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

Abstract

The catalyst for the paper was a rapid review of the literature which identified Australian research on nurse practitioners. This paper reports on those studies investigating individual nurse practitioner roles, framed in terms of the implementation science literature and three stages of implementation: exploration and adoption of the role, initial implementation of the role, and full operation of the role.Database searching of the peer-reviewed literature was supplemented with searching relevant web sites. Most studies focused on certain aspects of the nurse practitioner role rather than undertaking a comprehensive evaluation. There was no consistency in the way the roles were described, making it difficult to compare what may be similar roles in different studies. The research generally treats the nurse practitioner role as the independent variable, rather than the care provided by the nurse practitioner. The concept of implementation fidelity was absent from all studies, except for one which addressed the issue indirectly. Many studies included little contextual information, making it difficult to judge the role of context in influencing both implementation and patient outcomes and establish plausible links between the activities of the nurse practitioners and patient outcomes.Based on the findings, a checklist is recommended for use in future studies which would enhance the ability to make judgements about implementing nurse practitioner models of care; facilitate comparison of similar roles and increase the capacity to make informed decisions about the prospects for wider implementation of nurse practitioner roles or models of care. The catalyst for the paper was a rapid review of the literature which identified Australian research on nurse practitioners. This paper reports on those studies investigating individual nurse practitioner roles, framed in terms of the implementation science literature and three stages of implementation: exploration and adoption of the role, initial implementation of the role, and full operation of the role. Database searching of the peer-reviewed literature was supplemented with searching relevant web sites. Most studies focused on certain aspects of the nurse practitioner role rather than undertaking a comprehensive evaluation. There was no consistency in the way the roles were described, making it difficult to compare what may be similar roles in different studies. The research generally treats the nurse practitioner role as the independent variable, rather than the care provided by the nurse practitioner. The concept of implementation fidelity was absent from all studies, except for one which addressed the issue indirectly. Many studies included little contextual information, making it difficult to judge the role of context in influencing both implementation and patient outcomes and establish plausible links between the activities of the nurse practitioners and patient outcomes. Based on the findings, a checklist is recommended for use in future studies which would enhance the ability to make judgements about implementing nurse practitioner models of care; facilitate comparison of similar roles and increase the capacity to make informed decisions about the prospects for wider implementation of nurse practitioner roles or models of care. Serious debate regarding the introduction of the nurse practitioner role in Australia started about 25 years ago. Ten years later, in 2000, the first nurse practitioner was authorised to practice and the following year the first nurse practitioner was appointed to a position. From these humble beginnings, the number of nurse practitioners has steadily increased, as has the volume of Australian research into the nurse practitioner role. Australian research has taken place in the context of research from other countries with a longer history of nurse practitioners, particularly the USA, Canada and the UK (Brown and Grimes, 1995Brown S.A. Grimes D.E. A meta-analysis of nurse practitioners and nurse midwives in primary care.Nursing Research. 1995; 44: 332-339Crossref PubMed Scopus (227) Google Scholar, Carter and Chochinov, 2007Carter A.J.E. Chochinov A.H. A systematic review of the impact of nurse practitioners on cost, quality of care, satisfaction and wait times in the emergency department.Canadian Journal of Emergency Medicine. 2007; 9: 286-295Crossref Scopus (137) Google Scholar, Horrocks et al., 2002Horrocks S. Anderson E. Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors.British Medical Journal. 2002; 324: 819-823Crossref PubMed Scopus (830) Google Scholar, Jennings et al., 2015Jennings N. Clifford S. Fox A.R. O’Connell J. Gardner G. The impact of nurse practitioner services on cost, quality of care, satisfaction and waiting times in the emergency department: A systematic review.International Journal of Nursing Studies. 