Travel Medicine and Infectious Disease (2013) 11, 214e224

Available online at www.sciencedirect.com

journal homepage: www.elsevierhealth.com/journals / tmid

Providing travel health care e the nurses’role: An international comparison

Irmgard Bauer a,b,*, Sheila Hall c, Nahoko Sato d

a School of Nursing, Midwifery & Nutrition, James Cook University, Douglas Campus, Townsville,QLD 4811, AustraliabCentre for International Health, Curtin University of Technology, Perth, WA 6845, AustraliacTREC Ltd (Travel-Health Related Education & Care), New City Row, Blanefield, Glasgow G63 9JB, UKd Flight Crew Medical Services, Flights Operations, Japan Airlines Co. Ltd, Tokyo, Japan

Received 5 March 2013; received in revised form 16 April 2013; accepted 22 April 2013Available online 21 May 2013

KEYWORDSTravel health nursing;Continuouseducation;Professionaldevelopment;Practice nursing;General practice

* Corresponding author. School of NuTel.: þ61 7 47815312; fax: þ61 7 478

E-mail addresses: Irmgard.Bauer@

1477-8939/$ - see front matter ª 201http://dx.doi.org/10.1016/j.tmaid.20

Summary Background: In many countries, the responsibility for travel health lies with med-ical practitioners who delegate certain tasks to nursing staff. Elsewhere, nurses have taken aleading role and work independently in private or hospital-based clinics, occupational healthdepartments and general practices. The purpose of this study was to examine the roles andchallenges faced by nurses providing travel health care in Australia, Japan and the UK, andto compare educational and professional needs.Methods: Nurses involved in travel health care were invited to complete an online questionnairewith multiple choice, open-ended, and Likert Scale questions. SurveyMonkey’s statistical facil-ities analysed quantitative data; thematic content analysis was applied to qualitative responses.Results: Differences and similarities between the three countries were conveyed by 474 partic-ipants focusing on current positions, work arrangements, and educational and practical con-cerns. Clinical practice issues, including vaccination and medication regulations, werehighlighted with the differences between countries explained by the respective history of travelhealth care development and the involvement within their nursing profession.Conclusion: The call for more educational opportunities, including more support from em-ployers, and a refinement of the role as travel health nurse appears to be international. Nursesrequire support networks within the field, and the development of a specialist “travel healthnurse”would give a stronger voice to their concerns and needs for specific education and trainingin travel health care.ª 2013 Elsevier Ltd. All rights reserved.

rsing, Midwifery & Nutrition, James Cook University, Douglas Campus, Townsville QLD 4811, Australia.14026.jcu.edu.au (I. Bauer), admin@TRECtravelhealth.co.uk (S. Hall), Nahoko.Sato@jal.com (N. Sato).

3 Elsevier Ltd. All rights reserved.13.04.004

Providing travel health care e the nurses’ role: An international comparison 215

Introduction

The very first article in the inaugural journal of travelmedicine1 introduced travel medicine as a new interdisci-plinary field where ‘initiated general practitioners’, travelclinics or vaccination centres would see thousands of futuretravellers per year. Without being mentioned, nurses maybe presumed in their traditional role as assistants. Sincethen, the specialty has grown tremendously and today itsextensive body of knowledge serves as a standard of prac-tice for physicians, nurses and other travel health pro-fessionals.2 The key responsibilities of care are to assessrisk factors, provide travel health advice and administerany recommended vaccinations/prophylaxis.

In order to ensure the highest quality of care, a recog-nized professional role with a good command of travelmedicine’s body of knowledge is essential. Training op-portunities range from individual study days or short cour-ses provided by the pharmaceutical industry or educationalinstitutions, to formal training courses, leading to certifi-cates, diplomas, postgraduate diplomas and degrees,offered by universities or professional colleges. Examina-tions such as the International Society of Travel Medicine’sCTH� indicate a level of knowledge and expertise; suc-cessfully passing the new examination offered by the Fac-ulty of Travel Medicine of the Royal College of Physiciansand Surgeons of Glasgow (RCPSG) demonstrates that adoctor, nurse or other travel health professional has the‘ability to function as independent fully trained practi-tioner’.3 However, the actual roles of travel health pro-fessionals in different countries vary greatly.

Professional roles in travel medicine

In 1996, an international study of travel clinics demon-strated that nurses already played a major part in advisingtravellers.4 They did not, however, receive the appropriateeducation and training to fulfil their roles as, despiteadvising and immunizing significantly more travellers thantheir medical counterparts, 98% of UK nurses requestedtraining in travel medicine.5 In 2004, within 91 generalpractices offering travel medicine services in the UK, 97% ofthe main providers of advice were nurses6 and 75% of UKnurses working in clinics within higher-education estab-lishments had undertaken such training compared to only27% of doctors.7

Practice nurses

The role of a practice nurse has changed considerably overthe years from being the doctor’s handmaiden to repre-senting a nursing specialty with a particular set ofspecialized skills. Travel health is a more recent addition tothe already wide range of activities of a practice nurse. Theevolution of this role differs from country to country but,internationally, most nurses involved in travel healthappear to work in a general practice.

With approximately 9000 nurses working within generalpractice in Australia, the role of the Practice Nurse is aslowly emerging specialty,8 the fastest growing area innursing and the lowest paid.9 General practices are usually

run as small businesses where business agendas rule andnurses’ educational and professional needs are not neces-sarily a priority. In 2004, a report by the Royal AustralianCollege of General Practitioners and the Royal College ofNursing Australia explored the role of practice nurses andtheir educational needs to ensure high quality patient carein GP settings.10 Recommendations included the develop-ment of competency standards, provision of general prac-tice specific education and the development of clear careerpathways to advanced levels of practice. It may be quitesome time until this document is influencing practice,especially when it comes to the barriers practice nursesencounter as their roles expand in line with the changingprofile of patients’ needs11 as demonstrated in the man-agement of cardiovascular disease12 and mentioned in arecent study of practice nurses.13

In Japan, Certified Nurse Specialists (CNSs) work withineleven different fields, e.g. oncology14; however, incontrast to registered nurses, their qualifications are notregulated by law. Practice Nursing is not one of therecognized specialties, and nurses working in general/family practices are not seen as specialists.

In the UK, a radical reform in 1990 changed the employ-ment contract for general practitioners within the UK Na-tional Health Service. This new contract put much greateremphasis on health promotion and, as a result, many morepractice nurses were employed; their roles and re-sponsibilities increased dramatically and they embraced thenewly emerging need for the provision of travel healthadvice. Further government policy in 200015 introduced theconcept of Patient Group Directions (PGDs) enabling nursesto administer certain vaccines according to protocol,thereby encouraging practice nurses to further expand theirtravel health service provision. Without an official register,and based on the number of General Practices, the numberof practice nurses is estimated to well exceed 10,500.

