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Building chronic disease management capacity in General Practice: The South Australian GP Plus Practice Nurse Initiative
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Collegian (2014) xxx, xxx—xxx
Available online at www.sciencedirect.com
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Building chronic disease management capacity in General Practice: The South Australian GP Plus Practice Nurse Initiative Jeffrey Fuller, BN, MSc, PhD a,∗, Kristy Koehne, BN Hons, PhD, Grad Dip Mental Health Nursing b, Claire C. Verrall, Grad Dip Applied Science (Nursing), BN, Master Nursing Studies b, Natalie Szabo, BN, Grad Dip Primary Health Care, Masters Arts (Communication Management) c, Chris Bollen, MBBS, FRACGP, MBA d, Sharon Parker, BHlthSci (Nursing), MPH b a
Centre of Research Excellence in Primary Health Care Microsystems, School of Nursing and Midwifery, Flinders University, Adelaide, Australia b School of Nursing and Midwifery, Flinders University, Adelaide, Australia c Central Adelaide Local Health Network, Australia d Healthfirst Network, Underdale, South Australia, Australia Received 30 September 2013; received in revised form 2 February 2014; accepted 7 February 2014
KEYWORDS Practice nurse; Care coordination; Chronic disease
∗
Summary Aim: This paper draws on the implementation experience of the South Australian GP Plus Practice Nurse Initiative in order to establish what is needed to support the development of the chronic disease management role of practice nurses. Background: The Initiative was delivered between 2007 and 2010 to recruit, train and place 157 nurses across 147 General Practices in Adelaide. The purpose was to improve chronic disease management in General Practice, by equipping nurses to work as practice nurses who would coordinate care and establish chronic disease management systems. Method: Secondary analysis of qualitative data contained in the Initiative evaluation report, specifically drawing on quarterly project records and four focus groups conducted with practice nurses, practice nurse coordinators and practice nurse mentors.
Corresponding author. Tel.: +61 8 8201 7641; fax: +61 8 8276 1602. E-mail address: jeffrey.fuller@flinders.edu.au (J. Fuller).
http://dx.doi.org/10.1016/j.colegn.2014.02.002 1322-7696/© 2014 Australian College of Nursing Ltd. Published by Elsevier Ltd.
Please cite this article in press as: Fuller, J., et al. Building chronic disease management capacity in General Practice: The South Australian GP Plus Practice Nurse Initiative. Collegian (2014), http://dx.doi.org/10.1016/j.colegn.2014.02.002
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J. Fuller et al. Findings: As evidenced by the need to increase the amount of support provided during the implementation of the Initiative, nurses new to General Practice faced challenges in their new role. Nurses described a big learning curve as they dealt with role transition to a new work environment and learning a range of new skills while developing chronic disease management systems. Informants valued the skills development and support offered by the Initiative, however the ongoing difficulties in implementing the role suggested that change is also needed at the level of the Practice. While just over a half of the placement positions were retained, practice nurses expressed concern with having to negotiate the conditions of their employment. Conclusion: In order to advance the role of practice nurses as managers of chronic disease support is needed at two levels. At one level support is needed to assist practice nurses to build their own skills. At the level of the Practice, and in the wider health workforce system, support is also needed to ensure that Practices are organisationally ready to include the practice nurse within the practice team. © 2014 Australian College of Nursing Ltd. Published by Elsevier Ltd.
Introduction In 2011—2012, chronic disease accounted for 36% of all problems managed in General Practice in Australia at a rate of 56 per 100 encounters (Britt et al., 2012). Chronic disease management (CDM) requires a systematic approach that includes case management, education of patients towards self-management and the use of structured methods for patient monitoring, follow up and feedback (Bower, Gilbody, Richards, & Fletcher, 2006; Greb et al., 2009; McDonald et al., 2007; Øvretveit, 2011). In this context, Australian national and state governments have developed new funding, people and infrastructure support programs to better manage chronic disease in General Practice using practice nursing (Commonwealth of Australia, 2010; South Australian Department of Health, 2007). It is important therefore to understand what is needed to ensure that practice nurses have the capacity to undertake this role. General Practices in Australia are, in the main, private businesses. Income is largely generated through a subsidised consultation fee that is charged to patients for each service, with some additional funding to support CDM. Both the patient subsidy and CDM payments are provided through the taxation funded national health insurance scheme known as Medicare. Hence General Practice in Australia has developed a service model that tends to be reactive to patient presentations and is episodic according to funding based on throughput (Palmer & Short, 2010). While many Practices employ a practice nurse, often these are part time positions with roles that have in the past been mainly procedural, covering tasks to support the general practitioner, such as immunisations and wound care (Britt et al., 2012). Change is expected, however, in practice nurse employment and roles since the funding of nurses in General Practices was changed in 2012 from procedural reimbursements (e.g. tied to immunisations and wound care) to block funding of up to $125,000 per Practice each year (Bell, 2013). Practice nursing is a small but rapidly growing section of the Australian nursing workforce with an estimated increased in numbers by 38% over the five years from 2007 to 2012 (Australian Medicare Local Alliance, 2012). A practice nurse is defined as a ‘‘registered or enrolled nurse employed by, or whose services are retained by a general practice in a general practice [and who] may be either accredited or
non-accredited’’ (Parker, Keleher, Francis, & Abdulwadud, 2009). There is no regulation to entry other than the requirement that the nurse have a general license to practice as a registered or enrolled nurse by the Nursing & Midwifery Board of Australia. As a developing workforce, the roles, scope of practice and impact of practice nurses have in the past been poorly understood (Halcomb, Davidson, Daly, Yallop, & Toffler, 2004; Phillips et al., 2009). Practice nursing skills have been found to be under-utilised and barriers to practice include inadequate funding models, insufficient educational preparation for primary care, a lack of a career pathway and the variety and fragmentation of roles and workplaces in the sector (Gibson & Heartfield, 2005; Halcomb et al., 2005; Keleher, Parker, Abdulwadud, & Francis, 2009; Phillips et al., 2009). Despite health system reforms to improve the career and scope of practice nursing, the most recent 2012 national survey found a high proportion of practice nurses were ‘‘less than highly satisfied’’ about the recognition of their work, their opportunity to suggest practice changes, the use of their abilities, career promotion and the management of their practice worksite (Australian Medicare Local Alliance, 2012). Halcomb, Davidson, and Patterson (2008) concluded that much development is needed if practice nurses are to take a significant role in CDM in Australia and the need for professional development and support of nurses in General Practice has long been recognised (Gibson & Heartfield, 2005; Halcomb, Davidson, Salamonson, & Ollerton, 2008; Parker et al., 2009; Parker, Walker, & Hegarty, 2010; Senior, 2008). This paper describes a South Australian Initiative that was designed to build CDM capacity in General Practice through the employment and support of practice nurses as care coordinators. The paper discusses the issues that were documented during the implementation and evaluation of the Initiative and concludes with the nurse role fulfilment and support factors deemed important when developing nurse led CDM in General Practice.
