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What do Australians think of nurse practitioners?

Some years ago, I interviewed a nurse practitioner working in a metropolitan hospital who described how she had good support from the medical colleagues with whom she worked – but had also suffered quite a bit over the years from the resistance of organised medicine to nurse practitioners.

She had had to put up with newspaper headlines warning of “third world health care”, and with doctors making derogatory comments in front of patients. At one hospital, some medicos refused to work with her, and the residents once went on strike in protest. “I grew a lot through that process. I learnt a lot about the politics of healthcare,” she told me.

More recently, I interviewed another hospital-based nurse practitioner whose medical colleagues spoke very warmly of her work, including her role in upskilling and training medical staff. The times have changed quite a bit for nurse practitioners working in hospitals at least.

Of course, professional turf wars are not only an issue in Australia. Research into the experiences of pioneer NPs in the US in the 1960s and 1970s identified that they faced many obstacles and stresses, including intense resistance.

Still, Australia has lagged decades behind other countries in developing the NP role, and this seems to Croakey to be little short of a scandal at a time of workforce shortages.

And now that the NP role is finally being extended into the community, what have we seen?  More resistance, more headlines of doom and gloom. As is so often the case with health reform, the reaction is being driven by entrenched professional interests, rather than by any sense of what the community needs or wants.

So what does the community think of nurse practitioners?

Associate Professor Rhian Parker, a Senior Research Fellow from the Australian Primary Health Care Research Institute at the Australian National University, is investigating this very issue.

Rhian Parker writes:

General practitioners in many parts of Australia, particularly the ACT and rural and remote communities, are in short supply.

Patients in these areas often need to wait for several weeks for an appointment. Compounding this problem are the rising out-of-pocket costs to see a GP. This makes access to primary health care challenging in many areas of Australia.

The Federal Government has taken steps to address this dire situation by increasingly relying on nurses to ‘fill the gap’. One solution is the employment of nurse practitioners in general practices and other forms of community care.

A nurse practitioner is a registered nurse who has advanced qualifications and experience.  As of November 1, nurse practitioners are able to provide services funded under the Medicare Benefits Scheme (MBS) and prescribe medications that are subsidised by the Pharmaceutical Benefits Schedule (PBS).

The Australian Primary Health Care Research Institute (APHCRI) and Health Care Consumers’ Association of the ACT are investigating Australians’ views of the role of nurse practitioners in primary health care services, such as general practice.

Extensive consultations with people across Australia have been undertaken and findings have been used to develop a national survey for health consumers.

The findings from the consultations have revealed that people just want to be able to access primary health care when they need it.

People told us during the consultations that they know their own bodies and therefore they know when they need to see a GP and when they could see another health professional. There was a strong hope that there would be shorter waiting times to see a nurse practitioner for primary health care.

People with long-term medical conditions also hoped that it would be cheaper to see a nurse practitioner compared with a GP, particularly for appointments to renew prescriptions. Furthermore, there was a perception that nurses listen to patients, which engenders trust and confidence and, ultimately, leads to better quality of care.

While people’s response to nurse practitioners was largely positive, some important concerns were raised.

Would they become another ‘layer’ in the health system that the patient would then have to negotiate? What medical procedures were they qualified to carry out? How would they be distinguished from regular nurses in a primary health care setting? Will GPs be willing to give up some of their work and revenue?

Participants recommended that a public information campaign should be conducted to make people aware of nurse practitioners as an option in general practice and made it clear what they can and can’t do.

The findings from these consultations indicate that nurse practitioners should be given a go in primary health care.

Through the national survey we are conducting, all Australians can have their say about whether they would visit a nurse practitioner for primary health care at their general practice.

The online survey will be open until the end of November and is available through https://www.surveymonkey.com/s/nursesinprimaryhealthcare.

• Associate Professor Rhian Parker is a Senior Research Fellow from the Australian Primary Health Care Research Institute at the Australian National University.

Comments 7

  1. ron batagol says:

    I have written previously outlining the concerns that I and many others, have regarding the Medicare-financed type of rollout of the Nurse Practitioner , which has now officially commenced, and which has seen the official endorsemennt (by way of MBS rebates) of nurse practitioners having a role of diagnosing patients as quasi-medical primary care practitioners. To summarise my major concerns :

    With respect to nurses running primary care clinics in the community, as has now commenced, including the carrying out of diagnoses, quoting from an A.B.C interview “Life Matters” interview featuring Prof. Des Gorman Head of the University of Auckland’s School of Medicine in May 2009,: “it is the doctor, and only the doctor, with his or her training, expertise, and what Gorman calls “intellectual muscle (aka, I think, as professional expertise in differential diagnosis and referral), who is most appropriately skilled and trained, for example, to decide which of 6 or 7 kiddies who come through the door with seemingly similar presenting symptoms, require a lumbar puncture for suspected meningitis, or whether a patient with breathing difficulties is likely to have pneumonia, cardiac disease, asthma etc.”

    Furthermore, and this is a key point of difference between doctors and nurse practitioners, Prof.Gorman emphasises that much of the skill, expertise, judgment and professionalism that doctors acquire during their professional life derives from the early-career “apprenticeship” that they serve, rather than the formal university coursework they have undertaken in order to qualify as doctors

    In a similar vein, the Chair of the RACGP General Practice, Dr.Beres Wenck, in an interview with the Medical Observer ( 7th.August 2009 P21) stated: “GPs are the only ones who are qualified and trained to diagnose complex conditions.”

    Indeed, working as a clinical pharmacist, on hospital ward rounds over many years, I certainly observed first hand, the unique mixture of art, science, and experience that doctors draw upon in the differential diagnostic process.

