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Keywords:

  • Australia;
  • general practice;
  • nursing;
  • Primary Health Care

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusion
  8. References

Australia, in common with many other countries, is expanding the role of Primary Health Care (PHC) to manage the growing burden of chronic disease and prevent hospitalisation. Australia's First National Primary Health Care Strategy released in 2010 places general practice at the centre of care delivery, reflecting a constitutional division of labour in which the Commonwealth government's primary means of affecting care delivery in this sector is through rebates for services delivered from the universal healthcare system Medicare. A review of Australian nursing literature was undertaken for 2006–2011. This review explores three issues in relation to these changes: How PHC is conceptualised within Australian nursing literature; who is viewed as providing PHC; and barriers and enablers to the provision of comprehensive PHC. A review of the literature suggests that the terms ‘PHC’ and ‘primary care’ are used interchangeably and that PHC is now commonly associated with services provided by practice nurses. Four structural factors are identified for a shift away from comprehensive PHC, namely fiscal barriers, educational preparation for primary care practice, poor role definition and interprofessional relationships. The paper concludes that while moves towards increasing capacity in general practice have enhanced nursing roles, current policy and the nature of private business funding alongside some medical opposition limit opportunities for Australian nurses working in general practice.

What is known about this topic

  • Primary Health Care (PHC) is viewed as a means of reducing the burden of chronic disease.
  • General practice has been identified as a site for delivery of PHC.

What this paper adds

  • The term ‘PHC’ is poorly defined in Australian nursing literature.
  • PHC is associated with general practice and practice nurses in policy.
  • Funding through the Medicare Benefits Scheme for a limited range of nursing tasks limits capacity for advanced and comprehensive PHC in general practice.

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusion
  8. References

A number of demographic factors, including the ageing of the population and accompanying demand for hospital and healthcare services (Schofield & Earnest 2006), the ageing of the healthcare workforce (O'Brien-Pallas et al. 2004), the growing health burden of chronic illness in developed countries (Lopez et al. 2006) and mortality from non-communicable diseases in developing countries (World Health Organization 2008), have increased interest in Primary Health Care (PHC) as a means of managing demands on health budgets. The WHO (2008) identifies PHC as a means of redressing health inequities. They argue that international policy focuses upon curative services to the detriment of primary prevention and health promotion. In response, they call for health-care which is equitable and accessible (universal healthcare systems); consumer-centred; participatory and responsive to people's needs; and embraces public health activities to improve community health (WHO 2008, p. xvi).

In Australia, a growing interest in PHC is evidenced by the release of Australia's First National Primary Health Care Strategy in 2010. PHC is defined in policy by the Commonwealth government as a:

…socially appropriate, universally accessible, scientifically sound first level care provided by health services and systems with a suitably trained workforce comprised of multidisciplinary teams supported by integrated referral systems in a way that gives priority to those most in need and addresses health inequalities; maximises community and individual self-reliance, participation and control; and involves collaboration and partnership with other sectors to promote public health. (Department of Health & Ageing 2009, p. 22)

Primary Health Care is viewed by the Commonwealth government as a means of reducing the burden of chronic disease, reducing demand on hospital services and increasing equity of access to health services (Department of Health & Ageing 2009). General practice is at the centre of the National Primary Health Care Strategy. The Strategy seeks to improve access to services through integration of primary care or first-level services under population planning by Medicare Locals. Medicare Locals are the Australian variant of regional PHC organisations that have originated from Divisions of General Practice. The role of Medicare Locals under the strategy is to co-ordinate regional primary care delivery (Department of Health & Ageing 2010). PHC in this context is understood as targeting chronic disease management, with responsibility for this management largely placed with general practice. Chronic disease management is explicitly linked with hospital avoidance in policy with, for example, General Practitioners (GPs) receiving performance incentives under the National Primary Health Care Strategy for meeting benchmarks for diabetes care that prevents hospitalisation. Primary care, and in particular general practice, is also viewed as the appropriate venue for disease prevention activities and as such, primary care is often associated with practice nurses (PNs) who can be enrolled or registered nurses who are employed to provide services for general practice. While there are no formal qualifications beyond registration, the role of the nurse in general practice is one of the most rapidly changing roles in PHC. Associations such as the Australian Practice Nurse Association as well as Medicare Locals can provide educational support and some universities have embraced educational courses towards Graduate Certificate, Diploma and Masters in General Practice Nursing. Commonwealth government support for the PN role has involved investment in a Practice Nurse Incentives programme to expand the role of PNs to undertake health assessment and health promotion and prevention activities as well as targeting resources towards risk behaviours such as smoking (Department of Health & Ageing 2010).

