Advertisement

Australian research investigating the role of nurse practitioners: A view from implementation science

      Summary

      The catalyst for the paper was a rapid review of the literature which identified Australian research on nurse practitioners. This paper reports on those studies investigating individual nurse practitioner roles, framed in terms of the implementation science literature and three stages of implementation: exploration and adoption of the role, initial implementation of the role, and full operation of the role.
      Database searching of the peer-reviewed literature was supplemented with searching relevant web sites. Most studies focused on certain aspects of the nurse practitioner role rather than undertaking a comprehensive evaluation. There was no consistency in the way the roles were described, making it difficult to compare what may be similar roles in different studies. The research generally treats the nurse practitioner role as the independent variable, rather than the care provided by the nurse practitioner. The concept of implementation fidelity was absent from all studies, except for one which addressed the issue indirectly. Many studies included little contextual information, making it difficult to judge the role of context in influencing both implementation and patient outcomes and establish plausible links between the activities of the nurse practitioners and patient outcomes.
      Based on the findings, a checklist is recommended for use in future studies which would enhance the ability to make judgements about implementing nurse practitioner models of care; facilitate comparison of similar roles and increase the capacity to make informed decisions about the prospects for wider implementation of nurse practitioner roles or models of care.

      Keywords

      1. Introduction

      Serious debate regarding the introduction of the nurse practitioner role in Australia started about 25 years ago. Ten years later, in 2000, the first nurse practitioner was authorised to practice and the following year the first nurse practitioner was appointed to a position. From these humble beginnings, the number of nurse practitioners has steadily increased, as has the volume of Australian research into the nurse practitioner role. Australian research has taken place in the context of research from other countries with a longer history of nurse practitioners, particularly the USA, Canada and the UK (
      • Brown S.A.
      • Grimes D.E.
      A meta-analysis of nurse practitioners and nurse midwives in primary care.
      ,
      • Carter A.J.E.
      • Chochinov A.H.
      A systematic review of the impact of nurse practitioners on cost, quality of care, satisfaction and wait times in the emergency department.
      ,
      • Horrocks S.
      • Anderson E.
      • Salisbury C.
      Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors.
      ,
      • Jennings N.
      • Clifford S.
      • Fox A.R.
      • O’Connell J.
      • Gardner G.
      The impact of nurse practitioner services on cost, quality of care, satisfaction and waiting times in the emergency department: A systematic review.
      ,
      • Newhouse R.P.
      • Heindel L.
      • Weiner J.P.
      • Stanik-Hutt J.
      • White K.M.
      • Johantgen M.
      • et al.
      Advanced practice nurse outcomes 1990–2008: A systematic review.
      ,
      • Wilson A.
      • Zwart E.
      • Everett I.
      • Kernick J.
      The clinical effectiveness of nurse practitioners’ management of minor injuries in an adult emergency department: A systematic review.
      ).
      The catalyst for this paper was a rapid review of the nurse practitioner literature conducted for the NSW Ministry of Health (
      • Masso M.
      • Thompson C.
      Rapid review of the nurse practitioner literature: Nurse practitioners in NSW ‘Gaining Momentum’.
      ), which included identifying all the published Australian research on nurse practitioners up until the review was conducted. The review identified four categories of studies: (1) studies of nurse practitioners in particular clinical settings; (2) studies using surveys, interviews or focus groups to collect cross-sectional data from nurse practitioners; (3) studies using surveys or interviews to collect data to identify the views of others regarding nurse practitioners and (4) studies using work sampling and chart audit to investigate the work of nurse practitioners.
      Reflecting on our rapid review, several observations became apparent with regard to the first category of studies (i.e. nurse practitioners in particular clinical settings), including that some studies may have been conducted too early (before a role was fully implemented) or that there was insufficient information to determine whether or not the role was ‘fully implemented’. The purpose of this paper is to share those observations and explore how the future reporting of nurse practitioner research might be improved using the ‘lens’ of implementation science.
      There are many references in the literature to the ways in which the roles of nurse practitioners vary across countries, resulting in confusion about how the role is defined (
      • Duffield C.
      • Gardner G.
      • Chang A.M.
      • Catling-Paull C.
      Advanced nursing practice: A global perspective.
      ,
      • Stasa H.
      • Cashin A.
      • Buckley T.
      • Donoghue J.
      Advancing advanced practice – Clarifying the conceptual confusion.
      ). For example, some countries use the term ‘nurse practitioner’, whereas others tend to use the term ‘advanced practice nurse’ (
      • Pulcini J.
      • Jelic M.
      • Gul R.
      • Loke A.Y.
      An international survey on advanced practice nursing education, practice, and regulation.
      ). From the perspective of synthesising the results of multiple studies of the nurse practitioner role across different countries, this suggests that it cannot be assumed that each study is investigating the same thing (i.e. the nurse practitioner).
      Despite this, both the Australian research and the broader international literature, is generally underpinned by an implicit assumption that all nurse practitioners are indeed the same. For example, reviews of the literature usually start by ‘setting the scene’ in terms of current knowledge and development of the role and then describe the methods for searching the literature and culling the results, with the culling typically including consideration of study design or study quality. What is not usually undertaken is some consideration of whether the studies included in the review have all studied a similar role. An exception is a review which was restricted to studies from the USA because the authors believed that some features of the role (e.g. educational preparation, scope of practice) and the health system were so different from other countries that it would be inappropriate to include studies from outside the USA (
      • Newhouse R.P.
      • Heindel L.
      • Weiner J.P.
      • Stanik-Hutt J.
      • White K.M.
      • Johantgen M.
      • et al.
      Advanced practice nurse outcomes 1990–2008: A systematic review.
      ).
      Despite a recent emphasis on understanding what is meant by ‘implementation’, what influences implementation and how implementation can be evaluated, it is surprising that there is a general lack of clear conceptualisations and definitions of what is meant by the term ‘implementation’. Even when the term is defined, it is often difficult to comprehend how well an intervention has been implemented. The two main ways of conceptualising implementation are in terms of stages, a sequential process whereby an intervention (in this example the role of nurse practitioner) is progressively implemented (
      • Fixsen D.L.
      • Naoom S.F.
      • Blase K.A.
      • Friedman R.M.
      • Wallace F.
      Implementation research: A synthesis of the literature.
      ), and in terms of the degree to which an intervention has been implemented, referred to as implementation fidelity (
      • Carroll C.
      • Patterson M.
      • Wood S.
      • Booth A.
      • Rick J.
      • Balain S.
      A conceptual framework for implementation fidelity.
      ). If the role of a nurse practitioner is not fully implemented, it is difficult to differentiate between a role that may be very effective, but not fully implemented, and a role that is not effective (
      • Fixsen D.L.
      • Naoom S.F.
      • Blase K.A.
      • Friedman R.M.
      • Wallace F.
      Implementation research: A synthesis of the literature.
      ).
      For the purposes of considering Australian research involving nurse practitioners, the following stages of implementation provide a useful way of framing the research:
      • 1.
        Exploration and adoption of the role – making a decision to adopt an innovative role and developing a plan to implement that role.
      • 2.
        Initial implementation of the role.
      • 3.
        Full operation of the role (
        • Fixsen D.L.
        • Naoom S.F.
        • Blase K.A.
        • Friedman R.M.
        • Wallace F.
        Implementation research: A synthesis of the literature.
        ).
      These three stages have been used to structure the paper.

