How acceptable are primary health care nurse practitioners to Australian consumers?

Transcription

1 Collegian (2013) 20, Available online at jo ur nal homep age: How acceptable are primary health care nurse practitioners to Australian consumers? Rhian Parker, PhD a,, Laura Forrest, PhD a, Nathaniel Ward, MA a, James McCracken, PG Dip (Psych) a, Darlene Cox b, Julie Derrett b a Australian Primary care Research Institute, The Australian National University, Acton, ACT 0200, Australia b Health Care Consumers Association of the Australian Capital Territory, Australia Received 15 August 2011; received in revised form 22 November 2011; accepted 5 March 2012 KEYWORDS Nurse practitioner; Primary health care; Consumers; Acceptability Summary International evidence indicates that nurses working in primary care can provide effective care and achieve positive health outcomes for patients similar to that provided by doctors. Nurse practitioners employed in primary health care perform some tasks previously exclusive to the GP role due to their advanced skills, knowledge and training. In November 2010 Medicare provider rights and Pharmaceutical Benefits Scheme rights were provided for nurse practitioners working in private practice, and in collaboration with a medical practitioner. However, there is limited evidence about how acceptable nurse practitioners are to Australian consumers and what knowledge consumers have of the nurse practitioner role in the delivery of primary health care. The aim of this study was to examine Australian health care consumers perceptions of nurse practitioners working in primary health care. This paper reports on the results of seven focus groups (n = 77 participants) conducted around Australia. Focus groups participants were asked how acceptable nurse practitioners are as provides of primary health care. Although there was some confusion about the role of nurse practitioners and how this role differed from other primary health care nurses, participants in the focus groups were very positive about nurse practitioners and would find them acceptable in providing primary health care Australian College of Nursing Ltd. Published by Elsevier Ltd. Introduction There is abundant and consistent evidence that health systems with robust primary health care perform better across a range of indicators compared to systems without such a Corresponding author. Tel.: ; fax: address: Rhian.Parker@anu.edu.au (R. Parker). base (Starfield, Shi, & Macinko, 2005). Investment in services in primary health care results in healthier populations and lower overall costs for health care (Starfield, 2009). However, in many Western countries, including Australia, an ageing population and an increase in the prevalence of chronic conditions has presented a challenge to health services and policy makers in providing primary health care services, particularly when confronted with an ageing health workforce (Productivity Commission, 2005). Furthermore, some areas of Australia experience significant /$ see front matter 2012 Australian College of Nursing Ltd. Published by Elsevier Ltd. doi: /j.colegn

2 36 R. Parker et al. primary health care workforce shortages due to difficulties in attracting health professionals to rural and remote areas (Wakerman et al., 2006). There has also been an increasing trend towards the reduction of hours worked by general practitioners (GPs) and a feminisation of the general practice workforce has contributed to the trend of part-time work (Britt et al., 2009). In order to improve accessibility to primary health care, new models are being considered and introduced, which include advanced nursing roles. It has been suggested that nurse practitioners would be appropriately qualified and experienced to undertake these advanced nursing roles in general practice. Nurse practitioners are registered nurses who can demonstrate that they practice at an advanced level which is complemented by research, education and management, and who have completed a tertiary qualification, namely a masters degree (Nursing & Midwifery Board of Australia, 2010). Advanced practice nursing, which forms the basis of the role of nurse practitioners, involves using extended and expanded skills, having experience and knowledge in assessment, planning, implementation, diagnosis and evaluation of the health care that is required. The role of nurse practitioner was designed to improve access and provide cost effective care, target at-risk populations and serve rural and remote communities and to mentor and provide clinical expertise to other health care professionals (Australian College of Nurse Practitioners, 2010). Furthermore, in November 2010, Medicare provider rights for nurse practitioners working in private practice and in collaboration with a medical practitioner were introduced in Australia. Pharmaceutical Benefits Scheme rights were also introduced for those nurse practitioners working in States and Territories who were signatories to the Pharmaceutical Reform Agreement. Therefore, nurse practitioners are now in a position to practise in the primary health care setting. Previous studies have indicated that nurse practitioners are capable of functioning autonomously and collaboratively in extended clinical roles within a multidisciplinary team (Allnutt et al., 