Abstract
Background
Nurses are becoming increasingly important as providers of primary health care in Australia. In November 2010, Medicare provider rights and Pharmaceutical Benefits Scheme rights for nurse practitioners, working in private practice and in collaboration with a medical practitioner, were introduced in Australia. Although international evidence suggests that nurse practitioners would be appropriate and acceptable providers of care at the first point of contact, such as primary health care, there is little Australian evidence about what care consumers are willing to accept from nurse practitioners.
Objectives
To ascertain what care Australian health‐care consumers would accept from nurse practitioners in this setting.
Participants
Australian adults over 18 years of age.
Methods
National Survey delivered online. Information about the survey was disseminated through a media campaign, stakeholder engagement and through the health‐care consumer networks nationally.
Results
The total number of respondents that started the survey was n = 1883. Ninety‐five percentage (n = 1784) of respondents completed the survey. The majority of respondents were women, aged 25–54 years, had completed tertiary education and had an annual household income of more than A$80 000. The majority of the respondents (n = 1562, 87%) said they would be prepared to see a nurse practitioner for some of their primary health‐care needs.
Conclusions
The findings of this study suggest consumers are accepting of a range of activities undertaken by nurse practitioners in primary health care and this has relevance for primary health‐care workforce mix and organization, particularly for areas that are underserved by medical practitioners.
Keywords: consumer satisfaction, nurse practitioners, primary care
Background
Nurses are becoming increasingly important as providers of primary health care in Australia. Nurses have had a long but sometimes hidden history of working in community health roles.1, 2 However, their role and increasing numbers in commonwealth‐funded primary health‐care services, and particularly general practice, is a relatively recent phenomenon.3, 4 These developing roles for nurses have been facilitated by policy development that provides financial support to general practice through particular Australian government budget initiatives since 2002. In the 2010 budget,5 further initiatives were announced to help increase the number of nurses working in general practice and to adopt broader roles.
Further development of the nursing role and profession was the introduction of nurse practitioners who have been able to practise in Australia since 2000.6 Nurse practitioners are registered nurses who can demonstrate that they practise at an advanced level, which is complemented by research, education and management, and who have completed a tertiary qualification, namely a master's degree.7 Nurse practitioners work in diverse settings, and there are now 534 endorsed nurse practitioners in Australia.8 In November 2010, Medicare provider rights for nurse practitioners, working in private practice and in collaboration with a medical practitioner, were introduced in Australia. Collaborative arrangements can include co‐location with medical practitioners or working at a geographic distance from that medical practitioner. In some areas, particularly areas of general practitioner workforce shortage, nurse practitioners may be used as substitutes for general practitioners. In other areas, nurse practitioners may work in collaboration with general practitioners and other primary health‐care providers. Nurse practitioners are eligible to claim Medicare remuneration according to specific item numbers. These items are characterized by the length and nature of the consultation. The scheduled fees available to nurse practitioners range from A$9.20 to A$56.30. In comparison, scheduled fees for general practitioners range from A$34.30 to A$97.80 for comparable activity. Nurse practitioners and general practitioners are able to charge over and above the scheduled fee and this amount is paid by the patient and not by Medicare. Pharmaceutical Benefits Scheme rights were also introduced for those nurse practitioners working in States and Territories who were signatories to the Pharmaceutical Reform Agreement. These legislated changes to the nurse practitioner role have significant implications for the inclusion of nurse practitioners in primary health care.
International evidence suggests that that nurses working in primary care can provide effective care and achieve positive health outcomes for patients similar to that provided by doctors. They also achieve good patient compliance.9, 10 Furthermore, patients are as satisfied with the care provided at first contact by nurse practitioners as they are with that provided by doctors.11
International evidence also suggests nurse practitioners would be appropriate and acceptable providers of care at the first point of contact, such as primary health care,12, 13 in rural areas underserved by medical practitioners14 and for other specific populations,12, 15 as independent practitioners16 and to enable timely access.17 However, there is little Australian evidence about what care consumers are willing to accept from nurse practitioners working in primary health care. This paper reports on the first national survey examining what care Australian health‐care consumers would accept from nurse practitioners in this setting. The study was conducted between July 2010 and February 2011.
