Health promotion by primary care nurses in Australian general practice

Collegian (2013) 20, 215 221 Available online at www.sciencedirect.com j ourna l h omepage: www.elsevier.com/l ocate/coll Health promotion by primary care nurses in Australian general practice Helen Keleher a,, Rhian Parker b a Department of Health Social Science, School of Public Health and Preventive Medicine, Monash University, Australia b Australian Primary Health Care Research Institute, Australian National University, Australia Received 6 November 2011 ; received in revised form 14 July 2012; accepted 3 September 2012 KEYWORDS Primary care nursing; Health promotion; General practice Summary The pressures brought about by the increasing prevalence of poor health among some population groups as well as the rise in prevalence of chronic and complex conditions requires a nursing workforce skilled in health promotion. Primary care nurses have increasingly important roles in general practice settings but there is little exploration of the nature or extent of their health promotion work. This paper reports on a survey that investigated primary care nurses perceptions of their current and potential roles in health promotion in general practice settings. The survey respondents were primary care nurses in general practice. 78 nurses responded to advertisements seeking participation, and 58 surveys were completed and returned. Data were analyzed through a framework of downstream upstream health promotion actions. We found that the health promotion practices of primary care nurses were most commonly in the downstream realm of disease prevention and health education but nurses aspired to take on roles in more upstream work of partnerships and collaboration. Nurses opportunities are undoubtedly constrained by both the general practice setting and their educational preparation. However, nurses were very positive about the opportunities that their role and position offered for expansion of their health promotion work. Crown Copyright 2012 Australian College of Nursing Ltd. Published by Elsevier Ltd. Introduction Australia s first National Primary Health Care Strategy released in 2010 (Australian Government Department of Health and Ageing, 2010a) signaled a new direction for primary health care and major reforms to the sector have followed. Despite its limited emphasis on health promotion, the Strategy calls for greater community involvement Corresponding author. Tel.: +61 399031653. E-mail address: helen.keleher@monash.edu (H. Keleher). in primary health care, increased efforts in prevention and the promotion of health, and better alignment and integration of existing services in response to community needs (Australian Government Preventive Health Taskforce, 2009) Health promotion and prevention are integral to primary health care, and nurses are a growing part of the primary care workforce. That growth is an outcome of subsidies from Medicare, Australia s universal health insurer (Merrick, Duffield, Baldwin, & Fry, 2012). The Australian government provides significant financial incentives for general practices to employ primary care nurses, and as a 1322-7696/$ see front matter. Crown Copyright 2012 Australian College of Nursing Ltd. Published by Elsevier Ltd. http://dx.doi.org/10.1016/j.colegn.2012.09.001

216 H. Keleher, R. Parker result, there has been growth of about 15% each year in this workforce since 2007 (Australian General Practice Network, 2010) with greater increases expected from 2012 as general practice incentives in the 2010 Federal Budget for nurses are rolled out (Australian Government, 2010b). A stated aim of the initiative is that: Patients are expected to benefit from improved health outcomes through a greater focus on prevention, education, and chronic disease management (Australian Government, 2010a). Primary care (whether general practice or community health) is an appropriate location to address issues such as self-management of chronic conditions, as it is from this setting that the most common health problems in the community are addressed through preventive, curative, and rehabilitation services (Starfield, 1998). Evidence demonstrates that investment in services offered through primary care results in healthier populations and lower overall costs for health care (Starfield, 2009) This is particularly evident where increased investments in services in primary care have been shown to result in a decrease in hospital admission rates for chronic conditions (Gulliford, 2002; Starfield, Shi, & Macinko, 2005). The role of primary care (or practice) nurses has been established for longer in the UK, New Zealand and the USA, than in Australia (Joyce & Piterman, 2011; Keleher, Joyce, Parker, & Piterman, 2007). Joyce and Piterman (2011) have established the generalist nature of practice nurse work, noting that change is likely to evolve their roles in relation to qualifications, competencies and opportunities. There is considerable scope for primary care nurses to deliver health promotion and prevention interventions and our previous research has identified the range of roles in which nurses are involved including the management of complex health problems (Parker, Keleher, Francis, & Abdulwadud, 2009; Parker, Walker, & Hegarty, 2010). Joyce and Piterman found that practice nurse patient encounters were for a wide range of general and specific conditions, and they were commonly involved in medical examinations (20.7 per 100 encounters), immunizations (22.5), diagnostic tests (10.6), and dressings (15.8). Approximately 30% of encounters involved advice-giving (Joyce & Piterman, 2011). Nurses working in Australian general practices have been shown to be effective in a range of prevention activities such as smoking cessation (Zwar, Richmond, Forlonge, & Hasan, 2010). Nurses working in this setting have also been shown to be willing to advise patients about physical activity, but have significant gaps in their knowledge about current guidelines which suggests a lack of educational preparedness for such roles (Douglas et al., 2006). At the same time, despite the fact that patients expect primary care practitioners to provide information on prevention, this is often not forthcoming in general practice (Harris, 2008; Mazza et al., 2011). Disadvantaged populations are most at risk of lifestyle modifiable chronic conditions, yet Australian general practice currently struggles to provide accessible and effective activities and preventive interventions for disadvantaged groups (Harris, 2008). Given that many areas of general practitioner workforce shortage are also areas with more disadvantaged populations (Turrell, Oldenburg, Harris, & Jolley, 2004), nurses working in primary care in these areas may be able to effectively contribute to health promotion and prevention particularly in these areas. Australian general practice is employing an increasing number of practice nurses with close to 9000 nurses employed in 2009 (Australian General Practice Network, 2010). From January 2012 a new funding system for nurses working in general practice was in place in Australia (Australian Government, 2010b). Instead of remunerating nurses for specific tasks, funding of $25,000 per general practitioner (GP) (up to a maximum of five GPs per practice) is provided for the employment of a registered nurse (3 years minimum education) and $12,500 for employment of an enrolled nurse (1 year minimum education). One aim of this funding is to broaden the work of nurses in prevention. Primary health reforms are being given high profile as Australia seeks to reduce hospital costs, and increase prevention and health promotion through revamping of primary care systems. One major development has been the establishment of Medicare Locals. These are new, independent non-government organizations managed by Boards of Directors, with responsibility for population health. Access and equity, coordination, prevention and service integration across general practices, allied health and community health care providers. Medicare Locals also have a brief to identify and tackle local community healthcare needs and overcome service gaps (Australian Government Department of Health and Ageing, 2010b). As new performance indicators are developed, there will also be the need for growth and development of a skilled workforce able to deliver, and primary care nurses are well placed to increase their involvement in disease prevention and the promotion of health and wellbeing. These new organizational and funding structures will create opportunities for nurses to work in primary health care, and in prevention and health promotion, potentially in new roles with optimization of current practice nurse roles. Yet there is a dearth of knowledge in Australia about the role of primary care nurses in prevention and health promotion. Past funding models encouraged specific tasks rather than holistic care. Any broader role in health promotion was opportunistic rather than targeted. One of the key priority areas of the National Primary Health Care Strategy (Australian Government Department of Health and Ageing, 2010a) is to increase the focus on prevention and primary care nurses have important roles to play across the spectrum from prevention to health promotion. We have previously argued that understanding the capacity of the nursing workforce in primary health care settings is critical to advance Australia s goals for the promotion of health but we know little about the health promotion work of nurses in general practice (Keleher, Parker, & Francis, 2010). Our work has also shown that nurses are a highly skilled, and cost-effective workforce (Keleher, Parker, Abdulwadud, & Francis, 2009) Yet, our research has also reported that nursing courses have at best, only patchy teaching and learning about health promotion/primary health care, leaving a nursing workforce that is underprepared for this important work (Keleher et al., 2010). Pre-registration nursing programs have been slow to respond to the increased participation of nurses in primary health care or to the increasing importance of health promotion and prevention interventions. The Australian Nursing and Midwifery Council competencies are not easily mapped onto primary health care and prevention/health promotion for

