Research Paper no. 10 2007–08
Practice nursing in Australia
Dr Rhonda
Jolly
Social Policy Section
17 September 2007
Contents
This research paper explores aspects of the
recent development of practice nursing in Australia, particularly
those relating to government initiatives currently in place. The
paper also discusses some of barriers which may inhibit the further
development of practice nursing, and makes some comment on how
these could be addressed in the future.
Changing health needs and increased patient
expectations about health care delivery have led to recognition by
the nursing and medical professions and by government of the
potential to use the services of nurses more effectively to enhance
the delivery of primary care services.
Health care in the future will involve greater
health promotion, chronic disease monitoring and care of older
patients. This situation has led to recognition that general
practice needs to evolve to cope with an increasing complexity in
care. This will involve making more astute use of existing
resources and cultivating innovative use of other health
professionals, particularly practice nurses.
Early development
of a practice nurse specialisation has required a number of
actions:
- promotion of the specialty to nurses, general practitioners and
patients;
- providing incentives to nurses to embrace the specialty as a
legitimate nursing alternative, to general practitioners so that
they recognise the benefits to their practice and to patients so
they see positive health outcomes; and
- education and support for nurses to undertake practice nursing
work.
These tasks have required the cooperation of
the nursing and medical professions. They have also involved
government programs and support.
Barriers remain
for the further development of practice nursing. These barriers at
present limit the extent to which practice nursing is able to
maximise the resources of general practice into the future and to
contribute to better and safer patient care.
|
Introduction
Health workforce shortages have for some time caused
concern in Australia. A number of studies have emphasised an
underlying need to develop a more sustainable and responsive health
workforce, while maintaining a commitment to high quality and safe
health outcomes . [1]
The numbers of
health professionals have increased. However, demographic changes,
such as the ageing of the population and of the various health
workforces, have combined with increasing demands for health
services to escalate the problems associated with shortages.
In attempting to address health workforce
shortages generally and medical workforce shortages in particular,
federal governments have introduced a number of initiatives
including regulatory restrictions and incentive payments. [2] Some of these have
involved programs that encourage development of the practice nurse
specialisation.
The term practice nurse is generally applied
to qualified nurses who are employed by medical general
practices.
General practice nursing has been regarded as
a nursing specialty in the United Kingdom since 1966 and in New
Zealand since 1970. Practice nursing, however, is a relatively new
area of nursing specialisation in Australia.
Practice nursing in Australia traditionally
has been a means through which nurses have been able to accommodate
family commitments by engaging in part time employment which has
not involved shift work. Working in general practice therefore has
been seen as an expediency measure, rather than a career in itself.
Consequently, there has been little acknowledgement of the special
skills nurses need to work in general practice and almost no formal
education to prepare and support nurses in the practice nursing
role in Australia. For some time there was also speculation in
Australia that practice nursing was detrimental to nurses careers
as it was thought that professional competency could possibly be
diminished as a result of working in general practice.
In recent times, these views of practice
nursing have altered. One reason for this is that a combination of
factors, such as shortages in the general practitioner workforce,
rising patient expectations and an increase in the numbers of
elderly and chronic disease patients have combined to put
increasing pressures on the delivery of effective primary care. In
addressing these pressures, innovative solutions for the more
efficient delivery of primary care have been sought. One of these
solutions recognises the potential of nurses working in general
practice to improve and enhance the delivery of services in this
environment.
British research in the late 1990s suggested
that 25 to 70 per cent of the work undertaken by doctors could be
undertaken by nurses, [3] particularly in the areas of health promotion and
routine management of chronic diseases such as asthma, diabetes and
heart disease.
Giving nurses this extended role, according to
British analysis, can deliver many positive outcomes. Overall, it
can enhance the quality of service general practices can provide to
patients. It can also allow for safe substitution of services
previously provided by doctors alone, thus reducing the demand for
doctors. In addition, it is beneficial in terms of cost efficiency,
as nursing services cost less than medical services. [4]
Australian studies have concurred that there
is considerable potential to use practice nursing to improve the
delivery of services in general practice. However, it has been
argued that many issues need to be dealt with in developing
practice nursing to its optimum potential.
Some of these are being addressed. For
example, in moving towards the acceptance of practice nursing as a
specialty in its own right, a documented role description of the
specialisation has been developed in conjunction with competency
standards for the specialty. Other requirements remain in the
developmental phase. These include the provision of formal
education for practice nursing and the establishment of
professional and organisational support for practice nurses.
[5]
There has been considerable cooperation
between government and the medical and nursing professions in
working towards the development of the practice nursing specialty.
There is more to be done, however, to ensure practice nursing
evolves to make greater contributions in the general practice
environment.
United Kingdom
Practice nurses are now considered integral to
the health system in the United Kingdom. However, the specialty
first developed in an ad hoc manner in the 1960s as a reaction to
perceptions that community nursing was not adequately responding to
patients needs. [6]
It was not until National Health Service (NHS)
Reforms were introduced in the 1980s that the specialty developed
substantially, with the numbers of practice nurses rising from an
estimated 1900 in 1984 to over 7,500 by 1990. [7] Introduction of the 1990 NHS
General Practice Contract and subsequent renegotiations of the
Contract have also contributed to the development of practice
nursing and a rise in practice nursing numbers. [8] In 2003, there were approximately
25,000 practice nurses in the United Kingdom. [9]
Jane Broadbent argues that the focus of the
General Practice Contract on health promotion provided a new role
for practice nurses who were employed to undertake tasks rejected
by [general practitioners] and that practice nurses in the United
Kingdom have embraced this role with enthusiasm. [10]
Changes to the NHS in 2004 revealed that a
number of issues, such as pay and working conditions for practice
nurses, still need to be addressed, despite the fact that the
speciality is well established in the British system. [11] Nevertheless, the
various NHS changes have created further opportunities for practice
nursing to evolve. For example, practice nurses are able to become
partners in general practices, thereby taking on a more strategic
role in the delivery of primary care. They are also able to become
sub providers of services, such as sexual health or immunisation
services. [12]
One of the recent
changes to the NHS, however, the extension of nurse prescribing
rights, has met with opposition from the British medical
profession. Prescribing rights for nurses, which were introduced in
2002 for minor injuries, had previously been subject to criticism
but the British Medical Association (BMA) has contested an
extension granted in 2006 of the right to prescribe. [13] The BMA argued it was
not opposed to limited prescribing rights for nurses, as it saw
merit for patient outcomes in these rights, but it believed only
doctors have the necessary diagnostic and prescribing training that
justifies access to the full range of medicines for all conditions
. [14]
Currently, of the
over 6,500 nurses who are registered to the higher level of
prescribing in the United Kingdom under the extended prescribing
rights initiative, most are not engaged in practice nursing. Higher
level prescribing is mainly used by advanced nurse practitioners,
who use this prescribing to augment the care they provide in nurse
led clinics or in outreach work in palliative care. [15]
New Zealand
In 1970, the New Zealand government introduced
a practice nurse subsidy to encourage general practices to employ
nurses. According to one source, this was not initially successful
in that it did not automatically result in practice nurses assuming
greater clinical workloads. [16] However, since 1983, when the government
introduced a funding requirement that nurses undertake specific
clinical duties, practice nursing as a discipline has developed
significantly. As in the United Kingdom, practice nurses are an
integral component of the primary health care system, with New
Zealand general practices employing on average 2.4 practice nurses.
