An ethnographic exploration of the social organisation of general practice nurses' knowledge use: more than 'mindlines'?

AIM

To explore contextual, organisational and educational issues impacting on access to, and application of knowledge to everyday practice by general practice nurses, working in two rural primary-care practices in the UK.

BACKGROUND

Changes in primary-care healthcare delivery have resulted in substantive changes to practice nurses' roles. Practice nurses have taken on enhanced roles for which they were not prepared for in their initial training, little is known about how they access and apply knowledge.

METHODS

Ethnographic methods were used to gather data.

RESULTS

Practice nurses take a blended approach to knowledge use, using elements of evidence-based practice to support professional judgement. This is subject to several contextual influences, organisational, educational and from individual patients. Tensions exist between the position in which general practice nurses are situated and the nature in which knowledge is disseminated and used in primary care. Whilst examples of clinical mindlines were evident, these differed to those previously observed in general practitioners, practice nurses did not always have the mindline on which to draw and used an approach to practice that resembled 'bricoleur activity'.

CONCLUSIONS

The way in which general practice is structured results in variance in organisational structural arrangements for sharing and disseminating of knowledge. Despite a supportive organisational culture towards knowledge sharing, the position in which practice nurses are situated limits opportunities for discussion and reformulation of knowledge. Practice nurses are, however, prepared to adapt knowledge to meet the needs of individual patients.

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.

Scoping the role and education needs of practice nurses in London

Aims To identify education priorities for practice nursing across eight London Clinical Commissioning Groups (CCGs); to identify the education, training, development and support needs of practice nurses in undertaking current and future roles.

BACKGROUND

The education needs of practice nurses have long been recognised but their employment status means that accessing education requires the support of their GP employer. This study scopes the educational requirements of the practice nurse workforce and working with educational providers and commissioners describes a coherent educational pathway for practice nurses.

METHOD

A survey of practice nurses to scope their educational attainment needs was undertaken. Focus groups were carried out which identified the education, training, development and support needs of practice nurses to fulfil current and future roles. Findings A total of 272 respondents completed the survey. Practice nurses took part in three focus groups (n=34) and one workshop (n=39). Findings from this research indicate a practice nurse workforce which lacked career progression, role autonomy or a coherent educational framework. Practice nurses recognised the strength of their role in building relationship-centred care with patients over an extended period of time. They valued this aspect of their role and would welcome opportunities to develop this to benefit patients.

CONCLUSION

This paper demonstrates an appetite for more advanced education among practice nurses, a leadership role by the CCGs in working across the whole system to address the education needs of practice nurses, and a willingness on the part of National Health Service education commissioners to commission education which meets the education needs of the practice nurse workforce. Evidence is still required, however, to inform the scope of the practice nurse role within an integrated system of care and to identify the impact of practice nursing on improving health outcomes and care of local populations.

Workplace-based clinical leadership training increases willingness to lead

PURPOSE

The purpose of this paper is to reflect upon a workplace-based, interdisciplinary clinical leadership training programme (CLP) to increase willingness to take on leadership roles in a large regional health-care centre in Victoria, Australia. Strengthening the leadership capacity of clinical staff is an advocated strategy for improving patient safety and quality of care. An interdisciplinary approach to leadership is increasingly emphasised in the literature; however, externally sourced training programmes are expensive and tend to target a single discipline.

DESIGN/METHODOLOGY/APPROACH

Appraisal of the first two years of CLP using multiple sourced feedback. A structured survey questionnaire with closed-ended questions graded using a five-point Likert scale was completed by participants of the 2012 programme. Participants from the 2011 programme were followed up for 18 months after completion of the programme to identify the uptake of new leadership roles. A reflective session was also completed by a senior executive staff that supported the implementation of the programme.

