Extending the role of practice nurse: extending the role of practice nurses to manage patients with chronic conditions, and providing an opportunity to develop nurse practitioners within the community are two aims of a pilot project getting underway in Auckland.

A pilot project aimed at enhancing practice nurses' skills to enable them to manage the care of patients with cardiovascular (CV) disease and diabetes is underway in Auckland. A partnership between Auckland University's School of Population Health and the Healthwest Primary Health Organisation (PHO), it is being driven by nurse educator Margaret Horsburgh and the PHO's clinical nurse manager Sue Adams. It involves six general practices in Auckland, including some with high Maori and Pacific populations, and Maori providers in Northland. The practice populations range from 2000 to 9000.

Chronic disease management

Adams, who had worked for a primary health care trust in England developing nurse-led and joint nurse/GP clinics for the care of patients with chronic diseases, and Horsburgh were introduced by the PHO's chief executive Alan Greenslade. Adams, who had emigrated to work with the PHO in January, is involved in developing chronic disease management within the PHO. Horsburgh was interested in developing a research project which would give the School of Population Health a strong nursing focus. She was well aware that international research showed nurse-led programmes in primary care lead to a decreased risk of cardiovascular disease and diabetes. So her research interest and Adams' experience in England and work with the PHO fitted very well together. Horsburgh said linking her expertise as an educator and researcher with that of a very experienced nurse on the ground had been a vital part of the project's development.

Adams' work in England, which involved education and support of practice nurses, and the development of sound systems to access and manage data and audit tools within general practices, resulted in improved clinical outcomes for those patients with chronic diseases.

An integral part of the pilot ,project is a software programme which provides electronic clinical decision making support. The programme, Predict, provides clinicians and patients with a way of assessing the risk of CV disease and diabetes, along with patient education and the ability to download relevant resources. A disease management module will be added soon. Horsburgh says it is very user friendly and provides a vehicle for developing nurses' role in managing the care of patients with chronic diseases.

"Absolute commitment" was needed from the practices involved in the pilot project, Horsburgh said. That commitment included the ability to give the nurses involved the time to develop and run nurse-led clinics, an ability at a PHO level to provide an extra salary if needed to enable the nurse/s to be involved and the space for a nurse to run a clinic.

Adams says the development of good data systems and audit tools is essential. "Until practices have well organised data, they can't be adequately audited and improvements in clinical outcomes cannot be measured."

When talking with general practices initially about the project, Adams said there was a lack of confidence from some GPs and nurses about nurses' ability to manage the care of those with chronic conditions. "But that isn't justified. We are dealing with a skilled nursing workforce, many of whom are doing a huge amount already. With the mentoring and support the project will provide, nurses will be able to lead clinics. The nurses I worked with in England were not career nurses but within a year they were leading asthma clinics and running joint clinics with the GPs."

Collaboration with GPs

Clear, easy-to-follow protocols and templates to assist assessment and management of patients were important. Adams stressed that collaboration with GPs was essential to the success of the pilot project. Results of the work she was involved in England showed that both nurses and GPs enjoyed the enhanced teamwork such an approach to patient care fostered.

One of the first steps in developing the project is formal practice nurse education on the population-based screening needed to identify at-risk patients and other aspects of nurse-led clinics and patient care. Population screening is expected to start in the spring and Adams hopes to have data around improved clinical outcomes within a year.

The pilot practices would have different approaches to screening their patients. Adams said this could involve initiatives at marae, church halls and workplaces. One of the practices provides outreach services to the Pacific community on Auckland's North Shore. Once the at-risk patients have been identified, nurses will manage these patients in collaboration with the GP.

'Growing' nurse practitioners 

Horsburgh hopes the project will "grow some nurse practitioners from the ground up. The nurses working on the project will become experts in CV disease and diabetes and some may well want to go on to become NPs," she said. Adams is keen on the idea of the project "growing" its own NPs. "It is better for NPs to develop within their communities than to be imposed from the outside. And it is in primary care that the NP role will have the greatest impact."

She says the nurses involved in the project will be generic practitioners, with specific knowledge of cardiovascular disease and diabetes. "We want to moves nurses from being reactive to proactive practitioners, who think creatively about how to connect with hard-to-reach patients and who can plan and prioritise around the practice population, whether enrolled or not. Nurses have to connect with hard-to-reach populations if we are going to have any impact on the huge inequalities in health."

More practices would be added as the pilot project continues and other chronic conditions such as asthma and chronic obstructive pulmonary disease may be included as the project develops. Horsburgh says the project is "hugely exciting and just what a university should be doing--providing leadership in primary health care".