National regulation in Australia: A time for standardisation in roles and titles

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1 Collegian (2011) 18, available at SHORT COMMUNICATION National regulation in Australia: A time for standardisation in roles and titles Christine Margaret Duffield, PhD, RN, MHP, BScN, DNE, DipCompDirector, FAICD, FCHSE, FRCNA a,b,, Glenn Gardner, PhD, RN, FRCNA c,d,1, Anne M. Chang, PhD, RN, FRCNA c,e,2, Margaret Fry, PhD, RN, NP, MEd, BAppSci(Nursing) b,3, Helen Stasa, BA (Hons), BA (Hons) b,4 a WHO Collaborating Centre for Nursing, Midwifery and Health Development, Australia b Faculty of Nursing, Midwifery and Health, Centre for Health Services Management, University of Technology, Level 7, Jones Street, PO Box 123, Broadway, Sydney, NSW 2007, Australia c Faculty of Health, School of Nursing and Midwifery, Queensland University of Technology, 2 George St, Brisbane, QLD 4000, Australia d Clinical Nursing at Royal Brisbane and Women s Hospital, Herston, QLD 4029, Australia e Nursing Research Centre (NRC) and The Queensland Centre for Evidence Based Nursing & Midwifery (QCEBNM), Mater Health Services Raymond Terrace, South Brisbane, QLD 4101, Australia Received 19 November 2010; received in revised form 14 January 2011; accepted 14 January 2011 KEYWORDS Nursing; Roles; Advanced practice; Regulation Summary Background: The past few years has seen a growth in the number of new nursing roles and position titles in many countries, including Australia. The Australian situation is unique due to the lack of professional engagement and debate in determining the purpose of some of these new positions. Often these new roles have been poorly defined, and there is no national consistency in nomenclature. The recent move to a national nursing registration system provides an opportunity for change. Method: Discursive paper. Corresponding author at: Faculty of Nursing, Midwifery and Health, Centre for Health Services Management, University of Technology, Level 7, Jones Street, PO Box 123, Broadway, Sydney, NSW 2007, Australia. Tel.: ; fax: addresses: Christine.Duffield@uts.edu.au (C.M. Duffield), ge.gardner@qut.edu.au (G. Gardner), am.chang@qut.edu.au (A.M. Chang), margaret.fry@uts.edu.au (M. Fry), Helen.Stasa@uts.edu.au (H. Stasa). 1 Tel.: ; fax: Tel.: ; fax: Tel.: ; fax: Tel.: ; fax: /$ see front matter 2011 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved. doi: /j.colegn

2 46 C.M. Duffield et al. Results: New roles arise for a number of reasons, including a change in function or title for a preexisting role or in response to the establishment a completely new position. However, the lack of a co-ordinated approach to introduction of new roles may lead to role proliferation (the rapid increase or spread of new positions and position titles), role blurring (where the boundaries of different positions become less distinct) and role confusion (where both and health system clients experience a lack of clarity regarding the precise scope of roles). Conclusion: Professional nursing practice is defined by the impact on patient outcomes, not by position titles. As such, the potential positive impact of a new role on patient outcomes should be the primary consideration when considering its introduction. National regulation of the profession provides an opportunity for the profession to debate and determine some consistency in position titles, responsibilities and areas of specialty practice Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved. Introduction and background The past few years has seen a growth in the number of new nursing roles and position titles throughout Australia, a trend also occurring in other countries such as the United Kingdom, the United States, New Zealand and Hong Kong (Aranda & Jones, 2008; Asbridge, 2006; Cooper & Grant, 2009; McKenna et al., 2008; McKenna, Keeney, & Hasson, 2009). However, perhaps unique to Australia is the lack of professional engagement and debate in determining the need for, and purpose of, some of these positions. Often these new roles have been poorly defined, as has their scope of practice and responsibilities. More importantly, there is no national consistency in nomenclature. Australia is a relatively small country, with only 22 million people across a large land mass comprising six states and two territories (Australian Bureau of Statistics, 2010). Nurses salaries and conditions of employment have traditionally been industrially driven, negotiated by the respective nursing union with employers within each state and territory (NSW Department of Health, 2008; State Government of Victoria Department of Health, 2007; WA Health, 2007). As a result, positions and titles and, to some extent, role responsibilities, are determined industrially, rather than by the profession. Individual jurisdictions therefore have considerable freedom and flexibility in determining new positions and responsibilities, without reference