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.
The Grattan Institute, a public policy ‘think tank’, has just published a report entitled ‘Chronic failure in primary care’ (see here). It is disappointing there is little reference to nurses in the report but that aside, it does give a good insight into the problems (and some possible solutions) in Australian primary health care.
Some highlights of the report are as follows:
- Ineffective management of heart disease, asthma, diabetes and other chronic diseases costs the Australian health system more than $320 million a year in avoidable hospital admissions.
- Only a quarter of the nearly one million Australians diagnosed with type 2 diabetes get the monitoring and treatment recommended for their condition.
- Each year there are more than a quarter of a million admissions to hospital for health problems that potentially could have been prevented. Yet each year the government spends at least $1 billion on planning, coordinating and reviewing chronic disease management and encouraging good practice in primary care.
- Three quarters of Australians over the age of 65 have at least one chronic condition that puts them at risk of serious complications and premature death. Social, economic and environmental changes are the best way to prevent these diseases, but there are much better outcomes where good quality primary care services are in place.
- The focus must move away from GP fee-for-service payments for one-off visits; a broader payment for integrated treatment would help to focus care on patients and long-term outcomes.
- PHNs should be given more responsibility for local primary care services. The evidence shows that a consistent, coordinated approach to specific diseases helps primary care more effectively prevent and manage chronic conditions. In regional areas, clear targets and well-designed incentives for disease prevention are vital.
- There needs to be a focus on more flexible services, which might include greater use of nurses and allied health staff for assessment, planning, coordination, review and support of people with chronic disease.
- Practice and incentive payments are not working.
Do you agree there are fundamental problems with our primary health care system? Are there any easy, or even achievable, solutions? We would love to know what you think.
From 1 November 2015, Medicare benefits for the pre-school healthy kids check (including the nurse item #10986) will no longer be available. See here for the MBS notification.
The Australian Government has cited a lack of evidence around the current system providing a higher quality service and the increased annual cost of delivering pre-school health checks as factors behind its decision to remove the healthy kids check MBS items.
The four year old health check remains a recommended child health assessment, which can still be undertaken in general practice settings using time and complexity based MBS items #23, #36, #44 (and the Aboriginal and Torres Strait Islander health assessment item #715). The health checks can also be undertaken by State and Territory funded infant health clinics, where available.
With these changes in mind there is debate around whether the rebates for these consults accurately reflect the work required to undertake a comprehensive childhood health assessment or support the non face-to-face work undertaken outside of the consultation.
- Do you believe there will be a change in your health assessment rates for children in your area as a result of the Government’s decision?
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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 7 August 2015, the Minister for Health, the Hon Sussan Ley MP, released The Mental Health of Children and Adolescents, a report on the second Australian Child and Adolescent Survey of Mental Health and Wellbeing. The report, described as the largest ever national survey of youth mental health of its kind in Australian history, follows on from the first national survey of the mental health of children and adolescent which was undertaken 17 years ago.
Some key highlights of the report are set out below:
- One in seven children and young people experienced a mental disorder in the previous 12 months – the equivalent of 560,000 young Australians
- Attention deficit hyperactivity disorder (ADHD) was the most common mental disorder in children and adolescents
- Just over one third (35%) of 4-17 year-olds with a mental disorder had seen a general practitioner in the past 12 months
- Schools provided services to 40.2% of the children and adolescents with mental disorders who attended them, and 5.6% had seen a school nurse
- Around one in 10 12-17 year-olds (10.9%) reported having ever self-harmed
- Females aged 16-17 years had the highest rates of self-harm, with 16.8% having harmed themselves in the previous 12 months
- About one in thirteen (7.5%) 12-17 year olds had seriously considered attempting suicide in the previous 12 months.
While some of the information contained in the report is concerning, there are a number of positives, such as the large increase in the number of young people seeking help.
What is your experience of dealing with young people with mental health issues? Do you think there are adequate processes in place to identify mental disorders and provide the care and support needed?
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.