[17]
While the New Zealand Primary Health Care
(PHC) Strategy acknowledges that nurses are crucial to its
successful implementation, in 1998 a Ministerial Taskforce on
Nursing acknowledged that the value of this form of nursing was
still to be realised fully. The Taskforce noted also that
employment status and payment structures, as well as a lack of
consistent standards and attitudinal factors, created barriers to
further expansion of the specialty in New Zealand. [18]
Since that time, a strategic professional
development framework has been put in place and this is supported
by education and accreditation programs. [19] Funding remains contentious in New
Zealand, however, as nursing services are constrained by population
health funding that is linked to general practitioners. It is
argued that general practitioners in turn are reluctant to
relinquish control over general practice. As one observer notes, it
has been difficult for many to separate employee/employer status
from professional status. But supporters of practice nursing insist
this separation must be facilitated to allow the growth of clinical
autonomy of [practice nurses] as they attempt to expand their
current nursing services and meet the challenges put forward by the
PHC Strategy . [20]
One critic of the current situation is
particularly concerned that the issue of power and professional
practice autonomy for practice nurses has not been addressed in a
constructive and mutually respectful way . [21] This critic calls for a move away
from what she sees as an hierarchical health model to a shared
governance model. She considers that this will require recognising
equity of professional roles, ownership of responsibilities by all
staff, accountability for one s practice and commitment to a
partnership philosophy . [22] She sees this as resulting in positive outcomes
improved job satisfaction, higher organisational effectiveness and
better patient satisfaction and health outcomes. [23]
In opposition to this view, another observer
of practice nursing in New Zealand has concluded that despite the
existence of the types of barriers noted above, it appears that the
practice nursing model adopted has made a positive contribution to
the nation s health system. This is because general practitioners
and practice nurses actually work together rather than alongside
each other to deliver new and effective ways of providing care .
[24]
Back to top
The Australian Practice Nurse Association of
Australia defines its members as degree qualified, registered
nurses or certificate qualified, enrolled nurses [25] who are employed by, or whose
services are otherwise retained by general practice.
Nursing categories
Nurses are classified into two broad categories:
- registered nurses (who usually have a degree), and
- enrolled nurses (who usually hold a certificate or advanced
diploma).
Registered nurses make up the majority of all nurses.
Although the level of expertise varies within these groups, in
general, registered nurses perform more complex medical procedures
and hold more responsibility than enrolled nurses. For instance, in
most jurisdictions only registered nurses have the
authorityotherwise retained by general practicesto administer
medications.
There are also other differences between registered and enrolled
nurses. In general, registered nurses are more likely to be
employed in critical or intensive care and less likely in
geriatrics/gerontology; more likely to be employed in acute care
hospitals and less likely in nursing homes; less likely to be
working part-time; and more likely to work in capital cities, than
enrolled nurses. [26]
|
In 2004, a study by the Royal Australian
College of General Practitioners (RACGP) and the Royal College of
Nursing Australia (RCNA) [27] found that general practice nurses in Australia were
usually registered nurses who worked part time in medium to large
general practices. They often worked with other nurses, who could
be either enrolled or registered nurses. They had usually worked in
general practices for less than five years and importantly, they
had little general practice specific education.
The RACGP/RCNA study categorised the work
practice nurses undertook into four different, but overlapping,
responsibilities:
-
clinical care, which involved clinical based
procedures and activities
-
clinical organisation, which involved
activities that required management, coordination and
administration
-
practice administration, which required
providing administrative support to general practice as a business
enterprise and
-
integration, which required development of
effective communication channels within general practices and
between practices and other organisations and individuals.
[28]
Patient demographics of individual general
practices influence the roles practice nurses play within those
practices. The role for a practice nurse in an area with a large
proportion of young families, for example, is most likely to focus
on immunisation and child health issues.
Government initiatives and primary care
funding also influence the roles practice nurses play in the
general practice environment. [29]
As the table below from the Australian
Institute of Health and Welfare (AIHW) shows, in 2003, there were
236,645 nurses employed in nursing in Australia. Of these, 189,071
were registered nurses and 47,574 were enrolled nurses.
Persons employed in nursing in Australia -
2003
|
NSW
|
Vic
|
Qld
|
WA
|
SA
|
Tas
|
ACT
|
NT
|
Australia
|
Enrolled
|
12,625
|
17,446
|
6,245
|
4,183
|
5,180
|
929
|
631
|
335
|
47,574
|
Registered
|
61,855
|
49,089
|
33,218
|
16,800
|
16,703
|
5,425
|
3,189
|
2,792
|
189,071
|
All nurses
|
74,480
|
66,534
|
39,463
|
20,984
|
21,883
|
6,354
|
3,821
|
3,126
|
236,645
|
Rate (per 100,000 population)
|
1,115
|
1,355
|
1,038
|
1,076
|
1,434
|
1,331
|
1,182
|
1,575
|
1,191
|
Source: AIHW [30]
The AIHW has not published statistics on the
number of nurses working in general practice. However, it appears
that practice nurses do not make up a large percentage of nurses. A
National Practice Nurse Workforce Survey Report estimated that in
December 2005, approximately 5,000 practice nurses were
employed in general practice. Eighty two per cent of these were
registered nurses. Consistent with the nursing profession as a
whole, practice nurses were an ageing workforce with 73 per cent
over the age of 40 years. [31]
It appears that practice nurses have been
accepted unequivocally by the Australia medical profession as a
viable tool to augment the services of general practitioners. It
can be argued that one reason for this acceptance is that there is
no current suggestion that the employment of practice nurses will
diminish the role general practitioners play in the delivery of
primary care services. In contrast, the medical profession sees
nurse practitioners (see description below) as a threat; a
profession that could, at least partially, replace general
practitioners.
Nurse Practitioners:
United States
In the United
States, nurse practitioners are defined as registered nurses with
advanced academic and clinical experience. Nurse practitioners are
registered in America to provide some care previously offered only
by general practitioners and in most American states they are able
to prescribe medications, although the actual scope of their
practices can vary in compliance with state regulations.
Nurse practitioners
work mainly in the areas of health maintenance, disease prevention,
counselling and patient education in primary care settings, but
they are also employed in a number of specialties, including
neonatology, nurse-midwifery, paediatrics, school health, family
and adult health, women's health, mental health, home care,
geriatrics and acute care. [32]
Historically, nurse
practitioners have filled the gap in health care delivery to the
underserved segment of the American population. This includes those
living in rural areas, on American Indian reservations and in
poorer inner city areas. More recently, nurse practitioners may be
found in acute care settings, health maintenance organisations and
private practices.
United
Kingdom
Nurse Practitioners
in the United Kingdom are required to be registered nurses who have
undertaken a specific course to acquire skills necessary to be
accepted to practice. The Royal College of Nursing notes that nurse
practitioners offer a complementary source of care to that offered
by medical practitioners. Nurse practitioners also provide care to
people who previously had limited access to health care services
for example, [by] working in remote rural areas working with
homeless people, asylum seekers and refugees, and sex workers .
[33]
Australia
The New South Wales Department of Health describes nurse
practitioners as nurses who provide expert nursing care by working
with a high level of clinical decision making expertise based on
extensive skills and knowledge. Generally in Australia, nurse
practitioners are considered competent to:
- Diagnose and treat acute health problems, such as infections
and minor injuries
- diagnose, treat and monitor chronic diseases such as diabetes
and hypertension
- order, perform and interpret specific diagnostic tests
- possess, supply and prescribe specific formulary medications
and
- refer to, and accept referrals from other health professionals
as necessary. [34]
|
This attitude partially explains a continuing
interest shown by the medical profession in the development of
practice nursing in Australia. Clearly, if doctors are pivotal in
setting standards for education and role model guidelines, it is
unlikely that controversial debates about the scope of nursing
practice, such as those concerning prescribing rights which
recently surfaced in the United Kingdom, will arise. There is no
denying the genuine support for practice nurses amongst the medical
profession in Australia, but it should be acknowledged that this
support is counter to its opposition to alternative practitioners,
particularly nurse practitioners.
In the words of the Australian Medical
Association Council of General Practice (AMACGP):
Accrediting nurses to go out and independently
diagnose, prescribe and refer patients is the wrong way to go.
Independent nurse practitioners cannot and should not replace the
expertise and care provided by [general practitioners]. It would be
consigning patients in areas of workforce need to inferior health
care. The State Governments endorsing independent nurse
practitioners are looking for an easy, and vastly inferior,
solution which is also an irresponsible and dangerous path to
follow.
