Nursing Diagnosis And Care Plans

hello, i'm norman swan. welcome to this programon general-practice nursing. practice nursing presentsgreat opportunities and alternativesfor primary health care. there are health workforce shortagesand they continue to cause concern. many see nurses as criticalto a sustainable workforce committed to high-qualityand safe health care. there's been little acknowledgementof the skill nurses need to work in general practice,

and little formal educationto support practice nursing. tonight, we'll discuss the professionalissues in practice nursing - models of practice, training, educationand indemnity. if you're watching on your computer, you can type questionsdirectly to the studio. just click on the live talk tabon the web page you're looking at. that means we can ask you questions. here's one to get you going: as usual, there are a number of usefulresources available

on the rural health educationfoundation's website: now let's meet our panel. dr brian bowringhas been a rural general practitioner for more than 24 yearsin george town, tasmania, a small industrial-rural communitywith a 15-bed, acute-care hospital, located about an hour northof launceston. - welcome.- thank you. brian has been chair of the gp northrural workforce support in tasmania and tasmanian representative

on the australian rural workforceagencies group. julianne badenochis a registered nurse and midwife and has been a general-practice nursefor 12 years and works in a rural general practice onthe yorke peninsula in south australia. - welcome, julianne.- thank you. julianne has been a board director of the australian practice nursesassociation since 2004. julie porritt is a registered nurseand midwife with a mastersin health services management.

- welcome, julie.- thanks, norman. julie has extensive experiencein the health industry and hospital and primary care, and has held the role of principaladvisor for nursing in general practice with the australian general practicenetwork for seven years. she has recently taken up a roleas program manager for nursing in general practicewith general practice nsw. lynne walker is a registered nurseand midwife. lynne is also the subject coordinatorfor the post-graduate diploma

in primary-care nursing in the department of general practiceat the university of melbourne. - welcome, lynne.- thank you. lynne has worked in general practicefor ten years as a practice nurse, and was president of the australianpractice nurses association from 2001 to 2007, and is currently undertakingher masters of nursing leadership. welcome to you all. how many nurses are we talking aboutin australia, julianne?

in australia, we believe there arebetween 6,000 to 8,000, potentially more throughout australia. the agpn have done studies on that. norman: julie? yes, just over 8,000 was our last count. we're just doing a national censusat the moment. we know that 60% of practicesemploy one or more nurses. what's the pattern of practice?is it mostly rural practice? it's about 80% in ruraland only about 40% in metro.

have you looked at why the 40%don't have nurses? we recently did some workthrough the network. we asked practices that don'temploy a nurse why they weren't. we had just over 2,000 responses. the most common reason,particularly for urban practices, not to employ a nurse is the fact that they can't accessthe practice incentive program payment for employing a nurse. so they want to, but money is an issue?

even thoughwe know the business case is strong, even without the incentive payment, the fact that these practicescan't get the payment acts as a disincentive for them. it's almost a mindset for them - we can't go down that track,we don't get that payment. lynne, is it the same demographicpattern as general nursing - an ageing workforce?with all due respect to our panel. - we're all ageing, as you would know.- speak for yourself.

so, i would say, yes, it is. that's probably something to sayfor the entire health workforce. the age of gps, they're ageing as well. so, yes, in answer to your question. to what extent are nurses trainedfor practice nursing? there are two groups of nurseswho work in general practice - enrolled nurses, or division 2,as they're now known in victoria. they have a shorter training course. they would probably cover about 15%of the nursing workforce

in general practice. the other 85% would be division-1nurses, or registered nurses, who have a three-year training programas a basic. to what extent have they beenspecifically trained for the tasks? as doctors find out,they're not particularly well trained for general practicewhen they graduate. you can't imagine that nursesare any different. up until probably the last few years, there's been very littlepost-graduate education

for nursesto enter into general practice. they're probably not as well trainedas we'd like them to be. there are some courses aroundwhich some nurses are able to access, but there's a range of reasonswhy they don't. most are hospital-trainedthat go into general practice. how many post-graduate training schemesare there like yours? i would saymost of the larger universities now offer some sort of training. norman:what sort of things do you teach?

how to stand up to generalpractitioners, give them a hard time? 'get off my back.' strangely enough, gps don'tsend their nurses in for that one. we tend to teach them things likechronic-disease management, immunisation, taking pap tests, commonchronic conditions, nursing leadership. they are some subjects on offer. do you find people get confused betweenpractice nurses and nurse practitioners? people get confused all the time.nurses do as well. certainly gps get very confused.

