The Nurse Practitioner Series

Transcription

1 The Nurse Practitioner Series A series produced by the Office of the Chief Nursing Officer Department of Health, Western Australia in collaboration with the School of Nursing and Midwifery, Curtin University of Technology and School of Nursing and Public Health, Edith Cowan University Volume 1 Number 2 December

2 The Nurse Nurse Practitioner Practitioner Series. Series Volume 1 Number 2 December 2004 ISBN The Office of the Chief Nursing Officer publishes and distributes The Nurse Practitioner Series. The primary purpose of the series is to promote the development of the nurse practitioner role in Western Australia. Copies of The Nurse Practitioner Series are available from: Office of the Chief Nursing Officer Department of Health 189 Royal Street East Perth Western Australia Australia Volume 1 Number 2 December 2004 Department of Health Western Australia 2004 This work is copyright. It may be produced in whole or part for study or training purposes subject to the inclusion of an acknowledgement of the source and no commercial usage or sale. Reproduction for purposes other than those indicated above requires the written permission of the Department of Health Western Australia, 189 Royal Street, East Perth, Western Australia Disclaimer The opinions expressed within are the authors and not necessarily those of the Office of the Chief Nursing Officer, Department of Health Western Australia, Curtin University of Technology, the Editors, or the Editorial Board. Design and Layout: Office of the Chief Nursing Officer, Michelle Cabrera 4

3 Aim The primary aim of The Nurse Practitioner Series is to promote and disseminate information on approaches, activities, theory and research relating to the role and the implementation of nurse practitioners in Western Australia. Table of Contents Aim 5 Editor 7 Co-Editor 7 Editorial Board 8 Review Panel 9 Editorial 11 Leading Opinion 13 Development of Nurse Practitioners in New Zealand Frances Hughes & Stephanie Calder Commentary 25 The Western Australian Nurse Practitioner Project: An American Perspective Sally J. Reel Advanced Nursing Practice: Developing and Implementing 31 the Role of Advanced Nurse Practitioner in Ireland Kathleen Mac Lellan 5

4 Nurse Practitioners Role in Promoting Radiation 45 Safety in Western Australia Elizabeth Adams & Cecily Begley Nurse Practitioners in Western Australia 63 An Overview of Radiation Safety in Western Australia Radiological Council Discussion 73 The Feasibility of Nurse Practitioners in General Practice Scott Blackwell & Barbara O Neill Midwifery Initiative 81 Enhancing the Role for Midwives in Western Australia Kay Hyde Guidelines for Contributors

5 Editor Dr Phillip R Della PhD RN FRCNA RM Cert QMA B App Sci Grad Dip Man MBus Adjunct Professor Chief Nursing Officer Department of Health, Western Australia Professor r Phillip Della is currently the Chief Nursing Officer with the Department of Health, Western Australia. He has extensive and broad nursing experience in areas of clinical specialisation, nursing management, research and development. Phillip has directed a number of strategic developments in nursing including areas of workforce development, nurse practitioner legislation and professional enhancement. Phillip has worked as a management consultant and academic, lecturing in health service management and nursing management, and holds an Adjunct Senior Teaching Fellow position with the School of Public Health, Department of Health, Policy and Management, Curtin University of Technology. Co-editor Ms Elizabeth Adams RGN Cert(ODN) BNS(Hons) Dip(Mgt) Dip(Counselling) Dip(Phy & Chem) PGDip(Stats) MSc Principal Nursing Officer Office of the Chief Nursing Officer Department of Health, Western Australia Elizabeth Adams is currently the Principal Nursing Officer with the Office of the Chief Nursing Officer, Department of Health, Western Australia. Previously she worked with the Chief Nursing Officer in the Department of Health and Children in Ireland as a Nurse Research Officer on a national Study of Nursing and Midwifery Resource. Prior to this, she was a theatre superintendent in a large tertiary referral hospital (Mater Misericordiae University Hospital, Dublin). In 2003, Elizabeth became the first student of the School of Nursing and Midwifery, University of Dublin, Trinity College Ireland, to be awarded a Masters Degree in Science through Research. She has been recognised nationally and internationally for her research skills and was the first national and, subsequently European, winner of the Klinidrape and European Operating Room Nurses Association Research Nursing Foundation. 7

6 Editorial Board Dr Dianne Wynaden RN RMHN B.AppSc(Nursing) PGDip (HSc) MHSc PhD MA&NZCMHN Senior Lecturer/ Director of Research and Development School of Nursing and Midwifery Curtin University of Technology and Research Consultant Fremantle Mental Health Services Fremantle Hospital and Health Service Dr Dianne Wynaden is a senior lecturer and Director of Research and Development at the Curtin University of Technology School of Nursing and Midwifery. Dianne teaches across the undergraduate and postgraduate areas and supervises Higher Degree by Research Students. Her speciality area of nursing is mental health. Since 1997, Dianne has had a one-day-perweek research appointment with Fremantle Mental Health Services. Dianne has been the recipient of several grants and has referred publications in the area of mental health, nursing education, cross cultural care and qualitative research. Dr Gavin D Leslie RN IC Cert BAppSc Post Grad Dip (Clin Nurs) PhD FRCNA Associate Professor Critical Care Nursing Edith Cowan University and Royal Perth Hospital Dr Gavin Leslie has worked extensively within critical care holding industry positions from Registered Nurse through to Nurse Director. He was founding President of the Confederation of Australian Critical Care Nurses, which later formed the Australian College of Critical Care Nurses. He is also editor of Australian Critical Care, on the editorial board of Collegian and the American Journal of Infection Control, and peer reviews for Anaesthesia and Intensive Care and Critical Care Medicine. Gavin has worked for many years with the Nurses Board of WA on educational and research subcommittees and more recently with implementing the Nurse Practitioner legislation. He currently holds a joint appointment between Royal Perth Hospital (RPH) and Edith Cowan University (ECU). At RPH Gavin chairs the Area Nursing Research Review Committee and is a member of the hospital Ethics Committee. At ECU his responsibilities include Course Coordination for the Masters of Clinical Nursing Programme. 8

7 Mr Robin Moon RN RMHN RM BHSc(Nsg) Grad Dip Bus(Mgt) Grad Cert Men s Hth MRCNA RNP Robin Moon is a recent graduate of the Curtin University of Technology School of Nursing nurse practitioner program. He has extensive clinical nursing experience within a wide range of clinical areas in both rural and metropolitan healthcare facilities. He is currently working for the Mercy Community Services to implement men s health clinics at Balgo and surrounding communities. In addition he is putting together the required business case for the establishment of designated nurse practitioner positions at these communities. Review Panel International Reviewers: Dr Patrick C Brennan DCR HDCR CTC PhD Senior Lecturer and Director of Research School of Diagnostic Imaging, University College Dublin, Ireland Professor r Sally J Reel PhD APRN CFNP FAAN FAANP Clinical Professor & Coordinator Nurse Practitioner Options University of Arizona College of Nursing Arizona, United Stated of America Dr Frances Hughes Professor Faculty of Medical and Health Sciences Auckland University, New Zealand 9

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9 Editorial Welcome to the second issue of The Nurse Practitioner Series. The purpose of this series is to provide professional and academic debate into the development of this advanced nursing role, including its policy and legislative framework, educational preparation and practice development. The Editorial Board has been expanded to include a representative from Edith Cowan University and three international experts have been added to the International Review Panel. Together these new Board and Review Panel Members will ensure the continual development of The Nurse Practitioner Series. The development of the nurse practitioner role in Western Australia has now entered the next phase, where applications for designation have been received. Designation of a nurse practitioner area brings reality into practice, allowing registered nurse practitioners to deliver safe, quality care to defined patient populations within their scope of practice. The scope of practice is defined by the educational preparation and described in the approved clinical protocols. The work of nurse practitioners has been documented extensively in international literature and one current theme that emerges is their ability to reduce the fragmentation of care delivery. Fragmentation of care occurs when a patient is handed from one health professional to another for the prescribing of medications or the ordering of investigations such as x-rays. Registered nurse practitioners practising in approved designated areas reduce this fragmentation of care through their ability to prescribe medications and order diagnostic investigations themselves. In this issue, articles on the emerging role of nurse practitioners are presented from both an international and a State perspective. Dr Frances Hughes and Stephanie Calder highlight the evolutionary nature of the development of nurse practitioners in New Zealand. The article notes that the role of nurse practitioners is based on competencies established by the Nursing Council of New Zealand and the Ministry of Health s clear policy framework. Continuing with the international theme, Dr Kathleen Mac Lellan describes the development of advanced nurse practitioners roles as a part of the overall clinical career pathway in Ireland. The Irish nursing clinical pathway is linked with levels of educational preparation, responsibility and subsequent autonomy. Professor Sally Reel, who recently visited Western Australia as a Fulbright Senior Specialist, provides a commentary on the West Australian approach to nurse practitioners noting both the emerging strengths and challenges to the implementation of this role. In addition, Dr Scott Blackwell and Barbara O Neill present a discussion on the feasibility of nurse practitioners in General Practice based on the results of a study conducted by the Osborne Division of General Practice. Kay Hyde s article on midwifery enhancement acknowledges the work in advancing the delivery of midwifery practice and professional development. The enhanced role of the midwife includes the area of initiation of specific medications and investigations according to approved clinical protocols. The evidence to support this new emergent trend is based on the National Health and Medical Research Council s 1998 report into the services offered by midwives. The Radiation Safety Act 1975 was amended on 9 April 2003 to allow nurse practitioners to request the holder of a licence under the Act to undertake diagnosis or therapy. While approved clinical protocols will contain the list of investigations that the nurse practitioners can order, debate continues and two articles in this issue provide valuable information on this topic. Elizabeth Adams and Professor Cecily Begley highlight the nurse practitioners role in promoting radiation safety and the Radiological Council of Western Australia describes its role in ensuring radiation safety. 11

10 In conclusion,, it is important that nurse practitioners are allowed to function to their level of educational preparation and their legislative scope of practice. Barriers that prevent this must be identified and strategies to reduce them implemented. The prime focus of nurse practitioners is the delivery of safe, quality patient care within a defined scope of practice. Their ability to reduce the fragmentation of care delivery must be both acknowledged and encouraged. Dr Phillip R Della Adjunct Professor Chief Nursing Officer 12

11 Leading Opinion Development of Nurse Practitioners in New Zealand Dr Frances Hughes RN DNurs Chief Advisor Nursing Ministry of Health Wellington, New Zealand Stephanie Calder BA (Hons) Policy Analyst Ministry of Health Wellington, New Zealand Disclaimer This article has been written by Frances Hughes and Stephanie Calder in their personal capacity, and not on behalf of the Ministry of Health where the authors are employed. Any views expressed in this article are personal to the authors and are not necessarily the views of the Ministry of Health. The Ministry of Health accepts no responsibility or liability in respect to the contents of this article. Abstract The development of the nurse practitioner role in New Zealand is the result of years of planning based on both extensive consultation with the sector and the evidence available internationally and in New Zealand. The role of the New Zealand nurse practitioner is based on competencies set by the Nursing Council of New Zealand, located in policy from the government of New Zealand and a substantial body of international research and literature. There are now 11 certified nurse practitioners in New Zealand practising in a range of settings and areas of practice. Subsequently, barriers to practice have been identified which impede the ability of nurse practitioners to fulfi l the intent of the role they have been regulated to do. International research over decades has continued to play a role in breaking down barriers increasing the ability of nurse practitioners to practice in the way they are educated. The nurse practitioner role in New Zealand is evolutionary and the New Zealand Ministry of Health continues to engage the sector to ensure that nurse practitioners will flourish within our changing health environment. Key words: nurse practitioner, competencies, advanced practice, nurse prescribing, policy. 13

