how is primary health care conceptualised in nursing in australia? a review of the literature

Review

How is Primary Health Care conceptualised in nursing in Australia?

A review of the literature

Julie Henderson BA(Hons) PhD, Kristy Koehne RN PhD, Claire Verrall RN BN MN, Kristine Gebbie RN MN DrPH

and Jeffrey Fuller BN MSc(Primary Health Care) PhD

School of Nursing & Midwifery, Flinders University, Adelaide, SA, Australia

Accepted for publication 21 June 2013

CorrespondenceDr Julie HendersonSchool of Nursing & MidwiferyFlinders UniversityGPO Box 2100Adelaide 5001SA, AustraliaE-mail: [email protected]

What is known about this topic

• Primary Health Care (PHC) isviewed as a means of reducing theburden of chronic disease.

• General practice has beenidentified as a site for delivery ofPHC.

What this paper adds

• The term ‘PHC’ is poorly definedin Australian nursing literature.

• PHC is associated with generalpractice and practice nurses inpolicy.

• Funding through the MedicareBenefits Scheme for a limited rangeof nursing tasks limits capacity foradvanced and comprehensive PHCin general practice.

AbstractAustralia, in common with many other countries, is expanding the role ofPrimary Health Care (PHC) to manage the growing burden of chronicdisease and prevent hospitalisation. Australia’s First National PrimaryHealth Care Strategy released in 2010 places general practice at the centreof care delivery, reflecting a constitutional division of labour in which theCommonwealth government’s primary means of affecting care delivery inthis sector is through rebates for services delivered from the universalhealthcare system Medicare. A review of Australian nursing literaturewas undertaken for 2006–2011. This review explores three issues inrelation to these changes: How PHC is conceptualised within Australiannursing literature; who is viewed as providing PHC; and barriers andenablers to the provision of comprehensive PHC. A review of theliterature suggests that the terms ‘PHC’ and ‘primary care’ are usedinterchangeably and that PHC is now commonly associated with servicesprovided by practice nurses. Four structural factors are identified for ashift away from comprehensive PHC, namely fiscal barriers, educationalpreparation for primary care practice, poor role definition andinterprofessional relationships. The paper concludes that while movestowards increasing capacity in general practice have enhanced nursingroles, current policy and the nature of private business funding alongsidesome medical opposition limit opportunities for Australian nursesworking in general practice.

Keywords: Australia, general practice, nursing, Primary Health Care

Introduction

A number of demographic factors, including theageing of the population and accompanying demandfor hospital and healthcare services (Schofield & Ear-nest 2006), the ageing of the healthcare workforce(O’Brien-Pallas et al. 2004), the growing health burdenof chronic illness in developed countries (Lopez et al.2006) and mortality from non-communicable diseasesin developing countries (World Health Organization2008), have increased interest in Primary Health Care

(PHC) as a means of managing demands on healthbudgets. The WHO (2008) identifies PHC as a meansof redressing health inequities. They argue thatinternational policy focuses upon curative services tothe detriment of primary prevention and healthpromotion. In response, they call for health-carewhich is equitable and accessible (universal health-care systems); consumer-centred; participatory andresponsive to people’s needs; and embraces publichealth activities to improve community health (WHO2008, p. xvi).

© 2013 John Wiley & Sons Ltd 337

Health and Social Care in the Community (2014) 22(4), 337–351 doi: 10.1111/hsc.12064

In Australia, a growing interest in PHC is evi-denced by the release of Australia’s First National Pri-mary Health Care Strategy in 2010. PHC is defined inpolicy by the Commonwealth government as a:

…socially appropriate, universally accessible, scientificallysound first level care provided by health services and sys-tems with a suitably trained workforce comprised of multi-disciplinary teams supported by integrated referral systemsin a way that gives priority to those most in need andaddresses health inequalities; maximises community andindividual self-reliance, participation and control; andinvolves collaboration and partnership with other sectors topromote public health. (Department of Health & Ageing2009, p. 22)

Primary Health Care is viewed by the Common-wealth government as a means of reducing the bur-den of chronic disease, reducing demand on hospitalservices and increasing equity of access to health ser-vices (Department of Health & Ageing 2009). Generalpractice is at the centre of the National Primary HealthCare Strategy. The Strategy seeks to improve access toservices through integration of primary care or first-level services under population planning by MedicareLocals. Medicare Locals are the Australian variant ofregional PHC organisations that have originated fromDivisions of General Practice. The role of MedicareLocals under the strategy is to co-ordinate regionalprimary care delivery (Department of Health &Ageing 2010). PHC in this context is understood astargeting chronic disease management, with responsi-bility for this management largely placed withgeneral practice. Chronic disease management isexplicitly linked with hospital avoidance in policywith, for example, General Practitioners (GPs) receiv-ing performance incentives under the National Pri-mary Health Care Strategy for meeting benchmarks fordiabetes care that prevents hospitalisation. Primarycare, and in particular general practice, is also viewedas the appropriate venue for disease prevention activ-ities and as such, primary care is often associatedwith practice nurses (PNs) who can be enrolled orregistered nurses who are employed to provide ser-vices for general practice. While there are no formalqualifications beyond registration, the role of thenurse in general practice is one of the most rapidlychanging roles in PHC. Associations such as the Aus-tralian Practice Nurse Association as well as MedicareLocals can provide educational support and some uni-versities have embraced educational courses towardsGraduate Certificate, Diploma and Masters in GeneralPractice Nursing. Commonwealth government sup-port for the PN role has involved investment in aPractice Nurse Incentives programme to expand therole of PNs to undertake health assessment and

health promotion and prevention activities as well astargeting resources towards risk behaviours such assmoking (Department of Health & Ageing 2010).