Travel health nurses

Disappointingly, there is no dedicated literature on travelhealth nursing in Australia, and travel health is still notlisted as part of practice nurses’ scope of practice.13 Travelfeatures only as an example for immunizations in a recentsurvey of Australian general practice nurses’ work.16

Beadnell9 cited one (!) practice nurse mentioning travelmedicine as one area of activity. A comparison of US andAustralian travel medicine practice noted that nursesappear less utilized in this specialty in Australia comparedto the United States .17

To understand the context of Japanese nurses withintravel health care, knowledge of the unique historicalevolution of Japanese travel medicine is important. Re-strictions of overseas travel after World War II were onlylifted in 1964, expressly for business expatriates.18 Japa-nese travel medicine, therefore, has its roots in the medi-cal care of corporate travellers which explains its positionwithin occupational health to this day. Physicians’ lack ofknowledge of travel medicine, travellers’ lack of riskappreciation, and the unavailability of some vaccines andanti-malarials further account for a slower development oftravel medicine.18 In 2010, despite an increase in thenumber of international travellers within the general

216 I. Bauer et al.

population, there were only a dozen travel clinics in theentire country. Appropriate training and closer collabora-tion with the travel industry, as well as the foundation oftwo professional societies (Japanese Society of Travel andHealth e JSTH; Japanese Society of Travel Medicine eJSTM) reflect a rapid development of the discipline in thecountry today. Regrettably, nurses do not feature highlywithin this picture. Occupational health is workforcefocused and although ‘workers who travel may be exposedto new infectious diseases or to stresses related to travel’,travel related care is not recorded as a frequently per-formed task,19 and neither Occupational Health nor TravelHealth Nursing are included as one of the specialties ofCNSs.20 However, the need for specific knowledge of in-fectious diseases has increased especially after SARS andH1N1 outbreaks, and more Japanese quarantine stationnurses are now involved with the observation and care ofincoming travellers to Japan.21

Travel health care services in the UK have historicallybeen adopted and led by nurses working in general practicesettings. With the introduction of PGDs, the concurrentneed for increasing travel health advice was naturally takenon board by this new generation of practice nurses. Thisgrowing responsibility was supported by the Royal Collegeof Nursing with a guidance document in 200522 emphasizingthe importance of travel health education for nurses, and in200723 when a more comprehensive document of travelhealth competencies was published. This latter documentwas updated in 201224 to provide guidance for all nursesinvolved in the field of travel health care. Further travelhealth support is provided by two nationally recognizedorganizations, Health Protection Scotland, supporting theonline information database TRAVAX, and the NationalTravel Health Network and Centre (NaTHNaC) which alsohas a well recognized and respected information web site.The Royal College of Physicians and Surgeons Glasgow(RCPSG) was the first college in the UK to develop a Facultyof Travel Medicine and to accept entry of nursing colleaguesat all levels, from invited Fellows to Affiliate Members. Itsrecent publication provides recommendations for the bestpractice of travel medicine by all health care professionalsand is another useful resource for nurses involved in thisfield.25 However, most nurses are expected to providetravel health advice as just one facet of their expandedrole, and concern is frequently expressed at the insufficienttraining opportunities available.

Purpose of this study

Travel medicine has been developing internationally overthe past 20 years. In many countries, the responsibility forthis area of health care lies with the medical practitionerswith certain tasks being delegated to nursing staff. In otherregions, nurses have taken a leading role in this field andwork independently in private or hospital-based clinics,occupational health departments and general practice. Theopportunity for training and education varies greatly be-tween countries. The purpose of this study was to compareand contrast roles, competencies and challenges, and toexplore the educational and professional needs of nursesproviding travel health care in Australia, Japan and UK.

Method

Questionnaire

This descriptive study employed an online survey (Survey-Monkey SELECT) comprising of 21 multiple choice, ratingand open-ended questions which took 10e15 min to com-plete. The English version for participants in Australia andthe UK was translated into Japanese by NS. The questionswere based on the clinical and professional experience ofSH and NS, the limited literature available on travel healthnurses, and informal discussions at scientific meetings withnurses involved with travel health. All questions wereexamined for their validity in each country’s context. Thevalidity of the questionnaire was established by two travelhealth nurses; five travel health nurses piloted the surveyand minor modifications were made. A re-piloting was notrequired. The data collection in Australia and the UK tookplace in March/April 2012, in Japan in October/November2012.

Sampling

As there is no national register of nurses providing travelhealth care in these countries, no sampling frame wasavailable, and the electronic link to the survey was for-warded to a range of nursing and travel health organiza-tions with the request to forward it to their nurse members.A conference attendance roll was also used to distributethe link. The invitation to participate was extended to allnurses who were involved in providing travel health care atthe time of the study. Participants self-selected on thatbasis.

Analysis

Quantitative data were analysed using the analysis capa-bilities offered by SurveyMonkey SELECT to conductdescriptive analysis on the nominal and ordinal data fre-quencies, percentages, and cross-tabulations. This level ofanalysis was sufficient to meet the aims of this study as aninitial baseline investigation. Qualitative data were manu-ally analysed through content analysis and cross-validatedby IB and SH as the coordinators of the English part of thestudy. The Japanese answers were translated by NS, ana-lysed by IB, and cross-validated by SH and NS. The projectwas approved by the James Cook University ethics com-mittee (H4360) after satisfying the Japanese and UKrequirements.

Results

In total, 438 English responses were received. One responsewas invalid and six did not indicate the represented countryleaving 432 valid English responses: 101 in Australia and 331in the UK. There were 42 Japanese responses. Table 1presents each country’s sample description with practicenurses (Australia, 82.2%; UK, 82.5%) and those qualified forover 10 years (Australia, 87.1%; Japan 73.8%; UK, 92.7%)being the most represented. Practice Nursing is not a

Table 1 Sample description.

Country Australia Japan UK

Total respondents N Z 101 N Z 42 N Z 331Current position N Z 101 N Z 42 N Z 331Enrolled nurse 5 (5.0%) 0 (0.0%) 0 (0.0%)Registered nursea 30 (71.4%)

Practice nurse 88 (87.1%) 0 (0.0%) 273 (82.5%)

Nurse practitioner 1 (1.0%) 0 (0.0%) 24 (7.3%)Public health nurse 2 (2.0%) 9 (21.4%) 4 (1.2%)Midwife 1 (1.0%) 1 (2.4%) 0 (0.0%)Other 4 (4.0%) 2 (4.8%) 30 (9.1%)Years as qualified

nurse

N Z 101 N Z 42 N Z 331

Less than 1 year 0 (0.0%) 0 (0.0%) 2 (0.6%)1e5 Years 7 (6.9%) 2 (4.8%) 5 (1.5%)6e10 Years 6 (5.9%) 9 (21.4%) 17 (5.1%)More than 10 years 88 (87.1%) 31 (73.8%) 307 (92.7%)

a Practice nursing is not a specialty in Japan.

