Senior doctors and nurses across both hospital EDs agreed on the broad advanced practice dimensions of the NP scope of practice and acknowledged the autonomous nature of NP practice which differentiated the role from that of other clinical nursing roles in the ED. Whilst not specifically acknowledged by senior physicians, NPs and senior nurses perceived that NPs considered the psychosocial needs of the patient in addition to the clinical, and embraced more readily a team-based approach to care delivery. In addition, NPs at one site felt the non-clinical aspects of their role were under-emphasised in practice and lacked recognition by other doctors and nurses.
ICT as a facilitator of innovation
Many factors determined the NP role and scope of practice. While ICT was not initially identified as shaping the NP role, NPs agreed upon exploration of work practices that the integration of ICT into their work facilitated the advanced practice element of their role through contributing to the timely and quality of clinical decision making. The inability of participants to immediately conceptualise ICT use as separate from work processes indicates the extent to which NP have integrated technology into their nursing practice.
The accessibility and availability of electronic patient information through an integrated Area-wide database enhanced clinical decision making in two ways. Real-time access to requisite patient information was believed to expedite clinical decision making and patient access to appropriate care. Ubiquity of electronic patient information informed clinical decision making through a centralised patient database which sourced all hospitals in an Area. Although not greatly emphasised, one NP hinted at the potential of ICT to support a team-based, holistic model of care delivery through the ubiquitous nature of electronic information from a common patient database, facilitating information-sharing and communication between all health professionals across departments both within and across sites. The anticipated geographic expansion of the patient database and extended functionality of the EMR to reconcile the existing dichotomy of manual-electronic patient information repositories by a number of NPs is likely to see this benefit extended.
The reality of the NP role in reaching its disruptive potential is a contentious issue. International researchers have based the disruptive impact of NPs on their ability to complement physicians in care of subacute patients and their better accommodation of changing population health needs by espousing a preventative care paradigm. Because the NP role remains relatively new in Australian, the scarcity of NPs, their poorly defined and still-emerging roles, and existing healthcare regulations, professional standards and administrative procedures presently limit the impact of the NP beyond that of a sustaining innovation . However, the findings from this early study convey the considerable potential of ICT in advancing the disruptive characteristics of the NP role.
Results from this study complement the existing literature in exploring the integration and use of ICT to support roles in differing settings. The time-pressed ED environment saw NPs from our study emphasising the accessibility of electronic patient notes over remotely-located paper notes in the facilitation of timely diagnostic and therapeutic decision making, a key component of advanced practice. While knowledge-databases and clinical decision making tools were regularly used and cited as useful by our NP participants, the utility of electronic decision support elements of ICT were more thoroughly explored among NPs in primary care [23, 24] and critical care  settings where decision support software was perceived to support advanced practice and improve quality of care. Also raised as an area of interest in this study, support for electronic prescribing and medication management was acknowledged as an advantage by participants across a variety of care settings . However, successful integration of ICT into clinical work practices emerged as a consistent prerequisite for ICT adoption before potential benefits can be realised [23–28]. Whilst NPs in this study cited the lack of computer terminals as a barrier to ICT use, awkward user interfaces, relative computer illiteracy and perceived disturbances to the patient encounter and nurse-patient rapport were additional factors reported as limiting utilisation of such interventions.
As the NP role continues to expand and proliferate in the Australia healthcare system, the increased diffusion of mobile technology such as Personal Digital Assistants (PDAs) will support extension of non-clinical dimensions of work which may see practitioners removed from traditional treatment areas where stationary devices are readily available [24, 26]. Multimedia and telemedicine capabilities will facilitate communication with distant or offsite colleagues, supporting the holistic, team-based paradigm of care central to the advanced practice model of nursing.
Qualitative, exploratory studies looking at the use of ICT by NPs and their associated impact on role are scarce. Studies have sought to examine the relationship between ICT use and clinical indicator or outcome , quantitative, descriptive studies examining rates of use [30, 31] and statistical correlations between user attributes and patterns of use . Indicator data are valuable in providing a framework for evaluation, however they are limited in terms of explaining the nature of the relationship between variables or understanding the various contextual factors which often contribute to outcomes . This study aimed to address this gap in providing in-depth insights into the influence and impact of ICT on facilitating the potentially disruptive role of NPs. The findings present new evidence about the ways ICT is being integrated and is helping to shape the role of NP, however, the study was conducted at an early stage of NP implementation across sites and findings are likely to vary as both role and systems become increasingly established.