[35]
Practice nurses on the other hand, fit neatly
into existing cultural perceptions and practices. While the AMACGP
may see nurse practitioners as a threat, practice nurses are
perceived as an integral part of the general practice team.
They
complement and assist the work of the [general
practitioner], not become a substitute for general practitioners.
General practice nurses help doctors see more patients and spend
more time with patients who have chronic or complex illnesses but
they do so as part of the general practice team under the
supervision of a [general practitioner].
[36]
Regardless of this qualification, in the short
time practice nursing has been actively promoted as a viable
profession and as a means to relieve workforce shortages in general
practice, (albeit partially), it has been well accepted by general
practitioners.
Further development of the practice nursing
profession is needed to ensure it will continue to evolve to meet
the requirements of changing health needs and patient groups. A
number of strategies appear to be in place to accommodate this
need. However, a number of issues, such as those surrounding
regulatory and legislative constraints on the tasks practice nurses
can undertake, as well as those relating to long-standing
professional animosities, need to be resolved.
Back to top
In 2001/02 the Australian Government provided
funding to a Nursing in General Practice Initiative (NiGP
Initiative) over a four year period. This program was part of an
overall government strategy to improve access to medical services
for patients in rural Australia. The NiGP Initiative was to
contribute to the strategy by providing financial incentives for
general practitioners to employ practice nurses.
The initial NiGP Initiative consisted of three
components:
-
A practice incentive payment component. Funding
of $86.6 million was available through this component for the
payment of incentives to Practice Incentive Payment (PIP)
[37] eligible general
practices to encourage these practices to employ practice nurses
and/or Aboriginal Health Workers.
-
A training and support component. Funding of
$12.5 million under this component was provided to develop the
practice nurse role and to improve support structures for practice
nursing. Five priority areas were identified under this
component:
-
Informing consumers, nurses and general
practitioners about nursing in general practice and about the NiGP
Initiative
-
improving the capacity of Divisions of
General Practice to support nursing in general practice
-
making training for practice nurses more
available and accessible
-
encouraging nursing networks and mentoring
systems and
- providing an effective evaluation of the Initiative.
-
The third component, a Rural and Remote Nurse
Re-entry and Upskilling Scholarship Scheme was funded with $5.2
million.
The scholarship
component was established to encourage former nurses within rural
and remote Australia to return to the nursing workforce [38] and did not target
practice nurses exclusively.
In 2005,
Healthcare Management Advisors (HMA) was commissioned by the
Australian Government to evaluate the NiGP Initiative. HMA
concluded that the Initiative had been successful in helping to
increase the number of practice nurses employed in general
practices.
The table below
shows the proportion of PIP practices employing practice nurses
under the NiGP by Rural, Remote and Metropolitan Area (RRMA)
classification by quarter from February 2002 to February 2004.
Proportion of PIP practices accessing the
NiGP by RRMA
RRMA
|
Feb-02
|
May-02
|
Aug-02
|
Nov-02
|
Feb-03
|
May-03
|
Aug-03
|
Nov-03
|
Feb-04
|
1
|
26%
|
30%
|
40%
|
45%
|
45%
|
45%
|
43%
|
43%
|
48%
|
2
|
29%
|
43%
|
48%
|
45%
|
52%
|
55%
|
56%
|
59%
|
64%
|
3
|
55%
|
61%
|
65%
|
66%
|
66%
|
69%
|
69%
|
71%
|
71%
|
4
|
62%
|
66%
|
69%
|
69%
|
70%
|
71%
|
74%
|
75%
|
75%
|
5
|
56%
|
60%
|
65%
|
67%
|
68%
|
69%
|
70%
|
73%
|
74%
|
6
|
47%
|
51%
|
62%
|
67%
|
73%
|
71%
|
71%
|
70%
|
72%
|
7
|
47%
|
47%
|
53%
|
52%
|
49%
|
52%
|
52%
|
49%
|
50%
|
Total
|
55%
|
59%
|
64%
|
65%
|
66%
|
68%
|
69%
|
70%
|
71%
|
Source: HMA report [39].
RRMA classification RRMA allocates each
Statistical Local Area (SLA) within capital cities and metropolitan
centres (having a population of 100,000 or more) as metropolitan or
RRMA 1 and 2. Other SLAs are defined as Rural or Remote based on an
index of remoteness. The index is calculated by combining factors
relating to population density and distance. RRMA 7 is the most
remote classification). [40]
HMA found further that the Initiative had
helped to improve the capacity of Divisions of General Practice to
provide support to practice nursing. In addition, employment of
practice nurses under the Initiative had:
-
Improved the throughput of patients in general
practices which employed practice nurses and reduced patient
waiting times
-
given general practitioners more available time
and reduced their workforce pressures
-
provided opportunities for rural general
practitioners to liaise more effectively with other health
professionals about the care of patients and
-
increased patient awareness of practice nurses,
raised their profile and encouraged the idea that they should
receive specific practice nurse education.
[41]
Overall, HMA
concluded that practice nurses made a significant contribution to
the quality, access and affordability of primary health care in
Australia and that other incentives to encourage general practices
to employ practice nurses needed to continue into the future.
[42]
In response to the HMA report, the government
provided funding in the 2005/06 Budget of $129.7 million over an
additional four years to maintain the substance of the NiGP
Initiative. The PIP incentive component of the program received a
further $112.4 million in the Budget and the training and
professional support programs component was funded for $15.6
million.
The scholarship component that had been
previously funded was incorporated into the Australian Rural and
Remote Nurse Scholarship Program.
The PIP component of the NiGP Initiative had
previously been enhanced under the Strengthening Medicare
package in 2003. This package varied eligibility criteria for the
component so that an additional 650 general practices in urban
areas of workforce shortage became eligible to employ practice
nurses. An extra $78.5 million for the component over four years
included $5.5 million for practice nurse training. [43]
In addition, $2.6 million over the same four
year period was provided for practice nurses in regional and rural
areas to receive training to assist them to identify and respond to
domestic violence as part of a $75.7 million Women s Safety
Agenda. [44] General practitioners also received assistance to
release the practice nurses they employed for this training.
In 2004, also as part of Strengthening
Medicare, the Australian Government introduced Medical
Benefits Schedule (MBS) items for practice nurses who provide
immunisations and wound care on behalf of general practitioners.
Doctors retained responsibility for the provision of these
services, however, and patients were entitled to request that the
services were performed by general practitioners.
In January 2005, a further MBS item for
practice nurses who undertook pap smears on behalf of doctors in
rural areas was introduced. This was extended to urban areas in
November 2006. [45]
In July 2005, Chronic Disease Management items
which involved practice nursing were introduced. [46] These items allow general
practitioners to be assisted by practice nurses in developing and
maintaining GP Management Plans. Under these plans, patients
illnesses are assessed, goals for management of conditions are
agreed and patient actions, treatment and services to be provided
are identified. [47]
From November 2006, a Medicare rebate for
antenatal care delivered by midwives, nurses and registered
Aboriginal health workers in rural areas on behalf of general
practitioners or specialists was also made available. This item
does not include delivery or the management of labour and does not
replace antenatal care that may be considered more appropriately
provided by a medical practitioner. [48]
Over seven million services have been
delivered by practice nurses since the introduction of these items.
These include more than four million immunisations and two million
wound management services. [49]
Clearly, if practice nursing is to continue to
contribute to better health outcomes, it is important that the
government recognition and support the specialty has received
through the NiCP Initiative is supplemented and continued. It is
equally important in ensuring a holistic development of practice
nursing that practice nurses are aware of the skills they require
and that they are confident they can obtain those skills. So too,
it is important that professional, long term support mechanisms are
in place to sustain, guide and inform practice nurses and other
professionals with whom they work.
In achieving these aims for a future practice
nursing workforce, in 2005 the RCNA developed national competency
standards under a project funded by the Department of Health and
Ageing. The RCNA has argued that standards are an important
framework to assist nurses to assess their practice and
guide their professional development. The standards are not a stand
alone set of competencies, they are intended to be used in
conjunction with other core competency standards developed by the
Australian Nursing and Midwifery Council and endorsed by nurse
regulatory authorities in each state and territory. [50]
There are two sets of competency standards now
in place one for registered nurses; the other for enrolled nurses.
