Nurse practitioner access to radiology and laboratory services.
Abstract: With the advent of the New Zealand nurse practitioner (NP) role in 2001, ordering, conducting and interpreting diagnostic and laboratory tests became part of the NP scope of practice. However, anecdotal literature suggests there are national inconsistencies, barriers and limitations for some nurse practitioners in accessing diagnostic services. This paper is a report on a quantitative descriptive survey completed in 2008 exploring NP access to radiology and laboratory services. A purposive sample of all New Zealand registered NPs (as at 1 July 2008) were invited to participate (n=47). The response rate was 79% (n=37). The findings demonstrated some positive trends particularly in accessing laboratory tests, but generally there are barriers, inconsistencies and limitations for NPs when ordering tests. The majority of respondents directly order laboratory tests (75%, n=27) that are processed under their own name. Access to radiology services is variable. Only 44% (n=15) of respondents order plain x-rays/ultrasounds and 9% (n=3) order advanced radiology tests that are processed under their own name. The research highlighted the need for national consistency and improved NP access to radiology and laboratory services.

Key Words: New Zealand nurse practitioner, radiology tests, laboratory tests, barriers.
Article Type: Report
Subject: Medical tests (Usage)
Nurse practitioners (Surveys)
Nurse practitioners (Aims and objectives)
Authors: Unac, Fiona
Marshall, Bob
Crawford, Ruth
Pub Date: 03/01/2010
Publication: Name: Nursing Praxis in New Zealand Publisher: Nursing Praxis in New Zealand Audience: Academic Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2010 Nursing Praxis in New Zealand ISSN: 0112-7438
Issue: Date: March, 2010 Source Volume: 26 Source Issue: 1
Topic: Event Code: 220 Strategy & planning
Geographic: Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand
Accession Number: 291893134
Full Text: Background

In New Zealand, NPs are the highest level of clinical expert in the nursing profession. They are educationally prepared at Masters degree level (or equivalent) and they have a minimum of four years experience in their specialty scope (Nursing Council of New Zealand, 2002). NPs are required to practice within the legal boundaries of the NP scope of practice as well as demonstrating meeting NP competencies. This scope includes ordering, conducting and interpreting diagnostic and laboratory tests. However, the literature suggests inconsistencies in NPs access to diagnostic testing. Some NPs have been able to access diagnostic testing (Forde, 2005; Hewson, 2004; Renouf, 2005), whilst other NPs have had difficulties (Gardner, Carryer, Dunn, & Gardner, 2004; Renouf; Williams, 2008). This inconsistency is partly due to the position of key diagnostic stakeholders. In the New Zealand context these stakeholders include, but are not limited to the National Radiation Board, The Royal Australian and New Zealand College of Radiologists and the Medical Laboratory Science Board.

Access to Radiology Services

In New Zealand the National Radiation Laboratory (NRL) administers the Radiation Protection Act 1965 and the Radiation Protection Regulations 1982 under delegated authority from the Minister of Health and the Director-General of Health (National Radiation Laboratory, 2008). The NRLs position is that individual licensed radiologists and local radiology department policies determine whose radiology referrals will be accepted. The radiologist is therefore in the position of being the 'gate-keeper' where they hold the power to accept or decline referrals. Clearly within the interests of public safety it is important to have radiation restrictions. However, the NRL position provides for the possibility that one radiologist may deny NPs access to ordering radiology diagnostic tests whilst another individual radiologist may allow reasonable ordering access to NPs. This issue is further compounded because there are no specific NP education standards on the safe use of ionizing radiation, life time radiation dose and risks, as well as the benefits and limitations of specific diagnostic imaging modalities. In 2005, The Royal Australian and New Zealand College of Radiologists (RANZCR) drafted a position paper on NP roles in radiology and radiotherapy. They limited the role to requesting simple x-rays and ultrasound, on the proviso that adequate training and medical supervision is builtin; however, they do not support the interpretation of images or the conduct of associated therapy (Royal Australian and New Zealand College of Radiologists, 2005). This is in contrast to many international studies showing that NPs are competent in ordering and interpreting diagnostic tests (Freij, Duffy, Hackett, Cunningham, & Fothergill, 1996; Hemani, Rastegar, Hill, & Al-ibrahim, 1999; Horrocks, Anderson, & Salisbury, 2002; Meek, Kendall, Porter, & Freij, 1998; Organ et al., 2005). Subsequent to the completion of this study (Unac, 2008) the RANZCR recommended that radiologists work collaboratively with NPs and that requesting x-rays is a valid use of NP services (Leadbitter, 2009). This recent position from the RANZCR may prove to be a positive step in improving radiology access to NPs.