2015; 52: 421-435Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar, Newhouse et al., 2011Newhouse R.P. Heindel L. Weiner J.P. Stanik-Hutt J. White K.M. Johantgen M. et al.Advanced practice nurse outcomes 1990–2008: A systematic review.Nursing Economic. 2011; 29: 230PubMed Google Scholar, Wilson et al., 2009Wilson A. Zwart E. Everett I. Kernick J. The clinical effectiveness of nurse practitioners’ management of minor injuries in an adult emergency department: A systematic review.International Journal of Evidence-Based Healthcare. 2009; 7: 3-14Crossref PubMed Scopus (23) Google Scholar). The catalyst for this paper was a rapid review of the nurse practitioner literature conducted for the NSW Ministry of Health (Masso and Thompson, 2014Masso M. Thompson C. Rapid review of the nurse practitioner literature: Nurse practitioners in NSW ‘Gaining Momentum’. NSW Ministry of Health, North Sydney, NSW, Australia2014Google Scholar), which included identifying all the published Australian research on nurse practitioners up until the review was conducted. The review identified four categories of studies: (1) studies of nurse practitioners in particular clinical settings; (2) studies using surveys, interviews or focus groups to collect cross-sectional data from nurse practitioners; (3) studies using surveys or interviews to collect data to identify the views of others regarding nurse practitioners and (4) studies using work sampling and chart audit to investigate the work of nurse practitioners. Reflecting on our rapid review, several observations became apparent with regard to the first category of studies (i.e. nurse practitioners in particular clinical settings), including that some studies may have been conducted too early (before a role was fully implemented) or that there was insufficient information to determine whether or not the role was ‘fully implemented’. The purpose of this paper is to share those observations and explore how the future reporting of nurse practitioner research might be improved using the ‘lens’ of implementation science. There are many references in the literature to the ways in which the roles of nurse practitioners vary across countries, resulting in confusion about how the role is defined (Duffield et al., 2009Duffield C. Gardner G. Chang A.M. Catling-Paull C. Advanced nursing practice: A global perspective.Collegian. 2009; 16: 55-62Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar, Stasa et al., 2014Stasa H. Cashin A. Buckley T. Donoghue J. Advancing advanced practice – Clarifying the conceptual confusion.Nurse Education Today. 2014; 34: 356-361Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar). For example, some countries use the term ‘nurse practitioner’, whereas others tend to use the term ‘advanced practice nurse’ (Pulcini et al., 2010Pulcini J. Jelic M. Gul R. Loke A.Y. An international survey on advanced practice nursing education, practice, and regulation.Journal of Nursing Scholarship. 2010; 42: 31-39Crossref PubMed Scopus (186) Google Scholar). From the perspective of synthesising the results of multiple studies of the nurse practitioner role across different countries, this suggests that it cannot be assumed that each study is investigating the same thing (i.e. the nurse practitioner). Despite this, both the Australian research and the broader international literature, is generally underpinned by an implicit assumption that all nurse practitioners are indeed the same. For example, reviews of the literature usually start by ‘setting the scene’ in terms of current knowledge and development of the role and then describe the methods for searching the literature and culling the results, with the culling typically including consideration of study design or study quality. What is not usually undertaken is some consideration of whether the studies included in the review have all studied a similar role. An exception is a review which was restricted to studies from the USA because the authors believed that some features of the role (e.g. educational preparation, scope of practice) and the health system were so different from other countries that it would be inappropriate to include studies from outside the USA (Newhouse et al., 2011Newhouse R.P. Heindel L. Weiner J.P. Stanik-Hutt J. White K.M. Johantgen M. et al.Advanced practice nurse outcomes 1990–2008: A systematic review.Nursing Economic. 