Evolution of practice nursing in Australia

Trends and perspectives for improving quality of chronic kidney disease care: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

Chronic kidney disease (CKD) affects over 850 million people globally, and the need to prevent its development and progression is urgent. During the past decade, new perspectives have arisen related to the quality and precision of care for CKD, owing to the development of new tools and interventions for CKD diagnosis and management. New biomarkers, imaging methods, artificial intelligence techniques, and approaches to organizing and delivering healthcare may help clinicians recognize CKD, determine its etiology, assess the dominant mechanisms at given time points, and identify patients at high risk for progression or related events. As opportunities to apply the concepts of precision medicine for CKD identification and management continue to be developed, an ongoing discussion of the potential implications for care delivery is required. The 2022 KDIGO Controversies Conference on Improving CKD Quality of Care: Trends and Perspectives examined and discussed best practices for improving the precision of CKD diagnosis and prognosis, managing the complications of CKD, enhancing the safety of care, and maximizing patient quality of life. Existing tools and interventions currently available for the diagnosis and treatment of CKD were identified, with discussion of current barriers to their implementation and strategies for improving the quality of care delivered for CKD. Key knowledge gaps and areas for research were also identified.

Understanding primary care nurses' contribution to cancer early diagnosis: A systematic review

PURPOSE

Primary care nurses can contribute to cancer early diagnosis. The objective of this systematic review was to identify, appraise and synthesise evidence on primary care nurses' contribution towards cancer early diagnosis in developed countries.

METHOD

The following databases were searched in September 2017: MEDLINE, PsychINFO, CINAHL, SCOPUS, and EMBASE. Data were extracted on nurses': knowledge of cancer; frequency of 'cancer early diagnosis-related discussions' with patients; and perceived factors influencing these discussions. Studies were appraised using the Mixed Methods Appraisal Tool.

RESULTS

Twenty-one studies were included from: United States, United Kingdom, Ireland, Spain, Turkey, Australia, Brazil and Middle East. Studies were mostly of low quality (one did not meet any appraisal criteria, 15 met one, four met two, and one met three). Nurses' knowledge of cancer, and their frequency of 'cancer early diagnosis-related discussions', varied across countries. This may be due to measurement bias or nurses' divergent roles across healthcare systems. Commonly perceived barriers to having screening discussions included: lack of time, insufficient knowledge and communication skills, and believing that patients react negatively to this topic being raised.

CONCLUSIONS

Findings suggest a need for nurses to be adequately informed about, and have the confidence and skills to discuss, the topic of cancer early diagnosis. Further high-quality research is required to understand international variation in primary care nurses' contribution to this field, and to develop and evaluate optimal methods for preparing them for, and supporting them in, this.

An overview of the general practice nurse workforce in Australia, 2012–15

Several surveys of the general practice nurse (GPN) workforce have been undertaken in Australia over the last decade, but they have limitations, which mean that the workforce is not well-understood. The aim of this study is to describe the profile of the GPN workforce using the dataset available through the Australia Health Practitioner Registration Agency and to explore how it differs from the non-GPN nursing workforce, and if this workforce is changing over time. Data from labour force surveys conducted from 2012 to 2015 were used. Variables examined were age group, gender, remoteness area, hours worked, nurse type (enrolled (EN) or registered (RN)), years in the workforce and also intended years of work before exiting the workforce. When compared with the broader nursing workforce, a greater proportion of GPNs in 2015 were older (60 v. 51%), worked part-time (65 v. 48%) and worked in regional areas (35 v. 26%). Additionally, the characteristics of GPNs has changed between 2012 and 2015, with an increased proportion of younger nurses, more registered nurses and fewer working in remote areas. To ensure a sustainable workforce, particularly in rural and remote areas, strategies to recruit and retain this workforce will be needed.

The impact of general practice nursing care on patient satisfaction and enablement in Australia: A mixed methods study

BACKGROUND

The numbers of nurses in general practice in Australia tripled between 2004 and 2012. However, evidence on whether nursing care in general practice improves patient outcomes is scarce. Although patient satisfaction and enablement have been examined extensively as outcomes of general practitioner care, there is little research into these outcomes from nursing care in general practice. The aim of this study was to examine the relationships between specific general practice characteristics and nurse consultation characteristics, and patient satisfaction and enablement METHODS: A mixed methods study examined a cross-section of patients from 21 general practices in the Australian Capital Territory. The Patient Enablement and Satisfaction Survey was distributed to 1665 patients who received nursing care between September 2013 and March 2014. Grounded theory methods were used to analyse interviews with staff and patients from these same practices. An integrated analysis of data from both components was conducted using multilevel mixed effect models.

RESULTS

Data from 678 completed patient surveys (response rate=42%) and 48 interviews with 16 nurses, 23 patients and 9 practice managers were analysed. Patients who had longer nurse consultations were more satisfied (OR=2.50, 95% CI: 1.43-4.35) and more enabled (OR=2.55, 95% CI: 1.45-4.50) than those who had shorter consultations. Patients who had continuity of care with the same general practice nurse were more satisfied (OR=2.31, 95% CI: 1.33-4.00) than those who consulted with a nurse they had never met before. Patients who attended practices where nurses worked with broad scopes of practice and high levels of autonomy were more satisfied (OR=1.76, 95% CI: 1.09-2.82) and more enabled (OR=2.56, 95% CI: 1.40-4.68) than patients who attended practices where nurses worked with narrow scopes of practice and low levels of autonomy. Patients who received nursing care for the management of chronic conditions (OR=2.64, 95% CI: 1.32-5.30) were more enabled than those receiving preventive health care.

