An Exploration of Three New South Wales Nurse Practitioner Services in 2008

Background

To control increasing health costs, the Australian government initiated a range of health care reforms in the late 1990s. In 2000, the development of the Nurse Practitioner (NP) Service in New South Wales (NSW) was one strategy implemented to improve health care delivery. Supported by legislation, NPs extended their role beyond other nursing roles. The number of NPs in NSW doubled between 2004 and 2007, and NP Services flourished. With little published evidence, research was vital to justify the contribution of this new and rapidly evolving service model to existing health services and the acceptability of the new service model to patients seeking health care. Through interviewing relevant stakeholders and a medical record audit, this study generated knowledge about both the integration of the NP Service with existing health services and patient perceptions of the NP Service.

Aim and Research Objectives

Aim:

Using an intrinsic case study design, the aim of this study was to gain an understanding of the early implementation of the NSW NP Service in 2008.

Specifically, this study sought to answer five research objectives:

1) To understand the physical environment and organisational characteristics of the NP Service.

2) To investigate the patient care provided by the NP Service.

3) To examine NPs’ views about their role and its integration into the existing health care team.

4) To investigate health professionals’ views about the NP Service and its integration into the existing health care team.

5) To examine the patients’ experiences of the NP Service.

Methods

Using Stake’s (1995) classification, this intrinsic case study design was conducted from November 2008 to April 2009. The case was the NP Service and three services were studied as embedded units. Three NPs from three different health services (a mental health NP working in an emergency department, an emergency NP working in the subacute area of an emergency department and a neonatal NP working in neonatal intensive care), who met the inclusion criteria of being authorised and endorsed nurse practitioners, were sampled by geographical and service diversity. Data sources included participant observation, interviews and medical record audit. Participant observation examined the physical and organisational characteristics of the NP Service. The NPs were interviewed about their role and integration with health care teams using face-to-face semi-structured interviews. Semi-structured interviews were also conducted with 5 health professionals and 5 patients per site, selected using maximum variation sampling, about their views and experiences of the NP Service. A medical record audit of 10 consecutive patients (included those interviewed plus an additional 5 patients per site) was undertaken following consultation with the NP, to identify the elements of care provided by the NP. Qualitative data (interviews and participant observation) were analysed using thematic analysis, triangulation and concept modelling. Medical record audit data were analysed descriptively. Enablers and constrainers to the implementation of the NP Service were identified. Results were compared and contrasted within and between the three sites.

Findings:

Medical record audit data showed that all three NPs engaged in therapeutic communication (96.7%), prescribed medications (80%) and referred patients for further assessment (73.3%). From thematic analysis, four themes emerged that reflected the concept of evolution: speciation, adaptation, co-operation and succession. Enabling factors that supported the implementation of the NP Service included the legislated protection of the NP title and scope of practice, and the development of standards of practice. The perceived overlapping boundaries between the NP and other colleagues on the health team were identified as constrainers during implementation. Findings were consistent across all three sites.

Conclusion:

This thesis provides new knowledge on the implementation and evolution of the NP Service in NSW. New knowledge includes support given (or withheld) to the NP Services, the physical environment and organisational characteristics of each service, the diversity of patient care provided, the perceptions of NPs and health professionals regarding integration of the NP Service with existing services, and patients’ understanding of their experience with the NP Service. NPs have worked through the stages of speciation and adaptation to define the scope and work differentiating them from their colleagues. Through co-operation with their colleagues NPs continue to define their specific contribution to the health care team, but they experience ongoing impediments to establishing succession, primarily due to organisational and fiscal constraints within the workplace. Two key recommendations from this study were the need for better communication with patients and health professionals about the role of the NP Service and the need to generate short and long-term workforce strategies to sustain NP Services. If the NP Service is to be viable in the future, health services need to develop comprehensive communication strategies to promote the role of the NP Service and establish strong and formal succession planning programs.