FINDINGS

Workplace-based CLP is a low-cost and multidisciplinary alternative to externally sourced leadership courses. The CLP significantly increased willingness to take on leadership roles. Most participants (93 per cent) reported that they were more willing to take on a leadership role within their team. Fewer were willing to lead at the level of department (79 per cent) or organisation (64 per cent). Five of the 11 participants from the 2011 programme had taken on a new leadership role 18 months later. Senior executive feedback was positive especially around the engagement and building of staff confidence. They considered that the CLP had sufficient merit to support continuation for at least another two years.

ORIGINALITY/VALUE

Integrating health-care professionals into formal and informal leadership roles is essential to implement organisational change as part of the drive to improve the safety and quality of care for patients and service users. This is the first interdisciplinary, workplace-based leadership programme to be described in the literature, and demonstrates that it is possible to deliver low-cost, sustainable and productive training that increases the willingness to take on leadership roles.

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.

From the clinical to the managerial domain: the lived experience of role transition from radiographer to radiology manager in South-East Queensland

Introduction

This study seeks to add to current literature a descriptive account of the lived experience of radiographers' transition to, and experiences of, management roles and identifies additional resources and support that are perceived as being beneficial for this transition.

Methods

This study employed a descriptive phenomenological stance. Using purposive sampling, six South‐East Queensland based private practice radiology managers, who had held their position for longer than 3 months, participated in audiotape recorded in‐depth interviews exploring their transition to, and experiences of management in radiology. Thematic analysis was used to describe and make meaning of the data.

Results

Overall, five central themes emerged through thematic analysis of the data. The results indicate that all participants' had an underlying drive to succeed during their role transition and highlight the importance of a comprehensive orientation by a mentor; the training and support to enable preparation for the role, especially in the area of people management skills and communication; the importance of access to networking opportunities and the importance of concise expectations from higher management.

Conclusion

Role transition can be marred with uncertainty, however; key suggestions indicate the importance of having support mechanisms in place before, during and after transitioning to a managerial role.

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.

Trust and decision-making: How nurses in Australian general practice negotiate role limitations

AIM

To explore the importance of role recognition and relationships between the opportunities for decision-making, social support, and skill development, in a sample of nurses working in general practice in New South Wales, Australia.

BACKGROUND

Understanding how nurses make decisions about patients and their care in general practice will benefit organisations and public policy. This understanding is important as the role changes and opportunities for further role development emerge.

DESIGN

A sequential mixed methods design was used. Study 1 utilised the internationally validated Job Content Questionnaire to collect data about decision making, social support, skill development, and identity derived from the role. In 2008 a purposive sample of nurses working in general practice (n = 160) completed and submitted an online Job Content Questionnaire. Study 2 used a set of open-ended questions informed by Study 1 to guide semi-structured interviews. In 2010 fifteen interviews were undertaken with nurses in general practice. Demographic characteristics of both samples were compared, and the findings of both studies were integrated.

RESULTS

The integration of findings of Study 1 and 2 suggests that nurses defined their expertise as being able to identify patient need and communicate this to the general practitioner, the ability to do so led to the development of trusting relationships. Trusting relationships led to greater support from the general practitioner and this support allowed the nurse greater freedom to make decisions about patient care.

CONCLUSIONS

Nurses gained influence in clinical decision-making by building trusting relationships with patients and medical colleagues. They actively collaborated in and made decisions about patient care. These results suggest that there is a need to consider how nursing can more effectively contribute to care in general practice settings.

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.

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.

The new clinical leadership role of senior charge nurses: a mixed methods study of their views and experience

AIMS

To investigate the experience and views of senior charge nurses in relation to the implementation of a national clinical leadership policy.

BACKGROUND

The role of the senior charge nurse in providing clinical leadership is evolving. However, recent evidence suggests that research is needed to inform the development of leadership and quality improvement and to connect them.

METHODS

Data were collected using an electronic survey to all senior charge nurses in one locality and semi-structured interviews with a subsample of respondents. Fifty (54%) senior charge nurses responded to the survey and nine were interviewed.

RESULTS

Senior charge nurses reported mainly positive perceptions of clinical leadership, clinical team performance and improvement of care delivery for patients following the leadership programme implementation. Themes related to confidence, quality improvement and team performance were generated.

