|Just presented at the Curtin University Nurse Practitioner Forum via Skype (what a convenient way to present!). I just want to extend a “thank you!” to my colleagues who invited me to speak about Nurse Practitioners and their contributions to Primary Health Care. Overview from my session:|
- Worked from primary to quaternary care environments based both in the US and Australia
- Cardiology —> Cardiothoracic Surgery —> Nurse-led Walk-in Centre —> General Practice
- Have worked on several committees vested to PHC including:
- ACN-sponsored booklet: Nurses in General Practice: A Guide for the General Practice Team
- AMLA-sponsored booklet: Nurse Practitioners in Primary Care: Benefits for Your Practice
- ANF-sponsored standards: National Practice Standards for Nurses in General Practice
- AHR published article: Financial Viability, Benefits and Challenges of Employing a nurse Practitioner in General Practice
- Scope of practice – acute and chronic disease management with specialist expertise in cardiology
- Over 11,000 Australian practice nurses
- AHPRA: just over 1200 Nurse Practitioners nationally
- ACNP estimate: around 200 working in PHC
- Health Workforce Australia
- Shortage of general practitioners and specialists in regional and rural Australia
- Growing trend towards specialisation and sub-specialisation means we don’t have enough generalists; shortages anticipated into 2025
- This is being addressed by 2015 Accreditation Standards for Nurse Practitioners through ANMAC
- Impact of CLLEVER and CLLEVER2 research
- We also know that we are working up to a huge nursing shortage (109,000) by 2025
- Need to attract and retain nurses
- Career pathways – APNA currently working on a framework to support transition of nurses into general practice
- Imagine what would happen if just 1 in 10 practice nurses were supported to transition to generalist NP care, especially in rural and remote areas
Education and Training of NPs
- Generic professional standards are taught in schools, but
- Specialist practice is taught in the clinical environment through integrated workplace training, creating a very narrow focus and issues with clinical educational governanc
- Insufficient institutional/local policy and legislation precludes the holistic integration of skills needed for NP practice (namely, prescribing, referring and ordering/interpreting diagnostic tests)
- Insufficient time is allocated to the actual practice of skills needed to work at the level of an NP. (Employers expects learning to occur within their normal job duties without dedicated supernumerary time.)
- Mentors who are training have a poor understanding of the capability of the role, further narrowing its focus and transportability of skills.
- NP students aren’t trained how to transport their skills into the private sector, along with the financial implications and navigation that must occur.
- Targeting marginalised populations:
- Rural and Remote
- Healthcare card holders, elderly, children under 16 ($5 – 9 bulk-billing incentive for GPs)
- Bulk billing NPs cannot afford to serve these populations without a bulk-billing incentive – and these populations cannot afford to subsidise an NP’s salary!
- No remuneration for diagnostic and/or therapeutic procedures
- Melanoma excision ($37 vs. $270)
- Nothing for performing and interpreting ECGs or spirometry
- Nothing for inserting or removing Implanon
- Section 19(2) exemptions vastly underutilized for public sector NPs (16 sites in WA) and even those sites aren’t necessarily taking advantage of this opportunity.
Scope of Practice – PHC
- Unable to create MBS-reimbursable referrals to psychologists, dietitians, physiotherapists, etc.
- Can’t request specialist investigations, such as an echocardiogram
- Diagnostic Imaging
- Unable to order DXA Scans to monitor osteoporosis (or 3-region spinal Xrays to evaluate for vertebral fracture from significant height loss) and unable to start bisphosphonate therapy for those with fragility fractures.
- Unable to order pelvic ultrasounds to evaluate dysfunctional uterine bleeding
- Can diagnose and treat hyper and hypothyroidism but can’t order the thyroid uptake scan or the thyroid ultrasound for a nodular goiter BUT I can order abdominal US
- Institutional Restrictions
- National Diabetes Services Scheme – can’t sign form despite being able to diagnose and treat diabetes
- National Interpreter Service – NP’s can’t obtain free services like GPs, pharmacists, etc
- Workers Compensation, Centrelink, Drivers License Medicals
- Despite these issues, we are carving out a niche in PHC
- Western Australia leading the nation with over 65,000 professional attendances in 2013/14, followed by QLD
- These numbers are increasing
- So, we know it is possible to make it work!
- Integration with General Practice is key
- $25,000 PIP for nurses working at least 13 hours/week
- Find a champion and nurture them
- Specialist + Generalists = Opportunity: Look for market failures
- Chronic Disease Management Clinics
- Child Health Clinics
- Cardiovascular Health Clinics (ABPM)
- Women’s Health
- Lifestyle Modification Clinics
- Monitoring Primary Health Networks is crucial, as they cannot deliver services anymore except in circumstances of market failure.