Nursing in Australian general practice: directions and perspectives

Abstract

Primary health care services, such as general practices, are the first point of contact for many Australian health care consumers. Until recently, the role of nursing in Australian primary care was poorly defined and described in the literature. Changes in policy and funding have given rise to an expansion of the nursing role in primary care. This paper provides a review of the literature and seeks to identify the barriers and facilitators to implementation of the practice nurse role in Australia and identifies strategic directions for future research and policy development.

Aust Health Rev 2005: 29(2): 156-166

THE GENERAL PRACTITIONER (GP) remains the broker and gatekeeper to health care services in Australia, with some 90% of Australians visiting a GP each year.1 The clinical skills, expertise and knowledge level of clinicians working in primary care have evolved to meet the challenges created by a more informed consumer, advances in medical technology and a drive for improved health service outcomes.2 This paper seeks to outline the contribution of practice nurses to Australian primary health care, describe the international experience relating to practice nurse role development, determine the scope of the clinical practice boundaries and identify the barriers and facilitators to the practice nurse's role.

The growth of the nursing role in Australian primary care has been driven by multiple factors including the changing health care needs of consumers, shortage of GPs in rural areas and generally increasing GP workloads nationwide. The term "practice nurse" refers to either a State Board Registered or Enrolled Nurse who is employed to provide nursing services in the setting of general practice.3-7 This may be direct employment by an individual or group of GPs or through third party contracts with local Divisions of General Practice, community health services or other private providers of nursing services.8-13 In contrast, general community nurses are primarily employed by local health authorities or private health care organisations to deliver nursing care directly to the local population in their homes or at community health centres.8-11

Although many community nurses work within a primary care model, increasingly the services provided by the general community nurse are frequently under the direction of an acute care specialist following hospital discharge, although an increasing number of referrals are being received from chronic disease specialists. Specific criteria often exist to define the types of services that general community nurses can provide under pre-existing funding models. Further, these nurses are often subject to the policies and procedures of an overarching body, for example an Area Health Service. In contrast, the practice nurse provides services under the direct or indirect supervision of a general practitioner. It is important to establish the unique, yet complementary, role that the practice nurse has in the health system and the diversity between this role and that of the general community nurse. To date, the practice nurse role is related to streamlining business practices, preventing potential hospitalisations or improving general health status by services such as continence clinics or lifestyle risk factor counselling. Potentially, practice nursing can be considered a "specialty" area of general community nursing not unlike other areas such as public health, community mental health or community sexual health nursing.

An enduring concern is the limited regulation of the tasks that can be delegated to the practice nurse. Currently, the specific scope of the practice nurses work is defined through negotiation between the individual GP and nurse.12,13 In their evaluation of shared care between practice nurses and GPs in Australia, Willis et al.15 identified that there was significant variation in the role, patterns of referral and work of the practice nurse. They described this as being a continuum from the nurse working solely at the direction of the GP to the nurse having almost complete control over their workload.15 While this variable scope reflects the range of nurses' skill levels from novice to expert, it is also related to other factors such as the perceived ability of the nurse, often by a GP who may have a limited understanding of the professional scope of nursing practice,16 or experience in managing nursing resources.17,18 While the practice nurse has a personal responsibility to work within their scope of experience and the professional code of practice, nurses have historically been poor at negotiating with their employers.19 This, combined with the negative power relationship with the GP,3,12,20 leads to a multifaceted dilemma which complicates the process of defining the practice nurse role.

The role of the practice nurse

Nurses deliver health care services in primary care internationally, although the closest parallels to the Australian context can be found in the United Kingdom21 and New Zealand.22,23 In the UK, the number of practice nurses has more than trebled since 1988(21,24) and they have become integral to the health care system and delivery of primary care. This has occurred as part of the National Health Service Reform, which has a strong primary care focus, and the introduction of the 1990 GP contract.18,21,25,26 Although driven by health reform, the growth of practice nursing was not part of a central government plan but occurred in response to perceived local needs that were not being met by existing community nursing services.21 The subsequent ad hoc nature of practice nurse growth led to "an uncertain and ill-defined role" (page 7)21 where there is significant diversity in functioning between nurses and practices.24'27 Practice nurses have generally developed their own individual roles based upon local needs, individual practice demands, their perceived skill level and personal confidence.8,21,28 This situation can be seen to have several parallels to the Australian Government's recent injection of funds into practice nursing services.

