Advanced Practice Nursing: A title, a role or level of practice?

Australia is preparing for an ambitious and inclusive study into advanced practice nursing and midwifery.

Nurses and midwives currently working in the Australian health system know about the confusion surrounding the title of advanced practice nursing and that the meaning of advanced practice is ambiguous. The many definitions that are offered reflect elements of advanced practice nursing but are not drawn from robust research that takes the question of what is advanced practice to the Australian nursing and midwifery population.

The problem is particularly relevant for nurses working in primary health care where practice by necessity often draws on advanced skills and knowledge but there is no mechanism or framework available for nurses to demonstrate their advanced level of practice.

One advanced practice role that does have certainty, definition and evidence-based standards is the nurse practitioner. This is a specific level and type of practice that is protected and defined by a legislative and practice framework. But this role differs in many ways from other advanced practice roles particularly in the practice scope that is outside the registered nurse scope of practice.

The challenge now is to break the nexus between advanced practice and specific nursing/midwifery roles and titles. Early in 2014 there will be a national survey of all Australian registered nurses and midwives. This survey will achieve two objectives:

i. To map the titles and roles of advanced practice nursing across the eight Australian states and territories, and
ii. To delineate advanced practice from the foundation practice of the registered nurse/midwife and the advanced extended practice of the nurse practitioner.

This planned survey is essential for Australian nursing and midwifery to achieve clarity for the professions and the health industry relating to the service capability of different levels of practice. It also has implications for nursing and midwifery clinicians in career planning and postgraduate education options.

The national census will allow every nurse and midwife in Australia the opportunity to participate in this defining research. There will be further information about the survey in the new year through the Primary Times and other publications. Meanwhile, if you would like more information about the survey you can contact Glenn Gardner by emailing ge.gardner@qut.edu.au or Christine Duffield by emailing christine.duffield@uts.edu.au.

Tell us what you think: Self education expenses, Medicare Locals and PNIP

APNA is keen to hear your experiences and get your input on key issues we are currently raising with the Federal Government.

Please help us to provide a strong voice for you, and send your input to editor@apna.asn.au.

1. Proposed tax on self-education expenses

The Federal Government is proposing to put a $2000 annual cap on the amount a person can claim back through their tax, against their self-education expenses. This includes things like conference registration fees, travel and accommodation to attend conferences, CPD registration fees, the costs of undertaking university courses, etc. Previously there has been no limit on the amount that could be claimed back against out-of-pocket expenses on these kinds of activities. Medical groups are lobbying strongly against the cap.

We are concerned about the unintended consequences that this proposed

$2000 cap could have on nurses who are bearing their own costs for undertaking postgraduate courses, for upskilling through certificate courses or other professional development programs, or for attending conferences.

The government has put out a consultation paper and APNA is preparing input into a submission to the government on these issues.

We would like to hear from any members who believe the proposed cap will present a barrier to their education and professional development. If you can give us details of the impact the cap would have on you (or other nurses), and any ideas you have about what alternative approach should be taken. This will be really helpful in putting together our case.

2. Your experience with Medicare Locals

APNA has been asked to provide input into the national evaluation of Medicare Locals which is being undertaken by Ernst and Young along with the University of NSW and Monash University. We’re very keen to have input from our members around the country, on the following questions:

  • Can you please tell us about your relationship with your Medicare Local?
  • What are you looking for from your Medicare Local, and what do you think you can achieve by engaging with your Medicare Local?
  • What is helping to make this relationship work well, or hindering it from working well?
  • How would you like to see your relationship with your Medicare Local develop in the future?
  • Do you think your Medicare Local is making a difference, and in what ways?
  • In what ways do you think Medicare Locals are different from the former Divisions of General Practice, and what do you think Medicare Locals can achieve that Divisions did not?
  • What will be needed for Medicare Locals to be effective and sustainable primary health care organisations?
  • What do you think about the name “Medicare Local”?

3. Practice Nurse Incentive Program (PNIP)

As outlined in the current issue of Primary Times, we’ve been hearing a range of feedback from members about the impact the PNIP is having in their practices. The government is very keen to know more about what’s happening on the ground, and we’re keen to provide good information to help shape future funding arrangements for nursing in general practice.

Could you please send us your stories about PNIP and what it has meant for your practice. We need to hear from you whether your experience has been positive, or negative, or if you have seen no change at all we are keen to know that too.

