ALTERACIONES EN LA REPOLARIZACIÓN DEL ECG

Tensions are evident in the submissions regarding the constraints on nursing roles and practice in working within the GP-led primary and community care framework and the recognition of the potential of expanded nursing roles in PHC provision.

‘The health reform agenda offers an opportunity to consider an alternative model of primary health care that extends beyond the services of a general practitioner to a multidisciplinary model to offer comprehensive primary health care services. The current system of primary health care in Australia is not so much "primary health care" as "primary care"’. Submission 313:12(Nurs)

In coding the submissions for the meaning units encompassing role expansion, Halcomb et al.’s (2006) description of role expansion for nurses within primary care was used as it fitted well with the characterisations as provided by the submissions.

‘Role expansion is generally regarded as more far-reaching than role extension, encompassing a holistic rather than task-oriented approach to nursing interventions. Role expansion entails nurses taking their own initiatives and making independent decisions based on experience and education rather than relying on medical delegation of tasks, which occurs with role extension’ (Halcomb, Patterson et al. 2006:378).

Positioning nurses as autonomous health care providers in community settings is foregrounded as supporting the role of PHC nurses as ‘first contact’ practitioners for people in connecting with the health system. Many of the submissions, in

highlighting the limitations of current GP-led primary and community care funding on nurses’ autonomy, provide alternative funding mechanisms which support nurses autonomous positioning, as exemplified by the following quote:

‘Access to a recurrent source of funding based on a capitation model would help address the anomaly that exists with the current MBS items numbers which ignored the autonomous nature of nursing practice in reimbursing

general practitioners for services provided by a nurse’. Submission 313:14 (Nurs)

Within the coding framework, see Table 4, representations of the expansion of nurses roles as autonomous practitioners within and beyond the general practice setting are tabled within the sub meaning units ‘autonomous practitioner’, ‘gap filling’,

‘providing holistic care’ and ‘identification with community’ evidencing nursing’s significant identification with these aspects of PHC nursing in comparison to other primary interest groups.

While medicine and government support the centrality of general practice in the provision of PHC there is discussion within nursing and community/NGOs’ submissions about the need to recognise a broader community base for PHC provision to move beyond a focus on illness and the historical and cultural

understanding of the general practice setting as being for primary medical care. This would also support consideration for people who do not readily access general practice.

The expansion of general practice incorporating the delegated extension of nursing roles is central to PHC reform for many of the submissions by primary interest groups representing medicine. However, submissions by the other primary interest groups reveal enthusiasm for the potential of expanded nursing roles in PHC, with general practice discussed as one area of primary care within the primary and community care framework. Recognition of broad positionings and expanded roles of nursing in the community beyond the GP-led primary and community care framework is evident in submissions representing nursing, State Government and community/NGO groups. The tension between the positioning by medicine and these other primary interest groups for nursing in PHC is evidenced by the following quote:

‘As regulated health professionals, nurses work collaboratively with other health professionals, not under the 'supervision' or 'for and on behalf of' the GP. Recognising this for what it is: the efforts of the medical profession to

control the flow of funds under the guise of directing the practice of others’. Submission 313:14(Nurs)

While there are nurses practicing community health and primary health care outside the GP-led primary and community care umbrella, as the invited submission by Chiarella points out, comparatively less research has focussed on these nurses, research funding more recently has centred on practice nursing and community care nursing. One example given in the submission by Chiarella is the role of the school nurse:

‘Overall little is known about the role of the school nurse in Australia. Preliminary research indicates that school nurses engage in clinical care, health counselling, health promotion, school community development activities, networking/resource and referral, and general clinic management. However, it is unclear whether these accurately reflect the roles of school nurses, what proportion of time nurses spend on these various activities and what are the common health concerns of students presenting to school nurses. Part of this uncertainty appears to stem from the lack of standardised data collection methods for school nurses. Notwithstanding this uncertainty it seems that most undertake PHC work’. Submission Chiarella:7 (Nurs)

In recognising nurses’ potential as autonomous health care professionals providing PHC, the identity work of some of the primary interest groups highlighted an

expanded nursing identity in PHC and raised issues of concern regarding constraints to this expansion.

Addressing gaps in service provision

Recognition of the importance of a broad understanding of community health beyond the GP and general practice and the necessary expansion of the nurses’ role in these areas is voiced by many of the Community/NGO submissions. The Consumers Health Forum submits:

‘Currently, the Australian Government invests in primary health care, including through Divisions of General Practice. However, involvement of a wider range of health services is essential to a healthy community. Nurses, allied health services and community health educators have an important role to play’. Submission 509:5 (Com/NGO)

The contention by many of the submissions that extending the reach of general practice provides an inadequate framework with which to provide comprehensive PHC is exemplified in the following quote (with particular focus on rural settings)

‘The current ‘one size fits all’ model of Medicare funded general practice has proven particularly inadequate in addressing the complex primary care needs of remote and rural communities’ Submission Dunn:3(Ed)

In response to this recognition of the inadequacies of the current system nurses are characterised as ‘filling the gaps’ and ‘holding the fort’ (Submission 313). This gap filling role is discussed in these submissions in areas such as rural and remote PHC, aged care and health care provision for vulnerable and marginalised client groups. Nurses’ role expansion in these areas is described in terms of meeting the

discrepancy between perceived needs and health care availability. The gap filling role is discussed as being broader than merely a substitution for the absence of a GP. It is variously described as including filling in for a GP, filling the gap that isn’t filled by general practice and primary medical care, filling a gap in addressing the needs of people who do not use general practice services, filling a gap in

collaborative care between medical and social care and filling a gap between health care outside ‘primary and community care’ services. All of these gap filling roles are attributed as expanded nursing roles by submissions in this category.

