Practice nursing is one of the few growth areas in the Australian general practice workforce. Between 2003 and 2007, the number of practice nurses nearly doubled, to 7824.1,2 By contrast, in the 5 years to 2005, the Australian nursing workforce increased overall by only 6.6%.3,4 The growth of general practice nursing has been facilitated by a number of Medicare-rebatable items for nurses, incentives in rural areas to hire nurses, support from the Divisions of General Practice,5 and the federal government’s Nursing in General Practice program. Employing practice nurses has been touted as a way of solving health workforce shortages6 and improving quality of health care.7,8 Despite the largely positive rhetoric about practice nurses in the medical and mainstream media,9,10 there has been little detailed research on their roles or the ways in which they may be changing the general practice workplace.11
Australian general practices are small-scale, geographically dispersed businesses with considerable structural diversity. Australian studies on practice nursing have for the most part been small studies using interviews (which may have poor generalisability)12,13 or larger surveys of reported activities by nurses (which may overlook contextual issues).14,15 Our study aimed to describe the evolving roles of practice nurses in Australia and the impact of nurses on general practice function.
Tracing practice nurse activities is methodologically complex, particularly during a time of rapid change. Our study had two components:
A cross-sectional study exploring the scope and contextual determinants of nurse roles (Substudy 1); and
A 12-month longitudinal study exploring change in nurse roles and their impact on general practices as organisations (Substudy 2).
For Substudy 1, multiple data were collected during day-long visits (one per practice) to 25 practices in New South Wales and Victoria between September 2005 and March 2006 (Box 1). The diverse datasets gathered (using interviews, observations, photographs, field notes and practice maps) were designed to illuminate the relationships between nurse roles and the practice’s physical and managerial structure, as well as the perspectives of nurses, managers and general practitioners on nurse roles (Box 2).
For Substudy 2, action research (a process of collective problem-solving)17 was used to engage nurses, GPs and practice managers in identifying and introducing a change to the role of the practice nurse. The sampling frame included seven practices nominated by their Divisions of General Practice as “cutting edge” or “mainstream” general practices (one urban, three regional and three rural practices located in Victoria, NSW, Western Australia, South Australia and Queensland). The impact on the practice was followed with collection of baseline, process and outcome data over a 1-year period (between January 2007 and March 2008) and interviews with practice and Division staff (Box 2). Practices received minimal external support from the research team.
In both substudies, intra-case and inter-case analyses were performed for each practice by a multidisciplinary team (sociologist, nurse, GP, policy analyst). The team probed for emergent themes, using the constant comparison method,18 and cross-checked with practices. Emergent themes included structural elements (health care policy, environment, gender, nursing culture); practice-level elements (interprofessional relationships, time-use patterns, spatial structures); and individual factors. All data, including photographs and floorplans, were coded into a database using NVivo qualitative data analysis software, version 7 (QSR International, Melbourne, Vic), enabling triangulated data interpretation.
We identified six roles for nurses in general practice: patient carer, organiser, quality controller, problem solver, educator and agent of connectivity. We illustrate these with reference to Substudy 1, and discuss enhancement of these roles with reference to Substudy 2.
For nurses, “patient care” incorporates both clinical activities and relationships with patients. Nearly half (43.5%) of the observed nurse time was spent in clinical activities: vaccinations; patient education; wound management; chronic disease monitoring and support; Pap smears; tests such as spirometry and electrocardiograms; assisting with procedures; health assessments; and triage. Only 21% of the clinical activities undertaken by nurses were directly funded through Medicare.
[B]ecause I do health assessments I know a lot of them and they do ring me too for problems they have. I’m expecting someone to come over — I’ve just organised a new blood sugar monitor for her. She’s a diabetic and she rang me and said she wanted to know how to use it. So I’m going to go through that with her . . . she doesn’t have to see the doctor, it’s just a service, just an extra thing to fit into the day. [Practice nurse 2, Practice 5]
Nurses undertook the organisational aspects of patient care (recall systems, reminders, feedback of patient results, follow-up of specialist appointments) and systems supporting patient care (stocking drugs, cleaning and sterilising instruments, managing contaminated waste). A range of nurses’ desks, demonstrating the way they configure their workstations as places that communicate organisational and clinical activity, is shown in Box. The organisational features, such as crowded pin-up boards, “post-it” notes and flyers, are typical of nurses’ rather than doctors’ desks.
All respondents raised practice accreditation as an activity that called on nursing strengths in procedures and systematised practice.
I was involved in the first accreditation process and I really needed her expertise. Nurses, they understand a lot of — because of their hospital background — a lot of this bureaucracy-speak which is foreign to general practice. [GP, Practice 16]
In contrast to the organiser role, the problem solver role was characterised by more proactive and strategic behaviour. This role involved complex thinking, incorporating contextual scanning, assessment and rapid response.
In addition to the patient education included in the patient carer role, nurses were educational resources for practice staff. Nurses, who are used to training and professional development in the hospital system, speak of education as a resource for others and describe an explicit responsibility to distribute new knowledge to peers.