The Practice Nurse Initiative Set within the South Australian Department of Health GP Plus Health Care Strategy (2007), the GP Plus Practice Nurse Initiative (PNI) was delivered between January 2007 and June 2010. The purpose was to increase the number of
Please cite this article in press as: Fuller, J., et al. Building chronic disease management capacity in General Practice: The South Australian GP Plus Practice Nurse Initiative. Collegian (2014), http://dx.doi.org/10.1016/j.colegn.2014.02.002
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Building chronic disease management capacity in General Practice nurses in General Practice in metropolitan Adelaide and to develop the nurse role in CDM within the Practice team. The Initiative was expected to fund 50 full time practice nurse placements in General Practices over seven rounds of recruitment and training across the Central Northern (CNAHS) and Southern Adelaide Health Service regions. The CNAHS portion of the program was auspiced to the Adelaide North East Division of General Practice. Over the three and a half years of the Initiative, seven groups of nurses (157 in total) were recruited and trained across 147 General Practices in five Divisions of General Practice. The nurses were employed by the respective Division of General Practice using funds from the Initiative, with participating General Practices required to indicate intent to employ the nurse beyond the placement period. At the end of 20 weeks, if employment was desired by both parties, General Practices negotiated the terms of continuing employment directly with the nurses. The project records indicated that at the end of the Initiative, 82 of the 157 nurses (52%) were retained in their placement Practice. Prior to their placement, nurses attended four days of training which was doubled to eight days in 2008 in order to increase the focus given to CDM and the use of information technology. A training manual and orientation handbook was developed to align with the Competency Standards for Nurses in General Practice (Australian Nursing Federation, 2005) and to incorporate training in CDM guided by the National Chronic Disease Strategy (National Health Priority Action Council, 2006). The eight day training program covered professional practice, clinical care, management systems and collaborative practice. In addition, CNAHS funded the development of a dedicated chronic disease self-management (CDSM) training program from round four onwards. This was delivered by a specialist CDSM clinician based on the Flinders CDSM model including a day of cultural awareness training (Flinders University of South Australia, 2013). With the support of existing practice nurse coordinators within each Division and the employment by the Initiative of experienced practice nurses as mentors, it was expected the new practice nurses would assume responsibility for establishing CDM systems. In order to align CDM funding available under the Australian national health insurance program (Medicare), these new practice nurses were focused on supporting general practitioners in the development of GP Management Plans and Team Care Arrangements. General Practices were supported by the Initiative in their practice nurse business modelling through the use of a Practice Health Atlas, which brought together Medicare billing history, local demographic data and practice population data. This was to identify potential business opportunities within the chronic disease care program and the continuing financial viability of the practice nurse positions.
Method This paper is a secondary analysis of the synthesised PNI evaluation data that was sourced from the project records. Three of the research authors (JF, KK, CV) were not involved in the evaluation but were approached by the Adelaide North
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East Division of General Practice (NZ, CB) to write a paper on the issues experienced in implementing the Initiative and to help draw implications for future practice with reference to the wider literature. The authors did not have access to the raw evaluation data and so used the data contained in a 100 page ‘‘GP Plus Practice Nurse Initiative Final Evaluation Report 2007—2010’’ of which one of the authors (NZ) helped to compile. For the purpose of this paper we used two components of the report data. The first were data that enabled us to describe the Initiative, which were sourced from the quarterly PNI progress reports. The second data, which forms the main focus for this paper, were the findings of four focus groups held at the end of the Initiative in 2010. The purpose of the focus groups was to reflect upon the successes, weaknesses, management and facilitative processes, and also the challenges of the Initiative. Focus group participants had been recruited through an invitation sent out through the respective Divisions of General Practice that involved attendance at a dinner followed by a focus group discussion. Three focus groups were held with 41 practice nurses from three of the Adelaide metropolitan regions (North & East, Central & West and Hills) and one group with 10 practice nurse coordinators and practice nurse mentors. As a way to promote involvement of participants in group discussion, the focus groups used a ‘‘card storming’’ technique with each participant recording their comments related to the four purpose areas (successes, weaknesses, processes and challenges) prior to the facilitator prompting discussion (Kitzinger, 1994). The groups were conducted, audio recorded and reported to NZ and CB by a contracted evaluator who was not involved in the analysis or writing of this paper. The findings from the quarterly reports and focus groups, presented in the final report, were independently read by the three research authors (JF, KK, CV) to extract what each saw as the main issues. Differences were discussed and once agreement was reached, a draft of these main issues was given to the two authors from the Division (NZ, CB) for verification and to add interpretive insights from their involvement in the Initiative at a senior level.
Findings We constructed the following four themes from the issues that were described in the report; challenges experienced in fulfilling the role, the big learning curve for the nurses, the refinement of the Initiative over time and post placement employment negotiations.
Challenges in fulfilling the practice nurse role Challenges in fulfilling the practice nurse role were anticipated and while proactively managed through promotion of the role to general practitioners, practice managers and other Practice staff, a range of ‘‘new job’’ challenges were still experienced. Regarding their coordination role in CDM, some of the newly appointed nurses stated that they were unable to consolidate partnerships with other service providers until they felt confident in the system that they were now working. In addition, some reported feelings of isolation as they adjusted to a smaller clinical setting
Please cite this article in press as: Fuller, J., et al. Building chronic disease management capacity in General Practice: The South Australian GP Plus Practice Nurse Initiative. Collegian (2014), http://dx.doi.org/10.1016/j.colegn.2014.02.002
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without a team of nurses around them. Nurses were aware of stepping into a new role that required their transition into a new working environment. This environment was not always conducive to an easy transition, however, with one nurse describing this with ‘‘no precedent in my Practice, as the first nurse ever — no job description, no policy, no procedures’’. Others reported varying expectations from Practice staff and while some nurses described flexible practices which allowed them to establish their role over time, others spoke of constraints. For example, one nurse identified the challenge of working with ‘‘doctors who still see nurses as their handmaidens,’’ and another noted the expectation to ‘‘undertake tasks on behalf of the GP’’.
