Exploring factors affecting uptake of extended scope of … Tony PPTs A1.p… · Micro-enablers (Practice) • Need to advocate for extended practice roles I think one of the really

The University of Newcastle www.newcastle.edu.au

Exploring factors affecting uptake of extended scope of practice in rural areas Tony Smith1, Karen McNeil1,2, Rebecca Mitchell2, Brendan Boyle2, Nola Ries2 1 Faculty of Health and Medicine, University of Newcastle Department of Rural Health 2 Faculty of Business and Law, University of Newcastle

Health Services

Research & Innovation Group

2 | The University of Newcastle www.newcastle.edu.au

Introduction More needs to be done to support innovative models of health service delivery to:

• Improve service access in rural & remote areas

• Reduce the costs to patients of traveling long distances to receive relatively minor, low risk diagnostic tests or treatments

• Includes, though not specific to Nurse Practitioners (NPs)


Aims of this study

• Explore lived experiences and perceptions of NPs in rural practice (and colleagues, where possible) about barriers to and enablers of their extended scope of practice (ESoP) roles

• Adapt a socio-institutional theoretical model of macro-, meso- and micro-perspectives* to generalise about ESoP roles

* [Mulvale, Embrett, Razavi. BMC Family Practice 2016; 17(1): 83]


Background • Scope of practice of NPs includes:

• advanced health assessment, analysis & diagnosis; • order and interpret diagnostic tests; • prescribe some medications; and • refer patients to other health service providers.

• How many NPs? • Nursing and Midwifery Board of Australia

• Registrant data 1st Oct to 31st Dec 2016 • 1,478 = 0.48% of Registered Nurses & Midwives

• Registrant data 1st April to 30th June 2016 • 1,418 = 0.46% of Registered Nurses & Midwives

[http://www.nursingmidwiferyboard.gov.au/About/Statistics.aspx]


International comparison, 2015

[Maier et al. BMJ Open Sep 2016, 6 (9) e011901]

N = total number; NP = nurse practitioner; P = practising; PA = professionally active; R = registered/licensed to practice


Source: Australian College of Nurse Practitioners, 2015 Member Survey (Approx. 38% of members)

In 2009, 2nd National NP Census – 35.7% practiced in rural/remote [Middleton, et al. Aust Health Rev 2011 35(4): 448-454]

Most NPs practice in metropolitan locations


Methodology • In-depth semi-structured interviews • Recruitment: NSW Nurses & Midwives Assoc.

+ Australian College of Nurse Practitioners • Informants (n = 20):

– 15 NPs + 5 Colleagues/Managers – 11 ASGC-RA2; 6 RA3; 1 RA4; 2 RA5 * – 10 NSW; 3 SA; 2 Vic; 2 Qld; 2 WA; 1 NT

• NP specialties: – 5 Primary Care; 4 Emergency/Critical Care;

3 Aged Care; 2 Diabetes; 1 Continence

* RA2 - Inner Regional; RA3 - Outer Regional; RA 4 – Remote; RA5 – Very Remote


Macro- Meso- & Micro Barriers to and Enablers of Extended Scope of Practice Roles


Macro-barriers (Legal, regulatory, educational, economic and political)

• Legal and regulatory requirements limit practice and funding

‘Medicare, it's crap, in a nutshell. It just makes our lives really difficult. We've got four … time-based item numbers. That's all we can bill for. … I probably only generate enough income to support a third of my role, a third of my salary.’ (NP11, RA3, WA, Primary Care)

National policy & regulatory systems (MBS, PBS & other)


Macro-barriers (Legal and regulatory, education, economic and political)

• It is sometimes possible to work around barriers

‘We’re limited under MBS as to what we can have done – and that is a barrier in some ways because you can’t fully do things that you want to do, but … [The NP] … has to work around the limitations imposed by legislative limitations, like the MBS, but this is manageable.’ (NP1, RA2, NSW, Diabetes)

National policy & regulatory systems (MBS, PBS & other)


Macro-enablers (Legal and regulatory, education, economic and political)

• Role boundaries can be redefined and refined

‘… using the nursing model but being able to extend the scope of practice you’re able to provide a more comprehensive health service to that person and their family. … I am able to, and will manage within how I feel comfortable, looking at the renal disease and hypertension and infection and illnesses as well.’ (NP1, RA2, NSW, Diabetes)

Scope and boundary issues


Meso-barriers (Institutional and community)

• Poor understanding among other HS personnel

When I first started working with our Nurse Practitioner I didn’t understand the role, I didn’t understand what he was there to do. But once you understand exactly what they’re doing, I don’t think anybody would say they weren’t valuable to the ED. It really is, particularly in upper management when they don’t understand the role, … (NP3C, RA3, NSW, Emergency)

Lack understanding of role


Meso-barriers (Institutional and community)

• Poor understanding by community

So, I think that broader recognition from a national and societal perspective too. And with patients as well – I don’t think the role is really understood by the community. There are a lot of questions from clients and patients about what do you do sort of thing. So, I think it is just that broader societal understanding of extended practice roles. (NP2C, RA2, NSW, Aged Care)

Lack understanding of role


Meso-enablers (Institutional and community)

• NP roles are also well supported and valued

‘I love what I do out here. My community are very loyal to me. I’m booked out fully on my nurse practitioner days and patients have to wait a few weeks to get in, … I have provider numbers at both surgeries, so I actually don’t cost them a lot of money, …’

(NP12, RA2, Vic, Primary Care)

Community support


Meso-enablers (Institutional and community)

• Building local networks helps with acceptance

‘When I first started I spent a lot of time networking and trying to get good rapport with the GPs, particularly a lot of those that went to residential care facilities, and some GPs are fantastic and I’ll just ring them and like yep, no dramas, whatever, not a problem …’

(NP7, RA3, NSW, Age Care)

Networking & building rapport


Micro-barriers (Practice)

• How NP role fits with pre-existing roles

… it was a new position when I came to it … It's been an interesting journey because we've had to define where we sit within the structure…, so how do we work with the services that were pre-existing and that's taken two years to sort of work that out really. Lot of time and effort goes into sorting out the roles in relation to other pre-existing roles. (NP14, RA2, Vic, Continence)

Lack of role clarity


Micro-enablers (Practice)

• Interprofessional practice can be powerful

The thing that's helped me most in the organisation is the support I've had from the physicians here, who basically tell the registrars when they start, “… if there's any problems or you've got any questions just go and ask [the NP]", … That actually came to me directly from one of the other physicians. (NP13, RA2, NSW, Emergency/Critical Care)

Interprofessional support & collaboration


Micro-enablers (Practice)

• Need to advocate for extended practice roles

I think one of the really important roles of the NP is … to promote the role You have to get out there, you actually have to be the diplomat, be supportive of others and acknowledge their expertise as well, and through that you will get buy-in into it. … be proactive and go on the front foot to gain the support of peers and other health professionals. (NP1, RA2, NSW, Diabetes)

Negotiation, diplomacy, advocacy & promotion of role


Summary • NPs provide high quality

care that is accepted by patients and communities

• Too few NPs especially in RA3-5 locations

• Barriers and enablers exist at all levels

• Need for greater role clarity and advocacy


Recommendations • Peak bodies need to direct advocacy towards

addressing anomalies in MBS and PBS for NPs

• Promote NP role to nurses and other health professions through interprofessional teamwork

• Promote advanced practice roles to senior HS managers to ensure ongoing funding and sustainability

• Develop other ESoP and advanced practice roles in other health professions

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Exploring factors affecting uptake of extended scope of … Tony PPTs A1.p… · Micro-enablers (Practice) • Need to advocate for extended practice roles I think one of the really