2010; Gould, Johnstone, & Wasylkiw, 2007; Wasylkiw, Gould, & Johnstone, 2009; Wilson & Shifaza, 2008) and that patients are satisfied with nurse practitioner services (Agosta, 2009; Gagan, 2011; Halcomb, Caldwell, Salamonson, & Davidson, 2011; Knudtson, 2000). Supporting this potential new role is the international evidence which suggests that nurses working in primary health care can provide effective care, achieve positive health outcomes for patients similar to that provided by doctors, and achieve good patient compliance (Keleher, Parker, Abdulwadud, & Francis, 2009). Nurse practitioners employed in primary health care perform some tasks which were previously exclusive to the GP role due to their advanced skills, knowledge and training (Gould et al., 2007; Laurant, Hermens, Braspenning, Sibbald, & Grol, 2004; Wasylkiw et al., 2009). This includes making autonomous decisions regarding minor acute illness and injury, and management of some diagnosed chronic conditions (Roblin, Becker, Adams, Howard, & Roberts, 2004). Studies have shown that nurse practitioners provide at least equal quality care to general practitioners (GPs) and yield higher satisfaction among patients with no differences in health outcomes (Baldwin et al., 1998; Lemley & Marks, 2009; Williams & Jones, 2006). Hence, primary health care nurses, when adequately trained, provide a feasible alternative in managing minor acute illness and injury and stable chronic conditions and may help provide a solution to the GP workforce shortage by working in underserviced areas of primary care (Gould et al., 2007; Parker, Keleher, Abdulwadud, & Francis, 2009; Wasylkiw et al., 2009). Despite the fact that the general practice nursing role is growing rapidly in Australia (Australian General Practice Network, 2010) very few nurse practitioners are employed in primary health care settings and there is limited evidence about how acceptable nurse practitioners are to Australian consumers and what knowledge consumers have of the nurse practitioner role in the delivery of primary health care. Australian studies have previously described the acceptability of the general practice nurse role by consumers and concluded that these nurses should enhance the role of the GP and not replace it (Cheek et al., 2002; Hegney, Price, Patterson, Martin-McDonald, & Rees, 2004). This is the first national study examining Australian health care consumers knowledge and opinions of the role and use of nurse practitioners in Australian primary health care. This study was conducted between July 2010 and February The aim of this study was to examine Australian health care consumers perceptions of nurse practitioners working in primary health care. This paper will report on the findings of seven focus groups on how acceptable nurse practitioners are to consumers as providers of primary health care. Methods Ethics approval was received from the Human Research Ethics Committee at The Australian National University (ANU) to conduct this project (protocol no. 2010/282). A reference group was appointed to oversee the project progress. The Health Care Consumers Association of the ACT organised and facilitated the recruitment for the focus groups through their national network through various methods including , newsletters, advertisements in some local newspapers and information provided through consumer advisory boards. Seven focus groups with a total of 77 participants were conducted in five States and Territories in Australia in August and September 2010 and in a variety of community locations (Table 1). The focus groups were facilitated by an experienced researcher (RP) and digitally Table 1 Number of participants in each focus group. Location No. of participants Canberra, ACT 11 Ipswich, QLD 9 Brisbane, QLD 11 Bateman s Bay, NSW 14 Rockingham, WA 12 Northam, WA 9 Melton, VIC 10 TOTAL 77

3 How acceptable are primary health care nurse practitioners 37 Table 2 Demographics of the focus group participants. Gender Male 15 Female 62 Age range (yrs) recorded with the participants consent. These recordings were transcribed and identifying information about the participants was removed. The data were independently coded into recurring ideas and themes utilising a start list of codes (Miles & Huberman, 1994) through NVivo 8 software (QSR International Pty Ltd., Melbourne, Australia). Themes emerging were linked to the questions asked in the focus groups (see Box 1 ). This ensured the ideas, concepts and patterns that form the emergent themes are grounded in the data (Charmaz, 2006). All transcripts were independently coded by members of the research team (LF, NW) to reduce subjectivity. Findings There were more female participants than male and the majority of participants were aged over 61 years (Table 2). A range of concerns and perceptions were identified by consumers when discussing the acceptability of nurse practitioners as providers of primary health care. These included perceptions of the qualities of nurse practitioners and those of GPs but they also extended to cover issues of choice, questions of access, what kinds of things people thought nurse practitioners should do, ideal divisions of labour and perceptions of trust and relationship. One of the defining themes was people s views about the qualities of nurses and how these qualities