2011; 29: 230PubMed Google Scholar). Despite a recent emphasis on understanding what is meant by ‘implementation’, what influences implementation and how implementation can be evaluated, it is surprising that there is a general lack of clear conceptualisations and definitions of what is meant by the term ‘implementation’. Even when the term is defined, it is often difficult to comprehend how well an intervention has been implemented. The two main ways of conceptualising implementation are in terms of stages, a sequential process whereby an intervention (in this example the role of nurse practitioner) is progressively implemented (Fixsen et al., 2005Fixsen D.L. Naoom S.F. Blase K.A. Friedman R.M. Wallace F. Implementation research: A synthesis of the literature. University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network, Tampa, FL2005Google Scholar), and in terms of the degree to which an intervention has been implemented, referred to as implementation fidelity (Carroll et al., 2007Carroll C. Patterson M. Wood S. Booth A. Rick J. Balain S. A conceptual framework for implementation fidelity.Implementation Science. 2007; 2PubMed Google Scholar). If the role of a nurse practitioner is not fully implemented, it is difficult to differentiate between a role that may be very effective, but not fully implemented, and a role that is not effective (Fixsen et al., 2005Fixsen D.L. Naoom S.F. Blase K.A. Friedman R.M. Wallace F. Implementation research: A synthesis of the literature. University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network, Tampa, FL2005Google Scholar). For the purposes of considering Australian research involving nurse practitioners, the following stages of implementation provide a useful way of framing the research:1.Exploration and adoption of the role – making a decision to adopt an innovative role and developing a plan to implement that role.2.Initial implementation of the role.3.Full operation of the role (Fixsen et al., 2005Fixsen D.L. Naoom S.F. Blase K.A. Friedman R.M. Wallace F. Implementation research: A synthesis of the literature. University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network, Tampa, FL2005Google Scholar). These three stages have been used to structure the paper. The literature searching for the original rapid review was conducted in October 2013, involving database searching of the academic literature from 2000 to 2013, together with searching the web sites of government health departments, professional nursing organisations and universities within Australia running Masters degree programmes for nurse practitioners. Databases searched included Cinahl, Medline, Education Research Complete, ERIC, Health Source: Nursing/Academic edition, Psychology & Behavioural Sciences Collection, Summons and the APN Literature Database maintained by McMaster University. Search terms included ‘nurse practitioner’, ‘Australia’, ‘model’ and ‘theory’. A search was also conducted for the author Gardner, given the key contribution to the nurse practitioner literature by the Australian researchers Anne Gardner and Glenn Gardner. The Trove database was searched for Australian theses. Snowball searching consisted of reviewing the reference lists of key studies and using Google Scholar to track citations forward in time. The searches were re-run in March 2015 to identify additional Australian studies published in the intervening period. In total, 1862 papers were identified from searching the academic literature. After culling those papers based on a review of the title or abstract, full-text copies of 145 papers were retrieved. To this were added 17 reports from searching websites and 24 journal articles located as a result of snowball searching. Reviewing the full text of all these documents resulted in the papers reported here. Further details of the search strategies and the results of the searching can be found in the rapid review (Masso and Thompson, 2014Masso M. Thompson C. Rapid review of the nurse practitioner literature: Nurse practitioners in NSW ‘Gaining Momentum’. NSW Ministry of Health, North Sydney, NSW, Australia2014Google Scholar). The ‘exploration and adoption’ stage of implementing nurse practitioner roles in Australia consisted of a series of pilot projects in various states and territories; New South Wales (NSW Department of Health, 1996NSW Department of Health Nurse Practitioner Project Stage 3. Final report of the Steering Committee. NSW Health Department, Sydney1996Google Scholar), Victoria (Parker et al., 2000Parker J. Faulkner R. Dunt D. Long H. Watts J. Victorian Nurse Practitioner Project: Evaluation of eleven Phase 1 demonstration projects. The University of Melbourne, Melbourne2000Google Scholar, Pearson et al., 2004Pearson A. Nay R. Ward C. Lenten L. Lewis M. Nurse practitioner project: Phase 2 – External evaluation. School of Nursing and Midwifery, La Trobe University, Melbourne2004Google Scholar), the Australian Capital Territory (ACT Health, 2002ACT Health The ACT Nurse Practitioner Project: Final report of the Steering Committee. ACT Department of Health, Canberra2002Google Scholar) and Queensland (Queensland Health, 2003Queensland Health Nurse practitioner project report. Queensland Health, Brisbane2003Google Scholar). Papers reporting the results for particular models included in these pilots were subsequently published – sexual health (O’Keefe and Gardner, 2003O’Keefe E.J. Gardner G. Researching the sexual health nurse practitioner scope of practice: A blueprint for autonomy.Australian Journal of Advanced Nursing. 