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The plight of the perioperative nurse practitioner in Australia

Photo: The plight of the perioperative nurse practitioner in Australia
By Lisa Yang and Toni Hains

“A nurse practitioner is a registered nurse educated to a post graduate Masters level and authorised to function autonomously and collaboratively in an advanced and extended clinical role” (Queensland Government, 2011).

The nurse practitioner (NP) role was established in the United States (US) during the 1960s in response to a shortage of primary care doctors. Physicians began to pool resources and collaborate with nurses they identified as having a strong clinical focus, and the concept of advanced nursing practice was born.

The concept was to expand the number of accessible healthcare providers at a reasonable cost, together with a robust emphasis on advanced nursing practice in collaboration with a physician. The foresight to implement this role as a post graduate degree gave professional and formal recognition to the role of advanced nursing practice (Schober & Affara, 2009). The NP evolution then spread across the US and on the United Kingdom in the 1980’s.
Thirty-six years later the first NP roles were introduced to New South Wales with endorsement of the initial NPs in 2000. The role of the NP is now established in Australia with 1,380 NPs endorsed with the Australian Health Practitioner Regulation Agency (AHPRA) as of March 2016 (Nursing and Midwifery Board of Australia, 2016). The NP role in Australia is highly regulated with title protection and rigid competency standards.

According to a Nursing and Midwifery Workforce Report, the current clinical practice setting of the NP in Australia includes a plethora of specialties but what is not mentioned in the list is the NP working in the perioperative clinical setting (Australian Institute of Health and Welfare, Nursing and Midwifery Workforce, 2012). The role of the Perioperative NP is comprehensive and can include preoperative patient assessment and “work-up”, intraoperative surgical assisting and postoperative care including discharge education and planning, and wound care.

Bernadette Brennan, a pioneer in Australian advanced perioperative practice, proposed in 2001 that the advanced practice of the perioperative nurse in Australia could provide cost-effective and versatile service in the healthcare sector. This assertion, coupled with a mandate of the Australian Government in the Health Workforce Australia Work Plan 2013-14 to boost productivity (within healthcare) with an emphasis on “Supporting national implementation of new workforce roles”, suggests that the tole of the perioperative NP would provide cost benefits within the perioperative setting (Australian Federal Government, 2013). A recent paper investigating nurses as surgical assistants in Australia concluded that nurses in this role increase productivity by decreasing in-theatre preparation time and promote a decrease in operating time (Hains et al. 2016).

In Australia no nationally regulated criteria exists for the broader role of intraoperative surgical assistant; be that for medical or nursing personnel. The Royal Australasian College of Surgeons (RACS) has a position statement for the surgical assistant which does not outline specific qualifications required to perform this role (Royal Australasian College of Surgeons, 2015). The peak perioperative nursing body, the Australian College of Operating Room Nurses (ACORN), standard for this role states the Perioperative Nurse Surgeon’s Assistant (a category in which the perioperative NP can reside) must be a registered nurse with a minimum of three years’ perioperative experience (ACORN, 2015). This standard is not imposed by the Australian Health Professional Regulation Agency (AHPRA) or healthcare facilities that are responsible for credentialing surgical assistants.

Investigating practice in the private sector of the Australian healthcare system, the perioperative NP is able to seek remuneration in the form of a consultation fee for pre and post-operative care as long as these are not in addition to the surgeon billing the Medical Benefits Schedule (MBS). What is not provided for under the MBS if any care given by the perioperative NP in the intraoperative phase as surgical assistant. This provision is for medical personnel only (Victorian Government, 2014). So while NPs in Australia possess a Provider Number and a Prescriber Number they cannot access “Assisting at Operation” Item Numbers on the MBS. This means that the perioperative NP is a disruptive innovator who provides a service and fills gaps that exist in the healthcare system without the require support from the system (Christensen, 2016). Remuneration through the MBS would take the role of the perioperative NP from a disruptive innovator to a sustainable innovator providing a valuable service for appropriate remuneration.