there's a clear distinctionbetween the two. practice nurses are nurses employedin a general practice. nurse practitioners are nurses who havea minimum standard of education of a masters level and have a narrow butdetailed knowledge of a certain area. and competency - what are practicenurses out there doing, julianne? roles vary, particularly betweenregional and rural centres. i would say they're jacks and jillsof all trades and masters of many. some practices focus moreon clinical practices and tasks. increasingly, the roles of practicenurses are becoming more specialised

with more of a focus towardschronic-disease management, preventative healthand database searching and looking for peoplethat are underserviced, trying to find those and bring them in. i know that the agpn have done somerecent studies on that, haven't you? the australian general practice network in partnership withthe australian national university were funded through the australianprimary health care research institute to look at a three-year research project

looking at those factors that impact onthe role of nurses in general practice. through that study,we were able to identify that there were six key rolesfor nurses in general practice. that patient-carer rolethat julianne was just talking about is a very important partof what nurses do, but it's only a small partof what nurses bring to the practice. they also bring a problem-solving role. nurses are very proactive at looking at and anticipatingwhat might go wrong in a practice

and putting systems in placeto make sure things don't go wrong. they're organisers.they look after the quality systems. gps in our study readily identified that they divested a quality roleto their nurses because nurses do it better. nurses have a big role in education, educating not only the patientsbut the whole practice team - medical students, gp registrars, nursingstudents and even the gps themselves. nurses are what we callan agent of connectivity.

it's the nurses that actually linkthe team within the practice, but importantly,link that practice with its community. it's the nurse that builds relationships with other health organisationswithin the community. you've had a look at it as well, brian. we had a look in our practicewhat tasks the nurses were doing. the lower-end tasksof simple clinical practice, such as ecgs, pathology testing,point-of-care testing, were very important for us.

the higher-end and higher-level rolesthat we've been talking about with independence and autonomy is something that's difficultin general practice. the paradigm that i worked withwhen i first started practice was - we've always had practice nursesand they've always done clinical tasks and have been there to help. in those days,there wasn't this emphasis on competencies and scope of practice, it was an arrangement between the gpand the nurses.

supervision was by the gp. now the situation is thatsupervision of nurses is by nurses. they have to demonstrate to nursesthat they have the competencies. that seems to me quite logical. if we had a registrar in the practice, i wouldn't want them doing thingsthey didn't feel competent about. they'd have to demonstrate to methat they were competent. i would need to understandwhat my registrar could do. it's very important that, as gpswe do work with the nurses

and understandwhat their competencies are. we will then be able to seegreater roles for our nurses. your questions have come in,where you're located. let's get your answers to that. metropolitan - 36% of you. 10% regional. over half of you in rural and nobody from remote tonight.we usually have a few. that gives you an idea at leastwho's watching via the web.

let's ask the second question. we'd be interested to knowwhether your practice employs practice nurses: give us your answers to that question, and we'll come back to it. commenting on salary and wagesbeing considerably less than state-employed health nurses,lynne? there's no question that the salarythat's paid to practice nurses is well below the salary paid

to those nursesworking in acute and private sectors. norman:why is that? isn't there an award? there is an award. it's quite complicated. some of them are state awards. the awards and the industrial issues have probably been likea lot of other things, where they're focused onthe acute sector. the awards that are currentfor nurses working general practice

are not as up-to-date. it's a different system. it's a privatesystem, so it's quite different. a comment, julianne, about enrollednurses being put in rn nursing positions and practices,and being outside their comfort zone. yes, unfortunately,that still is happening. that's a big problem for those nurses working outsideof their scope of practice. it's very important that gpsand practice managers understand enrolled nurses must be supervisedby a nurse.

they cannot, due to legislation,be supervised by a gp. they must be supervised bya registered nurse. that does vary a littlebetween the states. it can be direct or indirect. in certain states,there have to be protocols in place so that it's well understood. a question, julie -is there an opportunity for clinical nurse consultantsin general practice networking some supervisionthat you might have in hospital?

there's room for advanced rolesfor nurses in general practice. many nurses are working at a level that we would describe as a clinicalnurse consultant level in a hospital. there is certainly a career pathwayfor nurses in general practice from the beginning practitionerthrough to more advanced roles, then through to nurse practitionerif that's what nurses choose to do. norman:but you don't necessarily get paid more? yes, the issue is thatthere isn't a pay structure. one of the elements that's differentfor nurses in general practice

to other settings is,because it is a business environment, nurses need to negotiatefor a higher wage. some have been very successfulin doing that. but it's not somethingthat is second nature to nurses. we're used to being employedwhere there is a set award so we don't have to negotiate,we can see what that award is. an online question - 'do you think current tertiary-educationprograms for nurses is adequate?' existing nursing courses?

probably not. as we've seen, the role has expandedhugely in the past five to ten years. the education providers haven't reallybeen able to keep up with offering what's required to do that role. there's not a lot of incentive for education providersto invest in education, given that the practice-nursingworkforce is quite small in comparison toother nursing specialties. it's expensiveto invest in those programs.