development of a Chronic Disease Service Referral Pathways document which outlined detailed referral pathways for the prevention and management of type 2 diabetes, coronary heart disease, asthma and COPD and mental health
Refinement of the Initiative
In the early stages of the PNI, it became evident that some practice nurses did not have sufficient information technology skills, which was a problem given the emphasis on the use of computer software and data entry in CDM. In a practice nurse focus group, one participant described the need to upskill:
The first group of practice nurses were placed for a period of 16 weeks and it soon became apparent that this time frame was insufficient, with the placement period increased to 20 weeks. This additional time was needed to establish systems for the delivery of CDM, such as the establishment of a register of Practice patients with diabetes so that care under the new diabetes funding from the national government could be initiated. By mid-2008, the length of the training was doubled and additional support was developed in recognition of the amount of change required in the Practices. The additional supports were provided by the Initiative in response to feedback from practice nurses, practice managers and general practitioners about what was needed to drive change to processes and systems in these Practices towards the management of chronic disease led by nurses. A proportion of the salary component to Practices was then used to engage a mentor (eleven in total). These mentors were experienced practice nurses who provided four to six months of assistance to ensure that the Practice was prepared for CDM when the PNI nurse commenced. This included mentors working with the Practice team to prepare them for potential role changes as a result of the employment of a practice nurse. Responses from the practice nurse coordinator/practice nurse mentor focus group indicated that the adaptability to change the level of support was a valued feature of the Initiative, as described by the following two participants:
I couldn’t use a computer — open the email, that’s all. It took a while to learn Medical Director software. I just had to learn it. [The Division] was very patient in helping me to upskill.
We were able to be flexible and change the model — assessing what was working and what wasn’t and looking at how it could be adapted. When we increased support we could do more education.
While individual ‘‘up- skilling’’ and mentorship were able to address this deficit, the recruitment process was refined in the second year to target candidates with more advanced information technology skills. Although it was common for new practice nurses to feel overwhelmed initially, with the role described as ‘‘just huge — you have to be a ‘jack of all trades’ more than any other area of nursing’’, there was congruity across the four focus groups that one of the best aspects of the Initiative was the opportunity to participate in training and learn and use new skills. The training prepared practice nurses to step into this role as one nurse described:
[We needed to] tailor the program to suit the needs of the Practices. We had to know the Practice and what they needed. In cases where the Practice wanted to employ their own nurse we developed a recruitment package.
A big learning curve for nurses new to General Practice For nurses new to General Practice, challenges emerged that necessitated a broader skill set than in the hospital setting. One of the new practice nurses described a learning curve in regards to the breadth of clinical skills required: I had worked with mums and babies for years and years, so I hadn’t worked with male patients or the elderly. That was like going back and learning a whole new set of skills. Everything had changed a lot, diabetes, asthma. It was a really big learning curve after many years of being very comfortable in the job I was in.
The diversity of the training was brilliant . . .. I felt really equipped after that, although it was a big shock to put all that into practice because there was just so much involved. The courses did stir up a lot of stuff that I had forgotten or didn’t know and it was very overwhelming. While the provision of Practice resources by the Initiative did not ease the learning curve as such, these did ensure that practical tools were available for the nurses to perform in their new role. For example, the PNI funded the
Post placement employment negotiations Practice nurses expressed concern about the need to negotiate their employment at the end of their placement period. While participating Practices were required to indicate intent to employ a practice nurse, this was not a binding commitment to each other by either the Practice or the practice nurse. This facilitated initial participation, but it also created anxiety for some nurses. One nurse described having ‘‘no idea for the [placement] period what would happen at the end and what amount of pay they would offer . . . which made it very difficult and stressful’’. Practice nurses described how negotiating a pay rate was foreign to them and they reported variability in the rates offered. There was a concern that at the completion of their placement, some ‘‘doctors will offer a rate less than that provided by the Division,’’ with one nurse recalling this:
Please cite this article in press as: Fuller, J., et al. Building chronic disease management capacity in General Practice: The South Australian GP Plus Practice Nurse Initiative. Collegian (2014), http://dx.doi.org/10.1016/j.colegn.2014.02.002
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Building chronic disease management capacity in General Practice When my practice offered me money, it was $6.00 less than what the Division was paying, but I couldn’t work for that amount, so I moved practices where they would pay me a better rate.
Discussion The retention of just over a half of the placement positions beyond the Initiative suggests that sufficient benefit was established in these General Practices for them to continue to employ a practice nurse. The evaluation did not ascertain what happened to the other practice nurses. The reasons that ongoing employment did not occur in just under half of the Practices may relate to the magnitude of changes that are required to demonstrate the value of employing practice nurses in CDM. The impact of the Initiative, however, needs to be considered as just one State-based strategy in the range of primary care reforms in Australia that cover new models of care, different arrangements for funding service delivery and new infrastructure (Commonwealth of Australia, 2010). Nevertheless, the focus of this paper on the implementation experience of this South Australian Initiative does enable some conclusions to be drawn about the employment of new practice nurses and what is needed to develop their CDM role. It was necessary in the implementation of the Initiative to increase the length of the placement, double the education provided to the nurses in response to their ‘‘big learning curve’’ and provide mentors. These were required to assist both the nurses and the Practices to deal with role fulfilment and establish CDM systems. These changes suggest that factors at both the level of the nurse and also the level of the Practice are important when developing CDM (Fuller et al., 2011; Wagner, Austin, & Von Korff, 1996). The ‘‘big learning curve’’ that was experienced by nurses new to General Practice is explained in part by changes in their organisational environment. These nurses had moved from employment in more specialist publicly funded health care settings with defined team roles, a nursing leadership structure and explicit rates of pay, to a smaller health care setting that operated with a private business model and a generalist role under a medically dominated leadership structure. It has been recognised that the nurse new to General Practice may experience anguish as they grapple with a new working environment; with different systems, hierarchy, pay and a potential lack of comradeship (Senior, 2008). In particular, the acute care nurse entering General Practice may grieve for the familiarity and perceived security of the hospital environment of past employment (Verrall, 2007). Acculturation to the new working environment was complicated by an expectation in some Practices that the role of the nurse was to undertake delegated tasks on behalf of the general practitioner. This was despite the aims of the PNI to position nurses in a collaborative role, with the capability to steer CDM systems. The challenge of shifting practice nursing to a collaborative team model have also been described elsewhere (Halcomb, Davidson, & Patterson, 2008; Keleher, Joyce, Parker, & Piterman, 2007; Mills & Hallinan, 2009). Research which has examined the feasibility, acceptability and sustainability of nurse-led CDM in General Practice reiterates the importance of collaborative care, with the
