Day in the life of a Primary Health Care Nurse

You’ve had an interesting career path, give us a little rundown of the last 20 years.

Like everyone I graduated with, I applied for a new-graduate position in a hospital. Most of my placements had been in metropolitan specialist wards and being a rural person, I pursued an 18-month new-graduate position in a rural area. This gave me a breadth of experiences at small and regional facilities.

Then I moved states and started working in a private theatre and day surgery. That was fast-paced and you stayed until the work was done. I also started working for a firm who worked with a variety of industries such as mining, abattoir, council and warehouse supporting employee health. This experience and my nursing career to date led me to complete a Grad Dip in Occupational Health and Safety Nursing.

When I moved again, I continued working in occupational health but this time through workers compensation rehabilitation support as well as employee health and wellbeing programs such as immunisations and smoking cessation programs. My focus on preventive health prompted me to do a Masters in Public Health. After I had children, I wanted to work somewhere that would use my qualifications and experience but had more family-friendly hours, so I started teaching undergraduate nurses and working in general practice. At the moment, I am teaching undergraduate nurses and doing a PhD.

So my clinical, teaching and research experience has been located largely in rural areas. This has been for lifestyle reasons but there is variety and continuity of care that appealed to me. Variety is experienced through exposure to people and medical issues across the lifespan. Continuity with patients and health colleagues means that ongoing relationships foster the rapport and therapeutic relationships needed for patient outcomes.

Can you explain some of the impacts you were able to make as a Primary Health Care Nurse?

Primary health care (PHC) is a broad area of work nurses can be involved in and includes areas such as school nursing, refugee health, occupational health and general practice. My roles in occupational health and general practice informed my drive for prevention. I remember a pivotal moment as a new grad trying pushing a man on a broken commode chair who was twice my weight. I reflected on workplace processes and my physical capacity, thinking “This situation is avoidable”.

I did further study around occupational health after seeing issues in the ward environment such as broken equipment not taken out of service, a gap in knowledge about safety obligations, and there seemed to be a lack of representation of nurses about these issues.

When working in occupational health the linkage between overall health and injury was apparent. Additionally, running preventive programs in industry such as Pit Stop Programs, heart week or diabetes week meant that many employees were engaging in health care who would not have ordinarily done so. This was valuable as medical issues were picked up and appropriate referrals and interventions could be made. For example, the development of a smoking cessation program. These experiences prompted me to complete a Masters in Public Health.

Within general practice, preventive care can include things such as immunisations, asthma management and as part of maximising function associated with chronic disease management (CDM). CDM is part of a team-based approach in meeting someone’s care needs for conditions such as diabetes, COPD and heart disease in a variety of ways including goal setting, referrals to other health professionals, care navigation, education and treatment.  

My role was largely around CDM, where I tried to support lifestyle behaviour change through smoking cessation, nutritional advice, moderating alcohol intake and encouraging physical activity. While this was after a ‘chronic disease’ had been diagnosed, real change and differences to people’s health can be made. For example, one man would routinely come and see me wanting to lose weight. This meant we could talk through barriers, goals and what other members of the primary care team were doing to support his needs.

Have you got any advice for nurses on the site currently looking at becoming a Primary Health Care Nurse?

As a starting point, there are a couple of things around skills and the general practice to understand. To inform where you think you would like to work get to know the practice – their patient demographics such as older people or families, and how nurses are utilised and run clinics, and what is in the GPN’s job description. From a knowledge and skills perspective, I found that good negotiation skills around the GPN’s role and remuneration, as well as communication skills in behaviour change, were helpful.

While I was an accredited immuniser, an understanding of immunisation, CDM, and Medicare billing is needed. In the current COVID-19 environment, the ability to use telehealth might be advantageous. The Australian Primary Health Care Nurses’ Association (APNA) and the Australian College of Nursing (ACN) might be a good place for people to start when looking for courses.

What things do you get to do as a Primary Health Care Nurse that you would not get to do as a hospital nurse?

You get to look after people and their families across the lifespan. The work is diverse and you expect the unexpected. However, to try and prevent chronic disease and keep people out of hospital care represents the biggest challenges and opportunities for GPNs.

What would your advice be to help nurses develop a better understanding of why patients struggle with managing thier health at times?

Chronic illness is complex and can be related to the social determinants of health such as poor urban design where physical environments have a lack of exercise infrastructure, or, perhaps someone has poor health literacy about food choices because of educational access. Working out what health concerns and priorities someone has takes empathy, understands their social determinants of health, and means that care is person-centred. When people feel listened to they are more on board with what you have to say, creating opportunities to have other interventions such as education about increasing vegetable intake in meals.  This often takes time though and ongoing support for the patient is needed.

There is always a danger that you want to fix everything. Sometimes, people’s lives are really hard. Additionally, often people present with more than one issue needing attention and there are always time pressures. So prioritising care based on what the patient wants to achieve that day is important. Where lifestyle risk is concerned though, the advantage of addressing one thing can help multiple conditions such as exercise and its impact on cardiovascular disease as well as diabetes.

Chronic conditions require ongoing care, which is often complex. As nurses, we need to have patience, empathy and ongoing therapeutic relationships with patients where there is trust and rapport. To do this, we need to be alongside patients on their journey, providing care ‘with’ rather than ‘to’ them.