[51]
The competency standards for registered nurses
emphasise the need for practice nurses to operate in accordance
with nursing and general practice codes and guidelines and with
regulatory and legislative requirements. In addition, amongst other
things they require practice nurses to improve and maintain their
nursing skills, work cooperatively within general practice teams
and strive always to deliver optimal patient care. [52]
The standards for enrolled nurses are similar
to those of registered nurses but with some provisos in accordance
with supervisory requirements placed on these nurses by various
nurse regulatory bodies.
An interpretive
toolkit has also been developed to accompany the nursing standards
to assist nurses, general practitioners and training providers. The
toolkit provides nurses with a self assessment tool, a sample
professional development plan and resources to help use the
competency standards. It provides general practitioners with sample
job descriptions and assistance to review the scope of nursing
practice for nurses they employ. [53]
A guide for nurses
and general practitioners was developed in 2001. It defines roles
and responsibilities for practice nurses and provides information
on other aspects of practice nursing, including information on
legislative and regulatory requirements. [54] The guide emphasises the positive
health outcomes for general practices from employing practice
nurses. It notes not only the improved quality of care that can be
gained, but also that practice nurses provide an opportunity to
institute a multi disciplinary approach in general practice which
can enable practices to increase services to the community, through
targeted or condition specific clinics for example. Additionally,
the guide points out that employment of practice nurses can be used
as an additional incentive when recruiting new general
practitioners to practices. [55]
A key
representative body for practice nurses was established in 2001.
This body, the Australian Practice Nurses Association (APNA)
provides representation, support and networks at local, state and
national levels for nurses in general practice. The APNA currently
has over 1100 members. [56]
The APNA vision for the development of
practice nursing is for practice nurses to be recognised as
professional members of collaborative teams and for these nurses to
be seen as playing a key role in management of patient health. At
the same time, the APNA is concerned that practice nurses are
appropriately remunerated and that they have a voice in determining
health policy. [57]
The following table
from the APNA website highlights the aims of the APNA and the
strategies it is undertaking to achieve its vision for practice
nursing.
Australian Practice Nurse Association
objectives and strategies for practice nursing
Objectives
|
Strategies
|
Supporting members to be recognised
|
Increase
support for general practice nurse research
|
Increase
APNA and practice nurse profile
|
Encourage and undertake effective policy development and
representation
|
Supporting members to be professional
|
Develop
and provide Continuing Professional Development
|
Provide
professional indemnity insurance
|
Provide
high quality, accessible and affordable education
|
Supporting members to become empowered
|
Support
development and maintenance of local branch Networks
|
Provide
information and support business acumen development
|
Advocate
effectively on behalf of members
|
Source: APNA [58]
APNA began an online learning service for
practice nurses in November 2006. The service delivers a range of
training from short courses to formal qualifications in areas
specific to the general practice clinical and business environment.
[59]
Mentoring in practice nursing has been seen as
important in developing the discipline due to the isolated nature
of the nursing professional experience in this speciality. In
examining possibilities for mentoring, researchers from the
University of South Australia found there were challenges in
establishing effective mentoring. These stem not only from the
fragmentation of the sector, but also from variation in size and
structure of practices and the diversity in nursing roles in
general practice. [60] The researchers concluded that appropriate resourcing
and infrastructure needed to be in place to deal with personal
development issues, professional relationship management and
overall learning to assist nurses to work in the general practice
environment.
A National Mentoring Framework has been
developed from the University of South Australia research that
identifies existing mentoring mechanisms and suggests options for
addressing future needs in practice nursing.
The ADGP has been particularly active in
promoting the employment of practice nurses amongst its members. It
has also worked in cooperation with state divisions of general
practice to this end. In 2003, the ADGP developed a series of
business case models to assist general practices in assessing the
benefits and implications of employing practice nurses. [61]
It also supervised a demonstration project
involving a series of workshops and the development of a resource
kit. The kit cited various models for employment of practice nurses
and documented barriers employers may encounter in employing these
nurses. [62]
In addition, the ADGP introduced a position of
Principal Policy Advisor on Nursing in General Practice. This
position was intended to foster the development of effective
linkages with practice nurse coordinators within Divisions, promote
nursing in general practice and provide strategic policy advice.
[63]
Divisions have also worked cooperatively to
promote the NiGP Initiative and to develop a national approach and
consistent standards that can be applied by general practitioners
to the employment of practice nurses.
It is expected that by 2009, the NiGP
Initiative and the work done by the ADGP and state based
organisations will have contributed significantly to the employment
of more practice nurses. [64]
Back to top
As noted earlier in this paper, development of
clear educational pathways and support mechanisms has been
recognised for some time overseas, and more recently in Australia,
as essential in ensuring that practice nurses are able to continue
to enhance the quality of care delivered in a general practice
setting. [65]
All indications are also that practice nurses
will be required to possess broader clinical knowledge and other
skills to cope with the types of activities they may be called upon
to deal with in general practice in the future. So the reality of
practice nurses currently not being prepared to meet the knowledge
requirements of the nurse working in the general practice team of
the future [66]
needs to be addressed as a priority in the ongoing development of
this nursing specialty.
The norm has been however, that general
practice specific clinical education for practice nurses has
traditionally been obtained on the job . While there have been some
clinical educational programs available to assist practice nurses
to improve clinical care skills, many of these have not been
accredited or evaluated. This situation is gradually changing with
the introduction of short and targeted accredited courses, in the
manner of those offered by the APNA.
Likewise, formal tertiary clinical education
initiatives, such as those supported by the ADGP and other
divisions of general practice, have been introduced to encourage
nurses to view practice nursing as a viable career option. The
University of the Sunshine Coast and the Sunshine Coast Division of
General Practice for example have developed graduate certificates
in general practice nursing. [67] Other Universities also offer practice nursing
courses or practice nursing units in the context of postgraduate
courses. [68] Such
programs are formally assessed. [69] Importantly, the Australian Government has begun
to recognise the value of these courses and has provided
scholarship assistance. [70]
In conjunction with these types of programs,
it has been argued that education for practice nurses needs to
involve a nationally consistent education system in specific areas
to ensure that general practice needs in wound care, first aid/CPR,
oxygen administration, pharmacology administration and pathology
collection education are fulfilled. [71] It could be argued further that such
specific training in conjunction with nationally consistent
standards is vital, given the expanded role for practice nurses,
which has resulted from the introduction of Medicare items in
immunisation and wound management. [72]
Additionally, some overseas research has
suggested that increasing the exposure of student nurses to nursing
in general practice through structured practice placements would
complement formalised education. [73]
Overseas studies have found that despite the
existence of formalised training for practice nurses, other
educational barriers persist. These include access to study leave,
protected learning time and funding for continuing education.
[74] These need
also to be addressed.
In terms of administration, as the RACGP/RCNA
Report has noted, some practice nurses have qualifications in areas
outside nursing which assist them in this aspect of their work.
However, as with clinical skills, it has been usual that most
practice nurses acquired their expertise in administration,
integration and other activities incidentally. The RACGP/RCNA
Report acknowledges that it is unreasonable to expect undergraduate
education to prepare all nurses for a general practice role in
population health or health promotion. [75] But at the same time, it seems
reasonably clear that these are essential qualifications for
practice nurses.
This lack of specific skills is, to some
extent, being addressed. The University of New England, for
example, has introduced a nurse leadership program which aims to
develop the leadership skills of practice nurses to enable their
effective involvement in the planning and delivery of primary care
services and the development of their profession.