there has been an increase in them and a lot of education done throughdivision networks and short courses. but at a post-graduate level, there still needs to bequite a lot of work done. fabian mccannfrom the kanahooka pharmacy asks, 'is there an industry databaseto search for nurses appropriate for gp clinic positions?'julie or julianne, do you know? the australian practice nursesassociation certainly has on its website a dedicated area where businessescan put in an advertisement

for a practice nurse. there's information on that website about general-practice nursing,which is useful. there's not a list of nurses for hire? many divisions of general practicemaintain databases of nurses interested inworking in general practice. the other programthat has just been introduced, because it was recognisedthere was a gap in providing an entry-level programfor nurses

that may be very experienced nursesin other sectors but not necessarilyfamiliar with general practice, there is now a national,entry-level program, a clinical-orientation programfor nurses interested inworking in general practice. which is another question online -'how easy or common is it for a nursefrom another area of practice, for example, emergency department, totransition to practice nursing?' lynne? the emergency departmentis probably one of the areas

that would streamline more easilyinto general practice. norman: if you'd beena cardiac intensive-care nurse, this might be hard. it might have different challenges, but most of uscame from the acute sector and we're all still aliveand talking about it, so it can be done. a lot depends onyour goals and objectives and the type of practicethat you will be employed in. if i were going for a job todayin general practice,

the questions i'd be askingas a potential employee would be around the role, and what is itthat's required for that practice. brian, tell me how money flows.what's the business model? certainly, norman. the majority of the workthat nurses in our practice would do would be procedural itemsunder the supervision of the gp. asking a nurse to do an ecgwould attract a medicare item. a substantial amount of the moniesthat nurses would earn would be evaluating immunisation,wound dressings.

all these thingsnow have medicare item numbers. some practiceshave nurses doing pap smears. that again attractsa medicare item number. there's some intangibles... you don't get rich on it,you or the nurse. there are some intangiblesthat are really hard to measure. how much do our nursescontribute financially to things likechronic-disease care plans? our practice is an industrial/ruralpractice in a mining/processing area.

how much do they contributeto the non-medicare dollars that we earn by doing health surveillance medicals,and that's substantial. the bottom line is, though,that besides income coming in, there's costs going out,and that varies from state to state. part of the $77,000 cost deficit thereis due to things like, our practice is big enoughthat it cops payroll tax. we would certainly say thatthat money is well-spent. we couldn't do without our nurses. they're indispensableto the way we practise.

we really need to befreeing up more of our time by having nurses do more. do you find your practicemore enjoyable? incredibly, and it's a team. it's not this vision some gps would havewhere it's a competitive thing. the nurses have been lookingafter a wound for several visits, we go in and consult with the nurse. it's a team consultationabout what the best method of managing the next few visits will be.

nine times out of ten,they'll suggest a dressing method and we'll think, fine. negotiate slightly, but it's a team,collaborative arrangement. i think that will be sharedby most members of the panel. i think that study julie referred to showed that only 21% of the rolewas clinical work. a big chunk of what nurses dois not funded by the mbs. are many gps charging for their nurses'time in a non-reimbursable way? do we know that?

i don't know if we collected figures, but we know anecdotally thatthat's not a common thing. some practices do chargefor nursing services. i was interested inbrian's business modelling because certainly agpn and other organisations have done the modellingaround the business case for nurses. generally,it shows a profit, not a deficit. it's just aboutwhat's included in those figures. i was interested in that modelbecause i hadn't seen that before.

norman: you can get on a treadmill. if what you're looking for from nurses is time with patientsand their families, and identifying problems and so on, being fee-for-service, thattask orientation could be frustrating. it's very frustrating. the general-practice nurse populationis a highly skilled population. unfortunately they're a bit bound upin a task-orientated funding mechanism. but for the general-practicenurse population out there,

every encounter they havewith their patient is another opportunityto help that patient in a holistic way. it's the way we work. funding doesn't reward us in any waywith that. when brian was talking abouthis funding model, what isn't countedis things we're doing behind the scenes. in attendance for wound management,we're talking about the whole patient. we're working out what's happening athome, do they need a medication review. can i say too, i don't know whetheryou took this into consideration, brian,

it's also the time you're saving the gp. it's not only the income generated,it's what the gp is able to do. if you weighed it up,would it increase revenue generation? no, that's quite difficult. how can we, in this simplistic model,quantify the controls the nurses bring? in accreditation,it's around the clinical standards, and nurses are largelyin control of that. what value do you place on that? that's an important point.

we shouldn't just talk aboutthe business model. it is not only the business model, it'sthe fact, and research tells us this, that having a nurse employed in generalpractice improves chronic-disease care, improves quality, reduces waiting times,all of those things. to what extent do gps get it that nurses are relatively independentpractitioners, that they're not to be supervisedby doctors? autonomous practitioners? there are many very successfulgp practice-nurse teams.