12 Background The development of the nurse practitioner role in New Zealand is a reflection of several years of planning based on international evidence and extensive consultation with the health and disability sector. The concept of implementing a nurse practitioner role in New Zealand was first proposed by the Ministerial Taskforce on Nursing in The taskforce was established by the Minister of Health to identify the barriers that prevent nursing from improving the service to its patients and devising strategies to remove those barriers (Ministerial Taskforce on Nursing, 1998). The taskforce considered the advanced role of nurse practitioners to be central to improved patient services and of providing highly skilled care and coordination of particular patient groups across the hospital and primary health care interface. In 1999, a consensus conference attended by a wide range of nursing organisations agreed to progress the issue of advanced clinical nursing practice (Ministry of Health, 2002). Also in 1999, the Medicines Act 1981 was amended to extend the prescribing rights to new or designated prescribers. The policy work to introduce nurse prescribing was the final catalyst for nurse practitioner development. The Nursing Council of New Zealand, the body responsible for the regulation of the nursing profession, was asked to develop a framework for advanced nursing practice. This resulted in the term Nurse Practitioner being used in New Zealand. In 2001, the Nursing Council completed the regulatory framework for nurse practitioners (Nursing Council of New Zealand, 2002). This followed extensive consultation with nurses and other interested parties. In the same year, the Ministry of Health, together with the Nursing Council of New Zealand, facilitated a two-day conference titled Innovations in Health. The conference provided the opportunity for registered nurses practising at an advanced clinical level to showcase possible future models of the nurse practitioner role. The conference demonstrated how the development of the nurse practitioner role was a pivotal opportunity for New Zealand s health and disability sector to plan for the development of new models of care delivery that would enhance the health status of their local populations. Numerous models of care delivery were identified at the conference and nurse practitioners provided innovative approaches on how to reach communities, and build on and complement existing services. The Nursing Council approved the first nurse practitioner in the scope of neonatology in December

13 In July 2002, New Zealand s Minister of Health, Hon Annette King, launched Nurse Practitioners in New Zealand (2002). The document: builds on information shared at the Innovations in Health conference provides a resource for the health and disability sector outlines the regulatory and policy framework for nurse practitioners highlights the significance of international evidence in the development of the role in New Zealand outlines possible models of practice and employment arrangements. Throughout 2002, the Ministry of Health and the Nursing Council embarked on a series of 21 regional roadshows around New Zealand. The roadshows were held to ensure that nurse practitioners became an integral part of the health workforce and that their skills were fully utilised to contribute to improved health outcomes in a cost-effective way. Table 1 demonstrates the development of advanced nursing practice from a policy perspective. Table 1 Development of advanced nursing practice from a policy perspective 1990s Transition of undergraduate education to Bachelor of Nursing Ministerial Taskforce on Nursing Medicines Amendment Act New Zealand Health Strategy Innovations in Health Conference Publication of Nurse Practitioners in New Zealand Associate Professor John Shaw Paper on extension of prescribing rights to other heath professionals Multidisciplinary working group on nurse prescribing Source: Hughes, 2002a 15

14 Regulatory Framework Before registered nurses can be approved by the Nursing Council to practise as nurse practitioners they must: have at least three to four years experience in a specific area of practice have a Master s level education meet the Nursing Council s competencies. Seven specific areas of practice have been identified for nurse practitioners: primary health care high dependency perioperative mental health palliative care disease management emergency and trauma. Within these broad scopes, nurse practitioners identify their specific area of practice by delineating their specialty, sub-specialty, population or client group as shown in Table 2. Table 2 - Areas of specialisation within specific areas of practice Practice scope Infant Child Adolescent Adult Aged Maori Mental health Disease management Perioperative Pacific people Immigrant Palliative care Emergency and trauma Primary health care High dependency Source: Ministry of Health,

15 The Nursing Council developed six general competencies for the nurse practitioner which are: articulate the scope of nursing practice and its advancement show expert practice working collaboratively across settings and within interdisciplinary environments show effective nursing leadership and consultancy develop and influence health / socioeconomic policies and nursing practice at a local and national level show scholarly research inquiry into nursing practice prescribe interventions, appliances, treatments and authorised medicines within the scope of practice (this competency is specific to nurse practitioners seeking prescribing rights). Within these competencies, nurse practitioners must manage complex situations; use and interpret laboratory and diagnostic tests; administer assessments, diagnosis, intervention, treatments; follow up within scope of practice; and evaluate the effectiveness of the client s response to prescribed interventions, appliances, treatments and medications, and take remedial action and/or refer accordingly. Collaboration and consultation with both consumers and their families as well as with other health professionals are central principles of the nurse practitioner s practice. Key Principles New Zealand has been fortunate to base its nurse practitioner model on substantial international evidence. The guiding principles for the role are the following: Nurse practitioners work towards health gain to address and reduce inequalities and inequities in health. In the New Zealand context this includes addressing the health needs of Māori and Pacific peoples. The nurse practitioner is the most advanced level of clinical nursing practice. The role is centred on patient and population needs and improving health outcomes. Nurse practitioners should continue to evolve in response to changing societal and health care needs. Population health status will drive the provision of nurse practitioner services. It is acknowledged that development of the role challenges the traditional boundaries of nursing practice. The role of the nurse practitioner will mostly complement the role of other health professionals but will inevitably overlap in some areas. This will enable substitution between groups to occur and thus promote efficiency and flexibility in the use of valuable resources. 17

16 Funding to Support the Development of the Role New Zealand Models Nurse practitioners, like registered nurses and other expert health professionals, are autonomous practitioners like other expert health professionals and do not require supervision of their practice by other disciplines. Nurse practitioners have a defined scope of practice and substantial clinical expertise in their chosen scope and are certified to practise as nurse practitioners by the Nursing Council of New Zealand. The practice of nurse practitioners, like other registered nurses, is based on collaboration. Interprofessional relationships between the nurse practitioner and other health team members is based on concern for mutual goals; equality in dimensions such as status, power, prestige, and access to information; and diversity in expertise, skills, knowledge and practice (Ministry of Health, 2002). The Ministry of Health has targeted funding to support registered nurses to complete the required academic study in order to apply to the Nursing Council to practise as nurse practitioners. In order to deliver on recommendations contained in the Government s Primary Health Care Strategy, substantial funding has been allocated to develop the primary health care nursing workforce. The strategy was released in 2001, and is considered the most comprehensive strategy to address health inequalities for decades. A portion of this funding has been used to provide scholarships to experienced primary health care nurses in rural areas to help them to complete their final year of study necessary to qualify to apply to the Nursing Council to practise as a nurse practitioner. This funding has provided a crucial opportunity for nurses in isolated areas to access postgraduate education that for many reasons they would not otherwise have had the opportunity to undertake and will ensure the gradual development of nurse practitioners in areas where there is a shortage of advanced clinical skills. There are now 11 certified nurse practitioners in New Zealand in a range of areas of practice. Nurse practitioners will work in multiple roles and settings in service delivery. The scopes of practice and consumer focus determine the choice of work settings and nurse practitioners work between provider groups in both rural and urban areas. Settings could include community health centres, Māori and Pacific providers, public health services, hospitals and hospital clinics, school and university student health clinics, workplaces, general practice or specialist clinics, rest homes and hospices, and home health care agencies. The nurse practitioner model provides a pivotal opportunity for New Zealand s District Health Boards and other providers to develop new models of care delivery to improve the health status of their populations. Four generic models are displayed in Table 3 and provide examples of possible models of care in New Zealand s health and disability sector. 18

17 Table 3 Nurse practitioner example models of care Model 1: Integrated nursing teams A team of nurses and nurse practitioners provides, co-ordinates and manages health promotion and disease prevention across the continuum of care. For example, integrated primary health care nursing teams work out of Primary Health Organisations and provide risk assessments, first-contact care, case management of clients with chronic conditions, and services for whānau, hapū, iwi and Māori communities. Model 2: Nurse consultancy The nurse practitioner works independently and refers clients to other health professionals where required. Collaborative practice arrangements and care decisions may also dominate. For example, nurse practitioners work within hospital settings, between primary and secondary or secondary and tertiary health care services, or between nongovernmental organisations, and provide leadership to nurses and referral to other disciplines. Model 3: Independent practice Nurse practitioners are self-employed and establish their own independent practices offering care and services direct to the public. For example, nurse practitioners contract themselves to provide services direct to clients of other agencies, hospitals, Primary Health Organisations and nongovernmental organisations. Model 4: Nurse practitioner specialty services / clinics The nurse practitioner is the recognised lead health professional within the health care team for establishing and managing specialty clinics or services for a particular health specialty and/or population group. For example, nurse practitioners lead pain management, anaesthetics, wound management, rehabilitation and disease management. Source: Ministry of Health,

18 Lessons Learned Several barriers have been identified that impede the ability of nurse practitioners to fulfil the intent of the role they have been regulated to do. The Ministry of Health is committed to working through these barriers, which include: restrictions in statutes which refer in a number of cases to specific health professionals contractual arrangements cultural issues and concern from some areas about the concept of advanced nursing. Legislative barriers A legislative scan has shown that approximately 60 New Zealand statutes refer to specific health practitioners in relation to activities under the legislation. The Ministry of Health s view is that some of these statutes present a significant barrier for nurse practitioners who are unable to perform parts of their role due to restrictive legislation. Contractual arrangements Community laboratory services in New Zealand are funded and provided through a services agreement between the 21 District Health Boards and the provider. A detailed schedule outlines the tests and lists the health professional groups that can access each test. While registered nurses can access some tests, they are not able to order many tests which fall well within their scope of practice and competencies. Cultural issues As the nurse practitioner role has been evolving in New Zealand, cultural issues within the health profession have arisen. Concerns have been raised that nurse practitioners independently diagnosing and prescribing medication could endanger patients (New Zealand Press Association, 2001). In 2003, a study of general practitioners (GPs) in the Northland region of New Zealand sought to explore perceptions of the nurse practitioner role. The study showed that the GPs viewed favourably nurse practitioner functions traditionally associated with nursing such as health teaching, home visiting, obtaining health histories and taking part in the evaluation of care. However, those functions traditionally associated with medicine such as prescribing, ordering laboratory tests and physical assessment were viewed as less favourable activities for nurse practitioners to perform (Mackay, 2003). 20

19 New Zealand s first nurse practitioner, Deborah Harris, describes how it is not that nurses are better than doctors or that doctors are better than nurses. It is, in fact, that we are different, that we come from different philosophies with similar goals, and that together we are able to achieve better outcomes for the patients in our care. This is the message that is the essence of advanced clinical practice for the nurse practitioner. The most important focus for the individuals within the team is for them to work individually and collaboratively for health gain for patients, using the skills their training has provided (Harris, 2002). The Ministry of Health continues to work with the profession and the health sector to both address and resolve existing barriers; and provide guidance and education about potential models of practice and implementation of the role. Nurse practitioners are in an extraordinary position to shift the paradigm of care to one where differences between professionals do not necessary imply inequality or justify exclusion. Nurse practitioners can help to bridge the chasm into which many consumers fall when they are unable to access and sustain the benefits of health care that others enjoy. However the mere development of the nurse practitioner role is threatening to others as the changes they bring about in care challenges existing systems. In the 100 years that nurse practitioners have existed internationally, the negative response to nurse practitioner development is well documented. Regardless, development has continued to go from strength to strength and from country to country. Research over the decades has continued to play a major role in breaking down barriers and increasing the ability of nurse practitioners to practise in the way they are educated. It has evolved from initial research which described their practice, to proving worth and comparing their practice with medical practitioners, to more recent research which focuses on their clinical outcomes and patient satisfaction (Table 4). Table 4 - Evolution of Nurse Practitioner Research Descriptive Legitimisation Proving worth Comparative Proving difference Economic modelling Cost effectiveness Clinical outcomes Source: Hughes, 2002 Who are they and what do they do? Do we need them? What can they offer? How do they compare to MDs? What do they do that is different? Are they cheaper? Are they cost effective? What are the effects of nurse practitioner practice on health outcomes of consumers? 21

