Nurse practitioners in primary healthcare

Position

This position statement has been developed in relation to nurse practitioners working in the primary healthcare sector, recognising the value nurse practitioners can add when they work collaboratively as part of a GP-led practice team delivering coordinated care.

The RACGP:

• supports the role of nurse practitioners within GP-led general practice teams, either collocated or external to the general practice location
• does not support nurse practitioners working autonomously in the primary healthcare sector.

Clinical roles, responsibilities and accountabilities within a GP-led general practice team should be assigned according to each health professional’s level of education, training, supervision and clinical expertise. Ultimate responsibility and oversight of patient care when provided as part of a GP-led general practice team should rest with GPs.

Background

Definition

A nurse practitioner is a Master’s prepared registered nurse who is endorsed by the Nursing and Midwifery Board of Australia (NMBA) to function ‘autonomously and collaboratively, in an advanced and extended clinical role, using nursing knowledge and skills.’^1,2

Over 1300 nurse practitioners are currently endorsed by the NMBA to work in a wide range of hospital and community healthcare settings, in both the public and private sectors, with other nurses, GPs, other medical and surgical specialists, and allied health professionals.³

Scope of practice

Nurse practitioner scope of practice is defined and regulated by their education, training, clinical experience, registration standards, endorsements and notations, positions of employment, clinical protocols and guidelines, drug formularies, and related federal, state and territory legislation.

Within their specialty area, nurse practitioners are authorised to independently perform physical assessments, order diagnostic tests, interpret test results, initiate referrals to other healthcare providers, prescribe specific medications and administer specific therapies.²

Recent changes to nurse practitioner course accreditation standards have expanded nurse practitioners’ scope of practice beyond specialist roles to encompass generalist practice.⁴

Nurse practitioner curricula promotes development of generalist capabilities, such as:

• self-sufficiency
• independent learning
• creative thinking
• the ability to deal with complexity, and
• use of traditional ‘competencies’ (knowledge, skills and attitudes) in novel and unpredictable environments.

The stated intention is to promote higher order thinking, independent decision making and clinical leadership in a range of specialist and generalist roles.⁵

Policy context

Since 2000, successive Australian governments (federal, state and territory) have supported establishment and expansion of the nurse practitioner workforce through:

• government funded pilot projects
• revision of national registration standards
• revision of course accreditation standards
• introduction of collaborative care arrangements – authorising nurse practitioners to:
  • use Medicare Benefits Schedule (MBS) consultation item numbers which are both time-tiered and based on the complexity of the patient’s condition
  • use a wide range of MBS funded pathology tests and diagnostic imaging
  • prescribe certain PBS medicines
  • refer patients to medical specialists
  • access professional indemnity insurance for independent collaborative practice
• introduction of associated legislative and regulatory reforms.

Issues

Independent nurse practitioners seeking the same level of authority, autonomy and scope of practice as GPs will compromise the quality, safety, efficiency and cost effectiveness of patient care.

General practitioner and nurse practitioner training programs are not equivalent

Nurse practitioner entry requirements and education and training programs are not equivalent to those completed by GPs. Attempts to perform at the same level and scope of practice as GPs without equivalent training will increase the risk of:

• mis- or delayed diagnoses
• inappropriate or delayed treatment – including pharmacological treatment
• adverse events resulting in physical or psychological harm to patient.

Fragmentation of care

Nurse practitioners intervening in the treatment of general practice patients independent of the GP-led team will compromise the quality, safety, efficiency and cost effectiveness of GP services and disrupt continuity of care through:

• fragmented medical records
• the provision of contradictory clinical advice
• missed opportunities to detect contra-indications
• multiple prescribers increasing the risk of poly-pharmacy and adverse drug interactions
• missed opportunities to initiate a range of opportunistic health promotion and disease prevention activities
• blurred lines of responsibility for preventive health care (eg screening or vaccination programs)
• diminished clinical governance / accountability.