NZ practice nursing expanded significantly following the introduction of government funding to promote the role. In 1970, the NZ government introduced the practice nurse subsidy scheme to encourage practice nurse employment.12 Docherty29 reports that the effectiveness of this funding was limited as many nurses continued to undertake non-nursing duties rather than adopting a full clinical load. Therefore, in 1983 the conditions of the funding were amended to require the nurse to specifically undertake nursing duties and have work space within the practice to provide direct patient care.12,29 NZ practice nursing has evolved significantly since this time and has become an integral component of the health system.

In 1997 a strategic plan for practice nursing was developed by the NZ Nurses Organisation.12 This plan identified the need for a clear career pathway, a marketing plan to boost the professional profile of this specialty, and adequate employment conditions to facilitate recruitment and retention.12 A stringent education and accreditation program supports the professional development framework.23 Despite such advancements in the practice nurse role in NZ, there is a paucity of published literature describing the role and associated issues.12 The apparent positive effect that strategic planning and professional development has offered NZ practice nurses in professional status and role development suggests the potential value of such planning in the Australian setting. Further research and evaluation is required, however, to substantiate such inferences.

Research on the practice nurse role has largely comprised descriptive studies that investigate the practice nurse role in isolation from other providers.30 In addition to identifying the practice nurse as a largely unexplored resource, key themes that emerge from the published literature identify that:

* practice nurses demonstrate a wide variation of skills, competencies and clinical experience;12,13,21

* there is considerable variation in the practice nurse role;21,31-33

* there are significant barriers to expansion of the role;12,13

* multidisciplinary interventions can effectively deliver secondary prevention strategies in chronic and complex disease;34

* practice nurses can potentially facilitate these multidisciplinary interventions;35,36

* practice nurses are generally favourably perceived by consumers, although there is some confusion about the nature of their role.

In Australia, practice nurses have potential to establish affiliations with local community groups that would make them more accessible and acceptable than ad hoc health promotion, screening or chronic disease management programs. This consideration is particularly important in Australian society given the cultural diversity within the community and the extended health care needs of those from culturally and linguistically diverse backgrounds. In these groups in particular, the GP has been shown to be a vital component of the health care system, maintaining the essential link between secondary and primary care.1

The evidence for the benefits of practice nurse intervention can be inferred from the positive results of clinical trials where general community nurses have been seconded to various roles within general practice.41-43 A major barrier to the continuation of such projects has been that funding of such inter- sectorial services is often not sustainable; a barrier which would be overcome through use of practice nurses to implement the interventions. The limited research available has supported this hypothesis.35'44'48 Further trials are required in multiple disease states within the Australian health care system.

Current practice nurse initiatives in Australia

In the Australian Federal Budget 2001-02, funding of $104.3 million was allocated to GPs in areas of high workforce pressure to employ additional practice nurses over a 4-year period.49,50 This was divided into funding for employment ($86.6 million), training and professional support ($12.5 million), and scholarships to encourage rural nurses to return to the workforce ($5.2 million).51 Although this funding was made available to areas of workforce shortage, in particular rural and remote areas, it is only since the allocation of this funding that work has begun to evaluate the changes to the culture and practice of primary care in Australia and the potential role for the practice nurse.

Proposed changes to the Medicare system will, reportedly increase practice nurse numbers by some 1600 nurses.52 While this is a positive step in improving primary care for Australians, it must be supported by a research and education infrastructure to ensure that strategic, as opposed to reactive, role development occurs which will contribute to improving patient outcomes. In addition to the completed reviews of the practice nurse role, educational needs and consumer perceptions,12,13,37,53,54 further well designed, largescale research is required. Such research should investigate the nature of collaborative practice between GPs and practice nurses; the potential for extending the practice nurse role to encompass case management models of chronic and complex conditions; and workplace issues, including professional supervision, remuneration scales, career pathways and professional regulation.

Much of the discussion in the Australian media surrounding practice nurses has focused upon the revamped Medicare package and the concurrent increases in practice nurse funding.52'55'56 While the popular press view the increase in practice nurse numbers positively, the role and scope of nursing professional practice does not appear to be well understood. Published commentary has described practice nurses as "nurses who perform some duties normally the preserve of the GPs"52 and as a general panacea for overworked and harried GPs. These articles fail to appreciate the scope of professional nursing practice and the significant contribution that practice nurses make to collaborative, multidisciplinary primary care. Given that the popular press is often a barometer of public views, this perception of practice nurses requires urgent attention by nursing associations to ensure that the public are apprised of the professional scope of these practitioners. This is particularly significant given the relative infancy of the practice nurse role and the finding that consumers who had greater exposure to a practice nurse exhibited a greater appreciation of their diverse role in health education, counselling and disease management than those who had not been involved with practice nurses.37

Development of the practice nurse role in Australia

The practice nurse role is subject to influence from diverse factors, including the national health agenda, contemporary legal requirements relating to health care delivery, economic and social concerns, professional issues, knowledge development, consumer needs and workforce supply and demand.13 The ways in which these factors currently enhance and constrain practice nurse role development are summarised in the Box.

