Heather Gale, Practice Nurse, Bowral
I have been Nursing for 30 years having split that time between the acute care and primary care sectors. I am a RN/Midwife, with Post graduate qualifications in Nurse Education and Master of Nursing. I have been a Practice Nurse for the last 8 years in a permanent part time role. The remainder of my week is spent Teaching at the University of Wollongong.
I share my Practice Nurse roles with 7 other Nursing colleagues, among them are 1 Nurse Practitioner, 4 RNs, 1 EEN, and 1 EN. Working with an average of 14 Doctors in any given week, each Practice Nurse has a significant role to play both unique to their scope of practice and to the contribution they make to the Practice patients in partnership with the Patients’ GP.
Our roles can include chronic disease management and patient education, complete INR management, health assessments, well women’s health including pap smears, minor operation assistance, aural health, childhood immunisation and travel vaccination, parent infant support services and general recall and reminder procedures to name a few. But such is the variety and scope of Nurse Practice in GP Land!
I am specifically supported to offer Lactation Consultation appointments, and receive internal referrals regarding the same in addition to a growing drop in service. I also offer general early parenting support and advice, as a follow up for issues raised by parents and babies at an immunisation appointment.
It is in General Practice that I have developed the most as a Nurse Professional. My exposure, education and training around advanced Nursing Skills has been an unsurpassed highlight in my nursing career thus far, as has working closely with GPs who love to share their medical knowledge, particularly in their knowledge of drugs and their efficacy, pathology, and differential diagnoses.
My Professional Development is empowered and enabled by the work of APNA in it’s concern for, and practical support of, the Practice Nurse workforce, and the tireless work of our Local PHN.
I love my work and sharing my working life with my nursing students.
APNA often gets a number of enquiries around supervision (specifically for Enrolled Nurses) and standards of practice. Below is a brief update around Standards of Practice and supervision.
As you may know, the Nursing and Midwifery Board of Australia (NMBA) recently updated Registered and Enrolled Nurses standards of practice. To practice in Australia, you must meet the NMBA’s professional standards. The revised standards can be found here.
They focused strongly on supervision of Enrolled Nurses. Below is a summary of supervision requirements for Enrolled Nurses.
Supervision of Enrolled Nurses by a Registered Nurse is a requirement of the Enrolled Nurse Standards for Practice.
- Supervision by a person other than a Registered Nurse is not consistent with the professional standards of the profession and may contravene requirements. Professional supervision relates to the quality and safety of care and is provided by a member of the same profession.
- A general practitioner or other Doctor, may have management responsibilities, but a member of the nursing profession, namely a Registered Nurse, must undertake professional supervision of an Enrolled Nurse. It is the obligation of the employing general practice to ensure that appropriate supervisory arrangements are in place.
- Supervision and delegation of work to an Enrolled Nurse can be direct or indirect, and will vary depending on the abilities, education, qualifications, scope of practice, experience of the Enrolled Nurse, and contextual factors such as the geographical setting and size of the practice. Click here to read more around context of practice.
What does supervision of enrolled nurses mean?
Supervision of enrolled nurses by registered nurses can be direct or indirect depending on: the competence of the enrolled nurse for the scope of nursing practice; the condition of the person receiving nursing care; and the context in which the care is given. At all times, the enrolled nurse remains accountable for their own actions and is responsible to the registered nurse for all delegated functions
Direct and Indirect Supervision
Direct Supervision is when the supervisor is actually present and personally observes, works with, guides and directs the person who is being supervised.
Indirect Supervision is when the supervisor works in the same facility or organisation as the supervised person, but does not constantly observe their activities. The supervisor must be available for reasonable access. What is reasonable will depend on the context, the needs of the person receiving care and the needs of the person who is being supervised.
The employer must ensure that supervisory arrangements are in place. Registered Nurses should be aware of their legal responsibility in regard to supervision of Enrolled Nurses.
