Models of primary health care nursing

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Featured in half-yearly report: Health Policy Developments 7/8

Abstract

Efforts to reorient primary health care in New Zealand towards a greater focus on population health and on a wider range of services are stimulating the development of new models of primary health care nursing practice.

Purpose of health policy or idea

The reform of the primary health care sector in New Zealand is stimulating the development of new and innovative models of primary health care nursing practice. In 2003, the Minister of Health allocated $7 million to support 11 new initiatives. Some case studies of evolving models of nursing practice are described in a recently-published report (Beatson, 2005). The models include generalist and specialist nurse-led services, community-based services, and nurses working within a collaborative multidisciplinary network. Examples include:

• a rural nurse specialist
• a nurse-led youth health clinic
• a nurse-led acute care team
• a neighbourhood nurse
• nurse-led services within a Union health clinic
• a mobile community ear clinic
• a specialised leg ulcer clinic. The models described in this report are neither representative of standard practice, nor necessarily examples of best practice. Moreover some of the models include elements of nursing practice that have been in place for many years. The case studies do, however, give a flavour of the types of models of practice that are evolving throughout the country. 
  
  The primary aim of these new models of practice is to utilise better the skills, knowledge and experience of nurses in the community setting. The Beatson report identifies where further work is required to define elements of primary health care nursing practice, and highlights a number of limitations for advancing nursing practice to achieve Nurse Practitioner status.

Main points

Main objectives

To develop new models of primary health care nursing.

Groups affected

Primary health care nurses, Other primary health providers, Users of primary health care services

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

Political and economic background

In 1998, a Ministerial Taskforce on Nursing reviewed the role of nurses in the New Zealand health system. It identified barriers to the development of nursing practice, and made recommendations for removal of some of these barriers. The thrust of these recommendations was towards expanding the scope of nursing through strategies such as access to funding, better career paths, improved education, and general workforce development including developing the role of nurse practitioner.

While some of the recommendations of the Taskforce have been enacted, the scope of nursing practice has generally been slow to develop. In 2001, the Minister of Health released the New Zealand Primary Health Care Strategy (King, 2001) which emphasises the need to reorient primary health care services away from individually-focussed treatment services towards population-based services which place a greater emphasis on prevention and health promotion. The Strategy also places emphasis on the role of the community in primary health care, and on the need for these services to be provided by a wider range of health professionals. The role of primary health care nurses is therefore central to the successful implementation of this national strategy.

Two key elements in the reform of primary health care services that have stimulated the emergence of new models of primary health care nursing include the development of Primary Health Organisations (see Health Policy Monitor Survey No. 2003(04)) and the payment of patient subsidies to these organisations by capitation rather than by fee-for-service. Capitation payment has allowed greater flexibility in patient management and choice of provider, including broadening the scope of services provided by primary health care nurses.

The Primary Health Care Strategy requires the Minister of Health to 'facilitate a national approach to primary health care nursing which addresses capabilities, responsibilities and areas of professional practice, as well as setting educational and career frameworks and exploring suitable employment arrangements' (King, 2001, p. 23). Towards this end, in 2002, the Minister of Health appointed a Primary Health Care Nursing Expert Advisory Group. Once again, a number of barriers to the development of the role of nurses in primary health care were identified, including the need for 'substantial culture change within nursing' to align it with the vision of the Primary Health Care Strategy. In spite of these barriers, many local examples of new models of nursing in the primary sector are now emerging.

Change based on an overall national health policy statement

The Primary Health Care Strategy

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

The models of care that are now emerging in New Zealand are mostly new but sometimes include elements of older models of primary health care nursing practice. What is new is the support of the central government for new models of nursing practice in the primary sector. This is illustrated both in the formation of the Expert Advisory Group by the Minister in 2003, and in the allocation of funds for the development of innovative models of primary health care nursing. From 2006, funds have also been allocated by the central government to provide scholarships for nurses currently practising in primary health care settings to undertake postgraduate nursing programmes in primary health care.

