Search tips
Search criteria

Results 1-25 (847588)

Clipboard (0)

Related Articles

1.  The evolution of nursing in Australian general practice: a comparative analysis of workforce surveys ten years on 
BMC Family Practice  2014;15:52.
Nursing in Australian general practice has grown rapidly over the last decade in response to government initiatives to strengthen primary care. There are limited data about how this expansion has impacted on the nursing role, scope of practice and workforce characteristics. This study aimed to describe the current demographic and employment characteristics of Australian nurses working in general practice and explore trends in their role over time.
In the nascence of the expansion of the role of nurses in Australian general practice (2003–2004) a national survey was undertaken to describe nurse demographics, clinical roles and competencies. This survey was repeated in 2009–2010 and comparative analysis of the datasets undertaken to explore workforce changes over time.
Two hundred eighty four nurses employed in general practice completed the first survey (2003/04) and 235 completed the second survey (2009/10). Significantly more participants in Study 2 were undertaking follow-up of pathology results, physical assessment and disease specific health education. There was also a statistically significant increase in the participants who felt that further education/training would augment their confidence in all clinical tasks (p < 0.001). Whilst the impact of legal implications as a barrier to the nurses’ role in general practice decreased between the two time points, more participants perceived lack of space, job descriptions, confidence to negotiate with general practitioners and personal desire to enhance their role as barriers. Access to education and training as a facilitator to nursing role expansion increased between the two studies. The level of optimism of participants for the future of the nurses’ role in general practice was slightly decreased over time.
This study has identified that some of the structural barriers to nursing in Australian general practice have been addressed over time. However, it also identifies continuing barriers that impact practice nurse role development. Understanding and addressing these issues is vital to optimise the effectiveness of the primary care nursing workforce.
PMCID: PMC3987204  PMID: 24666420
Practice nurse; Nursing workforce; Survey; Office nurse; General practice; Primary care, Australia
2.  Following the funding trail: Financing, nurses and teamwork in Australian general practice 
Across the globe the emphasis on roles and responsibilities of primary care teams is under scrutiny. This paper begins with a review of general practice financing in Australia, and how nurses are currently funded. We then examine the influence on funding structures on the role of the nurse. We set out three dilemmas for policy-makers in this area: lack of an evidence base for incentives, possible untoward impacts on interdisciplinary functioning, and the substitution/enhancement debate.
This three year, multimethod study undertook rapid appraisal of 25 general practices and year-long studies in seven practices where a change was introduced to the role of the nurse. Data collected included interviews with nurses (n = 36), doctors (n = 24), and managers (n = 22), structured observation of the practice nurse (51 hours of observation), and detailed case studies of the change process in the seven year-long studies.
Despite specific fee-for-service funding being available, only 6% of nurse activities generated such a fee. Yet the influence of the funding was to focus nurse activity on areas that they perceived were peripheral to their roles within the practice.
Interprofessional relationships and organisational climate in general practices are highly influential in terms of nursing role and the ability of practices to respond to and utilise funding mechanisms. These factors need to be considered, and the development of optimal teamwork supported in the design and implementation of further initiatives that financially support nursing in general practice.
PMCID: PMC3050696  PMID: 21329506
3.  Effectiveness of organisational infrastructures to promote evidence-based nursing practice 
Nurses and midwives form the bulk of the clinical health workforce and play a central role in all health service delivery. There is potential to improve health care quality if nurses routinely use the best available evidence in their clinical practice. Since many of the factors perceived by nurses as barriers to the implementation of evidence-based practice (EBP) lie at the organisational level, it is of interest to devise and assess the effectiveness of organisational infrastructures designed to promote EBP among nurses.
To assess the effectiveness of organisational infrastructures in promoting evidence-based nursing.
Search methods
We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, LILACS, BIREME, IBECS, NHS Economic Evaluations Database, Social Science Citation Index, Science Citation Index and Conference Proceedings Citation Indexes up to 9 March 2011.
We developed a new search strategy for this update as the strategy published in 2003 omitted key terms. Additional search methods included: screening reference lists of relevant studies, contacting authors of relevant papers regarding any further published or unpublished work, and searching websites of selected research groups and organisations.
Selection criteria
We considered randomised controlled trials, controlled clinical trials, interrupted times series (ITSs) and controlled before and after studies of an entire or identified component of an organisational infrastructure intervention aimed at promoting EBP in nursing. The participants were all healthcare organisations comprising nurses, midwives and health visitors.
Data collection and analysis
Two authors independently extracted data and assessed risk of bias. For the ITS analysis, we reported the change in the slopes of the regression lines, and the change in the level effect of the outcome at 3, 6, 12 and 24 months follow-up.
Main results
We included one study from the USA (re-analysed as an ITS) involving one hospital and an unknown number of nurses and patients. The study evaluated the effects of a standardised evidence-based nursing procedure on nursing care for patients at risk of developing healthcare-acquired pressure ulcers (HAPUs). If a patient’s admission Braden score was below or equal to 18 (i.e. indicating a high risk of developing pressure ulcers), nurses were authorised to initiate a pressure ulcer prevention bundle (i.e. a set of evidence-based clinical interventions) without waiting for a physician order. Re-analysis of data as a time series showed that against a background trend of decreasing HAPU rates, if that trend was assumed to be real, there was no evidence of an intervention effect at three months (mean rate per quarter 0.7%; 95% confidence interval (CI) 1.7 to 3.3; P = 0.457). Given the small percentages post intervention it was not statistically possible to extrapolate effects beyond three months.
Authors’ conclusions
Despite extensive searching of published and unpublished research we identified only one low-quality study; we excluded many studies due to non-eligible study design. If policy-makers and healthcare organisations wish to promote evidence-based nursing successfully at an organisational level, they must ensure the funding and conduct of well-designed studies to generate evidence to guide policy.
