Nurse-led services deliver high-quality, cost-effective care, but is Queensland ready for it?

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Like many countries, Australia’s healthcare system is facing major challenges. An ageing population and high burden of chronic disease have driven the need for service development and innovation. Nurses in particular have responded by reshaping healthcare services, and the last decade has seen a proliferation of advanced practice roles and nurse-led services seeking to improve patient experience and address gaps in health services.

While nurse-led care is expanding, the ad hoc development and lack of service evaluation in Australia has contributed to confusion around what ought to be defined as a nurse-led service. Nurse-led services exist on a continuum from the direct substitution of single medical tasks, through to comprehensive, advanced practice nursing models of care. The range of service models reflects the degree of professional autonomy exercised by the nurse, but all are defined by a registered nurse leading a service with primary care responsibility for a cohort of patients. Yet current information about the scope and nature of these services is lacking. 

The need for more coordinated service planning and systematic evaluation prompted a scoping study to inform future development. The study, “Nurse-led services in Queensland: A scoping study”, published in Collegian: Journal of the Royal College of Nursing Australia, looked at 257 nurse-led services through an online survey distributed through each Hospital and Health Service in Queensland. Service level data were collected on structure, process and outcome evaluation, as well as enablers and barriers to sustainability of care delivery models.

The researchers, led by Associate Professor Clint Douglas at the QUT School of Nursing, said that nurse-led service remains a contested space in a medically dominated healthcare system. Prominent medical associations, including the Australian Medical Association and Royal Australian College of General Practitioners, oppose nurse-led services and support expanded nursing roles only under the direction and supervision of medical practitioners. Whether a service is really nurse-led, and the level of autonomy in clinical practice, is often controlled by medical consultants.

Nurse-led services have low wait times, providing accessible specialist services to patients

Nursing advocates argue the expansion of nurse-led services has the potential to create a more accessible, productive and safer healthcare system, such as by reducing avoidable hospital admissions and improving access to diagnostic and therapeutic procedures. Indeed Queensland Health’s “Strengthening health services through optimising nursing: Strategy and action plan 2013–2016” said “Optimising the ability of nurses to work to their full regulated scope of practice will increase flexible service delivery options and enhance contestability. Expanding nurse-led services through a range of business models… improves integration of care, promotes self-care and wellness, and reduces the demand for acute services.”

There is a diverse and growing range of nurse-led services across Queensland. Nurses are rising to the challenge of leading person-centred primary care for chronic disease and responding to community needs by offering more flexible and innovative models of care. Nurses are leading teams across acute and community boundaries and treatment silos to provide care coordination and transitional care for those most at risk of hospital readmission.

The researchers said that their findings show that nurse-led services have low wait times, providing accessible specialist services to patients with complex health needs and communities with traditionally poor access to healthcare.

While registered nurses have been and continue to be pivotal in the development and delivery of innovative practice models, the research findings inform a policy agenda for nursing to more fully realise its contribution to healthcare reform. Foremost are funding models that make visible the contribution of nursing service and support equitable access to Medicare payment. 

Following a 2015 study of NP-led wound management in Australia, “Scoping study into wound management nurse practitioner models of practice”, the researchers argue that lifting restrictions to provider numbers for MBS and PBS for advanced practice nurses, such as NPs working in public hospitals, would promote high quality/value services. They said that nurse-led services need to be informed by an understanding of KPIs and funding models that are relevant to current political imperatives, as such factors drive decision-making at a health service level. Work also needs to be done to support nurses by developing credible business models that support effective and efficient service delivery.

The research team said they were optimistic that the shifting emphasis from volume-based to value-based healthcare will also drive organisational investment in nurse-led services – where “value” is defined as patient health outcomes achieved relative to the true costs of delivering those outcomes.

The ability to provide quality nurse-led services to the community depends on the availability of a highly skilled workforce, and a large number of nurse-led services appear to depend on an individual practitioner, creating breakdowns in continuity of service provision and a lack of succession planning. The study found that there is a need to create professional and educational pathways that prepare nurses for these roles. A master’s degree is the required education level for advanced practice nursing, yet only 39.2% of services were led by a master’s-prepared nurse. The study also found that registered nurse or clinical nurse led service activities did not meet advanced practice thresholds, and they appear to be best supported at the clinical nurse consultant or NP level. 

Expanding nurse roles are more likely to be accepted if there is multidisciplinary understanding of the potential benefits

The study found that the value of nurse-led services will be greatly diminished if they are co-opted into supporting a traditional medical model. Scope of practice and autonomy ought to reflect nursing expertise rather than be negotiated with medical colleagues. Role expansions are more likely to be accepted if there is multidisciplinary understanding of the potential benefits, and collaboration on the objectives of the service development project. Successful nurse-led services had clearly developed a shared vision for the service and were valued by the multidisciplinary team. 

The research team concluded that nursing must seize current opportunities to take the lead in redesigning healthcare to meet the challenges of the future. The study demonstrates the potential of nurse-led services in Queensland to more fully utilise nursing expertise in ways that offer safe, affordable and accessible care to the community. Nonetheless, nurses need to advocate for policy changes that replace an acute care focused system and associated entrenched medical model with services that are centred around and offer the best outcomes for the person needing care.