From registered nurse to nurse practitioner: What the journey entails

Nurse practitioner and APNA member Denise Lyons reflects on working as a nurse practitioner in primary health care in Australia. 

Becoming endorsed as a nurse practitioner requires registration as a registered nurse, as well as a Master’s degree in nursing and advanced clinical training. Nurse practitioners also undergo a rigorous process to gain endorsement by the Australian Health Practitioner Regulation Agency (AHPRA) and adhere to a code of ethics. There is a large body of evidence that suggests nurse practitioners deliver the same quality of care as doctors, and patient outcomes for nurse practitioners were comparable to physicians.

As most nurse practitioners start their careers as registered nurses, they are usually empathetic, attentive and good listeners, who provide holistic patient-centred care. Nurse practitioners working in primary care tend to focus more on prevention and, as we are educated differently than our medical colleagues, we have different models of how we care for patients. Nurse practitioners work in a collaborative care model with doctors and these roles complement each other to improve patient outcomes.

Care costs and avoidable hospitalisations are at their lowest when patients are treated by an optimal mix of primary care professionals, with everyone in the team working at the top of their scope of practice.

Why did I consider being a nurse practitioner?

Barely a week passes without being asked: "Why would you take on all of that extra responsibility for not much more pay?” “Why didn’t you just go to medical school?” “Why do you work in primary care – you’d make more money in the acute sector?”  And my answer? I love working as a nurse practitioner in primary care and being a member of a general practice team, where we complement each other’s skills and abilities to get the best health outcome for our patients. It is the best job I have ever had. 

The pinnacle of clinical care pathway for nursing is the nurse practitioner’s role. I would encourage other nurses who are considering the nurse practitioner role to jump right in. The nurse practitioner role was introduced in Australia in 2000¹. Since then, nurse practitioner positions have been established in all states and territories and in a number of disciplines. Nurse practitioners are playing an increasing role in meeting service system gaps, improving health outcomes, and potentially contributing to a reduction in healthcare costs by delivering care that is flexible, innovative, and professionally rewarding².

There are over 1,000 nurse practitioners working in Australia, and a recently published paper identified 77 privately practicing nurse practitioners in Australia, with the highest proportion of participants specialising in general practice or primary care, mental health and aged care community settings³. Although the number of nurse practitioners working in primary care is currently small, numbers are growing in response to recent policies, including changes in legislation allowing endorsed nurse practitioners working in collaboration with a medical practitioner to access the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS)⁴. The Australian Government is also encouraging primary care practices to consider working with nurse practitioners to improve the effectiveness and efficiency of the healthcare system⁵.

Nurse practitioners working in primary care tend to focus more on prevention and, as we are educated differently than our medical colleagues, we have different models of how we care for patients.

Legislative framework

Nurse practitioners practice in accordance with Commonwealth, state and territory legislation and professional regulations. This includes each state and territory’s poisons and/or therapeutic goods legislation, as well as other legislation relevant to the nurse practitioner scope of practice and professional role such as notifiable diseases legislation. Most states and territories have developed strategies and/or tools for developing and implementing the nurse practitioner role in their own jurisdiction. Regulation and endorsement of nurse practitioners is controlled by AHPRA working in cooperation with the Nursing and Midwifery Board of Australia (NMBA).

Standards for professional practice

The NMBA governs the professional conduct of nurse practitioners. Its publications are the core standards for nurse practitioners in Australia which include⁶: 

• Nurse practitioner standards for practice
• National competency standards for the registered nurse
• Code of ethics for nurses in Australia
• Code of professional conduct for nurses in Australia

Endorsement

To be eligible for endorsement as a nurse practitioner, the registered nurse must demonstrate the following⁷: 

• Current general registration as a registered nurse
• The equivalent of three years’ ful-time experience in an advanced practice nursing role, within the past six years from date of application seeking endorsement
• Successful completion of an NMBA-approved nurse practitioner qualification at Master’s level or education equivalence as determined by the NMBA
• Compliance with the NMBA’s Nurse practitioner standards for practice 
• Compliance with the NMBA’s Registration standard: Continuing professional development
• A list of the Australian tertiary institutions offering the Master of Nursing course can be found on the AHPRA website⁸.

Opportunities and challenges

'At times I feel like part of the role description should include ‘ambassador’, as I spend a lot of time educating stakeholders and have developed a quick one minute elevator speech to explain the role in almost any situation.'

Nurse practitioners can provide benefits for patients including increased access to more timely appointments and more choice of practice team member. This has the potential to improve patient satisfaction and health outcomes. Nurse practitioners can prescribe some medicines, order and interpret diagnostic tests, and refer patients to other health professionals. This can provide flexibility for general practitioners who may decide to take on more patients or to lighten their case load by referring appropriate patients to the nurse practitioner for collaborative case management, patient education and review. These opportunities reconfigure how the practice team works, by improving teamwork and enhancing shared patient encounters, which can contribute to greater job satisfaction for all team members. This has certainly been my experience.