PMCID: PMC4204172  PMID: 22336783
*Efficiency, Organizational; Evidence-Based Nursing [*methods]; Nursing Care [*standards]; Outcome and Process Assessment (Health Care) [standards]; Pressure Ulcer [prevention & control]; Humans
4.  How evidence-based workforce planning in Australia is informing policy development in the retention and distribution of the health workforce 
Australia’s health workforce is facing significant challenges now and into the future. Health Workforce Australia (HWA) was established by the Council of Australian Governments as the national agency to progress health workforce reform to address the challenges of providing a skilled, innovative and flexible health workforce in Australia. HWA developed Australia’s first major, long-term national workforce projections for doctors, nurses and midwives over a planning horizon to 2025 (called Health Workforce 2025; HW 2025), which provided a national platform for developing policies to help ensure Australia’s health workforce meets the community’s needs.
A review of existing workforce planning methodologies, in concert with the project brief and an examination of data availability, identified that the best fit-for-purpose workforce planning methodology was the stock and flow model for estimating workforce supply and the utilisation method for estimating workforce demand. Scenario modelling was conducted to explore the implications of possible alternative futures, and to demonstrate the sensitivity of the model to various input parameters. Extensive consultation was conducted to test the methodology, data and assumptions used, and also influenced the scenarios selected for modelling. Additionally, a number of other key principles were adopted in developing HW 2025 to ensure the workforce projections were robust and able to be applied nationally.
The findings from HW 2025 highlighted that a ‘business as usual’ approach to Australia’s health workforce is not sustainable over the next 10 years, with a need for co-ordinated, long-term reforms by government, professions and the higher education and training sector for a sustainable and affordable health workforce. The main policy levers identified to achieve change were innovation and reform, immigration, training capacity and efficiency and workforce distribution.
While HW 2025 has provided a national platform for health workforce policy development, it is not a one-off project. It is an ongoing process where HWA will continue to develop and improve health workforce projections incorporating data and methodology improvements to support incremental health workforce changes.
PMCID: PMC3922608  PMID: 24490586
Workforce planning; Workforce projections
5.  Stakeholder perceptions of a nurse led walk-in centre 
As many countries face primary care medical workforce shortages and find it difficult to provide timely and affordable care they seek to find new ways of delivering first point of contact health care through developing new service models. In common with other areas of rural and regional Australia, the Australian Capital Territory (ACT) is currently experiencing a general practitioner (GP) workforce shortage which impacts significantly on the ability of patients to access GP led primary care services. The introduction of a nurse led primary care Walk-in Centre in the ACT aimed to fulfill an unmet health care need in the community and meet projected demand for health care services as well as relieve pressure on the hospital system. Stakeholders have the potential to influence health service planning and policy, to advise on the potential of services to meet population health needs and to assess how acceptable health service innovation is to key stakeholder groups. This study aimed to ascertain the views of key stakeholders about the Walk-in Centre.
Stakeholders were purposively selected through the identification of individuals and organisations which had organisational or professional contact with the Walk-in Centre. Semi structured interviews around key themes were conducted with seventeen stakeholders.
Stakeholders were generally supportive of the Walk-in Centre but identified key areas which they considered needed to be addressed. These included the service's systems, full utilisation of the nurse practitioner role and adequate education and training. It was also suggested that a doctor could be available to the Centre as a source of referral for patients who fall outside the nurses' scope of practice. The location of the Centre was seen to impact on patient flows to the Emergency Department.
Nurse led Walk-in Centres are one response to addressing primary health care medical workforce shortages. Whilst some stakeholders have reservations about the model others are supportive and see the potential the model has to provide accessible primary health care. Any further developments of nurse-led Walk-in Centres need to take into account the views of key stakeholders so as to ensure that the model is acceptable and sustainable.
PMCID: PMC3529673  PMID: 23126431
6.  The Australian preventive health agenda: what will this mean for workforce development? 
The formation of the National Health and Hospitals Reform Commission (NHHRC) and the National Preventative Task Force in 2008, demonstrate a renewed Australian Government commitment to health reform. The re-focus on prevention, bringing it to the centre of health care has significant implications for health service delivery in the primary health care setting, supportive organisational structures and continuing professional development for the existing clinical and public health workforce. It is an opportune time, therefore, to consider new approaches to workforce development aligned to health policy reform. Regardless of the actual recommendations from the NHHRC in June 2009, there will be an emphasis on performance improvements which are accountable and aligned to new preventive health policy, organisational priorites and anticipated improved health outcomes.
To achieve this objective there will be a need for the existing population health workforce, primary health care and non-government sectors to increase their knowledge and understanding of prevention, promotion and protection theory and practice within new organisational frameworks and linked to the community. This shift needs to be part of a national health services research agenda, infrastructure and funding which is supportive of quality continuing professional development.
This paper discusses policy and practice issues related to workforce development as part of an integrated response to the preventive agenda.
PMCID: PMC2696455  PMID: 19463159
7.  The role of ICT in supporting disruptive innovation: a multi-site qualitative study of nurse practitioners in emergency departments 
The disruptive potential of the Nurse Practitioner (NP) is evident in their ability to offer services traditionally provided by primary care practitioners and their provision of a health promotion model of care in response to changing health trends. No study has qualitatively investigated the role of the Emergency NP in Australia, nor the impact of Information and Communication Technology (ICT) on this disruptive workforce innovation. This study aimed to investigate ways in which Nurse Practitioners (NP) have incorporated the use of ICT as a mechanism to support their new clinical role within Emergency Departments.
