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 previouslyIngrid van Beek, MBBS, MBA, FAFPHM, is Director, Kirketonat the Clinical Academic Nursing Unit, Faculty of Nursing, TheUniversity of Sydney and Sydney Hospital and Sydney EyeCarol 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 SydneyFCN(NSW) Reg. Psycholigist NSW, MAPsS is the Professorand Director, Urban Health Research Unit, Dept of Family andCommunity Nursing, The University of Sydney and SydneyRobyn 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.
Division of Targeted Research Fax +41(0)31 305 29 70 E-Mail [email protected] NRP Endocrine Disruptors Intermediate Summary Biological activity of complex mixtures of endocrine disruptors Project leader Prof. Dr. Hanspeter Naegeli Project number 4050-66572 English Summary Biological activty of complex estrogenic mixtures There is general concern that the permanent
DER DEUTSCHE SCHMERZTAG 2001 Anmeldung eines wissenschaftlichen Beitrags Titel : NEBENWIRKUNG BEI DER DURCHFÜHRUNG DER ANÄSTHESIE ZUR SCHMERZTHERAPIE BEI PATIENTEN MIT AKUTEN UND CHRONISCHEN SCHMERZEN IN DER SCHMERZPRAXIS, SCHMERZAMBULANZ SOWIE KLINIKEN PATIENTEN MIT MULTIMORBIDEN CHRONISCHEN SCHMERZEN. Autoren : Dr. med. Trang-Xuan Nguyen FA für Frauenheilkunde und Geburtshilfe