Int J Emerg Med (2010) 3:271–278 governed at the State rather than Federal level. Conse- quently, scope of practice and clinical governance guide- lines for NPs vary between jurisdictions. In general, these frameworks provide a decision making guide for NPs to determine their own scope of practice. Other barriers to role acceptance included lack of aware- ness of clinical governance structures and lack of support by hospital administration. While these concerns are not new [16], the widespread acceptance and successful implementa- tion of the NP role within EDs will necessitate that these issues be addressed. The resolution of these matters in a unified manner may require a closer working relationship between government, hospitals and professional bodies. Since the completion of this study, legislative amendments have been enacted which now require NPs to collaborate with medical practitioners to ensure effective continuity of care [25]. This may have some impact on the issue of clinical governance, but it is at least likely to improve the clinical interaction of emergency doctors and NPs. One concern regarding the NP role was the impact of NPs on junior medical staff educational opportunities. The educational opportunities of junior medical officers may already be limited by the anticipated influx of medical graduates which will peak in 2012; this is expected to result in competition for low acuity clinical cases and supervision [22]. Results of one review suggested that 25–70% of work undertaken by doctors could be completed by nurses [26]. While this review was not limited to studies completed in the ED, it does suggest that a large part of what doctors do could be completed by NPs. Many respondents remarked on the scope and appropriateness of practice of NPs working in EDs, particularly specific tasks that were or were not suitable. There has been an implicit expectation that NPs working as doctor substitutes will produce economic savings due to lower salary costs [24]. Economic savings are inherently linked to the funding model in place. While a large disparity in the salary of doctors and NPs working internationally may exist, the salary of NPs in Australia exceeds that of the junior doctor. Although some inter- viewees perceived NPs as a good investment, others opposed this view. For several interviewees, NP were deemed a worthwhile investment given that there is less turnover compared to doctors rotating through departments. While the perceptions of NPs by medical staff are important to the implementation of the NP role, the greatest threat to the sustainability of the role may be the unmet needs of NPs. Several interviewees suggested that the career progres- sion or structure of the NP role requires careful consider- ation if morale of NPs is to be maintained. More specifically, several respondents were concerned that the restrictive nature of the NP role can result in a high level of 277 task repetition. Although barriers to longevity of NPs in the ED have been raised by medical participants of this study, further exploration of factors affecting the sustainability of NPs within the ED are likely to be best clarified by studying the NPs themselves. Further, the educational and supervisory needs of NPs should not be underestimated. Clarification of clinical governance structures together with an educational programme that integrates NPs into both the nursing and medical disciplines is warranted. Conclusion With National Health Care reform on the agenda, and concerns regarding the anticipated impact on EDs of both the workforce shortage and the influx of medical graduates designed to address it, it is time to consider alternate ways of increasing the capacity of EDs to meet demand. The ED NP role has been suggested as a key strategy and is supported at Government level. The NP role is perceived internationally as being an integral component of the health workforce. While several qualitative comments from our study support this view, our quantitative data indicate several barriers to the ED NP role being viewed positively. While these findings require confirmation through a large- scale study, they point to a need to better define the ED NP role and address organisational and attitudinal barriers to their acceptance. Acknowledgements This study was supported by the Common- wealth of Australia Department of Health and Ageing. Conflicts of interest None. References 1. Australian Medical Association (2008) AMA submission to the National Health and Hospitals Reform Commission. http://www. ama.com.au/node/5654. Accessed Jul 2008:20–21 2. Australian Medical Association (2008) AMA position statement: health workforce reform. http://www.amawa.com.au/industrial/ policies/2008_workforce.pdf. Accessed 13 Jul 2008 3. Cameron P, Campbell D (2003) Access block: problems and progress. Med J Aust 178:99–100 4. Commonwealth of Australia, Department of Health and Ageing (2009) 2009–10 health and ageing portfolio budget. http://www. health.gov.au/budget2009. Accessed 3 Dec 2009 5. Queensland Labor (2009) Upgrades and nurse practitioners to break hospital bottlenecks. http://queenslandlabor.org/01_cms/ details.asp?ID=494. Accessed 3 Dec 2009 6. Commonwealth of Australia, Department of Health and Ageing (2009) Improving the Katherine hospital emergency department. http://www.health.gov.au/internet/ministers/publishing.nsf/ Content/mr-yr09-ws-ws009.htm. Accessed 21 Dec 2009