Participants perceive four key enablers to implementing a model of nursing care that included the provision of cervical screening and well women’s health services. The four enablers are: GPs being willing to relinquish the role of cervical screener and well women’s health service provider; PNs being willing to expand their role to include cervical screening and well women’s health services; clients preferring a female practice nurse to meet their cervical screening and well women’s health needs; and the presence of a culture that fosters interprofessional teamwork. Importantly the process of enacting each of these enablers is conditional on all members of the general practice team being in a position to identify their own professional development needs as well as gaps in service delivery related to their particular practice.
General practitioners relinquishing a traditional role
Participants identify that overall the GPs they work with are supportive of their role as well women’s health care providers. The reason why some GPs relinquish the provision of cervical screening in particular, and well women’s health services more generally is multifactorial and varies from general practice to general practice and within individual general practices.
Two participants perceive the ethnic backgrounds of some of the male GPs in their practices as influential in their decision to delegate this role to a PN. “One of them [male GPs] is a Sikh, so his religion sort of, you know, basically it’s easier for him to have a female nurse do them for him” (M10r119). Other participants thought that some GPs lack confidence in providing the service with one participant stating, “I think they [male GPs] felt a little uncomfortable doing the Pap smears themselves” (M16r31). Another commented that the procedure is “a little bit frightening for them, because they’re not females themselves” (M7r119). This same participant also comments that during a conversation with GPs she asked if they had done “obs and gynae” during their training and was told “No, we’re just expected to know how to do it” (M7r285).
“The men [male GPs], they couldn’t wait to offload them (M9r70)…I don’t think a lot of male GPs like doing Pap smears from what I’ve found, and it’s something that they are quite happy to get rid of”. (M9r74)"
One participant in the study identifies that while the male GPs in the practice where she works are still committed to providing cervical screening and well women’s health checks, the influence of female GPs being willing and happy to relinquish this role had resulted in her being authorised as a provider of cervical screening services.
“Two of the doctors [male GPs] flat out refused to let anyone else but themselves do Pap smears..[however] a lot of the female patients particularly asked for a female doctor to do their Pap smears and so [the female GPs] were always getting the [male GPs’ Pap smear clients] dumped on them…and they got sick of, you know, just seeing females…they wanted a bit more out of their practice…so they thought well a nurse could do them”. (M10 r71)"
Practice nurses expanding their role
For many PNs, developing knowledge and skills that can contribute to the expansion of their role in general practice is important, however as one participant pointed out it is equally important to acknowledge and “accept that there’s a lot of nurses that don’t want any more responsibility, or they don’t want to extend their roles. They’re happy to work within…what they currently do” (M3r218). For some participants their interest in women’s health and the needs of clients are motivating factors for them expanding their roles to include the provision of cervical screening, as the following quotes demonstrate:
“I’m a midwife and I see lots of women ante-natally and in general practice and one of the common things that I kept on having women say to me [was] ‘I feel comfortable with you. Why can’t you do a Pap smear with my six week post natal check?’ and so I thought…I understand why women would like familiarity with somebody…and so I sort of felt as though it would be something that I can add value to my service to women”. (M17r11)."
While electing to undertake a course in preparation for providing women’s health services is ultimately an individual PN’s choice, findings indicate that in some instances it may be a practice manager, a practice principle or a division of general practice who identifies a need and initially suggests that a PN undertake the training. “One of our lady doctors heard that they [Division of General Practice] had sponsorship funding available and suggested that I do it”. (M10r31).
Sharing knowledge with clients is an educational opportunity that PNs find rewarding in the reconfiguration of their role to include cervical screening and well women’s health services. PNs use these consultations as an opportunity to provide clients with information regarding sexual health and other health matters. As one participant pointed out, providing a cervical screening service enables her to “catch the young ones that are having sexual intercourse earlier, and just, you know, trying to educate the young kids on HPV [human Papillomavirus]” (M1r23). PNs may also extend the educational aspect of their role beyond the confines of consultation times and organise community health education events. One participant working in a remote area practice explains how she hosted a webcast event for clients and their partners about women “making their forties fabulous”. The event included dinner and encouraged clients to discuss any issues with the PN after the webcast (M4).