CONCLUSIONS

This study provides the first evidence of the importance of continuity of general practice nurse care, adequate time in general practice nurse consultations, and broad scopes of nursing practice and autonomy for patient satisfaction and enablement. The findings of this study provide evidence of the true value of enhanced nursing roles in general practice. They demonstrate that when the vision for improved coordination and multidisciplinary primary health care, including expanded roles of nurses, is implemented, high quality patient outcomes can be achieved.

Advanced training for primary care and general practice nurses: enablers and outcomes of postgraduate education

The aims of the present study were to understand enablers to participation in postgraduate education for primary care nurses (PCNs), and to explore how postgraduate education has advanced their nursing practice. Cross-sectional questionnaires were mailed out in April 2012 to current and past students undertaking postgraduate studies in primary care nursing at The University of Melbourne, Victoria, Australia. Questionnaires were returned by 100 out of 243 nurses (response rate 41%). Ninety-one per cent (91/100) of the respondents were first registered as nurses in Australia. Fifty-seven per cent were hospital trained and 43% were university educated to attain their initial nurse qualification. The respondents reported opportunities to expand scope of practice (99%; 97/98), improve clinical practice (98%; 97/99), increase work satisfaction (93%; 91/98) and increase practice autonomy (92%; 89/97) as factors that most influenced participation in postgraduate education in primary care nursing. Major enablers for postgraduate studies were scholarship access (75%; 71/95) and access to distance education (74%; 72/98). Many respondents reported an increased scope of practice (98%; 95/97) and increased job satisfaction (71%; 70/98) as an education outcome. Only 29% (28/97) cited an increase in pay-rate as an outcome. Of the 73 PCNs currently working in general practice, many anticipated an increase in time spent on the preparation of chronic disease management plans (63%; 45/72), multidisciplinary care plans (56%; 40/72) and adult health checks (56%; 40/72) in the preceding 12 months. Recommendations emerging from findings include: (1) increased access to scholarships for nurses undertaking postgraduate education in primary care nursing is imperative; (2) alternative modes of course delivery need to be embedded in primary care nursing education; (3) the development of Australian primary care policy, including policy on funding models, needs to more accurately reflect the educational level of PCNs, PCN role expansion and the extent of interprofessional collaboration that is evident from research undertaken to date. Nurses with postgraduate education have the potential to increase their scope of practice, take on a greater teaching role and provide more preventive and chronic disease services in primary care. Policies aimed at increasing access to education for nurses working in primary care would strengthen the primary care nursing profession, and enhance the delivery of primary health care services in Australia.

Strategies to promote practice nurse capacity to deliver evidence-based care

Purpose

– Evidence-based practice is pivotal to effective patient care. However, its translation into practice remains limited. Given the central role of primary care in many healthcare systems, it is important to identify strategies that bolster clinician-capacity to promote evidence-based care. The purpose of this paper is to identify strategies to increase Practice Nurse capacity to promote evidence-based sexual healthcare within general practice.

Design/methodology/approach

– A survey of 217 Practice Nurses in an Australian state and ten respondent-interviews regarding two resources to promote evidence-based sexual healthcare – namely, a clinical aide and online training.

Findings

– The perceived impact of both resources was determined by views on relevance and design – particularly for the clinical aide. Resource-use was influenced by role and responsibilities within the workplace, accessibility, and support from patients and colleagues.

Research limitations/implications

– This is the first Australian study to reveal strategies to promote evidence-based sexual healthcare among Practice Nurses. The findings provide a platform for future research on knowledge translation processes, particularly among clinicians who might be disengaged from sexual healthcare.

Practical implications

– Given the benefits of evidence-based practices, it is important that managers recognize their role, and the role of their services, in promoting these. Without explicit support for evidence-based care and recognition of the Practice Nurse role in such care, knowledge translation is likely to be limited.

Originality/value

– Knowledge translation among Practice Nurses can be facilitated by: resources-deemed informative, relevant, and user-friendly, as well as support from patients, colleagues, and their workplace.

A case study exploring employment factors affecting general practice nurse role development

Aim

The aim of this study was to explore the factors affecting role development in practice nursing in the United Kingdom.

Background

General practice is currently central to National Health Service reform, producing favourable conditions for the practice nurse role to be further strengthened and developed. However, the literature has continued to describe evidence that practice nurses are a disempowered, isolated group with many constraints reducing their ability to respond to opportunities to develop their role. The rationale for conducting the study was therefore to provide a greater understanding about the constraining factors and their influence on practice nurses wishing to develop their role.

Method

The method used to conduct the research followed a case approach, as the subject being investigated was complex with multiple inter-related factors and the approach was exploratory. The cases comprised six UK general practices and the participants within each case were a practice nurse, a GP and a practice manager.

Findings

A combination of factors was found to contribute to the way the practice nurse role evolves. These are education, practice culture, practice nurse personal characteristics and empowerment. Empowerment holds the key to maximising the conditions favourable to practice nurse role evolution. This is not, however, a ‘single’ factor; it represents the combined synergistic effects of practice culture and practice nurse personal characteristics on creating an empowering environment. The inter-relationship between these was captured in a framework and given the title ‘empowering employment principles’.