The focus on GP-led fee-for-service care delivery for PHC is supported by a constitutional division of labour where the provision of GP services is funded through the Australian Government health insurance programme (Medicare), while most other community healthcare services are a state government responsibility. As a consequence, the Australian Government's central means of effecting PHC delivery is through the Medicare Benefits Scheme (MBS). MBS rebates are provided for a range of medical, diagnostic and therapeutic services (Department of Health & Ageing 2011a) and can be claimed by medical practices for nursing services provided by PNs and Aboriginal health workers working under the direction of GPs. Rebates only apply to a small range of activities including immunisation, wound care, pap smears and chronic disease prevention and management activities (Patterson et al. 2007). Recent changes to the Medicare Act have also extended the capacity to apply for MBS provider numbers to nurse practitioners and midwives (Department of Health & Ageing 2011a, Harvey 2011, Lane 2012). Nurse practitioners, who work in collaboration with GPs, can apply for rebates for activities related to history taking, clinical examinations, organising investigations, implementing a management plan or preventative health-care (Department of Health & Ageing 2011b). These tasks largely replicate and support those activities performed by GPs.

The commitment of the Commonwealth government to the role of general practice in the delivery of PHC is evident in incentives for expansion of the PN role. In addition to the Practice Nurse Incentives programme, funding has been targeted towards employment of PNs in rural settings and training and support schemes (Patterson et al. 2007). There has been accompanying growth of nursing employment in primary care and in particular, within general practice. The 2006 census data identified 11% of the nursing workforce as working in primary care in both general practice and community health (Australian Institute of Health & Welfare 2009). The number of PNs across Australia in 2007–2008 was identified as being 8575, double the number working in general practice 4 years earlier (Department of Health & Ageing 2009). By 2011, a total of 9617 registered nurses and 2958 enrolled nurses identified general practice as their primary place of employment (AIHW 2012). In a move to achieve better co-ordination and efficiency across community health services, the Australian Government in 2011 sought to bring all community health service provision under one national auspice; however, resistance by some state governments meant that this did not occur. With this, albeit failed, national takeover of community health services and with increasing PN numbers, the focus in PHC nursing in Australia is firmly upon general practice. In the light of policy changes, the purpose of this paper is to review recent literature and selected policy documents in relation to PHC and nursing practice in Australia to determine first, how PHC is being defined in this literature and second to identify current nursing roles in relation to PHC.

Following Keleher (2001), we define PHC as both a philosophy and a systemic approach to reducing health inequities through intersectoral partnerships to meet basic needs. Health, in this context, is defined broadly as a:

State of complete physical, mental and social well-being and not merely the absence of disease or infirmity. (Declaration of Alma-Ata cited in Wass 2000, p. 263)

For this study, a further distinction was made between selective and comprehensive PHC strategies where selective strategies offer individual interventions such as screening or immunisation, and comprehensive PHC strategies address social determinants of health (Keleher 2001, p. 60). Baum (2007) argues that comprehensive PHC is intersectoral, grounded in community and driven by consumer rather than by professional priorities. As such, it is empowering and inevitably, political. Selective strategies, in contrast, are provided by the healthcare system, adopt a curative or disease prevention approach and often apply global rather than tailored approaches to health problems. A third goal of the paper, therefore, is to identify the barriers and enablers to the delivery of comprehensive PHC indicated in the literature.

Method

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusion
  8. References

Design/search methods

A search of peer-reviewed Australian and international literature was undertaken of the Informit, Cinahl and Ovid databases using the search terms ‘Primary Health Care’ in the abstract combined with ‘nurs*’ and ‘role’ in the subject. As a central goal of this paper was to see how the term ‘PHC’ was being defined in Australian nursing literature, the search was limited to papers using this term to ensure that the articles accessed focused upon the concept of PHC. The timeframe of 2006–2011 chosen for this review encompasses a period of rapid expansion of the PN role in Australia, but does not allow for the capture of literature addressing recent systemic and policy changes in the delivery of care. The search yielded 213 papers, which were reviewed independently by two authors to check suitability.

Articles were included in the study if the abstract discussed PHC and excluded when the professional role discussed was not a nursing role. The articles were primarily empirical studies undertaken in community settings with a small number of opinion pieces and literature reviews included where these commented upon policy directions or practice issues in relation to PHC (see Tables 1-3). The National Health and Medical Research Council (2000) in Australia provides guidelines for assessing the quality of evidence with greatest weight given to intervention studies with randomised allocation of subjects or literature reviews based on these studies. The empirical studies included in this review primarily evaluated existing practice or service delivery models and as such, the quality of evidence provided would be assessed as being low by National Health and Medical Research Council standards. As the purpose of the paper is to explore representations of PHC rather than best practice, this was not considered an obstacle. Following an independent review, two authors (KK and CV) undertook a combined review and allocated abstracts to either a ‘yes’, ‘no’ or ‘possible’ category on the basis of inclusion criteria. International papers from countries with comparable healthcare systems to Australia were included to inform the background and discussion, but were not subject to data extraction and analysis.