Health promotion by primary care nurses 217 Table 1 Framework for health promoting actions. Downstream actions Midstream actions Upstream actions Action areas Disease prevention Primary prevention Secondary prevention Tertiary prevention Communication Health information for all literacy levels Social marketing and behaviour change campaigns Health education and empowerment Personal skills for management of health and wellbeing Knowledge and understanding of what creates good health Supportive environments Community development Partnerships Engagement Empowerment Community action Infrastructure and systems change Healthy public policy Regulation and legislation Health services re-orientation Organizational change Intersectoral collaboration the purposes of teaching pre-registration nurses (Keleher et al., 2010). In the evolving landscape of Medicare Locals which are new Primary Health Care Organizations (PHCOs) in Australia from 2012, it will be important for primary health nurses to engage in continuing professional education and professional development through post-registration courses that expand their skills and knowledge in community practice, prevention and health promotion. We define health promotion in accordance with the Ottawa Charter for Health Promotion, as the process of enabling people to take control over those factors that determine their health (World Health Organization, 1986). Table 1 shows the classification of the various types of health promotion actions across levels from downstream to upstream, linking actions to outcome levels for health promotion work (Keleher, 2011). This organizing framework allows health promotion and prevention work to be explained in terms of levels of action from downstream, through the midstream to upstream actions. In this framework, disease prevention is regarded as downstream work which involves primary secondary and tertiary prevention as well as population initiatives including screening and immunization. The midstream level involves interventions for lifestyle changes including the provision of health information and education, and behaviour change interventions including campaigns, and community engagement and action. The upstream level includes systems development including infrastructure, systems change (reorienting health systems to primary health care and health promotion) and health promoting policies. As primary care is the principle model of service delivery in general practice, its work in prevention and health promotion, whether by nurses or general practitioners, is generally focused on downstream prevention work rather than more upstream community-based health promotion. This article reports on the qualitative responses from a survey that explored the health promotion work of primary care nurses working in general practice. We have previously reported on data from this survey in relation to education and career pathways (Parker, Keleher, & Forrest, 2011), whereby almost 85% of respondents reported that they did not have a career pathway in their general practice setting. Further, nurses felt that while the public had confidence in them, there is not good role recognition for the work that they do. We now report on analysis of the health promotion/prevention work reported by nurses to that survey. Methods Ethics approval was gained from Monash University s Human Research Ethics Committee. The survey was adapted for an Australian context from a survey developed in New Zealand (Ministry of Health New Zealand, 2003). The study was undertaken during August and September 2008. Registered nurse participants were recruited through advertisements in Australian General Practice Network (AGPN) newsletters, which are also sent to practice nurses. The advertisement invited practice nurses to contact the Chief Investigators by email if they wanted to participate. 78 nurses volunteered in response to advertisements and 54 returned a completed survey. A majority (96.5%) of the participants were female, aged between 22 and 60 years (mean age of 46 years). Respondents had worked in general practice for an average of 4.6 years with 50% working less than 3.5 years. All States and Territories were represented in the survey responses except the Northern Territory, and respondents worked in urban, rural, and mixed urban locations. The questions in the survey about health promotion and prevention were open-ended so nurses wrote freely with their responses to the questions. In accordance with qualitative analysis conventions, these responses were transcribed into a word document and then analyzed (Liamputtong, 2009). The analysis was conducted through close examination of the responses, to enable sense-making of what the respondents were telling us. Categories were identified and then mapped onto the Framework for Health Promoting Actions (Keleher, 2011) to guide understanding of the range of health promotion work that nurses reported. Findings Questions in the survey explored practice nurses understandings of their health promotion and prevention roles, what health promotion practices they undertook in their work, their opportunistic health promotion work and the triggers for opportunistic interventions, as well as their aspirations to extend their prevention and health promotion work.

