From the editor

RESEARCH PAPER
NURSE PRACTITIONERS: AN EVALUATION OF THE EXTENDED ROLE OF
NURSES AT THE KIRKETON ROAD CENTRE IN SYDNEY, AUSTRALIA
Eleanor Hooke, RN, is a Rural Outreach nurse and previously Ingrid van Beek, MBBS, MBA, FAFPHM, is Director, Kirketon at the Clinical Academic Nursing Unit, Faculty of Nursing, The University of Sydney and Sydney Hospital and Sydney Eye Carol Martin, RN, is at the Royal North Shore Sexual Health, Unit, and previously at the Clinical Academic Nursing Unit, Lydia Bennett, PhD, BA(Hons), RN, ICCert, DipTeach(nurs), Faculty of Nursing, The University of Sydney and Sydney FCN(NSW) Reg. Psycholigist NSW, MAPsS is the Professor and Director, Urban Health Research Unit, Dept of Family and Community Nursing, The University of Sydney and Sydney Robyn Dwyer, BA(Hons), is Resarch Fellow at Turning Point The authors would like to extend special thanks to Bronwyn Anderson and Alcohol and Drug Centre, Sydney, Australia Valda Wiles for their invaluable support and input throughout the course ofthis research study.
This study formed part of the Nurse Practitioner Project conducted by the Accepted for publication November 2000
Department of Health in New South Wales, Australia.
Key Words: nurse practitioner, survey, at-risk-youth, sex workers, drug users, primary health care
The aim of the present study was to formally
Context within which this study took place
evaluate the effectiveness, professional appropriateness
and acceptability of the extended role of the nurse
The 1990s in Australia can be described as the practitioner at the Kirketon Road Centre (KRC) in
decade of the emerging nurse practitioner. The Sydney, Australia. Data collection consisted of client
broad aims of this movement were to recognise, and staff surveys and case file review by two assessors
measure and evaluate the skills of the nurse practitioner, to (one medical and one nursing). This paper will report
foster the retention of expert clinicians in their area of on one section of this research, namely the case file
specialty, and to establish a system wherein these nurses review section of the study. Total study subjects were
could receive recognition of their status, function in an 1046 ‘at risk’ youth, sex workers and injecting drug
expanded nursing role and receive financial remuneration users attending KRC for their primary health care
for their specialist skills. The areas of primary health and needs between September 1994 and April 1995. Nurse
rural and remote nursing were key areas of focus. practitioners (NP) saw 613 of the clients who presented
The role of nurse practitioners in NSW was examined over this period. The majority of these clients were
using a three-stage strategy of working parties and women (77.3%). The majority of NP consults were
research projects spanning from 1992 to 1995. The three related to STD (51%), gynaecological (17%) and
stages consisted of stage one (NSW Health Department, hepatitis (16%) issues. The results demonstrated that
1992) which investigated the role and function of nurse nurse practitioners were professionally appropriate in
practitioners in NSW; stage two (NSW Health all aspects of expected ‘best practice’ in over 95% of
Department, 1993) which reviewed the role of nurse consultations.
practitioners and examined ways in which to assess andimplement the recommendations of the stage one workingparty; and stage three (NSW Health Department 1995)which examined evidence (through pilot projects such asthis one) evaluating the competency, safety, efficiency andfeasibility of nurse practitioners. RESEARCH PAPER
Definition of nurse practitioner
practitioners also staffed the ‘AIDS Bus’, an outreachprogram to street sex workers, ‘at risk’ youth and IDUs The title nurse practitioner ‘is restricted to registered which operated seven nights a week. In this setting nurses nurses who are authorised by the Nurses Registration were involved in assessment of primary health care needs, Board of New South Wales under the Nurses Amendment the provision of information and education regarding HIV (Nurse Practitioners) Act 1998 to practice as a nurse and other transmissible infections and emergency practitioner’ (NSW Nurses Registration Board). A nurse practitioner is a registered nurse working at an advancedpractice level leading into practice as an expert nurse, the The extended nurse practitioner role at KRC developed characteristics of which would be determined by the in part in response to the difficulties in attracting medical context in which they have been accredited to practice officers to this area of public health. Possible factors (NSW Health Department 1998). Nurse practitioners in contributing to this may have been that public health is not New South Wales (Australia) used this title prior to as well remunerated as other areas of medical practice and changes to the Nurses Act in 1998. Subsequent to these that the specific fields of substance abuse and sex industry changes, nurses cannot use this title until they have workers have low status within the medical profession. As fulfilled the requirements and have been registered as a a consequence of a shortage of medical officers, the nurse practitioner (NP) with the Nurses Registration Board.
