Elizabeth Adams

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Collaboration and Partnership
Elizabeth Adams
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Objectives

• Overview
• Office of the Chief Nursing Officer
• Policy Development
• Background - Nurse Practitioner project
• Definition/Core Concepts/Principles
• Overview of the Legislation
• Registration
• Education/Sponsorship
• Designation process
• Next Steps

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Australia - National View

• Australian Capital Territory
• New South Wales
• Northern Territory
• Queensland
• South Australia
• Tasmania
• Victoria
• Western Australia

Health care divided between Australian Gov.
and States Territories Gov. 8 Nurses
Boards 30 Acts related to regulation of nursing
practice 1992 ANMC - National body
Australia Nurses per 100,000 population 1,176
(WA 1,137)
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AustralianNursing and Midwifery Profile

• 260,075 registered and enrolled nurses
• Predominantly female 7.3 male (19,085)
• Average age 42.2 years
• Part-time 53.7
• 1,024 FTE nurses per 100,000

National Health Labour Force 2002
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Number of Nurses Midwives
4,284 Northern Territory
42,420 Queensland
29,408 Western Australia
91,590 New South Wales
4,438 Australian Capital Territory
24,391 South Australia
68,923 Victoria
5,863 Tasmania
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Western Australia
Southern Hemisphere 1/3 total landmass of
Australia Land mass of more than 2.5 million sq
km (1,000,000sq miles) Nearly the size of India
yet lt half percent of the population Indigenous
65,000 years (2.4 pop) Discovered - Dutch
1616 1st settlements Europeans/British
1820s Population 1,927,000
Australian Bureau of Statistics (2002)
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Western Australia
12,500 kilometres of coastline
West - Indian Ocean North - Timor Sea South -
Southern Ocean
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Perth
- Most isolated city in the world - Swan
River - flow into the Indian Ocean (6 miles) -
Closer to Southeast Asia than other Australian
city - 73 of the states population
Australian Bureau of Statistics (2002)
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Perth is approx 4500 kilometres by road or 4
hours by air to the east cost capitals
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Nursing and Midwifery Leadership
21st Century - recognised as a key to the daily
challenges of balancing competing demands of
cost-effectiveness, quality improvement
recruiting and retaining a professional
competent dynamic workforce (Stordeur,
Vandenberghe DHoore 2000)

• Profession challenged by
• Global shortage
• Epidemics - SARS, HIV/AIDS
• Bio-terrorism

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Leadership in the USA

• Non-clinical administrators have increased in
  number proportion of costs (Kramer 1998)
• Current structures nurse executives have limited
  responsibility for human financial resources to
  ensure quality (Duffield OBrien-Pallas 2002,
  Aiken et al, 2001, Fagan 2001)

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Organisational Trust

• Loss of trust in hospital administration is
  widespread and stems in part from a perception
  that initiatives have emphasised efficiency over
  patient safety (Institute of Medicine of the
  National Academes, 2004)
• Restructuring results in
• poorer patient outcomes
• loss of trust loyalty
• decreased job satisfaction
• increased turnover (Sovie 1998, Beyers 2000,
  Fagan 2001, Duffield 2004)

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Australia
Nursing leadership has been identified as one of
the critical elements in ensuring safe outcomes
for patients

• Government - ensure improved representation of
  nurses on bodies - health education
• Development of nurse leaders
• Involvement in policy development implementation

Recommendation 36
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Nursing Leadership Strategy Map
THE VISION To strategically position
the nursing profession in order to ensure quality
nursing care to the community of Western
Australia

• ACTION STRATEGIES
• Making nursing a
• profession of choice
• Increasing the
• recognition and value of
• nursing
• Investment in attraction,
• retention and
• development of nurses

Nursing Leadership Strategy
FOSTERING WORKFORCE DEVELOPMENT
DEVELOPING PROFESSIONAL STANDARDS
IMPROVING PROFESSIONAL DEVELOPMENT
BUILDING LEADERSHIP
ENHANCING PROFESSIONAL PRACTICE
Empowering the Nursing Profession
Leadership, Workforce Development, Professional
Practice
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Office of the Chief Nursing Officer
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Human Factors Policy Development Legislation Key
Stakeholders
Health Reform Client Health Improved
Workplaces Education Research Informed Nurses
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Australian Policy Cycle
Policy Analyses
Evaluation
Policy Instrument
Consultation Coordination
Decision
Implementation
Electoral Cycle
Bridgman and Davis (1998)
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Recruitment