      2. Methods

      The literature searching for the original rapid review was conducted in October 2013, involving database searching of the academic literature from 2000 to 2013, together with searching the web sites of government health departments, professional nursing organisations and universities within Australia running Masters degree programmes for nurse practitioners. Databases searched included Cinahl, Medline, Education Research Complete, ERIC, Health Source: Nursing/Academic edition, Psychology & Behavioural Sciences Collection, Summons and the APN Literature Database maintained by McMaster University. Search terms included ‘nurse practitioner’, ‘Australia’, ‘model’ and ‘theory’. A search was also conducted for the author Gardner, given the key contribution to the nurse practitioner literature by the Australian researchers Anne Gardner and Glenn Gardner. The Trove database was searched for Australian theses. Snowball searching consisted of reviewing the reference lists of key studies and using Google Scholar to track citations forward in time.
      The searches were re-run in March 2015 to identify additional Australian studies published in the intervening period. In total, 1862 papers were identified from searching the academic literature. After culling those papers based on a review of the title or abstract, full-text copies of 145 papers were retrieved. To this were added 17 reports from searching websites and 24 journal articles located as a result of snowball searching. Reviewing the full text of all these documents resulted in the papers reported here. Further details of the search strategies and the results of the searching can be found in the rapid review (
      • Masso M.
      • Thompson C.
      Rapid review of the nurse practitioner literature: Nurse practitioners in NSW ‘Gaining Momentum’.
      ).

      3. Results

      3.1 Exploration and adoption

      The ‘exploration and adoption’ stage of implementing nurse practitioner roles in Australia consisted of a series of pilot projects in various states and territories; New South Wales (
      • NSW Department of Health
      Nurse Practitioner Project Stage 3. Final report of the Steering Committee.
      ), Victoria (
      • Parker J.
      • Faulkner R.
      • Dunt D.
      • Long H.
      • Watts J.
      Victorian Nurse Practitioner Project: Evaluation of eleven Phase 1 demonstration projects.
      ,
      • Pearson A.
      • Nay R.
      • Ward C.
      • Lenten L.
      • Lewis M.
      Nurse practitioner project: Phase 2 – External evaluation.
      ), the Australian Capital Territory (
      • ACT Health
      The ACT Nurse Practitioner Project: Final report of the Steering Committee.
      ) and Queensland (
      • Queensland Health
      Nurse practitioner project report.
      ). Papers reporting the results for particular models included in these pilots were subsequently published – sexual health (
      • O’Keefe E.J.
      • Gardner G.
      Researching the sexual health nurse practitioner scope of practice: A blueprint for autonomy.
      ); the management of wounds and blunt limb trauma in rural and remote locations (
      • Chang E.
      • Daly J.
      • Hawkins A.
      • McGirr J.
      • Fielding K.
      • Hemmings L.
      • et al.
      An evaluation of the nurse practitioner role in a major rural emergency department.
      ); prevention, treatment and care of HIV/AIDS and transmissible infections (
      • Hooke E.
      • Bennett L.
      • Dwyer R.
      • van Beek I.
      • Martin C.
      Nurse practitioners: An evaluation of the extended role of nurses at the Kirketon Road Centre in Sydney, Australia.
      ); neonatal care (
      • Copnell B.
      • Johnston L.
      • Harrison D.
      • Wilson A.
      • Robson A.
      • Mulcahy C.
      • et al.
      Doctors’ and nurses’ perceptions of interdisciplinary collaboration in the NICU, and the impact of a neonatal nurse practitioner model of practice.
      ); and intensive care liaison (
      • Green A.
      • Edmonds L.
      Bridging the gap between the intensive care unit and general wards – The ICU Liaison Nurse.
      ).
      These studies of particular models provide examples of the need for great care when citing studies as ‘evidence’ in support of nurse practitioners, primarily because of the pilot nature of the studies. For example, the study by
      • Chang E.
      • Daly J.
      • Hawkins A.
      • McGirr J.
      • Fielding K.
      • Hemmings L.
      • et al.
      An evaluation of the nurse practitioner role in a major rural emergency department.
      only ran for three and a half months and pre-dates the introduction of authorised nurse practitioners in Australia. Training of the nurses in the pilot was limited to ‘an intensive series of lectures’ and four months of supervised clinical practice (
      • NSW Department of Health
      Nurse Practitioner Project Stage 3. Final report of the Steering Committee.
      ). The nurses could only recommend the ordering of pathology and radiology. Despite this, the paper was included in a systematic review of the impact of nurse practitioners on cost, quality of care, satisfaction and wait times in the emergency department based on its methodological quality rather than consideration of whether it represented a study involving a ‘fully implemented’ nurse practitioner role (
      • Carter A.J.E.
      • Chochinov A.H.
      A systematic review of the impact of nurse practitioners on cost, quality of care, satisfaction and wait times in the emergency department.
      ). The paper has also been cited in other papers as evidence of the value of nurse practitioners (
      • Hoskins R.
      Evaluating new roles within emergency care: A literature review.
      ,
      • Lutze M.
      • Ross M.
      • Chu M.
      • Green T.
      • Dinh M.
      Patient perceptions of emergency department fast track: A prospective pilot study comparing two models of care.
      ,
      • Middleton S.
      • Allnutt J.
      • Griffiths R.
      • McMaster R.
      • O’Connell J.
      • Hillege S.
      Identifying measures for evaluating new models of nursing care: A survey of NSW nurse practitioners.
      ).
      Another example is a paper reporting the results of the neonatal care project which makes quite clear that ‘at the time the study was conducted, NPs had not been formally implemented in the state of Victoria … No advanced practice model was in place in the units concerned’ (
      • Copnell B.
      • Johnston L.
      • Harrison D.
      • Wilson A.
      • Robson A.
      • Mulcahy C.
      • et al.
      Doctors’ and nurses’ perceptions of interdisciplinary collaboration in the NICU, and the impact of a neonatal nurse practitioner model of practice.
      , p. 107). The title of the paper (Doctors’ and nurses’ perceptions of interdisciplinary collaboration in the NICU, and the impact of a neonatal nurse practitioner model of practice) is somewhat misleading, which perhaps helps to explain why the paper has been cited as an example of the nurse practitioner role (
      • Allen J.
      • Fabri A.M.
      An evaluation of a community aged care nurse practitioner service.
      ).

      3.2 Initial implementation

      Research into ‘initial implementation’ of nurse practitioner roles largely consists of studies which have investigated nurses in training to become nurse practitioners, usually described as transitional nurse practitioners or nurse practitioner candidates. Using the ‘language’ of nurse practitioners, the roles of those in training to become nurse practitioners do not encompass the full scope of practice (
      • Gardner A.
      • Gardner G.
      • Middleton S.
      • Della P.
      The status of Australian nurse practitioners: The first national census.
      ).
      Australian studies of transitional or candidate nurse practitioners have primarily been conducted in emergency departments (
      • Considine J.
      • Martin R.
      • Smit D.
      • Jenkins J.
      • Winter C.
      Defining the scope of practice of the emergency nurse practitioner role in a metropolitan emergency department.
      ,
      • Considine J.
      • Martin R.
      • Smit D.
      • Winter C.
      • Jenkins J.
      Emergency nurse practitioner care and emergency department patient flow: Case–control study.
      ,
      • Fry M.
      • Rogers T.
      The Transitional Emergency Nurse Practitioner role: Implementation study and preliminary evaluation.
      ,
      • Fry M.
      • Fong J.
      • Asha S.
      • Arendts G.
      A 12-month evaluation of the impact of Transitional Emergency Nurse Practitioners in one metropolitan Emergency Department.
      ,
      • Jennings N.
      • O’Reilly G.
      • Lee G.
      • Cameron P.
      • Free B.
      • Bailey M.
      Evaluating outcomes of the emergency nurse practitioner role in a major urban emergency department, Melbourne, Australia.
      ,
      • Lee G.
      • Jennings N.
      A comparative study of patients who did not wait for treatment and those treated by Emergency Nurse Practitioners.
      ,
      • Lutze M.
      • Ratchford A.
      • Fry M.
      A review of the Transitional Emergency Nurse Practitioner.
      ). As an illustration of these roles not extending to the full scope of practice, two of the papers report on the work of a nurse practitioner candidate who had to discuss each patient with an emergency physician, obtain counter signatures for medications and verify the results of medical imaging and pathology (
      • Considine J.
      • Martin R.
      • Smit D.
      • Jenkins J.
      • Winter C.
      Defining the scope of practice of the emergency nurse practitioner role in a metropolitan emergency department.
      ,
      • Considine J.
      • Martin R.
      • Smit D.
      • Winter C.
      • Jenkins J.
      Emergency nurse practitioner care and emergency department patient flow: Case–control study.
      ).
      Studies involving transitional/candidate nurse practitioners have also taken place in aged care (
      • Allen J.
      • Fabri A.M.
      An evaluation of a community aged care nurse practitioner service.
      ,
      • Joanna Briggs Institute
      National evaluation of nurse practitioner-like services in residential aged care services: Final report.
      ,
      • Lee C.G.
      Role of the gerontological nurse practitioner in Australia.
      ) and mental health (
      • Papoulis D.
      An evaluation of mental health services in the Whyalla Hospital Accident and Emergency Department: A comparison of a new and old model of care.
      ). One of these involved a nurse practitioner candidate working in residential aged care who made recommendations for care, which were then discussed with the general practitioner who decided whether to act on the recommendations (
      • Lee C.G.
      Role of the gerontological nurse practitioner in Australia.
      ). Another paper reported that the nurse practitioner candidate was working ‘within the role boundaries of a registered nurse’ (
      • Allen J.
      • Fabri A.M.
      An evaluation of a community aged care nurse practitioner service.
      , p. 1203). The report of a nation-wide evaluation coined the term ‘nurse practitioner-like services’ to more accurately reflect the nature of the roles being evaluated (
      • Joanna Briggs Institute
      National evaluation of nurse practitioner-like services in residential aged care services: Final report.
      ).
      As with studies from the ‘exploration and adoption’ stage, some of these studies have been included in systematic reviews of the nurse practitioner literature (
      • Carter A.J.E.
      • Chochinov A.H.
      A systematic review of the impact of nurse practitioners on cost, quality of care, satisfaction and wait times in the emergency department.
      ,
      • Wilson A.
      • Zwart E.
      • Everett I.
      • Kernick J.
      The clinical effectiveness of nurse practitioners’ management of minor injuries in an adult emergency department: A systematic review.
      ), without any consideration given to the fact that the subjects of the studies were not fully qualified nurse practitioners. One recent systematic review recognised some of these studies as investigations of candidate/transitional roles but did not exclude the studies on that basis (
      • Jennings N.
      • Clifford S.
      • Fox A.R.
      • O’Connell J.
      • Gardner G.
      The impact of nurse practitioner services on cost, quality of care, satisfaction and waiting times in the emergency department: A systematic review.
      ).

