Copyright © eContent Management Pty Ltd. Contemporary Nurse (2003/4) 16: 83–91.

The nurse practitioner role in Fiji:

Results of an impact study

ABSTRACT The Nurse Practitioner role, a relatively new role in Fiji, was introduced by the
Ministry of Health in order to increase local access to adequate health care for
people living in remote areas. Both developed and developing countries have
introduced Nurse Practitioner or similar roles in order to provide a cost effective
and sustainable health workforce. This paper provides the results of a
qualitative, descriptive study undertaken to explore the introduction of this role
and its impact on health service delivery in Fiji. It involved semi-structured and
focus group interviews with nurse practitioners, key stake holders and
Key Words community members.The findings demonstrate the positive impact of the role
nurse
and its benefits to people living in the remote areas of Fiji. It also outlines the
practitioner; satisfaction of villagers with Nurse Practitioners and the extensive scope of

CN
Fiji; remote practice undertaken by these practitioners. Issues related to the introduction of
nursing; scope the role are also discussed. Finally, recommendations for future research and
of practice; practice are offered.
service delivery
Received 12 June 2003 Accepted 24 September 2003

KIM USHER
Associate Professor & DAVID LINDSAY
Head Senior Lecturer & Director
School of Nursing of Undergraduate Studies
Sciences School of Nursing Sciences
James Cook University James Cook University
Townsville, Queensland Townsville, Queensland

INTRODUCTION ing profession. A clear example of this has been

apidly changing patterns of health care and
R health care delivery, both nationally and
internationally, have strongly influenced (and
been influenced by) the evolution of the nurs-
the emergence of advanced clinical practice
roles, including that of Nurse Practitioners
(NPs).The role of the Nurse Practitioner is not
new. In fact, the role has been in existence for

Volume 16, Issue 1–2, December 2003/February 2004 CN 83

CN Kim Usher and David Lindsay
many years throughout the world (Turner &
Keyzer, 2002). Rural and regional areas in par-
ticular have been linked to NP roles, because
they are often under-served by medical and
allied health personnel and associated primary,
secondary and tertiary health care services.
Countries that have more recently embraced
the NP role include Britain, New Zealand, Swe-
den, Canada, Africa, the South and Western
Pacific and Australia. Clearly, both developing
and industrialised countries have seen the value
of this nursing role and the substantial capacity
these nurses have to contribute to the delivery
of cost effective and sustainable health care.The
need to develop new models of health care has
been necessitated by economic imperatives as
well as increasing nursing and medical speciali-
sation (Offredy, 2000). In Fiji, the Nurse Prac-
titioner role has evolved in response to a
chronic shortage of adequately prepared health
care workers to cover the needs of people
located principally in rural and remote regions
of Fiji. This paper provides an overview of the
nurse practitioner role in Fiji and describes the
results of a study undertaken by the authors to
examine the impact of the introduction of the
nurse practitioner role in that country.
BACKGROUND TO THE STUDY
Fiji is a multi-cultural country in the Western
Pacific region made up of over 300 islands,
approximately 100 of which are inhabited.The
Government of Fiji, the principal funding
source of health services in Fiji, provides pre-
ventive, promotive, curative and rehabilitative
services to all citizens via the Ministry of
Health (WHO, 2001a).The primary health care
model adopted by the Government is opera-
tionalised through a system of health centres
and nursing stations located strategically
throughout Fiji. Currently there are approxi-
mately 300 doctors and 1,750 nurses in Fiji and
a large proportion of the operational budget for
health goes towards human resource provision
(pers. Comm. Fiji Ministry of Health). How-
84 CN Volume 16, Issue 1–2, December 2003/February 2004
ever, there is still a shortage of health care
workers in Fiji. Stark, Nair and Omi (1999)
argue that such staff shortages present ethical
dilemmas because of the inequitable nature of
health service delivery to rural and remote
communities where the need may be greatest.