The focus on GP-led fee-for-service care deliveryfor PHC is supported by a constitutional division oflabour where the provision of GP services is fundedthrough the Australian Government health insuranceprogramme (Medicare), while most other communityhealthcare services are a state government responsi-bility. As a consequence, the Australian Govern-ment’s central means of effecting PHC delivery isthrough the Medicare Benefits Scheme (MBS). MBSrebates are provided for a range of medical, diagnos-tic and therapeutic services (Department of Health &Ageing 2011a) and can be claimed by medical prac-tices for nursing services provided by PNs andAboriginal health workers working under the direc-tion of GPs. Rebates only apply to a small range ofactivities including immunisation, wound care, papsmears and chronic disease prevention and manage-ment activities (Patterson et al. 2007). Recent changesto the Medicare Act have also extended the capacityto apply for MBS provider numbers to nurse practi-tioners and midwives (Department of Health &Ageing 2011a, Harvey 2011, Lane 2012). Nurse practi-tioners, who work in collaboration with GPs, canapply for rebates for activities related to historytaking, clinical examinations, organising investiga-tions, implementing a management plan or preventa-tive health-care (Department of Health & Ageing2011b). These tasks largely replicate and supportthose activities performed by GPs.

The commitment of the Commonwealth govern-ment to the role of general practice in the delivery ofPHC is evident in incentives for expansion of the PNrole. In addition to the Practice Nurse Incentives pro-gramme, funding has been targeted towards employ-ment of PNs in rural settings and training andsupport schemes (Patterson et al. 2007). There hasbeen accompanying growth of nursing employmentin primary care and in particular, within generalpractice. The 2006 census data identified 11% of thenursing workforce as working in primary care inboth general practice and community health (Austra-lian Institute of Health & Welfare 2009). The numberof PNs across Australia in 2007–2008 was identifiedas being 8575, double the number working in generalpractice 4 years earlier (Department of Health & Age-ing 2009). By 2011, a total of 9617 registered nursesand 2958 enrolled nurses identified general practice astheir primary place of employment (AIHW 2012). In amove to achieve better co-ordination and efficiencyacross community health services, the Australian Gov-ernment in 2011 sought to bring all community health

© 2013 John Wiley & Sons Ltd338

J. Henderson et al.

service provision under one national auspice; how-ever, resistance by some state governments meantthat this did not occur. With this, albeit failed,national takeover of community health services andwith increasing PN numbers, the focus in PHC nurs-ing in Australia is firmly upon general practice. Inthe light of policy changes, the purpose of this paperis to review recent literature and selected policy doc-uments in relation to PHC and nursing practice inAustralia to determine first, how PHC is beingdefined in this literature and second to identify cur-rent nursing roles in relation to PHC.

Following Keleher (2001), we define PHC as botha philosophy and a systemic approach to reducinghealth inequities through intersectoral partnerships tomeet basic needs. Health, in this context, is definedbroadly as a:

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

For this study, a further distinction was madebetween selective and comprehensive PHC strategieswhere selective strategies offer individual interven-tions such as screening or immunisation, and compre-hensive PHC strategies address social determinants ofhealth (Keleher 2001, p. 60). Baum (2007) argues thatcomprehensive PHC is intersectoral, grounded incommunity and driven by consumer rather than byprofessional priorities. As such, it is empowering andinevitably, political. Selective strategies, in contrast,are provided by the healthcare system, adopt a cura-tive or disease prevention approach and often applyglobal rather than tailored approaches to health prob-lems. A third goal of the paper, therefore, is to iden-tify the barriers and enablers to the delivery ofcomprehensive PHC indicated in the literature.

Method

Design/search methods

A search of peer-reviewed Australian and interna-tional 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 ofthis paper was to see how the term ‘PHC’ was beingdefined in Australian nursing literature, the searchwas limited to papers using this term to ensure thatthe articles accessed focused upon the concept ofPHC. The timeframe of 2006–2011 chosen for thisreview encompasses a period of rapid expansion ofthe PN role in Australia, but does not allow for the

capture of literature addressing recent systemic andpolicy changes in the delivery of care. The searchyielded 213 papers, which were reviewed indepen-dently by two authors to check suitability.

Articles were included in the study if the abstractdiscussed PHC and excluded when the professionalrole discussed was not a nursing role. The articleswere primarily empirical studies undertaken in com-munity settings with a small number of opinion piecesand literature reviews included where these com-mented upon policy directions or practice issues inrelation to PHC (see Tables 1–3). The National Healthand Medical Research Council (2000) in Australia pro-vides guidelines for assessing the quality of evidencewith greatest weight given to intervention studies withrandomised allocation of subjects or literature reviewsbased on these studies. The empirical studies includedin this review primarily evaluated existing practice orservice delivery models and as such, the quality of evi-dence provided would be assessed as being low byNational Health and Medical Research Council stan-dards. As the purpose of the paper is to explore repre-sentations of PHC rather than best practice, this wasnot considered an obstacle. Following an independentreview, two authors (KK and CV) undertook a com-bined review and allocated abstracts to either a ‘yes’,‘no’ or ‘possible’ category on the basis of inclusioncriteria. International papers from countries withcomparable healthcare systems to Australia wereincluded to inform the background and discussion,but were not subject to data extraction and analysis.

