Nursing in General Practice (NiGP) Program Guidelines and Protocols for Practice Nurses A Report by Maggie Stewart on behalf of General Practice Victoria November 2008
Background Australian general practices are privately owned and run Range from solo GP to practices with 12 GPs, allied health professionals and numerous reception staff Income is produced mainly through billing Medicare item numbers linked to a GP / PN consultation for a patient attendance
Backgound • Since 2001 the Australian Government Nursing in General Practice (NiGP) program has aimed to recruit, retain and maximise the contribution of PNs to primary care services. • From 2005 – 2007 the estimated number of PNs rose from 4924 to 7824, an increase of 60% (Australian General Practice Network 2007) • Increasing Medicare item numbers and increased usage of these items numbers means there is an increased need for a framework to ensure best evidence based practice.
Background • At present there is a lack of policies and guidelines for nurses working in general practice • A recent Australian Government discussion paper notes that “For those working in primary health care, disease specific guidelines developed for the hospital or specialist setting are often not relevant or useful for managing patients with ‘multi-morbidities’.”. (Australian Government Department of Health and Ageing, 2008.)
Background • Australian general practice has neither the resources or incentives to develop required policies / procedures / guidelines • General practice accreditation encourages QI activities BUT • Not compulsory • Does not include indicators specific to PN role
Background As an initial step towards addressing this need, General Practice Victoria (GPV), through the NiGP program, commissioned a literature search to investigate the existence of nursing protocols / policies and guidelines used in primary care settings.
Project Aim The aim of this project was to conduct a literature search in order to investigate the existence of nursing policies / protocols or guidelines used in primary care settings. This project aimed to: • Find any existing policies / protocols or guidelines used in primary care settings for nurses • Make recommendations for future work
Definitions The terms policy / procedure / protocol / guideline are often used interchangeably. This project uses the following definitions: • A policy is a deliberate plan of action to guide decisions and achieve rational outcomes. • A protocol is a rule, guideline, or document which guides how an activity should be performed. • A medical guideline is a document with the aim of guiding decisions and criteria regarding diagnosis, management and treatment in specific areas of healthcare. (Wikipedia 2008)
Method Literature Search The following word strings were used: • Nursing protocol* or nursing polic* • Nursing procedure* or nursing guideline* AND • General practi* or GP or family physician* or primary care or family practi*
Method - Literature Search The following rationale was used; • Key word searching • Subject heading searching • Controlled word search • Mesh headings • Boolean searching – and / or / not
Database holdings from 1996 – 2008 were searched. These were: Articles • Proquest 5000 • Medline • CINAHL • EMBASE • Informit Databases (health) – Australasian Medical Index • Google Scholar – set up preferences for LTU scholar.google.com Reports/Books • Libraries Australia Theses • Proquest Dissertations Google • Key word searching • Powered searching - powering another site with Google to enhance the search
Literature Review Search results were assessed for their relevance and applicability in the Australian general practice setting. Criteria for inclusion: • Nurse based • Within a general practice setting • Had policies / procedures / guidelines relevant to nurses • Provided a framework that could be adapted for an Australian setting
Literature review - Findings Proquest 5000: 61 results, 61 rejected • Articles rejected as they dealt with review or presentation of guidelines, current practice but did not provide a structure or framework that could be utilised to develop protocols/ policies / guidelines within Australian general practice.
Literature Review - Findings Medline: 7 results, 7 rejected • Whilst some of these results dealt with guidelines and protocols they did not provide a structure or framework that could be utilised to develop these for use within general practice. Examples:
Literature Review - Findings Informit: 38 results, 38 rejected • Only one result dealt with policy, in relation to treatment and prevention of alcohol-related problems, it did not provide a structure or framework that could be utilised to develop protocols / policies and guidelines for use within general practice (Result 4).
Literature Review - Findings CINAHL: 36 results, 36 rejected • Again, whilst some of these results dealt with guidelines and protocols they did not provide a structure or framework that could be utilised to develop protocols / policies and guidelines for use within general practice.
Literature Review - Findings Google Scholar: 91 results, 86 rejected • This search identified a number of UK and USA health websites that provide a policy framework that could be used within an Australian general practice setting. Each web site varies in the framework and way the policy is set out.
Policies were set out using variations of the following headings: Introduction and purpose Monitoring and review (of the policy) Quality control Devices Responsibilities Aim Objective Selection of patients Education and training requirements Equipment required Procedure (table) References and bibliography.
