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Australian Nurse Practitioner preferences for continuing education

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					Australian Nurse Practitioner preferences for continuing education
and existing access to electronic resources


Claire Newman
RN, Dip MH Nursing
Research Nurse
University of Technology Sydney Faculty of Nursing Midwifery and Health and
NSW Justice Health

Thomas Buckley
RN, BSc(hons) MN
Co-ordinator Master of Nursing (Nurse Practitioner)
Faculty of Nursing, Midwifery and Health
University of Technology, Sydney

Sandra V. Dunn
RN PhD FRCNA
Professor in Nursing - Clinical Practice
Charles Darwin University

Andrew Cashin
RN, MHN, NP, Dip App Sci, BHSC, GCert PTT, MN, PhD, FACMHN
Associate Professor Justice Health Nursing
University of Technology Sydney Faculty of Nursing Midwifery and Health

Corresponding author:
Claire Newman
(02) 8372 3003
Justice Health Nursing Professorial Unit
Suite 302 level 2, 152 Bunnerong Rd
Eastgardens 2036
Claire.Newman@justicehealth.nsw.gov.au




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Abstract

Background: NP access to computerised technology may increase their provision of

resources, provide point of care technology, and increase opportunities to participate

in continuing education (CE). Little is known about Australian NPs perceptions of the

importance of CE, their preferred methods to undertake CE in relation to prescribing

practices or their access to electronic resources at work

Purpose: To explore the viability of continuing education opportunities and

prescribing resources for Australian NPs via electronic mediums.

Methods: Focus groups were conducted to inform construction of an electronic

survey that was completed by 68 NPs from across Australia.

Results: The majority of respondents (93%) viewed CE to be very important and

preferred methods of continuing education included information by email, and

interactive online case studies. Respondents working in metro areas had increased

access to high speed internet in comparison to NPs working in rural or remote areas

(88% vs. 69%). Significantly more NPs working in metro areas had access to a PDA

than NPs working in rural or remote areas (44% vs. 6%).

Conclusion: This is the first national survey to report preference for CE and access to

technology of NPs in Australia. Electronic technology can provide programmed

support such as online learning and resources through computers and PDAs to

maximise NP prescribing potential.




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Introduction

The NP role in Australia was introduced in 1998 and as of mid 2007 there were

approximately 230 NPs nationally (Della et al, 2007). Similarly to the US, where

legislation authorising NPs was passed over forty years ago, Australian NPs have

advanced and extended nursing roles and are practicing in a wide range of specialities

including emergency, mental health, and palliative care. The development of the NP

role in the US has been accompanied by positive research findings in studies of NP

practice (Phillips, 2007; Towers, 2005). The NP role in the US has progressed to

encompass a wide range of improving services (Phillips, 2007). Most prominent in

this development is the authorisation of prescriptive authority where to date US NPs

have the authority to prescribe independently in 27 US states, and the authority to

prescribe within a collaborative agreement with a physician in the remaining 23 states

(Plonczynski, Oldenburg & Buck, 2003). Whilst Australian NPs have gained

prescriptive authority in all states and territories, except the Northern Territory where

this legislation is under review, their ability to prescribe is hindered by a requirement

to work within restrictive protocols and a lack of Commonwealth Government

funding through the pharmaceutical benefits scheme (PBS) (Cashin, 2007). It has

been suggested in literature that further barriers to prescriptive practice include

difficulties in the availability of and access to appropriate continuing education,

resources and clinical support as outlined below.



Nurse Practitioners and continuing education

Internationally, studies have found an association between the prescribing frequencies

of nurse prescribers and their engagement in continuing education. Studies conducted

in the United Kingdom (UK) reported a low uptake of prescribing practices amongst

qualified independent prescribers and identified that approximately only half of the

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samples reported engaging in formal CE (Latter, Maben, Myall & Young, 2007;

Courtenay, Carey & Burke, 2007). In a qualitative study conducted by Latter et al,

(2007) of 202 nurse prescribers, a significant proportion (95%) of respondents

reported engaging in self directed CE. However only 50% reported engaging in

formal CE. Similarly, Courtenay et al (2007) surveyed a convenience sample of

almost 1200 qualified independent nurse prescribers that represented over 25% of UK

registered nurse prescribers. The authors reported that only 58% of respondents

indicated undertaking CPD since commencing prescribing and 32% reported being

unable to access CPD.



A US study by Goolsby (2005) found high rates of prescribing amongst NPs to be

associated with the uptake of CE activities. A survey undertaken by the American

Academy of Nurse Practitioners (AANP) in 2004 collected data on the prescribing

patterns of a large sample (16,062) of practicing NPs representing all 50 states and the

District of Columbia. This survey found a high number (over 90%) of NPs continuing

to prescribe after obtaining prescribing authority than was found in the UK studies. It

is of note that 87% of respondents indicated being actively involved in continuing

education. It would appear plausible that participation in CE may be associated with

prescribing behaviour. The different contexts limit the certainty however of such a

tentative claim.