nurses’ role at KRC was developed and extended to meetclients needs. The expansion of the nurse practitioner role Aims of this study
at KRC also arose in response to perceived client needs fora streamlined service that would result in shorter waiting This study represents the first formal evaluation of the times. Nurses who had completed the Family Planning nurses’ role at Kirketon Road Centre (KRC) in Sydney, Nurse Practitioner Certificate and/or had training in sexual Australia. This study broadly aimed to evaluate whether health and venereology were encouraged to extend their the nurse practitioner (NP) role was effective and roles, with support and backup from the medical officers. clinically appropriate at KRC. The specific study aimswere to describe the services provided by nurse Clients service choice related to Kirketon Road Centre
practitioners at KRC, to assess whether nursinginterventions were clinically appropriate for the clients Clients do not have to produce any personal receiving this service and to evaluate the extent to which identification in order to access health care at KRC. At the nursing activities met the standards for ‘best practice’. It time of this study there were no other medical services in was anticipated that the results would indicate whether the area where clients were not required to provide modifications were required to the extended role of the NP identification, Medicare card or fee for service. Such and whether this extended role could be established in requirements often prevented this client group from other primary health care (PHC) settings. accessing health care as this marginalised and oftenchaotic population frequently do not have health care cards Background of nurse practitioners at Kirketon Road
or money. This assured client anonymity and confidentiality and further enhanced acceptability of theservice. At the time of this study the Kirketon Road Centre (KRC) was a primary health care facility of the Sydney KRC has demonstrated that an anonymous, non- Hospital Complex (now named The Sydney Hospital and judgemental service facilitates access to primary health Sydney Eye Hospital). This centre (located in Kings care services by marginalised populations. Other services Cross, Sydney) is primarily involved in the prevention, are following suit by providing easier access through treatment and care of HIV/AIDS and transmissible measures such as ‘drop in’ systems. This has enabled KRC infections among ‘at risk’ youth, sex workers and injecting to increasingly focus on the needs of the more Nurses have practiced within a multi-disciplinary team at KRC since the centre was established in 1987. During this time the nursing role has been developing andexpanding to meet the needs of the target populations.
A major early study on the role of Nurse Practitioners Clinical services provided by the nurse practitioners (NPs) in Canada (Spitzer et al 1974) revealed that the during the time of this study included: assessment of random substitution of family physicians by NPs resulted primary health care needs, sexually transmitted disease in no significant differences in patient outcomes in (STD) screening of sex workers, Pap smears, family physical, social or emotion based measures. Mundinger planning advice, venepuncture for HIV and hepatitis A, B (1980) warned that nurses must also demonstrate an and C, pre and post-test counselling, methadone expansion of their roles and the complementary and administration and needle and syringe exchange. Nurse helpful value of their services ‘rather than their ability to RESEARCH PAPER
assume basic medical care functions only’ (p. 131).
raises concerns regarding the development of protocols Almost two decades later critics of NPs say they are and standards that are the maximum for ideal care as this merely doing the work doctors don’t want, but Allen may precipitate potential malpractice problems by setting (1998) states NPs are educated, autonomous professionals, unrealistic/unachievable standards. This cautions the developing nursing rather than quasi medical roles.
importance of establishing infrastructure to support and Mundinger et al (2000) conducted a randomised trial assess NPs so that they are working within realistic between August 1995 and October 1997 where NPs had standards with strategies in place to provide specific the same authority, responsibilities, productivity and education and training where necessary (Offredy, 1998, administrative requirements, and patient population as 1999, 2000). Recent reports on NPs working in primary primary care physicians. They found that in an ambulatory health care suggests that sexual health is an ideal area in care situation in which patients were randomly assigned to which to develop protocols since 80% of clients have an either NPs or physicians, and, patients’ outcomes were uncomplicated sexually transmitted disease (Allen, 1998). comparable they reported that ‘no significant differenceswere found in patients’ health status (nurse practitioners vs physicians) at 6 months … No significant differences werefound in health services utilisation after either 6 months or1 year’ (p.59, 2000). Policies and procedures
US authors state that the nursing profession continues The policies and procedures used for this study were to debate the efficacy of blending or merging the clinical those already in operation at KRC. They were developed nurse specialist (CNS) and NP roles (Busen and collaboratively by both medical and nursing staff with Engleman, 1996). Establishment of managed care and the qualifications and experience in the areas of sexual health, instability of the healthcare market have driven many venereology, women’s health, family planning, substance CNSs in the USA into graduate programs to retool for abuse, public health and general practice.