What are the biggest misconceptions about being a Primary Health Care Nurse and nursing research?

I wasn’t aware of this until after I started as a GPN but there seems to be a perception that it is an area you go to before retirement. A nursing colleague even asked me if I will “go back to nursing”. The inference being that working in general practice is not actually nursing! However, working in general practice can be a cross between community, mental health, day surgery and emergency nursing where routine care such as dressings, immunisations, excisions take place as well as ‘walk-ins’ requiring immediate care such as cardiac symptoms or injuries. It can be a busy place.

One of the biggest misconceptions about nursing research is that it is not nursing. Nursing is such a diverse occupation and there are so many things to learn. Research is just one of those areas. In fact, engaging in research forms part of our practice standards. Just as any research needs to inform practice, the reverse is true too.

What does your role as a tutor involve?

I graduated a few years ago now, back when there was little support or exposure to the needs of university graduates. I wanted to contribute in some way to supporting current nursing students in becoming registered nurses and felt that tutoring was a good place to start. The role has meant teaching face-to-face, and more recently online, as well as marking assignments. However, working at a regional campus has had added benefits by supporting the same students across their nursing degree.

Can you explain to the readers your PhD thesis and why you are so passionate about it?

My PhD is about how GPNs and patients communicate lifestyle risk. It is a mixed-methods study that used video observation of GPN-patient CDM consultations and GPN interviews. We analysed nonverbal techniques, motivational interviewing and the GPNs’ perceptions of communicating lifestyle risk with patients.

When working in general practice, I noticed that there were many things that impacted the prevention of chronic disease. These could be time, funding, GPN education, workplace support, patient motivation, and collective willingness to have lifestyle risk discussions. I wanted to understand if what I was experiencing in my practice was the same for other GPNs. Importantly, I wanted to support GPN practice and enhance patient outcomes. So, being a curious person, and having a sense that I wanted a challenge, this led me to enrol in a PhD.

I have been funded by the Australian Government Research Training Scholarship and the National Tertiary Education Union Joan Hardy Scholarship. My thesis is due for submission later this year. Doing a PhD has also resulted in other research opportunities around PHC nurses’ experiences during COVID-19 as well as seed funding projects supporting bushfire recovery in local communities.

Has your research thrown up any unexpected findings?

Coming from a clinical perspective, I felt that I knew some of the answers but not to the depth required, and there was limited research about how GPNs and patients communicate lifestyle risk in general practice. It has been great to see how other GPNs and practices operate and prioritise this care.

Key PhD findings relate to the GPNs’ relational strategies used in the nonverbal and verbal communication of lifestyle risk, as well as communication skill needs at a pre and post-registration level, and, organisational and funding requirements linked to the value placed on GPNs communicating lifestyle risk with patients. Addressing the GPNs’ personal, professional, organisational and funding issues has the potential to better utilise this role in the prevention of chronic disease.

Has doing your PhD enabled other research opportunities?

The great thing about learning research skills is that it has resulted in other research opportunities collaborating with other organisations. This has occurred at a local level fostering rural research capacity for clinicians and academics alike in the formation of a health research network. I have been fortunate to be involved in a PHC nursing COVID-19 project involving the University of Wollongong, Australian National University and the University of Notre Dame. My research skills are also being used to support my community through seed funding projects around bushfire recovery and resilience.

What’s your advice for nurses keen on undertaking nursing research?

In a nutshell, there are 4 things I think are important for doing research:

1. Find a mentor. This can be through a research network, key person within your workplace or academic supervisor. Then, talk through your idea and be prepared for this to take a while to refine.
2. Seek opportunities and funding to be involved in research. This can take many forms from being a participant to doing a study. Some workplaces, through state health department research schemes, offer opportunities to conduct research. Additionally, funding can occur through scholarships such as those offered by unions, or if you are doing a PhD, the Australian Government Research Training Scholarship.
3. Know your team. Research is a team sport and on your team, you need mentor/s, your family and friends, and research allies. These will all be people who understand what your needs are that you will call on from time to time.
4. Patience and persistence. The research process can take a while, from stakeholder engagement, design, ethics, data collection, analysis, writing up, and publications. Your team needs these skills sometimes too.

How do you think healthcare in Australia can improve preventive care?

There is an opportunity to better utilise the PHC nursing workforce in the prevention of chronic conditions. However, ongoing and effective training, funding and workplace supports need to be in place. In Australia, there is an ageing population and increases in the chronic disease burden. Given the GPNs’ increasing role in CDM, this workforce is ideally placed to have enhanced capacity in the prevention and management of chronic disease through the communication of lifestyle risk.  We just need to bolster their capacity to do this carefully.

Do you have any primary health care resources you’d recommend?

APNA Tools and Resources

Guzys, D., Brown, R., Halcomb, E., & Whitehead, D. (2017). An introduction to community and primary health care (2nd, Ed.). Cambridge University Press.             

WHO’s Building the primary health care workforce of the 21^st century

Any final words of advice to nurses of Australia about our wonderful profession?

Nursing brings many opportunities and PHC is diverse. COVID-19 has provided many challenges but in the International Year of the Nurse and Midwife, we have shown our value and then some. As nurses, regardless of setting and challenge, we need to continue to learn and provide optimal care. Supporting research and utilising evidence-based practice is the key to effective care and professional development.

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