Nurse Practitioner
Scope of Practice
Name of NP
Anthony Sokolowski
Specialty
Emergency
Local Health District
Hunter New England
A Nurse Practitioner (NP) is a registered nurse educated and authorised to function autonomously
and collaboratively in an advanced and extended clinical role. The NP role includes the
assessment and management of patients using nursing knowledge and skills and may include but
is not limited to initiation of diagnostic investigations, prescribing of medications and direct
referral of patients to other health care professionals. The NP role is grounded in the nursing
profession’s values, knowledge, theories and practice and provides innovative and flexible health
care delivery that complements other health care providers (ANMC 2006). NPs practice
collaboratively as an interdependent member of the multidisciplinary health care team and provide
autonomous, patient centred care.
The scope of practice (ScOP) of the NP is determined by the context of practice, the education and
level of competence of the individual ANTHONY SOKOLOWSKI and forms part of the Nursing and
Midwifery Board of Australia Safety & Quality Framework.
Each NP must develop an individual ScOP that reflects their expertise and competence. While the
ScOP may be similar for NPs working in certain clinical specialties, it must reflect the capabilities,
expertise and competence of the individual. Establishing and ensuring competence to practice
within a ScOP is the responsibility of both the NP and employer. The employer and NP are to
ensure the defined ScOP is evidence based and in accordance with the LHD policy requirements
and the NMBA S&QF.
Clinical judgment regarding a particular clinical procedure or treatment plan is made by the NP in
light of the clinical data presented by the patient and the diagnostic and treatment options
available. In making clinical decisions the NP remains conscious of their level of expertise and
utilise available resources and expertise of the multidisciplinary health care team.
The authorising legislation for the use, possession, supply and prescription of medications by NPs
in NSW is the Poisons and Therapeutic Goods Act 1966 and the Poisons and Therapeutic Goods
Regulation 2008.
Regulation of NPs is in accordance with the Health Practitioner Regulation National Law (NSW) No
86a.
Practice will be in accordance with current best evidence and both relevant NSW Health and local
LHD policies, procedures and guidelines.
Anthony Sokolowski
Hunter New England Local Health District
23/01/2013
Practice Environment
Local Health District
HUNTER NEW ENGLAND HEALTH DISTRICT
Facilities/Facility Where Nurse Practitioner Role or Service Operates
BELMONT HOSPITAL / Emergency departments within the HNELHD.
Health Service Setting
EMERGENCY DEPARTMENT – CRITICAL CARE
Clinical Service
Specialist area of clinical nursing practice
EMERGENCY MEDICINE
Demographics and supporting services
The base place of employment is the Belmont Hospital; however the NP may work in any emergency department
within the HNELHD.
Model of care
Aim
To enhance emergency services and ensure timely appropriate patient care is delivered.
Practice environment
 Specific: Belmont Hospital is a Level 3 Service serving Newcastle and Lake Macquarie Regions;
Emergency presentations in and 2012 were 25,141
 General: Hunter New England Health District includes Tertiary, District, Rural and Community hospitals
providing public health service for more than 850,000 people from the Hunter, New England and Lower
North Coast regions.
 Across New South Wales there has been a 4-7% increase in the annual Emergency Department
presentations
Anthony Sokolowski
Hunter New England Local Health District
23/01/2013
Service description
Target Population for Service
All patients with injuries/illnesses presenting to the emergency department.
Operational aspects
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The primary model of care the NP works is Ambulatory care. . This involves the independent
management of minor injuries and conditions. This model of care is designed to meet service
gaps for patients presenting to the Emergency Department.
The NP’s secondary role is with remaining presentations to the Emergency Department
providing entails collaborative management of such patients.
The care provided by the NP may include triage, assessment, resuscitation and stabilisation,
ordering and interpreting diagnostic tests, independent prescribing, providing and facilitating
treatment, admitting, discharging, or referral of patients.
The focus of care is principally on Emergency Department presentations, however, the NP may
provide care within his scope of practice in other departments/units as part of an emergency,
disaster, pandemic response, or where requested by executive/senior staff. This may include
patient transport to other facilities.
As well as having a key role in the Emergency Department, this role includes the application of
primary health care and the provision of health education, implementation of health prevention
strategies, and acting as a resource for hospital/area health education and staff development.
