International Emergency Nursing (2010) 18, 147– 153
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Perceived barriers to the sustainability and progression of nurse practitioners Simon F.J. Keating RN, BN, Business Dip, GradDip NsG (Acute Care) MN (Emergency Nurse Practitioner) a,*, John P. Thompson RN, BN, CCC (Emergency Nurse Practitioner Candidate) a, Geraldine A. Lee NFESC, MPhil, BSc, RGN (Lecturer, Co-ordinator of Nurse Practitioner Masters programme) b a b
Emergency and Trauma Centre, The Alfred Hospital, Prahran, Victoria, Australia La Trobe University/Alfred Clinical School of Nursing, Alfred Hospital, Melbourne, Victoria, Australia
Received 14 July 2009; received in revised form 12 September 2009; accepted 15 September 2009
KEYWORDS Emergency nurse practitioner; Role progression; Sustainability
Abstract Background: In 1998 in Victoria, Australia, the Nurse Practitioner (NP) model was considered with projects exploring the potential for NP implementation in emergency departments. (EDs) Aims: The aim of this study is to explore the perceived barriers to progression and sustainability of the NP role in Victoria. A survey of the 17 EDs involved in the initial projects was undertaken targeting NP candidates, nurse managers and project officers. A total of 48 individuals were identified and contacted. The survey comprised of demographic details and statements about NP role sustainability and progression using a Likert scale Findings: A total of 37 participants (77%) completed the survey. Participants strongly agreed that there were barriers to sustainability, especially lack of ongoing funding from their own organisation and external sources. Other barriers included a lack of understanding from the organisation and medical staff about the role. The main barriers to role progression were the legislative constraints (n = 29, 78%) and the cost of Masters programmes (n = 29, 78%) Conclusion: This survey revealed a myriad of barriers to role sustainability and progression. These barriers need to be explored and progressed if the NP role is to continue to develop and expand
Crown Copyright ª 2009 Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Address: Alfred Emergency and Trauma Centre, Alfred Hospital, Prahran, Melbourne 3181, Victoria, Australia. Tel.: +61 3 9076 3405; fax: +61 3 8532 1100. E-mail address: [email protected]
(S.F.J. Keating). 1755-599X/$ - see front matter Crown Copyright ª 2009 Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ienj.2009.09.003
Introduction Healthcare delivery models are inherently flexible in order to respond to changing healthcare demands in terms of physical resources and suitably qualified personnel. The current pressures on the healthcare system in developed countries include the increasing ageing population, the increased prevalence of chronic disease, the greater acuity of patient presentations and the shortage of healthcare professionals (WHO, 2006). The challenge for healthcare organisations is to deliver care that is cost-effective and efficient to meet these demands. The nurse practitioner (NP) role was developed to improve healthcare delivery in an efficient and effective manner. The role first developed in the USA in the 1960s out of increased demand for healthcare and shortfalls in medical staffing (Asubonteng et al., 1995). Within the specialty of emergency nursing, NPs have been practicing in emergency departments (EDs) in both the USA and UK for many years. The NP in Australia is defined as a registered nurse educated and authorised (endorsed) to function autonomously and collaboratively in an advanced and extended clinical role within the context in which they practice (Australian Nursing and Midwifery Council, 2006). The role includes assessment and management of patients using nursing knowledge and skills and may include but is not limited to, direct referral of patients to other health care professionals, prescribing medication, ordering and diagnostic investigations and admission and discharge rights (Nurses Board of Victoria website, 2009). In Australia, the NP role was first developed in 1990 in the state of New South Wales and other states in Australia have consequently followed their lead. Research has demonstrated the benefits of the role in terms of patient satisfaction (Sakr et al., 1999; Barr et al., 2000; Byrne et al., 2000; Cooper et al., 2002) and efficiency (Jennings et al., 2008; Lee and Jennings, 2006). A systematic review by Carter and Chochinov (2007) examining the impact of cost, quality of care, satisfaction and wait time in EDs found that NP led care resulted in higher patient satisfaction, reduced waiting times and equal quality of care when compared to a mid-grade resident.