The barriers

Current funding arrangements for general practice

The Australian primary care funding situation differs somewhat to that described in the UK and NZ literature. The Australian Medicare system that provides reimbursement for GP services provides only limited reimbursement for many nursing services that have not been directly supervised by a GP.15 Currently suggested changes to the Medicare system, including the provision of provider numbers to practice nurses and increased item numbers for nursing services, are seen as positive yet insufficient attempts to address this issue.6,57,55 As part of the new MedicarePlus package, two items for services by practice nurses have been introduced to provide remuneration to GPs for practice nurses providing immunisations (Item 10993) and wound care (Item 10996). The schedule fee for these item numbers has been set at $10, with a Medicare rebate of $8.50.7 Although these fees can be augmented by the immunisation incentive payments and the new $5 bulk billing item,7 it remains unclear whether they will provide sufficient incentive to encourage GPs to employ additional practice nurses. A further item number (10998) was introduced on January 1 2005 to fund pap smears undertaken by accredited nurses in regional, rural and remote areas. This enhanced funding likely improves the accessibility of pap smears to women in regional, rural and remote areas. However, the variation in Medicare rebate by geographical location potentially sets up a two-tiered service, whereby patients in urban and outlying areas receive increasingly disparate health care delivery. Additional item numbers for aspects of practice nursing such as lifestyle counselling, chronic disease assessment and management, and patient education would be beneficial in demonstrating recognition of the advanced scope of the practice nurse role and their significant contribution to collaborative primary care.

Limiting expenditure on wages is one way for GPs to increase income.58 Most general practices employ a receptionist, suggesting receptionists are considered a necessity, while nurses are considered a more expensive option.58 In spite of this trend, anecdote suggests those GPs who have worked with a practice nurse are better able to appreciate their value and contribution to primary care.59,60

The perception of nursing in general practice

Despite the advantages, a large number of GPs remain unconvinced the employment of a nurse will improve their practice efficiency, effectiveness and patient outcomes.58 GPs are not clear how the employment of practice nurses can translate into economic efficiencies within their practice. In her exploration of Australian practice nursing, Patterson58 identified that around one third of GPs thought that their medical receptionists could be sufficiently trained to undertake nursing tasks. In this study, administrative and reception staff were clearly identified as undertaking nursing and medical tasks without formal, accredited education and training.58 Such practice potentially places these employees in violation of legislation regarding professional practice and the regulation of health care providers. Indeed, the title of "practice nurse" remains unprotected under the Nurses and Midwifery Act 2002 (NSW)55 and similar legislation in other states and territories. The nature of general practice as a business, however, means that GPs have the authority to employ any individual regardless of education level or experience and delegate to them whatever tasks they deem appropriate.58 Many GPs are not fully aware of differences in role and scope of practice between Registered Nurses (RNs), Enrolled Nurses (ENs), Assistants in Nursing (AINs) and the requirements of the various statebased Nurse Registration Boards. Such a finding is not surprising considering the lack of multidisciplinary education in both undergraduate and postgraduate curricula.

Despite the advantages inherent in the role and the growth of the specialty internationally, in Australia, practice nursing has a relatively low professional profile. As with all community-based nursing groups, there has been a paucity of published material on clinical practice within the Australian context.51 Thus, primary care nurses have failed to develop a professional profile akin to that of the acute care nursing specialties.13 Additionally, the isolated nature of the practice nurse role means that they frequently have poor representation in the management of health services and professional nursing groups. Research exploring the role of the primary health team frequently omits, or merely tacitly explores, the role of the practice nurse.62 At a time when the focus of health care is shifting from acute to primary care settings, it is disturbing that community-based nursing generally, and practice nursing in particular, has such a low profile and representation in health care decision making.63