20 What is important is that countries like New Zealand do not replicate unnecessary research and that we do not undertake research of the early eras as our international colleagues have successfully done this. We need to move beyond comparative, proving, descriptive research to the field of clinical outcomes. It is important to engage and have continuing dialogue with the groups that oppose nurse practitioner developments. Through this process we will have a more informed and better educated health care team, which ultimately will benefit from having nurse practitioners as its partner in care. Conclusion The nurse practitioner role in New Zealand is one that is evolutionary. Nurses use knowledge from many other disciplines, but add their own special knowledge to the gestalt and apply it in practice, in a manner uniquely their own. Nurses do for people what people would do for themselves if they had the will, the strength and the knowledge that the nurse has (Mezey et al 2003: 5). Nurse practitioners are not elite nurses, nor extensions of physicians or technicians. In New Zealand they are the highest level of clinical nursing. They are population-focused with complex case loads and provide leadership and influence policy agendas on health care. They provide expert clinical advice on nursing within their scope not only to other multidisciplinary team members but also to other nurses. Through their leadership they integrate research, policy and practice into their clinical judgements, they share common skills with other disciplines such as diagnostics, treatment interventions and prescribing, and utilise these skills and tools within a nursing framework and model. Nurse practitioners in New Zealand add value to the health workforce, not only for the New Zealand public through their health care delivery but to the health care team and also to the profession of nursing. The nurse practitioner positions have created a clear clinical role that will help retain nurses in clinical practice, a career pathway. New Zealand set a clear policy framework for nurse practitioners based on increased access to healthcare and benefits for the consumer. Research and international evidence played a large role in the ability to develop this role. It is important that we continue to add to the body of literature on this topic through outcome research. Nurse practitioners in New Zealand will flourish in our health environment where competition has been replaced with collaboration, and will have the opportunity to provide an innovative way of reaching communities and meeting health care needs across New Zealand s health and disability sector. 22

21 References Harris, D. (2002). The value of nurse practitioners. The New Zealand Medical Journal, 115(1163). Hughes, F. (2002). Nurse Practitioner Policy Development in New Zealand. Presentation at the 2nd ICN International Nurse Practitioner / Advanced Practice Nursing Network Conference. Adelaide: Australia. 31 October 2 November. Mackay, B. (2003). General practitioners perceptions of the nurse practitioner role: an exploratory study. The New Zealand Medical Journal, 116(1170). Mezey, M., McGivern, D., & Sullivan- Marks, E. (eds). (2003). Nurse and nurse practitioners. Boston: Little, Brown. Ministerial Taskforce on Nursing. (1998). Report of the Ministerial Taskforce on Nursing: Releasing the potential of nursing. Wellington: Ministry of Health. Ministry of Health. (2002). Nurse Practitioners in New Zealand.. Wellington: Ministry of Health. Nursing Council of New Zealand. (2002). The Nurse Practitioner: Responding to health needs in NewZealand (3rd Ed). Wellington: Nursing Council of New Zealand. New Zealand Press Association. (2001). Nurse Practitioners role concerns Medical Association. May

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23 Commentary The Western Australian Nurse Practitioner Project: An American Perspective Sally J. Reel PhD APRN CFNP FAAN FAANP Clinical Professor & Coordinator Nurse Practitioner Options University of Arizona College of Nursing I recently had the distinct privilege to serve as a Fulbright Senior Specialist to Curtin University of Technology School of Nursing and Midwifery and participate in the implementation of the first nurse practitioner program in Western Australia. The introduction of nurse practitioners in Western Australia is timely, and is concomitant with a growing need for providers to care for rural and remote and aging populations as well as a growing need within the general population for nurses with advanced education and skills. I applaud the work of many sectors to bring the concept of nurse practitioner education and practice to Western Australia. In the United States of America (USA), the nurse practitioner movement emerged in the 1960s during a time of social activism and scientific advancement. Societal events produced a climate where public service was valued and society was concerned about the maldistribution of health resources, especially physicians. The rationale for developing the nurse practitioner role came from nurse leaders committed to preparing graduate nurses for clinical specialties (Komnenich, 2005). In Western Australia, the same commitment from nurse leaders to prepare nurses for clinical specialties to meet the health needs of the State is also evident, and provides a strong platform to develop the role. During my visit, it was interesting to experience and to view some of the emerging strengths and challenges of the nurse practitioner movement in Western Australia and to find many issues similar to those we experienced in the USA. For example, nurse practitioner education is well established in the USA, and nurse practitioners are found in all 50 States. Our nurse practitioners are recognised as nurses who have advanced preparation and who work with people of all ages in various specialty areas. Research demonstrates that our nurse practitioners provide high quality, cost-effective care that is unique in approach to health care and results in high levels of patient satisfaction. Nurse practitioners practise at an advanced level and our practices include, but are not limited to, performing medical histories and physical examinations; diagnosing and treating acute problems such as infections and injuries; diagnosing and treating chronic diseases such as diabetes; ordering, performing and interpreting diagnostic studies; prescribing medications and treatments; as well as providing prenatal care, well child care, health maintenance, and health promotion interventions (American Academy of Nurse Practitioners, 2004). Our nurse practitioners also work in a variety of settings, both public and private, and both urban and rural, and have been recognised as integral health providers for rural settings since the 1970s. 25

24 It is clear that within Western Australia, nurse practitioners also have potential to serve widely throughout the industry sector as well. However, nursing and stakeholders have multiple opportunities and challenges. Despite a solid 40-year history of quality health care practice by nurse practitioners in the USA, we have experienced the inevitable scrutiny that questions the effectiveness and appropriateness of our scope of practice despite growing evidence that primary care delivered by nurse practitioners is equal to that provided by physicians (Mundinger et al., 2000). Through multiple meetings with many stakeholders, some key issues related to implementing the nurse practitioner role in Western Australia emerged, particularly role definition, educational and competency standards, scope of practice and credentialling issues. I will address each of these issues briefly, keeping in mind that my perspective is grounded in an American experience that may or may not have relevance for Western Australia. Role is an interesting phenomenon to watch surface and the debate about what a nurse practitioner is or is not is driven by many things including professional nursing, industry and other stakeholders. I suggest that Western Australia may want to carefully consider how the nurse practitioner role will emerge and be defined. This is an opportunity for Western Australia to demonstrate leadership throughout Australia about what the term nurse practitioner means for both the State and the nation. From my observations, the term nurse practitioner seems to be emerging as an umbrella term to include multiple forms of expanded roles or advanced nursing practice. Many seem to view the term nurse practitioner as the highest level of advanced nursing practice in Australia. From an outsider s perspective, the lack of a career ladder for clinical nurse consultants, coupled with no formal graduate educational opportunities for the clinical nurse consultant, is influencing emergence of multiple categories of nurse practitioner with potentially limited or very circumscribed scopes of practice. Part of the debate about the term might be is to determine some consensus about what the nature of nurse practitioner practice is, who the client will be, what the minimal educational standards and curriculum must include, and what the terminal competencies of the graduate will be. In the USA, for example, nurse practitioners have distinctive roles that are defined and classified within an advanced nursing practice role. Historically, primary care is the practice domain of the American nurse practitioner. However, we also recognise more than one type of advanced practice nurse including nurse practitioners, clinical nurse specialists, nurse anesthetists and nurse midwives, each of which has educational standards at the Master s degree (with exception of some midwifery certificates), require national certification through board examination, and state licensure and state-defined scope of practice relevant to the type of advanced practice position. Terminal competencies are also defined in the USA. The educational standard for nurse practitioner education in the USA is the Master s degree or post-master s level that was hastened by federal funding and national certification requirements (Joel, 2005). National certification for nurse practitioners entering practice today, for example, requires a Master s degree in nursing. However, we did not start out by requiring the Master s degree when nurse practitioners were introduced to the U.S. health care system in the 1960s. Today, we are debating whether the Doctor of Nursing Practice degree should be tomorrow s educational standard for advanced nursing practice. 26

25 Thus, while the nurse practitioner movement is just emerging in Western Australia, it seems timely to move educational standards toward the Master s degree even while the first cohort of students is completing the post-bachelor s certificate. Another emerging educational challenge I observed reflects a second needed debate: What is the clinical field of the graduate and what minimal educational standards are needed to produce the graduate? As noted, as I visited industry and talked with students and faculty. The clinical nurse consultant role in Western Australia appears to lack an educational or licensure standard to foster advanced practice or career advancement for clinical nurse consultant specialties. What I also observed among the first nurse practitioner students in Western Australia are roles that would more likely be called clinical nurse specialists in the USA. For example, while listening to student, industry and other stakeholder s descriptions of need, what appeared to be a common theme was the advanced clinical expert in circumscribed areas of practice (e.g. hepatology, oncology) who might be called something like an oncology nurse practitioner. While there are substantial opportunities among the emerging trends, good debate can help identify and define what clinical field of practice is really needed for industry and then what educational standards and outcome competencies must be demonstrated to produce this clinician. Undoubtedly, a well-trained, clinical expert has significant potential to impact industry through such evidence as reduced length of hospital stay, decreased complications and morbidities, early interventions, and disease prevention. This improves patient outcomes and has potential cost benefits to society. The challenge might be to determine what advanced practice roles best fit these emerging industry needs, what professional knowledge base is needed for these roles, and what skills best fit these roles. It may be advantageous to examine the current clinical nurse consultant structure and determine what professional development or enhanced educational strategies are required to improve industry services by further developing the clinical nurse consultant. By refining the emerging roles and terms, it may strengthen industry s vision for implementing these practices and developing business cases for employment. As noted earlier, primary care has been the historical domain for nurse practitioners in the USA, but new roles are emerging. The acute care nurse practitioner is emerging in both paediatric and adult settings and is developing in response to changes in industry that require new advanced roles for nurse practitioners related to care for the acutely ill patient (Keane & Becker, 2004). Both primary care and acute care seem to be emerging simultaneously as advanced practice roles in Western Australia. Another consideration for moving the nurse practitioner movement further into industry may be to define those differences in primary care and acute or tertiary care settings where nurse practitioners are likely to practise. Defining more clearly the vision for the nurse practitioner, coupled with a strong strategic plan for advancing the role, may provide the foundation to develop curriculum, credential nurse practitioners, determine appropriate scope of practice as well as to facilitate an easier process for preparing the business case. The professional debates about nurse practitioners for Western Australia also have implications for establishing national competency standards. In the USA, we have national entry-level competencies identified for program graduates prepared as adult, family, gerontological, paediatric, and women s health primary care nurse practitioners as well as psychiatric/mental health nurse practitioners. These identified competencies shape educational programs (National Panel for Psychiatric Mental Health NP Competencies, 27

26 2003 and U.S. Department of Health and Human Services, 2002). While we have four identified advanced nursing practice specialty areas nurse anesthetist, nurse midwifery, clinical nurse specialist, and nurse practitioner practice standards and competencies for all are driven by national standards, national certification, and state law all of which inform curriculum and practice. As the nurse practitioner role emerges, examining which populations are likely to benefit from nurse practitioner services may be part of the strategic argument for why the role needs to develop. Rural and remote as well as Aboriginal populations, for example, can substantially benefit from health care provided by nurse practitioners. Nurse practitioners have contributed significantly to improving health care access for rural and underserved populations in the USA. Determining which groups may benefit from nurse practitioners in Western Australia provides excellent opportunities for nursing as a profession to demonstrate solutions to both state and federal health initiatives. It is also important to consider what type of preparation is needed to best serve these populations. By and large, rural and remote practitioners need to function as multidisciplinary generalists and need a broad knowledge base from which to practise (Bushy, 2000). Primary care is the knowledge base needed, and the more remote the population, the more likely a generalist prepared to care for populations across the lifespan is ideal. Western Australia wisely adopted legislation to support the nurse practitioner movement. This is essential to define scope of practice, support reimbursement for services provided by nurse practitioners, and to sustain the new role. Legislation also sets parameters to assure quality because a legal scope of practice defines permissible boundaries for practice (Betts, Keepnews & Monarch, 2004). Health professionals are obligated to provide the highest quality of patient services. Strong legislation, a sufficiently rigorous educational preparation, and continuing education are essential professional obligations to assure quality care. Undoubtedly, there will be medico-legal debate and constraints in Western Australia similar to those we experience in the USA. Legislation at the early beginning of the nurse practitioner movement in Western Australia may help to level the playing field and provide the factors necessary to tackle the impractical turf wars that have historically plagued the nursing and medical professions over scope of practice issues. Legislation in Western Australia also provides a base to guide discussion about what type of preparation and legal regulations are needed to assure quality health care access to populations in Western Australia. In both Australia and the USA, for example, scope of practice for nurse practitioners is governed by individual state law. In the USA, state law also establishes the nature of the legal relationship between physician and nurse practitioner, which is usually accepted as collaborative. Defining the parameters of collaboration in Western Australia seems an important challenge to promote a fully utilised role. In addition, discussion between organised medicine and nursing seems necessary to define what collaboration means in Western Australia. For example, in the USA, collaboration generally does not mean delegatory or supervisory. However, collaboration is regulated and varies by state law from having a physician available for consultation or referral to submitting signed written agreements to some of the State Boards of Nursing sometimes for approval and sometimes for recording and documenting the parties agreement to participate in a collaborative agreement. Some states still require specific information such as lists or categories of medications that the nurse practitioners may prescribe. Yet, collaboration is changing in the USA with some states, including the District of Columbia, no longer requiring collaborative agreements with physicians. Every state also has some degree of prescriptive authority for nurse practitioners, which again, Western Australia wisely 28