The development of the Victorian NP model The development of the Victorian NP model was initially examined in order to determine if NPs could address the demands for diverse options in healthcare, improved service access and increased flexibility in models of healthcare delivery. To contextualize the population and healthcare needs in Victoria, it is important to outline the geography and population of the state. Victoria is in south-east Australia with a population of 5.2 million people with 3.8 million living in metropolitan areas and 1.4 million in regional Victoria (Dept. of Sustainability, n.d.). The state is 237,629 km2 and is larger than England in size (130, 410 km2). The metropolitan Melbourne area is 8806 km2. The nursing workforce comprises of 80,726 Registered Nurses and a lack of General Practitioners and specialist doctors in rural Victoria has been reported (Department of
S.F.J. Keating et al. Human Services, 2008). In 1997 the Victorian nurse practitioner project (VNPP) was established with the goal of fulfilling the service gap and to enhance healthcare delivery to all Victorians, in particular those located outside the major metropolitan areas. This would be achieved by (i) improved access to services, (ii) providing a greater diversity of services and (iii) improving the flexibility in mode of healthcare delivery. The VNPP (1999) recommended that changes be placed in order to facilitate the introduction of a NP role in Victoria. These include the establishment of appropriate university based NP courses, amendments to the Nurses Act 1993 to protect the title of NP, amendments to the Drugs Poisons and Controlled Substances Act, 1981 to provide limited prescribing, and all other relevant legislation be reviewed and amended as deemed necessary. As a result of the VNPP findings, the Department of Human Services (DHS) funded eleven projects in various specialties including emergency nursing, palliative care and renal nursing in metropolitan, regional, and rural locations. From an ED perspective, the first organisation to explore the NP role was Southern Health which comprises of Dandenong Hospital and the Monash Medical Centre (both are metropolitan hospitals in Melbourne) in 1998. Following this, a further 15 organisations gained funding to develop the NP role. All those given funding had to write service plan development reports outlining how the NP pilot was implemented and whether there were any barriers or issues to implementing and sustaining the role within their organisation. Seven Victorian organisations received funding and produced service reports (Austin Health, 2006; Bayside Health, 2006; Eastern Health, 2006; Goulburn Valley Health, 2006; Northern Health, 2006; Royal Women’s Hospital, 2006; Western Health, 2006). Several themes, regarding barriers, were common amongst all reports and could be placed under five subheadings: (i) educational requirements, (ii) organisational support, (iii) legislation shortfalls, (iv) lack of awareness among colleagues and (v) internal funding. Each of these issues will be addressed. Although funding was given to all organisations, not all organisations succeeded in developing the NP role in their EDs. This leads to an important question of what were the barriers for organisations in developing and sustaining the NP model. The aim of this paper is to explore the barriers to the progression and sustainability of the Emergency NP role in Victoria from 1998 to 2008.
Methods The research was performed by developing a questionnaire and surveying the relevant employees within Victorian health organisations who received DHS funding for the implementation of NP projects in EDs between 1998 and 2008.
Participants Those identified for inclusion, were those working in EDs and funded as part of the emergency nurse practitioner project between 1998 and 2008. This included NP and NP
Perceived barriers to the sustainability and progression of nurse practitioners
Survey The survey was developed by the authors following a review of the relevant NP literature and DHS reports on the initial NP implementation and subsequent reports. Preliminary validity and reliability was performed by two of the authors by devising the questionnaire and having six colleagues (who were aware of the NP role but were not potential participants in the survey) complete it and give feedback or comments. This preliminary process prior to the survey being conducted, ensured that all questions were relevant and valid and that there were no ambiguities with the questions.
Procedure A total of 48 participants were identified from DHS NP pilot project reports, from local networking (SK) and discussion with the Victorian emergency nurse practitioner collaborative. All potential participants were emailed the survey accompanied by instructions on rationale for the survey and consent was inferred via return of the survey. The survey was designed using a computer generated programme called ‘survey monkey’. This programme was designed to include collection of demographic information and questions on barriers to role progression and sustainability to be measured using a 5-point Likert scale (from strongly disagree to strongly agree). Once the survey was returned, all data was de-identified prior to analysis. The survey design allowed descriptive analysis to be performed.
role at the time of the survey (i.e. in 2008). Over a third were unit managers (n = 13, 37%), two thirds were NPs or nurse practitioner candidate (n = 22, 63%), three (9%) were project officers, and two respondents did not answer the question. These results also indicate that some participants are working in the capacity of dual roles. Respondents reported that the majority were in the same position at the time of the project (n = 23, 62%). Of the 38% (n = 14) who were not in the same role in 2008, seven cited a career move (n = 7), four cited lack of funding, one cited change in personal circumstances (n = 1) for change in position. Lack of organisational support for NP role was stated by one participant for role change, while one participant stated other reasons but did not provide any comments. The DHS initial project funding was used for project officers (n = 31, 89%), NP candidates (n = 17, 49%) and salary top-up for NP candidates (n = 19, 54%). The majority stated that no other funding was received (n = 30, 81%) other than the money from DHS. Respondents were asked to indicate the number of emergency nurse practitioners employed within their organisations at 1998, 2004 and 2008. Tables 1 and 2 highlight the results from metropolitan, rural and remote organisations, respectively.
