276 Themes 6: economic benefits and consequences Although some interviewees thought that having NPs in the ED was a good investment, others opposed this view. For example: “We are way behind in this regard, they are cheap and good, the government should embrace them as they are great for fast track and other core services”. “A nurse initiated and government supported beat up. I don’t think they have an enormous benefit, they demand a lot of money and divide nurses into two camps”. “They need to be considered as substitutes for doing the jobs of doctors. The problem we have here is that they are on the nursing budget and roster and included on the nursing numbers on a shift basis, so we had to close cubicles when they were on. They were considered nurses for the purpose of rostering and we did not always have a fast track nurse when they were on. But they do doctors’ things so we have had to change this so they really have to be considered as a substitute role for a number of medical duties rather than as a nursing job—they are a great asset”. “A very simple philosophy, when docs do more training we are rewarded with money and credibility. NPs have to pay for their own training and they have more responsibility, they may enjoy their additional responsibility but the hosp should sponsor them, they should not have to pay to for the hospital’s capacity problems. I would fund them and make them stay for a long time—it would be an $100 k investment”. “They are more expensive than a resident, they may well be better in some skills but there will always be parts of the diagnostic skill mix which they won’t have and may very well decrease exposure to things that a resident can give”. “To say that you can substitute with a junior officer is wrong in practice, it is more expensive in terms of economy and it significantly affects exposure to education for junior docs especially for exposure to minor injuries so the focus is completely wrong”. Theme 7: alternative roles suggested A minority of interviewees suggested alternative roles or models given the current workforce shortages. For example: “The other group of people which we are keen on is physicians assistants, QLD is trailing this. These things are all to do with streamlining service provision”. Int J Emerg Med (2010) 3:271–278 “Other nursing roles such as physicians assistants should be explored”. Theme 8: perceived value of NP role Some participants offered brief responses indicative of positive regard for the NP role. For example: “The are excellent” “A great asset” “An important and effective role” Discussion The shortage in the Australian medical workforce is particularly evident at the level of EDs which act as the gateway to the health service. The demographic profile of FACEMs is getting older as emergency physicians are ageing, Fellows are retiring faster than numbers can be replenished [18] and although numbers of Australia-based trainees is approaching that of Fellows (781 trainees, 1,064 Fellows in Australia at 26 November 2009, personal communication Jennifer Freeman, CEO ACEM), the rate of drop out from training programmes is high [18]. Although an increase in medical school places may go some way to address this concern, this increase may not produce a corresponding increase in consultant numbers for some time. A solution to the shortfall may be NPs. There is Federal and State support for the role of NPs [4–7] and some have claimed that demand for doctors may be reduced with increased availability of NPs [16]. Whether NPs should be considered doctor substitutes or doctor supple- ments is, however, an area of contention. We present data regarding the perceptions of the NP role by doctors working in EDs across Australia. Our results suggest mixed feelings toward the NP role with substantial resistance to NPs undertaking some of the work typically seen as being the domain of doctors. This is despite evidence demonstrating similar levels of health outcomes and resource use to doctors in primary care [24], improved key performance indicators (KPIs) and increased patient satisfaction in the ED setting [8–14]. While turf wars are one explanation for this resistance, another may simply be the lack of role delineation and definition, a common perception of respondents in this study. By contrast to the UK and other first world health systems, Australia has lagged behind in shifting the provision of care from doctors to nurses through the use of NPs. Thus it is logical to expect a lag in the clarity of the NP role in the Australian ED. The Australian health system is presently