The role of the nurse in general practice

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Overview

• Overview of nursing in general practice in Australia and overseas

• Practice Nurse role broadly

• What does a practice nurse look like

• How are nurses funded in general practice

• Nursing roles in chronic disease management and lifestyle risk factor management

• Challenges for the role and future opportunities

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Numbers of General Practice Nurses

State 2005 2007 2009 % change since 2007 % change since 2005

NSW 1157 2010 2441 21% 111%

VIC 1515 1926 2026 5% 34%

QLD 1112 1707 2061 21% 85%

SA 203 663 764 15% 276%

WA 722 895 986 10% 37%

TAS 126 266 332 25% 163%

NT 59 186 197 6% 234%

ACT 30 75 107 43% 257%

Total 4924 7728 8914 15% 81%

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Practice nursing overseas

United Kingdom

• Specialty started to develop in 1980’s• From 1900 nurses in 1984 to 25000 in 2003• Largely due to GP contract and focus on health promotion/chronic disease• Role developed further- nurse partners, sub-providers etc• Nurse prescribing rights

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New Zealand

• 1970- Practice nurse subsidy• 1983- Government introduced requirement that role include specific clinical

duties• Population health basis for funding• Some great models of teamwork and has been greater room for role

expansion

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Australian context

MBS definition

A general practice nurse is • RN/Div 1• EN/Div 2• Employed in a general practice• Or whose services are retained by a general practice

One part of a wider group of nurses working in primary health care including community nurses, school nurses, maternal child health nurses, occupation health nurses, sexual health, women’s health and more.

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Practice nurse role

• Clinical care– Clinical procedures and activities

• Clinical coordination– e.g. recall/reminder, population health approach

• Practice administration– Accreditation support

• Integration– Liaison with other providers

RACGP/RCNA 2004

Immunisation

Wound Management

Women’s health

Chronic disease clinics

ECGs, Pathology, Routine obs

Patient education

Care planning

Health assessments

To name a few!

Operating RolesNurse as patient carer Nurse as quality controller Nurse as organiser Nurse as problem solver Nurse as educator Nurse as agent of connectivity

Phillips et al 2009

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Evolution of role

• From ‘expediency measure’ to career • GP directed autonomous• Huge diversity in role• Rapid evolution

29.4% (2006 26.9%, 2005 21%) of Practice Nurses run a nurse-led clinic

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What does a practice nurse look like

• 88.7% RNs, • 10% EN/Div 2s• 42.9% aged between 41 -50, 33.4% aged between 51-60• Mean years spent in practice 7 years• Employment

– 24.0% full time– 58.9% part time– 16.4% casual

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Development of practice nursing

• NiGP program (2001) Commonwealth funded– Rural PIP Subsidy ($8000 per EFT GP) – Training and support

• Division of General Practice capacity building• Consumer information• Supporting training (scholarships)

• Encourage network and mentoring (APNA Seed funding)– Rural re-entry scholarships scheme (not just practice nurses) 2005/6 Federal

• Budget 2005 - funding continued $128m including $112m for PIP subsidy

– PIP subsidy extended to areas of workforce shortage

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Development of practice nursing

• PN item numbers introduced– Immunisation and wound management (2004)– Pap Smears (2005)

– Pap Smears and preventive care, antenatal care (2006)– Chronic disease management item numbers (2007)

• GPMP and TCAs replaced EPC and role of nurse expanded within thisFor and on behalf of GP

Over 20 million PN items claimed since 2004

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Indigenous item numbers

• Indigenous Health assessment• PN chronic disease item number 10987

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Advanced nursing roles in general practice – what do they look like?

• Chronic disease management– Nurse first doctor second clinics– Disease specific management e.g. diabetes, COPD, CVD

– Chronic disease self management/patient education– System management– Liaison with other health providers and carers

– And more • Prevention

– Lifestyle risk factor management including physical activity advice and coaching, weight management, smoking cessation

• Women’s health, sexual health, family and child health/immunisation, emergency management/triage, antenatal and postnatal care, pre-employment medicals, residential aged care, continence management, INR management etc

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Lifestyle risk factor management

• ‘Lifestyle nurse’ model • Weight management clinics• Smoking cessation interventions

– Development and evaluation of a primary care smoking cessation service - Nicholas Zwar,, Robyn Richmond, Gail Forlonge ,Julie Smith

• Pilot of project using practice nurses to provide safe alcohol use education and undertake brief interventions for high risk alcohol use –South City General Practice Network

• General health promotion• Walking group for socially isolated patients with chronic disease

The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its

recovery (or to peaceful death) that he would perform unaided if he had the necessary

strength, will or knowledge.

