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Australian nurse and the NNAS story- comparable

Published Nov 8, 2019


I am just writing up on this topic in case anyone needs information during there application process , there was not a lot when i was looking earlier this year.

I am an Australian Registered nurse, i studied in Queensland at USC and graduated 2016. I have been working as an RN ever since. Before i was an RN i was an EEN for a few years.

I started my NNAS application process 29/01/2019.

Form for registration with AHPRA sent 29/01/2019 via normal Australian post. Requesting a certificate of good standing, also sent the NNAS form to AHPRA to see if they would complete.


Sent education forms to University of the Sunshine coast to complete via normal post.


1st employment: sent employment form to previously worked at hospital on the 30/01/2019 with a registered international envelope inside.

Current employment form sent to NNAS via Registered international mail on 30/01/2019.

Student forms sent to SBIT via Australian Registered post on 30/01/2019 with an international registered envelope inside.

31/01/2019: Met with legal public notary. Notarised: Passport, drivers license, birth certificate and marriage certificate. Documents stamped, sealed, red ribbon and associated written document by lawyer also provided. Sent via international registered post.

01/02/2019: 1st employer has sent application form to NNAS via international post.

22/02/2019: AHPRA confirmed they have sent required documents to NNAS.

26/04/2019: documents received and under authentication by NNAS from USC (Uni RN degree)

26/4/19: documents stamped and sent today from SBIT- (TAFE for my EEN diploma)

19/6/2019: NNAS "ready for review"

19/10/2019: Ready for final review. Everything meets requirements.

02/11/2019: NNAS request additional from university via email. Date discrepancy.

06/11/2019: University confirms they have emailed NNAS the required clarification.

07/11/2019: Advisory report issued that night, and received a comparable report at 68.5%.

08/11/2019: applied to CARNA and i have emailed the requested documents. Now awaiting next steps from CARNA.

Get all your information together as soon as possible.

Send the application for AHPRA via their email, not via post (silly mistake on my behalf, i didn't realise i could, this would have made things a bit quicker).

Have a big discussion with your uni about what is required, do you own hours breakdown so nothing is missed. The more info they have the better. Ask for a copy of everything they send to NNAS, so the NNAS cant say something was missed (if the NNAS lose something for instance) This will also give you an opportunity to make sure everything looks right and ask the uni to make changes were needed. The schooling stuff takes the longest to get.

SEND EVERYTHING via EXPRESS international post- my mistake, my mail took nearly 4 weeks to arrive in the USA, and then one of the forms i sent with an express post arrived after 4 days, this would have sped up my time i believe. The NNAS is slow and will not give you a time frame after they have received all your information.

My Nursing hours breakdown from the NNAS report:

I had a total of 549 pages of syllabus combined sent to the NNAS.

960 hours of clinical placement

148 hours of lab hours

1050 direct theory hours:

Maternal/infant nursing: 8 hours and 2 hours of lab

Paeds: 51 theory hours, 2 lab hours and 40 placement hours

Mental health: 77 theory hours and 80 hours placement

Medical nursing: 296 theory hours, 41 lab hours, 260 placement hours

Surgical nursing: 135 theory hours, 34 lab hours, 260 placement hours

Geriatric nursing: 114 theory hours, 1 lab hour, 200 placement hours

Community Health: 87 theory hours, 8 lab hours, 200 placement hours

Anatomy & Physiology: 81 theory hours

Pathophysiology: 78 theory hours, 12 lab hours

Pharmacology: 124 theory hours, 47 lab hours

If anyone has any questions, ask away. Ill update on how CARNA goes, now i might need to study for the NCLEX!


naseo, BSN, RN

Thank you so much for the information! How did you get paeds and maternity hours? have you done the midwife degree as well ?? :)


tigress_8207, ASN, BSN

Hi thanks for the information.I applied to NNAS in December 2018 and am still waiting for my advisory report.When I called in October I was told they had an influx of applications and are trying to get all processed at the same time so give them a little more time so am kindda surprised that you have already received yours.Anyway nothing before its time and wishing you the best of luck going forward.

11 hours ago, naseo said: Thank you so much for the information! How did you get paeds and maternity hours? have you done the midwife degree as well ?? :)

No i didn't do Mid. My uni had "the child client" as an elective which i did and "child youth and family" as a core subject.


I am also graduated from USC , we studied child , youth and family as well. But They did not write anything in my pediatric hours section , have you done any obstetric placement or theory ? Thanks

3 hours ago, GARY SONI said: Hi, I am also graduated from USC , we studied child , youth and family as well. But They did not write anything in my pediatric hours section , have you done any obstetric placement or theory ? Thanks

Maternal/infant nursing: 8 hours and 2 hours of lab- this was my obstetric- no placement.

BlessedHighlyFavored RN

BlessedHighlyFavored RN, BSN, MSN

Hi Chelesa,

Thank you for sharing your story. Its really helpful because I'm in the same situation. Background: SC, USA license nurse completed BSN and MSN degrees in the US. I started my application in Feb 2019 and submitted all the required documents in Oct 2019. I received the "Ready for Review" status about two weeks ago. NNAS stated it will take up 12 weeks for the final review to be completed and then a report will be generated.

Also, I ran into some trouble with NNAS needing more documents and information from my schools but was able to get everything they requested. I do have copy of what the schools completed and submitted to NNAS as well.

I have a couple of questions:

1. When you received your report and the comparable score did it breakdown what the % meant?

2. When you applied to CARNA how long did it take for you to hear back?

3. Would you advise looking for a job before getting your license from CARNA?

4. This is probably a silly question but, do you think I have a chance of getting my report back in time to apply to CARNA?


Hi Chelsea,

I nearly cried when I read your post. I am wanting to be with my partner in Pennsylvania. I am about to start this process. I would love your support/help if you would be open to it? I did my Maternity nursing at the old Royal Women's Hospital years ago and then hospital based EN, then my Bachelor of Nursing at ACU, then post Grad Dip in Critical Care nursing, then Grad Cert in Adult and Voc education, then cert IV if training ect, plus a Masters in Education. I have certificates in Family Partnerships, Immunisation certified, and Clincial Supervision course/experience, I work in the kids hospital one day a week in recovery, I have ICU experience in Adults and kids, I work as a clinical nurse consultant 2 days a week in the children's obesity clinic....how do you think I'll go with registration in the US? Many thanks for any advice. I love your timeline....Thanks, Ingrid.

3 minutes ago, Ingrido said: Hi Chelsea, I nearly cried when I read your post. I am wanting to be with my partner in Pennsylvania. I am about to start this process. I would love your support/help if you would be open to it? I did my Maternity nursing at the old Royal Women's Hospital years ago and then hospital based EN, then my Bachelor of Nursing at ACU, then post Grad Dip in Critical Care nursing, then Grad Cert in Adult and Voc education, then cert IV if training ect, plus a Masters in Education. I have certificates in Family Partnerships, Immunisation certified, and Clincial Supervision course/experience, I work in the kids hospital one day a week in recovery, I have ICU experience in Adults and kids, I work as a clinical nurse consultant 2 days a week in the children's obesity clinic....how do you think I'll go with registration in the US? Many thanks for any advice. I love your timeline....Thanks, Ingrid.

I am not sure if it is the same process for the USA, this was for Canada. However I did get a comparable report from NNAS and I only had a very small amount of obs/paeds. You sound like u will do great! When I applied to CARNA in Alberta, they said I was not comparable and I had to complete 2 obstetrics courses, one online and one in person that went over a 3 days, I had a year to complete them but than COVID happened and no one can travel, so unsure on what I will do now.

Oh bummer, I got excited, I thought it was the USA...I hope I do great, it's such a complex system to navigate. Do you have any idea what or when you'll be able to move over? Where are you going to? How exciting either way!



I graduated from University of Sydney in December 2019. I have submitted my application to NNAS in January 2020 and required documents were sent by March 12, 2020 but still no update on my account. I called and emailed their support account but they couldn't provide any update. Is anyone in the same situation?

I would like to which province you are applying to and if your training was deemed comparable by the nursing college. Thanks for your help.

2 minutes ago, Maryamibidunni said: Hi Chelsea, I graduated from University of Sydney in December 2019. I have submitted my application to NNAS in January 2020 and required documents were sent by March 12, 2020 but still no update on my account. I called and emailed their support account but they couldn't provide any update. Is anyone in the same situation? I would like to which province you are applying to and if your training was deemed comparable by the nursing college. Thanks for your help.

you know much until August and then nothing will probably be finalised until November/December, it took 11 months for me and I was so fast with my documentation.

I got a comparable by the NNAS and not comparable by CARNA (Calgary, Alberta) I needed more obstetric hours. They said I needed to enrol in some courses in Canada about ($1000) 1 theory that I could do online for 6 weeks and 1 prac class done in Canada over 4-5 days. Than I would be deemed comparable. CARNA took about 4-6 weeks o get back to me also after the NNAS had submitted my application.

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ahpra case study 51

Outcomes of notifications to health practitioner boards: a retrospective cohort study

BMC Medicine volume  14 , Article number:  198 ( 2016 ) Cite this article

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A Correction to this article was published on 07 March 2018

This article has been updated

Medical boards and other practitioner boards aim to protect the public from unsafe practice. Previous research has examined disciplinary actions against doctors, but other professions (e.g., nurses and midwives, dentists, psychologists, pharmacists) remain understudied. We sought to describe the outcomes of notifications of concern regarding the health, performance, and conduct of health practitioners from ten professions in Australia and to identify factors associated with the imposition of restrictive actions.

We conducted a retrospective cohort study of all notifications lodged with the Australian Health Practitioner Regulation Agency over 24 months. Notifications were followed for 30–54 months. Our main outcome was restrictive actions, defined as decisions that imposed undertakings, conditions, or suspension or cancellation of registration.

There were 8307 notifications. The notification rate was highest among doctors (IR = 14.5 per 1000 practitioners per year) and dentists (IR = 20.7) and lowest among nurses and midwives (IR = 2.0). One in ten notifications resulted in restrictive action; fewer than one in 300 notifications resulted in suspension or cancellation of registration. Compared with notifications about clinical care, the odds of restrictive action were higher for notifications relating to health impairments (drug misuse, OR = 7.0; alcohol misuse, OR = 4.6; mental illness, OR = 4.1, physical or cognitive illness, OR = 3.7), unlawful prescribing or use of medications (OR = 2.1) and violation of sexual boundaries (OR = 1.7). The odds were higher where the report was made by another health practitioner (OR = 2.9) or employer (OR = 6.9) rather than a patient or relative. Nurses and midwives (OR = 1.8), psychologists (OR = 4.5), dentists (OR = 4.7), and other health practitioners (OR = 5.3) all had greater odds of being subject to restrictive actions than doctors.


