“Nurses working to top of scope” – it is a phrase frequently invoked by nursing executives to describe the future of the profession — one associated with empowerment, innovation, and improved care delivery. Yet for many Nurse Practitioners (NPs) working in public health settings, “top of scope” functions less as an enacted organisational commitment than as an aspirational slogan.
This disconnect is evident in the persistent underutilisation of advanced nursing capability, limited inclusion of NPs in governance structures, and inconsistent organisational support for a legislated role that is firmly embedded within contemporary models of care across Australian states and territories.
A system that does not practise what it preaches
The Nurse Practitioner role was established to improve access, continuity, and timeliness of care through advanced diagnostic expertise, autonomous clinical decision-making, and holistic management within legislated scope.
Despite the well-evidenced capacity of the role, organisational barriers persist across many settings. Governance arrangements are often opaque, and recognition of the NP role remains inconsistent across formal authority, role legitimacy, and operational enablement. Consequently, opportunities for genuine partnership between NPs and nursing leadership remain structurally constrained.
Nurse Practitioners are regulated by the Nursing and Midwifery Board of Australia; however, local credentialing processes are commonly overseen by non-NP clinicians, in contrast to the profession-specific, peer-led models applied in medicine. This arrangement creates misalignment between regulatory authority, role accountability, and expertise in advanced practice evaluation. In practice, credentialing frameworks frequently fail to resolve ambiguity around NP authorisation of practice extensions — such as referral and requesting rights across funding models — with issues often escalated without clear ownership, decision-making authority, or feedback. The result is a persistent governance gap between role assurance and scope authorisation.
Medicine’s enduring influence on nursing leadership
At the heart of this tension lies a reflex within nursing leadership: a continued reliance on medicine to legitimise the boundaries of advanced nursing practice. Decades after the NP role was legislated, many health services continue to require layers of medical approval for NP practice and governance. Although commonly justified as collaboration, such arrangements risk reinforcing hierarchical dependencies that sit uneasily with nursing’s regulatory autonomy.
Rather than standing confidently within the legislated legitimacy of NP practice, nursing leadership often continues to defer to inherited models of clinical authority that privilege medical oversight. In doing so, responsibility for defining and policing scope is displaced beyond the profession itself.
Traditional nursing leadership models, historically oriented toward administration and operations, have not consistently kept pace with the growing clinical autonomy of advanced nursing practice. This misalignment creates distance from diagnostic and therapeutic work and can constrain leadership’s capacity to assert nursing authority within contested clinical spaces.
Paradoxically, medicine frequently becomes a strong ally once the benefits of expert, nurse-enabled collaboration are demonstrated. Many of the strongest patient and service outcomes are observed in settings where multidisciplinary respect is embedded and leadership actively enables shared clinical authority. For many NPs, the primary source of constraint is therefore not medicine, but nursing governance itself — particularly where leadership structures remain cautious, procedurally focused, and distant from advanced clinical practice.
Reclaiming integrity and courage
Nursing leadership cannot credibly advocate for empowerment while maintaining structures that constrain NP practice. Organisational integrity requires alignment between stated values and enacted governance.
Nursing executives frequently cite contextual pressures to explain limits on advanced practice implementation, including workforce shortages, fiscal constraint, rising service demand, and system reform. These pressures are real. However, they are neither new nor unique to the settings in which NP roles are intended to operate — indeed, they have long formed the rationale for NP role development! After decades of pilot programs, evaluations, and demonstrated impact across diverse settings, the persistent framing of these conditions as barriers warrants closer scrutiny. At this point, the challenge is less one of evidence or design, and more one of organisational will, governance alignment, and leadership confidence in advanced nursing capability.
Continued reliance on short-term funding, pilot logic, or external endorsement risks obscuring a central truth: the NP role is no longer experimental. What is required now is deliberate and widespread integration into core service models.
A professional pathway worth believing in
Despite these challenges, the future of nursing is shaped by the calibre of its practitioners. Each year, more NPs emerge — clinicians of extraordinary capability, whose work is driven by responsibility to patients and communities, and whose innovation arises from need and self-belief rather than ambition. Yet without governance structures that fully enable advanced practice, public health services risk continuing to lose these clinicians to private and non-public sector roles where scope, autonomy, and contribution are more consistently supported.
The NP role does not represent a challenge to medicine, but a maturation of nursing’s clinical authority. It demonstrates that advanced practice, accountability, and collaborative care can coexist within clear professional boundaries.
If nursing leadership is serious about enabling practice at the top of scope, the task ahead is no longer conceptual. It is structural. It requires leaders to align governance, authority, and trust with the realities of advanced nursing practice — deliberately, consistently, and without further delay.