At the second stage of the review, abstracts in the‘yes’ or ‘possible’ categories were taken to theresearch team for further scrutiny. After thoseabstracts for inclusion were identified, a snowballingapproach was employed to scan all reference lists forfurther papers of relevance. Following this process, atotal of 37 papers were considered as meeting allinclusion criteria, and a further 22 internationalpapers were highlighted as relevant for comparison.

In addition, a review of the grey literature wasundertaken, with a particular focus on websites con-sidered pertinent to the role of nursing in Australia,including the Australian Nursing Federation (ANF),the Australian Practice Nurses Association, the RoyalCollege of Nursing Australia, the Australian College ofNurse Practitioners and the Australian College of Men-tal Health Nurses. These agencies were consideredintegral as they had combined to generate a consensusstatement regarding the role of the registered nursesand nurse practitioners in PHC, which informed thedevelopment of the National Primary Health Care Strat-egy. The websites of these agencies were scanned forpertinent documents regarding the role of PHC in


Primary Health Care in Australia

Table

1Summary

ofarticlesadoptingacomprehensivePrimary

HealthCare

(PHC)approach

Article

title

Typeofpaper

Setting

Rolesdiscusse

dDefinitionofrole

inrelatio

nto

PHC

Barriers/enablers

toPHC

Millsetal.(2010)

Thestatusofruralnursingin

Australia:12years

on

Literature

review

Ruralpractice

Ruralnurses,

nursepractitio

ners

Role

relatedto

social

determ

inants

ofhealthand

provisionofgeneralistcare

acrossthelifespan

LackofPHC

preparationdueto

aneducationalfocusupon

hospitalservicedelivery

Whitehead(2006)

Thehealth

-promotingschool:

whatrole

fornursing?

Literature

review

Sch

ools

Schoolnurses

Calls

fornursein

schools

to

movebeyondthetraditional

healtheduca

tionapproachto

encompassthehealth

promotin

gwhole

ofschool

approachincluding:

●Buildingschoolcapacityfor

health

promotio

n

●Linkswithotheragencies

●Participation

●Politicalactio

n

Insufficientresources

Lackofnursetraining

Insufficientresearchand

evaluationofoutcomes

Confusionabouttheschool

health

nurserole

andlackof

role

recognition

Highstaffturnover

Lackofcareerpathway(caught

betweenhealth

andeducation

andmarginalisedin

the

communityhealth

nursing

profession)

McMurray(2007)

Leadership

inprimary

health

care:aninternational

perspective

Opinionpiece

Generalpractice

Practicenurse

Focusuponsocialdeterm

inants

andtailoringthepracticenurse

role

topatientneeds

Nursesidentifiedasbeingin

primepositionto

identifyhealth

needs,increasehealth

literacy

andprovideleadership

inPHC

Annells

(2007)

Where

doespracticenursingfit

inprimary

health

care?

Opinionpiece

Generalpractice

Practicenurse

PHC

involvesa‘broadrangeof

health-relatedactivitiesfocused

onhealthpromotionanddriven

alsobytheprinciplesof

acce

ssibility,appropriate

technology,inter-sectoral

collaborationandpublic

participation’.(p.20)

‘Territoriality’amongprofessions

Educa

tionalpreparation

Fundingarrangements

GreeneandBurley(2006)

Thechangingrole

ofbush

nursesin

EastGippsland,

Victoria

Opinionpiece

Remote

rural

areas

Solo

remote

nurse

Referenceto

abroaderhealth

promotio

nrole

Fundingmismatch

McMurray(2010)

Empowerm

entandenterprise:

thepoliticaleconomyofnursing

Opinionpiece

Non-specific

Non-specific

Partnership

withcommunityand

patientunderscoredasthe

preferredmodelforallhealth

services

Reluctanceofnursesto

engage

withthepoliticalprocess

inthe

broaderhealthworld


J. Henderson et al.

nursing. Papers for possible inclusion were taken backto the team for final consideration. A total of four greypapers had a direct focus on nursing roles and PHCand were considered relevant for analysis.

Data extraction

The research team generated a template for dataextraction based on the research questions driving thereview. The template incorporated basic methodologi-cal information and more specific questions, whichsought to examine the way in which PHC was con-ceptualised. In particular, the template facilitatedenquiry regarding comprehensive versus selectivenotions of PHC, a distinction considered pertinent tothis review. Examination of selective versus compre-hensive PHC philosophies was guided by Baum’s(2007) definition of comprehensive and selective PHCas outlined above. Each paper was subject to analysisby two independent researchers and if there was adiscrepancy in the analysis, i.e. conflicting views of acomprehensive versus selective approach, the paperwas reviewed by a third author.

Results

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

Defining Primary Health Care

Tables 1–3 summarise findings in relation to the man-ner in which PHC is defined, the nursing roles associ-ated with PHC and barriers and enablers of PHC inthe articles reviewed. Of the 37 articles considered, 8were identified as having a comprehensive approachto PHC, 12 were viewed as adopting a selectiveapproach to PHC, 8 were viewed as having elementsof both and the remaining 9 articles did not providea definition of PHC and were not included in theTables, although considered in the thematic analysis.

