Copyright © eContent Management Pty Ltd. Contemporary Nurse (2014) 49: 27–34.
A regional approach to the education of nurse practitioner candidates to meet the health needs of rural Australians Karen Francis*,+,!, Michal Boyd*,#, Heather Latham*, Judith Anderson*, Angela Bradley* and Jan Manners* *School of Nursing, Midwifery and Indigenous Health, Charles Sturt University, Bathurst, NSW, Australia; +Monash University, Melbourne, VIC, Australia; !University of Adelaide, Adelaide, SA, Australia; #School of Nursing, University of Auckland, Auckland, New Zealand
Abstract: Background: Local health services expressed interest in supporting a nurse practitioner (NP) program specifically designed for rural practice environments. Aim: To develop and deliver a generalist NP program that prepares candidates for practice in rural contexts. Methods: The Master of Clinical Nursing (Nurse Practitioner) program was designed with an understanding of the burden of disease impacting on rural Australians, application of the national health priorities, the Australian Government’s refocus on preventative health care and rural health workforce shortages. Results: This program offers nurses who work in rural and remote settings an opportunity to advance their careers. Increasing the numbers of rural NPs will improve rural populations access to healthcare and potentially improve health outcomes. Conclusion: This program will equip those seeking endorsement as a NP to effectively work in rural contexts.
Keywords: nurse practitioner, educational program, rural, health care access, Australia
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he Australian government recognised the challenges that are faced by rural people in accessing basic health care services and the disparity in health outcomes between people living in rural and remote Australia in comparison with those living in metropolitan areas (Australian Government, 2010; Australian Institute of Health and Welfare [AIHW], 2012). In response, the role of nurse practitioners (NPs) was promoted to improve access to health care and address the disparity in health outcomes (Harvey, 2011). In New South Wales, Australia this began with the Nurses Amendment (Nurse Practitioner) Act (1998). The full realisation of the NP role has not been realised however due in part to the challenges of remote study (Harvey, 2011). The health of rural and remote Australians: Access to care and the burden of disease Australia is a vast island nation with a relatively low population that is largely located on the coastal fringes and in the capital cities of each state and territory (Francis, Chapman, Hoare, & Birks, 2013). The AIHW (2012) indicate that 29% of Australians live in rural/regional areas and 2% in remote and very remote areas. The health of this population is worse than those in metropolitan
communities (AIHW, 2012) with critical inequalities existing depending on age, cultural grouping and where people live. Those who are Indigenous experience 17–20 years decreased life expectancy than other Australians (Steering Committee for the Review of Government Service Provision [SCRGSP], 2005). This figure also increases dramatically with geographical remoteness (Dade Smith, 2007). Rural people are significantly more likely to die of heart disease, death rates are double the urban rate due to injury and older adult falls, and triple the urban rate due to road trauma (Dade Smith, 2007; Vines, 2011). Young females in regional areas are 30% more likely to be overweight or obese than those in the city (AIHW, 2006a) and diabetes hospitalisation rates are four times the urban rate (AIHW, 2006a, 2006b; Australian Bureau of Statistics [ABS], 2006). Factors such as isolation and exposure to environmental hazards including drought, flood and fire places significant financial pressure on farming families and increases their risk of developing anxiety, depression, family breakdown, grief and anger (Vines, 2011). The reduced health status of people living in rural and remote Australia can be directly
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attributed to living conditions, social isolation, socioeconomic disadvantage and distance from health services. McMurray and Clendon (2011, p. 100) suggest that one of the greatest barriers to health care access is geographic location (particularly in a climate of financial constraint). They highlight that a lack of education or information also impacts healthcare access. Health inequalities become worse the more remote the location, which also parallels socio-economic disadvantage. Decreased service access in general and also to new diagnostic technologies and treatment interventions, less affordable care and fewer healthcare resources affects quality and continuity of care which is compounded by a lack of transport and shortage of health professionals (Francis, McLeod, & Mills, 2012; Humphreys, Wakerman, Perkins, Lyle, & McGrail, 2011; Vines, 2011). AIHW (2012) highlights the differences between the metropolitan and rural and remote populations in relation to the social determinants of health. These determinants experienced by rural and remote populations include; lower levels of income, employment and education, higher occupational risks, particularly associated with farming and mining, vast geographical distances resulting in the need for more long distance travel and limited access to fresh foods and health services. In the next two decades the number of people aged 65 and over is projected to rise by 91% and the number aged 85 and over will more than double resulting in a significant increase in the burden of chronic diseases (AIHW, 2012). The impact for Australians living in rural and remote areas will be even more significant given the challenges in accessing health care and inequalities already existing for this population. In 2011 the ratio of RNs per 100,000 population was fairly evenly distributed across regional, rural and remote areas of Australia compared to medicine and allied health (Health Workforce Australia [HWA], 2013). However, Health Workforce Australia (HWA) confirmed that there are serious nursing workforce shortages particularly in rural and remote regions that if not addressed will continue to impact on health care 28
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access and therefore population health outcomes (Australian Nursing Federation Submission, 2010; HWA, 2013, p. 1). Brayley (2014) in her book Nurses of the Outback describes nurses who work in rural and remote Australia as ‘… outrageous, adventurous, strong, reliable and responsible nurturers of the people of the outback.’ She goes on to say that they are ‘… innovative, dedicated, well qualified and highly experienced’ (Brayley, 2014, p. 7). Many of these nurses work beyond their scope of practice in delivering much needed health care to people living in rural and remote locations. The potential of nurse practitioners to make a difference
The advanced skills of NPs to diagnose, treat, refer and prescribe certain medication are accepted as an appropriate strategy to enhance access to healthcare for those living in rural and remote areas. Yet, there are very few NPs employed in these high needs areas. The education and employment of NPs in rural and remote areas is supported by professional organisations such as the Remote Area Nurses of Australia Inc (CRANA, 2012) and the Centre for Remote Health in Alice Springs. Francis and Mills (2011) recognised the need to grow the rural NP workforce. It has become increasingly difficult for rural and remote communities to attract and retain general practitioners and allied health professionals. Industry and professional experts agree that well prepared NPs who have an established history of working collaboratively, will provide high level health care to meet the needs of the population. This view is supported by the findings of Della and Zhou (2009) in their report titled ‘The Evaluation of the Nurse Practitioner Role in NSW.’ This report clearly identified support for more NPs to enhance patient access to health care and improve clinical outcomes. However, nurses in rural and remote areas described feeling isolated and lacking access to NP programs that utilise flexible modes of delivery (Della & Zhou, 2009). Interviewees identified the need for more clinically focused courses with enhanced clinical skills for advanced practice.