Developing and retaining highly skilled
health workers is also an ongoing problem
(WHO, 2001b). In order to address this issue
the Fiji Ministry of Health in the late 1970s
introduced mid-level health providers. Medical
assistants were trained at the Fiji School of
Medicine between 1975 and 1984, with the
intention of forming a separate cadre of service
providers to fill medical practitioner vacancies
at health centers in the rural areas of Fiji.
Downes (2001) reports that due to a chronic
inability to provide sufficient medical officers to
work in health centres and as a result of
the phasing out of medical assistants, a further
mid-level provider role was trialled – that of
Primary Care Provider (PCP) – in an attempt
to ensure medical coverage at health centres in
the rural areas of Fiji in particular.This role did
not prove to be viable and was also phased out
after five years. Unfortunately very little is doc-
umented about the demise of these programs.
The introduction of the Nurse Practitioner
program in 1999 followed intense lobbying by
the Nurses and Midwives Board in Fiji, and a
long process of consultation and development.
This workforce strategy has seen health care
become more readily available for people living
in the more remote locations of Fiji (Downes,
2000; Usher, 2001). The introduction of the
nurse practitioner role in Fiji has allowed nurses
to pursue an advanced, legitimised role that
extends their scope of practice to include the
delivery of care not usually undertaken by nurs-
es. For example, the nurse practitioner is trained
to prescribe and administer a range of medica-
tions via a set of protocols and perform dental
extractions and male circumcisions. Protocols to
guide NP practice were developed in 1999 by a
multi-disciplinary team which included medical
 The nurse practitioner role in Fiji: Results of an impact study
specialists and members of the National Drug
and Therapeutics Committee. The protocols
were developed alongside the nurse practitioner
education curriculum and were specifically
designed for community based, primary care
nurse practitioners in remote settings.
LITERATURE REVIEW
It is not the aim of this paper to include a com-
plete review of the literature relating to the
role of the nurse practitioner, as this has been
adequately covered elsewhere (see for example
Solomon Cohen & Juszczak, 1997; Offredy,
1998; Hamric & Spross, 2000). However, there
continues to be much debate about their role,
centering on a number of key areas. Concerns
raised in the literature relate to defining the NP
role in terms of a service delivery ‘vacuum’ cre-
ated by the absence of medical staff and the
need for the nurse to take on minor medical
tasks (Turner & Keyzer, 2002), the fact that
definitions of the role differ across countries
(Offredy, 2000), and the interface between the
NP role and other advanced practice nursing
roles (RCNA 2000). Further issues relate to the
variation in educational preparation for the role
(Offredy, 2000), the utilisation of NPs across a
range of different and varied clinical contexts,
such as sexual health, wound care, rural, and
mental health care (Lindsay & Usher, 2002),
and issues related to appropriate remuneration
and career path structure (Usher, 2001; Lindsay
& Usher, 2002).
In Fiji, a nurse practitioner is an experienced
nurse who holds midwifery and public health
qualifications, has approximately 15 years of
service and who has successfully completed the
course run by the Fiji School of Nursing. The
comprehensive course is undertaken over 14
months and includes theory related to patho-
physiology, clinical interventions, pharmacolo-
gy, clinical diagnosis, and patient management.
It also includes an extended period of clinical
practice where the students spend time
attached to and assessed by a medical officer in
Volume 16, Issue 1–2, December 2003/February 2004
CN
an emergency department of a major hospital
in Fiji (Usher, 2001).
AIM OF THE STUDY
The aims of the study were to conduct an
impact evaluation of the introduction of the
nurse practitioner role, to explore issues relat-
ed to the role and function of the nurse practi-
tioner, and to determine future directions for
the nurse practitioner role in Fiji.
