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This document was prepared by the Primary Health Network of the College
of Nurses Aotearoa (NZ) Inc.,
and especially by
Dr Jenny Carryer, Dr Denise Dignam,
Barbara Docherty, Rose Lightfoot,
Jean Ross and Lyn Messservey.
This position paper is an update the strategy document Releasing the Potential
of Nursing in Primary Health Care of September 2000
INTRODUCTION
The key goal of this primary health care nursing strategy is to provide
the platform for an efficient and equitable delivery of primary health
care nursing in community settings. Mindful of the need for a cost effective
and well co-ordinated service, nurses working in this sector often experience
a sense of frustration when their patients have unmet or poorly met needs.
To this end a primary health care service which places people's need as
a first priority, and which provides primary health care professionals
with the opportunity for optimal contribution, is both essential and urgent.
Primary health care nursing encompasses population health, health promotion,
wellness care for children, adolescents and adults, first point of contact
care and community partnership. This service is provided in both urban
and rural settings and geographical areas on these boundaries and includes
a diverse patient mix of ethnic and cultural groupings.
The changing structure of primary health care in New Zealand and in particular
the role of nursing, has been recognised at Government level within the
recently released document The Primary Health Care Strategy (Ministry
of Health, 2001). This document has significant implications for the primary
health care nursing workforce, and has signalled opportunities and non-prescriptive
direction for primary health care nurses. In light of these opportunities
it is now the ideal time to discard the historical protection and finely
tuned description of the current titles and roles for nurses working in
the community and assert the identity of the primary health care nurse.
This identity would not preclude the possibility of retaining the 'title
and role' of particular nursing specialties within the primary health
care nursing umbrella.
Aligned to this, nursing and primary health care in general needs a strong
focus and certainty for vital educational and curriculum development.
In addition, nursing needs a shared voice to engage in professional dialogue
and a shared nursing vision to work within community partnerships. Such
interaction will ensure participation in both construction and direction
of policy.
The shared goal of nurses who provide care in the community and outside
the environs of a general hospital, is primary health care. This is the
service that many nurses deliver in a variety of settings that include:
Plunket and public health, rural and urban general practice, after hours
accident and medical centres, school and other community based clinics
including marae, and in people's homes and communities in remote areas.
EXECUTIVE SUMMARY
In line with the WHO definition (1996, p.9) the College believes that
until there is a change of emphasis from primary medical care to genuine
primary health care '... it remains largely a disjointed set of fragmented
provider and community groupings with little collective power to influence
decision making'. The College also believes that if the vision inherent
in the Government's primary health strategy is allowed full expression,
there is a significant opportunity to radically improve the delivery of
primary health care.
In focusing on the inequalities between the health status of Maori, non-Maori
and Pacific peoples, the challenge for nurses working in the primary health
care sector is to move beyond the current rhetoric and demonstrate leadership
in meeting the needs of these groups. This will best be demonstrated by
primary health care nurses developing and working in partnership to identify
those groups in the population who are unable to access health services,
and to deliver services which are culturally appropriate.
Nursing has for at least twenty years prepared graduates to deliver nursing
care in a variety of settings with the goal of improving health outcomes
to the population as a whole. Yet in spite of clear recommendations by
the Ministerial Taskforce on Nursing (Ministry of Health 1998b), structural,
educational and legislative barriers continue to impede the use of this
major potential resource in the community. However it is envisaged that
new and realisable opportunities will emerge for nursing and by nursing,
as a result of the Government's Primary Health Care Strategy. The absence
of a national educational framework for PHC nurses and the link to competency
based annual practising certificates are issues to be urgently addressed.
We do not consider that it is in the best interests of the New Zealand
population to have their primary health care services funded through the
governance of general practitioners, IPAs or similar. Indeed the Primary
Health Care Strategy has stated that the formation of Primary Health Organisations
(PHOs) will be 'not-for-profit bodies' and 'must be able to show that
all their providers and practitioners can influence the organisation's
decision-making, rather than one group being dominant'. Neither is it
useful to have other nursing services such as public health nurses and
Plunket nurses rigidly constrained by contractual boundaries which do
not always mesh with family nor community need.
During the last two decades these perceived barriers have resulted in
limited expressions of nursing potential, and have discouraged the collaborative
relationships often stated by many health professionals as being desirable
in order for populations to be best served. The College argues that integrated
primary health care nursing teams are an obvious vehicle for dissolving
barriers, crossing boundaries and supporting a continuum of care.
The proposed structure to progress this development is a Primary Health
Care Nursing Directorate established within the nursing sector. This Directorate
would take the form of a national network of senior primary health care
nurses who would provide clinical leadership and direction and a base
for evaluative research into primary health care nursing outcomes. The
major focus of such a Directorate would be to achieve an integrated and
co-ordinated system of primary health care nursing through collaboration
and input from each primary health care nursing sector.
It would be closely aligned with the Ministry of Health (although outside
its confines) and is envisaged as being also closely aligned with development
and implementation of Ministry Policy. Other key stakeholders would be
the College of Nurses Aotearoa, the Nursing Council of New Zealand and
the New Zealand Nurses' Organisation. A workable nursing governance structure
is an essential ingredient to lead the co-ordination and consolidation
of nursing services in the primary health care sector.
The move from a 'fee-for-service' arrangement to a needs-based funding
for population health care necessitates an alternative funding proposal
for nursing. This is suggested as a means of encouraging and supporting
the provision of primary health care nursing rather than to continue the
fragmented system which currently exists and which tends to favour primary
medical care.
A key role of the Primary Health Care Nursing Directorate would be the
immediate development of a robust and agreed national framework for appropriate
post-graduate education for all nurses in primary health care roles. Such
nurses would share a common set of generalist primary health care nursing
knowledge and skills and could then proceed, if appropriate, to develop
advanced nursing skills in their particular areas of professional practice.
