Exploring factors affecting uptake of extended scope of practice in rural areas

Transcription

1 Exploring factors affecting uptake of extended scope of practice in rural areas Tony Smith 1, Karen McNeil 1,2, Rebecca Mitchell 2, Brendan Boyle 2, Nola Ries 2 1 Faculty of Health and Medicine, University of Newcastle Department of Rural Health 2 Faculty of Business and Law, University of Newcastle Health Services Research & Innovation Group The University of Newcastle

2 Introduction More needs to be done to support innovative models of health service delivery to: Improve service access in rural & remote areas Reduce the costs to patients of traveling long distances to receive relatively minor, low risk diagnostic tests or treatments Includes, though not specific to Nurse Practitioners (NPs) 2 The University of Newcastle

3 Aims of this study Explore lived experiences and perceptions of NPs in rural practice (and colleagues, where possible) about barriers to and enablers of their extended scope of practice (ESoP) roles Adapt a socio-institutional theoretical model of macro-, meso- and micro-perspectives* to generalise about ESoP roles * [Mulvale, Embrett, Razavi. BMC Family Practice 2016; 17(1): 83] 3 The University of Newcastle

4 Background Scope of practice of NPs includes: advanced health assessment, analysis & diagnosis; order and interpret diagnostic tests; prescribe some medications; and refer patients to other health service providers. How many NPs? Nursing and Midwifery Board of Australia Registrant data 1 st Oct to 31 st Dec ,478 = 0.48% of Registered Nurses & Midwives Registrant data 1 st April to 30 th June ,418 = 0.46% of Registered Nurses & Midwives [ 4 The University of Newcastle

5 International comparison, 2015 N = total number; NP = nurse practitioner; P = practising; PA = professionally active; R = registered/licensed to practice [Maier et al. BMJ Open Sep 2016, 6 (9) e011901] 5 The University of Newcastle

6 Most NPs practice in metropolitan locations In 2009, 2 nd National NP Census 35.7% practiced in rural/remote [Middleton, et al. Aust Health Rev (4): ] Source: Australian College of Nurse Practitioners, 2015 Member Survey (Approx. 38% of members) 6 The University of Newcastle

7 Methodology In-depth semi-structured interviews Recruitment: NSW Nurses & Midwives Assoc. + Australian College of Nurse Practitioners Informants (n = 20): 15 NPs + 5 Colleagues/Managers 11 ASGC-RA2; 6 RA3; 1 RA4; 2 RA5 * 10 NSW; 3 SA; 2 Vic; 2 Qld; 2 WA; 1 NT NP specialties: 5 Primary Care; 4 Emergency/Critical Care; 3 Aged Care; 2 Diabetes; 1 Continence * RA2 - Inner Regional; RA3 - Outer Regional; RA 4 Remote; RA5 Very Remote 7 The University of Newcastle

8 Macro- Meso- & Micro Barriers to and Enablers of Extended Scope of Practice Roles 8 The University of Newcastle

9 Macro-barriers (Legal, regulatory, educational, economic and political) National policy & regulatory systems (MBS, PBS & other) Legal and regulatory requirements limit practice and funding Medicare, it's crap, in a nutshell. It just makes our lives really difficult. We've got four time-based item numbers. That's all we can bill for. I probably only generate enough income to support a third of my role, a third of my salary. (NP11, RA3, WA, Primary Care) 9 The University of Newcastle

10 Macro-barriers (Legal and regulatory, education, economic and political) National policy & regulatory systems (MBS, PBS & other) It is sometimes possible to work around barriers We re limited under MBS as to what we can have done and that is a barrier in some ways because you can t fully do things that you want to do, but [The NP] has to work around the limitations imposed by legislative limitations, like the MBS, but this is manageable. (NP1, RA2, NSW, Diabetes) 10 The University of Newcastle

11 Macro-enablers (Legal and regulatory, education, economic and political) Scope and boundary issues Role boundaries can be redefined and refined using the nursing model but being able to extend the scope of practice you re able to provide a more comprehensive health service to that person and their family. I am able to, and will manage within how I feel comfortable, looking at the renal disease and hypertension and infection and illnesses as well. (NP1, RA2, NSW, Diabetes) 11 The University of Newcastle

12 Meso-barriers (Institutional and community) Lack understanding of role Poor understanding among other HS personnel When I first started working with our Nurse Practitioner I didn t understand the role, I didn t understand what he was there to do. But once you understand exactly what they re doing, I don t think anybody would say they weren t valuable to the ED. It really is, particularly in upper management when they don t understand the role, (NP3C, RA3, NSW, Emergency) 12 The University of Newcastle

13 Meso-barriers (Institutional and community) Lack understanding of role Poor understanding by community So, I think that broader recognition from a national and societal perspective too. And with patients as well I don t think the role is really understood by the community. There are a lot of questions from clients and patients about what do you do sort of thing. So, I think it is just that broader societal understanding of extended practice roles. (NP2C, RA2, NSW, Aged Care) 13 The University of Newcastle

14 Meso-enablers (Institutional and community) Community support NP roles are also well supported and valued I love what I do out here. My community are very loyal to me. I m booked out fully on my nurse practitioner days and patients have to wait a few weeks to get in, I have provider numbers at both surgeries, so I actually don t cost them a lot of money, (NP12, RA2, Vic, Primary Care) 14 The University of Newcastle

15 Meso-enablers (Institutional and community) Networking & building rapport Building local networks helps with acceptance When I first started I spent a lot of time networking and trying to get good rapport with the GPs, particularly a lot of those that went to residential care facilities, and some GPs are fantastic and I ll just ring them and like yep, no dramas, whatever, not a problem (NP7, RA3, NSW, Age Care) 15 The University of Newcastle

16 Micro-barriers (Practice) Lack of role clarity How NP role fits with pre-existing roles it was a new position when I came to it It's been an interesting journey because we've had to define where we sit within the structure, so how do we work with the services that were pre-existing and that's taken two years to sort of work that out really. Lot of time and effort goes into sorting out the roles in relation to other pre-existing roles. (NP14, RA2, Vic, Continence) 16 The University of Newcastle

17 Micro-enablers (Practice) Interprofessional support & collaboration Interprofessional practice can be powerful The thing that's helped me most in the organisation is the support I've had from the physicians here, who basically tell the registrars when they start, if there's any problems or you've got any questions just go and ask [the NP]", That actually came to me directly from one of the other physicians. (NP13, RA2, NSW, Emergency/Critical Care) 17 The University of Newcastle

18 Micro-enablers (Practice) Negotiation, diplomacy, advocacy & promotion of role Need to advocate for extended practice roles I think one of the really important roles of the NP is to promote the role You have to get out there, you actually have to be the diplomat, be supportive of others and acknowledge their expertise as well, and through that you will get buy-in into it. be proactive and go on the front foot to gain the support of peers and other health professionals. (NP1, RA2, NSW, Diabetes) 18 The University of Newcastle

19 Summary NPs provide high quality care that is accepted by patients and communities Too few NPs especially in RA3-5 locations Barriers and enablers exist at all levels Need for greater role clarity and advocacy 19 The University of Newcastle

20 Recommendations Peak bodies need to direct advocacy towards addressing anomalies in MBS and PBS for NPs Promote NP role to nurses and other health professions through interprofessional teamwork Promote advanced practice roles to senior HS managers to ensure ongoing funding and sustainability Develop other ESoP and advanced practice roles in other health professions 20 The University of Newcastle