NATIONAL COMPETITION POLICY LEGISLA TION REVIEW Nurses Bill 1997 Report of the Review Panel 25 September 1998 The views expressed in this report are the views of the Review Panel and do not represent the views of the South Australian Govenunent. Any action taken in anticipation of the outcomes of the review process is at the risk of persons taking such action. -2- T ABLE OF CONTENTS TABLE OF CONTENTS .......... ...................... ........... ............. .... ................... .... ..... ........ .... ....... 2 INTRODUCTION .................. ............... .. .................. ........................................................... ..... 4 PART I: CENTRAL ISSUES ................ ..................... .................... ... ..................................... 5 Objectives ortlle Act ..... ..... ............. .. ... .................................................. ............ ................... 5 Markets ............ ............ ...................... ......... ...... .......... ...... .......... ............... .. ......................... . 5 Personal Health Care Services .................................... ... ............ ............. ........ ............ ....... 5 Health Care Organisations ............. ................... ......... ... .. ............... .. .... .............................. 7 Training Market ................................ ................................ ........ ...... .............. ...... ............... 7 Restrictions upon Competition ......... .............. ........ ............................................ ................... il Costs ......................................................................... .. ................................ .. ................... ....... S Public Benefits ................................. ........... ............................................................... ... .... ..... 9 PART 2: ANALYSIS OF THE RESTRICTIONS CONTAINED IN THE NURSES BILL ... 10 Title and Practice Protcction ............................. ........ ....... ... ............ ..... ........... .... ................. 10 Registration and Enrolment ... ...... ................................ .. ..................................... ....... .... .. 10 Scopc of Practice ................................ .'........... .................................. ....... .................. ... ... . 20 Rescrvation orTitlc ........................................ ............... ................................. .................. 22 Conclusion: Title and Practice Protcction ........................................................................ 23 Professional Standards ........................................................ .. .... ........... ... .............................. 24 Codes ..................... ........................................................................................................... 24 Standards ........ ................... ............................ ............. ... ............ ....................................... 24 Dissemination of Profcssional Standards ......................................................................... 25 Conclusion: Professional Standards .............................................................. ....... ........... . 25 Advertising ................................................................... .. ......................................... .... ..... 25 Approval of Training Courses ....... ... ............................. ................................. .. ................... 26 Appeals ... ........................ .... ..................... ................... .................................. ............ ....... 26 2:'1 Scplcm\wr I'l'll\ r'nlllf'<,'uti"u I'tllicy I~("\"I("\C " NUH,'S 14.II/fJ97 RCP'lr1llftlll" Rn" ,,"\\ (>,md Direct Entry into Specialised Fields of Nursing ...................... ........................... ............. 27 Conclusion: Approval of Training Courses .................................................................... 27 Nurses Board ............................................................... ......................................................... 28 Functions of the Board ..................................................................................... .. .............. 28 Nature of the Restriction .................................................................................................. 28 Unprofessional Condllct. .................................................................................................. 29 Legislative Restrainls .................................................................................... .. ................. 30 Conclusion: Nurses Board ................................................................................... ........... 32 PART 3: ADMINISTRATIVE REQUIREMENTS ................................................................ 33 Information to be Supplied by Midwives ........................................................................ 34 Fonns ............................................................................................................................... .15 PART 4: RECOMMENDATIONS .................................................................................... .. .... 36 PART 5: APPENDICES ....................................................................................... ................... 37 Appendix 1: Terms of Reference ......................................................................................... 37 Appendix 2: Compar.ison of Fees ........................................................................................ 40 Appendix 3: Re-entry Pathways for Nurses ......................................................................... 4 I Appendix 4: Material Considered by the'Review Panel.. ................................................ ... .43 Appendix 5: Consultation List .............. .............................................................................. 44 -4 - INTRODUCTION The following report concerns the review of the Nurses Bill 1997. The review is conducted in compliance with an obligation upon the South Australian Government under clause 5 0 f the Competition Principles Agreement. The Competition Principles Agreement is one of three agreements signed by the Commonwealth, State and Territory Governments in April 1995. These three agreements give effect to the National Competition Policy. The obligation contained in clause 5 of the Competition Principles Agreement concerns the review, and where appropriate reform, of proposed legislation which restricts competition. The guiding principle in undertaking this review is that the Nurses Bill should not restrict competition unless: a) the benefits of the restriction to the community as a whole outweigh the costs; and b) the obj ectives ofthe legislation can only be achieved by restricting competition. The TenllS of Reference for this review reflect the requirements of the Competition Principles Agreement. In addition, the Review Panel has considered whether administrative procedures required by the Nurses Bill are unnecessary or impose an unwarranted burden on any person. To satisfy the requirements of clause 5 of the Competition Principles Agreement the following documents have been reviewed: Nurses Bill 1997 Nurses Regulations 1986 Additionally, ProCessional Standards for the nursing profession currently developed or endorsed by the Nurses Board have been examined. This report is in five parts. The first part concerns the central issues of the review. The second part of the report contains the analysis of the restrictions contained in the Bill. The third part examines the administrative burden imposed by requirements of the Bill. The fourth part of the report lists the recommendations formulated as a result of the review. Finally, Part 5 of the report contains various appendices, including the Tenlls of Reference and consultation list. References to clauses are references to clauses of the Nurses Bill 1997, unless otherwise indicated. References to regulations are references to regulations contained in the Nurses Regulations 1986, unless otherwise indicated. ~<, Srl'lemhcr 1'1'))01 ('''IIl!'t"(llulIll'u lll:Y Rl'\,ICW - NllrS<'J Riff /'197 Report of the Rcvn:w Panel -5- PART 1: CENTRAL ISSUES Objectives of the Act The object of the Bill is to protect the public by ensuring nursing care is of a high standard, and is provided by persons who are identifiable within the community as possessing the necessary qualifications and/or experience to provide nursing services. The Bill achieves these objectives through systems of registration and enrolJl1cnt for nurses. The Bill also continues the existencc of the Nurses Board, and empowers thc Board to enforce the provisions of the Bill. Two submissions received during the consultation period supported this purpose being expressly stated at the outset of the Nurses Bill.' The Review Panel have concluded, however, that the preamble to the Bill, read in the context of the requirement that the Nurses Board exercise its functions in accordance with the requirements of clause 16(2) of the Nurses Bill, adequately reflect the objects of the Bill. Markets The purpose of the legislation review process is to analyse the effect of legislative restrictions upon competition in markets. The identi fication of the relevant markets is imperative, therefore, for an accurate assessment of the impact of legislative restrictions upon competition. 'Competition within markets' is competition in the broad sense of the ability to cnter and participate in a market, not 'competition' in the sense of an individual's rights to participate in a market. Competition policy is concerned with broad, competitive outcomes rather than marginal behaviour. The potential impact of legislated restrictions upon an individual's participation in a market, therefore, is only relevant to legislation review where the impact on the individual is symptomatic of broader anti-competitive outcomes caused by the legislated restriction. This distinction is important in the context of reviewing legislation which empowers a body to take disciplinary action against individuals participating in a profession. The ability to restrict or prevent an individual's participation in a profession is only relevant to the process of legislation review, if criteria for imposing such restrictions distorts general competitive conduct within a market. Personal Health Care Services In the context of nursing care, the provision of personal health care services is undertaken by two groups of people. The first of these are qualified l,urses who comprise the nursing profession. The nursing profession is divided into three groups of qualified nurses: specialist registered nurses (eg midwives and mental health nurses etc), registered nurses and enrolled nurses. The distinction between specialist registered nurses and registered nurses without specialised training in a particular field is maintained through the decisions of employers of these nurses. Employment choices will be influenced by considerations of the duty of care to I Australian Nursing Federation submission at 3; Royal College of Nursing submission at I. -6- patients and consumer preference. The Nurses Bill reinforces this distinction by empowering the Nurses Board to authorise specialist nursing qualifications for inclusion on the register or roll,' and by provisions which prohibit a person claiming they are a specialist nurse without being registered under the Nurses Bill as having this speciality. The distinction between registered nurses and enrolled nurses is enforced by the systems of registration and enrolment established under the Nurses Bill and by the legislative requirement for enrolled nurse supervIsIOn. A number of submissions received during the consultation process urged that midwifery be recognised as a profession independent of nursing.' The Review Panel gave substantial consideration to this matter. For the purposes of the review ..however, the decision was taken not to depart from the historical approach of considering midwifClY as a specialised field of nursing. The Review Panel notes, however, that the provision of opportunities for direct entry into the profession of midwifery through a South Australian undergraduate midwifery course, and increased consumer awareness and acceptance conceming the services which are provided by midwives, may lead to the recognition of midwifery as a profession which is distinct from nursing. While it is not the role of this review to put in place mechanisms for such an evolution to occur, the issues of direct entry into the profession of midwifery and the opportunities that may be created through an undergraduate course in midwifelY are discussed below in relation to the approval of training courses' The second group of people who provide personal health care services is personal care assistants. Personal care assistants are currently not regulated by statute. There is competition between nurses and personal care assistants on an individual basis where it is open to an employer to employ a personal care assistant instead of a registered or enrolled nurse to deliver personal health care. The Nurses Bill does not constrain the employment of personal care assistan~s by defining the scope of nursing practice and reserving this area exclusively to nurses. The constraints upon the employment of personal care assistants reflect the constraints imposed by the duty of care owed to clients of health care services. Where this duty of care can be satisfied by the employment of a personal care assistant rather than a nurse, the employer may choose between the employment of nurses or personal care assistants. Equally members of the public can exercise their right to choose between personal health care offered by a nurse or personal care assistant. Traditionally, the nursing profession has been distinct from other health-care professions in that there was limited competition between nurses in the manner that there is competition between, for example, dentists. Dentists are essentially business people who compete against other dentists for clientele. Nurses, by comparison, have not traditionally marketed their professional services individually, but rather were employed, predominantly by health care organisations. There is an increasing trend, however, towards nurses providing nursing services as self-employed business people. These nurses are in competition with not only , Clause 16( I leg) Nurses Bill Submissions received from the School of Nursing Flinders University, the Facility of Nursing University of South Australia. Australian College of Midwives submission at 1. 3 , Page 24 . .?S ScJltl'lIlhn ]')0111 ('"mpdm~ SCl'to:mhn 1"')1' 'nlllp<'utinll Pnllcy ){('vu.'w t.ur.H'S RIlIlr)l)7 Rl'I"'I'rt ufthc Rc\'/('w l';uH;1 - II - Under the Nurses Act 1984, the Nurses Board maintained separate registers for general nurses, psychiatric nurses, mental deficiency nurses and midwives. Several submissions received during the consultation period advocated for the retention of a separate register for midwives. 8 The Review Panel has considered these submissions and concluded that having a single register which notes the area of specialisation of the practitioner achieves the public benefits associated with registration. Recognition of specialised qualifications and experience on the single register, arguably provides the same level of recognition of these qualifications and experience in the area of specialty as registration on separate registers. The Nurses Bill, if enacted, will restrict the use of titles which denote that a person has the qualifications and experience denoted by certain titles such as "midwife':' unless the person meets the qualification and experience requirements of the Bill. Reservation of titles in this manner also identifies the specialised expertise of the specialist nurse without the need to have separate registers. Qualificatiolls Attaining a qualification which, in the oplllion of thl! Board, is necessary to ensure competency is an objective criteria for attaining registration or enrolment. A system of registration or enrolment in a profession which is based upon objective standards of competl!ncy, while being a restriction upon entering a profession, may bc justified where there is a risk of harm to the public from persons