218 H. Keleher, R. Parker How nurses describe their health promotion practice To the question, How do you describe health promotion work in a practice nurse context?, nurses commonly included some aspect of chronic disease management in their responses: To inform and educate the community in a nonconfrontational way about health prevention, and maintenance. Being able to inform patients with evidence based useful clinical information. The ability to offer clients the opportunity to discuss their health problems & help them achieve their goals & cover preventative measures to allow us to monitor health. Health promotion is being able to impart knowledge and other services to encourage good health practices in the community based on best practice and knowledge. Opportunistic health promotion and triggers for interventions Opportunities for health promotion/prevention practices To the question, Do you have opportunities to practice health promotion/prevention, and if so, what opportunities do you have for this practice?, 43 (of 58) nurses provided responses which show that their work in health promotion/prevention is mainly opportunistic, using brief interventions: As being opportunistic - as part of our time spent ie. clients eg immunisation, doing INR s/wound care etc.; also whilst performing health assessments, GPMP s; whilst attending a client also addressing possible needs of other members of family or friends eg Gardasil. Other nurses were engaged in group work or clinics, which they saw as providing opportunities for interventions for individuals: I find that opportunistic brief intervention/education is very beneficial through health assessment consults. This allows the client to have a think about what we have discussed and they return to obtain further advice/information or referral onto someone who can help. Interactive, fun, informative sessions that clients are encouraged to come along to. These sessions vary and include- Well Women, Strong Women; Type 2 Diabetes, Healthy Lifestyle, Feeding Our Mob- Healthy Food Ideas for Koori Kids- there are many more! Currently it s opportunistic- discussion of nutrition & exercise in all age groups to try to reduce onset Type 2 diabetes. Advertise within local community about Pap Smears now available by a female in community & importance of regular 2 yrly tests. A practice nurse provides heath promotion opportunistically as well as during routine health assessments. Examples are smoking cessation, weight management, blood pressure checks etc. Other nurses emphasized patient education: Health promotion for Practice Nurses is a complex job. Not only education regarding healthy lifestyles, practices and behaviours; but it is also assisting and supporting patients physically and emotionally to make positive changes in their lives. Further it involves reminders and recalls to participate in healthy behaviours. In addition, preventative health care is also part of health promotion for PN s. Health Education plus preventative measures education & promotion of healthy lifestyles. Promoting healthy lifestyle choices and encouraging those behaviours, promoting immunisations, promoting screening programs eg bowel cancer screening, PAP smears, mammograms, promoting appropriate development children, providing information. Health promotion is opportunistic. When patients come in for any reason I ask them some general health questions which guides me to information they might need. Ongoing education of patients often structured but identified according to the condition the patient present with, making it often opportunistic. We also use a recall system that identifies needs and patients. We use pamphlets to promote health care. We use nursing hours/appointments to sustain the message and support patients eg: weight loss, diabetes. We refer to outside agencies for support/education/treatment etc. for patients as needs identified. This nurse recognized the opportunities to refer people and was one of just a few who used the language of the social determinants of health: Mostly downstream 1:1 education. Also participation in screening and immunisation programs. We are able to link clients into services to address the social determinants of health such as housing, social work support. Potential for nurses to extend their prevention and health promotion work A total of 56 nurses responded positively to the question, What other health promotion/prevention work would you like to be doing as a practice nurse? Consistent with their understandings of health promotion and prevention, nurses explained their work in individual health education terms. Two areas most commonly nominated by nurses in the health promotion and prevention sphere were healthy lifestyles, and sexual health and screening. Practice nurses were familiar with the language of health promotion and disease prevention and could see opportunities to work beyond the management practices that currently dominate nurses work: I think that having more clinics involving health prevention and promotion would be beneficial. Nurses felt that they could enhance their role in healthy lifestyle coaching either through work with individual patients or a group clinic. Nurses expressed their