      3.3 Full implementation

      Earlier, we referred to ‘full operation’ as the stage of implementation which comes after ‘initial implementation’. Based on the papers we reviewed, judging whether or not ‘full operation’ had been achieved was difficult to determine, primarily because of the lack of suitable information upon which to base such a judgement. We could only find one example where it was explicitly stated that full implementation was not achieved, involving a Walk-in Centre staffed by nurse practitioners and other advanced practice nurses (
      • Parker R.
      • Forest L.
      • Desborough J.
      • McRae I.
      • Boyland T.
      Independent evaluation of the nurse-led ACT Health Walk-in Centre.
      ).
      The first 12 months of implementing a new nurse practitioner position has been described as a ‘period of transition’, during which time systems and relationships are established and the role is defined (
      • Desborough J.L.
      How nurse practitioners implement their roles.
      ). The barriers and enablers to implementing nurse practitioner roles are multi-faceted and operate at multiple levels – the nurse practitioners themselves (e.g. their skills, knowledge and capabilities), the team of people they work with, the organisation they work for and the broader system of funding and legislation (
      • DiCenso A.
      • Bryant-Lukosius D.
      • Bourgeault I.
      • Martin-Misener R.
      • Donald F.
      • Abelson J.
      • et al.
      Clinical nurse specialists and nurse practitioners in Canada: A decision support synthesis.
      ,
      • Masso M.
      • Thompson C.
      Rapid review of the nurse practitioner literature: Nurse practitioners in NSW ‘Gaining Momentum’.
      ). The scope and range of the various barriers suggest many reasons why a particular nurse practitioner may not be functioning to their full scope of practice and indicates that implementing a new position such as a nurse practitioner should involve organisational redesign and ‘reframing of professionalism and professional boundaries at the multiple layers of the healthcare system’ (
      • Niezen M.G.H.
      • Mathijssen J.J.P.
      Reframing professional boundaries in healthcare: A systematic review of facilitators and barriers to task reallocation from the domain of medicine to the nursing domain.
      , p. 166).
      Based on interviews with nurse practitioners,
      • Wilson K.
      • Coulon L.
      • Hillege S.
      • Swann W.
      Nurse practitioners’ experiences of working collaboratively with general practitioners and allied health professionals in New South Wales, Australia.
      identified three forms of collaboration – total collaboration, partial collaboration and non-collaboration – when working with general practitioners and allied health professionals. With partial collaboration, general practitioners and allied health staff ‘only supported NPs in select clinical circumstances’. In circumstances of non-collaboration, these other health professionals refused to ‘acknowledge the contribution of NP care’ (
      • Wilson K.
      • Coulon L.
      • Hillege S.
      • Swann W.
      Nurse practitioners’ experiences of working collaboratively with general practitioners and allied health professionals in New South Wales, Australia.
      , p. 24). Two factors were critical to establishing total collaboration: the length of time the nurse practitioner had spent working in the local area and the rapport they had established before becoming an authorised nurse practitioner. High levels of collaboration were associated with a long history of working in the local health service (
      • Wilson K.
      • Coulon L.
      • Hillege S.
      • Swann W.
      Nurse practitioners’ experiences of working collaboratively with general practitioners and allied health professionals in New South Wales, Australia.
      ). Although the authors of the research did not frame their findings in this way, these results suggest it can take time to achieve full implementation of a newly-created nurse practitioner role and that lack of collaboration from colleagues can hinder the achievement of full implementation.
      Table 1 summarises Australian studies of authorised nurse practitioners (in reverse chronological order by year of publication) where some degree of ‘full implementation’ is possible, largely by default i.e. the studies do not fall within the ‘exploration and adoption’ or ‘initial implementation’ categories. In total, 17 nurse practitioner roles were reported in 21 papers. The extent to which some studies are reporting nurse practitioner roles which have been fully implemented is debatable, primarily because of the lack of detail regarding implementation and nurse practitioner scopes of practice.
      Table 1Summary of Australian studies of authorised nurse practitioners in specific clinical roles.
      Clinical area/authorsStudy designInformation about the nurse practitioner role or implementation of the role
      Primary health care (mental health and aged care) (
      • Barraclough F.
      Nurse practitioner led services in primary health care in rural NSW – Two case studies.
      )
      Two mixed-method case studies, with data from interviews, administrative data, document review and observation of the nurse practitioners. Outcomes were not measured.Detailed description of how and why the nurse practitioner (NP) positions (one in each case study) were established, the settings in which they worked, the activities of the NPs and how they linked with other services. Limited information about use of medications and diagnostic investigations.
      General practice (
      • Helms C.
      • Crookes J.
      • Bailey D.
      Financial viability, benefits and challenges of employing a nurse practitioner in general practice.
      )
      Comparison of the costs of employing an NP with the revenue generated by the NP.Details regarding the background of the NP, their scope of practice (types of patients seen, clinical interventions) and role in chronic disease management. Limited information about patients seen by the NP.
      Emergency department fast track (
      • Lutze M.
      • Ross M.
      • Chu M.
      • Green T.
      • Dinh M.
      Patient perceptions of emergency department fast track: A prospective pilot study comparing two models of care.
      )
      Convenience sample of patients in two fast track units, one staffed by doctors and one staffed by NPs, completed a patient satisfaction survey.Limited information about the setting. Information about patients included demographic information and fast track inclusion criteria. Almost no information about NP scope of practice.
      Emergency department (
      • Li J.
      • Westbrook J.
      • Callen J.
      • Georgiou A.
      • Braithwaite J.
      The impact of nurse practitioners on care delivery in the emergency department: A multiple perspectives qualitative study.
      )
      Grounded theory study involving semi-structured interviews with NPs, senior doctors and five senior nurses in two large teaching hospitals to identify their perceptions regarding the impact of the NPs on emergency department functioning, other clinical roles and care delivery.Some information about the setting and history of the role. No information about scope of practice, types of patients seen or the nature of interactions between NPs and patients.
      Women's health clinic (
      • Elmer S.L.
      • Stirling C.M.
      Evaluation of the Nurse Practitioner role at the Hobart Women's Health Centre.
      )
      Mixed-methods study based on a realist evaluation approach. Data collection included interviews and surveys involving key stakeholders and clients; and retrospective audit of client database. Outcome measures included health literacy and client satisfaction.The report described the length of time the NP had been in the position, the focus of the position, the range of services provided (with supporting data), the nature of contact with clients and details about workload. The setting was described together with details of mechanisms underpinning the work of the NP.
      Emergency department (
      • Jennings N.
      • McKeown E.
      • O’Reilly G.
      • Gardner G.
      Evaluating patient presentations for care delivered by emergency nurse practitioners: A retrospective analysis of 12 months.
      )
      Retrospective audit of waiting time to be seen and length of stay for patients discharged home.Description of the NP model, including details of scope of practice, number of NPs, mix of full-time and part-time NPs, hours of work, average workload per shift and length of time NPs have been established in the ED. Description of setting, including patient inclusion criteria.
      Primary care in community pharmacies (
      • McMillan S.S.
      • Emmerton L.
