Working relationships between practice nurses and general practitioners in Australia: a critical analysis

This research set out to explore shared care between practice nurses and general practitioners in South Australia. Nine practice nurses (PNs), two nurse practitioners and 10 general practitioners (GPs) were interviewed in urban and rural practices in order to build up a picture of how GPs and PNs worked together. The interviews showed that shared care was not a reality, although practice nurses were very busy, enjoyed their work and were no longer performing as receptionists doing a little nursing on the side, but as highly skilled nurses. Questions that emerged included whether or not practice nurses are specialists or generalists; their relationship to nurse practitioners; the extent to which the doctor–nurse game explains the relationship between practice nurses and general practitioners; and the potential for expanding the practice nurse role.     

Negotiating the role of the practice nurse in general practice

The debate about the role of the practice nurse is not only about practice nursing per se, but raises broader issues about the organization of primary health care Two related issues emerge as significant the role of the practice nurse in providing primary health care, and the effective use of the practice nurse resource in the 'new' National Health Service This paper, by drawing on material from a qualitative study, specifically examines the type of work performed by practice nurses and the factors that influence this The responses of practice nurses, general practitioners, Family Health Service Authority (FHSA) advisers, community nurse purchasers and managers of community nursing provider units suggest that a consensus on the future development of practice nursing is unlikely The different stakeholders emphasized different issues, reflecting their own priorities and backgrounds Practice nurses' accounts of the future, for example, focused on professional issues General practitioners stressed the importance of role development which met then-General Medical Service responsibilities Purchasing agencies, provider units and FHSAs adopted a wider perspective and were more concerned to develop an effective and integrated primary health care service The tensions generated by their different interests and perspectives, and the subsequent organizational and policy initiatives that emerge, will provide the context in which the role of practice nurses will be negotiated     

A descriptive study of nurses employed by general practitioners in south-east Queensland.

The aim of this study was to describe the demographic and occupational characteristics of a sample of nurses employed by general medical practitioners and the factors perceived to be influential in their role development. Telephone and mail surveys were undertaken within one general practice division in South-East Queensland. Thirty-seven of the 67 (55%) practice nurses responded to the mailed questionnaire. Of these respondents, ten were collectively interviewed to elaborate on the survey results. Findings indicated that the primary work of these nurses is one of assistant to the doctor. Autonomous nursing initiatives are largely opportunistic. Perceived barriers to role expansion included Medicare restrictions, inadequate basic and ongoing education programs, financial and space limitations of the practice, reluctance of general practitioners, and a lack of professional support.     

Mentoring for nurses in general practice: an Australian study

This paper presents findings from a project conducted to recommend a national framework for mentoring for general practice nurses in Australia. The first phase identified challenges and key issues; the second and third phases (reported here) engaged practice nurses and general medical practitioners in discussion to advance thinking on the topic. Outcomes revolved around seven core areas: role confusion and diversity of practice nursing; lack of a defined career pathway for practice nurses; professional isolation of practice nurses; need for general practitioner support; expectations of mentoring; importance of resourcing and infrastructure; and roles, skills and qualities of mentors. Implications of these for the development of a systemic approach to supporting nurses in general practice are discussed, taking into account the inter-professional context and special working relationship between nurses and doctors. Findings revealed keen support for the idea of mentoring for nurses in general practice and indicate success will depend on appropriate resourcing and infrastructure through national, state and local coordination processes.     

Mentoring for nurses in general practice: an Australian study

This paper presents findings from a project conducted to recommend a national framework for mentoring for general practice nurses in Australia. The first phase identified challenges and key issues; the second and third phases (reported here) engaged practice nurses and general medical practitioners in discussion to advance thinking on the topic. Outcomes revolved around seven core areas: role confusion and diversity of practice nursing; lack of a defined career pathway for practice nurses; professional isolation of practice nurses; need for general practitioner support; expectations of mentoring; importance of resourcing and infrastructure; and roles, skills and qualities of mentors. Implications of these for the development of a systemic approach to supporting nurses in general practice are discussed, taking into account the inter-professional context and special working relationship between nurses and doctors. Findings revealed keen support for the idea of mentoring for nurses in general practice and indicate success will depend on appropriate resourcing and infrastructure through national, state and local coordination processes.     

Medical receptionists in general practice: Who needs a nurse?