Table 2 Work.

Australia Japan UK

Work setting N Z 101 N Z 42 N Z 329General practice 82 (81.2%) 1 (2.4%) 286 (86.9%)

Private travel clinic 6 (5.9%) 4 (9.5%) 13 (4.0%)Occupational HealthDepartment(industry)

4 (4.0%) 13 (30.9%) 18 (5.5%)

GovernmentHealth Department

2 (2.0%) 2 (4.8%) 2 (0.6%)

Pharmacy 0 (0.0%) 0 (0.0%) 0 (0.0%)Quarantine station 0 (0.0%) 17 (40.5%) 0 (0.0%)Hospital-based clinic 2 (2.0%) 2 (4.8%) 0 (0.0%)Other 5 (5.0%) 3 (7.1%) 10 (3.0%)Years providing travel

health care

N Z 99 N Z 42 N Z 330

Less than 6 months 4 (4.0%) 5 (11.9%) 10 (3.0%)7e11 Months 2 (2.0%) 2 (4.8%) 6 (1.8%)1e5 Years 44 (44.4%) 16 (38.1%) 77 (23.3%)6e10 Years 33 (33.3%) 12 (28.6%) 98 (29.7%)11e20 Years 11 (11.1%) 6 (14.3%) 103 (31.2%)

More than 20 years 5 (5.1%) 1 (2.4%) 36 (10.9%)Percentage

of working week

spent on travel

health

N Z 99 N Z 41 N Z 326

10% 59 (59.6%) 10 (24.4%) 225 (69%)

25% 30 (30.3%) 4 (9.8%) 72 (22.1%)50% 7 (7.1%) 6 (14.6%) 13 (4.0%)75% 1 (1.0%) 8 (19.5%) 4 (1.2%)90% 1 (1.0%) 4 (9.8%) 3 (0.9%)100% 1 (1.0%) 9 (22.0%) 9 (2.8%)

Providing travel health care e the nurses’ role: An international comparison 217

recognized specialty in Japan; 71.4% of the respondentswere Registered Nurses without a particular specialty.Because not every respondent answered every question,each table indicates the sample size per question.

Work

The comparison of work related aspects (Table 2) indicatedthat General Practice was the most represented worksetting in Australia (91.2%) and in the UK (86.9%). Othersettings were, in Australia, the community, council, uni-versity health services and a private travel business; inJapan educational institutions. In the UK, nurses were alsoemployed in private GP and walk-in centres, NHS walk-incentres or school medical centres. In Japan, most nursesproviding travel health care worked in quarantine stations(40.5%) followed by occupational health departments(30.9%). The majority of nurses in Australia (44.4%) and inJapan (38.9%) had been providing travel health care be-tween 1 and 5 years, whereas most British respondents(31.25%) had done so between 11 and 20 years, reflectingthe longer presence of travel health nursing in that country.The majority of Australian (59.6%), Japanese (24.4%) andUK (69%) colleagues spent about 10% of their working weekon travel health, indicating that travel health related carewas a rather small portion of their general practice work.However, in contrast to other countries, over 20% of Japa-nese nurses spent their time exclusively on travel healthcare though this may be a sampling issue reflecting theirpredominant work setting in occupational health andquarantine stations.

Education/training

With this evolving field of expertise, and in order to providehigh quality care, nurses require appropriate education andtraining. Table 3 indicates the level of training received atthe time of the survey. Most nurses had attended occasionalstudy days which included a travel health component

(Australia 75%; Japan 73.8%; UK 75.5%) in combination withother training opportunities of varying length. However,five Australian, nine Japanese (one-fifth of that sample)and two British nurses had not attended any travel healthtraining course. Others employed self-study, e.g. online.This question allowed for multiple answers.

Of those nurses who had completed a formal travelhealth education (Australia, 28.7%; Japan, 36.6%; UK,51.6%), the majority had obtained a certificate (Australia,86.2%; Japan, 93.3%; UK, 78.9%). A total of 97.9% ofAustralian and 91.4% of UK nurses had received generaltraining on aspects of vaccination, though 3.1% from theBritish cohort were unsure if they actually had receivedsuch training. Almost half of the Japanese nurses (43.9%)recalled such training.

Travel health clinical practice

The final focus was on the nurses’ actual clinical practice.First, the nurses’ role in prescribing and administeringtravel vaccinations was explored. Table 4 gives more detailon this and related questions. In Australia, most nurses(79.1%) administered vaccines after they had been pre-scribed by the doctor, and authorized/registered nurseimmunizers were required to adhere to a variety of pro-tocols, with the vaccinations generally prescribed by a

Table 3 Education/training.

Australia Japan UK

Travel health

training attended

(multiple answers)

N Z 92 N Z 33 N Z 327

Occasional studydays including travelhealth component

69 (75%) 31 (93.9%) 247 (75.5%)

Online training package 18 (19.6%) 1 (3.0%) 67 (20.5%)1 Day course 22 (23.9%) 9 (27.3%) 160 (48.9%)2 Day course 12 (13%) 7 (21.2%) 151 (46.2%)5 Day course 4 (4.3%) 1 (3.0%) 18 (5.5%)Courses of upto 12 weeks

3 (3.3%) 1 (3.0%) 10 (3.1%)

Courses of 13weeks to 1 year

2 (2.1%) 0 (0.0%) 32 (9.8%)

Other 17 (18.4%) 6 (18.2%) 29 (8.9%)Highest travel

health qualification

N Z 29 N Z 15 N Z 171

Certificate 25 (86.2%) 14 (93.3%) 135 (78.9%)

Postgraduate certificate 1 (3.4%) 0 (0.0%) 4 (2.3%)Diploma 2 (6.9%) 0 (0.0%) 23 (13.5%)Masters 1 (3.4%) 1 (6.6%) 9 (5.3%)Received general

vaccination training

(administration,

storage)

N Z 96 N Z 41 N Z 326

Yes 94 (97.9%) 18 (43.9%) 298 (91.4%)

No 2 (2.1%) 18 (43.9%) 18 (5.5%)Not sure 0 (0.0%) 5 (12.2%) 10 (3.1%)

218 I. Bauer et al.

doctor. Only one nurse had to refer patients to a travelclinic to obtain vaccinations and malaria prophylaxis. InJapan, 78.3% of the nurses stated that vaccines were pre-scribed and administered by a doctor. In the UK, the ma-jority (59.5%) were in the position to administer certainvaccines under the guidance of a Patient Group Direction(PGD) or protocol, or a combination of PGD and PSD (pa-tient specific direction).