2003; 21: 33-41Google Scholar); the management of wounds and blunt limb trauma in rural and remote locations (Chang et al., 1999Chang E. Daly J. Hawkins A. McGirr J. Fielding K. Hemmings L. et al.An evaluation of the nurse practitioner role in a major rural emergency department.Journal of Advanced Nursing. 1999; 30: 260-268Crossref PubMed Scopus (62) Google Scholar); prevention, treatment and care of HIV/AIDS and transmissible infections (Hooke et al., 2001Hooke E. Bennett L. Dwyer R. van Beek I. Martin C. Nurse practitioners: An evaluation of the extended role of nurses at the Kirketon Road Centre in Sydney, Australia.Australian Journal of Advanced Nursing. 2001; 18: 20-28PubMed Google Scholar); neonatal care (Copnell et al., 2004Copnell B. Johnston L. Harrison D. Wilson A. Robson A. Mulcahy C. et al.Doctors’ and nurses’ perceptions of interdisciplinary collaboration in the NICU, and the impact of a neonatal nurse practitioner model of practice.Journal of Clinical Nursing. 2004; 13: 105-113Crossref PubMed Scopus (41) Google Scholar); and intensive care liaison (Green and Edmonds, 2004Green A. Edmonds L. Bridging the gap between the intensive care unit and general wards – The ICU Liaison Nurse.Intensive and Critical Care Nursing. 2004; 20: 133-143Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar). These studies of particular models provide examples of the need for great care when citing studies as ‘evidence’ in support of nurse practitioners, primarily because of the pilot nature of the studies. For example, the study by Chang et al., 1999Chang E. Daly J. Hawkins A. McGirr J. Fielding K. Hemmings L. et al.An evaluation of the nurse practitioner role in a major rural emergency department.Journal of Advanced Nursing. 1999; 30: 260-268Crossref PubMed Scopus (62) Google Scholar only ran for three and a half months and pre-dates the introduction of authorised nurse practitioners in Australia. Training of the nurses in the pilot was limited to ‘an intensive series of lectures’ and four months of supervised clinical practice (NSW Department of Health, 1996NSW Department of Health Nurse Practitioner Project Stage 3. Final report of the Steering Committee. NSW Health Department, Sydney1996Google Scholar). The nurses could only recommend the ordering of pathology and radiology. Despite this, the paper was included in a systematic review of the impact of nurse practitioners on cost, quality of care, satisfaction and wait times in the emergency department based on its methodological quality rather than consideration of whether it represented a study involving a ‘fully implemented’ nurse practitioner role (Carter and Chochinov, 2007Carter A.J.E. Chochinov A.H. A systematic review of the impact of nurse practitioners on cost, quality of care, satisfaction and wait times in the emergency department.Canadian Journal of Emergency Medicine. 2007; 9: 286-295Crossref Scopus (137) Google Scholar). The paper has also been cited in other papers as evidence of the value of nurse practitioners (Hoskins, 2011Hoskins R. Evaluating new roles within emergency care: A literature review.International Emergency Nursing. 2011; 19: 125-140Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar, Lutze et al., 2014Lutze M. Ross M. Chu M. Green T. Dinh M. Patient perceptions of emergency department fast track: A prospective pilot study comparing two models of care.Australasian Emergency Nursing Journal. 2014; 17: 112-118Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, Middleton et al., 2007Middleton S. Allnutt J. Griffiths R. McMaster R. O’Connell J. Hillege S. Identifying measures for evaluating new models of nursing care: A survey of NSW nurse practitioners.International Journal of Nursing Practice. 2007; 13: 331-340Crossref PubMed Scopus (11) Google Scholar). Another example is a paper reporting the results of the neonatal care project which makes quite clear that ‘at the time the study was conducted, NPs had not been formally implemented in the state of Victoria … No advanced practice model was in place in the units concerned’ (Copnell et al., 2004Copnell B. Johnston L. Harrison D. Wilson A. Robson A. Mulcahy C. et al.Doctors’ and nurses’ perceptions of interdisciplinary collaboration in the NICU, and the impact of a neonatal nurse practitioner model of practice.Journal of Clinical Nursing. 2004; 13: 105-113Crossref PubMed Scopus (41) Google Scholar, p. 107). The title of the paper (Doctors’ and nurses’ perceptions of interdisciplinary collaboration in the NICU, and the impact of a neonatal nurse practitioner model of practice) is somewhat misleading, which perhaps helps to explain why the paper has been cited as an example of the nurse practitioner role (Allen and Fabri, 2005Allen J. Fabri A.M. An evaluation of a community aged care nurse practitioner service.Journal of Clinical Nursing. 