Conclusion

The ‘empowering employment principles’ illustrate the features most conducive to role evolution, thus providing a tool for practice nurses and their employers to enhance opportunities for nurses to develop their role.

Prevalence and associations of general practice nurses' involvement in consultations of general practitioner registrars: a cross-sectional analysis

OBJECTIVE

To establish prevalence and associations of general practice nurses' (GPNs) involvement in general practitioner (GP) registrars' consultations.

METHODS

A cross-sectional analysis from an ongoing cohort study of registrars' clinical consultations in five Australian states. Registrars recorded detailed data from 60 consecutive consultations per 6-month training term. Problems and diagnoses encountered, including chronic disease classification, were coded using the International Classification of Primary Care, second edition duplication system (ICPC-2plus) classification system. The outcome factor in our analysis was GPN involvement in management of individual problems and diagnoses. Independent variables were a range of patient, registrar, practice, consultation and educational factors.

RESULTS

We analysed 108 759 consultations of 856 registrars including 169 307 problems or diagnoses. Of the problems/diagnoses, 5.1% (95% confidence interval (CI) 5.0-5.2) involved a GPN. Follow-up with a GPN was organised for 1.5% (95% CI 1.4-1.5) of all problems/diagnoses. Significant associations of GPN involvement included patient age, male sex, Aboriginal or Torres Strait Islander status, non-English-speaking background (NESB) and the patient being new to the practice. Larger practice size, the particular training organisation, and the problem/diagnosis being new and not a chronic disease were other associations.

CONCLUSIONS

Associations with Aboriginal or Torres Strait Islander status and NESB status suggest GPNs are addressing healthcare needs of these under-serviced groups. But GPNs may be underutilised in chronic disease care.

An integrative review of facilitators and barriers influencing collaboration and teamwork between general practitioners and nurses working in general practice

AIM

To identify facilitators and barriers influencing collaboration and teamwork between general practitioners and nurses working in general (family) practice.

BACKGROUND

Internationally, a shortage of doctors entering and remaining in general practice and an increasing burden of chronic disease has diversified the nurse's role in this setting. Despite a well-established general practice nursing workforce, little attention has been paid to the ways doctors and nurses collaborate in this setting.

DESIGN

Integrative literature review.

DATA SOURCES

CINAHL, Scopus, Web of Life, Cochrane Library, Joanna Briggs Institute Library of Systematic Reviews and Trove (dissertation and theses) were searched for papers published between 2000 and May 2014.

REVIEW METHODS

This review was informed by the approach of Whittemore and Knafl (2005). All included papers were assessed for methodological quality. Findings were extracted, critically examined and grouped into themes.

RESULTS

Eleven papers met the inclusion criteria. Thematic analysis revealed three themes common to the facilitators of and barriers to collaboration and teamwork between GPs in general practice: (1) roles and responsibilities; (2) respect, trust and communication; and (3) hierarchy, education and liability.

CONCLUSION

This integrative review has provided insight into issues around role definition, communication and organizational constraints which influence the way nurses and general practitioners collaborate in a team environment. Future research should investigate in more detail the ways doctors and nurses work together in general practice and the impact of collaboration on nursing leadership and staff retention.

How is Primary Health Care conceptualised in nursing in Australia? A review of the literature

Australia, in common with many other countries, is expanding the role of Primary Health Care (PHC) to manage the growing burden of chronic disease and prevent hospitalisation. Australia's First National Primary Health Care Strategy released in 2010 places general practice at the centre of care delivery, reflecting a constitutional division of labour in which the Commonwealth government's primary means of affecting care delivery in this sector is through rebates for services delivered from the universal healthcare system Medicare. A review of Australian nursing literature was undertaken for 2006-2011. This review explores three issues in relation to these changes: How PHC is conceptualised within Australian nursing literature; who is viewed as providing PHC; and barriers and enablers to the provision of comprehensive PHC. A review of the literature suggests that the terms 'PHC' and 'primary care' are used interchangeably and that PHC is now commonly associated with services provided by practice nurses. Four structural factors are identified for a shift away from comprehensive PHC, namely fiscal barriers, educational preparation for primary care practice, poor role definition and interprofessional relationships. The paper concludes that while moves towards increasing capacity in general practice have enhanced nursing roles, current policy and the nature of private business funding alongside some medical opposition limit opportunities for Australian nurses working in general practice.

Roles and relationships between health professionals involved in insulin initiation for people with type 2 diabetes in the general practice setting: a qualitative study drawing on relational coordination theory

BACKGROUND

The majority of care for people with type 2 diabetes occurs in general practice, however when insulin initiation is required it often does not occur in this setting or in a timely manner and this may have implications for the development of complications. Increased insulin initiation in general practice is an important goal given the increasing prevalence of type 2 diabetes and a relative shortage of specialists. Coordination between primary and secondary care, and between medical and nursing personnel, may be important in achieving this. Relational coordination theory identifies key concepts that underpin effective interprofessional work: communication which is problem solving, timely, accurate and frequent and relationships between professional roles which are characterized by shared goals, shared knowledge and mutual respect. This study explores roles and relationships between health professionals involved in insulin initiation in order to gain an understanding of factors which may impact on this task being carried out in the general practice setting.

METHOD

21 general practitioners, practice nurses, diabetes nurse educators and physicians were purposively sampled to participate in a semi-structured interview. Transcripts of the interviews were analysed using framework analysis.