A cross-sectional qualitative study was undertaken in the Emergency Departments (EDs) of two large Australian metropolitan public teaching hospitals. Semi-structured, in-depth interviews were conducted with five nurse practitioners, four senior physicians and five senior nurses. Transcribed interviews were analysed using a grounded theory approach to develop themes in relation to the conceptualisation of the ED nurse practitioner role and the influences of ICT upon the role. Member checking of results was achieved by revisiting the sites to clarify findings with participants and further explore emergent themes.
The role of the ENP was distinguished from those of Emergency nurses and physicians by two elements: advanced practice and holistic care, respectively. ICT supported the advanced practice dimension of the NP role in two ways: availability and completeness of electronic patient information enhanced timeliness and quality of diagnostic and therapeutic decision-making, expediting patient access to appropriate care. The ubiquity of patient data sourced from a central database supported and improved quality of communication between health professionals within and across sites, with wider diffusion of the Electronic Medical Record holding the potential to further facilitate team-based, holistic care.
ICT is a facilitator through which the disruptive impact of NPs can be extended. However, integration of ICT into work practices without detracting from provider-patient interaction is crucial to ensure utilisation of such interventions and realisation of potential benefits.
PMCID: PMC3359193  PMID: 22462409
8.  Attitudes towards practice nurses--survey of a sample of general practitioners in England and Wales. 
Practice nursing has expanded rapidly since the 1990 contract for general practitioners. In 1990, a national survey was undertaken of the attitudes of a random sample of general practitioners towards practice nurses. Responses to the postal questionnaire were received from 41.9% of the 4800 general practitioners sampled. Of the responding general practitioners, 90.0% were satisfied with the role of the practice nurse within their practice. To fulfil the requirements of the 1990 contract for general practitioners 50.7% had created a new nursing post, and 83.1% had expanded the role of nurses already employed; 89.7% wished to see further expansion of the practice nurse's role. However, lack of space was the factor most frequently reported as limiting the expansion of the practice nurse's role, mentioned by 76.0% of general practitioners. Only 43.7% of general practitioners recognized lack of opportunities for practice nurse training as a hindrance to role expansion. The key to managing the expansion of the role of the practice nurse lies in the provision of resources and in training. A pressing need exists for a national training scheme based in general practice.
PMCID: PMC1372204  PMID: 8457361
9.  Healthcare reforms: implications for the education and training of acute and critical care nurses 
Postgraduate Medical Journal  2004;80(950):706-710.
This paper offers a wide ranging analysis of the drivers that resulted in scrutiny of medical, nursing, and healthcare professional roles. It suggests that what is needed is a coherent vision of the future shape of the health workforce. This requires moving beyond the presumption that reforming working practices primarily involves "delegating doctors" responsibilities to nurses. The paper argues that it is self evident that the implications of changes in healthcare roles and the ability of existing professionals to function effectively in the future will require education, training, and human resource investment supportive of the changes. It suggests a clear definition of competence and a national standard to practice is essential for nurses working in acute and acute critical settings. There should therefore be a correlation between levels of practice, levels of education, and remuneration. Furthermore, education programmes for senior nurses should sit coherently alongside the education programmes required by Modernising Medical Careers. Finally, the realisation of the government's service and modernisation agenda will require a culture change within higher education institutions, postgraduate deaneries, professional organisations, workforce development confederations, and NHS trusts.
PMCID: PMC1743166  PMID: 15579609
10.  A transition program to primary health care for new graduate nurses: a strategy towards building a sustainable primary health care nurse workforce? 
BMC Nursing  2014;13(1):34.
This debate discusses the potential merits of a New Graduate Nurse Transition to Primary Health Care Program as an untested but potential nursing workforce development and sustainability strategy. Increasingly in Australia, health policy is focusing on the role of general practice and multidisciplinary teams in meeting the service needs of ageing populations in the community. Primary health care nurses who work in general practice are integral members of the multidisciplinary team – but this workforce is ageing and predicted to face increasing shortages in the future. At the same time, Australia is currently experiencing a surplus of and a corresponding lack of employment opportunities for new graduate nurses. This situation is likely to compound workforce shortages in the future. A national nursing workforce plan that addresses supply and demand issues of primary health care nurses is required. Innovative solutions are required to support and retain the current primary health care nursing workforce, whilst building a skilled and sustainable workforce for the future.
This debate article discusses the primary health care nursing workforce dilemma currently facing policy makers in Australia and presents an argument for the potential value of a New Graduate Transition to Primary Health Care Program as a workforce development and sustainability strategy. An exploration of factors that may contribute or hinder transition program for new graduates in primary health care implementation is considered.
A graduate transition program to primary health care may play an important role in addressing primary health care workforce shortages in the future. There are, however, a number of factors that need to be simultaneously addressed if a skilled and sustainable workforce for the future is to be realised. The development of a transition program to primary health care should be based on a number of core principles and be subjected to both a summative and cost-effectiveness evaluation involving all key stakeholders.
PMCID: PMC4279900  PMID: 25550684
Primary Health Care; Practice Nurse; Graduate Nurse; Transition; Retention; Recruitment; Workforce; Sustainability; Australia
11.  Source country perceptions, experiences, and recommendations regarding health workforce migration: a case study from the Philippines 
Human Resources for Health  2014;12(1):62.
The Philippines continues to overproduce nurses for export. Little first-hand evidence exists from leading organisations in the Philippines concerning their experiences and perceptions in relation to Filipino nurse migration. What are their views about health workforce migration? This paper addresses this research gap by providing a source country perspective on Filipino nurse migration to Australia.
Focus-group interviews were conducted with key informants from nine Filipino organisations in the Philippines by an Australian-Filipino research team. The organisations were purposively selected and contacted in person, by phone, and/or email. Qualitative thematic analysis was performed using a coding framework.
