Issue 32 / 24 August 2015

ANOTHER review on “doctor versus nurse” role substitution with a brave finding that there are few differences between GPs and nurses based on very limited data. 
 
These studies are usually based on flawed health goals, provoke turf war arguments between professionals, and stifle the very real opportunities for nursing within primary care. 
 
Australia needs a smarter approach to workforce management to meet its health care needs. 
 
Task or role substitution has been the darling of health workforce researchers for many years. The supposition is that similar health outcomes will be achieved for lower costs by reassigning health care services to lesser trained and lesser paid providers.
 
Similarly, nurses have been trained to do colonoscopies and vitreal injections, and are involved in epidural care, but does that make them gastroenterologists, ophthalmologists or anaesthetists? 
 
Nurses have been trained to perform some primary care duties, but does this mean they can provide the comprehensive services or have the system value of the trained GP? More accurately, they are seen as nurses with a special skillset.
 
Australia, like other high-income countries, has introduced nurse practitioners in primary care with substantial support through Medicare
 
While general practice nurse numbers have grown substantially, the use of advanced nurse practitioners is limited. One reason is that practices that do engage nurse practitioners cannot pay salaries equivalent to the public sector, and many of the general practice roles they perform can be adequately met by practices nurses.
 
Countries undertaking health professional task/role substitution have found implementation to be complex, requiring greater oversight and regulation, yet reduced costs are not guaranteed. 
 
The introduction of a nurse practitioner-based walk-in clinic in Canberra attracted criticism. Although the primary goal was to ease accident and emergency workload at Canberra Hospital, paradoxically the clinics increased demand. 
 
The Canberra clinic mostly treated minor upper respiratory tract infections and musculoskeletal conditions, but had high referral rates to GPs and other agencies, and the cost of a service averaged $196 — more than four times that of general practice.
 
In the private sector, nurse practitioner-led clinics are increasingly operating in pharmacies, mostly via the drug company Apotex, which recently purchased the Revive clinics, adding to its nurse workforce. Apotex claims to have nurses and nurse practitioners providing screening programs, treatments and education services including “product recommendations” at more than 800 locations
 
Australia has strict laws regarding direct-to-consumer advertising and medical relationships with drug companies. So far regulators have not acted on drug companies delivering direct-to-patient clinical services via the nursing and pharmacy professions.
 
Nurse practitioners delivering GP services at higher cost than GPs and providing a workforce for drug companies are hardly examples of policy success.
 
The lesson to learn from this latest research and from our experience so far is that nurses are trained professionals who can be utilised as effective primary care agents. However, they can be more expensive and ineffectual if not actively managed and services targeted in the health system. 
 
Task substitution between GPs and nurses in the real world has, overall, not been successful.
 
To overcome this Australia should instead focus on producing a more effective health system by developing role delineations and collaboration in primary health care teams. Similarly, the nursing profession should recognise the important role general practice plays in the Australian health system and strive to complement rather than replace it. 
 
Primary care does not need nurses to duplicate or replace a GP, and does not need single-skill nurses trained in the hospital setting. Primary care needs a range of advanced nursing skills to complement the clinical skills of a GP and to help them deliver a comprehensive set of services to solve health sector priorities, such as palliative care, hospital-in-the-home programs, hospital avoidance programs, drug and alcohol services, advanced mental health skills, and telehealth-supported supervision of aged patients in their own home. These are roles where appropriately trained nurses can add value to the health system within a collaborative general practice model. 
 
Instead of concentrating on professional competitiveness between GPs and nurses, Australia should appreciate the added benefits nursing can bring to primary care, and start resourcing the training of nurses to provide a delineated skillset that will address and solve Australia health needs.
 
 
Dr Evan Ackermann is a GP  at the University Medical Centre, Southern Cross University, Gold Coast, Queensland, and the chair of the Royal Australian College of General Practitioners National Standing Committee – Quality Care.
 
 

Poll

Is it clear when it is appropriate for nurse practitioners to replace doctors for certain tasks?
  • No – best model yet to be determined (81%, 67 Votes)
  • Yes – role delineation is generally clear (16%, 13 Votes)
  • Don’t know (4%, 3 Votes)

Total Voters: 83

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7 thoughts on “Evan Ackermann: Nurse opportunities

  1. Ngaire Watson says:

    This article lacks referencing
    To say task substation has not been successful needs backing up. There is a high level of training required to be Nurse Practitioner, indeed some have a PhD. Turf war is the major factor. Some N’S work in remote areas. The medical profession should embrace their nursing colleagues instead of denigrating them.