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A regional approach to the education of nurse practitioner candidates Collaboration with industry partners In response to the health needs of the rural and remote population and in collaboration with industry partners an innovative NP program was developed by the University. Extensive industry, professional and community consultation was undertaken by senior nurse academics at the University. Meetings were held with the majority of Directors of Nursing and senior executive staff of public and private health services throughout the University footprint (Rural/Regional New South Wales and Northern Victoria). Key stakeholders including directors of nursing, senior nurse leaders, nurse educators, clinical nurse specialists, medical officers, Aboriginal health service managers and NPs in public, private and non Government organisations across western and southern regions and the north coast of NSW and northern Victoria informed the development of the program. Consultation with General Practitioners, medical specialists and representatives of the Indigenous communities and the University Indigenous Education Board also contributed to the development the program. Consultation highlighted the urgent need for NPs, especially in regional, rural and remote communities, to work with health professionals to achieve improved health outcomes for the population. Feedback from this consultative process affirmed the need for the program to focus on health assessment and advancing specialty knowledge in areas such as primary health care (PHC), mental health, Indigenous health, chronic illness and disease management, emergency/high dependency nursing, palliative care. In addition, leadership and management theory was identified as a consistent theme to be incorporated in the curriculum. Further, feedback supported a need for NPs to be prepared with a broad range of knowledge and skills as many contexts of practice are not supported by full-time services provided by medical practitioners, pharmacists, radiographers and other specialist services. The Master of Clinical Nursing (Nurse Practitioner) The importance of preparing NPs who will implement dynamic practice models to improve
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access to health care and enhance the overall capacity of the team to best serve their target population is an important focus of the course (Ministry of Health, NSW, 2012). Graduates will advance their knowledge and clinical skills to meet the Nursing and Midwifery Board of Australia (NMBA) Nurse Practitioner Standards for Practice (NMBA, 2014). This will entail working within generalist settings where they will assume key roles in advancing nursing practice through informing and leading contemporary changes to health care provision. As advanced health care practitioners, graduates will work and learn collaboratively within the wider interdisciplinary team and other professional groups. They will be critical to improving access to quality evidence-based health care and to meeting consumer healthcare needs, in rural contexts of practice (Gardner, Chang, & Duffield, 2007). In addition to the core areas (NMBA, 2014), the Master of Clinical Nursing (Nurse Practitioner) MCN (NP) graduates will have the opportunity to choose one or more specialty area(s) including emergency care, mental health, chronic and complex care, palliative care and rural PHC. Incorporation of advanced teaching technology The potential for technology to improve the health of people living in rural and remote Australia is recognised and has been addressed in the development of the course (Liaw & Kilpatrick, 2008). Equity of access to services can be improved by utilising technology such as telehealth where health professionals and patients in rural and remote locations can be linked to specialist services in larger centres. This also has the potential to reduce the need for travel across vast geographical distances to access health care. Local Area Health Services have agreed to collaborate in the use of this technology during the students’ Supervised Professional Experience when ‘live’ observed patient assessment is being undertaken. MCN (NP) students will also develop skills in the use of technology to initiate and access educational opportunities for themselves, their c lients and communities. Furthermore, they will be
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encouraged to utilise technology to establish networks to share information and conduct research. The course will be offered utilising the University’s integrated Online Learning Environment (OLE) (Charles Sturt University, 2014) that allows staff and students to access applications such as electronic submission of assignments (EASTS) and the e-Portfolio as well as a collection of new teaching and learning tools including online meetings, discussion groups and engaging the student in learning that is active and interactive. The OLE also provides for the diversity of student circumstances, skills and learning styles while acknowledging the constraints of time and access that students face, particularly students from rural and remote areas. Students studying the course by distance education will attend compulsory residential schools in subjects with a clinical component. These residential schools will be conducted on a CSU campus utilising the new Inter-Professional Simulation Centre that provides for versatile and flexible simulation options. A multi-disciplinary Community Engagement and Wellness Centre has been recently opened at one of the University campuses where learning in a clinic environment working with other health professionals will be facilitated. The University simulation facilities at a nearby campus will also be accessed together with the simulation facilities at the local Health Service that features a training room with high fidelity manikins linked via video and audio to an adjacent lecture room allowing for simulation scenarios with small groups and the option to view the simulation remotely. Course duration and entry requirements The MCN (NP) course will comprise 96 credit points where students will enrol in a combination of 8 (single subject) and 16 point (double point subject) subjects studied in a blended and flexible online learning mode. The course will be undertaken full time over one and a half years or part time over 2 years utilising three sessions in a year. To be eligible for the course applicants must hold current registration as a Registered Nurse (RN) with the Australian Health Professional Registration Authority (AHPRA) – Nursing and Midwifery, hold a graduate certificate in nursing, 30
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and provide evidence of 5 years (or equivalent part time experience) as an RN at both a specialist and advanced level. Applicants must be currently employed 0.5 FTE in an advanced practice role for the duration of the course and provide a letter detailing organisational support from their employer to enable the applicant to complete all the professional experience components of the course. Applicants are required to identify a Professional Experience Supervisor (PES) who must be a suitably qualified NP or medical practitioner with 3 years prescribing experience. The supervisor must be formally approved by the Program Leader to provide supervision and oversight to the student during the 320 hours of professional experience undertaken during the course. The hours of professional practice were based on consultation with key stakeholders (endorsed NPs and course coordinators of similar programs offered by other Australian Universities), a review of the literature and proposed hours being considered by ANMAC (2009). Students must have also satisfactorily undertaken study of pharmacology in a graduate certificate prior to enrolling in the course. Graduate expectations, course structure and supervised professional experience Graduates will demonstrate an advanced and integrated body of knowledge in core subjects including health assessment, pharmacology, pathophysiology, nursing specialty subjects, evidence based practice, diagnostic reasoning, clinical and professional leadership and advanced professional practice. Enrolment in two elective subjects will enable further study in some specialty nursing areas and may include study in a subject focussing on cultural competence in Indigenous health. Expert specialised cognitive and clinical skills will be developed to enable the graduate to analyse, critically reflect and synthesise complex information, problems, concepts and theories. Skills in research and the application of established theories to a body of knowledge and practice will enhance the work of the NP. The graduate will be skilled to interpret, diagnose and prescribe
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A regional approach to the education of nurse practitioner candidates as part of their role as a NP. They will demonstrate advanced skills in communication to share knowledge, skills and ideas and coordinate care as a member of the interprofessional team of health professionals. An important aspect of the role will include the involvement of the patient, their carer and the family in all aspects of the health care. The ANMC Standards for the Accreditation of the NP (ANMAC, 2009, p. 5) describe the requirement for professional experience placement as ‘the component of NP education that allows the student to put knowledge into practice within the consumer care environment’ that with the level of clinical supervision necessary to develop the skills and knowledge utilisation consistent with that required of the NP role. The MCN (NP) supervision model is designed to facilitate student achievement of the course learning outcomes and the NMBA Nurse Practitioner Standards for Practice (NMBA, 2014) and adopts a collaborative approach between the University, the health service agency/professional and the student. The students will be encouraged to work with their Academic Mentor (AM) and PES to practise confidently in an autonomous manner, making expert judgements being adaptable and accountable in leading advanced nursing practice. Students will complete at least 80 hours of mentored professional experience with the option of increasing this by an additional 80 hours (depending on the student’s choice of electives) as well as 320 hours of supervised professional practice. Philosophical underpinnings of the curriculum There are several important philosophical underpinnings of the curriculum. For instance, social justice addresses issues of equity and equality and recognition that health and wellness is influenced by all aspects of the human experience including socio-economic status, ethnicity, and culture. Part of the advanced nursing practice role will be to advocate for changes to the social and economic conditions that are the source of ill health, and in doing so promote health as a basic human right (Browne & Tarlier, 2008). A focus on PHC philosophy and values is the basis of rural and remote health care practice.
