A study of macro-, meso- and micro-barriers and enablers affecting extended scopes of practice: the case of rural nurse practitioners in Australia

BackgroundShortages of skills needed to deliver optimal health care in rural and remote locations raises questions about using extended scopes of practice or advanced practice models in a range of health professions. The nurse practitioner (NP) model was introduced to address health service gaps; however, its sustainability has been questioned, while other extended scope of practice roles have not progressed in Australia. This study aimed to explore the experiences and perceptions of NPs and their colleagues about barriers to and enablers of extended scope of practice and consider the relevance of the findings to other health professions.MethodsSemi-structured, in-depth interviews were conducted with primary, nurse practitioner informants, who were also invited to nominate up to two colleagues, as secondary informants. Data analysis was guided by a multi-level, socio-institutional lens of macro-, meso- and micro-perspectives.ResultsFifteen primary informants and five colleagues were interviewed from various rural and remote locations. There was a fairly even distribution of informants across primary, aged, chronic and emergency or critical care roles. Key barriers and enablers at each level of analysis were identified. At the macro-level were legal, regulatory, and economic barriers and enablers, as well as job availability. The meso-level concerned local health service and community factors, such as attitudes and support from managers and patients. The micro-level relates to day-to-day practice. Role clarity was of considerable importance, along with embedded professional hierarchies and traditional role expectations influencing interactions with individual colleagues. Given a lack of understanding of NP scope of practice, NPs often had to expend effort promoting and advocating for their roles.ConclusionsFor communities to benefit from extended scope of practice models of health service delivery, energy needs to be directed towards addressing legislative and regulatory barriers. To be successful, extended scope of practice roles must be promoted with managers and decision-makers, who may have limited understanding of the clinical importance. Support is also important from other members of the interprofessional health care team.

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title: Legislative hegemony and nurse practitioner practice in rural and remote Australia
abstract: Nurse practitioners were introduced into Australia in 1990 to improve access to health care in isolated communities where medical doctors are scarce. The slow uptake of nurse practitioners in these areas has largely been the result of legislation not affording them access to provider numbers through the Medicare Australia Act 1973. This has denied nurse practitioners the opportunity to become primary care providers because they cannot prescribe medications and order diagnostic tests at rebated costs. Recently this Act changed, making provision for nurse practitioners. Ironically the enactment of the new legislation still prevents nurse practitioners from practicing effectively. This paper describes the discursive practices in legislation, driven by traditional power brokers, which perpetuate the traditional role of nurses as care givers and fails to support the evolution of nurse practitioners as care providers. These continued practices effectively prevent nurse practitioners from working to their potential, despite government reassurance under recent health care reform in Australia.

title: Nurse practitioners for rural and remote Australia: creating opportunities for better health in the bush.
abstract: [Extract] Controversy has dogged the introduction of nurse practitioner (NP) positions in rural and remote Australia, 
despite the need for an increase in flexible and affordable 
health-care services outside metropolitan areas. Ironically, 
it was the need for a new model of rural and remote 
health care that provided the impetus for developing the 
NP role in Australia in the late 1990s. Almost a decade 
after the first NP was authorised to practise in rural New 
South Wales, the number of endorsed NPs in rural and 
remote areas remains low relative to those practising in 
large regional and metropolitan hospitals. Indeed, the 
majority of new positions have been created in specialty 
areas of nursing.

title: Nurse practitioners as an underutilized resource for health reform: evidence-based demonstrations of cost-effectiveness.
abstract: Healthcare reform in 2009 was motivated by an imperative to reduce the relentless increase in spending on medical care. Many efforts to solve the problem focused on applying proven principles of evidence-based practice and cost-effectiveness to find the least-expensive way to produce a specific clinical service of acceptable quality. This paper combines economic analysis and reviews published literature to show how the goals of healthcare reform can be accomplished by allowing independently licensed nurse practitioners to provide their wide range of services directly to patients in a variety of clinical settings. The paper presents extensive, consistent evidence that nurse practitioners provide care of equal or better quality at lower cost than comparable services provided by other qualified health professionals.

title: The complexities of defining nurse practitioner scope of practice in the Australian context.
abstract: To explore the legislative and regulatory constraints that defines nurse practitioner scope of practice within the Australian context.



Nurse practitioners have been endorsed to practice in Australia for over 13 years. However, despite this lengthy period, there still remains confusion amongst newly endorsed nurse practitioners and their employers as to what determines the scope of their practice in Australia.



A review of available policy and regulatory documents related to the Australian operational requirements for nurse practitioner scope of practice cited within or referred to by the Nursing and Midwifery Board of Australia.



Data were collected over a 2-month period in 2013. This utilized the current standards, codes and guidelines cited by the Nursing and Midwifery Board of Australia related to scope of practice and nurse practitioner, as well as legislation and regulation referred to in relation to nurse practitioner practice. Information was also obtained through government health and professional organization websites. All information in the literature regarding current and past status, and nomenclature of advanced practice nursing was considered relevant.  Providing a means of interpreting the determinants of nurse practitioner scope of practice within Australia.



The factors that determine nurse practitioner scope of practice, education, clinical experience, and competence leading to endorsement, are straightforward. However, the context of clinical practice, including jurisdictional restrictions, is major barriers to the expression of nurse practitioner scope of practice. These restrictions, although not insurmountable, continue to hinder nurse practitioners from practicing to their full scope of practice.

title: Identifying advanced practice: A national survey of a nursing workforce.
abstract: The size and flexibility of the nursing workforce has positioned nursing as central to the goals of health service improvement. Nursing's response to meeting these goals has resulted in proliferation of advanced practice nursing with a confusing array of practice profiles, titles and roles. Whilst numerous models and definitions of advanced practice nursing have been developed there is scant published research of significant scope that supports these models. Consequently there is an ongoing call in the literature for clarity and stability in nomenclature, and confusion in the health industry on how to optimise the utility of advanced practice nursing.



To identify and delineate advanced practice from other levels of nursing practice through examination of a national nursing workforce.



A cross-sectional electronic survey of nurses using the validated Advanced Practice Role Delineation tool based on the Strong Model of Advanced Practice.



Study participants were registered nurses employed in a clinical service environment across all states and territories of Australia.



A sample of 5662 registered nurses participated in the study. Domain means for each participant were calculated then means for nursing position titles were calculated. Position titles were grouped by delineation and were compared with one-way analysis of variance on domain means. The alpha for all tests was set at 0.05. Significant effects were examined with Scheffe post hoc comparisons to control for Type 1 error.