who are not competent to provide certain services. A universal threshold level of risk which will justify registration requirements across all professions cannot be identified as the risks associated with 'holding out' in different professions cannot be compared. In relation to the services provided by registered and cnrolled nurses, however, this degree of risk is assessed by the Review Panel as significant. Persons who hold themselves out to be qualified nurses should be competent in the delivery of nursing services. Objective criteria for entering a profession clearly 'sign post' the entry requirements which will be applied consistently to all person applying to enter the profession. Unlike criteria for admission which may he applied in arbitrary and discretionary manner by a regulating authority, objective entry requirements can promote competition within a profession as all person who attain the objective entry requirements will be admitted regardless of the prejUdices of the regulating authority. Similarly, it could be argued that objective criteria promote mobility within a profession, as the criteria to move from one field within the profession to another are clearly identified. The qualifications ana prescribed experience for different types of nurses are set out in regulations 6 and 7. The required qualifications relate to the completion of listed courses. The list includes both local and overseas courses. The prescribed experience set out in regulation 7 relutes to the clinical experience required to be registered as a registered nurse, psychiatric nurse or midwife, or to be enrolled as an enrolled nurse. The clinical experience is now included in training COllrses for registered and enrolled nurses and, therefore, has to an extent been subsumed into "qualifications" required for nurses. To become a specialist nurse 8 Submissions received from the Midwives Act Lobby Group at 2 and the Australian College of Midwives at 2 Ms Robyn Gilhcs' submission at 5 Ii - 1~ - further training and experience in the speciality is required. The issue of direct entry of qualified midwives is discussed below. ' One submission questioned whether the six week period for clinical placement of enrolled nurses was an unnecessarily long and arbitrary period. 'o The submission indicated that it may be possible for some aspiring enrolled nurses to demonstrate competency in a pcriod significantly shorter than six weeks. The relevant question in terms of competition policy is whether the six week period of clinical experience imposes costs which exceed the public benefits of requiring enrolled nurses to undertake a clinical placement of six weeks duration. The Review Panel have considered this contention and con~uded that six weeks is a minimal period for an aspiring enrolled nurse to integrate theory with nursing practice. A six week placement enables the aspiring enrolled nurse's technical competence to be assessed through repeated demonstration of competency over an extended period of time. The clinical placement is also an important period for the exposure of aspiring enrolled nurses to the culture and ethics of the health care system. There are, therefore, signilicant public benefits associated with requiring enrolled nurses to undergo a sustained period of clinical experience. The costs of the requirement are compliance costs imposed upon the individual. These costs are not assessed as substantial. The Review Panel conclude, therefore, that the six week clinical experience component of enrolled nurse training is not an unjustifiable restriction upon competition. In relation to nurses qualified outside South Australia, the experience prescribed by regulation 7 provides a 'checklist' for the Nurses Board when considering an application to be registered or enrolled, or detemlining appropriate conditions to attach to that registration or enrolment. The Board may under regulations 8 to 10 require that a person seeking registration or enrolment sit an examination. Candidates who fail an examination have rights to supplementary examination, however no candidate may sit for the examination in the same course more than three times. Examinations are a form of restriction on the entry of persons into the profession of nursing. The prohibition on a person sitting an examination more than three times is a barrier to entry into the profession. This is an intenncdiatc restriction upon competition. The costs associated with the requirement to sit examinations may be justified if the examination relates to attaining qualifications required to demonstrate competency, and undertaking the examination is the best means for assessing such competency. It is envisaged that the Nurses Board will not be empowered by regulations made under the Nurses Bill to require an applicant for registration or enrolment to sit an examination. While the register and the roll do reflect the numbers of nurses currently in the profession, the requirements for registration and enrolment do not solely constrain the numbers of enrolled and registered nurses. The numbers of people who can attain the necessary qualifications is limited by the numbers of places in Bachelor of Nursing courses and courses qualifying a person as an enrolled nurse. The numbers of places at universities and other teaching institutions is dependent upon funding to fue universities and other teaching institutions. Other restrictions upon the numbers of qualified nurses and specialist nurses includes the 9 Page 25 2S Septemher 1995 Competition Pulicy Rcnc\\ - Nllls,'s lIdll<')<)7 Rrp"n 01 the RnH:w Panel - 13 - availability of clinical practice placements, educational standards (including entry requirements) required to attend the university or other teaching institution, and the cost of attending such courses. No evidence was presented to the Review Panel to suggest that the systems of registration and enrolment to be imposed by the Nurses Bill, if enacted, would impact upon the numbers of practicing nurses in a manner which would compromise competition within health care delivery markets. Requirements determined by the Board Lo be necessary Registration and enrolment criteria such as "requirements determined by the Board to be necessary" may enable the Board to require attributes which>do not relate to the competency of the nurse. Demanding attributes unrelated to competency may be unjustifiable restrictions upon competition. The practice of the Board has been, however, to require matters which are linked to issues of competency. Generally competency is shown by the acquisition of a required qualification (see discussion above). Where such a qualification has not been attained, however, the Board will consider other attributes in determining whether the applicant is competent to be a registered or enrolled nurse. For example, requiring some nurses re-cntering the workforce or who have overseas qualifications to undergo a period of practical assessment to ensure they are competent in their field of practice. Fit alld proper persoll , "The fit and proper person" standard may also constitute an unjustifiable restriction upon competition depending upon how this standard is interpreted and applied by the Board. Again, criteria to determine whether a person is a fit and proper person to be registered or enrolled should be based upon ensuring the applicant is competent to provide nursing services within their field of practice. In assessing whether a person is a ' fit and proper person' the Board currently considers issues such as relevant language proficiency, physical or other impairment, and criminal convictions (where the offence indicates that the applicant's fiduciary duty to a patient may be compromised). Such considerations are all related to the competency of the person to be a registered or enrolled nurse. One submission received during the consultation process suggested that nurses with physical impairments should self-regulate, that is that they should be granted full registration by the Nurses Board and the nurse and the nurse's employer should determine the work duties appropriate for that nurse." Currently only 18 out of23,000 registered or enrolled nurses are subject to limitations on their registration or enrolment due to physical impairment. Most of these restrictions upon registration or enrolment relate to lifting restrictions. In registering or enrolling a nurse, the Nurses Board is certifying to the public, including employers, that the nurse is competent and capable of carrying out the duties within the area of competence for which the nurse is registered. If the nurse suffers a physical impairment which limits her or his ability to perform such duties, than there is a public benefit in limiting the scope of the nurse's registration or enrolment. The costs associated with this restriction are costs to the individual rather than a cost to the community, especially given the low number of nurses who are affected by such restrictions on practice. 