      Nurse practitioners: An insight into their integration into Australian community pharmacies.
      )
      Semi-structured interviews with pharmacists, NPs and pharmacy assistants used to describe the role of NPs in a chain of pharmacies and how they work with other pharmacy staff. No measurement of outcomes.Some general information about the setting and the NP role but no precise details (e.g. number of consultations, number and type of prescriptions). No information about clients seen or the nature of client/NP interaction.
      Chemotherapy unit (
      • Cox K.
      • Karikios D.
      • Roydhouse J.K.
      • White K.
      Nurse-led supportive care management: A 6-month review of the role of a nurse practitioner in a chemotherapy unit.
      )
      Descriptive study described as an ‘initial evaluation’. The study collected data on unscheduled occasions of service to a chemotherapy unit, seen by the NP. Outcome measures included waiting time to be seen, second reviews within 7 days, and admissions to hospital within 7 days.Brief description of the NP role and the setting, with details of when and why the role was introduced. Data are provided about the characteristics of patients seen by the NP.
      Emergency department fast track unit (
      • Dinh M.
      • Walker A.
      • Parameswaran A.
      • Enright N.
      Evaluating the quality of care delivered by an emergency department fast track unit with both nurse practitioners and doctors.
      ,
      • Dinh M.
      • Enright N.
      • Walker A.
      • Parameswaran A.
      • Chu M.
      Determinants of patient satisfaction in an Australian emergency department fast-track setting.
      )
      Convenience sample of adult patients randomised to initial assessment and treatment by a doctor or emergency nurse practitioner. Outcome measures included patient satisfaction, adverse events and patient-reported health status.Detailed information about the setting. Some general information about the NP and the nature of their role. Limited information about patients seen.
      Community mental health (
      • Longman J.
      • Barraclough F.
      • Barclay L.
      An evaluation of the Nimbin Integrated Services Project – Final Report.
      )
      Mixed methods case study, including data from interviews and administrative data sets. Outcomes included mental health presentations to hospital.Describes the setting and history of how the NP role was established, with data on client activity, source of referrals, referrals to other providers, and collaboration with other agencies.
      Mental health outpatients clinic (
      • Wand T.
      • White K.
      • Patching J.
      Realistic evaluation of an emergency department-based mental health nurse practitioner outpatient service in Australia.
      ,
      • Wand T.
      • White K.
      • Patching J.
      • Dixon J.
      • Green T.
      An emergency department-based mental health nurse practitioner outpatient service: Part 1. Participant evaluation.
      ,
      • Wand T.
      • White K.
      • Patching J.
      • Dixon J.
      • Green T.
      An emergency department-based mental health nurse practitioner outpatient service: Part 2. Staff evaluation.
      ,
      • Wand T.
      • White K.
      • Patching J.
      • Dixon J.
      • Green T.
      Outcomes from the evaluation of an emergency department-based mental health nurse practitioner outpatient service in Australia.
      )
      Prospective, mixed-methods, study based on a realist evaluation approach, including interviews with patients and staff; and collecting data on patient self-report measures (e.g. self-efficacy, psychological distress).Detailed information about the setting, role of the NP, patient characteristics (including presenting problems) and source of referrals.
      Acute pain management for patients undergoing major surgery, trauma or caesarean section (
      • Schoenwald A.V.
      Two hundred days of nurse practitioner prescribing and role development: A case study report from a hospital-based acute pain management team.
      )
      Prospective descriptive study. Outcomes included timeliness of assessment and non-pharmacological interventions for pain management.Description of how the NP role evolved and the nature of the role at the time of the study. Some information about the characteristics of the NP. The results include details of medications prescribed and brief reference to the range of non-pharmacological interventions employed by the NP.
      Emergency department fast track service (
      • Considine J.
      • Kropman M.
      • Stergiou H.E.
      Effect of clinician designation on emergency department fast track performance.
      )
      Retrospective medical record audit of waiting time by triage category and length of stay in the emergency departmentDescription of the setting. Some information about patients seen. Very little information about the scope of practice of the NPs and the nature of their interaction with patients.
      Minor injuries in an adult emergency department (
      • Wilson A.
      • Shifaza F.
      An evaluation of the effectiveness and acceptability of nurse practitioners in an adult emergency department.
      )
      Retrospective medical record audit (of waiting time by triage category) and prospective, self-administered, patient satisfaction survey.Description of the setting. Some information about patients seen by the NP, their presenting injuries and the use of diagnostic and therapeutic interventions.
      Emergency department fast track service (
      • Jennings N.
      • Lee G.
      • Chao K.
      • Keating S.
      A survey of patient satisfaction in a metropolitan emergency department: Comparing nurse practitioners and emergency physicians.
      )
      Prospective, self-administered, patient satisfaction survey, comparing results for patients treated by doctors and NPs.Description of the setting. Information about the role of the NP limited to one sentence which states that NPs were responsible for a continuum of care from initial assessment through to disposition. Brief description of patients seen by the NPs.
      Emergency eye clinic (
      • Kirkwood B.J.
      • Pesudovs K.
      • Loh R.S.
      • Coster D.J.
      Implementation and evaluation of an ophthalmic nurse practitioner emergency eye clinic.
      )
      Prospective, descriptive, study of consecutive new patients attending the clinic, comparing diagnosis and treatment by NP and ophthalmologist.Description of the setting. Description of the NP scope of practice, supported by data on conditions assessed and treated, assessment tools used, medications initiated and administered, and diagnostic tests ordered.
      Colorectal cancer screening clinic (
      • Morcom J.
      • Dunn S.V.
      • Luxford Y.
      Establishing an Australian nurse practitioner-led colorectal cancer screening clinic.
      )
      Retrospective medical record audit. Outcome measures included depth of insertion of flexible sigmoidoscope, client discomfort scores, pathology findings and client satisfaction.Description of how the role was established and the role of the NP in screening (using faecal occult blood testing and flexible sigmoidoscopy), patient education and follow-up.
      Most studies focused on certain aspects of the nurse practitioner role (e.g. patient satisfaction, impact on waiting times) rather than undertaking a comprehensive evaluation of the role. In general, the settings in which the nurse practitioners worked were well described. The quantity, quality and breadth of information about the role of the nurse practitioners were highly variable, with no consistency in the way the roles were described. Some studies focused on measuring outcomes and paid little attention to describing the nurse practitioner role. Other studies focused on describing the role of the nurse practitioner with little or no attention given to measuring outcomes. Some studies provided a description of how the role had been established and some included details of the patients seen by the nurse practitioners.
      The concept of implementation fidelity (of the nurse practitioner role) was absent from all the papers, except for one study which addressed the issue indirectly. That study identified an initially narrow scope of practice which broadened over time as collaboration with general practice improved. However, there were still ‘significant impediments to the effective functioning of the NP role’, primarily due to an inability to access items on the Medicare Benefits Schedule (
      • Elmer S.L.
      • Stirling C.M.
      Evaluation of the Nurse Practitioner role at the Hobart Women's Health Centre.
      ). It is not clear whether these two factors, working in opposite directions, resulted in a role that might be considered ‘fully implemented’.