Health promotion by primary care nurses 219 interest in working with patients who have chronic conditions through clinics, and groups. They saw them being conducted with general practices: Diabetic clinics/copd clinics: Run lifestyle clinics & preventative clinics for chronic disease management; or in the community: More community sessions, group workshops, topic workshops, diabetes education, nutrition promotion. These comments suggest that nurses saw their roles in healthy lifestyles in a multidisciplinary environment, working with nutritionists for example. Other comments focused on general health education and disease prevention activities that require recall and review strategies: Weight loss clinic, offering weekly weighs & reviews; I would like to establish clinics e.g. weight loss. Nurses were also keen on being engaged in smoking cessation programs. One nurse was keen on using needs assessment strategies to determine patient preferences: I would be interested to see what health promotion activities the patients would find interesting/useful and arrange those. Others were keen on establishing relationships with clients to promote regular dialogue about health management: Talking/discussing lifestyle with clients who are overweight & have minimal cholesterol/bp problems at present; I would like to be tackling the obesity epidemic. I would like to use Lifescripts and regular appointments with patients to encourage their weight loss attempts. I would also like to refer these patients to get some life coaching to achieve their weight loss goals. Again, these nurses showed their awareness of the complexity of promoting healthy lifestyles, and the importance of multidisiciplinary care for people with complex conditions to promote their self-management skills. Expanding their work in sexual health and screening was a strong area of interest for practice nurses who expressed interest in: Women s health- advice on contraception, importance of Pap smear, breast checks. Another wanted to bring her skills and experience to the general practice setting: I come from a sexual health background & work at a high HIV load clinic so STI screening & talking about behaviour change- safer sex practices/safer injecting etc. Some nurses showed their interest in working with groups who may be underserved including Aboriginal women and youth. One nurses identified: Cervical cancer screening and general women s, education and screening for remote Aboriginal communities. Another nominated her interest in young people s sexual health: STI awareness and education for 13+ male & female Indigenous people. Barriers and enablers for nurses extending their health promotion work Nurses were asked about barriers to extending their health promotion work and implementing broader activities. Common barriers were identified as time, space and resistance to nurses expanding their roles: Would like to run clinics, but lack of time, space and Drs are a problem. This nurse implies that attitudes are a barrier to nurses expanding their roles, but she was also saying that general practice may not have the facilities for clinics or group work. Other barriers included time available for nurses for prevention and health promotion work Time too limited to do extra - and funding issues: I would like to provide more work on weight management and smoking cessation but there is no Medicare funding to support this. Nurses were also aware of their limitations: Would like to do 4 year old health check but I am not confident to be checking eyes/ears as I am not a children s nurse. However, nurses recognized that doctors could also be enablers of their role expansion: Nurses get more work to do as the doctors recognise the ability of nurses and off load jobs. And the funding structures were also an important enabler: The immunisation payment for nurses (from government) means that we get to do everything e.g. height, weight, immunisation baby check, nutrition advice. Discussion Typically, respondent descriptions of health promotion in a general practice were in terms of individual health education and prevention work, which are at the downstream-midstream levels of health promotion action (Table 1). However, there was some recognition of equity issues in relation to the social determinants of people s health which suggests awareness that more upstream actions are needed to improve the health of more disadvantaged groups. Nurses responding to this survey were keen to strengthen their opportunities for group work and more specialized clinic based work. Many demonstrated a vision for how their skills could be better utilized whilst recognizing the constraints of the general practice setting. Nurses in this survey were positive about undertaking broader health promotion roles in key areas such as healthy lifestyle education and sexual health, and indicated their interest in working collaboratively with partners outside general practice settings. As primary care systems are strengthened, these findings suggest that there is considerable potential for nurses to increase both their capacity and opportunities for health promotion work, which is consistent with the aims of the National Primary Health Care Strategy (Australian Government Department of Health and Ageing, 2010a). Health promotion work by nurses in primary care settings has the potential to impact on health outcomes but expansion should only occur if that work is based on evidence about what works, and evaluated for its effectiveness. It is also imperative that primary care nurses engage in professional development and further education to broaden their understandings of health promotion and knowledge and skills that will enable them to practice effectively with, for example, groups and communities. Nurses represent the largest group of health professionals in the Australian health sector (Productivity Commission, 2006). Nursing is a versatile workforce but one which is currently not receiving adequate preparation in either primary health care or health promotion (Keleher et al., 2010). A small body of Australian literature has examined the