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The NP acts as a health resource and advocate, encouraging self-management and supporting coordinated care to empower people and the community in which they live (Dade Smith, 2007). The advanced clinical skills of the NP will expand the multi-disciplinary team capability to meet the health care needs of the community. For clinicians working in rural and remote areas, care is focused on the community rather than solely on the individual. To fully support the health care needs of the community, the NP must develop a trusting and credible relationship with community residents. NPs will understand the importance of building ‘social capital’ through activities that benefit the community and the individual as part of the community. Strong social capital is an important factor in the overall health of a community (Dade Smith, 2007). The challenge of educating the new generation of NPs is to develop their ability not only to know what to do but why they are doing it and to be able to clearly articulate the clinical reasoning and evidence-base behind their decisions. Benner, Tanner, and Chesla’s (2009) work invites the nursing profession to move beyond the constraint of competencies to a more holistic clinical reasoning approach. Without this grounding in clinical reasoning, competencies can become merely a list of ‘stripped down’ narrowly prescribed skills which are presented out of clinical context. Benner notes that ‘… good clinical judgement can never be reduced to the technical aspects of the situation or to a list of tasks to be accomplished’ (Benner, Sutphen, Leonard, & Day, 2010, p. 16). Benner suggests that a clinical reasoning approach integrates clinical and classroom learning into a seamless whole and thereby decreasing the fragmentation that students experience between classroom and clinical practice. To help facilitate this an important and distinguishing feature of the MCN (NP) will be the employment of NPs who will teach in the course and provide academic mentoring and guidance to the student (Anderson, 2011; Hoare, Mills, & Francis, 2013). Nurse practitioners enhance the overall capability of the multi-disciplinary team because of the care coordination and person-centred
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approaches they bring from their nursing background. The essential coordination of care concept is patient advocacy and customization of care to meet the specific values, needs and wishes of the patient including their spiritual and cultural needs (Ehrlich, Kendall, Muenchberger, & Armstrong, 2009). Wolff and Boult (2005) identified nine essential components of an effective coordination of care approach: Patient evaluation; individual care planning; evidence-based decision making; consumer empowerment; promotion of healthy lifestyles; coordination across multiple conditions; coordination across provider settings; caregiver support and education; and accessing community resources. These care coordination components will be key to the type of practice expected of a MCN (NP) graduate and will be important learning outcomes for the course. A coordination of care approach seeks continuity across social and health providers to decrease fragmented and disjointed care that currently plagues healthcare provision particularly in rural and remote areas. Effective coordination of care requires a highly collaborative team. Research has shown improved outcomes when the multidisciplinary primary care team works together as a cooperative cohesive unit (Wertenberger, Yerardi, Drake, & Parlier, 2006). A person-centred care philosophy is fundamental to a coordination of care approach and will underpin learning in the MCN (NP). This philosophy asserts that effective health care is based on a therapeutic relationship between professionals, patients and their significant others and that these relationships are built on trust, understanding and shared collective knowledge (McCormack, 2004). Effective communication is essential to a personcentred approach because it promotes knowledge sharing and collaboration among health care providers, patients, families, health care and social service providers, and funding bodies. Conceptual framework and learning and teaching strategies Learning and teaching will occur within an innovative conceptual framework to prepare the generalist NP for a role that is different and distinguishable from other medical and nursing practice 32
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roles. The NMBA Nurse Practitioner Standards for Practice (NMBA, 2014) identify four domains; clinical, education, research and leadership upon which the curriculum will be developed. Collaborative inquiry will be adopted to encourage students to use experiences to generate new knowledge by action and reflection. A case based approach will encourage students to draw on experiences to develop diagnostic reasoning, case presentation and clinical documentation skills (Chikotas, 2008; Popil, 2011). Collaborative inquiry will occur both online, in peer learning groups and during residential schools where small groups will engage in discussion during simulation session experiences where the power of decision making will be shared by teachers and students (Reese, Jeffries, & Engum, 2010; RutherfordHemming, 2012). Collaborative inquiry which will be fundamental to teaching and learning in the MCN (NP) will facilitate working together to overcome personal, social and technological barriers where learning is dynamic, relevant and challenging and helps build a partnership between the student, educator and the clinician (RutherfordHemming, 2012). The role of the AM and PES in particular, will be important in assisting students to facilitate learning given the close relationship that will be established as the student progresses through the course. The MCN (NP) will utilise a cognitive apprenticeship educational model first introduced by Collins, Brown, and Newman (1989) an instructional model for situated learning, with recent application to clinical skills teaching (Stalmeijer, Dolmans, Wolfhagen, & Scherpbier, 2009; Woolley & Jarvis, 2007). Broadly speaking, cognitive apprenticeship is a constructivist pedagogy that looks at supporting students to become ‘masters,’ that is, independent and skilled practitioners. In this education model, modelling, coaching, and scaffolding are at the core of cognitive apprenticeship and promote cognitive and metacognitive development. A variety of authentic assessments will be utilised including a case study report, professional experience contract and critical reflection, written examination, online discussion and peer learning groups, observed patient assessment in clinical practice and a mid-session formative and end of session summative evaluation undertaken by
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A regional approach to the education of nurse practitioner candidates the PES and AM using the Professional Experience Competency Assessment Tool (PECAT). This assessment will monitor the student’s progress towards achievement of the professional experience and NMBA Standards for Practice where the student will be observed conducting a ‘live’ clinical patient visit. The student will also undertake a selfevaluation using PECAT. Authentic practice based education supports life-long learning skills and the development of autonomous, professional, reflective practice. Students will learn through direct implementation of their professional roles in real workplace settings, thus grounding education in the preparation for practice roles post-graduation as a NP. Conclusion A comparison between the health status of urban and rural and remote dwelling people in Australia demonstrates marked inequalities in every national health priority area based on geographic location, age and culture. Improving access and equality to care will continue to be a challenge for governments at all levels. This regional approach by the University to the education of NPs who will work in partnership with health professionals and communities will ensure that they are well prepared to address many of the barriers people face in accessing health care. Through the provision of advanced nursing care the NP will make a valuable contribution to improving the health outcomes for Australians living in rural and remote areas. Acknowledgements The authors wish to thank the Course Advisory committee members who contributed to the development of the Master of Clinical Nursing (Nurse Practitioner) Program. References
Anderson, L. (2011). A learning resource for developing effective mentorship in practice. Nursing Standard, 25(51), 48–67. Australian Bureau of Statistics (ABS). (2006). Diabetes hospitalisations in Australia, 2003-04. Retrieved from http://www.aihw.gov.au/WorkArea/DownloadAsset. aspx?id=6442453554
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Australian Government. (2010). A national health and hospitals network for Australia’s future: Delivering better health and better hospitals. Canberra, ACT: Commonwealth of Australia. Australian Institute of Health and Welfare (AIHW). (2006a). Australia’s health 2006 (p. 483). Canberra, ACT: Author. Australian Bureau of Statistics (ABS). (2006b). National health survey: Summary of results, 2004–05. Canberra, ACT: Author. Australian Institute of Health and Welfare (AIHW). (2012). Australia’s health 2012. Australia’s health no. 13 (Cat. No. AUS 156). Canberra, ACT: Author. Australian Nursing Federation Submission. (2010). Australian Nursing Federation Submission to consultation by the Department of Health and Ageing on the development of a quality framework for the Medicare benefits schedule. Canberra, ACT: Author. Retrieved from http://anf.org.au/documents/submissions/ Sub_MBS_Quality_Framework.pdf Australian Nursing and Midwifery Accreditation Council. (2009). Nurse practitioner standards and criteria for the accreditation of nursing and midwifery courses leading to registration, enrolment, endorsement and authorisation in Australia – With evidence guide. Canberra, ACT: Author. Retrieved from http:// www.anmac.org.au/sites/default/files/documents/ ANMC%20Accreditation%20standards%20-%20 Nurse%20Practitioner.pdf Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass. Benner, P., Tanner, C., & Chesla, C. (2009). Expertise in nursing practice. New York, NY: Springer. Brayley, A. (2014). Nurses of the outback: 15 amazing lives in remote area nursing. Melbourne, VIC: Penguin. Browne, A. J., & Tarlier, D. S. (2008). Examining the potential of nurse practitioners from a critical social justice perspective. Nursing Inquiry, 15(2), 83–93. Charles Sturt University. (2014). Interact a scholarly community. Retrieved from http://www.csu.edu.au/ division/landt/interact/ Chikotas, N. E. (2008). Theoretical links: Supporting the use of problem-based learning in education for the nurse practitioner. Nursing Education Perspectives, 29(6), 359–362. Collins, A., Brown, J. S., & Newman, S. E. (1989). Cognitive apprenticeship: Teaching the crafts of reading, writing, and mathematics. In L. B. Resnick (Ed.), Knowing, learning, and instruction: Essays in honor of Robert Glaser (pp. 453–494). Hillsdale, NJ: Lawrence Erlbaum Associates.