      3.4 Nurse practitioners leading a service

      An additional complication when trying to ascertain whether a particular nurse practitioner role has been fully implemented arises in those situations where a nurse practitioner is in a formal leadership role. Leadership is a well-recognised component of the nurse practitioner role (
      • Nursing and Midwifery Board of Australia
      Nurse practitioner standards for practice.
      ) and clinical leadership has been identified as a core competency (
      • Carryer J.
      • Gardner G.
      • Dunn S.
      • Gardner A.
      The core role of the nurse practitioner: Practice, professionalism and clinical leadership.
      ).
      Some studies have been reported where nurse practitioners are described as leading a service. Unfortunately, it is not easy to identify the leadership role of the nurse practitioner, as distinct from the direct clinical care component of the nurse practitioner role, which can result in some confusion when it comes to interpreting the results of such studies. These studies have not been included in Table 1.
      As an example, a nurse practitioner in Tasmania coordinated a clinic involving an obstetrician, diabetes educator, dietician and antenatal nurse. The role of the nurse practitioner is not described in the paper reporting the results, other than stating that the clinic was led by the nurse practitioner (
      • Murfet G.O.
      • Allen P.
      • Hingston T.J.
      Maternal and neonatal health outcomes following the implementation of an innovative model of nurse practitioner-led care for diabetes in pregnancy.
      ). Another example involves the evaluation of a dementia outreach service consisting of a small team led by a nurse practitioner (
      • Borbasi S.
      • Emmanuel E.
      • Farrelly B.
      • Ashcroft J.
      A Nurse Practitioner initiated model of service delivery in caring for people with dementia.
      ,
      • Borbasi S.
      • Emmanuel E.
      • Farrelly B.
      • Ashcroft J.
      Report of an evaluation of a Nurse-led Dementia Outreach Service for people with the behavioural and psychological symptoms of dementia living in residential aged care facilities.
      ). Of the two papers reporting the evaluation, one paper describes the service and states that the evaluation is a ‘work in progress’ (
      • Borbasi S.
      • Emmanuel E.
      • Farrelly B.
      • Ashcroft J.
      A Nurse Practitioner initiated model of service delivery in caring for people with dementia.
      ). The main role of the team was to work with the staff in nursing homes to implement the clinical decisions of the nurse practitioner, aided by the team and the nurse practitioner engaging in ‘continuous reflection’ (
      • Borbasi S.
      • Emmanuel E.
      • Farrelly B.
      • Ashcroft J.
      A Nurse Practitioner initiated model of service delivery in caring for people with dementia.
      ). The second paper states that the focus of the evaluation was on the work of the clinical nurse, endorsed enrolled nurse, assistant-in-nursing and social worker on the team, rather than the nurse practitioner. Overall, the evaluation says more about the team than it does about the nurse practitioner, making it difficult to interpret the results as evidence in support of nurse practitioners in aged care or attribute the outcomes achieved to the leadership role of the nurse practitioner.
      A third example involves a study which investigated a mental health service for patients presenting to an emergency department consisting of nurses working in a mental health liaison role, with the service led by a nurse practitioner (
      • Wand T.
      • D’Abrew N.
      • Barnett C.
      • Acret L.
      • White K.
      Evaluation of a nurse practitioner-led extended hours mental health liaison nurse service based in the emergency.
      ). The leadership role of the nurse practitioner is well described – providing mentorship and ongoing support to the liaison nurses; fostering their professional development; acting as a source of clinical advice; and assisting implementation of the mental health liaison nurse service. The extent of the leadership role is not quantified, but the way the results are reported suggests a much closer link between the role of the nurse practitioner and the role of the team led by the nurse practitioner than in the two studies referred to above. In turn, this suggests that whatever improvements are attributable to the team are more strongly linked to the contribution of the nurse practitioner than in the two other examples of nurse practitioner-led services.

      4. Discussion

      Nurse practitioners were introduced into Australia after a relatively intensive period of ‘exploration’ involving pilot studies of one form or another. The decision to adopt the role was based on the favourable outcomes of those pilot studies. In the early research, several studies were published involving nurses ‘in training’ to become nurse practitioners, rather than fully-authorised nurse practitioners. All of this research played an important role in providing a foundation for the future development of the role. However, based on the arguments presented here, we believe that this research should not be considered as evidence in support of a ‘fully implemented’ nurse practitioner role and should not be cited as such, at least not without some form of qualification.
      The Australian research is characterised by the lack of a consistent approach to reporting the work done by nurse practitioners. This makes it difficult to compare what may be similar roles in different studies. The research generally treats the nurse practitioner role as the independent variable, rather than the care provided by the nurse practitioner, a finding that is consistent with earlier research from other countries (
      • Brown S.A.
      • Grimes D.E.
      A meta-analysis of nurse practitioners and nurse midwives in primary care.
      ).
      The context within which something is implemented will influence the process of implementation and the outcomes achieved (
      • Damschroder L.
      • Aron D.
      • Keith R.
      • Kirsh S.
      • Alexander J.
      • Lowery J.
      Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science.
      ,
      • Durlak J.A.
      • DuPre E.P.
      Implementation matters: A review of research on the influence of implementation on program outcomes and the factors affecting implementation.
      ). Despite this understanding of the influence of context, many of the Australian studies included little contextual information, particularly the ways in which context may or may not have influenced nurse practitioners’ scope of practice. This makes it difficult to judge the role of context in influencing both implementation and patient outcomes and establish plausible links between the activities of the nurse practitioner and patient outcomes. As has been pointed out, ‘it cannot be assumed that similar results would be obtained by nurse practitioners working in different settings or with different groups of patients’ (
      • Horrocks S.
      • Anderson E.
      • Salisbury C.
      Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors.
      , p. 822). There have been some attempts to address this issue by using ‘realist’ approaches to evaluation to link context, mechanisms and outcomes (
      • Elmer S.L.
      • Stirling C.M.
      Evaluation of the Nurse Practitioner role at the Hobart Women's Health Centre.
      ,
      • Wand T.
      • White K.
      • Patching J.
      Realistic evaluation of an emergency department-based mental health nurse practitioner outpatient service in Australia.
      ).
      We noted in the original rapid review that nurse practitioner research has not been strongly influenced by knowledge from fields such as organisational change, implementation science, diffusion of innovations and knowledge translation. For example, references cited in the Australian research are primarily from sources focusing either on nurse practitioners or a particular area of clinical practice (
      • Masso M.
      • Thompson C.
      Rapid review of the nurse practitioner literature: Nurse practitioners in NSW ‘Gaining Momentum’.
      ). In part, this may explain the lack of attention to the concept of implementation fidelity. The concept of ‘barriers’, which does feature in much of the nurse practitioner literature (
      • DiCenso A.
      • Bryant-Lukosius D.
      • Bourgeault I.
      • Martin-Misener R.
      • Donald F.
      • Abelson J.
      • et al.
      Clinical nurse specialists and nurse practitioners in Canada: A decision support synthesis.
      ,
      • Lloyd Jones M.
      Role development and effective practice in specialist and advanced practice roles in acute hospital settings: Systematic review and meta-synthesis.
      ), implies that nurse practitioners may not be working to the full extent of their role (because of the barriers). As has been noted recently, ‘it is the context of nurse practitioner practice … which form the major barrier to the expression of nurse practitioner scope’ (
      • Scanlon A.
      • Cashin A.
      • Bryce J.
      • Kelly J.G.
      • Buckley T.
      , p. 12).
      Researchers accept as a ‘given’ that the methods used in a study should be reported in sufficient detail that the study can be replicated by other researchers. The same standard should also apply to the subject of the study. In the implementation science literature there is concern about how poorly interventions are described. Even when interventions are described, the ‘dose’ or strength of the intervention is rarely measured. As a result, the readers of such investigations are left with very little knowledge about what changed or the relationship between what changed and the reported outcomes (
      • Michie S.
      • Fixsen D.
      • Grimshaw J.M.
      • Eccles M.P.
      Specifying and reporting complex behaviour change interventions: The need for a scientific method.
      ). This makes it difficult to adopt an intervention more widely: ‘we are often left knowing very little about the details of an intervention or the functional relationship between the components of the intervention and outcomes. Knowing the details and functional relationships are critical to any future introduction and scale-up of effective interventions’ (
      • Michie S.
      • Fixsen D.
      • Grimshaw J.M.
      • Eccles M.P.
      Specifying and reporting complex behaviour change interventions: The need for a scientific method.
      , pp. 1–2).
      To improve this situation, it has been suggested that eight characteristics of interventions should be reported (
      • Davidson K.W.
      • Goldstein M.
      • Kaplan R.M.
      • Kaufmann P.G.
      • Knatterud G.L.
      • Orleans C.T.
      • et al.
      Evidence-based behavioral medicine: What is it and how do we achieve it?.
      ,
      • Michie S.
      • Fixsen D.
      • Grimshaw J.M.
      • Eccles M.P.
      Specifying and reporting complex behaviour change interventions: The need for a scientific method.
      ). The following list takes those characteristics and makes some adjustments to suit the context of studying nurse practitioners:
      • The content or elements of the intervention (techniques) – in the case of nurse practitioners, this equates to their scope of practice.
      • Characteristics of the nurse practitioner.
      • Characteristics of patients seen by the nurse practitioner.
      • Characteristics of the setting, both the physical setting (e.g. hospital, community-based clinic) and the organisational setting (e.g. the team or group of clinicians with whom the nurse practitioner works, any overarching model of care of which the nurse practitioner is a part).
      • The mode of delivery (e.g. face-to-face).
      • The intensity (e.g. contact time).
      • The duration (e.g. number sessions with each patient over a given period).
      • Fidelity e.g. was the nurse practitioner able to function as intended? What mechanisms are in place to monitor the performance of the nurse practitioner?
      Examples of these characteristics are included in Table 2, with the format for scope of practice influenced by the Nurse Practitioner Research Toolkit from the Australian Nurse Practitioner Study (
      • Gardner G.
      • Gardner A.
      • Middleton S.
      • Della P.
      The Nurse Practitioner Research Toolkit.
      ). The examples are based on unpublished work undertaken by us for the Ministry of Health in New South Wales. We take a broader view of ‘characteristics of the setting’ than originally envisaged by Davidson et al. or Michie et al. by including both the physical and organisational settings. Although nurse practitioners can work in a fairly autonomous way, collaboration with other health professionals is usually central to the role. We also believe that ‘intensity’ and ‘duration’ are best described together, as indicated in Table 2.
      Table 2Checklist for reporting characteristics of the nurse practitioner role.
      CharacteristicExamples
      Characteristics of the nurse practitionerThe nurse practitioner previously worked as a clinical nurse consultant in the local area and was well known to general practitioners and other clinicians before commencing in the role.

