In our roles as Federal Professional Officers at the Australian Nursing & Midwifery Federation (ANMF) we talk about scope of practice on a daily basis. Every conversation we have about nursing scope raises the question of advanced versus expanded practice. Among the confusion one thing is clear, there is a notable lack of uniformity in the understanding and use of these terms.
The Australian Health Practitioner Regulation Agency (AHPRA) defines the scope of a profession as the full spectrum of roles, functions, responsibilities, activities and decision making capacity that individuals within that profession are educated, competent and authorised to perform. The scope of practice of an individual is then defined as that which they are educated, competent and authorised to perform.
Logically, the scope of practice of an individual nurse or midwife is more specifically defined than the scope of practice of their profession.
Advanced scope of practice is an increase in clinical skills, reasoning, knowledge and experience leading to the nurse being an expert working within the scope of traditional practice.
Expanded or extended scope includes expertise beyond the currently recognised scope of practice of the nursing profession.
In Australia, expanded or extended scope of practice for registered nurses is embedded in the nurse practitioner role using the established regulatory safety and quality framework and the protected title. Registered nurses seeking to expand or extend their individual scope beyond that of the profession must follow the nurse practitioner pathway to endorsement.
Over the last two years, Health Workforce Australia has undertaken a series of what they have termed Expanded Workforce Scope Projects as part of their work plan. Two projects involve nurses, one physiotherapists and one paramedics. The nursing projects are described as focussing on: “expanded” nurse roles in the Emergency Department (ED) and an “advanced” practice in endoscopy nursing role. This example demonstrates how the terminology can so easily be confused.
The implementation of “expanded” nurse roles in the ED is in response to an increasing demand in presentations to ED’s. These projects have sought to recognise and utilise professional nursing expertise that already exists by introducing models of care which support nurses working to full, or in some cases, an advanced scope of practice. Some of these projects include endorsed nurse practitioners. The eight project sites for the nurses in ED program have a focus on mental health, paediatric nursing, and rural and remote settings. Sites are spread across NSW and Victoria. Overall, the focus of the ED projects is in reality on ‘advanced’ not ‘expanded’ scope of nursing practice.
These models hold some promise in improving health outcomes for the community. However, they are not about ‘expanded’ scope but rather allowing individual nurses to work more fully, and at an expert level, within the scope of traditional nursing practice.
The pilot of an ‘advanced’ practice in endoscopy nursing role is in response to the expected increase in demand for endoscopies as a result of the National Bowel Screening Program. The two lead sites for this project are in Queensland and Victoria, with Queensland providing the education and training program for the six project participants. The project has been fraught with difficulty as endoscopy is clearly ‘expanded’ not ‘advanced’ practice for nurses. Performance of endoscopy includes expertise beyond the currently recognised scope of practice for the profession. For this model of ‘expanded’ practice to be acceptable and successful it needs to be embedded in the established nursing safety and quality framework for expanded practice - the nurse practitioner pathway.
In order to seek clarity around the many advanced practice roles in Australia, the ANMF has commissioned and funded the ANSWER 4 Nursing and Midwifery Project. This research project is being led by Professor Glenn Gardner from the Queensland University of Technology and Professor Christine Duffield from the University of Technology Sydney. It is a study of the activities and level of nursing and midwifery practice in different positions, titles and grades and advanced practice across the country. This work is essential to understand the meaning of advanced practice for the professions of nursing and midwifery in Australia and for the health industry to understand the capability of nurses and midwives working at different levels of practice. It also has implications for nurses and midwives when they’re considering their postgraduate education options and career planning.
It is important for the nursing profession in Australia to critically reflect on the terminology of advanced and expanded practice. We need to use a shared understanding to support registered nurses to work to their full and, in many cases, advanced scope of practice without undermining the expanded nurse practitioner role we’ve fought so hard to establish.
Remember, in the words of Gandhi, the future depends on what we do in the present.
Elizabeth Foley and Julianne Bryce
Federal Professional Officers