to other jurisdictions (National Nursing and Nursing Education Taskforce, 2006). As a consequence, it is possible to have differences in salary for the same position, different responsibilities for the same position title, or different titles for the same position across the country. It is, however, important to note that this lack of consistency in titles and responsibilities does not apply to Registered Nurse (RN), Enrolled Nurse (EN) and Nurse Practitioner (NP) titles as these are regulated across Australia (Nursing and Midwifery Board of Australia, 2010). However, on 1 July 2010, Australia moved to a system of national registration (and hence regulation) for all health professions (Commonwealth of Australian Governments, 2008). This move to national registration has seen control transferred away from individual states and territories. It is quite likely that for the nursing profession, the shift to national registration will highlight the lack of uniformity and comparability in the use of roles, titles and responsibilities across the country. New nursing roles or position titles arise under a variety of circumstances. Sometimes it may simply be a change in function or title for a pre-existing role, or a name change when an existing role has been redesigned which better reflects new responsibilities (Bridges & Meyer, 2007; Department of Health, 2000). At other times, a completely new position with different responsibilities and/or scopes of practice can be established, perhaps as a method of improving service delivery (Duffield, Gardner, Chang, & Catling-Paull, 2009). Importantly, any change to a role or a position title can potentially change individual s perceptions and expectations of the role or position, and, as a result, there can be important consequences for individuals who undertake the role, the profession, health consumers, and the health care system generally. This paper will explore some of the potential consequences of the ad hoc approach to the development of new roles taken to date in Australia, arguing that it is time the profession takes responsibility in leading the debate, particularly in defining specialty and advanced practice for. Consequences of a lack of national approach to defining practice The lack of a coordinated approach to defining clinical practice can lead to the emergence of a large number of highly specialized, small, and potentially similar areas of practice. Specialization occurs in response to several drivers including; assuming functions not valued by the medical profession; to compensate for medical staff shortages particularly in rural and remote areas; changes to or unmet patient needs requiring different skills; and in response to the introduction of new technology (Coombs, Chaboyer, & Sole, 2007; Hanson & Hamric, 2003). With this specialization often comes new position titles. New specialized titles and positions may also be introduced in response to needs of the population serviced (gerontology or paediatrics); the type of problem (wound or pain care); the practice setting (perioperative or emergency); the type of care required (rehabilitation or palliative care); the disease or pathology (oncology or orthopaedics) (Fulton, 2005); or the function undertaken (clinical practice, education, management or research). Gradually, the new position or title begins to be accepted in the organization, becomes embedded in their culture, the number of positions increases and from this, fur-

3 National regulation in Australia: A time for standardisation in roles and titles 47 ther subspecialties may arise (Coombs et al., 2007). Often, there is little evaluation of the need for these positions prior to or following their introduction. Importantly, as areas of specialty practice develop, there is an expectation that universities will provide appropriate and necessary programs to assist develop the skills and knowledge required in specialty. In a country the size and expanse of Australia this is not possible. As an example, the number of family and child health scattered across the entire country in 2009 was only 5615 (1.8% of the nursing workforce) (Australian Institute of Health and Welfare, 2009). The costs of developing and offering a course to a small number of students annually are too great for many education providers, particularly when considered in the context of the number of potential clinical specialties with similar expectations (Department of Education, 2009). Certainly, there are some notable exceptions, such as The College of Nursing, which offers training courses in a range of disciplines via distance education, although the numbers are still limited (The College of Nursing, 2010). Additionally, some specialty nursing groups, such as the Australian College of Critical Care Nurses (2010), are addressing frameworks for their areas of practice in policy statements. However, this is not consistent across specialties. Credentialing