27 legislated (Towers, 2003). Just as the USA grapples with the issues of boundaries and collaboration, it seems timely for Western Australia to begin similar dialogue. Thus, as new nursing roles emerge in response to changes in health care industry and society, wonderful opportunities to improve access to quality health care in Western Australia exist. Professional nursing in Western Australia, from my observations, values and holds a commitment to the highest standards for nurse practitioner education. As professional nursing grapples with assuring educational standards and competencies necessary to serve the public, so too must Australian society assure adequate support, including funding, for these educational nursing initiatives designed to further develop the profession and improve health care access and quality care. Defining what the role of nurse practitioner in Australia is with respect to health care needs will result in educational and regulatory standards and will test the boundaries of legislated authority to assure constant review and evolution of a reasonable scope of practice. My observations also affirm that professional nursing in Western Australia has the capacity and committed obligation to assure and regulate quality nurse practitioner practice, identify and develop needed resources and respond to the health needs of the State and nation. I look forward to seeing how the stakeholder groups will continue to develop the role and how Western Australian society receives nurse practitioners. It was a privilege to work with the nursing community in Western Australia and to participate in its history. I wish you every success. 29

28 References American Academy of Nurse Practitioners (2004). What is a Nurse Practitioner? Retrieved October 1, 2004, from Betts, V., Keepnews, D., & Monarch, K. (2004). The law, the courts, and the advanced practice nurse. In Lucille Joel (Ed.). Advanced Practice Nursing, (pp ). Philadelphia: F.A. Davis. Bushy, A. (2000). Orientation to Nursing in the Rural Community. Thousand Oaks, CA: Sage Publications. Joel, L. (2005). Advanced practice nursing in the current sociopolitical environment. In Joan Stanley, Advanced Practice Nursing, (2nd ed., pp ). Washington DC: F.A. Davis. Keane, A. & Becker, D. (2004). Emerging roles of the advanced practice nurse. In Lucille Joel (Ed.). Advanced Practice Nursing, (pp ). Philadelphia: F.A. Davis. Komnenich, P. (2005). The Evolution of Advanced Practice in Nursing. In Joan Stanley, Advanced Practice Nursing, (2nd ed., pp. 2-45), Washington DC: F.A. Davis. Mundinger, M., Kane, R., Lenz, E., Totten, A., Tsai, W., Cleary, P., Friedewald, W., Siu, A., & Shelanski, M. (2000). Primary care outcomes in patients treated by nurse practitioners or physicians. JAMA, 283 (1), National Panel for Psychiatric Mental Health NP Competencies, (2003). Psychiatric-mental health nurse practitioner competencies. Washington, DC: National Organization of Nurse Practitioner Faculties. Towers, J. (2003). Where are we now? The status of nurse practitioner practice in statute and regulation December Journal of the American Academy of Nurse Practitioners. 15 (2), U.S. Department of Health and Human Services. Health Resources and Services Administration, BrPH Division of Nursing. (April, 2002). Nurse Practitioner Primary Care Competencies in Specialty Areas: Adult, Family, Gerontological, Pediatric and Women s Health. Retrieved September 18, 2004, from

29 Advanced Nursing Practice: Developing and Implementing the Role of Advanced Nurse Practitioner in Ireland Kathleen Mac Lellan RGN, MSc, PhD Head of Professional Development and Continuing Education National Council for the Professional Development of Nursing and Midwifery Dublin, Ireland Abstract Nurse practitioner roles have developed internationally, expanding from initial population groups in primary care to include many other populations in both secondary and tertiary care settings. In Ireland the fi rst advanced nurse practitioner posts have emerged in acute care settings, notably in the emergency departments in general hospitals. Subsequently, posts in primary care are emerging and general hospital posts expanding to include breast care, diabetes, sexual health, rheumatology and other critical areas. Posts must meet the required criteria (level of autonomy, research, leadership and expert practitioner) outlined by the National Council for the Professional Development of Nursing and Midwifery in order to be established. The fi rst post was approved in emergency nursing in 2001, with the candidate accredited into the post in Candidates for advanced nurse practitioner posts must meet specifi ed criteria before being accredited and appointed into approved posts. The development of advanced nurse practitioner roles is part of an overall clinical career pathway from generalist to specialist and then advanced practice. Levels on this career pathway are linked with levels of educational preparation, responsibility and subsequent autonomy. Thirteen posts have been established to date in Ireland and many others are in progress. Advanced practice in nursing is fi rmly rooted in government policy and the development of advanced nurse practitioner roles in Ireland is part of the strategic development of the overall health service. Key words: nurse practitioner, career pathway, advanced practice. 31

30 Introduction The nurse practitioner role has developed internationally following the emergence of the role in the USA with Henry Silver and Loretta Ford in 1965 (Winson & Fox, 1995). Original roles developed due to the numbers of people without access to health care (Peterson-Sinclair, 1997) and primarily in the primary care setting (Cronenwett, 1995). Since then nurse practitioner practice has expanded to include many other populations in both secondary and tertiary care settings due to the need to improve access to healthcare, utilise the skills and expertise of nurses, and provide cost-effective quality care. Trials indicate high levels of patient satisfaction and high quality care with nurse practitioners (Cooper, Lindsay, Kinn & Swann 2002; Horrocks, Anderson & Salisbury, 2002; Reeve, Calabro &Adams-McNeill, 2000). In Ireland the first posts have emerged in acute care settings, notably in the emergency departments in general hospitals. Subsequently, posts in primary care are emerging and general hospital posts expanding to include breast care, diabetes, sexual health, rheumatology and many other critical areas. Ireland has chosen not to generate a list of proposed practice areas but encourages post development in direct response to identified patient/client need. Once a post meets the required criteria (level of autonomy, research, leadership and expert practitioner), this post will be approved as an advanced nurse practitioner (ANP) role. The term nurse practitioner is synonymous with advanced nurse practitioner. Candidates for ANP posts must meet the National Council for the Professional Development of Nursing and Midwifery s criteria before being accredited and appointed into approved posts. This paper outlines the development of ANP roles in Ireland from their inception in 2001 to proposed future development. The required educational preparation for the ANP postholder is detailed as are the requirements for preparing sites in which posts will be established. Background to Irish Nursing The last decade has witnessed unprecedented developments in Irish nursing. These developments have occurred with a view to retaining clinical nursing expertise at the patient/client interface within the context of changing health service needs and a modern health service reform programme. Reports such as the Report of the Commission on Nursing 1998: A Blueprint for the Future (Government of Ireland), Nurses and Midwives Understanding and Experiences of Empowerment in Ireland (Department of Health and Children, 2003a) and The Nursing and Midwifery Resource: Final Report of the Steering Group Towards Workforce Planning (DoHC, 2002) have supported and driven these developments. 32

31 Nursing in Ireland is regulated through the Nurses Act 1985 with An Bord Altranais (the nursing board) providing for registration, fitness to practice and education standards. In 1999 the National Council for the Professional Development of Nursing and Midwifery (National Council) was set up as a statutory agency to monitor the clinical career pathway, disburse continuing education funds and provide leadership in relation to professional development for nurses and midwives. Since 1994, registration education has been linked to 3rd level institutions through the registration/diploma in nursing studies. Under recommendations from the Report of the Commission on Nursing, (1998) pre-registration education has been solely at degree level since Since 1994 there has been increasing availability of post-registration education at higher/postgraduate diploma, Bachelor and Master s degree level. There are indications that more than 200 nurses have completed Master s degrees in nursing with a further 200 undertaking such programmes. A number of nurses are currently undertaking PhD programmes. The publication of the Scope of Nursing and Midwifery Practice Framework (An Bord Altranais, 2000a) has facilitated a new and empowering phase in Irish nursing. The framework was developed following consideration of national and international developments in nursing practice. Its aim is to support nurses in their determination, review and expansion of their scope of practice. Scope of practice is defined as the range of roles, functions, responsibilities and activities which a registered nurse is educated, competent and has authority to perform. The framework acknowledges the evolving roles of nurses and differentiates between the terms expansion and extension in favour of the former. Furthermore, it highlights the principles and values that should underpin role development and expansion. It is a pivotal document around which nurses in Ireland for the first time have the facility to develop their role within an agreed framework. Development of the Clinical Career Path The roots of specialism in Ireland can be traced to The Working Party on General Nursing Report (1980) which recommended the appointment of specialist nurses who would enhance the quality of nursing care and provide specialist-nursing advice to other nurses (Condell, 1998). However, until 1998 there was an absence of any framework for the development of a clinical career pathway in Ireland. The publication of the Report of the Commission on Nursing (Government of Ireland, 1998) detailed a new beginning for the development of clinical nurses. The Commission on Nursing was established following a Labour Court recommendation in March 1997 as a response to industrial action taken by nurses and midwives. The evolving role of nurses 33

32 reflecting their professional development was one of the terms of reference for the Commission, which subsequently made recommendations in relation to regulation of the profession, preparation for the profession, professional development, role of nurses and midwives in the management of services, nursing in the community, nursing in care of the older person, mental handicap nursing, midwifery and sick children s nursing. The development of ANP roles is part of an overall career pathway leading from generalist to specialist and then advanced practice. Levels on the clinical career pathway are linked with levels of educational preparation, responsibility and subsequent autonomy (see Figure 1). To support this each level is linked to particular pay scales to reflect respective levels of responsibility. It was felt the career pathway would support experienced nurses to remain at the clinical interface utilising their expert skills in improving patient outcomes and responding to health policy developments. Such an approach would lead to the creation of a multi-stage career pathway at clinical level. Responsibility for monitoring the career pathway lies with the National Council. Figure 1 - Clinical career pathway in Ireland Advanced Nurse Practitioners Core concepts Autonomy in clinical practice, professional and clinical leadership, expert practitioner & research (National Council for Nursing and Midwifery, 2001a) Master s degree level Clinical Nurse Specialist Core concepts Clinical practice, patient advocacy, consultation, education, research and audit (National Council for Nursing and Midwifery 2001b) Higher/ postgraduate diploma level Registration qualification (general, psychiatry, mental handicap) Domains of competence Professional/ethical practice, holistic approaches to care and integration of knowledge, interpersonal relationships, organisation and management of care, personal and professional development (An Bord Altranais, 2000b) Degree level 34

33 Establishment of ANPs in Ireland Part of the main functioning of the National Council as determined by the Report of the Commission on Nursing (1998) is to bring about a coherent approach to the progression of specialisation and the development of career pathways for nurses and midwives, and to monitor the ongoing development of nursing specialities, taking into account changes in practice and service need (Government of Ireland, 1998). To this end, the National Council has developed definitions and core concepts of the roles of the Clinical Nurse Specialist (NCNM, 2001b) and ANP (NCNM, 2001a). The definition of ANP as outlined by the National Council is as follows: Advanced nursing practice is carried out by autonomous, experienced practitioners who are competent, accountable and responsible for their own practice. They are highly experienced in clinical practice and are educated to masters degree level (or higher). The postgraduate programme must be in nursing or an area which is highly relevant to the specialist field of practice (educational preparation must include substantial clinical modular component(s) pertaining to the relevant area of specialist practice). ANPs promote wellness, offer healthcare interventions and advocate healthy lifestyle choices for patients/clients, their families and carers in a wide variety of settings in collaboration with other healthcare professionals, according to agreed scope of practice guidelines. They utilise advanced clinical nursing knowledge and critical thinking skills to independently provide optimum patient/client care through caseload management of acute and/or chronic illness. Advanced nursing practice is grounded in the theory and practice of nursing and incorporates nursing and other related research, management and leadership theories and skills in order to encourage a collegiate, multidisciplinary approach to quality patient/client care. ANP roles are developed in response to patient/client need and healthcare service requirements at local, national and international level. ANPs must have a vision of areas of nursing practice that can be developed beyond the current scope of nursing practice and a commitment to the development of these areas. Core Concepts of Advanced Nursing Practice The National Council outlines four core concepts of the ANP role: autonomy in clinical practice, expert practitioner, professional and clinical leadership, and researcher. Autonomy in Clinical Practice An autonomous ANP is accountable and responsible for advanced levels of decision-making which occur through management of specific patient/ client caseload. ANPs may conduct comprehensive health assessments and demonstrate expert skill in the clinical diagnosis and treatment of acute and/ or chronic illness from within a collaboratively agreed scope of practice framework. The crucial factor in determining advanced nursing practice, however, is the level of decision-making and responsibility rather than 35