2005; 14: 1202-1209Crossref PubMed Scopus (26) Google Scholar). Research into ‘initial implementation’ of nurse practitioner roles largely consists of studies which have investigated nurses in training to become nurse practitioners, usually described as transitional nurse practitioners or nurse practitioner candidates. Using the ‘language’ of nurse practitioners, the roles of those in training to become nurse practitioners do not encompass the full scope of practice (Gardner et al., 2009aGardner A. Gardner G. Middleton S. Della P. The status of Australian nurse practitioners: The first national census.Australian Health Review. 2009; 33: 679-689Crossref PubMed Scopus (51) Google Scholar). Australian studies of transitional or candidate nurse practitioners have primarily been conducted in emergency departments (Considine et al., 2006aConsidine J. Martin R. Smit D. Jenkins J. Winter C. Defining the scope of practice of the emergency nurse practitioner role in a metropolitan emergency department.International Journal of Nursing Practice. 2006; 12: 205-213Crossref PubMed Scopus (32) Google Scholar, Considine et al., 2006bConsidine J. Martin R. Smit D. Winter C. Jenkins J. Emergency nurse practitioner care and emergency department patient flow: Case–control study.Emergency Medicine Australasia. 2006; 18: 385-390Crossref PubMed Scopus (39) Google Scholar, Fry and Rogers, 2009Fry M. Rogers T. The Transitional Emergency Nurse Practitioner role: Implementation study and preliminary evaluation.Australasian Emergency Nursing Journal. 2009; 12: 32-37Abstract Full Text Full Text PDF Scopus (6) Google Scholar, Fry et al., 2011Fry M. Fong J. Asha S. Arendts G. A 12-month evaluation of the impact of Transitional Emergency Nurse Practitioners in one metropolitan Emergency Department.Australasian Emergency Nursing Journal. 2011; 14: 4-8Abstract Full Text Full Text PDF Scopus (14) Google Scholar, Jennings et al., 2008Jennings N. O’Reilly G. Lee G. Cameron P. Free B. Bailey M. Evaluating outcomes of the emergency nurse practitioner role in a major urban emergency department, Melbourne, Australia.Journal of Clinical Nursing. 2008; 17: 1044-1050Crossref PubMed Scopus (64) Google Scholar, Lee and Jennings, 2006Lee G. Jennings N. A comparative study of patients who did not wait for treatment and those treated by Emergency Nurse Practitioners.Australasian Emergency Nursing Journal. 2006; 9: 179-185Abstract Full Text Full Text PDF Scopus (19) Google Scholar, Lutze et al., 2011Lutze M. Ratchford A. Fry M. A review of the Transitional Emergency Nurse Practitioner.Australasian Emergency Nursing Journal. 2011; 14: 226-231Abstract Full Text Full Text PDF Scopus (7) Google Scholar). As an illustration of these roles not extending to the full scope of practice, two of the papers report on the work of a nurse practitioner candidate who had to discuss each patient with an emergency physician, obtain counter signatures for medications and verify the results of medical imaging and pathology (Considine et al., 2006aConsidine J. Martin R. Smit D. Jenkins J. Winter C. Defining the scope of practice of the emergency nurse practitioner role in a metropolitan emergency department.International Journal of Nursing Practice. 2006; 12: 205-213Crossref PubMed Scopus (32) Google Scholar, Considine et al., 2006bConsidine J. Martin R. Smit D. Winter C. Jenkins J. Emergency nurse practitioner care and emergency department patient flow: Case–control study.Emergency Medicine Australasia. 2006; 18: 385-390Crossref PubMed Scopus (39) Google Scholar). Studies involving transitional/candidate nurse practitioners have also taken place in aged care (Allen and Fabri, 2005Allen J. Fabri A.M. An evaluation of a community aged care nurse practitioner service.Journal of Clinical Nursing. 2005; 14: 1202-1209Crossref PubMed Scopus (26) Google Scholar, Joanna Briggs Institute, 2007Joanna Briggs Institute National evaluation of nurse practitioner-like services in residential aged care services: Final report. Commonwealth of Australia, Canberra2007Google Scholar, Lee, 2009Lee C.G. Role of the gerontological nurse practitioner in Australia. Doctor of Philosophy, University of Adelaide, Adelaide2009Google Scholar) and mental health (Papoulis, 2011Papoulis D. An evaluation of mental health services in the Whyalla Hospital Accident and Emergency Department: A comparison of a new and old model of care. Master of Nurse Practitioner, University of Adelaide, Adelaide2011Google Scholar). One of these involved a nurse practitioner candidate working in residential aged care who made recommendations for care, which were then discussed with the general practitioner who decided whether to act on the recommendations (Lee, 2009Lee C.G. Role of the gerontological nurse practitioner in Australia. Doctor of Philosophy, University of Adelaide, Adelaide2009Google Scholar). Another paper reported that the nurse practitioner candidate was working ‘within the role boundaries of a registered nurse’ (Allen and Fabri, 2005Allen J. Fabri A.M. An evaluation of a community aged care nurse practitioner service.Journal of Clinical Nursing. 