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CRANA. (2012). Council of remote area nurses of Australia (CRANA) framework for remote practice. The Council of Remote Area Nurses of Australia. Retrieved from https://crana.org.au/files/pdfs/ Framework_Remote_Practice_FINAL.pdf Dade Smith, J. (2007). Australia’s rural and remote health: A social justice perspective. Croydon, VIC: Pearson Education Australia. Della, P., & Zhou, H. (2009). Report on the evaluation of the nurse practitioner role in NSW. Perth, WA: Curtin University of Technology, p. 30. Ehrlich, C., Kendall, E., Muenchberger, H., & Armstrong, K. (2009). Coordinated care: What does that really mean? Health & Social Care in the Community, 17(6), 619–627. Francis, K., Chapman, Y., Hoare, K., & Birks, M. (2013). Australia and new Zealand, community as partner, theory and practice in nursing (2nd ed.). Sydney, NSW: Wolters Kluwer/Lippincott. Francis, K., McLeod, M., & Mills, J. (2012). Australian College of Nursing Rural Nursing and Midwifery Faculty: Advocating for greater equity in rural health. Australian Journal of Rural Health, 20(6), 344. Francis, K. L., & Mills, J. E. (2011). Sustaining and growing the rural nursing and midwifery workforce: Understanding the issues and isolating directions for the future. Collegian, 18(2), 55–60. Gardner, G., Chang, A., & Duffield, C. (2007). Making nursing work: Breaking through the role confusion of advanced practice nursing. Journal of Advanced Nursing, 57(4), 382–391. Harvey, C. (2011). Legislative hegemony and nurse practitioner practice in rural and remote Australia. Health Sociology Review, 20(3), 269–280. doi: 10.5172/hesr.2011.20.3.269 Health Workforce Australia (HWA). (2013). Australia’s health workforce series – Nurses in focus. Adelaide, SA: Health Workforce Australia. Humphreys, J., Wakerman, J., Perkins, D., Lyle, D., & McGrail, M. (2011). Access and equity in the provision of primary health care services in rural and remote Australia. Canberra, ACT: Department of Health and Ageing Conference. Liaw, S.-T., & Kilpatrick, S. (Eds.). (2008). A textbook of australian rural health. Canberra, ACT: Australian Rural Health Education Network. McCormack, B. (2004). Person-centredness in gerontological nursing: An overview of the literature. Journal of Clinical Nursing, 13(3a), 31–38. McMurray, A., & Clendon, J. (2011). Health and wellness 4: Primary health care in practice. Sydney, NSW: Elsevier.
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Ministry of Health, NSW. (2012). Nurse practitioners in NSW. Retrieved from http://www0.health.nsw.gov. au/policies/pd/2012/pdf/PD2012_026.pdf Nursing and Midwifery Board of Australia. (2014). Nurse practitioner standards for practice – Effective from 1 January 2014. Retrieved from http://www. nursingmidwiferyboard.gov.au/Codes-GuidelinesStatements/Codes-Guidelines/nurse-practitionerstandards-of-practice.aspx Nurses Amendment (Nurse Practitioner) Act. (1998). No. 102 1998. Sydney, NSW: Government of New South Wales. Popil, I. (2011). Promotion of critical thinking by using case studies as teaching method. Nurse Education Today, 31(2), 204–207. Reese, C., Jeffries, P. R., & Engum, S. A. (2010). Learning together: Using simulation to develop nursing and medical student collaboration. Nursing Education Perspectives, 31(1), 33–37. Rutherford-Hemming, T. (2012). Simulation methodology in nursing education and adult learning theory. Adult Learning, 23(3), 129–137. Stalmeijer, R. E., Dolmans, D. H. J. M., Wolfhagen, I. H. A. P., & Scherpbier, A. J. J. A. (2009). Cognitive apprenticeship in clinical practice: Can it stimulate learning in the opinion of students? Advances in Health Sciences Education, 14(4), 535–546. Steering Committee for the Review of Government Service Provision (SCRGSP). (2005). Overcoming indigenous disadvantage: Key indicators 2005, SCRGPS, productivity commission. Canberra, ACT: Author. Vines, R. (2011). Equity in health and wellbeing: Why does regional, rural and remote Australia matter? In Psych. Retrieved from Australian Psychological Society website: http://psychology.org.au/Content.aspx?ID=3960 Wertenberger, S., Yerardi, R., Drake, A. C., & Parlier, R. (2006). Veterans health administration office of nursing services exploration of positive patient care synergies fuelled by consumer demand: Care coordination, advanced clinic access, and patient self-management. Nursing Administration Quarterly, 30(2), 137–146. Wolff, J. L., & Boult, C. (2005). Moving beyond round pegs and square holes: Restructuring Medicare to improve chronic care. Annals of Internal Medicine, 143(6), 439–445. Woolley, N. A., & Jarvis, Y. (2007). Situated cognition and cognitive apprenticeship: A model for teaching and learning clinical skills in a technologically rich and authentic learning environment. Nurse Education Today, 27(1), 73–79. Received 28 July 2014
Accepted 14 November 2014
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A regional approach to the education of nurse practitioner candidates to meet the health needs of rural Australians Karen Francis*,+,!, Michal Boyd*,#, Heather Latham*, Judith Anderson*, Angela Bradley* and Jan Manners* *School of Nursing, Midwifery and Indigenous Health, Charles Sturt University, Bathurst, NSW, Australia; +Monash University, Melbourne, VIC, Australia; !University of Adelaide, Adelaide, SA, Australia; #School of Nursing, University of Auckland, Auckland, New Zealand
Abstract: Background: Local health services expressed interest in supporting a nurse practitioner (NP) program specifically designed for rural practice environments. Aim: To develop and deliver a generalist NP program that prepares candidates for practice in rural contexts. Methods: The Master of Clinical Nursing (Nurse Practitioner) program was designed with an understanding of the burden of disease impacting on rural Australians, application of the national health priorities, the Australian Government’s refocus on preventative health care and rural health workforce shortages. Results: This program offers nurses who work in rural and remote settings an opportunity to advance their careers. Increasing the numbers of rural NPs will improve rural populations access to healthcare and potentially improve health outcomes. Conclusion: This program will equip those seeking endorsement as a NP to effectively work in rural contexts.
