of proficiency in disease pathophysiology, advanced methods of assessment, pharmacologic principles and preparation of research papers along with the completion of a prescribing practicum supervised by a NZ approved prescriber. A pass is required in the Nursing Council assessment of Nurse Practitioner competencies and associated criteria. Nurse Practitioners seeking registration with prescribing rights are required to have successful completion of an approved prescribing component of the clinically-focused master’s programme, relevant to their specific area of practice.

Health Practitioners Competence Assurance Act – 2003

New Zealand is a country which has been tentatively balancing the pros and cons before allowing Nursing Practitioners’ to exercise their powers. However, there exists a fair degree of uniformity in the health policies and core fundamental functioning of the nursing practitioners of UK, Australia and New Zealand over the span of history though fundamental differences exist in academic levels of preparation, scope of practice and regulations (Currie et al, 2007). The Health Practitioners Competence Assurance Act 2003 (HPCAA) provided the legislative framework for standardizing the level of competence of practitioners and their fitness to maintain those standards throughout their professionally active life. The Act was passed by the New Zealand Parliament on September 11, 2003 and received the Royal assent a week later on September 18, 2003. The Act was fully operationalized a year later on September 18, 2004 (Ministry of Health, NZ).    The Act renders a structure to the prescribed guidelines and directives for health practitioners with an intention of protecting the community from any danger or harm from practice. Adoption of a single model of legislation for all practitioners enables coherence in processes and nomenclature throughout the professions. The primary purpose of the Act is defending the wellness and safety of the populace and it is comprised of mechanisms to guarantee that practitioners are fully competent and capable of putting into practice their respective professions for the total length of their professional careers. As per the Act, health practitioners who meet the prescribed norms for recording them as registered practitioners will be able to practice. At the same time it prevents the registered practitioners from practicing outside their settings of practice. The registration agencies will be responsible for licensing the practitioners on a yearly basis (Ministry of Health, 2002).

The Nursing Council of New Zealand was tentative initially as it allowed the now recognized Nursing Practitioner to function in a limited manner in domains associated with children’ and older adults’ practice only but later expanded the scope to broader horizons in numerous clinical settings provided they were able to meet the stringent standards specified for each clinical domain. The stringent standards included masters’ degree in the appropriate sub category in their area of practice and meting additional competency standards specified by the council (Nursing Council of New Zealand, 2005). A fully professional Nursing Practitioner is expected to be proficient in the legislative nuances as well as codes and areas of practice for which she is empowered. She should be able to communicate in an effective manner with the client, the client’s family and other healthcare professionals about the implications of the prescribed medications and other treatment modalities entrusted to her. She should be capable of evaluating the effectiveness of the prescribed intervention and able to undertake corrective procedures in case of adverse reactions.

Competencies for Practice

The nursing council of New Zealand requires that competencies in three domains of nursing practice must be fulfilled in order to qualify as a Nursing Practitioner (NC, 2008). The three essential domains are described below:

1. Professional Responsibility and Leadership: A Nursing Practitioner should be capable of leading as well cooperating in a fruitful manner with a multi-disciplinary team while making technically correct clinical decisions (Lee & Fitzgerald, 2003). Professional relationships should be maintained within the multi-disciplinary team and simultaneously the nursing practitioner should be capable of evaluating the clinical decisions taken for a particular client qualitatively. She should provide continuous educational and clinical support to colleagues as well as patients. They should also be capable for generating novel approaches in addition to nursing acquaintance and delivery of skilled care in diverse scenarios of patient care. The areas of nursing practice in relation to patient or population group as well as actions for health promotion, maintenance and restitution of health, prophylactic care, rehabilitation and palliative care should be well defined. A good Nursing Practitioner should be capable of using specialized assessment tools to evaluate patient health status, formulate the basis for differential diagnoses, execution of nursing interventions and recommended treatment modalities. They should refer the patient to other health professionals if need be. In general, they should be competent enough to manage complex situations and anticipate future course of actions rapidly. She should be capable of identifying and utilizing the most appropriate clinical, community and support-group resources for the benefit of the patient. When needed she should be capable of effectively providing correct clinical audit of the patient’s workload (Lee & Fitzgerald, 2003).
2. Management of Nursing Care: A fully capable Nursing Practitioner’s role is dynamic in nature and involves application of the latest evidence based knowledge and skills when confronted with unpredictable and complex situations in the clinical setting (Lee & Fitzgerald, 2003).When catering to a specialist field of nursing practice they must be able to conduct advanced, comprehensive and holistic health assessment of the patient. These competencies assure that nurses are applying assessment skills and diagnostic decisions at an advanced nurse practitioner level within their scope of practice and can relate this in a range of circumstances which involve the patient in decisions concerning the interventions shortlisted for them. The nurse practitioners are required to work autonomously and with self-confidence due to the skills acquired from prior experience and continuous education. At the same time they should be capable of using a conventional approach to supervise and measure patient’s reactions to interventions. The nurse practitioner looking for prescribing rights generally should be well educated and trained in Pharmacology in order to take accurate clinical decisions while prescribing. They must cooperate and hold discussions with other professionals and provide precise information to the patient and his family and other caregivers about the implications and benefits of the prescribed treatments, devices, interventions or medicinal drugs.
3. Interpersonal and inter-professional practice and quality improvement:  The competencies within this domain ensures nurses’ engage in professional, respectful relationship with the client, can work with other health professionals to ensure best health outcomes for the client and participate in monitoring and improving own practice. They should be well versed in clinical and social sciences to establish a good relationship in the nurse-patient- other healthcare professionals’ triad. They should be capable of establishing such relationships in complex and unfamiliar environments too, without dependence on any superior. They should be able to establish therapeutic links with the patient/client/community and able to elicit recognition and respect from those affected. Collaboration should be established at all levels of health services rendered at the community level, particularly in the specialty one is entrusted with. It is vital to add into clinical collaboration that optimizes health outcomes for client. It acts as a central agent to nurture coactions between members of all fields in the healthcare team to work toward faultless patient care. They should be capable of engaging in and leading informed critique at the systems level of healthcare (Lee & Fitzgerald, 2003).