would impact on the nurse practitioner role. Very few focus group participants had received care from a nurse practitioner and many were not sure if they had or not. There was an overall sense that the level of knowledge in the community about nurse practitioners and their role was low. As one participant stated:... in the general public I don t think they even know there s such a thing as a nurse practitioner. (Male, Ipswich) Role delineation issues: differences between nurse practitioners, other nurses and GPs There was confusion around role delineation between nurse practitioners and other types of health care professionals. The most problematic for participants were those between nurse practitioners and other nurses, as well as between nurse practitioners and GPs. In particular there was a lack n Box 1 Focus Group Questions Knowledge of nurse practitioners Do any of the participants know what a nurse practitioner is? Comparisons between nurse practitioners and other nurses working in primary care Comparison between nurse practitioners and doctors working in primary care Definition of nurse practitioners The participants were then provided with a definition of a nurse practitioner in writing: A nurse practitioner is a registered nurse educated to function autonomously and collaboratively in an advanced and extended clinical role. The role includes assessment and management of clients using nursing knowledge and skills and may include but is not limited to the direct referral of patients to other health care professionals, prescribing medications and ordering diagnostic investigations. Source: Gardner et al. (2004). Nurse Practitioner Standards Project: Report to Australian Nursing and Midwifery Council, Australian Nursing and Midwifery Council, Canberra. Experiences of nurse practitioners Have any participants experienced care from a nurse practitioner? Was the nurse practitioner identifiable compared to other nurses and health care professionals? What was the nurse practitioners role in providing care? Role and use of nurse practitioners in primary health care What role should nurse practitioners play in primary health care? What kinds of medical care would you prefer to see a nurse practitioner for rather than a regular nurse? What kinds of medical care would you be comfortable to see a nurse practitioner for rather than a doctor? What kinds of medical care would you not be comfortable to see a nurse practitioner for rather than a doctor? of understanding about the difference between a nurse practitioner and a practice nurse (i.e. between a nurse who is a qualified nurse practitioner and a nurse that works in a general practice setting). The following participant captures the sense of this, linking her own poor understanding about where the differences may lie with a lack of clarity that the general public may have:

4 38 R. Parker et al. I know everyone here has sort of got some idea about the health system but there is a lot of confusion just from the general population I d say about the difference between a registered nurse and a nurse practitioner, and the roles that they can and can t do and what they undertake. Say for instance me I didn t know there was a difference between a nurse practitioner and registered nurse. (Female, Brisbane) Just as with a general confusion around understandings of how a nurse practitioner differed from other types of nurses whether in their scope of practice or in how a particular title signalled role delineation there were also questions around how a nurse practitioner might be different from a GP. This surfaced in different ways, but for the most part it came out strongly once members of focus groups had been read the definition (Ryan, 2009) of an Australian nurse practitioner to provide context and information for the discussion. The following exchange is a fairly representative example of responses to the definition: Respondent: They sound just like a GP. (Female, Rockingham) Facilitator: Sounds like a GP OK. Respondent: I m surprised that they can prescribe medication. (Female, Rockingham) Respondent: I thought that too. (Female, Rockingham) Respondent: I was about to say how can they prescribe medication when a certain medication that only doctors can prescribe? (Female, Rockingham). The seeming similarities between GPs and nurse practitioners also meant that it became unclear for participants under what circumstances and for what reasons a health consumer would access a nurse practitioner rather than a GP. One of the more thematically interesting differentiations identified between the nurse practitioner and the GP related to a perception about how each profession approached health issues (which was in part due to training, but had other more subtle nuances). The following participant drew attention to this in the context of a discussion outlining a perception that GPs are in some ways more specialised and for this reason do not see the whole person, coupled with the idea that a nurse practitioner would have more of a whole person approach to delivering health care: Isn t that sort of a given because it s nursing? Sorry, because I was just thinking about the difference between a GP for me is that medical model. It s always a medical model. It s what s the issue and I ll fix that bit, not often a whole