    Now, contrast these concepts with the (APHCRI) and Health Care Consumers’ Association survey comments, stating that “People told us during the consultations that they know their own bodies and therefore they know when they need to see a GP and when they could see another health professional.”

    Unfortunately, the fact is that, in most cases, patients are simply unable to discriminate between, what is in fact, a well-intentioned non-medical presumptive diagnosis and a professionally-qualified differential diagnosis by a trained medical practitioner.

    Now, having said all that, is there a place in community primary care for nurse practitioners? of course there is. Their advanced training would be immensely valuable in collaboratively working alongside doctors, in seeing patients in primary care situations, rather than working in isolation, to assist in managing the huge workload that GPs have to shoulder, thereby improving the rate of patient throughput and ultimately making for easier and faster access to a doctor, with the doctor still having the ultimate responsibility for the diagnostic component of the consultations.

    Therefore, in the end, I certainly agree with the observation by the surveyers that “participants recommended that a public information campaign should be conducted to make people aware of nurse practitioners as an option in general practice and made it clear what they can and can’t do.” Perhaps I just have a different interpretation of what this may actually mean!

  2. raymond1 says:

    I don’t think doctor’s in primary care are against NP’s. They are just wary of the model of care that may develop. The UK has used NP’s successfully because they are very much integrated in the primary care team, working closely with the GPs in the practice.
    I think GP’s fear the setting up of a parallel, fragemented system. These fears were particularly raised with the ‘Revive Clinic’ model, that was set up in direct competition to general practice.
    NP’s will certainly help the capacity of the primary health system, but they should be integrated with the existing systems (as they are in the hospitals). NP’s aren’t neccessarily ‘cheaper’ either. Their lower salary is often offset by their restricted scope, increased investigations and they see less patients. (BTW An appt with Revive costs $65, -more than my GP!)

    Well-resourced, effective general practice will be very central to an effective primary care system. Reforms should work with this rather than against it. NP’s will be valuable in primary care, but defined by a restricted scope of practice, numbers around 400, and most employed in tertiary care, their impact will be limited.

    Having far more impact on the health system will be the looming ‘tsunami’ of medical students about to hit the system. Most will be funnelled in primary care, which will decrease the acute shortage of medical professionals in urban and rural areas.

    Also, does Croaky/Melissa Sweet seriously believe that medical practitioners are the sole instigators and participants in health turf wars?? The nursing union are very active participants in any turf war. Just witness the push by the nursing union for equal medicare rebates for NPs (despite having a restricted scope of practice).
    The ‘evil doctors/AMA’ thing gets a bit tiresome. Some more balance would be good….

  3. Melissa Sweet says:

    Just for the record, Croakey doesn’t believe the AMA and organised medicine are the only turf warriors. Of course not. But organised medicine has undue influence over health policy – it is the first group just about anyone seems to turn to for comment on proposed policy (whether journalists or policy makers) rather than asking how the community’s interests are being served.

    Also just for the record, I don’t think the most destructive turf wars are necessarily between professions, they are often within professions, services etc. I think the greater public would be horrified if they realised how often turf wars of various kinds affect decisions about resource allocation and how and where services are delivered. It’s one of the reasons that we should be aiming for population-based approach to planning and delivery, rather than lobbying-based decision making.

  4. Agnes With A Hat says:

    >> But organised medicine has undue influence over health policy

    How is any such influence ‘undue’? Why shouldn’t medical doctors be consulted in health policy? Please, enlighten me.

  5. ron batagol says:

    “We should be aiming for population-based approach to planning and delivery, rather than lobbying-based decision making?” Oh really? Well, if it is true,as I noted in my comments, that in a technically complex area of specialised health provision like medical differential diagnosis, where patients, with the best will in the world, are simply unable to discriminate between a well-intentioned non-medical presumptive diagnosis and a professionally-qualified differential diagnosis by a trained medical practitioner, how does it help in achieving better and safer community health care, to put into practice ( and fund through Medicare), a system which utilises health practitioners practising beyond their scope of training and expertise, purely on the basis that the community wants ready and prompt to access some sort of health practitioner to diagnose their health problems?( a population-based approach?). This is precisely the quick-fix that has occurred in setting up the Nurse Practitioner Clinics to diagnose and prescribe at the primary care level, without medical collaboration and advice. And I say that knowing only too well that there is a dire shortage of medical practitioners. What we really need in these situations is nurses ( and pharmacists, physios etc.)using their special and unique expertise, whilst working collaboratively to assist doctors in the various phases of primary care disease management in the community setting, but with the doctors co-ordinating and being responsible for the actual diagnostic process. Also as an observation it need not be mutually exclusive to ask the medical (and medical allied health) for their considered professional opinions on clinical questions relating to service supply models as well as seeking population feedback, since separating pure vested interests and turf wars from the broader public health interest isn’t exactly rocket science!

  6. Melissa Sweet says:

    Agnes, I most definitely did not say that doctors should not have input into health policy. Of course they should. But it’s fairly widely agreed that health care is changing, moving towards multidisciplinary, team-based care with more explicit effort to engage both patients and the broader community in decision-making, whether at the individual clinical level or service delivery level or broader planning and policy. There are many voices and types of expertise that need to be incorporated, not only those of doctors.

    Unfortunately much of our public debate around health has not caught up with these changes in health, and prominence tends to still be given to the medical lobby and often to just one particular part of the medical lobby, ie the AMA. Many doctors – at least many of the ones I know and speak with – are also concerned about this.

    Ron, I don’t know why you seem to assume that population health planning doesn’t incorporate technical expertise.

    BTW, I think a lot of people with a concern for equity and public health are concerned about expanding fee-for-service health care, regardless of the type of health professionals involved.

    There is more discussion on related matters in the 1 Dec post from a range of contributors giving health policy advice to the new Victorian Govt.

    Cheers, Melissa

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