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A need to be specific about general practice

With practice nurses doing a wider range of work in general practice their duties and responsibilities have to be clearly defined. By Eamon Merrick, Christine Duffield, Richard Baldwin and Margaret Fry.

Nursing features prominently in the future of Australia's primary healthcare sector. Nowhere is this more evident than in general practice. This is reflected in both the number of nurses working in general practice and their contributions to patient care.

The number of nurses working in general practice has increased three-fold in the past 10 years; and in 2009-10 it was estimated that practice nurses were involved in the care of 6 per cent of the patients who attended a general practice.

The increase in both the number of practice nurses and how much they contribute to care has, to a large extent, been influenced by Australian government policy.

The ability of the government to influence the primary healthcare sector in Australia is largely due to the dominance of Medicare as a mechanism of funding service provision. For example, since the introduction of Medicare funding for services provided by practice nurses there has been a significant growth in practice nursing activity.

This is illustrated by the 3.5 million more claims (between 2003-04 and 2008-09) paid by Medicare for immunisations provided by practice nurses; and the 2 million more claims for wound care services provided by practice nurses during the same period.

The introduction of funding for practice nurse services is one example of a number of different policies that are seeking to address the challenges faced by Australia’s healthcare system. The challenges are significant, and include: rising healthcare costs, increased demand for services, more people with more health complaints, more long-term health complaints, and workforce shortages.

The primary healthcare sector offers opportunities for addressing these challenges. In this sector patients can be guided through an often complex network of specialists, hospitals, diagnostic, and treatment services. Primary healthcare professionals can develop relationships with patients and this promotes continuity of care.

Where there is continuity of patient care there will be fewer acute episodes of illness and long-term health outcomes can be improved. The Australian government is seeking to strengthen the primary healthcare sector. This is most evident in the government’s response to the National Health and Hospitals Reform Commission report, and the resulting primary healthcare strategy, Building a 21st Century Primary Health Care System.

One aspect of the national strategy is the introduction of the “super-clinic”. The intention of which is to co-locate services and professionals, including practice nurses. It is hoped that doing so will achieve efficiencies of scale and promote multi-disciplinary team care arrangements.

While the primary healthcare sector is offering interesting opportunities for practice nurses, there is a need to ensure support for the further development of practice nursing. Practice nurses are, and will increasingly be called upon to take on new roles and responsibilities. It is likely that this will coincide with and involve new working arrangements. These working arrangements will represent a major shift from the traditional work structures that have prevailed in general practice.

Traditionally GPs have been the custodians of patient care, delegating responsibility when appropriate. The new working arrangements will require nurses to collaborate with medical colleagues on an equal basis. In addition, initiatives such as the super-clinic will create environments where practice nurses will find themselves working with a larger number of general practitioners and broader multidisciplinary teams. Within this more complex working environment practice nurses may need to take on additional clinical roles and provide leadership for a wider range of staff.

Practice nurses are, and more often will be required to exercise independent judgment, articulate their contributions to patient care, and demonstrate their ability to develop relationships with both patients and a wide range of professionals.

In Australia, leading researchers such as Elizabeth Halcomb and Christine Phillips are developing a body of evidence indicating that practice nurses are, at any one time: organising and delivering patient care, educating patients and other professionals, and connecting patients and services.

Despite this research there is still to be a clear articulation of the boundaries and the scope of nursing in general practice.

Practice nurses are currently being asked to broaden their scope of practice, and are doing so both for their patients and for the nursing profession. Yet they are doing so without a clear understanding of what it is that constitutes contemporary practice nursing.

This situation is contributed to by the traditional view of the general practitioner as the custodian of patient care, a view that remains pervasive. It is this view that results in the roles of practice nurses being negotiated on an ad hoc basis. Consequently there is a lack of clarity about what Australian practice nursing constitutes.

Practice nursing in Australia has entered into an important period of change. As government policy focuses on the primary healthcare sector there are significant opportunities for practice nurses.

These include opportunities to demonstrate their ability to work in multidisciplinary teams, to be accountable for the development of their own skills and abilities, and to prove themselves as leaders in the primary healthcare sector. By utilising emerging opportunities practice nurses can address the challenges facing the healthcare system. By doing so patients are likely to benefit from improved continuity of care and improved health outcomes.

Eamon Merrick is a doctoral candidate at the Centre for Health Services Management, Faculty of Nursing, Midwifery, and Health, University of Technology, Sydney. Christine Duffield is Associate Dean, research, and Richard Baldwin a senior lecturer at the centre. Margaret Fry is higher degree program co-ordinator in the faculty.

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