Table 1. Summary of articles adopting a comprehensive Primary Health Care (PHC) approach
Article titleType of paperSettingRoles discussedDefinition of role in relation to PHCBarriers/enablers to PHC

Mills et al. (2010)

The status of rural nursing in Australia: 12 years on

Literature reviewRural practiceRural nurses, nurse practitionersRole related to social determinants of health and provision of generalist care across the life spanLack of PHC preparation due to an educational focus upon hospital service delivery

Whitehead (2006)

The health-promoting school: what role for nursing?

Literature reviewSchoolsSchool nurses

Calls for nurse in schools to move beyond the traditional health education approach to encompass the health promoting whole of school approach including:

● Building school capacity for health promotion

● Links with other agencies

● Participation

● Political action

Insufficient resources

Lack of nurse training

Insufficient research and evaluation of outcomes

Confusion about the school health nurse role and lack of role recognition

High staff turnover

Lack of career pathway (caught between health and education and marginalised in the community health nursing profession)

McMurray (2007)

Leadership in primary health care: an international perspective

Opinion pieceGeneral practicePractice nurseFocus upon social determinants and tailoring the practice nurse role to patient needsNurses identified as being in prime position to identify health needs, increase health literacy and provide leadership in PHC

Annells (2007)

Where does practice nursing fit in primary health care?

Opinion pieceGeneral practicePractice nursePHC involves a ‘broad range of health-related activities focused on health promotion and driven also by the principles of accessibility, appropriate technology, inter-sectoral collaboration and public participation’. (p. 20)

‘Territoriality’ among professions

Educational preparation

Funding arrangements

Greene and Burley (2006)

The changing role of bush nurses in East Gippsland, Victoria

Opinion pieceRemote rural areasSolo remote nurseReference to a broader health promotion roleFunding mismatch

McMurray (2010)

Empowerment and enterprise: the political economy of nursing

Opinion pieceNon-specificNon-specificPartnership with community and patient underscored as the preferred model for all health servicesReluctance of nurses to engage with the political process in the broader health world

Kruske et al. (2006)

Primary Health Care, Partnership and Polemic: child and family health nursing support in early parenting

Empirical ethnographic studyChild/family health serviceChild/family health nursesPrevention of illness through screening and surveillance, and the promotion of health, incorporating the principles of PHC

Under-resourcing

Lack of continuity of relationships

Limited nurse interest in further education and research

Keleher et al. (2010)

Preparing nurses for primary health care futures: how well do Australian nursing courses perform?

Empirical mixed methodsEducational programmesExpanded role educationIncludes episodes of treatment and follow-up as well as system responses to tackle determinants of health. Grounded in a social model of health

Patchy adoption of PHC in nursing curricular

Unclear skills and knowledge requisites articulated in national competencies

Table 2. Summary of articles adopting a selective Primary Health Care (PHC) approach
Article titleType of paperSettingRoles discussedDefinition of role in relation to PHCBarriers/enablers to PHC

Olasoji and Maude (2010)

The advent of mental health nurses (MHNs) in Australian general practice

Empirical service evaluationGeneral practiceMental health nurses

Care planning and review

Medication management

Facilitating access to other services

Working with families and carers

Uses key terms regarding settings and principles (i.e. PHC, primary care) interchangeably

Unwillingness of MHNs to work in general practice

Poor remuneration

No career structure

Lack of education in PHC

Joyce and Piterman (2011)

The work of nurses in Australian general practice: a national survey

Empirical survey research on service encountersGeneral practicePractice nurse

Chronic disease focus

Health promotion is viewed as screening and immunisation activities

Limited evidence of team work

Medicare Benefits Scheme (MBS) funding arrangements are identified as inhibiting the PN role in comparison with other jurisdictions, e.g. UK

Joyce and Piterman (2009)

Farewell to the handmaiden: profile of nurses in Australian general practice in 2007

Empirical survey researchGeneral practicePractice nurses

No definition of PHC

All practice nurses did direct patient care, co-ordination of care and management of clinical environment, 90% did some practice management and admin and 57% provided some reception and secretarial work

Low pay

Educational focus on items attracting Medicare rebates

Laws et al. (2008b)

Should I and can I? A mixed methods study of clinician beliefs and attitudes in the management of lifestyle risk factors in primary health care

Empirical mixed methodsGeneral practicePractice nurse

Client assessment and care planning

Supports role of nurses in assisting in lifestyle change

Clinician beliefs and attitudes

Wilson (2007)

Planning primary health care services for South Australian young offenders: a preliminary study

Empirical qualitative methodsJuvenile detentionNurses serving as liaison

Liaison with other services

Patient assessment

Discharge planning

Recommends a liaison nurse located at a Division of General Practice as enabler

Larkins et al. (2006)

Consultation in general practice and at an Aboriginal community-controlled health service: do they differ?