The survey tool was able to identify position titles where nurses were practicing at an advanced level and to delineate this cohort from other levels of nursing practice, including nurse practitioner. The results show that nurses who practice at an advanced level are characterised by high mean scores across all Domains of the Strong Model of Advanced Practice. The mean scores of advanced practice nurses were significantly different from nurse practitioners in the Direct Care Domain and significantly different from other levels of nurse across all domains.



The study results show that the nurse practitioner, advanced practice nurse and foundation level registered nurse have different patterns of practice and the Advanced Practice Role Delineation tool has the capacity to clearly delineate and define advanced practice nursing. These findings make a significant contribution to the international debate and show that the profession can now identify what is and what is not advanced practice in nursing.

title: Developing the Nurse Practitioner Role in a Rural Australian Hospital: A Delphi Study of Practice Opportunities, Barriers and Enablers
abstract: To gain a consensus view of potential roles for Nurse Practitioners (NPs) in a rural Australian hospital and identify the barriers and enablers in their development and implementation. Developing the Nurse Practitioner role in a rural Australian hospital ‐ a Delphi study of practice opportunities, barriers and enablers Design A three round Delphi study.  A rural hospital.  Twenty eight nurses, five doctors, four consumers, two health service managers, two allied health practitioners, one midwife, three community workers, two administrators and three others with hospital affiliation.  Consensus at 75% level of agreement or greater, identifying service gaps which might benefit from NPs and the barriers and enablers impacting on the success of developing and implementing the role.  Introduce mental health, aged and critical care NPs initially. Barriers and enablers identified as impacting on the development and implementation of the role were: Educational access for isolated rural nurses ‐ local cohort learning with employment contracts encompassing fee assistance and designated study time. Acceptance from doctors ‐ supported role provided the proposed service is sustainable. Small teams of NPs would achieve this. Inappropriate Recruitment ‐ NP role matching service need, not individual.  clients are best served by NPs working across the care continuum. Co funding by acute and community providers could overcome the current constraints of commonwealth/state payment.  In developing and implementing NP roles at a rural health service the issues of access to tertiary education, creating a sustainable number of NP positions and financial cooperation from community and acute providers must be taken into account. Only then can nurses who wish to take on this NP role in a rural health service have the possibility of success.

title: Outcomes associated with nurse practitioners in collaborative practice with general practitioners in rural settings in Canada: a mixed methods study
abstract: BackgroundThe formalized nurse practitioner (NP) role in British Columbia is relatively new with most roles implemented in primary care. The majority of primary care is delivered by physicians using the fee-for-service model. There is a shortage of general practitioners associated with the difficulties of recruitment and retention, particularly in rural and remote locations. The uptake of the primary care NP role has been slow due to challenges in understanding the extent of its contributions. This study aims to identify the outcomes associated with the NP role in collaborative primary care practice.MethodsThree case studies where NPs were embedded into rural fee-for-service practices were undertaken to determine the outcomes at the practitioner, practice, community, and health services levels. Interviews, documents, and before and after data, were analyzed to identify changes in practise, access, and acute care service utilization.ResultsThe results showed that NPs affected how care was delivered, particularly through the additional time afforded each patient visit, development of a team approach with interprofessional collaboration, and a change in style of practise from solo to group practise, which resulted in improved physician job satisfaction. Patient access to the practice improved with increased availability of appointments and practice staff experienced improved workplace relationships and satisfaction. At the community level, access to primary care improved for harder-to-serve populations and new linkages developed between the practice and their community. Acute care services experienced a statistically significant decrease in emergency use and admissions to hospital (P = 0.000). The presence of the NP improved their physician colleagues’ desire to remain in their current work environment.ConclusionsThis study identified the diversity of needs that can be addressed by the NP role. Namely, the importance of time to enhance patient care and its associated benefits, especially in the fee-for-service model; the value of the NP’s role in the community; the acceptance of the clinical competence of NPs by their physician colleagues; the outcomes generated at the practice level in terms of organizational effectiveness and service provision; and substantiated the impact of the role in improving primary care access and reducing acute care utilization.

title: Institutional Work to Maintain Professional Power: Recreating the Model of Medical Professionalism
abstract: The creation of new roles commonly threatens the power and status of elite professionals through the substitution of their labour. In this paper we examine the institutional work carried out by elite professionals to maintain their professional dominance when threatened. Drawing on 11 case sites from the English National Health Service (NHS) where new nursing or medical roles have been introduced, threatening the power and status of specialist doctors, we observed the following. First, the professional elite respond through institutional work to supplant threat of substitution with the opportunity for them to delegate routine tasks to other actors and maintain existing resource and control arrangements over the delivery of services in a way that enhances elite professionals’ status. Second, other professionals outside the professional elite, but relatively powerful within their own professional group, are co-opted by the professional elite to engage in institutional work to maintain existing arrangements. Our work extends Lawrence and Suddaby’s typology of institutional work in three ways. First, we reveal how different types of institutional work interact, and how different types of institutional work cross categories of creating or maintaining institutions. Second, we show how an actor’s social position or status, both intra-professionally as well as inter-professionally, in the institutional field frame the institutional work they engage in. Third, the institutional work of ‘theorizing’ by professional elites appears particularly significant, specifically the focus of the institutional work to invoke the concept of ‘risk’ associated with any change in service delivery, which maintains the model of medical professionalism.