RESULTS

There were four closely interlinked themes identified which impacted on how health professionals worked together to initiate people with type 2 diabetes on insulin: 1. Ambiguous roles; 2. Uncertain competency and capacity; 3. Varying relationships and communication; and 4. Developing trust and respect.

CONCLUSIONS

This study has shown that insulin initiation is generally recognised as acceptable in general practice. The role of the DNE and practice nurse in this space and improved communication and relationships between health professionals across organisations and levels of care are factors which need to be addressed to support this clinical work. Relational coordination provides a useful framework for exploring these issues.

Practice nurse involvement in general practice clinical care: policy and funding issues need resolution

In Australia, primary care-based funding initiatives have been implemented to encourage general practices to employ practice nurses. The aim of this paper is to discuss limitations of the current funding and policy arrangements in enhancing the clinical role of practice nurses in the management of chronic conditions. This paper draws on the results of a real-world economic evaluation, the Primary Care Services Improvement Project (PCSIP). The PCSIP linked routinely collected clinical and resource use data to undertake a risk-adjusted cost-effectiveness analysis of increased practice nurse involvement in clinical-based activities for the management of diabetes and obesity. The findings of the PCSIP suggested that the active involvement of practice nurses in collaborative clinical-based activities is cost-effective, as well as addressing general practice workforce issues. Although primary healthcare organisations (e.g. Medicare Locals) can play a key role in supporting enhanced practice nurse roles, improvements to practice nurse funding models could further encourage more efficient use of an important resource. What is known about the topic? There is evidence that the increased involvement of practice nurses in clinical-based activities in the management of patients with chronic conditions (e.g. diabetes and obesity) is cost-effective. The Australian Government has implemented financial incentives to encourage general practices to recruit nurses and to expand nursing roles within collaborative models of care. There is currently insufficient engagement of practice nurses in clinical care. What does this paper add? This paper summarises evidence regarding the value of an enhanced practice nurse role in Australian general practice, and discusses refinements to current funding arrangements for practice nurses. What are the implications for practitioners? Delegating clinical role (e.g. patient education and monitoring clinical progress) to practice nurses in the management of patients with chronic conditions can improve clinical outcomes without adversely affecting general practice business models.

A tool to evaluate patients’ experiences of nursing care in Australian general practice: development of the Patient Enablement and Satisfaction Survey

Australian health policy initiatives have increasingly supported the employment of nurses in general practice. An understanding of the impact of nursing care on patients in this setting is integral to assuring quality, safety and a patient-centred focus. The aim was to develop a survey to evaluate the satisfaction and enablement of patients who receive nursing care in Australian general practices. The survey was to be simple to administer and analyse, ensuring practicality for use by general practice nurses, doctors and managers. Two validated instruments formed the basis of the Patient Enablement and Satisfaction Survey (PESS). This survey was refined and validated for the Australian setting using focus groups and in-depth interviews with patients, and feedback from general practice nurses. Test-retest and alternate form methods were used to establish the survey’s reliability. Feedback resulted in 14 amendments to the original draft survey. Questions that demonstrated a strong positive correlation for the test-retest and alternate form measures were included in the final survey. The PESS is a useful, practical tool for the evaluation of nursing care in Australian general practice, its validity and reliability established through a patient-centred research approach, reflective of the needs of patients accessing nursing services in this setting.

Australian practice nurses’ perceptions of their role and competency to provide nutrition care to patients living with chronic disease

Nutrition is important in the management of chronic disease, and practice nurses in the Australian primary care setting are increasingly providing nutrition care to patients living with chronic disease. The aim of the present study was to investigate practice nurses’ perceptions of their role and competency to provide nutrition care to patients living with chronic disease in Australia. Twenty practice nurses currently employed in general practice participated in an individual semi-structured telephone interview. Interviews were transcribed verbatim and thematically analysed. Practice nurses perceived themselves to be in a prime position to provide opportunistic nutrition care to patients. Participants perceived that the ideal role of a practice nurse is to advocate for nutrition and provide a basic level of nutrition care to patients; however, the interpretation of the term ‘basic’ varied between participants. Participants perceived that practice nurses are highly trusted and approachable, which they valued as important characteristics for the provision of nutrition care. Barriers to providing nutrition care included time constraints, lack of nutrition knowledge and lack of confidence. Participants were concerned about the availability and accessibility of nutrition education opportunities for practice nurses. The present study has demonstrated that practice nurses perceive themselves as having a significant role in the provision of nutrition care to patients with chronic disease in the Australian primary care setting. Further investigation of strategies to enhance the effectiveness of nutrition care provision by practice nurses is warranted.

How does care coordination provided by registered nurses "fit" within the organisational processes and professional relationships in the general practice context?

AIM

The aim of this study was to develop understanding about how a registered nurse-provided care coordination model can "fit" within organisational processes and professional relationships in general practice.

BACKGROUND

In this project, registered nurses were involved in implementation of registered nurse-provided care coordination, which aimed to improve quality of care and support patients with chronic conditions to maintain their care and manage their lifestyle.

METHOD

Focus group interviews were conducted with nurses using a semi-structured interview protocol. Interpretive analysis of interview data was conducted using Normalization Process Theory to structure data analysis and interpretation.

RESULTS

Three core themes emerged: (1) pre-requisites for care coordination, (2) the intervention in context, and (3) achieving outcomes. Pre-requisites were adequate funding mechanisms, engaging organisational power-brokers, leadership roles, and utilising and valuing registered nurses' broad skill base. To ensure registered nurse-provided care coordination processes were sustainable and embedded, mentoring and support as well as allocated time were required. Finally, when registered nurse-provided care coordination was supported, positive client outcomes were achievable, and transformation of professional practice and development of advanced nursing roles was possible.