11 Australian Nursing Federation submission at 5 2~ ScptcllIhc.-r I'NK Competition Puhey Review· NunC's Bill 1997" Reran o(thc Review Panel - 14 - Another submission highlighted the issue of persons being admitted to training courses in nursing who may not achieve registration in these professions as they are not considered "fit and proper" persons to be nurses." This issue goes beyond considerations of the restrictions upon competition contained in the Nurses Bill, and would involve a detailed consideration of the interrelationship between training opportunities and the entry into vocations. Such an enquiry is beyond the Terms of Reference for this review. Continuing competency While the criteria for registration and enrolment are based upon objective standards of competency, there is currently no on-going assessment or'this competency. The Nurses Board have indicated during the course of the revicw that they are considering the possibility of implementing a system of randomly auditing registered and enrolled nurses to assess the competency of nurses in their field of practice." Nurses would, at the time of enrolling or registering, complete a statutory declaration indicating that the nurse is competent to practice. Competency would be assessed in relation to competency standards for the field in which the nursc practised. For example, midwives would be assessed against standards devc10ped specifically in relation to midwifery practice. None of the submissions received during the public consultation process considered that the system of registration and enrolment significantly restricted the numbers of nurses practising, provided that the system was based upon objective standards of competency. Reinstaiemellt a/registration or enrolment: clause 26 Similar considerations to those discussed above arise in relation to the reinstatement of registration or enrolment where the registration or enrolment has been cancelled for unprofessional conduct. Clause 26(3) of the Bill prevents a person from applying for reinstatement within two years of the registration or enrolment being cancelled. Under Clause 26(6) the Board should reinstate the person's name to the register or roll if satisfied that the person: (a) has sufficient competence and capacity to practise in the field of nursing to the standards required by the Board for the purposes of the Act; and is a fit and proper person to be registered or enrolled. (b) The costs generated by clause 26(6) are private compliance costs borne by the person applying for reinstatement. These costs are not significant in terms of competition within health care delivery markets. Costs associated with a shortage of registered or enrolled nurses may result, however, if the Board inappropriately assesses whether a person should be reinstated. The criteria for reinstatement are based upon the competency and capacity of the nurse to undertake the duties of a registered or enrolled nurse. These criteria are appropriate and do not create significant costs for the communi ty. " Ms Robyn Gillies' submission at 4 11 Nurses Board of South Australia submission at 2 - 15 - The period of two years imposed by clause 26(3) is an arbitrary time which must elapse before a person can apply to the Board for reinstatement. This time period is not determined by reference to any objective criteria for measuring the competence and capacity of the person to fulfil professional duties. The period of two years, therefore, can on some interpretations be seen as an arbitrary penalty which must be 'served' by a nurse who has his or her registration or enrolment cancelled. Three submissions received during the consultation process considered the two year period prior to re-entry to be an unnecessarily long and arbitrary period before which a person could seek re-instatement as a nurse." Two of these three submissions, however, favoured some minimum time period being specified in the legislation. The Nurses Board of South Australia specifically suggested twelve months as an appropriate minimum period before which a person could~eek re-instatement. De-registration is a serious sanction which is used infrequently by the Board. It is only in the most serious eases of unprofessional conduct that a nurse will be suspended from practise. There is a public benefit in ensuring that a minimum time passes during which the de-registered person can assess their commitment to the profession of nursing and take necessary remedial steps to demonstrate their competency. The Nurses Board is currently evaluating the continued competency of nurses. This study, being conducted by the Australian Nursing Council Incorporated, is charged with developing a statement of indicators of continuing competence and to describe how these indicators may be applied in various circumstances." Such a study may, therefore, identify objective indicators of competency and capacity to be applied to nurses seeking reinstatement. It is envisaged that this study will be completed by the end of 1998. The costs of this restriction are significant in terms of the de-registered individual's right to practise, but trivial in terms of its affect on competition generally. While the Review Panel concludes that the public benefits associated with this restriction outweigh the costs generated by the restriction, the Review Panel would support the reduction of the time period from two years to twelve months. There is no alternative other than a legislative scheme of registration to achieve the objective of removing incompetent practitioners from a profession. The Review Panel recommends that clause 26(3) be amended to reduce the minimum period before which a person can seek reinstatement to the roll or register fr om two years to 12 month s. 1.4 Submissions received from the Australian Nursing Federation, tht! Nurses Board of South Australia and the Royal College of Nursing. 15 Australian Nursing Council Incorporated Continuing Competency in Nursing: A Chance to Voice Your Opinion - A Survey of Nurses' Views Commissioned by the Australian Nursing CouncilllJcorporaled (1998) 25 S!:r>lcmher I'>')K C'l'lfllpt'tilion "uliey Rc"itw . NurJI'J RJIII'JO' 1~t'J't,n .,fthc Rt\· ,~· ..... I';"I(·1 - 16 - Limited registration or enrolment: clause 27 Clause 27 enables limited registration or enrolment where, in the opinion of the Board, the applicant for registration or enrolment lacks the necessary qualifications or experience, or the mental or physical capacity, required for unrestricted enrolment or registration. Under subsection 27(2), the Board may impose restrictions upon the places in, and times at, which the applicant can practise nursing, limit the areas of nursing in which the applicant may practise, limit the period of enrolment or registration, impose conditions requiring supervision or impose any other condition as the Board thinks fit. The costs of this restriction are minimised if the Board utilises criteria which accords with community and professional views on whether a person ' sTiould be entitled to unrestricted enrolment or registration. The criteria which the Board uses is based upon the competence, including the physical capacity, of the nurse to carry out duties in their area of practice. An example of such restrictions arc weight restrictions which prohibit a nurse from lifting more than a specified weight. Such restrictions are discussed above in relation to clauses 23 and 24 of the Nurses Bill.'