Australian Capital Territory
Health (Nurse Practitioner Position and Scope of Practice) Approval 2015 (No 3)*
Notifiable instrument NI2015-171
made under the	
Health Regulation 2004 - section 8 (Approval of nurse practitioner positions) 

1	Name of instrument

This instrument is the Health (Nurse Practitioner Position and Scope of Practice) Approval 2015 (No 3).

2	Commencement

This instrument commences on the day after notification.

3	Scope of Practice for nurse practitioner positions

Under section 8, approval of nurse practitioner positions, I have approved the establishment of a new nurse practitioner position within the Shock Trauma Service –Canberra Hospital & Health Services. The scope of practice statement for this Nurse Practitioner position is attached. 

As this position is ‘new’, the clinical practice guidelines and medication formularies are a work in progress.  These will be finalised and endorsed by the local Clinical Practice Guideline Advisory Committee within the first three months of the position being established.  The endorsed Clinical Practice Guidelines will then be submitted for final approval and endorsement by the ACT Chief Nurse and Director-General ACT Health prior to being posted on the ACT Nursing & Midwifery Office website. 

Dr Peggy Brown
Director-General

5 September 2014

4.2	Detailed Scope of Practice statement 

The TNP is responsible and accountable for direct patient management and the resulting outcomes, working within the defined scope of practice which complies with the ANMAC National Competency Standards for Nurse Practitioners.

Patient management activities:
Provides comprehensive care to injured patients identified through daily negotiation and collaboration with the STS Consultant, as well as the on call General Surgeon/Registrar.  

ASSESSMENT:
•	Prioritises assessment based on patient presentation and condition; intervenes to address immediately life threatening conditions before continuing assessment
•	Performs comprehensive health history and physical examination
•	Performs daily tertiary assessment
•	Performs directed assessment for evaluation of clinical status changes as needed
•	Obtains information from previous medical records, the patient’s Primary Care Provider, family, and others to clarify the health history and findings on physical exam
•	Performs ongoing assessment of patient response to the plan of care and adjusts the plan accordingly
•	Communicates the assessment with appropriate members of the health care team (physicians, nurses, physiotherapists, pharmacists, nutritionists, social workers, case managers, financial specialists, others), patient, and family
•	Documents the assessment in the medical record in a timely and appropriate manner as determined by the institutional documentation guidelines

DIAGNOSIS:
•	Utilises diagnostic reasoning to formulate a differential diagnosis and make a diagnosis
•	Consults with other members of the health care team to identify additional diagnostic considerations and conclusions
•	Identifies and obtains additional data needed to clarify or narrow the diagnosis
•	Communicates the differential diagnosis with appropriate members of the health care team, patient, and family
•	Documents the diagnosis in the medical record in an appropriate and timely manner

MANAGEMENT PLAN:
•	Develops a plan of care that is individualised to the patient’s condition and diagnoses
•	The plan of care is 
o	directed at stabilising the patient’s condition 
o	is based on a risk/benefit analysis and designed to maximize benefits and minimize risks and complications 
o	reflects knowledge of pathophysiological processes 
o	is anticipatory of the usual progression of the disease and sequelae of specific treatment plans
o	identifies further diagnostic studies, specific interventions, and expected outcomes
o	utilises accepted standards of care and/or practice guidelines
o	is designed to be process and cost efficient
o	is dynamic and altered based on patient response
•	Works collaboratively with appropriate members of the health care team to refine the plan of care
•	Communicates the plan of care with appropriate members of the health care team, patient, and family
•	Documents the plan of care in the medical record in a timely and appropriate manner

INTERVENTION:
•	Implements the plan of care
•	Orders and interprets appropriate diagnostic tests
•	Orders treatments, medications, and interventions to be administered by other members of the health care team
•	treatments and interventions
o	are directed at resolution, slowing, or prevention of the pathophysiological process and its sequelae
o	reflect an understanding of the pathophysiological process and a knowledge of the current research regarding management of the disease
o	include, but are not limited to, fluid, electrolyte, and nutritional therapy; oxygen therapy and ventilator management; wound care regimens; rehabilitation therapy; nursing care activities; and specialty equipment
•	Intervenes directly as appropriate for the patient’s situation
o	advanced practice skills are performed after credentialing by the institution and include, but are not limited to advanced life support, suturing, chest tube placement and removal, drain insertion and removal, POP application, and other skills as determined and developed during practice
o	interventions may represent basic skills performed without additional credentialing including peripheral IV cannulation, urinary catheter placement, pulmonary suctioning, arterial blood gas sampling, and medication or blood product administration
•	Consults with other services as needed for specific interventions provided only by those services
•	Educates patient and family about the injury process, plan of care, and expected outcomes
•	Documents interventions in the medical record in an appropriate and timely manner