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alliance between practice nurses and general practitioners considered as intrinsic to confidence in the model of care (Hegney, Patterson, Eley, Mahomed, & Young, 2013; Schlicht, Morgan, Fuller, Coates, & Dunbar, 2013). Furthermore it has been found that practice nurses in more socially supported teams who self identify with their role are more able to exert influence in their workplace and contribute to organisational decision making (Merrick, Duffield, Baldwin, & Fry, 2012). The training and the use of practice nurse mentors and coordinators was clearly not sufficient to overcome all the barriers that the nurses experienced in developing their roles in CDM. We conclude that the required level of support also needs to be ascertained at the level of the General Practice and in the macro system and that these should be considered in future initiatives. It has been reported that the relative low rates of pay, lack of career structure and poor recognition in Practices for the expanding role of the practice nurse can operate as disincentives to practice nurses (Cheffins, Twomey, Grant, & Larkins, 2011; Halcomb, Davidson, & Patterson, 2008; Hegarty et al., 2012; Joyce & Piterman, 2009). At the Practice level, it is argued that changes towards a team based model are needed in order to recognise and incentivise the whole team and to move the traditional role of the practice nurse away from simply performing delegated tasks and providing administrative support to the general practitioner (Joyce & Piterman, 2009; Mills & Hallinan, 2009; Pearce, Hall, & Phillips, 2010). This move should be helped by the new model of funding that was changed in 2012, from the model that was based on a highly prescribed set of procedurally based Medicare item numbers to block funding. The anxiety described by the practice nurses in negotiating their terms of employment, including pay rates, may have been exacerbated by uncertainty in Practices about the sustainability of the funding model. Hegney et al. (2013) found that concerns about funding sustainability remain a barrier to the development of the practice nurse role in CDM. A recent study by Morgan et al. (2013), however, demonstrated that nurse led care can be funded within the current Australian national health care reimbursements to General Practice. Hence, an area for future support is the development of business case skills for General Practices to employ practice nurses in CDM, such as that prepared by the Australian Practice Nurses Association (King, Watts, & Brewerton 2011). Beyond the Practice and in the wider system it has been reported that the education of undergraduate nursing students is insufficient to prepare them to practice in primary health care and as we have noted above there is no specific education qualification required to work in General Practice (Keleher, Parker, & Francis, 2010). Hence, to advance the practice nurse role in CDM we conclude that attention needs to be paid to the nurse’s educational requirements as well as the provision of a supported and collaborative environment. In addition to the Initiative described in this paper national and state support programs have been developed. For instance, the peak primary health care planning body, the Australian Medicare Local Alliance (AMLA) is the auspice for the ‘‘Nursing in General Practice Program’’ that includes demonstration projects, leadership workshops, education grants, funding information and marketing, although this in not a career framework as exists in the UK and New
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Zealand (AMLA(a), n.d.; Parker et al., 2009). Significantly, the AMLA has a framework that articulates role levels of nursing in General Practice with associated education, experience, competencies, skills and activities which add to the 2005 ‘‘Practice Nurse Competencies’’ developed by the Australian Nursing Federation (AMLA(b), n.d.; ANF, 2005). Despite these programs, however, the structure of Australian General Practice, as a large number of relatively small private businesses, remains a major organisational influence on how the practice nurse role can be advanced. This is in comparison to other areas of nursing where employment is through government or other large organisations with collective employment agreements and with larger more obvious professional nursing structures. As an initiative of the South Australian Department of Health, the PNI did provide support to the Practices through funding, recruitment, training and mentorship. The support most consistently identified in this Initiative was the tailored and comprehensive training program that was directed at the development of new skills. These findings accord with research that has identified that one key constituent of successful CDM is having professionals with suitable knowledge, skills and level of expertise, along with mentoring and expert supervision (Bower et al., 2006; Renders et al., 2009). However, the literature on systematic models of CDM has also found that enablers are needed at multiple levels, such as in the clinical, organisational and macro systems, particularly when existing organisational processes and structures are a barrier to new collaborative workforce arrangements in primary health care (Fuller et al., 2011; May, Mair, Dowrick, & Finch, 2007).
Limitations As this paper is a secondary analysis of reported findings some caution is needed in the inferences that can be drawn. The contracted evaluator of the GP Plus PNI was not one of the authors of this paper and hence only limited assessment of rigour of the evaluation was possible. However, given the importance of learning from this PNI experience we considered that a sufficiently relevant account could be described in order to construct a narrative of the issues and to draw conclusions about what would be needed to develop practice nurses’ capacity in CDM.
Conclusion The PNI was a three and a half year project undertaken in South Australia which sought to improve CDM capacity by placing new practice nurses in General Practice with an ongoing comprehensive support system for 20 weeks. The Initiative resembled a work in progress that along with other national strategies has helped to increase capacity for CDM in General Practice. The critical success factor learnt from the Initiative was the provision of education and other supports to the nurses to help them through the learning curve associated with a new role, and also to the Practices to help them develop CDM systems. While the PNI helped many General Practices to employ a practice nurse, it was clear from the difficulties that the nurses faced in implementing their role that strategies are also needed at the organisational and
system levels to develop CDM by nurses in General Practice in Australia.
Acknowledgements Authors Claire Verrall, Natalie Szabo and Chris Bollen contributed to the Practice Nurse Initiative in the following positions: Claire Verrall was Practice Nurse Coordinator at GP Partners, Natalie Szabo was Project Coordinator and Chris Bollen was CEO of the Adelaide North Eastern Division of General Practice. This work was funded by the Adelaide North Eastern Division of General Practice. The authors would like to acknowledge the work of Amy Cotton who undertook focus groups and was one of the authors of the GP Plus Practice Nurse Initiative Final Evaluation Report (unpublished).