a lot of whether they get it or not, some of it is tied up withthe culture of the practice, whether they are able to work as a team. there's a whole body of work thatdivisions of general practice are doing, and need to do more of -sharing the successful models out there, having people come from other areas,even, and talk in divisions. i've heard of quite a bitof division training, but it's an important aspectof gps' learning - from peers,and nurses learning from peers.

do practice managersget practice nurses? in other words, do they understandwhat's needed in terms of management? sometimes not. i've met somevery switched-on practice managers who knew exactly whattheir nurses were capable of, but i don't think that would beas widespread as we would like. practices are big business now. they need to be managedvery efficiently. i would think knowingwhat all of your staff are able to do, what their strengths and weaknesses are,

would be fundamental to managementof any practice. there's probably more work to doin that area. some more questions - 'whilst there's a lot of material aroundfor educating nurses, particularly on the internet,that's hard to access for remote nurses who often don't have doctors presentall the time.' any suggestions how remote nursesworking in general practice can access educational materials? there's a lot of education onlinethat's free.

they're claiming that, in a remote area,that's not as easy as you'd think. i guess it comes with challenges. some education providersrun distance courses if they can't access the internet. julianne, you work in rural areas. it's not an issue for us in our region. we have very good it access. most of the organisations that do runthese programs, if you contact them, they're able to get these programsout to you by disk or whatever it takes.

especially through the apna, if they ring in,we can find ways to avail those nurses. the divisions are very supportive. it can be quite expensive. i know the modelthat rural and remote gps use is often just leaving the areaand going to a course. there's several very good courses. the nurses network runs an annual course and the conference and exhibitionruns two courses a year.

just go and get it all in one package. lynne, how is competencyscope of practice measured? how does an individual nurse knowwhat his or her scope of practice is, what their competencies are if we're talking abouta relatively informal sector? when you say, informal sector, scope of practice and competenciesis not something new for nurses. - it dates back to their training.norman: sure. it's an individual assessmenta nurse makes on their own practice.

it's not that hard for a nurseto determine their own competency. there are certain questionsyou would ask yourself. the regulatory authorities havedone a lot of work providing frameworks for decision-making,so that there's a process to work out - am i competent to do this? yes or no. it's really not an issue for nurses. they are clear, usually,about their own scopes of practice. there are specific competency standardsfor nurses that work in general practice.

it is relatively easy for a nurseto look at those competency standards. norman: if a gp wants to look at them,where would they find them? they're available on theaustralian nursing federation website. part of the package developedaround those competency standards was a lot of informationfor gps to assist them, and practice managers,to understand the competency standards and how they might use them. i must admit that in doing some readingaround this program, i came across them. i knew they were there, but it wasthe first time i'd had a look at them.

this is the culture that needs to changewithin general practitioners' minds, that this is somethingwe do informally ourselves. we wouldn't do a procedurewe didn't feel competent to do. nurses, it's a different situation. we need to understand this needfor competencies and scope of practice. it's vital that gps start embracing thisand looking into it and working with their nursesto understand how you can move forward. 'nurses are involved inquality and safety and the medical benefits scheduledoesn't reimburse for this.

isn't it valued by the practice and gps? it's certainly valued by the gps. without the quality, there's noaccreditation and without accreditation, there's certainly financial implicationsto the practice. i know that's not the universal model, but in the practicesthat have practice nurses, i would say it's virtually universal. they are in charge of the clinicalquality and sterilisation procedures. it's... it's...that's their responsibility.

julianne, is there a role forpractice nurses to prescribe medication, for example,in chronic-disease management? there's certainly not a role for general-practice nursesto prescribe medication. it is becoming on the forefrontof the role of nurse practitioners, but it's not within the scopeof practice for general-practice nurses. it's interesting, norman,that one of the things that changed the role for nursesin general practice in the uk was the fact that they instituteda post-graduate program for all nurses

so that they could prescribe. there was a lot of quality systemsput in place around that. the world didn't come to an end and patients werenone the worse for wear. for the nurse in general practice, beingable to see a number of presentations that they could treat adequatelyby prescribing a medication certainly has been a big boon and has really changed the waynurses are working. there's a rolefor general-practice nurses generally

to be discussing medicationswith their clients as part of their holistic care. that's just around quality useof medicine, which is very importantfor all health professionals. lynne, what's the most out-there roleyou've seen for practice nurses? it might be out-there for australia, butnot if you're living in another country where the role has beenmore clearly defined for many years. there's very good examplesof nurses running clinics, hiv medicine,looking after patients with hiv.

