The influence of funding models on collaboration in Australian general practice

A review of the growth and development of Australian practice nursing: Insights for the dietetic workforce

Aim

The aim of this scoping review was to provide an overview of the development of practice nurses, and the learnings that could be applied to improve the profile of dietetics practice in primary care.

Methods

A scoping review synthesising peer‐reviewed and other literature relevant to the development of Australian practice nurses was conducted. Structured searches using keywords ‘general practice’, ‘nurse’ and ‘Australia’ were conducted in PubMed and Google Scholar in June 2021. Key government websites, Department of Health and Services Australia, were searched to identify grey literature. One reviewer screened the titles and abstracts against inclusion criteria; two reviewers conducted full‐text screening independently. Data on the evolution of practice nursing were extracted based on its interest and transferability to the dietetics workforce.

Results

A total of 102 results (82 peer‐reviewed and 20 other literature) were included in the review. Key drivers for practice nurse role development in Australia were government funding, practice nurse practice standards, cost–benefit analyses of practice nurses, career and education opportunities, general practitioner and patient perspectives of practice nurses and, individual, community and local needs.

Conclusions

The practice nurse role has grown and strengthened and there are three key learnings that could be translated to strengthen the dietetics workforce in primary care. (1) Use and expansion of government funding, (2) furthering post‐tertiary education and career opportunities, including dietetic primary care practice standards and (3) targeting underserviced areas such as those that are rural and remote and building positive relationships with other stakeholders including practice nurses, general practitioners, patients and the broader primary care team.

The rich potential for education research in family medicine and general practice

Medical education is a rapidly growing field of research, incorporating diverse disciplinary perspectives to assist physician trainees in developing the complex skills needed for practice. Education science is happening in many medical specialties; however, Family Medicine or General Practice settings have not seen a proportional share of theory-driven education research. The limited nature of education research in Family Medicine is surprising, given that there are several aspects of general practice that make it a particularly unique and interesting context to study issues of general importance to medical education, and there is a particular need for education research to further the discipline of Family Medicine. It is important that the community of medical education researchers in Family Medicine have a strong understanding and perspective on the breadth and potential impact of their work, and what this means for the training that occurs within and for the discipline. This Reflection aims to inform strategic thinking, collaboration, and innovation in medical education research as it pertains to Family Medicine. It does so by discussing four hallmarks of Family Medicine practice and outlining their independent and interactive potential for medical education research.

The CKD-DETECT study: An RCT aimed at improving intention to initiate a kidney health check in Australian practice nurses

BACKGROUND

The burden of Chronic Kidney Disease (CKD) on the Australian health system is growing. Efforts to reverse this trend have not been successful. This paper evaluates the effectiveness of a targeted asynchronous web based e-learning module on general practice nurses' behavioural intentions in relation to opportunistic screening practices for people at risk of CKD.

DESIGN

Double blinded pre-post interventional randomised control design.

METHODS

Participants were nurses working in general practice settings in Australia. Participants were randomised to a knowledge based active control or targeted behavioural based intervention which were delivered using asynchronous e-learning modules. The intervention was designed to influence the behavioural constructs of the theory of planned behaviour (TPB): attitude, subjective norm and perceived behavioural control (PBC).

RESULTS

Of the 420 participants, we analysed the primary and secondary outcomes for 212 (50.47%) who had complete follow up data. There were no significant differences (p 0.424, [d] 0.04) in behavioural intention between the intervention and control groups at follow-up, when controlling for baseline values. However, regression models assessing the relationship between the change in the TPB constructs and behavioural intention at follow-up for all participants, regardless of study arm, demonstrated a significant change in intention to initiate a kidney health check. Although these changes could not be attributed to the effect of the intervention. Attitude (r2 = 0.3525, p 0.0004) and PBC (r2 = 0.3510, p 0.0005) models accounted for approximately 35% of the explained variance in behavioural intentions and social norm (r2 = 0.3297, p 0.0171) accounted for approximately 33% of the variance. When all TPB constructs were included in the model, 37% of the variance in intention was explained.

