The status of Australian nurse practitioners: the second national census

Nurse practitioners play an increasingly important part in the delivery of modern healthcare. In 2009, the Australian Federal Government committed AU$59.7 million to expand the role of the nurse practitioner within the Australian healthcare system.¹ Such an investment highlights the urgent need for a clearer understanding of the evolution of nurse practitioner practice in Australia.

A nurse practitioner is an advanced clinical role that has responsibility for assessment and management of clients, including the direct referral of patients, prescribing medications and ordering diagnostic investigations in both an autonomous and collaborative context (ANMC 2009, p. 4).² The first nurse practitioner was authorised in New South Wales in 2000; to date eight States and Territories in Australia have nurse practitioners. All States in Australia now have legislation protecting the title of nurse practitioner and their associated extended practice privileges.

The Australian Nurse Practitioner Project (AUSPRAC) was a three-phased project designed to inform Government, health service managers and clinicians on the status of the nurse practitioner service in Australia. The project aimed to address the dearth of information about authorised nurse practitioners and their practice in Australia.³ Phase One of AUSPRAC comprised two national surveys, the first of which was undertaken in late 2007 and was the first national census exploring the demography, scope of practice and barriers to nurse practitioner service throughout Australia.^4,5 The second phase involved undertaking work sampling and case studies to investigate the intersection of the nurse practitioner role in the healthcare team and examine work patterns.^6,7 Phase three of the study has examined patient outcomes after nurse practitioner intervention.

Key findings arising from the first national census of nurse practitioners highlighted the under-utilisation of authorised nurse practitioners in the healthcare workforce and, in particular, the under-utilisation of their advanced practiced skills for their patients. Less than three-quarters of authorised nurse practitioners (72.0%) were employed as nurse practitioners; older authorised nurse practitioners were significantly less likely to be employed compared to their younger colleagues and the majority (81.2%) of authorised nurse practitioners were employed in metropolitan areas. It was unclear from the census why 28% of authorised nurse practitioners were not working as nurse practitioners. However, results in general suggested a squandering of a highly experienced and expensive -to-train sector of the Australian healthcare workforce.⁴

In 2007, employed nurse practitioners considered their practice to be extremely limited by not having access to a Medicare Benefits Scheme provider number (78%) and not having access to rebates for medications under the Pharmaceutical Benefits Scheme (71%). Despite having State authority to autonomously prescribe medications and order diagnostic tests (within their defined scope of practice), without participation in these federal schemes, the cost to the patient can be very expensive and may have limited the nurse practitioner prescribing medications or ordering tests.⁴ This suggested their capacity to care for patients to the full extent of the nurse practitioner role as defined by legislation may have been seriously compromised.

In 2008, the newly elected federal Labor Government established the National Health and Hospitals Reform Commission (NHHRC) to review Australia’s healthcare delivery systems. The aim of the NHHRC was to ‘develop a long-term health reform plan for Australia’.⁸ The NHHRC report was released in June 2009 and consisted of 123 recommendations; two of which concerned the practice and regulation of nurse practitioners. First, the NHHRC supported national registration for healthcare professions (including nurse practitioners), replacing regulation and legislation at the State level. The NHHRC saw this as leading to more nationally consistent standard of practices. Second, and more importantly, the NHHRC recommended that Medicare rebates and PBS subsidies should apply to nurse practitioners consistent with their defined scopes of practice. To access these benefits, the NHHRC recommended nurse practitioners demonstrate they work in collaborative team models of care with general practitioners, specialists or obstetricians (NHHRC, June 2009).⁸

The Health Legislation (Midwives and Nurse Practitioners) Bill 2009 was introduced to Federal Parliament for consideration in the same month the NHHRC report was released.⁹ This Bill aimed to act on the NHHRC recommendations enabling nurse practitioners access to Medicare rebates and Pharmaceutical Benefits Scheme (PBS) subsidies. Given that lack of access to these schemes were identified as significant limitations to their practice by nurse practitioners in the first national census, the proposed legislation will be particularly welcomed and relevant.⁴ This Bill was passed by the Senate on the 16 March 2010 with amendments that specified nurse practitioners are required to demonstrate collaborative arrangements with medical practitioners in order to access the new proposed arrangements.¹⁰

This paper reports results from a repeat of the 2007 national nurse practitioner census undertaken in 2009 as part of the AUSPRAC suite of studies. The second national census aimed to profile nurse practitioners and their practice in Australia in 2009 and to descriptively compare these to the data from 2007.