Another arrangement for indirect supervision of an Enrolled Nurse may occur in a general practice that has multiple sites. The Registered Nurse provides indirect supervision for Enrolled Nurses employed in that practice. In this type of situation the Registered Nurse may move between clinics giving supervision to an Enrolled Nurse/s. This model is particularly applicable to practices located in rural or remote settings, or multiple sites where geographical distances make direct supervision impractical. Registered Nurses should be aware of their legal responsibility in regard to supervision of Enrolled Nurses.
Some of the nurse regulatory authorities have produced policy statements and guidelines for delegation to and supervision of enrolled nurses and these must be considered by employers of enrolled nurses. The Australian Nursing and Midwifery Council has guidelines on delegation and supervision.
There are also decision making frameworks to assist registered nurses and enrolled nurses make decisions about the way that nursing work is delegated to enrolled nurses. Click here to view these and read more.
Donna von Blanckensee – CEO CD Program Development
RN, Cert IV TAE, Grad Cert Advising on Chronic Disease Self-Management, Diploma Management
As a registered nurse and CEO of C D Program Development I am privileged to work with primary health care nurses and organisations across Australia, and while the location and size of primary health care organisations may vary, the dedication and commitment to improved patient outcomes and the strengthening of the primary health care team by nurses remains consistent.
In my work within the primary health care setting I continue to witness primary health care nurses increasingly step into leadership roles, roles that are resulting in new and innovative ways of meeting the increasing demands of the primary health care arena. In my role as CEO of CD Program Development I am able work with primary health care organisaitons and their nurses to design and implement patient management strategies that are resuting in more patients screened, identified and effectively managed with regard to their specific health care needs as well as raise the profile of the primary heath care nurse.
One of the many highlights during the last 12 months has been continuing to work with APNA to deliver part of the Foundations of General Practice Nursing workshops held in Adelaide, SA. I was again able to share valuable content, as well as my own passion and enthusiasm for primary health care with a room full of nurses new to general practice nursing. I always leave these workshops feeling confident that primary health care nursing is experiencing new levels of professionalism which will ultimately result in improved patient outcomes.
APNA often receives enquiries around medication administration by nurses in general practice.
The difficulty in answering these questions lies in the fact that each state and territory has its own drugs and poisons legislation, with different guidelines for rural and remote areas and for certain sectors of the healthcare worker community. APNA recommends nurses check with their local authority on questions around drug and poisons.
We’re interested in your experiences. To start the discussion, we thought it would be helpful to share a typical enquiry we receive around medication administration.
Q. What should I do when a patient brings a prescription medicine dispensed from the pharmacy (e.g. a vitamin B12 injectable supplement) in to the practice for me to administer?
A. To answer this question, our discussion would address the following:
- As with all procedures, consider what is within your individual scope of practice: what are you educated, authorised and competent to perform?
- We normally discuss the way in which the prescribing GP might document the medication order for nursing staff in the patient’s clinical notes (i.e. this might coincide with writing the prescription or the GP may prefer to see them again on the day of administration).
- We ask nurses to ensure the order is written and provides all of the required information, including authorisation for the nurse to administer the medication (i.e. dose, how often, pre and post follow up if required).
- Verbal orders can be difficult to manage when there is only one nurse in the practice and should be reserved for urgent situations – discuss with your practice team how this might be managed.
- We like to discuss the need for nurses to have a good understanding of the drugs they are administering. What are the potential side effects? Has the medication been stored appropriately prior to presentation? Is any pre-administration care required? What follow up is required? Is this a cytotoxic drug? If so, what appropriate measures need to be put in place to be able to administer this safely and within legislation in your practice?
- We always recommend you refer to the ‘6 Rights’ of medication administration (or the 8 rights, if you prefer to include right reason and right response):
- Right drug – check the order, medication and expiry date. If you don’t have another nurse to check the order and the medication, we recommend you check with the GP. Note that nursing students are NOT able to check medication with you.