Keywords: nurse practitioner, educational program, rural, health care access, Australia
T
he Australian government recognised the challenges that are faced by rural people in accessing basic health care services and the disparity in health outcomes between people living in rural and remote Australia in comparison with those living in metropolitan areas (Australian Government, 2010; Australian Institute of Health and Welfare [AIHW], 2012). In response, the role of nurse practitioners (NPs) was promoted to improve access to health care and address the disparity in health outcomes (Harvey, 2011). In New South Wales, Australia this began with the Nurses Amendment (Nurse Practitioner) Act (1998). The full realisation of the NP role has not been realised however due in part to the challenges of remote study (Harvey, 2011). The health of rural and remote Australians: Access to care and the burden of disease Australia is a vast island nation with a relatively low population that is largely located on the coastal fringes and in the capital cities of each state and territory (Francis, Chapman, Hoare, & Birks, 2013). The AIHW (2012) indicate that 29% of Australians live in rural/regional areas and 2% in remote and very remote areas. The health of this population is worse than those in metropolitan
communities (AIHW, 2012) with critical inequalities existing depending on age, cultural grouping and where people live. Those who are Indigenous experience 17–20 years decreased life expectancy than other Australians (Steering Committee for the Review of Government Service Provision [SCRGSP], 2005). This figure also increases dramatically with geographical remoteness (Dade Smith, 2007). Rural people are significantly more likely to die of heart disease, death rates are double the urban rate due to injury and older adult falls, and triple the urban rate due to road trauma (Dade Smith, 2007; Vines, 2011). Young females in regional areas are 30% more likely to be overweight or obese than those in the city (AIHW, 2006a) and diabetes hospitalisation rates are four times the urban rate (AIHW, 2006a, 2006b; Australian Bureau of Statistics [ABS], 2006). Factors such as isolation and exposure to environmental hazards including drought, flood and fire places significant financial pressure on farming families and increases their risk of developing anxiety, depression, family breakdown, grief and anger (Vines, 2011). The reduced health status of people living in rural and remote Australia can be directly
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attributed to living conditions, social isolation, socioeconomic disadvantage and distance from health services. McMurray and Clendon (2011, p. 100) suggest that one of the greatest barriers to health care access is geographic location (particularly in a climate of financial constraint). They highlight that a lack of education or information also impacts healthcare access. Health inequalities become worse the more remote the location, which also parallels socio-economic disadvantage. Decreased service access in general and also to new diagnostic technologies and treatment interventions, less affordable care and fewer healthcare resources affects quality and continuity of care which is compounded by a lack of transport and shortage of health professionals (Francis, McLeod, & Mills, 2012; Humphreys, Wakerman, Perkins, Lyle, & McGrail, 2011; Vines, 2011). AIHW (2012) highlights the differences between the metropolitan and rural and remote populations in relation to the social determinants of health. These determinants experienced by rural and remote populations include; lower levels of income, employment and education, higher occupational risks, particularly associated with farming and mining, vast geographical distances resulting in the need for more long distance travel and limited access to fresh foods and health services. In the next two decades the number of people aged 65 and over is projected to rise by 91% and the number aged 85 and over will more than double resulting in a significant increase in the burden of chronic diseases (AIHW, 2012). The impact for Australians living in rural and remote areas will be even more significant given the challenges in accessing health care and inequalities already existing for this population. In 2011 the ratio of RNs per 100,000 population was fairly evenly distributed across regional, rural and remote areas of Australia compared to medicine and allied health (Health Workforce Australia [HWA], 2013). However, Health Workforce Australia (HWA) confirmed that there are serious nursing workforce shortages particularly in rural and remote regions that if not addressed will continue to impact on health care 28
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access and therefore population health outcomes (Australian Nursing Federation Submission, 2010; HWA, 2013, p. 1). Brayley (2014) in her book Nurses of the Outback describes nurses who work in rural and remote Australia as ‘… outrageous, adventurous, strong, reliable and responsible nurturers of the people of the outback.’ She goes on to say that they are ‘… innovative, dedicated, well qualified and highly experienced’ (Brayley, 2014, p. 7). Many of these nurses work beyond their scope of practice in delivering much needed health care to people living in rural and remote locations. The potential of nurse practitioners to make a difference
The advanced skills of NPs to diagnose, treat, refer and prescribe certain medication are accepted as an appropriate strategy to enhance access to healthcare for those living in rural and remote areas. Yet, there are very few NPs employed in these high needs areas. The education and employment of NPs in rural and remote areas is supported by professional organisations such as the Remote Area Nurses of Australia Inc (CRANA, 2012) and the Centre for Remote Health in Alice Springs. Francis and Mills (2011) recognised the need to grow the rural NP workforce. It has become increasingly difficult for rural and remote communities to attract and retain general practitioners and allied health professionals. Industry and professional experts agree that well prepared NPs who have an established history of working collaboratively, will provide high level health care to meet the needs of the population. This view is supported by the findings of Della and Zhou (2009) in their report titled ‘The Evaluation of the Nurse Practitioner Role in NSW.’ This report clearly identified support for more NPs to enhance patient access to health care and improve clinical outcomes. However, nurses in rural and remote areas described feeling isolated and lacking access to NP programs that utilise flexible modes of delivery (Della & Zhou, 2009). Interviewees identified the need for more clinically focused courses with enhanced clinical skills for advanced practice.
