Nurse Practitioners: Barriers to practice

Jo Perks was one of the first nurse practitioners in Australia, gaining authorisation over a decade ago in 2005. Despite being authorised for many years Jo still experiences barriers in providing optimal care to her patients due to restrictions imposed on her practice.

Having worked at Leichhardt Women’s Community Health Centre in Sydney with patients who were largely disadvantaged and from culturally and linguistically diverse backgrounds, Jo was determined to provide the best quality care to her patients.

“Working at Leichhardt Women’s Community Health Centre gave me a strong background in grassroots primary healthcare. I was a leader in the sector and working autonomously with the support of a doctor at the centre,” Jo says.

“I was really excited when the nurse practitioner opportunity opened up in Australia. It took a bit of work to prove advanced practice because women’s health centres work on a multidisciplinary team model. I had to go through hoops to get authorised because of the way women’s health services operate.”

Jo was one of the first 100 nurse practitioners to be authorised in Australia but found it difficult to get a position once she gained her qualification.

“I was authorised in NSW in 2005 by the former Nurses Registration Board (statebased precursor to AHPRA). Leichhardt Women’s Community Health Centre was really supportive but once I was qualified they couldn’t afford to pay me the going rate,” Jo says.

“I got a position with Penrith Women’s Health Centre one day a week in 2009 and that was prior to changes to the MBS and PBS. At the time I was working collaboratively with a GP and not able to initiate a lot because I didn’t have access to the MBS and PBS.”

Changes to the PBS in 2010 allowed Jo to work more independently when she was able to register for a prescriber number.

“I started working at Liverpool Women’s Health Centre and a few of my hours were in private practice because I had applied for and been granted a prescriber number. In NSW if you work in private practice you can submit a scope of practice document that allows limited ability to prescribe. So I had some access to PBS medications.”

This is where things get frustrating for Jo, she now has limited access to prescribing rights but can’t order diagnostic tests under the MBS or vital PBS medications that are essential for her work in women’s health. These restrictions are not just professionally frustrating but financially disadvantage the women she works with.

“I am currently working across women’s health services in the western suburbs of New South Wales. My work is with women aged between 14 to 90, many are from disadvantaged backgrounds. I can do some prescribing on the PBS but I still can’t order a mammogram or pelvic ultrasound without the women paying the full fee due to restrictions under the MBS.”

Jo says a lot of the women who visit her clinic don’t want to go to male GPs because of cultural issues and don’t feel comfortable talking about reproductive health with a male.

“We do a lot of reproductive health and a lot of the things women tell us they don’t want to tell a male doctor,” Jo says. “One of the biggest barriers I face is the inability to order an ultrasound. A lot of women come to see me for a cervical screening test reporting pelvic pain.

“In order to investigate properly I need to order an ultrasound but I can’t do that under the MBS so the patient would have to pay the full cost. I have a good collaborating GP working with me and she orders the test under her name. Not all doctors are so supportive though and I’ve had a woman tell me a specialist ripped up a referral letter from me and refused to acknowledge my scope of practice.”

Vulnerable women are at risk of missing out on vital care due to MBS and PBS restrictions on nurse practitioners working in women’s health according to Jo. “I have countless stories of women who come to us for cervical screening many of whom have experienced sexual assault and I don’t want to send them off to a GP who might not have the appropriate background to provide the best care,” she says.

“I’ve had women who have waited for hours in a GP’s office only to be told they don’t have the necessary equipment. I’ve had a woman who was told she was too fat for a pap smear examination. This is happening to our clients because I can’t provide continuity of care due to outdated restrictions on my ability to order diagnostic tests.”

Jo has worked with the ANMF to lobby for changes to the MBS to allow nurse practitioners to provide the best quality of care to their clients.

“I provided a presentation to the MBS taskforce about a few months ago that the ANMF asked me to be involved in. I had some slides that had evidence-based information on pelvic ultrasound evidence to inform new guidelines,” Jo says.

“The taskforce has NPs on the panel as well as doctors so that is encouraging, but we need increased lobbying by the industrial and professional bodies as well to ensure nurse practitioners can provide the best care to patients and improve health outcomes.”

Jo works with a lot of women experiencing reproductive health issues and women with breast cancer and while she can prescribe continuing therapy for these women she can’t initiate medications.

“I can’t prescribe a first dose of tranexamic acid, which is a drug that plays a part in helping women who are experiencing heavy menstrual bleeding. Women experiencing hot flushes from breast cancer treatment are often helped by SSR drugs, but I can’t prescribe an initial dose, so I have to find a supportive GP to order that first dose,” Jo says. “These are the glitches in the system that prevent me from providing a complete cycle of care.

“It feels like women’s health was overlooked when deciding on MBS and PBS access for NPs back in 2010,” Jo says.

“If the barriers we face in women’s health were addressed I feel we could provide a timely and streamlined approach to the care we give. And I think it would be cost effective in the long run if my clients didn’t have to go to a GP who doesn’t need to see them.”

Jo intends to keep lobbying for greater access to PBS and MBS items for nurse practitioners working in women’s health so that NPs can provide continuity of care and improve patient outcomes.

“There is quite a way to go for nurse practitioners realising their full potential in women’s health,” Jo says. “I would like to see changes happening before I retire. There are so many women in our communities across Australia who rely on us and we must make sure we do the right thing by them. That’s why I will keep campaigning for positive changes and removal of the barriers that prevent us from providing that optimal care for some of the most vulnerable women in our communities.”

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