CONCLUSION

Registered nurse-provided care coordination could "fit" within the context of general practice if it was adequately resourced. However, the heterogeneity of general practice can create an impasse that could be addressed through close attention to shared and agreed understandings. Successful development and implementation of registered nurse roles in care coordination requires attention to educational preparation, support of the individual nurse, and attention to organisational structures, financial implications and team member relationships.

A model-based economic evaluation of improved primary care management of patients with type 2 diabetes in Australia

BACKGROUND

There are few studies investigating the economic value of the Australian practice nurse workforce on the management of chronic conditions. This is particularly important in Australia, where the government needs evidence to inform decisions on whether to maintain or redirect current financial incentives that encourage practices to recruit practice nurses.

OBJECTIVE

The objective of this study was to estimate the lifetime costs and quality-adjusted life-years (QALYs) associated with two models of practice nurse involvement in clinical-based activities (high and low level) in the management of type 2 diabetes within the primary care setting.

METHODS

A previously validated state transition model (the United Kingdom Prospective Diabetes Study Outcomes Model) was adapted, which uses baseline prognostic factors (e.g. gender, haemoglobin A1c [HbA1c]) to predict the risk of occurrence of diabetes-related complications (e.g. stroke). The model was populated by data from Australian and UK observational studies. Costs and utility values associated with complications were summed over patients' lifetimes to estimate costs and QALY gains from the perspective of the health care system. All costs were expressed in 2011 Australian dollars (AU$). The base-case analysis assumed a 40-year time horizon with an annual discount rate of 5 %.

RESULTS

Relative to low-level involvement of practice nurses in the provision of clinical-based activities, the high-level model was associated with lower mean lifetime costs of management of complications (-AU$8,738; 95 % confidence interval [CI] -AU$12,522 to -AU$4,954), and a greater average gain in QALYs (0.3; 95 % CI 0.2-0.4). A range of sensitivity analyses were performed, in which the high-level model was dominant in all cases.

CONCLUSION

Our results suggest that the high-level model is a dominant management strategy over the low-level model in all modelled scenarios. These findings indicate the need for effective primary care-based incentives to encourage general practices not only to employ practice nurses, but to better integrate them into the provision of clinical services.

Effectiveness of general practice based, practice nurse led telephone coaching on glycaemic control of type 2 diabetes: the Patient Engagement and Coaching for Health (PEACH) pragmatic cluster randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of goal focused telephone coaching by practice nurses in improving glycaemic control in patients with type 2 diabetes in Australia.

DESIGN

Prospective, cluster randomised controlled trial, with general practices as the unit of randomisation.

SETTING

General practices in Victoria, Australia.

PARTICIPANTS

59 of 69 general practices that agreed to participate recruited sufficient patients and were randomised. Of 829 patients with type 2 diabetes (glycated haemoglobin (HbA1c) >7.5% in the past 12 months) who were assessed for eligibility, 473 (236 from 30 intervention practices and 237 from 29 control practices) agreed to participate.

INTERVENTION

Practice nurses from intervention practices received two days of training in a telephone coaching programme, which aimed to deliver eight telephone and one face to face coaching episodes per patient.

MAIN OUTCOME MEASURES

The primary end point was mean absolute change in HbA1c between baseline and 18 months in the intervention group compared with the control group.

RESULTS

The intervention and control patients were similar at baseline. None of the practices dropped out over the study period; however, patient attrition rates were 5% in each group (11/236 and 11/237 in the intervention and control group, respectively). The median number of coaching sessions received by the 236 intervention patients was 3 (interquartile range 1-5), of which 25% (58/236) did not receive any coaching sessions. At 18 months' follow-up the effect on glycaemic control did not differ significantly (mean difference 0.02, 95% confidence interval -0.20 to 0.24, P=0.84) between the intervention and control groups, adjusted for HbA1c measured at baseline and the clustering. Other biochemical and clinical outcomes were similar in both groups.

CONCLUSIONS

A practice nurse led telephone coaching intervention implemented in the real world primary care setting produced comparable outcomes to usual primary care in Australia. The addition of a goal focused coaching role onto the ongoing generalist role of a practice nurse without prescribing rights was found to be ineffective.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN50662837.

A risk-adjusted economic evaluation of alternative models of involvement of practice nurses in management of type 2 diabetes

AIMS

To determine the cost-effectiveness of alternative models of practice nurse involvement in the management of type 2 diabetes within the primary care setting.

METHODS

Linked routinely collected clinical data and resource use (general practitioner visits, hospital services and pharmaceuticals) were used to undertake a risk-adjusted cost-effectiveness analysis of alternative models of care for the management of diabetes patients. These models were based on the reported level of involvement of practice nurses in the provision of clinical-based activities. Potential confounders were controlled for by using propensity score-weighted regression analyses. The impact of alternative models of care on outcomes and costs was measured and incremental cost-effectiveness estimated. The uncertainty around the estimates of cost-effectiveness was illustrated through bootstrapping.

RESULTS

Although the difference in total cost between two models of care was not statistically significant, the high-level model was associated with better outcomes (larger mean reductions in HbA(1c)). The upper 95% confidence intervals showed that the incremental cost per 1% decrease in HbA(1c) is only $454, and per one additional patient to achieve an HbA(1c) value of less than 53 mmol/mol (7.0%) is $323. Further analyses showed little uncertainty surrounding the decision to adopt the high-level model.