More needs to be done to refine practice nurse
training. The framework noted by the RACGP/RCNA clearly indicates
the complexity of this task. The Report concludes, as is also noted
throughout this paper, that practice nursing needs to be general
practice specific and that it needs to be offered as a career
option. It iterates also that practice nursing education for the
future should promote clinical and theoretical competence through
appropriate standards of assessment. [76]
Importantly, the Report argues that education
for practice nurses needs to be sustained by general practice
itself, and as such, practices need to be assisted to ensure the
right education systems are in place for practice nurses. [77]
In terms of continuing education also it may
be that a variant of the system that has existed since 1989 as a
requirement for vocational registration [78] of general practitioners could be
considered for practice nurses. General practitioners can receive
Continuing Professional Development (CPD) points for attending
workshops, seminars, presentations and short courses as well as for
the completion of more rigorous academic courses and clinical
education modules. [79]
Currently, the APNA promotes a voluntary CPD
program. The program assists practice nurses in identifying,
completing and recording job specific learning. There is currently
no CPD national registration requirement for nurses as there is for
general practitioners, but the APNA notes that states and
territories are gradually moving towards this option. [80]
An alternative nursing variant of CPD points
could possibly be linked to an incentive payment for nurses, rather
than to registration (see reference later in this paper to nursing
remuneration issues).
For practice nurses to become an unquestioned
and integral part of the general practice environment, patients
need to understand that nurses are autonomous qualified health
professionals.
In 2002, a University of South Australia study
found that patients were largely unaware of the role nurses played,
or could play in general practice. Patients understandings of the
role for nurses in this setting was particularly informed by their
view of general practice as sickness care a system they accessed
when they needed a specific service for their ill health or injury
rather than a system for preventative health care . [81]
Consequently, patients perceived nurses as
competent employees of general practitioners, not as medical
professionals in their own right. Patients were generally unaware
of the various levels of nursing qualifications, registration or
specialities. [82]
They expressed concern that nurses may act as gatekeepers who took
away consumer choice by preventing access to general practitioners
and they did not want nurses to substitute for doctors in
undertaking diagnosis. They were firmly of the view that the use of
nursing services in general practice should not increase costs to
consumers. [83]
In effect, the South Australian study
emphasised that patients needed to be informed about the practice
nurse role, the wellness benefits practice nurses can deliver in
health promotion and the chronic disease management role they can
play for an increasing number of people.
The University of South Australia study
recommended a number of strategies to begin to achieve these gaols,
including general practitioners brokering of attitudinal change
with regard to the contribution practice nurses can make to
enhanced primary care.
It appears the NiGP Initiative has made some
contribution to changing these attitudes. As noted elsewhere in
this paper, the Initiative has raised the profile of practice
nurses and demonstrated the potential that this profession has to
improve patient outcomes. But consumer education most likely needs
to be ongoing and more innovative as the role of practice nursing
expands in the future.
A General Practice Nurses Study commenced in
2005. The study is being undertaken collaboratively by the
Australian Divisions of General Practice and the Australian
National University with funding from the Australian Primary Health
Care Research Institute. The study will spend three years examining
the roles of nurses in general practice. Researchers expect the
study will deliver a better understanding of the processes and work
practices of general practice nurses.
The study will consider local, individual and
structural factors that influence the work of practice nurses. It
intends also to examine the ways in which practice nurses
contribute to the overall safety and quality of general practice
services . [84]
Ultimately, it is expected the study will suggest new models for
practice nursing.
In addition, other studies have been funded
under the National Competitive Grants Scheme to explore the
potential of expanded roles for nurses in general practice. These
include a grant to the University of Queensland over three years
from 2007 to consider the feasibility, acceptability and cost
effectiveness of nurse led models of chronic disease management in
general practice. [85] Findings from such studies may also result in the
emergence of new models for practice nursing generally.
The RACGP/ACNA study undertaken in 2004
identified a number of issues it believed impacted significantly on
nursing in general practice. Some of these, such as the issue of
recognition of practice nursing as a distinct specialisation, are
now beginning to be addressed. Others remain problematic.
How the health system should accommodate a
greater role for nursing in general practice is one such issue. As
noted earlier in this paper, changing demographics and the
emergence of additional demands on the health system in recent
times have affected the delivery of health services generally. In
primary care for instance, there has been a shift away from
treating illness to adopting preventative health and health
promotion strategies. There are multiple intentions and aims in
this focus shift. These include the intention to produce better
health outcomes for an ageing population and delay and reduce
healthcare costs in secondary and tertiary medical care.
Adopting a more preventative focus has
inevitably changed the nature of general practice, however. For
nurses, this has meant greater opportunities to vary the work they
undertake, but at the same time it has increased their workload. In
conjunction with the change in emphasis, improvements in technology
have also meant that potentially, nurses can expand the tasks they
undertake in general practice even further. At the same time,
technological change has brought with it the need for nurses to
gain more skills and sophisticated understandings of illnesses and
treatments.
This has occurred in an environment where the
nursing workforce is ageing. [86] Consequently, there are questions about whether
there will be sufficient numbers of nurses in the short term to
undertake enhanced roles that may be envisaged for them, regardless
of whether these will be in practice nursing or other specialties.
In the longer term, the situation may be equally problematic. This
is despite recent government commitments to funding considerable
increases in nursing training places. [87] Issues such as overall retention and
job satisfaction in the nursing profession in general remain
unresolved. Solutions will need to be found to ensure that the
numbers of nurses will meet expected demand for their services.
Retention and job satisfaction are related
factors. Nurses leave the nursing profession for a number of
reasons. Perhaps the most reported of these is that they consider
their rates of pay low in comparison with other health
professionals and in relation to the skill levels nursing demands.
[88] It is not
within the scope of this paper to discuss remuneration or job
satisfaction for nurses in detail. It is, however, important to
note that the issue of remuneration is intimately linked to
perceptions about skills requirement and acquisition. Given that
the need for greater skills for nurses and the ability to acquire
them quickly to cope with technological advances will increase in
the future, it is possible the nursing profession s dissatisfaction
over rates of pay will also intensify. [89]
There are other reasons which nurses cite for
not continuing in the nursing profession that are perhaps as
important as remuneration. A number of surveys have indicated that
a lack of career path for experienced nurses, overwork, staff
shortages, frustration, physical and emotional exhaustion and
perceptions that their work is undervalued and unappreciated and
that they are not respected by doctors, may contribute more to
attrition than pay. [90]
It is likely that practice nurses also
experience similar situations or reach similar conclusions as
nurses in general. It may be argued that because of a lack of clear
definition about what the practice nurse role encompasses, that
these nurses may be more frustrated. Further, issues such as
undervaluation of the work nurses perform in general practice due
to the lack of definition regarding what constitutes and/or should
constitute supervision, may even be more problematic for practice
nurses.
Indeed, it can be argued that the issues of
retention and dissatisfaction may be compounded for practice
nursing by the employer/employee relationship that currently
dominates in general practice. In this vein, the National
Association of Independent Nurses in Britain claims that
encouraging more nurses to act as contractors rather than employees
will not only lead to substantial increases in income and
professional autonomy, but it will help in the recognition of
nursing as a true profession . [91]
Some efforts have been made to address the
shortage of nurses. The Australian Government has increased
undergraduate nursing places significantly in recent times. Its
latest commitment of over 1000 new nursing places under the Backing
Australia s Future [92] program was made in July 2006, with the first of these
students commencing study in 2007. [93]
In addition, the government has introduced
scholarships and programs to encourage nurses who have left the
profession to return, as well as scholarships for undergraduate
nursing studies. These include the Commonwealth Undergraduate Rural
and Remote Nursing Scholarship Scheme [94] for undergraduates and the NiGP
Initiative re entry scholarship [95] noted earlier in this paper.
While these initiatives have the potential to
increase the numbers of nurses per se, there are few
specific initiatives aimed at encouraging nurses to enter practice
nursing or to return to nursing in a practice nursing role.
However, because of the nature of practice nursing, there may be
opportunities which have yet to be explored to encourage nurses who
have moved to other jobs in the health sector, such as health
education, sales of medical equipment and supplies or clinical
research to return to practice nursing.
The following table illustrates the
considerable number of nurses working in other professions.