Access to Laboratory Services

Access to ordering laboratory tests is dependent on specific health professionals' laboratory schedules. There were many changes to the funding of laboratory testing during the health reforms between the 1980s and early 2000s (Boswell & Tie, 2006). Tracking historical events with respect to which working parties developed the schedules, reviewed the schedules and decided which health professionals are authorised to order which tests, is complex. Each District Health Board (DHB) is currently responsible for both funding and provision of services within a defined geographical area. This situation has the potential for creating regional inconsistencies for NPs when ordering laboratory tests. In 2003, the Ministry of Health identified that NPs were unable to order and claim for some laboratory tests because of restrictions with the laboratory schedule (Hughes, 2003). However, there continues to be limitations in the current system due to NPs having specialty areas of practice. For example on the Hawke's Bay District Health Board (2006) Schedule Test Purchase List, NPs are unable to order fasting lipids, which is a necessary test for primary health care and NPs working with cardiac patients.

Research Aim

The aim of this research was to explore nurse practitioner access to radiology and laboratory services.

Methodology

The research design was a quantitative non-experimental descriptive survey. The data collection tool was a questionnaire with 21 items. The majority of questions used a Likert scale for respondents to rate how much they agreed or disagreed with each statement. The data were coded on an Excel 2007 (v.12.0.6425.100) spreadsheet with means and percentages calculated. The questionnaire was validated by a content experts approach. Three eminent nursing leaders on the NP role and a researcher with extensive experience in conducting quantitative studies critiqued the data collection tool. This original research may have benefited from a pilot study to examine test-retest reliability, however this was rejected because of the small population size.

Prior to conducting this research, ethical approval was obtained from the Multi-Region Health and Disability Ethics Committee of New Zealand as an Expedited Review and from the Eastern Institute of Technology. All 47 registered NPs (as at the 1st of July, 2008) were invited to participate. During July 2008 each NP was mailed an invitation to participate in the research, with an enclosed questionnaire. There was a risk that NPs could be identifiable by their postal area, so a third party collection officer was used to de-identify the completed questionnaires before forwarding them to the researcher. One respondent's data has not been included in the analysis as it is highly probable that this respondent accidentally transposed the Likert scale.

Results

The findings of the research are presented in four sections. The data are predominately presented in tables as mean percentage and absolute count by category. When analysing the Likert scale mean, a score greater than 2.0 indicates a positive response and a score less than 2.0 a negative response. Total responses within a category may not exactly total 100% due to rounding effects. Many respondents (78%, n = 28) made additional comments which have been included in the discussion to strengthen the quantitative findings. The questionnaire was assessed for internal reliability using Cronbach's alpha (SPSS v. 17) and good reliability was shown ([proportional] = 0.70).

General Access and the Nursing Council of New Zealand (Nursing Council) Diagnostic Competency

The respondents were initially introduced to general statements about ordering diagnostic tests. All respondents (100%, n=36) agreed that it is essential to order diagnostic tests as part of the diagnosis and treatment of their patients and that NPs should have direct access to diagnostic testing. All respondents (100%, n=36) were confident they met the Nursing Council's NP diagnostic competency--'uses and interprets diagnostic and laboratory tests'.

