SummaryBackground: Practice nurses are primarily employed by general practitioners, however littleis known about the barriers to practice nurse employment from the perspective of generalpractitioners (GPs).Aim: This paper seeks to explore solo, culturally and linguistically diverse (CALD) general prac-titioners’ perceptions of the practice nurse role, and to identify the barriers and facilitators ofthese doctors employing nurses within their practice.Methods: A descriptive study, using semi-structured interviews, was conducted from July toAugust 2010. Participants were CALD GPs working as solo practitioners who were members ofa Division of General Practice in South Western Sydney. Quantitative data were analysed usingdescriptive statistics and qualitative data were analysed using thematic analysis.Results: The response rate was 51%, however no demographic differences were identifiedbetween responders and non-responders. The majority of participants (73%) agreed thatpractice nurses could perform vital sign measurements or spirometry. Fewer participants(52—63%) believed practice nurses could perform breast checks, pap smears, or assessmentof medication regimes. Perceived barriers to employing a practice nurse included lack of spaceor equipment, legal implications, lack of a specific job description and language communi-cation issues. Participants identified the need for greater financial rebates, assistance withtraining practice nurses and assistance with business modelling as facilitators to practice nurseemployment.
of pr
Conclusion: The feasibility
linguistically diverse general praEmployment of practice nurses
he current focus on primary health care attempts toddress issues such as our ageing population and increas-ng chronic disease diagnoses; this has recently led to rapidrowth in the number of nurses employed in Australianeneral practices (Halcomb & Hickman, 2010). Federal fund-ng has provided support for the employment of nurses ineneral practice, reflecting governmental awareness of themportant role the practice nurse (PN) plays within generalractice (Walker, 2006). Between 2005 and 2007, the numberf nurses working in general practice increased by 59%, andearly 60% of general practices currently employ at least oneractice nurse (Australian General Practice Network, 2008).lthough PNs are primarily employed by general practition-rs (GPs), there is little known about the GP’s perspectivef employing a practice nurse.
Accredited practice nurses commonly serve as ‘sub-titutes’ for GPs by undertaking particular tasks such asap tests, immunisation and chronic disease managementSibbald, Laurant, & Reeves, 2006; Walker, 2006). Delegationf tasks to practice nurses allows the GP to spend addi-ional time with patients who have greater health needsWalker, 2006). However, there is a lack of understandingetween GPs and practice nurses relating to clearly definedoles which can contribute to confusion and challenges inhe general practice setting (Phillips et al., 2008). Expansionf the PN role can sometimes be challenged by the smallusiness nature of Australian general practice mixed withhe GPs’ attitudes and perceptions towards the hierarchaloles between doctors and nurses (Halcomb, Patterson, &avidson, 2006; Phillips et al., 2007, 2008). Some barrierso utilising PNs that have been identified in the litera-ure include a lack of training, poor GP understanding ofursing roles, liability concerns, billing structure withinhe practice, lack of professional nursing standards, PNmployment costs, part time or casual employment and lackf space (Gibson & Heartfield, 2005; Halcomb, Davidson,riffiths, & Daly, 2008; Phillips et al., 2008). Additionally,
he historical model of general practice has focussed pri-arily on general practitioners working in group or soloractices, with limited exposure to nurses. Whilst these bar-iers have been identified in the literature, these data haveeen collected from the perspective of the nurse. To date,he GPs perspective has not been fully explored. Given thePs role as the employer, it is important to understand these
ssues from their perspective.A significant proportion of the Australian community are
rom culturally and linguistically diverse (CALD) backgroundsSalamonson, Everett, Koch, Andrew, & Davidson, 2008).uch individuals may experience marginalisation and cane greatly disadvantaged when attempting to access healthare (Garrett, Dickson, Young, & Whelan, 2010). The rolef a GP is often central in empowering this vulnerableopulation to access vital health resources. Understand-bly, a significant number of CALD patients seek medicaldvice from GPs with a CALD background (Knox & Britt,
002). Anecdotally, the uptake of PNs has been less amongstALD GPs compared to other GPs. Given the increasingvidence to support the impact of the PN role on patient out-omes (Halcomb, Davidson, Yallop, Griffiths, & Daly, 2007),
ESNo
E.J. Halcomb et al.