This document provides the evidence and rationale for the development
of a resourced National Primary Health Care Nursing infrastructure in
order to ensure:
* The best possible outcomes for New Zealanders in line with Government
policy and strategic direction.
* The very best utilisation of nursing potential.
* The best possible outcomes for those groups who are disadvantaged through
current inequalities in health care access and provision.
* The development of strong, collaborative contractual opportunities for
all health professionals working in primary health care.
NB: In this document the term nurse refers always to registered nurse.
1. OPPORTUNITY
The goal of this document is to maximise nursing's contribution to meeting
the Government's key health strategies.
The vision of a new health system acknowledges the central role of a strong
primary health care system in improving health of New Zealanders and tackling
inequalities in health. The six key directions detailed in the Government's
Primary Health Care Strategy to align primary health care within this
vision are to:
* work with local communities and enrolled populations
* identify and remove health inequalities, by ensuring accessible and
appropriate services for lower socio-economic groups, Maori and Pacific
peoples
* offer access to comprehensive services to improve maintain and restore
people's health
* co-ordinate care across service areas
* develop the primary health care workforce
* continuously improve quality using good information.
The restructuring of the Primary Health Care Sector is part of the formation
of District Health Boards and Primary Health Organisations. There is now
a timely window of opportunity to concurrently implement a primary health
care nursing service, as an essential and integral part of the vision
for the sector. This discussion document provides the rationale for strongly
positioning nursing in the sector, and provides an opportunity for nursing
and other health professionals to work more collaboratively.
Any changes to nursing structures and developmental processes need to
be guided by some critical considerations including:
* Will such changes ensure improved patient outcomes?
* Is there a need for advanced nurse practitioners in primary health care,
and if so what infrastructure and processes will need to be established
in order to develop and support such a career structure?
* How can changes be implemented so as not to create a threat or division
amongst other health service providers in the primary health care sector?
* What mechanisms will best ensure primary health care nurses and medical
practitioners work in a way that complements the distinct contribution
that nursing and medicine make in the sector?
* What governance structures at all levels are best incorporated to ensure
nursing is critically involved?
2. PRIMARY HEALTH CARE
Until there is a change of emphasis from primary medical care to genuine
primary health care, '... it remains largely a disjointed set of fragmented
provider and community groupings with little collective power to influence
decision making' (WHO, 1996, p.9).2.1 The Nature of Primary Health Care
The desire for population based health care and an increased emphasis
on primary health care is long-standing. As recently as 1997 the World
Health Organisation reaffirmed five health promotion action areas, within
a Primary Health Care framework, as:
* To Build Healthy Public Policy
* To Create Supportive Environments
* To Develop Personal Skills
* To Strengthen Community Action
* To Reorient Health Services.
Nursing supports a comprehensive definition of Primary Health Care:
A conceptual framework for providing public health and primary care services;
it includes delivery of essential, affordable, accessible, and acceptable
health care to the community, with an emphasis on disease prevention and
health promotion, community involvement, multi-sectoral co-operation,
and appropriate technology (Stanhope and Lancaster, 1996, p.1100).
Primary care can then be separately and more usefully defined as:
Typically the point of first contact or the entry point into the health
care system, emphasises management of commonly occurring diseases or chronic
disease (Stanhope and Lancaster, 1996, p.1100).
As long as primary care is covertly understood as primary medical care
then community development, disease prevention and health promotion will
be marginalised. The health episode characterised by self-referral to
medical care is a reactive process to a health crisis rather than a proactive
intervention for health. Self-referral requires that patients are able
to make informed decisions, have motivation, transport, a belief that
the service is culturally appropriate and a certain level of private resource
to enable access to service.
3. MAORI HEALTH
In focusing on inequalities between the health status of Maori and non
Maori, the challenge for nurses working in the primary health sector is
to move towards a goal for health, which should be an equitable right,
available to all. Nursing and nurses must demonstrate leadership in meeting
the needs of Maori by developing and working in partnership to deliver
appropriate services. Effective, innovative and alternative health services
must be available to Maori.
3.1 Maori Health Overview
Nursing believes that achievement of positive health outcomes for Maori
is an integral component of any future primary health care development
strategy. Maori health is consistently identified as a health priority
at government level with funding being allocated accordingly. The Treaty
of Waitangi affords Maori the protection of taonga, of which health is
a fundamental component. Despite Maori health achieving priority status,
issues of accessibility, affordability and appropriateness of health services
continue to be of concern to both Maori and health professionals. Nursing
is in a prime position to address the issues of accessibility and affordability
and ultimately to increase their effectiveness in the primary health care
sector.
3.2 Maori Concepts of Health
A medical approach and an orientation toward disease have dominated the
New Zealand health care system. This approach, however, has not accommodated
the concept of health held by Maori, which encompasses a holistic worldview.
Health models such as Te Whare Tapa Wha (Durie, 1998) and Te Wheke (Pere,
1991) stress the complex interweaving of the physical, emotional, social,
spiritual and ancestral dimensions.
These dimensions determine both health and well being at the levels of
the individual, whanau, hapu and iwi. Put simply, health concerns for
many Maori extend well beyond the physical concerns expressed by many
non Maori health professionals. In order for health gains to be made amongst
Maori, recognition of broader concepts of health must be made by nurses
and other primary health care providers.
3.3 Community Development
Central to the notion of primary health care is community development
and working with community populations to maintain and improve health
at the level of the individual, whanau, hapu and iwi. For this to be achieved
Maori must have greater functional participation in the Health and Disability
Sector, not only from a Maori provider perspective but also from a mainstream
perspective.
The nature of Maori participation must be determined by Maori at the hapu-iwi
level, and then negotiated with the relevant Primary Health Organisations.
There also needs to be a greater responsiveness to the needs of Maori
as identified by Maori. This needs recognition that due to socio-economic
conditions some Maori are forced to operate in survival mode, and also
that many Maori health professionals working to empower communities are
overloaded.