Restrictive actions are the strongest measures health practitioner boards can take to protect the public from harm and these actions can have profound effects on the livelihood, reputations and well-being of practitioners. In Australia, restrictive actions are rarely imposed and there is variation in their use depending on the source of the notification, the type of issue involved, and the profession of the practitioner.

Peer Review reports

Many countries entrust oversight of doctors and other health professionals to practitioner boards. A core mission of such boards is to protect the public from unsafe practice. Boards rely on patients, practitioners and their peers, employers and other agencies to bring risks to their attention and can employ a range of assessment and investigation processes to evaluate concerns about a practitioner’s health, performance or conduct. In cases where a practitioner poses a risk to patient safety boards can initiate a range of actions, including imposing conditions on the practitioner’s registration or suspending their licensure to practice. Actions that restrict ability to practice may have profound effects on affected practitioners – damaging livelihood, reputation, and potentially personal well-being [ 1 , 2 ]. Imposing such actions therefore requires boards to chart a delicate course between protecting patients from harm and respecting the rights of practitioners [ 3 ].

Previous research has examined factors associated with disciplinary action against doctors. Studies have compared disciplined doctors with controls drawn from the broader medical workforce [ 4 – 7 ], with colleagues who were investigated or charged but not disciplined [ 8 ], and with colleagues who incurred less serious sanctions [ 9 ]. In general, these studies identify several risk factors for incurring disciplinary sanctions, including male sex, late career stage, and practice in certain specialties (surgery, obstetrics and gynecology, psychiatry, and general practice). In addition, longitudinal studies of doctors have shown higher rates of disciplinary actions among physicians who performed poorly during residency [ 10 ] and physicians who lack specialty certification [ 11 ]. Relatively few studies have focused these types of analyses on nurses [ 12 – 14 ], and fewer still have examined pharmacists [ 15 ], psychologists [ 16 ], dentists [ 17 , 18 ], and other allied health professions. Moreover, this body of research tends to be profession specific. For example, no previous studies have directly compared doctors’ likelihood of regulatory action with risks experienced by other health practitioners.

In Australia, 14 health professions, including doctors, nurses, dentists, psychologists, and pharmacists, are regulated by a unified scheme that has operated since 2010. The scheme covers all states and territories, which creates a rare opportunity to use national, longitudinal data to examine the incidence and outcomes of “notifications of concern” (hereafter, “notifications”) relating to multiple professions [ 19 ]. We conducted a retrospective cohort study of all notifications received by the national agency over a 2 year period. We estimated the incidence of notifications among health practitioners and tested for associations between various characteristics of notified practitioners (e.g., age, sex, profession) and notifications (e.g., issue type and source of notification) and the adjudicated outcomes of these notifications, particularly restrictive actions.

Our goal was to advance understanding of how this key regulatory regime operates. We were particularly interested in generating information with the potential to facilitate efficient adjudication and guide prevention efforts. We hypothesized that there would be systematic differences in rates of notification between professions, and that there would be relatively high rates of restrictive action against practitioners from certain professions (e.g., psychologists) and for notifications about certain issues (e.g., drug or alcohol misuse).

Australia’s system for regulating health practitioners incorporates a nationally-consistent process for registration across 14 professions [ 20 ]. Notifications regarding the health, conduct, and performance of practitioners are also consistently managed under the National Registration and Accreditation Scheme (Table  1 ), apart from two jurisdictions who operate alternative models of co-regulation: New South Wales (since the establishment of the scheme in July 2010) and Queensland (since July 2014) [ 19 ]. Ten professions have been regulated by the scheme since inception (medical practitioners, nurses and midwives, dental practitioners, psychologists, pharmacists, chiropractors, optometrists, osteopaths, physiotherapists, and podiatrists). A further four joined in July 2012 (Aboriginal and Torres-Strait Islander practitioners, Chinese medicine practitioners, medical radiation practitioners, and occupational therapists). Most notifications are made voluntarily by an individual or organization who wishes to raise a concern about a health practitioner. Mandatory notification by a fellow practitioner or employer is required in certain situations, such as where a practitioner has practiced while intoxicated by alcohol or drugs. Notifications are lodged with the Australian Health Practitioner Regulation Agency (AHPRA), before being referred to the relevant national board (e.g., the Medical Board of Australia, the Nursing and Midwifery Board of Australia).

With support from AHPRA, boards assess each notification and then initiate a more in-depth investigation in cases where this appears necessary. A board may decide no further action is warranted (before or after an investigation), require the practitioner to undergo an assessment of their health or performance, refer the matter to another regulatory body, or take the matter to a hearing before a tribunal.

Final outcomes take several different forms. Non-restrictive actions – typically a caution, reprimand or fine – may have financial or reputational consequences for practitioners but do not restrict their registration in any way. Restrictive actions are those which limit the practice of the profession or require practitioners to do certain things. The restrictive actions available are accepting an undertaking from the practitioner related to their clinical practice (e.g., further training, random drug testing, counselling); imposing specified conditions on practice (e.g., have a chaperone present when seeing female patients); suspending registration for a specified period; and seeking to cancel the practitioner’s registration. In some cases, the final decision will be made by a disciplinary tribunal rather than the board itself and only tribunals have the power to cancel a practitioner’s registration. A guiding principle of the scheme is that restrictive actions should involve the minimum regulatory force appropriate to manage the risk.

Study design

Using administrative data routinely collected by AHPRA, we identified all notifications about the health, performance, or conduct of a health practitioner lodged in 2011 and 2012. We then followed these notifications for 30–54 months (through to 30 June 2015) to identify their outcomes. We used data from the register of health practitioners to calculate notification rates and to identify predictors of restrictive actions.

Data collection

AHPRA provided us with data on all health practitioners registered between 1 January 2011 and 31 December 2012. This “practitioner extract” consisted of variables indicating the period during which each practitioner was registered; the practitioner’s age band, sex, profession, and state or territory of practice; and the remoteness, based on the practice location provided by the practitioner [ 21 ].

AHPRA also provided a data extract relating to all notifications lodged about registered practitioners during the same 2-year period. This “notification extract” included information collected at the time the notification was lodged (e.g., lodgment date, source of notification, primary issue raised), as well as information relating to the ensuing adjudication (e.g., closure date, case outcome). Anonymized, unique identifiers enabled us link the practitioner extract to the notification extract.

Data on notifications were not available from New South Wales ( n  = 188,297 practitioners). Although health practitioners in New South Wales are subject to similar requirements as those in other states, they are managed through separate co-regulatory arrangements. This means AHPRA does not hold the same kind of detailed information about the management of these notifications as it does for notifications from other jurisdictions. We also excluded practitioners in the four health professions that joined the scheme in 2012 ( n  = 35,954) and practitioners registered to an address outside Australia ( n  = 14,576). The notifications of interest thus came from all the other practitioners who were registered during 2011 and 2012 ( n  = 349,480).

To protect confidentiality, AHPRA provided practitioners’ birth dates in 5-year bands (e.g., 1970–1974). We recoded this variable to reflect each practitioner’s age group in 2010. We coded health professions into six categories: doctors, nurses and midwives, psychologists, pharmacists, dentists, and other health practitioners (chiropractors, optometrists, osteopaths, physiotherapists, podiatrists, oral health therapists, dental hygienists, dental prosthetics, and dental auxiliaries). The primary issue involved in each notification was originally coded into one of 149 categories. We recoded these issues into four categories and 15 sub-categories. These were performance issues (concerns about clinical care, poor communication, concerns about medication, delays in access to care); conduct issues (disruptive behavior, improper use or management of health information, non-compliance with regulatory requirements, unlawful use or supply of medications, unfair costs or misleading advertising, breaches of boundaries); health impairment issues (mental illness, drug misuse, alcohol misuse, physical or cognitive illness); and other issues.

The register of practitioners changes daily. We therefore used data on the dates practitioners became registered and unregistered with AHPRA to calculate practitioners’ exposure time – the period each practitioner could potentially receive a notification. For most practitioners, their exposure time began on 1 January 2011 and ended on 31 December 2012 (when observation of notifications ceased). For practitioners whose registration began and/or ended within this interval (e.g., new graduates, retirees), their exposure time was adjusted accordingly.

We used counts and percentages to describe the characteristics of notifications, including the reporting source, the primary issue, the time taken to resolve each notification, and the final determination. We then conducted three separate analyses.

First, we used negative binomial regression to estimate the incidence of notifications by practitioner profession, age, sex, area remoteness, and jurisdiction. By computing marginal effects, derived directly from model estimates [ 22 , 23 ], we are able to report these findings as adjusted incidence rates. We then performed multivariate logistic regression analysis to examine the factors associated with restrictive actions (undertaking, imposition of conditions, suspension or cancellation of registration) and a sensitivity analysis examining factors associated with any regulatory action (restrictive actions, cautions, reprimands or fines).

All analyses were conducted using Stata 13.1 [ 24 ].

Notification rates

In 2011–2012, 8307 notifications pertaining to 6920 practitioners were lodged with AHPRA. The overall rate was 6.3 notifications per 1000 practitioners per year (95% CI, 6.2 to 6.5).

Notification rates differed by profession, age, sex, and jurisdiction (Table  2 ). After adjusting for all of the variables shown in Table  2 plus jurisdiction, dentists had the highest rate of notifications (20.7 per 1000 practitioners per year), followed by doctors (14.5 per 1000 practitioners per year). Nurses and midwives had the lowest rate of notifications (2.0 per 1000 practitioners per year). Risk of notification generally increased with age – practitioners aged ≤ 25 years were at lowest risk (2.6 per 1000 practitioners per year) and practitioners aged 56–65 years were at highest risk (8.5 per 1000 practitioners per year). Men were at much higher risk of notification than women (8.9 vs. 4.0 per 1000 practitioners per year). Notification rates did not differ by remoteness of practice location ( P  = 0.48), but did by jurisdiction ( P  < 0.0001).

Source and type notifications

Nearly one-third of the notifications were lodged by patients or relatives and another 30% were lodged by state complaint commissioners (Table  3 ). The next most common sources of notifications were fellow practitioners (13.0%) and employers (9.5%).

