Exploring nurse practitioner practice in Australian rural primary health care settings: A scoping review

4.3.1 Conceptualisation of the NP role in rural Australia

Most sources described NPs in terms of the educational and practice requirements necessary for endorsement by the Nursing and Midwifery Board of Australia.^{16, 18, 29-34} They conceptualised NPs' role in terms of their scope of practice.^{8, 16, 29, 30, 33-36} Other sources noted the potential of NPs to improve health care access, health outcomes and consumer satisfaction within rural health services³⁰ address service gaps^{14, 32}; and adapt to changing community needs.¹⁴

Several sources reported NPs' descriptions of their role in primary health care that included providing care from a social and holistic perspective; with a focus on wellness, health promotion, prevention of ill health, management of chronic disease and encouraging community participation in health services.^{37, 38} Nurses in these articles also reportedly spoke about their goals of achieving equality in access to health services, and making a difference in the lives of individuals and the community.^{37, 38}

A lack of clarity about, and understanding of, the NP role by health professionals and the general public was also highlighted in several of the articles.^{18, 31, 35} Finally, several sources included in this review assumed readers' knowledge and understanding of the role of the NP and did not include a description.^37-41

4.3.2 Services and contexts where NPs practicing in rural Australia's primary health care settings

The review revealed a great number of commentary, narratives and personal accounts by NPs of their experiences in rural health settings, particularly in private and general practice settings, indicating significant support for their roles within communities. Whilst there is an absence of research outlining how the role of the NP functions in rural primary health care, articles described the NP role as incorporated into, or forming part of multidisciplinary teams^{8, 39}; nongovernment organisations^{8, 29}; local health districts (LHD) or health services.^{30, 36}

The review revealed that NPs were working in community mental health and drug and alcohol services^{8, 31, 34}; at remote Aboriginal Medical Services³⁷ and Aboriginal Community Controlled Health Services³⁹; primary care in rural and remote locations^{32, 37, 38}; providing nurse-led assessment and treatment centres and community-based clinics^{20, 21, 30, 36, 41, 42}; providing specialist aged care³⁵ and psychogeriatric services⁸; NP locum services¹⁴; and palliative care.³³ Some NPs worked across multiple health care settings, for example across hospital, residential aged care, general practice and community health.^{8, 41} There were also examples of where NPs have responded to the identified health care needs of vulnerable or underserved populations, or health service gaps by initiating NP-led clinics, including small communities where there is no longer a medical practitioner and remote holiday venues with no medical services.^{8, 29, 34, 39, 42}

4.3.3 Structures that support implementation of NP roles in rural primary health care

Articles included identified several structures that support rural NPs to undertake their role in primary health care. These included the acceptance of the role, advocacy and support of the role by the local community, key stakeholders and medical practitioners.^{8, 30, 34} Other articles cited support from management, staff and colleagues^{18, 31, 40, 41}; access to specialist health services^{35, 38}; collaborative arrangements with local hospitals, retrieval services, GPs and other health professionals^{29, 30, 37}; financial/sustainable models of funding support^{29, 36, 40, 41}; physical resources and information infrastructure^{37, 38}; and mentorship.³⁵ One article reported that some of the services provided by NPs to remote communities were supported by links to health outreach programs administered by larger organisations and consultations provided by specialists located in regional cities.³⁹

4.3.4 Barriers to implementing and sustaining NP roles in rural primary health care

The challenges or barriers to implementing NP roles were recurring themes in the literature. These impact the number of NPs entering the profession and, consequently the uptake in rural primary health care. Financial barriers, including lack of recurrent funding, inadequate reimbursement under the Medicare Benefits Schedule (MBS) subsidy schemes and current funding models^{8, 18, 20, 33, 35, 36, 41}; and prescribing restrictions under the Pharmaceutical Benefits Scheme (PBS).¹⁸ In addition, factors related to context such as risk of burnout due to lack of holiday relief and study leave^{8, 31, 40}; professional isolation^{8, 18}; and lack of mentorship⁸ were identified as further barriers to continuing in the NP role in primary health care. Additional barriers included a lack of integration within the wider health system³⁴; a lack of support from management staff and colleagues^{18, 40}; lack of resources including the availability of human and physical resources, information technology infrastructure^{37, 38}; and lack of time to give adequate primary care and nonclinical workload impacting clinical care.³⁸ The lack of awareness, clarity and understanding of the NP role by consumers and other health professionals was also identified as a barrier to gaining acceptance and support for the NP role.^{18, 29, 31}