For greater impact on the health status of Maori the method of determination
of services must be congruent with the needs of Maori. Nurses working
within the primary health care sector can facilitate the development of
communities through enabling priorities, needs and services determined
by the community, with the fundamental goal of improving health outcomes.
3.4 Accessibility
Accessibility of services includes critical factors which influence whether
an individual or whanau is able to safely access primary health care services.
These are transport, geographical location, financial resources, communication
and the reception provided by health professionals and other staff.
Although many Maori know when they require health care services, feelings
of whakaama often prevent them from effectively utilising these services.
Other factors can also impact, such as concern about outstanding accounts,
the need to pay prior to being able to access a service when money is
not available to do so, or the reception they experience is devoid of
respect and dignity. Many services are thus perceived as being inaccessible.
For some, geographical location and a lack of transport compound this.
There can be no doubt that affiliation with one primary health provider
could be advantageous to Maori, particularly from a continuity and relationship
perspective. However primary health care providers must demonstrate that
they are able to offer a range of services that give Maori choice, including
the accessing of tohunga and rongoa as acceptable and valid health care
options.
There will be Maori who may choose not to affiliate with one primary health
provider for a variety of reasons and there will be those who are reasonably
transient, thus making affiliation difficult. Some of this group previously
accessed the services of Emergency Departments. Because of the nature
of their need for health care and the fact that they did not meet the
service priorities, they are often turned away thus requiring them to
access private health services that are costly and/or unaffordable. The
result may be an essentially avoidable hospital admission.
3.5 Affordability
The status of Maori health is closely connected with socio-economic determinants
and there are many examples where Maori are unable to access primary health
care due to cost, location or the financial rules under which some primary
health care providers operate.
Inability to access primary health care services in a timely manner often
results in an unnecessary deterioration in health status. In addition
there is much need for good health promotion, such as parenting skills
or nutrition support.
We argue that the option of increased accessibility of nursing services
as proposed in this document has the potential to resolve some financial
barriers for Maori through both improved prevention and improved access.
3.6 Appropriateness and Cultural Determination
The appropriateness of a service has always been a major determinant for
Maori accessing primary health care services. The persistence by health
professionals and government agencies to achieve a national pan-Maori
approach to the delivery of primary health care services fails to recognise
the diversity that exists amongst Maori at the whanau-hapu-iwi level.
Therefore nursing must recognise the diversity which exists amongst Maori
by being receptive to Maori determining their health needs through the
formation of functional partnerships. Nursing is also in a prime position
to facilitate the cultural enrichment of health care services by ensuring
that traditional healing practices become legitimate options for Maori
consumers of health services.
Effective representation is crucial to ensuring that services are appropriate.
However, the nature of effective representation is problematic and must
be left to Maori to determine at the hapu-iwi level, rather than having
the nature of representation dictated to them as a group from a national
perspective. When the nature of representation is determined for groups
such as Maori, this invariably reduces the effectiveness of the representation
and thus affects the objectives of primary health for Maori.
Nursing must also make a concerted effort to attract Maori into the various
facets of the health workforce. This may require that present methods
of education delivery be reviewed to ensure that Bachelor of Nursing programmes
are delivered in a way which maximises the learning and subsequent success
of Maori, and prepares registered nurses to work in the primary health
care setting.
All primary health care sector nurses should undergo training to improve
their effectiveness when working with Maori. This training should be delivered
within a local context and build on the core cultural safety programme
embedded in the undergraduate degree.
4. THE CONSUMER PERSPECTIVE
The reason for the existence of any health professional group is the needs
of the people whom they serve.
4.1 Consumer Rights
The World Bank has at last acknowledged that income and wealth do not
"trickle down" (Woodward et al., 2000). The Bank acknowledges
the global increase in poverty and the need to focus on the association
between socio-economic status and poor health.
The close association between poorer socio-economic status and poor health
is well recognised as a result of extensive research. This research repeatedly
documents the existence of the relationship but fails as yet to tell us
the "nature of the differences between people who are in different
places on the SES spectrum or about their experience in relation to health"
(Chamberlain, 1997, p.400).
It is however evident that for Maori, Pacific Island people, and many
other New Zealanders, previous systems of community based care have not
addressed significant inequities. These inequities can be demonstrated
in morbidity, mortality, use of emergency and secondary services and in
different levels of well being across a wide range of indicators. This
remains of immense concern to nursing particularly as nurses know their
services to be under-utilised (Ministry of Health, 1998b).
The publication of the Code of Health and Disability Services Consumers'
Rights (1996) reflects the strong focus that New Zealand has on consumer
rights in health care, and the growing level of consumer activation is
an important development in providing health care. However, it is important
not to overlook those members and groups in communities who remain voiceless
and do not easily utilise the mechanisms of consumer participation.
4.2 Reaching the Hard to Reach
A significant proportion of New Zealanders are theoretically able to access
health care when it is required. There is however a well identified proportion
of the population who are unable to access health services or participate
in community decision making because of a range of factors, including
those identified by the National Advisory Committee on Health and Disability
(1998) associated with poor health status.
* Unemployment, leading to apathy, denial of existing health problems,
exacerbation of stress-related illnesses and depression, reluctance to
access primary health care, having no alternative but to choose cheaper,
less nutritional food sources.
* Financial, including lack of car, telephone, and/or medical insurance,
as well as costs of primary health care providers and prescriptions.
* Poor housing, usually due to little income for rent, repairs and maintenance,
and/or overcrowding.
* Limited general education, so that essential health promotion information
may not be accessed or utilised, or entitlement understood. Often this
is because the information itself is not delivered in a way which is appropriate
or meaningful, or the delivery of information is not tailored to the level
of need or understanding of the recipient.
* Cultural, including lack of understanding, and discomfort with health
care provided by people of different ethnicity from the recipient. Mainstream
health care providers are frequently unwilling to acknowledge or facilitate
the use of an individual's own cultural or alternative healthcare practices,
or to include these within routine healthcare provision. Similarly there
are well documented gender issues which may act as barriers to effective
services.