· Other more substantial conditions include requirements for supervision. The restrictions upon practice can be either trivial or intcrmediate depending upon the conditions placed upon practicc. These restrictions, however, impact upon the individual's right to practice. Provided the Nurses Board is imposing conditions which arc necessary to ensure the competency of the nursing profession then the costs in terms of competition are negligible. There is a benefit to the public in limitations being placed upon the registration or enrolment of persons where the skills or expertise of the person are insufficient for them to qualify for unrestricted registration or enrolment. This provision enhances involvement in the nursing profession by enabling. the Board to provide limited enrolment or registration to persons who otherwise would not qualify for registration or enrolment and, therefore, would be prevented from practising as nurses. Provided that the criteria which the Board apply are based upon competency, and are applied consistently then there are no anti-competitive costs of complying with this provision. There are, however, significant public benefits in permitting nurses to attain conditional registration or enrolment, thereby enabling them to continue working while ensuring health care standards are not compromised. While conditional registration or enrolment is a restriction upon the individual nurse, it is not an unjustifiable restriction upon competition. Conditional registration is also utilised by the Board to authorise nurses, particularly from overseas, to practise in Australia for the purposes of study or teaching. This is not a competition issue. Process oj registration and enrolment: clauses 25, 28 and 34 Clause 25 of the Nurses Bill outlines the process for registration and enrolment. Applications for registration and enrolment must be in a manner and form approved by the Board and be accompanied by the registration or enrolment fee (clause 28). Currently, the initial registration and enrolment fee is set at $60. "Page 10 2:'1 Septemher I<)"S lomrlCtltUln I'ulicy Rr:view . Nllt!!'! Riff 19'>17: Rcport (lfthc RC\'JcW Panel - 17 - Under clause 34 of the Nurses Bill, a person will not be registered or enrolled or have their enrolment or registration reinstated until the prescribed practice fee is paid. The current annual fee for registered nurses is $105. The current annual fee for enrolled nurses is $73.50. A fee of $35 is charged where a registered nurse attains the level of qualifications and expertise required to be authorised to practise in a specialised area such as midwifery. The form of application for enrolment under the Nurses Act 1984 is prescribed in the regulations. The costs of complying with this provision are likely to be minimal unless: a) b) the prescribed manner or form is unusual in its requirements; or the application fee is high. .. The Review Panel has assumed, for the purposes of this review, that the application fonn for registration and enrolment will not be dissimilar to the form currently contained in regulation 5 and have concluded, on this basis, that the manner and form requirement is a trivial restriction upon competition. The registration and enrolment fee may constitute a significant restriction upon competition if it dissuades entry into the profession, or is substantial and is passed on to consumers. The Clm-ent fee for registration of $105 is significantly higher than the cost of registering or enrolling as a nurse interstate. A comparative table of fees is contained in Appendix 2. The differences in the registration and enrolment fees paid by nurses in different jurisdictions reflects the differences in the income and expenditure of the regulatory authorities in each jurisdiction, the priorities of the regulatory body and the attitudes of the community within the jurisdiction to regulation. For example, the Nurses Registration Board in New South Wales registers the largest numbers of nurses of any Australian jurisdiction. The functions of this regulatory body, however, do not extend to hearing complaints against nurses. Such complaints arc assessed by the New South Wales' Health Complaints Commission. The regulatory authority, therefore, does not have the expenditure associated with determining such complaints. This is a cost which in South Australia must be met by the Nurses Board. Similarly, the attitudes of the community to regulation influences the numbers of complaints against nurses which are lodged with the Nurses Board for investigation and determination. For example in 1996, 150 complaints were lodged with the Nurses Board of South Australia. whereas only six complaints were lodged with the regulatory authority in the Northern Territory. This divergence in reporting can be attributed to many factors only one of which is differing attitudes to regulation. The outcome is, however, that there is significantly more work for regulatory authorities where the community is prepared to lodge complaints against professionals. In this context, it is appropriate to note that clause 43 of the Nurses Bill requires a health professional who is treating a nurse who believes that the ability of the nurse to provide nursing care is, or may be, seriously impaired by a mental of physical incapacity, to submit a report to the Board detailing the grounds for such a belief. Similarly, clause 45 requires employers to report unprofessional conduct to the Board. Such statutory obligations generate investigatory and disciplinary work for the Board, the costs of which are met by the fees charged for registration and enrolment. The public benefits of charging a registration or enrolment fee relate to recovery of the costs of administering the Nurses Bill. The Nurses Bill achieves significant public benefits through ensuring the competency of nurses. The system of registration and enrolment not only 25 Septemher I99R Cm"pclilion ('Illle}, RC\'i('w . NIlNC"J /WI1997. RCpCln of the Review Panel - IS - ensures the competency of persons entering the profession, but also provides a record of information available to the public and employers which indicates whether a nurse possesses specialist qualifications, has been disciplined by the Board, is subject to a decision of the Board suspending or cancelling their registration or enrolment, or has conditions attached to their right to practice. The availability of this information to consumers of nursing services facilitates consumer choice for nursing services and encourages competition in the market for nursing services. The amount of the fees is referable to the expense associated with the Nurses Board fulfilling its statutory role under the Nurses Act 1984. A similar fee structure will likewise be appropriate to fund the activities of the Nurses Board under the Nurses Bill, ifenacted. . One submission received during the consultation process contended that registration and enrolment fees were high.17 This submission did not provide any evidence, however, that the level of fees constituted a significant bamer to entry or participation within the profession of nursing. The Review Panel have concluded that the current registration and enrolment fees are only trivial restrictions upon competition. Board's approl'al required where a I/urse has I/otpractised/or fil'eyears: Clause 29: . Clause 29 prescribes that where a nurse has not practised for a period of five years or more the nurse must not practise nursing without first obtaining the approval of the Board. Prior to granting its approval, the Board may require the nurse to obtain qualifications and experience specified by the Board, and for that purpose may require the nurse to undertake specific training. The Board can also make its approval conditional. These conditions can relate to the places or times at which a nurse may provide nursing care, limit the areas of nursing in which the person can work, impose conditions regarding supervision, or any other condition as the Board thinks fit. There is a public benefit in ensuring that th7 skills and knowledge of nurses are current. This public benefit can be achieved if there is a restriction on the nurse practising without the approval of the Board. This is an intermediate restriction upon competition which imposes additional costs upon persons who have not practised for five years or more. The costs are justified if the conditions which the Board imposes are necessary [or the protection of the public and the maintenance of nursing standards. Similar restrictions exist in all Australian jurisdictions, except New South Wales. The current practice of the Board is to require a nurse who has not been registered or enrolled for a period of five years or more to undertake a formal course of training. The details of these courses are set out in Appendix 3. The Board does not consider other indicators of competency beyond the elapse of time. For nurses who have not been registered for a period exceeding twenty years, the Board requires that these nurses undertake an undergraduate course in nursing. Such requirements for re-training place significant costs on the nurses seeking to re-enter the workforce and may reduce the numbers of nurses available to practice. An arbitrary requirement for re-training does not attempt to assess the competency of the nurse wishing to re-enter the workforce. 