Labour Force Status of Females (A) with
Nursing Qualifications (B) - 2001
Females
%
|
Employed
|
83.5
|
Nursing
professional
|
61.3
|
Other
occupation
|
22.3
|
Unemployed
|
1.0
|
Not in
the labour force
|
15.5
|
Total
|
100.0
|
'000
|
Total
|
183.4
|
%
|
Unemployment rate
|
1.2
|
(a) Aged
15-64 years.
(b) Bachelor degree or higher in a nursing field.
|
Source: ABS Study of Education and Training 2001
[96]
The nursing workforce situation illustrates
the need for more far-sighted thinking about how the health system
generally will cope with change into the future. Carol Gaston cites
the example of the health system currently under stress because of
its continued dependence on acute hospitals to service health care
needs. Despite this situation the growth in chronic disease
requires that structures are in place in the community to enable
the management of chronic conditions at a local level. This means
changing the profile and role of some hospitals to provide for a
networked hierarchy of services as well as redeveloping other
hospitals to provide for short term stays and community
rehabilitation. [97] Gaston concludes that:
Making these changes will take time and will
require strong leadership to lead a change management process.
Leaders across the health system will need to make a commitment to
a better way of doing business, have the courage to challenge
existing power bases and norms, and be willing to take the
initiative to go beyond defined boundaries.
[98]
Papers presented at the National Health Reform
Summit in July 2007 make similar points. [99] New primary health care models will
need to be developed that address the social determinants of health
and operate within the context of wider population health needs.
From an overall health workforce perspective, the Summit papers
conclude this must entail a whole of government approach not only
for nurses, but for all health professionals. As one paper
observes:
The way the health workforce is educated,
regulated and works is inextricably linked to the way health care
is funded and provided and effective workforce planning can only be
achieved if structural changes are made by government.
[100]
Legislative and regulatory issues in relation
to the actual and potential role and scope of practice nursing may
be an issue for the future.
To date, however, in spite of the reality that
states and territories have different legislation governing the
administration of medicine, little consideration has been given to
how legislative requirements affect the practice nurse specialty.
[101] For
example, in Tasmania, nurses need to be registered as nurse
immunisers to provide immunisations under the supervision of a
general practitioner. [102] In Queensland, appropriately trained and registered
nurses are considered nurse immunisers and are able to provide
immunisations in accordance with certain protocols. [103] In the Australian
Capital Territory (ACT) nurses are able to provide immunisations
under a standing order that is signed by the Medical Director of
the ACT Population Health Unit. [104] Clearly, such diverse regulations
can have implications for the scope of practice for nurses working
in different jurisdictions.
More controversial than the administration of
medicines is perhaps the issue of prescribing rights. Currently,
nurse practitioners are entitled to prescribing rights in the
states and territories, although these vary in degree (see the
table below), but there have been calls for all nurses to be given
these rights in certain circumstances. The final report of the
Victorian Nurse Practitioner project [105] argues that granting prescribing
rights to nurse practitioners has improved patient care. In
addition, it has fostered relationships between patients and nurses
and within the health delivery team. As a bonus, the project report
considers nurse prescribing has the potential to reduce health
costs.
There are a number of sources which support
prescribing rights for nurse practitioners. [106] Further, the National Nursing
and Nursing Education Taskforce suggests that some form of
prescribing could be explored for use by registered nurses working
in areas like chronic disease management, mental health or primary
care
The idea of practice nurses gaining some form
of independence in prescribing is unlikely to be supported by the
Australian Medical Association (AMA) for similar reasons as those
advanced by its counterpart in the United Kingdom and noted earlier
in this paper nurses do not have the necessary expertise to
prescribe, and to grant them such rights would be detrimental to
patient care.
Further, many doctors consider prescribing
rights in the context of a debate about task substitution, which,
in turn, they see as a threat to the medical profession. The AMA
argues that research has indicated that when Australians are sick,
they want to see a doctor, not a lesser professional. [107] It considers that
task substitution produces a competitive regimen of overlapping
clinical roles and calls for reforms to the health system that
synergise the different skills of doctors, nurses and other health
professionals . [108] The AMA cites government funding to assist general
practitioners to employ practice nurses as an example noting:
General practitioners foresaw how this [practice
nurse incentives] could help them meet the needs of their patients.
The AMA lobbied for the program. Now it is GPs who are making sure
that the program is effective, delivering good outcomes for
patients at a modest cost for taxpayers.
[109]
Numerous overseas studies have found that
patients approve of, and readily accept task substitution and nurse
prescribing. Nurse prescribing has been seen by some commentators
as improving outcomes for patients by promoting people-centredness,
quality of care and accountability . [110] Additionally, it has been argued
that not only does it increase the competency of nurses, but it
also delivers benefits to primary care teams, fostering better
communication and sharing of information. [111] Supplementary arguments are that
nurse prescribing:
often leads to more timely interventions, hence
preventing the exacerbation of symptoms, and usually provides
easier supervision of chronic conditions and that nurse prescribing
promotes the maximization of resources by making the best use of
skill mix of the workforce. It also leads to less wastage as
patients are seen and reviewed more regularly.
[112]
The following diagram illustrates the various
nurse prescribing/medicine initiating regimes in force in
Australia.

Source: Source: The National Nursing and Nursing
Education Taskforce (See Appendix A for explanation of prescribing
terminology)[113]
Despite this type of evidence and while it is
supportive of practice nursing, the AMA does not share a view which
has been recently advanced by the Productivity Commission that
there is a potential to improve health outcomes by reconsidering
what are appropriate mixes of competencies and by job redesign and
substitution. [114]
The AMA argues
that such proposals will not achieve efficiencies and may
potentially affect safety and levels of care. It argues instead for
a team work approach to health care where the doctor continues to
be the natural and appropriate leader of the team and against what
it calls a competitive regimen of overlapping clinical roles .
[115]
But this argument
is not proven and it could in fact be accused of protecting
traditional professional boundaries. As the Productivity Commission
has suggested and what others have more enthusiastically advocated,
is that health workforce planning should be more flexible. It
should not simply be concerned with planning for numbers of a
specific type of practitioner; it should instead focus on planning
the mix of skills to provide adequate health services. [116]
It appears that general practitioner concerns
about medical indemnity may have delayed the development of
practice nursing in Australia. Watts et al argue that general
practitioners were initially fearful about the legal consequences
of actions and professional indemnity [and this overshadowed] their
consideration of the contribution nurses can make to general
practice health care . [117]
In 2006, in an assessment of medical
indemnity, the Medical Indemnity Policy Review Panel also
considered the introduction of practice nurse Medicare items had
brought uncertainty into medical indemnity coverage for doctors and
medical practices. The Panel recommended that investigation of the
issue was undertaken to find solutions. [118]
Since that time, guidelines have been produced
which describe the various responsibilities of employers and
employees. The RCNA guide to nursing in general practice for
example notes that if a patient is harmed as a result of negligence
or omission by a practice nurse in a general practice setting,
legal responsibility depends on whether the nurse is an employee of
a practice or an independent contractor. [119]
If a nurse is an employee, the employer is
legally liable. It is possible, however, for an employer to seek to
recover costs or for patients to sue both the nurse and the
employer. On the other hand, a nurse contractor bears
responsibility for negligence, but an employer could also face
legal proceedings if it could be proven that the nurse s negligence
was the result of a general practitioner s negligence.
The RCNA guide stresses that it is critical in
addressing indemnity concerns that practice nurses and general
practitioners identify, agree upon and monitor the issues that
govern the rights, roles and responsibilities of nurses in
particular practice settings. Nurses and general practitioners
should have a shared and accurate understanding of the scope and
availability of insurance coverage and the extent to which it
provides appropriate protection for the nurse. [120]
The RCNA guide warns that:
Under no circumstances should either a general
practitioner or nurse working in general practice assume that
everybody and everything will inevitably be covered under the usual
insurance arrangements that predated the introduction of the nurse
into the practice.
[121]
It appears the issue of medical indemnity has
been resolved for the time being by the provision of advice such as
that provided by the RCNA. If prescribing rights for nurses in
general practice were to be extended in the future, however, it is
likely that similar concerns about what the individual liabilities
of general practitioners and practice nurses may resurface.