Emergency NP numbers – metropolitan.
candidates (all individuals are candidates until they become endorsed as NPs), project officers and nurse unit managers.
5 4 1998
Table 2 Victoria.
Emergency NP numbers in rural and remote
A total of 37 people responded to the survey (response rate of 77%). Of these, the majority were between the ages of 31 and 45 years (n = 21, 57%) and the remainder were between 46 and 59 years (n = 16, 43%). The majority had completed Master degrees (n = 21, 57%) with eight participants completing post graduate diplomas (22%) and four had completed post graduate certificates (n = 4, 11%). (In Australia, post graduate certificates and diplomas are classified as post-graduate qualifications but not classified as Masters qualifications). The remainder had bachelor of nursing (n = 4, 11%). With regards to the location of the respondents at the time of the project in 1998, the majority reported were in metropolitan hospitals (n = 20, 57%) and the remainder from rural organisations (n = 15, 43%) with two respondents not answering this question. Respondents were asked about their role prior to the project commencing; nearly half were in clinical positions (n = 17, 46%), 43% (n = 16) in managerial positions and the remainder in education positions (n = 7, 19%). Two people did not specify their positions. The response count is greater than the participation rate suggesting that participants were employed in dual roles at the commencement of the project. Respondents were also asked about their current
2005 2006 2008
0 Bendigo Barwon LaTrobe Goulburn South Seymour Regional Valley West Heatlh
S.F.J. Keating et al.
Barriers to sustainability Respondents were asked to rate their agreement with various statements about what they perceived to the barriers to NP sustainability (see Table 3). Seventy percent agreed that lack of ongoing DHS funding was a barrier to sustainability (n = 26), with a further two thirds agreeing that lack of organisational funding was a barrier (n = 23). Fourteen respondents (39%) stated lack of specialty department funding as a barrier to sustainability. When asked if the lack of understanding from medical staff was a barrier to sustainability, over half disagreed with this statement (n = 20, 54%) while 16 (43%) agreed with the statement. Lack of understanding from nursing staff was not perceived as a barrier by the majority of respondents (n = 22, 61%), while 36% agreed with the statement (n = 13). Lack of organisational support was seen as a barrier to role sustainability by 25 respondents (70%) with the remainder disagreeing (n = 10, 28%) and one person unsure (n = 1, 2%).
Barriers to role progression As with the barriers to sustainability, respondents were also asked to rate their agreement with various statements about what they perceived to be the barriers to NP role progression (see Table 3). Over 78% (n = 29) of respondents felt that legislative constraints were a major barrier to role pro-
gression, with 16% (n = 6) disagreeing with this statement. Nearly two thirds (n = 23, 59%) cited Clinical Practice Guidelines as a barrier. In terms of education, the cost of completing a Masters degree was considered a barrier by 78% (n = 29) of respondents, and when asked if ongoing educational requirements were seen as a barrier 51% (n = 19) agreed with the statement, 37% (n = 14) disagreed and 10% (n = 4) were unsure. Also of note, two thirds of respondents felt that there a general lack of interest from clinical nurses to become a NP.