Referring to malaria prophylaxis, for the majority ofAustralian nurses (63.5%) it was always the doctor whoadvises and prescribes the medication, whereas most UKnurses (63.3%) advised the traveller and the doctor thensigned the prescription, with a similar response given by52.4% of Japanese colleagues.

In Australia (68.8%) and the UK (90.4%), traveller edu-cation/consultation was the next largest task whereas foralmost half (45.4%) of Japanese nurses, it was researchingthe geography. The nurses utilized a range of travel healthsources for reference and information with almost all(Australia, 100%; Japan 100%; UK, 99.7%) relying on theinternet combined with other sources (multiple answerspossible). When asked for the most frequently used sour-ces, 54.7% of the Australian nurses cited the internet, fol-lowed by 13.7% referring to work colleagues; a similarpattern being demonstrated by the Japanese colleagues. Inthe UK, virtually all nurses used the internet as the mainsource of information. Online videos and phone apps (fornurses and travellers) were suggested as potential additions

to available information sources, though some UK nursesdid not have permission to watch videos online at work.Surprisingly, the Japanese nurses did not suggest anyadditional sources. Despite all available and accessed in-formation sources, there were a number of topics thatnever seemed to be resolved satisfactorily. As the re-sponses varied widely, a summarized overview shall begiven here.

Twenty-seven (48%) Australian nurses (N Z 56) did notencounter issues but, for the remainder, uncertainty andconcerns focused predominantly on immunizations (indica-tion, boosters, children). Yellow fever (for elderly; reliablemaps), rabies and Japanese encephalitis were highlighted,however, uncertainties around other vaccines, e.g., hepa-titis A and B, polio, tetanus and BCG were never resolvedsatisfactorily. Malaria prophylaxis, especially long-term useand a lack of correct geographical distribution maps, wasanother issue. In Japan, reflecting the traditional occupa-tional health context, the biggest challenges (53.4%;NZ 22)included the legal health and vaccination requirements ofoverseas countries, available medical care (especially formother/child health), and information on rabies outbreakswith the ever-present question of what constitutes ‘low-risk’. In the UK, 45 (21%; N Z 205) colleagues felt in com-mand of clinical challenges; however, the majority sawyellow fever vaccination and malaria prophylaxis (long-termuse, multi-destination travel, breastfeeding) as perpetualproblems. Again, vaccinations in general caused multipleconcerns, e.g. immunization history, need for boosters,partially completed courses, pregnancy, infants/children,and travellers with medications such as methotrexate.Recommendations were generally seen as vague and notmuch help in clinical practice. For example, firm decisionshave to be made by nurses regarding subjective assess-ments, e.g. when does a short-stay become a long-stay;when does low-risk turn into high risk?

Lack of time is an often heard complaint in health set-tings; yet, the majority of respondents stated that theallocated appointment time allowed for satisfactory travelhealth care (Australia, 80.0%; Japan, 56.4%; UK, 80.7%).The finding that only a minority of nurses in Australia andthe UK are members of a professional international or na-tional travel health organization or specialist group(Australia, 10.5%, UK, 16.9%) should not be surprising as thesample consisted of nurses providing travel health care aspart of their larger remit rather than as specialized travelhealth nurses. However, half of the Japanese nurses weremembers of the Japanese Society of Travel and Health.

To conclude this section, the nurses responded to aLikert Scale with nine statements relating to their clinicalroles. To encourage a decision, no ‘undecided’ option wasoffered. Table 5 portrays a comparison of the three coun-tries. Apart from the importance of travel health care tothe individuals and their employers, on which all threegroups agreed, most of the remaining statements are linkedto training, knowledge and qualifications in travel health.Japanese nurses generally were less confident with givingbasic and complex travel health advice and also felt theywere not adequately prepared for the tasks required ofthem. Only Australian nurses appeared to experience pro-fessional conflict between nurses with travel health quali-fications and doctors without.

Table 4 Travel health clinical practice.

Australia Japan UK

When a traveller requires a vaccination, N Z 96 N Z 23 N Z 326I am an independent prescriber and can administerany licensed vaccines without supervision

4 (4.2%) 0 (0.0%) 85 (26.1%)

All vaccines I administer must be prescribed by a doctor 76 (79.1%) 3 (13.0%) 34 (10.4%)All vaccines are prescribed and administered by a doctor 0 (0.0%) 18 (78.3%) 1 (0.3%)I can administer certain vaccines underthe guidance of a PGD (Patient Group Direction) or protocol

15 (15.6%) 2 (8.7%) 194 (59.5%)

Other 1 (1.0%) 0 (0.0%) 12 (3.7%)When a traveller requires malaria advice and medication, N Z 96 N Z 21 N Z 324I am an independent prescriber and can administerany licensed anti-malarial medication

0 (0.0%) 0 (0.0%) 69 (21.3%)

I give advice and recommend anti-malarialmedication but the doctor signs the prescription

34 (35.4%) 11 (52.4%) 205 (63.3%)

The doctor will always advise the travellerand prescribe anti-malarial medication

61 (63.5%) 7 (33.3%) 9 (2.8%)

The traveller is advised to seek advice on malaria from a pharmacy 0 (0.0%) 0 (0.0%) 14 (4.3%)Other 1 (1.0%) 3 (14.3%) 27 (8.3%)Next largest task after vaccinations and malaria advice N Z 90 N Z 22 N Z 324Traveller education/consultation 62 (68.8%) 5 (22.7%) 293 (90.4%)

Preparing/completing official documentation, such as certificates 22 (24.4%) 3 (13.6%) 6 (1.9%)Administrative work 4 (4.4%) 3 (13.6%) 17 (5.2%)Researching geography 1 (1.1%) 10 (45.4%) 8 (2.5%)Other 0 (0.0%) 1 (4.55%) 0 (0.0%)Availability of reference and information sources (multiple answers) N Z 95 N Z 42 N Z 323Internet web sites 95 (100%) 42 (100.0%) 322 (99.7%)

Telephone help lines 36 (37.9%) 12 (28.6%) 218 (67.5%)Textbooks 65 (68.4%) 29 (69.0%) 213 (65.9%)Reference charts 56 (58.9%) 26 (61.9%) 101 (31.3%)Protocols/guidelines 62 (65.3%) 34 (81.0%) 208 (64.4%)Experienced work colleagues 67 (70.5%) 25 (59.5%) 147 (45.5%)Other 4 (4.4%) 0 (0.0%) 20 (6.2%)Of those sources, the most used is N Z 95 N Z 42 N Z 323Internet 52 (54.7%) 29 (69%) 315 (97.5%)