In recent times there has been considerable
promotion of the concept of a health team in general practice and
an accompanying acknowledgment of the valued roles nurses, (and
allied health workers), play in such teams. But at the same time,
there continues to be discussion about whether general
practitioners have abandoned long standing notions that nurses
should be subservient to doctors and that the role of nurses is
that of hand maiden to doctors, rather than cooperative
professionals, on an equal footing with doctors in some areas .
[122] The fact
that general practitioners are generally in an employer/employee
relationship with practice nurses, may possibly exacerbate or
perpetuate perceived or actual historical antagonisms.
If such a cultural situation is indeed the
case, moves towards a more collaborative model of general practice
teams in which nursing is seen as a profession complementary to
medicine, not primarily subservient to it, will necessarily involve
shifts in values, beliefs and attitudes that may linger in the
general practice environment.
The fact that so many general practitioners
now employ practice nurses indicates that practice nursing is
increasingly valued by the medical profession and that if remnants
of the hand maiden perception persist, they are being challenged. A
report in Australian Medicine indicates also that the
medical profession has embraced the concept of general practice
teams and health professionals working together cooperatively.
[123]
At the same time however, it can be argued
that practice nursing can not enjoy the success it has experienced
in the United Kingdom and New Zealand unless a more sophisticated
general practice team environment is nurtured into the future.
While consumers see nurses and general practitioners as a team,
[124] it appears
that this perception needs to become more obvious to the
professions themselves. At present there are limited opportunities
available for nurses and general practitioners to learn to work
together. These need to be explored and ways found to incorporate
stronger cooperative experiences into all stages of training for
doctors and nurses and into professional interactions.
It may be argued also (as noted earlier in
this paper) that the current notions of teams as solely general
practitioner centric may need to be re evaluated in light of an
increased emphasis on health prevention and chronic disease
management. [125]
A related issue to professional recognition is
that of funding for general practice nursing services under
Medicare. It can be argued that the effectiveness of general
practice nurses is impeded by the current Medicare payment system
under which nursing duties do not attract a payment unless through
a fee for service system. The RACGP/RCNA Report notes that the
health professions consider the current system hinders the adoption
of a more collaborative approach because it devalues the nursing
role. [126] Under
the current funding regime, activities which nurses routinely
perform without review by a doctor in other health care settings
must be reviewed by a general practitioner to obtain a payment in
the general practice setting. The RACGP/RCNA Report concludes that
these types of arrangements need to be reviewed and reconsidered if
general practice nursing is to be sustainable in the long term.
[127]
Back to top
Health workforce shortages persist in
Australia. These shortages, combined with an ageing population and
a greater incidence of chronic disease, have meant that there is an
increasing need to rethink ways in which health care in general
practice can be delivered more effectively and efficiently.
One response to the current situation,
improving the capacity of general practice to respond to the
changing health environment by making more use of the services of
nurses, has only recently been seriously promoted. International
studies have indicated that better use of the services of nurses
can bring a number of benefits to general practice. These include:
improved health outcomes in chronic disease, assistance in primary
acute care integration, better coordination of care, increased
workforce capacity, the provision of practical and professional
support to general practitioners and enhancement in the range of
services available to people attending general practice.
Review of research into the substitutability
of nurses for doctors has also suggested that nurses could assume
up to 70 per cent of the work currently undertaken by doctors and
that this could enhance the quality of primary care services.
In 2005, approximately 58 per cent of
Australian general practices employed practice nurses. [128] A number of
initiatives have been put in place to help raise this figure. These
initiatives have involved providing education and information to
general practitioners about the benefits of employing practice
nurses. They have also involved providing assistance to nurses to
encourage them to regard practice nursing as a legitimate
profession and to assist them to develop and maintain specific
practice nursing skills.
These strategies will help to develop practice
nursing as one of a number of viable solutions which could be
employed in the future as a broader range of patient services is
increasingly needed. Nurses in general practice are likely to be
called on increasingly to undertake a greater range of functions in
general practice which may contribute to the delivery of better
quality and safer patient care.
But there remain obstacles to be overcome if
practice nursing is to fulfil its promise. These include addressing
regulatory and other barriers which may either discourage general
practitioners to employ practice nurses or may prevent practice
nurses from fulfilling their potential as health professionals.
These are undoubtedly vexing issues which have consistently raised
concerns about appropriate roles and debates about the merits of
task substitution within the important context of improving patient
care and responding to a changing health environment.
These issues in turn are tied to a more
fundamental issue: How governments can work more productively with
the health professions to find ways to improve the capabilities of
the health system to respond to changing environments and workforce
needs. This clearly involves strategic, long-term workforce
planning. This planning needs to ensure that the overall supply of
medical practitioners and nurses is adequate, not only to meet the
general needs of the population, but also that these practitioners
are trained to meet the specific needs of an ageing population.
There is likely to be little benefit in increasing the numbers of
practice nurses for example if this simply exacerbates nursing
shortages elsewhere.
It is essential that government plays a
central role in this planning by introducing, maintaining and
coordinating short and longer term strategies that balance patient
and workforce needs. Introducing strategies to encourage nurses
employed in administrative roles to return to practice nursing, for
example, may produce short term workforce gains, but this type of
policy alone will not address longer term workforce needs. Longer
term strategies need to build on current policies which have begun
to enhance the profile of practice nursing and to provide better
support for specific practice nursing education. Similarly, these
strategies will not ultimately succeed unless they are part of
broader plan to increase nursing and general practitioner numbers
to accommodate the changed work patterns and expectations of health
workers.
Consequently, it is equally essential that
both the medical and nursing professions contribute to a continuing
planning process, that government encourages this participation and
that the professions abandon traditional ideas about role models
and attitudes. Greater strategic government involvement may
encourage conscious review of any antagonistic cultural ideas about
the role and contribution nurses can, and should make in the future
general practice environment. This involvement may help to resolve
issues in relation to the funding of services nurses provide in
general practice as well as promote more constructive and
cooperative dialogue about seemingly contentious matters, such as
limited prescribing rights.
At the same time, this constructive dialogue
needs to be in the context of a comprehensive whole of government
and stakeholder approach which seeks to transform the health system
to account for and accommodate changing demographics and health
needs identified in this paper.
Appendix A


Back to top
Endnotes
[2]. Regulations were introduced in 1996 under the
Health Insurance Act 1973 which generally restrict access
to Medicare for services provided to those medical practitioners
with post graduate qualifications. Incentive schemes include the
More Doctors for Outer Metropolitan Areas Measure.
[3]. M.Richardson, Identifying, evaluating and implementing
cost-effective skill mix , Journal of Nurse Management 5,
1999, pp.265-270. Quoted in M. Laurent, D. Reeves, R. Hermens,
J. Braspenning, R. Grol and B. Sibbald, Substitution of
doctors by nurses in primary care , Cochrane Database of
Systemic Reviews, 2004, Issue 4
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001271/frame.html
accessed 27 March 2007.
[6]. K. Aitkin and N. Lunt, Nursing in practice: The
role of the practice nurse in primary health care, Social
Policy Research Unit, University of York, 1995. Cited by E.
Halcomb, P. Davidson, J. Daly, R. Griffiths, J. Yallop and G.
Tofler, Nursing in Australian general practice; directions and
perspectives , Australian Health Review, Vol 29, No 2, May
2005, p.157.
[7]. K. Aitkin and N. Lunt, A census of direction ,
Nursing Times, 42, pp. 38-41. Quoted by J. Broadbent,
Practice nurses and the effects of the new general practitioner
contract in the British NHS: the advent of a professional project?
Soc. Sci. Med., Vol 47, No 4,
pp. 497 506.
[8]. In 1948, British general practitioners agreed to work
under a capitation system. However, problems in relation to
earnings under this system had arisen by the 1960s when doctors
lobbied for changes in pay and conditions under a general practice
contract system. See http://www.redbook.i12.com/rb/Docs/rb722.htm.