Literature Review - Findings Other Resources • Royal College of Nursing Australia developed a Nursing in General Practice kit. (RCNA, 2008. • This kit looks at the role of the practice nurse including competencies and scope of practice. • It does not provide a framework for developing a policy / procedure / guideline for the nurse working in Australian general practice
Discussion with Professional Nursing Bodies Discussion with: • Australian Nursing and Midwifery Council • Nurses Board of Victoria (NBV) • Australian Nurses Federation (ANF) • Department of Human Services (DHS) • Royal District Nursing Service (RDNS)
Australian Nursing and Midwifery Council Has developed a Code of Professional Conduct for Nurses in Australia which sets the minimum standards for practice a professional person is expected to uphold both within and outside professional domains. It recommends that: • Nurses practise in a safe and competent manner • Nurses practise in accordance with the standards of the profession and broader health system • Nurses practise and conduct themselves in accordance to laws relevant to the profession and practise of nursing • Nurses respect the dignity, culture, ethnicity, values and beliefs of people receiving care and treatment, and of their colleagues
Australian Nursing and Midwifery Council Nurses treat personal information obtained in a professional capacity as private and confidential Nurses provide impartial, honest and accurate information in relation to nursing care and health care products Nurses support the health, well being and informed decision making of people requiring or receiving treatment Nurses promote and preserve the trust and privilege inherent in the relationship between nurses and people receiving care Nurses maintain and build on the community’s trust and confidence in the nursing profession Nurses practice nursing reflectively and ethically
Australian Nursing and Midwifery Council Discussion with Australian Nursing and Midwifery Council proposed that the nurse needs to work with their employer to decide on best practice within their workplace.
Nurses Board Victoria Has developed a document titled “Guidelines: Scope of Nursing & Midwifery Practice”. This is a framework to enable nurses and midwives to make decisions about: • their current scope of practice, • any further education or professional development required to carry out their current role and • any professional development required to expand their role.
NBV It consists of: • principles to guide nursing and midwifery scope of practice decisions, • a flowchart to take the nurse through steps to be considered before undertaking a nursing or midwifery activity, • advice on what to do if you are asked to perform an activity outside current scope of practice, • advice on how to expand current scope of practice which includes a flowchart,
Nurses Board Victoria how nurses and midwives assess their own and peer competence, role of the health care organisation / employer in using the guidelines, the NBV role in investigating complaints relating to scope of practice, other documents to use with the guidelines and Additional NBV resources.
Nurses Board Victoria Discussion with the NBV proposed that the nurse needs to look at their scope of nursing practice guidelines and make decisions on their competency based on that. It was stated that it is up to the individual and their workplace to ensure that they have policies and procedures in place.
Australian Nurses federation Discussion with the ANF stated that: • Nurses need to practice within their competencies and scope of practice. • They need to ensure that they have workplace policies and procedures documented. • It is up to the nurse and employer to ensure that these are in place.
Department of Human Services Discussion with Manager Nursing Workforce Policy and Projects advised that the nurse needs to: • Follow existing best practice guidelines, • Follow National guidelines, • Look at their competencies and scope of practice with their employer and decide together on their approach to evidence based care. • Set out a protocol that explains; • National guidelines, • Cites evidence base, • Adopts and explains when something is offered and • Limitations to service provision
Royal District Nursing Service (RDNS) Whilst RDNS have developed policies and procedures for nurses working within the community these resources are not publicly available.
Conclusion • The literature search has shown that there is a lack of policies and procedures for nurses working within general practice. • Some of the web sites have a framework that could be used as a guide to writing policies / procedures / guidelines for the Australian general practice setting. • Nursing organisations have stated that nurses need to work within their scope of practice and within their competencies and that it is the responsibility of the nurse and their employer to develop policies / procedures / guidelines.
Conclusion In order for the nurse and general practice to carry out evidence-based best practice, policies / procedures and guidelines need to be developed.
Recommendations • Working group to look at development and trial of implementation of policies / procedures / guidelines for the practice nurse • Working group members to include representation from a range of National Bodies, such as: • Australian General Practice Network • Australian Practice Nurse Association • Nurses Board of Victoria • Royal College of Nursing Australia • Royal Australian College of General Practitioners • Australian Nursing and Midwifery Council
Recommendations • Responsibility for the project should be taken on by a lead agency that is skilled in the challenges of working within the general practice environment. • When developing these policies / procedures / guidelines legal and professional issues need to be considered, as well as the evidence base.