In September 2016, the Medical Observer published an online article calling for parity of remuneration between General Practitioners (GPs) and specialists. The article states that, “GP fees should be boosted to match specialists’ for identical services, according to a committee tasked with reviewing the design and structure of the Medicare Benefits Schedule regardless of the medical practitioner’s background qualification” (Medical Observer, 2016).

This statements sets precedence that if GPs should be paid the same as specialists for the same clinical services, then perioperative NPs should be paid the same as GPs for the same intraoperative assisting clinical services.

The perioperative NP has to date shown a trend toward cost saving in the Australian Healthcare System (Hains et al. 2017; Hains et al. 2016). If a small change to the MBS allowed the perioperative NP to access the ‘Assisting at Operation’ Item Numbers, this cost saving has the potential to increase as more NPs would be encouraged to practice in this setting.

About the Authors
Toni Hains is a PhD Scholar at the University of Queensland and a Perioperative Nurse Practitioner – Self Employed.
Lisa Yang is a Perioperative Nurse Practitioner – Self Employed

Reprinted with Permission of the Australian Nursing & Midwifery Federation

References
Australian Federal Government. 2013. Health Workforce Australia Work Plan 2013-14. www.hwa.gov.au/sites/uploads/HWA-work-plan-2013-14_vf_lr.pdf

Australian Institute of Health and Welfare. Nursing and midwifery workforce. 2012. A snapshot of nurse practitioners in Australia. Fact Sheet 6. Retrieved from http://anf.org.au/documents/reports/fact_sheet_snap_shot_nurse_practitioners.pdf

Brennan, B. 2001. The registered nurse as a surgical assistant: the “downunder” experience. Seminars in Perioperative Nursing, 10(2), 108-114.

Christensen, C. 2016. Disruptive Innovation. Retrieved from http://www.claytonchristensen.com/kep-concepts/

Foster, J. 2010. A history of the early development of the nurse practitioner role in New South Wales Australia.

Hains, T., turner, C., Gao, Y., & Stand, H. 2017. Valuing the role of the Non-Medical Surgical Assistant. ANZ Journal of Surgery, In Press.

Hains, T., Turner, C., & strand, H. 2016. Practice Audit of the Role of the Non-Medical Surgical Assistant in Australia, an Online Survey. International Journal of Nursing Practice. Doi: 10.1111/ijn.12462

Horrocs, S., Anderson, E., & Salisbury, C. 2002. Systematic review of whether nurse practitioner working in primary can provide equivalent care to doctors. BMJ 324(7341), 819-823.

Medical Observer. 2016. MBS reviewers push for GP fee parity. Medical Observer. Retrieved from www.medicalobserver.com.au/professional-news/mbs-reviewers-push-for-gp-fee-parity

Nursing Midwifery Board of Australia. 2016. Registrant Data - Nursing and Midwifery Board of Australia. Retrieved from www.nursingmidwiferyboard.gov.au/about/statistics.aspx

Queensland Government. 2011. Clinical Governance for Nurse Practitioners in Queensland: A guide. Brisbane: Queensland Government. Retrieved from www.health.qld.gov.au/_data/assets/pdf_file/0021/158223/np-impguide.pdf

Royal Australasian College of Surgeons. 2015. Position Statement – Surgical Assistants. Retrieved from www.surgeons.org/media/304233/2015-05-20_pos_fes-pst-028_surgical_assistants.pdf

Schober, M., & Affara, F. 2009. International council of nurses: Advanced nursing practice: John Wiley & Sons.

The Australian College of Operating Room Nurses. 2015. ACORN Standards for Perioperative Nursing, Nursing Role: Perioperative Nurse Surgeon’s Assistant (PNSA). Adelaide, South Australia: The Australian College of Operating Room Nurses Ltd.

Victorian Government. 2014. 10.5.22.6 the MBS Rules. Retrieved from http://www1.worksafe.vic.gov.au/vwa/claimsmanual/content/10entitlements_medicalandlikeservices/1%2015%2022%206%20the%20MBS%20rules.htm

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