CONCLUSIONS

The results provide a strong indication that the high-level model is a cost-effective way of managing diabetes patients. Our findings highlight the need for effective incentives to encourage general practices to better integrate practice nurses in the provision of clinical services.

Providing travel health care--the nurses' role: an international comparison

BACKGROUND

In many countries, the responsibility for travel health lies with medical practitioners who delegate certain tasks to nursing staff. Elsewhere, nurses have taken a leading role and work independently in private or hospital-based clinics, occupational health departments and general practices. The purpose of this study was to examine the roles and challenges faced by nurses providing travel health care in Australia, Japan and the UK, and to compare educational and professional needs.

METHODS

Nurses involved in travel health care were invited to complete an online questionnaire with multiple choice, open-ended, and Likert Scale questions. SurveyMonkey's statistical facilities analysed quantitative data; thematic content analysis was applied to qualitative responses.

RESULTS

Differences and similarities between the three countries were conveyed by 474 participants focusing on current positions, work arrangements, and educational and practical concerns. Clinical practice issues, including vaccination and medication regulations, were highlighted with the differences between countries explained by the respective history of travel health care development and the involvement within their nursing profession.

CONCLUSION

The call for more educational opportunities, including more support from employers, and a refinement of the role as travel health nurse appears to be international. Nurses require support networks within the field, and the development of a specialist "travel health nurse" would give a stronger voice to their concerns and needs for specific education and training in travel health care.

A qualitative evaluation of New Zealand consumers perceptions of general practice nurses

BACKGROUND

An important consideration in health service delivery is ensuring that services meet consumer needs and that consumers are satisfied with service delivery. Patient satisfaction can impact on compliance with suggested treatments and therefore impact on health outcomes. Comparatively few studies have explored consumer satisfaction with nurses in general practice.

METHODS

A sub-group of 18 consumers from a larger quantitative evaluation of consumer satisfaction with New Zealand general practice nurses participated in semi-structured telephone interviews. Interview data was analysed using thematic analysis.

RESULTS

Four major themes emerged from the data. These themes highlighted that, despite confusion experienced by some consumers regarding the practice nurse role, consumers were happy with the level of care provided by them. Consumers felt valued by Practice Nurses and considered them competent and highly knowledgeable. Findings also convey that consumers appreciate the accessibility and financial benefits of utilising the services of practice nurses.

CONCLUSIONS

Consumers are highly satisfied with practice nurse service delivery and value their relationships with these health professionals. Consumers revealed that greater clarity around the practice nurse role and their scope of practice may enhance their utilisation. Spreading the message of practice nurses being the right person to deliver care, within their scope of practice, at the right time may have the potential to provide more timely care within the primary care setting.

Nurse practitioners: an insight into their integration into Australian community pharmacies

BACKGROUND

Nurse practitioners (NPs) are independent health professionals with prescribing rights, and have recently established primary care roles in pharmacies.

OBJECTIVE

To describe the roles of pharmacy-based NPs in Australia.

METHODS

Semi-structured interviews were undertaken onsite or by telephone, with 28 staff of all 9 Revive NP Clinics in Western Australia. Participants comprised NPs representing 6 practices and pharmacy staff of all 9 practices. Questions explored the NPs' scope of practice and staff collaboration. Data are descriptively reported.

RESULTS

The NPs undertook a range of services, including medication prescribing according to clinical guidelines, provision and ordering of diagnostic services, vaccine administration and provision of medical certificates. Community pharmacists reported to continue ensuring the safe and quality use of medicines and to counsel clients. Both pharmacists and NPs provided consumer medicine information leaflets. NPs are authorized to write prescriptions for Pharmacist-Only (S3) Medicines.

CONCLUSIONS

NPs' primary healthcare roles appear to complement roles of community pharmacists. Potential exists for further collaboration and interdisciplinary care in health promotion and screening services. Clarification is needed with respect to prescribing and provision of Pharmacist-Only Medicines, and offering consumer medicines leaflets.

A spatial analysis of the expanding roles of nurses in general practice

Background

Changes to the workforce and organisation of general practice are occurring rapidly in response to the Australian health care reform agenda, and the changing nature of the medical profession. In particular, the last five years has seen the rapid introduction and expansion of a nursing workforce in Australian general practices. This potentially creates pressures on current infrastructure in general practice.

Method

This study used a mixed methods, ‘rapid appraisal’ approach involving observation, photographs, and interviews.

Results

Nurses utilise space differently to GPs, and this is part of the diversity they bring to the general practice environment. At the same time their roles are partly shaped by the ways space is constructed in general practices.

Conclusion

The fluidity of nursing roles in general practice suggests that nurses require a versatile space in which to maximize their role and contribution to the general practice team.