The second national census was conducted from May 2009 to July 2009. All Australian nurse practitioners who were authorised to practice in Australia at that time were eligible to participate. As in the 2007 survey,⁴ the registering authorities were asked to distribute the survey package on behalf of the researchers. The population numbers were obtained separately from each Australian nurse registering authority and used to calculate the study response rate. In South Australia, the registering authority were unable to distribute the surveys on behalf of the researchers, hence nurse practitioners in South Australia were recruited by advertisements placed on the Australian College of Nurse Practitioners website and by word-of-mouth (Snowballing technique).¹¹ Interested nurse practitioners from South Australia then contacted the researchers to request a survey package.

The initial survey package contained a covering letter explaining the purpose of the study, a plain language statement, a copy of the questionnaire and a reply-paid envelope. The second survey package contained reminder letters and were sent 14 days after the initial survey. The third survey packages were sent 14 days after the reminder letters.

Ethical approval was granted by Queensland University of Technology, James Cook University and the Australian Catholic University.

Our study used the instrument developed and previously described in full in the first national census.⁴ Some minor changes to six items in the original 2007 questionnaire were made to aid clarity as a result of the unanticipated responses during the first census. These changes have been described elsewhere.⁶

In brief, the 14-page, self-administered questionnaire first requested demographic data, which were based on the Nursing and Midwifery Labour Force Census conducted annually by each State and Territory nurse registering authority (9 questions).¹² Next, nurse practitioners were asked about general nurse registration and nurse practitioner authorisation (9 questions). Following this, we examined the nurse practitioner employment profile asking about their principal place of work, clinical fields and time spent on role responsibilities (16 questions). Next, we requested information about nurse practitioner’s clinical practice, specifically, whether practice was determined by protocols; nurse practitioner referral patterns, the diagnostic tests ordered, whether they had hospital admission and discharge privileges and their arrangements for professional indemnity insurance (12 questions). Finally, using a seven-point Likert scale ranging from ‘not at all limiting’ to ‘extremely limiting’, we examined limitations to current practice (8 questions).

Data were analysed using SPSS 17.0 (SPSS Inc., Chicago, IL). Frequencies were calculated for key variables to examine the current profile of nurse practitioners. As a sub-group of nurse practitioners completed both 2009 and 2007 survey, significance testing to evaluate changes over time and thus treating these results as independent samples, was precluded.

There were 408 questionnaires distributed to nurse practitioners in the current study. Of these, 24 were returned to sender. Questionnaires were received from 293 participants, resulting in a response rate of 76.3%. Approximately half the participants in the current survey (n = 149, 50.9%) entered the study in 2009 and did not participate in the 2007 census.

There were 202 nurse practitioners who participated in the 2007 census. Of these, 144 (71.3%) also completed the current survey. Of those who completed the 2007 census, there was no statistical difference between responders and non-responders to the 2009 census for age, sex, years since becoming a registered nurse, years authorised as a nurse practitioner, whether they had worked as a nurse practitioner in the previous week or pathway to authorisation. However, a statistically significant difference was found for State of residence (χ²₃ = 10.38, P = 0.016) and State first authorised as a nurse practitioner (χ²₃ = 9.96, P = 0.019). Specifically, 58% (n = 11) of 2007 survey participants from South Australia did not respond to the second survey, which was more than twice the attrition rate demonstrated in any other State; however, the absolute numbers involved were small.

The majority of participants were female (n = 232, 81.4%). The mean age of participants was 47.3 years of age (s.d. = 8.1) with 37.7% (n = 107) aged over 50. Approximately one-third of nurse practitioners resided in NSW (n = 88, 30.8%), with Western Australia (n = 66, 23.1%) and Queensland (n = 66, 23.1%) the next most common States in which nurse practitioners resided. In contrast to 2007, there was nurse practitioner representation from the Northern Territory (n = 6, 2.1%). Almost two-thirds of the total 2009 participants were employed in a metropolitan area (n = 133, 64.3%); however, this was a decrease from 2007 in which 81.8% (n = 117) of participants reported working in a metropolitan area (Table 1). Thirteen participants (6.4%) reported being authorised in two States.

Table 1.  Nurse practitioner demographics and authorisation

Participating nurse practitioners had worked a mean of 22.5 years (s.d. = 8.2) as a registered nurse or nurse practitioner (in comparison an average of 22.3 years (s.d. = 8.0) in 2007).