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Evidence for roles broadly

• Studies have shown that general practice nurses (GPNs) are as effective [i] as General Practitioners (GP) in performing certain primary care functions whilst receiving better results in patient satisfaction surveys.

– Nurse-led care may involve higher levels of patient satisfaction and quality of life than doctor-led care [ii]

– Nurses are better managers of interpersonal relationships [iii], through clearer communication, conducting effective counselling and possessing better interviewing skills

– GPNs can provide long-term care management and promote choice and positive health [iv]

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Access to PBS and MBS for Nurses Practitioners in 2010

• Federal Budget 2009• Nurse practitioners vs general practice nurses• Small numbers but expect to grow• High level of debate currently

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Future challenges for integration of nurses into general practice team

• Clinical governance

Funding

Regulatory authorities

Employer

Indemnity

‘To succeed as a team is to hold all of the

members accountable for their expertise’

Mitchell Caplan CEO, E*Trade Group Inc

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Other challenges for integration of nurses into general practice team

• Acceptance of role by other health professionals and community

• Rapid evolution of the role and influx of ‘novice’ practice nurses

• Funding• No current career path or definition of specialty or

CPD framework – but happening• Industrial environment – cottage industry• Infrastructure• Practice nurse vs primary health care nurse

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Future

• Key members of clinical team in general practice• Providing a comprehensive range of services • ? More specialization within general practice, including teams of nurses with

mental health nursing, domiciliary nursing, maternal child health nursing all in same building.

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References and links

[i] Horrocks, Sue et al (2002). "Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. (Primary Care)." British Medical Journal 324.7341 (April 6, 2002): 819(5).

[ii] Laurent, M et al (2008). ‘Substitution of Doctors by Nurses in Primary Care’, The Cochrane Library 2008, Issue 2, UK: John Wiley and Sons.

[iii] Chambers, Naomi (1998). ‘Nurse Practitioners for the UK’ in Nurse Practitioners in Primary Care, UK: Radcliffe Medical Press Ltd., p. 17.

[iv] ‘Key Roles and Responsibilities of Nurses in General Practice’ (2006), National Health Service, UK, viewed 16 May 2008 <http://www.wipp.nhs.uk/tools_gpn/key_roles_responsibilities_gpns.php>.

Other referencesEckermann, S. [2009], PHC RIS: practice nurses - enhancing primary health care

services in rural Australia’, Howard, S., Aust J Rural Health, 17(2), 111Halcomb EJ, Davidson PM, Salamonson Y, Ollerton R, & Griffiths R. (2008). Nurses

in Australian general practice: implications for chronic disease management. J Clin Nurs, 17(5A), 6-15.

Jolly R. (2007). Practice nursing in Australia. Canberra: Social Policy Section, Parliament of Australia.

Keleher H, Joyce CM, Parker R, & Piterman L. (2007). Practice nurses in Australia: current issues and future directions. MJA, 187 (108-110).

Halcomb EJ, & Davidson PM. (2006). The Role of Practice Nurses in an Integrated Model of Cardiovascular Disease Management in Australian General Practice. Australian Journal of Primary Health, 12(2), 34-44.

Hegney D, Eley R, Buikstra E, Rees S, & Patterson E. (2006). Consumers' Level of Comfort with an Advanced Practice Role for Registered Nurses in General Practice: A Queensland, Australia, Study. Australian Journal of Primary Health, 12(3), 44-51.

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Links

• Primary Health Care: A nursing consensus view http://www.anf.org.au/anf_pdf/publications/PHC_Australia.pdf

• Australian Practice Nurses website www.apna.asn.au

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Supporting nurses in general practice

1300 303 184www.apna.asn.au