xploring strategies to enhance the uptake of PNs amongstALD GPs is logically an important strategy to potentially
mprove outcomes of CALD patients.
urpose
his study sought to explore solo CALD GPs’ perceptions ofhe PN role and identify the barriers and facilitators of soloALD GPs employing PNs. Solo CALD GPs were the focus ofhe study as their solo practitioner status meant that theyere responsible for both patient care and practice man-gement issues within the practice. Additionally, evidenceuggests that overseas trained doctors are more likely toork in smaller practices (Bayram, Knox, Miller, Ng, & Britt,007).
ethodology
esign
descriptive design was used to acquire new knowledgeelating to the identified phenomenon, of which little isnown.
ecruitment and sample size
olo GPs who were identified on the membership databasef a single Division of General Practice as being from a CALDackground were identified. Those who did not currentlymploy a practice nurse were asked to participate in thetudy. The Division of General Practice covered four localovernment areas across South Western Sydney.
ata collection
ata were collected via semi-structured interviews betweenuly and August 2010. The interview comprised of 16tructured items that elicited quantifiable data, and then
semi-structured items that provided qualitative data.esearch interns (undergraduate nursing students) con-ucted the interviews after completing a training programun by the chief investigators. Interviews were conductedither via telephone (n = 38; 79%) or face-to-face (n = 7;5%). A small number of participants requested hard copiesf the interview questions via facsimile in lieu of an inter-iew (n = 3; 6%). With the participants’ consent, telephonend face-to-face interviews were audio-taped for data anal-sis purposes.
thical consideration
thics approval was granted from the University of Westernydney Human Research Ethics Committee (HREC Approvalo. H8519). Participation was voluntary and confidentialityf participants was maintained.
Culturally and linguistically diverse general practitioners’ utilisa
Table 1 Solo GPs from a CALD background practising in theSouth Western Sydney area (n = 94).
Characteristic
Age group, n (%)30—39 years 6 (6)40—49 years 19 (20)50—59 years 21 (22)60—69 years 37 (40)70 and over years 11 (12)
Gender — male, n (%) 83 (88)Language spoken by GP, other than English %
Arabic 9 (10)Chinese-related languageand dialects
20 (21)
Indian-related language anddialects
16 (17)
Vietnamese 32 (34)Multilingual 17 (18)
Years since graduation as amedical practitioner, years(range: 3—52) mean (SD)
29.8 (10.5)
Country where qualificationwas obtained(Australia/Overseas)%
57/43
Accredited general practice(yes/no) %
26/74
Recruitment outcome %Not contactable 21(22)Decline to participate 27(29)
Jp
Cn
AcHtodswt
A
FPpama(7P(SwSc5
cwtt
B
Gactfp
ct5ec44(to employing a PN. A number of participants clarified this
Consent to participate 46(49)
Data analysis
Quantitative data were entered into SPSS Version 18 soft-ware and analysed using descriptive statistics. For dataanalysis purposes, responses of ‘‘unsure’’ and ‘‘no’’ weregrouped together. Qualitative interview data and theinterns’ field notes were analysed using a reflexive, iterativeapproach to data management as described by Halcomb andDavidson (2006). Thematic analysis was used to analyse thedata, with common themes identified independently by tworesearch interns.
Results
Participant demographics
Of the 94 potential participants, 48 (51%) GPs consented toparticipate, 28 (30%) declined involvement in the study and18 (19%) could not be contacted. This represented approx-imately 16.5% of the GP membership of the Division. Thecharacteristics of this group are outlined in Table 1. Morethan half (n = 54; 57.4%) of participants obtained their med-ical qualifications in Australia. Non-English languages spoken
by GPs, in order of prevalence, were Vietnamese (34%), Chi-nese languages and/or dialects (21%), multi-lingual (18%),Indian languages and/or dialects (17%) and Arabic (10%).
bn‘
tion of practice nurses 139
ust over a quarter (n = 21; 26%) of the practices run byarticipants were accredited at the time of data collection.