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

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

able

1Continued

Article

title

Typeofpaper

Setting

Rolesdiscusse

dDefinitionofrole

inrelationto

PHC

Barriers/enablers

toPHC

Kruskeetal.(2006)

Primary

HealthCare,Partnership

andPolemic:child

andfamily

health

nursingsupportin

early

parenting

Empirical

ethnographic

study

Child/family

healthservice

Child/family

health

nurses

Preventionofillnessthrough

screeningandsurveillance,and

thepromotio

nofhealth,

incorporatingtheprinciplesof

PHC

Under-resourcing

Lackofcontin

uityofrelatio

nships

Lim

itednurseinterestin

further

educationandresearch

Keleheretal.(2010)

Preparingnursesforprimary

health

care

futures:how

welldo

Australiannursingcourses

perform

?

Empiricalmixed

methods

Educatio

nal

programmes

Exp

andedrole

educa

tion

Includesepisodesoftreatm

ent

andfollow-upaswellassystem

responsesto

tackle

determ

inants

ofhealth

.

Groundedin

asocialmodelof

health

PatchyadoptionofPHC

in

nursingcurricular

Unclearskillsandknowledge

requisitesarticulatedin

national

competencies



Table

2Summary

ofarticlesadoptingaselectivePrimary

HealthCare

(PHC)approach

Article

title

Typeofpaper

Setting

Rolesdiscussed

Definitionofrole

inrelatio

nto

PHC

Barriers/enablers

toPHC

OlasojiandMaude(2010)

Theadventofmentalhealth

nurses(M

HNs)in

Australian

generalpractice

Empiricalservice

evaluatio

n

Generalpractice

Mentalhealth

nurses

Care

planningandreview

Medicationmanagement

Facilitatingacce

ssto

other

services

Workingwithfamiliesandcarers

Useskeyterm

sregardingsettings

andprinciples(i.e.PHC,primary

care)interchangeably

Unwillingness

ofMHNsto

work

ingeneralpractice

Poorremuneratio

n

Nocareerstructure

Lackofeducationin

PHC

JoyceandPite

rman(2011)

Thework

ofnursesin

Australian

generalpractice:anational

survey

Empiricalsurvey

researchon

serviceencounters

Generalpractice

Practicenurse

Chronic

diseasefocus

Healthpromotio

nis

viewedas

screeningandim

munisatio

n

activities

Lim

itedevidenceofteam

work

Medicare

Benefits

Sch

eme

(MBS)fundingarrangements

are

identifiedasinhibitingthe

PN

role

incomparisonwith

otherjurisdictions,e.g.UK

JoyceandPite

rman(2009)

Farewellto

thehandmaiden:

profile

ofnursesin

Australian

generalpracticein

2007

Empiricalsurvey

research

Generalpractice

Practicenurses

NodefinitionofPHC

Allpracticenursesdid

direct

patientcare,co-ordinationof

care

andmanagementof

clinicalenvironment,90%

did

somepracticemanagement

andadmin

and57%

provided

somereceptio

nandsecretarial

work

Low

pay

Educa

tionalfocusonitems

attractin

gMedicare

rebates

Lawsetal.(2008b)

Should

IandcanI?

Amixed

methodsstudyofclinician

beliefs

andattitudesin

the

managementoflifestyle

risk

factors

inprimary

health

care

Empiricalmixed

methods

Generalpractice

Practicenurse

Clientassessmentandcare

planning

Supportsrole

ofnursesin

assisting

inlifestyle

change

Clinicianbeliefs

andattitudes

Wilson(2007)

Planningprimary

health

care

servicesforSouth

Australian

youngoffenders:aprelim

inary

study

Empiricalqualitative

methods

Juvenile

detentio

nNursesservingas

liaison

Liaisonwithotherservices

Patientassessment

Dischargeplanning

Recommendsaliaisonnurse

locatedataDivisionofGeneral

Practiceasenabler

Larkinsetal.(2006)

Consultationin

generalpractice

andatanAboriginalcommunity-

controlledhealthservice:do

theydiffer?

Empirical

prospectivesurvey

auditofconsultations

Severalclinicsin

ruralarea

Clinic

nurses

Focuse

sonindividualpatients

with

specificconditions

Indigenousnurseasculturalbroker

Nilidentified


J. Henderson et al.

Table

2Continued

Article

title

Typeofpaper

Setting

Rolesdiscusse

dDefinitionofrole

inrelationto

PHC

Barriers/enablers

toPHC

Lawsetal.(2010)

Anefficacytrialofbrieflifestyle

interventiondeliveredby

generalistcommunity

nurses

(CN

SNAPtrial)

Protocolpaperfor

empirical

quasi-experimental

study

Community-based

services

Generalist

communitynurses

DefinesPHC

asasetting

Interventionis

attheindividual

clientlevelandspecificto

physicalactivity,diet,weight

management,smokingand

alcohol

Lookingto

increaselifestyle

interventionswithoutincreasing

resources

Keleheretal.(2009)

Systematicreview

ofthe

effective

nessofprimary

care

nursing

Literature

review

Community-based

clinicalcare

Nursesin

community-based

care

Definedasprimary

care

Individualinterventions

Focusonpatients

withexisting

disease

aswellasissuessuch

as

preventionthroughchild-rearing

practices,smokingcessation

Nilidentifie

d

Harris

etal.(2008)