      Six months previously, the nurse practitioner moved to the area to take up a newly-created position.
      Characteristics of patients seen by the nurse practitionerChildren between the ages of 0 months and 18 years who attend the emergency department in triage categories 3, 4 or 5.

      People over the age of 65, residing either in their own home or a residential aged care facility, at risk of hospital admission.
      Characteristics of the settingThe nurse practitioners work in the emergency department fast track unit which operates in a designated area. Nurse practitioners provide the core staffing of the unit, with career medical officers and medication endorsed enrolled nurses.
      Mode of deliveryThe nurse practitioner is part of a larger team and provides one-to-one consultations for any clients booked to attend the clinic on their designated days. The nurse practitioner also provides a consultation/liaison service to the hospital wards.
      Intensity and durationThe nurse practitioner manages all aspects of patient care over a typical 3–4 h stay in the emergency department.

      Patients are booked for an initial half-hour clinic appointment, with follow-up appointments arranged according to patient need. The total time spent with each patient ranged from 0.5 h to 16 h.
      FidelityNumber of referrals to the nurse practitioner less than anticipated due to resistance from some general practitioners.

      It was intended that the role would operate outside normal business hours but this has not eventuated because of concern at the cost of paying penalty rates.

      The nurse practitioner is functioning to the full extent of their scope of practice.
      Scope of practice (content of the intervention)
      Capacity to admit and dischargeCan send people home from the emergency department without referral to the VMO/GP.

      Temporary admission rights (up to 72 h) for acute patients in local multi-purpose service.
      Diagnostic investigationsPlain X-rays, urine culture and sensitivity, wound swabs, throat swabs, vaginal swabs, nasopharyngeal aspirations, electrolytes, troponin, blood gases.

      The absence of an MBS provider number means that pathology can only be ordered in collaboration with general practitioners (in the case of a community-based nurse practitioner).
      Prescription of medications prescribedMost commonly prescribed medications are antibiotics and oral contraceptives.

      Has individual PBS number. Can prescribe PBS-subsidised medication for patients seen in their own home or community-based clinic.

      Can prescribe medications on an inpatient medication chart.
      Therapeutic interventionsCrisis management, counselling, cognitive behaviour therapy, medication review, patient education.

      Local anaesthesia, wound repair, removal of foreign body, intravenous fluids for rehydration, replacement of suprapubic catheters, splinting and plastering (back slabs).
      ReferralsReceives referrals from the local emergency department, hospital wards, paramedics, general practitioners and residential aged care facilities.

      Initiates referrals to sexual health, mental health and dental clinic.
      We believe that the characteristics in Table 2 constitute a useful checklist for the reporting of future studies of nurse practitioners. The level of detail that might be reported for each characteristic would vary depending on the nature of the nurse practitioner role and the nature of the study. For example, if a particular patient outcome is the focus of the study then patient characteristics might be reported in considerable detail. If the focus of the study is on the role of the nurse practitioner in improving coordination of care, there may be less detail regarding patient characteristics and much greater detail about the characteristics of the setting. What to report regarding fidelity very much depends on circumstances and the nature of the nurse practitioner's scope of practice and may not lend itself to brief description using a table format. The main point is that fidelity should be addressed, including the arrangements for monitoring performance e.g. clinical supervision, mentoring and peer review. One advantage of using the checklist in a table format is that it allows for the communication of a large amount of information in a concise format. It also makes it easier to stay within the word limits imposed by journals.
      Including information outlined in the checklist in future studies of nurse practitioners would enhance the ability to make judgements about implementing nurse practitioner models of care; facilitate comparison of similar roles (e.g. for a literature review or meta-analysis); and increase the capacity to make informed decisions about the prospects for wider implementation of a particular nurse practitioner role or model of care (e.g. because it has been possible to ‘fully implement’ the role). More detailed reporting can only enhance the ability to realise the potential of nurse practitioners and facilitate transferability of each role from one context to another.

      Acknowledgements

      The rapid review of the nurse practitioner literature which served as the catalyst for this paper was undertaken as part of a research project for the Nursing & Midwifery Office in the New South Wales Ministry of Health.