person. (Female, Canberra) Consistently comments like the one above dovetailed with the qualities of each type of healthcare professional. In this way such comments also relate to the acceptability of nurse practitioners and the nursing qualities they brought to this role. Qualities of nurses Discussions about the qualities of nurses identified nurses as good listeners, that they took their time with people, and that they were caring. These discussions were about the interpersonal dimension that nurses, and by extension nurse practitioners, bring to their professional role. Indeed, in identifying the differences between GPs and nurses one focus group participant said: I think the difference between doctors and nurses a doctor is there to do a job and a nurse is a people s person. (Male, Melton) Comments to this effect were common across focus groups, although they had different permutations. There was often linkages with the feeling that nurses listened to patients more than GPs. Underlying such comments was the idea that being listened to engendered a feeling that one s health concerns were being taken seriously. The following participant highlighted this in the context of GPs being very busy. Here he sketches out this aspect of the qualities of nurse vis-à-vis GPs in overt terms: [Nurses] take notes of what you re saying rather than look at you in a funny way as to say what the hell are you talking about, what do you know about it. Which is what doctors quite often do, they look down on you. (Male, Rockingham) While it is fair to say that not all participants necessarily felt that GPs looked down on them, it was common for them to report these kinds of sentiments in connection with conceptualisations of being listened to and nurses taking more time. In the following excerpt the participant draws attention to this based on her having met many nurse practitioners, but not being able to see one for her own health concerns: Because I ve met quite a number of nurse practitioners,... I wish I d been with her (a nurse practitioner) because they had more time and were listening better than the registrars who didn t even know me every time I came into the clinic. (Female, Brisbane) Apart from the connection the above participant makes to time and being listened too, the idea of being known and having relationships with health professionals also emerges. What is important to signal here is the way that the above quote draws attention to another quality people felt nurses have and that nurse practitioners would, as a consequence, bring to their role. Specifically, this was around ideas that nurses had quite a lot of experience and that this made them in many regards good health professionals. This quality centred on a perception that it was largely nurses who took on the responsibilities of ongoing care. In some cases this was even articulated as nurses having more specialist knowledge than doctors. This is about how understandings of nurses, and by extension nurse practitioners, link to perceptions of the kinds of tacit knowledge they have that can be brought to their nursing role (tacit knowledge is precisely that which is gained through personal and professional experience). Perceptions that nurses have a great wealth of knowledge and experience that makes them acceptable also articulated with ideas of trust. This linked with a general willingness to see nurse practitioners, a central component of this being that... lots of people have a lot of faith in nurses (Female, Northam). A participant from another focus group explicitly made the linkage between trusting a

5 How acceptable are primary health care nurse practitioners 39 nurse because of his or her experience, connecting this to issues around trusting a nurse to diagnose and prescribe: I think sometimes the nurses they re actually dealing with more, more often than the doctors are. I would trust a nurse no problem. They are seeing it much more often than what a doctor is. I think that though they re not legally bound to be able to tell you what it is or give you a prescription. If they tell me what it is I would believe them. (Female, Melton) Notions of caring and listening exhibited by nurses also had a bearing on perceptions of quality of care. Quality of care in this regard was connected to feeling comforted and cared for when one was unwell. This is how one focus group participant framed it: For the person in pain, it s very important, you know, to have someone listening, and comforting, you know? (Male, Bateman s Bay). Good and bad professionals While it is certainly true that there were perceptions of nurses as being more caring, better listeners, taking their time, and being trustworthy there was also a minor theme that is worth noting around ideas of there being both good and not so good health professionals. The perception here was that there would be nurse practitioners within the profession, like all types of health providers, who would be fallible, and would not necessarily provide good quality of care as a result: If I see a registered nurse, a nurse practitioner or a GP if I go and see a bad GP is probably going to do me more harm than going seeing a good registered nurse. Or you can see a bad registered nurse and you know you should have gone and seen a GP. It doesn t guarantee you anything. It