Australian Nurse Practitioner preferences for continuing education
and existing access to electronic resources
RN, Dip MH Nursing
University of Technology Sydney Faculty of Nursing Midwifery and Health and
NSW Justice Health
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
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
(02) 8372 3003
Justice Health Nursing Professorial Unit
Suite 302 level 2, 152 Bunnerong Rd
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.
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
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
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
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.
To explore the viability of continuing education opportunities and prescribing
resources for Australian NPs via electronic mediums.
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.
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.
A total of 68 authorised NPs participated in the survey. The sample represents 27% of
Australian authorized NPs.
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 approval was received from the Charles Darwin University Human Research
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
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
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).
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).
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,
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).
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.
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.
Table 1. Characteristics of study participants
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
- 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%
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
Table 2 Preferred methods of continuing education
Metro Rural and All respondents
n=52 remote n=68
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)
Downloadable print 46 (88) 14 (88) 60 (88)
Interactive modules on 45 (86) 14 (87) 59 (87)
Face to face lectures/ 46 (88) 12 (75) 58 (85)
Online video 42 (81) 14 (88) 56 (82)
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)
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