of specialty practice is not yet a feature in the Australian context, but its introduction could add yet another level of complexity to this situation (Considine & Fielding, 2010). The profession must debate and agree on what it sees as areas of nursing specialization for this country, and importantly then, the skills, knowledge and educational preparation required of those in the roles. A second consequence of the development of new roles is the potential for role proliferation, which refers to the rapid increase or spread of new positions and position titles (McKenna et al., 2009). Introducing a new title or position may create duplication and confusion, rather than clarity. An example is that of the nurse entrepreneur, defined as an independent, autonomous nurse who works directly with clients in a private practice setting, such as the client s own home (Caffrey, 2005; Wilson, Averis, & Walsh, 2003). However, there seems little to differentiate the tasks of the nurse entrepreneur from other with existing role titles such as private practice nurse. Another example is that of forensic, who apply nursing science to public and legal proceedings. Whilst acknowledging the appeal of such positions to the nursing workforce, Cashin (2007) has argued that the work performed by forensic does not differ greatly from the work performed by mental health or primary health care ; only the context of practice is different (Cashin, 2007). In other words, despite the diversity of titles used, there may in practice be very little difference in the roles and functions. Evolution of such specialized positions runs counter to the argument that the changing nature of the healthcare system and its demands in a country the size of Australia requires a flexible and portable workforce, with readily transferable skills which can be rapidly redeployed to areas of demand (Productivity Commission, 2005). Expanding the number of titles with potentially large areas of overlap in function and expertise is an inefficient use of scarce human resources. This can be highlighted by an example in the area of child and family health (Table 1), Table 1 Role titles child and family health. Paediatric Early childhood School Neonatal Family and child health Women s and children s health Child health Mothercraft Children s Child and family health Family health Women s and children s where 12 different position titles can be found (Duffield, 2008). From which of these would parents of an infant who is not gaining weight seek assistance? The answer is that probably all of them can provide guidance, despite the fact that they have distinct position titles. When introduced, these positions may have had well defined boundaries around their practice but in time, these boundaries have become blurred, a phenomenon referred to as role blurring (Brown, Crawford, & Darongkamas, 2000). As Table 1 shows, within the specialty of child and family health, as role titles proliferate they begin to become less meaningful both within the profession and externally. Consumers and staff are unsure who is responsible for particular tasks or the skills and competencies that are expected of particular title holders (McKenna et al., 2008, 2009). This in turn can lead to being asked to complete tasks which do not fully utilize their specialized skills. Conversely, underqualified staff may be asked to perform technical tasks for which they do not possess the specialized knowledge and training (Duffield & O Brien-Pallas, 2002). Related to the issue of role blurring is the problem of role confusion. When industrial bodies argue for new positions or titles as a basis for a wage increase, it is possible to have a range of different titles for what might be similar positions. One clear example of this is the role of Advanced Practice Nurses (APNs) in the state of NSW (Australia). APNs are defined as who use their higher level knowledge and skills to practice with a large degree of autonomy, and to initiate nursing actions (Gardner, Chang, & Duffield, 2007). In NSW, we find a range of different titles which may refer to APNs (Table 2). Whilst the title Nurse Practitioner (NP) is regulated in NSW (as it is across Australia) other APN positions have been industrially determined (rather than determined by legislation), and so the scope of practice differentiating them is less clear. One example of this is the position of Clinical Nurse Consultant (CNC). In NSW, the title CNC refers to a designated organizational position, rather than a role which requires a particular academic qualification. A similar situation pertains in Queensland, where a CNC is defined as a RN who has been appointed to the position on the basis of their skills and experience, rather than on the basis of their qualifications (Nurses (Queensland Public Hospitals) Award, 2004). Because the role of the CNC is complex and multifaceted with many different priorities, both CNCs and other health professionals have experienced considerable confusion regarding the expectations of this position (Chiarella, Hardford, & Lau, 2007). This lack of clarity has been magnified in NSW by the introduction of three different grading levels for CNCs (Grades 1, 2, and 3) (NSW Department of

