Primary health care services, such as general practices, are the first point of contact for many Australian health care consumers. Until recently, the role of nursing in Australian primary care was poorly defined and described in the literature. Changes in policy and funding have given rise to an expansion of the nursing role in primary care. This paper provides a review of the literature and seeks to identify the barriers and facilitators to implementation of the practice nurse role in Australia and identifies strategic directions for future research and policy development.
Aust Health Rev 2005: 29(2): 156-166
THE GENERAL PRACTITIONER (GP) remains the broker and gatekeeper to health care services in Australia, with some 90% of Australians visiting a GP each year.1 The clinical skills, expertise and knowledge level of clinicians working in primary care have evolved to meet the challenges created by a more informed consumer, advances in medical technology and a drive for improved health service outcomes.2 This paper seeks to outline the contribution of practice nurses to Australian primary health care, describe the international experience relating to practice nurse role development, determine the scope of the clinical practice boundaries and identify the barriers and facilitators to the practice nurse's role.
The growth of the nursing role in Australian primary care has been driven by multiple factors including the changing health care needs of consumers, shortage of GPs in rural areas and generally increasing GP workloads nationwide. The term "practice nurse" refers to either a State Board Registered or Enrolled Nurse who is employed to provide nursing services in the setting of general practice.3-7 This may be direct employment by an individual or group of GPs or through third party contracts with local Divisions of General Practice, community health services or other private providers of nursing services.8-13 In contrast, general community nurses are primarily employed by local health authorities or private health care organisations to deliver nursing care directly to the local population in their homes or at community health centres.8-11
Although many community nurses work within a primary care model, increasingly the services provided by the general community nurse are frequently under the direction of an acute care specialist following hospital discharge, although an increasing number of referrals are being received from chronic disease specialists. Specific criteria often exist to define the types of services that general community nurses can provide under pre-existing funding models. Further, these nurses are often subject to the policies and procedures of an overarching body, for example an Area Health Service. In contrast, the practice nurse provides services under the direct or indirect supervision of a general practitioner. It is important to establish the unique, yet complementary, role that the practice nurse has in the health system and the diversity between this role and that of the general community nurse. To date, the practice nurse role is related to streamlining business practices, preventing potential hospitalisations or improving general health status by services such as continence clinics or lifestyle risk factor counselling. Potentially, practice nursing can be considered a "specialty" area of general community nursing not unlike other areas such as public health, community mental health or community sexual health nursing.
An enduring concern is the limited regulation of the tasks that can be delegated to the practice nurse. Currently, the specific scope of the practice nurses work is defined through negotiation between the individual GP and nurse.12,13 In their evaluation of shared care between practice nurses and GPs in Australia, Willis et al.15 identified that there was significant variation in the role, patterns of referral and work of the practice nurse. …