Methods
Ethics approval to conduct this project was received from the Human Research Ethics Committee at The Australian National University (ANU) (protocol no. 2010/282). The national survey was delivered online via survey monkey (www.surveymonkey.com) and opened on 1 November 2010 and was available online throughout the month of November, 2010. Information about the survey was disseminated through a media campaign, stakeholder engagement and through the health‐care consumer networks nationally.
Survey respondents were provided with the following definition of nurse practitioners and asked whether they would be prepared to see a nurse practitioner for some of their primary health‐care needs.
Nurse practitioners are registered nurses with additional qualifications (a master's degree) who perform in an advanced clinical role. They can refer patients to other health professionals, prescribe medications and order diagnostic tests, for example, prescribe antibiotics and order diagnostic tests such as X‐rays or blood tests.
The survey data were summarized using numbers and percentages to describe the demographics of the respondents and the proportions responding to each question. Logistic regression was used to identify which participant characteristics and their access to general practice were most highly associated with perceived acceptability for activities that nurse practitioners could perform in primary health care.
Results
The total number of respondents who started the survey was n = 1883. Ninety‐five per cent (n = 1784) of respondents completed the survey. The majority of respondents were women, aged 25–54 years, had completed tertiary education and had an annual household income of more than A$80 000 (Table 1). Average full‐time annual earnings in Australia in the last quarter of 2010 were A$66 594.18
Table 1.
Demographics of survey respondents compared with the Australian population (ABS 2006 census data)
| Survey n (%) | ABS n (%) | |
|---|---|---|
| Gender | ||
| Female | 1453 (77.2) | 10 056 038 (50.6) |
| Male | 425 (22.6) | 9 799 249 (49.4) |
| Other | 5 (0.3) | – |
| Age (years) | ||
| 18–24 | 113 (6.0) | 2 704 276 (13.6) |
| 25–54 | 1276 (67.8) | 8 376 751 (42.2) |
| 55–64 | 371 (19.7) | 2 192 675 (11.0) |
| 65 and over | 123 (6.5) | 2 644 374 (13.3) |
| Median | 48 | 37 |
| Avg (range) | 18–100 | – |
| Children living with respondent | 836 (44.4) | – |
| Under the age of 18 years | 591 (73.9) | – |
| Education | ||
| Postgraduate degree | 770 (41.7) | 413 101 (4.94) |
| Graduate diploma and graduate certificate | 248 (13.4) | 228 550 (2.7) |
| Bachelor's degree | 412 (22.3) | 1 840 660 (22.0) |
| Advanced diploma and diploma | 108 (5.9) | 1 130 464 (13.5) |
| Certificate | 131 (7.1) | 2 662 780 (31.8) |
| Secondary education | 145 (7.9) | – |
| Primary education | 3 (0.2) | – |
| Pre‐primary education | 5 (0.3) | – |
| Other education | 23 (1.2) | – |
| Income | ||
| Under $10 000 | 20 (1.1) | – |
| $10 000–$24 999 | 66 (3.6) | – |
| $25 000–$49 999 | 144 (7.8) | – |
| $50 000–$64 999 | 134 (7.3) | – |
| $65 000–$79 999 | 201 (10.9) | – |
| $80 000–$99 999 | 289 (15.7) | – |
| $100 000–$150 000 | 485 (26.3) | – |
| Over $150 000 | 401 (21.7) | – |
| Don't know | 105 (5.7) | – |
| Median | – | $1027 (median weekly household income) |
| State or territory | ||
| ACT | 245 (13.0) | 324 034 (1.6) |
| NSW | 477 (25.3) | 6 549 177 (32.9) |
| NT | 18 (1.0) | 192 898 (1.0) |
| Qld | 309 (16.4) | 3 904 532 (19.7) |
| SA | 157 (8.3) | 1 514 337 (7.6) |
Of the 61% of survey respondents who had received care from a nurse working in general practice, only 18% reported the nurse was a qualified nurse practitioner, 51% reported the nurse was not a qualified nurse practitioner and 32% did not know if the nurse was a qualified nurse practitioner.