* Language is a contributing barrier to access. The burgeoning immigrant
population are particularly isolated, often having emotional or psychological
difficulties which can only be explored verbally, corresponding with a
lack of adequate professional interpreting services (Jones and Paramjits,
1998).
* Isolation, which includes not only the above, but also geographical
distance from health care facilities.
* Choice is considered to be a fundamental right. People experiencing
socio-economic disadvantage could well benefit from improved nursing services
in the community.
Most interventions to date have been aimed at increasing healthy behaviour
within low socio-economic groups and investigating the effects of poor
social and economic circumstances on health (Ministry of Health, 1998a).
The Committee stressed the need for health education to be combined with
personal support if it is to be effective, and recommended that stronger
emphasis be placed on reducing the socio-economic inequalities themselves
(RNZCGP, 1999).
Primary health care nurses represent a large segment of the workforce,
within which they are already well-distributed, potentially cost effective,
and mobile. Nursing offers a unique combination of knowledge, skills and
expertise that validates the nurse's position as an effective health professional,
facilitating access, ensuring acceptability and working as advocates to
reduce inequities for consumers.
5. THE NATURE OF NURSING AND THE CAPACITY OF PRIMARY HEALTH CARE NURSING
The values embodied in nursing are about the enabling of human health
potential in a wide range of contexts. This approach seeks to foster optimum
health in individuals and communities and is mindful of the particular
challenges and inequalities that may be present in different contexts.
* Nursing is a combination of many elements: knowledge, styles and models
of care, professional codes, clinical skills and attitudes. Central to
nursing is the patient relationship, which emphasises continuity of services
and care, and provides monitoring and evaluation of all health-care components
for that patient. Nursing acknowledges the inter-sectoral contributions
to health status and practices within key principles of equity, access,
self determination and inter-sectoral collaboration.
* Within nursing education a particular focus has been given to the complexities
surrounding health and wellness and the impact of socio economic factors
on the health experience. Increasingly nursing has developed a theoretical
focus not just on the causes of disease and poor health but on the underlying
source of those causative factors: unemployment, education status, income
and housing. For nurses, health sector reports provide affirmation for
the content and focus of our nursing education programmes and a stimulus
to prepare graduates with skills to deliver health care most effectively
to those who most need it.
* Nursing has pioneered the teaching of cultural safety in order to produce
practitioners who are acceptable to diverse and hard to reach groups.
Kearns (1997) notes that nursing's initiative in cultural safety represented
one manifestation of a broader trend towards transferring power in health
care. He argued that because cultural safety offers both an analysis,
and a solution to imbalances of power in society, it can contribute to
different ways of seeing and professionally practising in the community.
5.1 A Vision for primary health care nursing
Primary Health Care (PHC) Nurses will be registered nurses, with knowledge
and expertise in Primary Health Care. This will be derived from the undergraduate
nursing degree (or its equivalent for those registered prior to the degree
programme) and ongoing education relevant to their particular practice
area. This may be specific education relevant to Plunket nursing or additional
skills such as cervical smear taking, vaccination, asthma management,
population health and many other possibilities.
Their nursing practice occurs in a variety of urban and rural health care
settings, with a patient base that may be an individual, family group
or a population group. As primary health care nurses they will be directed
by evidence based practice and assume responsibility and accountability
for maximising patient benefit. PHC nursing, as a complementary source
of health care, is undertaken in collaboration with the patient and a
variety of health professionals.
In initiating nursing action, these nurses draw on extensive knowledge
including physiology, health promotion, disease prevention, life span
development, pharmacology, cultural safety and the application of appropriate
nursing interventions. This educational base assists nurses to make clinical
decisions concerning identification and management of common conditions,
co-ordination of consultation and referrals, and supports them in applying
theoretical concepts to the provision of high quality health care.
The theoretical and practice content of a nursing degree, relevant to
primary health care, includes:
* Health promotion
* Health education
* Parenting
* Child development and human development across the life span
* Mental health
* Disease prevention and management
* Alcohol and drug issues
* Sexuality and sexual health
* Communication skills at an advanced level
* Grief work
* Healthy ageing
* Physiology
* Pharmacology
* The application of appropriate nursing interventions.
The educational and theoretical base supports nurses to make clinical
decisions concerning the optimal achievement of good health, the identification
and management of common conditions, and co-ordination of consultation
and referrals. Patient benefit and community development is maximised
as PHC nurses work alongside the individuals, family groups and communities.
These nurses are responsible and fully accountable for their own practice
and for providing high quality health care.
A proportion of primary health care nurses will gain clinical Masters
degrees and practice as nurse practitioners within this scope of practice.
This group will have undertaken extended education which will include
advanced assessment and intervention, extended pharmacolgy, pathophysiology,
epidemiology and relevant health policy.
Nurse practitioners in primary health care may or may not choose to take
up the responsibility of prescribing depending on the needs of their client
group. Nurse practitioner scopes of practice in primary health care will
include family and child health, sexual and reproductive health, community
based disease management and screening, generalist first level services,
health education and counselling.
The Primary Health Care nurse will:
* be accountable for maintaining effective nursing practice through engagement
in ongoing professional development and post-graduate study as relevant
to her/his practice;
* implement nursing interventions based on best practice guidelines and
with regard to diverse political, social and cultural contexts in which
care is provided;
* be a reflective practitioner who audits the quality of nursing practice
through peer review, supervision or mentoring;
* work in integrated teams to provide a continuum of care which crosses
current boundaries, reaches the hard to reach and gives priority to promoting
health.