• Degree program over 30 years
• 2004 2,773 applicants for 741
• Cost - 15,000
• Highest entrance score in Australia

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Marketing
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On-line application for graduate nursing
position in the Public Health System

• 2004
• 23 hospitals sites
• 632 applicants
• 475 places

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Re-enter Re-fresh Re-join

• Commenced May 2002
• 620 nurses and midwives completed to date
• 1,346 additional nurses and midwives in the
  system (9,428 PHS)
• 2004 2005 12 refresher, 8 renewal registration
  courses

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Enhanced Role of the Midwife

• Working outside their
• scope of practice
• Tender to develop
• deliver a course
• initiate medications
• order routine pathology
• diagnostic tests
• Legislative changes
• Three pilot sites

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Improving working lives and opportunities for
nurses
Aim to reduce the reliance on agency nursing
(commenced June 2003) Central coordination for
the supply of temporary nurses between hospitals
and agencies Market testing - selecting agency
staff on price and quality Saved 25 million
2003/2004 (55 million) Recruited 239 nurses and
midwives 204 FTE decrease in agency use Panel
contract established in 2004
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New South Wales
1992 Working Party 1993 Ten pilots 1999
Legislation 2000 Six broad areas (NB) 2000 Master
courses X2 2001 NP appointed 2003 Roles
expanded 2004 35 authorised
Nurses per 100,000 population 1,078
National Health Labour Force (2002)
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South Australia
1996 Advisory Committee 1999 Report 2002 First NP
authorised 2004 Prescribing model 2004 5
authorised
Nurses per 100,000 population1,394
National Health Labour Force (2002)
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Victoria
1998 Taskforce -11 models 2000 Report 2001
Implementation Advisory Committee
18 models 2001 Legislation 2003 5 demo
projects 2004 Masters NB -15 applicants
Nurses per 100,000 population 1,328
National Health Labour Force (2002)
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Australian Capital Territory
1999 Steering Committee trial 4 service
models 2003 Masters approved 2004 Registration
policy 2004 Legislation
Nurses per 100,000 population1,175
National Health Labour Force (2002)
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Other States
Northern Territory 2004 NP project to be
developed within 2yrs Nurses per 100,000
population 1,055
Queensland 2002 Rural Legislation 2003 Trial 4
sites 2004 Report Nurses per 100,000 population
1,083
Tasmania 2004 Inaugural meeting NP Scoping
Project Nurses per 100,000 population 1,208
National Health Labour Force (2002)
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Why?
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Background Nurse Practitioner in Western
Australia

• 1998 Establishment of the Nurse Practitioner
  Steering Committee
• 1999 Development of the Nurse Practitioner
  Framework
• 2000 Nurse Practitioner Report
• 2001 Launch of Phase 2 Legislative process
• 2002 Nurses Amendment Bill 2002

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Western Australian Definition

• A nurse practitioner is a nurse registered with
  the Nurses Board of Western Australia and has the
  legislative authority for their advanced scope of
  nursing practice in a designated area
• (Della 2003)

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Core Concepts
Autonomy in Clinical Practice
Expert Practitioner
Core Concepts
Professional Clinical Leadership
Researcher
National Council for the Professional Development
of Nursing Midwifery, Ireland (2001)
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Five Principles Three Levels
Strategic Policy DOH - Office of the Chief
Nursing Officer Mid Level Policy Health
Service/Organisation Operational Policy Nurse
Practitioner
Quality
Equity
Client focused
Accountability
Consistency
Office of the Chief Nursing Officer, Department
of Health Western Australia (2003)
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Legislative Process

• November 2002 Nurses Amendment Bill introduced
  in the Legislative Assembly (55 Clauses)
• 20th March 2003 Nurses Amendment Bill passed in
  the Legislative Council
• 9th April 2003 Nurses Amendment Act 2003 came
  into effect
• 2004 Nurse Practitioner Code of Practice

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Legislation Nurses Amendment Act 2003

• Nurses Act 1992
• Medical Act 1894
• Misuse of Drugs Act 1981
• Pharmacy Act 1964
• Poisons Act 1964
• Poisons Regulations 1965
• Radiation Safety Act 1975
• Road Traffic Act 1974

