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Enabling primary health care nurses to work at full capacity and within scope
Australia’s health system faces significant challenges due to the growing burden of an ageing population, workforce pressures, chronic disease, and unacceptable inequities in health outcomes and access to services.1
This increased demand for healthcare services sees the growing need for a knowledgeable and skilled primary health care nursing workforce within the multidisciplinary team, which is enabled to work to their fullest capacity and to better contribute to positive patient outcomes.
Macinko et al considers that to achieve these objectives in Australia, the primary health care workforce will need to be effective and sustainable; however, due to significant challenges in supply, distribution, changing demands and role delineation this will be a challenge.2 If an effective nursing workforce is one which is utilised to its fullest capability, how can we facilitate this?
How the primary health care nurse workforce is supported and hence enabled to work effectively will depend upon several factors including the individual nurse, the intra-disciplinary and inter-disciplinary support and awareness, primary health care nursing financing as well as professional development, formal education, training and career frameworks.
APNA Workforce Survey 2016
An accessible, flexible and structured process
By enabling primary health care nurses to work to their fullest potential we can facilitate better outcomes for patients, enhance productivity and provide value for money for health services. One component to optimising the full scope of nursing practice and supporting practices that augment the use of nursing skills will include, but not be limited to, the effective preparation and supportive transition into practice at any career stage.
The APNA Transition to Practice Pilot Program aims to test and model an accessible, flexible and structured process to increase the confidence, competencies, skills and knowledge of both recently graduated and existing experienced nurses starting work in primary health care settings. The program supports nurses to understand and build confidence in their scope of practice through the combined influence of professional and clinical guidance, and through the elements of self-assessment and formal foundational education.
Throughout this program, and with the support of an experienced nurse provided to each transitioning nurse, it is anticipated that nurses new to primary health care develop a deeper understanding of their potential scope of practice within the primary health care multidisciplinary team. Tranche one of the program concluded in May 2017 and evaluation is underway; interim findings indicate that the majority of transitioning nurses make a direct link between the program and an increase in knowledge, skills or confidence (or a combination of these things).
Support and awareness of full scope of practice
The scope and functions of primary health care nursing have evolved over time. Whilst many nurses feel comfortable and confident in determining where their knowledge, skills, competencies and parameters lie, and are able to advocate for and define their positioning on this, the Transition to Practice Pilot Program tranche one nurses who are new to primary health care indicated that they were not.
Furthermore, a review of APNA’s nurse support and enquiry database indicates that many nurses seek assistance in understanding their scope of practice because they struggle with role ambiguity and a lack of clarity regarding how to define and utilise the scope of practice for nurses outside of the acute setting. Further confusion ensues due to the continued discussion and debate amongst nurses and nursing organisations around the merits and disadvantages of credentialing, certification and accredited practice, reducing the confidence of nurses in determining their individual scope of practice.
Murray-Parahi et al suggests that perceptions and attitudes by other health professionals or employers about the role of primary health care nurses may limit nurses’ ability to work to their full scope of practice.3 This is supported by APNA’s 2016 Workforce Survey findings, which reveal that of the respondents who had shown interest in working at a higher level within their scope of practice only 28% were empowered to do so through workplace support. These respondents had suggested to their employers that they could do more complex clinical activities and remain within their scope of practice; however, of these, 72% indicated that their employer did not want to extend their role.
Primary health care nursing financing
The way that healthcare is funded can influence the structure and viability of clinical service models and the roles and tasks of nurses that work within them. As an example – in the general practice setting, businesses draw from a variety of funding sources to fund the employment or contracting of nurses. These sources include the Medicare Benefits Schedule, the Practice Nurse Incentive APNA Workforce Survey 2016 Program, the Practice Incentives Program, grants, and patient revenue (private or copayment).5 These funding mechanisms will therefore have the potential to positively or negatively influence how and which areas of the nurses’ scope of practice are developed, supported or utilised effectively.
Nurses intending to access education to assist them in working to their full capacity are often hindered due to financial constraints, not only being able to afford the education itself but also the fiscal impact of time away from work to attend and complete professional development.
To offset some of the financial considerations, the Transition to Practice Pilot Program has provided funding to both the external experienced nurses who provided support to the transitioning nurses, as well as their workplaces. The funding is for the workplace to provide protected time, to enable the transitioning nurses to undertake some education and clinical and professional mentoring during work hours and provide financial support for professional development.
The utilisation of funding as it was intended varied between workplaces in tranche one. Whilst some displayed exemplary support and management of protected time, ensuring that both transitioning nurses and the nurse support have been allowed dedicated learning, this was not consistent across all workplaces.
To offset some of the financial constraints to access education, all nurses in the program were provided with unlimited access to a variety of both core (considered core to a primary health care nurse’s foundational knowledge and skills) and optional educational activities, to support improvements in clinical and non-clinical areas of care – competence, confidence, knowledge, skills – all required when determining an individual’s scope of practice.
Let’s refresh – what is scope of practice?