METHOD
A qualitative, explorative study was undertaken
to address the aims. A qualitative approach was
chosen as the most appropriate as it allowed the
researchers to gather rich data capable of provid-
ing a deeper understanding of the situation and
the issues involved (Streubert & Carpenter,
1999). It was also considered the best way to
find new knowledge because of the paucity of
research on the topic, the importance of the con-
text and process in shaping the outcomes of the
role introduction, and the desire to understand
the impact from the perspective of participants
(Sofaer 1999; Creswell 2003). Demographic and
epidemiological data was also collected to sup-
port the interpretation of the qualitative data
collected. As the interviews conducted with key
stakeholders, NPs and community group mem-
bers is the focus of this paper, the demographic
data is not presented.
The setting
The study was conducted in Fiji. The
researchers visited Suva, Nadi, Lautoka and a
number of rural areas on the main island of Fiji,
Viti Levu, Labasa, Savusavu and 2 remote com-
munities on Vanua Levu, and the hospital on
Taveuni Island.Visits were made to many of the
locations where the nurse practitioners were
stationed, to many Government Departments,
to other related stake holders such as AUSAID,
Fiji Nurses Association, Fiji Medical School, Fiji
Medical Association and the team leader for the
Fiji Health Management Reform Project.
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CN Kim Usher and David Lindsay
Sample
Non-randomised convenience sampling, appro-
priate for qualitative research (Streubert & Car-
penter, 1999; Creswell 2003), was utilised in
the study. A total of eighteen nurse practition-
ers, 54 stakeholders, and three community
focus group (22 community members) inter-
views were conducted. All nurse practitioners
employed in the NP role at the time of the
study were invited and agreed to be inter-
viewed. Interviews with NPs were conducted
either face-to-face or by telephone. Face-to-face
interviews were also conducted with various
key stakeholders such as the Fiji Nurses’ Associ-
ation,The Fiji Medical Association, and key per-
sonnel at the Ministry of Health. The rationale
for conducting interviews with the many key
stakeholders was to gain a broad understanding
of the role and its impact on the health care sys-
tem in the country. Focus groups were also held
with local community representatives. A total
of three focus groups were conducted and 22
community representatives took part in the
interviews. The focus group members were all
recruited by a formal invitation to participate
from the Ministry of Health. Ethics approval to
conduct the study was received and participants
were provided with information about the
nature of the study and their rights to confiden-
tiality, anonymity and refusal to answer ques-
tions or to withdraw from the study at any
time. Participants who agreed to participate
were asked to sign a consent form.
Data collection strategies
Initial activities included meetings with key
members of the government including the Min-
ister of Health, the Permanent Secretary for
Health and other key people in the Ministry of
Health and government. These meetings were
deemed necessary to gather sufficient back-
ground information on the development of the
role and the issues perceived to be surrounding
this role in Fiji. Other relevant information was
also collected and reviewed, including earlier
86 CN Volume 16, Issue 1–2, December 2003/February 2004
consultancies, legal documents, nurse practi-
tioner protocols, and related papers and
reports. Data was also collected to determine
caseloads and types of patients attended by
nurse practitioners.
Interviews, one of the most frequently used
qualitative data collection strategies, were
selected as the most appropriate way to gather
data (Streubert & Carpenter, 1999). A set of
semi-structured questions, useful when the
researcher wants to ask all interviewees a simi-
lar set of questions (Polit & Tatano Beck, 2004),
was devised for the nurse practitioners. The
questions asked were related to five broad
areas, namely:
• demographic details, such as length of
time in current post, length of nurse prac-
titioner experience, age
• details of patient consultations, such as
types of cases managed by the nurse,
interventions used, workload, referral
patterns, documentation;
• the scope of practice of the nurse practi-
tioner and adherence to set protocols;
• general issues related to their satisfaction
with the role and their working condi-
tions;
• future directions for the nurse practition-
er in Fiji.
