DISCUSSION PAPER

The discursive practices of nurse practitioner legislation in Australia

Clare Harvey, Andrea Driscoll & Dirk Keyzer

Accepted for publication 5 February 2011

Correspondence to C. Harvey:

e-mail: clare.harvey@flinders.edu.au

Clare Harvey BA (Cur) PhD RN

Lecturer in Nursing, Program Co-ordinator,

Master of Nursing (Nurse Practitioner)

School of Nursing and Midwifery, Flinders

University of South Australia, Adelaide,

South Australia

Andrea Driscoll PhD BN RN

Senior Research Fellow

Department of Epidemiology and Preventive

Medicine, Monash University, Melbourne,

Australia

Dirk Keyzer MSc DANS PhD

Adjunct Professor

School of Nursing and Midwifery, Flinders

University of South Australia, Adelaide,

South Australia

HARVEY C. , DRISCOLL A. & KEYZER D. (2011)HARVEY C. , DRISCOLL A. & KEYZER D. (2011) The discursive practices of nurse

practitioner legislation in Australia. Journal of Advanced Nursing 00(0), 000–000.

doi: 10.1111/j.1365-2648.2011.05650.x

AbstractAim. The aim of this paper was to examine the nurse practitioner legislative frame-

work in Australia from a critical social theory perspective.

Background. National regulation for nurses and midwives has superseded all pre-

vious state legislation with effect from July 2010. The aim of this change was to

streamline regulation processes across all health professionals requiring regulation, in

order to eliminate diverse state-based regulatory policies that were identified as hin-

dering transferability of the workforce across Australia. This paper explores the

changes with reference to nurse practitioners. Since their introduction to Australia

different legislative practices between states have presented difficult endorsement

procedures which have affected employment.

Data sources. Information for the paper is drawn from a doctoral study which ex-

amined the politics of advancing nursing in Australia, with particular reference to the

discourses of nurse practitioners. This is augmented by more recent legislative docu-

ments and policies, as well as media reports, to examine the process of change in

legislation and the unfolding discourses on employment and practice.

Implications to nursing. Nurse practitioner endorsement may be more complicated,

defeating the original premise of transferability of a skilled workforce across state

jurisdictions.

Conclusion. This paper exposes the influence that powerful discourses can have on a

major change to professional practice.

Keywords: critical social theory, nurse practitioner, nursing legislation, nursing policy

Introduction

Australia works on a federal system where powers are

divided between a central or commonwealth government,

also referred to as a federal government, and several regional

governments (or states). This has frequently created situa-

tions where both the Commonwealth and the states claim

authority over the same matter resulting in divergent policy

formations (About Australia 2010). The regulation of health

professions has traditionally been a state matter, and this has

created differing requirements between states. From July

2010, health professional regulation moved from a state to a

national system, with the introduction of the National

Registration and Accreditation Scheme for Health Profes-

sionals. The Council of Australian Governments (COAG)

signed an Intergovernmental Agreement on the health

� 2011 Blackwell Publishing Ltd 1

J A N JOURNAL OF ADVANCED NURSING

workforce making way for ten health professions, including

nurses and midwives, to be regulated under one national

authority (Council of Australian Governments 2008).

While the idea of a national regulation scheme is foreign to

Australians, it is routine in many other countries such as the

United Kingdom, South Africa and New Zealand (United

Kingdom, 2002; New Zealand Government, 2003; South

African Nursing Council, 2005). In these countries, nurses

are regulated nationally and are able to move across the

country without requiring re-registration in other state,

territorial or provincial jurisdictions. In Australia, this has

not been the case. There has been a separate act and

regulatory authority for each of ten recognized health

professions, in each state. This has meant that nurses wishing

to work in another state have had to re-register in that state.