In 1990 a change to this system imposed
different treatment on general practitioners. The British
Government had always dealt with general practitioners as
independent contractors, in 1990 however, general practitioners
were treated almost as business entrepreneurs. See http://www.bmj.com/cgi/content/full/314/7084/895.
According to the Royal College of
Nursing, the 1990 general practice contract introduced much more
closely specified terms and conditions and led to increases in
practice nurse numbers as general practitioners struggled to reduce
costs and meet more stringent contractual requirements.
http://www.rcn.org.uk/news/congress2003/display.php?ID=423&N=08
accessed 14 June 2007.
[10]. Aitkin and Lunt in Broadbent, op.cit.
[11]. For example, it was noted at the Royal Nursing College
Congress in 2003 that many practice nurses were denied annual NHS
pay increases, increments and discretionary enhancements. They were
unable to contribute to the NHS pension scheme and were not
eligible for cost of living allowances. Many were also subject to
the variable employment policies adopted by their general
practitioner employers.
http://www.rcn.org.uk/news/congress2003/display.php?ID=423&N=08
accessed 22 June 2007.
[13]. Under this extension, experienced nurses and
pharmacists who undergo specific training are able to prescribe a
broader range of drugs. Prescribing of controlled drugs, such as
morphine, continues to be limited.
[16]. B. Docherty, Nursing in general practice: A New
Zealand perspective, Caxton Press, Christchurch, 1996.
[18]. Ministry of Health, Report of the Ministerial
Taskforce on Nursing, Wellington, 1998. Quoted by E. McKinlay,
New Zealand practice nursing in the third millennium: Key issues in
2006 , New Zealand Family Physician, Vol 33, No 3, June
2006.
[27]. Watts, et al., op.cit.
[28]. General practice nursing in Australia,
op.cit
[37]. The PIP recognises general practices that provide
comprehensive, quality care and which are, either accredited or
working towards accreditation, against the Royal Australian College
of General Practitioners' (RACGP) Standards for General
Practices.
PIP payments made through the program are
in addition to other income earned by the general practitioners and
the practice, such as patient payments and Medicare rebates.
Payments focus on aspects of general practice that contribute to
quality care. PIP payments are mainly dependent on practice size,
in terms of patients seen, rather than on the number of
consultations performed.
[39]. HMA report, op.cit.
[45]. The Hon. Tony Abbott, Minister for Health and Ageing,
media release, 1 November 2006.
[48]. The Hon. Tony Abbott, Minister for Health and Ageing,
media release, op.cit.
[61]. Nursing in general practice. Business case
models, op.cit.
[65]. Watts et al, op.cit.
[70]. A government scholarship of up to $10,000 may be
available for post graduate study towards a certificate, diploma or
masters or doctorate under funding. The scholarship is administered
by the APNA.
[71]. Watts et al, op. cit.
[72]. Currently the
APNA manages a scholarship scheme under which $1500 is available
for practice nurses for continuing education in areas such as women
s health, mental health, cholesterol management and nutrition.
[75]. Watts et al, op. cit.
[78]. Doctors are generally eligible for vocational
registration if they are Fellows of the RACGP. Vocational
registration gives access to general practice specific billing
items listed in the Medicare Benefits Schedule. Services provided
by doctors without vocational registration do not attract full
Medicare rebates. To maintain vocational registration, doctors need
to undertake continuing medical education.
[87]. For example, in July 2006 the Australian government
announced (The Hon. John Howard, Prime Minister, media release 13
July 2006, http://www.pm.gov.au/media/Release/2006/media_Release2018.cfm)
that 1036 nursing places additional to increased places already
committed to in 2005 would be funded over four years at a cost of
$93 million. In addition, the government committed to providing
about $31 million over four years to increase its contribution
toward the cost of nurses clinical training from about $690 to
$1,000 a year per full-time student. Council of Australian
Governments communiqu , 14 July 2006, http://www.coag.gov.au/meetings/140706/index.htm#mental
accessed 12 April 2007.
[89]. The 2002 report for the New South Wales Nurses
Association, op.cit., argued for example that nurses pay is unfair
in comparison with other health professionals and that this is due
to the changing nature of nursing work. A random study of nurses in
Western Australia also found that 80 per cent of participants
considered nursing pay low relative to other health industry jobs
requiring similar skills and almost 90 per cent considered nurses
pay low relative to jobs requiring similar skills and
responsibilities in other industries. Interestingly, while this
study reported these survey results, it concluded that estimated
wage functions suggest nurses earnings are not very much different
to those of other women when controlling for factors such as level
of education and experience A. Dockery, Workforce experience
and retention in nursing in Australia, Women s Economic Policy
Analysis Unit, Curtin University of Technology, 2004, http://www.cbs.curtin.edu.au/files/WEPAU_WP-33_April_2004.pdf
accessed 12 April 2007.
Note: according to the Australian Bureau
of Statistics (ABS), in 2001 91 per cent of nurses were female. In
relation to remuneration the ABS also notes that in 2004,
full-time, adult, non-managerial nursing professionals earned
$1028.30 per week on average excluding overtime, and enrolled
nurses earned $715.30 per week. In comparison, the average earnings
per week across all full-time adult non-managerial employees were
$867.50,
http://www.abs.gov.au/ausstats/abs@.nsf/2f762f95845417aeca25706c00834efa/8a87ef112b5bcf8bca25703b0080ccd9!OpenDocument
accessed 12 April 2007.
[90]. For example: Senate Standing Committee on Community
Affairs, Report on the Inquiry into Nursing, the patient
profession. Time for action, 2002,
http://www.aph.gov.au/Senate/committee/clac_ctte/completed_inquiries/2002-04/nursing/report/
accessed 13 April 2007. Report for the New South Wales Nursing
Association, op.cit., and a survey of Directors of Nursing and
Chief Executive Officers, conducted by Aged and Community Services,
Tasmania (2001) giving the most cited reason for nurses leaving
aged care as workload/burnout. National Review of Nursing
Education, Discussion paper, 2001,
http://www.dest.gov.au/archive/highered/nursing/pubs/discussion/chap6.htm#4
accessed 13 April 2007.
[101]. Watts et al, op.cit.
[103]. In Queensland, for example, Registered Nurses
are able to apply for endorsement by the Queensland Nursing Council
as nurse immunisers on completion of an accredited program. They
are then permitted to act under the Health (Drugs and Poisons)
Regulation 1996, section 175(3), to be able to offer and administer
vaccinations in accordance with their organisation s Drug Therapy
Protocol and Health Management Protocol. See
http://www.acu.edu.au/__data/assets/pdf_file/0015/16323/Nurse_Immuniser_updated_Brochure_2007_ACU_.pdf
accessed 15 June 2007.
[104]. Immunisation in Tasmania, op.cit.
[110]. E. Fernvall Markstedt, Seventh Annual Meeting
of the European Forum of National Nursing and Midwifery
Associations and WHO, A case history from Sweden. Quoted
in Department of Health and Children, Consultation on the
extension of prescriptive authority to nurses and midwives,
Dublin, 2006, http://www.whc.ie/publications/Submissions_Nurse_Prescribing.pdf
accessed 22 June 2007.
[112]. K. Seager, Supplementary Prescribing , Bath and
North Somerset Primary Care Trust, 2003. Quoted in Department of
Health and Children, Dublin, op.cit.
[117]. Watts et al, op.cit.
[119]. Nursing in general practice, op.cit.
[123]. GPs the key to preventative care ,
Australian Medicine, Volume 19, Number 8, May, 2007.
[124]. J. Cheek, K. Price, A. Dawson, K. Mott, J.
Beilby and D. Wilkinson, Consumer Perceptions of Nursing and
Nurses in General Practice, Report to Commonwealth Department
of Health and Ageing, Adelaide: Centre for Research into Nursing
and Health Care, 2002 in Watts et al, op.cit.
[126]. Watts et al, op.cit.
[128]. ADGP, 2006, op.cit.