Thirty-eight percent of notifications involved concerns about performance, 31.5% involved concerns about conduct, and 5.6% involved concerns about the health of practitioners. Among notifications about performance, the most common issues arising were concerns about the quality of clinical care (30.7%) and communication (4.4%). Among notifications about conduct, allegations of disruptive behavior were the most common (8.1%), followed by concerns about improper use or management of health information (7.6%) and non-compliance with regulatory or administrative requirements (4.6%). Alleged breaches of sexual boundaries accounted for 2.7% of notifications.

Outcomes of notifications

Approximately 36% of notifications were resolved within 3 months, 74% within 1 year and 91% within 2 years. By the end of our follow-up period, 7898 (95%) of the notifications in the study sample had reached a final determination. The remaining results relate to these “closed” notifications.

For 68% (5363/7898) of closed notifications, the final determination was to take no further action after the Board had considered the issues raised (Fig.  1 ) (a decision to take no further action does not necessarily mean that the notification was groundless: it may mean that the threshold for regulatory action was not met or that there is no longer a risk to the public that needs to be managed because of actions the practitioner took during the assessment or investigation period). Ten percent (818/7898) of closed notifications resulted in restrictive actions, 11% (850/7898) in a caution, reprimand or fine, and 11% (867/7898) were referred to another official agency (e.g., police).

Overview of the number of practitioners, number of notifications, and outcome of notifications

Among notifications ending in restrictive actions, 38% (308/818) involved practitioners entering a legally enforceable but voluntary undertaking with the board; 60% (489/818) involved the imposition of formal conditions on the practitioner’s registration; and 3% (21/818) involved removal from practice through temporary suspension or permanent cancellation of registration by a tribunal. The 21 removals related to 19 different practitioners, and 14 of these notifications involved conduct issues (seven were breaches of boundaries), four involved performance issues, and one involved a health issue.

Predictors of restrictive action

The source of the notification, the primary issue of concern in the notification, and the notified practitioner’s profession were all strongly associated with the odds of a restrictive action (Table  4 , columns 2 and 3).

Compared with concerns about clinical care (the reference category), the odds of a restrictive action being imposed were significantly higher among notifications involving health impairments (drug misuse OR = 7.0, alcohol misuse OR = 4.6, mental illness OR = 4.1, physical or cognitive illness OR = 3.7), unlawful use or supply of medications (OR = 2.1), and breach of boundaries (OR = 1.7). On the other hand, the odds of restrictive action were significantly lower among notifications involving unfair costs or misleading advertising (OR = 0.1), delayed access to care (OR = 0.2), non-compliance with administrative or regulatory requirements (OR = 0.5), poor communication (OR = 0.5), and problems with the use of health information (OR = 0.6).

Compared with notifications lodged by patients or relatives, the odds of restrictive action were significantly higher among notifications lodged by employers (OR = 6.9), other agencies such as a health department (OR = 5.3), and fellow practitioners (OR = 2.9). Self-notifications also had significantly higher odds of ending in restrictive actions (OR = 4.0); these arise in a variety of situations, for example, a practitioner may self-notify a substance abuse issue to pre-empt notification by a third party.

The odds of restrictive action being taken in relation to notifications against dentists (OR = 4.7) and psychologists (OR = 4.5) were more than four times higher than in notifications against doctors, and nearly two times higher than in notifications against nurses and midwives (OR = 1.8). Notifications against male practitioners were no more likely to end in restrictive actions than those against female practitioners, nor were there differences in the odds of restrictive action according to the remoteness of the notified practitioner’s practice location.

Predictors of any regulatory action

The pattern of results when the outcome was any regulatory action (restrictive actions, cautions, reprimands, or fines) was broadly similar, although most ORs were smaller than those for restrictive actions alone (Table  4 , columns 4 and 5). The notable difference was for pharmacists. In this analysis they had odds of regulatory action that were nearly three times that of doctors suggesting that, compared with doctors, pharmacists who were the subject of a notification were more likely to receive cautions, reprimands, or fines.

Time to resolution

The time involved in resolving a case increased with the severity of the outcome. The median time to closure for cases that resulted in no further action was 9 months, compared with 34 months for cases that involved any regulatory action, 37 months for cases resulting in restrictive action, and 70 months for the 21 cases that resulted in suspension or cancellation of registration. Some of these delays fall outside of the control of AHPRA or the Boards, and relate, for example, to time spent waiting for a coroner or tribunal to conclude their consideration of a case.

Health practitioner boards are pivotal institutions in the regulation of healthcare delivery [ 25 ]. They play a critical role in deciding who is lawfully entitled to practice and in protecting the public from substandard practice. How practitioner boards execute their regulatory function has important consequences for affected practitioners [ 1 ], the profession, and the public [ 2 ].

Main findings

This study of notifications lodged over a 2-year period against practitioners from 10 health professions found an overall rate of six notifications per 1000 practitioners per year. Doctors and dental practitioners had relatively high notification rates and nurses and midwives had relatively low rates. Final determinations were made on the majority of notifications within a year, although around one in ten took more than 2 years to resolve. In nearly 70% of cases, no further action was taken. About 10% of notifications resulted in restrictive actions, almost all of which involved some form of undertaking or conditions on practice. Only 21 notifications – about 0.3% of the total lodged – resulted in removal from practice. Notifications from peers and employers, notifications about health problems (particularly drug or alcohol problems), and notifications against dentists and psychologists had the highest odds of ending in restrictive actions.

Strengths and limitations

An important strength of this study is the ability to analyze notifications from multiple jurisdictions and multiple professions, through the use of data from Australia’s National Registration and Accreditation Scheme. A few previous studies have shown inter-board variation in disciplinary decisions within a single profession [ 2 , 26 , 27 ], but none have compared decisions by boards regulating different professions. An additional strength of the study is its long follow-up time, which allowed us to observe the final outcomes of the vast majority of notifications.

The most significant limitation of the study is that we were not able to measure a number of practitioner-level variables that are likely to be related to the risks of regulatory action. These include patient volume, type of practice, history of disciplinary actions and, for doctors, performance issues during training and the country of their primary medical degree. Previous studies have identified associations between these factors and disciplinary outcomes [ 10 , 12 , 15 , 28 ].

Second, despite the lengthy follow-up period, 5% of the notifications in our sample did not have final decisions at the time the study data were extracted. Cases that take longer to resolve tend to involve more serious outcomes. Findings of serious misconduct are typically made by a tribunal after a hearing, which occurs at the end of the adjudication process, and the tribunal’s decision in such cases may be appealed [ 29 ]. The implication of this for our findings is that we may underestimate the number of notifications that end in restrictive actions, especially those involving suspension or cancellation of practice.

Third, we note that the Australian national scheme was still in its early years at the time of this study. Differences in decision-making between professions may reduce over time as Boards work together to develop more consistent approaches to the assessment and resolution of notifications.

Interpretation and implications

The regulation of health practitioners in Australia has the primary objective of protection of the public by ensuring that only competent and ethical practitioners are registered. Handling notifications of concern about a practitioner’s health, conduct or performance looms as a key role of the national multi-practitioner regulation agency, with a complex apparatus for receiving, assessing and investigating notifications. This study suggests some interesting lessons for other international health practitioner boards.

We found that notifications to practitioner boards about the health, conduct or performance of a health practitioner are a rare event, and responses to notifications that involve restrictive actions, such as conditions on or removal from practice, are rarer still.

The probability of restrictive actions varied widely depending on the source of the notification (with notifications from peers more likely to result in restrictive action than those made by patients) and by profession (with notifications about doctors less likely to result in restrictive actions than those against other professions).

The evidence that notifications made by fellow practitioners or employers are much more likely to lead to restrictive action than notifications made by patients and relatives or by complaint commissioners (which generally respond to patient complaints [ 30 ]) is perhaps unsurprising. One possible explanation is that peers are better positioned to recognize legitimate bases for a notification than are patients [ 2 ]. Relatedly, peers may refrain from notifying in all but the most egregious instances. A competing explanation relates to the adjudication process: notifications by peers may receive closer attention than notifications by patients. Given the increasing emphasis on the role of patients and families in patient safety, it would be of concern if issues raised by those on the receiving end of care are discounted in assessment processes dominated by peer opinion.

We found that nearly half of all notifications were due to concerns about performance issues, yet very few of these notifications resulted in restrictive actions. In contrast, relatively few notifications concerned health impairments, but a substantially larger proportion of them ended in restrictive actions. Part of the explanation for this difference may relate to issues of evidence and proof. What constitutes an unacceptable level of performance may be more difficult to determine, both for the notifier and the adjudicator, than the existence of an impairment that endangers safe care. Performance concerns inevitably raise the specter of judging what is acceptable care, an area where regulators (advised by members of the profession) have always treaded warily. Professional reticence to criticize poor care [ 31 ] and vigorous defense lawyers likely also play a part.

Consistent with previous studies, notification rates were higher among male practitioners and older practitioners [ 32 ]. However, there was no difference between males and females in the odds of restrictive action once a notification was received, and there was no trend for age.

Finally, the variation we observed between professions, both in the rate at which notifications were made, and the rate at which notifications ended in restrictive actions, is striking. Doctors, for example, had one of the highest rates of notifications, but those notifications were less likely to result in restrictive actions than in other professions. There are several possible explanations for such variation – they may be due to inter-professional differences, such as whether substandard care may directly cause harm (including pain), in the underlying rate of unprofessional behaviors, in the likelihood that any given episode of unprofessional behavior will be notified, in “case mix” (i.e., the nature and legitimacy of notifications), and in how strictly boards respond. We cannot disentangle these competing explanations because we did not observe unprofessional behavior directly, other than through the decisions of boards in cases that reach them.

Health practitioner boards are charged with upholding professional standards and maintaining public confidence in regulated health professions. This requires taking timely and appropriate action in response to concerns about the health, conduct, or performance of health practitioners. Our findings reveal significant variation in the use of restrictive actions depending on the source of the notification, the type of issue involved, and the profession of the practitioner. Further work is required to understand whether such variations are to be expected based on the nature and magnitude of the risks involved, and whether restrictive actions are effective in protecting the public from a future risk of harm.

Change history

07 march 2018.

The original article [1] contains a major error whereby all rates in Table 2 are mistakenly presented as 50% of their true values; this error was caused by a miscalculation in annualising the original values that represented the rates.

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This study was funded by the National Health and Medical Research Council (1092933) and the Australian Health Practitioner Regulation Agency. The funders had no role in the design and conduct of the study, the collection, analysis, interpretation of results or preparation of the manuscript.

