Primary Health Nursing in an Ideal World

Mary Jane Gilmer, RN, MSN, NP, MCNA (NZ)

I just received a second note from my primary care clinic that my smear was overdue.  Penning a quick note “Thank you but my cervix has been missing for the last 15 years” I promptly slid it into the post box wondering what would become of that bit of health history.  My experience plus a story shared by a colleague made me question the quality of health provision in primary care.  Her seven year old daughter was sent a note from her clinic stating that her smear was due 2018!  Information management is critical in this day and age of rapidly multiplying information.  However, actions resulting from haphazard utilisation of information can erode the trust of individuals who depend on this system to provide primary health care.  In this situation a nurse skilled in informatics would be able to prevent such programming errors.

The situations above beg to have the definition of primary health care revisited.  This article was written to expand the definition of primary health care by shaping a practice that might exist in an ideal world.  The aim of this article was to describe nursing in an ideal primary health care environment.  However, placing nursing in the centre of this discussion was incongruent to the definition of health (Figure 1). 

Nursing must be driven by the individuals that need nursing care.  It is from the individual’s not the professional’s perspective that health care in the ideal world will be discussed (Figure 2).   

Quality primary health care in New Zealand is currently defined as care that:

• is central to New Zealand’s health system providing first level of contact;
• involves community participation;
• is accessible to people in their communities; and
• is based on the World Health Organisation’s Declaration of primary health care :
• Scientifically-sound;
• Socially acceptable;
• Brings health care as close as possible to where people live and work.

Primary health care services include:

• Preventative services, health education, counselling, disease prevention and screening;
• Generalist first-level services inclusive of prevention, advice as well as treatment (MOH, 2001).

Registered nurses (RNs) in PHC are well-positioned to provide scientifically-sound, socially acceptable primary health care.  RNs have provided effective care in the home, clinic, workplace, and in community settings since the profession’s beginnings.  “Primary heath care nurses [PHCNs] work autonomously and collaboratively to promote, improve, maintain and restore health” (MOH, 2003).  PHCNs, both nurse practitioners (NPs) and RNs, have varied work settings and orientations providing care in the community and outside of the hospital. Some nurses provide specialised and some general health care.

In staying true to patient- or individual-centred health care, policymakers, health care providers, educators, researchers and drivers in the community must listen to and act upon the responses from individual(s) when queried about his or her health needs.  If New Zealand defends the health care system as patient-centred then assurances must be made that New Zealand knows what individual(s) want from his or her primary health care.

A theoretical question to an individual seeking quality primary health care

How do you see professionals within PHC assisting you to reach your optimal health?

A theoretical response

1. I would like to see a care provider that knew me and my medical and health history.  For example, I do not appreciate receiving reminders that are incongruent with my health care needs.  If a complete health history and physical examination were completed upon being enrolled in this primary health organisation (PHO) then they would have realised that I had a hysterectomy in 1990.  With a complete history my provider would also be aware of family health risks such as ovarian cancer which would make an examination important.  Of concern however is that I would only go in for a smear thinking that my woman’s check was complete.  RNs are not consistently completing a full woman’s health examination.  In many instances an examination of the ovaries is not done.

RNs are capable and competent to complete a full woman’s history and physical examination including rectal examination, breast examination, and a full pelvic examination.  The way that things are set up now, if I want to see an RN, the RN is only funded to do a smear.  I would probably not make an appointment to see my GP if I had already had a smear done.  This type of care is a barrier to access and not an efficient process to utilise resources.

2. I want a care provider that communicates to other providers involved with my care.  I enrolled in a PHO.  When I immigrated, a “spot” was found on my chest x-ray.  My provider in my PHO had no idea about this.  There was no communication between radiology and the PHO. 

This problem is an international one yet many communities are taking lessons from other high-risk domains such as aviation in order to improve the safety factor.  The Aviation Model has many elements.  This team approach is embedded with the individual’s safety at the centre of the action – see Table 1.

This is Table 1

Elements       Aviation                       Health Care                      PHC Nursing                         

This model has been used to improve safety in many types of health care issues.  An overall analysis identifies that there are several critical needs that must be aligned before this model can be used in a health care setting.  There must be a mandate from the team, and the team must have access to data and resources (Salas, et al., 2006).  Models utilising only one member of the team, such as the general practitioner, are embedded with possibilities for error.  In a team situation where all members are allowed to practise fully within their registration, the accountability will more likely be overlapped resulting in a safer model for the patient/individual.

3.  I would like a care provider who was part of a smooth, well-oiled machine.  As a patient, I would like to know that there are regular meetings with other PHC stakeholders.  Brainstorming sessions involving PHC nurses would assure me that problems are being identified and actioned.  I would like to see this at a PHC level.  I can imagine a meeting to take place as current community district health boards (DHBs) meet but with a twist.  At the table would be the DHB nursing leader for PHC, a representative from all of the PHC nursing groups, and community representation. (Figure 3)

Figure 3.  Monthly Primary Health Care Meeting - Communication Flow                

At this meeting, each representative could present concerns and decide on an action to improve the health of the community.  As a recipient of care, I can be assured that problems are being identified, the best-positioned professional is addressing the problem, there is less redundancy (translating to wise use of funds), and enhanced communication between all PHC stakeholders.