The professional relationship with the GP

Clinical supervision is a concern. While Enrolled or Division 2 nurses are required to be supervised by an RN,64 an RN does not require supervision by a more experienced nurse.65 The RN has a professional responsibility to practice within the accepted scope of practice and his or her individual professional competence. There has been controversy about the lack of professional monitoring of practice nurses, and the risk for these nurses to become further subservient to doctors and isolated from the nursing profession.18,66 Additionally, medical training has historically placed little emphasis upon human resource (HR) management18 or multidisciplinary collaborative practice.67 The professional relationship with the GP is also linked to the implicit power differences of the doctor-nurse divide, the economic power wielded through the employee-employer relationship, gender differences - and nurses' frequent lack of skills in negotiating conditions.8,19,26,66 A small minority of UK nurses have reportedly felt pressured to undertake clinical tasks about which they were unhappy.21 The relative professional isolation of practice nurses may also increase pressure to undertake tasks that nurses practising in acute care settings might not experience. The UK survey also found that the nature of clinical supervision was seldom clearly defined, but loosely based on implicit assumptions which varied from practice to practice.21 This is an important issue for Australian practice nurses in light of the lack of post-basic education, the multidisciplinary nature of the relationship and the dual role of the GP as both employer and clinical supervisor.

Lack of education and training opportunities

The rapid development of the practice nurse role has led to the recruitment of a diverse group of nurses who have a wide range of nursing qualifications and clinical experience.31,32 This, and the wide variation in roles, complicates the initial preparation and subsequent professional development for the practice nurse role. Additionally, GPs provide varying levels of support for continuing education, such as study leave and fee relief.13,58,59,68

Professional isolation has been identified as a major issue for practice nurses, with around 16% working alone in the UK.21,62 The vast geographical distances related to the population distribution in the Australian context intensify this isolation.69 This has implications for not only professional mentorship but also continuing access to education and professional development opportunities.70 Additionally, practice nurses identify a lack of supportive relationships in the workplace.21

Global shortage of qualified nurses

The global shortage of qualified nurses has focused on recruitment and retention.55 While new specialty areas such as practice nursing may enhance the retention of nurses due to improved conditions, flexible working hours and increased job satisfaction,18,61,71 losses from the health system will likely compound current human resource issues.

The facilitators

Australia's National Health Priorities

The 1996 Australian National Health Priorities of cardiovascular health, cancer control, injury prevention, mental health and diabetes mellitus reflect the increasing impact of chronic and complex disease states upon our society.72 Contemporary literature demonstrates the benefits of nursing intervention in improving quality of life, reducing hospital readmissions and increasing consumer compliance in chronic and complex disease states.73,74 The practice nurse is ideally positioned to provide this type of primary health care in the familiar and accessible environment of general practice.

Increasing the effectiveness of CP service delivery

Several advantages have been identified from the increase in practice nurse availability in general practice. Sibbald75 describes these advantages as being related to:

* the enhancement of available services in general practice, such as chronic illness management, wound care and health promotion, thus potentially reducing dependence of patients upon acute care facilities.21,24,25,64,65

* substitution for the GP in some interdisciplinary tasks, which in the UK, has allowed general practices to reach population-based targets for screening items such as immunisations and health screening.21,24

* delegation of screening, assessment and pathology tasks to the practice nurse releases the GP to spend more time with those clients who have greater complex medical needs.21,24

Unfortunately, much of the early literature regarding the role of practice nurses focuses upon how the practice nurses could save the GPs time, rather than how they could enrich client services66 and develop the nursing role as an integral component of the practice team. Further research is needed to explore the issues relating to the implementation of models of collaborative practice in general practice and their effectiveness on patient outcomes.

Consumer perceptions of nurses

As a profession, nurses are generally viewed as being amicable, ethical and trustworthy.13'69 Several studies have investigated consumer perceptions of the practice nurse role both in Australia37,40,53,54,80 and internationally.38'39'78'79 In 2002, the National Steering Committee on Nursing in General Practice conducted an Australia-wide focus group analysis of consumer perceptions of nursing in general practice.37 This study sampled 170 consumers from rural and metropolitan areas, with varying experience with practice nurses. The participants readily identified clinical tasks such as injections, wound care, dressings, health assessment (eg, blood pressure measurement, body weight), counselling and support37 as components of the practice nurse role. Fewer consumers identified the role of the practice nurse in health education, providing test results or health monitoring.37 Two potentially contradictory themes were expressed by participants in the Australian focus groups. Some participants felt that a client should see the GP first and then receive any required follow-up care by the practice nurse under the direction of the GP.37 The other view was that the practice nurse should triage, providing frontline assistance and offering subsequent referral to the GP if considered necessary.37 Participants with this view stressed that the practice nurse should not become a gatekeeper for the GP; but an enhancement of the GP and not a substitute for GP consultation.