Collaboration with key stakeholders, including relevant multidisciplinary inpatient teams,
external services, clinical supports and health care providers, such as GP’s and community
services.
Rostering of NP hours is aligned with service demands of the Emergency Department.
The NP position will be clinically line managed by the Director of the Emergency Department
and/or Staff Specialist, and the Director of Nursing and Midwifery Services for all administrative
aspects of the role.
The NP will be provided appropriate clinical work space in which patient review and all office
related works can be conducted.
The NP will be rostered four hours per week of non clinical time as per the Ministry of Health
Nurse Practitioners in NSW - Guideline for Implementation of Nurse Practitioner Roles - NSW
Health Document Number GL2012_004.
The NP will review the department’s monthly report of activity which is inclusive of Ministry of
Health key performance indicators, including length of stay, NEAT, Triage to time seen,
occasions of service, and unplanned representations within 48 hours.
Anthony Sokolowski
Hunter New England Local Health District
23/01/2013
Parameters of practice
Elements of care
Clinical Practice and Decision Making
ENP clinical practice encompasses the clinical episode for patients presenting to the Emergency Department. The
ENP will undertake assessment, diagnosis, planning of therapeutic interventions, care delivery and evaluation of
both adult and paediatric patients within the Emergency Department, associated hospital departments, and Hunter
New England Local Health District facilities as required. Where appropriate, the ENP will include health promotion
and/or health education activities and prevention education into the care of emergency patients. The ENP will work
in collaboration with other nursing, medical, ancillary, and allied health staff in the provision of care.
Clinical judgement and decision making carried out by the ENP is based on legislative entitlements and the
comprehensive knowledge gained through university specific NP master’s degree education, continued learning and
professional development, in addition to extensive clinical experience.
Under the approved scope of practice the ENP implements pathways and/or clinical practice when caring for
Emergency Department patients within existing local hospital and LHD policies, procedure and guidelines, and in
accordance with relevant policy directives of the NSW Ministry of Health.
 The NP attends to patients throughout the lifespan in accordance with his skill, training, and experience.
 When required, the NP will collaborate with senior medical staff where uncertainty exists with any aspect of
patient care or the presentation is outside his scope of practice.
 The NP will be mindful of age related aspects that could impact upon the health status of his patients, and
will factor this into their care.
Limitations and Referral Criteria (exclusions of care)
The Emergency NP will consult with or refer to a Senior Medical Officer (SMO) in the following situations:
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Unusual, unexpected, persistent or additional signs or symptoms despite prior appropriate evidence based
treatment
Any atypical presentation of a common illness which raises clinical concern or an unusual response to
treatment
Any sign(s) or symptom(s) of behavioural changes that cannot be attributed to a specific organic cause
Any severe injury that is life, sight, or limb threatening
Unexpected deterioration of a chronic condition
In potential life threatening situations including (but not exclusive to)
o Any sign(s) or symptom(s) that are that are threatening to life, limb, organ or eyes.
o Sign(s) or symptom(s) of obstruction of any system
o Signs of severe or widespread infection
o Abnormal vital signs without an identifiable focus
Any other conditions that the nurse practitioner feels is outside of his scope of practice or requires
consultation
Anthony Sokolowski
Hunter New England Local Health District
23/01/2013
Common presenting conditions and disease states managed by the NP (not exhaustive)
Common presentations appropriate to independent Nurse Practitioner management (not limited
to):
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Mild asthma
Bronchitis and Bronchiolitis
LRTI/Pneumonia
Croup
Skin conditions/infections/cellulitis
Sinusitis
URTI/sore throat/ pharyngitis/ tonsillitis
Pyrexia
Burns - minor
Eye conditions and injuries
Allergic conditions
Bites and stings (including marine)
Abdominal pain (suspected appendicitis)
Genitourinary infections and disorders
Nausea and vomiting
Wounds (acute and chronic)
Ear nose and throat problems (otitis media/externa, foreign body)
Epistaxis - minor
Diarrhoea and/or vomiting
Dental and oral health problems
Limb injuries: sprains/strains, fractures, dislocations
Musculoskeletal conditions/pains/injuries
Falls
Headaches, head injuries
Rashes or Urticaria
Complications during early pregnancy
Vascular conditions (ulcers, DVT)
Traumatic injuries – non life threatening
Exclusions from care
Patients with illnesses and injuries whom the NP feels are beyond his ability or expertise to manage independently.