17 Australian Nursing Federation at 6 2~ Septemher 199~ ('mupoelition Policy Rcview . Nu,st"s Rill 1997: Rcpo~ of the Rcvit'II, {J anel - 19 The Review Panel has concluded that other indicators of competency should be considered beyond the passing of time. Several of the submissions received during the course of the consultation process support this conclusion. ,8 The Review Panel notes that the fact that a nurse may have been out of the workforce for an extended period of time does not necessarily mean that the nurse is not competent to fulfil nursing duties. The converse is also true, that is the fact that a nurse is currently practising does not mean he or she is necessarily competent in the range of nursing duties he or she is required to undertake. As discussed above in relation clause 27 of the Nurses Bill, the Nurses Board is currently involved in the Australian Nursing Council's investigation into .indicators of continuing competence. This study may identify appropriate indicatoJ;,S of continuing competency. As indicated in relation to "Continuing Competence" above, the Nurses Board is considering implementing a system whereby nurses would self-regulate by completing a statutory declaration as to competence and undergoing random audits of nurses on the roll and register. Such a system of random audits may replace the current requirement of the Board as to retraining. Revocation or variation of conditions: Section 30 Section 30 empowers the Board to vary or revoke a condition attached to registration or enrolment. The power to vary conditions may be utilised to impose conditions which restrict competition. Depending upon the conditions imposed, this provision could restrict competition in a trivial through to intermediate manner. The cost of this restriction is minimal, especially if the Board introduces conditions which are reasonably required to protect the public interest. There is public benefit in enabling the Board to vary and q:voke conditions. The ability to revoke conditions may enhance competition. The ability to vary conditions may also enhance competition if the Board imposes less stringent conditions. Where the Board imposes more stringent conditions this may also be justified ifthe conditions are ip the public interest. Restriction of movement of lIurses betweell jurisdictions: Mutual Recognition Systems of registration and enrolment may inhibit movement of nurses between jurisdictions, where nurses enrolled or registered in another jurisdiction are unable to register or enrol in South Australia. Such a restriction reduces the pool of nurses within South Australia and thereby, reduces the level of competition between nurses. Registration and enrolment regimes established under the Nurses Bill, however, do not restrict movement of registered or enrolled nurses between jurisdictions due to the operation of the system of Mutual Recognition established under the Mutual Recognition Act 1992 (Commonwealth). Mutual Recognition enables nurses registered or enrolled in equivalent occupations interstate, to be registered or enrolled in South Australia. A nurse registered or enrolled pursuant to the Mutual Recognition regime is subject to the same laws regarding practice as other nurses registered in South Australia except in regard to laws requiring the attainment or possession 18 For example, submissions received from lbe Nurses Board of Soulb Australia, lbe Midwives Act Lobby Group, lbe Australian College of Nurses, lbe University of Soulb Australia, lbe Australian Nurses Federation and lbe Royal College of Nurses. 2S September 1998 Competition Policy Review . Nurus Bilt 1997: Repon ofthc Review Panel - 20 - of some qualification or experience relating to fitness to carry on nursing (see section 17 of the Mutual Recognition Act). The scheme of the legislation is essentially, therefore, that if a nurse satisfies the requirements for registration interstate they will be registered in South Australia without undertaking further training. The Mutual Recognition Act (s 20(5» does preserve the ability of the Nurses Board to impose conditions upon practice provided these conditions do not arise from the fact that the applicant is registered pursuant to the Mutual Recognition Scheme. While the Mutual Recognition scheme alleviates constraints upon the registration or enrolment of nurses from interstate, the scheme does not alter the restrictions embodicd within conditions imposed by the Nurses Board on practice. The impact of these condition,;; upon competition are analysed above. Scope of P,·aciicc Nurses and Personal Care Assistants Unlike some other professions, the sconl' ()f nursing Dractice is not clelim'ated and reserved_ exclusivl'lv to nurses bv the Nurses Bill. For example, under section 24 of the VeterinaJ), SlIrgeo/lS ACI only reglsl"'''U veterinary surgeDns can undertake veterinary treatment for fee or reward. The Nurses Bill does not prohibit a person from carrying out aets of nursing provided they do not hold themselves out as registered, enrolled nurses or specialist nurses. There is no restriction upon persons undertaking personal health care services, except the restrictions on 'holding out' to be a nurse without registration under the Nurses Bill. 'Reservation of Tile' provisions are discussed in detail below. One submission suggested that personal care assistants should work under the supervision of registered nurses. I' The submission highlighted section 23(3) of the Nurses Act 1984. Section 23(3) indicates that the Minister may authorise a person or group of people to undertake nursing care under the supervision of a registered nurse. The Review Panel notes that the Minister has not exercised this power in relation to personal care assistants. Personal care assistants, therefore, are cUTTently not regulated by statute and not required, by statute, to work under supervision. The Review Panel has considered this submission and concluded that this matter falls outside the TemlS of Reference for this review. Statutory requirements for the supervision of personal care assistants are likely to lead to the regulation of personal care assistants. Such regulation of personal care assistants is not contemplated by the Nurses Bill and is, therefore, outside of the scope of this review. Witltill tlte Nursillg Professioll Tile scopes of practice within the Nursing Profession, are divided between enrolled nurses and registered nurses, and between registered nurses and nurses with specialised training, such as midwives and mental health nurses. The scopes of practice of registered nurses and specialist nurses is delineated by the extent of professional duty to practice within cOlllpetency. A nurse who performs procedures outside of this area of competency is 111 breach of their duty of care to the patient and Illay be guilty of unprofessional conduct. 