CONCLUSIONS

'Leading Better Care' was reported to enhance senior charge nurse clinical leadership, with some development needed to link the details of change management with the wider strategic direction.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers may wish to ensure that their clinical leaders have clarity of role in order to inspire confidence. Some challenges were noted in achieving improvement in quality and it is possible that if improvement in quality is the cornerstone of patient-centred care then it needs to be placed centrally in workload considerations.

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.

Nurses' perceptions of leadership style in hospitals: a grounded theory study

AIM

This paper explores the leadership style of hospital managers.

BACKGROUND

Leadership has been widely studied in nursing from the perspective of nurses' psychological strain caused by nursing leadership. There is, however, little contained in the Western and Eastern literatures on the leadership style of hospital managers and certainly no study has explored managers' leadership style in Taiwanese hospitals from the nurses' stance.

DESIGN

Grounded theory.

METHODS

A sample of 28 nurses from seven teaching hospitals in Taiwan, Republic of China was selected through theoretical sampling. A multi-step analytic procedure based on the grounded theory approach was used to analyse the qualitative data.

RESULTS

The Chinese culture was found to affect the leadership style of Taiwanese hospital managers. They had extreme power and led nurses in a hierarchical manner. Nurse managers followed the autocratic leadership style of their hospital managers. The main category found in this study was thus hierarchical leadership.

CONCLUSIONS

The Confucian principles of authoritarianism and obedience were found to be part of the Taiwanese hospitals' organisational cultures and strongly impacted on the managers' leadership style. Hospital managers' treatment of doctors and nurses was dependent on their social rankings. Nurses' lowly ranking fed into these enculturated managerial tendencies of using power and obedience thus increasing psychological strain on nurses.

RELEVANCE TO CLINICAL PRACTICE

Managers of the hospitals demonstrate power and misuse obedience through their leadership style, resulting in deterioration of nurses' work environment. Nurses' managers are not given enough power by the hospitals in Taiwan. Subsequently, nurses feel themselves the lowest and most powerless subordinates. This study reveals that the Chinese cultural burdens are embedded in the leadership of Taiwanese hospitals. These findings enhance the knowledge of leadership and add to the understanding of managerial attitudes in Chinese hospitals located worldwide.

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.

Empowerment and enterprise: the political economy of nursing

Throughout the past decades, Australian nursing has made significant advances in the clinical, research, and political arenas. Capitalising on these advances is a critical step in empowering the professions and a sound investment in the health of the nation. There remains a need to energise and empower the professions, to see our work as an enterprise that has value and a sense of worth because of our professional activities as well as for the political and economic contributions we make to health and wellbeing, quality of life and social justice. The contributions made by nurses and midwives need to be articulated in the policy arena, focused in professional decision-making and elaborated in our research agendas. Our professional organisations provide opportunities for solidarity, and the leverage we need to effect change at the bedside, the community and the whole of society. Renewed commitment to primary health care at the global, national and community level provides a timely rallying call to the professions to refine the way we articulate our position in health care, re-commit to culturally appropriate, socially just actions and embolden our professional goals to inspire the next generations of nurses for a more equitable future.

Benefits and limitations of nurses taking on aspects of the clinical role of doctors in primary care: integrative literature review

AIM

This paper presents an integrative literature review of studies exploring the benefits and limitations of the recent expansion of the clinical role of nurses working in general practice in the United Kingdom.

BACKGROUND

Similar clinical outcomes and high levels of satisfaction with consultations undertaken by nurse practitioners compared to general practitioners in primary care have been reported in a Cochrane review [Cochrane Database of Systematic Reviews (2004) vol. 5, p. CD001271]. Since then, nurse consultations have increased considerably as general practitioners have delegated part of their clinical workload to other general practice nurses. However, whether all general practice nurses can fulfil this extended role remains open to question.

METHOD

An integrative review was performed. Nine electronic databases were searched. UK studies were included if they were published after the previous Cochrane review, i.e. between 2004 and 2009.