References – Search Results • Result 1 Hull, P. Husaini, B. Tropez-Sims, S. et al. (2008) EPSDT preventive services in a low-income pediatric population: impact of a nursing protocol. Center for Health Research, Tennessee State University, Nashville, TN 37209, USA. Clinical Pediatrics. 47(2):137-42, 2008 Mar • Result 2 T Paquay, L. De Lepeleire, J. Milisen, K. et al (2007), Tasks performance by registered nurses and care assistants in nursing homes: a quantitative comparison of survey data. International Journal of Nursing Studies. 44(8):1459-67, 2007 Nov. • Result 3 Pomfret, I. (2007), Urinary catheterization: selection and clinical management. British Journal of Community Nursing. 12(8):348-54, 2007 Aug. • Result 4 Heather, N. (1997) Where treatment and prevention merge : the need for a broader approach. Addiction ; 0965-2140; 92 Suppl. (1) March 1997; S133-S136 • Result 5 Antman E. Hand M. Armstrong P. Et al. (2007) Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee. Jan 15; 117(2): 296-329
References – Search Results • Result 6 Brokel J. (2003) A description of practice guidelines utilization and patient outcomes for persons with diabetes in five primary care practice models. University of Iowa, 2003; Ph.D. (243 p) • Result 7 Sherman S. Joseph A. Yano E. Et al. (2006) Assessing the institutional approach to implementing smoking cessation practice guidelines in Veterans Health Administration facilities. Military Medicine (MILIT MED), 2006 Jan; 171(1): 80-7 (21 ref) • Result 8 Leicestershire County and Rutland NHS Primary Care Trust Policies and Procedures (2008) available at http://www.lcrpct.nhs.uk/xform.asp?folder=Internet/PoliciesAndProcedures/Clinical/NursingPolicies. Accessed 11 November 2008. • Result 9 Heart of England NHS Foundation Trust, (2007) Resuscitation Policy & Procedures Resuscitation Training, NHS, England. Available at http://www.heartofengland.nhs.uk/upload/PDFs/equality/resus/Resus%20Training%20Policy%202007%20Final%20Draft.pdf . Accessed 22 October 2008. • Result 10 Glenroyd Medical Centre/Devonshhire Rd Surgery (no date) Protocol for the administration of Inactivated Influeza Vaccine to adults by Health care Assistants, Nurse Practitioner, UK. Available at http://www.nursepractitioner.org.uk/Documents/HCA%20Protocols/influenza_protocol.doc. Accessed 12 October 2008. • Result 11 Powys Local Heath Board (2006) Policy for Blood Glucose Monitoring by a Designated Person, Wales, NHS. Available at http://www.wales.nhs.uk/sites3/Documents/501/PLHB%20GNP%2000011%20Blood%20Glucose%20Monitoring%20by%20a%20Designated%20Person.doc. Accessed September 23 2008. • Result 12 Georgia Department of Human Resources Division of Public health, Public Health Nurse Protocol Manual 2008, Georgia Government, USA. Available at http://health.state.ga.us/programs/nursing/nursepublications.asp. Accessed 23 September 2008.
References - Other • Australian General Practice Network, National Practice Nurse Workforce Survey Report 2007, Australia. Available at http://www.agpn.com.au/site/index.cfm?display=8. Accessed September 23 2008. • Australian Government Department of Health and Ageing, Towards a National Primary Health Care Strategy. A Discussion Paper from the Australian Government 2008, Australia. Available at http://www.health.gov.au/internet/main/publishing.nsf/Content/D66FEE14F736A789CA2574E3001783C0/$File/DiscussionPaper.pdf. Accessed November 24 2008 • Australian Nursing and Midwifery Council (2008), Code of Professional Conduct for Nurses in Australia, ANMC, Canberra. Available at: www.anmc.org.au. Accessed 22 November 2008. • British Columbia Medical Association (2006), Ministry of Health Resource Manual for Nurse Practitioners, Clinical Practice Guidelines and Protocols, Available at www.healthservices.gov.bc.ca/msp/protoguides/index.html. Accessed 10 November 2008. • Nurses Board of Victoria (2007) Guidelines: Scope of Nursing & Midwifery Practice, NBV, Melbourne. Available at www.nbv.org.au. Accessed 22 November 2008. • Royal College of Nursing Australia (2008) Nursing in General Practice A Guide ForThe General Practice Team, RCNA Australia. Available at http://www.rcna.org.au/site/nursinggpkit.php Accessed November 2008 • Wikipedia (no date) Policy, Wikipedia The Free Encyclopedia. Available at http://en.wikipedia.org/wiki/Policy Retrieved from Google search policy, 22 November 2008 • Wiktionary (no date) Protocol, Wikipedia The Free Encyclopedia. Available at http://en.wiktionary.org/wilki/Protocol, Retrieved from Google search protocol, 22 November 2008 • Wikipedia (no date) Guideline, Wikipedia The Free Encyclopedia. Available at http://en.wikipedia.org/wiki/Guideline_(medical), Retrieved from Google search guideline, 22 November 2008