Work colleagues 13 (13.7%) 6 (14.3%) 5 (1.5%)Additional useful sources would be N Z 40 N Z 0 N Z 111Online videos 13 (3.2%) 35 (31.5%)Phone apps 2 (0.5%) 29 (26.1%)Time allocated for appointments allows satisfactory travel health care N Z 95 N Z 39 N Z 322Always 11 (11.6%) 2 (5.1%) 22 (6.8%)Most of the time 76 (80%) 22 (56.4%) 260 (80.7%)

Rarely 8 (8.4%) 13 (33.3%) 38 (11.8%)Never 0 (0.0%) 2 (5.1%) 2 (0.6%)Membership of Travel Health Organisation N Z 95 N Z 41 N Z 320No 85 (89.5%) 21 (51.2%) 266 (83.1%)

Yes 10 (10.5%) 20 (48.8%) 54 (16.9%)

Providing travel health care e the nurses’ role: An international comparison 219

Biggest challenge in daily practice

Towards the end of the survey, the nurses were asked todescribe the biggest challenge they faced in daily practice.Ninety-four Australian, 28 Japanese and 322 British nursesshared their views. A large amount of information wasoffered; therefore, a summarized overview shall sufficehere, with more detailed country-specific descriptions tobe published separately. Unless there were substantialdifferences in views between the countries, the various

topics are presented collectively. Time issues were a majorchallenge, i.e. time with the traveller e allocatedappointment time, amount of education time e which is incontrast to the figures presented earlier; time to meetadministrative requirements; and time for one’s own pro-fessional development. Educating and advising the trav-eller, the core of nurses’ work, also presented a formidablechallenge. The nurses’ aim was to give high quality carewith best possible information and advice. Many travellersfailed to acknowledge or perceive risk, especially young

Table 5 Professional statements (how strongly do you agree with the following statements?).

Stronglyagree

Agree Disagree Stronglydisagree

Ratingaverage

Responsecount

I feel confident when giving complex travelhealth advice and immunisations.

18.7% (17)0.0% (0)20.2% (64)

51.6% (47)

21.9% (9)59.9% (190)

27.5% (25)51.2% (21)

17.4% (55)

2.2% (2)26.8% (11)2.5% (8)

2.133.052.02

9141317

I feel confident when giving basic travelhealth advice and immunisations.

52.2% (48)

14.6% (6)75.5% (240)

47.8% (44)56.0% (23)

24.2% (77)

0.0% (0)21.9% (9)0.3% (1)

0.0% (0)7.3% (3)0.0% (0)

1.482.221.25

9241318

I have been expected to provide travelhealth care without having sufficient training.

7.5% (7)12.2% (5)2.8% (9)

24.7% (23)36.65% (15)

17.5% (56)

47.3% (44)

34.1% (14)52.2% (167)

20.4% (19)17.1% (7)27.5% (88)

2.812.563.04

9341320

My employers consider that travel healthcare is an important part of my work.

21.5% (20)26.8% (11)22.8% (73)

50.5% (47)

39.0% (16)

53.1% (170)

28.0% (26)29.3% (12)21.3% (68)

0.0% (0)4.9% (2)2.8% (9)

2.062.122.04

9341320

I consider travel health careto be an important part of my work.

32.3% (30)30.9% (13)40.0% (128)

61.3% (57)

61.9% (26)

55.6% (178)

6.5% (6)7.2% (3)4.1% (13)

0.0% (0)0.0% (0)0.3% (1)

1.741.761.65

9342320

Nurses play an important role in the provisionof travel health care in my country.

43.0% (40)24.4% (10)64.1% (205)

47.3% (44)

56.0% (23)

34.7% (111)

9.7% (9)17.1% (7)1.3% (4)

0.0% (0)2.4% (1)0.0% (0)

1.671.901.37

9341320

I feel that not enough training opportunitiesare made available for busynurses providing travel health advice.

44.1% (41)

9.7% (4)28.2% (90)

41.9% (39)53.6% (22)

45.5% (145)

12.9% (12)34.1% (14)22.9% (73)

1.1% (1)2.4% (1)3.4% (11)

1.712.222.02

9341319

Working in the same setting, thereis a potential conflict of rolesbetween a nurse with qualificationsin travel health and a doctorwithout such specialisation.

19.4% (18)2.4% (1)8.3% (26)

43.0% (40)

14.6% (6)32.4% (101)

33.3% (31)48.8% (20)

50.6% (158)

4.3% (4)34.1% (14)8.7% (27)

2.233.152.60

9341312

Working in the same setting,there is a potential conflictof roles between a nursewith qualifications in travel healthand a nurse without such specialisation.

12.0% (11)2.4% (1)7.0% (22)

35.9% (33)14.6% (6)25.9% (81)

46.7% (43)

53.6% (22)

56.5% (177)

5.4% (5)24.4% (12)10.5% (33)

2.463.092.71

9241313

First line, Australia; second line, Japan; third line, UK; 1, strongly agree; 2, agree; 3, disagree; 4, strongly disagree.

220 I. Bauer et al.

adults, or the more vulnerable, such as infants, pregnantwomen or elderly. Not appreciating the seriousness of somepotential conditions and the need for prevention, madehigh quality care particularly taxing.

Specific issues appear when advising visiting friends andrelatives regarding malaria prophylaxis and the need forimmunizations, with failure to complete courses or reluc-tance to receive prevention due to cost. Additionally,nurses’ advice had to compete with non-medical informa-tion sources, such as friends and the internet. A traveller’srisk assessment is an important part of a consultation madedifficult by patients with no record of their immunizationhistory or unsure of their exact itinerary. Two categories of‘problem patients’ were highlighted; those who presentvery late, so that only incomplete care can be given, andthose planning multi-destination trips, again making caredifficult if the actual destinations are not yet confirmed.

In terms of the nurses’ own preparation for the task, amajor challenge was ‘keeping up-to-date’ with currenthealth issues at world destinations but, more importantly,being able to attend training and education courses in travelmedicine. The most cited barriers were a lack of financialsupport from the employers, no time release, or limited

availability of suitable courses. Budget constraints did notonly affect travellers who had to pay for consultations, im-munizations and medication but often influenced the levelof care available so that nurses had to work especially hardto meet their own standards of care within a tight budget. Itappeared difficult to balance the necessary time and ma-terials for providing patient care whilst ensuring that abusiness is reasonably profitable. In addition, Australiannurses commented on possible conflicts between nurses andGPs including background knowledge in travel medicine/health and understanding of legal requirements when pre-scribing and administering vaccinations. Mental health is-sues occurring overseas and the decision to recall atraveller/expatriate was a concern in Japan.