Practice nurses experiences of mentoring undergraduate nursing students in Australian general practice

Internationally, the delivery of health services has shifted from secondary to primary care, necessitating an exponential growth of the nursing workforce and expansion of the nursing role in general practice. This growth, and the subsequent need to develop this workforce, has created a need to expose undergraduate nurses to general practice nursing as a viable career option. Concurrently, universities are struggling to find sufficient clinical places for their undergraduate students to gain clinical experience. It is logical, therefore, to increase the number of undergraduate nursing student placements in general practice. Through qualitative research methods, this paper seeks to explore the experiences of practice nurses mentoring undergraduate students on clinical placements within the general practice setting. Findings are presented in the following three themes: (1) Promoting Practice Nursing: We really need to get students in, (2) Mentoring future co-workers: Patience and reassurance, and (3) Reciprocity in learning: It's a bit of a two way street, which show the benefits of such placements. Clinical placements in general practice settings can be mutually beneficial in terms of providing quality teaching and learning experiences for students. Conversely, the experience provides an impetus for practice nurses to maintain currency of their clinical skills and knowledge through mentoring student nurses.

Practice-based chronic condition care coordination: challenges and opportunities

This paper explores issues related to the types of support that practice nurses require to engage in care coordination for people with chronic conditions. A sample of practice nurses and general practitioners participated in a focus group discussion to identify their perspectives on the role of practice nurses as providers of care coordination, the specific tasks that might be conducted and the types of support that might be required. The data were analysed using thematic analysis. The findings suggested there was considerable confusion about care coordination and a lack of conceptual clarity. Nevertheless, nurses were committed to engaging in activities that would promote care coordination. Four main themes emerged that indicated the importance of a developmental and well-supported implementation process. These themes included the need for cultural change within the whole practice, increased capacity to develop trusted and tested partnerships, appropriate role definition and a full understanding of the financial models that could support care coordination. Practice nurses clearly have a role in care coordination, but models of care coordination need to be localised and contextualised within specific GP practices. Cultural change will, in many instances, be critical to the development of localised programs. Broad supportive structures, including ongoing mentorship and administrative assistance (particularly with financial and procedural aspects of care coordination) will be required when implementing programs that enhance roles for practice nurses.

Following the funding trail: financing, nurses and teamwork in Australian general practice

BACKGROUND

Across the globe the emphasis on roles and responsibilities of primary care teams is under scrutiny. This paper begins with a review of general practice financing in Australia, and how nurses are currently funded. We then examine the influence on funding structures on the role of the nurse. We set out three dilemmas for policy-makers in this area: lack of an evidence base for incentives, possible untoward impacts on interdisciplinary functioning, and the substitution/enhancement debate.

METHODS

This three year, multimethod study undertook rapid appraisal of 25 general practices and year-long studies in seven practices where a change was introduced to the role of the nurse. Data collected included interviews with nurses (n = 36), doctors (n = 24), and managers (n = 22), structured observation of the practice nurse (51 hours of observation), and detailed case studies of the change process in the seven year-long studies.

RESULTS

Despite specific fee-for-service funding being available, only 6% of nurse activities generated such a fee. Yet the influence of the funding was to focus nurse activity on areas that they perceived were peripheral to their roles within the practice.

CONCLUSIONS

Interprofessional relationships and organisational climate in general practices are highly influential in terms of nursing role and the ability of practices to respond to and utilise funding mechanisms. These factors need to be considered, and the development of optimal teamwork supported in the design and implementation of further initiatives that financially support nursing in general practice.

The work, education and career pathways of nurses in Australian general practice

There is little understanding about the educational levels and career pathways of the primary care nursing workforce in Australia. This article reports on survey research conducted to examine the qualifications and educational preparation of primary care nurses in general practice, their current enrolments in education programs, and their perspectives about post-registration education. Fifty-eight practice nurses from across Australia completed the survey. Over 94% reported that they had access to educational opportunities but identified a range of barriers to undertaking further education. Although 41% of nurses said they were practising at a speciality advanced level, this correlated with the number of years they had worked in general practice rather than to any other factor, including level of education. Respondents felt a strong sense of being regarded as less important than nurses working in the acute care sector. Almost 85% of respondents reported that they did not have a career pathway in their organisation. They also felt that while the public had confidence in them, there was some way to go regarding role recognition.

Nurse-patient encounters in general practice: patterns in general practitioner involvement and use of nurse-specific Medicare items

A significant gap exists in knowledge about general practice nurses' (GPNs) patient care activities, despite their now strong presence in Australian general practice. The aim of this paper is to explore the extent of direct general practitioner (GP) involvement in nurse-patient consultations, and to compare consultations where nurse-specific Medicare items were claimable with consultations where they were not. Data from the Practice Nurse Work Survey, a national cross-sectional survey conducted between May 2007 and May 2008, were analysed. Of the total 5253 nurse-patient encounters, 29% did not involve any contact between the patient and a GP, either directly before, during or directly after the nurse consultation. Encounters without GP involvement were more likely to be indirect (e.g. by telephone) and off-site (e.g. home visits), and had higher rates of administrative actions such as documentation and arranging visits. Nurse-specific Medicare item numbers applied in less than half (42%) of nurse-patient encounters. Encounters where no such item applied were more likely to involve medical examinations, blood tests, electrical tracings, physical function tests, removal of sutures, test results, assisting at operations and preparing for procedures. These results confirm that existing data collections do not capture the extent and nature of GPNs' clinical work.

Quit in general practice: a cluster randomised trial of enhanced in-practice support for smoking cessation

BACKGROUND

This study will test the uptake and effectiveness of a flexible package of smoking cessation support provided primarily by the practice nurse (PN) and tailored to meet the needs of a diversity of patients.

