ADF Health September 2001 - Volume 2 Number 2Nurse practitioners in the ADF: Where are we?
NURSING PRACTICE has become more specialised and highly skilled in the past two decades in response to an everchanging environment of health care provision. Within the nursing profession, this had led to recognition of advanced nursing practice, defined by the Royal College of Nursing Australia (RCNA) as "a level of nursing that utilises extended and expanded skills, experience and knowledge in assessment, planning, implementation, diagnosis and evaluation of the care provided". 1 Advanced nursing practice can provide greater effectiveness and efficiency in health care. 2 Nurses working at the advanced level are able to integrate theory, practice and experience to increase autonomy in making interventions and judgements. 3 Advanced nursing practice by an experienced and educationally prepared nurse forms the basis for the role of nurse practitioner. 1 A nurse practitioner combines the skills of nursing with some of the decision-making autonomy traditionally allowed only to medical practitioners. The role of the nurse practitioner in Australia has been in development since 1990, when New South Wales established a pilot project to investigate the role of nurse practitioners. As nursing in the Australian military has followed the traditional model, it has seen nurses extend their roles and take on additional responsibilities within policy guidelines. However, the roles are not clearly defined, legitimised or regulated. It has been recognised that there is a definite role for nurse practitioners within the ADF. 4-6 With the development of the nurse practitioner role by nurse registering authorities, it is timely to formally establish the ADF requirements for advanced nursing practice and its recognition. This article provides an overview of nurse practitioners in the civilian and overseas military environment, and outlines ADF plans to establish recognition of military nurse practitioners. Nurse practitioner overviewThe role of the nurse practitioner has its roots in providing primary health care in the early 1960s. In the United States, United Kingdom and Canada, the role of the nurse practitioner arose from a shortage of primary care medical practitioners. 7 In the USA today, nurse practitioners work in a broad spectrum of specialties in many settings and manage both medical and nursing problems. 8 In the UK, nurse practitioners traditionally worked in primary health care, but are now recognised in secondary care settings. While originally linked to the shortage of doctors in rural and remote areas, the nurse practitioner in Canada now works in many acute care settings. Research on the effectiveness of the nurse practitioners in these countries has shown safe practice, cost effective care, 9,10 or outcomes at a level at least similar to that of medical practitioners within similar clinical settings. 11 Nurse practitioner roles are also being established in New Zealand, Bahrain, Botswana, South Africa and Scotland, but are at different stages of development. 7 In New Zealand, unlike most other countries, the nurse practitioner model is not necessarily based on advanced nursing practice. In New South Wales, the Nurses Amendment (Nurse Practitioner) Act 1998 established the role of the nurse practitioner and legally protected the title in that State. The nurse practitioner role is based on the Australian National Nursing Organisation's definition of a nurse practitioner: 12
Three core privileges are associated with the nurse practitioner role: prescribing from an agreed list of medications; ordering from an agreed list of diagnostic investigations; and referring patients to other health professionals. 13 These activities are to be performed in accordance with State guidelines for nurse practitioners. Nurse practitioner projects have been conducted or are being conducted in South Australia, Victoria, Western Australia, Australian Capital Territory and Northern Territory. All of the projects have investigated different aspects of the nurse practitioner role and have provided data to inform legislative changes necessary to implement the role. Overseas military nurse practitioners
A literature search reveals scant information on military nurse practitioners. The literature does show that nurse practitioners are employed in the United States Navy, Army, and Air Force. However, there is little research available on the nurse practitioner role or effectiveness within the military. The position of nurse practitioners within the US Navy gained momentum during the 1970s due to an increasing shortage of doctors within that service. 14 The US Navy used nurse practitioners to deliver primary medical care to ameliorate the doctor shortage. When the number of doctors increased, the US Navy nurse practitioner program ceased. However, direct recruitment of nurse practitioners in specialised areas (eg, Nurse Anaesthetists) continued. Since then, the US Navy has trained their military nurses in nurse practitioner roles by sponsoring them in graduate nurse practitioner programs. The United States Armed Services employ nurses as nurse practitioners, recruited in the traditional functional specialties:
Courses for Family Nurse Practitioners and Nurse Anaesthetists from Army, Navy and Air Force are conducted at the Graduate School of Nursing at the Uniformed Services University of Health Sciences in Maryland. 15 The second course of nurse practitioners in the two specialties graduated in 1996 and the number of graduates continues to grow. Other nurse practitioner specific training is undertaken outside of the military university environment. The ADF needAustralian Defence Force nurses care for currently serving members of the military, an age range of 16 to 60 years. Obstetric care is excluded, as this is done by private specialist medical practitioners in the civilian health environment. It is only on deployment for humanitarian reasons that paediatric or obstetric care is required. In these cases, Reserve nurses in the main are called upon to assist in patient care. Primary care has been an integral role of many ADF nurses who provide health care in a general practice setting and who are the first after-hours point of contact with a health professional for service personnel. In remote postings, ADF nurses fulfil a similar role to that of Rural and Remote Area Health Nurses - although, in some cases, they have not been trained to the same level to meet the needs of working in isolated areas. The basic role of the ADF nurse, in accordance with JP2060 (Report on the study into ADF requirements for deployable medical capabilities), 16 is the provision of primary health care in addition to low to high dependency nursing care, resuscitation, trauma and intensive care nursing, post-anaesthetic/ surgical nursing and aeromedical evacuation of deployed casualties. Perioperative nursing, infection control and education of staff and patients will also be essential, but rely on specialist skills. The basic role for the medical officer remains the assessment, diagnosis and treatment of injury and disease, and it will continue to be complemented by other health professionals in the ADF. One such professional is the ADF nurse working in an expanded nurse practitioner role, underpinned by advanced nursing practice. Advanced practice nurses will release medical officers for other higher priority clinical tasks. The advanced role includes health screening, health promotion, women's health services, family planning advice and limited management of common complaints in accordance with protocols. 5,7 These activities will support the mission of the Defence Health Service (DHS), which is to optimise the health of ADF personnel.