more independent roles in primary care settings (Busen The policies and procedures cover the areas of triage, and Engleman, 1996). The same debate on the roles of female and male sexual health screening, Pap smear, bi- CNSs, (titled clinical nurse consultants (CNCs) in NewSouth Wales, Australia), and NPs is current in Australia manual examination, breast examination, pregnancy and distinctions between muti-level CNCs with separate or testing, emergency contraception, testicular examination, additional career pathways for independent, acute care or throat swabs, venipuncture, HIV pre and post-test primary health NPs may be the direction best suited to the counselling and treatment of genital warts and molluscum current health care environment. Busen and Engleman (1996) state that in the US the roles varied mainly withrespect to performing physical examinations, prescribing Competency development
medications, performing and/or ordering laboratory tests, The competencies assessed in this project were prescribing treatments, and making referrals. Busen and developed by the clinical nurse consultant and the nursing Engleman, (1996) cited Elder and Bullough (1990) in unit manager of the Kirketon Road Centre in collaboration stating that the amount of time CNSs and NPs spent in with the clinical nurse consultant, Sydney Sexual Health direct patient care varied with 73% of time for NPs Centre, to provide for the special needs of nursing practice compared to 53% of time for CNSs. NPs were found to within the centre. They were modelled on the Australian practice mainly in primary care settings while CNSs Nursing Council Inc (ANCI) competencies. Further practiced in secondary or tertiary care settings, although development of these competencies has been conducted in collaboration with appropriate professional associations A number of factors have been identified as barriers to such as ASHNA, the Drug and Alcohol Nurses the successful implementation of NPs. These include: Association (DANA) and the Australian NursingFederation (ANF). (i) lack of role clarification and unclear responsibility;(ii) attitude towards the role and acceptance of the role Appropriateness of the role of the Nurse Practitioner at KRC was assessed by reviewing clinical files and (iii) restriction on the scope of practice; and (iv) a high caseload (Dillon and George 1997; Kleinpell The literature on protocols and policy development was examined to inform the evaluation of nursing practices at KRC prior to this study’s commencement. Moniz (1992) RESEARCH PAPER
consultation thereby allowing time for any outcomes to beresolved.
Professional appropriateness of the Nurse Practitioner
Finally, upon completion of the data collection phase of In aiming for professional appropriateness of nurse the project, nurse practitioners were asked to reflect upon practitioners working in this broad area of nursing their understanding of the role of an NP, the purposes of practice, expertise in a number of areas was considered to the pilot project and what they thought the project meant be desirable prior to employment. These included skills in for the nursing profession as a whole. Medical and the area of sexual health and venereology, women’s and counselling staff were also surveyed for their thoughts on reproductive health, nursing related to alcohol and other the appropriateness of the NP role at KRC.
drugs, psychiatric nursing and at least three years post- Characteristics of clients were analysed using the statistical package SAS (Version 6.04).
Each nurse at KRC was assessed as competent in the following skills prior to performance without supervision:venepuncture, intake, including pre and post HIV test counselling, asymptomatic female screen, asymptomaticmale screen, Pap smear, bi-manual examination, breast Demographic characteristics
examination, treatment of genital warts, pregnancy testingand counselling, morning after pill administration, Over the study period, a total of 1046 clients visits contraceptive consultation, microscopy interpretation of (including repeat attenders) were seen by Nurse wet film and of gram stain, post termination of pregnancy Practitioners (613 clients) or medical officers (433 checkup, methadone administration after assessment for clients). Table 1 shows demographic characteristics of intoxication, and needle and syringe exchange.
both Nurse Practitioner (NPs) and medical officer (MO)clients. The majority of clients seen by NPs were women Evaluation methods
(77.3%) with 21.4% men and eight (1.3%) transgenderclients. Over half the NP clients (54.3%) were in the 20 to The evaluation study design was a descriptive cross- 29 year age range with 8% of clients aged 19 years or less.
sectional investigation of nursing practice at KRC utilising The largest proportion of clients seen by NPs were pre-existing data collection forms and regular case filereview by two assessors.
