Setting up a nurse clinic: The building blocks for success

APNA’s Enhanced Nurse Clinics project identifies the key factors that influences the growth of nurse clinics within a primary health care setting

Author: Linda Govan, APNA

Nurse clinics are not a new concept, and operate in many settings from acute care to primary health care, both nationally and internationally. And while the format of these clinics may vary, their positive benefits and impacts are recognised¹ with studies indicating nurse clinics result in improved health outcomes, reduced waiting times for care and decreased rates of hospital admission. Furthermore, in areas experiencing health workforce shortages, including rural and remote areas with limited access to healthcare services, nurse clinics offer patients improved opportunities to access healthcare, treatment and advice.

With efforts to increase the acceptance and uptake of nurse clinics, which is a key focus of the APNA’s Enhanced Nurse Clinics project, we undertook a comprehensive user experience consultation. This process intends to better understand the needs of the sector and how best to support the adoption of nurse clinics and their role in the delivery of team-based approaches to care. The development of the tools and resources
needed to support this goal has helped us understand and highlight the factors which influence nurse clinics’ acceptance and uptake. It has also assisted us in identifying the key components (building blocks) required
when considering setting up and running a nurse clinic, within a primary health care setting. These resources will be available on the APNA website in January 2018.

Factors that influence the uptake of nurse clinics in primary health care

Through a series of consultations with primary health care nurses, practice and health service managers and general practitioners from August to November 2017, a number of themes have emerged which impact the uptake of nurse clinic models of care in primary health care settings.

These include: 

Lack of awareness and inspiration

Nurses and others involved in primary health care are frequently unaware that alternative models such as nurse clinics exist and have specific benefits. One example is increased clinical efficiency and the opportunity for nurses to work to their full scope of practice.

'Increasing the nurse scope (of practice) happens in this model, which really increases job satisfaction in this setting. That’s been really big for us.' Meghan Campbell from the Teen Clinic, in Bega Valley, New South Wales.

A lack of comprehensive information

The consultation revealed that there is no single source of accessible, credible and practical information for anyone interested in learning more about nurse clinics. Although there is a range of information available, it is scattered across multiple sites, mediums and levels of access.

Benefits of a nurse clinic at a glance

For the patient:
• Increased patient satisfaction
• Improved quality of life
• Improved clinical outcomes
• Increased understanding of chronic disease
• Improved access to health professionals such as allied health referrals

For the practice team:
• Improved communication amongst team members
• Increased respect for the role of the nurse in the clinic
• Increase in confidence among nurses

Reluctance to change how care is delivered in primary health care settings

Resistance to the concept of nurse clinics was reflected in a variety of ways ranging from a preference for the familiarity with the established systems and processes, to lack of knowledge regarding funding and sustainability, and a lack of clarity regarding the level of clinical expertise required to develop a nurse clinic. As one enhanced nurse clinic participant stated, being more flexible when booking patients helped improve the community’s acceptance of their nurse clinic model.

'I guess one thing we’ve noticed that’s changed is that we’ve all become a little more flexible in how we deal with young people. The whole practice has become more flexible like that. Even if somebody turns up and it’s not teen clinic time, reception will never turn them away. They just say, “Sure. Have a seat.” Then the nurses are called, and then we all work out how to squeeze them in, and make a plan for how we’re going to manage them that day.' Meghan Campbell from the Teen Clinic , in Bega Valley, New South Wales.

There are no blueprints

Without a comprehensible end-to-end view of operations and setup within a clinic, it has been difficult for nurses to fully understand all the steps involved in setting up a nurse clinic. This adds another barrier to the process. 

Unrealistic expectations of nurses

Current narratives around nurse clinics also suggest that nurses are solely responsible for the majority of tasks required in the operation of the clinic. This level of expectation places an unrealistic burden on nurses while undermining the collaborative team-based approach nurse clinics require for long-term success.

Clinics are similar but unique

Clinics face similar types of challenges to one another but they are, by nature, responsive to the needs of their patient communities. The interest and experience of the nurses operating the clinic, the type of treatment it provides and the workplace it operates from will vary from one clinic to another. Creating a single, one-size-fits-all model for all clinics to adopt is not only difficult, it diminishes the greatest advantage of the clinic model – adaptability. 

Training is difficult to access

Primary health care nurses often need to complete additional study and training to set up and run clinics. However, access to training is often impacted by cost (either to the nurse or the organisation) and availability. 

Let’s break it down

To understand the range of content to include and the level of detail we asked the following questions: 

Can you identify gaps in knowledge prior to starting your nurse clinic?

Responses ranged across: 
• a general lack of awareness of, and how to set up, a nurse clinic
• concern regarding level of clinical expertise required
• lack of financial knowledge including how to apply for grants, how to engage the team, what data to collect, information on systems, process, and the legalities required.

What were the key activities required in the planning stage?

Answers focused on: understanding the population health need, how to engage with the clinical leadership team, and  other internal and external stakeholders such as being clear about the model of care, the systems and processes, roles and responsibilities, professional development needs, and evaluation.

Essential knowledge in the operation of a nurse clinic?

Along with the above, the respondents reinforced the need for a strong clinical knowledge base supported by further professional development, a model based on the available evidence and with a well-defined scope, supported by policies and protocols. 

What does this tell us?

With a greater understanding of these factors, our challenge has been developing resources that address these needs and support the sector in adopting nurse clinics as a sustainable and effective means of addressing the increasing demands on the delivery of healthcare in the primary health care setting. 

To achieve this we have adopted a modular approach – the building blocks.

Acknowledging that there is no one-size-fits-all approach that will work for clinics, the consultation supported the concept of building blocks which are the key components required when considering setting up and running a nurse clinic. These building blocks can be arranged in any order. The success of the nurse clinic will then depend on developing a model that suits the local context, accounting for factors such as the community need, nursing availability and expertise and organisational capacity. 

And to support awareness of the building blocks, APNA has created an online resource that contains information that is  focused on the practical aspects of setting up nurse clinics, including templates and guidelines which are targeted and practical. In addition, we will showcase a number of clinics involved in the enhanced nurse clinic project in relation to their experience with all of the building blocks – what worked and what didn’t.

References
1. Howe, S., 2016. Nursing in Primary Health Care (NiPHC) Program – Enhanced Nurse Clinics: A review of Australian and international models of nurse clinics in primary health care settings.

The Building Blocks

A clear plan
• Identifying opportunities
• Creating the plan
• Aims and goals
• Clinic models

Funding
• Types of funding and how they apply to clinics
• Sustainability

Location and facilities
• Physical space
• Clinic operating times
• Equipment

Staffing and human resources
• Roles and responsibilities
• Human resource policies and planning
• Professional development
• Working as a team
• Formulating relationships

Best practice
• Evidence-based care
• Clinical guidelines
• Quality improvement approach

Patient engagement
• Patient pathways
• Creating appointments
• Reminders and recalls
• Promoting the clinic

Supporting systems and process
• Appointment systems
• Referrals
• Patient registers
• Forms, templates and policies
• Data management

Evaluation and improvement
• Health outcomes
• Clinic efficiency
• Evaluating the patient experience