The aim of this study was to determine the extent to which receptionists, working in general medical practices, are undertaking clinical tasks traditionally within the domain of nursing. A survey of 164 solo and principal general practitioners (GPs) practising within one division of general practice in south-east Queensland, Australia, yielded 84 responses (55%). The study found that some receptionists, while primarily employed for reception and clerical duties, were performing tasks that involved direct patient assessment, monitoring and therapy. Sixty percent of the GPs did not employ a nurse because of financial constraints and a perceived lack of need. These findings could be illustrative of the current trend in health care to appropriate the work of nurses to lesser-paid workers. Further investigation is indicated in order to determine the most appropriate non-medical staffing mix in general practice to achieve both quality care and financial viability.     

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

Aim This paper outlines the current state of Australian practice nursing, describes the context of general practice and establishes the importance of promoting leadership and management in this setting. Background Australian general practice nurses have emerged as key stakeholders in primary health care. However, their role in leadership and management has been largely invisible. The reasons for this are multifactorial, including the delay to establish a strong professional organization, their negative power relationships with general medical practitioners, limited nursing leadership and poorly defined roles. To date, the impetus for practice nurse growth has been largely external to the nursing profession. Growth has been driven by the increasing burden of chronic disease and workforce shortages. This has further weakened the control of nurse leaders over the development of the specialty. Conclusions The Australian practice nurse role is at a crossroads. While the practice nurse role is a viable force to improve health outcomes, the growing strength of the practice nurse challenges traditional professional roles and practice patterns. Implications for nursing management There is an urgent need to develop practice nurse leaders and managers to not only embrace the challenges of Australian general practice from an operational perspective, but also undertake a clinical leadership role. As clinical leaders, these nurses will need to develop a culture that not only optimizes health outcomes but also advances the status of the nursing profession.     

The role of the advanced practice nurse in facilitating a clinical research study. Screening for delirium

As advanced practitioners, clinical nurse specialists and nurse practitioners have a leadership role in integrating and promoting nursing research in clinical settings. In this quasi-experimental study, the role of the advanced practice nurse in developing and implementing an intervention that improved delirium screening by staff nurses is described. Screening practices of the treatment group nurses were accurate in 100% of the cases. Control nurses failed to detect any cases of delirium. A discussion of study findings and their relevance to advanced practice nursing are discussed.     

Acute care nurse practitioner practice: results of a 5-year longitudinal study.

The role of acute care nurse practitioners (ACNPs) has developed in capacity. More than 3500 advanced practice nurses have been certified as ACNPs, and the number of practice settings where these professionals work is continually expanding. Beginning in 1996, a series of surveys were conducted of nurse practitioners seeking national certification as ACNPs. What started as an attempt to gather information on the role of ACNPs evolved into a national 5-year longitudinal survey of ACNP practice. The cumulative results of the project are reported, and how the role of the ACNP was established in advanced practice nursing is discussed.     

Practice nurses experiences of mentoring undergraduate nursing students in Australian general practice

Internationally, the delivery of health services has shifted from secondary to primary care, necessitating an exponential growth of the nursing workforce and expansion of the nursing role in general practice. This growth, and the subsequent need to develop this workforce, has created a need to expose undergraduate nurses to general practice nursing as a viable career option. Concurrently, universities are struggling to find sufficient clinical places for their undergraduate students to gain clinical experience. It is logical, therefore, to increase the number of undergraduate nursing student placements in general practice. Through qualitative research methods, this paper seeks to explore the experiences of practice nurses mentoring undergraduate students on clinical placements within the general practice setting. Findings are presented in the following three themes: (1) Promoting Practice Nursing: We really need to get students in, (2) Mentoring future co-workers: Patience and reassurance, and (3) Reciprocity in learning: It's a bit of a two way street, which show the benefits of such placements. Clinical placements in general practice settings can be mutually beneficial in terms of providing quality teaching and learning experiences for students. Conversely, the experience provides an impetus for practice nurses to maintain currency of their clinical skills and knowledge through mentoring student nurses.     