Table 1: Characteristics of clients attending KRC between
14th September 1994 and 26th April 1995 (n=1046)
Over the period September 1994 to April 1995, the NP Consults
MO Consults
KRC operated clinics between the hours of 9.00am and 7.30pm. All clients attending the clinic on Wednesdays for either a nursing or a medical consultation were considered part of the study. Wednesday was selected as it was the optimal day to facilitate data collection requirements (due Age groups 15 - 19 years
to other commitments of staff and structures of activities At the time the study commenced, an average of 40 clients attended the clinic per day. It was considered that one day per week of data collection over an eight month Identified
period would result in a sample size sufficient for valid As part of standard procedure, all client visits were recorded on a visit sheet. This sheet recorded client details, practitioner status, investigations undertaken and the residence
services provided. A ‘triage’ form was also developed for the study. This was initially completed by the client upon arrival indicating reason for visit and arrival time and then the practitioner recorded when the client was actually seen A file review form was developed to assess the appropriateness of the consultation. The form was completed for each identified problem by two file * Not all clients had target group identified and clients may belong to more than reviewers, the clinical nurse consultant (CNC) and the groupof the then Eastern Sydney Area Health Service medical unit manager (MUM) four weeks after a Includes clients not providing a postcode and those with No Fixed Address RESEARCH PAPER
Sixty-eight percent of NP clients identified as parlour sex workers, 20.2% identified as street sex workers and46.3% identified as injecting drug users (IDUs). Nursepractitioners saw a higher proportion of parlour sexworkers while medical officers were more likely to seeIDUs and street sex workers.
Service provision
Table 2: Practitioner service
NP Consults
MO Consults
Reason for
Table 2 outlines details of the services provided by both presentation Results only
nurse practitioners (NPs) and medical officers (MOs). The majority of NP consults were related to STD (51%), gynaecological (17%) and hepatitis (16%) issues (predominantly vaccination). This pattern of service provision reflects the structure of KRC such that nurse practitioners perform the majority of routine sex worker screens thus freeing medical officers up for more complex clinical presentations. Routine sex worker STD screens are Consultation 0-15 minutes
asymptomatic screens for gonorrhoea and chlamydia performed on a fortnightly basis. Every three months, blood is also taken for HIV and syphilis and hepatitis B and C where appropriate. KRC has detailed policies and Services
provided
Table 3: Problems managed by nurse practitioners as
(n=1317)
identified through file review (n=501)
Identified problem
STD issues (e.g. herpes, STD information, penile lesion) Serology (STS, HIV, hepatitis A/B/C, LFTs) (e.g. nausea, sore eyes, constipation, proctitis) Percentages are percentages between NP and MO consults. All other percentages in table are calculated within either NP or MO consults.
* There was considerable data missing for both time client seen by practitioner and time client departed from service.
procedures for routine screens which NPs follow. About 30% of all NP consults involved serology for HIV and syphilis while 50% involved swabs forgonorrhoea and chlamydia. Hepatitis B and C serologywas not performed as frequently on sex workers as oninjecting drug users.
RESEARCH PAPER
Table 4: Clinical review of NP management of each identified problem (n=501)
DISAGREE
CLINICAL ASSESSMENT
Presenting problem documented clearly
Relevant health history documented clearly Results of physical examination documented CLINICAL MANAGEMENT PLAN
Protocol followed
Change in clinical management recommended REVIEW OF CLINICAL OUTCOMES
Expected outcomes for all identified problems
No significant clinical event from identified problem NP satisfied with clinical outcomes or progress MO satisfied with clinical outcomes or progress Clinical assessment and decision making
The second aspect of the practitioners’ work to be evaluated was the clinical management plan. Again, for For the purposes of the present report, only NP cases most components of the clinical management plan, were reviewed. A total of 501 separate issues were reviewers agreed that the NPs acted appropriately and identified and assessed through file review. The range of according to protocol in more than 95% of cases. The only health issues managed by NPs are outlined in Table 3. The aspect where there was substantial disagreement was in majority of the reviewed NP caseload consisted of routine the appropriate associated documentation section (18.6% screens (39.5%), results (13.4%), STD issues (9.6%) and of cases). This was generally because the client contact serology for HIV, HBV and HCV (7.8%). However, as can sheet for results requiring urgent action had not been be seen, NPs at KRC also managed a wide range of other completed or updated appropriately. This was in fact a health issues over the course of the study period including newly introduced documentation requirement and contraception, pregnancy, gynaecological issues, skin inadequacies were overcome by adding this task to the problems, wounds and wound dressings.
