THE NURSE PRACTITIONER ACT: Lesson learned from New South Wales

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Introduction, The twenty-first century has been associated with profound in societal values, action and advanced technology especially in health care services. This situation provides an opportunity for nurses to decided where nurses to go to ensure that nursing values are reflected in health care services. Participation in policy making is essential for nurses to influence decision makers. Nurse practitioners program with advanced role in rural areas is one of the New South Wales State policies that give fundamental changes in nursing role in health care services.
In this process, nurses involved actively in the preparation and decision of the policy and gaining support from various legislators and nurses organizations. This great achievement for nursing in Australia has taken many years in collaboration with the NSW Government and many nurse organizations. The changes in state or national health services involve many sectors such as government, medical association, health insurance, community and health care industry. Every sectors or stakeholders have they own interest and interest and try to influence each other with their power and strategies. Thus, understanding of power and policy making process is very important to reveal the core problem and make the best strategies to achieve the goals. 12 May 2008 is the first time Indonesian nurses exercise their power in forcing the legislative house for nursing act. The essay will give an example how the nurses should be acted to gain their right.

The Need for Nurse Practitioner, Nurse practitioner with advanced role such as diagnosing, prescribing and ordering pathological test for rural community is demanded and it must be supported. There are at least three facts that nurse practitioner can give good contribution in public health. The first, nurse practitioner works with highly professional standard. Under a nursing act, nursing board ensures that community is adequately provide with the highest standard to achieve and maintaining the highest professional standard of competence and conduct in nursing (NBSA, 2000). To ensure the safety, not every nurse has privileges as a nurse practitioner. Only nurses who have successfully completed their competency assessment will be eligible to register as nurse practitioner with the extended service privileges (ACT, 2002). Master degree background or equivalent with specific prerequisite is required to guarantee the quality of practice (Duffy, 2002).

The second evident is community satisfaction and cost effectiveness. Rural patients feel satisfy with the advanced role of NP. A randomized study conducted by Venning et all. (2005) proves that patients were more satisfied with NP consultations and there was no significant difference in patterns of prescribing or health status outcome between general practitioner and nurse practitioner. This study also concludes that health service costs of NPs and GPs were similar. Systematic review conducted by Donald et. all. (2002) concludes that nurse practitioner primary care at first point of contact improves patient satisfaction and quality of care compared with physician care, with no difference in health outcomes. Then, nurse practitioners also had longer consultation times and did more investigations. ICN confirms that nurse practitioners provide quality of care services in a range of setting and also improve patient and community access to health services (CNA, 2002).

The last fact is doctor shortage in rural areas. In Australia, there are only 16 per cent of doctors who work in rural areas while 30 per cent of the populations live in these areas (Aggleston, 2000). Then, even though the number of rural doctor in Australia increased by 12% between 1997 and 2002 but they want work in fewer hours. So, the total number of full-time equivalent was decrease from 275 to 271 per 100,000 populations (AIHW, 2004). Furthermore, prospective cohort study on retention showed that physicians who chose voluntarily to go to a rural area were far more likely to stay long term (Sepowski, 2004). These situations can not reduce waiting time and improve patients’ access for health services significantly.

In contrast, the proportion of nurses in rural areas was around 31 per cent (Jones & Cheek, 2001). It can be seen that there are more nurses willing to live in rural areas while doctors reluctant to do so. So, nurse would be a valuable resource to give health services for the rural and remote community. For that reason, Offredy and Townsend (2000) believe that NPs can provide better access and decrease waiting times; and in fact, it is appreciated by patients.

The Power in Nursing, Since doctors are more likely unwilling to practice in rural or remote areas (Pearson, 2002), raising the inequality in health care access for rural population. This situation inspires the Australian government to implement nurse practitioner program with advanced role. The advanced role of nurse practitioner is move toward from primary role of nurse (caring) to limited role of physician (cure). This situation leads unnecessary medical fears that nurses are attempting to displace doctors (Keyzer, 1997). More over, independent practice (such as diagnosing and prescribing) without direction of general practitioner can be interpreted as decreasing medical domination in health care services (Pearson, 2002). Because of these reasons, medical association such as AMA tried to renegotiate the traditional order in health care system (Keyzer, 1997).

As the extended role of nurse practitioner can be seen as an additional opportunity in nursing career (Armstrong, 2001) and a symbol of rejection from past perceived doctor subordination (Keyzer, 1997), nurses try to exercise their power to lobby the legislator to endorse the new practice has been done. The paragraphs below will describe the type, source and potential power of nurses can be exercised to influence the policy makers.