Not only has this created a duplication of regulatory services,

but it has been expensive for the individual paying separate

state registration fees. The separate jurisdictions appear to

work in countries like United States of America (USA) and

Canada principally because of a much larger population

base. Australia’s total population is approximately 22 million

people. This, together with the country’s expanse means it

has the lowest population density in the world with an

estimated two people per square kilometre. For access to

professionals such as nursing, state jurisdictions has

restricted the mobility and accessibility of this relatively

small workforce, already working in a challenged physical

environment. A recent national taskforce on Australia’s

healthcare workforce made recommendations to move its

regulation to a national system, so that a more effective use

of the existing national workforce could be established

(Productivity Commission 2005). This resulted in legislative

changes that combined regulatory requirements of ten health

professions inclusive of nursing and midwifery, medical,

chiropractic, dental, physiotherapy, optometry, osteopathy,

pharmacy, podiatry and psychology under one Health

Practitioner Act (Queensland Parliamentary Council

2009a). Although the transitional process for national

regulation is being managed centrally by the Australian

Health Practitioner Regulation Agency (AHPRA), the mag-

nitude of change has relied upon state support. This has

emanated from the original state regulatory authorities who

are not necessarily embracing such radical change to their

commanding status. Although most agree that the gains of a

nationally regulated health-care workforce are positive, the

changes are daunting for state authorities who have enjoyed

legislative power for more than a century. Because of this

change, there is concern that divergent interpretations of the

national legislation may sabotage anticipated streamlined

regulatory activities.

The endorsement processes for Nurse Practitioners (NP) is

one such process under threat. Since their inception, NPs have

faced convoluted policy directives and differing endorsement

processes across states (Productivity Commission, 2005;

Harvey 2010). The anticipated streamlining of processes

may not be a reality under the new order. To understand this

position, we describe old and new legislative arrangements in

Australia throughout this paper, with a focus on the impact of

change to NP endorsement and ensuing employment.

Although this paper describes the Australian experience of a

major policy change and its effects on one occupational

group, it presents important parallels for others to examine

when considering any far-reaching alteration to the gover-

nance of a workforce, regardless of occupation or country.

Background

Traditionally, each state in Australia has regulated nursing

through the enactment of nursing specific acts (Australian

Capital Territory, 2004; Government of Western Australia,

2006; South Australian Government 2006; New South

Wales, 2009). While the objectives of the regulatory author-

ities have been similar across the country, the legislation and

the supporting policies in each state have differed. Nurses

were entitled to register in other states through the Mutual

Recognition Act (1992), a federal act, which afforded a legal

transference of qualifications across geographical jurisdic-

tions. Despite this, nurses still had to pay an additional

application and registration fee.

With NPs, endorsement between states never afforded

simple regulation (or credentialing as it is called in USA),

despite the Mutual Recognition Act. For example, in South

Australia NP applicants did not have to create a formulary

for prescribing practice with the NP endorsement applica-

tion, whereas Victoria required a full formulary (Nurses

Board of South Australia 2006; Nurses Board of Victoria

2008). Therefore NPs moving from South Australia to

Victoria had to provide a formulary for prescribing on initial

application. These divergent practices are purported to be

eliminated with national regulation because there will be one

application process for Australia. From July 2010, all state

legislation involving the regulation of health professionals

was superseded with the Australian Health Practitioner

Regulation National Law Act 2009 (Queensland Parliamen-

tary Council 2009a). Instead of ten different health profes-

sions acts in each of the eight states, there is now one national

regulatory act promulgated under state regulations which

allow the Act to operate under state law (Figure 1).

In the lead up to national regulation, there have been

concerns as to how policy in the national arena will inform

C. Harvey et al.

2 � 2011 Blackwell Publishing Ltd

state NP endorsement processes, and how such variation will

remain in the regulatory processes that occur between the

states in Australia. Evidence of this is seen in the recent

changes that occurred in some state legislation just months

prior to the change over to national regulation (Victorian

Government 2005; Government of Western Australia 2006;

New South Wales Government 2008; South Australia Gov-

ernment 2008). This paper examines the discursive practices

of state legislation and regulatory policy to determine how

these practices are influencing the way in which the transition

to national NP endorsement is unfolding.

Discovering difference

This paper was informed by a larger doctoral thesis which

examined the discourses on NPs in Australia and how they

influenced practice. Regulation was one discourse that

created barriers to NP employment (Harvey 2010). The

study showed that endorsement had significant disparity

between states and that processes leading to application were

convoluted, demanding far more than that required by

legislation. Consequently Registered Nurses (RN) who were

eligible for NP endorsement frequently declined such oppor-

tunity. The combination of complicated endorsement pro-

cesses and professional opposition to the role was frequently

cited as barriers. This meant that RNs, especially in the more

remote regions opted to continue practising under standing

orders and protocols rather than working in the more

autonomous NP practice environment.