CONCLUSION

A targeted behavioural online intervention was no more effective than a knowledge based online program to improve primary health care nurses' intention to initiate a kidney health check in people at risk of chronic kidney disease.

RELEVANCE TO CLINICAL PRACTICE

Collaborative efforts are required by all staff working in general practice to develop models of care to improve screening practices for chronic kidney disease. Future research should focus on interventions that improve collaboration between health care professionals in the primary care setting and public health campaigns to increase awareness of risks of CKD and the importance of screening in the primary care setting.

Is the Counterweight Program a feasible and acceptable option for structured weight management delivered by practice nurses in Australia? A mixed-methods study

Nurse-led weight management programs, like the Counterweight Program in the United Kingdom, may offer a way for Australian general practices to provide weight management support to adults who are overweight or obese. During Counterweight, nurses provide patients with six fortnightly education sessions and three follow-up sessions to support weight maintenance. This study examined the feasibility, acceptability and perceived value of the Counterweight Program in the Australian primary care setting using a mixed-methods approach. Six practice nurses, from three general practices, were trained and subsidised to deliver the program. Of the 65 patients enrolled, 75% (n=49) completed the six education sessions. General practitioners and practice nurses reported that the training and resource materials were useful, the program fitted into general practices with minimal disruption and the additional workload was manageable. Patients reported that the program created a sense of accountability and provided a safe space to learn about weight management. Overall, Counterweight was perceived as feasible, acceptable and valuable by Australian practice staff and patients. The key challenge for future implementation will be identifying adequate and sustainable funding. An application to publically fund Counterweight under the Medicare Benefits Schedule would require stronger evidence of effectiveness and cost-effectiveness in Australia.

Supporting primary care nurses to work at an advanced level through changing practices' organisational governance

General practice nurses wishing to develop their careers in general practice are often unsupported, relying on the culture of individual practices. Given the structural diversity of Australian general practice, we qualitatively explored staff experiences of organisational governance, what supports are in place and can be used to assist nurses to advance. Semi-structured interviews with 28 staff (including nurses, GPs, receptions and practice managers) were undertaken across three practices, as part of a case-study approach. It was found that general practice staff know little of organisational governance and how it may be harnessed. Practical and flexible organisational governance were the most important factors in supporting general practice nurses to develop and utilise nursing skills, but advocacy from medical colleagues was necessary to support advancement. Barriers include funding structures, non-supportive cultures and inflexible organisational governance structures. Organisation governance has the potential to assist nurses to work at an advanced level, but significant financial, structural and cultural barriers may be too difficult for organisational governance resources alone to overcome. In addition to utilising resources, it may be useful for general practices to undertake a review of how they function as a team and reflect upon their practice culture.

Experiences of registered nurses in a general practice-based new graduate program: a qualitative study

Nurses are increasingly needed in primary healthcare settings to support community-based healthcare delivery. Programs to facilitate transition of new graduate nurses are well established in acute care; however, there are few similar programs reported in settings like general practice. This paper sought to explore the experiences of new graduate registered nurses and their registered nurse mentors in a new graduate program within Australian general practice. New graduates (n = 9) and their mentors participated in interviews before, during and at the conclusion of a 12-month new graduate program. Interviews were digitally audio-recorded and professionally transcribed verbatim before being analysed using thematic analysis. Eighteen new graduate and 10 mentor interviews were conducted, revealing four themes. Preparation and Opportunities describes the influence that pre-registration education had on preparing nurses for general practice employment. Exceeding Expectations highlights the positive experiences within the program. Program Challenges draws attention to the difficulties experienced by participants, and Future Career Intentions explores future career plans. This study highlights that a general practice new graduate nurse program has the potential to build the workforce. However, strengthening undergraduate preparation of nurses around primary health care and addressing funding issues in general practice, are important to promote the success of such programs.