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A regional approach to the education of nurse practitioner candidates Collaboration with industry partners In response to the health needs of the rural and remote population and in collaboration with industry partners an innovative NP program was developed by the University. Extensive industry, professional and community consultation was undertaken by senior nurse academics at the University. Meetings were held with the majority of Directors of Nursing and senior executive staff of public and private health services throughout the University footprint (Rural/Regional New South Wales and Northern Victoria). Key stakeholders including directors of nursing, senior nurse leaders, nurse educators, clinical nurse specialists, medical officers, Aboriginal health service managers and NPs in public, private and non Government organisations across western and southern regions and the north coast of NSW and northern Victoria informed the development of the program. Consultation with General Practitioners, medical specialists and representatives of the Indigenous communities and the University Indigenous Education Board also contributed to the development the program. Consultation highlighted the urgent need for NPs, especially in regional, rural and remote communities, to work with health professionals to achieve improved health outcomes for the population. Feedback from this consultative process affirmed the need for the program to focus on health assessment and advancing specialty knowledge in areas such as primary health care (PHC), mental health, Indigenous health, chronic illness and disease management, emergency/high dependency nursing, palliative care. In addition, leadership and management theory was identified as a consistent theme to be incorporated in the curriculum. Further, feedback supported a need for NPs to be prepared with a broad range of knowledge and skills as many contexts of practice are not supported by full-time services provided by medical practitioners, pharmacists, radiographers and other specialist services. The Master of Clinical Nursing (Nurse Practitioner) The importance of preparing NPs who will implement dynamic practice models to improve
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access to health care and enhance the overall capacity of the team to best serve their target population is an important focus of the course (Ministry of Health, NSW, 2012). Graduates will advance their knowledge and clinical skills to meet the Nursing and Midwifery Board of Australia (NMBA) Nurse Practitioner Standards for Practice (NMBA, 2014). This will entail working within generalist settings where they will assume key roles in advancing nursing practice through informing and leading contemporary changes to health care provision. As advanced health care practitioners, graduates will work and learn collaboratively within the wider interdisciplinary team and other professional groups. They will be critical to improving access to quality evidence-based health care and to meeting consumer healthcare needs, in rural contexts of practice (Gardner, Chang, & Duffield, 2007). In addition to the core areas (NMBA, 2014), the Master of Clinical Nursing (Nurse Practitioner) MCN (NP) graduates will have the opportunity to choose one or more specialty area(s) including emergency care, mental health, chronic and complex care, palliative care and rural PHC. Incorporation of advanced teaching technology The potential for technology to improve the health of people living in rural and remote Australia is recognised and has been addressed in the development of the course (Liaw & Kilpatrick, 2008). Equity of access to services can be improved by utilising technology such as telehealth where health professionals and patients in rural and remote locations can be linked to specialist services in larger centres. This also has the potential to reduce the need for travel across vast geographical distances to access health care. Local Area Health Services have agreed to collaborate in the use of this technology during the students’ Supervised Professional Experience when ‘live’ observed patient assessment is being undertaken. MCN (NP) students will also develop skills in the use of technology to initiate and access educational opportunities for themselves, their c lients and communities. Furthermore, they will be
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encouraged to utilise technology to establish networks to share information and conduct research. The course will be offered utilising the University’s integrated Online Learning Environment (OLE) (Charles Sturt University, 2014) that allows staff and students to access applications such as electronic submission of assignments (EASTS) and the e-Portfolio as well as a collection of new teaching and learning tools including online meetings, discussion groups and engaging the student in learning that is active and interactive. The OLE also provides for the diversity of student circumstances, skills and learning styles while acknowledging the constraints of time and access that students face, particularly students from rural and remote areas. Students studying the course by distance education will attend compulsory residential schools in subjects with a clinical component. These residential schools will be conducted on a CSU campus utilising the new Inter-Professional Simulation Centre that provides for versatile and flexible simulation options. A multi-disciplinary Community Engagement and Wellness Centre has been recently opened at one of the University campuses where learning in a clinic environment working with other health professionals will be facilitated. The University simulation facilities at a nearby campus will also be accessed together with the simulation facilities at the local Health Service that features a training room with high fidelity manikins linked via video and audio to an adjacent lecture room allowing for simulation scenarios with small groups and the option to view the simulation remotely. Course duration and entry requirements The MCN (NP) course will comprise 96 credit points where students will enrol in a combination of 8 (single subject) and 16 point (double point subject) subjects studied in a blended and flexible online learning mode. The course will be undertaken full time over one and a half years or part time over 2 years utilising three sessions in a year. To be eligible for the course applicants must hold current registration as a Registered Nurse (RN) with the Australian Health Professional Registration Authority (AHPRA) – Nursing and Midwifery, hold a graduate certificate in nursing, 30
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and provide evidence of 5 years (or equivalent part time experience) as an RN at both a specialist and advanced level. Applicants must be currently employed 0.5 FTE in an advanced practice role for the duration of the course and provide a letter detailing organisational support from their employer to enable the applicant to complete all the professional experience components of the course. Applicants are required to identify a Professional Experience Supervisor (PES) who must be a suitably qualified NP or medical practitioner with 3 years prescribing experience. The supervisor must be formally approved by the Program Leader to provide supervision and oversight to the student during the 320 hours of professional experience undertaken during the course. The hours of professional practice were based on consultation with key stakeholders (endorsed NPs and course coordinators of similar programs offered by other Australian Universities), a review of the literature and proposed hours being considered by ANMAC (2009). Students must have also satisfactorily undertaken study of pharmacology in a graduate certificate prior to enrolling in the course. Graduate expectations, course structure and supervised professional experience Graduates will demonstrate an advanced and integrated body of knowledge in core subjects including health assessment, pharmacology, pathophysiology, nursing specialty subjects, evidence based practice, diagnostic reasoning, clinical and professional leadership and advanced professional practice. Enrolment in two elective subjects will enable further study in some specialty nursing areas and may include study in a subject focussing on cultural competence in Indigenous health. Expert specialised cognitive and clinical skills will be developed to enable the graduate to analyse, critically reflect and synthesise complex information, problems, concepts and theories. Skills in research and the application of established theories to a body of knowledge and practice will enhance the work of the NP. The graduate will be skilled to interpret, diagnose and prescribe
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A regional approach to the education of nurse practitioner candidates as part of their role as a NP. They will demonstrate advanced skills in communication to share knowledge, skills and ideas and coordinate care as a member of the interprofessional team of health professionals. An important aspect of the role will include the involvement of the patient, their carer and the family in all aspects of the health care. The ANMC Standards for the Accreditation of the NP (ANMAC, 2009, p. 5) describe the requirement for professional experience placement as ‘the component of NP education that allows the student to put knowledge into practice within the consumer care environment’ that with the level of clinical supervision necessary to develop the skills and knowledge utilisation consistent with that required of the NP role. The MCN (NP) supervision model is designed to facilitate student achievement of the course learning outcomes and the NMBA Nurse Practitioner Standards for Practice (NMBA, 2014) and adopts a collaborative approach between the University, the health service agency/professional and the student. The students will be encouraged to work with their Academic Mentor (AM) and PES to practise confidently in an autonomous manner, making expert judgements being adaptable and accountable in leading advanced nursing practice. Students will complete at least 80 hours of mentored professional experience with the option of increasing this by an additional 80 hours (depending on the student’s choice of electives) as well as 320 hours of supervised professional practice. Philosophical underpinnings of the curriculum There are several important philosophical underpinnings of the curriculum. For instance, social justice addresses issues of equity and equality and recognition that health and wellness is influenced by all aspects of the human experience including socio-economic status, ethnicity, and culture. Part of the advanced nursing practice role will be to advocate for changes to the social and economic conditions that are the source of ill health, and in doing so promote health as a basic human right (Browne & Tarlier, 2008). A focus on PHC philosophy and values is the basis of rural and remote health care practice.