Chronic

disease

self-m

anagement:

implementationwithandwithin

Australiangeneralpractice

Literature

review

Generalpractice

Practicenurses

Majoremphasis

isonchronic

disease

management

PHC

andprimary

care

used

interchangeably

Preferenceforindividualover

groupeduca

tion

Directivecare

Cranstonetal.(2008)

Models

ofchronic

disease

managementin

primary

care

for

patients

withmild

tomoderate

asthmaorCOPD:anarrative

review

Narrativereview

Generalpractice

Practicenurses

Primary

focusis

onmedical

managementofpatients

with

chronic

conditions

Nilidentifie

d

Keleheretal.(2007)

Practicenursesin

Australia:

currentissuesandfuture

directions

Opinionpiece

Generalpractice

PN

(substitute

forMD

or

collaborative)

NodefinitionofPHC

Contrasts

substitutionmodelwhere

thenurseis

delegatedtasksonce

perform

edbytheGeneral

Practitioners

(GPs)andunderthe

supervisionoftheGPwitha

collaborative

modelwhere

the

nurseassu

mesindependenttasks

asamemberofamulti-D

team,

suchasin

chronic

disease

management

Supervision

Professionalindemnity

Fundingarrangements

Educatio

nandtraining

Lackofsystematic

policy

development

Halcombetal.(2008b)

Promotingleadership

and

managementin

Australian

generalpracticenursing:what

willittake?

Opinionpiece

Generalpractice

Practicenurse

Focusonindividualinterventions

within

generalpractice

Lackofnursinginvolvementin

divisionsofgeneralpractice

Part-tim

eandcasualemployment

Fundingmodels

includinglim

ited

MBSrebatesfornursingtasks



Table

3Summary

ofarticlescontainingelements

ofboth

acomprehensiveandselectivePrimary

Health

Care

(PHC)approach

Article

title

Typeofpaper

Setting

Rolesdiscusse

dDefinitionofrole

inrelationto

PHC

Barriers/enablers

toPHC

Al-Motlaqetal.(2010)

How

nursesaddresstheburden

ofdisease

inremote

orisolated

areasofQueensland

Empirical

qualitativestudy

Variety

ofclinics

inruralareas

ofQueensland

Nursesin

the

clinics/centres

Calls

forcommunity-controlledsocial

andhealth

-care,particularlyfor

ruralIndigenouscommunities;

howeve

r,in

practicedelivering

reactivesecondary

health

-care

–‘bandaid

service’

Workload

Tim

e

Provisionofreactiveratherthan

proactivecare

Lackofeducationalpreparation

Birksetal.(2010)

Models

ofhealthservicedelivery

inremote

orisolatedareasof

Queensland:amultiple

care

study

Empirical

qualitativestudy

Variety

ofclinics

inruralareas

ofQueensland

Nursesin

the

clinics/centres

PHC

definedas‘universalaccess

to

resources,diseasepreventionand

health

promotio

n,communityand

individualengagementin

self-care’.

(p.26)

Most

activitiesundertakenona1:1

basis

Demandforservices

Workloadandbeingoncallfor

isolatedcommunities

Willingnessto

operate

asaguideor

coachforothers

Capacity

andskilllevelofother

healthworkers

Lackofsupport

Halcombetal.(2008a)

Cardiovasculardisease

management:timeto

advance

thepracticenurserole?

Empiricalmixed

methods

Generalpractices

Practicenurse

(PN)

PHC

definedas‘“frontline”

managementforthose

who

presentedto

generalpracticefor

both

acute

health

issuesand

chronic

illnessmanagement’.(p.50)

Individualbuttailoredtherapiesfor

chronic

illness

Barriers

infiscalsystem

Resistanceto

changebyGeneral

Practitioners

(GPs)

Legalbarriers

Halcombetal.(2007)

Exploringthedevelopmentof

Australiangeneralpractice

nursing:where

wehavecome

from

andwhere

tofrom

here?

Empiricalcontent

analysis

ofthe

proceedingsof

PN

conferences

Multiple

settings

PNs

Nodefinitionprovided

Role

consistentwithPHC,butnot

madeexplicit

Anentrenchedlackofcollaboration

intheculture

ofgeneralpractice–

referringto

GPandnurse

Barbaro

etal.(2011)

Developmentalsurveillanceof

infants

andtoddlers

bymaternal

andchild

healthnursesin

an

Australiancommunity-based

setting:promotin

gtheearly

identificationofautism

spectrum

disorders

Empirical

quantitative

methods

Maternal/child

health

Maternalchild

health

nurses

Preventativefocusandsome

engagedcommunity/parental

participation,butprimarily

anexpert-

deliveredinterventionwithafocus

onthereductionofaspecific

disease

Nilidentified


J. Henderson et al.

Table

3Continued

Article

title

Typeofpaper

Setting

Rolesdiscusse

dDefinitionofrole

inrelationto

PHC

Barriers/enablers

toPHC

Lawsetal.(2008a)

Asquare

pegin

aroundhole?

