108MJA • Volume 187 Number 2 • 16 July 2007
GENERAL PRACTICE AND POLICY — REVIEW
The Medical Journal of Australia ISSN: 0025-
729X 16 July 2007 187 2 108-110
©The Medical Journal of Australia 2007
General practice and policy — review
able literature provides evidence about the roles and outcomes of
practice nursing, demonstrating the value of practice nurses to
primary care delivery.2 Australian studies of the practice-nurse
workforce are largely exploratory and descriptive, with little
evidence cited about models of practice or outcomes.3
Amid perceived threats to clinical practice and funding,1 some
general practitioners appear ambivalent about practice nursing.
The nursing profession in Australia has also displayed ambivalence
about the developments in practice nursing, somewhat reluctantly
accepting that practice nursing is now established as a field of
practice in the primary-care sector. Perhaps these politics have
undermined progress on workforce data collection, funding mod-
els, educational opportunities and career pathways, which is well
developed for other health professions. Nonetheless, the size of the
practice-nurse workforce and levels of health system activity
generated by these nurses warrant much closer attention. To keep
pace with other developed countries, we need to strengthen policy
and evidence frameworks for practice nursing in Australia, so as to
support quality outcomes and a better understanding of the
contributions of practice nurses to the health system.
ractice nurses are now employed in nearly 60% of Australia’s
general practices, and are being allocated an increasing
number of items in the Medicare Benefits Schedule.1 In
addition, substantial financial support is provided for general
practices to employ practice nurses, who are seen as a strategy to
address primary-care workforce shortages. However, there is a
policy vacuum around developments in practice nursing. Here, we
raise issues that will affect the sustainability of the practice-nurse
workforce if not addressed more systematically.
The Australian practice-nursing context
In the United Kingdom, Canada and the United States, consider-
The practice-nurse workforce
Australia has well established and comprehensive sources of
information for the medical workforce.4 Yet, despite the acknowl-
edged importance of health workforce data collections, data on the
practice-nurse workforce are as yet insufficient for the develop-
ment of effective policy and planning.5 A forthcoming data source
will be the annual nursing labour force survey which, from 2006,
has included practice nurses.
Data about the activity of practice nurses are also insufficient.
General practice data collections focus largely on GPs and give
only a partial picture of the roles and functions of practice nurses.
Medicare statistics show that 3.4 million practice-nurse Medicare
item numbers were claimed in 2006, representing 3.2% of all
Medicare items for general practice (see Box 1).6 The 2006 BEACH
(Bettering the Evaluation and Care of Health) report indicated that
practice-nurse activity was recorded in 3.9% of GP–patient
encounters in 2006.7 However, these figures seriously underesti-
mate the contribution of practice nurses to the delivery of primary
health care, because they are centred on the activity of the GP. They
do not take account of activities such as contributions to other
Medicare items (eg, Health Assessments, Practice Incentive Pay-
ments [PIPs] and GP Management Plans); services not claimed on
Medicare; and other functions of practice nurses, such as clinical
organisation, practice administration, and integration.8 Prelimi-
nary data from a new national study of practice-nurse activity
indicate that only 39% of practice-nurse consultations were eligi-
ble for a Medicare rebate.9
Medicare items for practice nurses
Medicare Benefits Schedule item numbers have been introduced
for practice nursing without cost–benefit analysis or a sound
evidence framework about how they might optimise population
health outcomes. Data collections for PIPs take into account the
work undertaken by nurses that attract PIP to general practices
without directly attributing this work to them. Some PIPs are
provided over and above fee-for-service payments to the practice,
for management of clinical conditions such as asthma, diabetes,
cervical screening and mental health. However, while PIP pay-
ments have been increasing (see Box 2),10 there are no data on who
performs the clinical work that attracts these payments. As the
delivery of primary care changes to include a range of health
professions within the general practice context, data collections of
primary care activity must also change to capture the full range of
service providers, to inform economic analysis of activity and more
accurately attribute contributions by different professionals.
The most suitable model of practice for practice nurses has not
been debated. Consequently, the strengths and weaknesses of
different models — often framed as either the substitution or
collaborative model — are not well understood. The substitution
model conceptualises the role of practice nurses as primarily
delegated, assuming that the nurse undertakes a delegated subset of
Practice nurses in Australia: current issues and future directions
Helen Keleher, Catherine M Joyce, Rhian Parker and Leon Piterman
• Almost 60% of general practices now employ at least one
• Australian Government initiatives to support the expansion of
practice nursing are not consistently based on strong
evidence about effectiveness, outcomes or efficiencies.