Reflective practice and daily ward reality: a covert power game

Background. The concept of reflection is propounded in the literature as an epistemology for practice that enables practitioners to solve their daily problematic situations through conscious thought processes which eventually leads to practice‐based knowledge. Hence, reflection became a central tenet of both theory development and educational provision in nursing. Furthermore, this centrality of reflection was reinforced by statutory nursing bodies and service providers by adopting it as the means for carrying out adequate professional practice. Although this may be the case, issues of implementation of reflection within the daily reality of practitioners are frequently overlooked within the literature. Moreover, little consideration appears to be given on the impact that the organizational culture and the politics of power may exert on the implementation of reflective practices within daily ward reality. Aims. This paper explores how reflection is viewed by nurses within their daily reality in the medical wards, examines the relationships between the organizational culture of these wards and the practitioners and investigates whether reflective methods of practice were being implemented when the study was conducted. Methods. An interpretative ethnographical methodology was implemented and the data collecting methods used were observation, interviews and qualitative content analysis with a group of 16 practising nurses from four medical wards of one NHS Trust in England. Two interviews were conducted with each nurse within 3‐week intervals. The content of these interviews evolved from the analysis of episodes of practice observed when the nurses were giving nursing care. These data were supplemented by narratives from the nurses’ in the form of written reflective accounts that were analysed via qualitative content analysis techniques. Findings. Four themes were generated: (i) relationships between nurses and doctors; (ii) relationships between nurses and managers; (iii) nursing practice; and (iv) nurses’ input in the outcome of a clinical situation. Conclusions. The concept of reflection appears to be invalidated by the organizational hierarchy of the wards on the basis of a power struggle game. The ward structure portrays reflection as an abnormal method of practice and knowledge development. This belittlement of reflection does not mirror the practitioners’ reality. Instead, it is an intelligent and intentional act on behalf of the dominant professional groups in the wards to create an illusionary picture of ward reality to allow them to survey and define nursing practice and thus maintain and remain in power. This is explicated by using Foucault's analysis and critical social theory framework. Hence, reflective processes are constrained by this covert power game; reflection, where used, is confined to nurses’ personal time and space. Relevance to clinical practice. The realization of this covert power game by individual clinical nurses can become the incipient point for formally using reflective methods in the practice setting.     

The practice nurse: roles and perceptions

In the winter of 1992, a postal survey was conducted on all practice nurses in Gateshead, England The aim of the research was to descnbe the work of practice nurses (nurses working with and employed by general practitioners), with particular reference to health promotion and communication, and to explore the practice nurses' perceptions of their roles The research found little conformity about what practice nurses do, apart from practical tasks This confirms the essentially practical nature of their work, with poor role definition with regard to screening, health promotion and prevention Training was found to vary, indicating a need for improvement Women's health and surveillance of the health of elderly people were used to illustrate these issues A wide consensus was found about what tasks are appropriate to practice nurses, indicating either that the list of tasks used in the survey accurately describes their potential role or that they are prepared to perform most tasks Practice nurses perceive themselves as the specialists in health promotion although it was not possible to gain an understanding of whether they had a conception of the wider issues involved, which illustrated a limitation of survey methods The information obtained will be relevant in the debate about the future of practice nurses, as well as the future of primary health care services in general     

Time to talk, time to see: changing microeconomies of professional practice among nurses and doctors in Australian general practice

In Australia, more nurses are entering general practice, and nurses' work is being funded in increasingly complex ways through Medicare. Little research has explored the ways doctors and nurses realign their priorities and activities when working together in general practice.We undertook rapid, intensive multimethod studies of 25 general practices to explore the ways in which the labour of nurses and doctors was structured, and the implicit decisions made by both professions about the values placed on different ways of working and on their time. Data collected included photographs, floor-plans, interviews with 37 nurses, 24 doctors and 22 practice managers, and 50 hours of structured observation. Nursing time was constructed by both nurses and doctors as being fluid and non-contingent; they were regarded as being 'available' to patients in a way that doctors were not. Compared to medical time, nursing time could be disposed more flexibly, underpinning a valorized attribute of nursing: deep clinical and personal contact with patients.The location of practice nurses' desks in areas of traffic, such as administrative stations, or in the treatment room, underpinned this valuable unstructured contact with patients. Changes to the practice nurse role through direct fee-for-service items for nurses may lead to greater congruence between the microeconomies of nursing and medicine in general practice. In a time of pressure upon a primary care workforce, this is likely to lead to more independent clinical work by nurses, but may also lead to a decrease in flexible contact with patients.     

Ethical practice guidelines: an evaluation

Ethical practice guidelines (EPGs) were developed for use in Central Sydney Area Mental Health Service to guide contemporary mental health nursing practice and serve as a resource for clinical mental health nurses in relation to their professional conduct and practice. This survey of mental health nurses aimed to ascertain feedback on the application of the EPGs in the clinical arena. Nurses from the Central Sydney Area Mental Health Service ( n = 350) were asked to complete a 15-item survey developed by the authors. A total of 121 nurses completed the survey. Findings from the survey reveal that the information provided in the EPGs is useful (91%) and the EPGs provide sufficient guidance for practice (94%). Most respondents (96%) reported feeling confident dealing with ethical practice situations and 75% indicated interest in further education and training in this domain. Findings from this survey support the need to explore avenues to facilitate education, discussion and reflective practice in relation to ethical mental health nursing practice .     

The changing face of nurses in Australian general practice.