Availability of data and materials

The data that support the research findings are owned by the Australian Health Practitioner Regulation Agency (AHPRA) but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Other researchers can apply to AHPRA for access to the data (see http://www.ahpra.gov.au/about-ahpra/what-we-do/data-access-and-research.aspx ). The authors are willing to make code used in the study available to other interested parties.

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MS: Sought access to the data, designed the analysis, undertook data management and statistical analysis, interpreted the results, prepared the first draft of the manuscript, revised the manuscript based on the comments from other authors, and approved the final version of the manuscript. DM: Sought funding for the study, designed the analysis, interpreted the results, revised the manuscript and approved the final version of the manuscript. RP: Sought funding for the study, interpreted the results, revised the manuscript and approved the final version of the manuscript. MB: Sought funding for the study, sought access to the data, designed the analysis, interpreted the results, revised the manuscript and approved the final version of the manuscript.

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Spittal, M.J., Studdert, D.M., Paterson, R. et al. Outcomes of notifications to health practitioner boards: a retrospective cohort study. BMC Med 14 , 198 (2016). https://doi.org/10.1186/s12916-016-0748-6

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ahpra case study 51

Regulating health professional scopes of practice: comparing institutional arrangements and approaches in the US, Canada, Australia and the UK

Human Resources for Health volume  19 , Article number:  15 ( 2021 ) Cite this article

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Fundamentally, the goal of health professional regulatory regimes is to ensure the highest quality of care to the public. Part of that task is to control what health professionals do, or their scope of practice . Ideally, this involves the application of evidence-based professional standards of practice to the tasks for which health professional have received training. There are different jurisdictional approaches to achieving these goals.

Using a comparative case study approach and similar systems policy analysis design, we present and discuss four different regulatory approaches from the US, Canada, Australia and the UK. For each case, we highlight the jurisdictional differences in how these countries regulate health professional scopes of practice in the interest of the public. Our comparative Strengths, Weaknesses, Opportunities, Threats (SWOT) analysis is based on archival research carried out by the authors wherein we describe the evolution of the institutional arrangements for form of regulatory approach, with specific reference to scope of practice.


Our comparative examination finds that the different regulatory approaches in these countries have emerged in response to similar challenges. In some cases, ‘tasks’ or ‘activities’ are the basis of regulation, whereas in other contexts protected ‘titles’ are regulated, and in some cases both. From our results and the jurisdiction-specific SWOT analyses, we have conceptualized a synthesized table of leading practices related to regulating scopes of practice mapped to specific regulatory principles. We discuss the implications for how these different approaches achieve positive outcomes for the public, but also for health professionals and the system more broadly in terms of workforce optimization.

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Fundamentally, the goal of health professional regulatory regimes is to ensure the highest quality of care to the public. Part of that task is to monitor and control what health professionals do, or their scope of practice. Ideally, this involves the application of evidence-based professional standards of practice to the tasks for which health professionals have received training. There are different regulatory approaches to achieving these goals across international and regional jurisdictions.

Regulatory authority lies in a range of professional as well as state institutions, revealing a continuum from professional autonomy to state control [ 1 ]. That is, professions and governments share regulatory authority to varying degrees, historically and between countries. There is even further complexity in the more contemporary era because in many cases new agencies and partnership organizations have been created to regulate at arms’ length from the professions and the state, in some cases in coordination across health professions within a given workforce. A shift from traditional professional self-regulation has occurred in many jurisdictions, often as a result of regulatory failures to protect the public [ 2 ]. Moreover, the regulation of health professionals and their work has become more constrained as governments strive to provide not only high-quality, but also cost-effective care to the public.

In this paper, we present and discuss four different regulatory approaches from the United States (US), Canada, Australia, and the United Kingdom (UK), highlighting the differences in how these countries regulate health professional scope of practice in the interest of the public. Across countries, the aims may be similar, but the mechanisms differ because of local historical policy legacies and cultural norms [ 2 ]. This makes comparative work challenging but also interesting. Whereas previous analyses have focused on professions and strategies, we focus on scopes of practice and institutional approaches. Our comparative examination finds that the different regulatory approaches in these countries have different implications for how health professional scopes are articulated and in turn how this can impact on health workforce optimization. They have each experienced different forms of regulatory failure and each are undertaking, in some cases, substantial reforms of their health professional regulatory models partly in response to these failures.

In this article, we are focused on the system-level impact of health professional regulation on scopes of practice. Regulation is only one of many system variables that influence scopes of practice. Others include collaborative practice agreements, delegation and supervision models, board certification, and funding arrangements. Professional associations may also impact scope of practice by seeking to defend or extend their members’ current scope as part of their advocacy role [ 3 ]. With few exceptions, however, the role of the regulator is separate from the role of professional associations and the regulators’ mandate of protecting the public interest imposes a unique impact on scope of practice.

Currently, one of the major influences on health professional scopes of practice globally is the COVID-19 pandemic. The pandemic has made clear the necessity of optimizing the workforce by ensuring all professionals are practicing to full scope [ 4 ]. Flexibility in scope has also been emphasized as a means to augment the health workforce, particularly in specific pandemic response areas. Maintaining public protection while ensuring access to the needed workforce is an important aspect of regulating scopes of practice that has become even more critical during the current public health crisis.

Health profession regulation, public protection, and scopes of practice

Although the core concern of health profession regulation is protection of the public, historically, achieving self-regulatory status was considered akin to achieving professional status [ 5 , 6 ]. As Larson [ 7 ] describes, regulation often helped to create a state-sponsored monopoly over the profession’s services. This status attainment may have been afforded to only a few professions, reflecting a hierarchy within a division of labour. Health professional regulation, for example, often resulted in the constraining of a health professions’ scope of practice or modality ‘crystalizing’ the dominance of the medical profession [ 8 , 9 ]. This differential outcome speaks to the dynamic relations that exist between the state and professions; a relationship that has evolved from granting state-sanctioned self-regulatory status [ 10 ] to funding health professional services and broader systems management.

Contemporary approaches to health professional regulation have increasingly focused on improving accountability to the public interest through more open, transparent, and publicly accountable processes for peer surveillance and control, in light of clinical mistakes threatening the safety of patient care [ 11 , 12 , 13 , 14 , 15 ]. Regulation by design should protect patients from the possibly deleterious effects of asymmetrical information between them and health professionals [ 16 ]. A focus on ‘patient safety’ challenges, what was traditionally the technical and esoteric domains of health professionals, was increasingly brought into the scope of political and managerial reform in healthcare [ 17 ].

The principles of right-touch regulation —where the level of regulation is proportionate to the level of risk to the public—have been used in varied ways by regulators across international jurisdictions to modernize regulation in the public interest [ 18 ]. This focus on risk management also highlights how health professions regulation must be flexible enough to support efficient and effective use of the health workforce. Nelson et al. [ 19 ] argued that regulating scopes of practice requires balancing the intersecting dimensions of flexibility —empowering teams to determine the relative responsibilities of the different practitioners based upon community need; and accountability —ensuring the optimization of scopes of practice within a professional regulatory environment. This intersection has sharpened during the COVID-19 pandemic with regulators being urged to enhance their flexibility, while maintaining accountability for protecting the public, as a way to augment the health workforce [ 20 ].

The pandemic has also highlighted a fundamental truth: society moves quickly while regulation and law tend to be more static, and regulatory frameworks need to be made nimbler and more responsive to meet the needs of modern society [ 21 ]. This is true as well in the regulation of scopes of practice as modern team-based care and technological advances increasingly transform health professional work. Despite the nexus between modernizing regulation and optimizing the health workforce, there is a gap in knowledge around the impact of different regulatory models on health professional scopes of practice.

We employed a comparative case study approach, informed by Yin’s [ 22 ] case study methodology, utilizing a similar systems policy analysis design [ 23 ]. This involved the collection and analysis of policy documents, published, and grey literature by locally situated investigators [ 24 ]. In two cases (US and Canada), the investigators were situated at arms-length from a professional regulatory body. In the other two cases (UK and Australia), the investigators are situated within regulatory structures. A common analytic template guided the comparative analysis along key institutional dimensions. Refinement of a preliminary analysis was undertaken after presentation to two different international audiences [ 25 , 26 ].

The unit of comparative analysis is at the systems-level rather than the individual profession level, with the comparison focused across the regulatory approaches in each jurisdiction. For each case, the health professions regulatory framework used in each country is described highlighting the emergence of new institutional structures between professions and the government (state) and approaches to regulating health professional scopes of practice. The presentation of the data is both thematic and semi-chronological by country, highlighting key events that have shifted structures, organizations, and interests. We draw out of each case the strengths, weaknesses, opportunities, and threats (SWOT) institutional analysis which enables an appreciation of the implications of the different regulatory approaches for health professional scopes of practice and health workforce optimization. From our results and these SWOT analyses, we have conceptualized a synthesized table of leading practices related to regulating scopes of practice mapped to specific regulatory principles.

The United States: regulating strict scopes of practice

In the United States, the regulation of health professions primarily falls to the states. State-based laws and regulations define specific legal scopes of practice for health professionals including the health services that can be legally offered (e.g., controlled acts) and the circumstances under which these services may be provided (the context for professional practice). Regulation occurs under the auspices of a range of state agencies, including departments of health, education, and other state agencies in which regulatory boards are housed. The configurations of state boards vary in scope of authority, level of autonomy, and control over administrative processes [ 27 ]. A 2020 report on state regulatory structures provides a comprehensive overview of these configurations and included survey responses from 161 representatives in 45 states and the District of Columbia [ 27 ]. In 26 of these jurisdictions, regulatory boards had full autonomy in decision-making; 16 states employed a mixed model where some regulatory bodies had autonomy while others used a central agency for decision-making. Four states relied exclusively on a central agency for decision-making and boards functioned only in an advisory capacity.

Although states have the constitutional authority to govern regulatory processes, the federal government is able to influence state governance. Recent advisory opinions from the Federal Trade Commission and several court rulings, including one from the US Supreme Court, cite the inherent risk in self-regulation, i.e. the potential for professional self-protection [ 28 ] and monopolistic practice in violation of federal anti-trust laws [ 29 ]. These advisories recommend active oversight of certain board decisions by external bodies [ 30 ] to avoid unnecessarily anti-competitive outcomes. Several states have proposed changes in the structure of professional regulatory boards or have created centralized review boards with the power to accept or reject board recommended regulatory changes [ 29 , 30 ].

A critical challenge associated with the regulation of health professions is state-to-state variation in scope of practice, which is limited by the location of the professional rather than by their skills and competencies. Most health professionals in the US are trained in nationally accredited educational programmes using standard curriculum and most complete national competency exams. Despite these national standards, some states limit a health professional’s ability to practice to the full scope of their demonstrated professional competency. State-based laws can restrict practice, which is especially relevant in times of crisis, and can also impede the provision of health services across state boundaries [ 31 ].

