Nursing in General Practice: still some way to go
A number of barriers and facilitators to an expanded role for practice nurses have been identified. These include legal and funding issues related to the lack of a system-level model, poor role definition for practice nurses, lack of space available in general practices and GP attitudes. Inter-professional issues, medico-legal concerns and a poorly defined scope of practice need to be addressed while a defined educational and career pathway for practice nursing to attract nurses to general practice is needed.
Practice nursing in Australia
Practice nurses are an integral part of multi-disciplinary primary health care and the Australian Government Department of Health and Ageing’s Nursing in General Practice Program encourages the inclusion of nurses in general practices as part of a flexible approach to delivering integrated health care. This approach in general practice is more than ever relevant given the current health work-force shortages, particularly in rural Australia.1 Measures include nurse-specific Medical Benefits Scheme (MBS) items, Practice Incentive Program (PIP) payments, professional support and training, and further study opportunities.2
These measures are bearing fruit. In 2006-07, Divisions of General Practice reported a total of 7 493 practice nurses, 50% higher than the 4 987 practice nurses reported in 2004-05.3 Over the same two year period, Divisions reported an extra 1 000 practices using practice nurses, from 37% of practices in 2004-05 up to 51% in 2006-07. However this use varies considerably across Australia, with a higher percentage of practice nurses working in rural and remote than in urban settings. The Northern Territory has the highest proportion of practices using practice nurses at 75%.
Benefits, barriers and facilitators
Evidence is emerging about the effects of practice nurses on Australian primary health care provision. Practice nurses are reported to have improved the flow of patients through general practices, reduced patient waiting time and reduced doctors’ workforce pressures.4
However, a number of barriers and facilitators to an expanded role for practice nurses have been identified. These include legal and funding issues related to the lack of a system-level model, poor role definition for practice nurses, lack of space available in general practices and GP attitudes.5,6,7 Inter-professional issues, medico-legal concerns and a poorly defined scope of practice need to be addressed5 while a defined educational and career pathway for practice nursing to attract nurses to general practice is needed.7
A study of roles and the demographic characteristics of practice nurses found similarities with national nurse demographics. Practice nurses reflect an ageing workforce, tend to work part-time and be hospital trained.5 Many of the tasks seen as appropriate for a practice nurse were not being performed by them. The study failed to find a relationship between level of education, clinical experience or rurality of the practice and the tasks performed. Analysis suggested that the practice nurse role is limited by extrinsic factors such as funding models and the political context in which health care is delivered, with the full potential of the practice nurse not being realised.
GP-nurse collaboration (rather than delegation by GP to nurse) and access to education and training contributes to an extended role for practice nurses.7,5 A broader role should include health promotion, preventive health care, health education and participation in an integrated, multi-disciplinary approach to care for the chronically ill and the elderly.6,8
Consumer perceptions of the practice nurse role vary by location. A Queensland study found that consumers were more comfortable with the practice nurse providing traditional services such as wound management and vaccinations than in diagnosing minor illnesses, regardless of their location.9 Despite the distance from other specialist services, patients in remote areas of Queensland were more likely to be uncomfortable with an extended role for practice nurses than those in a metropolitan setting.10 This has implications for the role of nurses in rural Australia where an expanded role is often required by circumstance and highlights the need for wider research into patients’ attitudes and for a public relations approach to this model of health care delivery.
Impact on health outcomes
While practice nurse roles have expanded over the last decade,11 Australia still lags behind the United Kingdom and New Zealand in practice nurse role development.12 There is further potential for the engagement of practice nurses in health care delivery roles to improve specific health outcomes, in line with government priorities.2 Practice nurses may have a role in providing care for patients with Chronic Obstructive Pulmonary Disease (COPD),13 cardiovascular disease14 and asthma.15 A Sydney study found that practice nurses increased early diagnosis of Chronic Obstructive Pulmonary Disease (COPD), finding a significant number of moderately severe cases through contacting at-risk patients and administering spirometry and questionnaires.13 However, a study of nurse run asthma clinics found no clear improvement in health outcomes or patients’ quality of life compared to usual care.15 These asthma studies were varied in design and indicate the need for stronger evidence about health outcomes arising from differ
ent models of care.
There is little Australian evidence on how the employment of practice nurses has affected costs of care. A review of overseas studies reporting on the substitution of doctors by nurses in primary care found that patient health outcomes were similar for care provided by doctors and nurses but that patients were more satisfied with the care provided by nurses, who gave longer consultations and more information to patients.16 There were both increases and decreases in costs. While salary differences between nurses and doctors can lower costs, differences in productivity caused by longer consultations and time spent delivering new services, such as health education, can increase costs in the short term. The possible long term population health advantages and health system cost savings of these practices are not easily measurable.