Nurse Practitioners Access to Radiology Services

The respondents were then asked about their radiology department's understanding of the NP scope of practice, their access to ordering radiology imaging, and whether the Nursing Council and the Ministry of Health have promoted the NP role to key radiology stakeholders. The findings of these questions are illustrated in Table 1.

Despite all respondents agreeing that NPs should have direct access to ordering diagnostic tests, less than half (44%, n=15) of respondents ordered plain x-rays/ultrasounds that were processed under their own name. Only 9% (n=3) of respondents ordered advanced medical imaging, processed under their own name. Table 2 illustrates how NPs ordered radiology tests.

Nurse Practitioners Access to Laboratory Services

The respondents here were asked the same questions as in the radiology section but this time with a laboratory focus. The findings are shown in Table 3.

Respondents generally considered that laboratory departments have a better understanding of the NP role than do radiology departments. However, 31% (n=11) of respondents still disagreed that laboratory departments have a good understanding of the NP scope of practice. A high proportion of respondents (78%, n = 28) agreed that laboratory departments were supportive in accepting their laboratory requests. However, the findings again show a strong sense of dissatisfaction with Nursing Council's and the Ministry of Health's lack of active promotion of the NP role to key laboratory stakeholders. Table 4 shows how NPs ordered laboratory tests.

When combining the 'directly ordering' categories the respondents have better access to laboratory tests (85%, n=31), than to plain x-rays/ ultrasounds (68%, n=23) or advanced medical imaging (18%, n=6). However the results show that 15% (n=6) of respondents do not directly order laboratory tests.

Nurse Practitioner Funding of Clinical Practice

The final question asked respondents how they were funded for clinical practice. The majority (83%, n=29) of respondents worked for a DHB. The remaining respondents were employed by a primary health organisation (n=2), a charitable trust (n=2), an iwi provider (n=1) or were self employed (n=1).

Discussion

General Access and Nursing Council Diagnostic Competency

Nurse practitioners work in a diverse range of specialties such as whanauora, wound care, adult urology, diabetes, adult respiratory care and pain management (Ministry of Health, 2006). Regardless of their specialty scope all respondents considered it essential to order diagnostic and laboratory tests. At the time this research was conducted there were inconsistencies between the NP scope of practice and the NP competency framework. Since the establishment of the NP role, the scope has included 'ordering, using and interpreting diagnostic and laboratory tests'. The diagnostic competency was limited to 'using and interpreting diagnostic and laboratory tests'. In September 2008, Nursing Council approved a new competency framework for the NP scope of practice (Nursing Council of New Zealand, 2008). The diagnostic competency is now strengthened to include the ordering of diagnostic tests. This strengthened competency has implications for NPs, employers, diagnostic departments, and the regulatory role of Nursing Council. If an NP does not have access to ordering diagnostic tests then they may not meet the NP competencies. This has legal considerations under the Health Practitioners Competence Assurance Act, 2003 (Ministry of Health, 2009).

Access to Radiology Services

The results in Table 1 show that 50% (n=17) of respondents indicate dissatisfaction with the radiology department's level of understanding of the NPs scope of practice. This finding supports the anecdotal New Zealand literature which identified a lack of knowledge of the NP role by many doctors (Cassie, 2003; Davis & Tweedie, 2008; Spence & Anderson, 2007) and allied health professionals (Davis & Tweedie; District Health Boards New Zealand, 2008; Minto, 2008) . One respondent commented "I don't think the x-ray folks know what a NP really is or that I am one. They process the request because it is an inpatient and probably some think it comes from a doctor".

Nearly all respondents (97%, n=35) agreed that NPs should have access to ordering plain x-rays and or ultrasounds with their scope of practice. However the respondents were more divided when considering whether NPs should have access to ordering advanced medical imaging. Only 55% (n=20) of respondents agreed. The literature indicates that NPs internationally, and specifically in the United States and the United Kingdom have access to ordering advanced medical imaging (Hemani, Rastegar, Hill, & Al-ibrahim, 1999; Howie, 2002; Royal College of Nursing (UK), 2007). In New Zealand, access to advanced medical imaging is usually only available to medical specialists (Ministry of Health, 2007). There may be a perception amongst NPs that if general practitioners have difficulty ordering advanced medical images then there is very little opportunity for NPs to order advanced radiology tests.