State licensing laws may also impede services when the consulting clinician is licensed in a state other than the one where the patient is located. To address this barrier, some states have opted to join interstate licensure compacts that allow a clinician who meets licensure requirements in one state to practice in other states in the compact. Although the models differ in detail, there is now a nurse licensure compact effective in 25 states [ 32 ] and an interstate medical licensure compact effective in 29 states and DC [ 33 ]. Other professions are developing interstate compacts as well, including emergency medical personnel and physical therapy. These compacts have been especially useful during the COVID-19 outbreak in the US, allowing clinicians to cross state borders and practice where there was great demand for health workers. In addition, in response to the need to quickly build workforce surge capacity during the pandemic, some states issued emergency regulations allowing physicians, nurses and other health professionals licensed and in good standing in other states to practice in their state.

Efforts to recognize new professions or modify scope of practice for existing health professions usually require the enactment of or amendment to state law, a process which is typically slow and, at times, adversarial. States often solicit input on proposed changes from stakeholders, including professional associations and, to a more limited extent, consumer groups. Emerging professions with fewer resources to mount advocacy campaigns may be disadvantaged in this process by more powerful and well-funded professional constituencies in a state.

Scope of practice regulations also affect the distribution of health professionals. Supervision requirements often result in the co-location of NPs and PAs with physicians, which limits their dispersion in underserved areas and results in reduced primary care capacity, especially in rural locations. A 2018 study that examined supply and distribution of NPs in the US found that the supply of NPs in geographic areas designated as health professions shortage areas was highest in states that recognized more autonomous scopes of practice for NPs [ 34 ]. In response to the COVID pandemic, some states temporarily waived supervisory requirements for NPs and PAs, which enabled them to practice where needed [ 35 ].

Health care in the US is changing and these changes have heightened discussion about the impacts of scopes of practice on access to needed services. Enacting regulations to support overlapping scopes of practice among health professionals is at the crux of many of the contentious debates occurring in states. Standardizing scopes of practice for health professions based on competencies would enable service delivery unencumbered by state boundaries. Proposing the establishment of new professions and expanding practice for existing professions must be based on the best available evidence and be within the parameters of training and competency for the profession [ 36 ].

Table 1 details the SWOT analysis of the US case.

Canada: regulating flexible scopes of practice through tasks

Health professional regulation falls under provincial and territorial jurisdiction in Canada. As such, and despite national-level accreditation and educational standards for many professions, there is substantial variation across the country in terms of regulatory models, which professions are regulated, and the activities that are regulated. As in the US case, this results in differential access to providers and services across the country.

What is common across Canada is the self-regulatory status of most health professions via the statutory delegation of authorities to the ministers of health to establish regulations, and to regulatory authorities (often called regulatory colleges) to govern their respective professions [ 37 , 38 , 39 ]. The introduction of new regulated health professions and scopes of practice changes therefore require either legislative or regulatory amendment. Professional regulatory authorities are responsible for establishing entry-to-practice credentials, maintaining a public register of health professionals, upholding standards of practice, and overseeing complaints and disciplinary proceedings. The regulators are expected to act in the public interest, which distinguishes them from professional associations that focus on professional interests [ 38 , 39 , 40 , 41 , 42 ].

The traditional model of health profession regulation across Canadian provinces is based on separate statutes and exclusive scopes of practice for each profession. There has been a trend to move away from this model towards umbrella frameworks characterized by overlapping scopes of practice [ 38 , 39 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 ]. This began with the Regulated Health Professions Act , 1991 (RHPA) [ 54 ] in Ontario and other provinces have since followed with similar umbrella legislation.

Umbrella frameworks apply uniform standards to the health professions that are governed by the legislation. The legislation sets out consistent provisions for governance, registration, complaints, discipline, appeals, public representation, regulation and by-law making powers. The umbrella act is accompanied by specific regulations or statutes for individual professions that confer title protection and include broad, non-exclusive scope of practice statements. These legislative statements are then used by the regulatory bodies to develop competencies, guidelines, and standards of practice. Legislative scope of practice statements and regulatory policies generally set the outer limits of the professions’ scope of practice.

In addition to title protection and non-exclusive scope of practice statements, the umbrella legislative frameworks enumerate a number of controlled or restricted acts. These controlled or restricted acts are an effort to balance promoting interdisciplinary care while still restricting higher risk activities to specific professional groups [ 39 ]. The same controlled activities may be granted to more than one profession and may also be delegated. The dominant position physicians maintain in the health care system is reflected in how many controlled acts they are authorized to perform [ 55 ].

The introduction of overlapping scopes of practice through the non-exclusive scope of practice statements and controlled acts model is also intended to enhance flexibility in the provider(s) who deliver services, as well as encourage interprofessional practice [ 47 , 48 , 49 ]. Other statutory changes to encourage collaboration, team-based models of care, and new providers have accompanied or followed the introduction of these umbrella frameworks [ 45 , 50 , 51 , 52 ]. Newfoundland and Labrador, for example, has established the Council of Health Professionals, an independent body that is responsible for coordinating the regulation of eight health professions. In Ontario, 2009′s Regulated Health Professions Statute Law Amendment Act [ 56 ] mandated the health regulators collaborate in the development of standards where controlled acts are overlapping.

Umbrella legislation with overlapping scopes of practice does not entirely prevent scopes of practice from being a barrier to collaborative, team-based care, as it effectively entrenches a narrower range of controlled activities [ 50 ]. A 2018 report commissioned by the Ontario government identified the current system as ill-suited for the future since it prevents a health professional from embracing a broader scope of practice or engaging in a controlled act even if that professional can demonstrate an appropriate level of competence [ 57 ]. These umbrella frameworks have nonetheless been considered a key instrument for introducing regulatory flexibility and loosening the restrictiveness of scopes [ 44 , 50 ]. At the very least, “Umbrella legislation with more flexible scopes of practice provides a possible foundation for collaborative models of care” ([ 19 ], p. 54).

Another Canadian province, Nova Scotia, has taken an alternative approach to facilitating regulatory collaboration and flexible scopes of practice. In 2012, Nova Scotia introduced the Regulated Health Professions Network Act [ 58 ] to establish a statutory Network of self-regulating health professions that enables voluntary regulatory collaboration. The Network legislation authorizes regulatory authorities to enter into agreements respecting the interpretation or modification of scopes of practice without the need for further legislative amendment, provided the provincial health minister determines the agreement is in the public interest [ 59 ]. Reform is currently proposed in British Columbia that would see a reduction in the number of regulatory authorities from 20 to six [ 60 ]; this reform recognizes that regulating single professions in isolation does not allow regulatory colleges to respond nimbly to the complexities of modern team-based care.

Health professional scopes of practice in Canada have traditionally been enshrined in regulatory regimes on the basis of history and politics rather than best utilizing skills and knowledge best meet contemporary population health needs [ 19 ]. That seems to be changing with the complement of regulatory reform recently undertaken and currently proposed in Canada to facilitate collaboration and provide more flexibility in order to support health workforce innovations. The COVID-19 pandemic has necessitated further emergency reforms to facilitate surge capacity, such as policies to allow for internationally educated health professionals to be granted emergency licensure and upskilling to allow for pandemic-related task shifting [ 61 ]. However, the continued reliance by most Canadian provinces on discrete regulatory authorities for individual professions and the lack of national coordination around scopes of practice form barriers to interjurisdictional mobility and efficient health workforce reform.

Table 2 details the SWOT analysis of the Canadian case.

Australia: national consistency in outer boundaries of scope of practice

Australia has seen a major transformation to the legal framework and institutions governing the regulation of health practitioners. Historically, the health professions were regulated by statute in models that were primarily profession specific and were based on both restricting practices and titles. This had the impact of constraining or protecting scopes of practice through statute and being relatively unresponsive to the changing needs of the population and design of the health care system and workforce. The legislation and institutions regulating health practitioners were separated not only by profession but also replicated for each of eight jurisdictions in the federation. This was a highly fragmented and duplicative system for a country relatively large by land mass yet with a small and distributed population. Despite having mutual recognition mechanisms, this model presented mobility barriers, different professional standards, and regulatory costs to practicing across borders.

In 2010, Australia moved away from this state/territorial regulatory system to the National Registration and Accreditation Scheme. This scheme was established with the enactment of the National Law (beginning with the Health Practitioner Regulation National Law Act [ 62 ] , enacted in Queensland as the host jurisdiction, followed by uniform legislation in the other states and territories). The National Law covers 15 registered professions. One regulatory agency, Ahpra, manages this scheme while 15 National profession-specific Boards establish professional standards for registration and practise for their respective professions. The National Boards are responsible for registering professionals, imposing any necessary conditions on registration, developing standards and codes of conduct, and considering complaints about registrants.

Scope of practice regulation in Australia is now primarily accomplished through title protection under the National Law and minimal scope of practice restrictions by the National Boards. The National Boards develop registration standards about the scope of practice of registered health practitioners and also address roles and competencies in broad terms in documents such as practice standards and codes of professional conduct, where there is often a requirement that the health professional recognize and work within the limits of their competence and scope of practice. For example, the Nursing and Midwifery Board of Australia includes a requirement that nurses practice within their scope of practice. The regulator defines scope of practice as “that in which nurses are educated, competent to perform, and permitted by law” and adds that “actual scope of practice is influenced by the context in which the nurse practices, the health needs of people, the level of competence and confidence of the nurse and the policy requirements of the service provider” (63), p. 6). As such, the National Boards do not provide detailed explanations of scope of practice or regulate through restricted acts but rather maintain the outer boundaries of practice through their registration and practice standards.

The National Boards are also authorized under the National Law to “endorse” the registration of certain professionals. An endorsement recognizes that a health professional has an extended scope of practice in a particular area of practice because they have additional qualifications that are approved by the National Board [ 64 ]. Registered nurses may be endorsed as nurse practitioners, for example, and dentists may be endorsed for the approved area of practice of conscious sedation. Each National Board sets the requirements for endorsement for areas of practice within their profession. These endorsements thus provide an expanded scope built upon the foundation and inclusive of the professional’s original scope of practice on registration in the profession.

In addition to endorsements, specialties and specialist titles may also be developed by the National Boards. As of the time of writing, specialist registrations may be granted in dentistry, medicine, and podiatry. A ministerial council comprised of the health ministers of all eight state and territories and the Commonwealth approves the standards set by each National Board for entry to practice, for endorsement of registration for advanced practice, and for specialist registration [ 65 ].

