Adolescents report that they welcome the opportunity to discuss health issues such as contraception, substance use and sexually transmitted infections with healthcare providers and trust their advice.3 However, few young people specifically seek help from primary care services for mental health and risk taking behaviours for a number of reasons. These include perceived lack of youth friendly service characteristics,4 fears about lack of confidentiality, costs, not knowing where to go and discomfort in disclosing health concerns.5
Essential strategies for 'youth friendly' healthcare
Youth friendly communication skills are important in engaging young people with healthcare. Also important is patient centred care, a hallmark feature of the general practice approach.6 Routine discussions about risky behaviours and mental health issues, using such frameworks as the HEADSSS7 assessment tool or similar are recommended.8–11
HEADSSS is a mnemonic for taking a psychosocial history covering: Home life; Education, employment, eating and exercise; Activities and peers; Drugs, cigarettes and alcohol; Sex and sexuality; Suicide, depression and mental health symptoms; and Safety issues.
The complex psychosocial nature of youth health risk behaviour also demands a comprehensive, collaborative approach that includes linkages between primary care providers and other youth service providers such as specialist mental health and substance abuse services or school nurses and welfare or justice services (a 'linkage role').12
The practice nurse role
The practice nurse role and its efficacy in primary care is well established in the United Kingdom, United States and New Zealand. Recent reviews have shown that nurses can achieve many health outcomes equal to those of general practitioners, often with higher patient compliance and satisfaction.13–15 Furthermore, health promotion and preventive care are roles already adopted by practice nurses in the United Kingdomº and New Zealand.15
Currently, 56.9% of general practices in Australia employ a total of 8914 practice nurses, which is an increase of 15% since 2007.16 Policy supports increasing the number of practice nurses as a strategy to address primary care workforce shortages.17 There is a growing need for practice nurses to be supported in expanding their roles.18 A recent study describing practice nurse consultations in Australia found that new policy reforms are supporting greater flexibility of nurses' roles and maximising efficient use of their skills.19 The Practice Nurse Incentive Program (PNIP) is a policy reform launched by the Australian government in January 2012. The PNIP aims to give practice nurses a greater focus on prevention, education and chronic disease management.20
With these policy reforms and expanding numbers and roles, it is timely to investigate how practice nurses in Australia can contribute to quality primary healthcare and preventive care for young people, as there is little research in this area. This paper reports on research conducted to inform a pilot for a randomised trial of an intervention training GPs and practice nurses to screen young people for health risks and provide a brief intervention for detected risks. The aim of the research was to provide information on acceptable roles for nurses, barriers and facilitators to performing these roles, and whether existing programs for training GPs in adolescent healthcare could be adapted for training practice nurses. We were also aiming to explore nurses' and key informants' views on a linkage role between the general practice and other youth services provided by nurses.
Methods
A qualitative approach comprising semi-structured single interviews and focus groups with key informants and practice nurses was used. See Table 1 for the themes covered.
Table 1. Interview schedule
| Themes for interview schedule with practice nurses | Themes for interview schedule with key informants |
|---|
- Current roles within the practice including work with young people
- Perception of a potential role for the practice nurse in youth primary care
- Perceptions of the current main health issues for youth and barriers to accessing care
- Confidence in dealing with youth and the skills perceived necessary to undertake consultations with young people
- Views about a linkage role with other relevant youth services
|
- Barriers and facilitators of the care of young people in the community
- Skills perceived a practice nurse would require to facilitate ‘ideal health care’
- Views about a linkage role with other relevant youth services
|
Participants and data collection
Key informants were chosen on the basis of their professional roles within services dealing with at risk young people. These services require robust linkages with primary care for referral of young people back into primary care for ongoing management, continuing holistic care and follow up. In addition, primary care requires robust linkages with these services when youth are detected with health or social risks requiring specialised management. Seventeen health and community sector professionals in Melbourne, Victoria, were selected using the snowballing technique. Key informant interviews were face to face. Their professional groupings are listed in Table 2.
Practice nurses: Twelve female practice nurses from across Victoria were interviewed. Practice nurses were recruited from a database of registered nurses who had enquired about postgraduate programs offered at The University of Melbourne. This sampling strategy was chosen to target practice nurses who were interested in education and expanded roles. All interviews were semi-structured and conducted by telephone as the participants were geographically dispersed.