• Reviews from other countries suggest that practice nurses can
achieve good health outcomes, but there is little information
about the Australian practice-nurse workforce, funding
models to support their work, scope of their practice, or its
• Australian practice nursing lacks a career structure and an
education framework to advance nurses’ skills and
• To maximise the contribution of nurses in primary care, a
more systematic approach is needed, with a stronger
evidence base for policy to support effective outcomes.
MJA 2007; 187: 108–110
MJA • Volume 187 Number 2 • 16 July 2007
GENERAL PRACTICE AND POLICY — REVIEW
a GP’s tasks and functions, with no scope of practice outside this
subset. This view is implicit in the Australian Government’s Nurs-
ing in General Practice Initiative, which is to “relieve workforce
pressure in general practice”.11 In contrast, a collaborative practice
model assumes that the practice nurse is an autonomous provider
— an independent professional with the ability to effectively
manage an episode of patient care. This is reflected in the new
Chronic Disease Management items, which indicate that a practice
nurse can (under certain circumstances) act autonomously, while
also being a member of a multidisciplinary team in a Team Care
Arrangement.12 Collaborative professional autonomous models are
also supported by the competency standards for nurses in general
practice, whereby nurses take personal responsibility for their own
competence and adherence to professional nursing standards.13
The evidence suggests a wide variation in practice-nurse roles,
ranging from traditional delegation of tasks and assistance to
doctors, through to advanced, independent practice in areas such
as preventive care, disease management and care coordina-
tion.3,8,14 Contextual factors that shape models of practice include
the professional characteristics of the nurse, the business orienta-
tion of the practice, and the needs of the local population.3
Systematic investigation is now required to provide evidence about
which models work most effectively for better health outcomes in
the context of satisfaction for practice nurses and GPs.
Other professional issues that remain unresolved in the develop-
ment of the practice-nurse workforce include supervision, profes-
sional indemnity, funding arrangements, education and training,
and the lack of a systematic approach to policy development and
evaluation. Registration boards require a nurse’s primary supervi-
sor to also be a nurse — supervision by GPs is not sufficient.
Systems for management of this responsibility are yet to be
established. There is also concern that the relative professional
isolation of practice nurses creates a vulnerability to pressure to
perform tasks beyond the recognised scope of practice.15
There is also confusion about professional indemnity insurance
for practice nurses, who may be only partly covered under the
general-practice indemnity insurance policy, with potential for
gaps in coverage and conflicts of interest if a claim arises.
Furthermore, if the nurse’s position description includes tasks or
practices not directly delegated by the GP, the insurance issues may
be “grey”. A clear guideline about professional indemnity insur-
ance coverage for GPs and practice nurses is essential.
Watts et al found that education for practice nurses is not
adequate to meet the demands of their current or future roles.8
Indeed, there is no comprehensive framework for the education of
practice nurses. Although the Australian Government has offered
scholarships for education in some clinical areas through the
Nursing in General Practice Training and Support Initiative: 2005–
09, these scholarships have not been tied to a quality audit of the
programs of study. Seventy-three per cent of nurses working in
general practice in Australia are aged over 40 years,1 and are likely
to have come from the hospital setting, with little training or
experience in primary care. A strategy is needed to provide
education and training pathways to support nurses to gain levels of
expertise (basic to advanced) based on knowledge, skill and
competencies. These pathways would allow practice nurses to
advance through a career framework, as has been developed in the
UK and New Zealand.8
Unfortunately, policy initiatives have failed to include mecha-
nisms for monitoring and evaluation, and have not been linked
with existing frameworks, such as those for professional education
and training, professional competencies and scope of practice,
quality of care, health outcomes and models of care. Future
development should include a quality-assured, comprehensive
educational framework, and should place role development for
practice nurses in the context of a national, coordinated approach
to primary health workforce development.
A strengthened practice-nurse workforce has the potential to drive
change and improve the delivery of many aspects of primary care,
as well as to relieve workload pressures on GPs, but there are
2 Service Incentive Payments made under the Practice
Incentives Program by quarter, 2002–200610
No. of payments (×1000)
Jan-03 Jan-04Jan-05 Jan-06
AsthmaCervical screening Diabetes Mental health
1 Medicare Benefit Schedule items for practice nurses, 2004–20066
2004 2005 2006
No.No. Increase* No.Increase*
Number of services (millions)
Total benefits paid ($millions)
*Increase on previous year.