While the factors leading to endorsement and specialist registration by a National Board are generally straightforward, the expression of these expanded scope of practice is often shaped by federal, state, and territory legislation around funding and prescription drugs that can form a barrier to practicing to full scope [ 66 , 67 , 68 ]. This has been found in particular in relation to nurse practitioner scope of practice where jurisdiction and clinical context continues to be a major influence on defining scope of practice [ 66 , 67 ]. Further, employers or professional associations may develop their own lists of skill sets that define scope of practice within specific settings or may use credentialing to verify the ability of practitioners to provide specialized practice within specific organizational environments [ 69 ].

As such, there remain jurisdictional differences in scopes of practice for some Australian health professions due to state legislation, clinical context-specific guidelines, and employer or professional association-level credentialing. However, the uniform legislation and regulatory authorities operating nationally provide title protection and set the outer boundaries of practice through registration and practice standards. This national coordination has been used during the COVID-19 pandemic response to facilitate a short-term sub-register for fast tracking a return to the workforce for experienced and qualified professionals [ 70 ] and to provide national guidance on telehealth [ 71 ].

Table 3 details the SWOT analysis of the Australian case.

The United Kingdom: differing regulatory approaches in a complex landscape

In the UK, there are ten separate statutory organizations, mostly called councils, that regulate health professionals. These ten regulatory authorities have a common set of core functions: setting standards for registrants, quality assuring courses of higher education, keeping the register, and managing allegations that registrants are unfit to practise. Despite the common set of activities, there are differences in legislation, standards, approach, and efficiency reflecting the way that the councils have evolved over many years. Some of the councils regulate single professions, while the Health and Care Professions Council (HCPC) regulates 15 different professions; some regulate hundreds of thousands of registrants while some only regulate a few thousand; some have been in existence for a long time while others were founded much more recently. Most are UK wide bodies except for the regulators of pharmacy and Social Work England which regulates social workers in England only.

The ten statutory regulators are overseen by the Professional Standards Authority for Health and Social Care (the Authority) that conducts and publishes regular performance reviews for each of the regulators. The Authority also reviews all final hearing decisions in fitness to practise cases and can take action where it believes the decision is not sufficient to protect the public. The Authority shares good practice in the sector, conducts research, and promotes new ideas such as right-touch regulation [ 72 ].

Determining scope of practice is complex and multi-faceted in the UK with many influences. As well as the professional regulators, there are many other organizations in the UK responsible for regulating different aspects of health systems and services. Professional regulators are just one of a somewhat crowded landscape governing practice, and individual scopes of practice are influenced by local or institutional factors. Since the core focus of professional regulators in the UK is ensuring fitness to practise, a crucial challenge is ensuring there are governance and oversight arrangements to mitigate the risk to the public when individual professionals practice outside their scope of competence.

Among the 10 professional regulators in the UK, there is no common approach to determining scope of practice, nor is there any agreed definition of scope of practice. One commonality is that regulators routinely state in their standards of practice that registrants are responsible for recognizing the limits of their knowledge, skill, and experience, and must not practice unless they are capable of doing so safely and effectively. Where they provide more detailed guidance on the limits of practice, they do so in different ways.

The HCPC, for example, defines scope of practice for registrants as “the limit of your knowledge, skills and experience...Determining what is and is not part of your scope of practice will be for you to decide using your professional judgement.” [ 73 ]. In the standards of conduct, performance and ethics, the HCPC prescribes that registrants must refer a service user to another practitioner if the services needed are outside a practitioner’s scope [ 74 ]. The HCPC publishes standards of proficiency guidance [ 75 ] for each of the 15 professions that it regulates, and notes that while these standards of proficiency may inform a registrant’s scope of practice, job descriptions, employer policies, legal restrictions, coverage by professional indemnity insurance, and guidance from professional bodies will also inform scope of practice. The HCPC thus prompts practitioners to determine their scope of practice based on their professional judgment.

The General Dental Council (GDC) takes a more formalized approach, publishing a document specifically addressing scope of practice for all of its registrant groups (dental nurses, orthodontic therapists, dental hygienists, dental therapists, dental technicians, clinical dental technicians, and dentists). Unlike the HCPC’s approach, which focuses on specific knowledge areas, the GDC sets out the tasks that each group can undertake. Establishing first, like the other regulators, that scope of practice describes the areas in which registrants have the knowledge, skills and experience to practise safely and effectively, for each group it then distinguishes between the skills and abilities all registrants in the group should have, additional skills which could be developed with further training, and additional skills that can be carried out if prescribed or directed from another registrant [ 76 ]. The guidance also defines what certain groups do not do; dental hygienists, for example, “do not: restore teeth, carry out pulp treatments, adjust unrestored surfaces, extract teeth.” ([ 76 ], p. 7). For registrants working at the highest level of risk—dentists—the guidance is at a higher level of abstraction rather than a list of tasks are in and out of scope: dentists may “diagnose disease…prescribe and provide endodontic treatment on adult teeth…prescribe and provide fixed orthodontic treatment” ([ 76 ], p. 11). This may be changing, as the GDC is currently engaged in a scope of practice review to explore whether its guidance document is working as intended. The aim of this review is to “provide as much flexibility to dental professionals as possible, so they are using their own professional judgment about the provision of care” [ 77 ].

While it is clear that scope of practice will evolve over time, both at the individual and the profession level, it is not clear how the arrangements by which scope of practice is currently determined at either level in the UK influence this evolution; for example, whether they present barriers to innovative approaches to the delivery of care. Nor is it clear how these different arrangements and influences relate to different levels of risk being managed by the different professions, and whether there are areas of unmanaged risk to patient safety. These considerations will be important to consider post-pandemic when emergency arrangements such as accelerated licensure for international nurses [ 78 ] and redeployment of health care professionals to areas where they are working “at the limits or beyond their normal scope of practice” are reconsidered ([ 79 ], p. 2).

Table 4 details the SWOT analysis of the UK case.

Leading practices for regulating scope of practice: a synthesized principle-based approach

From our results and the unique, context-specific SWOT analyses for each jurisdiction, we have developed this synthesis table of leading practices related to regulating scopes of practice that match specific regulatory principles (Table 5 ). These regulatory principles are adapted from Benton et al.’s [ 80 ] work and applied to our review of scope of practice regulation in these four jurisdictions.

Discussion and conclusion

This novel comparative study enables us to better understand the content and context of health professional regulation and its impact on scopes of practice across jurisdictions. With the spotlight on the health workforce during the global public health crisis of COVID-19, whether regulatory frameworks for scopes of practice are currently serving and protecting the public is a critical consideration.

These four country contexts were chosen because they each have some similarities—being high-income, English-speaking countries with historic colonial ties—yet our analysis reveals some unique characteristics insofar as regulation of scopes of practice is concerned. Despite their similarities, there were nevertheless a number of challenges, including a lack of a common regulatory language, different political environments, different institutional arrangements and distributions of tasks, varying legislative foundations, ongoing reform efforts, and an absence of a clear methodology for comparison.

In the UK, health profession regulation is primarily a national-level responsibility and consistency in accountability and oversight is achieved through the Authority. In the Australian case, the move to a National Regulation and Accreditation Scheme with Ahpra and the National Boards for 15 health professions provides much greater consistency, mobility, and workforce coordination and planning at a national level. Health professional regulation is a subnational (province/state) responsibility in Canada and the US. While there is a role in each of these countries for nationally based certifying bodies in developing and implementing professional standards and licensure exams, the subnational variability in regulation in both of these jurisdictions was considered a weakness that may hinders efficient and effective workforce planning. The US move towards greater interjurisdictional cooperation through the interstate licensure compacts is a promising model.

There are varying degrees of influence of state or quasi state actors in the regulatory process around scopes of practice. This is most notable in the UK through the Authority and in Australia through Ahpra. Within some Canadian jurisdictions, the province of Ontario for example, a Health Professional Regulatory Advisory Committee, provides advice to the provincial government regarding evidence-based changes required in professional regulation, including scope of practice reform; it also applies a common set of rules applicable across all regulated health professions and is composed entirely of non-health professionals. An overarching oversight authority for regulated health professions that resembles the Authority is currently proposed in the Canadian province of British Columbia [ 60 ].

The COVID-19 pandemic has made clear the necessity of optimizing the workforce by ensuring all professionals are able to practice to full scope [ 81 ] and there have also been calls to ensure that scopes of practice are not unnecessarily restricted during the pandemic [ 82 ]. Maintaining public protection while ensuring access to the needed health workforce has become increasingly important during the pandemic. A joint statement by health professional regulators in the United States describes their “common duty” during COVID-19 as doing whatever is possible to ensure access to care across the country [ 83 ]. Lippert [ 84 ] adds that part of the regulatory mandate must be to ensure the most efficient and effective means of moving health care providers to where they are needed. While beyond the scope of this paper, the effect of changes to scope of practice on the physical and psychological health and safety of the health workforce should be considered in future work. Pandemic response plans in many countries have failed to explicitly address these critically important considerations [ 61 ] and post-pandemic reversals on scope of practice expansions may have adverse effects on health care professionals’ wellbeing [ 35 ].

There would be value in further study of whether a common definition of scope of practice would be possible across jurisdictions and examining in greater depth the various influences on professional scope of practice, including state versus professional power, and the role of continuing professional development, competency assessment, and revalidation processes on expanded scopes of practice. Recent reforms across jurisdictions emphasized realities of modern health care provision, including a need for mobility and team-based care. The impact of scope of practice regulation on these modern realities of practice should also be examined in greater detail. Finally, further study could also examine public involvement in health professional regulation and its impact on scope of practice reform. In most US states, there is little public involvement in professional self-regulation. In the UK, the Health and Social Care Act 2008 [ 85 ] eliminated elected professional majorities on the governing boards of each regulatory council and public members now must make up at least half of each regulatory council. In Canada, there are moves for similar reform that would see boards of regulatory authorities achieve parity between professional and public members in some provinces and professions, while in others elected professional majorities remain as a vestige of traditional self-regulation. In Australia, Ahpra established a community reference group in 2013 meant to act as a conduit between communities and Ahpra and the National Boards. Greater public involvement in professional regulation, particularly around scopes of practice, would allow for a stronger public voice in health workforce planning and is another topic for future study across international jurisdictions.