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Merrick, E., Duffield, C., Baldwin, R., & Fry, M. (2012). Nursing in general practice: Organisational possibilities for decision latitude, created skill, social support, and identity derived from role. Journal of Advanced Nursing, 86(3), 614—624. Mills, J., & Hallinan, C. (2009). The social world of Australian practice nurses and the influence of medical dominance: An analysis of the literature. International Journal of Nursing Practice, 15(6), 489—494. Morgan, M., Coates, M., Dunbar, J., Reddy, P., Schlicht, K., & Fuller, J. (2013). The ReueBlue model of collaborative care using practice nures as case managers for depression alongside doaetes or heary disease: A radomised trial. BMJ Open, 3, e002171. http://dx.doi.org/10.1136/bmjopen-2012-002171 National Health Priority Action Council. (2006). National Chronic Disease Strategy. Retrieved from: http://www.health.gov. au/internet/main/publishing.nsf/Content/ 7E7E9140A3D3A3BCCA257140007AB32B/$File/stratal3.pdf Øvretveit, J. (2011). Does clinical coordination improve quality and save money? Vol. 2: A detailed review of the evidence. London: The Health Foundation. Palmer, G., & Short, S. (2010). Health care and public policy: An Australian analysis (4th ed.). South Yarra: Palgrave Macmillan. Parker, R., Keleher, H., Francis, K., & Abdulwadud, O. (2009). Practice nursing in Australia: A review of education and career pathways. BMC Nursing, 8(5). Parker, R., Walker, L., & Hegarty, K. (2010). Primary care nursing workforce in Australia. A vision for the future. Australian Family Physician, 39(3), 159—160. Pearce, C., Hall, S., & Phillips, C. (2010). When policy meets the personal: General practice nurses in Australia. Journal of Health Services Research & Policy, 15(Suppl. 2), 26—34. Phillips, C. B., Pearce, C., Hall, S., Kjakovic, M., Sibbald, B., Dwan, K., et al. (2009). Enhancing care, improving quality: The six roles of the general practice nurse. Medical Journal of Australia, 191(2), 92—97. Renders, C., Valk, G., Griffin, S., Wagner, E., van Eijk, J., & Assendelft, W. (2009). Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. Cochrane Database of Systematic Reviews, 1(1). Schlicht, K., Morgan, M., Fuller, J., Coates, M., & Dunbar, J. (2013). Safety and acceptability of practice-nurse managed care of depression in patients with diabetes or heart disease in the Australian TrueBlue study. BMJ Open, 3, e002195. http://dx.doi.org/10.1136/bmjopen-2012-002195 Senior, E. (2008). How general practice nurses view their expanding role. Australian Journal of Advanced Nursing, 26(1), 8—15. South Australian Department of Health. (2007). GP Plus Health Care Strategy. Retrieved from: http://www.sahealth.sa.gov.au/ wps/wcm/connect/6f9d058043a34090b563fded1a914d95/GP+ Plus+Health+Care+Strategy.pdf?MOD=AJPERES&CACHEID= 6f9d058043a34090b563fded1a914d95 Verrall, C. (2007, December). Nursing in general practice — When challenge becomes opportunity. Nursing Review, 31, 8—9. Wagner, E., Austin, B., & Von Korff, M. (1996). Organizing care for patients with chronic illness. The Milbank Quarterly, 74(4), 511—544.
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Building chronic disease management capacity in General Practice: The South Australian GP Plus Practice Nurse Initiative Jeffrey Fuller, BN, MSc, PhD a,∗, Kristy Koehne, BN Hons, PhD, Grad Dip Mental Health Nursing b, Claire C. Verrall, Grad Dip Applied Science (Nursing), BN, Master Nursing Studies b, Natalie Szabo, BN, Grad Dip Primary Health Care, Masters Arts (Communication Management) c, Chris Bollen, MBBS, FRACGP, MBA d, Sharon Parker, BHlthSci (Nursing), MPH b a
Centre of Research Excellence in Primary Health Care Microsystems, School of Nursing and Midwifery, Flinders University, Adelaide, Australia b School of Nursing and Midwifery, Flinders University, Adelaide, Australia c Central Adelaide Local Health Network, Australia d Healthfirst Network, Underdale, South Australia, Australia Received 30 September 2013; received in revised form 2 February 2014; accepted 7 February 2014
KEYWORDS Practice nurse; Care coordination; Chronic disease
∗
Summary Aim: This paper draws on the implementation experience of the South Australian GP Plus Practice Nurse Initiative in order to establish what is needed to support the development of the chronic disease management role of practice nurses. Background: The Initiative was delivered between 2007 and 2010 to recruit, train and place 157 nurses across 147 General Practices in Adelaide. The purpose was to improve chronic disease management in General Practice, by equipping nurses to work as practice nurses who would coordinate care and establish chronic disease management systems. Method: Secondary analysis of qualitative data contained in the Initiative evaluation report, specifically drawing on quarterly project records and four focus groups conducted with practice nurses, practice nurse coordinators and practice nurse mentors.
Corresponding author. Tel.: +61 8 8201 7641; fax: +61 8 8276 1602. E-mail address: jeffrey.fuller@flinders.edu.au (J. Fuller).
http://dx.doi.org/10.1016/j.colegn.2014.02.002 1322-7696/© 2014 Australian College of Nursing Ltd. Published by Elsevier Ltd.
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J. Fuller et al. Findings: As evidenced by the need to increase the amount of support provided during the implementation of the Initiative, nurses new to General Practice faced challenges in their new role. Nurses described a big learning curve as they dealt with role transition to a new work environment and learning a range of new skills while developing chronic disease management systems. Informants valued the skills development and support offered by the Initiative, however the ongoing difficulties in implementing the role suggested that change is also needed at the level of the Practice. While just over a half of the placement positions were retained, practice nurses expressed concern with having to negotiate the conditions of their employment. Conclusion: In order to advance the role of practice nurses as managers of chronic disease support is needed at two levels. At one level support is needed to assist practice nurses to build their own skills. At the level of the Practice, and in the wider health workforce system, support is also needed to ensure that Practices are organisationally ready to include the practice nurse within the practice team. © 2014 Australian College of Nursing Ltd. Published by Elsevier Ltd.
