Sally Hall

Following the funding trail: Financing, nurses and teamwork in Australian General Practice.

BackgroundAcross the globe the emphasis on roles and responsibilities of primary care teams is under scrutiny. This paper begins with a review of general practice financing in Australia, and how nurses are currently funded. We then examine the influence on funding structures on the role of the nurse. We set out three dilemmas for policy-makers in this area: lack of an evidence base for incentives, possible untoward impacts on interdisciplinary functioning, and the substitution/enhancement debate.MethodsThis three year, multimethod study undertook rapid appraisal of 25 general practices and year-long studies in seven practices where a change was introduced to the role of the nurse. Data collected included interviews with nurses (n = 36), doctors (n = 24), and managers (n = 22), structured observation of the practice nurse (51 hours of observation), and detailed case studies of the change process in the seven year-long studies.ResultsDespite specific fee-for-service funding being available, only 6% of nurse activities generated such a fee. Yet the influence of the funding was to focus nurse activity on areas that they perceived were peripheral to their roles within the practice.ConclusionsInterprofessional relationships and organisational climate in general practices are highly influential in terms of nursing role and the ability of practices to respond to and utilise funding mechanisms. These factors need to be considered, and the development of optimal teamwork supported in the design and implementation of further initiatives that financially support nursing in general practice.

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.

When policy meets the personal: general practice nurses in Australia.

Objective A significant focus of current health policy in Australia is to expand both the number and role of general practice nurses. Multiple new payment incentives have been instituted to encourage the use of practice nurses. This study explored the way these policies have framed their work. Methods Multimethod research using observation, workspace photographs and interviews with nurses, doctors and managers collected through rapid appraisal in 25 practices in two states, followed by case studies of the role of nurses in seven practices over one year. Results Many respondents reported unanticipated benefits in general practice functioning and teamwork as a result of employing a nurse, though this had not been a policy aim. Within funding constraints, nurses created new roles and manipulated old roles to fit their personal understanding of patient care. Policy initiatives targeting practice nurses are often based around tasks and system issues, rather than the personal creation of care and quality that patients require and nurses seek. Incentives in this study were targeted at both the uptake of nurses and specific nursing activities. Conclusion Policy development and funding structures would benefit from better understanding of nurses as agents of connectivity (rather than simply as performers of tasks) as well as the nature of teamwork in practices.

Divisions of general practice and practice nurse development in Australia

Abstract Nurses are consistently being seen as an integral part of a team approach to primary care service delivery, with significant policy initiatives being directed towards their employment in Australian general practice. Furthermore they are being increasingly recognised to add a value to general practice that is more than simply the ‘sum of its parts’.This recognition, for GPs and practices, has often occurred on the back of an experience that has been provided or illustrated by a Division of General Practice. Divisions as the face of ‘organised general practice’ in this country have been instrumental in providing a broad range of support strategies and development opportunities for practice nursing, especially over the last five to ten years. Essentially, the role of Divisions has been about increasing connectivity, and acting as ‘brokers’ of information, opportunities, and in some cases even resources. Divisions have made a significant contribution to achievements in practice nurse development, but this has not been without challenges. As the evolution of Australian practice nursing reaches a crucial stage, Divisions can play a pivotal role in advancing this development but must seek partnerships to be effective and should continue to broaden their scope.

Nurses and the wise organisation: techne and phronesis in Australian general practice

This paper draws on classical theories of wisdom to explore the organisational impact of nurses on Australian general practice. Between 2004 and 2008, numbers of general practice nurses doubled, the most rapid influx of nurses into any Australian workplace over the decade. Using data from the Australian General Practice Nurses Study, we argue that nurses had a positive impact because they introduced techne at the organisational level and amplified phronesis in clinical activities. In its Hippocratic formulation, techne refers to a field of definable knowledge, which is purposeful and useful and requires mastery of rational principles. Nursing, with its focus on system and accountability, brought techne out of the GPs consulting room and into the general practice as a whole. Nurses also exemplify phronesis, an Aristotelian virtue connoting a reasoned and honourable capacity to make judgements: the practical wisdom that defines the interaction between clinician and patient in general practice. At a time of significant GP shortage, doctors and nurses began to collaborate around their more complex and time-consuming patients, leading to a deepening of phronesis in the workplace. By bringing techne to bear on the organisation, and complementing and enhancing phronesis, nurses propel organisational wisdom in general practices.