Submissions by medicine groups do not address this nursing role of gap filling. General practice within these submissions, as the site for primary health care service delivery and coordination, is seen as expanding to meet the unfilled needs as

identified. The issue of nurses filling gaps in the provision of primary health care not met by GP-led primary or community care services is not raised.

While nurses are discussed as ‘holding the fort’ in service provision, their

contribution in this is acknowledged as being unrecognised within the development of health policy. This is attributed to factors such as professional boundaries and legislative barriers (Submission 313). There is also evidence of nurses working in expanded roles in voluntary capacities due to funding limitations, further silencing the recognition of this gap filling role.

Within the nursing submissions, it is the Nurse Practitioner role which is discussed as a viable means of addressing gaps in service provision primarily in the integration of care between primary care services and hospital and community care services

(Submission 14). However, the limitations placed on the expanded role of the Nurse Practitioner, beyond GP-led general practice, in addressing gaps in service provision is recognised by NGO/Community groups, as exemplified by this quote:

‘If nurse practitioners were permitted to work separately to a GP practice, it would provide an opportunity to improve the provision of primary health services in areas where there may be no doctor (e.g. in rural and remote Australia or even parts of metropolitan Australia)’. Submission 063:11(Com/NGO)

The gap filling role, as part of nurses’ role expansion beyond GP-led primary and community care, is also discussed as addressing the need for better integration of the provision of PHC between individuals and their community. Nurses working in advanced practice roles are identified as having a long term commitment to their local communities, areas of specialty and their work units, providing a means for strengthening local care and coordinating care across relevant services. They are described as providing connectivity and linking primary and social care, increasing access to services for hard to reach client groups.

The expansion of nursing roles in rural settings beyond the confines of general

practice and HACC funded community care services is discussed not only as a means of addressing rural GP shortages but also as an opportunity to enhance the provision of PHC.

‘This problem presents an opportunity to utilise the skills mix of nurses… and encourage broader roles for nurses in a range of settings including workplaces, schools, working with General Practitioners, in Community Health services and in rural and remote areas. Their role should also incorporate case management of people with chronic conditions or complex needs’. Submission 194:4 (Com/NGO)

Role expansion for providing holistic care

There is a high correlation within the nursing submissions for the meaning units related to the provision of holistic care. Nurses are characterised as having a holistic view of health and wellbeing. The importance given to the incorporation of

community as well as the individual client into the provision of ‘holistic’ care suggests this has particular significance for their identification as PHC providers. These meaning units are not recognised as being as significant for the other primary interest groups. Although the following quote represents the view of one submission for a specific client group, it is broadly representative of many of the other

submissions in their representation of nursing’s relationship with the provision of holistic health care.

‘Nurses have a holistic view of health and wellbeing and …nursing still provides for the day to day health and care needs of individuals and communities….CRANA members are in remote communities; they battle the daily problems with communities, they are part of the community. CRANA is an organization that fights for social justice and works towards improving the health outcomes for those most in need in our society. We urge the Commission to take a broad view of health when determining the future of the health system. It is the health of the whole community that matters and by that we mean the whole Australian community including those who live and work in rural and remote areas’. Submission 073:1 (Nurs)

Holism encompasses the broad identity of nursing in community, expanding the boundaries of primary and community care to encompass holistic care. Being able to work across perceived ‘boundaries’ of care to facilitate the connection between

organisations/services/people and in doing so enhance the professional capacity of other providers is an aspect of nursing’s positioning in PHC present in some of the nursing submissions.

‘Nurse practitioners represent value for money; they are able to cross boundaries in the health workforce and, through collaborative practice, can facilitate the capacity of each health care practitioner, including medical staff, to focus on their area of clinical practice expertise’. Submission 164:2 (Nurs)

In some submissions the representation of nurse as provider of holistic care incorporates the health of the whole community. Some nursing groups, such as CRANA (Submission 073), suggest that the full potential of nurses’ community connectedness as part of the expanded PHC nurse role is not recognised. In urging the NHHRC to broaden their view of health in their deliberations for preparing input to the draft PHC Strategy, CRANA incorporates the broad social determinants of health within its representation of the expanded role of nursing in PHC, recognising nurses as members of their community, working broadly towards improving the health of community members most in need. The connectedness to community and the recognition of this relational connection as integral to effective expanded nursing is reinforced by the following quote from a submission from the Faith Community Nursing group.