Only 49% (n=17) of respondents agreed that the radiology department they use is supportive in accepting their requests for x-rays/ultrasounds. Even fewer respondents (20%, n=7) agreed that the radiology department is supportive in accepting their requests for advanced medical imaging. These findings support the anecdotal literature around inconsistencies for NPs in accessing diagnostic tests. Seven respondents commented that they needed to individually negotiate access to radiology services. This negotiation can be fraught with frustration, whereby a respondent argued that "the NCNZ/MOH [Nursing Council of New Zealand/Ministry of Health] should have sorted out access before they stated NPs could order labs/x-rays". One respondent has found the hospital in which they work actively opposes any extension of ordering privileges. Another respondent has strict limitations on their access, whereby the NP is only permitted to order x-rays on adults which is limited to specific body parts such as the arms and legs. The respondent is not able to order spine x-rays, ultrasounds or x-rays on children. Two respondents recommended that a national collective policy be implemented to address the issue of national inconsistencies.

The respondents were asked if 'the Nursing Council and the Ministry of Health have actively promoted the NP role to key radiology stakeholders'. The majority of respondents (53%, n=19) disagreed. These questions were not intended to imply blame, but rather to explore a theme identified in the literature around NPs working in environments that were unprepared for them (Gardner et al., 2004; Harris, 2003; McMillan, 2008; O'Connor, 2008). Carryer (2007, 2008) also acknowledged there are funding and legislative barriers that impact on NPs, which are still unresolved (Cassie, 2008; Kilpatrick, 2008). The negative response to these questions may be indicative of the on-going frustrations that some NPs are experiencing.

Access to Laboratory Services

Table 4 shows that the majority of respondents (75%, n=27) directly order laboratory tests and the request is processed under their own name. Whilst this is an encouraging result, it still means that 1 in 4 respondents are either not ordering laboratory tests or are not being recognised for ordering laboratory tests. Thirteen respondents commented that they have no difficulty with accessing laboratory tests. They cited a variety of reasons, such as having an excellent relationship with the pathologists/ cytopathologists, working for a long time in an organisation, as well as ordering standard protocol tests for specific treatments. However three respondents argued that the limitations with the NP schedule (list) was a barrier to their practice.

Nurse Practitioner Funding of Clinical Practice

The New Zealand literature suggested that NPs working in primary health or non-hospital settings have greater difficulty in accessing diagnostic tests because of funding and legislative barriers (Hendricks & Smith, 2004; Trim, 2008). The majority (83%, n=29) of respondents worked for a DHB. Only 17% (n=6) of respondents were non-DHB funded. Due to the imbalance in sample size between the DHB and non-DHB funding categories, no statistical comparisons were performed. Of the six non-DHB funded respondents, four (66%) experienced professional barriers when accessing diagnostic tests. There were additional barriers for NPs working in rural settings where there are only a small number of radiology appointments available. One respondent commented "I practice in remote locations & patients are all seen by a medical practitioner who ... writes an x-ray request if he concurs with my request .These may be obvious boney deformities with high degree of suspicion of fractures. This creates a time delay between presentation, assessment & treatment of patients".

Limitations

One limitation of this study is the small population of NPs in New Zealand, when this study was conducted. Although there was a 79% response rate, the population group was only 47. Another limitation was the lack of exploration into variables such as specialty area, duration of NP registration, number of NPs in a region, and length of time in the work setting. These variables may have influenced the respondent's access to radiology and laboratory services. To protect anonymity the only variable asked was in relation to funding of clinical practice.