Discussion This study 10 years after the introduction of the NP role into Victorian EDs achieved a participation rate of 77%. Participants strongly agreed that there were barriers to sustainability, especially lack of ongoing funding from their own organisation and external sources. A lack of understanding from the organisation about the NP role was also reported as barriers. The main barriers to role progression were the legislative constraints (n = 29, 78%) and the cost of Masters programmes (n = 29, 78%). In terms of NP numbers, only two organisations have increased the numbers of NPs. The barriers to role progression and sustainability were identified and included lack of organisational support, legislation shortfalls, the educational requirements and lack of ongoing funding from the organisations. Kleinpell-Nowell (1999) reported the main
Survey responses regarding barriers to NP sustainability and role progression (n = 37). Strongly agree = 5 (n, %)
Not sure = 3 (n, %)
Disagree = 2 (n, %)
Strongly disagree = 1 (n, %)
Please rate the following statements regarding barriers to ENP sustainabilitya Lack of ongoing funding for the project from Department of Human Services 6 (16%) 20 (54%) Own organisation 11 (31%) 12 (33%) Specialty department 4 (11%) 10 (28%)
4 (11%) 3 (8%) 5 (14%)
7 (19%) 9 (25%) 12 (33%)
0 1 (3%) 5 (14%)
Lack of From From From
1 (3%) 1 (3%) 1 (3%)
13 (35%) 17 (47%) 5 (14%)
7 (19%) 5 (14%) 5 (14%)
5 (14%) 10 (27%) 11 (31%) 12 (32%) 6 (16%) 12 (32%) 7 (20%) 13 (35%)
1 4 0 2 0 5 1 5
support and understanding from medical staff nursing staff organisation
7 (19%) 4 (11%) 11 (31%)
Agree = 4 (n, %)
9 (24%) 9 (25%) 14 (39%)
Please rate the following each statements regarding barriers to ENP role progressionb Please rate the following in terms of barriers to role progression Legislative constraints (i.e. prescribing rights) 23 (62%) 6 (16%) 2 (5%) Clinical practice guidelines 8 (22%) 14 (38%) 1 (3%) Endorsement process 10 (28%) 13 (36%) 2 (6%) Ongoing educational requirements 5 (14%) 14 (38%) 4 (11%) Cost of completing Masters programmes 16 (43%) 13 (35%) 2 (5%) Imposed expectations of peers 0 17 (46%) 3 (8%) Lack of interest form clinical staff to undertake NP role 7 (20%) 17 (46%) 4 (11%) Perceived threat to junior doctors skill development 2 (5%) 13 (35%) 4 (11%) a
(3%) (11%) (5%) (14%) (3%) (14%)
Definition of sustainability: ‘‘to enable to bear something, to keep from failing, to strengthen, to encourage, to keep up, to prolong, to maintain’’. b Definition of role progression: ‘‘to progress, motion onward, movement in successive stages, to move forward, to advance, to be carried on, to proceed’’.
Perceived barriers to the sustainability and progression of nurse practitioners reasons why NP left their positions included: position terminated, not being utilised as a NP and limited role opportunity. Similarly Miller et al. (2005) highlighted the frustrations with performing non clinical duties and administrative tasks which were time consuming. The results indicate that successful NP role implementation requires organisational support (Watts et al., 2009). Survey participants agreed that individual organisations needed to support the NP role within the organisation for the role to be successful. The lack of organisational support has previously been identified as one of the main barriers to NP sustainability (Lindeke et al., 2005; Marsden et al., 2003). Support includes funding, amending organisational plans to implement and maintain the NP model. Important processes that need to be in place include a framework for NP processes and clinical governance. Mentorship programmes have previously been seen as a suitable method to ensure NP role progression occurs. This mentorship model can include medical and nursing staff (Lee and Fitzgerald, 2008). One of the recommendations by the VNPP (1999) regarding the endorsement of NP in Victoria was: ‘‘That the minimum educational requirement for recognition as a nurse practitioner be an accredited Masters level programme with a strong clinical focus and a research project component’’ (p. 26). The financial issues associated with becoming an NP include the cost of completing a Masters (the average price being AU$15,000, about £7000) as nurses usually are self-funded and may receive some financial support from their employer but not usually. Access to the appropriate educational and peer support for those in rural and remote areas was also identified as an issue for several of the organisations (Austin Health, 2006; Bayside Health, 2006; Goulburn Valley Health, 2006; Royal Woman’s Health, 2006; Western Health, 2006). NP candidates are usually paid at the same rate of pay until they become endorsed NPs. There are some scholarships available including those from the DHS and Royal College of Nursing Australia. In late 2008, the Federal Minister for Health and Ageing announced that the Australian Government would be investing AU$2.1 million (£1 million) with some of this money specifically for scholarships (up to AU$15,000 per annum for 2 years for 20 nurses) (Department of Health and Ageing). In response to student feedback, La Trobe University will have subsidized fees for the NP course. The results also highlight an agreement amongst NP’s that there is a general lack of interest in clinical nurses advancing to NP. One possible explanation for this may be that a large group of ED nurses have been practicing at an advanced level for many years and may be reluctant to undertake further study as they are already perceived as an expert. As well as the cost of becoming a NP, research highlights ongoing funding for the NP role in organisations was a major barrier to progression and sustainability (Bryant-Lukosius et al., 2004; Kleinpell-Nowell, 1999). While the DHS provided initial funding for the development of NP roles in various hospitals; each organisation was responsible for maintaining ongoing funding. This was highlighted as a major barrier to NP sustainability by several organisations (Austin Health, 2006; Bayside Health, 2006; Goulburn Valley Health, 2006; Royal Woman’s Health, 2006; Western Health, 2006) citing limited opportunities within existing hospital