Nurse Practitioner partaking in CE may potentially be increased through the

availability of electronic technology where web-based learning and distance education

courses could be completed online. In addition to CE such technology may provide an

effective source of information to NPs at the point of care. However, access to a

computer with appropriate internet connection is required in addition to NP

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confidence in using such sources. In conjunction with the digital revolution

international research has focused on the use of PDAs by nurses as both an

educational and resource tool (see for example, Davenport, 2004; Koeinger-Donohue;

2008). Personal Digital Assistants may be beneficial for providing NPs with updates

and point of care technology. The use of PDAs can allow NPs to store and access up

to date reference material, including detailed drug information, that is available at the

point of care in one’s hand, saving time for NPs and decreasing the risk of human

error and improving decision making (Krauskopf & Wyatt, 2006; Michael, 2007).



Little is known about Australian NPs perceptions of the importance of CE, their

preferred methods to undertake CE in relation to prescribing practices or their access

to electronic resources at work.



Aim

To explore the viability of continuing education opportunities and prescribing

resources for Australian NPs via electronic mediums.



Method

Study design:

In 2007, a total of almost 100 NPs, NP candidates, educators in NP courses and

managers of NP services participated in focus groups designed to discern the shape of

NP prescribing behaviours, enablers and inhibitors. Thematic analysis of the focus

group data, plus a comprehensive review of published and unpublished literature, was

used to inform the content of a national on-line survey.




                                                                                         5
The electronic survey was available for a two week period in November 2007 via the

National Prescribing Service and Australian Nurse Practitioner Association (ANPA)

websites. Invitations to complete the survey were sent to all ANPA members and all

participants in the original focus groups. In addition the survey was advertised in

specialty newsletters and at relevant professional conferences.



Study participants:

A total of 68 authorised NPs participated in the survey. The sample represents 27% of

Australian authorized NPs.



Data analysis:

Participant characteristics and outcome data are reported as raw data. Differences

between groups were analysed using chi-square test (X2 ) for categorical data. Data

were analysed using the program SPSS version 14.0 for Windows.



Ethical Considerations

Ethical approval was received from the Charles Darwin University Human Research

Ethics Committee.



Survey Results

Characteristics and Demographics of respondents

The sample characteristics are shown in Table 1. Seventy percent of the sample were

female and the majority of participants were practicing in nursing for more than 21

years. There was participant representation from every state and territory, with 56% of

authorised NPs located in New South Wales. Three quarters of participants practiced

in metro areas and the majority (94%) in the public sector. Over 30 specialty areas of

                                                                                     6
practice were identified by respondents. The largest speciality group with respondents

was emergency care (23%).



Importance of continuing education

Participants were surveyed on the importance of CE in relation to medication updates

and legislative requirements for prescribing. The responses are presented in Figure 1.

The majority of participants (93%) considered CE on medication updates very

important with the remainder rating it moderately important. Likewise, CE related to

legislative requirements for prescribing was rated as very important for almost three

quarters of respondents.



Preferred methods of continuing education

Respondents were asked to identify their preferred methods for continuing their

education. The most desirable sources of continuing education included information

by email (93% of participants), followed by conference workshops (90%), interactive

online case studies (88%), downloadable print packages (88%) interactive CD

modules (87%), face to face lectures/ workshops (85%) and online video

presentations (82%). Least desirable methods included downloadable case studies for

PDA’s, online discussion groups and downloadable audio files (Table 2).



Access to electronic resources

Participants were questioned on their access to electronic resources with internet

access while at work? The majority of respondents (84%) reported having access to

their own work computer with internet access while at work. However, NP’s

practicing in metro setting were more likely to have broadband/ network access at

work compared to rural and remote practitioners (88% vs. 69%), although this did not

                                                                                    7
reach statistical significance (X2: p=0.07). Additionally, participants were questioned

on whether they owned a PDA. Over one third (35%) of NPs identified owning a

PDA. Nurse practitioners practicing in the metro setting were more likely to report

having a PDA compared to rural or remote NPs (44% vs. 6%, X2: p=0.003).



Discussion

The results from this study indicated that the majority of NPs (94%) viewed CE to be

very important. This is comparable to the sentiment underpinning the result in the US

study by Goolsby (2005) in which 87% of NP respondents indicated being actively

involved in CE. Participants in metro areas had a higher preference for face to face

methods of CE in comparison to NPs located in rural and remote areas (88% vs. 75%

respectively). This may be related to the fact that the bulk of face-to-face CE is

provided in metro or large rural centres to ensure adequate participant attendance.