State Law Publisher www.slp.wa.gov
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Legislation

• Nurses Amendment Act 2003
• Nurses Act 1992
• Medical Act 1894
• Misuse of Drugs Act 1981
• Pharmacy Act 1964
• Poisons Act 1964
• Poisons Regulations 1965
• Radiation Safety Act 1975
• Road Traffic Act 1974

Registration Accreditation of education
program Professional standards Protection of title
State Law Publisher www.slp.wa.gov
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Legislation

• Nurses Amendment Act 2003
• Nurses Act 1992
• Medical Act 1894
• Misuse of Drugs Act 1981
• Pharmacy Act 1964
• Poisons Act 1964
• Poisons Regulations 1965
• Radiation Safety Act 1975
• Road Traffic Act 1974

Exception for Nurse Practitioners to provide
certain services plus exception to use radium
or x-ray for diagnosis
State Law Publisher www.slp.wa.gov
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Legislation

• Nurses Amendment Act 2003
• Nurses Act 1992
• Medical Act 1894
• Misuse of Drugs Act 1981
• Pharmacy Act 1964
• Poisons Act 1964
• Poisons Regulations 1965
• Radiation Safety Act 1975
• Road Traffic Act 1974

Offence to obtain drugs by fraudulent behaviour
from Nurse Practitioners plus Defence to a charge
of procession or use of a prohibited drug if
prescribed by a Nurse Practitioner
State Law Publisher www.slp.wa.gov
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Legislation

• Nurses Amendment Act 2003
• Nurses Act 1992
• Medical Act 1894
• Misuse of Drugs Act 1981
• Pharmacy Act 1964
• Poisons Act 1964
• Poisons Regulations 1965
• Radiation Safety Act 1975
• Road Traffic Act 1974

Allows a Pharmacist to supply medication on a
Nurse Practitioners prescription
State Law Publisher www.slp.wa.gov
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Legislation

• Nurses Amendment Act 2003
• Nurses Act 1992
• Medical Act 1894
• Misuse of Drugs Act 1981
• Pharmacy Act 1964
• Poisons Act 1964
• Poisons Regulations 1965
• Radiation Safety Act 1975
• Road Traffic Act 1974

Nurse Practitioners may prescribe and supply
Schedule 1 and 4 medications Formal
administrative provision as designated area is
defined in the Poisons Act 1964
State Law Publisher www.slp.wa.gov
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Legislation

• Nurses Amendment Act 2003
• Nurses Act 1992
• Medical Act 1894
• Misuse of Drugs Act 1981
• Pharmacy Act 1964
• Poisons Act 1964
• Poisons Regulations 1965
• Radiation Safety Act 1975
• Road Traffic Act 1974

Allowed to request the holder of a licence under
the Act to undertake diagnosis or therapy
State Law Publisher www.slp.wa.gov
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Legislation

• Nurses Amendment Act 2003
• Nurses Act 1992
• Medical Act 1894
• Misuse of Drugs Act 1981
• Pharmacy Act 1964
• Poisons Act 1964
• Poisons Regulations 1965
• Radiation Safety Act 1975
• Road Traffic Act 1974

In an offence of driving under the influence of
drugs alone, it is a defence if the drugs were
prescribed by a Nurse Practitioner
State Law Publisher www.slp.wa.gov
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Nurses Amendment Act Savings and Transition
Clause

• Nurses working in designated remote area nursing
  posts during
• the past 3 years may apply for registration to
  the Nurses Board of
• Western Australia within 6 months of the
  Commencement day
• Closed on 8th October 2003
• 22 nurses applied
• To date 15 remote area nurses registered

State Law Publisher www.slp.wa.gov
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Collaborative Practice Model

• an inter-professional process for communication
  and decision-making that enables the separate and
  shared knowledge skill of care providers to
  synergyistically influence the care provided
• Parallel model - stable versus complex patients
• Sequential model - initial assessment
• Shared care model - both see patient
• Collaborative model - patient chooses or is
  assigned

Way, Jones Busing (2000)
Arcangelo et al (1996)
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Summary of changes due to theNurses Amendment
Act 2003

• Allows for Nurse Practitioners to
• Prescribe schedule 1 and 4 medications
• Order routine diagnostic imaging tests
• Order routine pathology tests
• Work in an area designated by the DGH,
• within the specific clinical protocols
• developed in collaboration and partnership