Health workforce migration is perceived to have both positive and negative consequences. On the one hand, emigration offers a welcome opportunity for individual Filipino nurses to migrate abroad in order to achieve economic, professional, lifestyle, and social benefits. On the other, as senior and experienced nurses are attracted overseas, this results in the maldistribution of health workers particularly affecting rural health outcomes for people in developing countries. Problems such as ‘volunteerism’ also emerged in our study.
In the context of the WHO (2010) Code of Practice on the International Recruitment of Health Personnel it is to be hoped that, in the future, government recruiters, managers, and nursing leaders can utilise these insights in designing recruitment, orientation, and support programmes for migrant nurses that are more sensitive to the experience of the Philippines’ education and health sectors and their needs.
PMCID: PMC4230518  PMID: 25361523
Health workforce migration; Nurse migration; Philippines
12.  Practice nurses' workload, career intentions and the impact of professional isolation: A cross-sectional survey 
BMC Nursing  2010;9:2.
Practice nurses have a key role within UK general practice, especially since the 2004 GMS contract. This study aimed to describe that role, identify how professionally supported they felt and their career intentions. An additional aim was to explore whether they felt isolated and identify contributory factors.
A cross-sectional questionnaire survey in one large urban Scottish Health Board, targeted all practice nurses (n = 329). Domains included demographics, workload, training and professional support. Following univariate descriptive statistics, associations between categorical variables were tested using the chi-square test or chi-square test for trend; associations between dichotomous variables were tested using Fisher's Exact test. Variables significantly associated with isolation were entered into a binary logistic regression model using backwards elimination.
There were 200 responses (61.0% response rate). Most respondents were aged 40 or over and were practice nurses for a median of 10 years. Commonest clinical activities were coronary heart disease management, cervical cytology, diabetes and the management of chronic obstructive pulmonary disease. Although most had a Personal Development Plan and a recent appraisal, 103 (52.3%) felt isolated at least sometimes; 30 (15.5%) intended leaving practice nursing within 5 years.
Isolated nurses worked in practices with smaller list sizes (p = 0.024) and nursing teams (p = 0.003); were less likely to have someone they could discuss a clinical/professional (p = 0.002) or personal (p < 0.001) problem with; used their training and qualifications less (p < 0.001); had less productive appraisals (p < 0.001); and were less likely to intend staying in practice nursing (p = 0.009). Logistic regression analysis showed that nurses working alone or in teams of two were 6-fold and 3.5-fold more likely to feel isolated. Using qualifications and training to the full, having productive appraisals and planning to remain in practice nursing all mitigated against feeling isolated.
A significant proportion of practice nurses reported feeling isolated, at least some of the time. They were more likely to be in small practices and more likely to be considering leaving practice nursing. Factors contributing to their isolation were generally located within the practice environment. Providing support to these nurses within their practice setting may help alleviate the feelings of isolation, and could reduce the number considering leaving practice nursing.
PMCID: PMC2823612  PMID: 20205777
13.  Australian nurses in general practice, enabling the provision of cervical screening and well women’s health care services: a qualitative study 
BMC Nursing  2012;11:23.
The role of Australian general practice nurses (PNs) has developed exponentially since the introduction of service based funding in 2005. In particular, their role has expanded to include cervical screening and well women’s health care services provided under the supervision of a general practitioner (GP). While previous research identifies barriers to the provision of these services, this study sought to investigate enablers for nurse led care in this area.
A number of grounded theory methods including constantly comparing data, concurrent data collection and analysis and theoretical sampling are utilised in this qualitative, exploratory study. A purposive sample of PNs who completed the required program of education in order to provide cervical screening and well women’s health care services was recruited to the study. Data is presented in categories, however a limitation of the study is that a fully integrated grounded theory was unable to be produced due to sampling constraints.
Four enablers for the implementation of a change in the PN role to include cervical screening and well women’s health checks are identified in this study. These 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. Seven strategies for successfully implementing change from the perspective of PNs are also constructed from the data. This study additionally highlights the lack of feedback on smear quality provided to PNs cervical screeners and well women’s health service providers.
The influence of consumers on the landscape of primary care service delivery in Australia is of particular note in this study. Developing interprofessional teams that maximise each health care provider’s role will be fundamental to comprehensive service delivery in the future.
PMCID: PMC3514301  PMID: 23145901
14.  Use of information and communication technologies to support effective work practice innovation in the health sector: a multi-site study 
Widespread adoption of information and communication technologies (ICT) is a key strategy to meet the challenges facing health systems internationally of increasing demands, rising costs, limited resources and workforce shortages. Despite the rapid increase in ICT investment, uptake and acceptance has been slow and the benefits fewer than expected. Absent from the research literature has been a multi-site investigation of how ICT can support and drive innovative work practice. This Australian-based project will assess the factors that allow health service organisations to harness ICT, and the extent to which such systems drive the creation of new sustainable models of service delivery which increase capacity and provide rapid, safe, effective, affordable and sustainable health care.
A multi-method approach will measure current ICT impact on workforce practices and develop and test new models of ICT use which support innovations in work practice. The research will focus on three large-scale commercial ICT systems being adopted in Australia and other countries: computerised ordering systems, ambulatory electronic medical record systems, and emergency medicine information systems. We will measure and analyse each system's role in supporting five key attributes of work practice innovation: changes in professionals' roles and responsibilities; integration of best practice into routine care; safe care practices; team-based care delivery; and active involvement of consumers in care.
A socio-technical approach to the use of ICT will be adopted to examine and interpret the workforce and organisational complexities of the health sector. The project will also focus on ICT as a potentially disruptive innovation that challenges the way in which health care is delivered and consequently leads some health professionals to view it as a threat to traditional roles and responsibilities and a risk to existing models of care delivery. Such views have stifled debate as well as wider explorations of ICT's potential benefits, yet firm evidence of the effects of role changes on health service outcomes is limited. This project will provide important evidence about the role of ICT in supporting new models of care delivery across multiple healthcare organizations and about the ways in which innovative work practice change is diffused.