The majority of the respondents (n = 1562, 87%) said they would be prepared to see a nurse practitioner for some of their primary health‐care needs. Respondents were then asked to identify which primary health‐care practices they would be happy to see a nurse practitioner for. Practices were identified as highly acceptable (75%+ of respondents), moderately acceptable (50–74% of respondents) or of low acceptability (<50% of respondents) (Table 2).
Table 2.
Acceptability of activities provided by nurse practitioners
| Level of acceptability | Activity | n (%) |
|---|---|---|
| High (75% +) | Take medical history | 1584 (91) |
| Triage | 1554 (89) | |
| Provide repeat prescriptions | 1540 (89) | |
| Suture superficial lacerations | 1535 (88) | |
| Order diagnostic tests | 1477 (85) | |
| Diagnose minor infectious illnesses | 1458 (84) | |
| Pregnancy testing | 1424 (82) | |
| Diagnose minor muscle injuries | 1378 (79) | |
| Provide emergency contraception | 1345 (77) | |
| Moderate (50–75%) | Manage chronic or continuing conditions | 1283 (74) |
| Interpret diagnostic tests | 966 (56) | |
| Initiate a new prescription | 878 (50) | |
| Low (<50%) | Suture deep lacerations | 820 (47) |
| Diagnose significant health event | 760 (44) | |
| Diagnose serious acute illness | 653 (38) | |
| Diagnose chronic or continuing condition | 644 (37) |
Factors predicting participants' acceptability activities undertaken by nurse practitioners
When controlling for other demographic variables, logistic regression demonstrated that female participants were more likely to find most activities acceptable compared to male participants, with the exception of triage, initiating new prescriptions, suturing deep lacerations, diagnosing chronic or continuing conditions and diagnosing serious acute illnesses. Table 3 shows all the significant relationships identified in the 16 logistical regression equations. Details of modelling, including testing for robustness of results are available from the authors on request.
Table 3.
Factors predicting activities undertaken by nurse practitioners, which participants found acceptable
| Female participants were significantly more likely than male participants to find the following activities acceptable |
| Take a medical history |
| Diagnose minor infectious illnesses |
| Diagnose minor muscle injuries |
| Order diagnostic tests |
| Interpret diagnostic tests |
| Pregnancy testing |
| Provide emergency contraception |
| Provide repeat prescriptions |
| Suture superficial lacerations |
| Manage chronic or continuing condition |
| Diagnose significant health event |
| Older participants were significantly more likely than younger participants to find the following activities acceptable |
| Take a medical history |
| Interpret diagnostic tests |
| Suture superficial lacerations |
| Diagnose chronic or continuing condition |
| Manage chronic or continuing condition |
| Diagnose significant health event |
| Older participants were significantly less likely than younger participants to find the following activities acceptable |
| Pregnancy testing |
| Provide emergency contraception |
| Participants with children under 18 years of age living at home were significantly more likely than participants without children under 18 years of age living at home to find the following activities acceptable |
| Interpret diagnostic tests |
| Pregnancy testing |
| Provide emergency contraception |
| Suture superficial lacerations |
| Suture deep lacerations |
| Participants with an education less than a postgraduate degree were significantly less likely than participants with a postgraduate degree to find the following activities acceptable |
| Initiate a new prescription |
| Diagnose chronic or continuing condition |
| Manage chronic or continuing condition |
| Participants with a higher income were significantly less likely than participants with a lower income to find the following activities acceptable |
| Triage |
| Take a medical history |
| Diagnose minor infectious illnesses |
| Diagnose minor muscle injuries |
| Order diagnostic tests |
| Interpret diagnostic tests |
| Provide repeat prescriptions |
| Suture superficial lacerations |
| Suture deep lacerations |
| Diagnose chronic or continuing condition |
| Diagnose serious acute illness |
| Diagnose significant health event |
| Participants who identified as Aboriginal or Torres Strait Islander were significantly less likely than participants who did not identify as Aboriginal or Torres Strait Islander to find the following activity acceptable |
| Triage |
| Participants who identified as having a chronic or long‐term condition were significantly less likely than participants who did not identify as having a chronic or long‐term condition to find the following activities acceptable |