OBJECTIVE: To describe the workforce characteristics and current responsibilities of nurses working in Australian general practice settings. DESIGN: Survey research combining qualitative and quantitative data collected through telephone interview. SUBJECTS: 222 enrolled (RN Division 2 in Victoria) and registered nurses (RN Division 1 in Victoria) working in general practice in rural and urban areas of Australia. RESULTS: General practice nurses in Australia are likely to be RNs (84.7%) who work on a part-time basis (75.3%) in a medium to large practice (93.7%). Often the nurse has worked less than five full time equivalent years (52.3%) in a general practice environment and is likely to work in a practice where at least one other nurse works (64.4%). The nurse is likely to have some post-basic formal education (65.9%), and to have participated in professional development in the past two years (94.9%). The nurse performs a diverse range of activities within the general practice. No substantial differences were found in the workforce characteristics or role of urban and rural general practice nurses. CONCLUSION: It appears that nurses working in general practice are no longer the 'handmaiden' to the doctor but are professionals who perform a vast range of clinical, administrative and organisational responsibilities within the general practice primary health care setting.     

Health screening for women with physical disability in Australian general practice: A survey

BackgroundEarly detection of gynaecological issues improves health outcomes and reduces mortality. Such early detection is best achieved via regular, proactive health screening. Like other disadvantaged groups, women with physical disability have much lower gynaecological screening rates than the general population.AimThe aim of this paper is to explore the current role of general practice nurses in women’s health screening for individuals with physical disability.MethodsA national online survey of Australian general practice nurses was conducted.FindingsOne hundred and seventy-eight general practice nurses completed the survey. Sixty-one percent reported having experience in working with people with a physical disability. Around one third of participants reported having completed specific education about physical disability. Most general practices implemented strategies to facilitate physical access for those with disability. However, few general practices had a medical records system that enabled identification of physical disability. Thirty-seven participants reported providing women’s health screening for 89 women with a physical disability in the 4 weeks prior to the survey. A range of strategies were used to support women during these screening procedures. These could be broadly classified into; a) providing practical assistance to facilitate screening, and b) modifying technique and positioning for comfort.ConclusionsThe limited experience with disability amongst an experienced nursing cohort, and the difficulty inherent in identifying those with a disability within recall and reminder systems, adds complexity to the provision of screening for women with a disability. Whilst participants articulated some innovative and creative strategies to assist women with a disability during health screening, enhanced awareness amongst nurses and proactive strategies would likely enhance service accessibility in this vulnerable group.     

A pluralistic evaluation of nursing/practice development units

Nursing/practice development units (N/PDU) are perceived as centres for pioneering, evaluating and disseminating innovative practice development and facilitating the professional development of practitioners. This paper reports on a pluralistic evaluation research study of the nursing/ practice development unit accreditation programme provided by the University of Leeds, UK. Individual and focus group interviews were undertaken with key stakeholders involved in six nursing/practice development units. These included: clinical leaders, team members, executive nurses, trust board members, general medical practitioners, nursing/practice development unit steering group members, and accreditation panel members. Stakeholder perceptions of what constituted a successful nursing/practice development unit were elicited and then used to judge the success of the programme. Seven criteria for judging the success of nursing/practice development units were identified. These were: achieving optimum practice; providing a patient-orientated service; disseminating innovative practice; team working; enabling practitioners to develop their full potential; adopting a strategic approach to change and autonomous functioning. The findings highlighted differences between the rhetoric of a successful nursing/practice development unit and the reality in which they function. Whereas all the units were actively involved in innovative practice development, evaluation, dissemination and networking activities, several factors influenced the success of the units, in particular, the role of the clinical leader, the motivation and commitment of nursing/practice development unit members, financial resources, and the nature of support from managers, medical staff and education institutions. Although the nursing/practice development units had made significant progress in developing both healthcare practice and practitioners, there is still a need to consider how the claim that nursing/practice development units benefit patients can be substantiated.     

开展监护室专科护士临床实践对普通护士核心能力的影响

目的 通过开展监护室专科护士临床实践,比较实践前后监护室普通护士的核心能力得分情况,来了解监护室专科护士临床实践对普通护士核心能力产生的影响。方法 以整群抽样法选择上海中山医院外科监护室60名普通护士为实验组、肝外科监护室60名普通护士为对照组,在外科监护室中开展专科护士临床实践,于实践前后分别对两组进行核心能力测评,比较分析两组在实践前后核心能力的得分情况。结果 实践前,两组核心能力得分在各维度上差异无统计学意义(P>0.05)。实践后,实验组在核心能力各个维度的得分均有提升,且高于对照组,差异有统计学意义(P<0.05)。结论 开展监护室专科护士临床实践可以有效提高普通护士的核心能力。