What you had to say…

We had a strong response to this email and your feedback has been collected and de-identified for APNA to use for advocacy purposes. Please note responses are unedited and appear as written.

Click to read your feedback about:

  • Your experience of Medicare Locals
  • Practice Nurse Incentive Program (PNIP)
  • Proposed tax on self-education expenses

Ear syringing

APNA receives many queries from primary health care nurses about the performance of ear irrigation procedures. Among the most common questions received are:

  • Do I have to be accredited to perform ear irrigation?
  • How do I become accredited in ear irrigation?
  • What do I do when my practice manager has told me I am not covered by the practice insurance to perform this procedure yet the doctors still want me to perform it?
  • Does my PI insurance cover me if something goes wrong when I perform this procedure?

As nurses working in primary health care, we are accountable and responsible for the care we provide. Ultimately, it is our role to certify quality and safety in every task we perform, ensuring the best possible outcome for our patients and for ourselves.

Ear syringing is a good example of an activity in which we need to make a professional judgement. The risks and pitfalls of ear irrigation are many and this is evidenced by the number of medico-legal cases which arise. The ratio of litigation is 1:1000.

Complications and No. of cases
Failure to examine ear prior 5
Excessive pressure 26
Faulty equipment 26
Poor technique 43
Complication Ratio — MDU (Medical Defence Union (UK) Medico legal aspects related to ear syringing).

To meet this professional obligation, nurses who irrigate ears need to be able to demonstrate that they have:

  1. Undertaken ear irrigation in the presence of a mentor or suitably qualified clinician who can confirm the technique, which is sound, best practice, quality and safe. How do you verify you are providing patients with a safe and quality service.
  2. A checklist of the issues that need to be covered in patient history taking and examination.
  3. A protocol for the use of softening agents.
  4. A procedure for checking equipment — to ensure it is in working order at the point of use.
  5. A written procedure for ear irrigation that is evidence-based, current and provides safeguards to the known risks of ear irrigation.
  6. A post-procedure information sheet for patients.
  7. Professional indemnity insurance that covers this activity.

Thinking of ear irrigation as a combination of good skills and knowledge, a safe work system and patient involvement can assist nurses to generalise these questions and put these into practice when other areas of clinical complexity arise. The individual nurse must determine whether performing this procedure is within their scope of practice, according to and provided they can demonstrate the conditions above.

This article was originally published in APNA’s journal magazine Primary Times in September 2011 (page 4) – click here to view the issue online.

Getting your voices heard

One of the most important roles for APNA is listening to what our members have to say, and taking your issues forward to decision makers, including those in Federal Government.

We recently called for input from members on three key issues: how the Practice Nurse Incentive Program (PNIP) has affected your practice; what level of support you are getting from Medicare Locals; and how the proposed $2000 per annum cap on tax deductibility for self-education expenses would affect your continuing professional development.

We received some really interesting and informative input from APNA members on all of these issues. We provided these responses, in de-identified format, to the APNA Board, and also published them on our website earlier this month. In addition to keeping APNA management and Board informed of your issues, your input is being used to influence policy more broadly. I wanted to take this opportunity to let you know what we’ve done with your input so far…

Keep reading APNA CEO Kathy Bell’s message.

Supervision – Enrolled Nurses

What has your experience been?

Supervision is an element of the code of practice of the profession. The prevailing principle is that you have a duty to supervise – this is a broad obligation to the training nurse as well as to the community.

The GP can observe but not supervise an EN. This is according to the regulatory requirements of the EN’s training. Nursing and general practice are two different professions which adhere to separate regulations.

The EN must be supervised directly or indirectly by an RN. Indirect supervision is when the RN is easily contactable but does not directly observe the activities of the EN. The RN may be offsite but must be available for regular, direct communication with the EN. The absence of proximity requires robust processes to be in place for the direction, guidance, support and monitoring of the EN’s activities. While an EN is responsible for their actions, the RN is accountable.

As such, you may be the supervising RN even if you are not on the premises. Or you may have a nurse in another practice working at the same time as the EN in your practice, however, this supervising nurse would need an understanding of the capabilities of the EN they are supervising.