budgets. Several suggestions have been highlighted throughout the literature on solutions to this problem. These include role conversion, access to Medicare and the Pharmaceutical Benefits Scheme (PBS), key performance indicator rewards and third party payments or reimbursement (Bayside Health, 2006; Kaplan and Brown, 2004; Swan, 2000). Directorate relocation of funds is another option with one study (Phillips et al., 1995) demonstrating NP duties at the University of Massachusetts Medical Centre could be categorized under inpatient care and ambulatory care and thus could be funded under these categories. A discrepancy noted between this study and the literature was surrounding the lack of awareness of the NP role. Lack of the awareness of the NP role by nurses, doctors, allied health and patients is perceived as a barrier to role progression and sustainability throughout the literature (Appel and Malcolm, 2002; Clarin, 2007). For example, a study by Thrasher and Purc-Stephenson (2007) found that some registered nurses found it difficult performing tasks for patients being cared for by a NP citing confusion surrounding the NP role as the cause of the disagreement. Our results indicated that this was not the case within Victorian EDs. One local Victorian study found that staff attitudes toward the role of the NP in EDs were generally favourable and stated that further education about the NP role improves staff attitudes towards NPs (Lee et al., 2007). Legislation shortfalls have been reported as hindering autonomous NP practice (Appel and Malcolm, 2002; Driscoll et al., 2005). A number of the VNPP recommendations (1999) regarding legislation changes have already been amended, however a limitation to NP practice is the lack of provider numbers and Medicare provider numbers. A lack of Medicare provider numbers for NPs in Victoria means a medical specialist is unable to claim a rebate for a patient referred by an NP and therefore unlikely to accept the referral (Appel and Malcolm, 1999; Driscoll et al., 2005). The lack of a provider number provides challenges for NPs to work without relying on medical colleagues. In order to receive a Pharmaceutical Benefit under the Pharmaceutical Benefits Scheme (known as PBS) (i.e. the Australian government’s subsided medication scheme), a consumer is prescribed a drug listed in the Schedule of Pharmaceutical Benefits. The subsidy is automatically applied when the drug is dispensed at a pharmacy and the cost to the patient is the patient co-payment contribution rather than the full cost of the medication. NPs do not have access to PBS which results in the patient paying the full cost of the prescribed drug. Therefore, the majority of patients would prefer to see the doctor who could prescribe under PBS thus subsidizing the patient’s costs. This lack of PBS access restricts NPs ability to work autonomously without financially disadvantaging the patient. Changes to legislation can lead to improved healthcare benefits as outlined by Kaplan and Brown (2004). Changes made in the USA in 2000 regarding NP prescribing rights (including expanding NP drug formulary), demonstrated improved delivery of healthcare as well as taking a step closer to autonomous practice for NPs as they were able to meet the needs of the majority of their patients (Kaplan and Brown, 2004). In the May 2009 Federal budget, NPs were given approval for Medicare and PBS access that will probably come into
152 practice in 2010. However, this is a very recent development and prior to the Federal election in late 2007, there had been no indication that legislative changes were being considered. Therefore prior to the recent announcement, the concept that NPs would have access to Medicare or PBS was unknown. These changes will hopefully lead to improved service access, greater diversity in services provided and increased flexibility in the mode of healthcare delivery.
Limitations of the survey Although the survey produced a relatively good response rate, the design did not allow for in-depth analysis of the barriers. The on-line survey is a quick and easy method of undertaking research however it may not always reach all potential participants. The survey only attempted to gather perceived perceptions from those directly involved in the initial projects and inclusion of those in managerial or financial positions in the various organisations may have highlighted other issues.
Conclusions There are many barriers to NP role progression and role sustainability that have been clearly identified, including lack of organisational support, legislation shortfalls, the costs associated with undertaking a Masters degree and ongoing funding for the role. Since the survey was undertaken, new legislation will give NPs the ability to generate an income and there are various scholarships available for those undertaking Masters programmes. Recognising that some organisations have increased their NP numbers since the role was introduced through methods such as a relocation of resources and through a common nursing and medical budget shows flexibility and role sustainability. By continuing to explore the relevant issues, NPs and organisations can evaluate the role in terms of key performance indicators, audits and quality assurance relating to the role and demonstrating the positive impact of their practice. These barriers need to be acknowledged in order to develop methods and solutions in moving the role forward and confirming NPs as central to an efficient healthcare delivery model.
Acknowledgement The authors would like to thank all those who completed the survey.
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