1'.1 Australian Nursing Federation at 7 - 21 - Enrolled Nurses The scope of practice of enrolled nurses is delineated by the area of competence of the enrolled nurse. Due to the more limited training of enrolled nurses compared with registered nurses, the Nurses Act 1984 requires that an enrolled nurse be supervised by a registered nurse. Such a requirement constitutes a significant restriction upon the employment of enrolled nurses and the employment decisions of employers. After a substantial consultation process this requirement for supervision has been altered.'o The requirement now states: 24(2) Subject to this Act, enrolment as a nurse authorises the enrolled nurse: (a) to practise in the field of nursing under the supervision of a registered nurse, and (b) to practise without such supervision in the field of nursing in accordance with the terms and conditions of a written approval given by the Board. 24(3) An approval under this section may be specific or general and may be given upon such terms and conditions as the Board thinks fit 24(4) Any approval under this section may be withdrawn or varied by the Board at any time. The redr~fted provisiOl; enables the Board to approve the unsupervised practise of enrolled nurses in areas which are within their arca ofcompetence or in circumstances where, despite a registered nurse not being in attendance, there is adequate supervision of the enrolled nurse. Only one submission suggested that Enrolled Nurses should continue to be supervised solely by registered nurses.'1 The Review Panel have concluded that there is significant public benefit in having cnrolled nurses. Due to the more limited qualifications and experience of enrolled nurses there are also significant public benefits in ensuring the competency of the enrolled nurse to work within a defined area unsupervised, or under supervision of an appropriately qualified person. The costs generated by the requirement that enrolled nurses work within a limited area unsupervised or under the supervision of a suitably qualified person generates costs for health care organisations. These costs may impact upon competition between health care organisations as health care organisations which determine to employ unregulated personal care assistants will not face the costs associated with ensuring the enrolled nurse IS supervised. These costs, however, are outweighed by the public benefits described above. " Nurses Board of South Australia The Supel1'ision ofEnrolled Nurses: Final Issues Paper (April 1998) ~I Australian Nursing Federation submission at 3 - 22 The Review Panel consider that an alternative to legislatively requiring enrolled nurses to be supervised, and regulated, is that there is agreement throughout Australia regarding the scope of practice of enrolled nurses, and this agreement is reflected in training courses for enrolled nurses. Limitations upon the competency of enrolled nursing would, provided such agreement was reached, be preserved through the employment decisions of employers and the professional decisions of enrolled nurses. Enrolled nurses WOUld, therefore, be selfregulating. Until relevant regulatory authorities and providers of nursing training agree the scope of enrolled nurse practice, and the competences required for that practice, the Review Panel have concluded that supervision of the work of enrolled nurses must be continue to be legislatively regulated. Specialist Nurses The scopes of practice of specialist nurses are not delineated by the Nurses Bill. Under the Nurses Act 1984 separate registers of specialist nurses were kept by the Board. Under section 22 of the Nurses Bill there will be a single register which will include details of any specialist nursing qualifications held by the nurse. One submission received by the Review Panel suggests that the single register will "severely limit the numbers of midwives practising". 21 The Review Panel do not accept this contention. The move to a single register is an administrative mechanism. The Nurses Board will continue to register appropriately qualified and competent midwives who do not hold registered nursing qualifications, despite there being a single register. The expertise of specialist nurses is promoted by organisations representing such specialist nurses, and is demanded by employers requiring nursing staff to fulfil specialised roles. The demands of employers, therefore, protects the scope of practice of specialised nurses. As discussed above, the decisions of employers arc influenced by many factors and arc not mandated by provisions of the Nurses Bill. Reservation of Title Legislative reservation of titles ensures that only those qualified in a profession can utilise titles denoting such qualifications. The Nurses Bill protects the titles 'nurse', 'enrolled nurse', 'registered nurse', 'midwife', 'mental health nurse' and 'psychiatric nurse'. Title reservation is achieved by clauses 36 to 40 of the Nurses Bill which prohibit "holding out". Title reservation aims at ensuring that demarcations between registered nurses and enrolled nurses, between nurses and unregulated personal care assistants, between nurses and other professional health care providers and between registered nurses and specialist nurses are recognisable by the pUblic. The Review Panel recommends that the regulations made under the Nurses Bill, when enacted, define the term "midwife", "mental health nurse" and any other specialist nursing qualifications authorised by the Nurses Board in the future. Providing such definitions will augment the public benefit associated with preventing persons who are not qualified holding themselves as possessing specialist nursing qualifications and expenence. Any assessment of restrictions associated with reservation of title involves an assessment of the qualifications and / or experience required to utilise the title, and whether this level of expertise demands that the profession be recognised by the public through the lise of a ~2 Faculty of Nursing University of South Australia submission at 4 '! <, Sqltl'lllhcr I"')!; ( 'U1I1(X'IUl<1l1 !'.,hcy }{C\'ICW ..... ·/111'·\ ",ff /997 [~cp"l1 of the f(~'\W\\ I'Jlld - 23 - reserved title. The Review Panel have considered this issue and concluded that there is significant risk to the public through persons 'holding outl that they have specific nursing qualifications and experience when they do not. The alleviation of this risk through the statutOlY reservation of titles is a substantial public benefit. The submissions received emphasised the public benefit in the community being able to identifY qualified nurses." None of the submissions received alluded to any costs generated by the reserving oftitles. This review must also assess whether there is a need to legislate to ensure title reservation, or alternatively whether such title reservation can be achieved by the profession itself supported by laws prohibiting misrepresentation and false and misleading conduct. An example of such industry based title reservation is the use of the title Certifi"d Practising Accountant within the accounting profession. None of the submissions reccived during the course of the review suggcsted an altcmative means of delineating between personal carc assistants and nurses other than statutory title protection. The Review Panel recommends that the regulations made under the Nurses Bill, if enacted, define the term "midwife", "mental health nurse" and any other specialist nursing qualifications authorised by the Nurses Board in the future. Conclusion: Title and Practice Protection Systems of title and practice protection, such as those contained in the Nurses Bill, arc intennediate rcstrictions upon competition. Such restrictions will bc justified, where there is a real risk ofsignificani harm to the public which is alleviated by the system of registration or enrolment and prohibitions on 'holding out'. The Review Pancl have concluded that there is a significant risk of ham1 to the public if persons who do not hold relevant qualifications and experience hold themselves out to be specialist, registered or enrolled nurses. Thc costs of such restrictions are in the main compliance costs upon the individual. These compliancc costs do not discriminate between types of nurses in a manner which distorts competition. The compliance costs do impact upon competition between nurses and personal health care assistants in that nurses must bear costs which are not borne by personal care assistants. No evidence was presented to the Review Panel that such an influence upon competition in this market was substantial. The Review Panel have concluded that training opportunities, and employer choice have a greater influence upon competition betwccn personal care assistants and nurses, then the costs of complying with the title and practice protection provisions contained in the Nurses Bill. For these reasons the Review Panel have concluded that the public benefits of title and practice protection outweigh the costs generated by these restrictions. The Review Panel also consider that such title and practice protection can only be achieved by a system of registration or enrolment administered under an Act of Parliament. 