Three aspects of the total management of each For the clinical management plan overall, both the CNC identified problem were evaluated through file review.
and the MUM were satisfied in 96.5% of cases. Four of the Clinical assessment covered documentation of: presenting cases where the reviewers were not satisfied involved problem, relevant health history, allergy status, current poor/inadequate documentation, in two the reviewers felt treatment, physical examination and clinical findings. The the MO should have been consulted, in another two the two reviewers found that for each of these areas, NPs had reviewers felt that not all issues raised in the consultation not clearly or completely documented the relevant issues had been dealt with, while only one was reported as wrong contraceptive advice given. All of these cases were before RESEARCH PAPER
Table 5: Medications recommended by NPs (n=197)
The clinical review process demonstrated that only Recommended medications
1.8% (n=9) of investigations recommended were inappropriate (Table 4). These all occurred prior to November 1994 when many of the NPs were newly employed and in the process of familiarising themselves with KRC policies and procedures. Two were for wound Antiseptics/anti-infectives/anti-parasitics dressing and the problem identified by the reviewers was inadequate documentation such that the reviewers wereunable to ascertain whether swabs taken were appropriate as no description of the wound was included. In another case, LFTs had not been ordered for a blood screen when it would have been appropriate to do so, while on another December 1994 when the majority of the NPs were still occasion, urinalysis was not undertaken when the client involved with the orientation process and further training.
described symptoms consistent with a urinary tractinfection (UTI). Two further cases involved symptomatic The final component of the consultation to be evaluated clients, one with possible vaginal thrush where the was clinical outcomes. Both reviewers were satisfied with reviewers felt the NP should have undertaken a wet film clinical outcomes in 97.2% of cases. Reviewers were preparation and another case of ongoing UTI where repeat dissatisfied with clinical outcomes in three cases, which MSU was indicated. A final case, occurring in the second will be addressed in the discussion section of this paper.
week of data collection, involved perianal pruritis and thereviewers decided that the consult as a whole was Recommending medications
inadequate as the MO should have been consulted.
Table 5 outlines the types of medications recommended by the NPs. These medications were recommended by the NP and then the MO was consulted before administration.
Over half the medications (55.9%) recommended by the The findings overall provide strong support for the NPs were for hepatitis B and A vaccination (ie Engerix ability of nurses to perform enhanced clinical practice and and Haverix) or were contraceptive medications (Depo- the results augur well for the future of nurse practitioners.
provera, OCP or MAP). The recommended antibiotics The aim of the present study was to formally evaluate the were standard treatments for frequently encountered effectiveness, professional appropriateness and acceptability infections (eg Doxycycline for chlamydia, Trimethoprim of the extended role of the nurse practitioner at the for urinary tract infections). Topical vaginal medications Kirketon Road Centre. The results indicate that these nurse (predominantly Canesten) were recommended for the practitioners were appropriate and effective in their roles.
The findings indicate that according to both medical Recommending diagnostic pathology
and nursing assessments NPs had clearly or completelydocumented the relevant issues in more than 95% of client Ordering diagnostic pathology is a fundamental feature cases. The aspects of the total management of each of the NP role at KRC given that NPs are responsible for identified problem were evaluated through file review and routine sex worker screens. As such there were existing clinical assessment. In the areas of documentation of policies and procedures at the time of this study regarding presenting problem, relevant health history, allergy status, their indications. NPs at KRC could order the following current treatment, physical examination and clinical tests, without consultation, under the aegis of the medical findings the two reviewers found that for each of these, NPs satisfied the guidelines for ‘best practice’.
Blood for HIV, hepatitis A, B and C, syphilis serology Some of the areas in which ‘best practice’ was not and LFTs (liver function tests, in conjunction with achieved were due to inadequate documentation so that the reviewers were unable to ascertain whether the practicewas appropriate. Further cases (less than 5%) that demonstrated less than optimal practice were most likely Culture for chlamydia, gonorrhoea, candida, to occur in NPs who were new to KRC and occurred prior Microscopy, culture and sensitivity for midstream Only 1.8% (n=9) of investigations recommended were RESEARCH PAPER
The reviewers agreed that the NPs acted appropriately used in this study were in the early stages of their and according to protocol in their clinical management development and required expansion. Therefore it was plans in more than 95% of cases. Many of the problems anticipated that these competencies would undergo further identified involved poor documentation and all of these development in collaboration with the appropriate cases were before December 1994 when the majority of the NPs were still involved with the orientation processand required further training. In the clinical outcomes component of the consultation both reviewers were satisfied with these in 97.2% of cases.