Increased complexity, inefficiency and cost

Independent nurse practitioners seeking to provide care to patients in isolation from general practice will:

• increase the health system’s complexity and access points
• duplicate patient services (eg consultations, pathology and diagnostic imaging)
• make inappropriate and unnecessary referrals to other healthcare professionals / services
• increase waiting times for referred services
• reduce the efficiency of resource allocation and increase costs
• increase flow-on costs throughout the healthcare system.

Creation of a two-tiered primary healthcare system

If independent nurse practitioners are positioned as a wide-scale alternative to GP led care, a two-tiered primary healthcare system will eventuate where:

• patients who cannot access GP services (for example, due to cost or geographic location) receive nurse practitioner-led care instead, or
• nurse practitioners become the first point of contact for all patients within the healthcare system, where nurse practitioners:
  • screen and treat all minor ailments
  • triage and refer major or complex cases to GPs.

The first scenario has the potential to reduce equity of access to high quality healthcare and increase health disparities for already disadvantaged communities. The second scenario would diminish a GP’s ability to:

• detect early warning signs of disease and prevent further progression
• treat the full spectrum of clinical presentations and provide continuing, comprehensive, whole-person care
• efficiently manage the patient within the context of the MBS, increasing costs.

Use of nurse practitioners to address medical workforce maldistribution

Establishment and expansion of the nurse practitioner role in Australian settings was partially driven by medical workforce maldistribution issues faced by rural, remote and Aboriginal and Torres Strait Islander communities.^1,6,7 While nurse practitioners are a rapid and low-cost option to medical workforce shortages, they are not a long-term solution to these issues. Patients in rural, remote and Aboriginal and Torres Strait Islander communities should have access to the same standard of medical care as patients in metropolitan and regional areas.

Principles for nurse practitioners working in primary healthcare

General practice as first point of contact and coordinators of care

General practices should remain patients’ first point of contact within the healthcare system and retain ultimate oversight of patient care. This allows for comprehensive assessment, diagnosis, initiation of treatment and referral to appropriately qualified team members (including nurse practitioners) in accordance with their qualifications, areas of clinical expertise and levels of support.

Nurse practitioners as part of GP-led teams

Nurse practitioners should consult with patients as part of GP-led teams. This includes assumption of roles such as:

• clinical experts in some aspect(s) of primary health care, or
• generalists who can manage certain types of clinical presentations requiring generalist approach collaboratively with GPs.

Integration of nurse practitioners in the GP-led team with collaborative care arrangements

Nurse practitioner service integration into the GP-led team should occur through collaborative care arrangements.

All collaborative care models in general practice should incorporate the following principles:

• The nurse practitioner is employed, contracted by or otherwise retained by a GP or a general practice, or
• The nurse practitioner is embedded in the GP-led team and either sees patients on referral from the GP(s) or directly, based on practice arrangements, and
• The nurse practitioner must have a written collaborative care agreement (CCA) in place with the patient’s usual GP.

The RACGP provides guidance on how CCAs should be developed and what should be documented in:

• Collaborative Care Agreements: A guide for Collaborative Care Agreements in general practice
• RACGP Collaborative Care Agreement – general practitioner(s) and nurse practitioner(s)

Safe prescribing

The RACGP’s position on independent non-medical practitioner prescribing sets out principles for ensuring the high quality of prescribing in general practice is safeguarded.

Risk management and quality assurance

Risk management and quality assurance needs to be an integral part of nurse practitioners’ service delivery models. At a minimum, this would include:

• appropriate supervision arrangements
• assignment of clear roles, responsibilities and accountabilities within their scope of practice
• compliance with clinical standards (including accreditation for nurse practitioner practices with multiple nurse practitioners)
• obtaining informed consent – including full disclosure of risks
• patient risk profile analysis
• use of patient exclusion criteria
• clinical audit / performance monitoring
• peer and inter-professional review
• adverse event reporting
• processes for patient feedback and complaint escalation.