Although there is some confusion regarding the role of the practice nurse, those consumers who have had contact with this role have responded favourably.37,53,54,80 A key message voiced by consumers is that any expansion of the practice nurse role in Australia must not jeopardise the choice of the consumer to seek primary health care from a GP or result in any increased costs associated with the provision of primary health care.37

Support of practice nursing by the Division of General Practice

Although there has been limited formal evaluation of support provided by Divisions of General Practice to practice nurses, preliminary work and anecdotal evidence indicate that such support seems to facilitate positive role development.60 Formal practice nurse education is largely delivered through the Divisions.12 However, the emphasis is on the provision of clinical care, particularly in relation to national priority areas, rather than clinical coordination or professional integration.12 There is also a component of professional networking which reduces the professional isolation inherent in the practice nurse role. Further formal research is required to explore the benefits of Divisional support and the optimal models of delivery of such support to optimise access to all practice nurses.

Conclusions

On the basis of the literature review described above, several factors regarding the nursing role require further consideration, research and debate. These include the role of general practice nursing in collaborative practice such as chronic disease management, negotiation of competencies and scopes of clinical practice, and the development and evaluation of collaborative models of care to enhance patient outcomes. Professional nursing bodies also need to actively collaborate to develop practice nursing as a defined specialty, and work with medical general practice groups to reach mutually acceptable aims and objectives.

Acknowledgement

Information related to this article was presented to the Australian Council of Deans (Nursing) for an honorarium to the School of Nursing, Family and Community Health, University of Western Sydney.

Competing interests

None identified.

[Sidebar]

What is known about the topic?

Following the recognition of the benefits of general practice nursing there has been growth in this nursing practice in the United Kingdom, New Zealand and, to a lesser extent, Australia, yet the role and scope of practice remains unclear.

What does this study add?

This study provides a literature review of practice nursing and discusses the many barriers and facilitators to enhancement of this role in Australia.

What are the implications for practice?

The authors call for leadership from professional nursing bodies to define and develop the role, accompanied by discussion and debate throughout the health care system on the contribution of practice nursing to enhancing patient outcomes through collaborative models of care.

[Reference]

References

1 Commonwealth Department of Health and Family Services. General Practice in Australia: 2000. Canberra: Australian Government Printing Service, 2000.

2 Poulton B. Practice nursing: a changing role to meet changing needs. London: Department of Health, 1997.

3 Centre for General Practice Integration Studies. Developments in Primary Health Care Integration. Paper No. 2: Practice nurses. Sydney: University of New South Wales, 2001 September.

4 Logan Area Division of General Practice. What is a practice nurse? Woodridge, Queensland: LADGP1 2002. Available at: http://www.ladgp.com.au/PracticeNurses.htm (accessed Mar 2005).

5 Rural Doctors Association of Australia. Rural and remote nursing practice policy. Canberra: RDAA; July, 2003. Available at: http://www.rdaa.com.au/ nursing_practicepolicyfinal_0205027_.pdf (accessed Mar 2005).

6 Young L. Support for Medicare practice nurse plan. NursFtev2003: 1-3.

7 Australian Government Department of Health and Ageing. MedicarePlus: two new MBS items for services provided by practice nurses. Canberra: DoHA, 2004. Available at: http://www.health.gov.au/medicareplus/moreinfo/factsheets/fact02.htm (accessed Mar 2005).

8 Peachey M, Clarke J A. GP employer: the case for... the case against. Nurs Times 1987; 83(17): 34-5.

9 The Georgian Research Society. The attitudes of general practitioners towards practice nurses: a pilot study. Br J Gen Pract 1991; 41(342): 19-22.

10 Greenfield S, Stilwell B, Drury M. Practice nurses: social and occupational characteristics. J Roy Coll Gen Pract 1987; 37:341-5.

11 Robinson G, Beaton S, White P Attitudes towards practice nurses - survey of a sample of general practitioners in England and Wales. Br J Gen Pract 1993; 43: 25-9.

12 Watts I, Foley E, Hutchinson R, et al. General practice nursing in Australia. Canberra: Royal Australian College of General Practitioners and Royal College of Nursing, Australia, 2004.

13 Patterson EA. Primary health care nursing: a case study of practice nurses [PhD thesis]. NSW, Australia: Griffith University, 2000.