ADF nurses currently perform advanced life support and some other advanced roles in addition to primary health care. With the addition of agreed clinical guidelines and further training, the nurse practitioner role could be developed to allow qualified ADF nurses to undertake the less complicated care of ADF personnel (with the support of a multidisciplinary team). In the paper, "Nursing in the ADF: the way ahead", Group Captain Helen Doherty (Specialist Adviser, Nursing, DHS) suggests that ADF nurses deserve recognition for the diversity of skills and training that they undertake early in their military career and then practise for an extended period. 6 The proposal to develop a generic military nurse practitioner model was endorsed by the DHS Steering Committee in August 2000. Development of nurse practitioners in the ADFGuidelines for developing nurse practitioner models and seeking authorisation are available from some nurse registering authorities (eg, New South Wales and South Australia). At about the same time as the nursing paper and recommendations were endorsed, expressions of interest were called to participate in the ACT Nurse Practitioner Project and Trial from March to December 2001. The project is a collaborative one between the University of Canberra, the Nurses Board of the ACT and the ACT Department of Housing, Health and Community Care. With the support of the DHS executive, an application was submitted. The basis of this application was to formalise advanced practice already being undertaken by ADF nurses and to identify the appropriate education and training requirements for a military nurse practitioner. There would also be scope to further extend nursing practice. DHS could then benchmark the concept of military nurse practitioner against civilian standards to ensure that patient care meets best practice. On 6 February 2001, the ACT Health Minister announced that the ADF was one of four successful applicants to join the trial. Before starting the trial, the ADF sought ethical approval from the Australian Defence Human Research Ethics Committee. An ADF nurse was selected after input from individual service career managers and is participating in the trial as a member of staff at the Canberra Area Medical Unit, Duntroon, ACT. For the nurse practitioner under training it involves four days each week of nursing practice and one education day per week. There will be an assessment of the nurse practitioner under training at the end of the trial period. The ACT nurse practitioner trial follows similar lines to that of the New South Wales and Victorian projects, with the addition of educational support for the nurse practitioner participants. Anticipated outcomes from the ACT nurse practitioner trial include identification of:
Once the trial is completed, DHS is planning on developing the model of the military nurse practitioner to gain authorisation from the Nurses Board of the ACT. Issues such as agreed clinical guidelines and agreed lists of medications will need to be developed by committees and approved appropriately. Once authorisation has been gained, the proposed model will be put to other nurse registering authorities. However, much work will need to be undertaken at the end of the trial to advance the military nurse practitioner role. The other issue to be considered by DHS is where the dedicated positions for nurse practitioners should be. Initially, it will be the positions for the generic military nurse practitioner that will be developed. However, consistent with JP2060 requirements, 16 nurse practitioner positions might be considered and dedicated in specialty areas. ConclusionThe establishment of nurse practitioners in Australia and overseas has had a long evolution. Worldwide, the role of nurse practitioners is becoming more accepted and is being introduced to complement health care delivery and outcomes. In NSW, it has taken more than 10 years to establish the legal framework to authorise nurse practitioners to practise. The ADF was fortunate in being selected to participate in developing a military nurse practitioner role through participation in the ACT nurse practitioner trial in 2001. Outcomes of this trial will be available early next year, when further work by DHS will be required to formalise the outcomes for the ADF. This will establish a generic military nurse practitioner role that will complement the medical service provided in a collaborative framework. References
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