there's lots of examples nursesrunning well-women, antenatal clinics, looking after pregnant women. julianne: lifestyle.- lots of lifestyle counselling. there's a very good programin western australia, the street doctor program, where nursesand sometimes a gp as well take a van out to the streetand treat people that are homeless. there's certainly outreach worknurses do, going into child-care centresand immunising, taking work out of the practiceand into the community.

there's a number of examples of that. this is the end of the general-practicenursing that needs to expand. unless something dramatically changeswith workforce, the workforce isn't going to be there,and who's going to suffer? community. closing books in doctors' surgeriesis not an answer. there's got to be another wayof working cooperatively, not substituting,but work is done differently. nurses can fill a lot of that role. let's go to our first case study.

jackie is 50 years old. she smokes 30 cigarettes a day and comes to see the gp because she's got pain in her chest when she lifts heavy objects or goes upstairs. her mother died of a heart attack. she's not had palpitations, but has shortness of breath and a pain in her chest.

what's the role of the practice nurse here, brian? this may be seen in two ways. the person might not identify that they've got chest painat the front desk. if they did in our practice, the reception staff would automaticallyescort that person to a wheelchair, or if they were more able,straight to the practice nurse, who would do observations, an ecg.

norman: you've got protocols?- protocols, what to do. the monitor, the defibrillator would bethere, ready and waiting if needed. the doctor would be informedthe patient was there. the nurse might say, in a coupleof minutes the ecg will be done, but can you come soon? if they were in the waiting roomand informed the doctor, there might be more history taken beforehanding over to the practice nurse, but that would be soon, because you needthe test to decide what's going on. that's an exampleof a non-reimbursable activity?

the ecg is done not by mewhile i'm doing something else. the... (speaks indistinctly) ..that'sdone is purely a cost to the practice. if this was a less acute situation,there could be an educational role - in the ideal setting,education about smoking and risk factors this person hascould well be done by the practice nurse if this was a more chronic setting. it would definitely be done. as i said previously,every encounter with a patient is another opportunityto do lifestyle modification

or just seekinga bit of background information. while i'm doing an ecg on a patient,or any registered or enrolled nurse, we'll be seeking more information to seeif there's some way we can help them. if this is not a crisisat this point in time if we're doing this diagnostically, you would be havinga very good chat with them. let's say they have stable angina andthey get put on statins or beta-blockers or whatever elseto control their symptoms. do you have an ongoing rolein your practice with a woman like this?

i would encourage themto come back to the nurses for a chronic-disease management role. we would talk at that first encounterabout the value of setting up something along the linesof a general-practice management plan and booking a further appointmentfor that. let's take the answerto your previous question: does your practice employpractice nurses? 81% of you said yes. 10% no.

none of you are considering it. and 10% say you never would.i wonder why. we might ask that on another occasion. i'm just looking for the next question. it's interesting that those 10% whonever would are watching this program. they must have some interestin practice nursing. norman: they might be practice nurses. brian: that's very encouraging. there's an interesting question here -

'is there evidencethat nurses doing pap smears are better at itthan general practitioners?' there's certainly evidencethat nurse-taken blood pressure is more accurate thangp-taken blood pressure. there certainly is some evidence,norman. every year, the victorian cervicalscreening registry publishes a report on pap tests done in that state. for the last three or four years,it's clearly showed that the quality of the pap testwith the endocervical component

in those test taken by nursesexceeds that of those taken by gps. the numbers of paps takenis increasing as well. so there is some indication thatthat would be the case. it's an area wherethere is significant need. i don't believe that the government'sfunding model for greater incentives for the more overdue the lady isin having the pap smear is done a lot. so, another paradigm or wayfor addressing that problem. you certainly need it, and offering pap smearswith practice nurses may be something.

they're not doing it for some reason. is it, they don't want to do itwith the doctor? that same report shows that womenwho access nurses for that reason are usually the underscreened groupwho are difficult to engage with. and that... um... it's gone out of my head,what i was going to say. speaking generallyfor general practitioners, i might be shouted down by the gps. a lot of gps don't want to lose controlof this very important role they've had.

it's a way of relating very closelywith that patient. the build-up with that patient,they feel they'll lose if they hand over this test. women don't like men doing it to them. there's a percentage that preferthe male practitioner and a percentage that don't. the thing we have to remember is, as with most of the servicesthat nurses offer in general practices, it actually offers a choiceto the patient.

it's not about telling patientsthey can or can't see a person, it's about offering them a choice. if it's the right person they see,it's the right patient for the right provider of the serviceat the right time. i understand the data is that you don't need to ask the questionanymore about patient preference, or that patients are satisfiedwhen they see the nurse, normally. but when they're offered that option,what are the data here? julie, did you allude to this?