PMCID: PMC2776590  PMID: 19895703
15.  Non- medical prescribing in Australasia and the UK: the case of podiatry 
The last decade has witnessed a rapid transformation in the role boundaries of the allied health professions, enabled through the creation of new roles and the expansion of existing, traditional roles. A strategy of health care 'modernisation' has encompassed calls for the redrawing of professional boundaries and identities, linked with demands for greater workforce flexibility. Several tasks and roles previously within the exclusive domain of medicine have been delegated to, or assumed by, allied health professionals, as the workforce is reshaped to meet the challenges posed by changing demographic, social and political contexts. The prescribing of medicines by non-medically qualified healthcare professionals, and in particular the podiatry profession, reflects these changes.
Using a range of key primary documentary sources derived from published material in the public domain and unpublished material in private possession, this paper traces the development of contemporary UK and Australasian podiatric prescribing, access, supply and administration of medicines. Documentary sources include material from legislative, health policy, regulatory and professional bodies (including both State and Federal sources in Australia).
Tracing a chronological, comparative, socio-historical account of the emergence and development of 'prescribing' in podiatry in both Australasia and the UK enables an analysis of the impact of health policy reforms on the use of, and access to, medicines by podiatrists. The advent of neo-liberal healthcare policies, coupled with demands for workforce flexibility and role transfer within a climate of demographic, economic and social change has enabled allied health professionals to undertake an expanding number of tasks involving the sale, supply, administration and prescription of medicines.
As a challenge to medical dominance, these changes, although driven by wider healthcare policy, have met with resistance. As anticipated in the theory of medical dominance, inter-professional jurisdictional disputes centred on the right to access, administer, supply and prescribe medicines act as obstacles to workforce change. Nevertheless, the broader policy agenda continues to ensure workforce redesign in which podiatry has assumed wider roles and responsibilities in prescribing.
PMCID: PMC2821370  PMID: 20051138
16.  Running nurse-led secondary prevention clinics for coronary heart disease in primary care: qualitative study of health professionals' perspectives 
A randomised trial of nurse-led secondary prevention clinics for coronary heart disease resulted in improved secondary prevention and significantly lowered all-cause mortality at 4-year follow-up. This qualitative trial was conducted to explore the experience of health professionals that had been involved in running the clinics.
To identify the barriers and facilitators to establishing secondary prevention clinics for coronary heart disease within primary care.
Design of study
Semi-structured audiotaped telephone interviews with GPs and nurses involved in running clinics.
A stratified, random sample of 19 urban, suburban, and rural general practices in north-east Scotland.
Semi-structured telephone interviews with 19 GPs and 17 practice-based nurses involved in running nurse-led clinics for the secondary prevention of coronary heart disease.
Eight practices had run clinics continuously and 11 had stopped, with eight subsequently restarting. Participants accounted for these patterns by referring to advantages and disadvantages of the clinics in four areas: patient care, development of nursing skills, team working, and infrastructure. Most practitioners perceived benefits for patients from attending secondary prevention clinics, but some, from small rural practices, thought they were unnecessary. The extended role for nurses was welcomed, but was dependent on motivated staff, appropriate training and support. Clinics relied on, and could enhance, team working, however, some doctors were wary of delegating. With regard to infrastructure, staff shortages (especially nurses) and accommodation were as problematic as lack of funds.
Nurse-led secondary prevention clinics were viewed positively by most healthcare professionals that had been involved in running them, but barriers to their implementation had led most to stop running them at some point. Lack of space and staff shortages are likely to remain ongoing problems, but improvements in funding training and communication within practices could help clinics to be put into practice and sustained.
PMCID: PMC1472789  PMID: 16004737
coronary heart disease; primary care; secondary prevention
17.  Health Care Reform and the Federal Transformation Initiatives: Capitalizing on the Potential of Advanced Practice Psychiatric Nurses 
In the last decade the US federal government proposed a transformation vision of mental health service delivery; patient-centered, evidence-based and recovery oriented treatment models. Health care reform brings additional expectations for innovation in mental/substance use service delivery, particularly the idea of creating systems where physical health, mental health and substance use treatment is fully integrated. Psychiatric nurses, as one of the four core US mental health professions, have the potential to play a significant role in the both the transformation initiative and health care reform vision. However, psychiatric nurses, particularly advanced practice psychiatric nurses, are an untapped resource due in part to significant state regulatory barriers that limit their scope of practice in many states. The purpose of this paper is to document what is currently known about advanced practice psychiatric nurses and discuss policy implications for tapping into the strengths of this workforce. Strategies for facilitating utilization of advanced practice psychiatric nurses discussed.
PMCID: PMC3392024  PMID: 21233135
advanced nursing practice; nursing/health care workforce issues; health care quality
18.  Recognising the differences in the nurse consultant role across context: a study protocol 
BMC Nursing  2014;13:30.
The advanced practice role of the Nurse Consultant is unique in its capacity to provide clinical leadership across a range of contexts. However, the Nurse Consultant role has been plagued with confusion due to lack of clarity over function and appropriateness for purpose within health organisations across contexts. Changing health service delivery models are driving the emergence of new nursing roles, further clouding the waters related to role positioning and purpose. There is an urgent need for evidence of impact and demonstration of how Nurse Consultants contribute to health care outcomes. This study aims to gain a clearer understanding of the Nurse Consultant role and its impact in metropolitan and rural New South Wales (NSW) Australia.
The proposed study employs a sequential mixed method design, underpinned by Realistic Evaluation, to explore how Nurse Consultants contribute to organisational outcomes. The ‘context – mechanism – outcome’ approach of realistic evaluation provides a sound framework to examine the complex, diverse and multifaceted nature of the Nurse Consultant’s role.