220 H. Keleher, R. Parker changing work environments for nurses in primary care where good multidisciplinary practice is shown to improve outcomes and lower costs (Harris & Zwar, 2007). There is good evidence that nurses are effective in primary care and community settings, yet there is much potential for nurses to further optimize their workforce skills for effective and broad-based health care delivery by increasing their competencies in health promotion (Keleher et al., 2007; Raftery, Yao, Murchie, Campbell, & Ritchie, 2005). Yet, structural, organizational and professional barriers to prevention in general practice (Mazza & Harris, 2010) seem also to extend to the prevention and health promotion practice of primary care nurses in these settings. Similar to Calderón, Balague, Cortada, and Sánchez (2011) the findings from this survey suggest that primary care nurses are constrained in their health promotion practice, both by the setting of general practice and their skill base, as well as attitudes of general practitioners to nurses involvement in health promotion work. This reflects work by others that found internal power relationships between the GP (employer) and nurse (employee) is an obstruction to collaborative practice (Mills & Fitzgerald, 2008). General practice is primarily involved in treatment and to a lesser extent, in disease prevention (Britt et al., 2009) so more midstream and upstream health promotion has not really been seen as core business for general practice. There is also a disconnect between patient perceptions of prevention in general practice and government expectations of this sector (Mazza et al., 2011) which primary care nurses could potentially overcome. Constraints on nurses practicing prevention and self-management are also evident through the organization and funding of Australian general practice (Walters et al., 2012) which is a broader issue that governments could address. Health promotion, when practiced from the principles and action areas of the Ottawa Charter and subsequent Health Promotion Declarations and Charters (Catford, 2011) requires the acquisition of skills, knowledge and competencies that equip practitioners for practice (Joss & Keleher, 2011). Nurses (and general practitioners) who are primarily educated in acute care skills and knowledge, will gravitate towards disease prevention based on the medical model of treatment and care, rather than community development and outreach models in communities, which are based on the social model of health (Joss & Keleher, 2011). We have previously argued that Australian nurses are ill prepared by pre-registration courses for future careers in primary care, health promotion and prevention (Keleher et al., 2010; Parker et al., 2009). If nurses in general practice are to fulfill the roles in health promotion that they report in this survey they want to undertake (i.e. health education for healthy lifestyle support, clinics and sexual health), then adequate educational preparation is required. Furthermore, funding and time barriers to nurses undertaking these roles need to be addressed although some changes are underway. New systems of funding for nurses in general practice have the potential to liberate nurses to work in more diverse areas, including health promotion. At the same time the advent of Medicare Locals, with a focus on prevention and meeting the specific needs of communities, is likely to provide impetus to enable nurses working in general practice to expand their roles through health promotion activities (Australian Government, 2010a). Conclusions The responses to the survey reported here show that nurses are enthusiastic about being involved in health promotion and valued the work that they are currently able to do. Our results indicate the importance of education and training of nurses to expose them to the range of downstream upstream health promotion that may also inspire them to develop opportunities beyond their current boundaries. The re-design of primary care nursing work in the context of Medicare Locals would enable them to become more engaged in health promoting actions and support the national health reform focus on the primary care sector to strengthen health promotion and prevention activities (Australian Government, 2010a). The findings from this survey indicate the considerable potential for primary care nurses to work across the boundaries of general practice settings and to work more collaboratively with other health professionals in health promotion work. Nursing is a cost-effective, skilled workforce whose availability to be working more effectively in prevention and health promotion, appears to be under-utilized in primary care settings (Keleher et al., 2009). Understanding, and formulating a policy response to, the barriers and enablers of prevention and health promotion among primary care nurses is critical for the effectiveness of current primary health care reforms. It is critical that nursing organizations take leadership in these policy debates and in the formulation of policy that gives direction for future developments in primary care nursing. In particular, further research is needed to define the roles and responsibilities of nurses in prevention and health promotion in primary care settings, and their scope of practice in relation to educational preparation. References Australian General Practice Network. (2010). National Practice Nurse Workforce Survey. Canberra. Australian Government. (2010a). Budget Statements Department of Health and Ageing. Canberra. Australian Government. (2010b). Budget: A National Health and Hospitals Network for Australia s future. Australian Government Department of Health and Ageing. (2010a). Building a 21st century primary health care system: Australia s primary health care system. Canberra: Commonwealth of Australia. Australian Government Department of Health and Ageing. (2010b). Medicare locals: Discussion paper on governance and functions. Canberra: Commonwealth of Australia. Australian Government Preventive Health Taskforce. (2009). Australia: The healthiest country by 2020. National Preventative Health Strategy The roadmap for action. Canberra: Commonwealth of Australia. Britt, H., Miller, G. C., Charles, J., Henderson, J., Bayram, C., Pan, Y., et al. (2009). General practice activity in Australia 2008 2009 (No. GEP 25). Canberra: Australian Institute of Health and Welfare. Calderón, C., Balague, L., Cortada, J., & Sánchez, A. (2011). Health promotion in primary care: How should we intervene? A qualitative study involving both physicians and patients. BMC Health Services Research, 11(62).