title: Access All Areas: New Solutions for GP Shortages in Rural Australia
abstract: Shortages of GP services have a big impact. When people can’t see a GP, they get sick with conditions that could be prevented. This is costly for the health system and for individuals. Many parts of Australia have too few GP services. The number of services per person in the lowest-access rural areas is less than half that of the major cities. These gaps affect a significant proportion of the population. More than a million people, one in 20 Australians, live in the seven under-served rural areas discussed in this report – in places such as Tamworth, Goulburn and Mt Isa, as well as the Northern Territory and most of Western Australia. The problem has been around for generations. Successive policies have tried to fix it, but they have only solved the easiest problems by bringing GPs to inner regional centres, not to the areas with the greatest need. Many of the worst shortages have remained stubbornly high for decades, when the worst problems should be fixed first. At current rates of improvement, it would take more than 65 years for very remote areas of Australia to catch up to the levels of GP services that the big cities have today. Current responses – such as training more doctors, or paying them bonuses to move to rural areas – haven’t done enough. More of the same won’t fix the problem. We need new solutions that do more than tinker with the system. This report outlines a plan for the parts of rural Australia with the lowest access to GP services. We don’t aim to bring these areas up to the national average, just to end the most extreme shortages. To achieve this, we have to make the most of scarce resources, while keeping GPs at the centre of the system. The first step is to make much better use of pharmacists’ skills. Pharmacists are highly trained, have deep expertise in medicines, and are located in communities throughout Australia. But their role is far more limited in Australia than in many other countries. With the agreement of GPs and patients, pharmacists should be able to provide repeat prescriptions to people with simple, stable conditions. They should also be able to provide vaccinations and to work with GPs to help patients manage chronic conditions. We also need to increase access to other services, including diagnosis, which currently only GPs can provide. Australia should introduce physician assistants, health workers who practise medicine under the supervision of a doctor. There is good evidence that physician assistants could expand the care available in under-served areas, without compromising quality or safety, and at an affordable cost. The proposals in this report only apply to the seven rural areas with the worst shortages of GP services. They can be in place within five years. In 2011-12, they would have resolved the worst shortages for just $30 million. The costs would mostly have been offset by fewer, or less costly, hospitalisations as a result of better population health. Too many people have waited too long to get primary care. But the solution is surprisingly achievable, if we’re willing to adopt new responses to an old problem.

title: Descriptive, cross-country analysis of the nurse practitioner workforce in six countries: size, growth, physician substitution potential
abstract: Many countries are facing provider shortages and imbalances in primary care or are projecting shortfalls for the future, triggered by the rise in chronic diseases and multimorbidity. In order to assess the potential of nurse practitioners (NPs) in expanding access, we analysed the size, annual growth (2005–2015) and the extent of advanced practice of NPs in 6 Organisation for Economic Cooperation and Development (OECD) countries.  data analysis of national nursing registries, regulatory bodies, statistical offices data as well as OECD health workforce and population data, plus literature scoping review.  NP and physician workforces in 6 OECD countries (Australia, Canada, Ireland, the Netherlands, New Zealand and USA). Primary and secondary outcome measures The main outcomes were the absolute and relative number of NPs per 100 000 population compared with the nursing and physician workforces, the compound annual growth rates, annual and median percentage changes from 2005 to 2015 and a synthesis of the literature on the extent of advanced clinical practice measured by physician substitution effect.  The USA showed the highest absolute number of NPs and rate per population (40.5 per 100 000 population), followed by the Netherlands (12.6), Canada (9.8), Australia (4.4), and Ireland and New Zealand (3.1, respectively). Annual growth rates were high in all countries, ranging from annual compound rates of 6.1% in the USA to 27.8% in the Netherlands. Growth rates were between three and nine times higher compared with physicians. Finally, the empirical studies emanating from the literature scoping review suggested that NPs are able to provide 67–93% of all primary care services, yet, based on limited evidence.  NPs are a rapidly growing workforce with high levels of advanced practice potential in primary care. Workforce monitoring based on accurate data is critical to inform educational capacity and workforce planning.

title: Reframing professional boundaries in healthcare: a systematic review of facilitators and barriers to task reallocation from the domain of medicine to the nursing domain.
abstract: To explore the main facilitators and barriers to task reallocation.



One of the innovative approaches to dealing with the anticipated shortage of physicians is to reallocate tasks from the professional domain of medicine to the nursing domain. Various (cost-)effectiveness studies demonstrate that nurse practitioners can deliver as high quality care as physicians and can achieve as good outcomes. However, these studies do not examine what factors may facilitate or hinder such task reallocation.



A systematic literature review of PubMed and Web of Knowledge supplemented with a snowball research method. The principles of thematic analysis were followed.



The 13 identified relevant papers address a broad spectrum of task reallocation (delegation, substitution and complementary care). Thematic analysis revealed four categories of facilitators and barriers: (1) knowledge and capabilities, (2) professional boundaries, (3) organisational environment, and (4) institutional environment.



Introducing nurse practitioners in healthcare requires organisational redesign and the reframing of professional boundaries. Especially the facilitators and barriers in the analytical themes of 'professional boundaries' and 'organisational environment' should be considered when reallocating tasks. If not, these factors might hamper the cost-effectiveness of task reallocation in practice.

title: Lords of the Dance: Professionals as Institutional Agents
abstract: More so than other types of social actors, the professions in modern society have assumed leading roles in the creation and tending of institutions. They are the preeminent institutional agents of our time. Different professions work in various ways: some attempt to create general cultural-cognitive frameworks; others to devise normative prescriptions to guide behavior; and still others to exercise coercive authority. Also, individual professionals assume varying roles within their professional community: some concentrate on devising and testing general principles, others transport these ideas to varying communities; and still others work to apply the principles to individual cases. Professions themselves adhere to an institutional model, but this model has undergone important changes over time.

title: What Are Institutions
abstract: A primary aim of this paper is to establish some workable meanings of key terms of institutional theory including institution, convention and organization, by drawing on insights from several academic disciplines. Institutions are defined broadly as systems of established and prevalent social rules that structure social interactions. This, in turn, prompts some examination of the concept of a rule, and why rules are followed. The author discusses some general issues concerning how institutions function and how they interact with individual agents, their habits, and their beliefs. The paper also addresses the controversial distinction between institutions and organizations. D. North’s influential formulations of these terms are criticized for being incomplete and misleading. The author examines this distinction and what may be meant by the term formal when applied to institutions or rules. Here an organization is treated as a type of institution involving membership and sovereignty. Further types of institution are also considered, including the difference between self-organizing and other institutions. The article identifies an excessive bias in the discussion of institutions toward those of the self-organizing type, showing theoretically that these are a special case. The author argues that institutions also differ with regard to their degree of sensitivity to changes in the personalities of the agents involved.