Critical Discourse Analysis (CDA) was used to analyse the

discursive practices of NP implementation. CDA sits under

the umbrella of Critical Social Theory relying on qualitative

methods for data collection. It does not have a specific

direction of research nor a unitary theoretical framework

(Van Dijk 2004). Most branches of CDA ask questions about

the way discursively formed structures are played out in the

reproduction of social dominance through language and

action, described as discourse (Scollon 2001, Wodak 2001,

Van Dijk 2005).

In examining a major change such as regulatory practices,

discourse and the way it positions a certain group in society,

such as nursing, allows for the articulation of what is viewed

as truth and knowledge. In its formation it identifies the

tension created between people under examination, in this

case, regulatory practice for NP endorsement and how such

practices can both constrain and liberate it. It also reviews

what Foucault (1966) states as history behind what is

perceived as truth, which is closely connected to the way in

which operations and relations of power are transformed

over time. This premise supports the traditional underpin-

nings of nursing which has always been a subset of health

(Dolan et al. 1983, Barton et al. 1999, Chiarella 2002,

Gordon 2005, Gordon & Nelson 2005). Foucault describes it

as the ‘order of things’, where the understanding of infor-

mation has been handed down through history, by a

continuation of facts, generated in text and action by

powerful groups and institutions, and perpetuated through

the acceptance of those involved (Foucault 1966). Thus,

according to Fairclough (2001b), institutions related to

legislation and policy, are orders of discourse that conform

the actions of those in them.

Although it can be contended that regulatory practices are

directed by a nursing and midwifery authority (NMRA),

these institutions are not only informed by past texts and

actions through older versions of nursing legislation, but they

also inform and conform future practice. This is done

through the perpetuation of unconsciously accepted practices

and structures in regulatory language, without further anal-

ysis (Fairclough 2001b). Social linguistics contends that this

historical vision is discontinuous and is written by the

dominant groups of the time. Such activities as a national

change of regulation are therefore created by those who have

always controlled nursing business. Those involved with it

also shape the way nurses view the contemporary world, so

that nurses not only learn and accept the world as it is from a

constructed past, but also view the world from their own

individual experiences in a realm created by those with, and

in, power (Fairclough 2001a,b, Van Dijk 2004, 2005, Woods

2006).

When the immediate historical view of the nursing acts in

Australia is examined, nursing has maintained a position of

subservience in the healthcare order. Nurses carry out care as

Figure 1 Acts now supporting national regulation.

Western Australia’s Bill is still being read in that state’s Parliament at

the time of writing. Once passed, that state will fall under the

national jurisdiction.

JAN: DISCUSSION PAPER Nurse practitioner legislative framework in Australia

� 2011 Blackwell Publishing Ltd 3

a result of decisions made by a medical practitioner. Nurses

do not direct care or make decisions about it (Nelson &

Gordon 2004, Roxon 2008, Harvey 2010). This submissive

position is reinforced through the Competency Standards for

Registered Nurses in Australia where the focus is on

co-ordination of care and not the provision of care (Austra-

lian Nursing and Midwifery Council 2006b). The challenge

to this traditional nursing status has been the advent of NPs

who no longer retain a passive position because they are

legally empowered to practice as independent clinicians.

Resistance to change has manifested in the inclusion of

locally initiated endorsement controls, largely influenced by

other health professionals opposing the NP role. It is not

surprising then, that the national regulation scheme created

the idea among nurses that NP endorsement would be

streamlined. However, the emerging discursive interpretation

of this national regulation suggest that the traditional role of

the nurse is perpetuated in the new order, leaving the NP role

vulnerable to ongoing opposing or conflicting interpretation.

Looking back on the Australian NP endorsementjourney

The NP movement first emerged in USA in the 1960s in

response to the shortage of medical practitioners (doctors),

with nurses taking on traditionally accepted medical tasks.