There is a need for Australian research to further:
- investigate different models of care for an expanded practice nurse role to underpin a consistent national approach
- examine local variations in health outcomes and patient satisfaction arising from an expanded practice nurse role
- consider the likely long term health and economic advantages alongside short term cost differentials of an expanded role for practice nursing in Australia.
Projects to watch
Australian General Practice Nurses Study
This project, funded by the Australian Primary Health Care Research Institute is being conducted by the Australian General Practice Network and the Academic Unit of General Practice, ANU Medical School. The study was due for completion at the end of 2008.
The Divisions network Nursing in General Practice (NiGP) program
A key program under the Australian Government's Nursing in General Practice Training and Support Initiative, this program provides training and professional support for practice nurses.
Practice Nurse Work Survey
The Practice Nurse Work Survey aims to describe the services currently being provided, and the tasks undertaken, by nurses in Australian general practice. It is being conducted by Dr Catherine Joyce of the Department of General Practice, Monash University under a NHMRC Postdoctoral Research Fellowship.
- Australian Government Department of Health and Ageing. (2008). Report on the Audit of Health Workforce in Rural and Regional Australia. Canberra: Commonwealth of Australia.
- Department of Health and Ageing Nursing in General Practice Program. (2008). Department of Health and Ageing Nursing in General Practice Program website.
- Hordacre A-L, Howard S, Moretti C, Kalucy E. (2008). Moving ahead. Report of the 2006-2007 Annual Survey of Divisions of General Practice. Adelaide: Primary Health Care Research & Information Service, Department of General Practice, Flinders University, and Australian Government Department of Health and Ageing.
- Healthcare Management Advisers. (2005). Evaluation of the 2001 Nursing in General Practice Initiative Australian Government Department of Health and Ageing.
- Halcomb EJ, Davidson PM, Salamonson Y, Ollerton R, Griffiths R. (2008). Nurses in Australian general practice: implications for chronic disease management. J Clin Nurs, 17(5A), 6-15.
- Jolly R. (2007). Practice nursing in Australia. Canberra: Social Policy Section, Parliament of Australia.
- Keleher H, Joyce CM, Parker R, Piterman L. (2007). Practice nurses in Australia: current issues and future directions. MJA, 187(108-110).
- Halcomb EJ, Davidson PM. (2006). The Role of Practice Nurses in an Integrated Model of Cardiovascular Disease Management in Australian General Practice. Australian Journal of Primary Health, 12(2), 34-44.
- Hegney D, Eley R, Buikstra E, Rees S, Patterson E. (2006). Consumers' Level of Comfort with an Advanced Practice Role for Registered Nurses in General Practice: A Queensland, Australia, Study. Australian Journal of Primary Health, 12(3), 44-51.
- Hegney D. (2007). Practice nursing in rural Australia. Contemp Nurse, 26(1), 74-82.
- Hall S. (2007). Divisions of General Practice and practice nurse development in Australia. Contemp Nurse., 26(1), 37-47.
- Halcomb E, Davidson P, Yallop J, Griffiths R, Daly J. (2007). Strategic directions for developing the Australian general practice nurse role in cardiovascular disease management. Contemp Nurse., 26(1), 125-135.
- Bunker J, Zwar N, Vagholkar S, Dennis S, Crockett A, Marks G. (2008). A project to assess the effectiveness and feasibility of case finding of Chronic Obstructive Pulmonary Disease (COPD) by practice nurses in general practice. Paper presented at the General Practice and Primary Health Care Conference.
- Halcomb EJ, Davidson PM, Griffiths R, Daly J. (2008). Cardiovascular disease management: time to advance the practice nurse role? Aust Health Rev, 32(1), 44-55.
- Cranston J, Crockett A, Moss J. Pegram R, Stocks N. (2008). Models of chronic disease management in primary care for patients with mild-to-moderate asthma or COPD: a narrative review. Med J Aust 188((8Suppl) S50-2).
- Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald,B. (2004). Substitution of doctors by nurses in primary care Cochrane Database of Systematic Reviews, Issue 4(Art. No.: CD001271. DOI: 10.1002/14651858.CD001271.pub2.).
CITATION: Alfred A, Jackson Bowers E, Kalucy E. (2009). Nursing in General Practice: still some way to go. RESEARCH ROUNDup Issue 4. Adelaide: Primary Health Care Research & Information Service.
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