Final comments

At the end of the survey, additional comments wereinvited. In general, previously noted issues were rein-forced, such as time constraints and costs to patients. Thebiggest theme taken up again was training/education fornurses involved in travel health care. There is an enormous

Providing travel health care e the nurses’ role: An international comparison 221

demand for relevant courses of various lengths to ensurecare of the highest standard. Courses were known to beavailable (especially in the UK) though much demandedshort courses on particular topics seemed harder to find.The main barrier to attendance was time off work and thecost of such training. Although there are commendableexceptions, neither barrier is generally overcome by theemploying agency, public or private. In all three countries,training was seen as essential and should possibly bemandatory for any nurse involved in travel health. InAustralia, national endorsement was suggested to allownurses to give travel vaccinations and health advice inde-pendently e a system which is currently being developed inthe Netherlands.26 An Australian national immunizationregister would avoid reliance on travellers’ memory whenplanning an immunization schedule and also to potentiallydecrease unnecessary adverse reactions.

Professional issues also triggered some comment. Manynurses were happy to work alongside highly skilled col-leagues (nurses and GPs); but there were issues with nurseshaving a higher level of education in travel medicine thanthe prescribing doctors, and so having to accept pre-scriptions and advice not based on best practice as per thecurrent knowledge base of travel medicine. Many GPsacknowledged the nurses’ specialist knowledge by askingthem for advice when necessary; however, others consid-ered travel health care simply as provision of vaccines.Elsewhere, the travel health nurse worked independentlywith patients appropriately referred by other nurses anddoctors within the clinic.

Discussion

As expected, specialist knowledge and professional rolesfeatured highly in the results with both similarities anddifferences being highlighted between the three countries.The historical evolution of travel medicine in each countryprovides a fundamentally different context in which thenurses work. This context and the different standing of theprofession, including the respective legal and regulatoryframeworks, determine what nurses do today. The rela-tively long history of travellers’ health care in the UK, andthe development of more expanded nurse roles, mayeventually be mirrored in Australia where the notion oftravel health nursing is more recent and not yet acknowl-edged by formal nursing bodies. As described earlier, Jap-anese travel medicine is positioned in a completelydifferent context, and travel clinics outside occupationalhealth or quarantine settings are only now emerging. Theseclinics are small and managed by a doctor alone; however,it is expected that in the future nurses will be much moreinvolved in these new settings.

Different legislation is highlighted when it comes toprescribing and administering vaccines and medicationswith a variety of arrangements that reflect not only therequirements of the respective regulatory bodies but alsothe level of evolution of the profession. This is not uniqueto the three studied countries as a recent Dutch paper ontravel health nurse prescribers’ indicates.26

Despite those differences, the data suggest many simi-larities between nurses’ work, roles and challenges. For

example, it is well recognized that the UK has been at theforefront of travel health care provision and developmentof the specialty within the nursing profession. The results ofthis study reflect this in the years of experience and rolesundertaken by the UK based nurses. However, the Austra-lian and Japanese responses appear to demonstrate verysimilar concerns and dilemmas which remain unresolved inall countries, most concerning the lack of educational op-portunities. With current economic constraints, the phar-maceutical companies are providing fewer study days.Accredited training courses are infrequent and involveattendance fees and possible travel expenses to be met byeither the nurse or employer. With no compulsory trainingrequired before giving travel health care in any of our threestudy countries, the incentive to support training costs willbe of low priority in many instances.

The barriers to further education (time, time off work,and cost) often prevent much needed training. Nursesworking in dedicated travel medicine settings should haveless difficulty justifying their need for specific education. Itis predominantly the practice nurses, already deliveringcare in a range of medical fields, who lack travel healthtraining opportunities but are expected to provide anadequate level of care. However, the lack of mandatorytraining requirements is of grave concern and raises theissue of potential litigation due to poor practice in travelhealth care. This was highlighted in 2012 during a caseagainst a practice nurse in the UK where incompetenttravel health and immunization practice was cited.

Another similarity was the use of the internet for quickand reliable information. Most nurses felt they had sufficienttime to access this, although the figures were contradictedin the open-ended questions on challenges. This may meanthat a reasonable, but perhaps not the best possibleconsultation, can be achieved within the allocated time.Nurses in all three countries struggled with issues that werenever properly resolved, such as uncertainties regardingvaccinations, malaria prophylaxis, definitions (low/highrisk, short/long-term), correct maps and vague recommen-dations. These issues are longstanding and concern bothnurses and doctors providing travel health care. Theyshould, therefore, be the focus of attention for the benefitof all travel health professionals. More precise, evidence-based guidelines and matrices for decision-making need tobe produced as a matter of urgency. Similarly, the ‘biggestchallenges’ experienced by the nurses, such as travellersconsulting late, the absence of risk appreciation, lackingvaccination histories, or preference for non-medical advice,are issues experienced by doctors as well.

Recommendations

Although this study relied on self-selected conveniencesamples, the findings are nevertheless important andjustify recommendations in response to the nurses’concerns.

Future research

This study was a first basic comparison and this paper onlypresents an overview. More detailed country-specific data

222 I. Bauer et al.

will be published separately and country-appropriateinterpretation and recommendations will be made. Basedon the findings, more in-depth research with larger samplesshould be conducted in the three locations individually.This study should also encourage nurses in other countries,especially where travel health nursing is relatively new, toreplicate this project to compare internationally anddesign the appropriate recognition and expansion of nurses’roles.

Education

Although there is an improvement since the 1998 UK study5

which demonstrated that 98% of nurses highlighted a needfor travel health education, the numbers are still verylarge. More data are needed to distinguish the exacteducational needs between nurses with a tertiary degree intravel medicine and practice nurses/occupational healthnurses who provide travel health among a range of otherfields. Nevertheless, nurses in General Practice who providetravel health care regularly should be supported inobtaining a formal qualification, e.g. Certificate, Diplomaor Masters, if they so wish. For many practice nurses, travelhealth is only a small part of their daily work and they needto be updated in a range of fields. Suitable courses, offeredby reputable providers, could lead over time to a formaltertiary/professional qualification or be a series of stand-alone modules tailored to individual nurses’ needs. Nursesalso require easier access to travel medicine journals. CDswith selected relevant literature on travel health advice27

and travel/tropical medicine as prepared by the RCN areeducational, a convenient way to remain current in thefield and allow integration into a continuing professionaldevelopment (CPD) framework. Series of articles designedfor CPD28,29 are useful in meeting, for example, therequired 35 hours over three years of CPD in travel medi-cine in the UK.30 The benefits of online or distance educa-tion in nursing are well established,31 allowing nurses tostudy in their own time and at their own pace, overcomingsome of the cited barriers to CPD. Online study is not yetestablished in Japan but may be an additional way todeliver, for example, the yearly seminars currently avail-able through the JSTH, or continued education through theJapanese Society of Occupational Health.32 Distance edu-cation also opens up opportunities to study internationally,though tuition may be costly. Regardless of the study mode,the content must not only be guided by the evidence-basedbody of knowledge in travel medicine but by nurse-specificaspects as identified by the nurses themselves. Thesecourses must also be sympathetically priced to acknowl-edge the nurses’ wide variety of areas of practice. Nurses inall three countries were expected to provide travel healthcare without sufficient training. This is inconsistent withhigh quality care and must be remedied for the benefit ofthe traveller, the nurses and the employers.