Participants had worked as a nurse practitioner for a mean of 25.5 (s.d. = 20.3) months. This is an increase from 2007 where nurse practitioners reported they had worked a mean of 16.0 months (s.d. = 18.3).

In 2009, 71.5% (n = 208) of participants were employed as a nurse practitioner; this percentage was similar to that in 2007 (n = 145, 71.8%). Of those employed as a nurse practitioner, 72.6% (n = 151) worked full-time in their nurse practitioner role and 11.1% (n = 23) worked in a dual role. Again, of those who were employed as a nurse practitioner, the majority (n = 190, 91.3%) reported that their principal nurse practitioner job was a permanent position, whereas 6.3% (n = 13) were employed on a contractual basis. Participants belonged to a median of three professional organisations with 5.6% (n = 16) reporting that they were not a member of any professional organisation.

All further results relate to those nurse practitioners who were employed as such (n = 208). As in 2007, the most highly reported nurse practitioner clinical speciality was emergency (n = 63, 30.3%), followed by renal (n = 13, 6.3%), and then, jointly, mental health (n = 12, 5.8%), continence, women’s health and urology (n = 12, 5.8%), and community and primary health (n = 12, 5.8%). The largest increases in nurse practitioner speciality were in community and primary health (2007: n = 5, 3.4%; 2009: n = 12, 5.8%) and aged care and rehabilitation health (2007: n = 5, 3.4%; 2009: n = 11, 5.3%) (Table 2).

Table 2.  Clinical fields for those currently working as a nurse practitioner
Where percentages do no equal 100%, numbers were rounded

The median percent of time participants spent delivering direct patient care was 67.5%. This was followed by administration and management (median time 10.0%), education of patients (median time 5.0%), education of nurses (median time 5.0%), and education of medical and allied health colleagues (median time 4.0%). Worryingly, nurse practitioners reported that only 1.5% of their time was spent undertaking research (Table 3).

Table 3.  Patterns of clinical practice

There were minimal changes to the test ordering behaviour from 2007 and 2009. The majority of nurse practitioners reported ordering biochemistry (n = 190, 93.1%), haematology (n = 190, 93.1%), microbiology (n = 174, 85.3%), radiography (n = 173, 84.8%) and ultrasound tests (n = 140, 68.6%) (Table 3). Almost all nurse practitioners reported referring clients to allied health services (n = 200, 97.6%), whereas 83.4% (n = 171) reported referring to general practitioners and 86.3% (n = 177) to other specialists within their own health service. Referral to specialists outside their own health service was lower (n = 99, 42.5%) (Table 3).

Less than one-fifth of nurse practitioners reported having admission privileges (n = 37, 18.4%) although this was a slight increase from the 2007 data (n = 16, 11.0%). Almost one-third reported having discharge privileges (n = 64, 32.2%), compared to 29.4% (n = 42) in 2007 (Table 3).

Approximately 20% of participants were still waiting on approval for some or all of their clinical protocols (n = 46, 22.8%) compared to n = 34 (24.3%) in 2007, whereas almost one-third reported working under clinical protocols but still awaiting approval to prescribe (n = 55, 27.9%) compared to 30.4% (n = 42) in 2007) (Table 3).

The majority of participants reported that they considered the barriers of ‘no Medicare provider number’ (n = 182, 91.0%) and ‘no authority to prescribe medications through the Pharmaceutical Benefits Scheme’ (n = 182, 89.6%) as ‘limiting’ or ‘extremely limiting’ to their practice. Over two-thirds regarded ‘lack of legislative support’ (n = 155, 77.5%) and ‘no authority to issue workers compensation certificates’ (n = 121, 62.1%) as ‘limiting’ or ‘extremely limiting’ to their practice. Over half of participants identified ‘lack of organisational support’ (n = 105, 52.2%), and, more specifically, ‘lack of support from within the nursing profession’ (n = 117, 58.2%) as ‘limiting’ or ‘extremely limiting’ to their practice. Less than half of participants reported ‘no authority to issue sick certificates’ (n = 79, 43.1%) and ‘limits set by professional indemnity insurance’ (n = 70, 38.6%) as ‘limiting’ and ‘extremely limiting’ to their practice (Table 4).