Process of care
Referral pathway / initiation of contact with service
NP’s will refer their patients to the most appropriate clinician where required. This will be done either during or at the
completion of the NP consultation as deemed appropriate.
Criteria for referral
The NP will determine the most appropriate health professional in which to refer their patients to. Furthermore the
NP will determine the criteria for referral based upon what is clinically appropriate, taking into account evidence
based best practice, clinical pathways, and his own clinical limitations.
Anthony Sokolowski
Hunter New England Local Health District
23/01/2013
Diagnostic Investigations
The NP may request appropriate investigations which may include;
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Medical Imaging – including ordering and interpreting radiographs and ordering of ultrasounds
Advanced Imaging such as CT scans, MRI and Nuclear Imaging are to be ordered in consultation
with the In-charge Medical Officer, Consultant, or on-call specialty Registrar/Consultant, or
Radiology Registrar/Consultant. Interpretation of these will be attended by Senior Medical Officers
within the Emergency Department or by Radiologists.
 Electrocardiograph – request and interpret
 Blood pathology appropriate to the presenting issue – request and interpret
 Urine culture and sensitivity, Sexually transmitted infection tests (PCR) – request and interpret
 Swabs, cultures, and tissue samples appropriate to the presenting issue – request and interpret
Prescribing
The ENP is authorised under the Poisons and Therapeutic Goods Act 1966 to possess, supply and
prescribe medications (S2, S4, S4D and S8) that are contained in the NSW NP formulary relevant to the
Emergency Nurse Practitioner Scope of Practice.
Prescribing by the NP will follow NSW Health Nurse Practitioners in NSW Policy (PD2012_026). Salient
features of this are:
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In line with Commonwealth policy and legislative changes, list of medicines approved for prescribing
by Nurse Practitioners by the Pharmaceutical Benefits Advisory Committee (PBAC) is available within
the Pharmaceutical Benefits Scheme (PBS). Nurse Practitioners employed by NSW Health have
standing authority to prescribe from this list. The Director General, in accordance with s17a of the
Poisons and Therapeutic Goods Act 1966, has authorised Nurse Practitioners employed by NSW
Health to prescribe, those poisons, restricted substances and drugs of addiction included on this list
which will be updated from time to time as required to include other poisons, restricted substances
and drugs of addiction to reflect expanding scopes of practice (Guideline section 9.1)
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As independent prescribers Nurse Practitioners employed in a designated Nurse Practitioner position
within NSW Health may prescribe those poisons, restricted substances and drugs of addiction from
the formulary approved by the Director General for the practice of nursing as outlined by the relevant
SOP document (Guideline section 10.1)
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Poisons, restricted substances and drugs of addiction a Nurse Practitioner may wish to prescribe not
included on this list are collated into an appended formulary to be forwarded by the LHD DNM for
approval by the LHD CE (Guideline section 10.1)
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Nurse Practitioners should develop a list of preferred medications (P-drugs) in collaboration with
clinical supervisors and mentors which is consistent with the SOP. P-drugs do not require approval
at a local level to be prescribed as long as they are consistent with the approved NSW formulary
(Guideline section 10.2)
Prescribing References
Clinical Information Access Portal (CIAP) http://www.ciap.health.nsw.gov.au/home.html
Electronic Therapeutic Guidelines (eTG) http://www.tg.org.au/ (via CIAP)
Australian Medicines Handbook (AMH) http://amh.hcn.com.au/
National Prescribing Service http://www.nps.org.au/
MIMS Australia: http://proxy36.use.hcn.com.au/Search/Search.aspx
Micromedex: http://proxy63.use.hcn.com.au/micromedex2/librarian
UpToDate® http://www.uptodate.com/index
Anthony Sokolowski
Hunter New England Local Health District
23/01/2013
Appended Formulary
YES
Attached at Appendix A for approval
NO
Exclusions: A nurse practitioner must not prescribe, give a written or oral instruction or supply or administer medicines (1) that have not
been approved by the Therapeutic Goods Administration outside the terms of the manufacturer’s product information (off-label) unless
sufficient evidence to demonstrate safety.