Author:
Bronwyn Coulton, Stroke Nurse Practitioner, Melbourne, Victoria
5 Responses
This is excellent! Could we take this further to suggest that the old nursing career structure built in the 80’s is no longer relevant as the scope of practice for nurses and midwives has slowly shifted with the support of legislative and regulatory changes. As written, the hierarchical nursing leadership may be threatened by nurse practitioners, endorsed midwives, those with Doctorates and PhDs qualifications that exceed management’s own qualifications. Hence the call for another layer of control by requiring these practitioners to be credentialed when the NMBA have already endorsed their practice. Midwives too can choose to practice autonomously but continuity of care does not sit well in our fragmented and power driven public hospitals. We need a rethink of our career structure.
Thank you, Mary-Grace.
I think you highlight an important point — that many of the structures underpinning nursing and midwifery leadership, governance, and career progression were developed in a very different professional context to the one we now practice within. Scope of practice, educational preparation, legislative authority, and clinical responsibility have all evolved significantly over recent decades.
This inevitably creates tension when advanced and autonomous practice models are expected to function within older hierarchical frameworks. Credentialling, governance, and organisational oversight are important, but they should enable safe and effective practice rather than unnecessarily constrain it or duplicate existing regulatory endorsement.
One of the challenges I explored in the article is that the organisational structures overseeing credentialling processes may lack clear decision-making authority or advanced practice expertise when issues are escalated. That can create a real misalignment between regulatory authority, role accountability, and organisational governance.
I strongly agree that continuity of care models, particularly in midwifery and advanced nursing practice, challenge some of the fragmentation that has become normalised within large health services.
I’d also welcome stronger collective advocacy from nursing and midwifery leadership for the legislative and funding reforms needed to fully support advanced practice care models — including broader access to Medicare-funded services!
Thank you Bronwyn,
You have hit the nail on its head. I read your article feeling like you know exactly what I am going through with my current job in the public sector.
Agreed! We need to change the old ways of Nursing management/ executive to support and nurture advanced practicing Nurses.
This article resonated deeply with me.
Last year I went through an extraordinarily cumbersome recredentialling process that affected a large number of Nurse Practitioners within my organisation. Although we supported one another through our NP advisory forum, the experience was otherwise remarkably isolating.
What struck me most was the disconnect between organisational rhetoric about nurses working to their full scope of practice and the reality of the governance processes we were subjected to. We were all known quantities to the organisation, endorsed by AHPRA as Nurse Practitioners, and many of us had worked successfully within our roles for years. Yet if documentation was not provided by a specified deadline, we were prohibited from working. There was no provision for interim credentialling, limited communication regarding decision-making processes, and little opportunity to seek clarification or appeal decisions through nursing leadership channels.
Some Nurse Practitioners were forced to take annual leave while navigating an ever-growing list of requirements. As a casual employee, I did not have that option—I simply could not work and lost income. In my own case, despite having completed Advanced Life Support countless times throughout my career, a lapse in currency due to a period of sick leave could not be addressed through recognition of prior learning or professional experience.
My concern was never the requirement to demonstrate competence or maintain standards. Rather, it was the apparent absence of proportionality, flexibility, and professional trust within the process. At times it felt as though the system viewed experienced Nurse Practitioners as a governance risk to be managed rather than a workforce asset to be supported.
For me, this article accurately captures the gap that can exist between the aspiration of enabling advanced nursing practice and the organisational structures that often constrain it. If we genuinely want Nurse Practitioners to work to their full scope, governance processes must provide assurance without creating unnecessary barriers to practice.
Thank you, Ronnie, for sharing this experience so thoughtfully.
Your reflections capture a fundamental challenge in advanced practice nursing: how organisations can provide robust governance and assurance while also enabling the autonomy, expertise and professional judgement that define advanced practice.
Credentialling and scope of practice processes exist for an important reason — to support safe care, professional accountability and public confidence. However, effective governance should not simply seek to control risk; it should create the conditions in which highly skilled clinicians can practise safely, confidently and to their full scope.
The distinction you make between being accountable for maintaining competence and feeling treated as *a governance risk to be managed* rather than a workforce asset to be supported is particularly powerful.
For Nurse Practitioners and other advanced practice clinicians, mature governance requires both assurance and trust: transparent processes, proportional requirements, meaningful communication, and recognition that professional accountability is central to advanced practice itself.
Importantly, the design of these governance processes matters. While organisations retain responsibility for ensuring safe practice, advanced practice clinicians should be active partners in developing the frameworks that define, assess and support advanced practice. Governance is strongest when it is informed by those who understand the complexity and realities of the roles being governed.
Thank you again for adding such a valuable perspective to this conversation.