14 Bowling A. Doctors and nurses: delegation and substitution. In: Harrison A, Gretton J, editors. Health care UK - 1985. London: Chartered Institute of Public Finance and Accountancy, 1985.

15 Willis E, Condon J, Litt J. Shared care between practice nurses and general practitioners. Adelaide: The Flinders University of South Australia, 1998.

16 Bowling A. District health authority policy and the extended clinical role of the nurse in primary health care. J Adv Nurs 1985; 10: 443-54.

17 Center for Innovation in Primary Care. Looking after long-term illness: implications for practice consultation rates. Sheffield: Practice Data Comparison Project, 1999.

18 Hampson G. Practice Nurse Handbook. 4th ed. Oxford: Blackwell Science, 2002.

19 Adamson D. The pivotal role of the practice nurse. Proceedings of the Royal College of Nursing, Australia. 2nd National General Practice Nurse Conference: Working together - improving primary care through teamwork. 2004 October 21-23; Wollongong, New South Wales.

20 Hurley C, Kalucy L, Battersby M. General practitioners' collaboration with service co-ordinators. Aust J Primary Health 2002; 8(1): 45-51.

21 Atkin K, Lunt N. Nurses in practice: the role of the practice nurse in primary health care. York: Social Policy Research Unit, University of York, 1995.

22 New Zealand Ministry of Health. The Primary Health Care Strategy. Wellington: 2001. Available at: http:// www.moh.govt.nz (accessed Mar 2005).

23 New Zealand College of Practice Nurses. Strategic Plan 2002-2005. Wellington: New Zealand Nurses Organisation, 2003.

24 Harrison S, Dowswell G, Wright J. Practice nurses and clinical guidelines in a changing primary care context: an empirical study. J Adv Nurs 2002; 39(3): 299-307.

25 Willis E, Condon J, Litt J. Factors impacting on shared care working relationships between practice nurses and general practitioners: a literature review. Contemporary Nurse 2000; 9(2): 120-31.

26 Broadbent J. Practice nurses and the effects of the new general practitioner contract in the British NHS: the advent of a professional project? Soc Sci Med 1998; 47(4): 497-506.

27 Atkin K, Hirst M, Lunt N, et al. The role and selfperceived training needs of nurses employed in general practice: observations from a national census of practice nurses in England and Wales. J Adv Nurs 1994:20:46-52.

28 Walsh N, Roe B, Huntington J. Delivering a different kind of primary care? Nurses working in a personal medical service pilots. J Clin Nurs 2003; 12: 333-40.

29 Docherty B. Nursing in general practice: a New Zealand perspective. Christchurch: Caxton Press, 1996.

30 Halcomb EJ, Davidson P, DaIy J, et al. Australian nurses in general practice based heart failure management: implications for innovative collaborative practice. Euro J Cardiovasc Nurs 2004; 3(2): 135-47.

31 Bentley H. Back to the future. Λ/urs Times 1991; 87(24): 29-30.

32 Peachey M. Practice makes perfect. Nurs Times 1992; 88(11): 59-60.

33 Stark S, Warne T1 Street C. Practice nursing: an evaluation of a training practice initiative. Nurse Educ Today 2001; 21(4): 287-96.

34 Stewart S, Horowitz JD. Home-based intervention in congestive cardiac failure: long-term implications on readmission and survival. Circulation 2002; 105: 2861-6.

35 Campbell NC, Ritchie LD, Thain J, et al. secondary prevention in coronary heart disease: a randomised trial of nurse led clinics in primary care. Heart 1998; 80: 447-52.

36 Fitzmaurice DA, Hobbs FDR, Murray ET. Primary care anticoagulant clinic management using computerised decision support and near patient international normalised ratio (INR) testing: routine data from a practice nurse-led clinic. Fam Pract 1998; 15(2): 144-6.

37 Cheek J, Price K, Dawson A, et al. Consumer perceptions of nursing and nurses in general practice. Adelaide: Centre for Research into Nursing and Health Care, University of South Australia; 2002.

38 Coyle J, Calnan M, Williams S. Consumer satisfaction with GPs and the public's perception of practice nurses. Nurs Times 1993; 89(25): 44-6.

39 Phillips D, Brooks F Women users' views on the role and value of the practice nurse. Health Soc Care Community 1998; 6(3): 164-71.

40 Newsome S. Consumers support nursing in general practice but need help identifying who's a nurse and what they do. National Networks 2003; 38: 4-5.