Specific procedural activities
The NP will carry out any clinically indicated procedure that is within their particular expertise. Some of these
include (but not limited to):
Joint / fracture reductions
Insertion/change of in-dwelling catheters (urinary, naso/orogastric)
Removal of foreign body
Application and removal of plaster of paris and other rigid splints
Venepuncture, cannulation, blood collection, arterial puncture
Lumbar puncture
Resuscitation procedures
Joint aspiration
Collaborative arrangements (as required to facilitate access to MBS & PBS)
NP’s working within the HNELHD have a collaborative arrangement with the medical officers that are employed by
the service.
Clinical Governance Arrangements
Part A: Study, clinical supervision and mentorship arrangements
Clinical supervision and or mentoring opportunities will be pursued by the NP for ongoing professional
development.
Part B: Describe who the NP role / service articulates into organisational governance arrangements
Director of emergency/Staff Specialist/Clinical service on the emergency department in which the NP is working on
that particular day.
Clinical resources
The NP may utilise any relevant clinical resources within the department and wider health service (including online
resources) to carry out their clinical duties. NP’s will have access to Policy directives, Clinical Practice Guidelines,
and other directives provided by the HNELHD and NSW Health. Some of these include (but not limited):
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Clinical Information Access Portal (CIAP) http://www.ciap.health.nsw.gov.au/home.html
Electronic Therapeutic Guidelines (eTG) http://www.tg.org.au/ (via CIAP)
Anthony Sokolowski
Hunter New England Local Health District
23/01/2013
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Australian Medicines Handbook (AMH) http://amh.hcn.com.au/
National Prescribing Service http://www.nps.org.au/
MIMS Australia: http://proxy36.use.hcn.com.au/Search/Search.aspx
Micromedex: http://proxy63.use.hcn.com.au/micromedex2/librarian
UpToDate® http://www.uptodate.com/index
CIAP Emergency Care Guidelines http://www.ciap.health.nsw.gov.au/guides/emergency.html
Emergency Medicine: Reviews and Perspectives (EMRAP) http://www.emrap.org/
Emergency Medical Abstracts (EMA) http://ccme.org/EMA/
NSW Emergency Care Institute (ECI) http://www.ecinsw.com.au/
CIAP Clinical Guidelines: http://www.ciap.health.nsw.gov.au/home.html
Professional role activities
Clinical leadership, education and research
NP’s are highly educated and accredited professionals who have the highest clinical responsibilities and privileges
in the nursing profession. Therefore it is prudent that the NP be regarded as a leader in their clinical field and within
their own department. This may include, but not be limited to; clinical leadership on the floor, provision of education,
and professional input towards committees, guideline/directive formulation and other relevant matters.
NP’s are granted legislated non-clinical time that they may use at their own discretion for professional development
purposes. In so doing NP’s may have access to all clinical educational resources provided by, or available to, those
employed by HNELHD.
Evaluation
Strategy for evaluation of model and ScOP review
Resources available to evaluate the effectiveness of the NP service may be obtained from various sources such as
iPims. Furthermore the NP may carry out independent qualitative and/or quantitative surveys to evaluate their
service.
Performance Review / Evaluation
An annual performance review with be conducted with the Director of Emergency Medicine or Staff
Specialist and/or Clinical Service Manager.
Key Performance Indicators
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Unplanned representations managed by the NP
ED Length of Stay for NP managed care
Patient satisfaction (letters or complaints)
Adverse events (IIMS) related to NP managed care
NP performance review will occur annually, ideally after the evaluation of the service and review of the
model and ScOP has occurred. This will allow opportunity to develop an ongoing professional
development plan at performance review.
The review will be a 360° appraisal including individuals working alongside the NP in all aspects of the
role and will include areas such as communication, team work, technical competence, clinical leadership.
The ENP will present a summary of the review and a role activity report as part of the review.
Anthony Sokolowski
Hunter New England Local Health District
23/01/2013
The Multidisciplinary Support Committee agree that this scope of practice and model has
been developed collaboratively and is supported practice for the named nurse practitioner.
Multidisciplinary Support Committee Chair
Signature
Date agreed
Name:
Position:
Nursing Executive acknowledgement
Local Health District Director of Nursing and Midwifery Services
Signature
Date
Name:
Facility Director of Nursing and Midwifery Services
Signature
Date
Name:
Local Health District Chief Executive acknowledgement
Signature
Date
Name:
Anthony Sokolowski
Hunter New England Local Health District
23/01/2013
Appendix A
Appended Drug Formulary
If an appended formulary is required, the template is to be completed
and the formulary approved by the LHD CE.