haracteristics of study participants andon-participants
s the response rate in this study was slightly below thoseited in studies of related participant groups (Baruch &oltom, 2008), we analysed all three target groups (par-icipated, declined and non-contactable) for comparabilityf sample characteristics based on Divisional membershipata. As can be seen from Table 2, there were no statisticallyignificant demographic differences between those GPs whoere not contactable, those who declined to participate and
hose who participated in the study.
ppropriate tasks for practice nurses
ig. 1 shows the clinical skills that the participants perceivedNs could perform. The majority (n = 39; 81%) of participantserceived that PNs could perform vital sign measurementsnd could assess social support needs (n = 39; 81%). Approxi-ately three quarters of participants were comfortable with
PN performing technical skills such as collecting bloodn = 37; 77%), spirometry (n = 36; 75%) or ECG testing (n = 35;3%). Just over half of the participants were comfortable forNs to perform breast checks (n = 30, 63%) and pap smearsn = 27, 56%), or follow-up on pathology results (n = 30, 63%).ome GPs made comments such as ‘‘as long as my patientsere comfortable’’, referring particularly to breast checks.imilarly, just over half of the participants felt that PNsould undertake counselling for mental health issues (n = 26;4%) and assessment of medication regimes (n = 25; 52%).
Qualitative data identified an overall perception that PNsan perform the majority of clinical tasks as long as theyere appropriately trained. Additionally, it was identified
hat participants felt that having a PN undertake some ofhese tasks would help reduce a GP’s workload.
arriers to utilising nurses in general practice
Ps’ expressed a variety of perceived barriers to employing practice nurse (Fig. 2). When asked about this, participantsited lack of space or equipment as the most significant fac-or (n = 29; 60%). Space limitations were particularly an issueor solo GPs, with one GP stating ‘‘There is no space in myractice to even consider employing extra staff’’.
More than half of the participants identified legal impli-ations of extended nursing roles (n = 27; 56%), the beliefhat current structure in practice is appropriate (n = 25;2%) and lack of opportunity (n = 25; 52%) as barriers tomploying a PN. Fewer participants identified a lack of alear job description (n = 22; 46%), lack of training (n = 22;6%) and patients’ perceptions of the PN’s role (n = 21;4%) as barriers to PN employment. Surprisingly, only 1838%) participants cited communication issues as a barrier
y saying that they were close to retirement age and didot have any desire to change their current business model.‘At my age, I want to retire soon. My current model of
140 E.J. Halcomb et al.
Table 2 Comparison of characteristics: participants and non-participants.
Characteristic Notcontactable(n = 18)
Declined toparticipate(n = 28)
Participants(n = 48)
Significance
Age group (years) %30—39 11 4 6 0.856a
40—49 28 14 2150—59 28 21 2160—69 28 46 4070 and over 6 14 13
Gender (male)% 89 93 86 0.620a
Language spoken, other than English %Arabic 0 7 15 0.549a
Chinese-related languageand dialects
28 25 17
Indian-related language anddialects
22 18 15
Vietnamese 39 25 38Multilingual 11 25 17
Years since graduation as amedical practitioner (mean,SD) years
26.8 (8.2) 30.9 (10.6) 30.2 (11.2) 0.422b
Qualification obtained overseas%
29 46 44 0.499a
Accredited general practice(yes) %
36 22 26 0.638a
a Pearson Chi-square test.b
pm
A
Pttesbett(p
M
TbtweiOm
A
TtimHlutwcuebspw
D
Tta
One-way ANOVA.*P < 0.05 level (2-tailed).
ractice does not require a PN and I surround myself with aultidisciplinary list of contacts’’.
ssistance required to employ a PN
articipants were asked about the types of assistance thathey would require if they sought to employ a nurse inheir practice (Fig. 3). The majority (n = 35; 73%) consid-red greater financial rebates to be an important factor toupport GPs employing PNs. One participant qualified thisy stating ‘‘The additional money would be useful withquipment purchases and nurse promotion’’. Other poten-ial areas of assistance were identified as orientation andraining of the nurse (n = 33; 69%) and nurse recruitmentn = 31; 65%). Fewer than half (n = 23, 48%) of the partici-ants thought that business modelling would be helpful.