Empirical prospective survey audit of consultationsSeveral clinics in rural areaClinic nurses

Focuses on individual patients with specific conditions

Indigenous nurse as cultural broker

Nil identified

Laws et al. (2010)

An efficacy trial of brief lifestyle intervention delivered by generalist community nurses (CN SNAP trial)

Protocol paper for empirical quasi-experimental studyCommunity-based servicesGeneralist community nurses

Defines PHC as a setting

Intervention is at the individual client level and specific to physical activity, diet, weight management, smoking and alcohol

Looking to increase lifestyle interventions without increasing resources

Keleher et al. (2009)

Systematic review of the effectiveness of primary care nursing

Literature reviewCommunity-based clinical careNurses in community-based care

Defined as primary care

Individual interventions

Focus on patients with existing disease as well as issues such as prevention through child-rearing practices, smoking cessation

Nil identified

Harris et al. (2008)

Chronic disease self-management: implementation with and within Australian general practice

Literature reviewGeneral practicePractice nurses

Major emphasis is on chronic disease management

PHC and primary care used interchangeably

Preference for individual over group education

Directive care

Cranston et al. (2008)

Models of chronic disease management in primary care for patients with mild to moderate asthma or COPD: a narrative review

Narrative reviewGeneral practicePractice nursesPrimary focus is on medical management of patients with chronic conditionsNil identified

Keleher et al. (2007)

Practice nurses in Australia: current issues and future directions

Opinion pieceGeneral practicePN (substitute for MD or collaborative)

No definition of PHC

Contrasts substitution model where the nurse is delegated tasks once performed by the General Practitioners (GPs) and under the supervision of the GP with a collaborative model where the nurse assumes independent tasks as a member of a multi-D team, such as in chronic disease management

Supervision

Professional indemnity

Funding arrangements

Education and training

Lack of systematic policy development

Halcomb et al. (2008b)

Promoting leadership and management in Australian general practice nursing: what will it take?

Opinion pieceGeneral practicePractice nurseFocus on individual interventions within general practice

Lack of nursing involvement in divisions of general practice

Part-time and casual employment

Funding models including limited MBS rebates for nursing tasks

Table 3. Summary of articles containing elements of both a comprehensive and selective Primary Health Care (PHC) approach
Article titleType of paperSettingRoles discussedDefinition of role in relation to PHCBarriers/enablers to PHC

Al-Motlaq et al. (2010)

How nurses address the burden of disease in remote or isolated areas of Queensland

Empirical qualitative studyVariety of clinics in rural areas of QueenslandNurses in the clinics/centresCalls for community-controlled social and health-care, particularly for rural Indigenous communities; however, in practice delivering reactive secondary health-care – ‘band aid service’

Workload

Time

Provision of reactive rather than proactive care

Lack of educational preparation

Birks et al. (2010)

Models of health service delivery in remote or isolated areas of Queensland: a multiple care study

Empirical qualitative studyVariety of clinics in rural areas of QueenslandNurses in the clinics/centres

PHC defined as ‘universal access to resources, disease prevention and health promotion, community and individual engagement in self-care’. (p. 26)

Most activities undertaken on a 1:1 basis

Demand for services

Workload and being on call for isolated communities

Willingness to operate as a guide or coach for others

Capacity and skill level of other health workers

Lack of support

Halcomb et al. (2008a)

Cardiovascular disease management: time to advance the practice nurse role?

Empirical mixed methodsGeneral practicesPractice nurse (PN)

PHC defined as ‘“frontline” management for those who presented to general practice for both acute health issues and chronic illness management’. (p. 50)

Individual but tailored therapies for chronic illness

Barriers in fiscal system

Resistance to change by General Practitioners (GPs)

Legal barriers

Halcomb et al. (2007)

Exploring the development of Australian general practice nursing: where we have come from and where to from here?