41 Waldon P. Self-management of chronic diseases in the Macarthur Primary Health Nursing team: enhancing partnerships, not just behaviours. Proceedings of the General Practice and Primary Health Care Research Conference; 2004 June 2-4; Brisbane.

42 Bartels P, Burke J. Is teamwork the answer to chronic disease management in general practice. Proceedings of the General Practice & Primary Health Care Research Conference; 2004 June 2-4; Brisbane.

43 Murray A, Stephan A, Maehler B, et al. Partnerships: the way to support GPs in care planning. Proceedings of the General Practice & Primary Health Care Research Conference; 2004 June 2-4; Brisbane.

44 Pritchard A, Kendrick D. Practice nurse and health visitor management of acute minor illness in a general practice. J Adv Nurs 2001 ; 36(4): 556-62.

45 Griffin S, Kinmonth AL. Systems for routine surveillance for people with diabetes mellitus (Cochrane Review). In: The Cochrane Library, Issue 3, 2002. Oxford: Update Software.

46 Campbell NC, Thain J1 Deans HG, et al. secondary prevention in coronary heart disease: baseline survey of provision in general practice. BMJ 1998; 316: 1430-4.

47 Campbell NC, Thain J1 Deans HG, et al. secondary prevention in coronary heart disease: randomised trial of effect on health. BMJ1998; 316: 1434-7.

48 Moher M, Yudkin P, Wright I, et al. Cluster randomised control trial to compare three methods of promoting secondary prevention of coronary heart disease in primary care. BMJ 2001; 322(Jun 2): 1338-42.

49 Commonwealth of Australia Nursing in general practice: key national priorities. Canberra: Department of Health and Ageing General Practice Branch, 2002. National Networks January Edition. Available at: http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pcd-programs-nursing-networks.htm (accessed Mar 2005).

50 Commonwealth of Australia. Additional practice nurses for rural Australia and other areas of need: guidelines. Canberra: Department of Health and Aged Care, 2000.

51 Commonwealth of Australia. Information on the Nursing in General Practice 2001-2002 Federal Budget Initiative. Canberra: Department of Health and Aged Care. Available at: http://www.health.gov.au/internet/ wcms/Publishing.nsf/Content/health-pcd-programsnursing-budget.htm (accessed Mar 2005).

52 Dodson L, Wroe D. Health plan to boost doctors, nurses. The Age (Canberra) 2003 Oct 29: 3.

53 Hegney D, Buikstra E, Fallon T, et al. Consumer perceptions of practice nursing. Toowoomba: University of Southern Queensland, 2004.

54 Hegney D, Price K, Patterson EA, et al. Australian consumers' expectations for expanded nursing roles in general practice. Aust Fam Phys 2004; 33(10): 845-8.

55 The College of Nursing. MedicarePlus 'fails to deliver'. nursing.aust 2003; 4(4): 1-3.

56 GPs employ more nurses. Pharma in Focus 2004; 3 March.

57 Plenary Session - practice nurse initiative. Proceedings of the Royal College of Nursing, Australia. 2nd National General Practice Nurse Conference: Working together - improving primary care through teamwork. 2004 October 21-23; Wollongong, New South Wales.

58 Patterson EA. Future leaders in the provision of primary health care? Proceedings of the Inaugural National Practice Nurse Conference - new roads to travel: challenges for the expanding role of the practice nurse. 2003 November 6-8; Bunbury, Australia: Royal College of Nursing, Australia.

59 Smith J, Foster G. Expanding the role of the practice nurse to initiating and providing immunisations within a general practice. Proceedings of the Inaugural National Practice Nurse Conference - new roads to travel: challenges for the expanding role of the practice nurse. 2003 November 6-8; Bunbury, Western Australia: Royal College of Nursing, Australia.

60 Meadley L. HUDGP Practice Nurse/General Practitioner Interview Project. Proceedings of the Royal College of Nursing, Australia. 2nd National General Practice Nurse Conference: Working together improving primary care through teamwork. 2004 October 21-23; Wollongong, New South Wales.

61 Condon J, WiINs E, Litt J. The role of the practice nurse: an exploratory study. Aust Fam Physician 2000; 29(3): 272-7.

62 Mackereth CJ. The practice nurse: roles and perceptions. J Adv Nurs 1995;21: 1110-6.

63 Brookes K. Role perceptions and experiences of community health nurses in a contemporary health care system [Bachelor of Nursing (Honours) thesis]. Sydney: University of Western Sydney, 2003.