      References

        • ACT Health
        The ACT Nurse Practitioner Project: Final report of the Steering Committee.
        ACT Department of Health, Canberra2002
        • Allen J.
        • Fabri A.M.
        An evaluation of a community aged care nurse practitioner service.
        Journal of Clinical Nursing. 2005; 14: 1202-1209
        • Barraclough F.
        Nurse practitioner led services in primary health care in rural NSW – Two case studies.
        The University of Sydney, Master of Philosophy2014
        • Borbasi S.
        • Emmanuel E.
        • Farrelly B.
        • Ashcroft J.
        A Nurse Practitioner initiated model of service delivery in caring for people with dementia.
        Contemporary Nurse. 2010; 36: 49-60
        • Borbasi S.
        • Emmanuel E.
        • Farrelly B.
        • Ashcroft J.
        Report of an evaluation of a Nurse-led Dementia Outreach Service for people with the behavioural and psychological symptoms of dementia living in residential aged care facilities.
        Perspectives in Public Health. 2011; 131: 124-130
        • Brown S.A.
        • Grimes D.E.
        A meta-analysis of nurse practitioners and nurse midwives in primary care.
        Nursing Research. 1995; 44: 332-339
        • Carroll C.
        • Patterson M.
        • Wood S.
        • Booth A.
        • Rick J.
        • Balain S.
        A conceptual framework for implementation fidelity.
        Implementation Science. 2007; 2
        • Carryer J.
        • Gardner G.
        • Dunn S.
        • Gardner A.
        The core role of the nurse practitioner: Practice, professionalism and clinical leadership.
        Journal of Clinical Nursing. 2007; 16: 1818-1825
        • Carter A.J.E.
        • Chochinov A.H.
        A systematic review of the impact of nurse practitioners on cost, quality of care, satisfaction and wait times in the emergency department.
        Canadian Journal of Emergency Medicine. 2007; 9: 286-295
        • Chang E.
        • Daly J.
        • Hawkins A.
        • McGirr J.
        • Fielding K.
        • Hemmings L.
        • et al.
        An evaluation of the nurse practitioner role in a major rural emergency department.
        Journal of Advanced Nursing. 1999; 30: 260-268
        • Considine J.
        • Kropman M.
        • Stergiou H.E.
        Effect of clinician designation on emergency department fast track performance.
        Emergency Medicine Journal. 2010; 27: 838-842
        • Considine J.
        • Martin R.
        • Smit D.
        • Jenkins J.
        • Winter C.
        Defining the scope of practice of the emergency nurse practitioner role in a metropolitan emergency department.
        International Journal of Nursing Practice. 2006; 12: 205-213
        • Considine J.
        • Martin R.
        • Smit D.
        • Winter C.
        • Jenkins J.
        Emergency nurse practitioner care and emergency department patient flow: Case–control study.
        Emergency Medicine Australasia. 2006; 18: 385-390
        • Copnell B.
        • Johnston L.
        • Harrison D.
        • Wilson A.
        • Robson A.
        • Mulcahy C.
        • et al.
        Doctors’ and nurses’ perceptions of interdisciplinary collaboration in the NICU, and the impact of a neonatal nurse practitioner model of practice.
        Journal of Clinical Nursing. 2004; 13: 105-113
        • Cox K.
        • Karikios D.
        • Roydhouse J.K.
        • White K.
        Nurse-led supportive care management: A 6-month review of the role of a nurse practitioner in a chemotherapy unit.
        Australian Health Review. 2013; 37: 632-635
        • Damschroder L.
        • Aron D.
        • Keith R.
        • Kirsh S.
        • Alexander J.
        • Lowery J.
        Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science.
        Implementation Science. 2009; 4
        • Davidson K.W.
        • Goldstein M.
        • Kaplan R.M.
        • Kaufmann P.G.
        • Knatterud G.L.
        • Orleans C.T.
        • et al.
        Evidence-based behavioral medicine: What is it and how do we achieve it?.
        Annals of Behavioral Medicine. 2003; 26: 161-171
        • Desborough J.L.
        How nurse practitioners implement their roles.
        Australian Health Review. 2012; 36: 22-26
        • DiCenso A.
        • Bryant-Lukosius D.
        • Bourgeault I.
        • Martin-Misener R.
        • Donald F.
        • Abelson J.
        • et al.
        Clinical nurse specialists and nurse practitioners in Canada: A decision support synthesis.
        Canadian Health Services Research Foundation, Ottawa2010
        • Dinh M.
        • Enright N.
        • Walker A.
        • Parameswaran A.
        • Chu M.
        Determinants of patient satisfaction in an Australian emergency department fast-track setting.
        Emergency Medicine Journal. 2013; 30: 824-827
        • Dinh M.
        • Walker A.
        • Parameswaran A.
        • Enright N.
        Evaluating the quality of care delivered by an emergency department fast track unit with both nurse practitioners and doctors.
        Australasian Emergency Nursing Journal. 2012; 15: 188-194
        • Duffield C.
        • Gardner G.
        • Chang A.M.
        • Catling-Paull C.
        Advanced nursing practice: A global perspective.
        Collegian. 2009; 16: 55-62
        • Durlak J.A.
        • DuPre E.P.
        Implementation matters: A review of research on the influence of implementation on program outcomes and the factors affecting implementation.
        American Journal of Community Psychology. 2008; 41: 327-350
        • Elmer S.L.
        • Stirling C.M.
        Evaluation of the Nurse Practitioner role at the Hobart Women's Health Centre.
        University of Tasmania, 2013
        • Fixsen D.L.
        • Naoom S.F.
        • Blase K.A.
        • Friedman R.M.
        • Wallace F.
        Implementation research: A synthesis of the literature.
        University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network, Tampa, FL2005
        • Fry M.
        • Fong J.
        • Asha S.
        • Arendts G.
        A 12-month evaluation of the impact of Transitional Emergency Nurse Practitioners in one metropolitan Emergency Department.
        Australasian Emergency Nursing Journal. 2011; 14: 4-8
        • Fry M.
        • Rogers T.
        The Transitional Emergency Nurse Practitioner role: Implementation study and preliminary evaluation.
        Australasian Emergency Nursing Journal. 2009; 12: 32-37
        • Gardner A.
        • Gardner G.
        • Middleton S.
        • Della P.
        The status of Australian nurse practitioners: The first national census.
        Australian Health Review. 2009; 33: 679-689
        • Gardner G.
        • Gardner A.
        • Middleton S.
        • Della P.
        The Nurse Practitioner Research Toolkit.
        Australian Nurse Practitioner Study (AUSPRAC), 2009
        • Green A.
        • Edmonds L.
        Bridging the gap between the intensive care unit and general wards – The ICU Liaison Nurse.
        Intensive and Critical Care Nursing. 2004; 20: 133-143
        • Helms C.
        • Crookes J.
        • Bailey D.
        Financial viability, benefits and challenges of employing a nurse practitioner in general practice.
        Australian Health Review. 2015; 39: 205-210
        • Hooke E.
        • Bennett L.
        • Dwyer R.
        • van Beek I.
        • Martin C.
        Nurse practitioners: An evaluation of the extended role of nurses at the Kirketon Road Centre in Sydney, Australia.
        Australian Journal of Advanced Nursing. 2001; 18: 20-28
        • Horrocks S.
        • Anderson E.
        • Salisbury C.
        Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors.
        British Medical Journal. 2002; 324: 819-823
        • Hoskins R.
        Evaluating new roles within emergency care: A literature review.
        International Emergency Nursing. 2011; 19: 125-140
        • Jennings N.
        • Clifford S.
        • Fox A.R.
        • O’Connell J.
        • Gardner G.
        The impact of nurse practitioner services on cost, quality of care, satisfaction and waiting times in the emergency department: A systematic review.
        International Journal of Nursing Studies. 2015; 52: 421-435
        • Jennings N.
        • Lee G.
        • Chao K.
        • Keating S.
        A survey of patient satisfaction in a metropolitan emergency department: Comparing nurse practitioners and emergency physicians.
        International Journal of Nursing Practice. 2009; 15: 213-218
        • Jennings N.
        • McKeown E.
        • O’Reilly G.
        • Gardner G.
        Evaluating patient presentations for care delivered by emergency nurse practitioners: A retrospective analysis of 12 months.
        Australasian Emergency Nursing Journal. 2013; 16: 89-95
        • Jennings N.
        • O’Reilly G.
        • Lee G.
        • Cameron P.
        • Free B.
        • Bailey M.