Empirical content analysis of the proceedings of PN conferencesMultiple settingsPNs

No definition provided

Role consistent with PHC, but not made explicit

An entrenched lack of collaboration in the culture of general practice – referring to GP and nurse

Barbaro et al. (2011)

Developmental surveillance of infants and toddlers by maternal and child health nurses in an Australian community-based setting: promoting the early identification of autism spectrum disorders

Empirical quantitative methodsMaternal/child healthMaternal child health nursesPreventative focus and some engaged community/parental participation, but primarily an expert-delivered intervention with a focus on the reduction of a specific diseaseNil identified

Laws et al. (2008a)

A square peg in a round hole? Approaches to incorporating lifestyle counselling into routine primary health care

Empirical action research using qualitative methodsNon-general practice community health settingsNurses in three community settings

No definition of PHC

Role: assessment and counselling related to lifestyle risk factors

Two of three teams studied had a selective approach to PHC with a focus on the individual and post-acute care, rather than group- or community-directed approaches

Nil identified

Halcomb et al. (2006)

Evolution of practice nursing in Australia

Literature reviewGeneral practicePNs

No definition of PHC

Roles: immunisation and screening as well as ‘advanced practice’, e.g. complex wound care, lactation or chronic disease management

Structural, fiscal and interprofessional barriers

Parker et al. (2010)

Primary care nursing workforce in Australia: a vision for the future

Opinion pieceGeneral practicePNs

Focused upon chronic disease management through individualised interventions

Addresses capacity for expanded role

Extension of funding for more complex nursing tasks and less reliance upon funding from practices

Funding and opportunities for continuing education

Greater focus upon primary care in undergraduate curricula

Development of a career pathway

At the second stage of the review, abstracts in the ‘yes’ or ‘possible’ categories were taken to the research team for further scrutiny. After those abstracts for inclusion were identified, a snowballing approach was employed to scan all reference lists for further papers of relevance. Following this process, a total of 37 papers were considered as meeting all inclusion criteria, and a further 22 international papers were highlighted as relevant for comparison.

In addition, a review of the grey literature was undertaken, with a particular focus on websites considered pertinent to the role of nursing in Australia, including the Australian Nursing Federation (ANF), the Australian Practice Nurses Association, the Royal College of Nursing Australia, the Australian College of Nurse Practitioners and the Australian College of Mental Health Nurses. These agencies were considered integral as they had combined to generate a consensus statement regarding the role of the registered nurses and nurse practitioners in PHC, which informed the development of the National Primary Health Care Strategy. The websites of these agencies were scanned for pertinent documents regarding the role of PHC in nursing. Papers for possible inclusion were taken back to the team for final consideration. A total of four grey papers had a direct focus on nursing roles and PHC and were considered relevant for analysis.

Data extraction

The research team generated a template for data extraction based on the research questions driving the review. The template incorporated basic methodological information and more specific questions, which sought to examine the way in which PHC was conceptualised. In particular, the template facilitated enquiry regarding comprehensive versus selective notions of PHC, a distinction considered pertinent to this review. Examination of selective versus comprehensive PHC philosophies was guided by Baum's (2007) definition of comprehensive and selective PHC as outlined above. Each paper was subject to analysis by two independent researchers and if there was a discrepancy in the analysis, i.e. conflicting views of a comprehensive versus selective approach, the paper was reviewed by a third author.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusion
  8. References

The structure of the results reflects the three research questions that informed the analysis of the articles. These are: How is PHC defined in Australian nursing literature?; What are the roles associated with PHC?; and What are the barriers and enablers of delivery of comprehensive PHC in Australia?

Defining Primary Health Care

Tables 1-3 summarise findings in relation to the manner in which PHC is defined, the nursing roles associated with PHC and barriers and enablers of PHC in the articles reviewed. Of the 37 articles considered, 8 were identified as having a comprehensive approach to PHC, 12 were viewed as adopting a selective approach to PHC, 8 were viewed as having elements of both and the remaining 9 articles did not provide a definition of PHC and were not included in the Tables, although considered in the thematic analysis.

Few articles contain an explicit definition of PHC, but where it is included, the definition largely reflects the values encompassed by a comprehensive approach to PHC. Annells (2007, p. 20), for example, defines PHC as a philosophy which involves

A broad range of health-related activities focused on health promotion and driven also by the principles of accessibility, appropriate technology, inter-sectorial collaboration and public participation.

Likewise, Birks et al. (2010, p. 26) associate PHC with

Universal access to resources, disease prevention and health promotion, community and individual engagement in self-care, inter-sectoral approaches to health, and cost-effective solutions to promoting well-being that incorporate all aspects of an individual's life and environment.

Similar views are expressed in the grey literature. Chiarella (2008, p. 5), in a discussion paper prepared for the National Health and Hospital Reform Commission, identifies PHC as universally accessible, essential and affordable health-care, which involves full participation from the community and fosters self-determination.