Despite the difference in access to technology in different geographical locations, it

would appear that increased access to technology does not correlate with preference in

using this technology. Rural and remote NPs identified more of a preference for

receiving CE via PDAs in comparison to metro area NPs (75% vs. 65%), despite a

significantly higher amount of NPs in metro areas owning a PDA. Email was

identified as the most popular potential source of continuing education by 93% of

respondents. This is congruent with the high number of NPs with internet access

participating in the survey. These results are supported by the findings from a survey

of 4330 members of the Australian Nursing Federation, where it was identified that

80% of RNs level 3 and above had sole access to a computer, and the level of

experience and confidence with email was rated high (Eley, Fallon, Soar, Buikstra

and Hegney, 2008).



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Electronic technology in addition to increasing opportunities for NPs to participate in

CE activities may also provide an effective source of information to NPs at the point

of care. Availability of evidence based resources at the point of care would enable

NPs to access the best available clinical content when making prescribing decisions

(Chaiken, 2001; Chapman, 2007). Resources available at point of care for Australian

NPs may include electronic versions of the Australian Medicines Handbook and

National Prescribing Service resources. Other resources may potentially include

access to prescribing software such as that available to general practitioners. However

on exploration of internet access at work, whilst the majority of NPs practicing in

metro areas (88%) had access to broadband or network internet, only 69% of NPs

working in rural or remote areas had this access. It is imperative that rural and remote

area NPs have access to an appropriate internet connection in order to provide an

alternative to face-to-face methods of CE given its unavailability to these NPs.



Nurse Practitioners practicing in metro areas were significantly more likely to own a

PDA. Findings from the Australian Nursing Federation Survey identified that only 3%

respondents had ever used a PDA (Eley, Fallon, Soar, Buikstra and Hegney, 2008).

However, the results from our sample suggest that NPs are more likely to have access

to a PDA than registered nurses and highlight at this early stage the potential for

computerised support systems to be effectively integrated into NP prescribing

practice. In the US Davenport (2004) reported on the perceived benefits and barriers

of PDA use in clinical practice. From an email distributed survey of 76 nurses from

across 12 states, the most significant benefit identified by respondents was having

quick access to a current drug database and nursing reference books. Other benefits

included the ability to manage patient and procedure information and bedside data

entry. Highest rated barriers included the risk of storing confidential information,

                                                                                      9
associated costs with PDA ownership, and the limited research on PDA use in

nursing. However the reported results may have been influenced by the publishing

website that sold PDAs. It is also unknown what percentage of respondents were NPs,

or what percentage owned a PDA.



In Australia, the potential benefits of PDAs have been recognised in the state of

Western Australia (WA). In 2006 NP students in WA were given PDAs as part of a

pilot study with the aim of facilitating the students’ ability to become leaders with the

utilisation of technology in support of improved patient care and appropriate clinical

communication (Michael, 2007). The trial was successfully implemented with the

outcome resulting in the integration of PDAs into the student NP curriculum by 2008.

The use of PDAs were also recently found to improve the educational experiences of

student NPs in a small US study (Koeinger-Donohue, 2008). Whilst it has been

suggested that PDAs may benefit NPs by enabling point of care technology and

improving access to resources, it has been highlighted that many NPs may be phobic

of using PDAs due to the beliefs that patient data may be easily lost potentially

breaching confidentiality, the perceived unaffordable cost and fear of inaccurate

information (Krauskopf and Wyatt, 2006). It is of note that in this study the use of

PDAs in continuing education was the least preferred potential source of continuing

education, in addition to online discussion groups, as identified by 68% of

respondents. It has been suggested that PDA phobias could be overcome by

incorporating simple, practical strategies such as synchronisation of PDA with

desktop, taking responsible security measures and accessing Web sites that are

dedicated to healthcare-related PDA applications (Krauskopf and Wyatt, 2006), and

through online education programmes for NPs (Michael, 2007).



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Limitations

The results of this survey must be interpreted in light of a few limitations. Despite

multiple methods of advertisement of the survey (i.e. flyers, conferences, etc), the

completion of the survey was online which may have limited the ability of some NPs

without computer access (either at home or at work) to participate. Additionally,

respondents represented 27% of authorized NPs at the time of survey which may limit

genreralisation of the findings to all Australian NPs.




Conclusion

Nurse prescribers internationally have experienced a number of economic and

political barriers that limit their ability to utilise prescriptive authorisation. Electronic

technology can provide programmed support such as online learning and resources

through computers and PDAs to maximise prescribing potential. Such programmes

will be valuable to aid NP access to up-to-date information and potentially contribute

to the promotion of confident and effective NP prescribing.