Participants will be stakeholders, recruited across a large Local Health District in NSW, comprising rural and metropolitan services. A modified and previously validated survey will be used providing information related to role characteristics, patterns and differences across health context. Focus groups with Nurse Consultant’s explore issues highlighted in the survey data. Focus groups with other clinicians, policy makers and managers will help to achieve understanding of how the role is viewed and enacted across a range of groups and contexts.
Lack of role clarity is highlighted extensively in international and Australian studies examining the role of the Nurse Consultant. Previous studies failed to adequately examine the role in the context of integrated and complex health services or to examine the role in detail. Such examination is critical in order to understand the significance of the role and to ascertain how Nurse Consultants can be most effective as members of the health care team. This is the first Australian study to include extensive stakeholder perspectives in order to understand the relational and integrated nature and impact of the role across metropolitan and rural context.
PMCID: PMC4198326  PMID: 25320563
Nurse consultant; Nursing; Workforce; Role clarity; Advanced practice nurse
19.  A survey of diabetes care in general practice in Northern Ireland. 
The Ulster Medical Journal  2002;71(1):10-16.
We aimed to describe some key features of diabetes care carried out in primary care settings in Northern Ireland using a descriptive postal questionnaire survey sent to every general practice in Northern Ireland. 252 (70%) of practices responded. Of these 92% of practices have active registers of people with diabetes, identifying 1.9% of their population as having diabetes and 85% of practices use these registers for call/recall visits. Seventy five per cent of practices held diabetes clinics run by the general practitioner and nurse (63%) or a nurse alone (32%). Only 47% of practices felt they received adequate support from the acute diabetes team; with 29% meeting with them this team regularly and only 19% having a shared care protocol. Overall practices provided most of the routine care for 60% of their diabetic patients. The majority of GPs and practice nurses had received some diabetes education in the previous year. There has been a considerable change in the delivery of routine diabetes care in Northern Ireland. A large proportion of diabetes care now takes place in the community, much of it delivered by practice nurses. The organisational infrastructure necessary for the delivery of care is in place. Many practices have special interest in diabetes but the survey highlights a need for better communication and cooperation with secondary care. General practitioners recognise their educational needs in diabetes. They should also be aware of their practice nurses' needs, which should be addressed. There should be initiatives to improve the primary-secondary care interface in Northern Ireland.
PMCID: PMC2475362  PMID: 12137157
20.  Primary Care Research Team Assessment (PCRTA): development and evaluation. 
BACKGROUND: Since the early 1990s the United Kingdom (UK) Department of Health has explicitly promoted a research and development (R&D) strategy for the National Health Service (NHS). General practitioners (GPs) and other members of the primary care team are in a unique position to undertake research activity that will complement and inform the research undertaken by basic scientists and hospital-based colleagues and lead directly to a better evidence base for decision making by primary care professionals. Opportunities to engage in R&D in primary care are growing and the scope for those wishing to become involved is finally widening. Infrastructure funding for research-active practices and the establishment of a range of support networks have helped to improve the research capacity and blur some of the boundaries between academic departments and clinical practice. This is leading to a supportive environment for primary care research. There is thus a need to develop and validate nationally accepted quality standards and accreditation of performance to ensure that funders, collaborators and primary care professionals can deliver high quality primary care research. Several strategies have been described in national policy documents in order to achieve an improvement in teaching and clinical care, as well as enhancing research capacity in primary care. The development of both research practices and primary care research networks has been recognised as having an important contribution to make in enabling health professionals to devote more protected time to undertake research methods training and to undertake research in a service setting. The recognition and development of primary care research has also brought with it an emphasis on quality and standards, including an approach to the new research governance framework. PRIMARY CARE RESEARCH TEAM ASSESSMENT: In 1998, the NHS Executive South and West, and later the London Research and Development Directorate, provided funding for a pilot project based at the Royal College of General Practitioners (RCGP) to develop a scheme to accredit UK general practices undertaking primary care R&D. The pilot began with initial consultation on the development of the process, as well as the standards and criteria for assessment. The resulting assessment schedule allowed for assessment at one of two levels: Collaborative Research Practice (Level I), with little direct experience of gaining project or infrastructure funding Established Research Practice (Level II), with more experience of research funding and activity and a sound infrastructure to allow for growth in capacity. The process for assessment of practices involved the assessment of written documentation, followed by a half-day assessment visit by a multidisciplinary team of three assessors. IMPLEMENTATION--THE PILOT PROJECT: Pilot practices were sampled in two regions. Firstly, in the NHS Executive South West Region, where over 150 practices expressed an interest in participating. From these a purposive sample of 21 practices was selected, providing a range of research and service activity. A further seven practices were identified and included within the project through the East London and Essex Network of Researchers (ELENoR). Many in this latter group received funding and administrative support and advice from ELENoR in order to prepare written submissions for assessment. Some sample loss was encountered within the pilot project, which was attributable largely to conflicting demands on participants' time. Indeed, the preparation of written submissions within the South West coincided with the introduction of primary care groups (PCGs) in April 1999, which several practices cited as having a major impact on their participation in the pilot project. A final sample of 15 practices (nine in the South West and six through ELENoR) underwent assessment through the pilot project. EVALUATION: A formal evaluation of the Primary Care Research Team Assessment (PCRTA) pilot was undertaken by an independent researcher (FM). This was supplemented with feedback from the assessment team members. The qualitative aspect of the evaluation, which included face-to-face and telephone interviews with assessors, lead researchers and other practice staff within the pilot research practices, as well as members of the project management