5.2 Scope of practice
Primary Health Care nursing includes the following:
* merging personal health support with population based public health
to advance self empowerment for mobilising individuals, families and communities;
* nursing activity that provides primary health care directly or indirectly,
in collaboration with individuals, family groups and communities in order
to assist in the promotion, maintenance, restoration and preservation
of their health;
* nursing action that anticipates, assesses, responds to and evaluates
the health needs of individuals, family groups and communities who are
known to have or be at risk of a health deficit;
* nursing strategies that include leadership roles in advocacy and negotiation,
case management and delivery, case-finding, planning, education and research;
* nurse management of potential and actual complex health problems by
working in collaboration with other providers, individuals, consumers,
family groups and communities across the life span and on a continuum;
* the application of evidence based practice and the conduct of research;
* recognition of the Treaty of Waitangi and the right of tangata whenua
to self determine health.
5.3 Models of primary health care nursing
Models for delivery of primary health care nursing differ according to
specific needs of populations and the geographical areas to which this
service is provided. Such models may include:
5.3.1: Rural and outlying areas
Nurses working in outlying or rural areas mostly live and work as visible
members of the communities they serve. Because of this they are in an
ideal position to form natural links between their sector, the community
and other health professionals. Because of long standing difficulties
in retention of general practitioners in rural and remote areas, rural
nurses are developing a nursing role which differs in part to that of
their urban counterparts.
Special considerations for delivery of these nursing services include
issues relating to isolation and long distances. Additional stresses include
an emphasis on outdoor work which increases accident rates; mental health
problems due to isolation and the limited availability of counselling
or support groups; high alcohol and tobacco consumption; the distance
from main urban centres and the impact of this on medical and trauma emergencies.
Such a service delivery means ensuring that the complementary roles of
rural nurses, general practitioners, local hospital, farms, and schools
are closely linked, thus providing these nurses with a rare opportunistic
and total response to the health needs of their community.
5.3.2: Community and family assessment
Appleton (1996) found that nurses, when present, are the most likely to
identify vulnerable families who are experiencing crisis, ill health and
child abuse. The nurse's ability to support families at risk was found
to depend on their being able to utilise six inter-relating factors. These
factors were: knowledge of the family's community, reflection-on-action,
situations/families which caused the nurse to be concerned, the nurse's
own knowledge base and experience, past history of the family, and a degree
of gut feelings and instinct. Working with 'at risk' families is an example
where the primary health care nurse could also work across sectors to
improve the health and social situation for the family.
The health service requirements of families have to be assessed within
the overall framework of the community within which they live. Targeting
health services only to families with identified needs (such as a family
with a child with asthma) ignores other families who may be equally vulnerable
but do not fit the targeted sector. In the same manner, free medical care
to children under six allows the assumption that this group's needs are
being met, when there are many important ways of maintaining the health
of children that are not part of free medical care.
5.3.3: Community participation, action and partnerships
Primary health care nurses have been shown to work alongside communities
to set priorities for health promotion strategies, and to plan and implement
activities that help communities to achieve improved health (Te Ha o Te
Oranga o Ngati Whatua Maori Mobile Nursing Service).
Nurses recognise that relinquishing control is an important aspect of
community participation. Relinquishing control is not to abdicate responsibility
but rather to engage in the professional role of facilitation and co-ordination
that raises the health consciousness of the community. Few preventative
health strategies can be successful if they are planned in isolation from
the community towards which they are directed. If there is an agreed and
identified health issue within a community, nurses are in an ideal position
to lead as change agents and manage change in collaboration with communities.
5.3.4: General practice settings and first contact care
There is international evidence that nurses provide first-contact primary
clinical care as safely and effectively and with as much satisfaction
to patients as a general practitioner (Pearson, 1988; Marsh and Dawes,
1995; Richardson and Maynard, 1995; Campbell, 1997; Mundinger, 1998, 1999;
Grandinetti, 1999; Dobson, 1999; Mundinger et al., 2000; Kinnersley et
al., 2000; Shum et al., 2000; Venning et al., 2000).
Many authors also note that patient satisfaction was higher when nurses
provide first contact care due to the more collaborative, informative
and interactive style of nurses. In a British study, nurses trained in
ear care and working as part of primary health care teams helped to reduce
costs, GPs' work-loads, and the use of antibiotics. Patients also reported
improved satisfaction with their care (Fall et al., 1997).
Given appropriate education, nurses are able to identify conditions and
manage a vast range of primary (health) care related events. In particular
primary health care nurses are ideally placed to provide brief and opportunistic
interventions to assist patients in making lifestyle changes in harmful
behaviour. Research shows that the nursing skills valued by patients,
such as explaining, and listening to and understanding patients' needs
are not readily quantifiable.
However there is now a substantial international body of research showing
that nurse-led services have positive effects on health care delivery
and on the health outcomes of patients (Knaus et al., 1986; Krakauer et
al., 1992; Prescott, 1993). Evidence of this nature has been present in
various sources since the 1970s.
Significantly however more recent research has taken the form of randomised
controlled trials thus attempting to control the many variables which
have potentially invalidated the findings of previous work. In particular
the work of Mundinger et al. (2000) strongly argues that even within the
traditional medical model of primary (health) care, patient outcomes for
nurse practitioner and physician delivery of primary (health) care do
not differ.
5.3.5: Home visiting
Home visiting has historically been a particular feature of nursing services
in the community. The American Academy of Pediatrics (1998) provides considerable
evidence to support the health benefits of home visiting. The benefits
are wide ranging and include direct improvement in birth outcomes, significant
maternal health improvements and other long-term benefits.
The long term benefits were identified in a fifteen year follow up study
and included decreased use of welfare, decreased incidents of child abuse
and neglect and reduced maternal criminal behaviour. They conclude that
health visitation programmes can be an effective early intervention strategy.
The practice area of health visiting by nurses (as it is called in Britain)
is based on four principles. These are: the search for health needs, the
stimulation of an awareness of health needs, the influence on policies
affecting health, and the facilitation of health enhancing activities
(Buttigieg, 1995). This aspect of primary health care nursing embraces
health promotion, health teaching, monitoring and direct care.