- Right individual/patient – use a minimum of two identifiers. Ask the patient to identify themselves by name and date of birth. Ask them for their understanding of the medication you are about to administer, and deliver medication information. If there is an alert on the patient file that there is a person with a similar name in your practice please use normal processes to provide additional checks.
- Right dose – check the order and confirm appropriateness of the dose using a current drug reference. If necessary, calculate the dose and have another nurse or the GP calculate the dose as well.
- Right time – check the frequency of the ordered medication. Double-check you are giving the ordered dose at the correct time. Confirm when the last dose was given. Confirm whether follow up or examination is required prior to or post medication being administered. Place a recall or reminder for next dose or follow up.
- Right route – again, check the order and appropriateness of the route ordered. Confirm the patient can take or receive the medication by the ordered route.
- Right documentation – document administration AFTER giving the ordered medication. Using the clinical software, you may develop ways to consistently document the medication administration which includes information about the drug, expiry date, time, route, site of injection, and any other specific information as necessary (e.g. any pathology test or observation which needs to be checked before or after giving the drug).
Have you developed an easy process in your practice to improve medication management that you would like to share? We would love to hear from you.
Earlier this month the RACGP published their position on independent nurse-led clinics in primary health care. Many of the points made in this policy are compelling, including that to ensure whole-patient care and to avoid fragmentation of care, nursing services should be provided in a comprehensive and integrated primary health care setting wherever possible.
Over the next three years APNA will continue work initiating and supporting nurse clinics through the demonstration model to provide blueprints for the innovative delivery of clinical care by nurses in primary health care. The projects focus on developing nurse clinics in primary care in collaboration with primary health care nurses, the general practice or healthcare team, consumers and peak health organisations to address evidence-based, locally identified health needs.
- What do you think of the RACGP’s position?
- Are you interested in establishing a nurse clinic in primary health care to address your population health needs?
- Have you found there to be barriers to operating a nurse clinic?
- Have you worked out a successful nurse clinic model you’d like to share?
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On the 8th of July our President, Karen Booth and CEO, Alexis Hunt attended by invitation the MBS Review Stakeholder Forum in Canberra with a number of key industry leaders.
This forum is one of the three key initiatives currently being undertaken by the Department of Health to work collaboratively with health professionals to deliver a healthier Medicare. These priorities include the Medicare Benefits Schedule (MBS) Review Taskforce led by Professor Bruce Robinson, Dean of the Sydney Medical School, University of Sydney. The MBS Review Taskforce has been tasked with considering how services can be aligned with contemporary clinical evidence and improve health outcomes for patients.
The Primary Health Care Advisory Group (PHCAG), led by former AMA president and practising GP, Dr Steve Hambleton, will investigate options to provide; better care for people with complex and chronic illness; innovative care and funding models; better recognition and treatment of mental health conditions; and greater connection between primary health care and hospital care. Karen Booth has a lead role as a member of this group.
The third component of the Federal Government’s vision is a review of Medicare compliance rules and benchmarks, and will work with clinical leaders, medical organisations and patient representatives. The use of new techniques such as analytics and behavioural economics will provide more information to clinicians to enable them to better manage appropriate practices. As well, more information will be available to patients about fees charged by health professionals so they can make informed choices about their healthcare.
Some of the key outcomes of the MBS Review Stakeholder Forum included roundtable discussions on what major shifts will be required as part of the recommendations to the Review. The group identified a number of barriers to success which included a level of scepticism on the purpose and goals, financial implications of major changes, evidence or rather the lack thereof on more effective methodologies, inertia, workload and data availability. Some of the recommendations for overcoming these barriers as identified by participants included developing a clear case for change, high levels of consultation, robust commercial modelling, effective communication, connected systems and a well considered and designed implementation strategy.
We will provide updated information as we continue to work closely with these groups and forums.
We always want to hear from you on these matters and acknowledge you are the experts working in the field and have direct contact with patients and communities. We encourage you to provide us with your thoughts and feedback at every step of this journey so we can actively advocate on your behalf.