Nine statements were identified as tasks and components associated with the first phase of the nurse-led model of MA provision. In this phase, the pregnant woman contacts the PHC professional and the eligibility for MA is assessed. Panellists agreed (84%, IQR = 1) that all women with an unwanted pregnancy should be referred to an appropriately trained PHCN (Table 7.11, no. 1); however, it was noted that women should also have the option to visit a GP:
I think women should have a choice of who manages their medical top [termination of pregnancy] esp. in country areas for confidentiality /privacy, some may prefer to see only a dr or only a nurse (Physician4). In addition, the importance of having one provider in charge of the whole MA process was highlighted:
It is important for women to have a one stop shop which meets all their needs. It is often difficult to tell your story to several people (Nurse1). While most (90%, IQR = 1) panellists agreed a PHCN’s role should include non-directive pregnancy counselling (Table 7.11, no. 2), it was expressed by one
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panellist that most women already know that they want an abortion and, therefore, do not need to be counselled on the choice to terminate:
…clearly communicate the pros and cons for ALL pregnancy options, as well as the steps involved in referral pathways. The latter is important for women living in rural and regional areas to have all information, including costs related to services, waiting times, distance & travel, service
procedure & post health care & support (Other3).
When a woman decides to undergo a MA to terminate her pregnancy, panellists disagreed (80%, IQR = 0) that a sufficiently trained PHCN is not able to independently rule out any contra-indications to the use of MA (Table 7.11, no. 4). The tasks involved with the clinical assessment of contra-indications include taking a medical history, a physical examination, and assessing any comorbidities (RANZCOG 2016). There was overall consensus (80%, IQR = 1) that it is within the scope of practice of a registered PHCN to independently refer a woman for an ultrasound (for pregnancy dating and ectopic pregnancy screening) and blood tests (Table 7.11, no. 6).
Consensus (85%, IQR = 1) was also achieved for the statement that when practice GPs refuse to provide MA, PHCNs should be able to initiate pre-testing before referral (Table 7.11, no. 5). There was, however, a statistically significant difference in ratings between the panellists’ groups (KW test statistic = 7.968; p = 0.02), with physicians (24%) less likely to agree with the statement than nurses (41%; p = 0.03).
Opinions regarding the overall responsibilities of the PHCN in MA provision differed. While overall most panellists agreed (75%, IQR = 0.75) that MA provision in the PHC sector can be provided by a PHCN in cooperation with a GP (Table 7.11, no. 7), there was a statistically significant difference between the panellists’ groups (KW test statistic = 7.968; p = 0.02). Nurses (53%) were more likely to agree with the statement than panellists in the ‘other’ group (20%; p = 0.03). The scenario of MA provision by a PHCN in cooperation with a GP was welcomed by one PHCN:
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...it would be fantastic if nurses had extended skills like ordering of tests etc. Then nurses could do all the work up and the GP would have all the information in consultation with the nurse and after seeing the client to order the medication (Nurse9).
One physician, however, questioned a prescription-only role of GPs: As a GP, I would not feel comfortable with a prescription only role for abortion (Physician4).
Some panellists, on the other hand, favoured an alternative scenario, in which the PHCN becomes fully responsible for the MA process:
Appropriately trained PHCN led provision of MA, including authority to prescribe is the preferred model to significantly improve access to non- directive pregnancy choices counselling AND abortion services in rural areas (Other3).
Nurses can be trained to provide all steps of MTOP independently. ….If nurses were able to prescribe they could be trained to provide the treatment autonomously (Physician7).
It was additionally recommended that for PHCNs working in community health care settings, partnerships with service GPs should be set up:
There needs to be varying models that would allow nurse working in areas such as women's health clinics or community health to
independently prescribe and a collaborative model for use in a GP practice with a supportive GP (Nurse1).
While all steps of the first phase of the nurse-led model of MA provision are grounded within the PHCNs’ scope of practice (Australian Primary Health Care Nurses Association 2017), PHCNs in Victoria are currently not able to be independently responsible for the whole first phase MA process. They have to adhere to the MBS requirements (Department of Health 2017b) that request the personal attendance of the GP for specific services in order to qualify abortion requesting women for benefit refunds. Therefore, in addition to a first phase,
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fully autonomous nurse-led MA model, another first phase ‘legally feasible’ nurse-led model was constructed that takes into account the required
involvement of a GP. A third nurse-led model, referred to as the ‘absence of a (supportive) GP’ model, is included for PCHNs who work in settings that lack immediate support of a GP. In this situation, PHCNs would be able to initiate pre- testing before referral, albeit within the limits of above-described current MBS boundaries. This model only consists of the first phase of the MA provision process, as the following two phases are provided at another location by another provider. A framework of the first phase of the three proposed nurse-led MA models is shown in Figure 7.3. The steps specific for each model are depicted in a different colour.
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Figure 7.3 Framework for the first phase of the three proposed nurse-led models of MA
provision