‘The FCN seeks to create and strengthen individual and community capacity, facilitate resilience and nurture the relationships that keep people connected in community. Programs focus on relationship building, health promotion, illness management, disease prevention, nurturing holistic well-being, aiming to empower active participation in the management of personal and community health’. Submission 033:13 (Nurs)

Whilst not specifically using the term holistic care as a nursing position, Community groups including Women’s Health Vic (Submission 194) and the Consumer Health Forum (Submission 509) suggest expanded roles for nurses outside the current primary (general practice) and community care framework which takes on the

broader aspects of PHC in strengthening community health. These include practices such as harnessing community support and involvement, ensuring a well organised coordinated network of services and delivering care via a multidisciplinary team with a model based on population health.

However, there are inconsistencies in the use of the term ‘holistic’ in the nursing submissions in regards to the role of the community. Within some of the

submissions, holistic care refers to care provided for individuals and their community whereas other nursing submissions focus on patient centred care provided for

individuals and their families.

Ambiguous representations of nurses’ autonomy

Many of the submissions discussed the need for nurses, as integral to PHC reform in moving from an illness model of care to include health promotion practices and a social model of care, to be recognised as autonomous health professionals. This recognition extended to all community nurses including Practice Nurses in general practice and Nurse Practitioners. Nursing in Australia has a history of being ‘under’ medical supervision (Keleher 2000b). Despite this, the nursing profession, similar to other regulated health professions, affirms its position in providing autonomous practice.

‘Professional codes of ethics, codes of conduct, professional practice standards and employer policy and practice standards all influence nursing and midwifery practice. All these provide support for nurses and midwives, as autonomous regulated professionals, to determine their own scope of practice’.(Nursing in Primary Health Care Organising Committee 2008)

In Australia, Community Health Nurses and other nurses working in the community have a history of practice and community recognition of less direct ‘supervision’ (Keleher 2007f). Most of the primary interest groups, except for medicine,

foreground the potential benefits of nurses’ role expansion through recognition of autonomous nursing practice. Recognition of factors limiting the autonomous

practice of nurses including entrenched hierarchies and funding control is evidenced within the submissions

‘The Productivity Commission’s enquiry into Australia’s Health Workforce (2006), reports that nurses, as professional practitioners are under-utilised in terms of their capacity. It was suggested that this was due to entrenched hierarchies and traditional roles’. Submission 014:7 (Nurs)

‘Current funding of nurses in general practice significantly limits their contribution to general practice as an accessible, affordable health service’. Submission 042:8 (Nurs)

State funded health services in Australia have had a longer history of working with community nurses who have not worked directly under a delegation model. Some of the nursing submissions discuss broader community nursing roles including School Health Nurses, Faith Community Nurses and Child Health Nurses as autonomous health professionals working outside the general practice setting. Acknowledging the professional autonomy of nurses as health care providers and the significance this has on effective and sustainable collaborative care is highlighted by this State Government submission.

‘There is direct correlation between those organisations that create a quality work environment, where nurses’ and midwives’ autonomy, education and pursuit of excellence is valued and reflected by increased patient satisfaction and quality patient outcomes’. Submission 458:18 (Govt)

Many of the submissions describe and discuss the nurses’ role in terms of coordination of care. Whilst positioning nurses in a broad range of community settings including general practice, community health services and community care services, nursing’s focus of care is recognised as placing clients at ‘the centre of care’. This influences the way in which the submissions view collaboration within multidisciplinary teams. Limitations to nurses’ autonomous practice is recognised as impacting on the PHC Strategy aim of fostering a health system focused on ‘patient centred care’ as well as limiting nurses’ role expansion.

‘Breaking down the legislative and professional barriers to enhance the professional role of nurses, nurse practitioners and other allied health workers, is an important issue and one that needs addressing…making the patient 'the centre of care' needs more than rhetoric and access to professional health care by the community is a basic right, not something that is to be restricted due to territorial disputes, or a view that the patient belongs to any particular primary health carer’. Submission 481:1(NGO)

Whilst the recognition of nurses as autonomous health professionals is evidenced in some of the submissions, it is the Advanced Practice Nurse and Nurse Practitioner roles which are foregrounded as providing opportunities for autonomous nursing roles. Primary interest groups describe the Nurse Practitioner role as complementing GPs and other health professionals in a general practice. However, restrictions and limitations to the role of the Nurse Practitioner providing broader access to primary health care Nurse Practitioner services are noted by groups including nursing and community/NGOs.

‘Nurse practitioners… could provide services in smaller towns. However, nurse practitioners are not as widely used…In many cases nurse practitioners would be able to work in practices with GPs, providing a complement to the GP and other health professionals in the practice’. Submission 063:11 (NGO)

Some of the nursing submissions use the term ‘task transfer’ attempting to distance the discussion from the delegation/substitution debate whilst maintaining clarity regarding practicing from a distinctly autonomous nursing perspective. The

submission by the Royal College of Nursing (Submission 164) places a strong focus on the Nurse Practitioner role and describes the Nurse Practitioner’s ability to cross