Approachesto

incorporatin

g

lifestyle

counsellinginto

routine

primary

healthcare

Empiricalaction

researchusing

qualitative

methods

Non-general

practice

community

health

settings

Nursesin

three

community

settings

NodefinitionofPHC

Role:assessmentandcounselling

relatedto

lifestyle

riskfactors

Twoofthreeteamsstudiedhada

selectiveapproach

toPHC

witha

focusontheindividualandpost-

acute

care,ratherthangroup-or

community-directedapproach

es

Nilidentified

Halcombetal.(2006)

Evolutio

nofpracticenursingin

Australia

Literature

review

Generalpractice

PNs

NodefinitionofPHC

Roles:im

munisationandscreening

aswellas‘advancedpractice’,e.g.

complexwoundcare,lactatio

nor

chronic

diseasemanagement

Structural,fiscaland

interprofessionalbarriers

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

Universal access to resources, disease prevention and healthpromotion, community and individual engagement in self-care, inter-sectoral approaches to health, and cost-effectivesolutions to promoting well-being that incorporate allaspects of an individual’s life and environment.

Similar views are expressed in the grey literature.Chiarella (2008, p. 5), in a discussion paper preparedfor the National Health and Hospital Reform Com-mission, identifies PHC as universally accessible,essential and affordable health-care, which involvesfull participation from the community and fostersself-determination.

More commonly, however, the literature does notexplicitly define PHC, conflating it with primarycare. Keleher et al. (2010) make a distinction betweenprimary care, which is understood as episodic careand PHC, which addresses social determinants ofhealth and health inequities. Likewise, Bryant (2011)uses the term ‘primary care’ when discussing federalpolicy initiatives including extension of eligibilityfor MBS provider numbers and the advent of Medi-care Locals and ‘PHC’ when addressing the socialdeterminants of health. For the most part, however,the terms are used interchangeably. The term ‘PHC’is associated not only with a site, most commonlygeneral practice, for the delivery of care (see Harriset al. 2008, Laws et al. 2010) but also with a level ofcare delivery reflecting Commonwealth policy inwhich PHC is defined as ‘first-level care’ (Depart-ment of Health & Ageing 2009, p. 22). Halcombet al. (2008a, p. 50), for example, define PHC as‘“frontline” management’, whereas Olasoji andMaude (2010) contrast mental health-care in primaryhealth (read General Practice) with specialist mentalhealth-care provided by secondary and tertiaryservices.

Nursing roles within Primary Health Care

In keeping with a policy focus upon the delivery ofPHC through general practice, the most commonlycited nursing role is that of the PN. A number of arti-cles outline the tasks currently undertaken by PNs(Harris et al. 2008, Joyce & Piterman 2009, 2011, Phil-lips et al. 2009). The role is largely defined in terms ofchronic disease management and individuallyfocused health promotion and prevention activities.The tasks associated with PNs include care planningand review (Olasoji & Maude 2010); immunisation,health assessment and screening; diagnostic tests andwound care (Joyce & Piterman 2011); health educa-tion (Phillips et al. 2009); and reception and secretarial

work (Joyce & Piterman 2009). These tasks largelyreflect MBS rebates.

Other nursing roles discussed within this literatureinclude community, child and family health, schooland rural and remote nursing, all of which are identi-fied as providing a greater scope for comprehensivePHC activities. Factors which are identified as pro-moting comprehensive PHC activities in these settingsinclude lack of access to alternative staff and develop-ment of generalist roles (Mills et al. 2010); workingwith indigenous communities (Al-Motlaq et al. 2010);and partnerships between services and professions(McMurray 2007). Interestingly, the role of nurse prac-titioners is largely absent in this literature. Mills et al.(2010) suggest that this may reflect an initial policyfocus upon the employment of nurse practitioners inrural settings where few people have the requisiteeducation and also lack of access to MBS and pharma-ceutical benefit scheme rebates that until recentlymade nurse practitioner services cost-prohibitive.

Some articles argue for an expanded role for PNsto encompass comprehensive PHC activities. Hal-comb et al. (2008b) argue that PNs are positioned totake greater leadership in managing chronic diseaseand lifestyle risk factors. Parker et al. (2010) note thatPNs in the United Kingdom undertake extended rolesin chronic disease management and preventativehealth checks as well as telephone consultations andtriaging for home visits, whereas Annells (2007)argues for a greater role for PNs in promoting healthand well-being.

Barriers to delivering comprehensive PrimaryHealth Care

The articles identify a number of barriers to the deliv-ery of comprehensive PHC, particularly within gen-eral practice settings. This discussion will focus uponfour structural barriers, namely funding arrangementsand fiscal barriers; educational barriers; poor role def-inition and lack of career structure; and finally, work-ing relationships with other professions.

FundingAccess to resources and funding models were identi-fied as a barrier to the delivery of comprehensivePHC across community nursing settings and generalpractice. For rural nurses, lack of access to alternatehealth services and time constraints result in the pri-oritisation of emergency secondary and tertiary careover PHC within community settings (Al-Motlaqet al. 2010, Birks et al. 2010). In addition, negotiatingcomplex funding arrangements creates difficulties inimplementing ‘sustainable and equitable health


J. Henderson et al.

service models’ (Greene & Burley 2006, p. 82). Similararguments are made by community and family healthnurses who associate lack of resources with poor con-tinuity of care due to

Decreased opportunities for nurses to be available to thewomen 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 beenlimited largely to procedural tasks by virtue of theiremployment in private general practice with servicesreimbursed through MBS rebates. Joyce and Piterman(2011) found in a study of tasks undertaken byPNs that three tasks, immunisation, wound care andpap smears, all of which attract rebates, accountedfor 40% of the work undertaken by these nurses.Recent block funding in Australia for the employ-ment of PNs is, however, broadening this scope ofwork (Department of Health & Ageing 2013). Theycontrast this situation with that in New Zealand andthe United Kingdom where funding schemes aremore flexible, enabling enhanced practice nursingroles (Hoare et al. 2012). The prevalence of part-timeand casual employment in general practice is alsoidentified as a barrier insofar as it prevents nursingleadership within general practice (Halcomb et al.2008b).