5.3.6: Surveillance and monitoring
Nursing in the community includes aspects of surveillance and monitoring.
These are essentially public health strategies to determine efficacy in
both individual and population based interventions. An epidemiological
approach stresses that nursing interventions must be geared towards meeting
the health needs of the population. The economic approach is to suggest
that meeting all the health needs of the population is impossible, therefore
it is best to ask how scarce resources can be used to bring about health
gain (Robinson and Elkan, 1996).
A community based nurse who implements population health strategies will
do so while negotiating the tension between epidemiological approaches,
economic approaches and nursing responses to family, community and socio-cultural
assessment (Carryer et al., 1999). The notion of surveillance is one which
produces discomfort for both those required to provide it as well as those
on the receiving end (Walsh and Gough, 1999). Nurses argue that surveillance
is only acceptable as an integral part of overall caring and assistance
and that this is a very appropriate role when derived from the skill base
of nursing.
6. DRIVERS FOR CHANGE IN PRIMARY HEALTH CARE:
FROM A NURSING PERSPECTIVE
Nursing has for at least twenty years prepared graduates to deliver nursing
care in a variety of settings with the goal of improving health outcomes.
Structural, educational and legislative barriers continue to impede the
full and appropriate use of this potential resource in the community.
6.1 Nursing Workforce Issues
* There is a considerable tension between what nursing is in its theoretical
intent and focus, and what it has become due to patterns of utilisation.
The burden of care for nurses, patients, their families and caregivers
has demonstrably increased with changes in the nature of hospitalisation,
and especially the trend of shorter inpatient length of stay which transfers
significant burden to families and communities (Fagin, 2001).
* Retention of nurses has become a crucial issue as internationally the
shortage of nurses increases steadily. There is anecdotal evidence that
young graduates will not tolerate the wastage of their skills and knowledge
in community based practice that does not fully utilise their potential
contribution.
* The present primary health care funding arrangements for general practice
sees nursing activity negotiated through the medical profession. Nurses
in this setting are employed in the private sector within a model that
allows scope of practice to be determined at the discretion of the GP
without reference to a national nursing framework. General Practitioners
have no knowledge base from which to determine what is an appropriate
nursing service. Nurses working in other roles in the primary health care
sector are frequently employed within confined narrow contract specifications
that do not reflect human need.
* The contract culture of the recent health market, has altered nursing
to a commodity (Walsh and Gough, 1999), which is shaped and driven by
that market. We now see nursing work becoming increasingly specific and
in effect 'broken down' into disease categories or age ranges or even
in relation to body parts. This is complicated because on the one hand
specialisation is useful and allows for the development of a type of expertise.
Conversely it reduces the strength and usefulness of nursing, and supports
a medical and reductionist health service focus on what are often deeper
family and community health problems that would benefit from a more holistic
or 'global' response (Carryer et al., 1999).
* A steady reduction in the specific contribution of nurses to the community
has occurred as contracting pressure has precipitated reduction in numbers
of vital groups such as public health nurses. With the exception of practice
nurses, it is nurses working in primary health care delivery who appear
to have been substantially reduced in recent times, despite research which
indicates the increasing need for an effective public health service (Pybus,
1993; Dignam and Alpass, 1998).
* At the same time as we see a reductionist focus in the utilisation of
nurses there is an increase in other health practitioners such as strengthening
families co-ordinators, generic health care workers, community workers
and a range of support workers. The assumption that nursing offers nothing
tangibly different from medicine has influenced the preparation of a new
form of worker who it is presumed will provide a new type of service more
akin to the requirements of primary health care delivery. This is a supreme
irony for nursing which has spent years trying to break free from its
traditional shackles to medicine, yet finds that funding and delivery
structures continually trap nursing services under a medical umbrella
and then seek to replace them with a new type of practitioner (Carryer
et al., 1999).
* New graduates tend not to be employed in community settings, and this
forces them to work in hospitals first (Ministry of Health, 1998b). There
are difficulties with new nursing graduates transferring to community
settings in areas where leadership role models are scarce and where the
clinical career pathways in the community are absent. Leadership in primary
health care nursing is under-developed, and there is an absence of a nursing
governance structure. The primary sector has been unable to develop any
systematic approach to transition to practice or provide good quality
clinical placements for undergraduate nursing
students.
6.2 Repositioning Nursing
* There is a need to reposition nursing within a true primary health care
team in order to support the key objectives of the Primary Health Care
Strategy. Moving beyond the fragmentation and medicalisation which has
previously characterised primary health care delivery, means that expert
nursing services can contribute to meeting the trajectory of patient needs.
In order to achieve the population health objectives the unit of delivery
must become the primary health care team in its widest context. Historically
general practice has carried the burden of first contact care resulting
in a lack of continuity with other primary health care services.
* Primary Health Care is currently delivered from a number of public and
private service providers. Within such structures there are overlapping
boundaries and a lack of integrated service provision. A major driver
for health care delivery is the associated funding mechanisms, and the
principle to drive any structural changes must be the mandate to deliver
patient centred care. The professional aspirations and financial drivers
must be secondary to service provisions that hold the patient needs central.
The possibilities for structural changes in primary health care service
provision include increased nurse case management, family practitioner
roles (Litchfield et al., 1994), self referral services, co-ordinated
care and the adoption of primary health care teams as the linguistic and
practical manifestation of community based services.
* Throughout the 1990s the health reforms have supported, even if unintentionally,
the growth of primary medical care (Malcolm, 1993). A review is required
of the way service provision is negotiated, funded and delivered in the
primary healthcare sector to ensure consumers benefit from the full potential
contribution that nursing offers. Nursing management at Primary Health
Organisation (PHO) level with a clear and integrated nursing service structure,
will ensure that primary health care nursing has true governance and a
line of accountability. Tangible leadership at that level will at the
same time consolidate and strengthen the primary health care nursing workforce.