Development and expansion of nurses’ professionalrole

The political and legislative implications of the roleexpansion from a doctor’s handmaiden to independent

nurse practitioner (NP) will also be felt in travel medicine.These changes are evident in the comparison of the threegroups in this study and coincide with the historicaldevelopment of travel medicine as well as the nursingprofession.

In the UK, the role of the advanced nurse practitioner isan area of professional development open to nurses work-ing in general practice and often involves a supervisory roleof other practice nurses in a primary care team; but again,travel health services will usually be a part of their broadremit rather than a specific specialty.33 With very few ofthe respondents being independent prescribers, the needto work alongside medical practitioners for authorization ofprescription medication is obvious, but also restricts thenurses in their ability to work autonomously. This dividedresponsibility perhaps explains the reluctance for nurses tobe given time and financial support for training by theirmedical colleagues, who may perceive travel health care asvaccination based, and not appreciate the knowledgerequired to give a complete care package. The UK system ofproviding vaccination under PGDs is helpful in many in-stances but, unfortunately, does not apply to the majorityof travel vaccines (i.e., only the few provided free ofcharge within the NHS); therefore, written authorization bythe prescribing colleague is frequently required.

Australia does not have ‘travel health nurses’ as aseparate specialty. The relatively new role of masters-prepared NPs has attracted much debate34e37 thoughregistration and legislation seem in some instances unsat-isfactory. In October 2011, the position of a NP for a travelclinic was advertised but at the time of writing, the na-tional registration body for health professionals has yet toregister an NP in travel medicine. Travel medicine seems anideal field for NPs although this pathway may still have tomature. Accredited nurse immunizers are not licensed togive travel vaccinations independently. Some nurses in thisstudy suggested a national endorsement for nurses to givetravel health advice and vaccinations independently. Whilenumerous barriers can be expected, this is something that,with the appropriate training, should be explored. Howev-er, the creation of the specialty ‘travel health nurse’ shouldbe considered with some urgency.

The unique social and cultural context of Japanesenursing in a male dominated society influences the rate ofchange acceptable within and outside the profession.38

Therefore, the debate around the creation of NPs is muchmore recent and has been pursued, for example, for peri-and neonatal nursing, so far unsuccessfully.39 Adult careNPs graduated recently from the Oita University of Nursingand Health Sciences but with missing legislation, these NPswork as registered nurses.39 It is certainly too premature tosuggest NPs for travel health but travel health nursing couldbecome the 12th area for Certified Nurse Specialists (CNSs).In a country with a population of 123 million, and anincreasing amount of travellers, the number of travelclinics will have to rise, and well-educated travel healthnurse specialists will contribute to high quality care coin-ciding with a recent demand for the development of newnursing roles.40 Regardless of which path is taken in eithercountry, barriers to evidence-based practice need to beidentified41 so that a specialized body of knowledge can beestablished.

Providing travel health care e the nurses’ role: An international comparison 223

From special interest groups to national registers

At this point, there seems to be no particular organizedprofessional group of nurses working in travel health in thethree countries. The Royal College of Nursing in the UK doesnot now support its specialist Travel Health Forum group,but includes one representative from Travel Health within amore general Public Health Forum. This is of concern forthose involved in travel health care as the importance andemphasis on the specialty has been reduced. To give nursesin travel health a voice, they need to organize themselves,know the size of their group, their roles, and educationaland professional needs in order to provide support and workactively to develop their role. Nurses themselves need tobe proactive; they need to maintain independence andidentity, and not be swallowed up by a larger body. Politicaland legislative role development is hard work but should bemotivated by the aim of a national register of the specialty.Travel Health Nursing Special Interest Groups are a conve-nient and useful way to start getting together for support,mentoring and role development42 and should be incorpo-rated within a practice nurses organization, or nationalnursing organizations, such as the RCN or RCNA.

Another option of forming and networking as a profes-sional group to source updated knowledge is as a memberof a travel health organization. The data suggest thatAustralian and UK nurses are poorly represented in travelmedicine association, but the sample group included alarge number of practice nurses for whom travel health isonly part of a range of clinical fields. If only 10% of theirtime is devoted to travel health, belonging to other orga-nizations will be seen as much more important and cost willprohibit multiple memberships. Half of the Japanese nurseswere members, predominantly of the JSTH which enjoys agrowing number of nurse members,43 but the Japanesesample also focused more on nurses in specific travel healthrelated positions.

While UK nurses have the option of joining the BritishGlobal & Travel Health Association or becoming AssociateMembers of the RCPSG Faculty of Travel Medicine, thereare no similar organizations in Australia. The small popu-lation (23 million) and a correspondingly small number oftravel health practitioners may not make a national societyviable. However, nurses with little national support benefitfrom joining the international society (ISTM) and its NursingProfessional Group for support and shared participation inrole development globally. The ISTM should recruit nursemembers through targeted marketing among practicenurses, especially in Australia, and offer fees that reflectand accommodate the nurses’ obligations to a number ofmedical fields.

Conclusion

As the largest professional group providing travel healthcare, nurses will increasingly be at the forefront of thisspecialty. This study represents an initial baseline com-parison of nurses’ roles and challenges in three differentcountries, where both the historical evolution of travelmedicine and development of respective nursing pro-fessions, illustrate distinctive work contexts. Although the

sample sizes were small, the findings are important as theyclearly convey nurses’ educational and professional needs.In order to further develop the unique role of the travelhealth nurse, and to strengthen their voice within this areaof health care, a proactive approach is required. Largeformal nursing organizations may not always be the place tostart innovation. Rather, it is the nurses themselves andtheir demands that will necessitate the changes andencourage improvements, thereby ensuring travel healthcare of the highest standard.

Conflicts of interest

None.

Acknowledgement

We thank Prof Kyoko Namikawa for her assistance with theJapanese part of the study. We also wish to thank the variousnursing organizations and others who helped to announcethis study and so giving the nurses an opportunity to partic-ipate. Finally, we are grateful to our colleagues in Australia,Japan and the UK for their contributions to this project.