group, demonstrated a positive view of the pilot scheme. Several key areas were identified in relation to particular strengths of research practices and areas for development including: Strengths Level II practices were found to have a strong primary care team ethos in research. Level II practices tended to have a greater degree of strategic thinking in relation to research. Development areas Level I practices were found to lack a clear and explicit research strategy. Practices at both levels had scope to develop their communication processes for dissemination of research and also for patient involvement. Practices at both levels needed mechanisms for supporting professional development in research methodology. The evaluation demonstrated that practices felt that they had gained from their participation and assessors felt that the scheme had worked well. Some specific issues were raised by different respondents within the qualitative evaluation relating to consistency of interpretation of standards and also the possible overlap of the assessment scheme with other RCGP quality initiatives. NATIONAL IMPLEMENTATION OF THE PRIMARY CARE RESEARCH TEAM ASSESSMENT: The pilot project has been very successful and recommendations have been made to progress to a UK scheme. Management and review of the scheme will remain largely the same, with a few changes focusing on the assessment process and support for practices entering the scheme. Specific changes include: development of the support and mentoring role of the primary care research networks increased peer and external support and mentoring for research practices undergoing assessment development of assessor training in line with other schemes within the RCGP Assessment Network work to ensure consistency across RCGP accreditation schemes in relation to key criteria, thereby facilitating comparable assessment processes refinement of the definition of the two groups, with Level I practices referred to as Collaborators and Level II practices as Investigator-Led. The project has continued to generate much enthusiasm and support and continues to reflect current policy. Indeed, recent developments include the proposed new funding arrangements for primary care R&D, which refer to the RCGP assessment scheme and recognise it as a key component in the future R&D agenda. The assessment scheme will help primary care trusts (PCTs) and individual practices to prepare and demonstrate their approach to research governance in a systematic way. It will also provide a more explicit avenue for primary care trusts to explore local service and development priorities identified within health improvement programmes and the research priorities set nationally for the NHS.
PMCID: PMC2560501  PMID: 12049028
21.  GP recruitment and retention: a qualitative analysis of doctors' comments about training for and working in general practice. 
BACKGROUND AND AIMS: General practice in the UK is experiencing difficulty with medical staff recruitment and retention, with reduced numbers choosing careers in general practice or entering principalships, and increases in less-than-full-time working, career breaks, early retirement and locum employment. Information is scarce about the reasons for these changes and factors that could increase recruitment and retention. The UK Medical Careers Research Group (UKMCRG) regularly surveys cohorts of UK medical graduates to determine their career choices and progression. We also invite written comments from respondents about their careers and the factors that influence them. Most respondents report high levels of job satisfaction. A noteworthy minority, however, make critical comments about general practice. Although their views may not represent those of all general practitioners (GPs), they nonetheless indicate a range of concerns that deserve to be understood. This paper reports on respondents' comments about general practice. ANALYSIS OF DOCTORS' COMMENTS: Training Greater exposure to general practice at undergraduate level could help to promote general practice careers and better inform career decisions. Postgraduate general practice training in hospital-based posts was seen as poor quality, irrelevant and run as if it were of secondary importance to service commitments. In contrast, general practice-based postgraduate training was widely praised for good formal teaching that met educational needs. The quality of vocational training was dependent upon the skills and enthusiasm of individual trainers. Recruitment problems Perceived deterrents to choosing general practice were its portrayal, by some hospital-based teachers, as a second class career compared to hospital medicine, and a perception of low morale amongst current GPs. The choice of a career in general practice was commonly made for lifestyle reasons rather than professional aspirations. Some GPs had encountered difficulties in obtaining posts in general practice suited to their needs, while others perceived discrimination. Newly qualified GPs often sought work as non-principals because they felt too inexperienced for partnership or because their domestic situation prevented them from settling in a particular area. Changes to general practice The 1990 National Health Service (NHS) reforms were largely viewed unfavourably, partly because they had led to a substantial increase in GPs' workloads that was compounded by growing public expectations, and partly because the two-tier system of fund-holding was considered unfair. Fund-holding and, more recently, GP commissioning threatened the GP's role as patient advocate by shifting the responsibility for rationing of health care from government to GPs. Some concerns were also expressed about the introduction of primary care groups (PCGs) and trusts (PCTs). Together, increased workload and the continual process of change had, for some, resulted in work-related stress, low morale, reduced job satisfaction and quality of life. These problems had been partially alleviated by the formation of GP co-operatives. Retention difficulties Loss of GPs' time from the NHS workforce occurs in four ways: reduced working hours, temporary career breaks, leaving the NHS to work elsewhere and early retirement. Child rearing and a desire to pursue interests outside medicine were cited as reasons for seeking shorter working hours or career breaks. A desire to reduce pressure of work was a common reason for seeking shorter working hours, taking career breaks, early retirement or leaving NHS general practice. Other reasons for leaving NHS general practice, temporarily or permanently, were difficulty in finding a GP post suited to individual needs and a desire to work abroad. CONCLUSIONS: A cultural change amongst medical educationalists is needed to promote general practice as a career choice that is equally attractive as hospital practice. The introduction of Pre-Registration House Officer (PRHO) placements in general practice and improved flexibility of GP vocational training schemes, together with plans to improve the quality of Senior House Officer (SHO) training in the future, are welcome developments and should address some of the concerns about poor quality GP training raised by our respondents. The reluctance of newly qualified GPs to enter principalships, and the increasing demand from experienced GPs for less-than-full-time work, indicates a need for a greater variety of contractual arrangements to reflect doctors' desires for more flexible patterns of working in general practice.