METHODS/DESIGN

This study is a cluster randomised trial, with practices allocated to one of three groups 1) Quit with Practice Nurse 2) Quitline referral 3) GP usual care. PNs from practices randomised to the intervention group will receive a training course in smoking cessation followed by access to mentoring. GPs from practices randomised to the Quitline referral group will receive information about the study and the process of written referral and GPs in the usual care group will receive information about the study. Eligible patients are those aged 18 and over presenting to their GP who are daily or weekly smokers and who are able to give informed consent. Patients on low incomes in all three groups will be able to access free nicotine patches.Primary outcomes are sustained abstinence and point prevalence abstinence at the three month and 12 month follow-up points; and incremental cost effectiveness ratios at 12 months. Process evaluation on the reach and acceptability of the intervention approached will be collected through Computer Assisted Telephone Interviews (CATI) with patients and semi-structured interviews with PNs and GPs.The primary analysis will be by intention to treat. Cessation outcomes will be compared between the three arms at three months and 12 month follow-up using multiple logistic regression. The incremental cost effectiveness ratios will be estimated for the 12 month quit rate for the intervention groups compared to usual care and to each other. Analysis of qualitative data on process outcomes will be based on thematic analysis.

DISCUSSION

High quality evidence on effectiveness of practice nurse interventions is needed to inform health policy on development of practice nurse roles. If effective, flexible support from the PN in partnership with the GP and the Quitline could become the preferred model for providing smoking cessation advice in Australian general practice.

TRIAL REGISTRATION

ACTRN12609001040257.

The social world of Australian practice nurses and the influence of medical dominance: an analysis of the literature

In Australia, the number of practice nurses is growing at a rapid rate. On the nursing landscape, this group of nurses stand out because of their relationship with the Australian Government who both fund them, and concern themselves with their continuing professional development. This paper provides a construction of the social world of Australian practice nurses, identifying stakeholders in the business of practice nursing. Literature produced by the various social world segments is analysed for the influence of medical dominance on the role, image, power and politics of practice nurses.

The place of knowledge and evidence in the context of Australian general practice nursing

BACKGROUND

The purpose of the study was to ascertain the place of knowledge and evidence in the context of Australian general practice nursing. General practice nursing is a rapidly developing area of specialized nursing in Australia. The provision of primary care services in Australia rests largely with medical general practitioners who employ nurses in a small business model.

METHODS

A statistical research design was used that included a validated instrument: the developing evidence-based practice questionnaire (Gerrish et al. 2007). A total of 1,800 Victorian practice nurses were surveyed with a return of 590 completed questionnaires, equaling a response rate of 33%.

FINDINGS

Lack of time to access knowledge for practice was a barrier for participants in this study. In-service education and training opportunities were ranked as the number one source of knowledge for general practice nurses. Experiential learning and interactions with clients, peers, medical practitioners, and specialist nurses were also considered very important sources of knowledge. Research journals were ranked much lower than experiential learning and personal interactions. Participants assessed their own skills at sourcing and translating evidence into practice knowledge as low. Younger general practice nurses were more likely than older nurses to assess themselves as competent at using the library and Internet to locate evidence.

DISCUSSION

The predominantly oral culture of nursing needs to be identified and incorporated into methods for disseminating evidence from research findings in order to increase the knowledge base of Australian general practice nurses.

CONCLUSIONS

Findings from this study will be significant for policy makers and funders of Australian nursing in general practice. The establishment of a career structure for general practice nurses that includes salaried positions for clinical nurse specialists would assist in the translation of evidence into knowledge for utilization at the point of care.

Practice nurses in Australia: current issues and future directions

Almost 60% of general practices now employ at least one practice nurse. Australian Government initiatives to support the expansion of practice nursing are not consistently based on strong evidence about effectiveness, outcomes or efficiencies. Reviews from other countries suggest that practice nurses can achieve good health outcomes, but there is little information about the Australian practice-nurse workforce, funding models to support their work, scope of their practice, or its outcomes. Australian practice nursing lacks a career structure and an education framework to advance nurses' skills and knowledge. To maximise the contribution of nurses in primary care, a more systematic approach is needed, with a stronger evidence base for policy to support effective outcomes.

Depression, anxiety and stress in women following acute coronary syndrome: Implications for secondary prevention

OBJECTIVE

To document incidence of depression, anxiety, and stress in women more than 6 months following an acute coronary syndrome.

DESIGN

Participants were identified from a coronary care unit database. The Depression Anxiety Stress Scales 21 (DASS 21) was sent to potential participants via postal survey.

SETTING

A metropolitan teaching hospital in Melbourne, Australia.

PARTICIPANTS

The cohort of women was aged between 55 and 70 years. They had been admitted to hospital with a diagnosis of acute coronary syndrome (ACS) between 6 and 14 months prior to participating in this study.

MAIN OUTCOME MEASURES

Scores on Depression, Anxiety, and Stress Scale (DASS 21).

RESULTS

Of the 117 posted questionnaires, 39 women with a mean age of 63 (S.D. 4.97) responded to the survey, representing a response rate of 33.3%. Most participants scored within normal levels of depression (66.7%), anxiety (60.5%), and stress (70.3%), however, mild to extremely severe levels of each construct (33.4%, 39.6%, and 29.7%, respectively) were found.

CONCLUSIONS

The reporting of elevated levels of depression, anxiety and stress in a subset of women more than 6 months following an ACS event underscores the importance of ongoing screening for risk factors impacting on psychological well-being and the inclusion of this information in education and counseling strategies in both the inpatient and outpatient settings. Based on these pilot data, consideration of a screening system in the immediate post discharge period for women at risk and an education or support service are recommended.