When the EN is carrying out tasks under supervision of a nurse, the task must come under the scope of practice of the supervisor to ensure those tasks are carried out safely. If you are not able to perform a certain task, how can you supervise the EN to perform that task? Do you have competencies in the field to intervene if the EN is about to cause harm? As an RN you are required to determine the EN’s scope of practice.

If you are uncomfortable that the EN is working without supervision of an RN you should make this clear to your employer. It is also useful to have a written record of the arrangement.

APNA recommends that EN’s work under direct RN supervision, but acknowledges in some circumstances this may be the only option. The practice must ensure that patient safety is not compromised and the medico-legal risk of the practice is not increased.

  • What are your thoughts about this information?
  • Have you felt pressure, or have you been put in a situation that you have not felt comfortable about?
  •  Do you have any advice for nurses on how to facilitate EN supervision requirements?

What you had to say…

 

17 February 2014

As primary health care nurses we work daily with clients who are struggling with chronic disease and the impact it has on their health, their life and family. How often do we find many are also struggling with comorbidity of mental illness? APNA has been a member of the expert advisory group brought together by the Australian College of Mental Health Nurses (ACMHN) to develop learning resources to maximise health outcomes and improve the patient journey for people with chronic disease by improving the knowledge and skills of nurses to identify and manage mental health conditions associated with chronic disease.

Many physical health conditions increase the risk of mental illness, while poor mental health is known to increase the risk of diseases such as heart disease, stroke and cancer. Comorbidity of physical illness and mental health issues impacts on whether people seek help, diagnosis and treatment, and impacts on their physical and mental recovery. Good mental health is a protective factor in prevention and self-management of chronic disease.

To address the issue of unacceptably poorer health outcomes of people with chronic disease and the associated mental illnesses, nurses and midwives need to have the knowledge and skills to identify manage and refer their patients.

The Australian College of Mental Health Nurses has released a series of online resources aimed at improving the knowledge and skills of nurses to identify and manage mental health conditions associated with chronic disease.

No Health without Mental Health: the link between chronic disease and mental illness
A series of webinars on chronic disease and mental health will complement these learning resources. The first webinar features APNA Vice President Karen Booth.

Chronic Obstructive Pulmonary Disease and Mental Health Webinar
Monday 3 March 7:15-8:30pm AEDT

Improve how you identify and manage mental health conditions associated with chronic obstructive pulmonary disease by joining nursing professionals from across the country to participate in a free live webinar broadcast. The webinar is exclusively for nurses and will feature a facilitated panel discussion of a case study. Find out more here.

As always your thoughts are very welcome at president@apna.asn.au.

3 February 2014

In November 2013 APNA joined the National Asthma Council (NAC) Australia as a member body and member of the board. The other member bodies are the Royal Australian College of General Practitioners, the Pharmaceutical Society of Australia, the Australasian Society of Clinical Immunology and Allergy.

APNA’s Board believes involvement with the NAC is a natural fit, given the critical role that nurses fulfil in primary health care in Australia. APNA is pleased to formalise our relationship with the National Asthma Council Australia, and welcomes the opportunity for increased communication, collaboration and cooperation with our fellow health professions in ensuring the best possible care for people with asthma.

The NAC is a not-for-profit organisation working to improve health outcomes and quality of life for people with asthma.

As the national authority on asthma, the National Asthma Council Australia’s ongoing priorities are to:

  • provide the latest information on asthma to health professionals to help improve their quality of care
  • gather, analyse and share information on asthma
  • work with all members of the asthma community, including people with asthma and their carers, health professionals, patient support organisations, the health industry, and government agencies
  • continue to set the standard for best-practice asthma management

As primary health care nurses and in my case as a nurse working in general practice, many of us refer often to the NAC Asthma Management Handbook 2006. This publication is the NAC flagship publication and forms the foundation of all NAC resources. First published in 1989 and now in its sixth edition, the Asthma Management Handbook continues to set the standard for best practice asthma management in Australia.

The Asthma Management Handbook aims to be both comprehensive and user-friendly. While written primarily for general practitioners and community pharmacists, the Handbook emphasises a team approach to asthma care.

The NAC are currently hard at work finalising the new edition, which will be published in early 2014, and APNA will be actively involved in the launch and ensuring our members have access to this much anticipated and exciting new resource.

For further information see:

Media Release: Primary health care nurses join National Asthma Council

National Asthma Council Australia

As always your thoughts are very welcome at president@apna.asn.au