An important recommendation arising from this study Reviewers were dissatisfied with clinical outcomes in one is that a more structured education program for new KRC case where the client tested negative for exposure to nurse practitioners be implemented. This would serve to hepatitis B virus yet declined vaccination, in another increase the NPs level of knowledge and understanding where the client had abnormal results, yet the contact sheet about relevant areas of practice and to assist all NPs in had not been updated and in a third where, due to poor updating their knowledge base. The changes to the NSW documentation of suture removal from a wound, the Nurses Act (1998) will lead to more structured formalised reviewers were unable to determine whether the wound programs to prepare nurses for registration as NPs with the Concerns regarding the acquisition of skills and It is also recommended that protocols be developed knowledge among newly recruited nurses to the level and application for standing orders undertaken for where they could be assessed as being competent to medications such as hepatitis A and B vaccination, practice without supervision were experienced by the emergency contraception, depo-provera, administration of NUM and CNC during the term of this study. This repeat combined oral contraception, vaginal anti-fungal situation and the NP feedback led to the conclusion that preparations based upon clinical signs and symptoms and the process of orientation and ongoing education needed revision. Nursing reflections indicated that while most ofthe NPs believed that they had the prerequisite skills when they commenced at KRC, some of the NPs felt that these recommended medications and clear protocols can be skills had to be learnt on the job. It is proposed that a more developed and easily followed because there is limited structured education programme be implemented to assist choice of medication given for the particular presenting new NPs in gaining knowledge and understanding of problem. The existence of standing orders for these relevant areas of practice and medical conditions and to medications would facilitate service delivery to the assist all NPs in updating their knowledge base.
marginalised target populations by reducing therequirements for consultation with MOs and by freeing up At the commencement of this study, the extension of MOs thereby allowing them to concentrate on the more limited prescribing rights for nurse practitioners was seen as a potential benefit of any evaluation. The medicationsmost commonly recommended by NPs were in general It is recommended that the NPs competencies undergo the same as those recommended by NPs in their feedback further development in collaboration with appropriate regarding appropriate medications for limited prescribing professional associations such as the Australian Sexual rights. These included Engerix and Haverix (hepatitis B Health Nurses Association (ASHNA), the Drug and Alcohol Nurses Association (DANA) and the Australian contraception (MAP), repeat combined oral contraceptive administration and vaginal anti-fungal preparations. These Offredy reports that evidence from the Nurse medications were seen to be appropriate for standing Practitioner Project Report (NSW Health Department orders as there is a limited choice of medications for the 1993), as well as discussion with NPs interviewed during specific conditions. Establishment of the above the broader research program on NPs emphasized the need medications as standing orders would increase nurse for advanced education programs according to the practice autonomy and would reduce the amount of unnecessary specialty of NPs (Offredy, 2000). The current requirement consultation time with medical officers thereby allowing for registration of NPs will lead to the further development both NPs and MOs to attend to the more complex issues. of structured education programs (developed incollaboration with university postgraduate nursing Development of the competencies for this project was a programs) to better prepare NPs for this role. difficult task as competencies were still being developedat a national level and had not yet been ratified in all This research study indicated that NPs (as assessed special interest groups. It was acknowledged before by both nurses and physicians) were professionally commencement of this project that the competencies appropriate in all aspects of expected ‘best practice’ in RESEARCH PAPER
over 95% of consultations. The results support the conclusion that the extended role of nurses at KRC is Dillon A. and George S. 1997. Advanced neonatal Nurse Practitioners in the effective and professionally appropriate. This augurs well United Kingdom: Where are they and what do they do? for the future of nurse practitioners in Australia.
Elder, R. and Bullough, B. 1990. Nurse Practitioners and clinical nursespecialists: Are the roles mergin Kleinpell, R.M. 1997. Acute-care Nurse Practitioners: Roles and practice New South Wales Health Department. 1992. Nurse Practitioners in New South Allen, D. 1998. Putting the experts in charge. Wales: The role and function of Nurse Practitioners in New South Wales (StageOne). A Discussion Paper. NSW Health Department, Sydney, Australia.
Busen, N.H. and Engleman, S.G. 1996. The CNS with practitioner preparation:An emerging role in advanced practice nursing. Clinical Nurse Specialist.
New South Wales Health Department. 1993. Nurse Practitioner Review Stage 2.

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