Improving patient outcomes – Primary health care nurses working to the breadth of their scope of practice

Summary of key points

  • Primary health care nurses have a diverse scope of practice and are well positioned to address emerging healthcare challenges.
  • Primary health care nurses working to the breadth of their scope facilitate better outcomes for patients, enhanced productivity, and value for money for health services.
  • Barriers preventing primary health care nurses from working to their full capacity must be challenged in order to improve patient outcomes

APNA position

Nurses working to their full scope of practice as part of an interdisciplinary team can enable more integrated, efficient and accessible healthcare.

Nurses are skilled, regulated and trusted health professionals with extensive distribution across Australia. Primary health care nurses working to the breadth of their scope of practice facilitate better outcomes for patients, enhanced productivity and value for money for health services.

Primary health care nurse financing, intra-disciplinary and inter-disciplinary understanding and support of the nurse scope, and a lack of formal education, training and career frameworks are currently preventing primary health care nurses working to the breadth of their scope.

At a time of rising healthcare costs and increasing rates of complex health conditions and chronic disease, it is crucial that governments and stakeholders facilitate and enable primary health care nurses to work at full capacity within their scope of practice. 

Introduction

The pressure on Australia’s primary health care services is rapidly increasing due to an ageing population, rising patient expectations and increasing rates of chronic disease.1,2 This increased demand for healthcare services is resulting in a growing burden of healthcare costs, particularly in the hospital system. An effective primary health care system can prevent or more appropriately manage patients to reduce costly hospital admissions. 

Nurses are the largest health workforce in Australia, and are geographically spread across the country.3 Nurses are a skilled and regulated profession. The 2016 annual Image of Professions Survey reveals that nurses were rated as the most honest and ethical profession 22 years in a row.4 There is an opportunity to capitalise on the nurse role to combat emerging healthcare challenges. 

Background

Primary health care nursing refers to nursing that takes place within a range of primary health care settings, each sharing the characteristic that they are part of the first level of contact with the health system. In Australia, nurse practitioners, registered nurses (RN) and enrolled nurses (EN) practice in primary health care in a range of clinical and non-clinical roles, in urban, rural and remote settings such as: 

  • community settings including community controlled health services, correctional facilities (including juvenile and adult),
  • refugee health, the community health sector and roles within social service settings
  • general practice
  • domiciliary settings – in the home, including residential aged care, custodial/detention settings, boarding houses and outreach to homeless people
  • educational settings – including preschool, primary and secondary school, vocational and tertiary education settings
  • occupational settings – occupational health and safety and workplace nursing
  • informal and unstructured settings – including ad hoc roles in daily life, such as sports settings and community groups.

Nurses working in the primary health care sector may undertake work that includes5:

  • health promotion
  • illness prevention
  • chronic disease management
  • antenatal and postnatal care
  • child and family health nursing
  • treatment and care of sick people
  • rehabilitation and palliation
  • community development
  • population and public health
  • education and research
  • policy development and advocacy
  • indigenous health.

Scope of practice

Scope of practice for nurses is determined by professional registration (i.e. registered nurse or enrolled nurse), endorsement (i.e. prescribing scheduled medicines by nurse practitioners), educational background, nursing experience and clinical specialisation.6–11

There are two main elements to scope of practice:

Professional practice: The scope of professional practice is set by legislation. This includes professional standards such as standards for practice, codes of ethics and codes of professional conduct12.

Individual practice: The scope of practice of an individual nurse includes that which the individual is:

  • educated
  • authorised
  • competent, and
  • confident to perform.

A nurse can build their clinical and professional capabilities to expand their scope of practice through education and training to develop a broader skill set that remains within the legislated professional practice standards and competencies. 

An individual nurse’s scope of practice may vary considerably from that of another nurse. Tools such as the Nursing practice decision flowchart developed by the Nursing and Midwifery Board of Australia can assist nurses to determine their scope of practice.7 Nurses are accountable for making professional judgements about when an activity is beyond their own capacity or scope of practice.11

Benefits of primary health care nurses working to their full scope of practice

Primary health care nurses working to the breadth of their scope facilitates better outcomes for patients, enhanced productivity and value for money for health services.13,14

Primary health care nurses can facilitate increased access to healthcare.15,16 This may be via increased services, reduction in waiting times, more timely assessments and referrals. This is particularly important given the increasing burden of chronic disease and the challenges associated with workforce shortages in Australia’s primary health care system. 

Optimal use of the nursing skill set as part of the interdisciplinary team enables other health professionals, such as general practitioners, to focus their time on higher level diagnostic activity, intervention and care decision making, promoting an integrated care model and improved patient experiences.

Chronic disease prevention and lifestyle management are key components of primary health care nursing; a greater focus on early intervention and more structured management can reduce the burden on the health system in the long term.