A set of semi-structured and focus group inter-
view questions were devised for the key stake-
holders and community representatives and
these questioned focussed on 5 broad areas,
namely:
• satisfaction with the nurse practitioner
role;
• the scope of practice of the nurse practi-
tioner;
• issues with the nurse practitioner role,
workload issues, deployment decisions,
opportunities for leave and professional
development;
• an evaluation of the impact of the role in
their local community;
 The nurse practitioner role in Fiji: Results of an impact study
• their vision of the future role for the
nurse practitioner.
All interview data collected was tape recorded
and later transcribed verbatim by the research
team. The qualitative data was then analysed
using a qualitative content analysis method
(Mayring, 2000; Sandelowski, 2000). Data
analysis commenced immediately after the first
interview. The data was analysed for codes and
themes while transcription and subsequent
interviews were conducted. Data within each
code were then organised according to thematic
content in a process of moving from lower-
order to higher-order themes as the analysis
progressed.The analysis is reflected in the head-
ings used in the results section.
RESULTS
(i) Impact of the nurse practitioner
services on the consumer/patient,
service setting and costs to
government
It is clear that the nurse practitioners have an
extensive and highly autonomous role that
incorporates diagnostic, curative, preventative
and primary health elements of care.The nurse
practitioners currently perform many functions
in the remote areas that would usually be per-
formed by medical officers if such were avail-
able. The nurse practitioners carry a varying
case load depending upon their location. Some
see large numbers of patients (up to 200 per
day) routinely whilst others have a much smaller
load. One of the nurse practitioners is responsi-
ble for an 18 bed hospital on a remote island.
Responsibilities for that position include all out-
patient attendances, admissions, review of all
inpatients and discharges.
The nurse practitioners are also providing
health services to many people living in remote
village communities who would otherwise not
have access to such care.This service is provid-
ed in a cost effective manner, as the nurse prac-
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CN
titioners are paid more than other registered
nurses but less than doctors.They are available
to fill vacancies in the remote areas where no
doctors are available or willing to be located in
these areas. It is clear that the impact of the
nurse practitioner has been enormous in many
villages, where travel to the nearest health cen-
tre is often a long trip across difficult terrain.
Before the introduction of the nurse practition-
ers, these villages were serviced by public
health nurses who were unable to practice
under the extended protocols. Therefore, the
introduction of the NP has meant that more
comprehensive health care is now locally avail-
able to many people to whom health care was
previously unavailable, or which required a long
journey to the nearest health centre.
(ii) Scope of practice
The scope of practice of the nurse practitioners
interviewed in this study was extensive and
much greater than had originally been consid-
ered or covered by the protocols developed. For
example, it has become customary to use the
nurse practitioners to back-fill medical officer
positions at the smaller hospitals.This is consis-
tent with concerns raised by authors such as
Turner and Keyzer (2002). When this role is
performed by the nurse practitioner they are
expected to carry out all duties normally
assigned to the doctor. In addition, one nurse
practitioner works alongside doctors at a health
centre and sees a similar patient load to the doc-
tors. Whilst those nurses were managing this
extended scope of practice, it presents a real
concern for the future. Some of the nurses
interviewed expressed concerns about times
when they worked beyond what they consid-
ered to be their scope of practice, but believed
they should do so if they felt it was “the best for
the patient.” The tradition of service is very
strong within Fiji culture and strongly embed-
ded within the nursing profession. This is
further reinforced by the overtly Christian
beliefs of many Fijians. Nurse practitioners also
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CN Kim Usher and David Lindsay
reported undertaking tasks such as minor surgi-
cal interventions that were not included in the
protocols.