Introduction In 2011—2012, chronic disease accounted for 36% of all problems managed in General Practice in Australia at a rate of 56 per 100 encounters (Britt et al., 2012). Chronic disease management (CDM) requires a systematic approach that includes case management, education of patients towards self-management and the use of structured methods for patient monitoring, follow up and feedback (Bower, Gilbody, Richards, & Fletcher, 2006; Greb et al., 2009; McDonald et al., 2007; Øvretveit, 2011). In this context, Australian national and state governments have developed new funding, people and infrastructure support programs to better manage chronic disease in General Practice using practice nursing (Commonwealth of Australia, 2010; South Australian Department of Health, 2007). It is important therefore to understand what is needed to ensure that practice nurses have the capacity to undertake this role. General Practices in Australia are, in the main, private businesses. Income is largely generated through a subsidised consultation fee that is charged to patients for each service, with some additional funding to support CDM. Both the patient subsidy and CDM payments are provided through the taxation funded national health insurance scheme known as Medicare. Hence General Practice in Australia has developed a service model that tends to be reactive to patient presentations and is episodic according to funding based on throughput (Palmer & Short, 2010). While many Practices employ a practice nurse, often these are part time positions with roles that have in the past been mainly procedural, covering tasks to support the general practitioner, such as immunisations and wound care (Britt et al., 2012). Change is expected, however, in practice nurse employment and roles since the funding of nurses in General Practices was changed in 2012 from procedural reimbursements (e.g. tied to immunisations and wound care) to block funding of up to $125,000 per Practice each year (Bell, 2013). Practice nursing is a small but rapidly growing section of the Australian nursing workforce with an estimated increased in numbers by 38% over the five years from 2007 to 2012 (Australian Medicare Local Alliance, 2012). A practice nurse is defined as a ‘‘registered or enrolled nurse employed by, or whose services are retained by a general practice in a general practice [and who] may be either accredited or
non-accredited’’ (Parker, Keleher, Francis, & Abdulwadud, 2009). There is no regulation to entry other than the requirement that the nurse have a general license to practice as a registered or enrolled nurse by the Nursing & Midwifery Board of Australia. As a developing workforce, the roles, scope of practice and impact of practice nurses have in the past been poorly understood (Halcomb, Davidson, Daly, Yallop, & Toffler, 2004; Phillips et al., 2009). Practice nursing skills have been found to be under-utilised and barriers to practice include inadequate funding models, insufficient educational preparation for primary care, a lack of a career pathway and the variety and fragmentation of roles and workplaces in the sector (Gibson & Heartfield, 2005; Halcomb et al., 2005; Keleher, Parker, Abdulwadud, & Francis, 2009; Phillips et al., 2009). Despite health system reforms to improve the career and scope of practice nursing, the most recent 2012 national survey found a high proportion of practice nurses were ‘‘less than highly satisfied’’ about the recognition of their work, their opportunity to suggest practice changes, the use of their abilities, career promotion and the management of their practice worksite (Australian Medicare Local Alliance, 2012). Halcomb, Davidson, and Patterson (2008) concluded that much development is needed if practice nurses are to take a significant role in CDM in Australia and the need for professional development and support of nurses in General Practice has long been recognised (Gibson & Heartfield, 2005; Halcomb, Davidson, Salamonson, & Ollerton, 2008; Parker et al., 2009; Parker, Walker, & Hegarty, 2010; Senior, 2008). This paper describes a South Australian Initiative that was designed to build CDM capacity in General Practice through the employment and support of practice nurses as care coordinators. The paper discusses the issues that were documented during the implementation and evaluation of the Initiative and concludes with the nurse role fulfilment and support factors deemed important when developing nurse led CDM in General Practice.
The Practice Nurse Initiative Set within the South Australian Department of Health GP Plus Health Care Strategy (2007), the GP Plus Practice Nurse Initiative (PNI) was delivered between January 2007 and June 2010. The purpose was to increase the number of
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Building chronic disease management capacity in General Practice nurses in General Practice in metropolitan Adelaide and to develop the nurse role in CDM within the Practice team. The Initiative was expected to fund 50 full time practice nurse placements in General Practices over seven rounds of recruitment and training across the Central Northern (CNAHS) and Southern Adelaide Health Service regions. The CNAHS portion of the program was auspiced to the Adelaide North East Division of General Practice. Over the three and a half years of the Initiative, seven groups of nurses (157 in total) were recruited and trained across 147 General Practices in five Divisions of General Practice. The nurses were employed by the respective Division of General Practice using funds from the Initiative, with participating General Practices required to indicate intent to employ the nurse beyond the placement period. At the end of 20 weeks, if employment was desired by both parties, General Practices negotiated the terms of continuing employment directly with the nurses. The project records indicated that at the end of the Initiative, 82 of the 157 nurses (52%) were retained in their placement Practice. Prior to their placement, nurses attended four days of training which was doubled to eight days in 2008 in order to increase the focus given to CDM and the use of information technology. A training manual and orientation handbook was developed to align with the Competency Standards for Nurses in General Practice (Australian Nursing Federation, 2005) and to incorporate training in CDM guided by the National Chronic Disease Strategy (National Health Priority Action Council, 2006). The eight day training program covered professional practice, clinical care, management systems and collaborative practice. In addition, CNAHS funded the development of a dedicated chronic disease self-management (CDSM) training program from round four onwards. This was delivered by a specialist CDSM clinician based on the Flinders CDSM model including a day of cultural awareness training (Flinders University of South Australia, 2013). With the support of existing practice nurse coordinators within each Division and the employment by the Initiative of experienced practice nurses as mentors, it was expected the new practice nurses would assume responsibility for establishing CDM systems. In order to align CDM funding available under the Australian national health insurance program (Medicare), these new practice nurses were focused on supporting general practitioners in the development of GP Management Plans and Team Care Arrangements. General Practices were supported by the Initiative in their practice nurse business modelling through the use of a Practice Health Atlas, which brought together Medicare billing history, local demographic data and practice population data. This was to identify potential business opportunities within the chronic disease care program and the continuing financial viability of the practice nurse positions.
Method This paper is a secondary analysis of the synthesised PNI evaluation data that was sourced from the project records. Three of the research authors (JF, KK, CV) were not involved in the evaluation but were approached by the Adelaide North
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East Division of General Practice (NZ, CB) to write a paper on the issues experienced in implementing the Initiative and to help draw implications for future practice with reference to the wider literature. The authors did not have access to the raw evaluation data and so used the data contained in a 100 page ‘‘GP Plus Practice Nurse Initiative Final Evaluation Report 2007—2010’’ of which one of the authors (NZ) helped to compile. For the purpose of this paper we used two components of the report data. The first were data that enabled us to describe the Initiative, which were sourced from the quarterly PNI progress reports. The second data, which forms the main focus for this paper, were the findings of four focus groups held at the end of the Initiative in 2010. The purpose of the focus groups was to reflect upon the successes, weaknesses, management and facilitative processes, and also the challenges of the Initiative. Focus group participants had been recruited through an invitation sent out through the respective Divisions of General Practice that involved attendance at a dinner followed by a focus group discussion. Three focus groups were held with 41 practice nurses from three of the Adelaide metropolitan regions (North & East, Central & West and Hills) and one group with 10 practice nurse coordinators and practice nurse mentors. As a way to promote involvement of participants in group discussion, the focus groups used a ‘‘card storming’’ technique with each participant recording their comments related to the four purpose areas (successes, weaknesses, processes and challenges) prior to the facilitator prompting discussion (Kitzinger, 1994). The groups were conducted, audio recorded and reported to NZ and CB by a contracted evaluator who was not involved in the analysis or writing of this paper. The findings from the quarterly reports and focus groups, presented in the final report, were independently read by the three research authors (JF, KK, CV) to extract what each saw as the main issues. Differences were discussed and once agreement was reached, a draft of these main issues was given to the two authors from the Division (NZ, CB) for verification and to add interpretive insights from their involvement in the Initiative at a senior level.
Findings We constructed the following four themes from the issues that were described in the report; challenges experienced in fulfilling the role, the big learning curve for the nurses, the refinement of the Initiative over time and post placement employment negotiations.