Prescribing Reference: Australian Medicines Handbook, Australian Therapeutic
guidelines, Australian Injectable Drug Handbook.
The Nurse Practitioner may prescribe/advise their patient a course of any medication
that does not require a prescription. The Nurse Practitioner may prescribe their patient
any prescription medication approved by the Australian Government PBS listing, as well
as the medications set out below.
Dosages are not transcribed into formulary in order to avoid transcription error
Class
Drug name
(generic)
Clinical
presentation
Antidote
Acetylcysteine
Paracetamol
overdose
Antiarrhythmic
Adenosine
SVT
Topical anaesthetic
Amethocaine
Blood
Red cells
Ocular
emergencies
Trauma, severe
hypovolaemia
Antipsychotic
Droperidol
Benzodiazepine
antagonist
Anitvenom
Flumazenil
NSAID
Ketorolac
Anthony Sokolowski
Funnel web spider
AV
Severe acute
anxiety or
psychosis induced
disturbed behaviour
Benzodiazepine
overdose
Funnel web spider
bites
Notes
Under direction of,
after consultation
with, or in the
presence of a
medical practitioner
Under direction of,
after consultation
with, or in the
presence of a
medical practitioner
Moderate/severe
pain
Hunter New England Local Health District
23/01/2013
Vitamin supplement
Magnesium
Sedative, hypnotic
Midazolam
Inhaled anaesthetic
Nitrous oxide
Antiviral
Oseltamivir
Antidote
Red back spider AV Red back spider
bites
Rh D
Females with Rh
Immunoglobulin
negative blood group
post child birth,
abortion, or ectopic
pregnancy.
Seasonal and/or
Treatment/prevention
pandemic influenza of influenza
vaccines
Snake AV’s
Snake bites
Under direction of,
after consultation
with, or in the
presence of a
medical practitioner
Suxamethonium
Emergency airway
Under direction of,
management
after consultation
with, or in the
presence of a
medical practitioner
Propofol
Emergency airway
Under direction of,
management
after consultation
with, or in the
presence of a
medical practitioner
Oxytocin
Post-partum
haemorrhage
Tamulosin
BPH relief
hydrochloride
Thiopentone
Emergency airway
Under direction of,
management
after consultation
with, or in the
presence of a
medical practitioner
Immunoglobulin
Vaccine
Antidote
Neuromuscular
blocking agent
Anaesthetic agent
Synthetic pituitary
hormone
Selective alpha
blocker
Anaesthetic agent
Anthony Sokolowski
Eclampsia and preeclampsia.
Hypomagnesaemia,
Torsades de pointes.
Seizures. Relaxant
for musculo-skeletal
trauma.
Severe pain,
procedures.
Influenza
Hunter New England Local Health District
Subject to Public
Health policy and
Procedure
23/01/2013
Approval of Appended Nurse Practitioner Formulary
POISIONS AND THERAPEUTICS GOODS ACT 1966
Section 17A
Nurse Practitioner Authority to Possess, Use, Prescribe
or Supply Substances
I,(insert name of officer) Chief Executive of (insert name of Local Health
District) being the duly appointed delegate of the Director-General of the
Department of Health in accordance with section 21 of the Health Administration
Act 1982 and subject to this authority;
Do hereby approve the attached formulary pursuant to the provisions of section
17A (1b) of the Poisons and Therapeutics Goods Act 1966, I authorise (insert
name of Nurse Practitioner) while employed by the (insert name of
Facility/LHD) as a Nurse Practitioner to possess, use, supply or prescribe poisons
and restricted substances and drugs of addiction within the attached formulary for
the purposes of the practice of their profession as Nurse Practitioner.
Dated this _____________________ day of ______________________ 20
______________________________ (signature)
______________________________ (name)
Anthony Sokolowski
Hunter New England Local Health District
23/01/2013
Authors
Mr Anthony Sokolowski
Nurse Practitioner, Belmont Hospital
Hunter New England Local Health District
Acknowledgements
Mr Matthew Lutze
Nurse Practitioner, Canterbury Hospital
Sydney Local Health District
Mr Mike Maw
Nurse Practitioner, Tomaree Hospital
Hunter New England Local Health District
Anthony Sokolowski
Hunter New England Local Health District
23/01/2013