(iii) Issues related to the role
Concerns were raised by some of the people
interviewed about the practice of using nurse
practitioners to replace medical officer posi-
tions at hospitals. Not only does this leave the
nurse in an exploited position where they may
feel compromised, it also leaves the community
from where the NP is taken without adequate
health care. This is a problem because it is not
usual practice to replace the NPs when they are
taken away for short periods of time. Concerns
were also raised during the study about the lack
of a formal career path for nurse practitioners
as well as inadequate opportunities to attend
continuing education programs away from their
remote locations. NPs and medical officers
were of the belief that the current NPs
deserved a formal career structure that was
recognised by the Ministry of Health.Without
this it seems that the current NPs may not
remain in the position for an extended period
of time as they would be losing opportunities
for advancement within the Ministry in the
usual nursing career pathway. Concerns were
also raised about the process of placing NPs in
remote areas. Currently the NPs are allocated a
placement by the Ministry and have little
opportunity to be involved in that decision.
Some NPs expressed an unwillingness to be
placed in remote areas, and others felt strongly
that they should have more involvement in
decisions about their work location. Ensuring a
sustainable health workforce is a global prob-
lem, exacerbated by a low distribution of health
workers in rural and remote areas, relative to
their urban counterparts. However, given this
role was introduced in Fiji as a strategy to pro-
vide health care to people in isolated areas, this
issue must be addressed in the context of the
role and the future of the nurses currently
undertaking the role.
88 CN Volume 16, Issue 1–2, December 2003/February 2004
(iv) Consumer satisfaction with the
role
The communities served by the nurse practi-
tioners value the role and have great confidence
in the nurses in the positions. They supported
the introduction and continuation of the role
and saw it as a viable way to provide health care
that met their needs. In fact, the villagers were
so impressed by the level of care provided by
the NPs in the village that they supported their
continuation as a replacement for doctors in the
future. In other words, they favoured having a
NP placed in their community in the future
rather than a doctor saying that the NP provid-
ed a better service that incorporated the med-
ical care needed in remote villagers but also
offered the care that only nurses provide (such
as education and prevention roles). All commu-
nity members raised concerns about their
future should the NP be removed from the vil-
lage and demonstrated a clear commitment to
further development of the role in Fiji. The
support for the NP is clear in the village where
they are afforded respect usually reserved for
doctors.They are also supported in kind by the
villagers who offer them vegetables and other
commodities produced in the village.
Key stakeholders also expressed high satisfac-
tion with the introduction and incorporation of
the NP role within the health care structure in
Fiji. Medical officers spoke of how the intro-
duction of NPs had resulted in reduced case
loads at health centres, improved services to
people in remote communities, improved
health outcomes overall for people in remote
communities, and enhanced service delivery
when placed in other health services such as
accident and emergency departments and out-
patient clinics. The practice of utilising NPs to
replace medical officers on leave at smaller hos-
pitals was considered effective. The medical
officers interviewed expressed high regard for
the service provided by the NPs when under-
taking these rotations. Clearly, the medical offi-
cers who work closely with the NPs found
 The nurse practitioner role in Fiji: Results of an impact study
them to be extremely efficient colleagues
whose judgement they trusted.
(v) Future directions
All groups interviewed were supportive of the
continuation of the role in the health care sys-
tem in Fiji. Some people supported the role
being extended to offer an advanced practice
role that could be implemented in major hospi-
tals and health centres where medical officers
are scarce. For example, there was a clear call
to extend the role to areas such as intensive
care and paediatric inpatients. There was also
support for the continuation of NP placement
in the paediatric outpatient and emergency
clinics. Interviewees also offered suggestions
for additional theory that should be added to
the current educational program, with particu-
lar emphasis on removing areas of overlap with
courses undertaken as part of the entry require-
ments. For example, to gain entry to the NP
course it is a requirement to have already com-
pleted the midwifery program, however, the
NP course covers a lot of the content and prac-
ticals that are covered in the initial midwifery
program. There was also a call to re-evaluate
the entry requirements for the course, especial-
ly the requirement to have a midwifery qualifi-
cation. Some people were of the opinion that
the midwifery undertaken as part of the Fiji
nurses’ original nursing qualification may be
sufficient for NPs in some areas.