RESULTS

Eight studies were identified, most using qualitative methodology. The evidence suggested that the changes in nurses' role have been predominantly driven by the perceived increase in workload arising from the new general practitioner contract. Delegating work to nurses provided a means of organizing workload within a practice without necessarily allowing patient choice. Patients generally thought that all general practice nurses would be able to deal with simple conditions, but they would prefer to consult with a general practitioner if they thought it necessary. There were concerns about nurses' knowledge base, particularly in diagnostics and therapeutics, and their levels of training and competence in roles formerly undertaken by general practitioners.

CONCLUSION

There have been few studies in this key area of healthcare policy. There is a need for better training and support for nurses undertaking roles in consultation and for patients' views to be better represented.

Validation of the Professional Practice Environment Scale in Australian general practice

PURPOSE

To validate the Professional Practice Environment Scale (PPE) in Australian general practice.

METHODS

The PPE was modified slightly for appropriateness for the practice setting and administered to a sample of 342 Australian general practice nurses via an online survey tool. The factor structure of the 38-item PPE was examined using principal components analysis with Varimax rotation.

FINDINGS

An eight-factor solution accounted for 71.6% of the variance. Low factor loading (<0.3) or cross-component loadings were detected in eight items. A comparison of Cronbach's alpha values demonstrated little change in the deletion of eight items from four of the eight related components.

CONCLUSIONS

Findings demonstrated that a 30-item version of the PPE was reliable and valid for use to assess the professional practice environment of nurses working in Australian general practice.

CLINICAL RELEVANCE

A tool to measure the professional practice environment in general practice is important as it will assist in monitoring the impact of the work environment on the recruitment, retention, and satisfaction of nurses in this setting.

The work of nurses in Australian general practice: A national survey

BACKGROUND

Following recent reforms to Australia's health system, nurses now comprise a significant and growing sector of the Australian primary care workforce, but there is little data describing the services they provide.

OBJECTIVES

This study aimed to describe the patient consultations of nurses in Australian general practice, including patient characteristics, reasons for the consultation, treatments provided and other actions taken.

DESIGN

The study was a national cross-sectional survey, with each participating nurse collecting information about 50 nurse-patient encounters.

SETTING

General practice settings in all regions of Australia.

PARTICIPANTS

108 nurses volunteered in response to advertisements and 104 returned completed study materials. Participants included Registered (Division 1) and Enrolled (Division 2) nurses working in a general practice setting.

METHODS

Data were collected between May 2007 and May 2008 using a profile questionnaire and a series of encounter forms. Information was gathered on reasons for encounter, patient characteristics, and actions taken. Data were classified using the International Classification of Primary Care.

RESULTS

The final data set included 5,253 nurse-patient encounters. 37.2% of patients (95% CI 33.3-41.2) were aged 65 and over, and 57.1% were female (95% CI 54.9-59.5). The majority of encounters (90.7%) were with existing patients of the practice (95% CI 89.1-92.7). The most common reasons for encounter were general and unspecified problems (35.4 per 100 encounters; 95% CI 31.8-39.1), followed by skin-related problems (20.0; 95% CI 17.3-22.8), and cardiovascular problems (11.0; 95% CI 8.7-13.3). Common management actions included medical examinations (20.7 per 100 encounters), immunisations (22.5), diagnostic tests (10.6), and dressings (15.8). Approximately 30% of encounters involved advice-giving.

CONCLUSIONS

The findings confirm the generalist nature of the General Practice Nurse role, with a wide range of patient types and clinical conditions. There is a clear influence of current funding and organisational arrangements on work patterns, with tasks that have specific funding (including immunisations and wound care) featuring prominently in nurses' work. Whilst nurses' rates for presenting conditions were similar to doctors at a general level, specific actions taken and problems managed differed. New policy reforms in Australia are supporting greater flexibility in the General Practice Nurse role, maximising efficient use of nurses' skills in the primary health care context.