Availability of data and materials

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Leslie, K., Moore, J., Robertson, C. et al. Regulating health professional scopes of practice: comparing institutional arrangements and approaches in the US, Canada, Australia and the UK. Hum Resour Health 19 , 15 (2021). https://doi.org/10.1186/s12960-020-00550-3

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2. Supervision

3. professional development.

a range of specifically developed, practically oriented, skills based activities included in workshops such as case scenarios and role plays as well as convenient e-learning modules.

The key component of the 5+1 pathway is psychological practice, also referred to as placement. This involves securing employment in the workforce in a psychological role which is approved by PsyBA.

A total of 1,360 psychological practice hours must be completed. A minimum of 500 hours of the provisional psychologist’s role must involve direct or face-to-face client contact (60 of these hours may involve simulated client contact). This includes performing specific tasks of psychological assessment, intervention, and prevention. The remainder of the time comprises client-related activities such as case formulation and writing case notes and reports.

We provide pre-placement support if needed to help you secure suitable psychology placements that meet PsyBA psychological practice requirements. This support is tailored to your individual needs and includes suggesting job roles and passing on information about job opportunities with our partner organisations, reviewing resumes, job search techniques and strategies, and interview practice.


Individual and group supervision provides the provisional psychologist with a professionally stimulating and supportive opportunity for growth and networking. Supervision is a mentoring relationship that provides direction, guidance and instructive critique to assist you in meeting the board’s core competencies for general registration and your own professional goals. This process is fundamental to achieving PsyBA core competencies.

Over the course of the program, you will be given the opportunity to work with a variety of the College’s supervisors who have a diverse range of specialities and areas of interest, providing a rich and varied learning experience. All our supervisors are current practitioners.

Professional Development

The purpose of professional development (PD) is to increase the knowledge and skill level of provisional psychologists across all core competencies of professional practice. PD workshops cover advanced topics building of your 5th year training related to psychological assessment and diagnosis, intervention planning, implementation and evaluation of interventions and theoretical and empirical knowledge of psychological principles. In addition, professional development modules guide and support your emerging professional identity as a psychologist and provide insight and guidance around professional practice opportunities and skills such as career planning, self-development and self-care.

Our program provides you with everything you need to prepare case reports, successfully undertake the National Psychology Examination and begin to develop your identity as an early career psychologist. We provide a range of specifically developed, practically oriented activities, including workshops and e-learning modules.

All our professional development activities are delivered online.

4. Assessment Tasks and National Psychology Exam

Assessment of core competencies

The successful completion of Board assessment tasks is fundamental to achieving general registration.

For each of the core competencies, PsyBA requires specific training objectives and detailed assessment tasks to be completed progressively over the period of the internship. Progress reports must be provided by the supervisor and submitted to the Board by the provisional psychologist every six months. The Colleges’ Professional Development activities along with our guidance and support with these assessment tasks are what sets us apart.

Case reports

Case reports are a major component of the internship. They are an educational and developmental process intended to help the provisional psychologist cultivate and refine clinical skills and demonstrate clinical knowledge and skills through their work with clients in the workplace.

Four case reports (supervisor assessed) must be completed by the provisional psychologist during the internship, two must be focused on assessment of a client, and two must focus on intervention. One assessment and one intervention case report must be assessed by the Board to ensure that they demonstrate competence. Our supervisors support and guide you through the preparation of these, we provide training on writing case reports, and we provide a review process ensuring case reports are of a high standard and more likely to meet with Board approval when submitted.

National Psychology Exam

The provisional psychologist must pass the National Psychology Exam during their sixth year of training. At the College of Professional Psychology, we have a library of Board recommended exam readings, e-learning exam preparation modules and NPE study groups guided by an experienced supervisor to support your success.


To enrol in our 5+1 Psychology Registration Program, you must have completed an approved five-year  tertiary psychology qualification .

Program applicants are required to undergo a selection process that consists of an application and a structured interview. This process gives both the applicant and the College the opportunity to ensure that our program fits with your individual needs and goals.

Students with Overseas Qualifications

Overseas psychology qualifications will have to be assessed for their Australian equivalence by the Australian Health Practitioner Regulation Agency (AHPRA).

You may need to provide proof of proficiency in English. This involves getting a score of 7.0 or more in an International English Language Testing System (IELTS).

More information can be found on the Psychology Board of Australia website  .

The College of Professional Psychology was founded on the principle that by providing psychologists with the best professional and practical skills, they can go on to make a positive contribution to the mental well-being of the wider community.

Our supervisors, keen to give back and support the psychology profession, provide their time and expertise at a rate that allows us to keep our program fees to a minimum.

5+1 program:  $15,000

(payable in 4 x instalments)

The fees cover all components of the registration program, including regular individual and group supervision, professional development workshops, e-learning modules, assistance with finding placement if needed and other online networking opportunities. Also included is access to psychometric tests, assistance with submitting paperwork to AHPRA, workshop notes and resources.

Why choose the College of Professional Psychology?

Good to know

The start date of your internship program is the date the Board approves your provisional registration and you have a Board approved job role.



Issues by year


Article types

Adherence by orthopaedic surgeons to AHPRA and Australian Orthopaedic Association advertising guidelines

Objectives: To examine adherence to Australian Health Practitioner Regulation Agency (AHPRA) and Australian Orthopaedic Association (AOA) advertising guidelines by AOA members.

Design, setting: Cross‐sectional survey, Australia.

Participants: Two samples of AOA member orthopaedic surgeons: 81 randomly selected from a list of AOA members with publicly available contact details (AOA random sample); and a sample obtained by searching with Google for “orthopaedic surgeon” and the name of the major city in each of the eight Australian states and territories in turn; the top eight results for each search were considered for inclusion (AOA Google sample).

Main outcome measures: Non‐compliance of advertising material, by surgeon sample, with the AHPRA and AOA guidelines; associations between non‐compliance and sample, state, location (metropolitan, regional), and subspecialty.

Results: Of the 81 surgeons in the AOA random sample, 52 (64%) were non‐compliant with at least one aspect of the AHPRA guidelines, and 53 (65%) were non‐compliant with at least one aspect of the AOA guidelines. Of the 59 surgeons in the AOA Google sample, 48 were non‐compliant with the AHPRA guidelines (81%) and 46 with the AOA guidelines (78%). Incidence of non‐compliance with the AHPRA guidelines was influenced by sample source (AOA Google v AOA random: incidence rate ratio [IRR], 1.37; 95% CI, 1.01–1.87), but not non‐compliance with the AOA guidelines (IRR, 1.09; 95% CI, 0.77–1.55).

Conclusion: A large proportion of AOA members who advertise online do not comply with AHPRA and AOA advertising guidelines.

The known : Advertising influences patients by shaping their perceptions of surgeons and procedures, prompting requests for specific procedures, and guiding their expectations. Evidence for the low quality of health information on orthopaedic surgeon websites has been reported overseas.

The new : Online advertising complied with medical board and association guidelines for only 20 of 81 randomly selected Australian Orthopaedic Association surgeons, and seven of 59 surgeons at the top of Google search result lists.

The implications : Given increasing reliance on online health information, surgeons should take care with the information they publish online. We recommend stricter enforcement of professional advertising guidelines.

Direct‐to‐consumer advertising is common in orthopaedic medicine, particularly by surgeons who use new medical technologies. 1 Advocates argue that the advertisements are empowering educational tools that support informed decision making by patients. 2 However, critics voice concerns about inaccuracies, misleading claims, and biased information, as the primary aim of advertising is to increase the demand for particular services. 3 Several studies have identified inaccuracies and misleading information in online orthopaedic surgery advertisements that could lead to negative outcomes for patients. 4 , 5 , 6 , 7 Concerns have also been expressed about the quality of medical advertising in other surgical specialities, especially those in which elective surgery predominates and robotic technology is increasingly popular, such as plastic surgery, 8 urology, 9 and gynaecology. 10 Direct‐to‐consumer advertising influences decision making by shaping patient perceptions of surgeons and procedures, prompting requests for specific procedures or brands of implant, and guiding their expectations of treatments. 1 , 11

The internet is a popular and cost‐effective medium for advertising. A recent systematic review found that the internet and physicians are the sources of health information most frequently consulted by patients. 12 The commercial nature of the internet allows surgeons to adopt strategies such as search engine optimisation and paid advertisements to increase the probability of being placed among the top search results. This is important, as patients are most likely to visit the webpages linked with the top ten search results. 13 Patients are accordingly more likely to view information on the websites of surgeons using more aggressive marketing strategies.

In Australia, it has been a criminal offence since 2009, under section 133 of the Health Practitioner Regulation National Law , 14 to promote a regulated health service in a manner that could improperly influence health care choices. Health service promotional activities are governed by the Australian Health Practitioner Regulation Agency (AHPRA), which in 2014 published advertising guidelines to protect patients from false or misleading claims and to facilitate informed health care choices. 15 In 2020, the Australian Orthopaedic Association (AOA) published a professional code with specific guidelines for their members. 16 However, little is known about adherence to these guidelines by orthopaedic surgeons in Australia.

The primary objective of our cross‐sectional study was to assess adherence to AHPRA and AOA advertising guidelines by orthopaedic surgeons who advertise their services online. Our secondary objective was to examine factors associated with non‐compliance with these guidelines. We thereby hope to improve awareness of the obligations of clinicians and to inform future guideline enforcement by regulatory bodies.

We undertook a cross‐sectional survey of online advertising during April–August 2020 by orthopaedic surgeons who are AOA members (about 90% of registered orthopaedic surgeons in Australia). The study protocol was prospectively registered with the Open Science Framework ( https://osf.io/67gav ; 20 March 2020). All variations to the registered protocol, implemented before sampling commenced, are listed in the Supporting Information , table 1.

We used two sampling methods that reflect how people access information about orthopaedic surgeons. First, a list of 500 AOA members who have elected to make their details publicly available (about 40% of AOA members) was generated with the “find a surgeon” tool on the AOA website ( https://www.aoa.org.au ). Using the Australian Bureau of Statistics sample size calculator ( https://www.abs.gov.au/websitedbs/d3310114.nsf/home/sample+size+calculator ), we estimated that a sample of 81 orthopaedic surgeons was required for our survey (95% confidence level; confidence interval, ±10 percentage points). Each surgeon was assigned a random number in Excel 16.37 (Microsoft), and advertising material for the 81 surgeons assigned numbers 1–81 was included in our “AOA random sample”; if a surgeon had no online advertising, they were replaced by the next surgeon on the list.