odels of PN employment
he majority of participants (n = 28; 57%) preferred theusiness model of a nurse employed by the Division and con-racted out to the GP for an agreed number of hours pereek. Fewer participants expressed an interest in directly
mploying a nurse themselves (n = 16; 33%), whilst 4 partic-pants (21%) stated they did not have a preference (Fig. 4).ne participant stated ‘‘I’d prefer a nurse employed only iny practice, but cost is an issue for me’’.
tocn
wareness of government incentives
he majority of respondents (n = 35; 73%) were aware ofhe incoming government initiative to provide block fund-ng to employ PNs. Information sources were either word ofouth, via reading GP-related publications and mass media.owever, qualitative responses suggest that participants had
imited information. Participants disclosed that they werenaware of the qualifying criteria and how to access the ini-iative. As expected, there was a general perception thatith the impending Federal election at the time of the dataollection, they were unsure if this initiative would changender a new government. A small number of participantsxpressed that they would need to obtain accreditation toe eligible whilst others were not sure the incentive wasubstantial enough to warrant the employment of a PN. Onearticipant stated ‘‘The $25,000 is not enough incentive. Itill not cover the wages [of a PN]’’.
iscussion
he findings of this study revealed that solo CALD GPs prac-ising in South Western Sydney were over-represented byn ageing GP workforce. Despite this, their views regarding
he roles and functions of PNs were not dissimilar to previ-us findings which demonstrated the under-utilisation of theapacity and skills of PNs, and the lack of professional recog-ition of the PN role in general practice settings (Halcomb,
Culturally and linguistically diverse general practitioners’ utilisation of practice nurses 141
that
roabod(Tratu2btcanft
Figure 1 Appropriate tasks
Davidson, Salamonson, Ollerton, & Griffiths, 2008; Price,Patterson, & Hegney, 2006). It is likely that most of theseGPs have been practising as solo practitioners, with no expe-rience of working with PNs who perform both core clinicalskills, as well as undertake advanced and expanded nursingskills (Halcomb, Davidson, Salamonson, et al., 2008). Rea-sons identified by participants for not employing a PN in theirgeneral practice can be summarised by four key themes:(a) cost benefit related to funding incentive of employinga PN; (b) lack of space in the practice setting; (c) lack ofinterest to employ a PN; and (d) GP’s belief about patients’perception of PNs.
Cost benefit and funding incentive of employing aPN
A number of issues were raised by the participants relatedto the financial benefits of employing a PN in their generalpractice. Despite participants’ recognition of the benefits
that PN employment may bring, the GPs remained concernedabout the potential financial burden of this undertaking.Being unclear about the financial rebates, coupled with thelimited understanding of the potential scope of the PN’s
aeGn
can be performed by a PN.
oles and functions within the practice were likely to bene explanatory factor for this perception. The concernbout the economic benefits of employing PNs is not withoutasis, in light of the current Medicare structure, wherebynly a limited list of nursing activities generate an indepen-ent fee-for-service income for the general practice settingHalcomb, Davidson, & Brown, 2010; Phillips et al., 2007).his concern is supported by Oldroyd et al. (2003) who alsoeported that the employment of a PN by solo GPs was notffordable despite funding incentives. This gives credence tohe idea that the current health care funding system deval-es the role of the PN in general practice (Price et al.,006). Nevertheless, increasing the fee-for-service reim-ursement alone for nursing activities is not likely to behe solution. According to Sibbald et al. (2006), the finan-ial gains as a result of nurse—doctor substitution are rarelychieved as doctors continue to provide same service asurses, leading to duplication rather than substitution. Theyurther suggested that financial viability is only possible ifhe GP focuses on performing tasks only doctors can perform
nd discontinue services delegated to nursing staff (Sibbaldt al., 2006). This is clearly not what most of the CALDPs in this study were aiming to achieve in the ‘small busi-ess’ structure of their practice. Calculations of financial
142 E.J. Halcomb et al.
rs to
vrb
L
Iico
serbtt
Figure 2 Barrie
iability, therefore, are complex and need to consider aange of factors beyond the amount of revenue a nurse canring in to the practice.
ack of space in the practice setting
n the current study, the lack of space to accommodate a PNn the practice setting was a prevailing and common con-ern articulated by study participants. Due to the naturef the nursing activities undertaken by PNs, the lack of
sfo2
Figure 3 Assistance requ
employing a PN.
pace can be a limiting factor (Halcomb, Davidson, Griffiths,t al., 2008; Phillips et al., 2008). However, further explo-ation is required to determine if this lack of space cane overcome with some modification of existing spaces inhe practice setting, as previous studies have cited thathe workspace of PNs is often a central non-private space
uch as the treatment room, which can be very effectiveor frequent, non-directive contact with patients and wereften described in very positive terms by PNs (Phillips et al.,008).
ired to employ a PN.