Education and expertise, Patients satisfaction with NP practices, the same clinical outcomes and no significant different in prescribing with GP (CNA 2002; Donal et all., 2002; Venning et all., 2005) give the evidences that the expertise of NP and GP in the particular area is equal. Good education background and experience make the expertise of NP as independent practitioner is recognized by community and it can be an essential part of power of nurses. These valid data or evidences come from rigorous nursing research in order to prove that NP practice based on sufficient evidences. Excellent nursing research findings are only the way to counter the allegation made by other profession (Diers, 1992 cited in Diers, 1998). The data have more powerful effect because it does not seem self-serving (Diers, 1998). Thus, it can be proved that nurses have expert power. And then, nurse be able to influence others with their expertise, special skills or knowledge (Robin, et all., 2001) to achieve the goals. Moreover, the increasing number of nurses prepared at the baccalaureate, master and doctoral levels are the factors related to expert power and control (Wolf, 1985). The recognition of independent nature of nursing practice with its inherent rights and responsibilities is another essential move forward expert power and control (Gagnon & Duste, 1993). Education background in university can expose students to campus activism, protest and organization which are trying to affect change (Lerner, 1985). So, nurses have power and political knowledge and awareness from campus. Then, some of them actively involved in nursing associations to influence health policy trough group action. Professional organization Professional organization is the most important sources of power in modern society (Ferguson, 1993) and it is a powerful instrument available to nurses (Joel, 1985). Organization is politically important in a democracy because through its numerical strength and coordination, it is only the way to overcome adversarial forces (Maraldo & Kinder, 1985). Furthermore, nursing strength in political arena lies on its numbers. Regardless the expertise of nurse to serve humanity, their view of health care is delivered will be unheard without the leverage of number (Maraldo & Kinder, 1985). Mason, Talbott and Leavitt (1993) believe that nursing organizations provide an opportunity for nurses to influence health and public policy through collective action. The organizations with controlling a huge number of members will increase their power in negotiations (Robin, et all., 2001). For example, ANF was established in 1942 and it has 145,000 members (ANF, 2003) while AMA has 27,000 members (AMA, 2003). ANF supports The National Nurses Organizations, involving 50 professional bodies to develop nursing specialties organization. These organizations meet twice annually to debate and seek consensus on professional issues such as nurse practitioners (DEST, 2001). Using Luft’s group theory perspective (1970 cited in Wolf, 1985), these nurses organisations already achieved stage of cohesiveness and met four criteria (open system, goal-attainment, integration, and pattern and organisation). In this stage, the group is able to confront issues and it has power and control.

The Tactic to achieve the goals, Tactic or strategy is a translation of power bases into specific action to achieve certain goals (Robin, et all, 2001). There are some strategies to influence other stakeholders are used by nurses. ReasonsReason is the most popular strategy to affect changes (Robin et all., 2001). Organizations use reasons in their position statements, publications and lobbies to support or against policy. For NP policy, the acceptable reasons are improving access to health services in rural areas (CNA, 2002), community need (RCNA, 2002), insufficient number of practitioners (Aggleston, 2000), cost effectiveness (Venning et all.2005), and the nurse competences (NBSA, 2002). However, other strategies are needed to foster the impacts. Coalition Coalition is getting support of other people in the organization to back up the request (Robin et all., 2001). Coalition is one of the most significant and valuable political strategies for creating concerted action to reach defined goals (Leavit & Pinsky, 1998). Organizations are particularly active and involved during health care reform debate. In this circumstances, ANF coalition with other 50 nurses organizations to support the NP policy (Jones & Cheek, 2001). Meanwhile, ANC collaborate with NCSBN to provide the guideline of licensure. Then, the position is endorsed by RCNA (Robert, 1996). So, it can be seen that almost nurses’ organizations not only in Australia but also in many western countries have the same voice to support the NP policy. The biggest moral and technical support also came from the biggest nursing organization, ICN. ICN states that NP improves the quality of care and improves health care access for communities (CNA, 2002). BargainingIn this term, bargaining means as negotiation to exchange the benefits of favors (Robin et all., 2001). In this situation, the government needs nurses to improve the coverage and the access of health services in the rural areas where doctors are unavailable (Armstrong, 2001). On the other hand, nurses need legality for the expansion role in the new practice model from the government as regulatory body (Peel, 2002). Both nurses and the government exchange the benefit to each other. In this situation, timing is very important aspect that can influence policy makers.

Conclusion, The formalized establishments of NP role become an inspiration for both governments and nurses’ organizations in developed and developing countries. It is understandable that governments need to save public budget allocation and maintain health services access and quality while nurses need to expand their career to be more attractive. Alternative models of health services move forward from traditional role, concept and values. People at each point on the political spectrum have different mind-set about changing in existing concept and values, status quo that have more benefit from the old system tend to try to stop the progressive change. Every stakeholders has they own hidden agendas; they try to influence each other and want to be the director to drive the change direction. Thus, understanding power concept and politic and utilize every resources using proper combination of strategies is only the way to reach the goals.

Perhaps all the activities have done by friends from Australia inspire the nurses in Indonesia to move in achieving the professional right similar with other nurses in the world


ACT : Australian Capital Territory

AIHW : Australian Institute of Health and Welfare

AMA : Australian Medical Association

ANC : Australian Nursing council

ANF : Australian Nurse Federation

CNA : Canadian Nurses Association

DEST : Department of Education Services and Training

GP : General Practitioner

ICN : International Council of Nurses

NBSA : Nursing Board of South Australia

NCSBN : National Council of State Board of Nursing (The United State)

NP : Nurse Practitioner

NSW : New South Wales

RCNA : Royal Colleague of Nursing Australia


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