34 the nature or difficulty of the task undertaken by the practitioner. Nursing knowledge and experience should continuously inform the ANP decision making, even though some parts of the role may overlap the medical or other healthcare professional role. Professional and Clinical Leadership ANPs are pioneers and clinical leaders in that they may initiate and implement changes in healthcare service in response to patient/client need and service demand. They must have a vision of areas of nursing practice that can be developed beyond the current scope of nursing practice and a commitment to the development of these areas. They provide new and additional health services to many communities in collaboration with other healthcare professionals to meet a growing need that is identified both locally and nationally by healthcare management and governmental organisations. ANPs participate in educating nursing staff and other healthcare professionals through role-modelling, mentoring, sharing and facilitating the exchange of knowledge both in the classroom, the clinical area and the wider community. Expert Practitioners Expert practitioners demonstrate practical and theoretical knowledge and critical thinking skills that are acknowledged by their peers as exemplary. They also demonstrate the ability to articulate and rationalise the concept of advanced practice. Education must be at Master s degree level (or higher) in a programme relevant to the area of specialist practice and which encompasses a major clinical component. This post-graduate education will maximise pre- and post-registration nursing curricula to enable the ANP to assimilate a wide range of knowledge and understanding which is applied to clinical practice. Researcher ANPs are required to initiate and co-ordinate nursing audit and research. They identify and integrate nursing research in areas of the healthcare environment that can incorporate best evidence-based practice to meet patient/client and service need. They are required to carry out nursing research which contributes to quality patient/client care and which advances nursing and health policy development, implementation and evaluation. They demonstrate accountability by initiating and participating in audit of their practice. The application of evidence based practice, audit and research will inform and evaluate practice and thus contribute to the professional body of nursing knowledge both nationally and internationally. 36

35 The document Framework for the Establishment of Advanced Nurse and Advanced Midwife Practitioner Posts outlines the process for approval of ANP posts and accreditation of ANPs (NCNM, 2001a). The process for the establishment of an ANP service comprises two important parts. Firstly, the service applies to have the job description and site approved for an ANP post. Figure 2 outlines the process. Figure 2 - Establishment of ANP posts: Part 1 - Job description and site preparation Job Description Site Preparation Identification ion of need for ANP post Development of job description Submission of Site preparationation application to National Council Review of application by accreditation committee, National Council ANP Requirements Nurses may conform to the definition of, or meet the accreditation criteria for, ANPs (see Table 1); however, they will be eligible to apply to be accredited as an ANP only when they are employed in an approved ANP post. Each nurse must undergo the accreditation process of the National Council before he/she can use the title ANP. Therefore, the title must only be used by nurses who are accredited as ANPs by the National Council. Table 1 - Criteria for eligibility for application for ANP accreditation 1. Be a registered nurse on An Bord Altranais live register; 2. Be registered in the division of An Bord Altranais live register for which the application is being made; 3. Be educated to Master s degree level (or higher). The postgraduate programme must be in nursing or an area which reflects the specialist field of practice. Educational preparation must include a substantial clinical modular component(s) pertaining to the relevant area of specialist practice; 4. Have a minimum of seven years post-registration experience, which will include five years experience in the chosen area of specialist practice; 5. Have substantive hours at supervised advanced practice level; 6. Have the competence to exercise higher levels of judgment, discretion and decision-making in the clinical area above that expected of the nurse working at primary practice level or of the clinical nurse specialist; 7. Demonstrate competencies relevant to context of practice; and 8. Provide evidence of continuing professional development. 37

36 Secondly, the nurse recruited by the service provider applies to be accredited as an ANP to the approved post (see Figure 3). Figure 3 - Establishment of ANP posts: Part 2 - Individual accreditation Accreditation of the ANP Application form and portfolio completed Submission of application ation to National Council Review of application by accreditation committee, National Council An accreditation committee comprising of seven members reviews all applications for both post and person. The committee consists of: Chief Nursing Officer (Department of Health and Children) Senior nurse manager member of the National Council Discipline-specific member of the National Council Third-level institution, member of the National Council Discipline-specific person outside the National Council Chief Executive Officer, National Council Head of Professional Development and Continuing Education, National Council. To date 13 ANP posts have been developed by services and approved by the National Council and seven ANPs have been accredited into these posts. Their areas of practice include emergency, rheumatology and sexual health. The posts established reflect service needs identified in specific areas and their development has required creativity and leadership on behalf of all those involved. The development of these initial posts has paved the way for other service providers to use nursing expertise to respond to patient/client and service need. The anticipated healthcare need, scope of practice and clinical outcomes for the approved posts are outlined below (see Table 2). 38

37 Table 2 - Examples of ANP posts approved in Ireland Post (Areas of clinical practice) Identified healthcare need Scope of practice examples of sample activities Clinical outcomes anticipated Emergency Increased patient attendance to accident and emergency with minor injuries accounting for approximately 20-40% of attendances Assessment, treatment, discharge or referral of patients with a range of common emergency department complaints (e.g. soft tissue injuries in upper and lower limbs, minor burns, chronic wound management) Reduction in waiting times Reduction in delays in assessment and treatment Increased patient satisfaction Sexual Health Rheumatology Increased incidence of sexually transmitted infections Prevalence of Rheumatoid Arthritis is between 0.5 and 1% of population Sexual health promotion and screening, and management of uncomplicated sexually transmitted infections and young persons clinics Chronic rheumatic disease management, development of childhood and adolescent rheumatology services, complex case management, biologic therapy, pain management Provision of holistic care with responsive streamlined services Reduction in waiting times Increased patient satisfaction Empowerment of patients and families Timely access to expert holistic care Reduction in waiting times Increased patient satisfaction Research on ANP Posts in Ireland Considerable research about ANPs in Ireland has been undertaken. Table 3 outlines some of these studies. Table 3 - Research on ANP Posts in Ireland Title Numbers Main outcomes Lived experiences of student ANPs undertaking a training programme (Focus group and interview) (McCawley 2002) Patient satisfaction with ANP service in an inner-city emergency department (Questionnaire) (Keenan 2002) An evaluation of the role and scope of practice of ANPs in an urban teaching hospital (Chart review) (Small 1999) Attitudes and perceptions of medical and nursing staff to an ANP service (Questionnaire) (Olivia Smith 2000) Patients perception of an ANP service (Interviews) (Dunne 2001) Focus group (1) Interview (7) Positively evaluated training programme Suggested areas for course refinement (radiology and pharmacology). Master s degree level preparation integral part of the role High level satisfaction Holistic approach to care offered Majority of patients were young males with hand injuries who self-referred Favourable triage times Very positive Concern regarding erosion of traditional role of nurse and litigation Communication, waiting times and satisfaction with ANPs very positive 39

38 Discussion The development of ANP roles in Ireland is part of the strategic development of the overall health service and is taking place in the context of contemporary health and social policy, the requirements of population health and the service planning process. National policy including both the national health strategy document Quality and Fairness: A Health System for You (2001) and the Report of the National Task Force on Medical Staffi ng (2003) recommend the development of further ANP posts in nursing within the framework of the National Council. Such support for ANP roles at national level is welcomed by Irish nurses and provides for a developing framework for the clinical career pathway for nurses. The issue of introducing nurse prescribing is currently being considered by a national project being conducted under the auspices of An Bord Altranais and the National Council. Such development is critical to ensure the autonomy of the ANP role. There are three education programmes at Master s degree level currently in place to prepare nurses to advanced practice level. Dedicated education programmes will need to develop further and on a regional basis to support the continued development of the ANP role in Ireland. The development of ANP roles takes place within the context of the entire career pathway, for nurses with intraprofessional working and leadership encouraged. The career pathway which is based on robust processes and criteria, provides attractive options for nurses upon registration as they embark on their career. It is hoped that creating avenues for nurses at the patient/client interface to increase their levels of responsibility, develop skills and expertise, and become more competent in particular areas will enhance service provision, retain staff and contribute to population health. Irish nurses have enhanced and expanded their roles to provide for service need and greater quality patient care in a strategic and planned manner and are critical to the successful implementation of Ireland s current health service reform programme. Evaluation of the ANP role at national level is important in order to review processes and effectiveness of the role. To this end, the National Council has commenced a research project with specific terms of reference to review the effectiveness of the role and factors affecting its development. It is anticipated that this research will provide valuable recommendations for the continued development of nurses to this level of practice in Ireland. Irish nurses can look forward to a rich and rewarding career which is contributing to the quality and scope of the Irish health service. A second edition of the National Council framework for the establishment for ANPs in Ireland will be published in November The process for establishment of posts and accreditation of ANPs will remain the same 40

39 however additions to the document include descriptors for core competencies for advanced practice and templates for the job description and portfolio. An accredited ANP will now form part of the National Council accreditation committee. These additions reflect the stage of development of advanced practice in Ireland and will support the continued development of ANP roles. 41

40 References An Bord Altranais. (2000a). Scope of nursing and midwifery practice framework. Dublin: An Bord Altranais. An Bord Altranais. (2000b). Requirements and standards for nurse registration education programmes (2nd edn). Dublin: An Bord Altranais. Condell, S. (1998). Changes in the professional role of nurses in Ireland: A report prepared for the commission on nursing. Dublin: Stationery Office Dublin. Cooper, M.A., Lindsay, G.M., Kinn, S. and Swann, I.J. (2002). Evaluating emergency nurse practitioner services: A randomized controlled trial. Journal of Advanced Nursing, 40(6), Cronenwett, L.R. (1995). Molding the future of advanced practice nursing. Nursing Outlook, 43(3), Department of Health and Children (2001). Quality and fairness: A health system for you. Dublin: Stationery Office Dublin. Department of Health and Children. (2002). The nursing and midwifery resource: fi nal report of the steering group towards workforce planning. Dublin: Nursing Policy Division, Department of Health and Children. Department of Health and Children. (2003a). Nurses and midwives understanding and experiences of empowerment in Ireland.. Dublin: Nursing Policy Division, Department of Health and Children. Department of Health and Children. (2003b). Report of the national task force on medical staffing. Dublin: Stationery Office Dublin. Dunne, G. (2001). Patients perception of an ANP service. Unpublished. MSc (Nursing) Dissertation. University of Dublin. Government of Ireland. (1985). Nurses Act Dublin: Stationery Office Dublin. Government of Ireland. (1998). Report of the commission on nursing: A blueprint for the future. Dublin: Stationery Office Dublin. 42

41 Horrocks, S., Anderson, E. and Salisbury, C. (2002). Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal, (324), Keenan, M. (2002). Patient satisfaction with ANP service in an inner city emergency department. Unpublished. MSc (Nursing) Dissertation. University of Dublin. McCawley, N. (2002). A qualitative study of the lived experiences of student advanced nurse practitioners undertaking the training programme. Unpublished. MSc (Nursing) Dissertation, University of Dublin. National Council for the Professional Development of Nursing and Midwifery. (2001a). Clinical nurse/midwife specialists intermediate pathway. Dublin: National Council for the Professional Development of Nursing and Midwifery, Dublin. National Council for the Professional Development of Nursing and Midwifery. (2001b). Framework for the establishment of advanced nurse/midwife practitioners. Dublin: National Council for the Professional Development of Nursing and Midwifery. National Council for the Professional Development of Nursing and Midwifery. (2004). An evaluation of the effectiveness of the role of the clinical nurse and midwife specialist. Dublin: National Council for the Professional Development of Nursing and Midwifery. Peterson-Sinclair, B. (1997). Advanced practice nurses in integrated health care systems. Journal of Obstetric, Gynaecologic and Neonatal Nursing, 26(2), Reeve, K., Calabro, K. and Adams-McNeill, J. (2000). Tobacco cessation intervention in a nurse practitioner managed clinic. Journal of Academy of Nurse Practitioners, 12(5), Small, V. (1999). An evaluation of the role and scope of practice of ENPs in an urban teaching hospital. Unpublished. MSc (Nursing) Dissertation, University of Dublin. 43