Challenges in fulfilling the practice nurse role Challenges in fulfilling the practice nurse role were anticipated and while proactively managed through promotion of the role to general practitioners, practice managers and other Practice staff, a range of ‘‘new job’’ challenges were still experienced. Regarding their coordination role in CDM, some of the newly appointed nurses stated that they were unable to consolidate partnerships with other service providers until they felt confident in the system that they were now working. In addition, some reported feelings of isolation as they adjusted to a smaller clinical setting
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without a team of nurses around them. Nurses were aware of stepping into a new role that required their transition into a new working environment. This environment was not always conducive to an easy transition, however, with one nurse describing this with ‘‘no precedent in my Practice, as the first nurse ever — no job description, no policy, no procedures’’. Others reported varying expectations from Practice staff and while some nurses described flexible practices which allowed them to establish their role over time, others spoke of constraints. For example, one nurse identified the challenge of working with ‘‘doctors who still see nurses as their handmaidens,’’ and another noted the expectation to ‘‘undertake tasks on behalf of the GP’’.
development of a Chronic Disease Service Referral Pathways document which outlined detailed referral pathways for the prevention and management of type 2 diabetes, coronary heart disease, asthma and COPD and mental health
Refinement of the Initiative
In the early stages of the PNI, it became evident that some practice nurses did not have sufficient information technology skills, which was a problem given the emphasis on the use of computer software and data entry in CDM. In a practice nurse focus group, one participant described the need to upskill:
The first group of practice nurses were placed for a period of 16 weeks and it soon became apparent that this time frame was insufficient, with the placement period increased to 20 weeks. This additional time was needed to establish systems for the delivery of CDM, such as the establishment of a register of Practice patients with diabetes so that care under the new diabetes funding from the national government could be initiated. By mid-2008, the length of the training was doubled and additional support was developed in recognition of the amount of change required in the Practices. The additional supports were provided by the Initiative in response to feedback from practice nurses, practice managers and general practitioners about what was needed to drive change to processes and systems in these Practices towards the management of chronic disease led by nurses. A proportion of the salary component to Practices was then used to engage a mentor (eleven in total). These mentors were experienced practice nurses who provided four to six months of assistance to ensure that the Practice was prepared for CDM when the PNI nurse commenced. This included mentors working with the Practice team to prepare them for potential role changes as a result of the employment of a practice nurse. Responses from the practice nurse coordinator/practice nurse mentor focus group indicated that the adaptability to change the level of support was a valued feature of the Initiative, as described by the following two participants:
I couldn’t use a computer — open the email, that’s all. It took a while to learn Medical Director software. I just had to learn it. [The Division] was very patient in helping me to upskill.
We were able to be flexible and change the model — assessing what was working and what wasn’t and looking at how it could be adapted. When we increased support we could do more education.
While individual ‘‘up- skilling’’ and mentorship were able to address this deficit, the recruitment process was refined in the second year to target candidates with more advanced information technology skills. Although it was common for new practice nurses to feel overwhelmed initially, with the role described as ‘‘just huge — you have to be a ‘jack of all trades’ more than any other area of nursing’’, there was congruity across the four focus groups that one of the best aspects of the Initiative was the opportunity to participate in training and learn and use new skills. The training prepared practice nurses to step into this role as one nurse described:
[We needed to] tailor the program to suit the needs of the Practices. We had to know the Practice and what they needed. In cases where the Practice wanted to employ their own nurse we developed a recruitment package.
A big learning curve for nurses new to General Practice For nurses new to General Practice, challenges emerged that necessitated a broader skill set than in the hospital setting. One of the new practice nurses described a learning curve in regards to the breadth of clinical skills required: I had worked with mums and babies for years and years, so I hadn’t worked with male patients or the elderly. That was like going back and learning a whole new set of skills. Everything had changed a lot, diabetes, asthma. It was a really big learning curve after many years of being very comfortable in the job I was in.
The diversity of the training was brilliant . . .. I felt really equipped after that, although it was a big shock to put all that into practice because there was just so much involved. The courses did stir up a lot of stuff that I had forgotten or didn’t know and it was very overwhelming. While the provision of Practice resources by the Initiative did not ease the learning curve as such, these did ensure that practical tools were available for the nurses to perform in their new role. For example, the PNI funded the
Post placement employment negotiations Practice nurses expressed concern about the need to negotiate their employment at the end of their placement period. While participating Practices were required to indicate intent to employ a practice nurse, this was not a binding commitment to each other by either the Practice or the practice nurse. This facilitated initial participation, but it also created anxiety for some nurses. One nurse described having ‘‘no idea for the [placement] period what would happen at the end and what amount of pay they would offer . . . which made it very difficult and stressful’’. Practice nurses described how negotiating a pay rate was foreign to them and they reported variability in the rates offered. There was a concern that at the completion of their placement, some ‘‘doctors will offer a rate less than that provided by the Division,’’ with one nurse recalling this:
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Building chronic disease management capacity in General Practice When my practice offered me money, it was $6.00 less than what the Division was paying, but I couldn’t work for that amount, so I moved practices where they would pay me a better rate.