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The NP acts as a health resource and advocate, encouraging self-management and supporting coordinated care to empower people and the community in which they live (Dade Smith, 2007). The advanced clinical skills of the NP will expand the multi-disciplinary team capability to meet the health care needs of the community. For clinicians working in rural and remote areas, care is focused on the community rather than solely on the individual. To fully support the health care needs of the community, the NP must develop a trusting and credible relationship with community residents. NPs will understand the importance of building ‘social capital’ through activities that benefit the community and the individual as part of the community. Strong social capital is an important factor in the overall health of a community (Dade Smith, 2007). The challenge of educating the new generation of NPs is to develop their ability not only to know what to do but why they are doing it and to be able to clearly articulate the clinical reasoning and evidence-base behind their decisions. Benner, Tanner, and Chesla’s (2009) work invites the nursing profession to move beyond the constraint of competencies to a more holistic clinical reasoning approach. Without this grounding in clinical reasoning, competencies can become merely a list of ‘stripped down’ narrowly prescribed skills which are presented out of clinical context. Benner notes that ‘… good clinical judgement can never be reduced to the technical aspects of the situation or to a list of tasks to be accomplished’ (Benner, Sutphen, Leonard, & Day, 2010, p. 16). Benner suggests that a clinical reasoning approach integrates clinical and classroom learning into a seamless whole and thereby decreasing the fragmentation that students experience between classroom and clinical practice. To help facilitate this an important and distinguishing feature of the MCN (NP) will be the employment of NPs who will teach in the course and provide academic mentoring and guidance to the student (Anderson, 2011; Hoare, Mills, & Francis, 2013). Nurse practitioners enhance the overall capability of the multi-disciplinary team because of the care coordination and person-centred
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approaches they bring from their nursing background. The essential coordination of care concept is patient advocacy and customization of care to meet the specific values, needs and wishes of the patient including their spiritual and cultural needs (Ehrlich, Kendall, Muenchberger, & Armstrong, 2009). Wolff and Boult (2005) identified nine essential components of an effective coordination of care approach: Patient evaluation; individual care planning; evidence-based decision making; consumer empowerment; promotion of healthy lifestyles; coordination across multiple conditions; coordination across provider settings; caregiver support and education; and accessing community resources. These care coordination components will be key to the type of practice expected of a MCN (NP) graduate and will be important learning outcomes for the course. A coordination of care approach seeks continuity across social and health providers to decrease fragmented and disjointed care that currently plagues healthcare provision particularly in rural and remote areas. Effective coordination of care requires a highly collaborative team. Research has shown improved outcomes when the multidisciplinary primary care team works together as a cooperative cohesive unit (Wertenberger, Yerardi, Drake, & Parlier, 2006). A person-centred care philosophy is fundamental to a coordination of care approach and will underpin learning in the MCN (NP). This philosophy asserts that effective health care is based on a therapeutic relationship between professionals, patients and their significant others and that these relationships are built on trust, understanding and shared collective knowledge (McCormack, 2004). Effective communication is essential to a personcentred approach because it promotes knowledge sharing and collaboration among health care providers, patients, families, health care and social service providers, and funding bodies. Conceptual framework and learning and teaching strategies Learning and teaching will occur within an innovative conceptual framework to prepare the generalist NP for a role that is different and distinguishable from other medical and nursing practice 32
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roles. The NMBA Nurse Practitioner Standards for Practice (NMBA, 2014) identify four domains; clinical, education, research and leadership upon which the curriculum will be developed. Collaborative inquiry will be adopted to encourage students to use experiences to generate new knowledge by action and reflection. A case based approach will encourage students to draw on experiences to develop diagnostic reasoning, case presentation and clinical documentation skills (Chikotas, 2008; Popil, 2011). Collaborative inquiry will occur both online, in peer learning groups and during residential schools where small groups will engage in discussion during simulation session experiences where the power of decision making will be shared by teachers and students (Reese, Jeffries, & Engum, 2010; RutherfordHemming, 2012). Collaborative inquiry which will be fundamental to teaching and learning in the MCN (NP) will facilitate working together to overcome personal, social and technological barriers where learning is dynamic, relevant and challenging and helps build a partnership between the student, educator and the clinician (RutherfordHemming, 2012). The role of the AM and PES in particular, will be important in assisting students to facilitate learning given the close relationship that will be established as the student progresses through the course. The MCN (NP) will utilise a cognitive apprenticeship educational model first introduced by Collins, Brown, and Newman (1989) an instructional model for situated learning, with recent application to clinical skills teaching (Stalmeijer, Dolmans, Wolfhagen, & Scherpbier, 2009; Woolley & Jarvis, 2007). Broadly speaking, cognitive apprenticeship is a constructivist pedagogy that looks at supporting students to become ‘masters,’ that is, independent and skilled practitioners. In this education model, modelling, coaching, and scaffolding are at the core of cognitive apprenticeship and promote cognitive and metacognitive development. A variety of authentic assessments will be utilised including a case study report, professional experience contract and critical reflection, written examination, online discussion and peer learning groups, observed patient assessment in clinical practice and a mid-session formative and end of session summative evaluation undertaken by
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A regional approach to the education of nurse practitioner candidates the PES and AM using the Professional Experience Competency Assessment Tool (PECAT). This assessment will monitor the student’s progress towards achievement of the professional experience and NMBA Standards for Practice where the student will be observed conducting a ‘live’ clinical patient visit. The student will also undertake a selfevaluation using PECAT. Authentic practice based education supports life-long learning skills and the development of autonomous, professional, reflective practice. Students will learn through direct implementation of their professional roles in real workplace settings, thus grounding education in the preparation for practice roles post-graduation as a NP. Conclusion A comparison between the health status of urban and rural and remote dwelling people in Australia demonstrates marked inequalities in every national health priority area based on geographic location, age and culture. Improving access and equality to care will continue to be a challenge for governments at all levels. This regional approach by the University to the education of NPs who will work in partnership with health professionals and communities will ensure that they are well prepared to address many of the barriers people face in accessing health care. Through the provision of advanced nursing care the NP will make a valuable contribution to improving the health outcomes for Australians living in rural and remote areas. Acknowledgements The authors wish to thank the Course Advisory committee members who contributed to the development of the Master of Clinical Nursing (Nurse Practitioner) Program. References
Anderson, L. (2011). A learning resource for developing effective mentorship in practice. Nursing Standard, 25(51), 48–67. Australian Bureau of Statistics (ABS). (2006). Diabetes hospitalisations in Australia, 2003-04. Retrieved from http://www.aihw.gov.au/WorkArea/DownloadAsset. aspx?id=6442453554
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Australian Government. (2010). A national health and hospitals network for Australia’s future: Delivering better health and better hospitals. Canberra, ACT: Commonwealth of Australia. Australian Institute of Health and Welfare (AIHW). (2006a). Australia’s health 2006 (p. 483). Canberra, ACT: Author. Australian Bureau of Statistics (ABS). (2006b). National health survey: Summary of results, 2004–05. Canberra, ACT: Author. Australian Institute of Health and Welfare (AIHW). (2012). Australia’s health 2012. Australia’s health no. 13 (Cat. No. AUS 156). Canberra, ACT: Author. Australian Nursing Federation Submission. (2010). Australian Nursing Federation Submission to consultation by the Department of Health and Ageing on the development of a quality framework for the Medicare benefits schedule. Canberra, ACT: Author. Retrieved from http://anf.org.au/documents/submissions/ Sub_MBS_Quality_Framework.pdf Australian Nursing and Midwifery Accreditation Council. (2009). Nurse practitioner standards and criteria for the accreditation of nursing and midwifery courses leading to registration, enrolment, endorsement and authorisation in Australia – With evidence guide. Canberra, ACT: Author. Retrieved from http:// www.anmac.org.au/sites/default/files/documents/ ANMC%20Accreditation%20standards%20-%20 Nurse%20Practitioner.pdf Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass. Benner, P., Tanner, C., & Chesla, C. (2009). Expertise in nursing practice. New York, NY: Springer. Brayley, A. (2014). Nurses of the outback: 15 amazing lives in remote area nursing. Melbourne, VIC: Penguin. Browne, A. J., & Tarlier, D. S. (2008). Examining the potential of nurse practitioners from a critical social justice perspective. Nursing Inquiry, 15(2), 83–93. Charles Sturt University. (2014). Interact a scholarly community. Retrieved from http://www.csu.edu.au/ division/landt/interact/ Chikotas, N. E. (2008). Theoretical links: Supporting the use of problem-based learning in education for the nurse practitioner. Nursing Education Perspectives, 29(6), 359–362. Collins, A., Brown, J. S., & Newman, S. E. (1989). Cognitive apprenticeship: Teaching the crafts of reading, writing, and mathematics. In L. B. Resnick (Ed.), Knowing, learning, and instruction: Essays in honor of Robert Glaser (pp. 453–494). Hillsdale, NJ: Lawrence Erlbaum Associates.