Culturally and linguistically diverse general practitioners’ utilisation of practice nurses 143
mode
riept
D
TpbGPipstibgerortea
mwmti
A
Figure 4 Preferred
Lack of interest to employ a PN
A lack of inertia for change was expressed by some partici-pants regarding the potential for employment of a PN in theirpractice. This finding is not unexpected, taking into consid-eration the long-standing history of solo practice amongstsome of the participants, and the ageing profile of this groupof GPs, with some expressing an intention of retirement inthe near future. The concern about legal implications ofthe extended role of a PN is a valid concern. Although eachhealth practitioner is liable for their own clinical practice,as the employer of the PN, GPs have the added obligation ofensuring adequate training and supervision (Sibbald et al.,2006).
GPs’ beliefs of patients’ perception of PNs
This study revealed that participants were concerned ifpatients would be receptive to a PN providing care.Although previous studies have shown that patients view PNsfavourably (Halcomb, Caldwell, Davidson, & Salamonson,2011; Phillips et al., 2007), it needs to be taken into con-sideration that language and cultural barriers could be anissue for PNs practising in a CALD setting. Although poten-tially more challenging to recruit and collect data from,future research around consumer perceptions of PNs needsto include consumers from CALD backgrounds (Halcombet al., 2011).
Study strengths and limitations
Anecdotally CALD GPs are a difficult group to engage withfor a variety of reasons. This study utilised a small sample ofsolo GPs in a single outer metropolitan Division of GeneralPractice who did not employ a practice nurse. These GPsagreed to participate in the study within a relatively smalldata collection period. Therefore, the views of these GPsmay not be generalisable to all solo GPs across Australia.
However, given that responders and non-responders werenot significantly different in their demographic character-istics, we can be confident that data were gained from abroad cross section of eligible GPs.
Estd
l of PN employment.
This study specifically targeted solo GPs who did not cur-ently employ a PN. Whilst the opinions of this group aremportant, it may be that those GPs who have had experi-nce of working with a PN and exposure to models of generalractice incorporating nurses may have a different percep-ion in relation to these issues.
irections for future research, policy and practice
o date there have been few attempts to explore GPs’erceptions of the PN role and understand the rationaleehind a GP’s decision whether or not to employ a PN.iven the significant impact that GP employers have on theN role, employment conditions and models of practice, its important that further research focus on exploring theerspectives of GPs. The feasibility of PN employment inolo CALD GP practice remains a challenge that needs fur-her exploration. Clearly, from this study, PN employments not an ideal option for some CALD GPs, however, it maye a model that is worthwhile considering for the youngerroup of CALD GPs with intention of quality improvement orxpanding their practice. Additionally, the changes occur-ing in contemporary general practice, such as the evolutionf Medicare locals, may provide the support and structuresequired to facilitate the employment of nurses in innova-ive models. Such models may include casual or part-timemployment across practices, provision of specialist nursest a central location or the provision of one-off clinics.
Since this study was conducted the Australian govern-ent has introduced the Practice Nurse Incentive Programhich provides block funding for practice nurse employ-ent. Providing GPs with business cases that demonstrate
he financial impact of such funding on the practice is anmportant step in promoting PN employment.
uthor contributions
JH & YS conceived and designed the study, as well as over-eeing the project, conducting the data analysis and draftinghe manuscript. MC, JC & LL recruited participants, con-ucted the data collection, prepared the literature review,
1
um
A
TPGs
R
A
B
B
G
G
H
H
H
H
H
H
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P
P
S
S
44
ndertook the initial data analysis and contributed to theanuscript.
cknowledgements
his study was funded by Macarthur Division of Generalractice. The research team are very grateful to all of thePs who so generously gave their time to participate in thistudy.
eferences
ustralian General Practice Network. (2008). National practicenurse workforce survey report 2007.