Participants in this study identify an important enabler to a new model of service delivery as being the number of clients who prefer a female clinician to provide their cervical screening and well women’s health services. Prior to one participant commencing employment, the general practice where she works had a “list of women who were waiting to have their Pap smear, once either a female doctor started or they had a [female] nurse doing it as well”. (M16r81). Interestingly, another participant also perceives a difference between clients related to age, with younger women much preferring a female clinician.
“The younger girls would rather see a female whether that’s a nurse or a doctor; they would just rather a female…The older ladies who’ve had all their babies…they don’t care. They know it’s got to be done…they probably prefer a lady but they are not going to complain if they have to see a man. But I think the early age group… to them it’s important that they see a lady”. (M9r170)"
Meeting general practice’s female clients’ expressed needs provides the impetus for a number of PNs to enrol in the training program as the following participant, who works in a practice with all male GPs, explained:
“I have started in a new surgery and a lot of women were coming in and wanting to know if there was a female there, you know, mainly to do Paps smears. So I thought, well, I should do something about this”. (M2r39)"
Reasons cited for clients choosing PNs over GPs to provide cervical screening and well women’s health checks include: Difficulty in getting an appointment with a female GP, the familiar face of a PN who works in a practice with high GP turn over, PNs’ listening skills, the additional time that PNs have to spend with clients, and that; clients feel more comfortable with a PN and are more likely to ‘talk’ about their women’s health needs.
“They can chat to me about things they would never dream of talking [about] to a GP. I’ve had women come and say “Look, I’ve never asked a GP about this, but…” you know, and ask me things”. (M4r28)"
An important finding in this study was that a client choosing a PN to provide cervical screening and well women’s health checks indicates their understanding of these procedures as preventative care as opposed to treatment for an identified illness.
“Sixty percent [of clients] at the moment are choosing me. We think a lot of the reason behind this is simply because they’re not unwell. They’re well women and they’ve said, “I don’t need to see the doctor, there’s no reason for seeing the doctor” (M14r215)… They still have that idea [a doctor is for when you are unwell] in their heads, so that’s probably where our primary health care message in nursing is coming a lot stronger. Umm because we’re looking at it saying look, we’re able to provide this preventative health measure and people are still thinking, well, you know the doctor’s for when I’m sick…so that’s where I think nurses in general practice will probably lead the way”. (M14r219)"
In rural and remote areas GPs are often either visiting or change regularly. A PN therfore can be the most consistent healthcare provider in these communities and as such they feel part of the community in a way that GPs may not, with a concomitant sense of responsibility. The same rural PN who organised the webcast event in her community also describes how she views her role as:
“Not just going and learning a training program and bringing that [back] on a nine to five basis, but really expanding that out into the community” (M4r229)….you feel that anything that you can do to help provide better care, or provide information, or just be an avenue where someone might come and need to talk to you. I think it is a really important part, because there’s often not the resources that there are in other places or people aren’t sure where to avail themselves of those resources”. (M4r231)"
A culture of interprofessional teamwork
Findings from this study demonstrate that narrowing the gap between assessed community need and the services provided by a general practice relies on the development of an interprofessional team demonstrating collegial interactions, shared planning for policy and procedure frameworks, a commitment to appropriate infrastructure, and an investment in knowledge and skills development. Each of these factors influence PN’s ability to provide cervical screening and well women’s health services with the lower end of the scale resulting in PN’s role being relegated to that of a “Pap smear technician” (M14r171, M17r244).
The quality of collegial interactions between PNs, GPs, receptionists and practice managers is an important consideration in changing models of health service provision in general practice. Participants cited many positive collegial interactions with general practice team members using words such as “support”, “mutual respect”, “trust” and “acceptance” to characterise their interprofessional relationships. One participant employed in a private practice with four GPs comments that the GPs “had instant trust to let me go ahead” (M1r133) based on her previous experience of working in the practice and the quality of the course of education she had undertaken.
In practice environments where collegial interactions are limited, PNs are unlikely to provide full cervical screening and well women’s health services and may be limited to providing a technical service; undertaking a Pap smear service as part of a GP consult.