42 Smith, O. (2000). Attitudes and perceptions of medical and nursing staff to an ENP service.unpublished.msc (Nursing) Dissertation, University of Dublin. Winson, G. and Fox, J. (1995). Nurse practitioners: the north american experience. British Journal of Nursing, 4(22), Working Party on General Nursing. (1980). Report of the working party on general nursing. Dublin: Stationery Office Dublin. 44

43 Nurse Practitioners Role in Promoting Radiation Safety in Western Australia Ms Elizabeth Adams RGN Cert(ODN) BNS(Hons) Dip(Mgt) Dip(Counselling) Dip(Phy & Chem) PGDip(Stats) MSc Office of the Chief Nursing Officer Department of Health, Western Australia Prof Cecily Begley RGN RM RNT DipNEd Dip Stats FFNRCSI MSc PhD Chair of Nursing and Midwifery/Director, School of Nursing and Midwifery Studies Trinity College Dublin, Ireland Abstract On 9 April 2003 legislation came into effect to allow nurse practitioners to practise in designated areas in Western Australia using evidence-based clinical protocols. The legislative changes included amendments to the Radiation Safety Act 1975 to allow a nurse practitioner to request the holder of a licence under the Act to undertake diagnosis or therapy. X-rays, because of their high energy levels, can result in cellular death, mutation or abnormal division. Adverse effects from exposure to lowlevel ionising radiation increases the risk of cancers, although the precise level at which radiation presents a health hazard has not been established with any great certainty. Radiation has a cumulative effect and it may be a number of years, or even decades before low dose induced cancers become apparent. Most researchers agree that there seems to be a direct relationship between health risks and the amount of radiation exposure, but exactly what these risks are remains the subject of much debate. Ionising radiation regulations require that all necessary steps are taken to restrict, so far as is reasonably practicable, the extent to which patients and health-care personnel are exposed to ionising radiation. Without expert practitioner knowledge, understanding, and well-informed evidencebased practice regarding ionising radiation, personal health and that of colleagues and patients would be compromised. It is recommended by the International Commission on Radiological Protection that occupationally exposed workers take as many precautions as possible to minimise exposure through the principles of justifi cation, optimisation and dose limitation. 45

44 There is a signifi cant body of knowledge relating to radiation that nurse practitioners must assimilate and incorporate into their clinical practice to ensure the safe, effi cient and effective use of the resource. This paper provides a brief background on the history, legislation, international and national governing bodies, dosimetry, sources, biological effects and basic principles to prevent unnecessary exposure of patients and health-care personnel to ionising radiation. Keywords: nurse practitioners, radiation sources, deterministic and stochastic effects, prevention of exposure. Introduction On 9 April 2003 amendments to seven Acts and one Regulation came into effect to allow nurse practitioners to practise in designated areas of Western Australia. The Radiation Safety Act 1975 was one Act amended to allow a nurse practitioner to request the holder of a licence under the Act to undertake diagnosis or therapy. Nurse practitioners in Western Australia can only practise using evidence-based clinical protocols in an area designated by the Director General of Health. The amendments to the Poisons Regulations 1965 requires that before the Director General of Health can designate an area, clinical protocols for the specific area must be approved by the Executive Director of Population Health, Chief Medical Officer and the Chief Nursing Officer (Department of Health, 2003a). Prior to applying for an area to be designated, the health service/organisation must establish a clinical protocol and a peer review panel that is representative of the interdisciplinary team. If the scope of practice for the designated area is to include a requisition for the use of radiation, the interdisciplinary and peer review panel must include representatives with expertise in this field, for example radiologists, physicists, radiographers and/or technologists (Department of Health, 2003b). In regard to the use of radiation in diagnosis and treatment, clinical protocols must reflect the legislation and assist nurse practitioners to make appropriate decisions to implement the current best evidence into practice. The development and use of clinical protocols will ensure that the request for diagnosis or therapy is justified, safe and leads to an optimum and appropriate outcome for the patient. With the privilege to request diagnosis or therapy, nurse practitioners have a legal, professional, ethical and moral responsibility to ensure the safe and efficient use of the resource. In addition, nurse practitioners are responsible and accountable for their clinical decisions and therefore must have a knowledge and understanding of the legislation and regulations governing radiation exposure, dosimetry, benefits and dangers of ionising radiation, and the prevention of unnecessary exposure (Department of Health, 2003a). 46

45 Historical Overview In November 1895, x-radiation was discovered by Wilhelm Conrad Roentgen, a professor of physics at the Institute of Wurzburg in Germany (Strohl, 1990). He was awarded the first Nobel Prize for Physics in 1901 and died from carcinoma of the intestines in 1923, possibly as a result of his experimentation with x-radiation (Bury, 2002). Ionising radiation can be injurious to living cells, even in small doses. Radiation can disturb the delicate bio-chemical functions of living tissue. The hazards were not appreciated at first, particularly the effects of repeated low dose exposure which were not manifested for many years. By 1922, 100 cancerous deaths of radiologists had been recorded, which led to the development of international societies and protection recommendations (Cullinan, 1995). International Bodies In 1928, an independent non-governmental body of experts formed the International X-ray and Radium Protection Committee, later renamed the International Commission on Radiological Protection (ICRP). Its purpose was to establish basic principles and recommendations on radiation protection. In the early days it simply recommended a dose limit that should not be exceeded. It now assumes that there is no dose level at which we can be sure that there is no risk. As with all activities that carry some risk, the balance between the possible dangers and benefits obtained has to be considered. The ICRP s body of scientific experts is recognised worldwide and has been providing advice on protection and radiation for 76 years (ICRP, 1990a). Recommendations from the ICRP have been accepted and incorporated by groups such as the International Atomic Energy Agency into their basic safety standards for radiation protection, which are published in conjunction with the World Health Organisation, the International Labour Organisation, the Organisation for Economic Co-operation and Development/Nuclear Energy Agency, and the Australian Radiation Protection and Nuclear Safety Agency (ARPANSA). In 1990, the recommendations from the ICRP were universally agreed upon and became known as ICRP 60. The ICRP recommends that any exposure above the natural background should be as low as is reasonably achievable. The ICRP emphasises that ionising radiation needs to be treated with care rather than fear and that its risks should be kept in perspective with other risks (ICRP, 1990b). 47

46 Another International and inter-governmental body was founded in 1955 by the General Assembly of the United Nations into the United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR). UNSCEAR was directed to assemble, study and disseminate information on observed levels of ionising radiation and radioactivity in the environment (UNSCEAR, 1988). Australian Bodies Regulatory controls in Australia regarding radiation safety have existed since the 1950s. Under Section 15(1)(a) of the Australian Radiation Protection and Nuclear Safety Act 1998, ARPANSA was deemed the Australian Government agency charged with responsibility for protecting the health and safety of people and the environment from the harmful effects of ionising radiation. (ARPANSA, 2001). The Radiation Health and Safety Advisory Council and the Radiation Health Committee established under the Act to advise the ARPANSA and develop policies, standards and codes has expert members from each State and Territory including Western Australia (ARPNSA and NOHSC, 2002). Among other functions, ARPANSA has the responsibility for promoting uniformity of radiation protection and nuclear safety policy and practices across Australia. It has published the National Directory for Radiation Protection Edition 1.0 to provide an overall agreed framework for radiation safety and comprehensive resources to establish and maintain a uniform legislative framework for radiation in Australia (ARPANSA, 2004). The Directory is a dynamic document, with changes being made to accommodate new issues as they arise. The regulatory framework in each Australian jurisdiction must follow the principles and requirements outlined in the directory in relation to radiation protection, management, technical issues, and the process for verification of safety and security, risk management and intervention actions for accidental or abnormal exposures (ARPANSA, 2004). In addition, ARPANSA publishes the Radiation Protection Series which has four categories: Radiation Protection Standards, which set fundamental requirements for safety Codes of Practice, which set practice-specific requirements that must be satisfied to ensure an acceptable level of safety Recommendations providing guidance on fundamental principles for radiation protection 48

47 Safety Guides providing practice-specific guidance on achieving the requirements set out in the standards and codes (ARPANSA, 2004). Other national organisations that make a significant contribution to radiation protection are: The National Health and Medical Research Council (NHMRC), which in the past published recommendations on radiation protection in its Radiation Health Series. The National Occupational Health and Safety Commission (NOHSC), which was established by the Australian Government under the National Occupational Health and Safety Commission Act 1985 to develop and implement a national occupational health and safety `strategy (ARPNSA and NOHSC, 2002). Each state in Australia has legislation relating to protection against exposure to ionising radiation. Permissible levels of exposure to ionising radiation and radioactive materials in the legislation are generally based on the recommendations from ARPANSA and the International Commission on Radiological Protection (ARPANSA, 2004). In Western Australia the regulatory and registration authority established under section 13 of the Radiation Safety Act 1975 is the Radiological Council. The Radiological Council administers the licensing and registration of radioactive substances and apparatus, and advises the Minister on the technical aspects of radiation protection. Radiation Dose Measurement Radioactivity is measured in terms of the number of disintegrations per second. The unit of radioactivity is the Becquerel (Bq), which corresponds to one disintegration per second. The Becquerel is a very small unit; for example, an adult contains several thousand Becquerels of a naturally radioactive substance called potassium-40. This means that every second there are several thousand radioactive nuclei, each emitting radiation inside us (Glass, Basinki, & Krasne, 1999). The amount of radiation energy that is absorbed per kilogram of tissue is called the absorbed dose and is measured in units known as Grays (Gy). A further distinction must be made regarding types of radiation since alpha radiation is much more damaging than either beta or gamma, so its dose needs to be weighted according to its potential to cause damage. Alpha radiation therefore has 20 times the weight of others. This weighted dose is known as the equivalent dose and is measured in units called Sieverts 49

48 (Sv). The Sievert is the SI unit and has largely replaced an older unit called the rem. One Sievert is equal to 100 rems and a milli-sievert (msv) is onethousandth of a Sievert (Plaut, 1993). Another refinement is made to the measuring unit, as some parts of the body are more vulnerable than others. For example, radiation is more likely to cause fatal cancer in the lung than the thyroid. Different parts of the body are also given weightings (Antonelli et al., 1995). Once it has been weighted appropriately, the dose equivalent becomes the effective dose. If all of the individual dose equivalents received by a group are totalled, the result is called the collective effective dose expressed in Man-Sieverts (Man-Sv) (Plaut, 1993). Natural Radiation Sources Radiation has always been in existence and surrounding us in our daily lives. UNSCEAR (2000a) estimates the worldwide annual per capita dose of natural radiation is 2.4 msv (range between 1 msv and 10 msv). However, the range is wide and it is estimated that 65 per cent of people would expect to have an annual effective dose between 1 msv and 3 msv, approximately 25 per cent would have less than 1 msv and 10 per cent would have an effective dose greater than 3 msv. Table 1 presents the average radiation dose from natural sources. Table 1 - Average radiation dose from natural sources Source External exposure Worldwide average annual effective dose (msv) Typical range (msv) Cosmic rays 0.4 * Terrestrial gamma rays 0.5 ** Internal exposure Inhalation (mainly radon) 1.2 *** Ingestion 0.3 **** Total Note: * Range from sea level to high ground elevation ** Depending on radionuclide composition of soil and building materials *** Depending on indoor accumulation of radon gas **** Depending on radionuclide composition of foods and drinking water Source: United Nations Scientific Committee on the Effects of Atomic Radiation (2000, Volume I, p5) 50