23 For example, submissions received from the Nurses Board of South Australia and Flinders University. - 24 - Professional Standards The second category of restriction identified by the Revicw Panel is restrictions upon conduct in the nursing profession contained within Professional Standards enforced by the Nurses Board. These Professional Standards reflect the agreed standards of the profession against which the Board assesses the competence and capacity of a nurse to fulfil his or her professional role. There are two types of Professional Standards approved by the Nurses Board: a) Codes approved by the Nurses Board; and b) standards developed by the Nurses Board. Clause 16(1)(1) empowers the Board to "endorse codcs of condnct for nurses". This function should be expanded as the Nurses Board not only endorses Professional Standards developed by other bodies, but also develops its own Professional Standards. The Review Panel recommends that clause 16(1)(f) be redrafted to state: "to approve p rofessional standards to be observed by nurses". Codes The Codes endorsed by the Board do restrict entry into and conduct within the nursing profession. A "code of conduct" under the Bill is a code of conduct endorsed by the Board under the Nurses Bill. There is no indication in the Bill which codes are endorsed by the Board. For the purposes of this review the following codes, which are cUlTently endorsed by the Nurses Board, are assumed to continue under the Nurses Bill: Code of Ethics (July 1993) Code of Conduct (July 1995) National Competency Standard (January 1997) Standards for Practice for Mental Health Nursing in Australia (May 1995) The Nurses Board are also in the process of endorsing the Competencies for Midwifery Practice developed by the Australian College of Midwives. Standards An aspect of the Code of Conduct is to uphold the agreed standards of the profession. The Nurses Board formulates and endorses standards regarding aspects of nursing practice. Currently the standards developed by the Board relate to the administering of medication and the use of restraint. The standards are disseminated to all registered and enrolled nurses, and to applicants for registration and enrolment. The standards reflect objective criteria against ]J 1!1l" I.:n Il"\\ I':JIl,"( - 42Re-Entrv Pathwavs for General Nurse (Szmervised) (Enrolled Nurses) Certificate IV in Community Services & Health - EN Module Available at: Department of Employmcnt, Technical & Furthcr Education (DET AFE) campuses: • Western Adelaide Institute • Spencer Institute • Torrens Valley Institute • Royal Adelaide Hospital Varied throughout the ycar Intakcs: 3 months part-time Duration: Prerequisitcs: • Maintaining a safe workplace • Manual handling Senior First Aid • Aged Cal"e Organisation Association (ACOA) Available at: ACOA 2-3 times per year Intakcs: I year (I day/month and clinical for 9 months) Duration: For Nurse Assistants (with previous 12 months full time employmcnt) Program: currently employed on day duty Re-entry students undertake 'Y. of the Enrolled Nurse Program" - 43 - Appendix 4: Material Considered by the Review Panel Documents ------- Can the Professions Survive under a National Competition Policy: A Joint Conference on Competition Law and the Professions (Pelth, April 1997) Australian Council of Professions National Competition Policy and the Professions (no date) Australian Health Minister's Advisory Council Filial Reporl>of the Workillg Group Adl'isillg 011 Regulatory Requirements for Unregistered Health Occupations (20 February 1997) Australian Nursing Council Incorporated Continll~ng COlllpetence ill Nursing (1998) Nurses Boan] of South Australia Review of the Nurses Act: Options Puper (June 1995) Nurses Board ofSout\t Australia Standards (l997) Nurscs Board of South Australia Approval of Courses: SUlIIdards. Criteria (Deccmber 1997) National Competition Council National COlllpetitioll Polic), alld the Nursing Profession (20 May 1998) Pew Health Professions COlllmission, Report of the Taskforce on Health Care Workforce Regulation Reformillg Health Care Workforce Regulation: Policy COllsiderations lor the 21'" CelltlllY (US; December 1995) Submissions Midwives Act Lobby Group (2 August 1998) Nurses Board of South Australia (2 September 1998) School of Nursing Flinders University (4 September 1998) Australian College of Midwives Incorporated (4 September 1998) Ms Robyn Gillies (4 September 1998) Faculty of Nursing, University of South Australia (4 September 1998) Australian Nursing Federation (7 September 1998) Royal College of Nursing (IO September 1998) ']<; Septl'mher I ')Q~ COI11('ICti tion Policy Revi ew - !JllrUJ Rill/99) . RC flOit of the k c\·,("w 1'311('1 - 44- Appendix 5: Consultation List REQUESTS Ms Di Patterson Nurses Memorial Foundation SA Inc. 10 Farner Terrace MARION SA 5043 rds Chris Hannan lith 13 Avenue WOODVILLE NORTH SA 5012 Mrs H Hancock PO Box 85 URAIDLA SA 5142 . ., Ms Karen Grech Senior Lecturer Faculty of Nursing University of SA ADELAIDE SA 5000 Mr Christopher Headland Rcsthavcn 43 Marlborough Street MALVERN SA 506\ Professor Annette Summers Deputy Dean Faculty of Nursing University of SA North Terrace ADELAIDE SA 5000 Ms Helen Tolstoshev Nurses Board of SA 200 East Terrace ADELAIDE SA 5000 CONSUMERS Julie Pearse, Midwives Action Lobby Group, 24 Dalton Avenue, ALDGATE SA 5154 Dales St Womens Centre, Attention: Olympia Kourakis, 56 Dale street, PORT ADELAIDE SA 5061 Mr John Wilsoll Health Services Co-ordinator Nganampa Health Council PO Box 2232 ALlCE SPRINGS NT 087\ Australian College of Midwives, 20A Williams St, NORWOOD SA Women's Health Statewide, Attention: Ms. V. Toovey 64 Pennington Terrace NORTH ADELAIDE SA 5006 Ms L Cusack President Royal College of Nursing, Australia 200 East Terrace ADELAIDE SA 5000 !S ScrllClllh(,T i'NtI ('UnlpcltllOn I'nhev Review - N""C' R,IIIYIJ7" Rcpt)n t.ftlie Review romcl - 45 Ms GGago Secretary Australian Nursing Federation (SA Branch) 18 Dequetteville Terrace KENT TOWN SA 5067 Professor Judith Clare Dean, School of Nursing FEnders University of SA GPO Box 2100 ADELAIDE SA 5001 President Private Hospitals Directors of Nursing Assoc PO Box 1140 NORTH ADELAIDE SA 5006 Mr Karl Mortimer Acting Executive Director Disability Services. SAHC' 7 Floor Citi Centre II Hindmar~h Square Mr R Iveson President Australian College of Mental Health Nurses PO Box 253 EASTWOOD SA 5063 Ms M Eastaugh President Australian College of Midwives (SA Branch) PO Box 1063 Kent town SA 5071 Mr K Goodall Professor A Pearsoll Clinical Nursing Executive Director Hospitals and Health Services Association of University of Adelaide North Ten"aee SA ADELAIDE SA 5000 PO Box 546 KENT TOWN SA 5071 Dr J Pincombe Dean, Faculty of Nursing University of SA North Terrace ADELAIDE SA 5000 Associate Professor Fran Sutton Mental Health Nursing Research Education unit Glenside Hospital Campus 226 Fullarton Road EASTWOOD SA 5063 Mr D Edwards Director of Nursing Mt Gambier Hospital Inc Post Office MOUNT GAMBIER SA 5290 & Mr David White Chief Nursing Officer SA Health Commission 7 Floor, Citi Centre 11 Hindmarsh Square ADELAIDE SA 5000 Mr D Elliott Director of Nursing Murray Bridge SM Hospital Inc PO Box 346 MURRAY BRIDGE SA 5253 Ms S LeBrun Director of Nursing Pt Lincoln Health and Hospital Service Inc PO Box 630 PORT LINCOLN SA 5606 Ms A Bates Director ofNurcf 19?f{ ['tllllf'Clition Policy KCVU:W. Nlfrsr:I Hill 1991. RCJ'K'Irt orlhc Rc\'icw j':mel