i don't know that we've looked at thatdata. some practices may have done that. there was research done a few years agofor consumers. the outcome was, practice nurseswere very acceptable to patients, but they did point outthat it needed to be a team and that they needed to be reassured that the doctors and nurseswere working together, that it wasn't one replacing the other. also, that patients still had accessto the gp whenever they needed it. practice nurses,that's one thing they do very well,

is triage patients,so that those most in need of care get it when they need it. i think... sorry. the other element thatthat research showed is that patients identified there would be some thingsthey would rather ask the nurse about. in my experience, whilst i'm nota credentialed pap-smear provider any longer -i've gone on to greener pastures. norman: you broke your stick, did you?

something like that. i do know that clientsthat came to see me for a pap smear, very many of themcame for another reason. it wasn't the pap smearthat brought them. norman: it was their ticket of entry.- that's right. there is certainly that role. this is the point wherethe gp conversation starts. it could be about time,it could be about gender. but separating itis even more important.

they're coming alongwith a problem they want to discuss and figuring the way they canget a longer appointment is to book a pap smear. then you do the well-woman check and don't do a particularly good jobon the problem they want to raise. it gets rushed. we have to differentiate that nursesperforming a lot of these roles, like for the pap providers, it's the underscreened womenand the normal woman.

often they do have other problems, butour services are targeted to well women. there's a lot of screeningwhich happens in general practice, and there's going to be more screeningas we move into that prevention mode. there's no reason why nurses can'tbe involved in screening practices, rather than diagnosticand ongoing management. there's a lot of patient educationneeded. what we haven't touched on hereare indigenous patients and the role of the practice nurse here, when you've got a non-aboriginal,mainstream general practice

with practice nurses, how does that playout with indigenous patients? julianne? as it is, general practice does havea fairly high indigenous clientele. we do have onevery fabulous practice nurse who certainly has a focus onindigenous clients. they are increasinglycoming into our fold. it's been fabulous. there's a lotof preventative-health messages. is this woman an aboriginal person? no, she isn't.married to a local cop, actually. female, white.she is doing some great work.

i think this is a rolethat's certainly going forward. that may have something to do withthe fact, we also know from researchthat patients perceive that nurses would have more timefor them than the gp - the gp is busy,better not waste the gp's time. a nurse mightgo a bit more slowly with me, give me time to actually ask the thingsi want to ask. the apna recentlyundertook a trial consumer survey. one of the thingsthat came out of it was,

the consumer was very satisfiedwith practice nurses. it was about the timeand the easy access. in particular, the 18- to 35-year-oldswere very satisfied. we're not sure what that was about, but we think this related to easy accessand provision of information. for those of you who saidyou won't consider having one or you don't have a practice nurse,the question is, if you don't have a practice nurse, what are the reasons?:

let's see what your reasons are. while we're doing that,let's go to our next case study. diane is a 46-year-old mother who works part-time. she's made an appointment to see her practice nurse for a regular pap smear. the practice nurse takes diane's pap smear, but during the consult, measures blood pressure

and diane's bp is 140/95. she's got a bmi of 28.she's only slightly overweight. she has no history of hyperglycaemia, however her fatherdoes have type-2 diabetes. but the practice nurse feelsdiane is at risk. what should and does the practice nursedo in this situation? i think it's probablya very common scenario, really. what the practice nurse will dois have a consultation to address what the patient came in for

and have a general discussionabout lifestyle issues and refer her back to the gp. she obviously needs some screeningand addressing of the hypertension, so i would thinkshe'd be sent back to the gp for a work-up of the problemsthat have been identified. some surgeries would do a random sugarthere and then. i didn't hear.i must have been daydreaming. did you sayyou'd do the diabetes risk assessment? that's something i would do.

it's a great opportunity. for me,the lights are coming on straightaway. i'm very much an average practice nurse,and the lights are coming on. she scores 7 for being 46 years of ageand having a family history. that immediately puts her at risk. i would be asking herto do the ausdrisk tool herself and ensuring that she comes backto see her gp and have a fasting blood-glucose levelat some point. i'd be touching base about diabetes,et cetera,

finding out what her knowledge base is. all this can be done very quicklyin that one consult. there would be very fewhospital-based nurses who would even knowabout the ausdrisk tool. this is really a toolfor general practice. how do nurses learnabout that sort of thing? that's wherethe new orientation program comes in. nurses can nurse in any environment. they're delivering nursing care.that doesn't change.

what's differentabout general practice is, it's a different environment to work in. there are those things about medicare and various epc itemsand things like that only pertinent to general practice. there's probably a million and oneexamples we could quote of patients going into hospitaland coming out with problems that weren't addressedwhen they were there because medical and nursing staff,for a variety of reasons,

weren't able to touch on. i think that's just a symptomof our system. the fact that these patients can accessthat kind of care in general practice is very valuable for the community. of course, this woman doesn't qualifyfor an epc item. not at this point,but she's highly likely to. that's the key rolefor the practice nurse - ensuring that this person hasthe level of care they need over the 12 months to make surethey have optimal diabetic care.