“I do the Pap smear, the doctor would check the cervix, then the consult would continue and I would just leave the room. So I was really there just to do the mechanical thing of taking the Pap smears” (M12r51)."
Receptionists, and in some instances practice managers, are a general practice’s front line contact and as such play a key role in promoting nurse led cervical screening and well women’s health clinics. Delivering a quality service requires the support of the whole practice team in order for a change to be effective. The importance of receptionists to the successful delivery of services is highlighted in the following participant’s comment that “receptionists are the gatekeepers always and if they are not promoting your service you’re never going to get any patients”. (M3r170). Another participant identifies the commitment and support of the practice manager as instrumental in enabling her to deliver a well women’s health clinic as opposed to “having that [Pap smear] technician type role” (M14r171).
PNs working in practices that have developed specific position descriptions incorporating the provision of cervical screening with policies and procedures related to the service are more likely to provide well women’s health checks than practices that do not have this infrastructure in place. Developing documented cervical screening processes provides an opportunity for team members to consider and decide how cervical screening will be delivered in their particular general practice and to allocate tasks and responsibilities. Numerous participants referred to policy frameworks as a positive mechanism for identifying the scope of their practice.
“I think that’s really important to…decide what role I was going to play, how far I was going to take it, let’s say, if I’m doing the Pap smear and was I going to follow up the results, was I going to inform the patients of the results…was all that my responsibility or did they (GPs) just want me to just physically do the Pap smears” (M3r95)"
Space and time, or a commitment to infrastructure, are also important factors in the provision of Pap smears. Dedicated PN consulting rooms and appropriate duration of appointment time allocations enables PNs to run nurse-led clinics, including cervical screening and well women’s clinics. Dedicated consulting space allows ownership of a space that PNs can adapt and arrange to suit their individual practice and provides a comfortable, safe, private environment for clients. Time allows comprehensive client histories to be taken and provides an invaluable opportunity for PNs to identify other health issues that a client may be experiencing and an opportunity to provide health information and referral. In this study, almost half of all participants have access to dedicated space and are allocated between 20 and 45 minutes for this service, with 30 minutes being the most common time allocation. The following participant’s quote demonstrates the significant benefits that dedicated PN space and time accords clients:
"I have one of the consulting rooms…Each month we work out what days I’m doing my clinic and that room…[is] booked out to me (M14r255). I have half an hour appointments with clients and if they [the client] feel that I’m not pressed for time, they’re more willing to sort of [say] “well actually there’s something else bothering me too” (M14r115)."
Developing the required knowledge and skill set to effectively provide a cervical screening and well women’s health check clinic extends beyond PNs attending a course of education. Knowledge exchange with GPs and peers provides a valuable teaching and learning opportunity that develops interprofessional teamwork. The availability and accessibility of GP’s expert advice supports the extension of PN’s knowledge beyond that acquired in the course.
"If I need to talk something through…there is always an open [GP] door there…I see something visually that I mightn’t be sure of, that might be a little bit different…I can grab one of them [GP} to come and have a look (M6r19)."
One participant also spoke of sharing knowledge gained during cervical screening training with a newly trained GP:
"I’ve just had a new one [GP] start…she’s through the medical school…and just starting her GP now, and she said “Look we weren’t educated to this max at all”, and so…I’m in there doing with her, with her Paps teaching her if she’s just, you know, like she’s unsteady (M1r49)."
Peer networks also provide PNs with valuable support and additional opportunities to exchange knowledge and seek advice. Peer networks are usually formed and coordinated through divisions of general practice, although continuity of networks is reliant on individual’s commitment and a coherence between members.
"I had a sixteen year old who…had booked in for it [a Pap smear] and I was thinking, oh sixteen, you know, that’s a bit young. But discussed it with the others and they said “Oh no, it’s sixteen” but then I had to get back to them and say well, she’s been sexually active for four years and she has got a baby already, so you know. And they all came back and said “Oh well, yeah you’ve go to do it in that case”. But it flows outside the criteria of when you are supposed to do Pap smears, so I wasn’t too sure about it, but we got is resolved in the end (M10r279)."