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Nurse practitioners (NPs) provide high levels of clinically focused, autonomous nursing care in a variety of contexts within Australia. NPs care for people and communities with problems of varying complexity.
The NP scope of practice is built on the platform of the registered nurse (RN) scope of practice and must meet the regulatory and professional requirements for Australia including the Nursing and Midwifery Board of Australia (NMBA) Registered nurse standards for practice, Safety and quality guidelines for nurse practitioners, Code of conduct for nurses and International Council of Nurses’ Code of ethics for nurses.
The Nurse practitioner standards for practice (the standards) build on, and expand upon, those required of an RN. NPs understand the changes in the scope of practice from that of an RN, and the ways that these changes affect responsibilities and accountabilities. NPs are RNs endorsed as an NP by the NMBA and practice at an advanced level. NPs can practice independently and work collaboratively in multi-professional environments.
The standards in this document are the minimum standards that are applicable across diverse practice settings and patient/client populations for both beginning and experienced NPs.
NP attributes are consciously cultivated through formal learning that includes a work-based component. In Australia, the educational requirement for endorsement of NPs is a Master’s degree. This formal learning builds on demonstrable advanced practice within the RN scope.
NPs have a high degree of systems literacy and can independently manage care across a variety of health systems to maximise outcomes. NPs engage in support of systems; complex and critical thinking; integrate information and/or evidence; judiciously use clinical investigations; and skilfully and empathetically communicate with all involved in the care episode, including the person receiving care and their family and community, and health professional colleagues.
NP attributes are clinically focused, and NPs are capable in research, education and leadership as applied to clinical care (Refer Figure 1). Research includes leading processes that stimulates improved or new evidence-based care and quality management. NPs educate others related to the focus of, and available options, of care. NPs are leaders and lead care and care teams. NPs engage in reflective practice and support others in this process through clinical supervision or mentoring.
NPs can manage and are accountable for, complete episodes of care including wellness focused care, as the primary provider of care or part of a care team. NPs collaborate and consult with health consumers, their families and community, and other professionals, including health personnel, to plan, implement and evaluate integrated care that optimises outcomes for recipients, their progression through the health system and access to relevant systems of care.
As part of providing care, NPs can independently request and interpret any diagnostic and/or screening investigations within their scope of practice to facilitate diagnosis and/or screening processes. This informs diagnosis and care planning. Care can include nursing interventions that involve initiation, titration or cessation of any medicines in their scope. NPs practice encompasses technical and procedural skills that are applied as part of their responsibility in initiating and managing complex healthcare requirements. NPs take responsibility for following-up on any components of care initiated. They are accountable for care provided and self-monitor their work.
The standards have been written so as to be easily accessible to a variety of groups, including NPs, governments, regulatory agencies, education providers, healthcare professionals and the community. It should be noted that the criteria written below the Statements are indicative of NP behaviours, they are not intended to be exhaustive. Rather, they are examples of activities that demonstrate the statement for that standard.
These standards should be read in conjunction with other relevant NMBA documentation, and in conjunction with the attached Glossary, which clearly describes the way in which key terms are used in the standards.
In Figure 1, the Nurse practitioner standards framework is illustrated. The four domains are:
The expression of the knowledge and skills contained in the education, research and leadership domains is integrated across the four clinically focused standards.
Collectively, these attributes expressed in NPs’ knowledge, skills and affect, are applied in the education domain through educating those receiving care, peers and colleagues. The use of knowledge in the research domain is evidenced through the judicious application of research evidence in formulating practice decisions, self- regulation and the improvement to and development of new systems of care. The domain of leadership, initially evident in clinical work, increases in capacity to all levels of health services and includes community and political engagement.
Figure 1: Nurse practitioner standards framework
The NP:
Advanced practice is where nurses incorporate professional leadership, education, research and support of systems into their practice. Their practice includes relevant expertise, critical thinking, complex decision-making, autonomous practice and is effective and safe. They work within a generalist or specialist context and they are responsible and accountable in managing people who have complex healthcare requirements.
Advanced practice in nursing is demonstrated by a level of practice and not by a job title or level of remuneration.
Advanced practice for the purpose of the nurse practitioner endorsement requires 5,000 hours clinically-based advanced practice in the past six years. Attributes are characteristics that underpin competent performance. Refer to the NMBA Registered nurse standards for practice
Autonomous practice is having the authority to make decisions and the freedom to act in accordance with one's professional knowledge base (Skar 2010).