  2. Thinus van Rensburg says:

    Dear SydGrl

    Indeed some referencing is called for – in regards to your statement.

    And indeed all GPs have at least a MBBS and most of us have at least the FRACGP and/or FACCRM on top of that. To compare a PhD against that, in terms of a clinical skillset, is not necesarily comparing apples with apples.

    Nor is referrring to people working in remote areas comparing like-minded skills. It is nothing about denigrating anyone – simply a matter of recognising the limitations of people seeking to take on the role of a GP.

    I am assuming you are  Nurse Practitioner? Bit hard to know when someone hides behind a pseudonym

  3. Jennifer Cramer says:

    There are inconsistencies in statements that barely distinguish between nurses in general, practice nurses in GP clinics and nurse practitioners. Practice nurses bring scope for expansion of GP clinic services (and profits). Unlike genneral practitioner office based clinics, the service provided by nurse practitioners may encompass not only certain medical aspects of assessment and treatment. In addition, the NP will address associated aspects of client care needs and its follow-up. Primary care is not solely within the scope of expertise for GPs! Neither GPs or nurses are qualified as ‘gastroenterologists’, ‘ophthalmologists’, or ‘anaesthetists’ merely by performing specifc basic procedures relevant to these medical specialities. It depends how ‘cost’ and benefit is measured as to the value of any health care provider. 

  4. Jennifer Hill says:

    It frustrates me to see the same tedious arguments over territory and professional ownership distracting once again from how we can build a system to meet the needs of patients. I am vastly more interested in how we make sure that whoever has the necessary skill to provide the best, most appropriate and most timely care to meet the needs of patients is enabled to deliver that care. It’s time to move on from turf wars toward a collaborative, patient centred, sustainable healthcare system. 

  5. Sue Ieraci says:

    This article goes to the heart of a major misunderstanding about clinical practice – the practical task vs the cognitive task. Our society has always underestimated the congitive task of medical practice – seeing the “blood and guts” of emergency surgery being heroic, when working out that a patient does not need surgery, or wisely watching and waiting, can often be more heroic.

    Medical training and nursing training are fundamentally different. Nursing training IS, by its very nature, more task orientated – it is much more about caring and treating than about diagnosing and prescribing care.

    I see a fundamental issue with nurse practitioners in generalist specialties – their training cannot possibly encompass the entire casemix in sufficient depth. IN contrast, an experienced dialysis nurse, or mental health nurse, can certainly develop deep expertise and competence within that limited scope of practice. 

    In generalist specialties, there is no defined scope of practice. A competent GP needs to know as much about contraception as chest pain assessment, blood pressure control and infectious diseases. They need to weigh up the risks and benefits of anticoagulation and antidepressants in the very elderly.

    I see this in my own specialty of Emergency Medicine. Our NPs function best in the Fast track area – where cases are relatively simple to diagnose, and often procedural – such as injuries and wounds. They cannot function at the level of a registar (on an equivalent pay scale) in the main ED, where scope of practice is unlimited – from major trauma to the febrile child.

    Interprofessional respect works both ways. 

  6. Sue Ieraci says:

    A message for SydGrl: the references are embedded as links in the text. No task substitution here.

  7. Mack Madahar says:

    There are a number of reasons why NPs are not a success in private practice. The following article highlights some of the struggles in daily practice. http://blogs.crikey.com.au/croakey/2015/08/04/nurse-practitioners-challenges-and-opportunities-2015-and-beyond/. To evaluate success of a model, the system must alllow NPs to function to the full scope of their practice and remnumerated accordingly. The source article actually states and I quote “Conclusion: There were few differences in primary care provided by Nurse Practitioners and physicians; for some measures NP care was superior. While studies are needed to assess longer term outcomes, these data suggest that the NP workforce is well-positioned to provide safe and effective primary care.”. The only reason practice nurses (not to be confused with NPs) survive is the PNIPs. Simply put, it is not about role substituton, rather making the best of resources and NPs are a resource underutilised at present. It is hoped PHCAG will see it differently. 

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