Health promotion by primary care nurses 221 Catford, J. (2011). Health promotion The journey from Alma Ata and Ottawa to Bangkok and Nairobi. In H. Keleher, & C. Mac- Dougall (Eds.), Understanding health. South Melbourne: Open University Press. Douglas, F., Van Teijlingen, E., Torrance, N., Fearn, P., Kerr, A., & Meloni, S. (2006). Promoting physical activity in primary care settings: Health visitors and practice nurses views and experiences. Journal of Advanced Nursing, 55(2), 159 168. Gulliford, M. C. (2002). Availability of primary care doctors and population health in England: Is there an association? Journal of Public Health Medicine, 24(4), 252 254. Harris, M. (2008). The role of primary health care in preventing chronic disease, with particular focus on the lifestyle risk factors of obesity, tobacco and alcohol. Commissioned paper for the National Preventive Health Taskforce. Harris, M. F., & Zwar, N. A. (2007). Care of patients with chronic disease: The challenge for general practice. The Medical Journal of Australia, 187(2), 104 107. Joss, N., & Keleher, H. (2011). Competencies for public health and health promotion: Build your own career! In H. Keleher, & C. Mac- Dougall (Eds.), Understanding health. South Melbourne: Open University Press. Joyce, C., & Piterman, L. (2011). The work of nurses in Australian general practice: A national survey. International Journal of Nursing Studies, 48(1), 70 80. Keleher, H. (2011). Program planning and evaluation. In H. Keleher, & C. MacDougall (Eds.), Understanding health. South Melbourne: Oxford University Press. Keleher, H., Joyce, C., Parker, R., & Piterman, L. (2007). Practice nurses in Australia: Current issues and future directions. The Medical Journal of Australia, 187(2), 108 110. Keleher, Parker, Abdulwadud, & Francis. (2009). The effectiveness of primary and community care nursing in primary care settings. A systematic literature review. International Journal of Nursing Practice, 15(1), 16 24. Keleher, H., Parker, R., & Francis, K. (2010). Preparing nurses for primary health care futures: How well do Australian nursing courses perform? Australian Journal of Primary Health, 16, 211 216. Liamputtong, P. (2009). Qualitative research methods. South Melbourne: Oxford University Press. Mazza, D., & Harris, M. F. (2010). Improving implementation of evidence-based prevention in primary care. Medical Journal of Australia, 193, 101 102. Mazza, D., Shand, L. K., Warren, N., Keleher, H., Browning, C. J., & Bruce, E. J. (2011). General practice and preventive health care: A view through the eyes of community members. Medical Journal of Australia, 195(4), 180 183. Merrick, E., Duffield, C., Baldwin, R., & Fry, M. (2012). Nursing in general practice: Organizational possibilities for decision latitude, created skill, social support and identity derived from role. Journal of Advanced Nursing, 68(3), 614 624. Mills, J., & Fitzgerald, M. (2008). The changing role of practice nurses in Australia: An action research study. Australian Journal of Advanced Nursing, 26(1), 16 20. Ministry of Health New Zealand. (2003). Primary Health Care and Community Nursing Workforce Survey 2001. Wellington. Parker, R., Keleher, H., & Forrest, L. (2011). The work, education and career pathways of nurses in Australian general practice. Australian Journal of Primary Health, 17, 227 232. Parker, Keleher, Francis, & Abdulwadud. (2009). Practice nursing in Australia: A review of education and career pathways. BMC Nursing, 8.(5). Parker, R., Walker, L., & Hegarty, K. (2010). Primary care nursing workforce in Australia: A vision for the future. Australian Family Physician, 39(3), 159 160. Productivity Commission. (2006). Australia s Health Workforce: Research report. Canberra. Raftery, J. P., Yao, G. L., Murchie, P., Campbell, N. C., & Ritchie, L. D. (2005). Cost effectiveness of nurse led secondary prevention clinics for coronary heart disease in primary care: Follow up of a randomised controlled trial. British Medical Journal, 330, 707. Starfield, B. (1998). Primary care: Balancing health needs, services and technology (Revised ed.). New York: Oxford University Press. Starfield, B. (2009). Toward international primary care reform. Canadian Medical Association Journal, 180(11), 1091 1092. Starfield, B., Shi, L., & Macinko, J. (2005). Contribution of primary care to health systems and health. The Milbank Quarterly, 83(3), 457 502. Turrell, G., Oldenburg, B. F., Harris, E., & Jolley, D. (2004). Utilisation of general practitioner services by socio-economic disadvantage and geographic remoteness. Australia and New Zealand Journal of Public Health, 28(2), 152 158. Walters, J. A. E., Courtney-Pratt, H., Cameron-Tucker, H., Nelson, M., Robinson, A., Scott, J., et al. (2012). Engaging general practice nurses in chronic disease self-management support in Australia: Insights from a controlled trial in chronic obstructive pulmonary disease. Australian Journal of Primary Health, 18(1), 74 79. World Health Organization. (1986). Ottawa charter for health promotion. Geneva: World Health Organization. Zwar, N. A., Richmond, R. L., Forlonge, G., & Hasan, I. (2010). Feasibility and effectiveness of nurse-delivered smoking cessation counselling combined with nicotine replacement in Australian general practice. Drug and Alcohol Review, 30(6), 583 588.