Editorial

Nursing the future in Australia

Robyn Gallagher
Chronic and Complex Care, Faculty of Nursing, Midwifery and Health, University of Technology, Sydney, Sydney NSW

Margaret Fry
Higher Research Degree Program Coordinator, Faculty of Nursing, Midwifery and Health, University of Technology, Sydney NSW

Christine Duffield
Assoc. Dean Research, Centre for Health Services Management, Faculty of Nursing, Midwifery and Health, University of Technology, Sydney NSW

PP: 118 - 120

Article Text

Workforce issues, particularly shortages and their consequences, have dominated the health debate over the past few years. What has received less debate is the use and appropriateness of current roles given projections about supply, distribution and skill mix needed to meet future demands for services.

Two important international trends in health underlie the projected increases in demand. The first of these is that better health care and nutrition have resulted in longer life expectancies, with an average increase of nine years recorded in all OECD countries (The OECD Health project, 2004), although the trend is most prominent in western countries. For example, in Australia in the last 50 years, the number of people aged 65 years or more has doubled and the number of people over 85 years has increased sevenfold (Australian Institute of Health and Welfare [AIHW], 2009). This is an important change because the incidence of disability and chronic disease increases with age. For instance, 76% of Australians aged over 65 years have a disability, long term condition or chronic illness (AIHW, 2009), increasing the potential need for healthcare, in particular hospital care, when multiple conditions accumulate over time. Indeed, older people represent a growing proportion of hospital inpatients. In the five years from 2003 to 2008, there was a 21% increase of patients aged 75-84 years requiring hospitalisation, and close to a 30% increase for those aged 85 years and older (AIHW, 2009).

The second important trend in health is that advanced technology has enabled people of all ages to survive previously fatal injuries and illnesses, but often not without consequences such as long-term disability and chronic illness. For example, while the number of deaths due to myocardial infarction has decreased dramatically, there has been a corresponding increase in the incidence of heart failure (American Heart Association, 2009). Chronic diseases, such as heart disease, stroke, cancer, chronic respiratory diseases and diabetes are often debilitating for the patient and complex for healthcare staff to treat, not only because of the care required for the progressive primary illness, but because a cascade of secondary conditions may occur (NIH, 2009). This means that health staff require specialised knowledge to provide care and to manage the technology used, particularly for acute exacerbations for the primary condition, but also to have an understanding of coexisting conditions. Finally, the combination of both trends, an ageing population and increased chronic and complex conditions, means that health providers are faced with patients with multiple health conditions and uncertain illness trajectories requiring specialty care.

Health services are struggling to meet patient demand in both the acute and primary care health setting. The increased and increasing service demands on these settings are presenting a variety of challenges for clinicians, policy strategists and managers. The loss of function and social support that may occur with ageing further complicates matters-providing care where it is needed, which may not be where health professionals are located. This will be particularly so in remote and rural locations.

A significant obstacle to ensuring continuity of care between providers remains the lack of a nationally integrated medical health record system. Optimising the transfer of medical knowledge through shared medical record systems has been shown to enhance patient management, provide greater continuity of care, improve documentation and reduce duplication within services (Hansagi, Olsson, Hussain, & Ohlen, 2008). Integration of health services would enhance continuity of care between primary health care and acute service agencies as the number of elderly and complex patients increases. Greater quality of data, monitoring and evaluation processes would be achieved if agencies 'shared' a one medical record system. A 'shared' medical record system would enhance patient safety, access, sustainability and encourage greater collaborative patient centred model approaches.

The increasing service health demand and transfer of patient into an outpatient or primary care environment requires a more collaborative and interdisciplinary approach than currently exists within service models which involve expanding the scope of practice for many healthcare workers and in particular, Nurse Practitioners. International reforms have identified that Nurse Practitioner led services have reduced demand on acute hospital services. While it is difficult to quantify the reduction, a range of between 10 and 53% was supported in the UK, USA and Europe. Other relevant literature has found that Nurse Practitioner models improved healthcare access, sustainability and reduced GP workload (Carter & Chochinov, 2007; Phillips & McCann, 2005).

The potential of the Nurse Practitioner workforce to impact on primary healthcare and acute services may prove critical in reforming the delivery of services in the Australian context (Hoffman, Tasota, Zullo, Scharfenberg, & Donahoe, 2005; Sakr et al., 2003). In the UK, Canada and US, Nurse Practitioners have provided appropriate and safe care to a large number of patient conditions with high patient satisfaction (Horrocks, Anderson, & Salisbury, 2002; Kinnersley et al., 2000). In the UK, Nurse Practitioner led Walk in Centres and Minor Injury units are managing safely, quickly and appropriately up to 50,000 patients annually (Sakr et al., 2003). Internationally, Nurse Practitioners are located now in the intensive care services, emergency services, surgical services, cardiology services, neurological services, general medicine services, primary care and oncology services. Within these services, Nurse Practitioners are managing acute, chronic and complex patient conditions within in-patient and/or outpatient settings. No appreciable difference has been found between Nurse Practitioners and doctors in achieving health outcomes or in resource utilization. However, greater patient satisfaction and compliance in following practice guidelines are commonly found.

However, the use of these highly skilled nurses may not be sufficient to meet future demands for care. Patients often access acute services based on their own perceptions of urgency, the need for a range of investigative services and availability of their GP (Sakr et al., 2003; Salisbury & Munro, 2003). Hence, patient's perception of their urgency and needs significantly impact on healthcare provider choice (Anantharaman, 2008). Although challenging, there is a need to change patient perceptions and behaviour in relation to utilisation of health services and provider groups (Hamilton, 2007). In the UK patient, media campaigns to advertise services was a key factor that influenced patient choice. Salisbury and Munro (2003) were critical of the implementation of some Nurse Practitioner led services and cited lower activity levels the result of poor advertisement.

The challenge for architects of the Australian healthcare system is to provide a greater number and range of expanded roles to meet projected increased demands for care, particularly in primary care settings. Nurse practitioners are one obvious solution but the slowness with which this option is being undertaken is a concern. As numbers of elderly and chronically ill children and adults increase, the gap between providers available and those needed grows.

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