Table 2. Key informants interviewed
| Key informants | Number |
|---|
| Accident and emergency (physician) |
1 |
| Acute youth mental health service (Intake worker/psychologist) |
2 |
| School nurses |
7 (focus group) |
| Education welfare service (student welfare coordinator) |
1 |
| Hospital adolescent health service (adolescent medicine physician) |
3 |
| Juvenile justice facility (general practitioner) |
2 |
| Adolescent medicine addiction service (addiction medicine physician) |
1 |
Data analysis
All interviews were audiorecorded and transcribed verbatim. A directed content analysis approach was applied21 and the use of NVivo 7 enabled complex organisation and retrieval of data. This directed approach uses key concepts or existing research findings (in this case, perceived health issues, barriers and facilitators of care and the role of the practice nurse) as predetermined categories to inform the interview schedule and analyse the findings.
Ethics approval
The study was approved by The University of Melbourne Human Research Ethics Committee and was undertaken during 2007.
Results
Perceived current health issues for young people
Practice nurses (PN) and key informants (KI) identified mental health and risk taking behaviours to be significant health issues facing young people, in addition to sexual/reproductive health, diet and obesity.
'I think mental health is a big issue … the stress and pressures that are on kids these days are quite different to what they have been.' (PN 11)
'So there's alcohol problems, smoking problems, drug problems, problems with contraception, sexually transmissible infections (STIs), chlamydia is a big factor.' (PN 12)
Barriers to young people accessing healthcare
Confidentiality
The most significant barrier for young people perceived by both key informants and practice nurses was concern about confidentiality, particularly when the general practice was located in a smaller community.
'So I think confidentiality is the huge issue in our particular setting because it's a small town and everybody knows everything.' (PN 7)
'If I go and talk to this GP and they see mum tomorrow, will they tell mum everything I've said to them? That's certainly an issue.' (KI 5)
Accessibility
Accessibility issues, including cost and time pressure on GPs, were seen by key informants and nurses as a significant barrier to young people accessing care.
'And the problem being it's so busy, there's 10 minute appointments, and I think that the kids aren't given that – the extra time.' (PN 2)
Facilitators and barriers to optimal care by the practice nurse
'Youth friendly' environment
Practice nurses most often mentioned an appealing 'youth friendly' practice environment and assurances of confidentiality as facilitators to care for young people. Other perceived facilitators included reasonable consultation cost, the use of specific youth clinics and sufficient time given to the young person.
Communication skills
Both practice nurses and key informants noted that good communication skills and being nonjudgemental were significant facilitators to care.
'Young people are very sensitive I think to feeling like people are judging them and making some opinion about them.' (KI 5)
'I think it's a confidentiality thing too. I think it comes back to them feeling comfortable and knowing that they can trust that person. I think trust is a big thing for these young people.' (PN 10)
One practice nurse said she doubted whether all PNs would have the appropriate skills to do such work:
'I know some practice nurses … and I can only talk about what I know in my own area, I wouldn't be sure that many of them would be able to respond in a comfortable manner.' (PN 4)
Confidence
Key informants and practice nurses noted confidence as an important facilitator in dealing with young people, particularly in knowing when to refer a young person, administering a screening questionnaire and providing a brief intervention. None of the practice nurses had received training in health for young people and some felt that education on consulting and counselling young people would boost their confidence in tackling the issues adolescents presented with.
'If I had the right skills I don't have a problem. And I find that now with my practice, if I have the knowledge and the skills to deal with it, I'm comfortable and that's fine. It's just when it gets out of my comfort zone and my knowledge base that it becomes difficult.' (PN 8)
Training
The need for practice nurses to gain confidence in working with young people and take part in training about youth health was mentioned by both practice nurses and key informants in this study.
One rural practice nurse felt that while training was a good idea it would be difficult for many to attend.
'Well, certainly for rural it would probably be much easier if it was a distance education component with, you know, perhaps some onsite visits to adolescent mental health areas.' (PN 11)
Remuneration
Despite this readiness to provide care to young people, practice nurses recognised that there were remuneration issues that would need to be addressed to facilitate this care.