title: Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory
abstract: In the third edition of the classic text, Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory, Juliet Corbin continues to present the basics of grounded theory in the context of an evolving world of qualitative research. In doing so she is able to share the traditional essences of the method as put forth in the first two editions while weaving in contemporary changes resulting from her reflections on emergent method, methodology, theory, and who she has become as a researcher

title: ‘Gearing Up’ to improve interprofessional collaboration in primary care: a systematic review and conceptual framework
abstract: BackgroundInterprofessional Primary Care Teams (IPCTs) have been shown to benefit health systems and patients, particularly those patients with complex care needs. The literature suggests a wide range of factors that may influence collaboration in IPCTs, however the evidence base is unclear for many of these factors. To target improvement efforts, we identify studies that demonstrate an association between suggested factors and collaborative processes in IPCTs.MethodsA systematic review of 25 years of peer-review literature was conducted to identify studies that test associations between policy, organizational, care team and individual factors, and collaboration in IPCTs. We searched Medline, ProQuest subject, ProQuest abstract, CINAHL, HealthSTAR, and Embase electronic databases between January 1990 to June 2015 and hand-searched reference lists of identified articles.ResultsThe electronic searches identified 1421 articles, nine of which met inclusion criteria.Eighteen factors were significantly associated with collaboration in at least one article.We present the findings within a proposed conceptual model of interrelated ‘gears’. The model offers a taxonomy of factors that policy makers (macro gear), organizational managers (meso gear), care teams (micro gear) and health professionals (individual gear) can adjust to improve interprofessional collaboration in IPC teams. Thirteen of the eighteen identified factors were within the micro gear, or team level of decision-making. These pertained to formal processes such as quality audits and group problem-solving; social processes such as open communication and supportive colleagues; team attitudes such as feeling part of the team; and team structure such as team size and having a collaboration champion or facilitator. Fewer policy (eg governance), organizational (eg information systems, organizational culture) or individual (eg belief in interprofessional collaboration care and personal flexibility) level factors were identified.ConclusionsThe findings suggest that individual IPCTs have opportunities to improve collaboration regardless of the organizational or policy context within which they operate. Evidence supports the importance of having a team vision and shared goals, formal quality processes, information systems, and professionals feeling part of the team. Few studies assessed associations between collaboration and macro and meso factors, or between factors across levels, which are priorities for future research.

title: Barriers and enablers to advanced practitioners' ability to enact their leadership role: A scoping review.
abstract: Advanced roles such as nurse practitioner, nurse consultant and advanced nurse or midwife practitioner are increasing across the world. In most countries, clinical practice, education, leadership and research are the four components that define the advanced practitioner's role. Of these, leadership is perhaps the most important part of the role, but its study has largely been neglected. There is a risk that failure to identify and respond to barriers to enacting the advanced practitioners' leadership role will limit the extent to which they can become strategic leaders for professional development, and jeopardise the long-term sustainability of the role.



To identify the barriers and enablers to advanced practitioner's ability to enact their leadership role.



A search of the research literature was undertaken in electronic databases (PubMed, CINAHL, PsycINFO, ProQuest Dissertation and Theses, from inception to 4-6th June 2015), unpublished research in seventeen online research repositories and institutes, and hand search of 2 leadership journals (March/April 2010-4th June 2015).



Using pre-set inclusion criteria, the 1506 titles found were screened by two authors working independently. The 140 full text reports selected were reviewed by two authors separately and 34 were included, and data extracted and cross-checked. Any disagreements were discussed by the scoping team until consensus was reached. Using content analysis, the barriers and enablers relating to leadership enactment were sorted into themes based on their common characteristics, and using a Structure-Process-Outcome conceptual framework were categorised under the four structural layers: (1) healthcare system-level, (2) organisational-level, (3) team-level, and (4) advanced practitioner-level.



Thirteen barriers to, and 11 enablers of, leadership were identified. Of these a majority (n=14) were related to organisational-level factors such as mentoring, support from senior management, opportunity to participate at strategic level, structural supports for the role, and size of clinical caseload. Advanced practitioner-level factors relating to personal attributes, knowledge, skills and values of the advanced practitioner were identified.



Although building leadership capabilities at advanced practitioner-level and team-level are important, without key inputs from healthcare managers, advanced practitioners' leadership enactment will remain at the level of clinical practice, and their contribution as change agents and innovators at the strategic level of service development and development of the nursing profession will be not be realised.

title: Collaborative arrangements for Australian nurse practitioners: A policy analysis
abstract: In Australia in 2010, nurse practitioners (NPs) were granted legislated access to the Medical Benefits Scheme (MBS) and Pharmaceutical Benefits Scheme (PBS) as providers. These schemes are the federal schemes for third‐party reimbursement for health care and medications. As a condition of access to the schemes, it was determined that collaborative arrangements needed to be in place as part of eligibility criteria for NPs. This article is the first published policy analysis of this determination. Data sources Published literature and available grey literature (including meeting minutes), and media content, was accessed and analyzed.  The policy that was the National Health Collaborative arrangements for Nurse Practitioners Determination to amend the Australian National Health Act 1953 was a success. The policy led to NP access as providers to the MBS and PBS in Australia. Implications for practice Understanding the policy process as it relates to the determination of the need for collaborative arrangements demystifies the process and origins of the policy for NPs in Australia. Understanding the determination means NPs in Australia will not artificially reduce scope of practice based on recommendations from the medical lobby. Clear research direction is provided that may inform the next policy cycle.

title: The internationally present perpetual policy themes inhibiting development of the nurse practitioner role in the primary care context: An Australian–USA comparison
abstract: This paper plots international evidence of nurse practitioner efficacy, cost and quality against identification and discussion of barriers of nurse practitioner practice reported in the Australian and United States of America primary care contexts. It is identified that the evidence for the full utilisation of nurse practitioners as an integrated part of health service management internationally is strong, yet significant barriers remain to this happening in both countries. The barriers discussed remain consistent across time despite the evidence that has emerged. This phenomenon of consistent barriers, despite evidence of nurse practitioner efficacy, reasonable cost, and high quality is discussed as a clear example of where evidence alone is not enough to change policy.

title: Nurse practitioner roles in Australian healthcare settings.
abstract: There is evidence of support for nurse practitioner (NP) roles in national and international literature. However, despite this, and numerous Australian government feasibility and evaluation studies, barriers to implementing NP roles in mainstream health care and developing them to their full potential remain. A study was undertaken to explore nurse practitioners', managers' and nurse policymakers' perceptions of the roles in general, and this article reports on the findings from the initial survey phase. The article also discusses barriers to full integration and development of NPs.