4 48 C.M. Duffield et al. Table 2 Title Titles given to advanced practice in NSW. Notes Clinical Nurse Specialist Grades 1 and 2 Clinical Nurse Consultant Grades 1 3 Nurse Practitioner This is a personal classification awarded to an individual, not a position (NSW Department of Health, 2000). Not equivalent to the CNS classification in the USA. A NSW CNS is defined as an RN who applies a high level of clinical knowledge and skills to provide complex care with minimum direct supervision (NSW Department of Health, 2008). A CNC in NSW is equivalent to a CNS in most other countries and some Australian jurisdictions. A CNC in NSW is an RN with at least 5 years post-registration experience and approved qualifications relevant to the field in which they are appointed (NSW Department of Health, 2008). A NP in NSW is an RN who is authorised by the Nurses and Midwives Board of New South Wales to practice as a nurse practitioner. The classification is regulated by registering authorities (NSW Department of Health, 2005, 2010). Table 3 First-line nurse manager and advanced practice nurse titles in Australia. First-line nurse manager Nursing unit manager Clinical nurse manager Nurse manager Clinical nurse consultant Advanced practice nurse Clinical nurse specialist Level 2 nurse Senior registered nurse Clinical nurse consultant Nurse practitioner Health, 2000). Whilst some variability among CNC roles may be desirable given the dynamic nature of the health care system and the need for flexibility, consistency in core characteristics of practice is needed to prevent role ambiguity (Bryant-Lukosius, DiCenso, Browne, & Pinelli, 2004; O Baugh, Wilkes, Vaughan, & O Donohue, 2007). This confusion in role titles extends further. At the national level, and of greater concern, is that with no coordinated approach to developing positions and titles, it is possible to have the same title refer to very different positions and responsibilities in different jurisdictions. Table 3 illustrates this point. Depending on the State or Territory, the title CNC can be used to describe an individual who is a nursing unit manager (a management position) or an advanced practice nurse (senior clinician) (Northern Territory Government, 2009; NSW Department of Health, 2000; Nurses (Queensland Public Hospitals) Award, 2004). Additionally worrying is the finding that the same role title may be used by with very different levels of qualifications within the same jurisdiction (Considine & Fielding, 2010). Summary and conclusion There is nothing to suggest that the public care about the titles which are used by nursing staff. In fact, the myriad of different designations may simply confuse them (Barton, 2006). Nevertheless the number continues to increase. As new positions and titles are often industrially driven in Australia it may simply be a method of increasing wages. However, it has been suggested elsewhere that an individual who has a highly specific title may feel that they have a unique, individual nursing identity when compared to someone who has a more general title such as registered nurse (Prime Minister s Commission on the Future of Nursing & Midwifery in England, 2010): a question of status. Nurses may be seeking to define themselves as very highly skilled practitioners using titles such as clinical nurse specialist, clinical nurse consultant or nurse practitioner. Whatever the reason, given the consequences outlined above, the proliferation of positions and titles in Australia cannot continue to occur in such an ad hoc manner. Health care is expensive and nursing human resources consume a significant portion of the health budget. Our professional nursing practice is not defined by a title, or the number of roles we have. Rather, our practice is defined by the impact on patient outcomes. The potential positive impact of a new role or position classification on patient outcomes should be the primary consideration when considering whether or not there are grounds for introducing new positions or changing titles. National regulation of the profession provides an opportunity for the profession to debate and determine some consistency in position titles, responsibilities and areas of specialty practice. Importantly, it is time to consider what is meant by advanced practice in nursing and the experience and qualifications required to undertake these roles. Many years ago Brown (1998, p. 163) described role legitimacy as the recognition of competencies and the right to practice a particular health care role that is conferred by the profession, regulatory authorities, and specialty organizations. 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