i think you've touched ona important point, norman. the models of fundingfor general practice need to change if general-practice teams are going tobe able to deliver the best care. as lynne said, the best person. salaried care delinked from piece rates. yeah, that's exactly right.a blended payment system. another important point is the capacityof the nurses to pick up problems. there's huge opportunityfor nurses to pick up issues which can then be addressed,and that's not funded either.

do you conduct teaching sessionsin your practice, mutual learning or things like that? we have regular clinical meetingswhere practice issues are discussed. we have registrars. nurses are welcometo come to those meetings, depending on the topic. but i wouldn't saythat we'd have meetings that had a sectionthat was specifically nurse-orientated. something to think about. one of things we found from theaustralian general practice nurse study

was that those practiceswhere there is good teamwork and autonomy for the nurses, they're the practices that have regularteam meetings and clinical meetings between the gps and the nursesand allied health professionals. it's part of the third standardsof general practice, that there be clinical meetings attended by all health professionalsproviding clinical care. as you said, there's certainly evidence. on reflection, i've probablyundersold ourselves a little bit.

meetings are attended. norman:it's getting better all the time, brian. digging myself out of the hole. our next case study is this general practice which has no female gp, has employed a nurse who's undergone education in women's and sexual health. the nurse has established

a well-woman's clinic, and marketed to women in her area identified as underscreened. the practice has agreed on a policy for the patients that the nurse will target cervical-cancer screening, pathways for referral and billing of patients. she will have an appointment system

using mbs item numbers. there may be an out-of-pocket expense in line with practice policy for some patients. is that what's happeningin the real world? yes, it is. increasingly. it's part of the processthat we need to go through, to educate patientsthat sometimes there will be a cost,

and that seeing the nurse for a servicethat is comparable to the gp is actually not a cheaper service. it's as good as, and therefore it willcost as much money as with the gp. before we go on,there's a comment from anne callum from gp partners in queensland - 'this 46-year-old lady should qualify for the 45- to 49-year-old health checkmedicare item.' yes, but she still needs to see the gp. that was the differential.

what's the journeythat practice has to take to get to this pointwith this well-woman's clinic, julianne? it needs to be absolutelya team effort. there needs to be protocols, as stated here,in place before we even get started. the consensus needs to be, this is where we want goand this is how we're going to do it. the nurse needs to be credentialedand confident in her role and that she has a great relationshipwith everybody in the team,

including her practice managerand all the other nurses. the funding doesn't necessarily reflect the work that will be donealong the way. it is about more choice. is there a professional-indemnity issuehere? no, i don't think so. it's just important for the practiceto let their medical insurer know that the nurse would be doing that. otherwise, there's not an implication.

you could probably summarise itby saying that, whenever you introduce a servicelike this into a practice, there needs to be a general agreementand culture within the practice that it will work in a certain way,there will be a team, this is how it will work, we're all clear about our roleand responsibilities. there's a clear referral pathway,there's a clear billing procedure. the receptionists knowwhat the billing procedure is, so everybody is crystal-clearon how the system works.

a comment from leanne kotz,moonta medical centre. 'i'm a practice nurse, and believewe are a vital part of the gp team and should be paid the equivalentto hospital nurses and not a much lower award rate.' feeding backinto our earlier discussion. there's no reason why not.they're just as competent. it's just the historical evolutionof the system. - tomorrow, when you get to tasmania...- i'll have a revolver in my hand. nurses in the practice we work atcertainly are. thank you, leanne.

i'm sure i'll be shouted down -it's not the only attraction - but the hours of work probably are why a lot of nurses opt outof the higher-paying hospital work for a more nine-to-five-type,regular practice. we've done a bit of work around that. there are a number of reasons. the so-called family-friendly hoursare only one. there are elements aroundpatient continuity. nurses love that as well,just like gps do.

it's something they don't getin the acute sector. it's also the scope of practice,the variability of role. julianne: holistic care.- the holistic care. let me take the question we had earlier,then i'll come back to the point. if you don't have a practicenurse, what are the reasons? 100% said cost. the sample was lowgiven that almost all of you did have practice nurses, butthose of you who answered, it was the cost.