PATIENT CARE EVALUATION:
•	Performs ongoing evaluation of the patient’s response to the plan of care
•	The evaluation process
o	is interdisciplinary and collaborative
o	is used to modify the plan of care
o	is objective and uses expected outcomes as the measurement standard
o	includes subjective data from the patient and family
o	includes a cost and process efficiency analysis
•	Evaluates patient and family understanding of information provided; clarifies and provides additional information/education as needed
•	Documents the evaluation and plan revision in the medical record in an appropriate and timely manner
•	Communicates the evaluation with health care team, patient and family as appropriate

Non-direct patient care management activities:
Success of the TNP role is directly impacted by the system within which care is delivered. The TNP is responsible for development, evaluation, and modification of the system in order to keep the care delivery process competitive within the rapidly changing healthcare environment and to support the institution’s mission statement and goals.

•	Oversee/manage and coordinate the quality and safety of clinical care provided to the major trauma patient through the care continuum, benchmarking with quality standards as endorsed by the AusTQIP collaboration and the Royal Australasian College of Surgeons
•	Review, develop and evaluate trauma clinical policies procedures, processes, standards, and work practices against best available evidence/ research to achieve clinically and strategically focused outcomes.
•	Lead and participate in committees regarding clinical practice review and workforce development to provide advice to senior management and other staff development.
•	Develop strategic business plans for trauma services in collaboration with senior management for service programs and implement procurement processes to ensure alignment with organisation / corporate plans and direction
•	Participate in the development coordination of grant and funding requests for trauma research proposals/projects and monitor budget expenditure, as well as manage and coordinate the publication of research project findings in relevant refereed journals 
•	Analyse financial data to identify opportunities for cost containment activities
•	Analyse outcome data and quality indicators to identify opportunities to improve quality of care
•	Analyse patient satisfaction data to identify opportunities to improve patient satisfaction
•	Is an active member of the RACS Trauma Verification Team as authorised by RACS 
•	Communicates results of research or its clinical application through publication in national journals or presentation at national conferences

Accountability and support systems:
The TNP reports to the Director of Nursing, Surgical & Oral Health.  Patient care management is carried out with the guidance of the Trauma Director, Deputy Director, Trauma Consultants and Surgical Registrars.  The TNP is accountable for his/her clinical decisions and actions.

Context of practice
The TNP will be an integral component of trauma care. Their contribution includes examination and management of injured patients in the emergency department, subsequent hospital day patient care (writing progress notes, interpreting radiographic and laboratory data, arranging studies), outpatient clinical follow-up care, procedures (e.g. suturing, POP application), supervision of patients during transport for procedures, medication adjustment, patient and family counselling, coordination of care, and discharge planning. The TNP may also perform trauma service management functions such as nursing education, trauma coordinator duties, quality improvement tasks, chart review, and research activities, however clinical duties take priority to these. 

Limitations & Boundaries of practice
Within the scope of this position, the TNP practices collaboratively and autonomously.  When patient management needs exceed the TNP scope of practice, skills, or knowledge base, the TNP is responsible for recognising this limitation and consulting with the Trauma Team and other disciplines.  The Trauma Director (or delegate) is available for consultation with the TNP at all times.  The plethora of resources available at Canberra Hospital is readily available and accessible to the TNP to assist with and perform patient assessments, clinical decision making, and interventions.  

Role of the Supervising Consultant/Registrar 
The supervising Consultant/Registrar for the TNP are senior registrar staff or above. These physicians maintain a collaborative and collegial relationship with the TNP and together will participate in making clinical decisions. When appropriate, each team member will inform the others of changes in the patient’s clinical status and of the plan of care. Supervising physicians will abide by all physician roles described in this document, including: being available for consultation/patient evaluation, review and countersigning (if required) of patient charts, as well as participation in TNP evaluation, including chart audits. 

Patients evaluated by the TNP for/on admission to the hospital will be presented to the Trauma Consultant the day of evaluation for discussion of the assessment, diagnosis, and management plan. The TNP will discuss all inpatient cases with the supervising physician daily. Physician consultations and recommendations will be recorded in the patient record. 

Mandatory supervising consultation will be obtained in the following situations: 
•	Emergencies 
•	Bleeding 
•	Evidence of infections 
•	Abnormal radiographic or diagnostic test results 
•	Adverse drug reactions 
•	Whenever a situation goes beyond the scope of practice/experience of the nurse practitioner 
•	Whenever the patient fails to respond to the management plan in an appropriate amount of time 
•	At the patient, physician, or nurse practitioner’s request