Competence is the combination of skills, knowledge, attitudes, values and abilities that underpin effective and/or superior performance in a profession/occupational area. Refer to the NMBA Registered nurse standards for practice
Cultural safety was developed in a First Nations’ context and is the preferred term for midwifery and nursing. Cultural safety is endorsed by the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM), who emphasise that cultural safety is as important to quality care as clinical safety. However, the ‘presence or absence of cultural safety is determined by the recipient of care, it is not defined by the caregiver’ (CATSINaM, 2014b, p. 9).
Cultural safety is a philosophy of practice that is about how a health professional does something, not [just] what they do. It is about how persons are treated in society, not about their diversity as such, so its focus is on systemic and structural issues and on the social determinants of health.
Cultural safety represents a key philosophical shift from providing care regardless of difference, to care that takes account of persons’ unique needs. It requires nurses and midwives to undertake an ongoing process of self-reflection and cultural self-awareness, and an acknowledgement of how a nurse’s/ midwife’s personal culture impacts on care.
In relation to Aboriginal and Torres Strait Islander health, cultural safety provides a decolonising model of practice based on dialogue, communication, power sharing and negotiation, and the acknowledgment of white privilege. These actions are a means to challenge racism at personal and institutional levels, and to establish trust in healthcare encounters (CATSINaM, 2017a, p. 11).
In focusing on clinical interactions, particularly power inequity between patient and health professional, cultural safety calls for a genuine partnership where power is shared between the individuals and cultural groups involved in healthcare.
Cultural safety is also relevant to Aboriginal and/ or Torres Strait Islander health professionals. Non-Indigenous nurses and midwives must address how they create a culturally safe work environment that is free of racism for their Aboriginal and/or Torres Strait Islander colleagues (CATSINaM, 2017b).
Independence in these standards is the defining characteristic of NP practice that recognises the educational and advanced practice attributes beyond the Registered nurse standards for practice. This independence is inherent in the NP standards for practice and integrates aspects of the often-complex nursing practice for which the NP initiates and is responsible. NPs work collaboratively as part of a healthcare team and have the authority to diagnose and implement treatments without oversight from another health practitioner. Nurse practitioner (NP) is a registered nurse endorsed as an NP by the NMBA. The NP practises at a clinical advanced level, meets and complies with the Nurse practitioner standards for practice, is able to practice independently and has direct clinical contact. NPs practice collaboratively in multi-professional environments. The NP practices within their scope under the legislatively protected title ‘nurse practitioner’ under the National Law.
Person/people in these standards is used to refer to those individuals who have entered into a therapeutic relationship with an NP. Person/people encompass patients, clients, consumers and families that fall within the NP scope and context of practice.
Prescribing is defined as the steps of information gathering, clinical decision making, communication and evaluation which results in the initiation, continuation or cessation of a medicine.
Research includes the creation of new knowledge and/or the use of existing knowledge in a new and creative way so as to generate new concepts, methodologies, inventions and understandings. This could include synthesis and analysis of previous research to the extent that it is new and creative: (Australian Code for the Responsible Conduct of Research, 2018, p.5)
Scope of practice is the full spectrum of roles, functions, responsibilities, activities and decision-making capacity that individuals within that profession are educated, competent and authorised to perform. Some functions within the scope of practice of any profession may be shared with other professions or other individuals or groups.
The scope of practice of all health professions is influenced by the wider environment, the specific setting, legislation, policy, education, standards and the health needs of the population.
The scope of practice of an individual is that which the individual is educated, authorised and competent to perform.
The scope of practice of an individual nurse or midwife may be more specifically defined than the scope of practice of their profession. To practise within the full contemporary scope of practice of the profession may require individuals to update or increase their knowledge, skills or competence. Decisions about both the individual’s and the profession’s practice can be guided using the Decision-making framework (DMF). When making these decisions, nurses and midwives need to consider their individual and their respective profession’s scope of practice.
Standards for practice are the expectations of the NPs practice in all contexts. They inform the education accreditation standards for NPs, the regulation of NPs and the determination of NPs capability for practice. These standards guide consumers, employers and other stakeholders on what to reasonably expect from an NP regardless of their area of practice or their years of experience.
Supports health systems is a clinical domain in the NP standards framework and describes the advanced practice activities and functions of NPs as described in ‘support of system’s (see below).
Support of systems is a practice domain of the Strong Model of Advanced Practice1 and is a contemporary feature of advanced practice. It is described as activities that promote quality and safe patient care and facilitate the optimal progression of patients through the healthcare system. NPs demonstrate the advanced practice activities in this domain that include:
1. Developed in the USA by a group of advanced practice nurses and academics at Strong Memorial Hospital, University of Rochester Medical Centre