just says well I know what their scope is and people work within that. (Male, Brisbane) Appropriate education and training With some qualifications, most participants expressed a willingness to see nurse practitioners. One of the major qualifications was in knowing that nurse practitioners had received appropriate training. Assuming that this training was in place and of a reasonable standard, some participants felt that they would be quite happy to accept an extended scope of practice from a nurse practitioner. One participant framed it this way: Sometimes you feel very comfortable with them. And I think a, a nurse who s goes, you know, who s got the training, but not up to the, up to the same level as a doctor would, but very, you know, very good background, and I d like to see that. And, so that they can actually, more than diagnose a cold, and use some of that expertise, you know, to go further. (Female, Bateman s Bay) Training was in fact a major concern for many focus group participants in terms of the acceptability of the nurse practitioner role. One of the apparent interests for focus group members in this regard was in understanding what kind of scope of practice nurse practitioners would have and how the training would reference this. This included what, if any, kinds of specialisations there would be in the training: I guess the thing that I m thinking is that when we talk about a registered nurse, or we talk about a doctor, or we talk about a traditional hierarchical situation where we assume the doctor has the responsibility and the nurse answers to the doctor. I guess I see the nurse practitioner as reframing that concept and it s about equal but different. So I m interested in knowing more about I don t know about, what the specialist training is that a nurse practitioner does and what s the expectations in that training about, what responsibilities they would have. Because I think training is all about what you can do but also about, you know freedom within a structure what you can t do. (Female, Brisbane) Consumer choice of practitioners Understanding what kinds of training nurse practitioners had was intimately connected to notions of consumers having choice about who they could see for their primary health care needs. What emerged from the focus group material was a very clear sense of a division of labour between GPs and nurse practitioners. For nurse practitioners, participants tended to report that they would be happy to see them for minor or everyday health concerns. For reasons of providing context what tended to count as minor were things like coughs colds, sore throats, dealing with minor wounds and triaging. Some consumers saw that seeing a nurse practitioner for minor ailments would free up the GP to deal with more complex medical concerns, but was also connected to not wasting the GP s time. In discussing a role for a nurse practitioner in a general practice setting the following participant stated this in these terms: I think the nurse perhaps should be the first port of call between the patient and the doctor so that she can then refer more serious cases to a doctor. Whereas there s a lot of people who go to see a doctor who really aren t that sick anyway, and she could sort of pass those people off, rather than waste the doctor s time and him seeing them. (Male, Rockingham) While the focus group material indicated a willingness to see a nurse practitioner for many things, many participants explicitly stated that there were times when they would rather see a GP. In particular, people would rather see a GP for things that they considered more complex, although perceptions of what counted as complex seemed to be slightly elastic. Partly this was linked to perceptions of appropriate divisions of labour between nurse practitioners and GPs but it also had a bearing on the types of training each health care professional received. The following participant signals the training aspect of her preference for a GP in relation to the seriousness and by extension complexity of her own conditions: Most of my conditions I wouldn t want to go to the nurse practitioner for. They are serious enough that I would want to go straight to the doctor I wouldn t want to waste time going to somebody who I knew really wasn t to the level of a GP. (Female, Rockingham)

6 40 R. Parker et al. In commenting on the nature of her relationship with her own GP, the following participant also indicated a willingness to see a nurse practitioner for minor or ordinary types of health concerns. This being the case, she also noted that she would rather see a GP when she was unsure what might be wrong with her: I was one of the... I m one of those lucky people who has a wonderful GP. But I m very happy to see a nurse practitioner for ordinary things. But if I ve got something new that s sort of really unrelated to any of my other complex healthcare needs, then I will want to see my GP as a first port of call, rather than a nurse practitioner. (Female, Canberra) This reflected a general view across the focus groups about diagnosis and feeling confident in the health care professional to catch whatever the health issue might be. While some were happy for nurse practitioners to work in a triaging capacity, the overall sense was that making initial diagnoses of