The Australian Health Practitioner Regulation Agency defines the scope of a profession as the full spectrum of roles, functions, responsibilities, activities and decision-making capacity that individuals within the profession are educated, competent and authorised to perform.6
The Nursing and Midwifery Board of Australia standards for practice for both enrolled and registered nurses state that scope of practice is, ‘that in which nurses are educated, competent to perform and permitted by law. The actual scope of practice is
influenced by the context in which the nurse practises, the health needs of people, the level of competence and confidence of the nurse and the policy requirements of the service provider.’7
This means that the scope of practice of an individual nurse is determined by their registration (registered nurse or enrolled nurse), endorsement (e.g. nurse practitioner/ scheduled medicines for registered nurses for rural and isolated practice), as well as their educational background, previous nursing experience and clinical specialisation.
However, the scope of practice of an individual nurse or midwife may be more specifically defined than the scope of practice of their profession. An individual’s scope of practice incorporates one’s knowledge, training, skills, experience and competence.7 Regardless of job title, nurses may be required to undergo professional development to practice to their full scope or they may require opportunities to practice at their full capacity.
What does this mean?
There are two elements to consider when thinking about nurse scope of practice – scope of professional practice, and scope of the individual’s practice which fits within their professional practice.7,8
The scope of professional practice is set by legislation; professional standards such as competency standards, codes of ethics, conduct and practice and public need, demand and expectation. It may therefore be broader than that of any individual within the profession.
To practice within the full scope of practice of the profession may require individuals to update or increase their own knowledge, skills or competence. The scope of practice of an individual nurse may therefore be described as that which the individual is:
- authorised, and
- competent and confident to perform
In addition, the scope of an individual’s practice is also influenced by the:
- context in which they practise
- consumers’ health needs
- experience of the individual nurse
- fiscal constraints or enablers
- service provider’s frameworks and policies,
- quality and risk management systems, and
- organisational culture
Tools to assist nurses determine their scope of practice
The Nursing and Midwifery Board of Australian has developed a set of tools and principles to assist all nurses in the process of making decisions about whether specific tasks are within their individual scope of practice. The Nursing practice decision flowchart and Nursing practice decisions summary guide, and A national framework for the development of decisionmaking tools for nursing and midwifery practice can assist nurses to make decisions around scope of practice.4,9
In reviewing this information nurses are encouraged to:
- Conduct a self-assessment with regard to their own knowledge, skills and abilities
- Identify and consider client need/benefit and what the specific activity or task entails – i.e. does it have legislative requirements or not?
- Consider their context of practice and the organisational support available
- Establish what relevant training or education is required and what is available
- Determine how to ensure they will be performing this activity safely
- Consult with their professional indemnity insurer and ascertain if this will include cover for provision of the new service
- Establish mechanisms to ensure continuity and recency of practice in this area
- Ensure there is a policy and procedure in place which supports the procedure including skill review regularly
For nurses working in primary health care in general practice, additional resources can be found in the National Practice Standards for Nurses in General Practice and National Toolkit for Nurses in General Practice.10,11
A strong primary health care system has been shown to reduce health inequities, improve patient health outcomes, reduce costs, and increase patient satisfaction regarding their care.12 A strong primary health care nursing workforce that is supported and enabled to develop and work to their fullest capacity will better contribute to positive patient outcomes. Tranche two of the Transition to Practice Pilot Program commenced in April 2017 and included 27 recently graduated and experienced nurses transitioning into primary health care and 20 external clinical and professional nurse mentors who will support them. This tranche aims to continue to evaluate what influences and contributes to the future development of an effective and confident workforce by building knowledge, skills and confidence in nurses new to primary health care.
1. The National Primary Health Care Strategy, 2013. http://www.health.gov.au/internet/main/publishing.nsf/content/6084A04118674329CA257BF0001A349E/$File/NPHCframe.pdf [Accessed May 2017]
2. Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Co-operation and Development (OECD) countries, 1970–1998. Health Serv Res 2003; 38: 831-865.
3. Murray-Parahi et al. 2016 ENsCOPE: Scoping the Practice of Enrolled Nurses in an Australian Community Health Setting
4. APNA Workforce survey 2016 https://www.apna.asn.au/profession/apna-workforce-survey
5. Larter Consulting: An Overview of Primary Health Care Funding – (NiPHC) Program – Transition to Practice Pilot Project (TPPP). 2016 [unpublished]
6. Australian Health Practitioner Regulation Agency: https://www.ahpra.gov.au/Support/Glossary.aspx
7. Nursing and Midwifery Board Australia; Standards for Practice. http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx
8. Nursing and Midwifery Board Australia; A national framework for the development of decision-making tools for nursing and midwifery practice. http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Frameworks.aspx
9. Nursing and Midwifery Board Australia; codes and guidelines Decision making Framework http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Frameworks.aspx
10. Practice Standards for Nurses working in General Practice http://anmf.org.au/pages/professional-standards
11. National Toolkit for Nurses in General Practice: http://www.anmf.org.au/documents/ANMF_National_Toolkit_for_Nurses_in_General_Practice.pdf
12. Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Co-operation and Development (OECD) countries, 1970–1998. Health Serv Res 2003; 38:831-865.