Economic benefits for general practices include opportunities to generate new revenue streams through MBS billing and gap fees, and potentially by working differently as a practice team. The practice can realise cost efficiencies, for example by increasing practice capacity while reducing average cost per consultation. As general practitioners do not have to be involved in patient consultations, there is no need for patients to wait for the general practitioner’s sign off as the consultation can be billed under the nurse practitioner provider number. This also removes unnecessary duplication of work in cases where patients might otherwise see a nurse practitioner rather than a general practice nurse and general practitioner.

Thus the addition of a nurse practitioner to a primary health care team has the potential to address workforce issues  and potential shortages. The nurse practitioner also offers a more efficient mix of clinical skills within the overall practice team – the right person delivering the right level of service at the right time. And the challenges? Yes there are a few, but they have not been insurmountable in my experience.

Recognition and acceptance of the nurse practitioner role by other healthcare professionals, patients and the general community

There has been very good support and enthusiasm for this role from both patients and general practitioners. A huge part of the process has involved education of patients and other healthcare professionals. At times I feel like part of the role description should include ‘ambassador’, as I spend a lot of time educating stakeholders and have developed a quick one minute elevator speech to explain the role in almost any situation. As there are strategies and/or policies supporting and promoting the nurse practitioner role in place around most states and territories, I am optimistic that the role will become ‘normalised’ over time. It is heartening to know that there is very strong evidence of patient satisfaction with care provided by nurse practitioners and this body of evidence is growing.⁹

Cost of education

Study assistance schemes and scholarships for nurses are available in most states and territories, which can provide financial support for the costs of undertaking tertiary studies.

Lack of a clear career pathway

It is important to clearly identify the need and justification for the role before implementation. I don’t believe that I would have found as much professional satisfaction in the role without the cooperation and support of the fantastic healthcare team I work in. They have provided assurance of the availability of a nurse practitioner position and ongoing support before I undertook the commitment to study. I have also received great support from the Australian College of Nurse Practitioners, the national peak body for nurse practitioners in Australia.

So to come back to my original question – why would I consider being a nurse practitioner?

My initial impetus for moving into the nurse practitioner role was to increase patient access to care, to provide a cost-effective and high quality care, and to improve my overall satisfaction at work by increasing my ability to work autonomously. I can honestly say these goals have been met, and I love my job! I would encourage any nurses who are thinking of taking the step to do so. You won’t regret it. 

References

1. Masso, M., & Thompson, C. (2017). Australian research investigating the role of nurse practitioners: A view from implementation science. Collegian, 24(3), 281-291. http://www. collegianjournal.com/article/S1322-7696(16)30006-3/fulltext 
2. King J, Corter A, Brewerton R, Watts I 2012, Nurse practitioners in primary care: benefits for your practice, Australian General Practice network, Auckland: Julian King & Associates Limited; Kinnect Group. http://www.nbmphn.com.au/Resources/Programs-Services/Primary-Care-Support/Nursing/PD-Guidelines/Nurse-Practitioner-Business-Cases.aspx
3. Currie, J., Chiarella, M., & Buckley, T. (2016). Workforce characteristics of privately practicing nurse practitioners in Australia: Results from a national survey. Journal of the American Association of Nurse Practitioners, 28(10), 546-553. http://onlinelibrary.wiley.com/doi/10.1002/2327-6924.12370/full
4. Currie, J., Chiarella, M., & Buckley, T. (2016). Workforce characteristics of privately practicing nurse practitioners in Australia: Results from a national survey. Journal of the American Association of Nurse Practitioners, 28(10), 546-553. http://onlinelibrary.wiley.com/doi/10.1002/2327-6924.12370/full
5. Australian Government Department of Health. Nurse Practitioners. http://www.health.gov.au/internet/main/ publishing.nsf/Content/work-nurse-prac
6. http://www.nursingmidwiferyboard.gov.au 
7. http://www.nursingmidwiferyboard.gov.au/Registration-Standards.aspx
8. http://www.ahpra.gov.au/Education/Approved-Programs-of-Study.aspx
9. Sue Randall, Tonia Crawford, Jane Currie, Jo River, Vasiliki Betihavas, Impact of community based nurse-led clinics on patient outcomes, patient satisfaction, patient access and cost effectiveness: A systematic review, In International Journal of Nursing Studies, Volume 73, 2017, Pages 24-33, ISSN 0020-7489, https://doi.org/10.1016/j.ijnurstu.2017.05.008

Source: Primary Times Summer 2017 (Volume 17, Issue 4)