Nurses operated as agents of connectivity between different disciplines within the practice and between patients and the practice. Observations revealed that nurses spent 45% of their time in contact with patients and 16% of their time in contact with other general practice staff. Triaging is a signal nursing activity, and nurses often undertook informal surveillance of the waiting room. This allowed them to have intercurrent conversations with patients, which (in the accounts of administration staff) helped to mollify dissatisfied patients and to ensure that sick patients were given priority.
Nursing work is generally very busy, with nurses rapidly cycling between many roles or undertaking them concurrently. An example of cycling between five roles in one rural general practice is presented in Box 4. While undertaking several clinical tasks, the nurse also left the room to locate lost files, oversee the transfer of pathology specimens to the courier, and have a conversation with a patient in the waiting room. She then educated her nursing colleague about oral rehydration. The layout of the practice, with a central treatment room affording ready access from the GP consultation rooms and reception desk, reinforced her connectivity role.
The nurse roles addressed in Substudy 2 are listed in Box 5. The patient carer role was addressed most frequently, reflecting its primacy in the eyes of all clinicians in general practice. Enhancing the nurse role in one area often had the complementary effect of advancing other roles (Box 6). Open communication between GPs, managers and nurses was an important determinant of successful enhancement of nurse roles. In Practice 29, which failed to enhance the patient carer role through one project, the collaborative planning process resulted in identification of another project to (successfully) enhance this role. The inability of Practice 27 to introduce a change in the educator role was because of the lack of priority given to education and connectivity by doctors in a practice that lacked systems for formal interdisciplinary communication.
Our study showed that practice nurses perform at least six roles, often alternating rapidly between them. The six roles elaborate on, and are consonant with, the four domains of practice articulated in a 2004 Australian report on practice nurse roles: administration, clinical care, integration and practice management.14 The connectivity role represents a fundamental nursing strength that has also been described in Australian hospital studies.19 The function of nurses as agents of connectivity has been implicitly taken up in the interim report of the National Health and Hospitals Reform Commission20 in its calls for nurses to be in schools, provide aged-care outreach, support disabled patients, and foster connections between hospital and community. Complexity theory suggests that interconnecting, complex relationships and linkages within an organisation help it to be resilient and adaptive.21-23 Our study suggested that the connectivity role of nurses may help drive organisational resilience in general practice.
Although GPs recognised the nurse roles of patient carer, organiser and quality controller, they were less aware of the problem-solver, educator and connectivity roles. Representations from GPs on the potential scope of practice of nurses may, therefore, underplay some key nursing contributions to general practice. At present, these roles are supported by the more flexible working patterns of nurses. In adjusting the funding structure for nurses, care should be taken not to create perverse incentives to limit nurses’ clinical capacity or undermine the flexibility that gives practice nursing much of its savour for nurses and value for practices.24,25
1 Characteristics of participating practices, Substudy 1
Private + experimental collaborative model with state partners |
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2 Description of datasets for each substudy
A range of nursing stations in general practice, illustrating the organiser role of nurses
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This workstation, reminiscent of a hospital nurses’ station, overlooks a multibed treatment room. |
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The organisational function of this workstation is indicated by the profusion of “post-it” notes on the noticeboard, although patients also consult the nurse in this space. |
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This workstation is in a transitional space where the nurse cannot consult with patients. It is a site of purely organisational activity. The sign above the station reads “Good practice nurses are worth their weight in gold”. |
5 Changes introduced to nurse roles, Substudy 2
Nurse-led collaboration for better mental health care communication |
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6 Case study of multiple role enhancement (Practice 30)
This urban practice, consisting at baseline of seven doctors, one part-time nurse and a practice manager, had long waiting times and struggled to accommodate “walk-in” patients. The general practitioners spent a lot of unpaid time on the phone providing advice or following up patients.
Abstract
Objective: To describe the evolving roles of practice nurses in Australia and the impact of nurses on general practice function.
Design, setting and participants: Multimethod research in two substudies: (a) a rapid appraisal based on observation, photographs of workspaces, and interviews with nurses, doctors and managers in 25 practices in Victoria and New South Wales, conducted between September 2005 and March 2006; and (b) naturalistic longitudinal case studies of introduced change in seven practices in Victoria, NSW, South Australia, Queensland and Western Australia, conducted between January 2007 and March 2008.
Results: We identified six roles of nurses in general practice: patient carer, organiser, quality controller, problem solver, educator and agent of connectivity. Although the first three roles are appreciated as nursing strengths by both nurses and doctors, doctors tended not to recognise nurses’ educator and problem solver roles within the practice. Only 21% of the clinical activities undertaken by nurses were directly funded through Medicare. The role of the nurse as an agent of connectivity, uniting the different workers within the practice organisation, is particularly notable in small and medium-sized practices, and may be a key determinant of organisational resilience.
Conclusion: Nurseing roles may be enhanced through progressive broadening of the scope of the patient care role, fostering the nurse educator role, and addressing barriers to role enhancement, such as organisational inexperience with interprofessional work and lack of a career structure. In adjusting the funding structure for nurses, care should be taken not to create perverse incentives to limit nurses’ clinical capacity or undermine the flexibility that gives practice nursing much of its value for nurses and practices.