Second, a sample of orthopaedic surgeons was obtained by searching with Google (default search settings) for “orthopaedic surgeon” and the name of the major city in each of the eight Australian states and territories in turn (“AOA Google sample”). The top eight search results for each search, including paid advertisements and sponsored results, were considered for inclusion; only surgeons who were AOA members were included in our sample. If the search result pertained to a group practice, the practice as a whole was included for assessment.

Authors of this article who were involved in data collection were excluded from both samples.

Advertising material: inclusion criteria and assessment

We assessed online items published by or on behalf of an orthopaedic surgeon that were related to the surgeon or their services. The items were typically personal or clinic websites, but we also included online videos, news articles, and social media pages. Sites not generated by the surgeon, such as user‐generated sites, were not included.

Online advertising material was copied and stored electronically. Identifying information (eg, name, practice name, location, state) was removed by a researcher not involved in data extraction for that content. To maximise validity, assessment of compliance was piloted three times by a roundtable of five data collectors, and disagreements and uncertainty regarding compliance were discussed. Other data collection was completed by at least two independent assessors; any disagreements were resolved by discussion, with mediation by a third assessor if necessary. AHPRA website advertising resources 17 were used to clarify “compliance” under the AHPRA guidelines, and members of the AOA advertising subcommittee were available for consultation regarding AOA guidelines.

We used checklists to assess the compliance of de‐identified online material with the five main sections of the AHPRA advertising guidelines 15 and the four main sections of the AOA advertising guidelines 16 ( Box 1 , Box 2 ). Compliance with each section was recorded, and failure to comply with any section of a guideline was deemed to constitute non‐compliance with the guideline.

The primary outcome was non‐compliance of advertising material, by surgeon sample, with the AHPRA and AOA guidelines. The statistical significance of differences between sample types in the proportions of surgeons classified as non‐compliant was assessed in two‐proportion z tests; P  < 0.05 was deemed statistically significant.

In a priori inferential exploratory analyses, we examined associations between levels of AHPRA and AOA non‐compliance and the sample type (AOA random, AOA Google), state of practice, location of practice (regional or metropolitan 18 ), and orthopaedic subspecialty. The number of guideline items not observed by a surgeon was used to score overall non‐compliance, separately for the AHPRA and AOA guidelines. The non‐compliance scores were included as count outcomes in a multivariable exploratory Poisson regression analysis, together with sample type, state, location, and subspecialty as explanatory variables. We report incidence rate ratios (IRRs) with 95% confidence intervals (CIs) for each explanatory variable. Statistical analyses were undertaken in Stata 12.1.

Ethics approval

Formal ethics approval was not required for our study because we analysed de‐identified, publicly available data.

We assessed advertising material for 81 surgeons in the AOA random sample and 59 in the AOA Google sample; four surgeons were included in both samples ( Supporting Information , table 2). The most frequent subspecialty was hip and knee surgery (92 of 140 surgeons, 66%) ( Box 3 ). One surgeon was excluded from the AOA random sample because they were involved in data collection for this study; two surgeons were excluded from the AOA Google sample because they were not AOA members.

Twenty surgeons in the AOA random sample (25%) were fully compliant with both sets of guidelines. Fifty‐two were non‐compliant with the AHPRA guidelines (64%): 39 because of misleading or deceptive advertising (48%), 20 because they cited testimonials (25%), and 33 who aroused unreasonable expectations of benefit (41%). Fifty‐three surgeons were non‐compliant with the AOA guidelines (65%), including 44 who made claims of superior performance (54%) ( Box 4 ).

Seven surgeons in the AOA Google sample (12%) were fully compliant with both sets of guidelines. Forty‐eight were non‐compliant with the AHPRA guidelines (81%): 34 because of misleading or deceptive advertising (58%), 31 because they cited testimonials (53%), and 34 who aroused unreasonable expectations of benefit (58%). Forty‐six surgeons were non‐compliant with the AOA guidelines (78%): 41 who made claims of superior performance (69%), 30 who referred to specific brand names (51%), and 27 who referred to specific brand names but did not state whether they had commercial relationships with the companies (46%). Overall, AHPRA guideline non‐compliance was more frequent in the AOA Google sample than the AOA random sample ( P  = 0.026), but overall non‐compliance with the AOA guideline was similar for the two groups ( P  = 0.11) ( Box 4 ; Supporting Information , table 3).

AHPRA compliance scores were influenced by sample type (AOA Google v AOA random: IRR, 1.37; 95% CI, 1.01–1.87), but AOA compliance scores were not (IRR, 1.09; 95% CI, 0.77–1.55). The incidence of non‐compliance with AHPRA guidelines was lower in Victoria (IRR, 0.60; 95% CI, 0.38–0.93) and higher in South Australia (IRR, 1.60; 95% CI, 1.14–2.25) than in New South Wales. Non‐compliance with the AOA guidelines was more frequent in South Australia (IRR, 2.28; 95% CI, 1.51–3.43), the Northern Territory (IRR, 2.37; 95% CI, 1.37–4.10), and Tasmania (IRR, 1.89; 95% CI, 1.09–3.25) than in NSW. Differences in compliance by geographic location and subspecialty were not statistically significant ( Box 5 ).

We found that many AOA members do not comply with AHPRA and AOA advertising guidelines. Non‐compliance was often characterised by unverified claims of reputation and skill, or misleading representations of the benefits of treatment. We did not investigate the reasons for these breaches, but our findings suggest that surgeons, or those responsible for their online material, either do not fully understand the guidelines or intentionally violate them seeking commercial advantage. 2 Previous studies have found that health information on orthopaedic surgeon websites was of low quality, characterised by exaggeration, subjective information, and no supporting scientific references. 4 , 5 , 6 , 7 Our findings are consistent with these reports, suggesting that poor quality online material is common in orthopaedic medicine. Our study, however, is the first to examine the nature of online information published by orthopaedic surgeons in Australia.

We found that guideline violations were frequent in advertisements for robotic surgery. Promising results regarding the effectiveness of orthopaedic robotic systems, compared with traditional methods, have been reported. 19 , 20 However, systematic reviews have found that differences in patient outcomes are not statistically significant, and their authors have criticised the lack of secure evidence for safety and long term outcomes data. 21 , 22 Installing robotic surgery systems can cost as much as $1 000 000, 23 and these costs are likely to be passed onto patients. The AOA guidelines specifically advise surgeons not to claim that the clinical outcomes of robotic surgery are superior to those of standard surgery, but this advice was breached by 14% of surgeons in the AOA random sample and 29% of the AOA Google sample. Specific robotic systems were advertised with claims of greater accuracy and shorter recovery times, but rarely mentioned their disadvantages or robust evidence for their value. An American study similarly found that 86% of United States hospital websites advertising robotic surgery made claims of clinical superiority. 24

The medical device industry has undoubtedly contributed to improving orthopaedic care. However, many surgeons have financial links with the industry, and this could lead them to prefer certain products and potentially compromise patient care. 25 Surgeons should therefore disclose any financial incentives for choosing the treatments they provide. In our study, 26% of surgeons in the AOA random sample and 51% in the AOA Google sample mentioned specific brands in their advertising; only one clarified that they had no commercial relationship with the company, and only two of all 140 surgeons declared any commercial relationships. In the United States, the level of payments by drug and device manufacturers to orthopaedic surgeons is higher than for all other specialties. 26 Orthopaedic surgeons in Australia may also be exposed to financial incentives, but no relevant data are publicly available.

In our multivariate analysis, violation of AHPRA and AOA guidelines was more frequent in the AOA Google sample than in the AOA random sample. This may indicate more aggressive marketing strategies by surgeons whose advertising does not comply with guidelines. Second, the frequency of non‐compliance differed between states; some instances may have been responses to similar violations by other surgeons in the same location, attempting to maintain competitiveness. Finally, violations were more frequent among hip and knee surgeons, but the difference was not statistically significant. This information may be useful for directing future audits of advertising material by regulatory bodies, and for stimulating discussion and practice change in specific subgroups.

Our findings suggest that audits of practitioner compliance and stricter enforcement of advertising guidelines are needed to improve the quality of information on orthopaedic surgeon websites. This may be supported by the newly proactive approach of AHPRA to advertising compliance, 27 but may also require targeted action by the AOA, including independent audits, providing education for their members, and disciplinary action against members who fail to respond to feedback about their advertising material.

Strengths and limitations

Strengths of our study included our inclusion of the AOA random sample, removing identifying information to reduce measurement bias, prospectively registering the research protocol we had developed by consensus, and having at least two independent assessors evaluate compliance by each surgeon. However, interpretation bias was possible, and the statistical power of our inferential analysis was limited by small subgroup sizes for most categories. Further, subspecialty categorisation was imperfect, as some surgeons work in more than one subspecialty. Our guideline compliance scores may have underestimated the extent of non‐compliance, as we recorded only one instance of non‐compliance when multiple subsections of a guideline were violated. This may have also reduced the statistical power of our regression analysis.

Many AOA members who advertise their services online do not comply with AHPRA and AOA advertising guidelines. Further, surgeons whose websites appear among the top Google search results violated guidelines more frequently than a random sample of AOA members. As patients increasingly rely on online health information, it is important that surgeons recognise that misleading information on their websites can have serious implications for informed patient decisions. Increasing patient demand for specific treatments can lead to inappropriate use of health care resources and adoption of novel technologies of still uncertain efficacy. Our findings suggest surgeons must take greater care with the information they publish online, and that the AHPRA and AOA must undertake further steps to enforce compliance with their advertising guidelines.

Box 1 – Criteria for assessing compliance with the Australian Health Practitioner Regulation Agency (AHPRA) advertising guidelines: prohibited advertising 15

Box 2 – Criteria for assessing compliance with the Australian Orthopaedic Association (AOA) advertising guidelines: prohibited advertising 16

Box 3 – State, geographic location, and subspecialty of the Australian Orthopaedic Association member surgeons included in our study, by sample group

Box 4 – Non‐compliance of Australian Orthopaedic Association member surgeons with Australian Health Practitioner Regulation Agency and Australian Orthopaedic Association advertising guidelines, by sample type

Box 5 – Australian Health Practitioner Regulation Agency (AHPRA) and Australian Orthopaedic Association (AOA) guideline non‐compliance scores: multivariate regression analysis*

Received 16 June 2021, accepted 9 December 2021

Michael Gillespie is president of the Australian Orthopaedic Association. Alexander Burns and Michael Solomon are current members of the Australian Orthopaedic Association Advertising Complaints Subcommittee.

Publication of your online response is subject to the Medical Journal of Australia 's editorial discretion. You will be notified by email within five working days should your response be accepted.

Do you have any competing interests to declare? *


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