Since then NPs have been established in United Kingdom and

Canada with varying degrees of success, and with issues

related to professional boundary issues, misunderstanding of

the role and organizational resistance still affecting imple-

mentation (Barton et al. 1999, Affara 2006). Similar expe-

riences have plagued NPs in Australia with divergent views of

role location and scope of practice being debated since its

inception. Following findings from earlier pilot projects

across a variety of clinical contexts it was agreed that NPs

were best suited to rural and remote regions where access to

medical care was difficult and where nurse initiated care is

often the only entry for communities into the healthcare

system (New South Wales Health 1995, Hegney 1996,

Hegney et al. 1997). Nineteen years later this country is only

beginning to embrace NPs. Not only did it take 8 years of

discussion and lobbying to introduce the first NP Framework

for Practice (New South Wales Health 1998) but it was only

in 2001 that the first NP was employed in Outback NSW

(Australian Nursing Federation 2001). Contrary to early

belief, metropolitan acute and specialist settings have taken

up NP positions rather than the more remote areas. Since the

first NP, other states and territories have worked towards

establishing a framework for NPs with varying degrees of

success (Victorian Government 1999; South Australian Gov-

ernment 1999; The Australian Capital Territory 2002;

Queensland Government 2003; Nursing Board of Tasmania

2006).

Under the former state based legislation, endorsement

focused exclusively on the ability of NPs to carry out what is

traditionally considered medical extensions to practice, these

being prescribing medication, undertaking advanced clinical

assessment and ordering diagnostic tests (Queensland Parlia-

mentary Counsel 1992; New South Wales Health 1998;

Australian Capital Territory 2004; South Australian Govern-

ment 2006; Western Australian Government 2006) for

example:

A code of practice referred to in subsection (1)(b) is to contain only

information recommended by the Commissioner, as defined in the

Health Act 1911 section 3(1), with respect to the functions of nurse

practitioners, including —

(a) the possession, use, supply or prescription of poisons, as defined in

the Poisons Act 1964 section 5(1), by a nurse practitioner;

(b) the requesting, or undertaking, of diagnostic testing or therapies;

(c) the undertaking of treatments by a nurse practitioner; and

(d) such other functions as are necessary or convenient with respect to

the practice of nursing as a nurse practitioner and the conduct of a

nurse practitioner, and anything incidental or conducive to those

functions.

(Government of Western Australia 2006, p. 67)

Some 6 years after the first NP framework was announced in

New South Wales in 1998 nursing attempted to dispel the

medical lobbyist claims of NPs being mini doctors by creating

a broader and more nursing focused definition of a NP.

A nurse practitioner is a registered nurse educated and authorised to

function autonomously and collaboratively in an advanced and

extended clinical role. The nurse practitioner role includes assessment

and management of clients using nursing knowledge and skills and

may include but is not limited to the direct referral of patients to

other health care professionals, prescribing medications and ordering

diagnostic investigations. The nurse practitioner role is grounded in

the nursing profession’s values, knowledge, theories and practise and

provides innovative and flexible health care delivery that comple-

ments other health care providers. The scope of practice of the nurse

practitioner is determined by the context in which the nurse

practitioner is authorised to practise. (Australian Nursing and

Midwifery Council 2006a, p. 1)

However, it has not dispelled this pseudo doctor view still

constantly and consistently being depicted by the media and

the Australian Medical Association (AMA) (Australian

C. Harvey et al.

4 � 2011 Blackwell Publishing Ltd

Medical Association Victoria, 1999; Brooker 2002; Dunn

2004, Australian Medical Association, 2005). These views

have undermined NPs by publicly suggesting that NPs are

second rate healthcare providers (Barrett 2001; Durham

2002, Australian Medical Association, 2003, 2005, Dunn

2004). State regulatory authorities attempted to allay pubic

fears by integrating operational, professional and legislative

frameworks into their endorsement process. Although well

meaning in design, this boundary overlap has resulted in

elaborate endorsement requirements for NPs, which has

negative impact on employment potential (Harvey 2010).

Pathways to endorsement

Under the state regulatory system there have been three NP

endorsement pathways in operation across Australia. The

first pathway requires an applicant to have completed a state

NMRA approved Master of Nurse Practitioner programme,

the second allows an application clinical master’s degree

which, with a portfolio of evidence demonstrating advanced

nursing practice, supports the application for NP endorse-

ment. The third pathway is through the Mutual Recognition

Act (1992) allowing the transference of qualifications across

states. These pathways were captured succinctly by the

former state Nurses Board of Victoria.

Although the pathways have been clear, NP endorsement

application criteria has varied across state borders with some

states linking it to employment guarantees. Although there is

a debate for and against this requirement, more than half of

endorsed NPs were found to be working in different nursing

roles or are not employed at all (Harvey 2010).

All states have similar processes which include all or some

of the following activities either individually in the health

service, or in combination with the state NMRA,

• A professional portfolio providing advanced standing in

the specialty area of practice

• A business case which in some instances has to be signed as

approved by the employer, while some boards require a

letter of support from the employer.