Views of GPs and Practice Nurses on Support Needed to Respond to Pandemic Influenza: A Qualitative Study

INTRODUCTION Five years ago Australia, and the world, placed itself on heightened alert for pandemic influenza, based on concerns about the potential spread of the avian influenza virus. This prompted a flurry of preparation activity involving general practice, with information from various sources; government, colleges and divisions of general practice. METHOD To assess how general practitioners and practice nurses perceive this information, practice nurses and general practitioners were interviewed as part of a larger project exploring the role of the Australian general practice sector in an influenza pandemic. Results were validated by two focus groups and scenario sessions. FINDINGS Participants perceived that non-government organisations rarely gave useful information during a pandemic outbreak. Local divisions were perceived as having a practical and useful role, providing hands-on support to practices during a pandemic outbreak. Our participants did not perceive any coordination in the delivery of information sent by all the organisations involved in a pandemic response and therefore rejected our second hypothesis. CONCLUSIONS More planning needs to go into the coordinated response of the general practice sector to a pandemic, and such a response should include the support of local Divisions, both as a conduit for information and to assist practices to develop response plans.

Where There Is No Gold Standard: Mixed Method Research in a Cluster Randomised Trial of a Tool for Safe Prioritising of Patients by Medical Receptionists

Abstract Medical receptionists have been shown to play a key role in general practice as the first point of contact for patients. They frequently make decisions about appointment allocation which effectively prioritise access to medical care, but may have limited tools or structures to assist them with this. We report the methods of a study evaluating a customisable tool (POPGUNS – Prioritisation of Patients: A Guide for Non-clinical Staff ) to support safe prioritisation of patients. This paper reports methodological challenges in a study of this nature where contamination of the study population is an early complication, no current gold standard exists to define safe triaging, contextual differences between practices lead to inter-practice variation, and proxy outcomes (improvement in receptionist response to written scenarios of varying urgency) are used. We have attempted to respond to these challenges by: observing the determinants of inter-practice variation; developing a multi-member panel to constitute appropriate standards for practices; and monitoring self-reported prioritisation decisions by practice receptionists through the use of simulated patients.

A spatial analysis of the expanding roles of nurses in general practice

BackgroundChanges to the workforce and organisation of general practice are occurring rapidly in response to the Australian health care reform agenda, and the changing nature of the medical profession. In particular, the last five years has seen the rapid introduction and expansion of a nursing workforce in Australian general practices. This potentially creates pressures on current infrastructure in general practice.MethodThis study used a mixed methods, ‘rapid appraisal’ approach involving observation, photographs, and interviews.ResultsNurses utilise space differently to GPs, and this is part of the diversity they bring to the general practice environment. At the same time their roles are partly shaped by the ways space is constructed in general practices.ConclusionThe fluidity of nursing roles in general practice suggests that nurses require a versatile space in which to maximize their role and contribution to the general practice team.

People-centred integration in a refugee primary care service: A complex adaptive systems perspective

Purpose Services for refugees and asylum seekers frequently experience gaps in delivery and access, poor coordination, and service stress. The purpose of this paper is to examine the approach to integrated care within Companion House (CH), a refugee primary care service, whose service mix includes counselling, medical care, community development, and advocacy. Like all Australian refugee and asylum seeker support services, CH operates within an uncertain policy environment, constantly adapting to funding challenges, and changing needs of patient populations. Design/methodology/approach Interviews with staff, social network analysis, group patient interviews, and service mapping. Findings CH has created fluid links between teams, and encouraged open dialogue with client populations. There is a high level of networking between staff, much of it informal. This is underpinned by horizontal management and staff commitment to a shared mission and an ethos of mutual respect. The clinical teams are collectively oriented towards patients but not necessarily towards each other. Research limitations/implications Part of the service’s resilience and ongoing service orientation is due to the fostering of an emergent self-organising form of integration through a complex adaptive systems approach. The outcome of this integration is characterised through the metaphors of “home” for patients, and “family” for staff. CH’s model of integration has relevance for other services for marginalised populations with complex service needs. Originality/value This study provides new evidence on the importance of both formal and informal communication, and that limited formal integration between clinical teams is no bar to integration as an outcome for patients.