        Evaluating outcomes of the emergency nurse practitioner role in a major urban emergency department, Melbourne, Australia.
        Journal of Clinical Nursing. 2008; 17: 1044-1050
        • Joanna Briggs Institute
        National evaluation of nurse practitioner-like services in residential aged care services: Final report.
        Commonwealth of Australia, Canberra2007
        • Kirkwood B.J.
        • Pesudovs K.
        • Loh R.S.
        • Coster D.J.
        Implementation and evaluation of an ophthalmic nurse practitioner emergency eye clinic.
        Clinical and Experimental Ophthalmology. 2005; 33: 593-597
        • Lee C.G.
        Role of the gerontological nurse practitioner in Australia.
        Doctor of Philosophy, University of Adelaide, Adelaide2009
        • Lee G.
        • Jennings N.
        A comparative study of patients who did not wait for treatment and those treated by Emergency Nurse Practitioners.
        Australasian Emergency Nursing Journal. 2006; 9: 179-185
        • Li J.
        • Westbrook J.
        • Callen J.
        • Georgiou A.
        • Braithwaite J.
        The impact of nurse practitioners on care delivery in the emergency department: A multiple perspectives qualitative study.
        BMC Health Services Research. 2013; 13
        • Lloyd Jones M.
        Role development and effective practice in specialist and advanced practice roles in acute hospital settings: Systematic review and meta-synthesis.
        Journal of Advanced Nursing. 2005; 49: 191-209
        • Longman J.
        • Barraclough F.
        • Barclay L.
        An evaluation of the Nimbin Integrated Services Project – Final Report.
        University of Sydney, Lismore, NSW, Australia2012
        • Lutze M.
        • Ratchford A.
        • Fry M.
        A review of the Transitional Emergency Nurse Practitioner.
        Australasian Emergency Nursing Journal. 2011; 14: 226-231
        • Lutze M.
        • Ross M.
        • Chu M.
        • Green T.
        • Dinh M.
        Patient perceptions of emergency department fast track: A prospective pilot study comparing two models of care.
        Australasian Emergency Nursing Journal. 2014; 17: 112-118
        • Masso M.
        • Thompson C.
        Rapid review of the nurse practitioner literature: Nurse practitioners in NSW ‘Gaining Momentum’.
        NSW Ministry of Health, North Sydney, NSW, Australia2014
        • McMillan S.S.
        • Emmerton L.
        Nurse practitioners: An insight into their integration into Australian community pharmacies.
        Research in Social and Administrative Pharmacy. 2013; 9: 975-980
        • Michie S.
        • Fixsen D.
        • Grimshaw J.M.
        • Eccles M.P.
        Specifying and reporting complex behaviour change interventions: The need for a scientific method.
        Implementation Science. 2009; 4
        • Middleton S.
        • Allnutt J.
        • Griffiths R.
        • McMaster R.
        • O’Connell J.
        • Hillege S.
        Identifying measures for evaluating new models of nursing care: A survey of NSW nurse practitioners.
        International Journal of Nursing Practice. 2007; 13: 331-340
        • Morcom J.
        • Dunn S.V.
        • Luxford Y.
        Establishing an Australian nurse practitioner-led colorectal cancer screening clinic.
        Gastroenterology Nursing. 2004; 28: 33-42
        • Murfet G.O.
        • Allen P.
        • Hingston T.J.
        Maternal and neonatal health outcomes following the implementation of an innovative model of nurse practitioner-led care for diabetes in pregnancy.
        Journal of Advanced Nursing. 2014; 70: 1150-1163
        • Newhouse R.P.
        • Heindel L.
        • Weiner J.P.
        • Stanik-Hutt J.
        • White K.M.
        • Johantgen M.
        • et al.
        Advanced practice nurse outcomes 1990–2008: A systematic review.
        Nursing Economic. 2011; 29: 230
        • Niezen M.G.H.
        • Mathijssen J.J.P.
        Reframing professional boundaries in healthcare: A systematic review of facilitators and barriers to task reallocation from the domain of medicine to the nursing domain.
        Health Policy. 2014; 117: 151-169
        • NSW Department of Health
        Nurse Practitioner Project Stage 3. Final report of the Steering Committee.
        NSW Health Department, Sydney1996
        • Nursing and Midwifery Board of Australia
        Nurse practitioner standards for practice.
        Nursing and Midwifery Board of Australia, Canberra2013
        • O’Keefe E.J.
        • Gardner G.
        Researching the sexual health nurse practitioner scope of practice: A blueprint for autonomy.
        Australian Journal of Advanced Nursing. 2003; 21: 33-41
        • Papoulis D.
        An evaluation of mental health services in the Whyalla Hospital Accident and Emergency Department: A comparison of a new and old model of care.
        Master of Nurse Practitioner, University of Adelaide, Adelaide2011
        • Parker J.
        • Faulkner R.
        • Dunt D.
        • Long H.
        • Watts J.
        Victorian Nurse Practitioner Project: Evaluation of eleven Phase 1 demonstration projects.
        The University of Melbourne, Melbourne2000
        • Parker R.
        • Forest L.
        • Desborough J.
        • McRae I.
        • Boyland T.
        Independent evaluation of the nurse-led ACT Health Walk-in Centre.
        Australian Primary Health Care Research Institute, The Australian National University, Acton, ACT2011
        • Pearson A.
        • Nay R.
        • Ward C.
        • Lenten L.
        • Lewis M.
        Nurse practitioner project: Phase 2 – External evaluation.
        School of Nursing and Midwifery, La Trobe University, Melbourne2004
        • Pulcini J.
        • Jelic M.
        • Gul R.
        • Loke A.Y.
        An international survey on advanced practice nursing education, practice, and regulation.
        Journal of Nursing Scholarship. 2010; 42: 31-39
        • Queensland Health
        Nurse practitioner project report.
        Queensland Health, Brisbane2003
        • Scanlon A.
        • Cashin A.
        • Bryce J.
        • Kelly J.G.
        • Buckley T.
        The complexities of defining nurse practitioner scope of practice in the Australian context. 23(1). Collegian, 2015: 129-142 (in press)
        • Schoenwald A.V.
        Two hundred days of nurse practitioner prescribing and role development: A case study report from a hospital-based acute pain management team.
        Australian Health Review. 2011; 35: 444-447
        • Stasa H.
        • Cashin A.
        • Buckley T.
        • Donoghue J.
        Advancing advanced practice – Clarifying the conceptual confusion.
        Nurse Education Today. 2014; 34: 356-361
        • Wand T.
        • D’Abrew N.
        • Barnett C.
        • Acret L.
        • White K.
        Evaluation of a nurse practitioner-led extended hours mental health liaison nurse service based in the emergency.
        Australian Health Review. 2014; 39: 1-8
        • Wand T.
        • White K.
        • Patching J.
        Realistic evaluation of an emergency department-based mental health nurse practitioner outpatient service in Australia.
        Nursing & Health Sciences. 2011; 13: 199-206
        • Wand T.
        • White K.
        • Patching J.
        • Dixon J.
        • Green T.
        An emergency department-based mental health nurse practitioner outpatient service: Part 1. Participant evaluation.
        International Journal of Mental Health Nursing. 2011; 20: 392-400
        • Wand T.
        • White K.
        • Patching J.
        • Dixon J.
        • Green T.
        An emergency department-based mental health nurse practitioner outpatient service: Part 2. Staff evaluation.
        International Journal of Mental Health Nursing. 2011; 20: 401-408
        • Wand T.
        • White K.
        • Patching J.
        • Dixon J.
        • Green T.
        Outcomes from the evaluation of an emergency department-based mental health nurse practitioner outpatient service in Australia.
        Journal of the American Academy of Nurse Practitioners. 2012; 24: 149-159
        • Wilson A.
        • Shifaza F.
        An evaluation of the effectiveness and acceptability of nurse practitioners in an adult emergency department.
        International Journal of Nursing Practice. 2008; 14: 149-156
        • Wilson A.
        • Zwart E.
        • Everett I.
        • Kernick J.
        The clinical effectiveness of nurse practitioners’ management of minor injuries in an adult emergency department: A systematic review.
        International Journal of Evidence-Based Healthcare. 2009; 7: 3-14
        • Wilson K.
        • Coulon L.
        • Hillege S.
        • Swann W.
        Nurse practitioners’ experiences of working collaboratively with general practitioners and allied health professionals in New South Wales, Australia.
        Australian Journal of Advanced Nursing. 2005; 23: 22-27