Aligning nursing practice with community need

The people of Tairawhiti had the most to gain by improved access to primary health care services and a reduction in inequalities. Fee reduction was only a small contribution and did little to increase primary health care nursing

Tairawhiti. General practices were fully subscribed and most refused to take new registrations as validated by the following manager’s comment:

I think they then become lucky if they can enrol with anyone at all and that becomes their only option and I then believe what we talk about inequality is all about different ways. I believe that access is still a problem for some. (I.3, p.1)

This doctor shortage was also established by one nurse participant:

I’ve been with the organization for about nine years now, and when I started there were a lot of doctors you don’t have that now; the numbers have really dwindled. (FG.1, p.2)

A doctor shortage juxtaposed with a burgeoning aging population and those living with chronic conditions should have instigated closer examination and repositioning of the nursing workforce to fill this void. Laurant et al. (2005) assert doctor-nurse substitution has the potential to reduce a doctor’s workload depending on the particular context of care. Both Cumming and Gribben (2007) and Goodyear-Smith and Janes (2008) state that in some parts of New Zealand at least, the doctor shortage has resulted in nurses taking on more roles traditionally performed by GPs. This is evidenced by the substantial growth in the development of nursing roles and nursing capability within some PHO environments. The following PHO based manger acknowledged this potential:

We have a diminishing medical practitioner workforce, we have an aging population who have complex needs they don’t always need x level of services they could have. We don’t have to traditionally deliver the services we have, we could look at new models of care which are nurse led and it seems that the Primary Health Care Strategy was permissive to create that environment. (I.5, p.5)

This excerpt confirms that despite increasing demand, diminishing medical workforce and the potential nursing offered, change was not instigated. Traditional models of care continued in most parts of Tairawhiti. The nurses themselves identified nurse led services as providing a solution to the doctor shortage and meeting the needs of the community:

I think we need to develop more nurse led clinics because nurses are comfortable about the skills that they have. (FG.2, p.7)

As this comment suggests, there were nurses who were comfortable with their skill mix. This was obvious in the more remote rural areas of the Tairawhiti district which faced increased difficulty in attracting a medical workforce, so nurses were required to expand their roles:

Someone had to step up into the gap and shortage and because nurses are women who are passionate. We are passionate about our people who we are looking after and there is a whole void in there then we usually step up. (FG.2, p.8)

This confidence did not apply to all nurses in Tairawhiti, another nurse (practice nurse) viewed ‘stepping up’ to fill the doctor shortage void as negative:

Well to me, you know it looks like there are less doctors so let’s make these nurses come up to scratch and fill the gaps.... However, we are putting our neck on the chopping board. (FG.5, p.7)

The comment “putting our neck on the chopping board” related to the perceived threat to their nursing registration. In the general practice setting there is limited support for nursing in a predominantly doctor centric business model.

As mentioned previously, fear and learned helplessness has negated the ability of nurses to expand their role. However, if using evidence-based practice and working within the very enabling nursing scope of practice, then expanding nursing practice is safe and effective. Scopes of practice for nursing are set by the Nursing Council of New Zealand. Within that scope, registered nurses are “accountable for ensuring that all the health services they provide are consistent with their education and assessed competence, meet legislative requirements and are supported by appropriate standards”14

Overall, there appeared to be inconsistencies in understanding of the potential the nursing workforce offered. As a consequence nurses were not being utilised according to their skill set as suggested by the following manger:

I think that you know, in that respect primary care is not taking good enough advantage of practice nurses. (I.4, p.8)

This manager inferred there was greater capacity within the practice nurse role, the comment interestingly but not surprisingly confined to practice nurses. Equally so, it was understood by two managers that development in the practice nurse role in Tairawhiti had occurred, albeit inconsistent and piecemeal:

Within practices themselves we’ve actually seen an increase in the development of practice nurse’s role. This is my understanding, not based on huge knowledge of research or anything. (I.6, p.2)

I guess in a lot of ways local bits did come into it, and the chances of actually getting the nursing workforce to do things in a different way did occur, the innovations funding money was certainly one of those. Nurse led clinics have certainly come on board since then, but it has been very ad hoc approach, not as systematic as it should have been. It has been very much dependent on the champions for moving those sorts of things along rather than the whole district wide thing. (I.7, p.2)

There was obviously some expansion in the role but whether this utilisation was consistently applied across the district, and to the level of ability and effectiveness, was doubtful. The Expert Advisory Group on Primary Health Care Nursing (2003) states models of nursing practice vary according to populations and geographical area. Cumming et al. (2005) confirm that nationally, variability of expansion of the practice nurse role is determined by the GP as the employer. It is noted that where nursing development did take place, it was more noticeable in practices where the PHO had embraced the principles of the Primary Health Care Strategy to improve the health of their enrolled population and in the management of chronic conditions (Cumming et al., 2005; Finlayson et al., 2009). Care Plus in particular activated an

expansion of the primary health care nursing role in the general practice setting.