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Table 1. Characteristics of study participants
                                   Nurse
                               Practitioners
                                  (n=68)
                              Number
Age in years (SD)                47.1        7.5
Female                             53      78%
Years practicing as an RN
<5 years                            0
5 - 10 years                        3       4%
11-25 years                         7      10%
16 - 20 years                      10      15%
21 - 25 years                      14      21%
>25 years                          34      50%
Location of practice
Metro                              52     76%
Rural                              12      18%
Remote                              4       6%
Practicing in public sector        64     94%
Practicing in private sector        4       6%
Jurisdiction of NP
authorisation
 - New South Wales                 36     53%
 - Australian Capital               6       9%
   Territory                        1     1.5%
 - Northern Territory               7      10%
 - Queensland                       5       7%
 - South Australia                  8      12%
 - Victoria                         5     7.5%
Western Australia




                   70

                   60

                   50
  No respondents




                   40

                   30

                   20

                   10

                   0
                        A little bit important   Moderately important   Very important


Figure 1 How important to your continuing education: Updates on medications
including new medications, medication alerts and withdrawals




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Table 2 Preferred methods of continuing education
                           Metro    Rural and All respondents
                           n=52     remote       n=68
                                     n=16
                             N (%)        N (%)     N (%)
Email                       47 (90)    16 (100)     63 (93)
Conference workshops        46 (88)     15 (94)     61 (90)
Interactive online case 46 (88)         14 (88)     60 (88)
studies/tutorials
Downloadable         print 46 (88)      14 (88)     60 (88)
packages
Interactive modules on 45 (86)          14 (87)     59 (87)
CD
Face to face lectures/ 46 (88)          12 (75)     58 (85)
education evenings
Online video                42 (81)     14 (88)     56 (82)
presentations
Download case studies/ 34 (65)          12 (75)     46 (68)
quizzes for PDA
Online discussion groups    36 (69)       6 (37)    42 (62)
Downloadable audio files 33 (63)          9 (56)    42 (62)
(e.g. MP3)




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Reference List

Cashin, A. (2007) Issues and Challenges in Advancing the Nurse Practitioner Role.
Collegian. 14(4), 4-5.

Chaiken, B. (2001) Evidence-Based Medicine: A Tool at the Point of Care. Nursing
Economics. 19(5), 234-235.

Chapman, S. (2007) Developing decision support systems for nurse prescribers. Nurse
Prescribing. 5(6), 251-255.

Courtenay, M., Carey, N. & Burke, J. (2007) Independent extended and
supplementary nurse prescribing practice in the UK: A national questionnaire survey.
International Journal of Nursing Studies. 44(7), 1093-1101.

Davenport, C. (2004) Analysis of PDAs in Nursing: Benefits and Barriers. [Accessed
on 28/05/2008]. Available at: www.pdacortex.com/Analysis_PDAs_Nursing.htm.

Della, P., Fielding, K., Hagen, D., Harford, E., Kerr, K. & Wilson, S. (2007) National
progress on nurse practitioner numbers. The Nurse Practitioner Series. 2(1), 33-37.

Eley, R., Fallon, T., Soar, J., Buikstra, E., & Hegney, D. (2008) Nurses’ confidence
and experience in using information technology. Australian Journal of Advanced
Nursing. 25(3), 23-35.

Goolsby, M. (2005) 2004 AANP National Nurse Practitioner Sample Survey, Part II:
Nurse Practitioner Prescribing. Journal of the American Academy of Nurse
Practitioners. 17(12), 506-511.

Koeniger-Donohue, R. (2008) Handheld Computers in Nursing Education: A PDA
Pilot Project. Journal of Nursing Education. 47(2), 74-77.

Krauskopf, P. & Wyatt, T. (2006) Even Techno-Phobic NPs Can Use PDAs. The
Nurse Practitioner. 31(7), 48-52.

Latter, S., Maben, J., Myall, M. & Young, A. (2007) Evaluating nurse prescribers’
education and continuing professional development for independent prescribing
practice: Findings from a national survey in England. Nurse Education Today. 27(7),
685-696.

Michael, R. (2007) The way to the future. The Nurse Practitioner Series. 2(1), 38-42.

Phillips, S. (2007) NPs Face Challenges in the U.S. and the UK. The Nurse
Practitioner. 32(7), 25-29.

Plonczynski, D., Oldenburg, N. and Buck, M. (2003) The past, present and future of
nurse prescribing in the United States. Nurse Prescribing. 1(4), 170-174.

Scudder, L. (2006) Prescribing patterns of Nurse Practitioners. The Journal of Nurse
Practitioners. 2(2), 98-106


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Tilleczek, K., Pong, R. & Caty, S. (2005) Innovations and issues in the delivery of
continuing education to Nurse Practitioners in Rural Northern Communities.
Canadian       Journal     of      Nursing     Research.      37(1),      147-161.




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