• The formulary of drugs that the NP will use

• A job description outlining the scope of practice

• Clinical Practice Guidelines for the clinical presentations

the NP intends to manage

• Evidence of ongoing learning

• Case studies demonstrating advanced practice in accor-

dance with the ANMC Competency Standards for NPs

• Clinical viva with a panel which included a nurse, doctor

and pharmacist

Western Australia, New South Wales, South Australia and

Victoria also had to gain approval for the NP position with

the highest healthcare authority in the state. This entailed

preparing a business case, developing clinical practice guide-

lines (CPG), setting up an interdisciplinary team committee to

manage development, and the construction of a job descrip-

tion and scope of practice. All this had to be achieved before

the NP could apply for employment into a position. Many

times, this work was initiated by the nurse wishing to work a

NP rather than the organizations wanting to employ a NP

(Harvey 2010). NPs described onerous and unreasonable

preparation requirements for this process, likening it to a

90,000 word thesis (Harvey 2010). For example, Western

Australia required further information.

The template contains sections which must be included in the

application; however, additional information to assist the Director

General of Health to consider the application may be incorporated. It

is important to note that the application including the business case

and clinical protocols must be signed off by the most senior officer of

the health service/organization (Western Australia Government

2003, p. 3).

In other words, the application and the completion of a

master’s degree were not necessarily sufficient for successful

endorsement or employment.

Not only has the regulatory/employment boundary been

interwoven, educational requirements have not been straight

forward either. Under the former state acts, there is no

reference to the level of education for NPs, yet it is during

the period after NP implementation in 1998 that a decision

was made to set the education level at a master’s degree. The

type of degree has varied between states. For example, in

South Australia, only a NMRA approved Master of Nurse

Practitioner was acceptable (Nurses and Midwives Board of

South Australia 2010), whereas others allowed the second

pathway (Figure 2) (Nurses Board of Victoria 2008). In

addition some states ordered evidence demonstrating

‘advanced standing’. For example, in New South Wales

applicants were required to obtain references from nurses,

allied health and medical colleagues who had worked with

them. This was additional to a portfolio demonstrating

advanced practice over a 6-year period, a Curriculum Vitae

(CV), and the presentation of a clinical case study indicating

their ability to practice at an advanced level, including

prescribing ability, patient assessment and ordering diagnos-

tic tests (Nurses and Midwives Board of New South Wales

2004). In South Australia, the process required applicants to

demonstrate practice around 12 identified professional and

clinical practice statements, in addition to providing a CV,

exemplars demonstrating advanced nursing skills, and

excerpts from a personal practice diary (Nurses Board of

South Australia, 2006).

JAN: DISCUSSION PAPER Nurse practitioner legislative framework in Australia

� 2011 Blackwell Publishing Ltd 5

These discursive practices are such that no other health

professional is required to undertake similar exhaustive

checks and balances either for endorsement or for employ-

ment. Harvey (2010) found that what was asked of NPs goes

far beyond any standard human resource requirement.

Foucault’s ‘order of things’ referred to earlier in the paper

manifests in nurses seeking recognition for their clinical

ability through the NP role. However requirements to comply

with the dominant discourse through endorsement practices

make it difficult for them to succeed. The traditional status

quo of healthcare hierarchy is therefore unconsciously

maintained. This tradition was exposed in a commissioned

inquiry into Australia’s health workforce.

In seeking to introduce nurse practitioners, each jurisdiction has

moved at a different pace, with seemingly uncoordinated processes of

review and different trial procedures. While jurisdictions have had to

work through their own legislative barriers to change, such as

Poisons Acts and so on, it appears that opportunities for greater inter-

jurisdictional learning, coordination and cooperation have been

missed. (Productivity Commission 2005, p. 55)

This sentiment has been echoed in other reports as well

(Garling 2008, Roxon 2008; National Health and Hospitals

Reform Commission 2009) so that despite NPs being

identified as important to health reform, the endorsement

requirements for NPs has barred this potential (Common-

wealth of Australia 2008). Under the new national regula-

tion, it has been long anticipated that hurdles described under

state law, will be resolved. Nevertheless, it seems that recent

state legislative changes to regulation seek to maintain the

balance of power in the states, rather than transference of it

to national regulation, and so undermining health reform as

much as the establishment of NPs.