64 Commonwealth Department of Health and Aged Care. Additional practice nurses for rural Australia and other areas of need: questions & answers. Canberra: DHAC, 2000.

65 Royal College of Nursing Australia. Fact sheet no. 1: nurses in general practice: roles. Canberra: RCNA. Available at: http://www.rcna.org.au/content/nigp.pdf (accessed Mar 2005).

66 Bowling A, Stilwell B, editors. The nurse in family practice: practice nurses and nurse practitioners in primary health care. London: Scutari Press, 1988.

67 Humphris D. Multi-professional learning: is it the way forward? Proceedings of the RCN National Practice Nurse Conference. 2004 Jun 30 - JuI 2; Winchester, England.

68 Atkin K, Lunt N, Parker G, et al. Nurses count: a national census of practice nurses. York: Social Policy Research Unit, University of York, 1993.

69 Heath R National Review of Nursing Education: Discussion Paper. ISBN O 642 77230 4 DETYA No. 6793. HERC01A. Canberra: Commonwealth Department of Education, Science and Training and Commonwealth Department of Health and Ageing, 2001.

70 Heartfield M, Gibson T, Chesterman C, et al. Developing a mentoring framework for general practice nurses: options paper. Canberra: Commonwealth Department of Health and Ageing, Nursing and Allied Health Branch, 2003.

71 Martin C. Practice makes perfect? Nurs Times 1987; 83(17): 28-31.

72 Australian Institute of Health and Welfare, Commonwealth Department of Health and Family Services. First report on National Health Priority Areas 1996. Canberra: Australian Government Publishing Service; 1997. (AIHW Cat. No. PHE 1.)

73 Stewart S, Pearson S, Horowitz JD. Effects of a homebased intervention among patients with congestive heart failure discharged from acute hospital care. Arch Int Med 1998; 158: 1067-72.

74 Davidson P, Stewart S, Elliott D, et al. Addressing the burden of heart failure in Australia: the scope for home-based interventions. J Cardiovasc Nurs 2001; 16(1): 56-68.

75 Sibbald B. Keynote address: nurses in general practice: an evolution in primary care. Proceedings of the General Practice and Primary Health Care Research Conference: Primary Health Care Research - Evolution or Revolution? 2003 June 19-20; Canberra.

76 Patterson EA, McMurray A. Collaborative practice between registered nurses and medical practitioners in Australian general practice: moving from rhetoric to reality. Aust J Adv Nurs 2003; 20(4): 43-8.

77 Lockwood A, Maguire F General practitioners and nurses collaborating in general practice. Aust J Prim Health 2000; 6(2): 19-29.

78 South Tyneside Patient Satisfaction Workshop. Who should give lifestyle advice in general practice and what factors influence attendance at health promotion clinics? Survey of patients' views. Br J Gen Pract 1995; 45:669-71.

79 Coyle J, Calnan M, Williams S. Changing perceptions. Nurs Times 1993; 89(25): 44-6.

80 Consumers Health Forum of Australia. Consumer expectations of general practice in Australia. Canberra: CHF, 1999. Available at: http://www.chf.org.au/ Docs/Do wn loads/195_conexpectationGP.pdf (accessed Mar 2005).

(Received 9 Jun 2004, accepted 10 Mar 2005)

[Author Affiliation]

Elizabeth J Halcomba, RN, BN(Hons), GradCertlC, Doctoral candidate

John P Daly, RN, MEd(Hons), PhD, Professor of Nursing and Foundation Head of School

School of Nursing, Family and Community Health, University of Western Sydney, Sydney, NSW.

Patricia M Davidson, RN, MEd, PhD, Associate Professor of Nursing and Director

Nursing Research Unit, University of Western Sydney and Western Sydney Area Health Service, Sydney, NSW.

Rhonda Griffiths, RN, CM, DrPH, Professor of Nursing and Director

Center for Applied Nursing Research, University of Western Sydney and South Western Sydney Area Health Service, Sydney, NSW.

Julie Yallop, RN, Senior Research Fellow

Cardiovascular Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC.

Geoffrey Toiler, MB BS, MD, FRACP, Professor of Cardiology

Department of Cardiology, Royal North Shore Hospital, Sydney, NSW.

Correspondence: Mrs Elizabeth J Halcomb, School of Nursing, Family and Community Health, University of Western Sydney, Locked Bag 1797, Penrith South DC, Sydney, NSW 1797. e.halcomb@uws.edu.au