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Policy Making Process

• Incorporates scientific methodologies but relies
  on
• human judgement
• With human involvement - try for clarity, but
  often
• ambiguity and unintended consequences
• Making policy is at best a very rough process.
  Neither social scientists
• nor politicians, nor public administrators yet
  know enough about
• the social world to avoid repeated error in
  predicting the consequences
• of policy moves. A wise policy maker consequently
  expects that his
• policies will produce unanticipated consequences
  he would have
• preferred to avoid

Charles E Lindblam (1959) The Science of
Muddling Through, Public Administration Review
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Currently no access to

• Medicare Provider Number
• OR
• Access to PBS

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Nurse Practitioner Framework

• The Legislation defines two separate but
  integrated processes

Guiding Framework for the Implementation of Nurse
Practitioners in Western Australia (2003)
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Nurses Board of Western Australia
www.nbwa.org.au

• Nurses Act 1992 requires the Board to ensure that
  the
• community is adequately provided with the highest
  
• nursing standards of competence and conduct in
• nursing
• Required to act in the public interest
• Endorse professional standards

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Pathway to Registration
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Educational Programwww.curtin.edu.au

• Postgraduate diploma in clinical specialisation
  (Nurse Practitioner) at Curtin University of
  Technology (Tender 2002)
• Course offered via internal external modes
• Alternative mode of entry/ Recognition of prior
  learning
• Structure
• Professional Foundations, Diagnostics,
  Pharmacology
• Nursing Leadership, Pharmacotherapeutics
• Research and Internship
• Edith Cowan University - currently developing a
  Masters program

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Student Profile

• 5 years to 37 years experience
• PhD qualifications
• Masters level
• Bachelor of Science (Nursing) Postgraduate
  course (majority)
• 55 students
• 37 students currently sponsored by DOH
• (Government commitment to sponsor 60 nurse
• practitioners over a 3 year period)

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Diversity in Practice

• Accident and Emergency 13
  Nephrology/Renal 3
• Aged Care 2 Occupational
  Health/Safety 1
• Alcohol and Other Drugs 1
  Perioperative 1
• Cardiac Transplant 2 Public
  Health 1
• Community 1 Respiratory
  2
• Community Paediatrics 1
  Rural and Remote 10
• Continence 1 Sexual Health 1
• Diabetes education 2 Womens
  Health 1
• Forensic 1 Wound Stomal
  Therapy 4
• General Practice 2
• Haemophilia 1
• Haematology/Oncology 1
• Hepatology 2
• Mental Health 1
• Total number of enrolled students 55

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Registration Summarywww.nbwa.org.au

• Registration for 3 year period - Notify if not
  practiced
• Fee apply
• Title protected section 47 Nurses Act 1992 -
  penalty
• No authority to work independently - designated
  area
• Demonstrate competence to practice
• NBWA has disciplinary powers to suspend

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Designated Area

• Designation
• Poisons Act 1964 was amended to allow the
  Director General to
• designate areas for the purposes of authorising a
  nurse practitioner
• to possess, use and supply poisons in accordance
  with the
• regulations under the Act
• regardless if the site is public or private
• not limited to clinical specialty or geographical
  location

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Lateral Thinkingin Developing the Role

• Condition-based specific patient conditions
  mental health, diabetes, chronic disease
  management
• Population-based specific patient populations or
  geographic area
• Scope-based broad-based primary care patient
  populations

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Process for Designation

• Bottom up approach, health service must
• Demonstrate the need for a Nurse Practitioner in
  a specific area of advanced clinical practice
• Responsibility to ensure that the Nurse
  Practitioner will have access to required
  resources

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Application Requirements Business Case, Job
Description and Clinical Protocols
www.nursing.health.wa.gov.au
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Business Case Template

• Description of site evidence of need
• Partnership collaboration
• Role definition, responsibility, authority
  accountability
• Current practice expected benefits
• Outline implications of role on service
• Adopt WA Clinical Governance Framework
• Commit to audit and evaluate service
• Annual report to DGH
• Identify professional indemnity cover

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Workable Environment
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Partnership Collaboration

• Responsibility/Accountability
• Coordination
• Co-operation
• Assertiveness
• Autonomy
• Mutual Respect
• Values based upon practice
• Structure behavioural elements

Norson (1995) Way, Jones Busing (2000)
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Clinical Protocol Template

• Covers advanced practice now permitted under the
  NP legislation
• (medications, pathology and diagnostic imaging
  tests)
• National Health and Medical Research Council
• Guidelines for the Development, Implementation
  Evaluation of Clinical Practice
• Guidelines (1999) http//www.nhmrc.gov.au
• Outcome focused
• Best available quality of evidence
• Multi-disciplinary team - consumers
• Regular review
• Developed in a collaborative framework
• Clinical Protocol Panel Peer Review Panel

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Why Clinical Protocols ?