| Interpret diagnostic tests |
| Initiate a new prescription |
| Participants who have a regular general practice they attend were significantly less likely than participants who do not have a regular general practice to find the following activities acceptable |
| Diagnose chronic or continuing condition |
| Diagnose significant health event |
| Participants who think there are enough GPs to service their area were significantly less likely than participants who do not think there are enough GPs to find the following activities acceptable |
| Triage |
| Take a medical history |
| Diagnose minor infectious illnesses |
| Diagnose minor muscle injuries |
| Order diagnostic tests |
| Interpret diagnostic tests |
| Pregnancy testing |
| Provide emergency contraception |
| Provide repeat prescriptions |
| Suture superficial lacerations |
| Diagnose chronic or continuing condition |
| Manage chronic or continuing condition |
| Diagnose serious acute illness |
| Diagnose significant health event |
| Participants who think that it is expensive to see a GP were significantly more likely than participants who do not think it is expensive to see a GP to find the following activities acceptable |
| Triage |
| Take a medical history |
| Diagnose minor infectious illnesses |
| Diagnose minor muscle injuries |
| Order diagnostic tests |
| Interpret diagnostic tests |
| Pregnancy testing |
| Provide emergency contraception |
| Initiate a new prescription |
| Provide repeat prescriptions |
| Suture superficial lacerations |
| Suture deep lacerations |
| Diagnose chronic or continuing condition |
| Manage chronic or continuing condition |
| Diagnose serious acute illness |
| Diagnose significant health event |
There were some differences evident according to participants' age, with younger participants more likely to find pregnancy testing and the provision of emergency contraception as acceptable activities for nurse practitioners to undertake. Whereas older participants found activities such as taking a medical history, interpreting diagnostic tests, suturing superficial lacerations, diagnosing and managing chronic or continuing conditions and diagnosing significant health events more acceptable than younger participants.
Participants who had children under 18 years of age living at home were significantly more likely than those who did not have children under 18 of age living at home to find pregnancy testing and emergency contraception, interpreting diagnostic tests and suturing both deep and superficial lacerations acceptable.
Participants with a higher income were, in general, less likely to find most of the activities acceptable for nurse practitioners to undertake compared with participants with a lower income. Some of these activities included diagnosing minor infectious illnesses and minor muscle injuries, ordering and interpreting diagnostic tests, providing repeat prescriptions and suturing superficial and deep lacerations.
There were no observed differences between participants who identified as having a disability and those who did not identify as having a disability in terms of finding the different activities acceptable for nurse practitioners to undertake.
Chi‐squared analysis indicated that participants who identified as having a chronic or long‐term condition were significantly more likely to find nurse practitioners providing a repeat prescription (P = 0.02) and managing a chronic or long‐term condition (P = 0.01) as acceptable. However, using logistic regression to control for other demographic variables did not demonstrate any differences in acceptability of participants who have or do not have a chronic or long‐term condition for these two activities. Instead, the regression analysis demonstrated that participants who identified as having a chronic or long‐term condition were significantly less likely than participants who did not identify as having a chronic or long‐term condition to find nurse practitioners interpreting diagnostic tests and initiating new prescriptions acceptable.
Participants who thought there were enough general practitioners servicing their area found most activities less acceptable for nurse practitioners to undertake compared to those who did not think there were enough GPs servicing their area, with the exception of initiating a new prescription and suturing deep lacerations. Similarly, participants who thought it was expensive to see a GP were significantly more likely to find all activities acceptable for nurse practitioners to undertake compared to those who do not think it expensive to see a GP.
