Personal touch at the practice

Practice nurses perform myriad tasks in doctors' surgeries, one of the most important is to communicate with patients. By Flynn Murphy

It is 1pm on a Wednesday at Glebe Medical Centre in Sydney's inner west, and nurse Jessica Turner is sneaking a sandwich in between patients.

"It's very busy, especially now that I do pap smears as well," the full-time practice nurse explains between bites.

Last month, Turner completed a course in women's health at Family Planning NSW, which has allowed her to expand her scope of practice at the centre, qualifying her to perform breast examinations and pap smears. The course was part-funded by the clinic she works at, and part by a government subsidy.

"We encourage our nurses to improve their skill sets in private practice. We see it as an investment in our staff," says Dr Ryan Quan Vo, co-director of the centre, which took out the Sydney Small Business of the Year award last year.

Glebe Medical Centre is a 10-room, multi-disciplinary practice with GPs, allied health practitioners, and full-time nursing support. It's busy right now but not chaotic, a wall poster advertises a new smartphone app that lets patients book an appointment at the touch of their screen.

Vo says his clinic caters to a diverse demography, from the socio-economically disadvantaged to young professionals, and is open seven days a week, bulk billing for five. It has sister-clinics in Rozelle and Drummoyne, each of which has a full-time nurse. Turner joined the centre last September, after six months working in the transplant ward of the Royal Prince Alfred Hospital. She previously worked at a drug and alcohol clinic in Ultimo.

"It's a completely different skill set here," she says. Being a practice nurse means "less drama" than working in the hospital system. It also meant a pay cut - with no possibility of overtime - but offers a work/life balance that suits her better than regular night shifts at the hospital down the road.

"Having practice nurses greatly benefits doctors and patients," says Vo. "Nurses can provide additional services that the doctor may not have time for - for instance our nurses are responsible for our vaccines inventory: ordering, checking, and administering vaccines to children. This can take quite a while, and having a nurse to do that can really take the pressure off the doctors."

"These extra skills do greatly help patients because they mean patients can see nurses to get these procedures done, and often that means there are very minimal waiting times, as opposed to having to book in to see a doctor."

For Vo, nurses are ideally suited to handle follow-up care and inquiries.

"Also, a lot of the time a patient, when they see a doctor, may not have an opportunity to [get an] answer to all the questions they wanted, or they've forgotten during the consultation. Seeing a nurse gives us an opportunity to get more feedback from the patient. If a patient calls up the practice with a query, most of the clinical questions are directed to our nurse first."

Julianne Badenoch, president of the Australian Practice Nurse Association, which represents about 3500 nurses, says the core benefits offered by practice nurses were in the realm of time, and access. "[Patients will] get time, they will get a qualified professional who knows what they are talking about, and they will be given more opportunities to self-manage their care."

"There's a good business case for practice nurses," she adds.

Vo says Glebe Medical Centre receives incentive payments from Medicare for employing a practice nurse, but that the practice has been financially worse off since the federal government replaced the nursing item number system with the Practice Nurse Incentive Program last year.

"But there's a huge benefit to the practice having a full-time nurse," he said. "We still see the benefits outweighing the financial costs. It also lets the doctors see more patients.

"The GPs that have had nurses in their clinics for a long time, most of them tell me they wouldn't survive without them," adds Badenoch. "They may well say that with a smile, but I think they actually mean it. We share the load."

For a former actor, and a direct descendent of legendary Irish writer James Joyce, Turner is plain-spoken. For her, this is just part of the job.

"We free [doctors] up to get more patients, but between the two of us, patients get that complete, holistic care. I can't tell you the amount of times I've been researching stuff out of work hours and contacting patients with information. That's what nurses do. It's our job to manage vulnerability and fear.

"Good doctors know the value of nurses, and know how we're supposed to work as a team. Half the time that means explaining to patients in language they can understand what their issue is, and what the treatment is. A lot of time patients come to me and are still a bit confused about what it all means. They need reassurance.

"I had a woman recently who was diagnosed with gestational diabetes, and she walked out of the doctor's office thinking it was her fault. Her way of rectifying that was she was just not going to eat. I explained what it was, how it wasn't her fault, and that by all means she had to keep eating and just lay off the sugar. English was her second language, and she needed a simple explanation."

Badenoch would like to see the scope of practice expanded for more practice nurses like Turner. "I think it's happening - at the end of the day, nurses just need to be able to demonstrate they are educated, authorised and competent to perform new roles. They just need to back them up and demonstrate it."

Turner is positive about her career prospects, and says nurses need to be proactive about building careers for themselves in clinics.

Vo agrees: "There are a gamut of roles within private practice, and opportunities for nurses to expand their skill sets and do more procedures in women's health, chronic disease management, diabetes, and then further on if a practice is large enough they will run clinics and manage clinics, overseeing junior nurses. There are opportunities to become senior nurses and practice managers."

Asked whether these opportunities would be available at his own clinics, Vo said he wanted to bring on more nurses, and planned to open a women's health clinic - the lynchpin of which would be Turner.

Badenoch said the "negativity and turf wars of the past" were coming to an end when it came to GPs and practice nurses, though the nurse practitioner role, which included the expansion of the scope of nurses to prescribe certain medications, remained controversial.

Badenoch, who herself works as an RN at a beach resort clinic in South Australia, said at her site, collaboration was key.

"You never know what it's going to be next - a broken arm, a kid scalping themselves on the pool - in the practice I work in it's a team effort. We are consulted all the way along. Patients generally see the nurse before they see the doctor, and half the work is done.

"[APNA is] still constantly told by our members that they want a career pathway, they want a direction that lets them build on their skills," she said.

To that end, this year APNA is working on a proposed education and career pathways structure for nurses in primary health care. "We've found that a lot of practice nurses love the work they're doing, their hours and the variety of their care, but far fewer were satisfied with the recognition they received, and their opportunities [for career advancement]."

Badenoch said the organisation would invite the Australian Nurses Federation to partner with them in order to tackle union-centred issues such as equitable pay.

"The practices that welcome nurses benefit, and the community benefits. Particularly in rural areas where there are such significant workforce shortages."

Turner says when it comes to collaborations between GPs and practice nurses, as long as the patients come first, it doesn't matter whose egos are bruised.

"Many doctors don't mean to come off as being dismissive, but often they are so busy, and patients don't understand what's going through their heads - so they feel like they're not getting listened to, or that the doctor doesn't care. If you look at the reality of some doctors, they've spent their whole life studying, and then you've got these very intelligent people who lack social skills and whose identity is wrapped up in being a doctor.

"I was doing a pap smear the other day with a woman, who is about 50. She'd been having crazy menopausal symptoms for years, but was still menstruating. So the doctor said 'nope, it's not menopause, you're fine'.

"So I get to her and she's saying 'I'm going crazy, I'm having mood swings, I'm newly married and accusing my husband of cheating but I know he's not cheating!' - the symptoms were unmanageable for her. It was just a case of listening to her and saying 'you're perimenopausal, you're not crazy, it's going to come'.

"Problem shared, problem halved."

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