title: Advanced roles for nurses working in general practice: A study of barriers and enablers for nurses in rural Australia
abstract: Rural Australians have poorer access to health services than Australians living in metropolitan areas primarily because of shortages in the health professional workforce. Nurses taking on advanced skills could help this situation by relieving doctors but our understanding of the factors that enhance or inhibit uptake is poorly understood in rural areas of Australia. The aim of this study is to identify the barriers and enablers associated with the implementation of advanced nursing roles in rural general practice specifically although an urban general practice was included to ensure that the diversity of practices were represented. The selection of general practices was based on ( 1 ) . a standardised classification system that uses geographic location and population base as the key criterion and ( 2 ) . ease of access for the research team. The general practices were all located within 3 hours drive of the researchers’ home base. Using case study design four rural and one metropolitan located general practices were included. The researchers compared recorded nursing activities with job descriptions, educational opportunities and advanced competency standards. Interviews with practice principals, practice managers and nurses were undertaken. Findings are categorised as: personal which includes motivation, knowledge and time; workplace which includes status, guidelines and practice conventions and routines; and policy which includes national payment systems, and scope of practice. The potential for nurses to advance their practice and meet the needs of patients, particularly in the specialist areas of chronic care and health promotion, is still under developed in the rural practices. The findings have led to the development of a framework for the introduction of advancing practice roles for nurses that will meet the needs of a currently, under-served community.

title: An investigation of barriers and enablers to advanced nursing roles in Australian general practice.
abstract: Over the past decade, there has been substantial increase in nurses' roles in primary health care, particularly in general practice settings. Simultaneously, there has been an expansion of advanced roles for nurses across a range of clinical environments. This paper draws upon findings from a study that sought to develop a framework to support development of advanced nursing roles in general practice. It presents findings from one part of that study that explored barriers and facilitators to the development of these roles. Twenty-three key leaders from nursing, general practice and professional organisations participated in semi-structured interviews. Data were analysed using thematic analysis. A range of factors was identified as key to developing advanced roles in general practice. These included increasing awareness and attractiveness of practice nursing, health reform activities, practice limitations, education and professional development. Understanding complex systems and workforce issues is required to promote active intervention that can facilitate development of advanced nursing roles in Australian general practice.

title: Medical workforce issues in Australia: “tomorrow's doctors — too few, too far”
abstract: Medical workforce issues in Australia: “tomorrow’s doctors — too few, too far” William J Glasson, Robert A Bain 556 Could it be sarcoid arthritis? Francisco J Ruiz-Ruiz, Fernando J Ruiz-Laiglesia, Juan I Perez-Calvo, Carmen B Torrubia-Perez 556 Cardiovascular risk among urban Aboriginal people Zhiqiang Wang, Wendy E Hoy 557 Peter L Thompson, Pamela J Bradshaw, Margherita Veroni, Edward T Wilkes 557 A comparison of buprenorphine treatment in clinic and primary care settings: a randomised trial John R M Caplehorn 557 Amy E Gibson 558 Troponin testing: an audit in three metropolitan hospitals Paul M Bailey 558 Richard X Davey 559 Pneumococcal meningitis masquerading as subarachnoid haemorrhage Lloyd K Morgan 559 Taposh Chatterjee, John R Gowardman, Tony D Goh 560 Dosing information for paediatric patients: are they really “therapeutic orphans”? Amanda J Caswell 560

title: Health workforce design for the 21st century.
abstract: The Australian health workforce has changed dramatically over the last 4 years, growing in size and changing composition. However, more changes will be needed in the future to respond to the epidemiological and demographic transition of the Australian population. A critical issue will be whether the supply of health professionals will keep pace with demand. There are current recorded shortages of most health professionals, but this paper argues that future workforce planning should not be based on providing more of the same. Rather, the roles of health professionals will need to change and workforce planning needs to place a stronger emphasis on issues of workforce substitution, that is, a different mix of responsibilities. This will also require changes in educational preparation, in particular an increased emphasis on interprofessional work and common foundation learning.

title: Unlocking skills in hospitals: better jobs, more care
abstract: Enabling less highly-trained hospital workers to play a bigger role could improve jobs for doctors and nurses, save public hospitals nearly $430 million a year and fund treatment for more than 85,000 extra people, argues this report. Overview Hospitals are under pressure. They face rising demand, a squeeze on funding and skills shortages in key areas. They have to change. One problem is that too many health professionals squander their valuable skills on work that other people could do. In most cases, it doesn’t take 15 years of post-school training to provide light sedation for a stable patient having a simple procedure. Nor does it take a three-year degree to help someone bathe or eat. But tradition, professional culture and industrial agreements often dictate that highly-trained health professionals spend their time doing straightforward work. This wastes money, makes professional jobs less rewarding and often does not improve care. There are many ways that hospitals can get a better match between workers and their work. This report looks at three examples. The first is using more nursing assistants to provide basic care to patients. The second is letting specialist nurses do common, low-risk procedures currently done by doctors. The third is employing more assistants to support physiotherapists and occupational therapists. These changes can maintain or improve the safety and quality of care. They are among the easiest to take up. Hospitals don’t have to be reorganised or new professions created. They would save public hospitals $430 million a year. That could fund treatment for more than 85,000 extra people. These ideas are supported by solid evidence. They have been tried successfully in Australia, with good results for patients. Hospital CEOs we surveyed for this report strongly support them. Despite all this, progress is painfully slow. Formidable barriers in the form of regulations, culture, tradition and vested interests stand in the way. We need a new mechanism to overcome these barriers – a way to get from isolated trials to broad change. Creating that mechanism is even more important than the examples in this report. People may disagree with specific examples. But no-one can argue that all hospital work is done by the right person, or that a good way currently exists to get change throughout the system. Two things are needed. Hospitals, regulators and professional bodies must improve rules and regulations. State governments must invest money and expertise in spreading good practices. If we don’t update workforce roles, there will be a cost. Hospitals already struggle to provide enough care. Waiting lists are long and demand is growing fast. It’s hard to keep some hospital workers in their jobs. Government budgets are also under pressure. If action isn’t taken to make hospitals more efficient, tougher decisions about who will miss out on care are inevitable. Current workforce roles were designed in the days of the horse and buggy. The choice to update them should be easy. It means more and better care, more rewarding jobs for hospital professionals and a more sustainable system.

title: Perceived barriers to the sustainability and progression of nurse practitioners.
abstract: In 1998 in Victoria, Australia, the Nurse Practitioner (NP) model was considered with projects exploring the potential for NP implementation in emergency departments (EDs).