Educational barriersEducational barriers relate to both the availability ofeducation about PHC and the willingness of nursesto undertake further education. Keleher et al. (2010),in a review of the content of 38 pre-registrationundergraduate Bachelor of Nursing courses, foundthat few offered stand-alone units in public or popu-lation health, health promotion and disease preven-tion or in indigenous health with only fiveuniversities offering stand-alone community health orPHC courses in the first year, 12 in the second yearand 11 in the third year. In general, the undergradu-ate nursing degrees are focused upon high-level acu-ity illnesses and tertiary care delivery. For Parkeret al. (2010), lack of undergraduate exposure to pri-mary care/PHC undermines its attraction as a careerchoice.

Lack of postgraduate education preparation inPHC is also identified in particular in rural settings.Al-Motlaq et al. (2010), for example, identify a lack ofaccess and time to undertake education in relation toPHC among nurses working in rural Queensland. Alack of educational opportunities is also evident forPNs. Merrick et al. (2012) found that 44.4% of NewSouth Wales PNs who responded to a survey held a

hospital certificate as their highest educational qualifi-cation. Education for PNs often occurs through shortcourses addressing the specific tasks covered by MBSrebates rather than through postgraduate qualifica-tions (Halcomb et al. 2006).

Poor role definition and lack of career structureA number of articles identify poor role definition anda lack of career structure as a significant impedimentto further development of PHC roles in both generalpractice and community nursing settings (Whitehead2006, Halcomb et al. 2008b, Olasoji & Maude 2010,Parker et al. 2010). For some, a lack of career struc-ture is related to employment within general practice,which limits the range of tasks performed (Parkeret al. 2010). For others, it arises from employmentoutside the health system. Whitehead (2006) notes,for example, that the practice of school nurses is gov-erned by both the health and education systems. ForKeleher et al. (2010), an impediment to role definitionis limited development in the National CompetencyStandards for Registered Nurses of competencies forPHC practice. While the Australian Nursing and Mid-wifery Council acknowledges that nurses practiseacross a number of settings, health promotion and ill-ness prevention activities receive little attention in thenational competencies. The authors note, however,that the ANF has developed competencies for PNs,which supplement, but do not supersede, the nationalcompetencies. These competencies incorporate under-standing of the cultural and socioeconomic character-istics of the community and emphasise the role ofhealth promotion and prevention, reflecting a com-prehensive approach to PHC.

Working relationships with other professionsWorking relationships within teams have also beenidentified as a barrier to comprehensive PHC particu-larly within general practice, which is largely thedomain of GPs and PNs (Keleher et al. 2010). The lit-erature identifies many incidents of medical opposi-tion to extended nursing roles. The AustralianMedical Association, for example, has generallyopposed expansion of nursing roles into tasks previ-ously the domain of doctors, an attitude which is par-ticularly evident in relation to nurse practitioners(Elsom et al. 2009). Annells (2007) argues thatemployment in general practice constrains nursingcapacity to deliver comprehensive PHC due to medi-cal control of these settings. Likewise, Halcomb et al.(2007, 2008b) identify entrenched barriers to profes-sional collaboration arising from employment of prac-tice managers with managerial control over PNswithin general practice, gender differences and



limited nursing representation in the key organisa-tions representing general practice such as the previ-ous Divisions of General Practice.

Discussion

Australia, in common with other countries, is devel-oping policies to reduce the burden of chronic illnessand prevent hospitalisation through a greater use ofcommunity services (Department of Health & Ageing2009, 2010, Finlayson et al. 2012). The inauguralNational Primary Health Care Strategy promotes theuse of general practice as a means of addressing theseneeds, with the development of Medicare Locals facil-itating regional co-ordination of primary care ser-vices. PHC is defined within the National PrimaryHealth Care Strategy as ‘first-level care’, a distinctionthat is reflected in the Australian nursing literature.Wass (2000, p. 10) argues that PHC has increasinglybecome associated with ‘the first point of contact withhealth services’ rather than a philosophy of care thatpromotes equity, participation and social justice.While equity through universal access to services isincorporated within the inaugural National PrimaryHealth Care Strategy, there is less evidence of otheraspects of a PHC philosophy. This is particularly evi-dent in relation to the social determinants of health,which appear to be viewed largely as ‘non-healthissues’ in the National Primary Health Care Strategy,which focuses almost exclusively on improvement ofhealth through health services (Department of Health& Ageing 2009, p. 24).