49 Man-made Sources The largest and increasing man-made source of radiation exposure is medical use (UNSCEAR, 2000a). Medical radiation is used for both diagnosing and treating disease. It includes diagnostic radiology, radiotherapy, nuclear medicine and interventional radiology. Diagnostic x-radiation is the commonest form and in most industrial countries there are between 300 and 900 examinations for every thousand inhabitants, of which over half of these are x-ray examinations. Although there are less data from the developing countries, information indicates that their examination rates do not exceed 100 to 200 per thousand inhabitants. UNSCEAR (2000b) reports that diagnostic exposures administer relatively low doses to individual patients (effective doses range msv typically). Therapeutic exposures are considerably higher than diagnostic procedures. Prescribed dose ranges suggested for therapeutic exposures are estimated to be typically between 20 and 60 Gy (UNSCEAR, 2000a). Over recent years there have been regulatory and technical improvements that, if applied correctly, should reduce unnecessary doses to patients and health-care personnel from x-ray examinations. Data reviewed by the British National Radiological Protection Board in 1996 from 375 United Kingdom hospitals showed an average reduction of 30 per cent in mean doses for common types of x-ray examinations compared with a similar survey conducted in the mid-1980s. These dose reductions are attributed to the establishment of diagnostic reference levels in the early 1990s, resulting in improved departmental quality assurance and clinical audit programs (Wall, 2001). In 2001, ARPANSA published a National Competition Policy Review of Radiation Protection Legislation (ARPNSA, 2001). The review found that data were limited on the extent to which radiation was used in Australia. However, it estimated that approximately 100,000 Australians were influenced occupationally by radiation protection legislation. The majority of those who used radiation were health workers involved in diagnostic or therapeutic use of x-rays or radioactive pharmaceutical products used in nuclear medicine (ARPNSA, 2001). 51

50 Biological Effects of Ionising Radiation Uncertainty exists about the biological effects of ionising radiation at low doses and according to UNSCEAR (2000b) much about the process remains to be learned. Since there is minimal research on low doses, data are derived from high-dose studies. Studies on approximately 86,572 people who survived the atom bomb explosion at Hiroshima and Nagasaki in 1945 have found that cancer is the only cause of increased mortality (UNSCEAR, 2000b and ICRP, 1990b). In the Life Span Study cohort of survivors, there were 7,587 deaths from solid tumours during 1950 to Of the cancer deaths, 334 were attributed to radiation exposure. During the same period, 87 of the 249 leukaemia deaths could be attributed to radiation exposure. Approximately half of the atomic bomb population are still alive and UNSCEAR (2000b) states additional study is necessary in order to obtain the complete cancer experience of the group. In addition to the atom bomb survivors, UNSCEAR (1994) also relies on research on cancer rates among: Pacific Islanders contaminated by fall out from bomb tests in 1945 Uranium miners and people who receive radiation therapy Nuclear energy workers such as those employed at the Sellafield processing plant in Cumbria, United Kingdom and information acquired through nuclear accidents, for example, Chernobyl The Hiroshima and Nagasaki studies, however, are the only studies that for more than 57 years have closely followed large numbers of people of all ages who were exposed relatively uniformly to radiation over their whole bodies (Draper et al., 1997). Ionising radiation is harmful as it changes the electrical charge of some atoms and molecules in cells, removing an electron from the atom. The genetic material Deoxyribonucleic acid (DNA) is the most critical structure affected in this way (UNSCEAR, 2000b). Cells are mostly composed of water; therefore, most radiation interactions occur with water molecules. DNA may be altered by a direct or indirect incident. Radiation ionises water molecules and electrons are released. The ionised water molecules can react further forming highly reactive molecules such as hydrogen peroxide, or radicals such as hydroperoxyl. These reactive species can then indirectly attack the DNA. Chemical changes of the DNA chains may simply damage sections that may be repaired with little or no effect on the overall cell function, or they may cause lethal change such as the inability to synthesise an essential enzyme (Sommargren, 1995). Damage to cellular components (epigenetic changes) may influence the functioning of the cell and initiate progression to a malignant state (Parker, Pearce, Dickinson, Aitkin & Craft, 1999). 52

51 If damage occurs in cells generating sperm or ova, inheritable genetic defects may occur (Ackland, 1993). Somatic effects such as cancer can be another possible occurrence. Damage depends upon the amount of radiation received (dose) and the time-span over which it is received (rate) (House, 1999). One gene that is lost or mutated in more than half of all human tumours is the TP53 protein. UNSCEAR (2000b) states misrepaired radiation damage gives the potential for progression to cancer induction or hereditary disease. According to UNSCEAR, examples of organs known to be affected by radiation are the lungs, breast and thyroid gland, but not other organs such as the prostate gland. In conclusion, UNSCEAR (2000b) indicates that from what is known, even at low doses, radiation may act as a mutational initiator of tumorigenesis. Deterministic and Stochastic Effects The biological effects of radiation are generally classified as being either deterministic or stochastic. Deterministic effects are associated with high doses and stem primarily from killing of cells. Stochastic effects are associated with low doses and stem primarily from damage to cells. With deterministic effects, the size of the dose largely determines the severity of the biological effects. The biological effect will not be seen below the threshold for the effect (Glaze, 1994). To place limits and risks in context, high doses cause deterministic effects as shown in Table 2. Table 2 - Deterministic effects 20Sv: Death will occur within hours due to CNS failure 5-10Sv: Death within days due to destruction of cells in gut lining 2-5Sv: Death within weeks due to bone marrow failure. Note: A Sievert (Sv) is a very large measure of radiation. Occupational exposure is recorded in milli Sieverts (msv). Source: Glaze, S. (1994) On the other hand, with stochastic effects there is no threshold dose. The probability or chance of a biological effect such as a cancer or genetic effect increases with dose. As the dose is reduced, risks of effects are reduced; however, the risk is assumed to be always greater than zero. The severity of the effect is unrelated to dose (Lentle, 2000). To evaluate the effect of longterm exposure to low dose ionising radiation, Berrington, Darby, Weiss & Doll (2001) examined mortality patterns of British radiologists from 1897 to It was shown that radiologists who had registered with a radiological society before 1921 had a significantly higher death rate from cancer than that of medical practitioners in general. However, on examination of radiologists registered after 1921, the data showed that the total mortality rate from cancer was not significantly increased and this was attributed to improvements in radiation protection practices. 53

52 Prevention of exposure Historically the ordering of x-ray examinations has come exclusively from within the boundaries of the medical profession throughout the world. In recent years with the development of advanced nursing practice and nurse practitioners roles, there has been a paradigm shift towards nurses ordering routine diagnostic imaging tests. As this is a new phenomenon in nursing, there is considerably more research published on physician x-ray ordering than nurse x-ray ordering (Tye, 1997). Indiscriminate use of radiation occurs when diagnostic tests are ordered without first considering a number of issues, such as: Will the test provide useful new information not obtainable by other means? Will the results of the diagnostic tests lead to changes in the patient s treatment? These tests are occasionally ordered as routine or as rule-outs. It is reported that x-rays are sometimes ordered for trauma patients to protect against malpractice suits (Oakley, 1990). Between 1979 and 1981, studies by the Royal College of Radiologists in Britain found considerable overutilisation of routine preoperative x-rays and skull radiography following head injury (Sanford, 1991). In a more recent survey, the Royal College of Radiologists in Britain found that some doctors were ordering up to 25 times more x-ray examinations for every 100 patients than some of their colleagues and were unable to explain this phenomenon. It also revealed that five or six centres could not meet the legal requirements set out in the 1988 Ionising Radiation Regulations, which specify that doses of radiation must be kept as low as reasonably achievable (Wall, 2001). In a survey conducted between 1987 and 1989, The British National Radiological Protection Board stated that the overuse of x-rays was causing up to 250 of the 160,000 cancer fatalities occurring each year. It went on to state that this statistic could be lessened by eliminating unnecessary examinations, reducing repeat x-rays and reducing radiation doses delivered in each examination (National Radiological Protection Board, 1993). Internationally, studies that have specifically investigated emergency nurse practitioners ordering x-rays report no significant differences in the ability to request appropriately compared to casualty officers (Macleod & Freeland 1992, Freij, Duffy, Hackett, Cunningham & Fothergill, 1996). In Australia, one study that examined the intention to treat found a good correlation between nurses and medical personnel in the rate of finding abnormalities on x-ray, with 41 per cent for nurses and 36 per cent for medical staff (Kelly, McCarthy, Richardson, Parris & Kerr, 1995). Another Australian study in a single metropolitan emergency department investigated whether triage nurses could safely, accurately and appropriately order x-rays for patients 54

53 with distal limb injuries. Following the completion of an education program, triage nurses offered patients the option of having an x-ray before seeing the physician. During the 12 month study, triage nurses ordered 49 per cent (n=876) of x-rays and physicians ordered 51 per cent (n=930). The abnormality rate for x-rays ordered by nurses was 43 per cent (n=390) compared with 33 per cent (n=309) for medical staff. The study concluded that with a structured education program, triage nurses at one institution safely assessed patients and ordered appropriate distal limb x-rays prior to physicians assessments (Fry, 2001). Radiation Protection Radiation protection deals with exposure to radiation in three groups: occupational, medical and public. The ARPANSA (2002) base its recommendations for the prevention of exposure on the ICRP 60 (1990) guidelines, which promote and encourage three principles: justification, optimisation and dose limitation. Justification Justification involves a demonstration that every exposure is justified in terms of the benefit it brings against the risk. Optimisation The aim of optimisation is to ensure that the magnitude of individual doses and the number of people exposed should be kept as low as reasonably achievable. This is known as the ALARA principle. The three combined approaches to the ALARA principle are as follows: Exposure time Experience is a major factor for reducing exposure time in fluoroscopy procedures, as is the use of image-freezing devices. Sharing work involving high levels of exposure can help to reduce individual doses considerably. Distance The amount of radiation exposure received is directly correlated to the distance from the source and is governed by the inverse square law. The inverse square law states that the distance from the source will influence the dose-rate received, which decreases in proportion to the distance squared from the source. Table 3 illustrates the concept of inverse square law. 55

54 Table 3 - Illustration of the inverse square law Distance Distance Increased Body Dose 1 metre units 2 metres 2 squared = 4 metres 25 units 4 metres 4 squared = 16 metres 6.25 units Note: Doubling the distance reduces the exposure rate by a factor of four Shielding Adequate shielding wearing lead rubber aprons, gloves, lead glasses, thyroid shields and portable lead screens reduce doses significantly, but not completely, to radio-sensitive organs (Brennan, 1995). Dose Limitation Doses received are monitored routinely using thermoluminescent dosimeter (TLD) badges for whole body dosimetry, with any unusually high doses being investigated. Fetal doses during pregnancy should not exceed 1mSv and this can only be achieved through diligence and commitment to the ALARA principle (ICRP, 1990a). Current legislation demands that designated workers and members of the public do not exceed the dose limits shown in Table 4. Table 4 - Dose limits for designated workers and members of the public Application Occupational Public Effective dose Annual equivalent dose 100mSv over a 5 year period 1 msv per year to lens of the eye 150 msv / year 15mSv / year the skin 500 msv / year 50mSv / year the hands & feet 500mSv Source: Australian Radiation Protection & Nuclear Safety Agency and National Occupational Health & Safety Commission (2002) UNSCEAR (2000a) has undertaken reviews on a number of medical procedures and has found that a steady increase in use is indicated. It is expected that use will continue to increase facilitated by advances in technology and economic developments. It is predicted that there will be continued growth in computed tomography and interventional procedures due to the advances in radiopharmaceuticals for diagnostic therapy and an increased demand for radiotherapy due to an ageing population (UNSCEAR, 2000a). 56

55 With the predicted rise in the use of radiation for diagnostic procedures influencing workplace exposures, and the occurrence of unnecessary exposure and poor practice, the impact on health-care personnel and patients would seem to indicate a possible increase in exposure to radiation if it is not actively managed (Shigemastu & Mendelsohn, 1995). Conclusion The precise level at which ionising radiation presents a health hazard is unknown and the literature suggests that any exposure may involve some risk (Sommargren, 1995). Chronic low-level exposure to ionising radiation is much more difficult to analyse and quantify than acute exposures, and the health consequence in low-level exposure is poorly understood (Weinberg, Kripalani, McCarthy & Schull, 1995). Current recommendations regarding occupational and public exposure are largely derived from the long-term follow-up of the survivors of the atomic bombing at Hiroshima and Nagasaki and supplemented to some extent by studies of individuals exposed in the workplace or as a result of diagnostic or therapeutic irradiation. However, these studies have a number of limitations when used to project risk in other populations (UNSCEAR, 2000b). It is professional expert practice in every area of nursing that ensures optimal quality care for patients and a safe working environment for colleagues. Nurse practitioners are required to have higher levels of judgement, discretion and decision-making in the clinical setting (Department of Health, 2003). There is a significant body of knowledge relating to radiation that nurse practitioners must assimilate and incorporate into their clinical practice. Without expert knowledge, understanding, and well-informed evidence-based practice of ionising radiation, personal health and that of colleagues and patients will be compromised. Nurse practitioners can do much to foster radiation safety in hospitals by having the knowledge and understanding to diminish overexposure to patients, thus reducing the radiation dose both to themselves and other health care workers. Therefore, it is important for nurse practitioners to understand the factors influencing exposure and to promote and practise the principles of justification, optimisation and dose limitation. 57