More commonly, however, the literature does not explicitly define PHC, conflating it with primary care. Keleher et al. (2010) make a distinction between primary care, which is understood as episodic care and PHC, which addresses social determinants of health and health inequities. Likewise, Bryant (2011) uses the term ‘primary care’ when discussing federal policy initiatives including extension of eligibility for MBS provider numbers and the advent of Medicare Locals and ‘PHC’ when addressing the social determinants of health. For the most part, however, the terms are used interchangeably. The term ‘PHC’ is associated not only with a site, most commonly general practice, for the delivery of care (see Harris et al. 2008, Laws et al. 2010) but also with a level of care delivery reflecting Commonwealth policy in which PHC is defined as ‘first-level care’ (Department of Health & Ageing 2009, p. 22). Halcomb et al. (2008a, p. 50), for example, define PHC as ‘“frontline” management’, whereas Olasoji and Maude (2010) contrast mental health-care in primary health (read General Practice) with specialist mental health-care provided by secondary and tertiary services.

Nursing roles within Primary Health Care

In keeping with a policy focus upon the delivery of PHC through general practice, the most commonly cited nursing role is that of the PN. A number of articles outline the tasks currently undertaken by PNs (Harris et al. 2008, Joyce & Piterman 2009, 2011, Phillips et al. 2009). The role is largely defined in terms of chronic disease management and individually focused health promotion and prevention activities. The tasks associated with PNs include care planning and review (Olasoji & Maude 2010); immunisation, health assessment and screening; diagnostic tests and wound care (Joyce & Piterman 2011); health education (Phillips et al. 2009); and reception and secretarial work (Joyce & Piterman 2009). These tasks largely reflect MBS rebates.

Other nursing roles discussed within this literature include community, child and family health, school and rural and remote nursing, all of which are identified as providing a greater scope for comprehensive PHC activities. Factors which are identified as promoting comprehensive PHC activities in these settings include lack of access to alternative staff and development of generalist roles (Mills et al. 2010); working with indigenous communities (Al-Motlaq et al. 2010); and partnerships between services and professions (McMurray 2007). Interestingly, the role of nurse practitioners is largely absent in this literature. Mills et al. (2010) suggest that this may reflect an initial policy focus upon the employment of nurse practitioners in rural settings where few people have the requisite education and also lack of access to MBS and pharmaceutical benefit scheme rebates that until recently made nurse practitioner services cost-prohibitive.

Some articles argue for an expanded role for PNs to encompass comprehensive PHC activities. Halcomb et al. (2008b) argue that PNs are positioned to take greater leadership in managing chronic disease and lifestyle risk factors. Parker et al. (2010) note that PNs in the United Kingdom undertake extended roles in chronic disease management and preventative health checks as well as telephone consultations and triaging for home visits, whereas Annells (2007) argues for a greater role for PNs in promoting health and well-being.

Barriers to delivering comprehensive Primary Health Care

The articles identify a number of barriers to the delivery of comprehensive PHC, particularly within general practice settings. This discussion will focus upon four structural barriers, namely funding arrangements and fiscal barriers; educational barriers; poor role definition and lack of career structure; and finally, working relationships with other professions.

Funding

Access to resources and funding models were identified as a barrier to the delivery of comprehensive PHC across community nursing settings and general practice. For rural nurses, lack of access to alternate health services and time constraints result in the prioritisation of emergency secondary and tertiary care over PHC within community settings (Al-Motlaq et al. 2010, Birks et al. 2010). In addition, negotiating complex funding arrangements creates difficulties in implementing ‘sustainable and equitable health service models' (Greene & Burley 2006, p. 82). Similar arguments are made by community and family health nurses who associate lack of resources with poor continuity of care due to

Decreased opportunities for nurses to be available to the women beyond the first universal home visit. (Kruske et al. 2006, p. 61)

Practice nurses face additional funding barriers. The scope of PNs' work has until recently been limited largely to procedural tasks by virtue of their employment in private general practice with services reimbursed through MBS rebates. Joyce and Piterman (2011) found in a study of tasks undertaken by PNs that three tasks, immunisation, wound care and pap smears, all of which attract rebates, accounted for 40% of the work undertaken by these nurses. Recent block funding in Australia for the employment of PNs is, however, broadening this scope of work (Department of Health & Ageing 2013). They contrast this situation with that in New Zealand and the United Kingdom where funding schemes are more flexible, enabling enhanced practice nursing roles (Hoare et al. 2012). The prevalence of part-time and casual employment in general practice is also identified as a barrier insofar as it prevents nursing leadership within general practice (Halcomb et al. 2008b).