* Collaboration between health professionals is critical to the success
of primary health care teams. At present many community based nurses work
in assistive and somewhat compensatory roles, unable to contribute as
full and equal members of a multi-disciplinary team due to limited access
to resources, physical workspace and postgraduate education (Ministry
of Health, 1998b). New ways of working collaboratively need to be developed
and implemented by nurses and medical practitioners. However barriers
to this occurring in a constructive way will continue if the present structures
which govern ownership and funding of IPAs and general practices are translated
into the PHOs. For these reasons a primary health care role needs to be
developed which encompasses the notion of collaboration relevant to the
partnership concept between health professional and the consumer of health
services and which removes the notion of nurses primarily being employees.
6.3
The need to develop a cohesive framework for primary health care post-graduate
nursing education
One of the major difficulties created by the current diverse roles and
titles of nurses in primary health care is the lack of a unifying focus
for post-graduate education in this context. As identified by the Report
of the Ministerial Taskforce on Nursing (Ministry of Health, 1998b) there
is a paucity of funded post graduate education for all nursing scopes
of practice but it is especially poor in primary health care.
This directly allows at best, limited, and at worst, very poor nursing
practice in many community based settings. It also reduces the confidence
of many practitioners of long standing to take on expanded or more challenging
roles.
Whilst the context and some specifics of delivery will be different for
various nurses practising in the variety of nursing roles that exist,
there is, as previously discussed a core body of knowledge related to
nursing in the community. Thorough groundwork is done in the undergraduate
programme but there is a need to develop postgraduate/post registration
courses at certificate and diploma level to extend existing nurses in
the community and maintain the life long learning of community based nurses.
Similarly work needs to be done (and has commenced) to develop an agreed
curriculum for a primary health care scope of practice in the clinical
Masters degree for nurse practitioners.
7. FUNDING
It is not in the best interests of the New Zealand population to have
their primary health care services funded via governance mechanisms that
create inequities for those providing the service. The Primary Health
Care Strategy (Ministry of Health, 2001) states that 'most Government
funding of primary health care services ... has led to an uneven and inequitable
distribution of resources.' Nursing must therefore be fully involved in
any nursing funding and delivery processes at a governance level.
7.1 Current Funding Issues
7.1.1 In District Health Boards
Currently public health nurses provide a range of services that are bound
by funding streams (mental health, personal health public health, disability
support services) and the resultant contracts which arise from them. This
along with the separation of the health promotion role has placed artificial
boundaries and severe limits around the scope of practice of public health
nurses. Similarly the public/private split between practice nurse/GP work
and district nurses means that some patients will see a number of nurses
in any one day, each for a different reason. The confusion of terminology
regarding the roles of outreach nurses also places them within a secondary/tertiary
and sometimes a primary split.
7.1.2 In General Practice Boards
The practice nurse subsidy has long been a major barrier to the development
of primary health care nursing in this context. It was introduced in 1970
to improve the delivery of health services in rural areas but has been
of limited benefit to practice nurses in the long term. Michel (1997)
noted that the lack of evidence as to health benefit through the utilisation
of practice nursing services is largely because the employing general
practitioners are not accountable for utilisation of the nursing service.
This lack of accountability and the frag-mentation of the present funding
delivery process can be directly related to a funding system that does
not require accountability procedures or process and the lack of a central
agency that monitors its use at a national level. There are clear indicators
that the full potential of practice nurses is greatly impeded in many
general practice settings because of the factors already discussed elsewhere
in this document.
7.1.3 Community nursing services
It is also not useful to have nursing services, such as public health
nurses and Plunket nurses, rigidly constrained by contractual boundaries
that do not always meet with family and community need. Over the past
20 years this has resulted in limited expressions of nursing potential
and has discouraged the real possibilities of collaborative relationships
between professionals working in primary health care.
Currently Government proposes to move towards a more capitated system
of funding based on a population approach through patient affiliation
(enrolment). This would mean that health professional groups or individuals
would be paid a lump sum per person enrolled with them and would require
consumers to willingly nominate a service provider. The per capita sum
could be for a given or total range of health services.
There is considerable debate in the literature as to the efficacy of such
a funding system. Although it has been lauded as allowing practice nurses
more autonomy within their practice, capitation per se may not necessarily
change the nature of services if the funding and allocation of service
and tasks is still decreed by the general practitioner or IPA governance.
Cumming and Mays (1999) in reviewing some of the limited research, conclude
by suggesting the need to remain cautious about automatic benefits from
capitation without additional concurrent changes in New Zealand's primary
health care delivery.
It is however imperative that any capitation formula such as presently
envisaged, should not be based on the present Practice Nurse Subsidy allocation
of funding as this will further undermine and devalue the role of nurses
working in primary health care.
There are a number of ways the present funding system could be better
managed in order to allow nursing services to be more appropriately utilised
and accessed. This would include redirection of the monies presently provided
for nursing services via the Practice Nurse Subsidy Scheme and transfer
of monies spent on public health nurses to the primary health organisations.
The payment of salaries to primary health organisation staff will assist
in direct purchasing of nursing services and more effective team structures.
Over and above the resources allocated to the delivery of primary health
care, there is a significant amount of resource directed to the provision
of community health related services. These are mainly provided through
District Health Boards as price volume contracts although some such as
Well Child are purchased through the Royal NZ Plunket Society and iwi
providers.
The DHB's community related services are currently broken down into Home
Health, which provides a range of domicilary nursing and other services,
and Public Health, which includes services such as communicable disease
screening and management, well child services and health promotion. Purchasing
services in this way clearly not only fragments service delivery but results
in gaps and duplication.