Another limitation was the lack of a pilot study to examine test-retest reliability. To address this limitation, Conbach's alpha (SPSS v.17) was used to determine the internal consistency of items in the survey instrument. A score of [proportional] = 0.70 suggests the questionnaire had satisfactory internal reliability.

Conclusions

This research is the first study in New Zealand specifically exploring NPs access to radiology and laboratory testing and provides a platform for further research on this issue. The study identified positive trends particularly in accessing laboratory tests but responses suggest there are a number of inconsistencies, barriers and limitations for NPs when ordering diagnostic tests.

The information provided by the NP respondents suggests the Nursing Council's diagnostic competency needs to be more specific. At the time of conducting this research the diagnostic competency was limited to 'uses and interprets laboratory and diagnostic tests'. In September 2008, this competency was strengthened to include 'orders and interprets diagnostic tests'. However, it is recommended that there be further strengthening of competency criteria to ensure 'ordering laboratory and radiology tests' is included.

Access to ordering radiology services would be further enhanced if a national radiology schedule for NPs is developed. The authors do not suggest that NPs need to have a specific endorsement to order and interpret radiology tests, but rather by having clear registration standards on education and peer review processes, NPs will have direct access to order tests on a NP radiology schedule.

Currently NPs have reasonable access to tests on laboratory schedules; however there are limitations in the types of tests a NP can order. It is recommended that a national laboratory NP schedule be formulated along the same as the general medical practitioner schedule.

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Fiona Unac, RN, MN, Clinical Nurse Specialist,

Radiology Department, Hawke's Bay District Health Board, Hastings

Bob Marshall, PhD, Research Professor,

Eastern Institute of Technology, Taradale, Hawke's Bay

Ruth Crawford, RN, MPhil (Nursing), Principal Lecturer,

Eastern Institute of Technology, Taradale, Hawke's Bay
Table 1.
Nurse practitioners and radiology services

                                                     Response % (n)

Statement                                  Disagree  Neither    Agree

The radiology department that I use has a  50% (17)  21% (7)   18% (6)
good understanding of the nurse
practitioners scope of practice (n=34)

Nurse practitioners should have access to   0% (0)    3% (1)   97% (35)
ordering plain x-rays &/or ultrasound
within their scope of practice (n=36)

Nurse practitioners should have access to   8% (3)   36% (13)  56% (20)
ordering advanced radiology requests e.g.
MRI & CT within their scope of practice
(n=36)

The radiology department that I use is     20% (7)   17% (6)   49% (17)
supportive in accepting my requests for
plain x-rays &/or ultrasound (n=35).

The radiology department that I use is     36% (13)  28% (10)  19% (7)
supportive in accepting my requests for
advanced imaging requests (e.g. MRI,CT)
(n=36)

The Nursing Council of New Zealand has     72% (26)  25% (9)    3% (1)
actively promoted the NP role to key
stakeholders (e.g. radiology departments,
national radiation board etc) to ensure
ease of access in ordering radiology
tests (n=36).

The Ministry of Health has actively        63% (22)  31% (11)   6% (2)
promoted the NP role to key stakeholders
(e.g. radiology departments, national
radiation board etc) to ensure ease of
access in ordering radiology tests
(n=35).

                                            Response % (n)

Statement                                    N/A    Mean *

The radiology department that I use has a  12% (4)   1.6
good understanding of the nurse
practitioners scope of practice (n=34)

Nurse practitioners should have access to  0% (0)    3.0
ordering plain x-rays &/or ultrasound
within their scope of practice (n=36)

Nurse practitioners should have access to  0% (0)    2.5
ordering advanced radiology requests e.g.
MRI & CT within their scope of practice
(n=36)

The radiology department that I use is     14% (5)   2.3
supportive in accepting my requests for
plain x-rays &/or ultrasound (n=35).

The radiology department that I use is     17% (6)   1.8
supportive in accepting my requests for
advanced imaging requests (e.g. MRI,CT)
(n=36)

The Nursing Council of New Zealand has     0% (0)    1.3
actively promoted the NP role to key
stakeholders (e.g. radiology departments,
national radiation board etc) to ensure
ease of access in ordering radiology
tests (n=36).