110MJA • Volume 187 Number 2 • 16 July 2007
GENERAL PRACTICE AND POLICY — REVIEW
challenges in establishing an effective and sustainable practice-
nurse workforce. For the work of practice nurses to be seen as
contributing to the larger primary care national agenda, high-
quality data collections are needed that will permit analysis of their
actual practice, the quality of care they provide, and its outcomes.
In addition, practice nurses need a quality education and career
framework that will attract those seeking an alternative to hospital
careers. Policy development in primary care has been reactive to
the needs of general practice and workforce shortages, without a
genuine understanding of, or commitment to, professional support
for the practice-nurse workforce. Box 3 shows specific suggestions
for a more proactive and evidence-based approach to developing
primary care nursing policy and practice.
Helen Keleher, PhD, Professor of Health Science
Catherine M Joyce, BA(Hons), MPsych, PhD, Senior Research Fellow,
Department of General Practice
Rhian Parker, BScEcon(Hons), MSc, PhD, Senior Lecturer, Department
of Health Science
Leon Piterman, MRCP, FRACGP, MAFOM, Professor of General
Practice, and Head of School of Primary Health Care
School of Primary Health Care, Monash University, Melbourne, VIC.
1 Australian Divisions of General Practice. National Practice Nurse Work-
force Survey. Canberra: ADGP, 2006.
2 Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse
practitioners working in primary care can provide equal care to doctors.
BMJ 2002; 324: 819-823.
3 Halcomb EJ, Patterson E, Davidson PM. Evolution of practice nursing in
Australia. J Adv Nurs 2006; 55: 376-390.
4 Productivity Commission. Australia’s health workforce. Research report.
Canberra: Productivity Commission, 2005.
5 Australian Health Ministers Conference. National Health Workforce Stra-
tegic Framework. Sydney: AHMC, 2004.
6 Medicare Australia. Medicare statistics. http://www.medicare.gov.au/
(accessed Apr 2007).
7 Australian Institute of Health and Welfare. General practice activity in
Australia 2005–2006. Canberra: AIHW, 2007. (AIHW Cat. No. GEP 19.)
8 Watts I, Foley L, Hutchinson R, et al. General practice nursing in Australia.
Melbourne and Canberra: Royal Australian College of General Practition-
ers and Royal College of Nursing, Australia, 2004.
9 Joyce C, Piterman L. The Practice Nurse Work Survey: nurses working
together with general practitioners. Presentation at the General Practice
and Primary Health Care Research Conference, Sydney, May 2007.
10 Medicare Australia. General practice statistics reports. http://www.medi-
11 Australian Government Department of Health and Ageing. Guidelines
for the Divisions Network Nursing in General Practice program. Can-
berra: Commonwealth of Australia, 2006.
12 Australian Government Department of Health and Ageing. Chronic
disease management (CDM) Medicare items. Q & As. Updated with 1
November 2006 MBS fees. Canberra: Commonwealth of Australia, 2006.
programs-epc-chronicdisease (accessed Apr 2007).
13 Australian Nursing Federation. Competency standards for nurses in
general practice. Canberra: ANF, 2006. http://www.anf.org.au/nurses_
gp/ (accessed Apr 2007).
14 Healthcare Management Advisors. Evaluation of the 2001 nursing in
general practice initiative. Canberra: Australian Government Department
of Health and Ageing, 2005. http://www.health.gov.au/internet/wcms/
publishing.nsf/Content/pcd-nursing-eval (accessed May 2007).
15 Halcomb EJ, Davidson PM, Daly JP, et al. Nursing in Australian general
practice: directions and perspectives. Aust Health Rev 2005; 29: 156-166.
(Received 30 Apr 2007, accepted 5 Jun 2007)
3 Recommendations for future development of policy on
• Tracking of the practice-nurse workforce.
• Collection of data on primary care activity by provider type, linked
to health outcomes and quality of care.
• Framework for an education and career pathway for practice
• Development of guidelines for practice nurse supervision.
• Clear guidelines about professional-indemnity requirements for
• Nationally consistent standards for the development of the
• An evidence-based approach to the development of policies
related to practice nursing.