Educational barriers

Educational barriers relate to both the availability of education about PHC and the willingness of nurses to undertake further education. Keleher et al. (2010), in a review of the content of 38 pre-registration undergraduate Bachelor of Nursing courses, found that few offered stand-alone units in public or population health, health promotion and disease prevention or in indigenous health with only five universities offering stand-alone community health or PHC courses in the first year, 12 in the second year and 11 in the third year. In general, the undergraduate nursing degrees are focused upon high-level acuity illnesses and tertiary care delivery. For Parker et al. (2010), lack of undergraduate exposure to primary care/PHC undermines its attraction as a career choice.

Lack of postgraduate education preparation in PHC is also identified in particular in rural settings. Al-Motlaq et al. (2010), for example, identify a lack of access and time to undertake education in relation to PHC among nurses working in rural Queensland. A lack of educational opportunities is also evident for PNs. Merrick et al. (2012) found that 44.4% of New South Wales PNs who responded to a survey held a hospital certificate as their highest educational qualification. Education for PNs often occurs through short courses addressing the specific tasks covered by MBS rebates rather than through postgraduate qualifications (Halcomb et al. 2006).

Poor role definition and lack of career structure

A number of articles identify poor role definition and a lack of career structure as a significant impediment to further development of PHC roles in both general practice and community nursing settings (Whitehead 2006, Halcomb et al. 2008b, Olasoji & Maude 2010, Parker et al. 2010). For some, a lack of career structure is related to employment within general practice, which limits the range of tasks performed (Parker et al. 2010). For others, it arises from employment outside the health system. Whitehead (2006) notes, for example, that the practice of school nurses is governed by both the health and education systems. For Keleher et al. (2010), an impediment to role definition is limited development in the National Competency Standards for Registered Nurses of competencies for PHC practice. While the Australian Nursing and Midwifery Council acknowledges that nurses practise across a number of settings, health promotion and illness prevention activities receive little attention in the national competencies. The authors note, however, that the ANF has developed competencies for PNs, which supplement, but do not supersede, the national competencies. These competencies incorporate understanding of the cultural and socioeconomic characteristics of the community and emphasise the role of health promotion and prevention, reflecting a comprehensive approach to PHC.

Working relationships with other professions

Working relationships within teams have also been identified as a barrier to comprehensive PHC particularly within general practice, which is largely the domain of GPs and PNs (Keleher et al. 2010). The literature identifies many incidents of medical opposition to extended nursing roles. The Australian Medical Association, for example, has generally opposed expansion of nursing roles into tasks previously the domain of doctors, an attitude which is particularly evident in relation to nurse practitioners (Elsom et al. 2009). Annells (2007) argues that employment in general practice constrains nursing capacity to deliver comprehensive PHC due to medical control of these settings. Likewise, Halcomb et al. (2007, 2008b) identify entrenched barriers to professional collaboration arising from employment of practice managers with managerial control over PNs within general practice, gender differences and limited nursing representation in the key organisations representing general practice such as the previous Divisions of General Practice.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusion
  8. References

Australia, in common with other countries, is developing policies to reduce the burden of chronic illness and prevent hospitalisation through a greater use of community services (Department of Health & Ageing 2009, 2010, Finlayson et al. 2012). The inaugural National Primary Health Care Strategy promotes the use of general practice as a means of addressing these needs, with the development of Medicare Locals facilitating regional co-ordination of primary care services. PHC is defined within the National Primary Health Care Strategy as ‘first-level care’, a distinction that is reflected in the Australian nursing literature. Wass (2000, p. 10) argues that PHC has increasingly become associated with ‘the first point of contact with health services' rather than a philosophy of care that promotes equity, participation and social justice. While equity through universal access to services is incorporated within the inaugural National Primary Health Care Strategy, there is less evidence of other aspects of a PHC philosophy. This is particularly evident in relation to the social determinants of health, which appear to be viewed largely as ‘non-health issues’ in the National Primary Health Care Strategy, which focuses almost exclusively on improvement of health through health services (Department of Health & Ageing 2009, p. 24).

The primary site nominated for the delivery of PHC is through general practice. PNs have a significant and emerging role in the delivery of primary care, reflected not only in the growth of the role but also in the extent to which PHC is associated with practice nursing in recent Australian nursing literature. While the use of PNs is consistent with the United Kingdom and New Zealand, there are significant differences in nurse capacity for extended practice between jurisdictions depending upon policy and employment context (Hoare et al. 2012). In the United Kingdom, a reduction in working hours of junior doctors, practice-based commissioning of services where funding is provided to practices to purchase services for patients and Personal Medical Service contracts between the health trust and general practice have enabled greater flexibility in use of staff (Bonsall & Cheater 2008, Hoare et al. 2012). In addition, mechanisms in the United Kingdom have been created for the inclusion of nurses in clinical governance through their involvement in the development of the quality and outcome framework and their role in achieving quality outcomes to ensure funding under current practice-based contracts (Hoare et al. 2012). New Zealand moved from dependence upon reactive private general practice towards a more planned PHC model under the 2001 Primary Health Care strategy, which established Primary Health Organisations (PHOs), which have a financial and administrative role in managing service delivery through capitation payments for the number of people enrolled in a medical service. This strategy promoted an extended role for PNs not only through funding for disease prevention and health education programmes to reduce health inequities but also through a role in clinical governance by collecting information about local health needs (Finlayson et al. 2012). It is clear from these examples, however, that the extension of nursing responsibilities does not necessarily lead to greater opportunities to deliver comprehensive PHC, as extended roles may involve adoption of tasks previously performed by GPs.