Encouraging and enabling primary health care nurses to work at full capacity within their scope of practice will provide benefits at all levels, from individual and team, to the healthcare system nationally and most importantly to the health and wellbeing of the Australian community.

Barriers to optimal scope of practice

A number of barriers are currently preventing nurses from working to their full scope of practice.

Primary health care nurse financing

Primary health care nursing is funded from both public and private sources. The way that healthcare is funded can influence the structure and viability of clinical service models and the roles and tasks of primary health care nurses who work within them. For example, there is no single definitive funding source for nursing services in general practice and the sector as a whole has not yet devised innovative solutions to provide greater support to primary health care nursing. In reality practice managers and practice principals will draw from a variety of funding sources to fund the employment or contracting of nurses.

These sources include the Medicare Benefits Schedule (MBS), the Practice Nurse Incentive Program, the Practice Incentives Program, grants, and patient co-payments.17–20 Merrick et al. highlight that MBS policy assumes that general practitioners are responsible for and direct the delivery of primary health care nursing activities in general practice models.13

The International Council of Nurses’ definition of nursing states that it:

‘encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings.’21

The complexities of the current financing structure in general practice constrain primary health care nursing practice, including the ability to initiate and lead care that would usually fall within a nurse’s scope of practice. It should be noted here that financing structures impacting on primary health care nursing practice is less of an issue in state government-funded primary health care settings such as community health and prisons where activity is not tied to MBS billing.

A report by the Grattan Institute indicates that the current fee-for-service payment model in the general practice setting is not suited to managing more complex conditions such as chronic disease.22 The report also suggests that simple reforms to the primary health care sector could result in savings of more than $320 million a year on avoidable hospital admissions and chronic disease conditions. One of the reforms suggested includes paying for performance and incentives for collecting and reporting performance data rather than fee-for-service models.

The Australian Government’s proposed Health Care Homes model is based on a bundled payment method and aims to better integrate and coordinate healthcare. This model may provide an important small first step towards coordinating healthcare resources to best meet patient needs. 

Intra-disciplinary and inter-disciplinary support and awareness of full scope of practice

Perceptions and attitudes by other health professionals or employers about the role of primary health care nurses may limit a nurses’ ability to work to their full scope of practice.14 The scope and functions of primary health care nursing have evolved and expanded into some areas of practice that have traditionally or historically been assumed the responsibility of other medical professionals.

This has the potential to create professional tensions between primary health care nurses and medical professionals such as general practitioners.23 Therefore a greater understanding and support for the full breadth of the primary health care nurse role by all members of the health care team is essential to enhancing intra-disciplinary collaboration and effective patient care.

APNA’s 2016 Workforce Survey reveals that 161 respondents had suggested to their employers that they could do more complex clinical activities and remain within their scope of practice.24 However, of these, 72% (116) indicated that their employer did not want to extend their role.

Furthermore, delegated medical care and ad hoc agreements between employers/other members of the healthcare team and nurses working in primary health care has resulted in a lack of clarity regarding the nurse scope13. In countries such as the Netherlands and Sweden, where primary health care nurses have clearly defined roles and responsibilities, appropriate training and supervision, nurses have been able to implement a broader scope of practice.13

Formal education, training and career frameworks

There is currently a lack of formal education and training pathways into primary health care nursing and until recently no framework for skills development and career progression.25 There is also an absence of a clearly defined career pathway for primary health care nurses.26 

A career and education framework would assist nurses in primary health care to be employed at their appropriate skill level and encourage career progression. Furthermore it would enable health services to better assess and implement an optimal primary health care staff skill mix.27 APNA has recently developed a Career and Education Framework and Toolkit for nurses in primary health care, in line with international models and funded by the Commonwealth Department of Health. The framework will highlight the breadth of primary health care nursing roles and aims to improve recruitment and retention of the workforce. 

APNA recommendations

Patient care could be improved through nurses working to their full scope of practice and therefore APNA recommends the following:

Employers and other health professionals:

  • Support team-based care and empower and enable primary health care nurses to work at full capacity within their scope of practice.
  • Invest in the future of primary health care nurses by offering primary health care nursing student placements.

Governments/Policy makers:

  • Continue to support the development, implementation and evaluation of career and education pathways, transition to practice initiatives and nurse clinics in primary health care.
  • Continue to support continuing professional development for primary health care nurses including access to scholarships, grants and bursaries for education and training.
  • Develop and implement a primary health care nursing financial model that is flexible, accessible, sustainable, uncomplicated and nurse led.

Nursing associations/Regulatory bodies:

  • Continue to support primary health care nurses to understand and enhance their scope of practice.
  • Continue to address the barriers to optimising the primary health care nursing workforce. For example, increase nursing skills and confidence via further initiatives like the Nursing in Primary Health Care (NiPHC) Program.