As mentioned in Chapter Three, Care Plus was introduced into PHOs in 2004 and provided extra primary care visits for patients with chronic conditions to improve their care management (MoH, 2004). Nationally Care Plus became a nurse led service in some practices (CBG Health Research Ltd, 2006). One of the manager participants confirmed the increase in consultations by nurses for Tairawhiti patients with chronic conditions:

Probably the only kind of big addition I see to their roles changing is the addition of the chronic care stuff. The diabetic annual reviews and Care Plus and chronic care, I mean they should have been looking after their chronic care patients before. But now there is more. (1.1, p.8)

Four nurses confirmed nurse led clinics were operating:

It’s really come into vogue where practice nurses actually do have their own clinics and also they’re starting to have, like the doctors will have their client list, now the nurses are getting their own client lists. (FG.2, p.6)

Definitely looking at us working on more chronic care, we are taking over a lot of that so they can see more patients as well. So there are nurse led clinics. (FG.4, p.2)

We are already doing nurse led clinics. (FG.4, p.2)

There are nurses that are ready are putting their hands up and saying ‘give me a go, I’m happy to do a clinic, and I’ve got the skills to be able to do it’. (FG.2, p.7)

There is research showing that that primary care currently delivered by physicians could be carried out by nurses at a much lower cost with similar outcomes (International Council of Nurses, 2008a; Laurant et al., 2005). Nurse led health services have a positive effect on health care delivery by offering a comprehensive role in case management, reducing inequalities, and improving health outcomes for clients (Finlayson et al., 2009; Hoare et al., 2011; Laurant et al., 2005; Marshall et al., 2011). Nurse led clinics are associated with higher

levels of patient satisfaction, longer consultations and higher rates of investigations compared to doctor led clinics (Laurant et al., 2005). Despite the evidence, one of the biggest barriers to nurse led services is the perceived restrictions imposed by the current funding structures; more income is generated for the practice by seeing a doctor as opposed to a nurse (Finlayson et al., 2009). Docherty et al. (2008) concur that the support for nursing autonomy, professional recognition and accountability is not reflected by the funding structures.

GPs continue to argue that there is no financial incentive to use nurses fully and that the nurses are there to support the doctor (Finlayson et al., 2009). By arguing for the vulnerability of personal investment in their businesses, GPs have retained the right to significantly determine the nature of nursing services (Carryer, 2004; Docherty et al., 2008; Kent et al., 2005). General practice has been moulded around the GP with few decisions made by nurses for nursing, which has hindered the development of practice nursing at a national level and restricted advanced nursing practice (Arroll et al., 2004).

In a New Zealand practice nurse cost benefit analysis, Hefford et al. (2010) identified that the actual role of practice nurses varied markedly between practices; the financial impacts were also variable and complex. Variables included nurse cost per minute, duration of the nurse consultation, revenue per nurse consult event, and the percent of nurse consults requiring GP time. If there was the same remuneration for the same task, regardless of who provided the service, there would likely be an increased use of nurse time. The authors conclude that the same effect could be achieved by a no fee policy or capitation only.

Another variable was limited understanding of the nursing potential. One manager acknowledged a vague understanding of the different perspective nursing offered:

The nurses would be coming from a family perspective wouldn’t they? (I.10, p.8)

Eggleton and Kenealy (2009) state the difference to the consultation was not who performed the consultation, whether nurse or doctor, but the length of time spent with the patient. Starfield (1998) argues it is the interaction between practitioner and patient that contributes to the establishment of long- term relationships and facilitates effectiveness. A number of nurses acknowledged the benefits of the relationships they had established with their patients:

We are the ones who develop the relationship with people. Unlike the GPs who get a snippet in a 10 minute consult. We are the ones who establish the meaningful relationship; we really get to know them. (FG.3, p.2)

You build a relationship with them and you see them more than once most times. (FG.2, p.3)

You make a connection and you can see the changes. As primary health care nurses we probably have more of an impact in this community because if you do something good then that person you spoke to tell their whanau about what you did with that young person, you know that all sets it up for next one. (FG.2, p.20)

Finlayson et al. (2009) confirm that in many areas there has been an increased acceptance by the community of nursing’s input as first port of call. Additional research has identified that the skills valued by clients (such as explaining, listening and understanding their needs) while not readily quantifiable, are time consuming and considered fundamental to working in the community (Carryer, Budge, Hansen, & Gibbs, 2010; Carryer, Snell, Hunt, Perry, & Blakey, 2008; Holdaway, 2002; International Council of Nurses, 2008a; Lindberg, Ahlner, Ekström, Jonsson, & Möller, 2002; Vukic & Keddy, 2002). One manager and two nurses identified the comprehensiveness of the nursing services provided:

If someone goes to the doctor they get antibiotics. If a nurse saw them under a standing order you are not simply giving a bottle of antibiotics....So what becomes a bottle of antibiotics from the GP surgery, becomes a whole education package and integrating care under a standing order. (I.3, p.10)