Agpn ihpo presentation final

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  • Over 60% of general practices employ one or more practice nurses
  • Strong role in chronic disease and lifestyle management i.e. well-being clinics, smoking cessation etc
  • Evidence for nurse role in prevention in general practice It is well-established that a focus on primary care for prevention reaps benefits: Primary care promotes a holistic approach to patient treatment, and the World Health Organisation (WHO) had previously asserted that preventative care techniques ‘help individuals and families to cope with illness and chronic disability’ [i ] , improving their quality of life. General Practice Nurses (GPN) are well-versed in preventative care, and have already been engaged in screening, health promotion and lifestyle risk factor counselling activities. GPNs are key providers of childhood and adult immunisation services in many countries including Australia. In most states there are legislative arrangements in place to support an autonomous role for nurses in immunisation that includes the administration of adrenaline. Research evidence is still scarce about the specific contribution of nurses to lifestyle risk factor counselling. However, an evaluation of a research project of GPNs providing smoking cessation counselling conducted in the Southern Highlands of New South Wales revealed very encouraging results. [ii ] It was found that nurses spend more time counselling patients, increasing their chances of quitting. Practice nurses were also ‘uniquely positioned’ and ideal for the role, as compared to General Practitioners (GP). GPNs possess the opportunity for lifestyle risk factor identification in almost every aspect of their daily activities, allowing the potential for identifying at-risk clients. Nurses establish more contact time with patients. Research indicates that the quality of consultations is relational to the amount of time spent between physician and patient. [iii ] Nurses spend more time with patients than doctors. Extended contact time facilitates nurses’ ability to compile detailed, accurate patient medical histories, to undertake comprehensive assessment of the patients, and to assess the patient’s family’s medical risks. [iv] The patient-nurse interactions act to enhance the therapeutic relationship, which create more opportunities to promote lifestyle changes. Nurses are essential members of the multi-disciplinary team in primary health care as their extensive communication skills enable them to contribute to preventative care by providing a broad scope of knowledge and skills. Studies have shown that general practice nurses (GPN) are as effective[v] as General Practitioners (GP) in performing 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[vi] Nurses are better managers of interpersonal relationships[vii], through clearer communication, conducting effective counselling and possessing better interviewing skills GPNs can provide long-term care management and promote choice and positive health.[viii] Nurses’ roles can be extended to better support frontline care. It must be noted that evidence from other countries has not demonstrated any cost savings in supplementing doctors with nurses. However, practice nurses were found to be as proficient as GPs, and hence, such a practice has demonstrated no adverse outcomes.[ix] Supplementing doctors with practice nurses, if carefully managed, promotes the use of effective chronic disease control and preventative health functions GPNs can coordinate care and function as the pivotal contact person for care providers and patients, ensuring quality care and reducing service overlaps or lapses. [i] World Health Organisation: European Health for All Series; No. 6. Health21: The Health for All Policy Framework for the WHO European Region (1998). Copenhagen: Regional Office for Europe, p. 139. [ii] Zwar, Nicholas et al, Development and Evaluation of a Primary Care Smoking Cessation Service , University of New South Wales, viewed 21 May 2008, <http://customers.ilisys.com.au/rcnao/UserFiles/Forlonge,%20Gail.pdf> [iii] Corrie, Karen and Watts, Ian (2002). Literature on the Relationship Between Quality and Length of Consultations , Royal Australian College of General Practitioners. [iv] Thompson, Lee (2008). ‘The Role of Nursing in Governmentality, Biopower and Population Health: Family Health Nursing’ in Health and Place , no. 14, p. 79. [v] 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).  [vi] Laurent, M et al (2008). ‘Substitution of Doctors by Nurses in Primary Care’, The Cochrane Library 2008 , Issue 2, UK: John Wiley and Sons. [vii] Chambers, Naomi (1998). ‘Nurse Practitioners for the UK’ in Nurse Practitioners in Primary Care , UK: Radcliffe Medical Press Ltd., p. 17. [viii] ‘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>. [ix] Laurent, M et al (2008), ‘Substitution of Doctors by Nurses in Primary Care’, The Cochrane Library 2008 , Issue 2, UK: John Wiley and Sons.
  • 6 nurses around a kitchen table in Melbourne.
  • Agpn ihpo presentation final

    1. 1. The role of the nurse in generalpractice
    2. 2. 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 2
    3. 3. Numbers of General Practice NursesState 2005 2007 2009 % change since 2007 % change since 2005NSW 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% 3
    4. 4. Practice nursing overseasUnited 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 4
    5. 5. 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 5
    6. 6. Australian contextMBS definitionA general practice nurse is• RN/Div 1• EN/Div 2• Employed in a general practice• Or whose services are retained by a general practiceOne 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. 6
    7. 7. Health Practice nurse role assessments • Immunisation Clinical care – Clinical procedures and activities Wound • Clinical coordination – e.g. recall/reminder, population health approach Management • Practice administration Women’s health – Accreditation support • Integration Chronic disease – Liaison with other providers RACGP/RCNA 2004 clinicsOperating Roles ECGs, Pathology,Nurse as patient carer Routine obsNurse as quality controllerNurse as organiserNurse as problem solver Patient educationNurse as educatorNurse as agent of connectivity Care planning Phillips et al 2009 To name a few! 7
    8. 8. 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 8
    9. 9. 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 9
    10. 10. 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 10
    11. 11. 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) For and on • GPMP and TCAs replaced EPC and role of nurse expanded within behalf of GP thisOver 20 millionPN itemsclaimed since2004 11
    12. 12. Indigenous item numbers• Indigenous Health assessment• PN chronic disease item number 10987 12
    13. 13. Advanced nursing roles in general practice – what do they looklike?• 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 13
    14. 14. 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. 14
    15. 15. 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] 15
    16. 16. 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 16
    17. 17. Future challenges for integration of ‘To succeed as a teamnurses into general practice team is to hold all of the members accountable for their expertise’• Clinical governance Mitchell Caplan CEO, E*Trade Group Inc Indemnity Funding Employer Regulatory authorities 17
    18. 18. Other challenges for integration of nurses into general practiceteam • 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 18
    19. 19. 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. 19
    20. 20. 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 references Eckermann, S. [2009], PHC RIS: practice nurses - enhancing primary health care services in rural Australia’, Howard, S., Aust J Rural Health, 17(2), 111 Halcomb 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. 20
    21. 21. 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 21
    22. 22. Supporting nurses in general practice1300 303 184www.apna.asn.au 22

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