The role of the practice nurse in the care of young people
Practice nurses reported that their work with young people involved mainly procedures such as immunisations and Pap tests.
Linkage roles and outreach
The majority of nurses believed they could have a more prominent role in the care of young people, and felt that having a linkage role with other agencies, schools and health professionals would provide more holistic care.
'There's little pockets of people that are interested in adolescent health or deal with adolescents, but there's no central person. So you know, maybe the practice nurse can … provide that role.' (PN 2)
Practice nurses were viewed by key informants as being able to bridge some of the barriers for young people accessing primary care. Service coordination, outreach work and setting up youth clinics were some suggested roles. Key informants also agreed that forming linkages between general practices and other services facilitated care for young people and that practice nurses could undertake this important role with appropriate knowledge of the healthcare system.
'I think you'd need a knowledge of how the mental health system works, and how the drug and alcohol system works, and how the youth system works and how they all fit in together.' (KI 9)
Key informants specifically mentioned types of linkage work for nurses including service coordination, outreach work and setting up of youth clinics.
Health promotion
Some practice nurses also emphasised their role in health promotion and rapport building for all age groups including young people.
'Sometimes they feel perhaps the nurse has got a little bit more time … often doctors send patients, including adolescents, over to us for certain information or brochures, that sort of thing.' (PN 12)
Discussion
Health reforms over the last decade have resulted in increasing numbers and scope of practice of nurses employed in general practices, particularly in areas of workforce shortage.22 It has been suggested, however, that Australian government initiatives to support the expansion of practice nursing are not consistently based on strong evidence about effectiveness, outcomes or efficiencies.17 This study suggests that expanding the role of the practice nurse in youth friendly, preventive primary healthcare is acceptable and worthy of further effectiveness studies.
Strikingly, our data show that both nurses and key informants were responding similarly to the major interview themes. This is encouraging for healthcare reform as both frontline primary care and specialist clinicians share perspectives on strategies to achieve youth friendly primary healthcare and nurses' role within this.
Nurses and key informants recognised the prevalent psychosocial health burdens young people experience and the barriers they perceive in accessing healthcare and both believed that, with good communication skills and appropriate training, practice nurses could have an important role in the preventive care of young people. This creates the need for effective methods of integrating preventive care into routine clinical practice.4 Also reported by participants was the importance of a linkage role for practice nurses within the practice and to community and specialist services, to facilitate a coordinated approach to care.
The barriers and facilitators for nurses working with young people in this study were very similar to those reported by GPs in earlier studies.23 So the adolescent healthcare principles in previous evidence based general practice training initiatives24,25 are likely to be applicable to training nurses, but additional training would be required for the linkage role. This finding informed the design of training modules for practice nurses for our later use in the randomised trial.
This study was conducted when Australian practice nurses were largely funded through Medicare item numbers for a range of procedures that excluded young people. Practice nurses in Australia have since reported that they are positive about the expansion of their roles to include more preventive health activities26 including health promotion and direct preventive care.27 This study is timely, with the PNIP starting in 2012, in articulating nurses' and youth health providers' strong support for the role of the general practice nurse being expanded to include youth friendly preventive healthcare for young people.
Study limitations
There were limitations to this study. The sample of practice nurses was taken from a large database of nurses interested in postgraduate study and may not be representative of practice nurses in general. However with the recent reforms, and a desire to develop a career structure for practice nurses,26 postgraduate training is likely to become a feature for most practice nurses as their roles are expanded.
A further limitation of this study is that the views of GPs were not concurrently obtained. However, these views were sought in unpublished work previous to this study and informed the need to further test the role of practice nurses in young people's healthcare with input from nurses and other youth related professionals.
Implications for general practice
- Practice nurses want a role in the care of young people in general practice, if appropriately trained in healthcare principles for young people and resourced for this work.
- This study is being reported on at an opportune time, when we can begin to consider the roles for nurses in preventive care for young people with the Practice Nurse Incentive Program changes in 2012.
Conflict of interest: none declared.
Acknowledgements
We would like to thank the key informants and nurses who took time out of their busy work schedules to participate in this study. This study was funded by beyondblue: The National Depression Initiative.