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CRANA. (2012). Council of remote area nurses of Australia (CRANA) framework for remote practice. The Council of Remote Area Nurses of Australia. Retrieved from https://crana.org.au/files/pdfs/ Framework_Remote_Practice_FINAL.pdf Dade Smith, J. (2007). Australia’s rural and remote health: A social justice perspective. Croydon, VIC: Pearson Education Australia. Della, P., & Zhou, H. (2009). Report on the evaluation of the nurse practitioner role in NSW. Perth, WA: Curtin University of Technology, p. 30. Ehrlich, C., Kendall, E., Muenchberger, H., & Armstrong, K. (2009). Coordinated care: What does that really mean? Health & Social Care in the Community, 17(6), 619–627. Francis, K., Chapman, Y., Hoare, K., & Birks, M. (2013). Australia and new Zealand, community as partner, theory and practice in nursing (2nd ed.). Sydney, NSW: Wolters Kluwer/Lippincott. Francis, K., McLeod, M., & Mills, J. (2012). Australian College of Nursing Rural Nursing and Midwifery Faculty: Advocating for greater equity in rural health. Australian Journal of Rural Health, 20(6), 344. Francis, K. L., & Mills, J. E. (2011). Sustaining and growing the rural nursing and midwifery workforce: Understanding the issues and isolating directions for the future. Collegian, 18(2), 55–60. Gardner, G., Chang, A., & Duffield, C. (2007). Making nursing work: Breaking through the role confusion of advanced practice nursing. Journal of Advanced Nursing, 57(4), 382–391. Harvey, C. (2011). Legislative hegemony and nurse practitioner practice in rural and remote Australia. Health Sociology Review, 20(3), 269–280. doi: 10.5172/hesr.2011.20.3.269 Health Workforce Australia (HWA). (2013). Australia’s health workforce series – Nurses in focus. Adelaide, SA: Health Workforce Australia. Humphreys, J., Wakerman, J., Perkins, D., Lyle, D., & McGrail, M. (2011). Access and equity in the provision of primary health care services in rural and remote Australia. Canberra, ACT: Department of Health and Ageing Conference. Liaw, S.-T., & Kilpatrick, S. (Eds.). (2008). A textbook of australian rural health. Canberra, ACT: Australian Rural Health Education Network. McCormack, B. (2004). Person-centredness in gerontological nursing: An overview of the literature. Journal of Clinical Nursing, 13(3a), 31–38. McMurray, A., & Clendon, J. (2011). Health and wellness 4: Primary health care in practice. Sydney, NSW: Elsevier.
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Ministry of Health, NSW. (2012). Nurse practitioners in NSW. Retrieved from http://www0.health.nsw.gov. au/policies/pd/2012/pdf/PD2012_026.pdf Nursing and Midwifery Board of Australia. (2014). Nurse practitioner standards for practice – Effective from 1 January 2014. Retrieved from http://www. nursingmidwiferyboard.gov.au/Codes-GuidelinesStatements/Codes-Guidelines/nurse-practitionerstandards-of-practice.aspx Nurses Amendment (Nurse Practitioner) Act. (1998). No. 102 1998. Sydney, NSW: Government of New South Wales. Popil, I. (2011). Promotion of critical thinking by using case studies as teaching method. Nurse Education Today, 31(2), 204–207. Reese, C., Jeffries, P. R., & Engum, S. A. (2010). Learning together: Using simulation to develop nursing and medical student collaboration. Nursing Education Perspectives, 31(1), 33–37. Rutherford-Hemming, T. (2012). Simulation methodology in nursing education and adult learning theory. Adult Learning, 23(3), 129–137. Stalmeijer, R. E., Dolmans, D. H. J. M., Wolfhagen, I. H. A. P., & Scherpbier, A. J. J. A. (2009). Cognitive apprenticeship in clinical practice: Can it stimulate learning in the opinion of students? Advances in Health Sciences Education, 14(4), 535–546. Steering Committee for the Review of Government Service Provision (SCRGSP). (2005). Overcoming indigenous disadvantage: Key indicators 2005, SCRGPS, productivity commission. Canberra, ACT: Author. Vines, R. (2011). Equity in health and wellbeing: Why does regional, rural and remote Australia matter? In Psych. Retrieved from Australian Psychological Society website: http://psychology.org.au/Content.aspx?ID=3960 Wertenberger, S., Yerardi, R., Drake, A. C., & Parlier, R. (2006). Veterans health administration office of nursing services exploration of positive patient care synergies fuelled by consumer demand: Care coordination, advanced clinic access, and patient self-management. Nursing Administration Quarterly, 30(2), 137–146. Wolff, J. L., & Boult, C. (2005). Moving beyond round pegs and square holes: Restructuring Medicare to improve chronic care. Annals of Internal Medicine, 143(6), 439–445. Woolley, N. A., & Jarvis, Y. (2007). Situated cognition and cognitive apprenticeship: A model for teaching and learning clinical skills in a technologically rich and authentic learning environment. Nurse Education Today, 27(1), 73–79. Received 28 July 2014
Accepted 14 November 2014
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