References

1. Steffen R, DuPont H. Travel medicine: what’s that? J TravelMed 1994;1:1e3.

2. Kozarsky P. The body of knowledge for the practice of travelmedicine-2006. J Travel Med 2006;13:251e4.

3. Jones M, Walker E, Chiodini P, Angus B, Boyne L, Grieve A.Travel medicine has come of age and a new examination marksthe 21st birthday. Travel Med Infect Dis 2009;7:179e80.

4. Hill D, Behrens R. A survey of travel clinics thought the world. JTravel Med 1996;3:46e51.

5. Carroll B, Behrens R, Crichton D. Primary health care needs fortravel medicine training in Britain. J Travel Med 1998;5:3e6.

6. Hoveyda N, McDonald P, Behrens R. A description of travelmedicine in general practice: a postal questionnaire survey.J Travel Med 2004;11:295e9.

7. Porter J, Knill-Jones R. Quality of travel health advice inhigher-education establishments in the United Kingdom and itsrelationship to the demographic background of the provider. JTravel Med 2004;11:347e53.

8. Halcomb E, Patterson E, Davidson P. Evolution of practicenursing in Australia. J Adv Nurs 2006.

9. Beadnell C. Nurses in general practice: a moving force. ANJ2011;18:25e8. 55:376e90.

10. Watts I, Foley E, Hutchinson R, Pascoe T, Whitecross L,Snowdon T. General practice nursing in Australia. Canberra:Royal Australian College of General Practitioners & Royal Col-lege of Nursing Australia; 2004.

11. Carrigan C. Expand nurses’ roles in primary care: it won’t hurta bit. ANJ 2008;15:24.

12. Halcomb E, Davidson P, Griffiths R, Daly J. Cardiovasculardisease management: time to advance the practice nurse role?Aust Health Rev 2008;32:44.

13. Parker R, Keleher H, Forrest L. The work, education and careerpathways of nurses in Australian general practice. Aust J PrimHealth 2011;17:227e32.

14. Komatsu H. Oncology certified nurse specialist in Japan. JapanJ Clin Oncol 2010;40:876e80.

224 I. Bauer et al.

15. Department of Health. The NHS plan e a plan for investment,a plan for reform. Available from:. London: Department ofHealth http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4002960;2000.

16. Joyce C, Piterman L. The work of nurses in Australian generalpractice: a national survey. Int J Nurs Stud 2011;48:70e80.

17. Virk A, Fischer P. Travel medicine: an American view of theAustralian perspective. Travel Med Infect Dis 2005;3:77e9.

18. Hamada A. Past, present and future of travel medicine inJapan. Travel Med Infect Dis 2010;9:187e91.

19. Ishihara I, Yoshimine T, Horikawa J, Majima Y, Kawaorto R,Salazar M. Defining the roles and functions of occupationalhealth nurses in Japan: results of job analysis. AAOHN J 2004;52:230e41.

20. Japanese Association of Certified Nurse Specialists. Availablefrom: www.jpncns.jp/ch7_english/top.html [retrieved 28November 2011].

21. Ishida K. Account of SARS turmoil as a quarantine officer Jap-anese. Travel Med 2003;18:13e5.

22. Royal College of Nursing. Delivering travel health services, RCNguidance for nursing staff. London: Royal College of Nursing;2005.

23. Royal College of Nursing. Competencies: an integrated careerand competency framework for nurses working in travelhealth medicine. London: Royal College of Nursing; 2007.

24. Chiodini J, Boyne L, Stillwell A, Grieve S. Travel health nursing:career and competence development, RCN guidance. London:Royal College Nursing; 2012.

25. Chiodini J, Anderson E, Driver C, Field V, Flaherty G, Grieve A,et al. Recommendations for the practice of travel medicine.Travel Med Infect Dis 2012;10:109e28.

26. Overbosch F, Koeman S. van den Hoek A, Sonder, G. Dutchtravel health nurses: prepared to prescribe? J Travel Med 2012.http://dx.doi.org/10.1111/j.1708-8305.2012.00660.x.

27. Bauer I. Educational issues and concerns in travel healthadvice: is all the effort a waste of time? J Travel Med 2005;12:45e52.

28. Chiodini J. Providing a travel health service in primary care.Nurs Stand 2005;19:57e65.

29. Chiodini J. Immunisation: promoting travel health. Prim Hlth C2010;20:30e8.

30. Green A.What’s in a name?Continuing professional developmentin travel medicine. Emporiatrics 2011;Autumn/Winter:8e9.

31. Atack L, Luke R. Impact of on online course on infection controland prevention competencies. J Adv Nurs 2008;63:175e80.

32. Hatanaka J. Continued education system of occupationalhealth nurses in the Japanese Society of Occupational HealthJapanese. Occupational Health J (Japan) 2010;33:13e5.

33. Royal College of Nursing. RCN competencies advanced nursepractitioners e an RCN guide to the advanced nurse practi-tioner role, competencies and programme accreditation.London: Royal College of Nursing; 2008.

34. Considine J, Fielding K. Sustainable workforce reform: casestudy of Victorian nurse practitioner roles. Aust Health Rev2010;34:297e303.

35. Elsom S, Manias E, Happell B. The clinical nurse specialist andnurse practitioner roles: room for both or take your pick? Aust JAdv Nurs 2006;24:56e9.

36. Harvey C, Driscoll A, Keyzer D. The discursive practices ofnurse practitioner legislation in Australia. J Adv Nurs 2011;67:2478e87.

37. Tuaoi LA, Cashin A, Hutchinson M, Graham I. Nurse practitionerpreparation: is it time to move beyond masters level entry inAustralia? Nurs Educ Today 2011;31:738e42.

38. Turale S, Ito M, Nakao F. Issues and challenges in nursing andnursing education in Japan. Nurse Educ Pract 2008;8:1e4.

39. Eklund W. Japan and its healthcare challenges and potentialcontribution of neonatal nurse practitioners. J Perinat NeonatNur 2010;24:155e66.

40. Onishi M, Kanda K. Expected roles and utilization of specialistnurses in Japan: the nurse administrators’ perspective. J NursManage 2010;18:311e8.

41. Gerrish K, Ashworth P, Lacey A, Bailey J, Cooke J, Kendall S,et al. Factors influencing the development of evidence-basedpractice. J Adv Nurs 2007;57:328e38.

42. Tori K, Morley E. Nurse practitioner special interest groups:effective or not? J Nurse Pract 2011;7:565e70.

43. Hashimoto C, Sato N. Travel medicine and the role of nursing.Health Care 2009;51:811e6.