The Ministry of Health has actively        0% (0)    1.4
promoted the NP role to key stakeholders
(e.g. radiology departments, national
radiation board etc) to ensure ease of
access in ordering radiology tests
(n=35).

N/A=Not applicable. * In the calculation of the mean
'Disagree-1, 'Neither-2, 'Agree-3.

Table 2.
Nurse practitioners current access to ordering radiology tests (n=34)

                                                             Advanced
                                             Plain x-ray     medical
                                                &/or       imaging i.e.
Nurse practitioner categories for ordering   ultrasound       CT/MRI
radiology tests                                 % (n)         % (n)

I directly order this test and the request    41% (14)        9% (3)
is 'processed' under my own name

I directly order this test, however my         24% (8)        9% (3)
request is 'processed' under a medical
practitioner

I cannot order this test under my own name     9% (3)         9% (3)
so I 'pp' the forms with a medical
practitioner's name

I cannot order this test, so a medical         3% (1)         0% (0)
practitioner pre-signs all my x-ray forms
and I then autonomously order the tests

I cannot order this test, and I require my     9% (3)        53% (18)
request forms to be completed by a medical
practitioner on a case by case basis

If other specify                               15% (5)       21% (7)

Table 3.
Nurse practitioners and laboratory services

                                                  Response %(n)

Question                                  Disagree  Neither     Agree

The laboratory department that I use has  31% (11)  25% (9)   42% (15)
a good understanding of the nurse
practitioners scope of practice (n=36)

Nurse practitioners should have access     0% (0)    0% (0)   100% (35)
to ordering laboratory tests within
their scope of practice (n=36)

The laboratory department that I use is    0% (0)   19% (7)   78% (28)
supportive in accepting my laboratory
requests (n=36)

The Nursing Council of New Zealand has    53% (19)  39% (14)   9% (3)
actively promoted the NP role to key
stakeholders (e.g. laboratory
departments, medical laboratory science
board) to ensure ease of access in
ordering laboratory tests (n=36)

The Ministry of Health has actively       53% (19)  42% (15)   6% (2)
promoted the NP role to key stakeholders
(e.g. laboratory departments, medical
laboratory science board) to ensure ease
of access in ordering radiology
laboratory tests (n=36)

                                           Response %(n)

Question                                   N/A    Mean *

The laboratory department that I use has  3% (1)   2.1
a good understanding of the nurse
practitioners scope of practice (n=36)

Nurse practitioners should have access    0% (0)   3.0
to ordering laboratory tests within
their scope of practice (n=36)

The laboratory department that I use is   3% (1)   2.8
supportive in accepting my laboratory
requests (n=36)

The Nursing Council of New Zealand has    0% (0)   1.6
actively promoted the NP role to key
stakeholders (e.g. laboratory
departments, medical laboratory science
board) to ensure ease of access in
ordering laboratory tests (n=36)

The Ministry of Health has actively       0% (0)   1.5
promoted the NP role to key stakeholders
(e.g. laboratory departments, medical
laboratory science board) to ensure ease
of access in ordering radiology
laboratory tests (n=36)

N/A=Not applicable. * In the calculation of the
mean 'Disagree-1, 'Neither-2, 'Agree-3.

Table 4.
Nurse practitioners current access to ordering laboratory tests (n=36)

Current access to ordering laboratory tests                     % (n)

I directly order laboratory tests and the request is           75% (27)
processed under my own name

I directly order this test, however my request is processed    11% (4)
under a medical practitioner

I cannot order this test under my own name so I 'pp' the        6% (2)
forms with a medical practitioner's name

I cannot order this test, so a medical practitioner             0% (0)
pre-signs all my laboratory forms and I then autonomously
order the tests

I cannot order this test, and I require my request forms to     3% (1)
be completed by a medical practitioner on a case by case
basis

If other specify                                                6% (2)
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