A history of the early development of the nurse practitioner role in New South Wales, Australia

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Changes in the health care environment have required concomitant changes in approaches to health care, and the roles and functions of health care professionals worldwide. The nurse practitioner (NP) role was first introduced in the United States of America (US) in the 1960s to help address critical health care needs that were designed to improve access to health services. The NP role has continued to evolve in the US and other countries including Canada and the United Kingdom (UK) across a range of health care settings. In Australia, New South Wales (NSW) was the first state to consider the potential for the NP role in 1990 (NSW Department of Health, 1992). The purpose of this research was to trace and document the early development and implementation of the NP role in NSW. This study adds to the nursing literature by documenting historical events in the inception of the NP role, particularly factors that affected the development and its implementation of the NP role in the NSW health care system. In addition the study preserves the oral histories of figures who were instrumental in the introduction of this new clinical career pathway for nurses, and a new model of care into the Australian health care system. This thesis constitutes original historical research into the development of the NP role in NSW. An historical, descriptive design was used that included recorded interviews with 10 pioneer nurse practitioners and 17 key stakeholders involved in the development of the NP role. Documents were collected that were central to the key historical events, and these documentary accounts were compared and contrasted with the information provided through the interviews. The data was analysed using qualitative thematic analysis. The development of the NP role began at a nursing conference in 1990 because a nurse asked the NSW Health Minister whether he supported the NP role. This one question triggered a cascade of events. Between 1990 and 1998 the NP role was legislated and the title of the NP protected through the Nurses Amendment (Nurse Practitioners) Act 1998 (NSW). During this time four committees were formed, four reports had been generated and 10 pilot projects undertaken. In 1997, the NSW Minister for Health established an implementation process for NP authorisation, education and regulation. On May 11, 2001 the NSW Minister for Health announced the first NP to be appointed into a position in remote NSW and in September 2002, NPs were introduced into metropolitan areas of NSW. Disparate visions and vested interests in relation to the NP role inevitably affected the development of the role and the way it was enacted. Stakeholders who had a ‘sense of gain’ and supported the NP role saw its benefits for the health care system, and for nursing. Those who fought to maintain the status quo were ultimately driven by a sense of ‘loss and fear.’ There was considerable fear about the effect of the NP role on the roles of other health care professionals. There was much interplay between those trying to maintain the status quo and those who were trying to counterbalance the sense of loss and fear. The development and implementation of the NP role became an arduous process of negotiation and compromise. Further complexities arose in understanding tradition’s historical legacy on the NP role. The findings illuminated that some doctors were not only resistant to the NP role but had not adapted to the professional status of nursing. Similarly, the findings indicate that there are still many nurses who have not adapted to the advancement of nursing. As a consequence, they also hanker for the supposedly good old days, and strongly opposed new developments such as the introduction of NPs. The findings attest to significant disruption to professional-working relationships with some health care professionals torn between their personal, professional and organisational commitments. Long-term professional relationships between the NPs, nurses, doctors and managers were challenged. The study’s findings demonstrate the need to assess an organisation’s readiness when introducing a new nursing role and an assessment of the environmental conditions to support role implementation. The findings also revealed the importance and influence of language in introducing a new nursing role such as that of the NP. There was confusion surrounding the use of certain terms (e.g., advanced practice) within and beyond nursing. The NPs found the authorisation process particularly challenging. The findings show that, with any newly introduced process, there needs to be detailed guidance and an assessment that candidates are able to meet the requirements set by the regulatory body. Only because of the resilience and perseverance of the nurse leaders, the NPs and others who supported the role, has the NP movement been able to gain momentum. One of the principal findings of this study has been the political maturation of the nurse leaders during the development of the NP role that, in turn, has benefited nursing. There was considerable resistance to the NP role by some powerful medical organisations and the findings show that it is important to engage the media and educate the public about the NP role and its value, to help garner support early on in the development of the role. In addition, because of the political nature of the role, NPs require education in using and managing the media and also education about managing themselves in the politics of health care. All of these findings are discussed in detail in this thesis.
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