Currently PHC nursing services are funded in a variety of ways all of
which ensure that nurses are often not in a position to determine the
nature of the service they provide and the outcomes of that service. This
restricts their ability to provide a primary health care service; rather,
they provide only some aspects of such a service. The plethora of titles,
the general confusion surrounding the role of nurses in community positions
and contractual commodification has added to fragmentation and failure
to deliver comprehensive primary health care. Simplifying the vast number
of nursing titles within the community, by utilising the umbrella name
of primary health care nurse is long overdue. Within that name the varying
scopes of practice and their specialties can continue to function.
8. NURSING CRITERIA FOR A PRIMARY HEALTH CARE INFRASTRUCTURE
Changes need to occur in the way service provision is negotiated, funded
and delivered in the Primary Health Care sector to create a fairer distribution
of resources to different professional groups, and to ensure consumers
benefit from the full potential contribution that nursing offers. What
is required is a new infrastructure that is recognised and accepted by
key stakeholders, responsible for leading and consolidating the repositioning
of Primary Health Care Nursing in the sector.
8.1 Explanation of the Proposed Infrastructure
This proposed infrastructure is envisaged to sit outside the Ministry
of Health but closely aligned to development and implementation of Ministry
Policy, as an essential framework necessary to lead the co-ordination
and consolidation of nursing services in the primary health care sector.
This proposed infrastructure should be robust enough to endure any further
health service changes that may occur in the future.
Inherent in the philosophical intent for such an infrastructure there
will be a commitment to:
* working with other key stakeholders
* strengthening the position of nursing inter-sectorally
* establishing and maintaining ongoing effective relationships with other
health providers
* developing an effective partnership with Maori
* improving the health status of the community as a whole by being responsive
to consumer driven needs
8.2 National Primary Health Care Nursing Directorate
A National Primary Health Care Nursing Directorate will have responsibility
for:
* Ensuring ongoing relationship and negotiation with Ministry of Health
and other key stakeholders in Primary Health Care including the College
of Nurses Aotearoa, NZ Nurses' Organisation, Council of Maori Nurses,
Royal NZ College of General Practitioners (RNZCGP), Clinical Training
Agency (CTA), educational institutions and other Primary Health Care providers.
* Providing professional leadership for PHC nurses by ensuring a process
for nursing governance at a national and regional level and embracing
all primary health care nurses.
* Overseeing the development of a nationally consistent, competency based
career pathway which is relevant to all PHC nurses regardless of setting,
based on the Nursing Council of New Zealand's Nursing Practice Framework.
* Overseeing the development of a nationally consistent postgraduate education
framework, based on the Nursing Council of New Zealand's Frameworks, Guidelines
and Competencies for Post Graduate Nursing Education. It is envisaged
that all post graduate education be accredited against the benchmarks
provided in this framework to ensure consistency and quality of education.
* Providing leadership and guidance in the development of practice models
and implementing a research/evaluation process.
* Providing nursing advice to central policy development initiatives that
impact on primary health care.
8.3 Primary Health Organisations (PHO)
The development of a PHO needs to involve the particular community in
which it will be situated. It then becomes an appropriate and focused
structure for the provision of primary and community based services working
in a reflexive manner with the District Health Board.
It is envisaged that there would be strong nursing leadership and management
at the level of the Primary Health Organisation (PHO) in order to provide
nursing advice, management, co-ordination and governance of the nursing
service for the region. This would need to be underpinned by an identifiable
structure that supports nurses in the delivery of any nursing service.
The suggested nursing criteria for Primary Health Organisations are as
follows:
Governance
* Management structures must be multidisciplinary with sufficient nurses
appointed for nursing leadership and management skills. Nursing is concerned
to see that PHO governance includes consumers and tangata whenua.
Health of populations
* There will be demonstrated integrated primary health care nursing services
with explicit mechanisms as to how the PHO will interface with District
Nurses, Public Health Nurses, and Plunket nurses in an integrated nursing
team.
* Evidence of demonstrated nursing research.
Education and Prevention
* All primary health care nurses will function within the scope of primary
health care nursing (including nurse practitioners) as defined by the
Nursing Council of New Zealand.
* Quality improvement processes around the provision of nursing services
will be developed.
* There will be evidence of ongoing development of the nursing workforce.
An ongoing system for clinical governance will be developed.
Relationship with other health and non-health agencies
* Nursing links and strategic alliances will be clearly identified and
maintained across all nursing boundaries and this will be a component
of integrated nursing teams (NGOs and social agencies).
Teamwork
* Integrated primary health care nursing teams will work within the framework
of the primary health care team.
.
Community and people focused
* Evidence of where nursing services are located and how this matches
population need will be demonstrated.
* Evidence that nursing services meet the needs of the population will
be demonstrated.
Needs based funding
* Requirements of components of nursing care delivery and skill level
of nurses required will be developed.
* Evidence that community and population needs analysis is a foundation
of nursing services will be demonstrated.
8.4 Priorities for action by nursing management at PHO level:
* Establish a governance structure and processes for nurses providing
services in primary health care regardless of roles or settings, that
ensures quality, appropriate scope and quality of nursing services.
* Develop standards for safe patient care, ensuring nurses are able to
demonstrate competency at the level at which they are practising.
* Clarify with the PHO management a workable mechanism for distribution
of funding that enables the development of a transparent system to plan,
implement and evaluate primary health care nursing service for the region.
* Develop links with educational institutions to ensure nurses have access
to education and training linked to and supporting the primary health
care nursing career pathway.
* Establish credentialling requirements that reflect capabilities of nurses
with different educational requirements to ensure education and competencies
are financially rewarded at the appropriate level.
9. CONCLUSION
The Government's primary health care strategy seeks to improve health
outcomes by delivering comprehensive community-focused primary health
care.
The College of Nurses Aotearoa believes that the full expression of the
vision contained in this strategy offers the first genuine chance for
effective primary health care. We are committed to the establishment of
primary health organisations with appropriate multi-disciplinary and consumer
governance.
This document offers a rationale and strategies for ensuring the strengthening
of the nursing contribution by addressing the employment, contractual
and educational constraints which have confined nursing to fragmented
or assistive roles.
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