Table 4.  Limitations and enablers for practicing nurse practitioners
Where percentages do no equal 100%, numbers were rounded

The results of the present census of Australian nurse practitioners provide valuable information on the development and utilisation of this innovative healthcare model in the unique context of the Australian healthcare infrastructure. Internationally, the lack of uniformity in nurse practitioner models of care and clinical and statutory protocols has inhibited comparative research between the countries who have ostensibly implemented this role.³ Emergency remains the most common clinical field in which Australian nurse practitioners are employed (n = 63, 30.3%), which clearly differentiates the Australian model from the family practice role most common in the United States and Canada.¹³

The increasing number of nurse practitioners receiving authorisation through the completion of a degree suggests a more clearly defined pathway to becoming a nurse practitioner in Australia. This is important to the sustainability of the nurse practitioner work force in terms of accessibility and uniformity of qualification and authorisation, considering 37.7% of nurse practitioners who responded to the census were over 50 years of age.

Alarmingly, 22.8% (n = 46) of participants were waiting on approval for some or all of their clinical protocols. Although this represents a small decrease from 24.3% (n = 34) of participants in 2007, this is nonetheless indicative of the underutilisation of nurse practitioners and the bureaucratic barriers constraining nurse practitioner practice.

A slightly increased proportion of nurse practitioners appear to have admission privileges (n = 16, 11.0% in 2007 to n = 37, 18.4% in 2009) and discharge privileges (n = 42, 29.4% in 2007 to n = 64, 32.2% in 2009), although in absolute terms these numbers remain low. Although this is an improving trend, more nurse practitioners require this authority if the role is to be utilised to its optimal potential in promoting the efficiency of patient treatment and discharge within the already overburdened Australian healthcare system.

Task allocations, patterns of referral and test ordering behaviour demonstrated minimal changes, however, as these are inherently linked with the nurse practitioner clinical practice areas these are likely to change depending on how fast the nurse practitioner role expands within specific services. Notably, participants spent a median of 1.5% of their time undertaking research. Although this is a small improvement from 2007 in which participants reported spending no time on research, nurse practitioners represent the most senior nursing clinician role and the nursing profession must support and encourage them to undertake research.

Although in absolute terms there was a decrease in nurse practitioners’ perception of barriers as ‘limiting’ and ‘extremely limiting’ from 2007 to 2009 including lack of authority to prescribe through the PBS (n = 131, 92.2% in 2007, n = 182, 89.6% in 2009), lack of Medicare provider number (n = 133, 93.0% in 2007, n = 182, 91.0% in 2009) and lack of legislative support (n = 120, 83.3% in 2007, n = 155, 77.5% in 2009), the number of nurse practitioners rating these as ‘limiting’ and ‘extremely limiting’ remains unacceptably high. How these data may change following the introduction of the Health Legislation Amendment (Midwives and Nurse Practitioners) Act 2010 (Cth), anticipated in late 2010, requires future research on patterns of practice and nurse practitioner’s perceived limitations of practice, especially considering 89.6% of participants considered a lack of legislative support as ‘limiting’ or ‘extremely limiting’ to their practice. Of major concern is a perceived lack of support within nurse practitioner’s own organisation and also from within the nursing profession itself, with over half of participants describing both these factors as ‘limiting’ or ‘extremely limiting’ or to their practice. This is worrying both in terms of the development and evolution of the nurse practitioner role of a cohesive workforce without adequate internal and external professional support. Further, it is uncertain how the ‘collaborative arrangements’ mandated in the new legislation will be operationalised and whether or not, once implemented, how they will enhance or constrain the practice of the nurse practitioner. This amendment received criticism from the Australian College of Nurse Practitioners whose president at the time stated ‘the AMA and all stakeholders will need to ensure that their approach is truly collaborative and not an exclusionary or gatekeeping role’.¹⁴

The substantial difference in response rate and attrition rate demonstrated in South Australia, where the Nursing and Midwifery Board of South Australia were unable to assist with survey distribution, reflects the difficulties of reaching populations without the assistance of the relevant regulatory body. This highlights the importance of collaboration between research and regulatory organisations in obtaining a robust sample of the relevant population for a census such as this.

The role of the nurse practitioner in Australia is still developing and it is important that it is researched and critically evaluated in this formative stage to ensure the efficacy and sustainability of the clinical role, adequate professional and political support and to obtain optimal outcomes for healthcare consumers. In particular it will be important to follow the potential changes to practice resulting from access for nurse practitioners to MBS and PBS provider numbers. The stable employment status of NPs without these privileges, as documented from our two surveys, provides a strong baseline for continuing research on a national level, including a repeat census at a later date.

The authors declare that no conflicts of interest exist.