conditions was the realm of the GP. In this sense diagnosing complaints tended to count more as the kind of complex work that people would rather see a GP for. There was the feeling here that if nurse practitioners could take on more of the minor work, then this would also free up GPs to deal with this kind of more complex work. This would also mean that people would have better access to GPs when they felt that they had something more complicated. There was also a preference by some participants to see a GP if there were relapses in serious conditions that had previously been under control, or, as was the view of the following focus group participant in remission: Well I ve had cancer I ve had breast cancer and I m still monitoring it now. And I would think that if I thought my cancer had come back, I would want to see the GP. (Female, Ipswich) Discussion and conclusion A limitation of this study is that health care consumer participants from the focus groups had very limited experience of receiving primary health care from nurse practitioners. However, this is likely to be due to the small number of nurse practitioners currently practising in Australia and a smaller subset who are based in primary health care. Nevertheless, this study found that Australian consumers were accepting of appropriately trained nurse practitioners as primary health care providers particularly for routine visits and the management of less complex conditions. Participants in the focus groups were very positive about nurse practitioners and would find them acceptable in providing primary health care. Much of the acceptability from participants was based on their perceptions and experiences of the nursing profession as a whole which was linked to values and skills attributed to the nursing profession. Nurses, and therefore nurse practitioners, are perceived to be people persons and are perceived to be caring, good listeners, trustworthy, and take their time during consultations. These values and skills provided the basis for the focus group respondents approval towards appropriately trained nurse practitioners being acceptable primary health care providers, in particular for minor ailments and less complex conditions. In terms of specific tasks that nurse practitioners could undertake, the participants felt that nurses could undertake routine tasks thus enabling GPs to have time to undertake more complex tasks. International evidence also suggests that consumers are accepting of the nurse practitioner role and in particular for minor illness and injury (Kviz, Misener, & Vinson, 1983). A study from the United Kingdom found that the ability to prescribe medication, make nurse practitioners acceptable as primary care providers according to a majority of participants (Williams & Jones, 2006). An Australian study found that 95% of patients who had received care from a nurse practitioner were confident in the care they had received from the nurse practitioner and 97% said they would see a nurse practitioner again (Allnutt et al., 2010). Furthermore, Haidar (Haidar, 2008) found that after receiving care from a nurse practitioner, 75% of consumers were accepting of nurse practitioners and would not have preferred to have seen a doctor. The introduction of nurse practitioners to the primary health care workforce offers the potential of increased access for consumers, particularly if nurse practitioners can be enticed to work in areas where the GP workforce is reduced such as rural and remote areas. Nevertheless, the addition of nurse practitioners to the primary health care workforce is unlikely to be acceptable to consumers as a substitution for GPs, as the findings suggest that there were situations, usually considered more serious, when consumers would choose to see a GP instead of a nurse practitioner. Alternatively, participants also noted that there were times when seeing a GP would waste their time and therefore, seeing a nurse practitioner for triage and more minor illness and injury would be acceptable. The issue of when and why consumers would be prepared to see nurse practitioners merits further study as nurse practitioners become established in primary health care roles, either in general practice or in nurse clinics in the community. References Agosta, L. J. (2009). Patient satisfaction with nurse practitionerdelivered primary healthcare services. Journal of the American Academy of Nurse Practitioners, 21(11), Allnutt, J., Allnutt, N., McMaster, R., O Connell, J., Middleton, S., Hillege, S., et al. (2010). Clients understanding of the role of nurse practitioners. Australian Health Review: A Publication of the Australian Hospital Association, 34(1), Australian College of Nurse Practitioners. (2010). Australian College of Nurse Practitioners Potted History. Available from: Australian General Practice Network. (2010). National Practice Nurse Workforce Survey. Canberra. Baldwin, K. A., Sisk, R. J., Watts, P., McCubbin, J., Brockschmidt, B., & Marion, L. N. (1998). Acceptance of nurse practitioners and physician assistants in meeting the perceived needs of rural communities. Public Health Nursing (Boston, Mass.), 15(6), Britt, H., Miller, G., Charles, J., Henderson, J., et al. (2009). General practice activity in Australia Canberra: Australian Institute of Health and Welfare.