Discussion The retention of just over a half of the placement positions beyond the Initiative suggests that sufficient benefit was established in these General Practices for them to continue to employ a practice nurse. The evaluation did not ascertain what happened to the other practice nurses. The reasons that ongoing employment did not occur in just under half of the Practices may relate to the magnitude of changes that are required to demonstrate the value of employing practice nurses in CDM. The impact of the Initiative, however, needs to be considered as just one State-based strategy in the range of primary care reforms in Australia that cover new models of care, different arrangements for funding service delivery and new infrastructure (Commonwealth of Australia, 2010). Nevertheless, the focus of this paper on the implementation experience of this South Australian Initiative does enable some conclusions to be drawn about the employment of new practice nurses and what is needed to develop their CDM role. It was necessary in the implementation of the Initiative to increase the length of the placement, double the education provided to the nurses in response to their ‘‘big learning curve’’ and provide mentors. These were required to assist both the nurses and the Practices to deal with role fulfilment and establish CDM systems. These changes suggest that factors at both the level of the nurse and also the level of the Practice are important when developing CDM (Fuller et al., 2011; Wagner, Austin, & Von Korff, 1996). The ‘‘big learning curve’’ that was experienced by nurses new to General Practice is explained in part by changes in their organisational environment. These nurses had moved from employment in more specialist publicly funded health care settings with defined team roles, a nursing leadership structure and explicit rates of pay, to a smaller health care setting that operated with a private business model and a generalist role under a medically dominated leadership structure. It has been recognised that the nurse new to General Practice may experience anguish as they grapple with a new working environment; with different systems, hierarchy, pay and a potential lack of comradeship (Senior, 2008). In particular, the acute care nurse entering General Practice may grieve for the familiarity and perceived security of the hospital environment of past employment (Verrall, 2007). Acculturation to the new working environment was complicated by an expectation in some Practices that the role of the nurse was to undertake delegated tasks on behalf of the general practitioner. This was despite the aims of the PNI to position nurses in a collaborative role, with the capability to steer CDM systems. The challenge of shifting practice nursing to a collaborative team model have also been described elsewhere (Halcomb, Davidson, & Patterson, 2008; Keleher, Joyce, Parker, & Piterman, 2007; Mills & Hallinan, 2009). Research which has examined the feasibility, acceptability and sustainability of nurse-led CDM in General Practice reiterates the importance of collaborative care, with the
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alliance between practice nurses and general practitioners considered as intrinsic to confidence in the model of care (Hegney, Patterson, Eley, Mahomed, & Young, 2013; Schlicht, Morgan, Fuller, Coates, & Dunbar, 2013). Furthermore it has been found that practice nurses in more socially supported teams who self identify with their role are more able to exert influence in their workplace and contribute to organisational decision making (Merrick, Duffield, Baldwin, & Fry, 2012). The training and the use of practice nurse mentors and coordinators was clearly not sufficient to overcome all the barriers that the nurses experienced in developing their roles in CDM. We conclude that the required level of support also needs to be ascertained at the level of the General Practice and in the macro system and that these should be considered in future initiatives. It has been reported that the relative low rates of pay, lack of career structure and poor recognition in Practices for the expanding role of the practice nurse can operate as disincentives to practice nurses (Cheffins, Twomey, Grant, & Larkins, 2011; Halcomb, Davidson, & Patterson, 2008; Hegarty et al., 2012; Joyce & Piterman, 2009). At the Practice level, it is argued that changes towards a team based model are needed in order to recognise and incentivise the whole team and to move the traditional role of the practice nurse away from simply performing delegated tasks and providing administrative support to the general practitioner (Joyce & Piterman, 2009; Mills & Hallinan, 2009; Pearce, Hall, & Phillips, 2010). This move should be helped by the new model of funding that was changed in 2012, from the model that was based on a highly prescribed set of procedurally based Medicare item numbers to block funding. The anxiety described by the practice nurses in negotiating their terms of employment, including pay rates, may have been exacerbated by uncertainty in Practices about the sustainability of the funding model. Hegney et al. (2013) found that concerns about funding sustainability remain a barrier to the development of the practice nurse role in CDM. A recent study by Morgan et al. (2013), however, demonstrated that nurse led care can be funded within the current Australian national health care reimbursements to General Practice. Hence, an area for future support is the development of business case skills for General Practices to employ practice nurses in CDM, such as that prepared by the Australian Practice Nurses Association (King, Watts, & Brewerton 2011). Beyond the Practice and in the wider system it has been reported that the education of undergraduate nursing students is insufficient to prepare them to practice in primary health care and as we have noted above there is no specific education qualification required to work in General Practice (Keleher, Parker, & Francis, 2010). Hence, to advance the practice nurse role in CDM we conclude that attention needs to be paid to the nurse’s educational requirements as well as the provision of a supported and collaborative environment. In addition to the Initiative described in this paper national and state support programs have been developed. For instance, the peak primary health care planning body, the Australian Medicare Local Alliance (AMLA) is the auspice for the ‘‘Nursing in General Practice Program’’ that includes demonstration projects, leadership workshops, education grants, funding information and marketing, although this in not a career framework as exists in the UK and New
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Zealand (AMLA(a), n.d.; Parker et al., 2009). Significantly, the AMLA has a framework that articulates role levels of nursing in General Practice with associated education, experience, competencies, skills and activities which add to the 2005 ‘‘Practice Nurse Competencies’’ developed by the Australian Nursing Federation (AMLA(b), n.d.; ANF, 2005). Despite these programs, however, the structure of Australian General Practice, as a large number of relatively small private businesses, remains a major organisational influence on how the practice nurse role can be advanced. This is in comparison to other areas of nursing where employment is through government or other large organisations with collective employment agreements and with larger more obvious professional nursing structures. As an initiative of the South Australian Department of Health, the PNI did provide support to the Practices through funding, recruitment, training and mentorship. The support most consistently identified in this Initiative was the tailored and comprehensive training program that was directed at the development of new skills. These findings accord with research that has identified that one key constituent of successful CDM is having professionals with suitable knowledge, skills and level of expertise, along with mentoring and expert supervision (Bower et al., 2006; Renders et al., 2009). However, the literature on systematic models of CDM has also found that enablers are needed at multiple levels, such as in the clinical, organisational and macro systems, particularly when existing organisational processes and structures are a barrier to new collaborative workforce arrangements in primary health care (Fuller et al., 2011; May, Mair, Dowrick, & Finch, 2007).
Limitations As this paper is a secondary analysis of reported findings some caution is needed in the inferences that can be drawn. The contracted evaluator of the GP Plus PNI was not one of the authors of this paper and hence only limited assessment of rigour of the evaluation was possible. However, given the importance of learning from this PNI experience we considered that a sufficiently relevant account could be described in order to construct a narrative of the issues and to draw conclusions about what would be needed to develop practice nurses’ capacity in CDM.
Conclusion The PNI was a three and a half year project undertaken in South Australia which sought to improve CDM capacity by placing new practice nurses in General Practice with an ongoing comprehensive support system for 20 weeks. The Initiative resembled a work in progress that along with other national strategies has helped to increase capacity for CDM in General Practice. The critical success factor learnt from the Initiative was the provision of education and other supports to the nurses to help them through the learning curve associated with a new role, and also to the Practices to help them develop CDM systems. While the PNI helped many General Practices to employ a practice nurse, it was clear from the difficulties that the nurses faced in implementing their role that strategies are also needed at the organisational and
system levels to develop CDM by nurses in General Practice in Australia.
Acknowledgements Authors Claire Verrall, Natalie Szabo and Chris Bollen contributed to the Practice Nurse Initiative in the following positions: Claire Verrall was Practice Nurse Coordinator at GP Partners, Natalie Szabo was Project Coordinator and Chris Bollen was CEO of the Adelaide North Eastern Division of General Practice. This work was funded by the Adelaide North Eastern Division of General Practice. The authors would like to acknowledge the work of Amy Cotton who undertook focus groups and was one of the authors of the GP Plus Practice Nurse Initiative Final Evaluation Report (unpublished).
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Please cite this article in press as: Fuller, J., et al. Building chronic disease management capacity in General Practice: The South Australian GP Plus Practice Nurse Initiative. Collegian (2014), http://dx.doi.org/10.1016/j.colegn.2014.02.002