aruch, Y., & Holtom, B. C. (2008). Survey response rate levelsand trends in organizational research. Human Relations, 61(8),1139—1160.
ayram, C., Knox, S., Miller, G., Ng, A., & Britt, H. (2007). Clin-ical activity of overseas-trained doctors practising in generalpractice in Australia. Australian Health Review, 31(3), 440—448.
arrett, P. W., Dickson, H. G., Young, L., & Whelan, A. K. (2010).‘‘The Happy Migrant Effect’’: Perceptions of negative experi-ences of healthcare by patients with little or no English: Aqualitative study across seven language groups. Quality andSafety in Health Care, 17, 101—103.
ibson, T., & Heartfield, M. (2005). Mentoring for nurses in generalpractice: An Australian study. Journal of Interprofessional Care,19(1), 50—62.
alcomb, E. J., Caldwell, B., Davidson, P. M., & Salamonson, Y.(2011). Development and psychometric validation of the GeneralPractice Nurse Satisfaction Scale. Journal of Nursing Scholar-ship, 43(3), 318—327.
alcomb, E. J., & Davidson, P. M. (2006). Is verbatim transcriptionof interview data always necessary? Applied Nursing Research,19, 38—42.
alcomb, E. J., Davidson, P. M., & Brown, N. (2010). Uptake ofMedicare chronic disease items in Australia by practice nurses
and Aboriginal health workers. Collegian, 17(2), 57—61.
alcomb, E. J., Davidson, P. M., Griffiths, R., & Daly, J. (2008). Car-diovascular disease management: Time to advance the practicenurse role? Australian Health Review, 32(1), 44—55.
W
E.J. Halcomb et al.
alcomb, E. J., Davidson, P. M., Salamonson, Y., Ollerton, R., &Griffiths, R. (2008). Nurses in Australian general practice: Impli-cations for chronic disease management. Journal of ClinicalNursing, 17(5a), 6—15.
alcomb, E. J., Davidson, P. M., Yallop, J., Griffiths, R., & Daly, J.(2007). Strategic directions for developing the Australian gen-eral practice nurse role in cardiovascular disease management.Contemporary Nurse, 26(1), 125—135.
alcomb, E. J., & Hickman, L. (2010). Development of a clinician-led research agenda for Australian general practice nurses.Australian Journal of Advanced Nursing, 27(3), 4—11.
alcomb, E. J., Patterson, E., & Davidson, P. M. (2006). Evolutionof practice nursing in Australia. Journal of Advanced Nursing,55(3), 376—388.
nox, S. A., & Britt, H. (2002). A comparison of general practiceencounters with patients from English-speaking and non-English-speaking backgrounds. Medical Journal of Australia, 177,98—101.
ldroyd, J., Proudfoot, J., Infante, F. A., Davies, G. P., Bubner, T.,Holton, C., et al. (2003). Providing healthcare for people withchronic illness: The views of Australian GPs. Medical Journal ofAustralia, 179, 30—33.
hillips, C., Dwan, K., Pearce, C., Hall, S., Porritt, J., Yates, R.,et al. (2007). Time to talk, time to see; Changing microe-conomics of professional practice among nurses and doctorsin Australian general practice. Contemporary Nurse, 26(2),136—144.
hillips, C., Pearce, C., Dwan, K., Hall, S., Porritt, J., Yates, R.,et al. (2008). Charting new roles for Australian general practicenurses. Canberra: Australian Primary Health Care Research Insti-tute.
rice, K., Patterson, E., & Hegney, D. (2006). Being strategic: Uti-lising consumer views to better promote an expanded role fornurses in Australian general practice. Collegian, 13(4), 16—21.
alamonson, Y., Everett, B., Koch, J., Andrew, S., & Davidson, P.(2008). English-language acculturation predicts academic per-formance in nursing students who speak English as a secondlanguage. Research in Nursing & Health, 31(1), 86—94.
ibbald, B., Laurant, M. G., & Reeves, D. (2006). Advanced nurse
roles in UK primary care. Medical Journal of Australia, 185(1),10—12.
alker, L. (2006). Practice nurses. Working smarter in generalpractice. Australian Family Physician, 35(1/2), 20—22.