PMCID: PMC2560447  PMID: 12049026
22.  Nursing and midwifery regulatory reform in east, central, and southern Africa: a survey of key stakeholders 
In sub-Saharan Africa, nurses and midwives provide expanded HIV services previously seen as the sole purview of physicians. Delegation of these functions often occurs informally by shifting or sharing of tasks and responsibilities. Normalizing these arrangements through regulatory and educational reform is crucial for the attainment of global health goals and the protection of practitioners and those whom they serve. Enacting appropriate changes in both regulation and education requires engagement of national regulatory bodies, but also key stakeholders such as government chief nursing officers (CNO), professional associations, and educators. The purpose of this research is to describe the perspectives and engagement of these stakeholders in advancing critical regulatory and educational reform in east, central, and southern Africa (ECSA).
We surveyed individuals from these three stakeholder groups with regard to task shifting and the challenges related to practice and education regulation reform. The survey used a convenience sample of nursing and midwifery leaders from countries in ECSA who convened on 28 February 2011, for a meeting of the African Health Profession Regulatory Collaborative.
A total of 32 stakeholders from 13 ECSA countries participated in the survey. The majority (72%) reported task shifting is practiced in their countries; however only 57% reported their national regulations had been revised to incorporate additional professional roles and responsibilities. Stakeholders also reported different roles and levels of involvement with regard to nursing and midwifery regulation. The most frequently cited challenge impacting nursing and midwifery regulatory reform was the absence of capacity and resources needed to implement change.
While guidelines on task shifting and recommendations on transforming health professional education exist, this study provides new evidence that countries in the ECSA region face obstacles to adapting their practice and education regulations accordingly. Stakeholders such as CNOs, nursing associations, and academicians have varied and complementary roles with regard to reforming professional practice and education regulation.
This study provides information for effectively engaging leaders in regulatory reform by clarifying their roles, responsibilities, and activities regarding regulation overall as well as their specific perspectives on task shifting and pre-service reform.
PMCID: PMC3706367  PMID: 23800079
Sub-Saharan Africa; Education; HIV; Midwifery; Nursing; Regulation; Stakeholders; Task sharing; Task shifting
23.  Job satisfaction among nurses working in the private and public sectors: a qualitative study in tertiary care hospitals in Pakistan 
Many low and middle income countries lack the human resources needed to deliver essential health interventions. A health care system with a limited number of nurses cannot function effectively. Although the recommended nurse to doctor ratio is 4:1, the ratio in Pakistan is reversed, with 2.7 doctors to one nurse.
A qualitative study using narrative analysis was undertaken in public and private tertiary care hospitals in Pakistan to examine and compare job satisfaction among nurses and understand the factors affecting their work climate. Interactive interviews were conducted with nurses working with inpatients and outpatients.
All of the respondents had joined the profession by choice and were supported by their families in their decision to pursue their career, but now indicated that they were dissatisfied with their jobs. Three types of narratives were identified, namely, “Working in the spirit of serving humanity”, “Working against all odds”, and “Working in a functional system and facing pressures of increased accountability”. Nurses working in a public sector hospital are represented in the first two narrative types, whereas the third represents those working in a private sector hospital. The first narrative represents nurses who were new in the profession and despite hard working conditions were performing their duties. The second narrative represents nurses working in the public sector with limited resources, and the third narrative is a representation of nurses who were working hard and stressed out despite a well functioning system.
The study shows that the presence of a well trained health workforce is vital, and that certain aspects of its organization are key, including numbers (available quantity), skill mix (health team balance), distribution (urban/rural), and working conditions (compensation, nonfinancial incentives, and workplace safety). This study has identified the need to reform policies for retaining the nursing workforce. Simple measures requiring better management practices could substantially improve the working environment and hence retention of nurses.
PMCID: PMC3887073  PMID: 24453494
job satisfaction; nurses; health workforce; Pakistan
24.  Oral Health Nursing Education and Practice Program 
Nursing Research and Practice  2012;2012:149673.
Millions of Americans have unmet oral healthcare needs and profound oral health disparities persist in vulnerable and underserved populations, especially poor children, older adults, and racial and ethnic minorities. Nurses can play a significant role in improving the quality of oral health including access to care with appropriate education and training. The purpose of this paper is to describe New York University College of Nursing's response to this challenge. The Oral Health Nursing Education and Practice (OHNEP) program is a national initiative aimed at preparing a nursing workforce with the competencies to prioritize oral disease prevention and health promotion, provide evidence-based oral healthcare in a variety of practice settings, and collaborate in interprofessional teams across the healthcare system. The overarching goal of this national initiative is to create an educational infrastructure for the nursing profession that advances nursing's contribution to reducing oral health disparities across the lifespan.
PMCID: PMC3362947  PMID: 22685642
25.  What evidence is there to support skill mix changes between GPs, pharmacists and practice nurses in the care of elderly people living in the community? 
Workforce shortages in Australia are occurring across a range of health disciplines but are most acute in general practice. Skill mix change such as task substitution is one solution to workforce shortages. The aim of this systematic review was to explore the evidence for the effectiveness of task substitution between GPs and pharmacists and GPs and nurses for the care of older people with chronic disease. Published, peer reviewed (black) and non-peer reviewed (grey) literature were included in the review if they met the inclusion criteria.
Forty-six articles were included in the review. Task substitution between pharmacists and GPs and nurses and GPs resulted in an improved process of care and patient outcomes, such as improved disease control. The interventions were either health promotion or disease management according to guidelines or use of protocols, or a mixture of both. The results of this review indicate that pharmacists and nurses can effectively provide disease management and/or health promotion for older people with chronic disease in primary care. While there were improvements in patient outcomes no reduction in health service use was evident.
When implementing skill mix changes such as task substitution it is important that the health professionals' roles are complementary otherwise they may simply duplicate the task performed by other health professionals. This has implications for the way in which multidisciplinary teams are organised in initiatives such as the GP Super Clinics.
PMCID: PMC2749853  PMID: 19744350

Results 1-25 (847588)