A narrative review and synthesis to inform health workforce preparation for the Health Care Homes model in primary healthcare in Australia

The Australian Government Health Care Homes (HCH) model recently implemented in general practice targets people with chronic complex conditions. Identifying how general practitioners (GPs) and practice nurses (PNs) can work within this model is important given existing health workforce challenges. A narrative review and synthesis has been undertaken to develop a preliminary understanding of this, incorporating literature describing health workforce challenges, GP and PN functions, and team-based care; supplemented by interviews with key informants from within the primary healthcare system. Narrative synthesis principles guided literature analysis. Interview data were thematically analysed. A clear rationale for health workforce reform was ascertained and functions for the GP and PN under the HCH model were determined. The model was found to be an opportunity for an enhanced PN role in a team-based approach to care with the GP. Challenges to advancing the PN role and team-based care were identified, including the medical dominance of the health system and the significant culture change required by general practices to fully implement the model. Enablers included strong nursing leadership and improved ongoing education for PNs to unlock their capacity. The HCH model is an opportunity to strengthen primary healthcare, provided concerted action is taken regarding these challenges and enablers.

Job satisfaction and career intentions of registered nurses in primary health care: an integrative review

Background

There has been a significant growth of the international primary health care (PHC) nursing workforce in recent decades in response to health system reform. However, there has been limited attention paid to strategic workforce growth and evaluation of workforce issues in this setting. Understanding issues like job satisfaction and career intentions are essential to building capacity and skill mix within the workforce. This review sought to explore the literature around job satisfaction and career intentions of registered nurses working in PHC.

Methods

An integrative review was conducted. Electronic databases including: CINAHL, MEDLINE, Scopus and Web of Science, and reference lists of journal publications were searched for peer-reviewed literature published between 2000 and 2016 related to registered nurse job satisfaction and career intentions. Study quality was appraised, before thematic analysis was undertaken to synthesise the findings.

Results

Twenty papers were included in this review. Levels of job satisfaction reported were variable between studies. A range of factors impacted on job satisfaction. Whilst there was agreement on the impact of some factors, there was a lack of consistency between studies on other factors. Four of the six studies which reported career intentions identified that nearly half of their participants intended to leave their current position.

Conclusion

This review identifies gaps in our understanding of job satisfaction and career intentions in PHC nurses. With the growth of the PHC nursing workforce internationally, there is a need for robust, longitudinal workforce research to ensure that employment in this setting is satisfying and that skilled nurses are retained.

Australian primary health care nurses most and least satisfying aspects of work

AIMS AND OBJECTIVES

To identify the aspects of working in Australian primary health care that nurses rate as the most and least satisfying.

BACKGROUND

The nursing workforce in Australian primary health care has grown exponentially to meet the growing demand for health care. To maintain and further growth requires the recruitment and retention of nurses to this setting. Understanding the factors that nurses' rate as the most and least satisfying about their job will inform strategies to enhance nurse retention.

DESIGN

A cross-sectional online survey.

METHOD

Nurses employed in primary health care settings across Australia were recruited (n = 1166) to participate in a survey which combined items related to the respondent, their job, type of work, clinical activities, job satisfaction and future intention, with two open-ended items about the most and least satisfying aspects of their work.

RESULTS

Patient interactions, respect, teamwork, collegiality and autonomy were identified as the most satisfying professional aspects of their role. Personal considerations such as family friendly work arrangements and a satisfactory work-life balance were also important, overriding negative components of the role. The least satisfying aspects were poor financial support and remuneration, lack of a career path, physical work environment and time constraints. National restructuring of the primary health care environment was seen as a barrier to role stability and ability to work to a full scope of practice.

CONCLUSIONS

This study has identified a range of positive and negative professional and personal aspects of the primary health care nursing role, which may impact on staff recruitment and retention. Findings from the study should be considered by employers seeking to retain and maximise the skills of their primary health care workforce.

RELEVANCE TO CLINICAL PRACTICE

Understanding the factors that nurses perceive as being the most and least satisfying aspects of the work is can open up dialogue about how to improve the working experience of nurses in primary health care.