4.  I would like to know that a health care provider is not glued to the office.  Health can be defined as a dynamic concept divided into different layers of prevention.  Primary prevention involves efforts to prevent a disease from happening.  Secondary prevention prevents the development of complications from having a disease.  Tertiary prevention prevents adding on to the complications and attempting to prevent morbidity or in its widest sense to prevent barriers to well-being even if it is in the context of end of life issues.
 
As an individual moves around this continuum of health, it would be reassuring to know that access continues even if I cannot make it to the clinic.  This access, in its widest interpretation, means care is not only provided when referred by a doctor.  PHCN would offer many services to me and to know that I would not have to go through a medical gatekeeper for a non-medical health issue would enhance access.

I would like to attend group education sessions provided by the PHC DHB.  RNs should be skilled educators.  Addressing education out of the clinic translates primary prevention to individuals before they become a patient.  As a health care user, I like the sound of that and would more likely access health care outside of the clinic walls.

5.  I would like a provider with whom I can communicate.  Chronic Care Model of Health (Wagner, et al., 2001) exquisitely addresses information technology in relation to this.

If I am able to email my provider to communicate I am provided more access to care.  This may reduce rushed, reactive visits with lack of active follow-up.  I can be alerted about health issues in the community filtering down from the PHC meetings, public education sessions, and individual concerns.  RNs are professional health educators well-positioned to enhance this aspect of care.
6.  For quality PHC, I would like a nurse or doctor that I could trust.  I believe that this is a process issue rather than a blaming issue.  Nurses in many practice settings are not fully free to practise to their full capability.  Barriers related to working as employees of general practitioners result in RNs doing tasks that are administrative which ultimately take time away from health care.  Assistants are most likely needed but whether that should be the nurse is a concern.  If a nurse fell under the DHB PHC umbrella then there would be a clear pathway for a nurse to develop professionally.  As a patient, that would be reassuring that my care is up-to-date and not in a vacuum.
As a patient, I would like to see signs that this professionalism is occurring.

• RNs would have time to return my phone call with best-practice in mind.
• RNs would sign his or her name to letters instead of ‘practice nurse’ enhancing accountability and professionalism.  If I need to talk to someone about my cervix (remembering that I don’t have one) I should at least be able to know the name of the person with whom I’m talking.

7. I would like a PHC provider that uses best knowledge available to help me make decisions.  How do I know that my provider is well-connected to accepted guidelines?  I would like to see opportunities to participate in research if participants are being recruited.  Most clinics seem far from this connection again resulting in reduced access.  Many opportunities exist to have tertiary institutions connect with clinicians.  Translating research into practice involves participating as well as synthesising results for individuals partnered in health.  Evidence suggesting that these behaviours are taking place includes:

• Sharing sites describing evidence-based care including point-of-care-evidence-that-matters.
• Seamless collaboration among stakeholders involved with individuals which includes individuals receiving consult notes.

8.  I would like to be seen as an individual having the ability to make decisions that are in my best interest.  This includes the type of PHC professional I would like to see.  Nurse-led clinics are a start to this vision.  There is still a huge barrier and that barrier is funding the clinics.  Individuals are not allowed to enrol under a nurse practitioner.  Nurse practitioners are able to practise close to communities in response to articulated community needs.  Due to funding schemes, individuals must enrol under a general practitioner.  This is incongruent to New Zealand’s Health Strategy.  If as an individual I was having some dysthymia and not a major clinical depression, counselling would not be funded.  Under an ideal world, I would be able to see a community mental health nurse (CMHN) with a self-referral.  The CMHN would be able to intervene with cognitive behavioural therapy to possibly prevent this dysthymia from progressing into a depression.  This improves access, provides care close to home within my PHO umbrella and is congruent with the definitions of health and the Strategy.
In conclusion, as an individual seeking health care in an ideal world I would like to have access to:

• Providers who had the knowledge and time to understand my health and needs, starting off my relationship with a thorough history and physical examination that was professionally documented;
• Providers who were strong communicators to colleagues, communities, and individuals partnered in care;
• Providers who were able to practise without walls;
• Providers freed up to practise in their full capacity utilising best-evidence health care;
• Providers who are willing to include me on my health care journey team.

The path for quality primary health care has been fully described in the document Investing in Health (Ministry of Health, 2003).  PHC nursing is in a prime position to drive quality primary health care.  The Ministry of Health appears dedicated to the Strategy however much work is yet to be done in order for PHC to get closer to the ideal.  In order to achieve this mandate the MOH must allow and support the team member most involved with primary health care prevention, the RN.
Mary Jane Gilmer, RN, MN, NP Primary Health Care Across the Lifespan
mgilmer@eit.ac.nz

References

Ministry of Health (2001). Primary Health Care Strategy.  Retrieved 15 April, 2007 from www.moh.govt.nz

Ministry of Health (2003). Investing in Health: Whakatohutia te oranga tangata: A framework for activating primary health care nursing in New Zealand.  Retrieved 14 April, 2007 from www.moh.govt.nz.

Salas, E., Wilson, K., Burke, C., & Wightman, D. (2006). Does crew resource management training work?  An update, an extension, and some critical needs. Human Factors, 48(2), 398-412.