4.3.5 Discussion

The objective of this review was to identify available research evidence regarding NPs practising in Australian rural primary health care. The findings of this review have demonstrated limited research evidence in the literature about NPs practising in rural primary health care, how NPs are addressing service gaps in rural areas and a significant gap in knowledge of the value that NP roles contribute to healthcare outcomes in primary health care settings.

The lack of awareness, understanding and ambiguity surrounding the NP role and scope of practice was frequently highlighted in the literature as impacting managers' and health professionals' acceptance and support for NPs, as well as interprofessional collaboration that limits the further development and implementation of NP roles.^{9, 18, 20, 40} In one article, NPs reported that the lack of understanding of the NP scope of practice meant that they needed to expend effort promoting and advocating for their roles.¹⁸ It is important to note that historically, (that is from the introduction of NPs), there have been reports in the literature of the public's and health professionals' poor understanding of the NP role and uncertainty about role boundaries and scope of practice, as well as opposition by some doctors and medical organisations.^{9, 13, 18}

A lack of community awareness was also identified in the analysis of submissions and survey responses to the Nurse Practitioner 10 Year Plan¹⁹ with respondents indicating that the role of NPs was either not known at all, or slightly known in Australia.⁴³ The ‘Transforming Health Care Campaign’ being led by the Australian College of Nurse Practitioners, with support from the Federal Government Department of Health, aims to address this issue and raise the profile of NPs within and across health care organisations.⁴⁴ Whilst there is limited evidence of support for NPs by some individual doctors, recent policy statements from medical organisations such as the Royal Australian College of General Practitioners (RACGP) in relation to the NP 10 Year Plan¹⁹ indicate that medical professionals' resistance to the further development of the NP role persists, with the RACGP raising concerns about the Plan and contending that the proposal will result in “fragmented care”.^{45, 46}

Whilst the initial vision for NPs was to improve rural and remote populations' access to health care services, the findings of this review highlight that innovative practice opportunities driven by passionate NPs responding to identified unmet need in their communities are significant enabling factors.^{8, 20, 29, 34, 42} In addition, a commitment to providing equitable care, rather than ‘one-size fits-all’ service led initiatives initiated by health services, are key components of service delivery, as are organisational structures that have sound succession planning and opportunities for ongoing professional development^{29, 33, 34, 39, 41, 42} A similar finding of inconsistent development and implementation of the NP workforce has been reported in New Zealand, with ad hoc NP-led services being initiated by individual RNs and innovative service leaders, rather than through strategic workforce planning that recognises and responds to community-level needs.^{47, 48}

This review identified a number of specialised areas of practice and primary health care settings as opportunities to develop and implement a NP-led model of care^{29, 33-35, 39} and reports where NPs worked in a primary health care role in multiple different locations⁴¹ or in one location moving across community health, into aged care facilities, palliative care services and into inpatient services.³⁰ However, there is a need to broaden the focus of attention to NPs working in rural primary health care more widely, particularly in private primary health care settings such as general practice. Although several papers described why and how NP roles or NP led primary health services were developed or reported the results of evaluations conducted during the early postimplementation phase, there is an absence of research studies that evaluate the impact of NP interventions several years after their inception. Longer term evaluations are integral in investigating the health outcomes experienced by individuals accessing NP services, the impact of NPs in improving health service delivery and equitable access to health services, and to provide evidence of the economic viability and long-term sustainability of NP services.