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Effect of Time on a Clinicians Performance
CLINICAL SKILLS AND JUDGEMENT
(P)
UP TO DATEKNOWLEDGE
Time following education
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Errors Adverse Events
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Error in Medicine
1991 Harvard Medical Practice Study Population
based study of injury in patients hospitalised
in the State of New York in 1984. .. ...4 of
patients suffered an event increasing their LOS
or resulting in measurable injury. . . ...for NY
state, this equaled 98,609 . . . ...nearly 14
of these injuries were fatal. . . ...If these
rates are typical in the U.S., then 180,000
people die every year as a result of injury
Leape (1994)
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Dr Spin
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Definitions
Errors are failures of planned actions to be
completed as intended, or the use of wrong plans
to achieve what is intended Adverse events are
injuries caused by medical intervention as
opposed to the health condition of the patient A
large proportion of adverse events are the result
of errors

Office of Safety and Quality in Health Care
(2004) www.health.wa.gov.au/safetyandquality/
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Human Error
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Systems Approach
The fundamental premise is that humans will make
errors in the best organisations These errors
are recognised as the consequences of problems
that predated the errors Therefore changes must
be made to the workplace and system
Office of Safety and Quality in Health Care
(2004) www.health.wa.gov.au/safetyandquality/
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• Every system is perfectly designed to achieve
  the results it gets Don Berwick

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Judgement and Flexibility
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Clinical Protocols

• Submitted as part of the designation process
  (with agreement for publication on website)
• Approved by the Director General of Health, Chief
  Nursing Officer, Chief Medical Officer
  Executive Director of Population Health
• Any alteration or amendment to the clinical
  protocol must be submitted to the DGH for approval

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Overview of Designation Process

• Identify need - demonstrate through research,
  feasibility studies, audit or needs analysis
• Develop Business Case, JDF Clinical Protocols
• Written application to DGH
• Advise in writing if approval granted or not
• Following written approval position advertised
• DGH has the power to revoke designation

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Evaluation Framework

• Clinical Governance activities that promote,
  review, measure monitor care
• into a unified coherent whole
• Office of Safety Quality in Health Care
• Priority is to develop consistent policies
  standards to enable a
• system wide framework
• Framework of four pillars
• Clinical performance evaluation
• Professional development management
• Clinical risk
• Consumer value
• www.health.wa.gov.au/safetyandquality/

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Barriers

• Physicians
• negative impact on income
• impeding recruitment and retention
• responsibility and liability concerns
• Nurse Practitioners
• skills and knowledge limitations (novice to
  expert)
• restrictions on scope
• inadequate public professional awareness
• unsupportive environments and resistance

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• Practice-based academically-referenced series
• Promote disseminate information on approaches,
  activities, theory and research relating to the
  role implementation
• Published twice a year
• Next publication April 2005

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Current Focus

• Nurse Rules
• Remote Area Nursing Posts
• Designation of areas
• Education and Registration of Nurse Practitioners
• Medicare Provider Number/PBS
• Implementation and evaluation of designated Nurse
  Practitioner sites

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Vision to Reality

• Vision is a factor in relation to the
  successful integration
• Collaborative shared vision developed in
  partnership
• encompasses common values and understanding of
  the
• mission and the desired outcomes

IBM Business Consulting Services (2003)
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• Office of the Chief Nursing Officer
• Department of Health
• Phone [phone]
• Website www.nursing.health.wa.gov.au
• Email elizabeth.adams_at_health.wa.gov.au

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Questions?
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Setting the change agenda
Professional Practice
Workforce Issues
Strategic Leadership
Professional Standards
Education
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Office of the Chief Nursing Officer
Nursing Midwifery
Professional Agenda
Industrial Agenda
Office of the Chief Nursing Officer
Current Status
Strategic Direction
Politics
Health Care Providers Agenda
Department of Health Agenda
Government Agenda