Transition to national registration – implicationsfor NPs

During the preparatory years leading up to national regula-

tion, state nursing legislation has changed in four states

(Victorian Government 2005; Government of Western Aus-

tralia 2006; New South Wales Government 2008; South

Australia Government 2008). The additional changes neces-

sitated significant adjustments to regulatory process of NP

endorsement despite previous amendments that were adopted

to address NP endorsement processes. It is unclear when

examining literature, as to who or what was responsible for

initiation of such change so close to a national regulatory

transition. The significance of it is the nursing profession’s

tacit acceptance of such change. Degeling (1996, p. 106)

suggests that such actions occur because of the ‘capacity of

players to influence the informational underpinning of plan-

ning as a product not simply of their political perspicacity and

skill, but also of the structural power which is afforded them

(and not others) within prevailing institutional agendas’.

In Victoria the Nurses Act 1993 (Amended 2004) was

amended in June 2004 to include the NP legislation.

Nurse has completed a NBV approvedMasters of Nurse PractitionerCommenced 2009 onwards

Nurse has completed a Masters not approved specifically for the purpose

of endorsement as a NP

Nurse has completed a NBV approved Masters of Nurse PractitionerCommenced prior to 2009

Nurse has been authorised as a NPunder other Australian state, territory

or New Zealand legislation

Nurse has completed a Masters programand has worked as an independent

prescriber overseas(Excluding New Zealand)

Pathway 1

Pathway 2

Pathway 3

Figure 2 Pathways to nurse practitioner endorsement (Nurses Board of Victoria, 2008).

C. Harvey et al.

6 � 2011 Blackwell Publishing Ltd

However, shortly afterwards the state promulgated the

Health Professions Act 2005 which required significant

policy change for the endorsement of NPs (Victorian Gov-

ernment 2005). Despite initial concern, the Nurses Board of

Victoria (NBV) changes were viewed as positive because

there was a streamlining of activities which resulted in clear

endorsement pathways and policies (Nurses Board of Victo-

ria 2008). The move also pre-empted one regulation for all

health professionals. However, other state’s changes have

been less positive for NPs.

In South Australia (SA), the change from the Nurses Act

1999 (South Australian Government 2006) to the Nursing and

Midwifery Practice Act 2008 (South Australia Government

2008), came into operation in March 2010, 4 months before

national legislation was enacted. The monumental and tem-

porary change raises questions as to why it occurred and what

drove such a change, with such implicit nursing agreement. Of

significance was the annulment of a second endorsement

pathway, effectively emphasizing an already inflexible process.

It significantly affected nurses preparing for NP endorsement

with anecdotal evidence of applicants being advised to

complete an additional master’s degree, accredited by the

state NMRA, before endorsement could be considered. Not

only that, but it was in conflict with the incoming national

regulation which made provision for a second pathway.

The Nursing and Midwifery Board of Australia may endorse the

registration of a registered health practitioner whose name is included

in the Register of Nurses as being qualified to practise as a nurse

practitioner if the practitioner—

(a) holds either of the following qualifications relevant to the

endorsement—

(i) an approved qualification;

(ii) another qualification that, in the Board’s opinion, is substantially

equivalent to, or based on similar competencies to, an approved

qualification; and

(b) complies with any approved registration standard relevant to the

endorsement. (p. 96)

When examining other jurisdictions, for example, Victoria

and New South Wales, signified their compliance with the

Health Practitioner Regulation National Law Act 2009 by

maintaining the second pathway (New South Wales Govern-

ment 2009; Victorian Parliamentary Council 2009). Remov-

ing a second pathway for endorsement of NPs directly

contradicts the second of six principle objectives of national

registration relating to educational and regulatory flexibility

(Queensland Parliamentary Council 2009b). The South

Australian position also contradicts the law of the state that

was promulgated to make way for national regulation

(Health Practitioner Regulation National Law (South Aus-

tralia) Act 2010).