DISCUSSION
Clearly, the NP role is an efficient and cost
effective way to deliver health care to villagers
in the rural and remote areas of Fiji. Their
impact as a health workforce initiative has
therefore been positive.The villagers who cur-
rently have access to the service provided by
these NPs find the role to be extremely benefi-
cial to the health of their community. The NPs
are providing health care to these communities
that would be provided by a medical officer if
one was available to be placed in that location.
Volume 16, Issue 1–2, December 2003/February 2004
CN
Given that the NPs deliver this care under a set
of protocols means that the villagers now have
access to safe and holistic care that was previ-
ously not available to them.The introduction of
the NP role in Fiji also means the Ministry of
Health is now able to deliver an affordable and
efficient health service to people in remote
locations. This has many implications for the
future. For example, the provision of this serv-
ice to remote villagers has the potential to
decrease hospital admissions and re-admissions,
reduce the average length of stay in hospital,
improve compliance with treatment regimens
such as wound care and medications, and
improve health outcomes through improved
monitoring of diseases such as diabetes and car-
diovascular. It also has the potential to reduce
deaths that may have been avoided if adequate
health care was available. As a result, an overall
decrease in the morbidity and mortality statis-
tics for remote villagers can be expected in the
next few years. This outcome of the introduc-
tion of the NP role is highly desirable, as equi-
table distribution of health care services to all
people is a fundamental human right, a view
raised as an ethical issue by Stark, Nair and Omi
(1999). In other words, the delivery of health
care to all people should be a goal of health
service providers and must include those peo-
ple living in isolated locations. Achievement of
this goal remains elusive and as yet fully realised
in Fiji.The professional isolation, especially that
experienced by many of these nurses can be
profound, and the working conditions at times
extreme. Appropriate remuneration commen-
surate with their level of autonomy and scope
of practice remains an important issue. Devel-
opment of a career structure and access to con-
tinuing and tertiary education are fundamental
to ensuring the role remains viable. So too is a
review of the NP scope of practice.Whilst the
scope of practice for the NPs is legislated by the
Nurses, Midwives and Nurse Practitioners Act
of 1998, it appears that the actual scope of
practice performed by these nurses goes
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CN Kim Usher and David Lindsay
beyond the developed protocols. Obviously we
must be concerned about safety issues when
nurses work beyond their scope of practice,
however, it is also important to realise that this
new role offers nurses in Fiji the opportunity to
be involved in a redefinition of nursing as sug-
gested by Turner and Keyzer (2002).
CONCLUSION
Clearly the introduction of the Nurse Practi-
tioner role to the health services of Fiji has
been significant.The NPs are currently provid-
ing advanced levels of health care to people in
many remote areas of Fiji where such services
were previously not available.The impact of the
introduction of this role has therefore made a
significant difference to the health care of peo-
ple in these areas, and has the potential to
greatly enhance the health of people living in
remote areas in the future.This service is being
provided in an efficient and cost effective way
that is sustainable.The Fiji experience has some
important implications for the ongoing devel-
opment of the nurse practitioner role and offers
interesting insights that can add to the debate
about the development and responsibilities
associated with this emerging role.
Future research should be conducted to
explore the ongoing development and effective-
ness of the role, and the impact of its introduc-
tion on health service delivery in Fiji. In
addition, nurse practitioner posts should be
considered in specialist areas, such as attach-
ments to specialty areas in generalist hospitals,
as suggested by the stake holders. This would
allow the nurse practitioners to further develop
their role away from the intended remote area
focus.
Acknowledgement
This study was funded by the World Health
Organisation, Western Pacific Region and the
Fiji Ministry of Health and all assistance is
gratefully acknowledged. The study was made
possible through the cooperation of the Min-
90 CN Volume 16, Issue 1–2, December 2003/February 2004
istry of Health and by the assistance of the
Director of Nursing Services, Fiji, Mrs Rigieta
Nadakuitavuki, and the Principal of the Fiji
School of Nursing, Mrs Iloi Rabuka. We also
thank all who took part in the study.
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