Education providers:

Ensure that nursing curriculum and training is inclusive of primary health care nursing.

Primary health care nurses:

  • Use the appropriate standards for practice, codes of ethics and codes of professional conduct to determine their professional scope of practice.
  • Use professional judgement, by considering their educational attainment and professional experience, to determine their individual scope of practice.
  • Strengthen and extend their scope of practice by updating or enhancing their knowledge, skills, confidence and competence.
  • Strengthen their scope of practice by engaging in continuous quality improvement activities to enhance nursing care and therefore patient outcomes.
  • Form strategic alliances within the nursing profession and with other disciplines to promote and advocate for nurses to be equal partners in primary health care.
  • Understand the opportunities and challenges that different funding mechanisms present to ensure patients can access the care they need.

References
1. Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of doctors by nurses in primary care (Review) Substitution of doctors by nurses in primary care. 2004;(2). Available from: http://www.thecochranelibrary.com
2. Zurmehly J. A qualitative case study review of role transition in community nursing. Nurs Forum. 2007;42(4):162–70. 
3. Health Workforce Australia. Australia’s Future Health Workforce – Nurses Detailed Report. 2014;(August). 
4. Morgan R. Roy Morgan Image of Professions Survey 2016: Nurses still most highly regarded - followed by Doctors, Pharmacists & Engineers. 2016. 
5. Keleher H, Parker R, Abdulwadud O, Francis K. Systematic review of the effectiveness of primary care nursing. Int J Nurs Pract. 2009;15(1):16–24. 
6. Australian College of Nursing. Nursing in general practice. A guide for the general practice team. 2015. 
7. Nursing and Midwifery Board of Australia. A national framework for the development of decision-making tools for nursing and midwifery practice. 2007. 
8. Australian Nursing & Midwifery Federation. National Practice Standards for Nurses in General Practice. 2014. 
9. Nursing and Midwifery Board of Australia. Registered nurse standards for practice. 2016. 
10. Nursing and Midwifery Board of Australia. Nurse practitioner standards for practice. 2014. p. 1–5. 
11. Nursing and Midwifery Board of Australia. Enrolled nurse standards for practice. 2016. 
12. Nursing and Midwifery Board of Australia. Professional Codes and Guidelines [Internet]. 2015. Available from: http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements.aspx 
13. Merrick E, Duffield C, Baldwin R, Fry M, Stasa H. Expranding the role of practice nurses in Australia. Contemp Nurse. 2012;41(1):133–40. 
14. Murray-Parahi P, Edgar V, Descallar J, Comino E, Johnson M. ENsCOPE: Scoping the Practice of Enrolled Nurses in an Australian Community Health Setting. Int Nurs Rev. 2017;64(1):59–68. 
15. Primary Health Care Research & Information Service. PHCRIS Getting Started Guides: Introduction to nursing in primary health care [Internet]. 2017. Available from: http://www.phcris.org.au/guides/nursing_and_phc.php
16. The Royal Australian College of General Practitioners. Putting prevention into practice - guidelines for the implementation of prevention in the general practice setting (2nd edition) [Internet]. 2006. Available from: https://www.racgp.org.au/your-practice/guidelines/greenbook/a-framework-for-prevention-in-general-practice/key-strategies-for-improved-prevention-performance/practice-nurses/
17. Australian Government Departrment of Human Services. Practice Nurse Incentive Program [Internet]. Available from: https://www.humanservices.gov.au/organisations/health-professionals/services/medicare/practice-nurse-incentive-program
18. Australian Government Department of Health. MBS Online. 2017. 
19. Australian Medical Association. Setting medical fees and billing practices. 2015. 
20. Australian Government Department of Health. Aged Care Funding Instrument (ACFI) User Guide 2017. 2017. 
21. International Council of Nurses. Definition of nursing [Internet]. 2017. Available from: http://www.icn.ch/who-we-are/icn-definition-of-nursing/
22. Duckett S, Swerissen H. Building better foundations for primary care. 2017. 
23. Price K. Nurses in general practice settings: Roles and responsibilities. Contemp Nurse. 2007;26(1):7–14. 
24. APNA. Primary health care nurses seek autonomy and progression in a fulfilling career. Primary Times. 2016;16(3):6–7. 
25. McKenna L, Halcomb E, Lane R, Zwar N, Russell G. An investigation of barriers and enablers to advanced nursing roles in Australian general practice. Collegian [Internet]. 2015;22(2):183–9. Available from: http://dx.doi.org/10.1016/j.colegn.2015.02.003
26. Parker R, Keleher H, Forrest L. The work, education and career pathways of nurses in Australian general practice. Aust J Prim Health. 2011;17(3):227–32. 
27. Anonymous. UK career framework a success. Aust Nurs J. 2013;20(11):19.

Source: Primary Times Spring: Volume 17 Issue 3 2017

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