Discussion
Overall, Australian health‐care consumers' experience of receiving primary health care from nurse practitioner is limited. However, this is likely to be due to the small number of nurse practitioners currently practising in Australia and a smaller subset who are primary health care–based nurse practitioners. Despite this, Australian consumers are accepting of a broad range of activities that could be undertaken by nurse practitioners in primary health‐care settings. In common with international evidence, women were more accepting of the nurse practitioner's role.19
Activities nominated by the majority of respondents as highly acceptable practices for nurse practitioners to undertake in primary health care included taking a medical history, triaging patients, diagnosing minor illnesses and injuries and undertaking reproductive clinical practices such as pregnancy testing and providing emergency contraception. These findings are similar to those of Kvis et al.20 who also suggested that consumers find the diagnosis of minor illness and injury as an acceptable practice for nurse practitioners to undertake. However, there are other studies which detail practices such as health promotion, patient education and preventative care as well as episodes of depression, emotional, social and family problems as acceptable practices for nurse practitioners to undertake.17, 21, 22 Other highly acceptable practices to the survey respondents included suturing superficial lacerations, ordering diagnostic tests and providing repeat prescriptions. These latter practices are possibly an acknowledgement of nurse practitioners' qualifications and advanced clinical practice experience. The recent amendment in Australian legislation of the eligibility of nurse practitioners to qualify for a Medicare Provider Number and be allowed to prescribe specified medications under certain conditions through the Pharmaceutical Benefits Scheme correlates with consumers' expectations of types of tasks nurse practitioners should be able to perform.23
It is surprising that the management of chronic or long‐term conditions was only moderately acceptable given that practice nurses have been shown to play an integral and effective role in primary health care in the management of hypertension and hyperlipidemia in diabetes.24 Even survey respondents who have a chronic or long‐term condition were not more likely to find the management of chronic or long‐term conditions by nurse practitioners more acceptable than respondents who do not have a chronic or long‐term condition. This contrasts to participants in other studies who stated they would be willing to receive individualized health risk assessments and follow‐up care for chronic disease from nurse practitioners.21, 22 This moderate response to nurse practitioners managing chronic or long‐term conditions may be due to Australian health‐care consumers' inexperience of consulting nurse practitioners for primary health care, and perceptions about nurses' roles in primary health care may change over time if nurse practitioners become a more common feature within the multidisciplinary primary health‐care team.
The practices that were least acceptable to consumers who completed the survey included suturing deep lacerations and diagnosing significant health events, serious acute illnesses and chronic or continuing conditions. These practices are probably seen as more within the skill set and domain of the medical practitioner.
Some of the findings about acceptability are related to the age of respondents, and it is not surprising that younger patients are more accepting than older patients of nurse practitioners providing pregnancy testing services and emergency contraception. Similarly, it is not surprising that patients with higher incomes were somewhat less accepting of nurse practitioners than those with lower incomes as those with higher incomes can more easily afford to see a doctor.
Conclusion
A limitation of this study is that it deals with perceptions rather than experience. That is, as nurse practitioners are not currently practising in large numbers in Australian primary health‐care settings, very few consumers will have experienced care from nurse practitioners in that setting. A further limitation is that the delivery of the survey online meant that it was only accessible to those people who have access to the Internet. Nevertheless, the findings of this study have relevance for primary health‐care workforce mix and organization and particularly for those areas in Australia that are underserved by medical practitioners: rural and remote areas and some outer metropolitan areas. To date, one response to health workforce shortages in primary care has been to increase the role of the registered nurse in general practices and, in rural and remote areas, to also increase the numbers of overseas trained doctors. Whilst these strategies have had some success, the formalization of the role of the nurse practitioner through the provision of Medicare provider rights and the right to prescribe certain medications offers another response to workforce shortages. Given consumer acceptability of nurse practitioner's roles, nurse practitioners working in collaboration with general practitioners have the potential to provide many primary health‐care services and to provide timely access for consumers.
Acknowledgements
This Research was funded by a grant for the Australian Department of Health and Ageing. The information and opinions contained in it do not necessarily reflect the views or policies of the Australian Government Department of Health and Ageing.
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