2005; 14: 1202-1209Crossref PubMed Scopus (26) Google Scholar, p. 1203). The report of a nation-wide evaluation coined the term ‘nurse practitioner-like services’ to more accurately reflect the nature of the roles being evaluated (Joanna Briggs Institute, 2007Joanna Briggs Institute National evaluation of nurse practitioner-like services in residential aged care services: Final report. Commonwealth of Australia, Canberra2007Google Scholar). As with studies from the ‘exploration and adoption’ stage, some of these studies have been included in systematic reviews of the nurse practitioner literature (Carter and Chochinov, 2007Carter A.J.E. Chochinov A.H. A systematic review of the impact of nurse practitioners on cost, quality of care, satisfaction and wait times in the emergency department.Canadian Journal of Emergency Medicine. 2007; 9: 286-295Crossref Scopus (137) Google Scholar, Wilson et al., 2009Wilson A. Zwart E. Everett I. Kernick J. The clinical effectiveness of nurse practitioners’ management of minor injuries in an adult emergency department: A systematic review.International Journal of Evidence-Based Healthcare. 2009; 7: 3-14Crossref PubMed Scopus (23) Google Scholar), without any consideration given to the fact that the subjects of the studies were not fully qualified nurse practitioners. One recent systematic review recognised some of these studies as investigations of candidate/transitional roles but did not exclude the studies on that basis (Jennings et al., 2015Jennings N. Clifford S. Fox A.R. O’Connell J. Gardner G. The impact of nurse practitioner services on cost, quality of care, satisfaction and waiting times in the emergency department: A systematic review.International Journal of Nursing Studies. 2015; 52: 421-435Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar). Earlier, we referred to ‘full operation’ as the stage of implementation which comes after ‘initial implementation’. Based on the papers we reviewed, judging whether or not ‘full operation’ had been achieved was difficult to determine, primarily because of the lack of suitable information upon which to base such a judgement. We could only find one example where it was explicitly stated that full implementation was not achieved, involving a Walk-in Centre staffed by nurse practitioners and other advanced practice nurses (Parker et al., 2011Parker R. Forest L. Desborough J. McRae I. Boyland T. Independent evaluation of the nurse-led ACT Health Walk-in Centre. Australian Primary Health Care Research Institute, The Australian National University, Acton, ACT2011Google Scholar). The first 12 months of implementing a new nurse practitioner position has been described as a ‘period of transition’, during which time systems and relationships are established and the role is defined (Desborough, 2012Desborough J.L. How nurse practitioners implement their roles.Australian Health Review. 2012; 36: 22-26Crossref PubMed Scopus (17) Google Scholar). The barriers and enablers to implementing nurse practitioner roles are multi-faceted and operate at multiple levels – the nurse practitioners themselves (e.g. their skills, knowledge and capabilities), the team of people they work with, the organisation they work for and the broader system of funding and legislation (DiCenso et al., 2010DiCenso A. Bryant-Lukosius D. Bourgeault I. Martin-Misener R. Donald F. Abelson J. et al.Clinical nurse specialists and nurse practitioners in Canada: A decision support synthesis. Canadian Health Services Research Foundation, Ottawa2010Google Scholar, Masso and Thompson, 2014Masso M. Thompson C. Rapid review of the nurse practitioner literature: Nurse practitioners in NSW ‘Gaining Momentum’. NSW Ministry of Health, North Sydney, NSW, Australia2014Google Scholar). The scope and range of the various barriers suggest many reasons why a particular nurse practitioner may not be functioning to their full scope of practice and indicates that implementing a new position such as a nurse practitioner should involve organisational redesign and ‘reframing of professionalism and professional boundaries at the multiple layers of the healthcare system’ (Niezen and Mathijssen, 2014Niezen M.G.H. Mathijssen J.J.P. Reframing professional boundaries in healthcare: A systematic review of facilitators and barriers to task reallocation from the domain of medicine to the nursing domain.Health Policy. 2014; 117: 151-169Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar, p. 166). Based on interviews with nurse practitioners, Wilson et al., 2005Wilson K. Coulon L. Hillege S. Swann W. Nurse practitioners’ experiences of work