The challenge for all health care delivery is to undertake research to demonstrate ‘what works’ and ‘what needs to be improved’; as noted by Woods and Murfet,¹⁶ there is an ‘onus and opportunity for NPs to demonstrate how their practice adds value to the health care system’. Although several small reports in this review evaluated the impact of NP models of care on, for example patient outcomes, health care utilisation and staff and/or patient satisfaction,^{14, 33, 36, 39} there is a recognised need by NPs, researchers and government (federal and local) for more robust evaluation research demonstrating the contribution and value of the NP role in the primary health care context.^{14, 40, 45, 46} Insecure and short-term funding for NPs also impedes the ability to evaluate the longer term impacts of NP models of care, on improved patient outcomes, access to primary health care and financial sustainability.⁴⁹ It is important to note that in a role that is primarily ‘clinical’ with limited if any support for undertaking the research required this is a particularly difficult undertaking. For NPs to undertake this research, the support of academic researchers and health economists is required.¹⁶

The barriers and enablers to implementing NP roles were a recurring theme in the literature, with economic, legislative, regulatory, resourcing, job availability, support from management and colleagues and organisations' inability to back-fill the NP for leave and professional development, being consistently cited.^{18, 29, 31, 33, 35, 40, 41} There are additional challenges in remote or very remote areas with NPs in several studies reporting that their ability to provide primary health care was compromised by poor resourcing, limited availability of specialist health services and lack of time.^{37, 38}

Whilst noting that there have been some changes made to the National Medicare Benefit Schedule (MBS) with limited NP-specific MBS item numbers added, the current reimbursement/funding model makes it very difficult for NP positions to be financially viable in, for example, private practice or to be employed in primary care such as in general practice.⁵⁰ This particularly impacts negatively on marginalised, vulnerable and rural and remote communities who are unable to afford out of pocket costs.⁵⁰ There is also the tension between general practice as a business and providing care where both NPs and GPs are chronically underfunded.

With respect to factors that enable the implementation of NP roles in rural primary health care, this review found that examples of successful projects or NP-led models of care were those that addressed an identified unmet population health care need or service gap; had secured community support and sometimes funding as well; and had engaged key stakeholders in the planning and implementation of the NP service.^{8, 29, 34, 42} Successful prospective practice models also demonstrated collaboration between health professionals and integration with other service providers.^{29, 30, 33, 36, 39, 42}

4.3.6 Recommendations for further research

This review highlighted a need for robust research demonstrating the value of the NP role in rural primary health care settings, in improving health outcomes, reducing inequities to health care access and enhancing multidisciplinary practice. Well-designed evaluation studies of rural and remote NP practice incorporating an analysis of the impact of the various complex systems involved in delivering healthcare would be beneficial in developing an understanding of how to improve access to care in these contexts.

Continual evaluation of the NP role and scope of practice will allow prospective planning and development in regional and rural areas, thereby enabling implementation of NP roles that can meet the needs of underserved communities. This will require bipartisan legislative support (federal, state and territory) and the Nursing and Midwifery Board of Australia (NMBA) support. Any potential research that reviews primary health care in regional and rural areas will need to track the potential of the NP role, including but not limited to NP job availability being recorded. To support the needed research, NPs in primary health care need assurance in the form of continuity of NP roles within services in combination with strong links to tertiary level academic institutions to continue professional development and maintain a research platform.

4.3.7 Limitations of this review

The limitations of this review are first, the restricting to Australian sources only. Whilst the inclusion of international publications may have provided additional insights into NPs practising in rural primary health care, the decision was made to exclude based on the difficulties in making cross country comparisons due to differences in health systems. Second, the publication time frame was limited to 2012–2022 because whilst the themes in many of the earlier papers remained consistent over time, there had been changes, albeit limited and insufficient, to MBS rebates and prescribing regulations affecting NPs under the PBS.

The potential for interpretation bias is acknowledged given that each of the authors have previously worked as nurses in clinical practice, with Author 1 endorsed to practice as a NP. However, Author 1 has not practiced in that role for more than 20 years. Careful adherence to the review process was maintained to mitigate this potential limitation.

Whilst the current review identified 19 papers only, which could suggest caution is required when interpreting the results, it nonetheless synthesises the available sources and highlights the gap in the literature and potential areas for future research.