7 How acceptable are primary health care nurse practitioners 41 Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualitative analysis. London: Sage Publications. Cheek, J., Price, K., Dawson, A., Mott, K., Beilby, J., & Wilkinson, D. (2002). Consumer perceptions of nursing and nurses in general practice: Centre for research into nursing and health care. Adelaide, South Australia: University of South Australia. Gagan, M. (2011). Patient satisfaction with Nurse Practitioner care in primary care settings. Australian Journal of Advanced Nursing, 28(4), Gould, O. N., Johnstone, D., & Wasylkiw, L. (2007). Nurse practitioners in Canada: Beginnings, benefits and barriers. Journal of the American Academy of Nurse Practitioners, 19(4), Haidar, E. (2008). Evaluating patient satisfaction with nurse practitioners. Nursing Times, 104(26), Halcomb, E., Caldwell, B., Salamonson, Y., & Davidson, P. (2011). Development and psychometric validation of the general practice nurse satisfaction scale. Journal of Nursing Scholarship, 43(3), Hegney, D., Price, K., Patterson, E., Martin-McDonald, K., & Rees, S. (2004). Australian consumers expectations for expanded nursing roles in general practice. Australian Family Physician, 33(10), Keleher, Parker, Abdulwadud, & Francis. (2009). The effectiveness of primary and community care nursing in primary care settings. A systematic literature review. International Journal of Nursing Practice, 15(1), Knudtson, N. (2000). Patient satisfaction with nurse practitioner service in a rural setting. Journal of the American Academy of Nurse Practitioners, 12(10), Kviz, F., Misener, T., & Vinson, N. (1983). Rural health care consumers perceptions of the nurse practitioner role. Journal of Community Health, 8(4), Laurant, M. G., Hermens, R. P., Braspenning, J. C., Sibbald, B., & Grol, R. P. (2004). Impact of nurse practitioners on workload of general practitioners: Randomised controlled trial. British Medical Journal, 328(7445), 927. Lemley, K. B., & Marks, B. (2009). Patient satisfaction of young adults in rural clinics. Policy, Politics, & Nursing Practice, 10(2), Miles, M. B., & Huberman, A. M. (1994). Qualitative data analysis: An expanded sourcebook. Thousand Oaks, Calif: Sage. Nursing and Midwifery Board of Australia. (2010). Registration standard for endorsement of nurse practitioners. Canberra: Australian Health Practitioner Regulation Agency. Parker, Keleher, Abdulwadud, & Francis. (2009). Practice nursing in Australia: A review of education and career pathways. BMC Nursing, 8(5) Productivity Commission. (2005). Australia s Health Workforce, Research Report. Canberra. Roblin, D. W., Becker, E. R., Adams, E. K., Howard, D. H., & Roberts, M. H. (2004). Patient satisfaction with primary care: Does type of practitioner matter? Medical Care, 42(6), Ryan, D. (2009). Nurse practitioners: Standards and criteria for the accreditation of nursing and midwifery courses leading to registration, enrolment, endorsement and authorisation in Australia with evidence guide. Dickson ACT: Australian Nursing & Midwifery Council. Starfield, B. (2009). Toward international primary care reform. Canadian Medical Association Journal, 180(11), Starfield, B., Shi, L., & Macinko, J. (2005). Contribution of primary care to health systems and health. The Milbank Quarterly, 83(3), Wakerman, J., Humphreys, J., Wells, R., Kuipers, P., Entwistle, P., & Jones, J. (2006). A systematic review of primary health care delivery models in rural and remote Australia Canberra: Australian Primary Health Care Research Institute. Wasylkiw, L., Gould, O. N., & Johnstone, D. (2009). Exploring women s attitudes and intentions to seek care from nurse practitioners across different age groups. Canadian Journal On Aging La Revue Canadienne Du Vieillissement, 28(2), Williams, A., & Jones, M. (2006). Patients assessments of consulting a nurse practitioner: The time factor. Journal of Advanced Nursing, 53(2), Wilson, A., & Shifaza, F. (2008). An evaluation of the effectiveness and acceptability of nurse practitioners in an adult emergency department. International Journal of Nursing Practice, 14(2),