The primary site nominated for the delivery ofPHC is through general practice. PNs have a signifi-cant and emerging role in the delivery of primarycare, reflected not only in the growth of the role butalso in the extent to which PHC is associated withpractice nursing in recent Australian nursing litera-ture. While the use of PNs is consistent with the Uni-ted Kingdom and New Zealand, there are significantdifferences in nurse capacity for extended practicebetween jurisdictions depending upon policy andemployment context (Hoare et al. 2012). In the UnitedKingdom, a reduction in working hours of juniordoctors, practice-based commissioning of serviceswhere funding is provided to practices to purchaseservices for patients and Personal Medical Servicecontracts between the health trust and general prac-tice have enabled greater flexibility in use of staff(Bonsall & Cheater 2008, Hoare et al. 2012). In addi-tion, mechanisms in the United Kingdom have beencreated for the inclusion of nurses in clinical gover-nance through their involvement in the developmentof the quality and outcome framework and their role

in achieving quality outcomes to ensure fundingunder current practice-based contracts (Hoare et al.2012). New Zealand moved from dependence uponreactive private general practice towards a moreplanned PHC model under the 2001 Primary HealthCare strategy, which established Primary Health Or-ganisations (PHOs), which have a financial andadministrative role in managing service deliverythrough capitation payments for the number of peo-ple enrolled in a medical service. This strategy pro-moted an extended role for PNs not only throughfunding for disease prevention and health educationprogrammes to reduce health inequities but alsothrough a role in clinical governance by collectinginformation about local health needs (Finlayson et al.2012). It is clear from these examples, however, thatthe extension of nursing responsibilities does not nec-essarily lead to greater opportunities to deliver com-prehensive PHC, as extended roles may involveadoption of tasks previously performed by GPs.

Until recently, the Australian policy context hasprovided less scope for a role for nursing within clini-cal governance of primary care services. The authorsin this review note the exclusion of nurses from thegovernance of the Divisions of General Practice and aresultant lack of nursing leadership in primary care(McMurray 2007, Halcomb et al. 2008b). The estab-lishment of Medicare Locals should provide scope forfurthering nursing leadership; however, with theirestablishment based on the previous Divisions ofGeneral Practice, it remains to be seen how this willdevelop. In addition, continued reliance upon MBSfunding is viewed as limiting the development ofextended nursing roles in primary care through pre-scription of the range of tasks, which attract MBSrebates.

While there has been an extension of MBS rebatesto nurses in some settings, critics (Harvey 2011,Joyce & Piterman 2011, Lane 2012) argue that thesechanges need to be understood within the context ofmedical dominance of the healthcare system. Joyceand Piterman (2011) note that MBS rebates for activ-ities undertaken by PNs are largely limited to asmall range of those activities that promote chronicdisease self-management. Likewise, Harvey (2011)states that the requirement that nurse practitionersbe ‘employed or engaged by one or more specifiedmedical practitioners’ to claim rebates limits autono-mous practice [Section 5: National Health 2010Collaborative arrangements for nurse practitioners(Determination 2010) National Health Act 1953 citedin Harvey 2011, p. 275]. Similar limitations apply toautonomous midwifery practice with the eligibilityfor a provider number depending upon approval,


J. Henderson et al.

and the development, of services with obstetricians(Lane 2012).

There is limited discussion of community nursingand notably, nursing practitioner roles within thereviewed literature. Hansen et al. (2007) argue thatwhile the introduction of PHOs in New Zealand hasenhanced the role of PNs, it has diminished the roleof public health and community health nursing. Theprimary reasons offered for a diminishing role areemployment by Area Boards rather than through theDepartment of Health, which has fragmented nursingleadership alongside competitive tendering for capi-tation funding to provide services. As a consequence,the nursing role has shifted from a generalist role toone providing a limited range of specialist services inthe area of primary prevention and health promo-tion. In contrast, healthcare changes in the UnitedKingdom have provided scope for advanced practicein PHC. Hoare et al. (2012) estimate that there wereapproximately 2000 nurse practitioners working inprimary care in the United Kingdom in 2006. Allnurse practitioners have prescribing rights and theyare viewed as a cost-effective alternative to GPs,often providing after-hours services and managingchronic illness, tasks which are largely selected pri-mary care activities (Caldow et al. 2006). We are yetto see what impact the advent of Medicare Localswill have upon the community health nurses in Aus-tralia; however, given that the central means of fund-ing primary care is through MBS rebates, thesechanges are unlikely to enhance the role of commu-nity health nurses and that of comprehensive PHCdelivery.

This review seeks to explore the manner in whichPHC is conceptualised in the Australian nursing liter-ature. Despite the process adopted for accessing andassessing the suitability of articles for this review,some limitations must be noted. First, there are anumber of authors who are leaders in this area andwho have published extensively. As such, their viewsmay be overrepresented within this review. Second,some of the studies drawn upon have small samplesizes, reflecting the size of the pool of employeesworking within these areas. Third, comprehensivePHC is frequently associated with extended nursingpractice within these articles. It is our contention,however, that extended practice is frequently associ-ated with selective PHC activities. Despite the limita-tions, there is evidence of a shift in the definition andlocation of PHC practice, which is in line with andreflects Commonwealth policy changes and which islikely to become even more evident in future publica-tions as general practice is established as the centralpoint for PHC delivery.

Conclusion

This paper reviews recent Australian nursing litera-ture in relation to PHC practice. It found that PHC islargely associated with practice nursing in Australiannursing literature, reflecting policy changes, whichmake general practice the central site for delivery ofprimary care services. In contrast to that in othercountries, the role of the PN in Australia is limited byfunding mechanisms, which provide rebates for alimited range of nursing tasks. Recent policy changessuch as the development of Medicare Locals have thepotential to enhance the role of nursing within pri-mary care, but while funding is limited to a smallrange of tasks and paid to the general practice, thescope for extended and comprehensive PHC roles islikely to be limited.

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how is primary health care conceptualised in nursing in australia? a review of the literature

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