Nurse Practitioner Practice in an Emergency Department in NZ

The UK standard defines an Emergency Nurse Practitioner (ENP) as “an accident and emergency nurse who has a sound nursing practice base in all aspects of accident and emergency nursing, with formal post-basic education in holistic assessment, physical diagnosis, treatment and health promotion” (Davidson & Rogers, 2008). This definition is more or less met with by the current requirements for Nursing Practitioners in the Australasian region too. Both the Australian Nursing Council (ANC) and Nursing council of New Zealand (NCNZ) in an endeavour to develop competency standards for Nursing Practitioners launched a research group in December 2003 though it did not consider specialist branches such as ENPs. For the latter, rigorous standards have been prescribed in which possession of a master’s degree in the concerned sub specialty is essential. Every ENP in New Zealand has to apply for accreditation with the particular state nursing board to which she is affiliated and has to follow the prescribed protocols. Though these standards are strict in nature, they have been adopted due to an over cautious approach which is not justified due to the success figures of corresponding ENPs in the UK. The similarity in healthcare systems in the UK, Australia and New Zealand suggests a need for development of international standards which can enable ENPs to function in a better way and also be eligible for international migration (Currie et al, 2007). In Australia and New Zealand, emergency care is available at both private and public systems of healthcare.  It is difficult to maintain a medical taskforce comprising of trained physicians with prescribing rights catering to the total population within even an otherwise developed country due to paucity of staff and remote location of certain communities. In order to provide the benefits of the latest medical and healthcare technology, it is therefore essential to delegate prescribing responsibilities and decision making capabilities to well qualified and trained nursing practitioners who can achieve similar, if not better end points of healthcare delivery as compared to full-fledged physicians. Success of such programs in the UK serves to add another point in favour of this perception. My area of activity includes services rendered in medical, surgical, orthopaedics, gynaecology, plastics, trauma and preventative care specialties in an emergent situation. The patient population I am responsible for is well differentiated into those above thirteen years of age. My duties which include preparation of comprehensive health history of the patients, their clinical assessment, differential diagnoses, planning of care and decisions about the necessary pharmacological and non pharmacological interventions provide adequate experiences in familiarization with the nuances of evidence based and learned decision making policies and appropriate procedures necessary for such patients. Equipped with an appropriate and thorough education leading to a master’s degree in my concerned specialty in combination with the experiential knowledge I have gained so far can definitely assist me in attaining the status of a qualified Emergency Nursing Practitioner provided I am able to meet the competency standards set forth by the concerned authorities in New Zealand.

References

Auckland District Health Board. (2008). Hospital advisory committee. Retrieved March 22, 2010, from http://www.adhb.govt.nz/downloads/minutes/commpubh/2008/HAC%20Minutes%203%20Dec%202008.pdf

Currie, J, Edwards, L, Colligan, M et al, 2007. A time for international standards?: Comparing the Emergency Nurse Practitioner  role in the UK, Australia and  New Zealand, Australasian Emergency Nursing Journal, Volume 8, Issues 1-2, Pages 5-8

Davidson, J & Rogers, T, 2005. A lesson from the UK?, Australasian Emergency Nursing Journal, Volume 8, Issues 1-2, Pages 5-8

Geraci, E.B. et al. (1994). An observational study of the emergency triage nursing role in a managed care facility. J Emerg Nurs, 20(3):189-94.

Hansen, H.E. (1999). Research Utilization and Interdisciplinary Collaboration in Emergency Care, Academic Emergency Medicine, 6(4): 271-279.

Lee, G A & Fitzgerald, L 2003. A clinical internship model for the nurse practitioner programme, Journal of Biomedical Informatics, Volume 36, Issues 4-5, Pages 342-350

Lim, A G, Honey, M & Kilpatrick, J, 2009. Framework for teaching pharmacology to prepare graduate nurse  for prescribing in  New Zealand, Australasian Emergency Nursing Journal, Volume 12, Issue 2, Pages 32-37

Ministry of Health. (2002). Nurse Practitioners in New Zealand. Wellington: New Zealand

Ministry of Health. (n.d.). New Zealand ministry of health. Retrieved March 22, 2010, from www.moh.govt.nz

Read, S.M. et al. (1992). Nurse practitioners in accident and emergency departments: what do they do? BMJ, 305(6867):1466-70. http://nurse-practitioners.advanceweb.com/Editorial/Content/Editorial.aspx?CC=188462