The aim of this study is to explore the perceived barriers to progression and sustainability of the NP role in Victoria. A survey of the 17 EDs involved in the initial projects was undertaken targeting NP candidates, nurse managers and project officers. A total of 48 individuals were identified and contacted. The survey comprised of demographic details and statements about NP role sustainability and progression using a Likert scale



A total of 37 participants (77%) completed the survey. Participants strongly agreed that there were barriers to sustainability, especially lack of ongoing funding from their own organisation and external sources. Other barriers included a lack of understanding from the organisation and medical staff about the role. The main barriers to role progression were the legislative constraints (n=29, 78%) and the cost of Masters programmes (n=29, 78%)



This survey revealed a myriad of barriers to role sustainability and progression. These barriers need to be explored and progressed if the NP role is to continue to develop and expand.

title: How has the profile of Australian nurse practitioners changed over time?
abstract: To examine longitudinal changes in the profile of Australian nurse practitioners surveyed in both 2007 and 2009 ('resurveyed respondents') and to determine differences between nurse practitioners who completed the census only in 2009 ('new respondents') and resurveyed respondents.



The nurse practitioner role is integral to the development and sustainability of advanced practice roles in healthcare systems. However, its success depends upon support from policy makers, health services and nursing. A census of Australian nurse practitioners previously was conducted in 2007 to obtain national data on the role and scope of practice of nurse practitioners in Australia.



A quantitative self-administered survey.



Questionnaires were sent to all authorised Australian nurse practitioners in 2009.



A total of 408 surveys were administered with 293 questionnaires completed (response rate 76.3%). Of these, 49% of participants also had completed the 2007 survey. There were no differences in the limitations and enablers identified in 2007 compared to 2009, indicating that perceived barriers had not been addressed over time, nor had there been substantial improvements. New respondents were more likely to have worked as a nurse practitioner in the previous week (p < 0.004). There was a significant increase in the number of nurse practitioners waiting on approval for some or all clinical protocols (p = 0.024).



Conditions enabling work to full scope of practice continue to be perceived as suboptimal by Australian nurse practitioners. Supportive strategies are needed to enable the role to be effectively utilised.

title: Health managers and health reform
abstract: This qualitative study was undertaken with a diverse sample of Australian health managers to exam- ine their perceptions regarding the health system and to understand how they learned to become health manag- ers. The fi ndings showed that they viewed the health system as one of constant change, mostly non-adaptive, and a system of parts controlled by bureaucrats and political interests. While the respondents enjoyed their managerial role, they see it as contested between the professions. This study concluded that greater emphasis on the education and train- ing of health managers and their continuing professional development is required if they are to manage increasingly complex, dynamic and changing health systems. In Australia, the health debate continues with the recently announced national health reform agenda. The perceptions of health managers in health reform and change management are impor- tant given that they are said to be central to the implementation of health reform and the management of change. n Australia, the health debate continues with the recently implemented national health reform agenda. The perceptions of health managers in health reform and change management are important given that they are said to be central to the implementation of health reform and the management of change. Given the central role of health managers in implementing health reform, this study through an interpretivist phenomenological approach describes the perceptions of a diverse range of Australian and New Zealand health managers about the health system in which they are engaged and about their role as health managers. This article traverses the history and context of health care reform in Australia, describes studies and theories relevant to the managerial role and managing health care organisations. It describes the methods utilised in this study. It presents the results of the reality of the perceptions of this group of health managers as perceiving the health system as one of constant change, contested roles, their career journey and their solutions to address- ing the challenges they face. The implications and limitations of this study are then presented.

title: Six principles to enhance health workforce flexibility
abstract: AbstractThis paper proposes approaches to break down the boundaries that reduce the ability of the health workforce to respond to population needs, or workforce flexibility.Accessible health services require sufficient numbers and types of skilled workers to meet population needs. However, there are several reasons that the health workforce cannot or does not meet population needs. These primarily stem from workforce shortages. However, the health workforce can also be prevented from responding appropriately and efficiently because of restrictions imposed by professional boundaries, funding models or therapeutic partitions. These boundaries limit the ability of practitioners to effectively diagnose and treat patients by restricting access to specific skills, technologies and services. In some cases, these boundaries not only reduce workforce flexibility, but they introduce inefficiencies in the form of additional clinical transactions and costs, further detracting from workforce responsiveness.Several new models of care are being developed to enhance workforce flexibility by enabling existing staff to work to their full scope of practice, extend their roles or by introducing new workers. Expanding on these concepts, this theoretical paper proposes six principles that have the potential to enhance health workforce flexibility, specifically:1. Measure health system performance from the perspective of the patient.2. Minimise training times.3. Regulate tasks (competencies), not professions.4. Match rewards and indemnity to the levels of skill and risk required to perform a particular task, not professional title.5. Ensure that practitioners have all the skills they need to perform the tasks required to work in the environment in which they work6. Enable practitioners to work to their full scope of practice delegate tasks where requiredThese proposed principles will challenge some of the existing social norms around health-care delivery; however, many of these principles are already being applied, albeit on a small scale. This paper discusses the implications of these reforms.Proposed discussion points1. Is person-centred care at odds with professional monopolies?2. Should the state regulate professions and, by doing so, protect professional monopolies or, instead, regulate tasks or competencies?3. Can health-care efficiency be enhanced by reducing the number of clinical transactions required to meet patient needs?

title: Medical acceptance of the nurse practitioner role in Australia: A decade on
abstract: In Australia, nurse practitioners (NPs) were first endorsed in 2000. After more than a decade, the number of NPs remains relatively small with previous research suggesting medical resistance as a key reason for this. This article presents a selection of narratives from a study that explored the transition experiences of newly endorsed NPs with particular attention to relationships with their medical colleagues. 
 
 
A critical ethnographic approach was undertaken to explore the experiences of 10 Australian NPs who were interviewed three to four times for up to an hour throughout their first year of practice. 
 
 
Participants’ narratives provide insight into their transition to practice and the barriers and facilitators to their new role. In contrast to previous research, medical colleagues were generally supportive and collegial while resistance was demonstrated most often by senior nurses yielding positions of power. 
 