Until recently, the Australian policy context has provided less scope for a role for nursing within clinical governance of primary care services. The authors in this review note the exclusion of nurses from the governance of the Divisions of General Practice and a resultant lack of nursing leadership in primary care (McMurray 2007, Halcomb et al. 2008b). The establishment of Medicare Locals should provide scope for furthering nursing leadership; however, with their establishment based on the previous Divisions of General Practice, it remains to be seen how this will develop. In addition, continued reliance upon MBS funding is viewed as limiting the development of extended nursing roles in primary care through prescription of the range of tasks, which attract MBS rebates.

While there has been an extension of MBS rebates to nurses in some settings, critics (Harvey 2011, Joyce & Piterman 2011, Lane 2012) argue that these changes need to be understood within the context of medical dominance of the healthcare system. Joyce and Piterman (2011) note that MBS rebates for activities undertaken by PNs are largely limited to a small range of those activities that promote chronic disease self-management. Likewise, Harvey (2011) states that the requirement that nurse practitioners be ‘employed or engaged by one or more specified medical practitioners' to claim rebates limits autonomous practice [Section 5: National Health 2010 Collaborative arrangements for nurse practitioners (Determination 2010) National Health Act 1953 cited in Harvey 2011, p. 275]. Similar limitations apply to autonomous midwifery practice with the eligibility for a provider number depending upon approval, and the development, of services with obstetricians (Lane 2012).

There is limited discussion of community nursing and notably, nursing practitioner roles within the reviewed literature. Hansen et al. (2007) argue that while the introduction of PHOs in New Zealand has enhanced the role of PNs, it has diminished the role of public health and community health nursing. The primary reasons offered for a diminishing role are employment by Area Boards rather than through the Department of Health, which has fragmented nursing leadership alongside competitive tendering for capitation funding to provide services. As a consequence, the nursing role has shifted from a generalist role to one providing a limited range of specialist services in the area of primary prevention and health promotion. In contrast, healthcare changes in the United Kingdom have provided scope for advanced practice in PHC. Hoare et al. (2012) estimate that there were approximately 2000 nurse practitioners working in primary care in the United Kingdom in 2006. All nurse practitioners have prescribing rights and they are viewed as a cost-effective alternative to GPs, often providing after-hours services and managing chronic illness, tasks which are largely selected primary care activities (Caldow et al. 2006). We are yet to see what impact the advent of Medicare Locals will have upon the community health nurses in Australia; however, given that the central means of funding primary care is through MBS rebates, these changes are unlikely to enhance the role of community health nurses and that of comprehensive PHC delivery.

This review seeks to explore the manner in which PHC is conceptualised in the Australian nursing literature. Despite the process adopted for accessing and assessing the suitability of articles for this review, some limitations must be noted. First, there are a number of authors who are leaders in this area and who have published extensively. As such, their views may be overrepresented within this review. Second, some of the studies drawn upon have small sample sizes, reflecting the size of the pool of employees working within these areas. Third, comprehensive PHC is frequently associated with extended nursing practice within these articles. It is our contention, however, that extended practice is frequently associated with selective PHC activities. Despite the limitations, there is evidence of a shift in the definition and location of PHC practice, which is in line with and reflects Commonwealth policy changes and which is likely to become even more evident in future publications as general practice is established as the central point for PHC delivery.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusion
  8. References

This paper reviews recent Australian nursing literature in relation to PHC practice. It found that PHC is largely associated with practice nursing in Australian nursing literature, reflecting policy changes, which make general practice the central site for delivery of primary care services. In contrast to that in other countries, the role of the PN in Australia is limited by funding mechanisms, which provide rebates for a limited range of nursing tasks. Recent policy changes such as the development of Medicare Locals have the potential to enhance the role of nursing within primary care, but while funding is limited to a small range of tasks and paid to the general practice, the scope for extended and comprehensive PHC roles is likely to be limited.

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  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusion
  8. References
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