Initiators of idea/main actors

• Government

• Providers

• Payers

• Patients, Consumers

Approach of idea

The approach of the idea is described as:
new:

Innovation or pilot project

Local level - Different models of nursing practice are emerging in different localities.

Stakeholder positions

While the central government is very supportive of efforts to find new models of nursing practice, the implementation of new models often requires a significant culture change by various groups including patients, other services providers and the nurses themselves. Other services providers sometimes feel threatened, especially if new models of practice cross disciplinary boundaries. In most of the examples described in the Beatson report, developing relationships and working collaboratively with other professional groups were fundamental to the success of the model.

Actors and positions

Government
Ministry of Health	very supportive		strongly opposed
Providers
Nurses and other members of primary health care teams.	very supportive		strongly opposed
Payers
Primary Health Organisations	very supportive		strongly opposed
Patients, Consumers
Users of primary health care nursing services	very supportive		strongly opposed

Actors and influence

Government
Ministry of Health	very strong		none
Providers
Nurses and other members of primary health care teams.	very strong		none
Payers
Primary Health Organisations	very strong		none
Patients, Consumers
Users of primary health care nursing services	very strong		none

Positions and Influences at a glance

Adoption and implementation

There are no national models or guidelines for the development of new approaches to primary health care nursing practice in New Zealand. Most of the emerging models are shaped by the needs of particular communities or districts and by the resources that are available. Many of the initiatives have been driven either by the nurses themselves, or by leadership displayed by a particular person or organisation.In some cases, implementation has been assisted by the allocation of special funding for these new initiatives in nursing practice by the Ministry of Health.

Monitoring and evaluation

The 11 primary health care nursing initiatives funded by the Ministry of Health in 2003 are currently being monitored and evaluated.

Dimensions of evaluation

Process, Outcome

Expected outcome

Development of new models of primary health care nursing practice has the potential to improve the accessibility, quality and efficiency of primary health services. Some of the new models are improving accessibility by taking nursing services to the population in locations such as kindergartens, schools, churches and shopping centres. The quality of services should be improved as long as new models of nursing practice are supported by adequate opportunities for professional training and development. Efficiency should also be improved if nurses are used more effectively within primary health care teams. However barriers remain to the development of models of nursing practice that are focussed on populations rather than on individuals (Beatson, 2005). These include:

• Constraints imposed by the inflexibility of some employment contracts.
• The lack of structures which provide essential linkages between primary health care nurses and broader intersectoral initiatives and public health serivces.
• Postgraduate programmes which focus on increasing specialisation rather than developing the multiple levels of skills and practices that are central to primary health care.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

References

Sources of Information

• Beatson. E. (2005) Evolving Models of Primary Health Care Nursing Practice. http://www.moh.govt.nz/moh.nsf/wpg_Index/Publications-Evolving+Models+of+Primary+Health+Care+Nursing+Practice
• Ministerial Taskforce on Nursing (1998) Report of the Ministerial Taskforce on Nursing: Releasing the Potential of Nursing. Wellington: Ministry of Health.
• King (2001) Primary Health Care Strategy. Wellington: Ministry of Health www.moh.govt.nz/moh.nsf/ea6005dc347e7bd44c2566a40079ae6f/7bafad2531e04d92cc2569e600013d04?OpenDocument
• Ministry of Health (2003) Investing in Health: A Framework for Activating Primary health Care in New Zealand. Wellington: Ministry of Health www.moh.govt.nz/moh.nsf/238fd5fb4fd051844c256669006aed57/a4d86036478a63a7cc256bde006ff204?OpenDocument

Author/s and/or contributors to this survey

CHSRP

Suggested citation for this online article

CHSRP. "Models of primary health care nursing". Health Policy Monitor, April 2006. Available at http://www.hpm.org/survey/nz/a7/2