Implications for practice 
This study provides insight into the influences that key health professionals have over the transition of NPs. Despite the fact there are still negative attitudes being expressed by some medical associations, in this study medical colleagues were largely supportive of the NP role and that integral to the development of these interprofessional relationships was mutual respect and effective communication.

title: Interprofessional practice and professional identity threat
abstract: The implementation of interprofessional practice (IPP) within healthcare appears to be fraught with difficulties, despite the attention it has received in the literature. Although there are examples where IPP has reaped significant benefits, it has also been shown to impede team performance. We demonstrate that a key cause of failure in IPP can be attributed to interprofessional conflicts based on threats to professional identity, and provide insight into how professional identity faultlines have the potential to be activated and conflict induced when there is differential treatment of professional groups, different values between professions, assimilation, insult or humiliating action and simple contact within the team. This has significant implications for the management of interprofessional healthcare teams and provides information for team leaders and health managers.

title: Nurse practitioners and medical practice: opposing forces or complementary contributions?
abstract: The medical profession in Australia has expressed concern about the expansion of nursing practice into areas that are traditionally the domain of medicine. Particular apprehension is raised in relation to the prescription of medications. This paper will consider and critique the argument that the standard of care provided by a nurse practitioner would be of lesser quality than that provided by a medical practitioner.



Despite the medical profession's opposition for nurse practitioner roles, there is little evidence suggesting that the quality of services offered by a nurse practitioner would be inferior.



Available evidence suggests that care and treatment from nurse practitioners in primary health care is equal to that provided by medical practitioners.

title: The struggle to professionalize: An ethnographic account of the occupational position of Advanced Nurse Practitioners
abstract: This article considers what happens when subordinate occupations challenge established roles and hierarchically organized professional divisions. Charting the struggles of a group of Advanced Nurse Practitioners to be recognized as a profession, the article considers the ways in which claims to licence, place and mandate are employed to negotiate new occupational spaces. Such spaces are shown to emerge as a consequence of the interplay of individual demands and favourable supply side conditions, the latter being required to support the development of new models of working in marginal positions. In a departure from accounts that place managerialism and entrepreneurialism in opposition to professionalism, the article shows how the executive authority that comes with entrepreneurial ownership can bolster professionalizing claims, disrupting and reversing hierarchically organized professional divisions. Identified as a context specific form of ordinal switching, the article considers whether such reversals herald a long-term shift in dominant—subordinate professional relations.

title: The Triumph and Continuing Struggle of Nurse Practitioners in New South Wales, Australia
abstract: Finally nurse practitioners in New South Wales, Australia, are legally recognized after more than a decade of struggle. In this article the authors provide an update on the nurse practitioner movement, including the continuing conflict with the medical profession as nursing strives to achieve full implementation and acceptance of the nurse practitioner role in New South Wales. Discussion includes nurse practitioner role legislation and authorization process. The issues and concerns expressed by the medical and nursing professions are outlined, and the authors make recommendations to strengthen and support the advanced professional role and status of nurse practitioners.

title: Spheres of influence or autonomy? A discourse analysis of the introduction of Nurse Practitioners in rural and remote Australia.
abstract: This paper is a report of a study to examine the social discourses of nursing within health care as these produce understandings about autonomy for Nurse Practitioners, where autonomy refers to the ability of Nurse Practitioners to practise as professionals in their own right.



Nurse Practitioners were recently introduced to the nursing career pathways in Australia. Despite a plethora of international information, the role implementation in rural and remote Australia is slow with a number of influences emerging to hinder progress.



Critical discourse analysis was used to examine the differences between policy and the reality of implementation. The notion of autonomy was used to explore texts in policy documents relating to Nurse Practitioner authorization and published between 1995 and 2006, and these were compared with the experiences of nurses working in Nurse Practitioner positions.



Policy texts indicate support for advanced practice and the autonomy of Nurse Practitioners. The process for authorization; however, has constraints which support nurses' progress but also hinder it. Subsequent acceptance of Nurse Practitioners has also been problematic as colleagues struggle to understand the role within the current healthcare system.



There is a significant gap between the rhetoric of policy and the implementation of Nurse Practitioner roles in rural and remote Australia. Whilst policy supports the notion of autonomy, the experiences of nurses indicate a mere shift in the traditionally-accepted boundaries of nurses' roles. Evidence from the United Kingdom and United States of America suggests that the findings in this study are relevant internationally as well as nationally.

title: How emergency nurse practitioners view their role within the emergency department: A qualitative study.
abstract: The Emergency Nurse Practitioner (ENP) role has become established over the last two decades within emergency care. This role has developed to meet the rising demands of healthcare, combat the continuing medical workforce shortfall and address targets around healthcare delivery within emergency care. The ENP role has been widely evaluated in terms of patient satisfaction, safety and outcome. To date there is no published literature exploring what drives senior nurses to undertake this role which involves additional clinical responsibility and educational preparation for no increase in pay.



This research seeks to explore how Emergency Nurse Practitioners view their role within the Emergency Department and Emergency Care Team.



A qualitative approach was utilised in order to gain greater in-depth understanding of ENPs' perspectives. A purposive sample of eight ENPs was chosen and semi-structured interviews were digitally recorded. The transcribed interviews were subjected to thematic analysis to look for any recurrent themes.



Following analysis of the data, four main themes emerged with a total of eight sub themes. The findings suggested that whilst the role had been accepted amongst doctors within the ED, there was still a lack of understanding of the role outside the ED and conflict still existed amongst junior nurses. ENPs were motivated to undertake the role in order to gain greater job satisfaction. The findings also highlighted the concerns regarding financial remuneration for the role, lack of standardisation of the role and educational preparation.



The study concludes that education has a key role in the development and acceptance of the role and that ENPs are disappointed with the lack of financial remuneration for the role.

title: The impact of nurse practitioner services on cost, quality of care, satisfaction and waiting times in the emergency department: a systematic review.
abstract: To provide the best available evidence to determine the impact of nurse practitioner services on cost, quality of care, satisfaction and waiting times in the emergency department for adult patients.



The delivery of quality care in the emergency department is emerging as one of the most important service indicators in health delivery. Increasing service pressures in the emergency department have resulted in the adoption of service innovation models: the most common and rapidly expanding of these is emergency nurse practitioner services. The rapid uptake of emergency nurse practitioner service in Australia has outpaced the capacity to evaluate this service model in terms of outcomes related to safety and quality of patient care. Previous research is now outdated and not commensurate with the changing domain of delivering emergency care with nurse practitioner services.



A comprehensive search of four electronic databases from 2006 to 2013 was conducted to identify research evaluating nurse practitioner service impact in the emergency department. English language articles were sought using MEDLINE, CINAHL, Embase and Cochrane and included two previous systematic reviews completed five and seven years ago.



