Expanded scope roles in primary health – what makes them work?

ABSTRACT

INTRODUCTION:

The demand for better integration between primary and secondary healthcare frequently leads to discussion about expanded scope of practice for nursing, paramedic and allied health professionals and the role these clinicians could play in facilitating improved access to timely and appropriate healthcare. From a workforce perspective, expanded scope of practice has also been advocated as a mean of fostering workforce retention. Models of expanded scope roles in nursing and paramedicine have been trialled nationally and internationally in both acute and community care settings. Where they have been successful, trials have resulted in reduction in hospital presentation and admission; improved patient timeliness and access to care; and patient satisfaction. This paper will examine the characteristics of successful expanded scope programs.

METHODS:

Exploratory case-study analysis of successful integration of expanded health care roles.

RESULTS & CONCLUSION:

One size does not fill all. Successful models of integrated expanded health care roles in primary health care settings are built on stakeholder’s capacity and preference, community need, and political good will. Collaborative, congruent, multi-disciplinary care teams that prioritise patient-centred care within a dynamic primary care setting have merit and are more likely to foster flexibility and sustainability of expanded roles.

WHAT THIS STUDY ADDS:

• WHAT IS ALREADY KNOWN ON THIS SUBJECT:

• Different perceptions on expanded scope of practice inform current models in nursing, paramedicine and allied health.

• WHAT DOES THIS STUDY ADD:

• Although variations exist in the understanding and definition of expanded scope of practice; there are commonalities between successful models of expanded scope of practice.

• Successful expanded scope of practice roles are responsive to stakeholders’ needs and preferences.

• Facilitators of successful expanded scope of practice roles include professional autonomy, education and training, and political good will.

Jakki Germann1; David Lim1; Leo McNamara1,2; Sonya Osborne3; and Vivienne Tippett1

1 School of Clinical Sciences, 2 School of Public Health and Social Work, 3 School of NursingQueensland University of Technology

INTRODUCTION

Expanded scope of practice was mooted in the National Health and Hospitals Reform Commission reports as a mean of addressing health and medical workforce shortage and maldistribution, improved workforce retention by providing flexible work options and career paths, and the potential to alleviate health disparity between urban and remote Australia. In recent times, Health Workforce Australia has invested significant funds in trialling and evaluating innovative models of expanded scope of practice. See, for example, its Extending the Role of Paramedics program. Evaluation of Health Workforce Australia’s Expanded Scopes of Practice program was not publicly available as the preparation of this poster. Nonetheless, we maintained that lessons can be learnt from existing models of expanded scope of practice to inform future models especially in the pre-hospital setting. Our objective for this study was to compare and contrast different models of expanded scope of pre-hospital practice to ascertain enablers of successful models.

METHODS

An exploratory case-study analysis was utilised.[1] Four ‘cases’ of pre-hospital expanded scope of practice models were analysed:

• Canadian Expanded Scope Paramedic;

• United Kingdom Paramedic Practitioner,

• Australian (Queensland) Expanded Care Paramedic; and

• Australian Nurse Practitioner.

Case study methodology was employed in the systematic comparison of our cases. This allowed us to generalise within limits what works where (in what practice context) and when (in what temporal context) and in what order.[1] Case study designs is commonly used in health policy research. For this study, our primary sources of data were published literature (2002 to 2014) and interviews with stakeholders. A mixture of content and thematic analyses were utilised to identify themes and sub-themes.[2] The measure of validity included negative case analysis and coherence of the data.[3]



For additional information please contact:

David LimSchool of Clinical Sciences, Queensland University of TechnologyEmail: c113.lim@qut.edu.auPhone: (07) 3138 3347

Ambulance Corps. CC-BY State Record of NSW.

RESULTS & CONCLUSION

Expanded scope of practice vary across our four cases (Table 1). The Australian Nurse Practitioner has the widest scope of clinical practice while the Canadian Expanded Scope Paramedic has the least scope of pre-hospital clinical practice. Similarly, there are differences in clinical responsibilities and professional autonomy across the four models. Nonetheless, successful models of expanded scope of pre-hospital practice, regardless of practice context, reflect the stakeholders’ capacity and preference for the non-traditional role. Successful models of expanded scope practice are responsive to stakeholders’ (including community) needs and preferences, build on existing infrastructure and organizational culture and capacity. Successful models of pre-hospital expanded scope of practice are responsive and adaptive to political and environmental changes. Collaborative, congruent, multi-disciplinary care teams that prioritise patient-centred care within a dynamic primary care setting have merit and are more likely to foster flexibility and sustainability in expanded scope roles.

Curriculum/Academic qualification

Autonomy Scope of practice Regulation Initiator of model

Canadian Expanded Scope Paramedic

In-house;Equivalent to Australian Qualifications Framework (AQF) Level 6

Limited Treat and transfer;Treat and release;Treat and refer

Provincial clinical governance;Registered practitioners

Provincial and municipal government; local community;EMS industry

United Kingdom Paramedic Practitioner

University;Equivalent to AQF Level 9

High degree

Treat and transfer;Treat and release;Treat and refer;Treat and limited consult

National Health Services

National Health Service;Local community

Australian (Queensland ) Expanded Care Paramedic

University;Equivalent to AQF Level 8

Somewhat Treat and transfer;Treat and release;Treat and limited consult

State (Queensland Ambulance Service)

Industry; local needs

Australian Nurse Practitioner

University;Equivalent to AQF Level 9

High degree

Treat and release;Treat and consult;Treat and refer

AHPRA; Individual scope of practice (approved by Health Dept. and/or public/private provider)

Public/private health provider/ State Department of Health/ individual practitioner;local needs

© Queensland Ambulance Service. Used with permission.

RECOMMENDATION

• Future research is required to ascertain patient/ client acceptance of expanded scope models, better understanding of the relationship of elements of successful expanded scope models, and how these elements support patient-centred care.

REFERENCE

1. Yin, R.K., Case study research: design and methods. 4th ed. 2009, Thousand Oaks, California: SAGE Publications.

2. Miles, M.B. and A.M. Huberman, Qualitative data analysis: an expanded sourcebook. 2nd ed. 1994, California: SAGE Publications.

3. Creswell, J., Qualitative inquiry and research design choosing among five traditions. 1998, Thousand Oaks, CA: SAGE Publications.

Table 1. Key elements of expanded scope models of practice