While SA appeared as the only state to create this

additional impediment, a draft document for accreditation

of master of NP programmes (Australian Nursing and

Midwifery Council 2009) acknowledged that:

The ‘second pathway’ wherein a completed master’s degree in

something other than, though relevant to, nurse practitioner practice

is used as the basis to meet requirements for nurse practitioner

authorisation (or endorsement or registration) that currently operates

in some jurisdictions would be able to continue under the transition

arrangements beyond 2010 referred to in the preamble. Thereafter,

the ‘single pathway’, indicated as criterion 1, would be the national

standard. (Australian Nursing and Midwifery Council 2009b, p 13)

Clearly, the misinterpretation of the law is not conducive to a

streamlined and smooth transition to a national regulatory

system. If we accept that nurses are a product of their history,

then it can be argued that players work unconsciously in

accordance with the prevailing ideologies that are in opera-

tion in the institutions of the social order, and which are

manifested in the symptoms that are displayed as a result of

it. As Fairclough (2001b, p. 31) suggests, ‘as far as social

world is concerned, social structures not only determine

social practice, they are also a product of social practice, and

social structures not only determine discourse, they are a

product of discourse’. Thus ‘nurses are asked to justify their

existence and describe their central importance’ in which the

traditional ‘virtue strategy is clearly not working’ (Nelson &

Gordon 2006, p. 27). On the other hand nurses have created

a space in science by embracing the technical and scientific

paradigm in their education of NPs which Nelson and

Gordon (2006, p. 26) call the ‘knowledge script’. This

knowledge script has manifested in NP practice through the

legislation endorsing the use traditionally accepted medical

activities. This has manifested in complex and exhaustive NP

endorsement processes entwined in legislation that has used

the medical script to describe nursing practice that no longer

fits with traditional nursing definitions. The traditional cycle

of dominance emerges even in the creation of new nursing

knowledge, and nurses, as much as the health system itself,

has embraced it.

This paper has highlighted that although the move to

national regulation has heralded a streamlined process for NP

endorsement those in charge of regulatory practice have

maintained control using the guise of institutional interpre-

tation that combines the virtue script with the knowledge

script. It has created conflicting interpretations and compli-

cated endorsement processes to justify NPs. Degeling (1996,

JAN: DISCUSSION PAPER Nurse practitioner legislative framework in Australia

� 2011 Blackwell Publishing Ltd 7

p. 114) says that what is important in this examination is the

‘recognition that the scripts of individual planning episodes

are not under the control of planners’…rather they vary

according to what ‘socially and historically (and hence,

discursively) is seen to be appropriate in specific settings and

also according to what dominant players (usually people

other than planners) see as being consonant with their

interests’. This positioning appears to have been accepted by

those nurses affected by it, through their silence despite the

consequences it has on their advancement and employment.

While regulation has afforded liberation in NP endorsement,

nursing has created hurdles that are counterproductive.

Conclusion

This paper has outlined the influence that powerful, albeit

habitually and unconsciously sanctioned discourses can have

on major change to workforce policy. In embracing a change

to legislation that promises professional emancipation, the

compliance to a traditional status of nursing has perpetuated

divergent and somewhat convoluted practices driven by local

agenda in Australian nursing regulation. This manifests in the

activities that are adopted and endorsed in the change process.

While this paper has described the Australian experiences of

one legislative change, it signifies how powerful discourses

work to maintain a status quo in any change process that may

alter the balance of power. As Fairclough (2001b) contends,

even when such major directives are provided, for example,

the healthcare reforms being implemented in Australia, those

groups in powerful positions will continue to control change

through the reinforcement of powerful discourses embedded

in all threads of a society or group. The powerful discourse

permeates unconsciously through communication and action

in daily practice, so that even when change is initiated,

nothing really changes. Further research is needed to examine

the impact of regulatory change on nursing as a profession in

Australia over the next decade. History repeats itself through

action and language, and the impediments that NPs have

experienced over the last 60 years in other countries, need not

be repeated here in Australia, if the profession takes steps to

manage the discourses that are directing change to them,

rather than with them.

Funding

This research received no specific grant from any funding

agency in the public, commercial or not-for-profit sectors.

Conflict of interest

No conflict of interest has been declared by the authors.

Author contributions

CH was responsible for the study conception and design. CH

performed the data collection. CH, AD & DK performed the

data analysis. CH, AD & DK were responsible for the

drafting of the manuscript. CH, AD & DK made critical

revisions to the paper for important intellectual content. CH

provided statistical expertise. CH provided administrative,

technical or material support. DK supervised the study.

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What is already known about this topic

• National regulation is being introduced in Australia

from 1 July 2010.

• This means that the Nursing and Midwifery Regulatory

Authorities in all states and territories of Australia will

no longer exist in their current form after promulgation

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• Nursing and Midwifery will need to realign Nurse

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