A Nurse Practitioner (NP) is a Registered Nurse with the experience and expertise to diagnose and treat people of all ages with a variety of acute or chronic health conditions. NPs have completed additional university study at Master’s degree level and are the most senior clinical nurses in our health care system.
The title “Nurse Practitioner” can only be used by a person who has been endorsed by the Nursing and Midwifery Board of Australia. Once upon a time, the opposition to their introduction from factions of the medical profession was strident and vocal. In 2020 they have ably demonstrated their worth through the NSW bushfires and their contribution during Covid-19, both in Australia and overseas. In America, longstanding legislative structural barriers to enabling the NPs to practise to full scope were overturned overnight.
The intent of introducing NPs into Australia was to address the need for high-level services to underserved groups. However, in the early days, the majority of NPs supplemented services in areas such as emergency departments, neonatal intensive care units and specialist areas, such as burns, endocrine and neurosurgery. As the role has become more established, so NPs have moved into greater numbers of primary health care roles, such as outreach into nursing homes, drug and alcohol support, mental health and nurse practitioner-led walk-in clinics.
When (albeit extremely limited) access to Medicare provider numbers was established in 2008, a small number of NPs set up in private practice, and it was at this stage the roles were able to expand to fill more of the community gaps that had been identified back in 1988, when the NP Stage One report was published. In Australia, patients choosing to see a NP for their healthcare are able to do so in every State and Territory, across both the public and private health sectors, and spanning across metropolitan to remote areas Currently, there are 2,097 NMBA-endorsed NPs and since 2010 approximately 25% of those endorsed NPs now access the MBS and Pharmaceutical Benefits Scheme (PBS) for the benefit of their patients.
Many NPs provide care for marginalised, underserved and/or vulnerable communities and populations across Australia. The NPRG report advises that “over the past five years, service volumes [for NPs] have grown at 43% per year, and average benefits per service has increased by 4% annually” (p.19).
Experience from the United States reveals billing codes used to track health service provision, as is currently seen with the MBS and the provision of general practitioner services, can be used to demonstrate safety, cost-effectiveness and efficacy of NP-directed health services. This allows the insurer and funder for such services to monitor for and assure value for healthcare expenditure. Such research has resulted in valuable evidence to demonstrate that NPs able to work to their full scope of practice are more likely to work in underserved areas, have improved patient outcomes and improve the health consumer’s experience as they intersect with the health system.
During the catastrophic bushfires from January 2020 onwards and then later during the second wave of Covid-19 in Melbourne, this propensity for NPs to be deployed to underserved areas of need has been well demonstrated. For example, Nurse Practitioners and other staff from Northern Sydney LHD were deployed to Murrumbidgee LHD during the bushfire crisis in NSW to locations such as Tumbarumba, Gundagai and Temora. Here they undertook roles such as setting up pop-up clinics in community evacuation centres, working in Multi-Purpose Service (MPS) emergency departments and across the residential aged care facilities (RACFs) to provide much-needed support to local GPs and other medical providers. Most (although not all) reported a good rapport with the local medical staff once they had explained their role and also once they had cared for patients and thus perhaps “proved” themselves.
Some of the NPs from Northern Sydney LHD provided de-identified reflections on their deployment experiences. One observed:
The role of the NP in the fire response cannot be underestimated. We used our advanced assessment skills, flexibility in practice, and experience to adapt to a dynamic environment, work in with a new health service, and provide the appropriate care to those who were very vulnerable and/or isolated. Much of the work was mental health and social work-related; we used the notion of a physical assessment to identify patients who may need to be linked in with these other services, which meant that most people got both a physical assessment and were then linked in with either mental health or social work (or both). This was an excellent way to work, as it capitalised on everyone’s experience and expertise and ultimately delivered the best results to patients.
Another described the types of problems they confronted on a daily basis:
The assistance provided varied greatly from basic first-aid to acute and chronic and complex care assessments and education to working out how we could get food and fresh drinking water to certain areas. Physical and mental health aside, a portion of the deployment included how to get individuals linked in for assistance with Centrelink and/or government grants. This was a huge challenge with no phone lines or Internet access as they were damaged in the fires.
During the Covid-19 response, NPs have again been filling the gaps. Richard Newman, an Emergency and Primary Care NP in New South Wales, was working out of prisons and correctional centres during the lockdown. His reflections on this experience are as follows:
As travel restrictions tightened, telehealth services increased. This was to supplement the decrease in on-site Medical Officer support and rising Hospital access challenges. Months would go by with no regular MO visiting. This provided unique challenges in managing patient safety and my Scope of Practice. Clear communication with my patients and supporting medical and NP team, patient advocacy, enhanced triage and prioritisation of patients requiring Medical Officer assessment assisted in ensuring patient safety was maintained.
Utilising the NP standards of practice, I was able to remain flexible and adaptable to my patients’ needs. This meant, at times, using telehealth services to examine patients collaboratively with surgeons and specialists 150kms away. Although the NP role is an autonomous role, I was also able to engage with my wider team of experienced NPs and undertake clinical supervision, case discussion and education to ensure that great outcomes were achieved for all patients.
Standard 4 of the NP standards of practice focusses on evaluation outcomes and improving practice. This has meaning for both the expectation of my organisation to support the system planning for Covid-19 and share the skills learned through my activities at the national level; as well as participate at the international level. In terms of international activities, I was tasked to spend 6 weeks overseas providing national, provincial and local level response to regions of emerging Covid—19. The team was required to identify organisational gaps and support the wider system to mitigate these risks through strategies such as education and mentorship for management and frontline clinical staff, policy review and evaluation, implementation of clinical guidelines and operationalising safe practices in austere and resource-limited environments.
Leanne Boase, co-author of this paper, is one of the very few people in her local area in Victoria who was still willing to see patients face to face throughout the pandemic. However, in the early days, she was unable to access PPE due to being a NP. She explains that they had to fight on a National Level for PPE via the Primary Health Networks, and there were no supplies available otherwise.
They had no response for 4-5 weeks, then finally a breakthrough via the Deputy CMO meant primary care NPs could at last start seeing patients face to face. While dealing with this issue, on behalf of herself and other Primary Care NPs, she was aware that her community needed her to be working to full capacity, which included seeing some patients face-to-face. Every health care worker was needed to be working to full capacity during the pandemic. Telehealth was essential, but this provision had to occur in the context of being able and willing to provide face to face care when medically needed and that necessitated access to PPE.
These accounts are important because they demonstrate the flexibility and value-add that NPs brought in both these times of crisis. It is ironic that at the end of a year of such outstanding courage and service, the “reward” should be the MBS Review Taskforce’s response to the Nurse Practitioner Reference Group’s report. When the time comes to roll out the vaccines for Covid-19, Primary Care NPs will be well-positioned to assist, and we can only hope that the initial problems encountered during the pandemic do not recur to prevent NPs from playing their valuable part.