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59 United Nations Scientific Committee on the Effects of Atomic Radiation. (2000a). Sources and effects of ionising radiation. Vol. I: Sources. New York: United Nations. United Nations Scientific Committee on the Effects of Atomic Radiation. (2000b). Sources and effects of ionising radiation. Vol. II: Effects. New York: United Nations. Wall, B. F. (2001). Diagnostic reference levels the way forward. The British Journal of Radiology, 74, Weinberg, A.D., Kripalani, S., McCarthy, P.L. & Schull, W.J. (1995). Caring for survivors of the Chernobyl disaster. JAMA, 274 (5), Western Australian Government. Poisons Regulations Government Printer. Western Australian Government. Radiation Safety Act Government Printer. Perth: Perth: 61

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61 Nurse Practitioners in Western Australia An Overview of Radiation Safety in Western Australia Radiological Council of Western Australia Abstract In Australia, the states and territories have responsibility for radiation safety in their jurisdictions, enacting separate (but similar) controlling Acts and Regulations. Commonwealth departments and agencies using radiation are regulated by the Australian Radiation Protection and Nuclear Safety Agency (ARPANSA). In 1954, Western Australia became the fi rst jurisdiction in Australia to proclaim laws to regulate radioactive substances and x-ray equipment. Under the present Radiation Safety Act 1975, controls apply to the possession and use of prescribed radioactive substances, x-ray equipment and electronic products, the latter including higher-powered lasers and some ultraviolet light-emitting devices (transilluminators). To give effect to these controls, the Act established the Radiological Council with powers designed to ensure radiation safety. Radiation is ubiquitous and we are exposed to both man-made radiation and natural background radiation. Of all the man-made sources of ionising radiation, the greatest source of exposure is the use of x-rays and radioactive substances for medicine and related purposes. The average radiation dose to the Australian population from the medical use of ionising radiation has been estimated at around 800 μsv per year (Australian Nuclear Science and Technology Organisation [ANSTO], 2000). Applying an internationally accepted risk factor and then assuming that the risk exists regardless of the dose, the implication is that the medical uses of ionising radiation in Australia may be responsible for some 800 cancer deaths each year. No limits are set for the dose received by a patient from diagnostic or therapeutic radiation procedures. This is because their exposure to the radiation is assumed to be justifi ed on the grounds that the exposure poses a lesser risk than the risk of an undiagnosed or untreated ailment. However, all radiation exposures should be kept as low as possible after considering the risk-benefit factors. 63

62 The Radiological Council is concerned that nurse practitioners should possess the relevant radiation safety training at a formal level, so that radiation safety issues and radiation safety principles are understood. From this understanding, the benefi t versus the risk to a patient may be properly assessed. The Council strongly believes that the formulation of clinical protocols without its input has the potential to result in unnecessary and avoidable radiation exposure to the public. Keywords: Radiological Council, radiation safety, risk, radiation injury, nurse practitioners Introduction In Australia, the states and territories have responsibility for radiation safety in their jurisdictions, enacting separate (but similar) controlling Acts and Regulations. Commonwealth departments and agencies using radiation are regulated by the Australian Radiation Protection and Nuclear Safety Agency (ARPANSA). ARPANSA also convenes the national Radiation Health Committee which has Commonwealth, State and Territory representation. Its prime roles are to ensure legislative uniformity across the country and to prepare national Codes of Practice and other guidance documents for radiation users. In 1954, Western Australia became the first jurisdiction in Australia to proclaim laws to regulate radioactive substances and x-ray equipment. Under the present Radiation Safety Act 1975, controls apply to the possession and use of prescribed radioactive substances, x-ray equipment and electronic products, the latter including higher-powered lasers and some ultraviolet light-emitting devices (transilluminators). To give effect to these controls, the Act established the Radiological Council with powers designed to ensure radiation safety. The function of the Council is, therefore, to administer the Radiation Safety Act and in particular: implement controls through the licensing of individuals to use or be responsible for the use of radiation, and by the registration of premises and the radioactive substances or radiation-emitting devices used on those premises conduct inquiries into alleged contraventions of the Act or regulations, and to suspend or cancel licences and registrations advise the Minister for Health, and to make recommendations with respect to the technical aspects of radiation safety requirements and as 64

63 to the methods used for the purpose of preventing or minimising the dangers arising from any dealing with radioactive substances, x-ray equipment, other radiation-emitting devices and electronic products, including the preparation of regulations investigate and prosecute offences against the Act. It should be noted that the Radiation Safety Act 1975 is the prime regulatory instrument for radiation safety in Western Australia. Section 10(1) states that the Minister is charged with the duty of protecting the public health and safety against the dangers of radiation, but is required at all times to have regard to the expressed views of the Radiological Council. Administrative and scientific support for the Council is provided by officers of the Department of Health s Radiation Health Branch. Registration All x-ray equipment, non-exempt quantities of radioactive substances and prescribed electronic devices, must be registered along with the premises where they are used. Registrations may be subject to a number of conditions, restrictions and limitations imposed under section 36 of the Act. Such conditions carry similar weight to the regulations and failure to comply is an offence. Registrations may be held by individuals, companies or organisations with the registrant held legally responsible for ensuring compliance with the Act, regulations and any conditions, restrictions or limitations that may be imposed on the registration by the Council. The registrant also must nominate a suitably qualified or trained person to be the Radiation Safety Officer. Licensing Users of radioactive substances, x-ray equipment and other radiationproducing devices generally either must be licensed or work under the direction and supervision of a licensee. Applicants must have appropriate qualifications, competence and experience and may be required to attend a relevant radiation safety course and pass an examination. Some radiation users are exempt from these requirements although they nevertheless may be required to hold prescribed qualifications. Dentists, for example, are exempt from licensing for the purpose of possessing and using x-ray equipment for dental radiography. For medical diagnosis, radiographers are also exempt but are required to work under the direction and general supervision of a licensed medical practitioner (usually a radiologist). 65

64 Through regulations and imposed conditions, restrictions and limitations, the use of x-ray equipment for medical diagnosis is restricted to licensed radiologists, radiographers, and to those persons approved by the Council as x-ray operators. X-ray operators who attend an approved course and pass an examination are permitted to use only low-powered mobile x-ray equipment and only for plain radiography of the chest and extremities, although provision is made for medical emergencies outside the Perth Metropolitan Area. Compliance Testing of Diagnostic X-ray Equipment Studies of radiation doses in Australia and overseas have identified poor equipment performance as a major contributor to unnecessary patient exposure from medical diagnostic x-ray procedures. To address this problem, the Council initiated a compulsory quality assurance program for all human diagnostic x-ray equipment. The program requires mammographic, C-arm fluoroscopy and U-arm fluoroscopy equipment to be tested annually; other fluoroscopy, radiographic and computed tomography (CT) equipment to be tested every two years; and dental equipment every three years to ensure compliance with the regulations and other Council approved requirements (Radiological Council, 2000). Tests may only be performed by persons holding a licence for the purpose and the results must be certified by a qualified expert. Ionising Radiation Sources and Effect Natural Background Radiation Ionising radiation is not a new feature of our environment. We are exposed to a range of natural (background) radiation sources which, in Australia, results in each of us receiving an annual effective dose in the range of μsv. (The Sievert (Sv) is a unit of radiation dose). Contributing factors to the natural background radiation are: Cosmic radiation Radiation from soil and building materials Radioactivity in the air we breathe Radioactivity from food and drink. 66

65 Man-made Radiation Of all the man-made sources of ionising radiation, the greatest source of exposure is the use of x-rays and radioactive substances for medicine and related purposes. The average radiation dose to the Australian population from the medical use of ionising radiation has been estimated at around 800 μsv per year (ANSTO, 2000). Although comprising only a small fraction of the total number of x-ray examinations, CT forms a large component of the population s radiation dose from medical x-rays, each procedure generally delivering radiation doses much greater than comparable radiographic procedures. For example, a CT examination of the chest may result in an effective dose of 8000 μsv, while a plain chest x-ray results in dose of 50 μsv. However, if clinically necessary, CT can have significant diagnostic advantages over plain radiography. The utility of CT images in providing valuable clinical information has led to a marked increase in CT scanning. However, not all examinations are clinically justified. In some jurisdictions, the public (the worried well ) are encouraged through advertising and other forms of publicity to self-refer for whole body CT examinations to screen for possibly non-existent medical problems without regard to the radiation dose and potential risks. However, in Western Australia, all diagnostic procedures (except approved screening programs) must be referred by an appropriate practitioner. In Australia, Medicare data indicate that CT use has increased by 140 per cent over the decade (Dickie & Fitchew, 2004). A national survey performed in the UK indicated that CT procedures represent about 2 per cent of the annual total of all x-ray examinations, yet account for 20 per cent of the total population dose (Shrimpton, Miles, Green & Lomas, 1992). More recent studies in the UK show that within 10 years, CT has doubled its contribution to the population dose and is responsible for 40 per cent of the total dose (Hart & Wall, 2002). The contribution from conventional radiography and fluoroscopy, however, has nearly halved to 44 per cent (Hart & Wall, 2002). 67

66 Medical Doses No limits are set for the dose received by a patient from diagnostic or therapeutic radiation procedures. This is because their exposure to the radiation is assumed to be justified on the grounds that the exposure poses a lesser risk than the risk of an undiagnosed or untreated ailment. However, all radiation exposures should be kept as low as possible after considering the risk-benefit factors. For some procedures (e.g. screening mammography) dose guidance levels apply. Cancer risk At high doses (> 100 msv) radiation exposure is a known carcinogen. Although there is no direct evidence of cancers arising from the lower radiation doses typical of diagnostic medical practice, experts generally agree that there is no threshold and that all ionising radiation exposure carries a risk of fatal cancer, that risk increasing with dose. The International Commission on Radiological Protection (ICRP) estimates that the risk of fatal cancer to the whole population is 5 x 10-2 Sv -1, from which an incidence of five fatal cancers for every 100 persons exposed to 1 Sievert can be derived. The mean radiation dose to the Australian population of approximately 20,000,000 (Australian Bureau of Statistics, 2002) from the medical uses of ionising radiation (diagnostic x-rays and nuclear medicine) has been estimated as perhaps 800 μsv per year (ANSTO, 2000). The number of fatal cancers in the population from this average dose can then be estimated, using the risk factor. Accepting the ICRP risk factor and the assumption that the risk exists regardless of the dose, the implication is that the medical uses of ionising radiation in Australia may be responsible for some 800 cancer deaths each year. Other Radiation Risks to patients It is presumed that medical x-ray exposures provide a direct benefit to the exposed individual with the benefit outweighing the perceived small risk. However, persons authorised to refer patients for x-ray examinations should be satisfied that the imaging technique selected is appropriate and that it is justified in the clinical circumstances. It has been reported in the United Kingdom (National Radiological Protection Board, 1990) that at least 20 per cent of x-ray examinations are clinically unhelpful in the sense that the probability of obtaining information useful for patient management is extremely low. 68

67 Effects from the medical use of radiation have been observed in patients and in those occupationally exposed to radiation since the discovery of x-rays in Effects with a threshold dose and for which the severity of the injury increases with dose are known as deterministic effects. These include radiation induced cataracts and skin burns. However, this type of effect is rare. In the 1990s, reports appeared in the United States, New Zealand and Australia of patients who had suffered moderate to severe skin damage as a result of very high radiation doses from the use of diagnostic x-rays. In at least one case a skin graft was necessary. These doses were the result of prolonged exposure to fluoroscopic x-rays for real time imaging during lengthy or repeated invasive cardiovascular procedures. In one incident, a 40-year-old patient who underwent two coronary angiograms and a coronary angioplasty in the one day received a skin dose estimated to be in excess of 20 Gy (see Figure 1). The Gray (Gy) is a unit of absorbed dose. 1Gy = 1 J/kg. (a) (b) Figure 1: Skin damage to a 40-year-old patient who underwent two coronary angiograms and a coronary angioplasty in the one day: (a) 6 to 8 weeks after procedure, (b) 18 to 21 months after procedure (Shope, 1996) 69