It's time to recognise the value that nurses bring

Opinion: Karen Booth, APNA President 

Medical Observer, 29 November 2023

We hear a lot about nurses being a cost to general practice when the truth is they bring tremendous value to any practice.  

Nurses love primary health care and like being busy because they know it means that more people are getting access to care. APNA does an annual Workforce Survey which shows that nurses not only do health checks and SNAP assessments but also want to do more preventive health care.  

We hear a lot about nurses being a cost to the practice, but we don’t hear enough about the invaluable contribution those same nurses make every day. According to APNA’s Workforce Survey, in 2022 the average primary health care nurse had 21 years of experience (11 in PHC) while 30 per cent have completed or are studying for postgraduate qualifications.  

For example, while a nurse is seeing a patient for a health check or for supported care and care planning for complex chronic health issues (often long appointments), we know that the General Practitioner can do two or three other consultations during that time.  The doctor can then see the complex patient, with all their information collated by the team nurse, and can move straight into higher-level decision making for either ongoing care or for new problems identified during the nurse component of the CDM consult.  

Clever practices will have an appointment book for nurses, in just the same way they do for doctors. This gives visibility to all workers in the practice and highlights the workload of all clinical staff, including the nurses.  

On most days nurses are dealing with a diverse mix of patients and are using a wide range of their skill set, just like the GPs. According to the Workforce Survey, a nurse’s top five activities include infection and prevention control, immunisation and cold chain management, wound care management, and use of recall or reminder systems. Nurses may be doing baby checks and immunisations, seniors’ health checks, health coaching and self-care education and care planning, as well as wound care and assisting with procedures. In between there will be triage, both onsite and by telephone, as well as seeing emergency walk-in patients.  

The beauty of having a nurse onsite is that the nurse’s ability to manage a heavy workload reduces the need to disturb the GPs mid-consult. The nurse is also available for urgent onsite care such as performing an ECG when a patient complains of chest pain, or organising hospital admissions and urgent referrals when needed, whilst the doctor continues with consultations. Having a nurse can help increase patient throughput, meet population health activity targets that contribute to QIPIP, as well as contribute to the bottom line. 

Having some level of workload predictability helps keep the practice and the patient flow running smoothly. It also helps team flexibility when a more urgent care situation arises, which is where scheduled appointments help manage the load for the whole clinical team.  Problems arise when expectations for the work to be completed by nurses in a single session are unrealistic or excessive. APNA members often seek advice on how to manage employer issues when they are only given 15 minutes to assess patients and prepare a care plan and may face a full session of back-to-back care plans. 

In clinics where the nurse does not have booked appointments, the workload can be unpredictable. I was recently at a nurse education workshop where a young nurse spoke of working in a practice with 10 GP consultation rooms. In one instance, three doctors came to her at the same time; one wanting a health assessment, another a care plan and the third wanting her to set up and assist with a surgical procedure. The GPs then had a debate over who should take precedence. The nurse said this was not an isolated occurrence, and other nurses acknowledged similar issues in their practices. 

These are but two examples of situations causing stress for the nurses trying to balance patient needs when only limited time is allocated for care, as well as unrealistic expectations of employers. Such situations also contribute to nurses feeling a lack of respect, adding to exhaustion levels and staff turnover. In 2022, APNA’s Workforce Survey showed three quarters of nurses felt exhausted or stressed at work, while one in four nurses planned to leave their job in the next two to five years. Loss of staff should be viewed as a loss of investment — most of us would like to protect our investments. 

Lack of pay parity, particularly for nurses working in general practice, is also a huge problem. Nurses are moving out of general practice into the tertiary sector, aged care, and contract work agencies, driven by cost-of-living pressures. The Modern Nurses Award is a complex document and the lack of understanding of how the Award applies to nurses and their level of experience and level of autonomy is confusing to employers and nurses alike. This often leads to nurses being scheduled into incorrect pay points of lesser value than are enjoyed by their tertiary award peers. APNA has a member-only nurse pay calculator on its website illustrating the range of pay levels nurses receive in general practice across the country. 

Lack of understanding of the role and scope of primary health care nurses, especially in general practice, also contributes to a sense of being undervalued. One of the greatest limitations on a nurse’s scope of practice are the MBS descriptors that describe requirements for billing rather than the requirements for patient care. NUrse under-utilisation is a huge issue, with 32 per cent of nurses telling APNA’s Workforce Survey they are not fully utilised often or most of the time. Whilst general practice is a business and absolutely needs to be paid for any care given to patients, the MBS items do not align or reflect the legislative framework that covers the scope and work of nurses. The same limitations do not apply in the hospital sector, nor in services with block funding.  

APNA members look forward to the Scope of Practice Review reducing some of the confusion around scope of practice, as well as changes to funding that will allow more flexible use of nurses and enhance team care. Making sure that the work of nurses is visible, and appropriately valued and supported, will go a long way to enhancing true team care. 

Karen Booth is the President of the Australian Primary Health Care Nurses Association.