A three step approach was used. Following a comprehensive search, two reviewers assessed all identified studies against the inclusion criteria. From the original 1013 studies, 14 papers were retained for critical appraisal on methodological quality by two independent reviewers and data were extracted using standardised tools.



Narrative synthesis was conducted to summarise and report the findings as insufficient data was available for meta-analysis of results. This systematic review has shown that emergency nurse practitioner service has a positive impact on quality of care, patient satisfaction and waiting times. There was insufficient evidence to draw conclusions regarding outcomes of a cost benefit analysis.



Synthesis of the available research attempts to provide an evidence base for emergency nurse practitioner service to guide healthcare leaders, policy makers and clinicians in reform of emergency service provision. The findings suggest that further high quality research is required for comparative measures of clinical and service effectiveness of emergency nurse practitioner service. In the context of increased health service demand and the need to provide timely and effective care to patients, such measures will assist in evidence based health service planning.

title: An evaluation of the implementation of Advanced Nurse Practitioner (ANP) roles in an acute hospital setting.
abstract: To evaluate the impact of implementing Advanced Nurse Practitioner roles on patients, staff members and organizational outcomes in an acute hospital.



The worldwide development of advanced practice roles in nursing has been influenced by increasing demands and costs of health care. A key issue in the UK has been the reduction in hours junior doctors can work. While there is evidence these roles can have a positive impact in a variety of clinical specialties, little is known about the impact advanced nurses substituting for junior doctors can have on patients, staff members and organizational outcomes in general hospital care settings.



Collective case study.



A collective case study in a district general hospital in England was undertaken in 2011-2012. Interviews with strategic stakeholders (n = 13) were followed by three individual case studies. Each case study represented the clinical area in which the roles had been introduced: medicine, surgery and orthopaedics and included interviews (n = 32) and non-participant observation of practice.



The ANPs had a positive impact on patient experience, outcomes and safety. They improved staff knowledge, skills and competence and enhanced quality of working life, distribution of workload and team-working. ANPs contributed to the achievement of organizational priorities and targets and development of policy.



ANPs undertaking duties traditionally performed by junior doctors in acute hospital settings can have a positive impact on a range of indicators relating to patients, staff members and organizational outcomes which are highly relevant to nursing.

title: Aged care nurse practitioners in Australia: evidence for the development of their role.
abstract: To consider evidence surrounding the emerging role of nurse practitioners in Australia with a particular focus on the provision of healthcare to older people.



Methods used included keyword, electronic database and bibliographic searches of international literature, as well as review of prominent policy reports in relation to aged care and advanced nursing roles.



This paper reports on evidence from systematic reviews and international studies that show that nurse practitioners improve healthcare outcomes, particularly for hard to service populations. It also maps out the limited Australian evidence on the impact of nurse practitioners' care in aged care settings.



If Australia is to meet the health needs of its ageing population, more evidence on the effectiveness, economic viability and sustainability of models of care, including those utilising nurse practitioners, is required.

title: The importance of supervisor-nurse relationships, teamwork, wellbeing, affective commitment and retention of North American nurses.
abstract: Using Social Exchange Theory, this study examines links between supervisor-nurse relationships, teamwork, psychological wellbeing and turnover intentions for nurses in the USA.



Nurses in the USA comprise the biggest workforce of any country in the world. However, nurses continue to be in short supply even with an aggressive campaign to attract foreign nurses. The shortage of qualified registered nurses has negative implications for patient care and mortality because it affects problem-solving and teamwork as a result of poor communication among nurses.



The study uses a cross-sectional design and 730 completed surveys were obtained using a self-report strategy.



The findings indicate that supervisor-nurse relationships, teamwork and wellbeing explain almost half of nurses' commitment to their hospital and their intentions to leave. Further, there was evidence of a generational effect in that Baby Boomer nurses perceived higher levels of wellbeing and commitment, and lower intention to leave.



These findings suggest that management must focus on improving the quality of workplace relationship as a first step in retaining skilled nurses. It may be time for management to embed performance indicators for all levels of management, linked to ensuring effective workplace relationships.

title: How leaders influence organizational effectiveness
abstract: The flexible leadership theory explains how top executives and other leaders can influence the financial performance of a business organization. Three key determinants of financial performance are efficiency, adaptation, and human capital. A wide range of leadership behaviors, management programs, structural forms, and external initiatives can be used to influence these performance determinants. Management programs and systems are usually more effective when they are mutually compatible and appropriate for the situation. Effective performance requires a cooperative effort by the multiple leaders in an organization, and they must be flexible and adaptive as the situation changes. The theory provides a way to integrate findings from several different and largely separate literatures.

title: Nurses who work in rural and remote communities in Canada: a national survey
abstract: BackgroundIn Canada, as in other parts of the world, there is geographic maldistribution of the nursing workforce, and insufficient attention is paid to the strengths and needs of those providing care in rural and remote settings. In order to inform workforce planning, a national study, Nursing Practice in Rural and Remote Canada II, was conducted with the rural and remote regulated nursing workforce (registered nurses, nurse practitioners, licensed or registered practical nurses, and registered psychiatric nurses) with the intent of informing policy and planning about improving nursing services and access to care. In this article, the study methods are described along with an examination of the characteristics of the rural and remote nursing workforce with a focus on important variations among nurse types and regions.MethodsA cross-sectional survey used a mailed questionnaire with persistent follow-up to achieve a stratified systematic sample of 3822 regulated nurses from all provinces and territories, living outside of the commuting zones of large urban centers and in the north of Canada.ResultsRural workforce characteristics reported here suggest the persistence of key characteristics noted in a previous Canada-wide survey of rural registered nurses (2001-2002), namely the aging of the rural nursing workforce, the growth in baccalaureate education for registered nurses, and increasing casualization. Two thirds of the nurses grew up in a community of under 10 000 people. While nurses’ levels of satisfaction with their nursing practice and community are generally high, significant variations were noted by nurse type. Nurses reported coming to rural communities to work for reasons of location, interest in the practice setting, and income, and staying for similar reasons. Important variations were noted by nurse type and region.ConclusionsThe proportion of the rural nursing workforce in Canada is continuing to decline in relation to the proportion of the Canadian population in rural and remote settings. Survey results about the characteristics and practice of the various types of nurses can support workforce planning to improve nursing services and access to care.