let me go to the next question, 'causewe're getting to the end of the program. this is to the nurses watching: it would be interesting to hearthat question. i interrupted you, lynne. i was going to sayon the subject of payment, if we think about howthe corporate world works, there's incentives for people to workto capacity, to have through-put. we don't seem to have that culturein general practice. i would suggest that when briangoes back to his practice tomorrow,

he might think about paying his nursesa percentage of the pip income for the outcomes payments.i don 't really understand why... that's fine, and it gives people payment and goes along with the systemat the moment, but the reality is, don't we want to getbetter health outcomes out of this, and that you're just playingthe fee-for-service game? the reality is, that's how we work. if we talk about rewardand incentivising and getting nurses to stayin general practice,

which is probably becominganother problem, their retention, maybe if they're paid more,the attraction will be higher. the pay-for-performance systemthat they have in the uk, where it doesn't matter who does thework, the income comes to the practice, is maybe something we need to look at inaustralia to better reward the teams. the health reform commissionhas made statements along that regard. if general-practice nursingis to go forward, that's something that needsto be addressed, this model of payment. julie from wuchopperenoutreach health service asks,

'do you see a role forchild-health nursing in general practice extending beyond providing immunisationsand funded by medicare?' there's no reason whyany primary-care nurse couldn't be situated general practice,whether it be a child-health nurse, immunisation nurse,occupational health and safety. the only barrier we have at this pointis how they're funded. the actualworking together as part of a team and looking after the communityand public health is a great idea. do we know about churn -

what sort of turnover there isof general-practice nurses? we don't collect statistics nationallyabout the level of turnover. we do know anecdotally that nurses havecome into general practice and left. sometimes that's beenbecause they haven't been supported, another reason why we've introduceda standard orientation program, so they do have some supportto learn that role. but no, we don't have national figuresto do work around that. that's somethingthat could be looked at. some work we have seen through apna

is that the turnover is often related todissatisfaction in not being able to workat their full scope of practice. how much do you have to learnabout teamwork? doctors are not very good at it,usually. not generally. in rural practice, gps are much morelikely to be team-orientated. they just have to be. they have to work with ambulanceofficers, paramedics, hospital staff. so they probably do thismuch more easily.

i think in our practicethat's been the case to an extent. the ability to go onand develop protocols that enable the higher-scope-of-practicetype of nursing to happen is the difficult step. if we are going to make inroadsinto primary care, this is where it's going to be,not in general practice. to have a good team, you have towork at it, a bit like a marriage. you have to want it to work, and you have to invest timeand education and all those things.

i don't think general practice does thatvery well at all. it's something that has to changein undergraduate programs too, not just for doctors, for nursesand for allied health professionals - that there is moreinterprofessional learning and instruction aroundworking as a team, because i think you do need to learnto have that skill. it isn't second nature. how often is the practice nurse marriedto the gp? do we know that figure? we've got more important thingsto think about.

it could affect the dynamicin the practice. it does. lots of practice managersare actually the wives of gps. i don't think we should go there. we're on wobbly ground. i understand. this is an important concept. practice management maybe hasa few more years' earlier development, but it's a developing art as well. practices now would havevisiting dieticians. if they've got good efficiencyin the practice,

they would probably haveallied-health services visiting. let's go to the answer to your question: and the answer is mostly no. lynne: well, isn't that interesting?brian: i'm not surprised. an underutilised group of people. absolutely. here's a handy one for our last questionfrom one of our online viewers - 'as an ambitious nurse, why wouldi go into general-practice nursing?' here's your elevator pitch,as they say in america.

it's actually a fabulous job. it's a job which createsa lot of opportunities, a role you can make very interesting,and you can do it exceptionally well. patients love it.there are lots of reasons to go into it. just because it's not perfectthe way it is doesn't mean we should stop trying,and take opportunities when they arise. there is a new dimensionin primary-health care and i think practice nursesare really at the forefront of that. we've had seven yearsof really good groundwork

in providing the frameworkthat they need to really move on from here. with federal-government initiativesaround supporting more primary care, practice nursesjust need to seize the day. - julianne?- i love that - 'seize the day.' it is the best job on earth. norman: really?- absolutely. i'm very passionate about that. the only thing i've ever donethat was better was delivering a baby.

it is a very highly skilled workforceout there just waiting to graband run with the potential. there's no other job in nursingwhere you get to see the whole patient - you get to see your outcomesin the long-term, you get to see the impact on the familyand in the community. i'd recommend any nurse worth their saltgiving a good look at it. norman: brian?- observing from the outside, it is the long-term relationship that practice nurses developwith patients and families.

we've all talked about it. julie: and the team.- working as a team. thank you all very much indeed. let's hope we have a better-utilisedpractice-nurse workforce the next time we do a program on it. i hope you've enjoyed this programon general-practice nursing. if you're interested in obtaining moreinformation about issues raised, there are resources on the rural healtheducation foundation's website: don't forget to completeand send in your evaluation forms

and register for cpd pointsby completing the attendance sheet. i'm norman swan.from all of us, bye for now. captions bycaptioning and subtitling international funded by the australian governmentdepartment of families, housing, community servicesand indigenous affairs